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Rules/Other as amended, taking into account amendments up to Private Health Insurance (Prostheses) Amendment Rules 2010 (No. 1)
These Rules revoke the Private Health Insurance (Prostheses) Rules 2010 (No. 1) and determines benefits for listed prostheses and medical treatments.
Administered by: Health
Registered 27 Jan 2011
Start Date 05 Oct 2010
End Date 13 Jan 2011
Date of repeal 21 Feb 2011
Repealed by Private Health Insurance (Prostheses) Rules 2011 (No. 1)
Table of contents.

 

 

 

Private Health Insurance (Prostheses) Rules 2010

(No. 2)

 

As amended

Made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007

This compilation was prepared on 18 January 2011 taking into account amendments up to the Private Health Insurance (Prostheses) Amendment Rules 2010 (No.1).

Prepared by the Department of Health and Ageing, Canberra.



 

 

 

 

 


Contents

 

 

Part 1                   Preliminary                                                                                            3

1.           Name of Rules                                                                                        3

2.           Commencement                                                                                      3

3.           Revocation                                                                                             3

4.           Definitions                                                                                              3

Part 2                   Benefit requirements                                                                             5

5.           Listing of, and benefits, for prostheses                                                   5

6.           Benefits for prostheses provided as part of hospital treatment                 5

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

8.           Timing of applications to have a prosthesis listed                                    6

9.           Minister may have regard to recommendations and advice                        7

Notes                                                                                                                                 8

 

 

Schedule                                                                                                                          10

 

 


Part 1        Preliminary

1.               Name of Rules

These Rules are the Private Health Insurance (Prostheses) Rules 2010 (No. 2).

2.               Commencement

These Rules commence on 14 August 2010.

3.               Revocation

These Rules revoke the Private Health Insurance (Prostheses) Rules 2010 (No. 1).

4.               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

5.               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 6 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 7 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.

6.               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 5(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 5(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 5(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 5(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.

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

(1)        For a no gap prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 5(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’.

(2)        For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 5(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.

8.               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.


9.               Minister may have regard to recommendations and advice

(1)        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.

(2)        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.

Notes

 

The Private Health Insurance (Prostheses) Rules 2010 (No.2) as shown in this compilation are amended as indicated in the tables below.

 

 

Table of Instruments

 

Instrument

Date of FRLI registration

Date of commencement

Application, saving or transitional provision

 

Private Health Insurance (Prostheses) Rules 2010 (No.2)

 

 

30 July 2010

(see F2010L02191)

 

14 August 2010

 

 

Private Health Insurance (Prostheses) Amendment Rules 2010 (No.1)

 

 

22 September 2010

(see F2010L02500)

 

5 October 2010

 

 

 

Table of Amendments

ad. = added or inserted     am. = amended     rep. = repealed     rs. = repealed and substituted

Provision affected

How affected

 

Schedule............................

 

am. 2010  No.  F2010L02500

 

 

 

 

 

 

 

 

Note

1.      All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See www.frli.gov.au

 



Part A - Prostheses List                                                                          August 2010

CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

Group 1- Cardiothoracic Mechanical Valves

     Group 1c - Bi-Leaflet, rotatable

                 Advanced Biomedical Pty Ltd

AB002          ATS medical open pivot heart valve               Pyrolythic Carbon, Double Velour                  16-33mm                             $6,000.00

                   model 500FA standard flexi-cuff aortic           Polyester, Titanium

                   valve series, ATS medical open pivot

                   heart valve model 500DM standard

                   flexi-cuff mitral valve series

AB064          ATS medical open pivot heart valve               Pyrolythic Carbon, Double Velour                  16-33mm                             $6,000.00

                   model 501DA advanced performance             Polyester, Titanium

                   (AP) aortic valve series, ATS medical

                   open pivot heart valve model 501DM

                   advanced performance (AP) mitral valve

                 Medtronic Australasia Pty Ltd

MC292          Advantage Heart Valve - Aortic Model           A7760 - Pyrolytic carbon, PET                      Diameter 19-31 mm                 $6,000.00

                   A7760

MC324          Advantage Supra Aortic  Heart Valve            Mechanical Heart Valve Pyrolite Carbon           Diameter (mm): 19 - 25             $6,000.00

                                                                            leaflets Pyrolite carbon ring

MC681          Advantage Mitral                                    Mechanical Heart Valve                              23mm-33mm                         $6,000.00

                 Reid Healthcare

RH001          Aortic On-X Prosthetic Heart Valve                                                                         27-29mm, 19mm, 21mm,           $6,000.00

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

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

                   23; ONXM-25; ONXM-27/29;

                   ONXM31/33; ONXMC25/33

                 Sorin Group

SA129           Optiform                                              Mechanical Valve                                      19mm to 33mm                      $6,000.00

