Private Health Insurance (Prostheses) Rules 2007 (No. 2) (Cth)

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Private Health Insurance (Prostheses) Rules 2007 (No.2)

I, PENNY SHAKESPEARE, delegate of the Minister for Health and Ageing, make these Rules under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.

Dated 17 May2007

____________________________________

Penny Shakespeare

Assistant Secretary

Private Health Insurance Branch,

Acute Care Division

Department of Health and Ageing

Contents

8. Minister may have regard to recommendations and advice 6

Schedule7

Part 1Preliminary

1.Name of Rules

These Rules are the Private Health Insurance (Prostheses) Rules 2007 (No.2).

2.Commencement

These Rules commence on 1 June 2007.

3.Definitions

Note: Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislative Instruments Act 2003. These terms include:

complying health insurance policy

hospital-substitute treatment

hospital treatment

medicare benefit

In these rules:

accredited podiatrist has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

Act means the Private Health Insurance Act 2007.

gap permitted prosthesis means a prosthesis listed in the Schedule where an amount is specified for that prosthesis in the column under the heading 'Minimum Benefit' and a different amount is specified in the column under the heading 'Maximum Benefit'.

no gap prosthesis means a prosthesis listed in the Schedule where an amount is specified for that prosthesis in the column under the heading 'Minimum Benefit' and no amount is specified in the column under the heading 'Maximum Benefit'.

private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals withthe status ofcertainhospitals for which a declaration had been made before the commencement of the Act.

professional service has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

public hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a public hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals withthe status ofcertainhospitals for which a declaration had been made before the commencement of the Act.

Schedule means the Schedule in these Rules.

Part 2Benefit requirements

4.Listing of, and benefits, for prostheses

For item 4 of the table in subsection 72-1 (2) of the Act:

  1. (a)

    the Schedule lists the prostheses (listed prostheses) the Minister has listed under subsection 72-10 (5) of the Act and section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and

    Note: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.

  2. (b)

    rule 5 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis in circumstances where:

    1. (i)

      a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis; or

    2. (ii)

      the provision of the prosthesis is associated with podiatric treatment by an accredited podiatrist; and

  3. (c)

    rule 6 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis in circumstances where a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis.

5.Benefits for prostheses provided as part of hospital treatment

(1) For a no gap prosthesis provided as part of an episode of hospital treatment by a private hospital in the circumstances mentioned in paragraph 4 (b), the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.

(2) For a gap permitted prosthesis provided as part of an episode of hospital treatment by a private hospital in the circumstances mentioned in paragraph 4 (b):

  1. (a)

    the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and

  2. (b)

    the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.

(3) For a no gap prosthesis provided as part of an episode of hospital treatment by a public hospital in the circumstances mentioned in paragraph 4 (b):

  1. (a)

    the minimum benefit is the lesser of the following amounts:

    1. (i)

      the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or

    2. (ii)

      the amount of the insured person’s liability to the public hospital for that prosthesis; and

  2. (b)

    the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit'.

(4) For a gap permitted prosthesis provided as part of an episode of hospital treatment by a public hospital in the circumstances mentioned in paragraph 4 (b):

  1. (a)

    the minimum benefit is the lesser of the following amounts:

    1. (i)

      the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or

    2. (ii)

      the amount of the insured person’s liability to the public hospital for that prosthesis; and

  2. (b)

    the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in the Schedule.

6.Benefits for prostheses provided as part of hospital-substitute treatment

(5) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 4 (c) the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.

(6) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 4 (c):

  1. (a)

    the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and

  2. (b)

    the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.

    Note: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules 2007― see paragraph 121-10 (3) (a) of the Act.

7.Timing of applications to have a prosthesis listed

As a matter of normal administrative practice, applications made under subsection 72-10 (2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the prosthesis will be listed in the Schedule the next time the Minister makes or varies the Rules.

Note 1: Under subsection 72-10 (5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.

Note 2: Under subsection 72-15 (3) of the Act, the Minister may remove a prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.

8.Minister may have regard to recommendations and advice

(7) In making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses and Devices Committee.

  1. (8)

    In setting the minimum and the maximum (if any) amounts for a prosthesis, the Minister may have regard to the amounts as negotiated between the Prostheses and Devices Negotiating Group and the applicant.

Note

1. All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003.See A - Prostheses

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

Abbott Australasia Pty Ltd

AY012 JoStent Coronary Stent Graft Stainless Steel/PTFE 9 - 26 mm x 2.5 - 5 mm $3,222.00

AY013 JoStent F1 Coronary Stent Stainless Steel 9 - 26 mm x 2.5 - 4 mm $780.00

AY020 TriMaxx Coronary Stent Triplex, multicellular Length 8-28mm; Diameter 2.25- $1,248.00

4.00mm

Advanced Biomedical Pty Ltd

AB001 ATS Medical open pivot aortic valved Pyrolythic Carbon, Double Velour 21- 33mm $5,928.00

graft model 502AG Polyester, Titanium

AB002 ATS medical open pivot heart valve Pyrolythic Carbon, Double Velour 16-33mm $5,909.00

model 500FA standard flexi-cuff aortic Polyester, Titanium

valve series, ATS medical open pivot

heart valve model 500DM standard flexi-

AB064 ATS medical open pivot heart valve Pyrolythic Carbon, Double Velour 16-33mm $5,909.00

model 501DA advanced performance Polyester, Titanium

(AP) aortic valve series, ATS medical

open pivot heart valve model 501DM

advanced performance (AP) mitral valve

Atrium Australia-Pacific Rim Pty Ltd

AC022 Flyer RX Coronary Stent System Stainless Steel Coronary Stent Dia 2-5mm, Length 6-40mm $780.00

Biomet Australia Pty Ltd

BI929 Sternalock Screws Ti 2.4-2.7mm x 8-12mm $44.00

BI930 Sternalock Plates - xyphoid, "L" & square 4 hole $195.00

BI931 Sternalock Plates - "X" & "T" 5-8 hole $300.00

Biotronik Australia Pty Ltd

BT024 Philos DR Model 122450 Implantable Multiprogrammable, rate responsive, One size only $9,360.00

Pacemaker

BT027 Philos SLR Model 122456 Implantable Single pass, multiprogrammable, rate One size only $6,760.00

Pacemaker responsive, VDDR

BT028 Philos SR Model 122459 Implantable Multiprogrammable, rate responsive, One size only $5,928.00

Pacemaker

BT029 Philos DR-A Model 122600 Implantable Multiprogrammable, rate responsive, 5mm ports, One size only $9,360.00

Pacemaker

Prostheses List by Category and Sponsor Page 1 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

BT030 Philos SR-B Model 122610 Implantable Multiprogrammable, rate responsive, 5/6mm port, One size only $5,928.00

Pacemaker

BT036 PHILOS S Implantable Cardiac Pulse Multiprogrammable SSI One size only $4,264.00

Generator Cat No 122 453

BT046 Protos VR/CLS Single chamber rate responsive, closed One size only $5,928.00

loop system.

BT047 Protos DR/CLS Dual chamber, rate responsive, closed One size only. $9,360.00

loop system.

BT052 Cardiac Airbag Single chamber ICD rate responsive One size only. $15,600.00

BT053 Lexos DR Dual chamber ICD, rate responsive One size only. $43,680.00

BT054 Lexos VR Single chamber ICD, Rate responsive One size only. $36,400.00

BT055 Lexos A+ Single chamber ICD, rate responsive One size only. $40,560.00

pricing, dual chamber sensing.

BT056 Stratos LV Multiprogrammable, Biventricular, DDDRV One size only $12,480.00

BT058 Lekton Motion Coated flexible stent, Balloon mounted Diameter 2.5mm to 4mm, $1,248.00

Length 8 - 30mm

BT060 Philos II DR Multiprogrammable, rate responsive, One size only $9,360.00

BT062 Philos II SR Multiprogrammable, Rate Responsive, One size only $5,928.00

SSIR pacemaker

BT063 Selox SR Lead, pacemaker, implantable, 45, 53, 60cm length $1,248.00

BT064 Kentrox SL-S steroid Fractal coated steroid electrode, dual 16 and 18 cms tip to second $7,488.00

shock coil shock coil

BT065 Lekton Motion Mega Amorphous silicon carbide coated Diameter 4.5 and 5 mm; Length $1,248.00

13 - 40 mm

BT066 Selox ST Transvenous Bipolar Passive Steroid 53 and 60cm lengths $1,248.00

Ventricular Pacing Lead, fractal coated

BT067 Selox JT Fractal coated steroid electrode 45 and 53cm lengths $1,248.00

BT068 Kentrox RV-S steroid Fractal coated steroid electrode, single 65cm lengths $7,488.00

shock coil

BT069 Lekton Motion Petite Amorphous silicon carbide coated Diameter 2, 2.25, 2.5mm; $1,248.00

Length 8-20mm

BT070 Corox OTW UP Steroid Coronary Sinus Lead 77, 87cm $3,000.00

Prostheses List by Category and Sponsor Page 2 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

BT071 Philos II DR-T Dual Chamber Rate Responsive with One size only $9,360.00

Home Monitoring

BT074 Xelos DR-T High energy ICD with home monitoring. Packed in one small size $45,760.00

Dual chamber

BT075 Lumos VR-T Single Chamber ICD with home one size only $40,560.00

monitoring and IEGM online

BT076 Lumos DR-T Dual Chamber ICD with home monitoring one size only $43,680.00

BT077 Kentrox SL steriod Dual shock coil fractal steroid eluting 65, 75cm lengths $9,000.00

passive fixation electrode

BT078 Kentrox RV Steroid single shock coil fractal steroid eluting 65, 75 cm lenghts $9,000.00

passive fixation electrode

BT079 Cylos DR-T Dual chamber dual sensor rate responsive one size $9,360.00

with home monitoring system option

BT080 Cylos VR single chamber dual sensor rate responsive one size only $5,700.00

BT081 Kronos LV-T CRT ICD with home monitoring one size $40,560.00

BT082 PRO-Kinetic Cobalth Chromium coronary stent system 8-40mm length 2-5mm diameter $1,200.00

BT083 Setrox S Bipolar active fixation lead with fractal length 45, 53, 60cm $1,248.00

coated and steroid eluting electrode

BT084 Linox SD Fractal coated and steroid electrode, 65, 75cm length, 16, 18mm elec $9,360.00

active fixation quadrapolar

BT085 Stratos LV-T Multiprogrammable Biventricular DDDRV One size only $12,480.00

with Home Monitoring

Boston Scientific Pty Ltd

BS069 Express 2/Liberte Coronary Stent Consists of a balloon expandable stent, Stent lengths: 8,12,16,20,24,28 $1,248.00

pre-mounted on a Maverick 2 Monorail & 32 mm Stent diameters: 2.25,

delivery catheter. 2.5, 2.75, 3.0, 3.5, 4.0, 4.5 &

BS074 Taxus on Express2 Coronary Stent balloon expandable stent with conformal Length 8 - 32mm; Diameter $3,450.00

System Models 38001-0822 to 0840; polymer/drug matrix coating, pre- 2.25 - 5.0mm

38001-1222 to 1250; 38001-1622 to mounted on high pressure monorail

1650;

38001-2022 to 2050; 38001-2422 to

2450; 38001-2827 to 2850; 38001-3227

BS099 Taxus Liberte Paclitaxel-Eluting Coronary 316L Stainless Steel Stent with Translute 2.0mm-5.0mm & 8mm-32mm $3,450.00

Stent System Polymer and Paclitaxel

Prostheses List by Category and Sponsor Page 3 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

BS112 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1 39cc, 82g $47,840.00

connector H230

BS113 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1 39cc, 82g $47,840.00

connector H235

BS114 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1 43cc, 90g $47,840.00

connector H239 High Energy

Edwards Lifesciences Pty Ltd

EL028 Baxter Sterile Grafts, Implants & Carpentier-Edwards Classic Annuloplasty 24mm-40mm $2,200.00

Prostheses, Non-Animal Origin Ring. Composition: Titanium Alloy;

Annuloplasty: Ring-Mitral Ring with Silicone Rubber; Polyester Fabric

Holder; Mitral Cosgrove-Edwards Carpentier-Edwards Physio Annuloplasty

Annuloplasty System Model 4600; Classic Ring. Composition: Elgiloy Bands;

Polyester Film Strips; Silicone Rubber;

Polyester Cloth, Cosgrove-Edwards

Annuloplasty Band. Composition: Silicone

Rubber; Polyester Cloth. Carpentier-

Edwards Tricuspid Ring. Composition:

Titanium Alloy; Silicone Rubber;

EL029 SE SIL Ball Valve Aortic Models Starr Edwards - Silastic Ball Valve. 16mm-34mm $3,850.00

1200/1260, SE SIL Ball Valve Mitral Composition: Stellite Alloy No. 21;

Polytetrafluroethelyne; polypropylene

cloth; Silicone rubber (contains 2% by

weight barium sulphate for radiopacity)

EL030 CE Supra Annular Aortic Valve Model Carpentier-Edwards SAV Bioprosthesis. 19mm-33mm $4,350.00

2650 Carpentier-Edwards S.A.V Composition: Porcine Valve; Elgiloy

Bioprosthesis Model 6650 Mitral Valve Alloy; Silicone Rubber,

EL031 Carpentier-Edwards Perimount Pericardial Carpentier-Edwards Pericardial Models 2900/6900 19-33mm, $4,900.00 $5,144.00

Bioprosthesis - Models 2900/6900

Bioprosthesis. Composition: Bovine Model 6900P 25, 27, 29, 31,

Carpentier-Edwards Perimount Plus Pericardium; Elgiloy Alloy; Silicone

Pericardial Bioprosthesis Mitral - Model Rubber, Polytetrafluoroethylene

6900P

EL032 Baxter Edwards Prima Plus Stentless Edwards Prima Plus. Porcine Valve; 19mm-29mm for pack of 7 items $4,600.00

Bioprosthesis Model 2500P Prosthetic Woven Polyester Cloth.

Heart Valve

EL033 Baxter Augmentation / Substitution Edwards Pericardial Patch. Bovine 10cm x 16cm $740.00

Material, Human or Animal Origin, Sterile Pericardium.

Pericardial Patch.

Prostheses List by Category and Sponsor Page 4 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

EL039 Edwards Perimount Magna Model 3000 Carpentier-Edwards Perimount Magna 19MM Aortic Pericardial Tissue $4,900.00 $5,690.00

composition: Glutaraldehyde treated Valve; 21MM Aortic Pericardial

bovine pericardium/elgiloy wireform Tissue Valve; 23MM Aortic

stent/polyester band/silicone rubber Pericardial Tissue Valve; 25MM

suture ring/polytetrafluoroethylene Aortic Pericardial Tissue Valve;

cloth/polyester cloth. 27MM Aortic Pericardial Tissue

Valve; 29MM Aortic Pericardial

Tissue Valve

EL049 Edwards Etlogix Annuloplasty Ring Titanium/silicon/dacron polyester 24mm/26mm/28mm/30mm/32m $2,350.00

cloth/plastic template Mitral valve annular m/34mmd

repair device designed specifically for

patients with Ischemic Mitral regurgitation

EL050 Edwards MC3 Tricuspid Annuloplasty Annuloplasty Ring, 26mm to 36mm in 2mm $2,350.00

titanium/silicone/polyester velour

cloth/plastic template

Guidant Australia Pty Ltd

GU009 Fineline II Sterox IROX Lead Model 4458, Model 4459 52cm, 58cm $1,248.00

GU011 Fineline II Sterox IROX Lead Model 4456, Model 4457 52cm, 58cm $1,248.00

GU012 Fineline II Sterox IROX Lead Model 4479, Model 4480 45cm, 52cm $1,248.00

GU013 Fineline II EZ Sterox IROX Lead Model 4472, Model 4473 & Model 4474 45cm, 52cm, 58cm $1,248.00

GU016 Fineline II EZ Sterox IROX Lead Model 4469, Model 4470 & Model 4471 45cm, 52cm, 58cm $1,248.00

GU023 Guidant Aust Selute Picotip Steroid Model 4033, Model 4034, Model 4035, 45cm, 52cm, 59cm $1,248.00

Eluting Bipolar Lead Model 4063, Model 4064

GU028 Guidant Aust Selute Picotip VDD Lead Model 4340, Model 4341, Model 4342 & $1,544.00

Model 4343

GU037 Myocardial Pacing Lead Model 4312 and 4316 54cm and 35cm $1,144.00

GU056 Easytrak Lead Model 4510, Model 4511, Model 4512 65cm, 72cm, 80cm $3,120.00

Transvenous Coronary Sinus Lead

GU079 Pulsar Model VDD 870 Titanium 3.2mm/IS-1 $5,200.00

GU102 Stents ACS Multilink Coronary Stent; ACS 1.5mm - 8.0mm $1,248.00

Megalink Peripheral Stent; ACS RX

Herculink Peripheral Stent. Stainless steel

GU105 Multilink Coronary Stent System Stainless Steel Length 1.5mm - 8.0mm $1,248.00

GU107 Ventak Prizm HE DR Model 1853 & Model 1858, titanium, dual One size only $40,560.00

chamber, adaptive rate

Prostheses List by Category and Sponsor Page 5 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GU110 Ventak Prizm II VR Model 1860, titanium, single chamber, One size only $40,560.00

adaptive rate

GU111 Ventak Prizm II DR Model 1861, titanium, dual chamber, One size only $43,680.00

adaptive rate

GU112 Endotak Reliance S Lead Model 0127 & Model 0128, defibrillation 59cm, 64cm $7,500.00

lead, 9fr introducer (silicone coated),

steroid eluting, high impedence

GU115 Endotak Reliance Lead Model 0147, Model 0148 & Model 0149, 59cm, 64cm, 90cm $7,500.00

defibrillation lead, 9fr introducer (silicone

coated), steroid eluting, high impedence

GU118 Endotak Endurance EZ Leads Model Defibrillation lead, steroid eluting, 64, 70, 100cm $7,500.00

0154, Model 0155, Model 0156 trilumen lead body contains one

conductor for pacing/sensing and two

conductors for defibrillation.

