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 |
