ADDENDUM A.--List of Ambulatory Payment Classifications (APCs

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status

Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC Group Title

0001 Level I Photochemotherapy

0002 Fine needle Biopsy/Aspiration

0003 Bone Marrow Biopsy/Aspiration

0004

Level I Needle Biopsy/ Aspiration Except Bone

Marrow

Level II Needle Biopsy /Aspiration Except Bone

Marrow 0005

0006 Level I Incision & Drainage

0007 Level II Incision & Drainage

0008 Level III Incision and Drainage

0009 Nail Procedures

0010 Level I Destruction of Lesion

0011 Level II Destruction of Lesion

0012 Level I Debridement & Destruction

0013 Level II Debridement & Destruction

0015 Level III Debridement & Destruction

0016 Level IV Debridement & Destruction

0017 Level VI Debridement & Destruction

0018 Biopsy of Skin/Puncture of Lesion

0019 Level I Excision/ Biopsy

0020 Level II Excision/ Biopsy

0021 Level III Excision/ Biopsy

0022 Level IV Excision/ Biopsy

0023 Exploration Penetrating Wound

0024 Level I Skin Repair

0025 Level II Skin Repair

0027 Level IV Skin Repair

0028 Level I Breast Surgery

0029 Level II Breast Surgery

0030 Level III Breast Surgery

0032 Insertion of Central Venous/Arterial Catheter

0033 Partial Hospitalization

0035 Placement of Arterial or Central Venous Catheter

0041 Level I Arthroscopy

0042 Level II Arthroscopy

0043 Closed Treatment Fracture Finger/Toe/Trunk

0045 Bone/Joint Manipulation Under Anesthesia

0046 Open/Percutaneous Treatment Fracture or Dislocation

0047 Arthroplasty without Prosthesis

0048 Arthroplasty with Prosthesis

0049

0050

0051

Level I Musculoskeletal Procedures Except Hand and

Foot

Level II Musculoskeletal Procedures Except Hand and

Foot

Level III Musculoskeletal Procedures Except Hand and Foot

Status

Indicator

S

T

T

Relative

Weights

0.3940

1.0937

2.2627

Payment

Rate

$21.39

$59.38

$122.84

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$7.09

$4.28

$11.88

$24.57

T

T

T

T

P

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

1.5774

7.3105

14.5749

18.6725

3.1587

1.7847

6.2703

15.8319

17.7459

29.2783

37.2809

11.5584

3.8397

0.2236

27.2538

42.8551

1.9233

13.5546

3.3675

1.7487

11.4943

16.8303

0.6597

0.6806

2.1800

0.8203

1.1420

1.5832

2.7343

16.7332

0.9567

3.9807

31.9719

30.3786

47.4707

19.9376

25.1166

34.9381

$85.64

$396.88

$791.26

$1,013.71

$171.48

$96.89

$340.41

$859.50

$963.41

$1,589.49

$2,023.94

$627.49

$208.45

$12.14

$1,479.58

$2,326.56

$104.41

$735.87

$182.82

$94.94

$624.01

$913.70

$35.81

$36.95

$118.35

$44.53

$62.00

$85.95

$148.44

$908.43

$51.94

$216.11

$1,735.72

$1,649.22

$2,577.14

$1,082.39

$1,363.56

$1,896.75

$22.10

$71.59

$24.12

$8.34

$10.08

$27.88

$11.18

$14.20

$20.35

$57.31

$227.84

$16.04

$71.87

$113.25

$219.48

$354.45

$40.37

$34.75

$115.49

$329.72

$303.74

$632.64

$763.55

$41.83

$3.51

$804.74

$268.47

$535.76

$537.03

$695.60

$17.13

$79.38

$158.25

$202.74

$34.30

$19.38

$68.08

$171.90

$192.68

$317.90

$404.79

$125.50

$41.69

$2.43

$295.92

$465.31

$20.88

$147.17

$36.56

$18.99

$124.80

$182.74

$7.16

$7.39

$23.67

$8.91

$12.40

$17.19

$29.69

$181.69

$10.39

$43.22

$347.14

$329.84

$515.43

$216.48

$272.71

$379.35

Page 1 of 30 8/6/2003 2:47 PM



APC Group Title

0052

Level IV Musculoskeletal Procedures Except Hand and Foot

0053 Level I Hand Musculoskeletal Procedures

0054 Level II Hand Musculoskeletal Procedures

0055 Level I Foot Musculoskeletal Procedures

0056 Level II Foot Musculoskeletal Procedures

0057 Bunion Procedures

0058 Level I Strapping and Cast Application

0060 Manipulation Therapy

0068 CPAP Initiation

0069 Thoracoscopy

0070 Thoracentesis/Lavage Procedures

0071 Level I Endoscopy Upper Airway

0072 Level II Endoscopy Upper Airway

0073 Level III Endoscopy Upper Airway

0074 Level IV Endoscopy Upper Airway

0075 Level V Endoscopy Upper Airway

0076 Level I Endoscopy Lower Airway

0077 Level I Pulmonary Treatment

0078 Level II Pulmonary Treatment

0079 Ventilation Initiation and Management

0080 Diagnostic Cardiac Catheterization

0081 Non-Coronary Angioplasty or Atherectomy

0082 Coronary Atherectomy

0083

Coronary Angioplasty and Percutaneous

Valvuloplasty

0084 Level I Electrophysiologic Evaluation

0085 Level II Electrophysiologic Evaluation

0086 Ablate Heart Dysrhythm Focus

0087 Cardiac Electrophysiologic Recording/Mapping

0088 Thrombectomy

0089

Insertion/Replacement of Permanent Pacemaker and

Electrodes

Status

Indicator

T

S

T

T

T

T

T

T

T

T

T

T

T

T

S

S

T

T

T

S

T

T

T

T

T

T

T

S

S

S

Relative

Weights

59.3417

10.3392

36.3284

44.5652

40.4579

34.6065

116.1611

42.6430

14.8188

24.2685

18.8851

25.1591

25.4248

1.0785

0.3151

1.1234

28.6334

3.1393

0.9012

1.6987

3.4396

14.4952

20.4113

9.3560

0.2772

0.7731

2.2837

36.0982

34.8355

100.3996

Payment

Rate

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$2,315.05

$804.50

$1,317.51

$1,025.25

$1,365.86

$1,380.29

$58.55

$3,221.60

$561.30

$1,972.23

$2,419.40

$2,196.42

$1,878.75

$6,306.27

$253.49

$355.34

$405.81

$475.91

$17.11

$60.99

$1,554.48

$170.43

$48.93

$92.22

$186.73

$786.93

$1,108.11

$3.43

$30.49

$591.64

$12.89

$26.68

$73.38

$295.70

$445.92

$507.93

$15.05

$41.97

$123.98

$189.82

$7.52

$14.55

$1,959.74

$1,891.18

$838.92

$5,450.59

$1,293.59

$435.09

$822.28

$655.22

$1,722.59

$463.01

$160.90

$263.50

$205.05

$273.17

$276.06

$11.71

$3.42

$12.20

$310.90

$34.09

$9.79

$18.44

$37.35

$157.39

$221.62

$101.59

$3.01

$8.39

$24.80

$391.95

$378.24

$1,090.12

$644.32

$112.26

$394.45

$483.88

$439.28

$375.75

$1,261.25

0090 Insertion/Replacement of Pacemaker Pulse Generator

0091 Level II Vascular Ligation

0092 Level I Vascular Ligation

0093 Vascular Reconstruction/Fistula Repair without Device

0094 Level I Resuscitation and Cardioversion

0095 Cardiac Rehabilitation

0096 Non-Invasive Vascular Studies

0097 Cardiac and Ambulatory Blood Pressure Monitoring

0098 Injection of Sclerosing Solution

0099 Electrocardiograms

0100 Cardiac Stress Tests

0101 Tilt Table Evaluation

T

T

T

T

S

S

S

X

T

S

X

S

87.2850

28.5187

25.1347

20.6662

2.6412

0.5984

1.7332

1.0565

1.1630

0.3708

1.6726

4.3675

$4,738.62

$1,705.90

$1,548.25

$348.23

$1,364.54

$1,121.95

$143.39

$32.49

$94.09

$57.36

$63.14

$20.13

$90.80

$237.11

$505.37

$277.34

$48.46

$16.24

$47.05

$23.80

$15.17

$41.44

$105.27

$947.72

$309.65

$272.91

$224.39

$28.68

$6.50

$18.82

$11.47

$12.63

$4.03

$18.16

$47.42

Page 2 of 30 8/6/2003 2:47 PM



APC Group Title

0103 Miscellaneous Vascular Procedures

0104 Transcatheter Placement of Intracoronary Stents

0105 Revision/Removal of Pacemakers, AICD, or Vascular

0106

Insertion/Replacement/Repair of Pacemaker and/or

Electrodes

0107 Insertion of Cardioverter-Defibrillator

0108

Insertion/Replacement/Repair of Cardioverter-

Defibrillator Leads

0109 Removal of Implanted Devices

0110 Transfusion

0111 Blood Product Exchange

0112 Apheresis, Photopheresis, and Plasmapheresis

0113 Excision Lymphatic System

0114 Thyroid/Lymphadenectomy Procedures

0115 Cannula/Access Device Procedures

0119 Implantation of Infusion Pump

0121 Level I Tube changes and Repositioning

0122 Level II Tube changes and Repositioning

0123

Bone Marrow Harvesting and Bone Marrow/Stem Cell

Transplant

0124 Revision of Implanted Infusion Pump

0125 Refilling of Infusion Pump

0130 Level I Laparoscopy

0131 Level II Laparoscopy

0132 Level III Laparoscopy

0140 Esophageal Dilation without Endoscopy

0141 Upper GI Procedures

0142 Small Intestine Endoscopy

0143 Lower GI Endoscopy

0146 Level I Sigmoidoscopy

0147 Level II Sigmoidoscopy

0148 Level I Anal/Rectal Procedure

0149 Level III Anal/Rectal Procedure

0150 Level IV Anal/Rectal Procedure

0151

Endoscopic Retrograde Cholangio-Pancreatography

(ERCP)