The helix is

composed of platinum iridium.

GU120 Insignia Plus DR Model 1297, Insignia Dual Chamber Rate Responsive One size only $9,360.00

Plus DR Model 1298 Permanent Pacemaker

GU121 Insignia Entra DR Models Dual Chamber Rate Responsive One size only $9,360.00

Permanent Pacemaker

GU122 Flextend Lead Models 4086, 4087 & Bipolar, steroid eluting, transvenous 45,52,59cm $1,248.00

silicon pace/sense leads with an

extendable/retractable active fixation for

implantation into the atrium or ventricle

GU123 Endotak SQ Array XP Lead Model 0085 Endotak SQ Array XP Lead Model 0085 70 cm $4,680.00

is used in addition to an Endotak

endocardial leads for patients with a high

DFT (Defibrillation Threshold)

GU124 Insignia Entra SR Models 1195 & 1198 Single Chamber Rate Responsive One size only $5,928.00

Permanent Pacemaker

GU126 Insignia Plus SR Model 1194 Single Chamber Rate Responsive One size only $5,928.00

Permanent Pacemaker

GU127 Multilink Coronary Stent System - Frontier 316L Stainless steel stent Length 1.5 - 8.0mm $2,496.00

GU128 Multilink Coronary Stent System - Vision Cobalt chrome stent Length 1.5 - 8.0mm $1,248.00

GU129 LV-1 Lead Adaptor to IS-1 Connects Left ventricular leads to IS-1 One size only $500.00

ports in pacemakers and defibrillators to

replace abnormal cardiac excitation

Prostheses List by Category and Sponsor Page 6 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GU130 Y Adaptor Connects multiple defibrillator electrodes One size only $500.00

to a common port, enabling the use of

shocks to revert Ventricular Tachycardia

and normal cardiac function to return

GU132 Vitality DR Model 1871 This device acts to defibrillate the heart Model 1871 Vitality DR Dual $43,680.00

chambers when the patient enters into an Chamber Rate Responsive

arrhythmia or uses shocks or anti tachy Pacemaker/Defibrillator

pacing to revert Ventricular Tachycardia

(VT) or Ventricular Fibrillation (VF).

While also acting as a dual chamber

GU133 Vitality VR Model 1870 This device acts to defibrillate the heart Model 1870 Vitality VR Single $40,560.00

chambers when the patient enters into an Chamber Rate Responsive

arrhythmia or uses shocks or anti tachy Pacemaker/Defibrillator

pacing to revert Ventricular Tachycardia

(VT) or Ventricular Fibrillation (VF).

While also acting as a single chamber

GU134 Contak Renewal 2 This device acts to defibrillate the heart One Size Only $45,760.00

chambers when the patient enters into an

arrhythmia or uses shocks or anti tachy

pacing to revert Ventricular Tachycardia

(VT) or Ventricular Fibrillation (VF).

While also acting as a biventricular

GU137 Vitality AVT Dual chamber defibrillator, with atrial and One size only $45,760.00

ventricular therapy

GU138 Easytrak 2, Model 4514,4515, 4516, The Easytrak 2 lead is a dual electrode $6,240.00

4517, 4518, 4519, 4520 version of the Easytrak lead. The

Easytrak 2 lead is a coronary sinus lead,

steroid eluting, dual electrode, pace/sense

lead.

The lead provides chronic pacing

and sensing of the left ventricle by

placement in the coronary venous

GU139 Insignia Ultra SR Lodel 1190 Implantable Cardiac Pacemaker One size only $5,928.00

GU140 Insignia Ultra DR Model 1291 Implantable Cardiac Pacemaker One size only $9,360.00

GU141 Insignia Ultra DR Model 1290 Implantable Cardiac Pacemaker One size only $9,360.00

GU142 Contak Renewal TR2 CRT - P Model Implantable Cardiac pacemaker 45x54x8.5mm, 14cc, 26gm $12,480.00

H140, Model H145

GU143 Contak Renewal TR CRT -P Model Implantable cardiac pacemaker 45x54x8.5mm, 14cc, 26gm $9,360.00

H120, Model H125

Prostheses List by Category and Sponsor Page 7 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GU144 Contak Renewal 4 HE CRT-D Model Implantable dual-chamber defibrillator one size only $47,840.00

H197, Model H199

GU145 Endotak Reliance G Lead Model 0164, Implantable defibrillator/pacemaker lead Lead Lengths: 59 - 90cm $9,000.00

Model 0165, Model 0166, Model 0167

GU146 Endotak Reliance SG Lead Model 0160, Implantable defibrillator/pacemaker lead Lead Lengths: 59 - 90cm $9,000.00

Model 0161, Model 0162, Model 0163

GU147 Contak Renewal 4 CRT-D Model H190, Implantable dual-chamber defibrillator One size only $45,760.00

Model H195

GU148 Vitality 2 EL VR - Model T177 Implantable Cardiac Defibrillator 35cc 90g $40,560.00

GU149 Vitality 2 DR - Model T165 Implantable Cardiac Defibrillator 30cc; 82g $43,680.00

GU150 Vitality 2 EL DR - Model T167 Implantable cardiac Defibrillator 35cc; 90g $43,680.00

GU151 Vitality 2 VR - Model T 175 Implantable cardiac defibrillator 30cc; 82g $40,560.00

GU152 Easytrak IS-1 Lead, Models 4535 to 4538 Implantable left ventricular pacemaker lead 80 - 90cm $3,120.00

GU153 Easytrak 2 Is-1 Lead - Models 4542, Implantable left ventricular pacemaker lead 80 to 100cm $6,240.00

4543 & 4544

GU154 Contak Renewal 4 AVT CRT -D - Model Implantable Cardioverter Defibrillator 37cc; 89g $50,960.00

M170 and M175 with Cardiac Resynchronisation Therapy

GU155 Contak Renewal 4 AVT HE CRT - D - Implantable Cardioverter Defibrillator 40cc; 89g $52,000.00

Model M177, M179 with cardiac resynchronisation Therapy

GU156 Easytrak 3 Lead - Models 4521, 4522, Implantable left ventricular pacemaker lead 80 to 100cm $6,240.00

4523, 4524, 4525, 4526 and 4527

GU157 Vitality AVT - Model A155 Implantable cardiac defibrillator with both 30cc $45,760.00

Atrial and Ventricular tachyarrhythmia

therapy

GU158 Endotak Reliance SG Passive Fixation Lead Endotak Reliance SG Passive Fixation 54cm - 90cm $7,200.00

Lead: Models 0170, 0171, 0172, and

0173 Implantable cardioverter defibrillator

lead with GORE ™ ePTFE covered

GU159 Endotak Reliance G Passive Fixation Lead Endotak Reliance G Passive Fixation 54cm -90cm $7,200.00

Lead: Models 0174, 0175, 0176 and

0177. Implantable Cardioverter

defibrillator lead with GORE ™ ePTFE

GU160 Endotak Reliance Active Fixation Lead Endotak Reliance Active Fixation Lead: 54cm - 90cm $7,200.00

Models 0157, 0158 and 0159 Implantable

cardioverter defibrillator lead

Prostheses List by Category and Sponsor Page 8 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GU161 Endotak Reliance S Active Fixation Lead Endotak Reliance S Active Fixation Lead: 54cm - 90cm $7,200.00

Models 0137, 0138 and 0139

GU162 Easytrak 3 IS-1 Lead Models 4548, 4549 and 4550. Silicone Sizes 80 to 100cm $6,240.00

and polyurethane insulation and

polyurethane protective sleeve

GU163 ENDOTAK RELIANCE G Lead 018 Series Endotak Reliance G Lead: Models 0184 to 59-90cm $7,200.00

0187.

Implantable cardioverter

defribrillator lead.

Active fixation.

GU164 ENDOTAK RELIANCE SG Lead 018 Endotak Reliance SG Lead: Models 0180 59-90cm $7,200.00

to 0183.

Implantable cardioverter

defibrillator lead.

Active fixation.

GU165 Acuity Steerable Lead Steerable IS-1 bipolar CS LV Lead 80cm, 90 cm, 100cm $6,240.00

Models 4554, 4555, 4556

Johnson & Johnson Medical Pty Ltd

JJ026 BX Velocity with Hepacoat System Balloon expandable, stainless steel, $1,220.00

heparin coated

JJ200 BX Velocity Stent and Delivery System Stainless steel stent Diameter: 2.25-5.0 mm; Length $1,220.00

8 - 33 mm

JJ239 BX Sonic Stainless steel coronary stent mounted on Dia 2.25 - 4.0mm, lengths 8 - $1,220.00

a balloon delivery system 33mm

JJ302 CYPHER Sirolimus-Eluting Stent & Stainless steel coronary stent with Diameter 2.25 - 5.0mm, length $3,450.00

Delivery System Model

CRS - 23300, Rapamycin (an immunosuppressive and 8-33mm

08225, 08250, 08275, 08300, 28225, antiproliferative drug) bound to the stent

28250, 28275, 28300, 33225, 33250,

33275, 33300, 13225, 13250, 13275,

18225, 18250, 18275, 18300, 23225,

23250, 23275, 23350, 23400, 08350,

08400, 28350, 28400, 33350, 33400,

13300, 13350, 13400, 18350, 18400,

23450, 23500, 28450, 28500, 33450,

33500, 08450, 13450, 18450, 18500

Prostheses List by Category and Sponsor Page 9 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

JJ481 CYPHER SELECT Sirolimus-Eluting Stainless steel coronary stent with Diameter 2.25 - 5.0mm, length $3,450.00

Stent & Delivery System Sirolimus (an immunosuppressive and 8 - 33mm

anti-proliferative drug) bound to the stent

by a polymer. Model CRA-23300, 08225,

08250, 08275, 08300, 28225, 28250,

28275, 28300, 33225, 33250, 33275,

33300, 13225, 13250, 13275, 18225,

18250, 18275, 18300, 23225, 23250,

23275, 23350, 23400, 08350, 08400,

28350, 238400, 33350, 33400, 13300,

13350, 13400, 18350, 18400, 23450,

23500, 28450, 28500, 33450, 33500,

JJ587 CYPHER Select Plus Sirolimus Eluting Stainless steel coronary stent with Diameter 2.25 - 5.00mm, $3,450.00

Coronary Stent Sirolimus bound to the stent by a polymer Length 8 - 33mm

Medtel Australia Pty Ltd

ME065 Amplatzer Duct Occluder Nitinol Wire Mesh 5 - 24mm $10,200.00

ME066 Amplatzer Septal Occluder Nitinol Wire Mesh 4mm - 40mm $10,200.00

ME067 Amplatzer Muscular VSD Occluder Nitinol Wire Mesh 4 - 24mm $10,200.00

ME068 Amplatzer PFO Occluder Nitinol Wire Mesh 25mm & 35mm $10,200.00

ME074 Amplatzer Membranous VSD Occluder Nitinol wire mesh, double disc occluder 4-24mm, Length 7-10mm $10,200.00

and delivery system

Medtronic Australasia Pty Ltd

MC002 Medtronic Sprint Quattro Lead Model Silicone and polyurethane 65-100cm $9,360.00

6944RV/SVC 65cm; Model 6944RV/SVC

75cm; or Model 6944RV/SVC 100cm;

Medtronic Sprint Quattro Lead Model

6944RV/SVC 58cm

MC005 Medtronic Duran Annuloplasty Ring; Annuloplasty Devices - Models 610R & Model 610R 25-35mm & Model $1,900.00

Duran Ancore Ring 620R; Duran Ancore 620R Silicone / Barium Sulphate, Dacron. 620R 23-35mm

Chordal Model 620RG

MC006 InSync model 8040 Stimulator Titanium 14.4cc $9,360.00

MC008 Medtronic Capsurefix Model 5568 Pacing Silicone Polyurethane 30 - 85cm $1,144.00

Leads

MC009 Medtronic Epicardial Pacing Leads IS-1 Silicone 35 - 53cm $1,144.00

Model 5071

Prostheses List by Category and Sponsor Page 10 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC010 Medtronic Capsure SP Novus Model Silicone Polyurethane 45 -110cm $1,144.00

5092; Capsure SP Novus Lead Model

5592; Medtronic Capsure Model 4023

Lead; Medtronic Capsure Model 4024

Lead (med.dexamethasone) Medtronic

Capsure Model 4523(MED) Medtronic

Capsure Model 4524 Lead; Medtronic

Capsure Model 5023M Lead; Medtronic

Model 5024M Capsure Lead; Medtronic

Model 5024M Capsure Lead; Medtronic

Capsure Model 5524M SP Bipolar Lead

MC011 Capsure EPI steroid eluting bipolar Silicone 25 - 60cm $1,716.00

epicardial lead Model 4968 - ventricle

MC012 Medtronic Hancock Valved Conduit Porcine bioprosthesis, dacron 12, 14, 16, 18, 20, 22, 25, $5,750.00

Model 100/150

MC013 Medtronic Hall Heart Valve Aortic Model A7700/M7700 Titanium. Pyrolite. A7700 - Diameter 20-31mm, $5,000.00

A7700, Medtronic Hall Heart Valve Mitral Dacron, A7700EZ/M7700EZ Titanium. M7700 - Diameter 23-33mm,

Model M7700, Hall Easy Fit Aortic Heart A7700EZ - Diameter 19-29mm,

Valve Model A7700, Hall Easy Fit Mitral M7700EZ - Diameter 23-31mm

Heart Valve Model M7700

MC015 Freestyle bioprosthesis Models 995xx, 995MSxx 19 - 35mm $5,110.00

MC018 Medtronic Sprint Lead Model 6942RV/SVC Model 6942-65, Model 6942-75, Model 65 - 100cm $7,488.00

6942-100; Silicone

MC019 Medtronic Gem DR Model 7271 Titanium 62cc $36,400.00

MC020 Medtronic Gem Model 7227Cx; Gem Titanium 49cc, 40cc $34,320.00

Model 7227 Implantable Cardioverter

MC025 Medtronic Sprint Lead Model 6932RV Model 6932-65, Model 6932-75, Model 65 - 100cm $7,488.00

6932-100; Silicone

MC026 Medtronic Transvene SVC Lead Model Model 6937-35, Model 6937-52, Model 35 - 110cm x 660mm $2,340.00

6937-58, Model 6937-110; Silicone;

MC027 Model 6721 Unipolar Epicardial Patch Model 6721S-50, Model 6721M-50, 370, 660, 840mm $2,340.00

Leads S/M/L Model 6721L-50; Silicone

MC028 Medtronic Reveal ILR Model 9525, Titanium 8cc $3,635.00

Implantable Cardiogram Recorder;

Reveal Plus Implantable Loop Recorder

MC029 Medtronic Kappa 400 pacemaker Model Titanium 13.9cc $9,048.00

KDR401

Prostheses List by Category and Sponsor Page 11 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC030 Medtronic Kappa 400 Pacemaker Model Titanium 11.6cc, 11.7cc $5,616.00

KSR401

MC035 Medtronic lead Extender Kit Model: Silicone 14 - 50cm $530.00

6984M, 6981M, 6985M, 5866-24M,

5866-38M, 5866-40M, 6986M, 5866-

37M; Bipolar Lead Adaptor Kit Model 2872

MC036 Medtronic Lead End Cap Kit Model: Silicone or Polyurethane; Plug to Seal IS- 10 - 25mm, IS-1 Pin Plug - One $80.00

5867-3M; Medtronic Adaptor Kit Line 1 connector in a pacemaker or Size only

5866-23; Connector Sleeve 5866-45;

defibrillator, Silicone

Metronic lead sleeve kit model: 5866-46;

Medtronic Pinplug kit. Model 6719, IS-1

MC037 Medtronic Attain Cardiac Vein Pacing Polyurethane; 4 FR Polyurethane, 5 FR 58 - 75cm: 85cm/75cm/110cm $2,735.00

Lead Model 2187; Medtronic Coronary Electrode Tip, Kit Includes: Stylet x 3, or 75-110cm; 75cm/85cm