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 1 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 St. Jude Medical Australia Pty Ltd

SJ037            St Jude Medical Aortic Expanded Cuff           Aortic Expanded Cuff, Aortic                        Aortic Expanded 19 -31mm,       $6,000.00

                   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

SJ039            Regent Prosthestic Heart Valves                  Standard Cuff - Model 17AGFN-751 -             Standard cuff - 17-23mm, Flex    $6,500.00

                                                                            23AGFN-751, Flex Cuff - Mode                    cuff - 17-23mm

                                                                            17AGFN-756 - 23AGFN-756

SJ116            Regent Prosthestic Heart Valves                  Standard Cuff - Model 25AGFN-751 -             Standard cuff - 25-29mm, Flex    $6,000.00

                                                                            29AGFN-751, Flex Cuff - Mode                    cuff - 25-29mm

                                                                            25AGFN-756 - 29AGFN-756

     Group 1e - Tilting Disc, rotatable

                 Medtronic Australasia Pty Ltd

MC013          Medtronic Hall Heart Valve Aortic Model       A7700/M7700 Titanium. Pyrolite.                   A7700 - Diameter 20-31mm,      $5,100.00  $5,625.00

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

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

                   Aortic Heart Valve Model A7700, Hall                                                                     M7700EZ - Diameter 23-31mm

                   Easy Fit Mitral Heart Valve Model M7700

Group 1: Single Chamber ICD's

     Generation 3

                 Guidant Australia Pty Ltd

GU148          Vitality 2 EL VR - Model T177                   Single Chamber ICD                                  35cc; 90g                            $40,560.00

GU151          Vitality 2 VR - Model T 175                       Single Chamber ICD                                  30cc; 82g                            $40,560.00

                 Sorin Group

SA139           OVATIO VR 6250                                 Titanium, single chamber, sterile, VR               29cc                                  $40,560.00

                                                                            6250, 34J

            a

                 Sorin Group

SA149           PARADYM VR 8250                             Single Chamber implantable cardioverter           Dimensions: 58.4 x 73.4 x        $42,640.00

                                                                            defibrillator with rate response                       11mm; Weight: 90 grams;

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 2 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 St. Jude Medical Australia Pty Ltd

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

                                                                            defibrillator

SJ114            Atlas II VR-168                                     Single chamber cardioverter defibrillator           38cc, 77g                            $42,640.00

SJ121            Current VR 1107-36                                Single Chamber Cardioverter Defibrillator         38cc 76g                            $42,640.00

            a, d

                 St. Jude Medical Australia Pty Ltd

SJ142            Analyst VR CD1217-36                           Single Chamber Cardioverter Defibrillator         79g, 41cc                            $42,640.00  $44,640.00

                                                                            with RF Telemetry and ST Segment

                                                                            Monitoring

            A,C,D

                 Medtronic Australasia Pty Ltd

MC722          Virtuoso                                              VR ModelImplantable Cardioverter                 37cc, 68g                            $42,640.00

                                                                            Defibrillator, Single Chamber

            A,D

                 Biotronik Australia Pty Ltd

BT090           Lumax 340 VR-T                                   ICD-VR 34 J with bidirectional Home              One size only                       $42,640.00  $45,640.00

                                                                            Monitoring. Single chamber

BT098           Lumax 340 VR-T XL                               ICD-VR with 40 J output, bidirectional             One Size Only                      $42,640.00  $45,640.00

                                                                            Home Monitoring and High Longevity

                 Boston Scientific Australia Pty Ltd

BS136           TELIGEN 100 HE VR DF-1/IS-1                Single chamber ICD, High Energy with RF       31.5cc, 9.9mm                      $42,640.00

                 Medtronic Australasia Pty Ltd

MC939          Virtuoso II                                           VR Model - Implantable Cardioverter               37cc, 68g                            $42,640.00

                                                                            Defibrillator, Single Chamber

                 St. Jude Medical Australia Pty Ltd

SJ124            Current RF VR 1207-36                           Single Chamber Cardioverter Defibrillator         79g, 41cc                            $42,640.00

                                                                            with RF Telemetry

            A,D,E

                 Boston Scientific Australia Pty Ltd

BS132           Teligen 100 HE VR 4-SITE                       Single chamber ICD, high energy with             30.5cc, 9.9mm                      $43,390.00

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 3 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            D

                 Biotronik Australia Pty Ltd

BT087           Lumax 300 VR-T                                   ICD-VR with bidirectional Home                   One Size Only                      $40,560.00  $43,560.00

                                                                            Monitoring. Single chamber

                 St. Jude Medical Australia Pty Ltd

SJ216            AnalyST VR CD1217-30                          Single chamber cardioverter defibrillator            73g, 37cc                            $40,560.00  $42,560.00

                                                                            with RF telemetry and ST segment

     Generation 4

            a, d, e

                 St. Jude Medical Australia Pty Ltd

SJ232            Current Accel VR CD1215-36Q                  Single Chamber Cardioverter Defibrillator         80g, 42cc                            $44,670.00

                                                                            with RF Telemetry and SJ4 connector

SJ237            AnalyST Accel VR CD1219-36Q                Single Chamber Cardioverter Defibrillator         79g, 41cc                            $44,670.00

                                                                            with RF Telemetry and ST Segment

                                                                            Monitoring and SJ4 connector.