0152 Percutaneous Abdominal and Biliary Procedures

0153 Peritoneal and Abdominal Procedures

0154 Hernia/Hydrocele Procedures

0155 Level II Anal/Rectal Procedure

0156 Level II Urinary and Anal Procedures

0157 Colorectal Cancer Screening: Barium Enema

0158 Colorectal Cancer Screening: Colonoscopy

Status

Indicator

T

T

Relative

Weights

12.1256

80.8877

Payment

Rate

$658.29

$4,391.31

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$223.63

$131.66

$878.26

T

T

T

T

T

S

S

S

T

T

T

T

T

T

S

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

S

T

18.9084

49.9534

290.5429

4.0076

27.4545

2.5105

32.5959

40.8955

56.6318

6.3480

7.8542

9.0138

8.3227

3.9986

7.5876

4.1171

16.8557

22.2565

$1,026.52

$2,711.92

$15,773.28

489.5275

$26,575.96

7.7075

$418.43

3.7128

14.0169

34.8318

19.9529

37.3583

25.6233

129.8988

2.2058

8.4398

18.8763

8.2940

21.2745

26.8861

9.9148

3.1438

2.4771

7.4187

$201.56

$760.96

$1,890.98

$1,083.22

$2,028.14

$1,391.06

$7,052.08

$119.75

$458.19

$217.57

$1,490.48

$136.29

$1,769.60

$659.53

$2,220.18

$1,001.89

$3,074.48

$1,239.22

$344.63

$107.24

$426.40

$489.35

$451.83

$217.08

$411.92

$223.51

$915.08

$1,208.28

$1,024.78

$450.27

$1,154.97

$1,459.62

$538.26

$170.67

$134.48

$402.75

$370.40

$542.39

$3,429.62

$131.49

$211.96

$609.71

$485.91

$459.35

$43.80

$93.97

$298.10

$143.38

$152.78

$186.06

$64.40

$63.38

$293.06

$437.12

$245.46

$113.02

$410.87

$464.85

$188.89

$46.55

$100.69

$205.30

$542.38

$3,154.66

$5,315.19

$83.69

$40.31

$152.19

$378.20

$216.64

$405.63

$278.21

$1,410.42

$23.95

$91.64

$204.96

$90.05

$230.99

$291.92

$107.65

$34.13

$26.90

$80.55

$43.51

$298.10

$27.26

$353.92

$444.04

$614.90

$68.93

$85.28

$97.87

$90.37

$43.42

$82.38

$44.70

$183.02

$241.66

0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy

0160

Level I Cystourethroscopy and other Genitourinary

Procedures

S

T

2.7168

6.8152

$147.49

$369.99

$36.87

$105.06

$29.50

$74.00

Page 3 of 30 8/6/2003 2:47 PM



APC Group Title

0161

0162

Level II Cystourethroscopy and other Genitourinary

Procedures

Level III Cystourethroscopy and other Genitourinary

Procedures

0163

Level IV Cystourethroscopy and other Genitourinary

Procedures

0164 Level I Urinary and Anal Procedures

0165 Level III Urinary and Anal Procedures

0166 Level I Urethral Procedures

0167 Level III Urethral Procedures

0168 Level II Urethral Procedures

0169 Lithotripsy

0170 Dialysis

0180 Circumcision

0181 Penile Procedures

0183 Testes/Epididymis Procedures

0184 Prostate Biopsy

0187 Miscellaneous Placement/Repositioning

0188 Level II Female Reproductive Proc

0189 Level III Female Reproductive Proc

0190 Level I Hysteroscopy

0191 Level I Female Reproductive Proc

0192 Level IV Female Reproductive Proc

0193 Level V Female Reproductive Proc

0194 Level VI Female Reproductive Proc

0195 Level VII Female Reproductive Proc

0196 Dilation and Curettage

0197 Infertility Procedures

0198 Pregnancy and Neonatal Care Procedures

0199 Obstetrical Care Service

0200 Therapeutic Abortion

0201 Spontaneous Abortion

0202 Level VIII Female Reproductive Proc

0203 Level IV Nerve Injections

0204 Level I Nerve Injections

0206 Level II Nerve Injections

0207 Level III Nerve Injections

0208 Laminotomies and Laminectomies

Status

Indicator

Relative

Weights

T

T

16.5822

21.8578

T

T

T

T

T

T

X

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

S

T

4.4274

1.1079

1.3207

19.8088

0.1679

2.6966

15.7365

18.8194

25.3207

16.1823

5.1958

1.3718

16.8630

33.6435

1.2115

14.0780

16.8401

30.1066

30.3485

44.5329

5.9427

18.4967

29.0094

21.7612

3.8073

18.3633

17.2803

38.8053

11.8511

2.2209

5.2584

6.5998

40.6521

Payment

Rate

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$900.23

$1,186.64

$249.36

$1,826.47

$65.77

$764.28

$17.59

$914.23

$1,634.46

$218.73

$555.84

$1,647.59

$405.60

$2,417.65

$1,115.69

$322.62

$1,004.17

$1,574.89

$1,181.39

$206.69

$240.36

$60.15

$71.70

$1,075.40

$9.12

$146.40

$854.32

$1,021.69

$1,374.64

$878.52

$282.07

$74.47

$915.48

$304.87

$621.82

$96.27

$90.71

$16.70

$424.28

$2.65

$39.11

$171.13

$397.84

$483.80

$338.23

$32.19

$996.93

$938.13

$307.83

$329.65

$2,106.70

$1,032.28

$643.38

$276.76

$120.57

$285.47

$358.30

$2,206.96

$40.13

$75.55

$123.69

$180.05

$237.33

$48.07

$12.03

$14.34

$215.08

$1.82

$29.28

$170.86

$204.34

$274.93

$175.70

$56.41

$14.89

$183.10

$365.29

$13.15

$152.86

$182.85

$326.89

$329.52

$483.53

$64.52

$200.83

$314.98

$236.28

$41.34

$199.39

$187.63

$421.34

$128.68

$24.11

$57.09

$71.66

$441.39

0209

0212

Extended EEG Studies and Sleep Studies, Level II

Nervous System Injections

0213 Extended EEG Studies and Sleep Studies, Level I

0214 Electroencephalogram

0215 Level I Nerve and Muscle Tests

0216 Level III Nerve and Muscle Tests

0218 Level II Nerve and Muscle Tests

0220 Level I Nerve Procedures

S

T

S

S

S

S

S

T

11.5352

2.9989

3.2422

2.2459

0.6390

2.8332

1.1296

16.5293

$626.23

$162.81

$176.02

$121.93

$34.69

$153.81

$61.32

$897.36

$280.58

$74.92

$70.41

$58.12

$15.76

$67.98

$125.25

$32.56

$35.20

$24.39

$6.94

$30.76

$12.26

$179.47

Page 4 of 30 8/6/2003 2:47 PM



APC Group Title

0221 Level II Nerve Procedures

0222 Implantation of Neurological Device

0223