Sinus Pacing Lead Model 2188; Valve lifter, Attain Lead & Anchoring

Medtronic Attain SD Model 4189; Sleeve; 4 FR Polyurethane Body, 6.1FR

Medtronic Attain Side-Wire Model 4191

MC052 Medtronic Capsure VDD2 Model 5038 Silicone; Contents: 1 x lead with 11.5cm, 13.5cm, 15.5cm $1,544.00

AV Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

lifter, 2 x fixation tools, extra stylets

MC053 Capsure EPI steroid eluting unipolar Silicone 25 - 50cm $1,544.00

epicardial lead Model 4965 ventricle

MC197 Medtronic AVE S660 Coronary Stents, Stainless Steel S660 Coronary Stent - Diameter $1,144.00

S670 Coronary Stents, S7 Coronary (2.5mm-2.75mm), Length

Stents, BeStent2, (9mm-24mm); S670 & S7

Coronary Stent - Diameter

(3mm-4mm), Length (9mm-

30mm); BeStent2 - Diameter

(2.5mm-4mm), Length (9mm-

MC198 Medtronic Hall rotatable aortic valved Titanium, pyrolite, dacron 20 - 33mm $6,800.00

collagen impregnated conduit Model R7700

MC200 Medtronic A/Asia AT500 DDDRP Pacing Titanium, silicone One size only, 14.9cc $11,440.00

System Model AT501

MC201 Medtronic A/Asia Gem III VR Model Titanium One size only, 39.2cc $36,400.00

7231CX

MC202 Medtronic Gem III DR Model 7275 Titanium One size only, 39.5cc $38,480.00

Implantable Cardioverter Defibrillator

Prostheses List by Category and Sponsor Page 12 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC208 Medtronic Sprint Quattro Secure Lead Leads, Defibrillator, Implantable, Silicone, 58-100cm $9,360.00

Model 6947 58cm; Model 6947 65cm; polyurethane, platinized tantalum coils,

Model 6947 75cm; Model 6947 100cm steroid eluting tip

MC225 Attain Over the Wire Model 4193 Titanium, polyurethane 78-88cm $3,120.00

MC226 Medtronic Insync III Triple Chamber Titanium One size only $12,480.00

Pacemaker Model 8042

MC227 Medtronic Gem III AT Model 7276 Titanium 39.5cc $40,560.00

Implantable Cardioverter Defibrillator

MC229 Medtronic Capsure SP Novus Model Silicone, platinum 30-100cm $1,144.00

5594 Lead 30cm

MC237 Gem Model 7227B Implantable Titanium, "B" Style Connector 56cc $33,800.00

Cardioverter Defibrillator

MC238 Gem Model 7227D Implantable Titanium, "D" style connector 53cc $33,800.00

Cardioverter Defibrillator

MC239 Gem Model 7227EImplantable Titanium, "E" style connector 55cc $33,800.00

Cardioverter Defibrillator

MC241 Medtronic Kappa Pacemaker Model KDR Cardiac Pacemaker, Titanium 13.9cc $9,048.00

MC242 Medtronic Kappa KSR 900 Model KSR Cardiac Pacemaker, Titanium 9.7,10.5,11.0 cc $5,928.00

901,903, 906

MC243 Medtronic Kappa KVDD 900 Model Cardiac Pacemaker, Titanium 11.1cc $6,552.00

KVDD 901

MC245 Marquis DR Model 7274 Implantable Titanium 36cc $43,680.00

Cardioverter Defibrillator

MC246 DF-I Y-Adaptor/Extender Model 6726 Silicone Lengths 25cm, 37cm $537.00

25cm & 37cm

MC251 Implantable Subcutaneous Defibrillator Silicone and Platinum Alloy Lengths 41-85cm inclusive $4,680.00

Lead Model 6996SQ 41cm, 58cm, 85cm

MC252 Medtronic InSync Marquis Implantable Titanium Volume 38cc $40,560.00

Cardioverter Defibrillator Model 7277

MC253 Medtronic Marquis VR 7230CX Titanium, Sterile, Single Chamber Volume 36cc $40,560.00

Implantable Cardioverter Defibrillator

MC254 CapSure Sense pacemaker lead Models Titanium Nitride 30 - 85cm $1,248.00 Also grouped in Pacemaker Lead

Group 8

MC292 Advantage Heart Valve - Aortic Model A7760 - Pyrolytic carbon, PET Diameter 19-31 mm $5,909.00

Prostheses List by Category and Sponsor Page 13 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC301 Model 3830 PACING LEADS Active fixation pacemaker lead 59 - 75 cm $2,600.00

Composition: Insulation is polyurethane,

Electrodes are Titanium Nitride coated

Platinum, the screw is steriod-coated

MC306 InSync III Marquis Model 7279 Titanium One size only - Volume 38cc $45,760.00

MC317 Maximo VR Model 7232Cx Titanium One size only 38.5cc $42,640.00

MC318 Maximo DR Model 7278 Titanium. Dual chamber One size only 38.9cc $45,760.00

MC319 EnPulse VDD; Model E2VDD01 EnPulse VDD pacemaker with IS1 One size only $6,760.00

connector.

Titanium silicone

MC321 EnPulse SR Series: Model E2SR01, EnPulse SR - Pacemakers - with IS1 One size only $6,000.00

Model E2SR03, Model E2SR06 connector; with 3.2mm low profile

connector; with 5mm connector.

MC322 EnPulse DR Series: Model E2DR01, EnPulse DDDR Pacemakers - with IS1 one size only $11,440.00

Model E2DR03, Model E2DR06, Model connector and normal battery size; with

E2DR21, Model E2DR31, Model E2DR33 3.2mm low profile connector and normal

battery size; with 5/6 mm connector and

normal battery size; with IS1 connector

and small battery size; with IS1

connector and large battery size; with

3.2mm low profile connector and large

battery size. Titanium and silicone.

MC324 Advantage Supra Aortic Heart Valve Mechanical Heart Valve Pyrolite Carbon Diameter (mm): 19 - 25 $5,909.00

leaflets Pyrolite carbon ring

MC325 InSync Sentry Model 7298 Defibrillator, Titanium 40cc $50,000.00

MC329 Medtronic Driver, Micro Driver Coronary Cobalt Alloy Driver Stent: diameter (2.25 - $1,248.00

Stent System 4.5mm), length (8-30mm);

Micro-Driver Stent: diameter

(2.25 - 2.75mm), length (8 -

MC330 Medtronic Kappa 400 Pacemaker Model Titanium 11.6cc, 11.7cc $5,616.00

KSR 403

MC331 Medtronic Sprint Lead Model 6943 Model 6943-58, Model 6943-65, Model 58 - 100cm $7,488.00

6943-75, Model 6943-100; Silicone

MC332 Medtronic Kappa Pacemaker KDR 903 Cardiac Pacemaker, Titanium 13cc, 14.2cc $9,048.00

and KDR 906

MC333 Medtronic Kappa Pacemaker Model KDR Cardiac Pacemaker, Titanium 12.1cc, 11.1cc, 13.1cc $9,048.00

901, KDR921 and KDR931

Prostheses List by Category and Sponsor Page 14 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC336 Medtronic Capsure Z Novus Model 5054 Silicone; Contents: 1 x lead with 45-58cm $1,248.00

Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

lifter, 2 x fixation tools, extra stylets

MC337 Medtronic Capsure Z Novus Model 5554 Silicone; Contents: 1 x lead with 45-58cm $1,248.00

Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

lifter, 2 x fixation tools, extra stylets

MC338 Medtronic Capsurefix Novus Model 5076 Silicone; Contents: 1 x lead with 45-85cm $1,248.00

Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

lifter, 2 x fixation tools, extra stylets

MC340 Medtronic Kappa 400 pacemaker Model Titanium 13.9cc $9,048.00

KDR403

MC341 Medtronic Sprint Lead Model 6945 Model 6945-58, Model 6945-65; Silicone, 58 - 100cm $7,488.00

Model 6945-75, Model 6945-100; Silicone

MC349 Entrust Model D 153ATG, Dual chamber, AT 33cc, 63g $45,760.00

Therapies, 30J

MC358 Intrinsic Model 7287, Implantable Cardioverter 36cc, 75g $43,680.00

Defibrillator

MC359 Intrinsic Model 7288, Implantable Cardioverter 38cc, 76g $45,760.00

Defibrillator

MC360 EnRhythm Model P150 1DR, Rate Responsive dual 21g, 13cc $11,440.00

chamber pacemaker with Anti-

Tachycardia functions: DDDRP

MC362 EnTrust Model D154DRG, dual chamber, VT 35cc, 68g $45,760.00

Therapies, 35J

MC363 EnTrust Model D153DRG, Dual chamber, VT 33cc, 63g $43,680.00

Therapies, 30J 33cc, 63g

MC364 EnTrust Model D154ATG, Dual chamber, AT 35cc, 68g $45,760.00

Therapies, 35J

MC365 EnTrust Model D153VRC, Single chamber, 30J 33cc, 63g $40,560.00

MC366 EnTrust Model D154VRC, Single chamber, 35J 35cc, 68g $42,640.00

Prostheses List by Category and Sponsor Page 15 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC371 Medtronic Capsurefix Model 6940 Pacing Silicone Polyurethane 30 - 85cm $1,144.00

Lead;

Medtronic Tined IS-1 Model

4557M; Medtronic Capsurefix Model

4067/8/4568 Pacing Leads;

Medtronic

Capsurefix Model 5067 Pacing Leads;

Medtronic Capsurefix Model 5068 Pacing

Leads; Capsure SP Novus Pacing Lead

Model 4092; Capsure SP Novus Pacing

MC372 CapSure Sense pacemaker lead Models Titanium Nitride CapSure Sense Lead Model $1,248.00

4074 & 4574 4074 - 30cm to 85cm; CapSure

Sense Lead Model 4574 - 30cm

MC680 Spyder Proximal Anastomotic Device 6-clip assembly $590.00

MC681 Advantage Mitral Mechanical Heart Valve 23mm-33mm $5,909.00

MC695 Sprint Fidelis Lead Model 6949, dual-coil, screw-in 58-100cm $9,360.00 $10,000.00

MC696 Sprint Fidelis Lead Model 6948, dual-coil, tined 58-100cm $9,360.00 $10,000.00

MC697 Sprint Fidelis Lead Model 6931, single-coil, screw-in 58-100cm $9,360.00 $10,000.00

MC698 Sprint Fidelis Lead Model 6930, single-coil, tined 58-100cm $9,360.00 $10,000.00

MC699 Attain OTW Model 4194 Lead Model 4194 78cm, 88cm $6,240.00

MC700 InSync Maximo Model 7304 40cc, 35J $47,840.00

MC701 Mosaic Cinch, Aortic, Mitral Models 305cxx, 310cxx 19mm - 35mm $4,350.00

MC709 Posterior Annuloplasty Band; Colvin - Annuloplasty - Model 610B & 620B Model 610B: 25-35mm; Models $1,900.00

Galloway Future Band Model 638B; Silicone / Barium Sulphate, Dacron. 620B & 620BG: 23-35mm,

Duran Ancore Band 620B; Duran Ancore Models 638B semi-regid metal alloy core, Model 638B - 26-38mm

Chordal Model 620BG silicone coating, polyester knit fabric, kit

includes-band, malleable handle, template

with suture markers, sizers

MC713 Adapta Pacemaker VDDR Pacemaker 11.1cc $6,760.00

Models ADVDD01 23.6g

MC714 U-Clips (Valve Repair) Double Arm, Mitral Valve Repair 2-packs $500.00

MC720 Concerto CRT-D Implantable Cardioverter Defibrillator 38cc $50,000.00

with Cardiac Resynchronisation Therapy

MC721 Virtuoso DR Model 37cc, 68g $45,760.00

Implantable Cardioverter Defibrillator,

Dual Chamber

Prostheses List by Category and Sponsor Page 16 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC722 Virtuoso VR Model 37cc, 68g $42,640.00

Implantable Cardioverter Defibrillator,

Single Chamber

MC726 Adapta Pacemaker DR Pacemaker 11.1-14.2cc $11,440.00

Models ADDR01, ADDRS1, ADDRL1, 23.6g-31.3g

ADDR06, ADDR03

MC727 Adapta Pacemaker DDD Pacemaker 12.1cc $5,200.00 $6,500.00

Models ADD01 27.1g

MC728 Adapta Pacemaker SR Pacemaker 9.7 - 11.0cc $5,928.00 $6,188.00

Models ADSR01, ADSR06, ADSR03 21.5 - 22.5g

MC730 Attain StarFix LV Lead Over the wire left Ventrucular Lead 78, 88, 103cm $5,000.00 $6,240.00

MC732 Endeavour Drug Eluting Coronary Stent Cobalt Alloy, ABT - 578 Diameter: 2.25mm-4.5mm; $3,450.00

System Length: 8.00mm-38.0mm

Neich Medical Pty Ltd

NM003 R Stent Evolution 2 Coronary Delivery 316LVM Stainless Steel Balloon Lengths - 9-33mm; Diameters - $1,144.00

System Expandable Stent (Tubular) 2.5-4.0mm

Pacing Importers Pty Ltd

PI001 Excimer Laser Stent Polyester Fibre optic catheter 2.5 and 2.2mm $6,800.00

PI002 Excimer Laser Stent Polyester Fibre optic fibre catheter 0.457mm, 0.9mm, 1.4mm, $6,800.00

1.7mm and 2.0mm

PI003 Med-X-Flexy Stent Tubular Stent, Stainless steel 316L, Gold Dia 5 - 9mm length: 20 - $780.00

markers

Progressive Medical Pty Ltd

PG001 Alto II VR Single Chamber ICD Debrillator, implantable, automatic $36,400.00

PG002 Talent II DR Pacemaker Model 233 Dula Chamber Pacemaker. 99% titanium 57.5 x 37.2 x 8mm $9,360.00

PG003 Swift 4040 1CT lead length 58 cm - 69 cm $7,280.00

PG004 Alto II DR Dual Chamber Implantable One size only $38,480.00

Cardioverter Defibrillator

PG005 Symphony DR 2550 Active Implantable pacemaker 1 size only $9,360.00

PG006 Symphony SR Titanium one size only $5,928.00

PG007 OVATIO CRT-D 6750 Titanium, dual chamber ICD with CRT 30cc $45,760.00

PG008 OVATIO VR 6250 Titanium, single chamber, sterile, VR 29cc $40,560.00

6250, 34J

Prostheses List by Category and Sponsor Page 17 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

PG009 OVATIO DR 6550 Titanium dual chamber ICD, 29 cc 29cc $43,680.00

Reid Healthcare

RH001 Aortic On-X Prosthetic Heart Valve 27-29mm, 19mm, 21mm, $5,500.00

Models ONXA-19; ONXA-21; ONXA- 23mm, 25mm, 25-33mm, 27-

23; ONXA-25; ONXA-27/29; ONXM-23; 29mm, 31-33mm, 23mm,

ONXM-25; ONXM-27/29; ONXM31/33;

St. Jude Medical Australia Pty Ltd

SJ009 Photon Micro DR Model V-232 37cc $38,480.00

Defibrillators/Cardioverters

SJ010 Photon Micro VR Model V-194 36cc $40,560.00

Defibrillators/Cardioverters

SJ011 Atlas DR Model V-240 Dual chamber implantable cardioverter 37cc $45,760.00

defibrillator with rate response

SJ012 Atlas VR Model V-199 Single chamber implantable cardioverter 36cc $42,588.00

defibrillator with rate response

SJ013 Transvenous Superior Vena Cava Lead TVL lead system models SV01, SV02, SV01- 100cm; SV02 - 45cm; $7,280.00

Model SV01, Transvenous Superior Vena SV03 transvenous leads SV03 - 55cm

Cava Lead Model SV02, Transvenous

Superior Vena Cava Lead Model SV03

SJ016 Riata Transvenous Tachyarrhythmia Lead Quadripolar, dual-coil, steroid eluting, One size only $9,360.00

Model 1570, Model 1571 active fixation tachyarrhythmia leads

SJ019 REGENCY SC 2406L, SCX 2408L, SC Single Chamber, Standard VVIC, IS-1/5- 8.6cc, 18.5-19gm $4,264.00

2407M/S

SJ020 REGENCY SC+ 2402L Single Chamber, VVI, Autocapture, IS-1 8.6cc, 18.5gm $4,264.00

SJ022 REGENCY SR+ 2400L Single Chamber, Rate Response, 8.6cc, 18.5gm $5,928.00

Autocapture, IS-1

SJ023 TENDRIL SDX 1488T, 1388T Single, Active Fixation, Steroid Eluting, 46cm-58cm $1,248.00

Low Polarisation Lead, IS-1

SJ024 PASSIVE PLUS DX 1342T, 1343K, Single, passive fixation, steroid eluting, 46-58cm $1,248.00

1345K, 1346T low polarisation lead; Models: Bipolar

Atrial Lead, IS-1 Unipolar Atrial Lead, IS-

1 Unipolar Ventricular Lead, IS-1 or

Bipolar Ventricular Lead, IS-1

SJ025 St Jude Medical Integrity SR5142 Single chamber, rate responsive Volume 10.4cc, weight 23gm $5,928.00

