Private Health Insurance (Prostheses) Rules 2007 (No. 2) (Cth)
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 May 2007
____________________________________
Penny Shakespeare
Assistant Secretary
Private Health Insurance Branch,
Acute Care Division
Department of Health and Ageing
Contents
Part 1 Preliminary 3
1.Name of Rules 3
2.Commencement 3
3.Definitions 3
Part 2 Benefit requirements 4
4.Listing of, and benefits, for prostheses 4
5.Benefits for prostheses provided as part of hospital treatment 4
6.Benefits for prostheses provided as part of hospital-substitute treatment 5
7.Timing of applications to have a prosthesis listed 5
8.Minister may have regard to recommendations and advice 6
Schedule 7
Part 1 Preliminary
Name of Rules
These Rules are the Private Health Insurance (Prostheses) Rules 2007(No.2).
Commencement
These Rules commence on 1 June 2007.
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 with the status of certain hospitals 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 with the status of certain hospitals for which a declaration had been made before the commencement of the Act.
Schedule means the Schedule in these Rules.
Part 2 Benefit requirements
Listing of, and benefits, for prostheses
For item 4 of the table in subsection 72-1 (2) of the Act:
(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.
(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:
(i)a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis; or
(ii)the provision of the prosthesis is associated with podiatric treatment by an accredited podiatrist; and
(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.
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):
(a)the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and
(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):
(a)the minimum benefit is the lesser of the following amounts:
(i)the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or
(ii)the amount of the insured person’s liability to the public hospital for that prosthesis; and
(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):
(a)the minimum benefit is the lesser of the following amounts:
(i)the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or
(ii)the amount of the insured person’s liability to the public hospital for that prosthesis; and
(b)the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in the Schedule.
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):
(a)the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and
(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.
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.
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.
(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
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
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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