            A,D

                 Biotronik Australia Pty Ltd

BT100           LUMAX 540 VR-T                                High Energy, Single-Chamber ICD                 Diamensions: 66*55*13 mm     $43,920.00  $45,640.00

                                                                            (Implantable Cardiac Defibrillator) with            Volume/Weight : 37.2cc/92g

                                                                            Advanced Patient Management Via unique

                                                                             Home Monitoring Technology

                                                                            incorporatin Automatic Threshold

                                                                            Monitoring and Extended Longevity.

                 Medtronic Australasia Pty Ltd

MC813          Secura VR                                            Fully Automatic, Wireless Implantable              37cc                                  $43,920.00

                                                                            cardioverter defibrillator with high energy

                                                                             capability and therapies for ventricular

                                                                            tachyarrhythmia

                 St. Jude Medical Australia Pty Ltd

SJ147            Current Accel VR RF CD1215-36                Single Chamber Cardioverter Defibrillator         79g, 38cc                            $43,920.00  $44,640.00

                                                                            with RF Telemetry

SJ154            AnalyST Accel VR CD1219-36                  Single Chamber Cardioverter Defibrillator         79g, 41cc                            $43,920.00  $44,640.00

                                                                            with RF Telemetry and ST Segment

                                                                            Monitoring

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 4 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            D

                 St. Jude Medical Australia Pty Ltd

SJ212            AnalyST Accel VR CD1219-30                  Single chamber cardioverter defibrillator            73g, 37cc                            $41,820.00  $44,560.00

                                                                            with RF telemetry and ST segment

SJ213            Current Accel VR RF CD1215-30                Single chamber cardioverter defibrillator            73g, 37cc                            $41,820.00  $44,560.00

                                                                            with RF telemetry

Group 10: Pacemaker/ICD Extenders

                 Medtronic Australasia Pty Ltd

MC831          Medtronic Lead Extender Kit Model:             Silicone                                                 37 - 50cm                               $530.00

                   6984M, 6981M, 6985M,6986m

Group 11: Pacemaker/Lead Accessories

                 Medtronic Australasia Pty Ltd

MC036          Medtronic Lead End Cap Kit Model:              Pin Plug Kits to Seal Unused Pacemaker           One Size Per Model                    $80.00

                   5867-3M; Medtronic DF-1 Port Pin              or Defibrillator Port; Sizing Sleeve -

                   Plug Kit: Model 6719, Medtronic IS-1           Silicone or Polyurethane

                   Port Pin Plug Kit: Model 6725;

                   Medtronic Upsizing Sleeve: Model 5866-

Group 12: Coronary Stents

     Sub-Group 1: General Purpose Drug eluting stents

                 Abbott Australasia Pty Ltd

AY023          Xience Everolimus Eluting Stent System         Everolimus Eluting Stent System                    2.25mm to 4.0mm widths, 8mm   $3,450.00

                                                                                                                                       to 28mm lengths

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 5 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

AY037          Xience PRIME LL Everolimus Eluting          Coronary Artery Stent, Drug Eluting               XIENCE PRIME LL 2.50; 2.75; $3,450.00

                   Coronary Stent; Xience PRIME                                                                              3.00; 3.50; 4.0 x 33MM; 

                   Everolimus Eluting Coronary Stent;                                                                          XIENCE PRIME LL 2.50; 2.75;

                   Xience PRIME SV Everolimus Eluting                                                                     3.00; 3.50; 4.0 x 38MM; 

                                                                                                                                      XIENCE PRIME SV 2.25 x 08;

                                                                                                                                      12; 15; 18; 23; 28MM; XIENCE

                                                                                                                                       PRIME 2.50 x 08; 12; 15; 18;

                                                                                                                                      23; 28MM;  XIENCE PRIME

                                                                                                                                      2.75 x 08; 12; 15; 18; 23;

                                                                                                                                      28MM;  XIENCE PRIME 3.00 x

                                                                                                                                       08; 12; 15; 18; 23; 28MM; 

                                                                                                                                      XIENCE PRIME 3.50 x 08; 12;

                                                                                                                                      15; 18; 23; 28MM;  XIENCE

                                                                                                                                      PRIME 4.00 x 08; 12; 15; 18;