Pacemaker, Cardiac Implantable

Prostheses List by Category and Sponsor Page 18 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

SJ026 St Jude Medical Integrity AFX DR5346 Dual chamber, rate responsive pacemaker Volume 11cc, weight 23.5gm $9,360.00

Pacemaker, Cardiac, Implantable

SJ027 St Jude Medical Microny II SR+ Model Single Chamber Rate Responsive Volume 5.9cc, Weight 12.8gm $5,928.00

2525T Pacemaker

SJ028 Integrity Micro DR 5336 Pacemaker Dual Chamber Rate Responsive Volume 8cc, Weight 18gm $9,360.00

SJ029 Integrity Micro SR 5136 Pacemaker Single Chamber Rate Responsive Volume 8cc, weight 18gm $5,928.00

SJ030 Identity SR 5172 Single Chamber Rate Responsive Volume 8cc, Weight 17gm $5,928.00

SJ031 Identity XL DR 5376 Dual Chamber Rate Responsive Volume 11cc, Weight 23.5gm $9,360.00

SJ032 Identity DR 5370 Dual Chamber Rate Responsive Volume 8cc, Weight 18gm $9,360.00

SJ033 Aescula LV Model 1055K Left Ventricular Pacing Lead 75cm $2,735.00

SJ035 SJM Tailor Annuloplasty Ring Fully Flexible 25mm - 35mm $2,150.00

SJ036 St Jude Medical Coated Aortic Valved Coated Aortic Valved Graft 21mm - 33mm $6,800.00

SJ037 St Jude Medical Aortic Expanded Cuff Aortic Expanded Cuff, Aortic Aortic Expanded 19 -31mm, $5,909.00

Heart Valve; St Jude Medical Aortic Hemodynamic Plus Cuff, Mitral Aortic Hemodynamic 17 -

Hemodynamic Plus Cuff Heart Valve; St Hemodynamic Cuff, Aortic & Mitral 27mm, Mitral Hemodynamic 17

Jude Medical Mitral Hemodynamic Plus -27mm, Rotatable 17 - 33mm

Cuff Heart Valve; St Jude Medical

Mechanical Heart Valve Masters Series

SJ038 St Jude Medical Toronto SPV Valve Tissue Heart Valves, Bioimplant TSPV: 21 - 29mm, Bioimplant $4,800.00

Model SPA-101, St Jude Medical Aortic: 21-27mm, Bioimplant

Bioimplant Heart Valve Mitral: 27-32mm

SJ039 St Jude Medical Regent Prosthetic Heart Standard Cuff - Model 17AGN-751 - Standard cuff - 17-29mm, Flex $5,909.00

Valves 29AGN-751, Flex Cuff - Model cuff - 17-29mm

17AGFN-756 - 29AGFN-756

SJ040 Frontier 3x2 Model 5510 Biventricular Stimulation Device with AF Height 48mm, Length 52mm, $9,360.00

suppression Depth 6mm

SJ048 Epic Plus VR Model V-196 Implantable Single Chamber sensing and bradycardia 32cc $40,560.00

Cardioverter Defibrillator pacing

SJ049 Epic Plus DR Model V-236 Implantable Dual Chamber sensing, bradycardia 33cc $43,680.00

Cardioverter Defibrillator pacing with atrial fibrillation suppression

SJ050 Verity ADx Model XL DC 5256 Dual - Dual Chamber multi-programmable rate- 11cc, 23.5g $5,200.00

Chamber pacemaker adaptive pacing devices with extended

longevity

SJ051 Verity Adx Implantable Pacemaker, Dual - Chamber, multi-programmable, 45x52x6mm,11cc, 23g, 5mm or $9,360.00

Models XL DR 5356 and XL DR 5357M/S rate-responsive pacemaker withAF 6mm M/S

Prostheses List by Category and Sponsor Page 19 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

SJ053 Verity Adx Model XL SC 5056 Single Chamber multi-programmable rate- 10.5cc, 23g $4,264.00

implantable pacemaker adaptive pacing device with extended

longevity

SJ054 Identity ADx Model VDR 5480 Single Chamber multi-programmable rate- 8cc, 18g $6,760.00

implantable pacemaker adaptive pacing device with extended

longevity

SJ055 Integrity ADx Model SR 5160 implantable Single Chamber multi-programmable rate- 8cc, 17g $5,928.00

pacemaker adaptive pacing device

SJ056 Integrity ADx Model DR 5360 and XL Dual-Chamber, multi-programmable, rate- Model DR 5360 - 8cc, 18g, $9,360.00

DR 5366 responsive pacemaker with AF Model XL DR 5366 - 11cc,

SJ057 Verity ADx Model XL VDR 5456 Single Chamber multi-programmable rate- 11cc, 23.5g $6,760.00

implantable pacemaker adaptive pacing device with extended

longevity

SJ058 St Jude Medical Australia Ventritex Contour MD Models V - 175 AC, V-175C 57-65cc, 109 - 118g $33,462.00

Contour MD Models V-175AC, V-175D and V-175D Single chamber

and V- 175C Defibrillators/Cardioverters Defibrillators/Cardioverters

SJ059 Identity ADx Models DR 5380 and XL Dual-Chamber, multi-programmable, rate- ADx DR 5380: 43x44x6mm, $9,360.00

DR 5386 adaptive pacing devices with AF 18g and 8cc

ADx XL DR 5386: 44x52x6mm,

23.5g and 11cc

SJ060 Identity ADx Model SR 5180 implantable Single Chamber multi-programmable rate- 8cc, 18g $5,928.00

pacemaker adaptive pacing device

SJ061 Identity Adx Model XL DC 5286 Dual Identity ADx Model XL DC Model 5286 11cc, 23.5g $5,200.00

Chamber Pacemaker is an implantable, multi-programmable

rate-adaptive pacing device with AF

SJ062 Epic HF Model V-339 Implantable Cardioverter/defibrillator with dual One size only $45,760.00

Cardiac Defibrillator chamber (atrial and RV) sensing and

bradycardia pacing with ventricular

SJ063 Atlas DR Model V-242 ICD Implantable Dual Chamber Cardio-verter 38cc/78g $45,760.00

Defibrillator

SJ064 Atlas + HF Model V - 341 ICD - Atlas + HF ICD is a cardioverter 40cc/81g $47,840.00

Defibrillator, Implantable, automatic, defibrillator with dual chamber (atrial and

dual-chamber RV) sensing and bradycardia Pacing with

ventricular resynchronisation therapy.

SJ065 Atlas + VR Model V-193 ICD Single chamber implantable cardio-verter 38cc, 77g $42,640.00

defibrillator

Prostheses List by Category and Sponsor Page 20 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

SJ066 Atlas + VR - C Model V-193C ICD Single chamber implantable cardio-verter 38cc, 77g $42,640.00

defibrillator

SJ067 Epic + HF Model V-350 ICD Epic + HF V-350 ICD is a cardioverter 36cc / 73g $45,760.00

defibrillator with dual chamber (atrial and

RV) sensing and bradycardia pacing with

ventricular resynchronisation therapy.

SJ068 Atlas + DR Model V-243 ICD Implantable Dual Chamber Cardio-verter 38cc, 78g $45,760.00

Defibrillator

SJ069 St Jude Medical Biocor Porcine St Jude Medical Biocor Porcine Aortic Valves - Tissue Annulus $4,350.00

Prosthetic Heart Valve Prosthetic Heart Valve is manufactured Diameter - 21-29mm, Implant

from selected procine aortic valve cusps Height - 11-15c; Mitral Valves -

that have been cross-linked with a Tissue Annulus Diameter - 25-

35mm, Implant Height - 8-

SJ070 Epic + DR Model V-233 ICD Dual Chamber Implantable Cardio-verter 33cc 70g $43,680.00

Defibrillator

SJ071 Epic + DR Model V-239 ICD Dual chamber implantable cardio-verter 33cc 70g $43,680.00

defibrillator

SJ072 Frontier II - Model 5596 Biventricular Cardiac Resynchronisation 49mm(h) x 52(1) x 6(t), 25g $12,480.00

Device with AF suppression algorithm -

Titanum

SJ073 Tendril SDX Models 1688T and 1688TC Endocardial Steroid-Eluting Active 100cm, 25cm, 34cm, 40cm, $1,248.00

Fixation Pacing Lead 46cm, 52cm, 58cm, 85cm, 7F

SJ074 Riata Transvenous tachyarrhythmia Leads Tri-polar Active - Fixation, Steroid- 60cm, 65cm, 8F introducer $9,360.00

Model 1582 Eluting, Single shock Coil

SJ075 Riata Transvenous Tachyarrhythmia Lead Quadripolar, dual-coil, steroid eluting, One size only $9,360.00

Model 1580, Model 1581 active fixation tachyarrhythmia leads

SJ076 Verity Adx Model XL SR 5157 M/S Single Chamber multi-programmable 11cc, 23g $5,928.00

implantable pacemaker rate-adaptive pacing devices with

extended longevity

SJ077 Verity Adx Models XL SR 5156 Single Chamber multi-programmable 11cc, 23g $5,928.00

implantable pacemaker rate-adaptive pacing devices with

extended longevity

SJ078 IsoFlex S, Models 1645K, 1643K, 1635K Endocardial, Steroid Eluting, Silicone, 34cm, 40cm, 46cm, 52cm, $1,248.00

Passive Fixation Leads with Fast-Pass 58cm, 85cm, 7F

SJ079 QuickSite Model 1056K Unipolar, Steroid Eluting, Titanium Nitride 75cm, 6F and 86cm, 6F $3,120.00

Electrode, Guidewire/Stylet-placed Left

Heart Lead with Fast-Pass Coating

Prostheses List by Category and Sponsor Page 21 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

SJ081 Riata i Transvenous Tachyarrhythmia Active fixation leads, Steroid Eluting, 60cm, 65cm, 75cm, 8F $9,360.00

Leads Model 1590/1591 Dual Shock Coil Defibrillation Lead

SJ082 Isoflex S, Models 1646T, 1642T and endocardial, Steroid Eluting, Silicone, 34cm, 40cm, 46cm, 52cm, $1,248.00

Passive Fixation Pacing Leads with Fast- 58cm, 85cm, 7F, 120cm 8F

Pass Coating

SJ083 Riata Transvenous Tachyarrhythmia Lead Tri-polar Passive-Fixation, Steroid 60cm, 65cm, 8F introducer $9,360.00

Model 1572 Eluting, Single Shock Coil

SJ084 Riata i Transvenous Tachyarrhythmia Active Fixation, Steroid Eluting, Single 60cm, 65cm, 75cm, 8F $9,360.00

Lead Model 1592 Shock Coil Defibrillation Lead

SJ085 Riata iTransvenous Tachyarrhythmia Passive Fixation, Steroid-Eluting, Dual 60cm, 65cm, 70cm, 8F $9,360.00

Leads Models 1560 and 1561 Shock Coil Defibrillation Lead

SJ086 Riata i Transvenous Tachyarrhythmia Passive Fixation, Steroid Eluting, Single 60cm, 65cm, 70cm, 8F $9,360.00

Lead Model 1562 Shock Coil Defibrillation Lead

SJ087 St Jude Medical Rigid Saddle Ring Rigid Annuloplasty Ring 24 - 34mm $2,400.00

SJ088 SJM Tailor Annuloplasty Band Flexible double-velour, polyester fabric 25 - 35mm $2,150.00

SJ089 Victory XL DR 5816 and DR 5810 Dual Chamber Rate Responsive 44x52x6mm; 23.5g; 11cc $9,360.00

SJ090 Victory SR 5610 single chamber rate responsive 41x44x46mm 17g 8cc $5,928.00

SJ091 Premere PFO Closure System Percutaneous, transcatheter, self- Left Atrial Anchor diameter $9,820.00

expanding, dual anchor, occlusion device 20mm and 25mm

SJ092 Epic II + DR V-258 Epic II + DR V-258 Implantable 35cc, 72g $43,680.00

Cardioverter Defibrillator

SJ093 Epic II VR V-158 Implantable Cardiac Single Chamber Cardioverter Defibrillator 34cc, 70g $40,560.00

Defibrillator

SJ096 Riata ST 7000/7001/7002 Active-Fixation True-Bipolar, Dual-Coil, 60, 65cm 7F introducer $9,360.00

(7002 - Single-Coil) Steroid-Eluting

Steroid Eluting, Endocardial Defibrillation

SJ097 Isoflex P 1644T and 1648T Endocardial, Steroid Eluting, 1648T - 34-85cm 1644T - 34- $1,248.00

Polyurethane, Passive-Fixation Bipolar

Pacing Leads with Fast-Pass Coating

SJ098 Epic II+ HF V-357 Epic II + HF V-357 Cardiac 36cc, 74g $45,760.00

Resynchronisation Therapy Defibrillator

with V-V Timing programmability

SJ099 QuickSite 1056T Bipolar Steroid-Eluting, Titanium Nitride 75cm, 6F and 86cm, 6F $6,240.00

Coated Electrodes Guidewire/Stylet-

Placed Keft Heart Lead with Fast-Pass

Prostheses List by Category and Sponsor Page 22 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

SJ100 Epic II HF V-355 Epic II HF V-355 Cardiac 36cc,73g $45,760.00

resynchronisation Therapy Defibrillator

with V-V Timing programmability

SJ101 Epic II DR V-255 Epic II DR V-255 Implantable 34cc, 72g $43,680.00

Cardioverter Defibrillator

Tag Medical

TM001 AnnuloFlo Annuloplasty System Annuloflex Ring or AnnuloFlo Ring 26-36mm $1,600.00

TM002 CarboSeal Ascending Aortic Prosthesis, Mechanical Conduit AP 21-33mm, CP 21 - 33mm $6,800.00

sterile, CarboSeal Ascending Aortic

Prosthesis with Handle Model AP21,

Model AP23, Model AP25, Model AP27,

Model AP29, Model AP31, Model AP33,

Carboseal Valsalva

TM003 Optiform Mechanical Valve 19mm to 33mm $4,950.00

TM039 Mitroflow Pericardial Bioprosthesis 19-27mm $4,445.00 $4,950.00

Terumo Corporation Australia

TU001 Tsunami Gold Coronary Stent Stainless Steel mounted on balloon Diameter 2.0mm - 4.0mm, $1,248.00

Length 10mm - 30mm length

TU036 Gelweave Valsalva Graft Woven vascular prosthesis, polyester, Diameter 24 - 34 mm, Overall $3,250.00 $3,528.50

gelatin sealed length 18.4 - 19.6cm

TU037 Gelweave Plexus Graft Multi Branched, for Aortic Arch 22 - 34 mm x 40 cm $2,100.00

reconstruction, Polyester, Woven, gelatin

sealed

TU038 Gelweave Graft Straight Thoracic Graft, with antiflo side 22-34 mm x 20-40 cm $1,677.00 $1,744.00

branch, Polyester, woven, gelatin sealed

W L Gore & Associates

GT117 Gore-Tex - Cardiovascular Patch ePTFE 0.4mm Thickness 2 x 9cm $233.00

GT118 Gore-Tex - Cardiovascular Patch ePTFE 0.4mm - 3 x 6cm $275.00

0.6mm - 2.5cm x 15cm & 5cm

x 7.5cm

GT120 Gore-Tex Cardiovascular Patch ePTFE 0.6mm Thickness 5 x 15cm $510.00

GT121 Gore-Tex Cardiovascular Patch ePTFE 0.6mm Thickness 10 x 15cm $925.00

GT122 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 6 x 12cm $353.00

GT123 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 8 x 16cm $630.00

Prostheses List by Category and Sponsor Page 23 of 547

CARDIO-THORACIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GT124 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 12 x 12cm $732.00

GT125 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 15 x 20cm $1,425.00

GT126 Acuseal Cardiovascular Patch Vascular ePTFE 0.5mm Thickness 1 x 9cm; 0.8 $217.00

x 7.5cm

GT127 Acuseal Cardiovascular Patch Cardiac ePTFE 0.5mm Thickness 3 x 6cm & 5 $264.00

x 7.5cm

GT128 Helex Septal Occluder ePTFE 15-35mm $10,200.00

Zynergy Medical Pty Limited

ZY001 Carbostent Coronary stent - includes Carbostent Dia 2.5mm x Length 9, 12, 15, $780.00

Syncro & Carbostent Sirius 19, 25mm; Dia 3.0mm x Length

9, 12, 15, 19, 25, 32mm; Dia

3.5mm x Length 9, 12, 15, 19,

25, 32mm; Diameter 4.0mm x

Length 9, 12, 15, 19, 25, 32mm

BR & CT Enterprises Pty Ltd

BC001 Titanium Head To suit blue or grey implants $179.00

BC004 Titanium PORP with Fixed Bell and Maximum lengths of 5.0mm $360.00

Removable Head (grey) and 5.5mm (blue) -

adjustable in 1mm increments;

BC007 Titanium Middle Ear Total Implant with Maximum lengths of 7.0mm $360.00

Removable Shoe or Head (grey) and 7.5mm (blue) -

adjustable in 1mm increments;

