APG Fee Schedule Procedures

(only periods with changes are shown)

Revised for January 1, 2013 Updates:

Effective Date > Jan 1, 2011 Apr 1, 2011 Jul 1, 2011 Jan 1, 2012 Jan 1, 2013
HCPCS Code HCPCS Code Description Reimbursement Amount
(per unit)
Max units Reimbursement Amount
(per unit)
Max units Reimbursement Amount
(per unit)
Max units Reimbursement Amount
(per unit)
Max units Reimbursement Amount
(per unit)
Max units
61885 Insrt/redo neurostim 1 array - - $ 11,794.40 1 $ 11,794.40 1 $ 11,794.40 1 $ 11,794.40 1
64568 Inc for vagus n elect impl - - $ 19,630.40 1 $ 19,630.40 1 $ 19,630.40 1 $ 19,630.40 1
81025 Urine pregnancy test - - - - $ 3.19 1 $ 3.19 1 $ 3.19 1
86480 Tb test cell immun measure - - $ 69.78 1 $ 69.78 1 $ 69.78 1 $ 69.78 1
86580 TB intradermal test - - $ 5.00 1 $ 5.00 1 $ 5.00 1 $ 5.00 1
86701 HIV-1 - - - - $ 10.00 1 $ 10.00 1 $ 10.00 1
86702 HIV-2 - - - - $ 15.22 1 $ 15.22 1 $ 15.22 1
86703 Hiv-1/hiv-2 single assay - - - - $ 15.44 1 $ 15.44 1 $ 15.44 1
87390 Hiv-1 ag eia - - - - $ 19.86 1 $ 19.86 1 $ 19.86 1
87391 Hiv-2 ag eia - - - - $ 19.86 1 $ 19.86 1 $ 19.86 1
90473 Immune admin oral/nasal - - $ 8.57 1 $ 8.57 1 $ 8.57 1 $ 8.57 1
90655 Flu vaccine no preserv 6-35m - - $ 15.45 1 $ 15.45 1 $ 15.45 1 $ 15.45 1
90656 Flu vaccine no preserv 3 & > - - $ 12.54 1 $ 12.54 1 $ 12.54 1 $ 12.54 1
90657 Flu vaccine 3 yrs im - - $ 5.68 1 $ 5.68 1 $ 5.68 1 $ 5.68 1
90658 Flu vaccine 3 yrs & > im - - $ 11.37 1 $ 11.37 1 $ 11.37 1 $ 11.37 1
90660 Flu vaccine nasal - - $ 22.32 1 $ 22.32 1 $ 22.32 1 $ 22.32 1
90669 Pneumococcal vacc 7 val im - - $ 95.48 1 $ 95.48 1 $ 95.48 1 $ 95.48 1
90732 Pneumococcal vaccine - - $ 43.25 1 $ 43.25 1 $ 43.25 1 $ 43.25 1
G0008 Admin influenza virus vac - - $ 13.23 1 $ 13.23 1 $ 13.23 1 $ 13.23 1
G0009 Admin pneumococcal vaccine - - $ 13.23 1 $ 13.23 1 $ 13.23 1 $ 13.23 1
G0432 EIA HIV-1/HIV-2 screen - - - - $ 15.44 1 $ 15.44 1 $ 15.44 1
G0433 ELISA HIV-1/HIV-2 screen - - - - $ 15.44 1 $ 15.44 1 $ 15.44 1
G0435 Oral HIV-1/HIV-2 screen - - - - $ 13.50 1 $ 13.50 1 $ 13.50 1
J0475 Baclofen 10 MG injection $ 176.50 8 $ 176.50 8 $ 176.50 8 $ 176.50 8 $ 176.50 8
J2997 Alteplase recombinant - - $ 38.87 80 $ 38.87 80 $ 38.87 80 $ 38.87 80
Q4081 Epoetin alfa, 100 units ESRD - - - - - - $ 0.98 600 $ 0.98 600
J0882 Darbepoetin alfa, esrd use - - - - - - $ 3.12 80 $ 3.12 80
J0885 Epoetin alfa, non-esrd - - - - - - $ 9.82 80 $ 9.82 80
J0886 Epoetin alfa 1000 units ESRD - - - - - - $ 9.82 60 $ 9.82 60
S4993 Contraceptive pills for bc - - - - - - - - $ 6.00 3
V2100 Lens spher single plano 4.00 - - - - $ 5.00 2 $ 5.00 2 $ 5.00 2
V2215 Lens lenticular bifocal - - - - $ 26.50 2 $ 26.50 2 $ 26.50 2
V2600 Hand held low vision aids $ 150.00 1 $ 150.00 1 $ 150.00 1 $ 150.00 1 $ 150.00 1
V2610 Single lens spectacle mount $ 545.00 1 $ 545.00 1 $ 545.00 1 $ 545.00 1 $ 545.00 1
V2615 Telescop/othr compound lens $ 835.00 1 $ 835.00 1 $ 835.00 1 $ 835.00 1 $ 835.00 1
V2784 Lens polycarb or equal - - - - $ 10.00 2 $ 10.00 2 $ 10.00 2

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