Implantation or Revision of Pain Management

Catheter

0224 Implantation of Reservoir/Pump/Shunt

0225 Implantation of Neurostimulator Electrodes

0226 Implantation of Drug Infusion Reservoir

0227 Implantation of Drug Infusion Device

0228 Creation of Lumbar Subarachnoid Shunt

0229 Transcatherter Placement of Intravascular Shunts

0230 Level I Eye Tests & Treatments

0231 Level III Eye Tests & Treatments

0232 Level I Anterior Segment Eye Procedures

0233 Level II Anterior Segment Eye Procedures

0234 Level III Anterior Segment Eye Procedures

0235 Level I Posterior Segment Eye Procedures

0236 Level II Posterior Segment Eye Procedures

0237 Level III Posterior Segment Eye Procedures

0238 Level I Repair and Plastic Eye Procedures

0239 Level II Repair and Plastic Eye Procedures

0240 Level III Repair and Plastic Eye Procedures

0241 Level IV Repair and Plastic Eye Procedures

0242 Level V Repair and Plastic Eye Procedures

0243 Strabismus/Muscle Procedures

0244 Corneal Transplant

0245 Level I Cataract Procedures without IOL Insert

0246 Cataract Procedures with IOL Insert

0247 Laser Eye Procedures Except Retinal

0248 Laser Retinal Procedures

0249 Level II Cataract Procedures without IOL Insert

0250 Nasal Cauterization/Packing

0251 Level I ENT Procedures

0252 Level II ENT Procedures

0253 Level III ENT Procedures

0254 Level IV ENT Procedures

0256 Level V ENT Procedures

0258 Tonsil and Adenoid Procedures

0259 Level VI ENT Procedures

0260 Level I Plain Film Except Teeth

0261

Level II Plain Film Except Teeth Including Bone

Density Measurement

0262 Plain Film of Teeth

0263 Level I Miscellaneous Radiology Procedures

0264 Level II Miscellaneous Radiology Procedures

0265 Level I Diagnostic Ultrasound Except Vascular

0266 Level II Diagnostic Ultrasound Except Vascular

0267 Level III Diagnostic Ultrasound Except Vascular

T

T

T

T

T

T

T

T

T

T

T

T

T

T

S

S

T

T

T

T

T

T

T

T

T

T

T

T

T

X

S

S

S

X

X

X

X

Status

Indicator

T

T

Relative

Weights

Payment

Rate

25.8194

$1,401.71

188.7735

$10,248.32

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$463.62

$280.34

$2,049.66

T

T

T

T

T

S

26.0352

34.0161

56.0375

159.6795

163.6124

51.1329

$1,413.42

$1,846.70

$3,042.22

$8,668.84

$8,882.35

$2,775.95

$453.41

$621.80

$282.68

$369.34

$608.44

$1,733.77

$1,776.47

$555.19

59.4977

0.7379

2.0880

4.9739

14.5435

21.5482

4.9900

19.6866

34.0324

3.2016

6.2432

17.3397

21.9830

29.2193

21.1035

$3,230.07

$40.06

$113.36

$270.03

$789.55

$1,169.83

$270.90

$1,068.77

$1,847.58

$173.81

$338.94

$941.35

$1,193.44

$1,586.29

$1,145.69

$771.23

$14.97

$50.94

$103.17

$266.33

$511.31

$72.04

$818.54

$58.96

$110.62

$315.31

$384.47

$597.36

$431.39

37.4885

12.5751

22.8428

5.0192

4.7544

$2,035.21

$682.69

$1,240.11

$272.49

$258.11

$803.26

$226.11

$495.96

$104.31

$95.08

28.3307

1.5381

1.8643

6.5416

$1,538.05

$83.50

$101.21

$355.14

$524.67

$29.23

15.1698

21.4368

35.0866

21.0273

$823.55

$1,163.78

$1,904.82

$1,141.55

$113.41

$282.29

$321.35

$437.25

389.1764

$21,128.00

$9,394.83

0.7845

$42.59

$21.29

1.3238

0.7851

2.1875

3.0022

1.0245

1.6234

2.4805

$71.87

$42.62

$118.76

$162.99

$55.62

$88.13

$134.66

$9.82

$43.58

$79.41

$27.81

$44.07

$65.52

$307.61

$16.70

$20.24

$71.03

$164.71

$232.76

$380.96

$228.31

$4,225.60

$8.52

$646.01

$8.01

$22.67

$54.01

$157.91

$233.97

$54.18

$213.75

$369.52

$34.76

$67.79

$188.27

$238.69

$317.26

$229.14

$407.04

$136.54

$248.02

$54.50

$51.62

$14.37

$8.52

$23.75

$32.60

$11.12

$17.63

$26.93

Page 5 of 30 8/6/2003 2:47 PM



APC

0268

Group Title

Ultrasound Guidance Procedures

0269 Level III Echocardiogram Except Transesophageal

0270 Transesophageal Echocardiogram

0271 Mammography

0272 Level I Fluoroscopy

0274 Myelography

0275 Arthrography

0276 Level I Digestive Radiology

0277 Level II Digestive Radiology

0278 Diagnostic Urography

0279

Level II Angiography and Venography except

Extremity

0280

Level III Angiography and Venography except

Extremity

0281 Venography of Extremity

0282 Miscellaneous Computerized Axial Tomography

0283

0284

Computerized Axial Tomography with Contrast

Material

Magnetic Resonance Imaging and Magnetic

Resonance Angiography with Contras

0285 Myocardial Positron Emission Tomography (PET)

0287 Complex Venography

0288 Bone Density:Axial Skeleton

0289 Needle Localization for Breast Biopsy

0296 Level I Therapeutic Radiologic Procedures

0297 Level II Therapeutic Radiologic Procedures

0299 Miscellaneous Radiation Treatment

0300 Level I Radiation Therapy

0301 Level II Radiation Therapy

0302 Level III Radiation Therapy

0303 Treatment Device Construction

0304 Level I Therapeutic Radiation Treatment Preparation

0305 Level II Therapeutic Radiation Treatment Preparation

0310 Level III Therapeutic Radiation Treatment Preparation

0312 Radioelement Applications

0313 Brachytherapy

0314 Hyperthermic Therapies

0320 Electroconvulsive Therapy

0321 Biofeedback and Other Training

0322 Brief Individual Psychotherapy

0323 Extended Individual Psychotherapy

0324 Family Psychotherapy

0325 Group Psychotherapy

X

X

S

S

S

S

X

S

S

S

S

S

S

S

X

S

S

S

S

S

S

S

S

S

X

Status

Indicator

S

Relative

Weights

1.2640

Payment

Rate

$68.62

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$13.72

S

S

S

S

S

S

S

S

X

3.2517

5.9057

0.6548

1.4086