0.3mm and 0.4mm in diameter

BC008 Titanium Middle Ear Total Implant with Maximum lengths of 7.0mm $360.00

Adjustable Head (grey) and 7.5mm (blue) -

adjustable in 1mm increments;

BC009 Titanium Shoe to suit Titanium Middle Ear Implants To suit blue or grey implants $126.00

BC010 Ventilation tube Ventilation tube - Silicone - T-tube, T- 1.1mm; 1.27mm lumen $19.00

tube grommet

BC011 Ventilation Tubes - Collar Button Teflon, w/o wire 1.10mm, 1.25mm, 1.50mm $12.00

BC012 Ventilation Tubes - Collar Button Teflon w/wire, and titanium w/o wire 0.76mm, 1.00mm, 1.25mm, $15.00

1.50mm lumen

BC013 Ventilation Tubes - Collar Button Titanium w wire 1.00mm, 1.25mm, 1.50mm $19.00

BC014 Ventilation Tubes - Shepherd Teflon, w or w/o wire 1.15mm lumen $12.00

Prostheses List by Category and Sponsor Page 24 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

BC015 Ventilation Tubes - Shepherd Titanium, w/o wire 1.00mm, 1.25mm lumen $17.00

BC016 Ventilation Tubes - Shepherd Titanium with wire 1.00mm, 1.25mm lumen $19.00

BC017 Ventilation Tubes - Silicone Armstrong Grommet, Donaldson w & 1.1mm & 1.5mm lumen $15.00

w/o Tab, Paparella 1 and Paparella 2

Cochlear Limited

CO006 Nucleus 24 Cochlear Implant System Set of assistive listening & maintenance Lapel Microphone: 40-150cm, $785.00

Accessories for SPrint Adult devices, consisting of: Lapel Microphone; Personal Audiocable - one size

Personal Audiocable; Battery Charger; only, Battery Charger - one size

Pouch (adult style), Ear Hook; Battery only, Pouch (adult style), Ear

case; Mic Lock; Lapel clip; TV/Hi-Fi Hook (small and large) Battery

Cable; Mic sleeve; Dry pack; Accessory case - single, Mic Lock - one

case; AC adaptor; Telecoil; and Mic clip size only, Lapel clip - one size

only, TV/Hi-Fi Cable - one size

only

Mic sleeve - one size

only, Dry pack - one size only

Accessory case - one size only,

AC adaptor - one size only,

Telecoil - one size only, Mic clip

- one size only

CO007 Nucleus 24 Cochlear Implant System Set of assistive listening & maintenance Lapel Microphone: 40-150cm, $785.00

Accessories for SPrint Child devices, consisting of: Lapel Microphone: Personal Audiocable - one size

40-150cm, Personal Audiocable; Battery only,Battery Charger - one size

Charger; Pouch (adult style), Ear Hook; only, Pouch (adult style), Ear

Battery case; Mic Lock; Lapel clip; Hook (small and large), Battery

TV/Hi-Fi Cable; Mic sleeve; Dry pack; case - single, Mic Lock - one

Accessory case; AC adaptor; Telecoil; size only, Lapel clip - one size

only, TV/Hi-Fi Cable - one size

only, Mic sleeve - one size only,

Dry pack - one size only,

Accessory case - one size only,

AC adaptor - one size only,

Telecoil - one size only, Mic clip

- one size only,

FM Cable - to

suit Sonic Air Easy Listener

CO013 Nucleus 24k Cochlear Implant Model CI24R (ST) One size only $10,600.00

CO014 Nucleus 24 Contour Advance Cochlear Model CI24R (CA) One size only $11,600.00

Implant

Prostheses List by Category and Sponsor Page 25 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

CO017 SPrint Speech Processor Consists of: SPrint Speech Processor - Processor: One Size Only, $4,282.25

body worn speech processor to suit Transmit Cable, 8-28cm,

Nucleus 24 cochlear implant system; Headset Cable 45-100cm,

transmit cable; headset cable; headset; Headset: 0.5-4.0 magnet

battery case - double; batteries - AA; strength, Hook small and large

microphone cover; belt clip; and hook

CO019 ESPrit 3G Speech Processor - Includes speech processor with titanium Cable lengths: 6, 8, 10, 20, 28cm $6,790.00

ear hook, 6 high powered zinc air

batteries, cleaning brush, microphone

puffer, earmould compatible earhook,

soft earhook cover, magnet, drying

capsules, accessory adaptor and socket

covers, signal check, coil/cable (x2),

CO020 Nucleus Cochlear Implant Accessory Kit Accessory set consists of accessory Lapel microphone comes in $500.00

- ESPrit 3G Speech Processor adapter cable, lapel microphone & lapel lengths of 40-150cm

clip, battery cover set and accessory case

CO021 Nucleus Freedom Implant with Contour Cochlear implant. Titanium casing, one size only $13,570.00

Advance Electrode removable magnet, 22 half-banded

platinum electrodes, moulded in a durable

CO022 Nucleus Freedom Speech Processor Speech processor, and accessories - One size only $11,500.00

CO023 Nucleus Freedom Speech Processor Speech processor, and accessories - one size only $8,050.00

REPLACEMENT

CO024 Nucleus Freedom Implant with Straight Cochlear implant with straight electrode One size only $12,570.00

Electrode in a titanium casing, with a removable

magnet, banded platinum electrodes

moulded in a silicone seal.

CO025 BAHA - Bone Anchored Hearing Aids Abutment Snap Coupling 5.5mm $895.00

CO027 BAHA - Bone Anchored Hearing Aids Flange fixture 4mm and 3mm $895.00

CO028 BAHA - Bone Anchored Hearing Aids Cover screw unigrip One size only $364.00

CO030 BAHA - Bone Anchored Hearing Aids Flange Fixture - Titanium Self Tapping 4mm and 3mm $1,035.00

CO032 BAHA - Bone Anchored Hearing Aids Flange Fixture - Titanium Self Tapping 4mm and 3mm $2,500.00

with BAHA Abutment

Prostheses List by Category and Sponsor Page 26 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

CO033 BAHA - Bone Anchored Hearing Aid - The BAHA Hearing Aids (Compact & $6,000.00 To be claimed only for patients

Various Models Cordelle II in various colours) are the with deafness who have

external hearing processors which are problems using air conduction or

attached to the implanted titanium fixture conventional hearing aids which

by a snap coupling.

This allows the is made worse when a hearing

sound transmission using bone

conduction for patients where

conventional hearing devices are not

CO040 Baha Divino Digital sound processor for Baha hearing One Size But Left/Right Ear $6,000.00

system Orientations

Device Technologies Australia Pty Ltd

DE191 Canaliculus Intubation Sets Silicone, SS & Nylon 17.7 x .064 x 29cm, 15.5 x .051 $165.00

x 33cm

Endocorp Pty Ltd

EC018 Exmoor Plastics Ear Vent Drains - Without hole, teflon 1.14 mm lumen dia x 2.54 mm $13.00

Reuter Bobbin inner flange dia x 2.54 mm outer

flange dia x 0.76 inter flange.

1.52mm total length

EC019 Exmoor Plastics Ear Vent Drains - Collar Teflon 1.14 mm lumen dia x 2.24 mm $12.00

Button inner flange dia x 2.24 mm outer

flange dia x 1.27 inter flange.

1.78 mm total length

EC020 Exmoor Plastics Ear Vent Drains - Teflon 1.14 mm lumen dia x 3.0 mm $14.00

Collar Button inner flange dia x 3.0 mm outer

flange dia x 1.27 inter flange.

1.78 mm total length

EC021 Exmoor Plastics Ear Vent Drains - Teflon 1.4 mm lumen dia x 2.55 mm $14.00

Collar Button inner flange dia x 2.55 mm outer

flange dia x 0.85 inter flange.

1.35 mm total length

EC022 Exmoor Plastics Ear Vent Drains - Collar Teflon 1.75 mm lumen dia x 2.85 mm $15.00

Button inner flange dia x 2.85 mm outer

flange dia x 0.95 inter flange.

1.46 mm total length

EC024 Exmoor Plastics Ear Vent Drains - Teflon Shephards Drain 1.14 mm lumen dia x 2.36 mm $14.00

Shepards Drain inner flange dia x 2.36 mm outer

flange dia x 1.42 inter flange.

2.41 mm total length

Prostheses List by Category and Sponsor Page 27 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

EC026 Exmoor Plastics Ear Vent Drains - Teflon Teflon Shephards Drain with wire 0.97 mm lumen dia x 2.08 mm $14.00

Shephards Drain with wire grasping inner flange dia x 2.08 mm outer

flange dia x 1.42 inter flange.

2.41 mm total length

EC031 Exmoor Plastics Ear Vent Drains - With tab, silicone rubber 1.1 mm lumen dia x 2.25 mm $20.00

Donaldson Grommet inner flange dia x 2.25 mm outer

flange dia x 0.76 inter flange.

2.25 mm total length

Endotherapeutics Pty Ltd

ET031 Serenocem Cement Reaction bonded polymer composite One size only - box of 2 $1,560.00

formed by the neutralisation gelletation of

a basic inorganic ionomer

ET032 Serenocem Granules Reaction bonded polymer composite 0.5 - 1mm granules, 1gm or $1,070.00

formed by the neutralisation gelletation of 5gm; 2 - 3mm granules, 1gm or

a basic inorganic ionomer 5gm - 3 pouches

ET040 Vox Implants Vox Implants are solid, irregularly One size only $8,200.00

textured, medical grade

Polydimethylsiloxane Elastomer implants

suspended in a hydrogel carrier

Enta Surgical Pty Ltd

ES001 Trocar Myringotomy Tube Myringotomy Tube with Trocar - Gold One Size Only $20.00 $38.00

Coated Silver; Myringotomy Tube with

Trocar - Titanium; Myringotomy Tube

with Trocar, with wire - Gold Coated

Silver; Myringotomy Tube with Trocar,

with wire - Titanium

Gary L Hinz and Associates Pty Ltd

GH001 NeoZoline Otological Ventilation Tubes Armstrong, Collar Button, Shepard, 1.10mm, 1.14mm, 1.27mm, $13.00

Reuter, Donaldson, Paparella, Shah 1.40mm, 0.76mm

Gyrus Australasia Pty Ltd

GY001 Canal Wall Prosthesis Grote, HA Small - Large $543.00

GY002 Ossicular Prosthesis Malleus, Incus and Goldenberg Footplate - HA One size only $126.00 $915.00

Stapes

GY003 Ossicular Prosthesis Attic Defect Plate, HA 7-14mm $335.00

GY004 Ossicular Prosthesis Incus a) Applebaum HA, b) Goldenberg HA, a) small - large, b) one size only, $580.00

c) Kartusch HA, d) Grote HA, e) Wehrs c) short, medium, long, d) 7-

(single & double notched) HA 10mm, e) short, average,

Prostheses List by Category and Sponsor Page 28 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GY005 Ossicular Prosthesis - PORP Sheehy plastipore, Drum to stapes, Grote One size only $190.00 $360.00

Malleus to stapes, modified, centered or

offcentered

GY006 Ossicular Prosthesis - PORP/TORP Goldenberg Malleable/HA One Size Only $360.00 $580.00

GY007 Ossicular Prosthesis Incus a) Grote HA, b) Wehrs (single & double a) one size only, b) Short, $625.00

notched) HA medium, long

GY008 Piston: Stapes Prosthesis a) Schuknecht Malleus att Piston. a) 0.6x5.5mm-0.8x6.5, b) $90.00

Stainless steel, b) Cawthorne. 0.3x0.8x3.5-0.3x0.8x6mm, c)

Fluoroplastic, c) Fluoroplastic, d) 0.6x0.6x3.5-0.8x0.6x6mm,

Schuknecht. Stainless steel, e) Causse.

d) 0.4x3.5-0.5x5mm, e) one

size only

GY009 Ossicular Prosthesis -TORP a) black spanner strut HA, b) black oval a) one size only, b) 7-10mm, c) $360.00 $675.00

top TORP HA, c) black oval top PORP, 0.5-0.7mm

universal, HA/fluoroplastic

GY010 Ossicular Prosthesis -TORP Fisch plastipore, Causse modified One size only $360.00

plastipore, Shea modified plastipore/

fluoroplastic, Austin modified plastipore,

GY011 Ossicular Prosthesis -TORP a) Shea malleable, HA/plastipore, b) Shea a) one size only, b) 4-8mm $360.00

plastipore

GY012 Piston: Stapes Prosthesis a) Armstrong. Platinum, b) McGee. a) 0.6x3.5-0.8x5mm, b) $104.00

Stainless steel, c) Richards.

Teflon & 0.6x3.25-0.8x5.5mm,

c) 0.4x4-0.4x5mm

GY013 Piston: Stapes Prosthesis Fisch-Type Platinum or Stainless Steel 0.4mm x 6mm $104.00

GY014 Piston: Stapes Prosthesis Bucket Handle Fluoroplastic and stainless 0.4 x 1 x 3.5mm - 0.6 x 1 x 5mm $104.00

steel

GY015 Piston: Stapes Prosthesis Platinum Fluoroplastic 0.6x3.5mm - 0.8x5mm $104.00

GY016 Piston: Stapes Prosthesis Platinum Fluoroplastic 0.6x3mm - 0.8x5.75mm $104.00

GY017 Piston: Stapes Prosthesis McGee Shepherd's Crook - Stainless 0.6x3.5mm - 0.6x5.5mm $104.00

GY018 Septal Button Plastipore One size only $149.00

GY019 Ventilation Tube Shepard grommet, fluoroplastic or 1.02 -1.14mm $20.00

silicon, vent tube w/wire.

GY020 Ventilation Tube Shepard, fluoroplastic, w/Tab & wire 1.02 -1.14mm $20.00

GY021 Ventilation Tube Shepard, Ultrasil Silicon & Blue Poly 1.02 - 1.14mm $20.00

GY027 Ventilation Tube T-Tube Richards Silicon, Soft Silicon, 1.14mm $20.00

Prostheses List by Category and Sponsor Page 29 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GY028 Ventilation Tube T-Tube Richards Modified Silicon & 1.32mm $20.00

GY029 Ventilation Tube T-Tube Richards Modified Soft Silicon 1.32mm $20.00

GY030 Ventilation Tube Butterfly T-Tube Silicon & Ultrasil Silicon - one size only. Ultrasil - $20.00

one size only.

GY032 Ventilation Tube Armstrong Beveled Grommet Ultrasil 1.14mm $20.00

Silicon w/Tab

GY033 Ventilation Tube Grommet - Sha Mini. Teflon 0.76mm $20.00

GY034 Ventilation Tube Shah. Teflon, Silicon 5.1mm $20.00

GY035 Ventilation Tube Shah. Teflon, Fluorplastic w/Wire 1.14mm $20.00

GY036 Ventilation Tube Shah. Teflon, Fluorplastic without Wire 1.14mm $20.00

GY037 Ventilation Tube Armstrong Beveled Plain End One size only $20.00

GY038 Ventilation Tube Armstrong Beveled Plain End Silcon One size only $20.00

GY039 Ventilation Tube Bobbin - Reuter Stainless Steel 1mm $20.00

GY040 Ventilation Tube Bobbin - Reuter Stainless Steel Without Wire 1.14-1.27mm, $20.00

w/wire 1mm

GY041 Ventilation Tube Bobbin - Reuter Fluoroplastic 1mm I.F 1mm $20.00

Without Holes

GY042 Ventilation Tube Bobbin - Reuter Fluoroplastic 1mm I.F 1.14mm $20.00

Without Holes

GY043 Ventilation Tube Bobbin - Reuter Fluoroplastic 1mm I.F 1.14mm $20.00

GY044 Ventilation Tube Bobbin - Reuter Fluoroplastic 1mm I.F 1.14mm $20.00

GY045 Ventilation Tube Bobbin - Reuter Fluoroplastic 0.5mm I.F 1.27mm $20.00

GY048 Ventilation Tube Collar Bobbin Fluoroplastic 1.27mm $20.00

GY049 Ventilation Tube Collar Bobbin Fluoroplastic 0.75mm $20.00

GY050 Ventilation Tube Collar Bobbin Fluoroplastic 1.14mm $20.00

GY051 Ventilation Tube Collar Bobbin Fluoroplastic 1.27x0.5mm $20.00

GY052 Ventilation Tube Collar Button Ultrasil Silicon 1.27mm $20.00

GY053 Ventilation Tube Collar Button Fluoroplastic Blue 1.27mm $20.00

GY054 Ventilation Tube Collar Button Fluoroplastic w/Wire 1.27mm $20.00

GY055 Ventilation Tube Collar Button Silicon 1.27mm $20.00

GY056 Ventilation Tube Collar Button Titanium 1.14mm $20.00

Prostheses List by Category and Sponsor Page 30 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GY057 Ventilation Tube Collar Button Titanium 1.27mm $20.00

GY058 Ventilation Tube Donaldson Silicon 1.14mm $20.00

GY059 Ventilation Tube Donaldson Soft Silicon 1.14mm $20.00

GY060 Ventilation Tube Donaldson Silicon w/Tab 1.14mm $20.00

GY061 Ventilation Tube Donaldson Fluoroplastic 1.14mm $20.00

GY062 Ventilation Tube Donaldson Ultrasil Silicon 1.14mm $20.00

GY063 Ventilation Tube Duravent Silicon 1.27mm $20.00

GY064 Ventilation Tube Duravent Blue Ultrasil 1.27mm $20.00

GY065 Ventilation Tube Paparella w/tab Fluoroplastic, Silicon, 1.02 - 2.03mm $20.00

Soft Silicon, Ultrasil

GY067 Ventilation Tube Shea w/Tab - Silicone 0.76mm $20.00

GY068 Ventilation Tube Shea Parasol w/Tab Small Flange - 1.02mm $20.00

GY069 Ventilation Tube Shea Parasol w/Tab - Silicone 1.02mm $20.00

GY070 Ventilation Tube Shea Parasol w/Tab - Silicone 1.52mm $20.00

GY071 Ventilation Tube Straight Fluoroplastic or Polyethylene 0.89 x 12mm, 0.86 x 7mm, $20.00

1.14 x 12mm, 1.14 x 7mm

GY072 Vocal Cord Medialisation Implant Vocom Larynx Medial Implant - 3 - 7mm Head $675.00

Hydroxylapatite

GY073 Vocal Cord Medialisation Implant Vocom Shim for Medial Implant - 1mm - 3mm Offset $345.00

Hydroxylapatite

GY074 Wehrs II Stapes Prostheses Wehrs HAPEX Incus Prostheses, Single 0.6 - 1.57mm Shaft Dia $675.00

& Double Notch

GY078 Dornhoffer Prostheses Hydroxyapetite head/HAPEX shaft PORP 0.8mm Shaft Dia TORP, 1.3mm $360.00

and TORP Shaft Diameter PORP

GY080 Ossicular Chain Prosthesis Micron adjustable TORP/PORP. Titanium 2-10mm, 2-5mm $360.00 $500.00

GY081 Piston: Stapes Prosthesis Smart: Nitinol/Flouroplastic 0.5, 0.6, 0.8 x 3.75-4.75mm $255.00 $535.00

Medical Vision Australia Pty Ltd

MF001 Endoxane Silicone tracheal and bronchial stents - 10 - 20mm diameter, 20 - $1,000.00

Dumon 60mm length

MF002 Tracheobronxane Silmet Nitinol wire - tracheal and bronchial 12 - 20mm diameter, 20 - $2,500.00

stenets - Dumon 90mm length

Prostheses List by Category and Sponsor Page 31 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

Medtronic Australasia Pty Ltd

MC255 Medtronic Xomed Australia Material ePTFE - expanded polytetrafluroethyelene 0.75cm x 40cm x 0.6mm; $1,110.00

Implantable Sterile - Gore Thyroplasty 0.4cm x 20cm x 0.6mm; 0.6cm

x 20cm x 0.6mm

MC256 Pressure Pulse Generator Meniett 20 Composition - Polycarbonate One size only $5,060.00 To be claimed only where

medical therapy such as lifestyle

(general health assessment and

stress reduction) and oral

medications (diuretics, anti-

emetics, anti-vertigo and

MC258 Ossicular, Incus and Stapes Flex H/A, Dense H/A, Titanium, SS, 0.4 - 1.17mm x 0.9 - 4.0mm x $330.00

Fluroplastic, Polycel; Roberson Stapes 4.0 x 10.2mm; 4.0 - 4.75mm

Prostheses & Big Easy Piston. Middle Ear

Prostheses

MC259 Ossicular, Incus and Stapes Flex H/A, Polycel, SS Small, Medium, Large, 0.6 x 2.2 $190.00

x 8.0mm

MC260 Ossicular, Incus and Stapes H/A, Polycel, SS 0.6 - 0.8mm x 3.0 - 4.0mm x $236.00

7.0 - 8.0mm

MC261 Ossicular, Incus and Stapes Polycel, SS, Fluroplastic 0.6 - 1.17mm x 0.3 - 4.0mm x $106.00

4.75 - 8.0mm

MC262 Ossicular, Incus and Stapes Platinum, Fluroplastic, SS, Polycel 0.4 - 1.17mm x 2.2 - 8.8mm x $104.00

3.5 - 10.0mm

MC263 Ossicular, Incus and Stapes SS, Fluroplastic, Polycel 0.5 - 0.6mm x 3.5 - 6.0mm and $104.00

One Size Only

MC264 Septal Button Silicone 3cm $149.00

MC265 Silicone Blocks Netterville Phonoform Block - Right, Right - One size only, Left - $275.00

Left, Wedge & Strip One size only, Wedge - One size

only & Strip - One size only

MC266 Prostheses Ossicular Incus and Stapes H/A, Polycel, SS 0.6 - 4.0mm x 2.7 - 5.0mm x $179.00

1.5 - 10.0mm

MC267 Ossicular, Incus and Stapes Universal Middle Ear Prosthesis, titanium 2.5 - 4.0mm x 10.0mm $360.00

round and cam head design

MC268 Activent Antimicrobial Ventilation Tube Silicone, Silver Oxide, Fluroplastic 0.76 - 1.52mm x 2.1 - 9.5mm x $20.00

1.0 - 12.0mm

MC269 Activent Antimicrobial Ventilation Tube Silicone, Silver Oxide, Fluroplastic 1.02 - 1.27mm x 0.9 - 2.4mm $20.00

MC270 Activent Antimicrobial Ventilation Tube Silicone & Silver Oxide. Sheehy 1.27 x 2.9 x 1.3mm $20.00

Prostheses List by Category and Sponsor Page 32 of 547

EAR, NOSE & THROAT

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC271 Vent Tube Silicone, Fluroplastic, Titanium, SS 1.02 - 1.27mm, 1.58 - 2.7mm $20.00

MC272 Vent Tube Silicone, Fluroplastic 1.02 - 1.52mm x 0.9 - 4.45mm $16.00

MC273 Vent Tube Silcone Fluroplastic 1.02 - 1.27mm x 1.3 - 3.0mm $12.00

MC274 Vent Tube Titanium, Fluroplastic 1.02 - 1.27mm x 1.0 - 3.5mm $12.00

MC275 Vent Tube Fluroplastic, Silicone 1.14 - 1.27mm x 0.9 - 3.0mm $14.00

MC276 Vent Tube Silicone, Fluroplastic, H/C Flex 0.76 - 1.27mm x 1.0 - 7.5mm $20.00

MC277 Vent Tube Silicone, Fluroplastic, C-Flex 0.89 - 1.52mm x 2.3 - 12.0mm $18.00

MC278 Vent Tube Silicone, Fluroplastic 0.76 - 1.27mm x 1.5 - 12.0mm $20.00

MC279 Vent Tube Microgel, Titanium, SS 1.02 - 1.27mm x 2.7 - 9.1mm $20.00

MC280 Vent Tube Silicone, Fluroplastic 1.02 - 1.52mm x 1.3 - 12.0mm $20.00

Morton Surgical Pty Ltd

MG003 Micromedics Ventilation Tubes Micromedics;Shepard;1.0mm / $12.50

1.14mm lumen;Fluroplastic /

Silicone;w.tab / w.wire;box of 6

/ box of 50

MG011 Micromedics Ventilation Tubes Micromedics; Donaldson; $19.50

1.14mm lumen; Silicone /

Fluroplastic; w.tab; box of 6 /

MG012 Micromedics Ventilation Tubes Micromedics; Paparella-I / $15.50

Paparella-II; 1.14mm / 1.42mm

lumen; Silicone; box of 6 / box

of 50

MG013 Micromedics Ventilation Tubes Micromedics; T-tubes; $17.50

(12x10)/(5x8)/(5x4)/(8x5.5);

1.14mm / 1.27mm / 1.4mm

lumen; silicone; box of 6 / box

MG014 Micromedics Ventilation Tubes Micromedics; Armstrong; $14.50

bevelled straight / grommit /

w.wire;

7mm / 7.5mm /

1.14mm; silicone / fluroplastic;

MG015 Micromedics Ventilation Tubes Micromedics; Collar Button; $10.50

GT162 Gore-tex Vascular Grafts Thin Wall Grafts (ePTFE) Diameter 4 - 10mm, Length 50cm $790.00

GT163 Gore-tex Vascular Grafts Thin Wall Grafts (ePTFE) Diameter 3 - 10mm, Length 60cm $930.00

GT164 Gore-Tex Vascular Grafts Thin wall grafts (ePTFE) Dia 3 - 10mm, length 70cm $1,000.00

GT165 Gore-tex Vascular Grafts Thin Wall Grafts (ePTFE) Diameter 4 - 10mm, Length 80cm $1,135.00

GT166 Gore-tex Vascular Grafts Thin Wall Grafts (ePTFE) Diameter 4 - 10mm, Length 90 - $1,250.00

100cm

GT167 Gore-tex Vascular Grafts Vascular Grafts - Aorto-Pulmonary & Diameter 3.5 - 5mm, Length $216.00

Systemic-Pulmonary Shunts (ePTFE)

Stretch & Non Stretch

GT168 Gore-tex Vascular Grafts Vascular Grafts - Aorto-Pulmonary & Diameter 3.5 - 5mm, Length $257.00

Systemic-Pulmonary Shunts (ePTFE)

Stretch & Non Stretch

GT169 Diastat Vascular Access Graft Dialysis Grafts - Standard & Stretch 6mm diameter x 45-50cm length $761.00

Ringed (ePTFE) Std & Stretch ringed dialysis

graft/6mm diameter 5-10cm

radial support length 20cm length

GT171 Gore-tex Vascular Grafts Standard Wall Grafts Stretch Tapered Diameter 4-6mm & 4-7 mm, $825.00

Length 45 - 48cm

GT172 Gore-tex Vascular Grafts Standard Wall Grafts Stretch Tapered Diameter 4-7 mm, Length 70cm $1,025.00

GT174 Gore-tex Vascular Grafts Ringed Grafts Removable Standard 4-7 mm x 45cm - Rings 10cm $825.00

Wall/Stretch Wall Tapered (ePTFE) Length

GT175 Gore-tex Vascular Grafts Ringed Grafts Removable Standard Wall 4-7 mm x 70cm - Rings 30cm $1,200.00

Tapered (ePTFE) Length

GT176 Gore-tex Vascular Ring Graft Ringed Grafts Fixed Standard & Thin Diameter 6 - 10mm x 30 - 70cm $1,155.00

Wall (ePTFE) Length ,Ringed Section 20 -

50cm Lengths

Prostheses List by Category and Sponsor Page 540 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GT177 Gore-tex Vascular Ring Graft Ringed Grafts Fixed Thin Wall & Ringed Diameter 6 - 10mm x 30 - 70cm $1,300.00

Standard Wall (ePTFE) Length, Ringed Section 20 -

50cm Lengths

GT178 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 6 - 8mm x 60 - 70cm $1,375.00

Length,

Ringed Section 30cm

Length

GT179 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 5 - 6mm x 70cm $1,600.00

Length,

Ringed Section 60cm

GT180 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 5 - 6mm x 80cm $1,700.00

Length, Ringed Section 60cm

GT181 Gore-tex Vascular Ring Graft Ringed Grafts Fixed Standard Wall & Diameter 6 - 10mm x 30 - 70cm $1,350.00

Stretch

Standard Wall (ePTFE) Lengths, Ringed Section 20 -

50cm Lengths

GT182 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 6mm, Lengths 80 - 90 $1,800.00

cm, Ringed Section 60cm

GT183 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 8mm, Lengths 80 - 90 $1,900.00

cm, Ringed Section 70cm

GT184 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 6 - 8mm x 70cm $1,490.00

Stretch (ePTFE) Length, Ringed Section 30cm

GT185 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 6mm x 80cm Length, $1,500.00

Stretch (ePTFE) Ringed Section 30cm Length

GT186 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 6mm x 70cm Length, $1,600.00

Stretch (ePTFE) Ringed Section 60cm Length

GT187 Gore-tex Vascular Ring Graft Ringed Grafts Removable Thin Wall Diameter 6 - 8mm x 70cm $1,650.00

Stretch (ePTFE) Length, Ringed Section 60 -

GT188 Excluder Endovascular Prostheses Abdominal Stent Graft Nitinol & ePTFE - Diameter 12 - 14.5mm x 10 x $3,450.00 $5,300.00

Contralateral Leg 14cm Length

GT189 Excluder Endovascular Prostheses Abdominal Stent Graft Nitinol & ePTFE - Diameter 23 - 28.5mm, Length $3,100.00

Aortic Extender 3.3cm

GT190 Excluder Endovascular Prostheses Abdominal Stent Graft Nitinol & ePTFE - Diameter 10 - 14.5mm, Length $3,700.00

Iliac Extender

GT191 Excluder Endovascular Prostheses Thoracic Stent Graft Nitinol & ePTFE Diameter 26-40mm x 10cm $13,400.00

GT192 Gore-tex Vascular Grafts Standard Wall Grafts Tapered (ePTFE) 4.5-6.5mm & 6-8mm Diameter $1,025.00

x 70-90cm Lengths

GT193 Gore-tex Vascular Grafts Standard Wall Grafts (ePTFE) 6-10mm Diameter x 40cm $605.00

Prostheses List by Category and Sponsor Page 541 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GT194 Gore-tex Vascular Graft Standard wall grafts, tapered (ePTFE) Diameter 4.5-7mm, lengths 40- $605.00

50cm

GT195 Gore-tex Vascular Graft Standard wall grafts (ePTFE) Diameter 6mm x 20cm length $314.00

GT196 Gore-tex Vascular Ring Graft Ringed grafts fixed standard/thin wall Diameter 4-6mm x 10-15cm, $670.00

(ePTFE) ringed section 2.5-5cm lengths

GT197 Gore-tex Vascular Ring Graft Ringed grafts fixed standard/thin wall Diameter 8mm x 30cm, ringed $830.00

(ePTFE) section 20cm length

GT198 Gore-tex Vascular Ring Graft Ringed grafts fixed standard/thin wall Diameter 5-8mm x 60-70cm, $1,320.00

(ePTFE) ringed section 20-30cm lengths

GT199 Gore-tex Vascular Ring Graft Ringed grafts fixed thin wall stretch Diameter 6-8mm x 60-80cm, $1,355.00

ringed section 20-30cm lengths

GT200 Gore-tex Vascular Graft Standard wall grafts stretch (ePTFE) Diameter 6-12mm x 20cm $325.00

GT211 Gore-Tex Intering Vascular Graft ePTFE integrated rings in the wall of a Dia 6-8mm, 40cm radial $1,440.00

stretch thin walled graft supported length x 40cm length

GT212 Gore-Tex Intering Vascular Graft ePTFE integrated rings in the wall of a Dia 6-8mm, 60cm radial $1,880.00

stretch thin walled graft supported length x 60cm length

GT213 Gore-Tex Intering Vascular Graft ePTFE integrated rings in the wall of a Dia 6-8mm, 80cm radial $2,120.00

stretch thin walled graft supported length x 80cm length

GT214 Gore-Tex Intering Vascular Graft Internally radially supported vascular 4-6 tapered diameter 38cm $825.00

graft (ePTFE) radial support length 45cm

length; 4-7 tapered diameter

38cm radial support length

45cm length; 6mm diameter

40cm radial support length

GT215 Gore-Tex Intering Vascular Graft ePTFE integrated rings in the wall of a Dia 6mm, 5cm radial supported $935.00

stretch and non-stretch walled graft length x 45cm length - non-

GT216 Gore-tex Axillobifemoral Vascular Graft Stretch vascular graft with removable Diameter 8mm $1,950.00

rings (ePTFE)

GT218 Gortex Propaten Vascular Graft Stretch Thin Wall Graft (ePTFE) 6mm diameter 30cm Removable $1,800.00

Ring - 70cm length

GT219 Gortex Propaten Vascular Graft Stretch Thin Wall Graft (ePTFE) 6mm diameter 60cm Removable $1,820.00

Ring - 70cm length

GT220 Gortex Propaten Vascular Graft Stretch Thin Wall Graft (ePTFE) 6-8mm diameter 60-70 $1,920.00

Removable Ring - 80cm length

Prostheses List by Category and Sponsor Page 542 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

GT221 Gortex Propaten Vascular Graft Stretch Thin Wall Graft (ePTFE) 6-8mm diameter Non-Ringed $840.00

40cm length

GT222 Gortex Propaten Vascular Graft Stretch Thin Wall Graft (ePTFE) 6-8mm diameter Non-Ringed $1,260.00

80cm length

William A Cook Aust Pty Ltd

WC037 Coil - Embolisation MWCE Standard Stainless Steel Diameters: .025, .035, .038 and $111.00

.052, Extended Lengths: 1cm to

20cm, Coil Taper Diameters:

2mm to 10mm

WC038 Coil - Embolisation Coils MWCE- Tornado Platinum Diameters: .018, .035 and .038, $214.00