3.5837

3.2967

1.6025

2.4462

2.7365

$176.53

$320.61

$35.55

$76.47

$194.56

$178.97

$87.00

$132.80

$148.56

$87.24

$146.79

$16.80

$38.24

$92.92

$69.09

$41.72

$60.47

$66.07

$35.31

$64.12

$7.11

$15.29

$38.91

$35.79

$17.40

$26.56

$29.71

S

S

S

S

11.0678

19.0237

6.6888

1.6813

$600.86

$1,032.78

$363.13

$91.28

$174.57

$353.85

$115.16

$44.51

$125.19

$190.57

$120.17

$206.56

$72.63

$18.26

4.6121

7.0207

19.5044

6.2829

1.2854

3.6386

3.1381

8.1532

5.7427

1.5112

2.1337

6.1992

2.8636

$250.39

$381.15

$1,058.87

$341.09

$69.78

$197.54

$170.36

$442.63

$311.77

$82.04

$115.84

$336.55

$155.46

$409.56

$107.20

$44.80

$69.20

$172.51

$62.36

$23.17

$127.49

$66.95

$41.52

$91.38

$50.08

$76.23

$211.77

$68.22

$13.96

$39.51

$34.07

$88.53

$62.35

$16.41

$23.17

$67.31

$31.09

1.6599

3.6649

13.7085

3.6892

13.1258

5.0930

5.4480

1.2462

1.3091

1.7955

2.8219

1.5820

$90.11

$198.96

$744.22

$200.28

$712.59

$276.49

$295.77

$67.65

$71.07

$97.48

$153.20

$85.89

$325.27

$40.06

$101.77

$80.06

$21.78

$21.26

$18.27

$18.02

$39.79

$148.84

$40.06

$142.52

$55.30

$59.15

$13.53

$14.21

$19.50

$30.64

$17.18

Page 6 of 30 8/6/2003 2:47 PM



APC Group Title

0330 Dental Procedures

0332

Computerized Axial Tomography and Computerized

Angiography without Contras

0333

Computerized Axial Tomography and Computerized

Angio w/o Contrast Material

0335 Magnetic Resonance Imaging, Miscellaneous

0336

Magnetic Resonance Imaging and Magnetic

Resonance Angiography without Cont

MRI and Magnetic Resonance Angiography without

Contrast Material followed 0337

0339 Observation

0340 Minor Ancillary Procedures

0341 Skin Tests

0342 Level I Pathology

0343 Level II Pathology

0344 Level III Pathology

0345 Level I Transfusion Laboratory Procedures

0346 Level II Transfusion Laboratory Procedures

0347 Level III Transfusion Laboratory Procedures

0348 Fertility Laboratory Procedures

0352 Level I Injections

0353 Level II Allergy Injections

0355 Level III Immunizations

0356 Level IV Immunizations

0359 Level II Injections

0360 Level I Alimentary Tests

0361 Level II Alimentary Tests

0362 Level III Otorhinolaryngologic Function Tests

0363 Level I Otorhinolaryngologic Function Tests

0364 Level I Audiometry

0365 Level II Audiometry

0367 Level I Pulmonary Test

0368 Level II Pulmonary Tests

0369 Level III Pulmonary Tests

0370 Allergy Tests

0371 Level I Allergy Injections

0372 Therapeutic Phlebotomy

0373 Neuropsychological Testing

0374 Monitoring Psychiatric Drugs

Status

Indicator

S

Relative

Weights

0.5609

Payment

Rate

$30.45

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$6.09

$6.09

S

S

S

S

S

S

X

X

X

X

X

X

X

X

X

X

X

K

K

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

3.3916

5.4299

6.4453

6.4817

9.3215

7.2016

0.6232

0.1468

0.2169

0.4662

0.6278

0.2589

0.3877

0.9646

1.2207

0.1076

0.4106

0.2667

0.4353

0.8794

1.7088

3.5574

2.5384

0.8536

0.4415

1.1915

0.5828

0.9321

2.5282

0.8858

0.4084

0.5529

2.1165

1.1062

$184.13

$294.78

$349.91

$351.89

$506.05

$390.97

$33.83

$7.97

$11.78

$25.31

$34.08

$14.06

$21.05

$52.37

$66.27

$5.84

$22.29

$14.48

$23.63

$47.74

$92.77

$193.13

$137.81

$46.34

$23.97

$64.69

$31.64

$50.60

$137.25

$48.09

$22.17

$30.02

$114.90

$60.05

$91.27

$146.98

$151.46

$175.94

$240.77

$3.08

$5.88

$12.55

$17.04

$3.10

$5.31

$13.19

$42.45

$83.23

$17.15

$9.06

$18.95

$15.16

$25.30

$44.18

$11.58

$4.44

$10.09

$22.98

$36.83

$58.96

$69.98

$70.38

$101.21

$78.19

$6.77

$1.59

$2.36

$5.06

$6.82

$2.81

$4.21

$10.47

$13.25

$1.17

$4.46

$2.90

$4.73

$9.55

$18.55

$38.63

$27.56

$9.27

$4.79

$12.94

$6.33

$10.12

$27.45

$9.62

$4.43

$6.00

$22.98

$12.01

0375 Ancillary Outpatient Services when Patient Expires

0376 Pkgd cancer chemo, other

0377 Sep cancer chemo, other

0378 Infusion of pkgd cancer

0379 Infusion, separate cancer

0380 Pkgd cancer chemo, both

0381 Sep cancer chemo, both

0382 Infusion, pkgd noncancer

S

S

S

S

S

T

S

S

2.1479

0.6673

4.3955

2.4298

5.1857

2.1596

4.6839

$1,150.00

$116.61

$36.23

$238.63

$131.91

$281.53

$117.24

$254.28

$230.00

$23.32

$7.25

$47.73

$26.38

$56.31

$23.45

$50.86

Page 7 of 30 8/6/2003 2:47 PM



APC Group Title

0383 Infusion, separate noncancer

0384 GI Procedures with Stents

0385 Level I Prosthetic Urological Procedures

0386 Level II Prosthetic Urological Procedures

0387 Level II Hysteroscopy

0388 Discography

0389 Non-imaging Nuclear Medicine

0390 Level I Thyroid Imaging

0391 Level II Thyroid Imaging

0392 Adrenal Imaging

0393 Red Cell/Plasma Studies

0394 Hepatobiliary Imaging

0395 GI Tract and B12 Studies

0396 Bone Imaging

0397 Vascular Imaging

0398 Cardiac Imaging

0399 Cardiac Add-on Imaging

0400 Hematopoietic Imaging

0401 Pulmonary Imaging

0402 Brain Imaging

0403 CSF Imaging

0404 Renal Imaging

0405 Non-renal GU Studies

0406 Tumor/Infection Imaging

0407 Thyroid Radionucliide treatment

0408 Non-thyroid Radionucliide treatment

0409 Red Blood Cell Tests

0410 Mammogram Add On

0411 Respiratory Procedures

0412 IMRT Treatment Delivery

0413 IMRT Treatment Plan

0414 Reconstruction CT Angiography of Aorta

0415 Level II Endoscopy Lower Airway

0600 Low Level Clinic Visits

0601 Mid Level Clinic Visits

0602 High Level Clinic Visits

0610 Low Level Emergency Visits