TORNADO Coil Taper Diameters: 2mm to

10mm

WC039 Cook Embolization Coil Hilal Platinum Diameters: .018, Extended $204.00

Lengths: .5cm to 6cm, Coil

Diameters: Straight to 10mm

WC042 Zenith AAA Endovascular Graft - Custom AAA Aorto Uni Iliac (AUI) Graft Neck 20-32mm Length 74- $10,200.00

Craft

WC043 Inferior Vena Cava Filter Birds Nest Vena Cava Filter Filter Catheter French Size 11.0 $1,962.00

Length 40, 75 cm Introducer

Sheath Assembly French Size

12.0 Femoral/Jugular Approach

WC044 PVA Embolisation particles Embolization & Occlusion Particle Size Ranges (microns) $200.00

50-100, 100-200, 200-300,300-

500, 500-700, 700-1000, 1000-

1500, 1500-2000, 2000-2800

WC045 Cook H & L-B - Endostent Converter Diameter 20 thru 36 Length 80- $2,750.00

WC047 Cook H & L-B - Endostent Leg Extensions Diameter 18 thru 24 Length 55 $2,750.00

WC048 Cook H & L-B - Endostent Body Extensions Diameter 22 thru 36 $2,750.00

WC049 Cook H & L-B - Endostent - Tri-Fab Body Extension Diameter 22-32 mm Length $4,770.00

112-239mm

WC051 Cook H & L-B - Endostent - Tri-Fab Leg Extension Diameter 10-12 Length 36-71 $2,750.00

WC055 Peripheral Vascular Stent (ZA Stent); Vascular Stent Introducer Catheter Length 60 - $1,535.00

Zilver Stent 80 cm, Diameter 6 - 10 mm,

Length 1 - 8cm

WC061 Detachable Coil System Microembolisation Coils - Platinum 011/018 2-20mm diameter, 2 - $785.90

50cm length

Prostheses List by Category and Sponsor Page 543 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

WC076 Flipper-Patient Ducts Arteriosus- Detachable Coil for PDA Closure Coil Diameter 3,5,6.5 & 8 mm $233.95

Occluding System Number of Loops (3,4,5)

WC093 Cook Implantable Injection/Infusion Ports Petite or Standard, single or multiple 3 - 12 Fr pre-attached or $490.00

chamber Polysulfone Port which may detached catheter or valve system

include micropuncture or standard

WC094 Cook Implantable Injection/Infusion Ports Mini or Petite or Standard, single or 3 - 12 Fr pre-attached or $523.00

multiple chamber titanium Port which detached catheter or valve system

may include micropuncture or standard

WC096 Cook Vena Cava Filter Universal Filter Diameter up to 40mm, Length $2,300.00

up to 60mm

WC103 Zenith Iliac Plug Zenith AAA Endovascular Graft Diameter 14, 16, 18, 20, 22, $2,750.00

WC111 Cook Central Venous Catheterisation Kit Single lumen peripherally inserted catheter 3 - 6 Fr, 40 - 80cm $132.55

set, which may include catheter,

standard or micropuncture introducer set

WC112 Cook Central Venous Catheterisation Kit Double or triple lumen peripherally 3 - 8 Fr 40 - 80cm $199.50

inserted catheter set, which may include

catheter, standard or micropuncture

WC113 Cook Central Venous Catheterisation Kit Single lumen peripherally inserted catheter Fr 3, 4, 5 and Length 50 and $114.00

set, includes catheter, needle, J-wire,

MPIS wire and introducer

WC114 Cook Central Venous Catheterisation Kit Double lumen peripherally inserted Fr 6, 7 and Length 58 and 60cm $145.00

catheter set, includes catheter, needle, J-

wire, MPIS wire and introducer

WC115 Cook Implantable Injection/Infusion Port Mini, single or multiple chamber titanium 3 - 12 Fr pre-attached or $639.00

Port which may include micropuncture detached catheter or valve system

introducer set

WC133 Zenith Flex AAA Endovascular Graft - Stainless steel Dia 22 - 32mm, length 82 - $5,675.00

body only

WC153 Zenith AAA Endovascular Graft ZCOM - 1000, AAA bifurcated stent- Proximal body 24 - 36mm $12,500.00

graft, woven polyester and stainless steel diameter and 76 - 137mm long.

Distal bifurcated body 24mm

diameter and 76 - 121mm long.

Ipsilateral cuff 12-24mm

diameter. Contralateral leg

extension 8 - 24mm diameter

and 37 - 122mm long

Prostheses List by Category and Sponsor Page 544 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

WC156 Zenith AAA Endovascular Graft ZFEN-1000 Fenestrated AAA bifurcated Fenestrated body 24 - 36mm $16,525.00

stent-graft, woven polyester and stainless diameter and 76 - 137mm long.

Distal bifurcated body 24mm

diameter and 76 - 121mm long.

Ipsilateral cuff 12- 24mm

diameter. Contralateral leg

extension 8 - 24mm diameter

and 37 - 122mm long

WC157 Zenith TAA Endovascular Graft TX2, two piece thoracic stent-graft, Proximal piece 22 - 42mm $18,400.00

woven polyester and stainless steel diameter and 115 - 216mm long.

Distal piece 26 - 42mm

diameter and 127 - 207mm long

WC159 Zenith TAA Endovascular Graft TX1, one piece thoracic stent-graft, 22 - 42mm diameter and 115 - $10,800.00

woven polyester and stainless steel 216mm long

WC160 Zenith TAA Endovascular Graft Thoracic Proximal Extension Dia 22 Length 77; Dia 24 $6,400.00

Length 77;Dia 26 Length 77;

Dia 28 Length 80; Dia 30

Length 80; Dia 32 Length 80;

Dia 34 Length 77; Dia 36

Length 77; Dia 38 Length 77;

Dia 40 Length 81

WC164 Cook Implantable Injection/Infusion Ports Dual or Multiple Chamber Titanium Port 3 - 12 Fr pre-attached or $746.00

which may include micropuncture or detached catheter or valve system

standard introducer set

WC168 Cook Vascular/Biliary Stent Vascular/Biliary stent 3 - 6 Fr delivery system, 3 - $1,800.00

20mm diameter, 2 - 20cm

WC173 Cook Embolisation Coils Nester Platinum Diameters: .018 and .035, $241.85

Extended Lengths: 14cm, Coil

Diameters: 3mm to 10mm

WC175 Cook Z Stent Gianturco Vena Caval and Venous Design Double Stent - 20, 30, 40mm $1,230.00

Diameters, 50mm Length

WC176 Cook Z Stent Gianturco Vena Caval and Venous Design Triple Stent - 20, 30, 40mm $1,465.00

Diameters, 75mm Length

WC186 ZenithThoracic Endovascular Graft Thoracic Proximal Graft 22mm to 42mm diameter; $9,200.00

115mm to 216mm length

WC187 Zenith Thoracic Endovascular Graft Thoracic Distal Graft 26mm to 42mm diameter; $9,200.00

127mm to 207mm length

Prostheses List by Category and Sponsor Page 545 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

WC188 Zenith Thoracic Endovascular Graft Thoracic Body Extension 22mm to 42mm diameter; $6,250.00

77mm to 81mm length

WC189 Cook Z Stent Gianturco Vena Caval and Venous Design Single Stent - 15, 20, 30mm $990.00

diameters; 25mm length

WC190 Detachable Mreye Embolization Coils Standard Mreye Diameters: .035 and .038, $65.00

Extended Lengths: 1cm to

20cm, Coil Diameters: 3mm to

WC191 Cook Intravascular Embolization Hilal Platinum (Soft) Diameters: .018; Extended $149.00

Lengths: 5cm to 3cm, Coil

Diameters: Straight to 10mm

WC192 Detachable Mreye Embolization Coils Jackson Mreye Diameters: .035 and .038 $133.90

Extended Lengths:

4cm to 6cm

Coil Diameters: 3mm to 12mm

WC201 Cook Central Venous Catherisation Kits Turbo-Flo Peripherally Inserted Central 4Fr - 60cm and 5Fr - 60cm $132.55

Venous Catheter Set, Single Lumen

Polyurethane with Micropuncture Peel-

Away Sheath Introducer and Wire Guide

WC202 Cook Central Venous Catheterisation Kits Turbo-Flo Peripherally Inserted Central 5Fr - 60cm $121.00

Venous Catheter Set, Single Lumen

Polyurethane with Peel Away Sheath

Introducer and Wire Guide

WC203 Cook Central Venous Catherisation Kits Turbo-Flo Peripherally Inserted Central 5Fr - 60cm $145.00

Venous Catheter Set, Dual Lumen

Polyurethane with Peel-Away Sheath

Introducer and Wire Guide

WC204 Cook Central Venous Catheterisation Kits Turbo-Flo Over-The-Wire Peripherally 4Fr - 60cm and 5Fr -60cm $132.55

Inserted Central Venous Catheter Set,

Single Lumen Polyurethane with

Micropuncture Peel-Away Sheath

WC205 Cook Central Venous Catheterisation Kits Turbo-Flo Over-The Wire Peripherally 5Fr - 60cm $156.00

Inserted Central Venous Catheter Set,

Dual Lumen Polyurethane with

Micropuncture Peel-Away Sheath

WC206 Cook Central Venous Catheterisation Kits PICC Peripherally Inserted Central 3Fr - 50cm and 4Fr and 5Fr - $238.99

Venous Catheter Set, Single Lumen

Silicone with Micropuncture Peel-Away

Sheath Introducer and Nitinol Wire Guide

Prostheses List by Category and Sponsor Page 546 of 547

VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

WC207 Cook Central Venous Catheterisation Kits PICC Peripherally Inserted Central 3Fr - 50cm and 4Fr and 5Fr - $132.55

Venous Catheter Set, Catheter without

Clamp, Single Lumen Silicone with

Micropuncture Peel-Away Sheath

WC208 Cook Central Venous Catheterisation Kits PICC Peripherally Inserted Central 4Fr - 60cm and 5Fr - 60cm $241.25

Venous Catheter Set, Catheter without

Clamp, Single Lumen Silicone with

Micropuncture Peel-Away Sheath

Introducer and Nitinol Wire Guide

WC209 Zenith Composite AAA Endovascular Proximal Composite Body 1 or 2 internal Stents, 24-36mm $4,850.00

diameter, 73-129mm Length

WC210 Zenith Fenestrated AAA Endovascular Distal Fenestrated Body Diameter 12-24mm, 1st length $4,900.00

28-62mm, 2nd length 76-

WC211 Zenith Fenestrated AAA Endovascular Proximal Fenestrated Body 1 or 2 internal Stents, 24-36mm $8,875.00

Diameter, 73-129mm Length

WC221 Cook Spectrum Silicone Long Term Single lumen catheter CVC impregnated 4Fr, 5Fr $185.00 Temporary approval pending

Catheter Set with antibiotic with or without clamp review of catheters

WC222 Cook Spectrum Silicone Long Term Dual lumen catheter CVC impregnated 7Fr $208.00 Temporary approval pending

Catheter Set with antibiotic with or without clamp review of catheters

WC223 Cook Spectrum Silicone Long Term Triple lumen catheter CVC impregnated 8Fr $253.00 Temporary approval pending

Catheter Set with antibiotic with or without clamp review of catheters

WC224 Cook Spectrum PICC Set / Line Single lumen PICC catheter with 4fg, and 5fg 60cm $165.00 Temporary approval pending

antibiotic impregnation review of catheters

WC225 Cook Spectrum PICC Set / Line Dual lumen PICC catheter with antibiotic 6fr and 60cm $220.00 Temporary approval pending

impregnation review of catheters

WC227 Peripherally Inserted C/V Catheter with Micropuncture single lumen PICC with 4/5Fr $200.00 Temporary Listing pending

Anibiotic impregnation ABRM review of catheters

WC229 Peripherally Inserted C/V Catheter with Micropuncture double lumen PICC with 6/7Fr $239.00

Anibiotic impregnation ABRM

WC230 Cook Spectrum CVC Catheter 3 Lumen Triple lumen CVC line with antibiotic 5Fr, 7Fr, 9Fr $120.00

with antibiotic impregnation impregnation

WC231 Cook Spectrum 5 Lumen CVC Catheter 5 lumen CVC with antibiotic impregnation 10Fr $180.00

with antibiotic impregnation

Grand Total: 9331 Records

Prostheses List by Category and Sponsor Page 547 of 547

PART B - Human Tissue List

CARDIO-THORACIC

Billing Code Facility Minimum Benefit Maximum Benefit

Aortic Valved Conduit Patch

QHV09 Queensland Heart Valve Bank $4,706.00

Heart Valve - Aortic

QHV01 Queensland Heart Valve Bank $4,706.00

RPH01 Royal Perth Hospital $3,833.00

SHV01 Sydney Heart Valve Bank, Darlinghurst NSW $5,350.00

TBV01 Donor Tissue Bank of Victoria $5,923.00

Heart Valve - Pulmonary

QHV02 Queensland Heart Valve Bank $4,706.00

RPH02 Royal Perth Hospital $3,833.00

SHV02 Sydney Heart Valve Bank, Darlinghurst NSW $5,350.00

TBV02 Donor Tissue Bank of Victoria $5,923.00

Human Coronary Arteries

SHV03 Sydney Heart Valve Bank, Darlinghurst NSW $987.00

Mitral Valve Patch

QHV03 Queensland Heart Valve Bank $985.00

Pericardium

TBV50 Donor Tissue Bank of Victoria $440.00

Pericardium Patch

QHV05 Queensland Heart Valve Bank $985.00

Pulmonary Conduit

TBV03 Donor Tissue Bank of Victoria $909.00

Pulmonary Conduit - Large

QHV07 Queensland Heart Valve Bank $985.00

Pulmonary Conduit - Small

QHV06 Queensland Heart Valve Bank $985.00

Pulmonary Valved Conduit For Patch use

QHV08 Queensland Heart Valve Bank $4,706.00

Page 1 of 16

CARDIO-THORACIC

Billing Code Facility Minimum Benefit Maximum Benefit

Tricuspid Valve Patch

QHV04 Queensland Heart Valve Bank $985.00

Page 2 of 16

OPHTHALMIC

Billing Code Facility Minimum Benefit Maximum Benefit

Amnion Corneal Graft

AUB01 Australian Biotechnologies $800.00

Cornea

LEM01 Lions Eye Bank - Melbourne $1,747.00

LEN01 Lions NSW Eye Bank $1,000.00

LEW01 The Lions Eye Bank of WA $2,000.00

QEB01 Queensland Eye Bank $1,345.00

SAE01 The Eye Bank of SA $840.00

TBV04 Donor Tissue Bank of Victoria $800.00

Cornea For Lamellar

LEN03 Lions NSW Eye Bank $600.00

Cornea for Sclera

LEM02 Lions Eye Bank - Melbourne $150.00

LEN02 Lions NSW Eye Bank $150.00

SAE02 The Eye Bank of SA $60.00

Human Amniotic Membrane for Transplantation

LEM03 Lions Eye Bank - Melbourne $770.00

SCLERA

LEW02 The Lions Eye Bank of WA $200.00

QEB02 Queensland Eye Bank $230.00

Page 3 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Achilles Tendon

NBB01 New South Wales Bone Bank $1,560.00

PBT01 Perth Bone & Tissue Bank $2,000.00

QBB01 Queensland Bone Bank $1,560.00

TBV05 Donor Tissue Bank of Victoria $904.00

Achilles Tendon with Bone Plug

NBB02 New South Wales Bone Bank $1,900.00

TBV06 Donor Tissue Bank of Victoria $1,841.00

Anterior Cruciate Ligament Unit

PBT02 Perth Bone & Tissue Bank $1,700.00

Autologous Chondrocyte Transplantation

MTE01 Mercy Tissue Engineering Pty Ltd $9,996.00

MTE03 Mercy Tissue Engineering Pty Ltd $11,349.00

MUA01 Monash University, Dept of Surgery, Alfred Hospital, Tissue Culture Laboratory $8,694.43

MVS22 Institute of Medical & Veterinary Science, SA $9,538.00

VAP01 Verigen Australia Pty Ltd $9,556.00

Autologous Chondrocytes

MTE02 Mercy Tissue Engineering Pty Ltd $2,509.00

VAP03 Verigen Australia Pty Ltd $2,593.00

Autologous Chondrocytes Implant and Matrix

ORT01 Orthogen Australia Pty Ltd $11,400.00

Autologous Skull Flap

MVS23 Institute of Medical & Veterinary Science, SA $1,396.00

Bone - Chips/cubes 40cc

TBV09 Donor Tissue Bank of Victoria $874.00

Bone - Chips/cubes 80cc

TBV10 Donor Tissue Bank of Victoria $1,663.00

Bone Plug/Dowel - Cancellous

PBT03 Perth Bone & Tissue Bank $500.00

TBV07 Donor Tissue Bank of Victoria $610.00

Page 4 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Bone Plug/Dowel - Tricortical

TBV08 Donor Tissue Bank of Victoria $673.00

Cancellous Bone Matrix (CBM)

VIM01 Victorian Institute of Forensic Medicine $556.00

VIM02 Victorian Institute of Forensic Medicine $1,110.00

Cartilage (costal) segments

PBT11 Perth Bone & Tissue Bank $300.00

QBB12 Queensland Bone Bank $200.00

TBV17 Donor Tissue Bank of Victoria $350.00

Cortical Struts

(Freeze Dried) 1 strut

QBB02 Queensland Bone Bank $600.00

Cortical Struts (1 strut)

TBV14 Donor Tissue Bank of Victoria $685.00

Cortical Struts (2 struts)

TBV13 Donor Tissue Bank of Victoria $1,370.00

Cortical Struts 10-15cm

PBT06 Perth Bone & Tissue Bank $1,550.00

Cortical Struts>15 - 20cm

PBT07 Perth Bone & Tissue Bank $1,950.00

Cortical struts>20cm

PBT48 Perth Bone & Tissue Bank $2,200.00

Cortico - Cancellous Freeze Dried 20g

QBB03 Queensland Bone Bank $1,740.00

Disc - Freeze Dried

QBB04 Queensland Bone Bank $650.00

Dowel Plug

NBB05 New South Wales Bone Bank $1,080.00

QBB13 Queensland Bone Bank $1,080.00

Elbow - joint

QBB14 Queensland Bone Bank $2,100.00

Page 5 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

TBV18 Donor Tissue Bank of Victoria $4,710.00

Fascia Lata

TBV21 Donor Tissue Bank of Victoria $724.00

Fascia Lata - Large (15cm x 10cm)

PBT15 Perth Bone & Tissue Bank $1,400.00

Fascia Lata - Small (>10cm x >5cm)

NBB09 New South Wales Bone Bank $800.00

Fascia Lata - Small (10cm x 5cm)

PBT16 Perth Bone & Tissue Bank $800.00

Fascia Lata (per sq cm)

NBB08 New South Wales Bone Bank $4.00

QBB11 Queensland Bone Bank $5.00

Femoral Condyle

PBT21 Perth Bone & Tissue Bank $1,900.00

Femoral Head

ACT01 ACT Bone Bank $1,638.00

APH01 The Avenue Private Hospital Prahan Victoria $1,131.00

CSA01 Central Sydney Area Health t/a Rachel Forster Bone Bank $802.00

DHR01 The Douglas Hocking Research Institute - Bone Bank $1,060.00

HBB01 The Hobart Private Hospital Bone Bank $1,400.00

LPH01 Lingard Private Hospital $1,103.00

MMH01 Mater Misericordiae Hospital North Sydney $400.00

MVS05 Institute of Medical & Veterinary Science, SA $1,595.00

NBB16 New South Wales Bone Bank $1,750.00

PBT22 Perth Bone & Tissue Bank $1,900.00

QBB27 Queensland Bone Bank $1,775.00

RNB01 The Royal Newcastle Hospital Bone Bank $1,619.00

SVN01 St Vincent's Private Hospital (NSW) $731.00

TBV26 Donor Tissue Bank of Victoria $2,113.00

Femoral Head - Half (Freeze Dried)

QBB29 Queensland Bone Bank $500.00

Page 6 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Femoral Head - Whole (Freeze Dried)

QBB28 Queensland Bone Bank $800.00

Femoral Rings

NBB17 New South Wales Bone Bank $1,400.00

PBT24 Perth Bone & Tissue Bank $1,400.00

QBB30 Queensland Bone Bank $1,260.00

Femoral Rings - (Freeze Dried)

QBB31 Queensland Bone Bank $650.00

Femur - > 15cm

QBB19 Queensland Bone Bank $1,460.00

Femur - Cortical Portions < 15cm

QBB17 Queensland Bone Bank $1,560.00

Femur - Cortical portions> 1/3

QBB18 Queensland Bone Bank $1,100.00

Femur - Distal (shaft & condyles)

MVS02 Institute of Medical & Veterinary Science, SA $2,290.00

PBT17 Perth Bone & Tissue Bank $2,900.00

TBV22 Donor Tissue Bank of Victoria $3,460.00

Femur - Distal Half

NBB10 New South Wales Bone Bank $2,370.00

Femur - Distal half > 15cm

QBB20 Queensland Bone Bank $2,370.00

Femur - Distal third

NBB11 New South Wales Bone Bank $1,144.00

Femur - Distal third < 15cm

QBB21 Queensland Bone Bank $2,270.00

Femur - Entire

MVS03 Institute of Medical & Veterinary Science, SA $2,290.00

NBB12 New South Wales Bone Bank $5,539.00

PBT18 Perth Bone & Tissue Bank $4,900.00

Page 7 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

QBB22 Queensland Bone Bank $3,685.00

TBV23 Donor Tissue Bank of Victoria $5,794.00

Femur - Middle third

NBB13 New South Wales Bone Bank $2,250.00

QBB23 Queensland Bone Bank $1,865.00

TBV24 Donor Tissue Bank of Victoria $1,887.00

Femur - Proximal (shaft, trochanter, neck)

MVS04 Institute of Medical & Veterinary Science, SA $2,290.00

PBT20 Perth Bone & Tissue Bank $2,900.00

TBV25 Donor Tissue Bank of Victoria $3,434.00

Femur - Proximal half

NBB15 New South Wales Bone Bank $2,570.00

Femur - Proximal half > 15cm

QBB25 Queensland Bone Bank $2,570.00

Femur - Proximal third

NBB14 New South Wales Bone Bank $1,040.00

Femur - Proximal third < 15cm

QBB24 Queensland Bone Bank $2,120.00

Femur - Segment

NBB56 New South Wales Bone Bank $1,500.00

Femur - Shaft Half

NBB57 New South Wales Bone Bank $2,200.00

Femur - Shaft Third

NBB55 New South Wales Bone Bank $1,500.00

Femur - Trochanter Milled

QBB26 Queensland Bone Bank $800.00

Femur- 1 Condyle only

TBV46 Donor Tissue Bank of Victoria $1,065.00

Femur-Proximal(Shaft, trochanter, neck and head)

TBV51 Donor Tissue Bank of Victoria $3,332.00

Page 8 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Fibula - Entire

MVS07 Institute of Medical & Veterinary Science, SA $2,290.00

NBB18 New South Wales Bone Bank $3,200.00

PBT25 Perth Bone & Tissue Bank $2,100.00

QBB32 Queensland Bone Bank $2,220.00

TBV27 Donor Tissue Bank of Victoria $6,041.00

Fibula - Segment

NBB54 New South Wales Bone Bank $1,925.00

Fibula - Segment (12cm)

MVS14 Institute of Medical & Veterinary Science, SA $2,290.00

NBB20 New South Wales Bone Bank $1,881.00

TBV29 Donor Tissue Bank of Victoria $932.00

Fibula - Segment (6cm)

MVS13 Institute of Medical & Veterinary Science, SA $2,290.00

NBB19 New South Wales Bone Bank $1,300.00

TBV28 Donor Tissue Bank of Victoria $610.00

Fibula - Shaft

TBV30 Donor Tissue Bank of Victoria $1,968.00

Fibula segment (prox / distal)

PBT28 Perth Bone & Tissue Bank $1,200.00

Fibular Strut < 10cm:

QBB06 Queensland Bone Bank $1,210.00

Fibular Strut > 10cm:

QBB07 Queensland Bone Bank $1,335.00

Freeze Dried Milled Bone <30gm

PBT37 Perth Bone & Tissue Bank $750.00

Freeze Dried Milled Bone 30 - 50gm

PBT38 Perth Bone & Tissue Bank $900.00

Freeze-dried Cancellous Cubes (6)

QBB09 Queensland Bone Bank $1,335.00

Page 9 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Freeze-Dried Cancellous Strips (2)

QBB10 Queensland Bone Bank $650.00

Hemipelvis - Acetabulum

NBB21 New South Wales Bone Bank $2,568.00

PBT29 Perth Bone & Tissue Bank $2,400.00

QBB33 Queensland Bone Bank $2,320.00

TBV31 Donor Tissue Bank of Victoria $2,686.00

Hemipelvis - Complete

MVS08 Institute of Medical & Veterinary Science, SA $2,290.00

NBB24 New South Wales Bone Bank $5,825.00

PBT30 Perth Bone & Tissue Bank $4,500.00

QBB37 Queensland Bone Bank $3,685.00

TBV32 Donor Tissue Bank of Victoria $6,093.00

Hemipelvis - IIliac crest

NBB22 New South Wales Bone Bank $2,321.00

PBT31 Perth Bone & Tissue Bank $1,100.00

QBB34 Queensland Bone Bank $2,060.00

TBV33 Donor Tissue Bank of Victoria $2,428.00

Hemipelvis - Tricortical wedge

QBB35 Queensland Bone Bank $1,005.00

Hemipelvis - Tricortical wedge (Freeze Dried)

QBB36 Queensland Bone Bank $700.00

Hemipelvis -Tricortical iliac wedge

NBB23 New South Wales Bone Bank $1,005.00

PBT32 Perth Bone & Tissue Bank $600.00

TBV34 Donor Tissue Bank of Victoria $920.00

Humeral Head

QBB44 Queensland Bone Bank $1,350.00

TBV37 Donor Tissue Bank of Victoria $1,484.00

Humeral Head Addition

Page 10 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

NBB26 New South Wales Bone Bank $1,419.00

Humerus - Cortical portions/blocks < 10cm

QBB38 Queensland Bone Bank $1,110.00

Humerus - Cortical portions/blocks > 10cm

QBB39 Queensland Bone Bank $1,330.00

Humerus - Distal

MVS19 Institute of Medical & Veterinary Science, SA $2,290.00

TBV49 Donor Tissue Bank of Victoria $1,979.00

Humerus - Distal half

NBB25 New South Wales Bone Bank $1,200.00

Humerus - Entire

MVS20 Institute of Medical & Veterinary Science, SA $2,290.00

NBB29 New South Wales Bone Bank $2,828.00

QBB43 Queensland Bone Bank $2,570.00

Humerus - Proximal half

NBB27 New South Wales Bone Bank $1,658.00

QBB40 Queensland Bone Bank $1,260.00

Humerus - Proximal half with rotator cuff

NBB28 New South Wales Bone Bank $2,500.00

QBB41 Queensland Bone Bank $2,245.00

Humerus - Proximal with rotator cuff

MVS09 Institute of Medical & Veterinary Science, SA $2,290.00

PBT34 Perth Bone & Tissue Bank $2,500.00

TBV35 Donor Tissue Bank of Victoria $2,336.00

Humerus - Proximal w'out rotator cuff

PBT35 Perth Bone & Tissue Bank $1,100.00

QBB42 Queensland Bone Bank $1,260.00

TBV36 Donor Tissue Bank of Victoria $2,485.00

Humerus - Ring

NBB53 New South Wales Bone Bank $1,300.00

Page 11 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Humerus - Segment

NBB52 New South Wales Bone Bank $1,400.00

Humerus - Shaft Half

NBB51 New South Wales Bone Bank $1,500.00

Humerus - Shaft Whole

NBB50 New South Wales Bone Bank $2,750.00

Humerus - Whole

PBT33 Perth Bone & Tissue Bank $3,000.00

Humerus - Whole with rotator cuff

NBB30 New South Wales Bone Bank $2,941.00

Medial Ligament

NBB31 New South Wales Bone Bank $1,529.00

TBV38 Donor Tissue Bank of Victoria $1,599.00

Meniscal Graft

PBT47 Perth Bone & Tissue Bank $1,800.00

Meniscus

QBB05 Queensland Bone Bank $1,160.00

Meniscus with Ligaments

TBV39 Donor Tissue Bank of Victoria $1,927.00

Meniscus without Ligaments

TBV40 Donor Tissue Bank of Victoria $1,046.00

Milled Bone - 15cc

NBB58 New South Wales Bone Bank $720.00

Milled Bone - 30g

NBB03 New South Wales Bone Bank $1,050.00

Milled Bone - 40cc

TBV11 Donor Tissue Bank of Victoria $1,046.00

TBV15 Donor Tissue Bank of Victoria $760.00

Milled Bone - 60cc

Page 12 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

QBB45 Queensland Bone Bank $1,675.00

Milled Bone - 60g

NBB04 New South Wales Bone Bank $1,675.00

Milled Bone - 60g max

QBB46 Queensland Bone Bank $1,200.00

Milled Bone - 80cc

TBV12 Donor Tissue Bank of Victoria $1,870.00

TBV16 Donor Tissue Bank of Victoria $1,445.00

Milled Bone <30g

PBT08 Perth Bone & Tissue Bank $1,600.00

Milled Bone >50g

PBT10 Perth Bone & Tissue Bank $2,350.00

Milled Bone 30 - 50g

PBT09 Perth Bone & Tissue Bank $2,050.00

Patella

NBB32 New South Wales Bone Bank $875.00

QBB47 Queensland Bone Bank $750.00

TBV41 Donor Tissue Bank of Victoria $915.00

Patella tendon

QBB48 Queensland Bone Bank $1,715.00

Patella Tendon and Patella

TBV42 Donor Tissue Bank of Victoria $1,927.00

Patella tendon with Bone Plugs

NBB33 New South Wales Bone Bank $1,357.00

Patellar unit whole with tibial block

PBT40 Perth Bone & Tissue Bank $2,100.00

Primary MACI plus 1/2

VAP02 Verigen Australia Pty Ltd $10,891.00

Proximal Third Tibia with - Patella Tendon

QBB08 Queensland Bone Bank $2,370.00

Page 13 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Radius

MVS18 Institute of Medical & Veterinary Science, SA $2,290.00

NBB06 New South Wales Bone Bank $2,673.00

PBT13 Perth Bone & Tissue Bank $1,800.00

QBB15 Queensland Bone Bank $1,865.00

TBV19 Donor Tissue Bank of Victoria $2,796.00

Radius - Ring

NBB49 New South Wales Bone Bank $1,680.00

Radius - Segment

NBB48 New South Wales Bone Bank $1,925.00

Radius - Shaft

NBB47 New South Wales Bone Bank $2,750.00

Rib (5cm)

MVS21 Institute of Medical & Veterinary Science, SA $382.00

PBT41 Perth Bone & Tissue Bank $300.00

TBV43 Donor Tissue Bank of Victoria $437.00

Scaphoid

QBB49 Queensland Bone Bank $900.00

Shaft - Femur / Tibia Middle third

PBT19 Perth Bone & Tissue Bank $2,500.00

Tibia - Condyles only

TBV47 Donor Tissue Bank of Victoria $1,491.00

Tibia - Cortical < 15cm

QBB50 Queensland Bone Bank $1,275.00

Tibia - Cortical > 15 cm

QBB51 Queensland Bone Bank $1,560.00

Tibia - Distal

MVS17 Institute of Medical & Veterinary Science, SA $2,290.00

TBV48 Donor Tissue Bank of Victoria $1,922.00

Tibia - Middle third seg

Page 14 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

NBB34 New South Wales Bone Bank $1,400.00

QBB53 Queensland Bone Bank $900.00

Tibia - Plateau (prox 1/3)

NBB35 New South Wales Bone Bank $2,065.00

Tibia - Proximal third < 15cm

QBB54 Queensland Bone Bank $2,065.00

Tibia - Proximal with Patella Tendon

NBB46 New South Wales Bone Bank $3,647.00

Tibia - Proximal:

without Patella

PBT45 Perth Bone & Tissue Bank $2,300.00

Tibia - Proximal: 16-25cm

TBV45 Donor Tissue Bank of Victoria $2,215.00

Tibia - Proximal: 7-15cm

TBV44 Donor Tissue Bank of Victoria $2,299.00

Tibia - Proximal: half

MVS11 Institute of Medical & Veterinary Science, SA $2,290.00

NBB36 New South Wales Bone Bank $2,290.00

Tibia - Proximal: with Patella & Tendon

PBT44 Perth Bone & Tissue Bank $2,900.00

Tibia - Ring

NBB45 New South Wales Bone Bank $1,300.00

Tibia - Shaft Half

NBB43 New South Wales Bone Bank $2,200.00

Tibia - Shaft Third

NBB42 New South Wales Bone Bank $2,065.00

Tibia - Shaft Whole

NBB41 New South Wales Bone Bank $2,750.00

Tibia - Strut

QBB52 Queensland Bone Bank $400.00

Page 15 of 16

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Tibia - Whole

MVS16 Institute of Medical & Veterinary Science, SA $2,290.00

NBB37 New South Wales Bone Bank $3,685.00

QBB55 Queensland Bone Bank $3,685.00

Tibia - Whole with Patella Tendon

NBB44 New South Wales Bone Bank $5,042.00

Tibialis Tendon

PBT46 Perth Bone & Tissue Bank $1,450.00

Ulna

MVS15 Institute of Medical & Veterinary Science, SA $2,290.00

NBB07 New South Wales Bone Bank $2,464.00

PBT14 Perth Bone & Tissue Bank $1,500.00

QBB16 Queensland Bone Bank $1,865.00

TBV20 Donor Tissue Bank of Victoria $2,577.00

Ulna - Ring

NBB40 New South Wales Bone Bank $1,680.00

Ulna - Segment

NBB39 New South Wales Bone Bank $1,925.00

Ulna - Shaft

NBB38 New South Wales Bone Bank $2,200.00

Page 16 of 16

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