0611 Mid Level Emergency Visits

0612 High Level Emergency Visits

0620 Critical Care

0648 Breast Reconstruction with Prosthesis

0649 Prostate Brachytherapy Palladium Seeds

0651 Complex Interstitial Radiation Source Application

0652 Insertion of Intraperitoneal Catheters

0653 Vascular Reconstruction/Fistula Repair with Device

0654

Insertion/Replacement of a permanent dual chamber pacemaker

Relative

Weights

3.8691

4.9130

5.4818

3.9265

5.1538

0.7739

4.7542

4.2797

4.0000

0.1385

0.1473

0.4207

5.2832

1.8419

36.0040

66.4829

118.8122

28.5174

11.7450

1.6475

2.8434

3.7174

6.7081

4.0720

4.4370

3.9372

4.2445

2.4737

6.6521

1.6033

6.0369

4.8012

20.9920

0.9376

1.0031

1.5603

1.4146

2.4881

4.3235

9.2657

55.5345

119.0281

10.0459

28.0692

Status

Indicator

S

S

S

S

S

S

S

S

S

X

S

S

S

S

S

S

S

T

S

S

S

S

T

T

T

S

S

S

S

S

V

V

V

V

V

S

T

S

S

T

V

T

S

T

Payment

Rate

$210.05

$266.72

$297.60

$213.17

$279.79

$42.01

$258.10

$232.34

$217.16

$7.52

$8.00

$22.84

$286.82

$99.99

$1,954.62

$3,609.29

$6,450.20

$1,548.18

$637.62

$89.44

$154.37

$201.81

$364.18

$221.06

$240.88

$213.75

$230.43

$134.29

$361.14

$87.04

$327.74

$260.65

$1,139.63

$50.90

$54.46

$84.71

$76.80

$135.08

$234.72

$503.03

$3,014.91

$6,461.92

$545.38

$1,523.85

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$0.00

$660.84

$304.54

$44.72

$77.18

$100.91

$182.09

$110.53

$120.44

$106.87

$115.21

$67.15

$180.57

$43.52

$105.02

$133.36

$148.80

$106.58

$139.90

$21.01

$116.17

$2.31

$463.30

$19.57

$36.47

$54.14

$145.78

$109.08

$42.01

$53.34

$59.52

$42.63

$55.96

$8.40

$51.62

$46.47

$43.43

$1.50

$1.60

$4.57

$57.36

$20.00

$390.92

$721.86

$1,290.04

$309.64

$127.52

$17.89

$30.87

$40.36

$72.84

$44.21

$48.18

$42.75

$46.09

$26.86

$72.23

$17.41

$65.55

$52.13

$227.93

$10.18

$10.89

$16.94

$15.36

$27.02

$46.94

$100.61

$602.98

$1,292.38

$109.08

$304.77

T

T

32.4880

103.8544

$1,763.74

$5,638.15

$352.75

$1,127.63

Page 8 of 30 8/6/2003 2:47 PM



APC Group Title

0655

Insertion/Replacement/Conversion of a permanent dual chamber pacemaker

Transcatheter Placement of Intracoronary Drug-

Eluting Stents 0656

0657 Placement of Tissue Clips

0658 Percutaneous Breast Biopsies

0659 Hyperbaric Oxygen

0660 Level II Otorhinolaryngologic Function Tests

0661 Level IV Pathology

0662 CT Angiography

0664 Proton Beam Radiation Therapy

0665 Bone Density:AppendicularSkeleton

0668 Level I Angiography and Venography except Extremity

0669 Digital Mammography

0670 Intravenous and Intracardiac Ultrasound

0671 Level II Echocardiogram Except Transesophageal

0672 Level IV Posterior Segment Procedures

0673 Level IV Anterior Segment Eye Procedures

0674 Prostate Cryoablation

0675 Prostatic Thermotherapy

0676 Level II Transcatheter Thrombolysis

0677 Level I Transcatheter Thrombolysis

0678 External Counterpulsation

0679 Level II Resuscitation and Cardioversion

0680 Insertion of Patient Activated Event Recorders

0681 Knee Arthroplasty

0682 Level V Debridement & Destruction

0683 Level II Photochemotherapy

0684 Prostate Brachytherapy Iodine Seeds

0685

Level III Needle Biopsy/Aspiration Except Bone

Marrow

0686 Level III Skin Repair

0687 Revision/Removal of Neurostimulator Electrodes

0688

Revision/Removal of Neurostimulator Pulse Generator

Receiver

0689 Electronic Analysis of Cardioverter-defibrillators

0690

Electronic Analysis of Pacemakers and other Cardiac

Devices

0691 Electronic Analysis of Programmable Shunts/Pumps

0692

Electronic Analysis of Neurostimulator Pulse

Generators

0693 Level II Breast Reconstruction

0694 Mohs Surgery

0695 Level VII Debridement & Destruction

Status

Indicator

Relative

Weights

Payment

Rate

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

T

S

S

S

T

T

T

T

T

S

S

S

S

T

T

S

X

X

S

T

S

T

T

T

T

T

S

S

T

T

S

T

S

S

T

T

S

T

142.2244

101.3662

1.5630

5.6035

3.2220

1.7330

3.3215

5.8751

9.6828

0.7225

10.4896

0.9111

26.5472

1.6392

39.1363

26.7626

101.1198

49.3613

3.7505

3.0769

2.0622

5.4862

61.4222

96.7483

7.6815

1.7915

104.7194

4.8912

17.0868

19.9913

42.5880

0.5427

0.3986

2.9894

0.9625

38.6469

3.3272

19.1377

$7,721.22

$5,503.07

$84.85

$304.21

$174.92

$94.08

$180.32

$318.95

$525.67

$39.22

$30.66

$90.16

$156.47

$569.47

$49.46

$1,441.22

$237.76

$521.95

$88.99

$2,124.67

$1,452.91

$5,489.69

$2,679.78

$203.61

$167.04

$111.95

$44.50

$988.43

$649.56

$55.06

$297.84

$3,334.55

$95.30

$5,252.37

$2,090.21

$417.02

$174.57

$97.26

$35.01

$5,685.11

$265.54

$927.63

$1,085.31

$162.29

$52.25

$2,098.10

$180.63

$1,038.97

$116.83

$341.70

$499.24

$2,312.06

$1,132.91

$29.46

$21.64

$10.35

$81.15

$26.13

$798.17

$72.25

$266.59

$53.11

$185.53

$217.06

$462.41

$5.89

$4.33

$32.46

$10.45

$419.62

$36.13

$207.79

$1,544.24

$1,100.61

$16.97

$60.84

$34.98

$18.82

$36.06

$63.79

$105.13

$7.84

$113.89

$9.89

$288.24

$17.80

$424.93

$290.58

$1,097.94

$535.96

$40.72

$33.41

$22.39

$59.57

$666.91

$1,050.47

$83.40

$19.45

$1,137.02

Page 9 of 30 8/6/2003 2:47 PM



APC Group Title

0697 Level I Echocardiogram Except Transesophageal

0698 Level II Eye Tests & Treatments

0699 Level IV Eye Tests & Treatments

0700 Antepartum Manipulation

0701 SR 89 chloride, per mCi

0702 SM 153 lexidronam, 50 mCi

0704 IN 111 Satumomab pendetide per dose

0726 Dexrazoxane hcl injection, 250 mg

0728 Filgrastim 300 mcg injection

0730 Pamidronate disodium , 30 mg

0732 Mesna injection 200 mg

0733 Non esrd epoetin alpha inj, 1000 u

0734

Injection, darbepoetin alfa (for non-ESRD use), per 1 mcg

0800 Leuprolide acetate, 3.75 mg

0802 Etoposide oral 50 mg

0807 Aldesleukin/single use vial

0810 Goserelin acetate implant 3.6 mg

0811 Carboplatin injection 50 mg

0812 Carmustine, 100 mg

0813 Cisplatin 10 mg injection

0820 Daunorubicin 10 mg

0821 Daunorubicin citrate liposom 10 mg

0822 Diethylstilbestrol injection 250 mg

0823 Docetaxel, 20 mg

0827 Floxuridine injection 500 mg

0828 Gemcitabine HCL 200 mg

0830 Irinotecan injection 20 mg

0831 Ifosfomide injection 1 gm

0832 Idarubicin hcl injection 5 mg

0836 Interferon alfa-2b inj recombinant, 1 million

0838 Interferon gamma 1-b inj, 3 million u

0840 Melphalan hydrochl 50 mg

0842 Fludarabine phosphate inj 50 mg

0843 Pegaspargase, single dose vial

0844 Pentostatin injection, 10 mg

0849 Rituximab, 100 mg

0850 Streptozocin injection, 1 gm

0852 Topotecan, 4 mg

0855 Vinorelbine tartrate, 10 mg

0856 Porfimer sodium, 75 mg

0857 Bleomycin sulfate injection 15 u

0858 Cladribine, 1mg

0861 Leuprolide acetate injection 1 mg

0862 Mitomycin 5 mg inj

0863 Paclitaxel injection, 30 mg

0864 Mitoxantrone hcl, 5 mg

Status

Indicator

Relative

Weights

Payment

Rate

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

S

S

T

T

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

1.4621

0.9355

2.2211

2.4359

7.4586

16.1415

2.9212

1.9860

2.2544

2.0537

0.4908

0.1782

0.0463

3.3020

0.4830

7.0936

4.9549

1.5475

0.9972

0.3594

0.6052

2.9697

1.3274

4.0041

2.1836

1.4523

1.8626

1.1616

3.2438

0.2000

2.4742

4.4072

3.6854

5.7621

17.4201

5.5636

1.3942

7.9075

1.1683

25.3788

2.2352

0.7031

0.8223

0.9557

1.2674

3.1513

$39.69

$18.72

$54.26

$37.03

$0.50

$35.85

$5.24

$77.02

$53.80

$16.80

$10.83

$3.90

$6.57

$32.24

$14.41

$43.48

$23.71

$15.77

$20.22

$12.61

$35.22

$2.17

$26.86

$47.85

$40.02

$62.56

$189.14

$60.41

$15.14

$85.86

$12.69

$275.56

$24.27

$7.63

$8.93

$10.38

$13.76

$34.22

$15.88

$10.16

$24.12

$26.45

$80.98

$175.26

$31.72

$21.56

$24.48

$22.30

$5.33

$1.93

$176.10

$10.86

$134.32

$239.26

$200.08

$312.82

$945.72

$302.04

$75.69

$429.29

$63.43

$1,377.79

$121.35

$38.17

$44.64

$51.88

$68.81

$171.08

$2.51

$179.26

$26.22

$385.10

$269.00

$84.01

$54.14

$19.51

$32.86

$161.22

$72.06

$217.38

$118.55

$78.84

$101.12

$63.06

$79.38

$50.79

$120.58

$132.24

$404.92

$876.31

$158.59

$107.82

$122.39

$111.49

$26.65

$9.67

Page 10 of 30 8/6/2003 2:47 PM



APC Group Title

0865 Interferon alfa-n3 inj, human leukocyte derived, 2

0884 Rho d immune globulin inj, 1 dose pkg

0888 Cyclosporine oral 100 mg

0890 Lymphocyte immune globulin 250 mg

0891 Tacrolimus oral per 1 mg

0900 Alglucerase injection, per 10 u

0901 Alpha 1 proteinase inhibitor, 10 mg

0902 Botulinum toxin a, per unit

0903 Cytomegalovirus imm IV/vial

0905 Immune globulin, 1g

0906 RSV-ivig, 50 mg

0909 Interferon beta-1a, 33 mcg

0910 Interferon beta-1b /0.25 mg

0911 Streptokinase per 250,000 iu

0916 Imiglucerase injection/unit

0917 Inj, Adenosine, 90 mg

0925 Factor viii per iu

0926 Factor VIII (porcine) per iu

0927 Factor viii recombinant per iu

0928 Factor ix complex per iu

0929 Anti-inhibitor per iu

0930 Antithrombin iii injection per iu

0931 Factor IX non-recombinant, per iu

0932 Factor IX recombinant, per iu

0949 Plasma, Pooled Multiple Donor, Solvent/Detergent T

0950 Blood (Whole) For Transfusion

0952 Cryoprecipitate

0954 RBC leukocytes reduced

0955 Plasma, Fresh Frozen

0956 Plasma Protein Fraction

0957 Platelet Concentrate

0958 Platelet Rich Plasma

0959 Red Blood Cells

0960 Washed Red Blood Cells

0961 Infusion, Albumin (Human) 5%, 50 ml

0963 Albumin (human), 5%, 250 ml

0964 Albumin (human), 25%, 20 ml

0965 Albumin (human), 25%, 50ml

0966 Plasmaprotein fract,5%,250ml

1009 Cryoprecip reduced plasma

1010 Blood, L/R, CMV-neg

1011 Platelets, HLA-m, L/R, unit

1013 Platelet concentrate, L/R, unit

1016 Blood, L/R, froz/deglycerol/washed

1017 Platelets, aph/pher, L/R, CMV-neg, unit

1018 Blood, L/R, irradiated

1019 Platelets, aph/pher, L/R, irradiated, unit

Relative

Weights

1.5823

0.2312

0.0482

2.1958

0.0236

0.5473

0.0214

0.0460

5.0754

0.8103

6.0142

2.8010

1.9843

1.6055

0.0531

2.3474

0.0085

0.0253

0.0168

0.0085

0.0168

0.0117

0.0104

0.0168

Status

Indicator

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

Payment

Rate

$85.90

$12.55

$2.62

$119.21

$1.28

$29.71

$1.16

$2.50

$275.54

$43.99

$326.50

$152.06

$107.73

$87.16

$2.88

$127.44

$0.46

$1.37

$0.91

$0.46

$0.91

$0.64

$0.56

$0.91

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$17.18

$2.51

$0.52

$23.84

$0.26

$5.94

$0.23

$0.50

$55.11

$8.80

$65.30

$30.41

$21.55

$17.43

$0.58

$25.49

$0.09

$0.27

$0.18

$0.09

$0.18

$0.13

$0.11

$0.18

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

2.0608

1.4575

0.4860

1.9770

1.5750

1.5414

0.6870

1.1296

1.4326

2.6638

0.7319

3.4713

0.7911

1.9432

7.7071

0.9447

2.1361

8.2851

0.9101

5.0012

6.5175

2.1950

6.7353

$111.88

$79.13

$26.38

$107.33

$85.51

$83.68

$37.30

$61.32

$77.77

$144.62

$39.73

$188.45

$42.95

$105.49

$418.41

$51.29

$115.97

$449.79

$49.41

$271.51

$353.83

$119.16

$365.65

$22.38

$15.83

$5.28

$21.47

$17.10

$16.74

$7.46

$12.26

$15.55

$28.92

$7.95

$37.69

$8.59

$21.10

$83.68

$10.26

$23.19

$89.96

$9.88

$54.30

$70.77

$23.83

$73.13

Page 11 of 30 8/6/2003 2:47 PM



APC Group Title

1020 Pit, pher,L/R,CMV,irrad

1021 RBC, frz/deg/wsh, L/R, irrad

1022 RBC, L/R, CMV neg, irrad

1045 Iobenguane sulfate I-131per 0.5 mCi

1064 I-131 sodium iodide capsule

1065 I-131 sodium iodide solution

1084 Denileukin diftitox, 300 MCG

1086 Temozolomide,oral 5 mg

1091 IN 111 Oxyquinoline, per .5 mCi

1092 IN 111 Pentetate, per 0.5 mCi

1095 Technetium TC 99M Depreotide

1096 TC 99M Exametazime, per dose

1122 TC 99M arcitumomab, per vial

1167 Epirubicin hcl, 2 mg

1178 Busulfan IV, 6 mg

1203 Verteporfin for injection

1207 Octreotide injection, depot

1305 Apligraf

1409 Factor viia recombinant, per 1.2 mg

1501 New Technology - Level I ($0 - $50)

1502 New Technology - Level II ($50 - $100)

1503 New Technology - Level III ($100 - $200)

1504 New Technology - Level IV ($200 - $300)

1505 New Technology - Level V ($300 - $400)

1506 New Technology - Level VI ($400 - $500)

1507 New Technology - Level VII ($500 - $600)

1508 New Technology - Level VIII ($600 - $700)

1509 New Technology - Level IX ($700 - $800)

1510 New Technology - Level X ($800 - $900)

1511 New Technology - Level XI ($900 - $1000)

1512 New Technology - Level XII ($1000 - $1100)

1513 New Technology - Level XIII ($1100 - $1200)

1514 New Technology-Level XIV ($1200- $1300)

1515 New Technology - Level XV ($1300 - $1400)

1516 New Technology - Level XVI ($1400 - $1500)

1517 New Technology - Level XX ($1500-$1600)













Status

Indicator

S

S

S

S

K

K

S

S

S

S

S

S

S

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

S

S

S

S

S

S

S

S

S

S

S

S

S

S

S

S

S

S

Relative

Weights

9.6266

6.5287

3.9139

2.9293

0.1007

0.0002

15.0913

0.0643

4.0535

4.0824

3.7042

3.8103

9.6556

0.3597

6.0245

16.1946

1.1849

11.2075

17.9693

Payment

Rate

$608.44

$975.54

$25.00

$75.00

$150.00

$250.00

$350.00

$450.00

$550.00

$650.00

$750.00

$850.00

$950.00

$522.62

$354.44

$212.48

$159.03

$5.47

$0.01

$819.29

$3.49

$220.06

$221.63

$201.10

$206.86

$524.19

$19.53

$327.06

$879.19

$64.33

$1,050.00

$1,150.00

$1,250.00

$1,350.00

$1,450.00

$1,550.00

$1,650.00

$1,750.00

$1,850.00

$1,950.00

$2,250.00

$2,750.00

$3,250.00

$3,750.00

$4,250.00

$4,750.00

$5,250.00

$5,750.00

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$121.69

$195.11

$5.00

$15.00

$30.00

$50.00

$70.00

$90.00

$110.00

$130.00

$150.00

$170.00

$190.00

$104.52

$70.89

$42.50

$31.81

$1.09

$0.00

$163.86

$0.70

$44.01

$44.33

$40.22

$41.37

$104.84

$3.91

$65.41

$175.84

$12.87

$210.00

$230.00

$250.00

$270.00

$290.00

$310.00

$330.00

$350.00

$370.00

$390.00

$450.00

$550.00

$650.00

$750.00

$850.00

$950.00

$1,050.00

$1,150.00

Page 12 of 30 8/6/2003 2:47 PM



APC Group Title









1538 New Technology - Level I ($0 - $50)

1539 New Technology - Level II ($50 - $100)

1540 New Technology - Level III ($100 - $200)

1541 New Technology - Level IV ($200 - $300)

1542 New Technology - Level V ($300 - $400)

1543 New Technology - Level VI ($400 - $500)

1544 New Technology - Level VII ($500 - $600)

1545 New Technology - Level VIII ($600 - $700)

1546 New Technology - Level IX ($700 - $800)

1547 New Technology - Level X ($800 - $900)

1548 New Technology - Level XI ($900 - $1000)

1549 New Technology - Level XII ($1000 - $1100)

1550 New Technology - Level XIII ($1100 - $1200)

1551 New Technology-Level XIV ($1200- $1300)

1552 New Technology - Level XV ($1300 - $1400)

1553 New Technology - Level XVI ($1400 - $1500)






















1604 IN 111 capromab pendetide, per dose

1605 Abciximab injection, 10 mg

1606 Anistreplase, 30 u

Status

Indicator

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

S

S

S

S

S

S

S

S

T

T

T

T

T

K

K

K

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

Relative

Weights

12.4029

5.2806

25.3116

Payment

Rate

$850.00

$950.00

$1,050.00

$1,150.00

$1,250.00

$1,350.00

$1,450.00

$1,550.00

$1,650.00

$1,750.00

$1,850.00

$1,950.00

$2,250.00

$6,250.00

$6,750.00

$7,250.00

$7,750.00

$8,250.00

$8,750.00

$9,250.00

$9,750.00

$25.00

$75.00

$150.00

$250.00

$350.00

$450.00

$550.00

$650.00

$750.00

$2,750.00

$3,250.00

$3,750.00

$4,250.00

$4,750.00

$5,250.00

$5,750.00

$6,250.00

$6,750.00

$7,250.00

$7,750.00

$8,250.00

$8,750.00

$9,250.00

$9,750.00

$673.34

$286.68

$1,374.14

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$170.00

$190.00

$210.00

$230.00

$250.00

$270.00

$290.00

$310.00

$330.00

$350.00

$370.00

$390.00

$450.00

$1,250.00

$1,350.00

$1,450.00

$1,550.00

$1,650.00

$1,750.00

$1,850.00

$1,950.00

$5.00

$15.00

$30.00

$50.00

$70.00

$90.00

$110.00

$130.00

$150.00

$550.00

$650.00

$750.00

$850.00

$950.00

$1,050.00

$1,150.00

$1,250.00

$1,350.00

$1,450.00

$1,550.00

$1,650.00

$1,750.00

$1,850.00

$1,950.00

$134.67

$57.34

$274.83

Page 13 of 30 8/6/2003 2:47 PM



APC Group Title

1607 Eptifibatide injection, 5mg

1609 Rho(D) immune globulin h, sd, 100 iu

1611 Hylan G-F 20 injection, 16 mg

1612 Daclizumab, parenteral, 25 mg

1613 Trastuzumab, 10 mg

1614 Valrubicin, 200 mg

1615 Basiliximab, 20 mg

1618 Vonwillebrandfactrcmplx, per iu

1620 Technetium tc99m bicisate

1625 Indium 111-in pentetreotide

1628 Chromic phosphate p32

1716 Brachytx source, Gold 198

1718 Brachytx source, Iodine 125

1719 Brachytx source,Non-HDR Ir-192

1720 Brachytx source, Palladium 103

1775 FDG, per dose (4-40 mCi/ml)

1783 Ocular implant, aqueous drain device

1814 Retinal Tamp, silicone oil

1818 Integrated keratoprosthesis

1884 Embolization protective system

1888 Endovas non-cardiac ablation catheter

1900 Lead coronary venous

2614 Probe, percutaneous lumbar disc

2616 Brachytx source, Yttrium-90

2632 Brachytx sol, I-125, per mCi

7000 Amifostine, 500 mg

7011 Oprelvekin injection, 5 mg

7015 Busulfan, oral, 2 mg

7024 Corticorelin ovine triflutat

7025 Digoxin immune FAB (ovine)

7027 Fomepizole, 15mg

7030 Hemin, per 1 mg

7031 Octreotide acetate injection

7034 Somatropin injection

7035 Teniposide, 50 mg

7036 Urokinase 250,000 iu inj

7037 Urofollitropin, 75 iu

7038 Muromonab-CD3, 5 mg

7041 Tirofiban hydrochloride 12.5 mg

7042 Capecitabine, oral, 150 mg

7043 Infliximab injection 10 mg

7045 Trimetrexate glucoronate

7046 Doxorubicin hcl liposome inj 10 mg

7049 Filgrastim 480 mcg injection

7051 Leuprolide acetate implant, 65 mg

9000 Na chromate Cr51, per 0.25mCi

9002 Tenecteplase, 50mg/vial

9003 Palivizumab, per 50mg

Status

Indicator

H

H

K

H

H

H

H

H

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

H

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

Relative

Weights

0.1426

0.1863

2.1566

3.7304

0.7384

9.6183

11.2007

0.0168

3.3106

6.8170

2.0103

1.3399

0.6695

0.3053

0.8104

5.8606

163.4011

3.9932

2.7246

0.0263

3.4880

4.4789

0.2215

0.0119

1.0339

0.9206

1.5530

5.1032

1.1321

5.8452

4.2976

0.0290

0.6841

1.2099

4.6362

3.1998

68.9392

1.2631

23.2303

6.3850

Payment

Rate

$7.74

$10.11

$117.08

$202.52

$40.09

$522.17

$608.07

$0.91

$179.73

$370.09

$109.14

$72.74

$36.35

$16.57

$44.00

$318.17

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$1.55

$2.02

$23.42

$40.50

$8.02

$104.43

$121.61

$0.18

$35.95

$74.02

$21.83

$14.55

$7.27

$3.31

$8.80

$63.63

$8,870.88

$216.79

$147.92

$1.43

$189.36

$243.16

$12.03

$0.65

$56.13

$49.98

$84.31

$277.05

$61.46

$317.33

$233.31

$1.57

$37.14

$65.68

$251.69

$173.71

$3,742.64

$68.57

$1,261.15

$346.64

$1,774.18

$43.36

$29.58

$0.29

$37.87

$48.63

$2.41

$0.13

$11.23

$10.00

$16.86

$55.41

$12.29

$63.47

$46.66

$0.31

$7.43

$13.14

$50.34

$34.74

$748.53

$13.71

$252.23

$69.33

Page 14 of 30 8/6/2003 2:47 PM



APC Group Title

9004 Gemtuzumab ozogamicin inj,5mg

9005 Reteplase injection

9009 Baclofen refill kit - per 2000 mcg

9010 Baclofen refill kit - per 4000 mcg

9012 Arsenic Trioxide

9015 Mycophenolate mofetil oral 250 mg

9018 Botulinum toxin B, per 100 u

9019 Caspofungin acetate, 5 mg

9020 Sirolimus tablet, oral 1 mg

9021 Immune globulin 10 mg

9022 IM inj interferon beta 1-a

9023 Rho d immune globulin 50 mcg

9024 Amphotericin b lipid complex

9025 Rubidium-Rb-82

9100 Iodinated I-131albumin, per 5 uci

9104 Anti-thymocycte globulin rabbit

9105 Hep B imm glob, per 1 ml

9108 Thyrotropin alfa, per 1.1 mg

9109 Tirofiban hcl, per 6.25 mg

9110 Alemtuzumab, per 10 mg

9111 Inj, bivalirudin, per 250 mg vial

9112 Perflutren lipid micro, per 2ml

9113 Inj, pantoprazole sodium, vial

9114 Nesiritide, per 0.5 mg vial

9115 Inj, zoledronic acid, per 1 mg

9116 Inj, Ertapenem sodium, per 1 gm vial

9117 Y-90 ibritumomab tiuxetan

9118 IN-111 ibritumomab tiuxetan

9119 Pegfilgrastim, per 1 mg

9120 Inj, Fulvestrant, per 50 mg

9121 Inj, Argatroban, per 5 mg

9122 Inj, Triptorelin pamoate, per 3.75 mg

9200 Orcel, per 36 cm2

9201 Dermagraft, per 37.5 sq cm

9202 Octafluoropropane

9203 Perflexane lipid micro

9204 Ziprasidone mesylate

9205 Oxaliplatin

9217 Leuprolide acetate suspnsion, 7.5 mg

9500 Platelets, irradiated

9501 Platelets, pheresis

9502 Platelet pheresis irradiated

9503 Fresh frozen plasma, ea unit

9504 RBC deglycerolized

9505 RBC irradiated

9506 Granulocytes, pheresis

Status

Indicator

G

G

G

G

K

K

K

G

G

K

K

G

G

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

K

G

G

G

K

K

K

G

G

G

K

K

K

K

K

K

Relative

Weights

Payment

Rate

17.5020

10.1332

0.7478

0.7340

0.4837

0.0373

0.1272

0.5334

0.0520

0.0080

0.9417

0.0523

0.4174

2.5939

0.0071

2.9801

1.5621

6.6059

2.2328

7.6422

$358.63

$121.22

$414.89

$397.81

$148.20

$22.80

$144.40

$203.40

$45.31

332.7763

$18,066.09

38.3972

$2,084.55

$467.09

$175.16

7.9288

2.1253

$14.25

$415.24

$1,135.25

$430.45

$115.38

$142.50

$41.56

$94.46

$950.17

$550.12

$40.60

$39.85

$26.26

$2.02

$6.91

$28.96

$2.82

$0.43

$51.12

$2.84

$22.66

$140.82

$0.39

$161.79

$84.80

5.5128

1.2398

6.7772

7.3552

1.1560

3.9764

1.8011

20.7004

$299.28

$67.31

$367.93

$399.31

$62.76

$215.87

$97.78

$1,123.80

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

$71.73

$24.24

$82.98

$59.46

$22.15

$3.41

$21.58

$30.40

$6.77

$3,613.22

$416.91

$69.82

$26.18

$190.03

$110.02

$8.12

$7.97

$5.25

$0.40

$1.38

$5.79

$0.56

$0.09

$10.22

$0.57

$4.53

$28.16

$0.08

$32.36

$16.96

$2.13

$62.07

$169.69

$86.09

$23.08

$21.30

$6.21

$14.12

$59.86

$13.46

$73.59

$79.86

$12.55

$43.17

$19.56

$224.76

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Page 30 of 30 8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs

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