                                                                                                                                      23; 28MM

                 Boston Scientific Australia Pty Ltd

BS099           Taxus Liberte Paclitaxel-Eluting                   316L Stainless Steel Stent with Translute           2.0mm-5.0mm & 8.0mm-38mm   $3,450.00

                   Coronary Stent System                             Polymer and Paclitaxel

BS125           Promus Everolimus Coronary Stent               Cobalt chromium alloy stent coated with            2.25mm to 4.0mm diameter,        $3,450.00

                                                                            a blended polymer mixed with Everolimus.        8mm to 28mm length

BS175           PROMUS Element                                  Platinum chromium alloy stent coated               8mm to 38mm with a reference    $3,450.00

                                                                            with a blended polymer mixed with                 vessel diameter of 2.25mm -

                                                                                                                                      4.0mm.

BS176           Taxus Element                                       Platinum chromium alloy stent coated               (8mm to 38mm) with a              $3,450.00

                                                                            with a blended polymer mixed with                 reference vessel diameter of

                 Johnson & Johnson Medical Pty Ltd

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, 2835

JJ481            CYPHER SELECT Sirolimus-Eluting            Stainless steel coronary stent with                   Diameter 2.25 - 5.0mm, length 8  $3,450.00

                   Stent & Delivery System                           Sirolimus (an immunosuppressive and               - 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,

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 6 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

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

                 Medtronic Australasia Pty Ltd

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

                   System                                                                                                           Length: 8.00mm-38.0mm

MC769          Endeavor Sprint Drug Eluting Stent               Cobals Alloym ABT - 578                           Diameter: 2.25mm-4.0mm;         $3,450.00

                                                                                                                                      Length: 8.0mm-30.0mm

MC816          Endeavor Resolute Drug Eluting                  Cobalt Alloy, ABT - 578, BioLinx                  Diameter:2.25mm-4.0mm;          $3,450.00

                   Coronary Stent System                                                                                        Length: 8.00mm-30.0mm

     Sub-Group 2: General Purpose Bare metal stents

                 Abbott Australasia Pty Ltd

AY025          Stents                                                 ACS Multilink Coronary Stent; ACS               1.5mm - 8.0mm                      $1,248.00

                                                                            Megalink Peripheral Stent; ACS RX

                                                                            Herculink Peripheral Stent. Stainless steel

AY026          Multilink Coronary Stent System                 Stainless Steel                                          Length 1.5mm - 8.0mm             $1,248.00

AY028          Multilink Coronary Stent System -                Cobalt chrome stent                                   2.25mm to 4.0mm widths, 8mm   $1,248.00

                                                                                                                                       to 38mm lengths

                 Atrium Australia - Pacific Rim Pty Limited

AC030          Cinatra Cobalt Chromium Coronary              The Cinatra Cobalt Chromium Coronary           Diameter range: 2.5mm -           $1,248.00  $1,372.00

                   Stent System                                         Stent System consists of a balloon                   3.5mm.  Length range: 8mm -

                                                                            expandable Cobalt Chromium stent

                                                                            premounted on a rapid exchange system

                 Bio Excel Australia Pty Ltd

BE001           Gazelle Coronary Stent                             Stainless Steel                                          Diam 2.25-4.0mm  Length 8-      $1,248.00

                 Biotronik Australia Pty Ltd

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

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 7 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

BT107           PRO-Kinetic Energy                                The PRO-Kinetic Energey stent is a                 The PRO-Kinetic Energy stent is  $1,248.00

                                                                            tubular, balloon-expandable stent sculpted         available in 66 different

                                                                             by laser from a single tube of L-605                diameter/length combinations.  It

                                                                            cobalt chromium (CoCr) alloy.  The stent          is available in lengths from

                                                                             consists of circular segments at each end          8mm to 40mm.  It is

                                                                             followed by a transition zone and                   premounted on a delivery

                                                                            helicoidally arranged struts in the middle.           system which has nominal

                                                                             Each loop of the helix is connected to the          balloon diameters between

                                                                             next loop by 3 longitudinal struts.  The             2.0mm and 5.0mm.

                                                                            stent surface is fully coated with a layer

                                                                            of amorphous hydrogen-rich silicon

                                                                            carbide (aSiC:H).  This material has

                                                                            semiconducting properties that efficiently

                                                                            prevent the electron transfer from

                                                                            fibrinogen to the metal surface in vitro. 

                                                                            Thereby the conversion from fibrinogen

                                                                            to fibrin and it's depoisition at the stent

                                                                            surface is reduced.  Additionally, aSiC:H -

                                                                             coated stents exhibit a lower adhesion

                                                                            and activation of blood platelets and

                                                                            leucocytes.  Finally, the release of

                                                                            potentially allergenic ions from a silicon

                                                                            carbide coated stent is substantially

                                                                            reduced in comparison to an uncoated

                                                                            metal stent3.  This coating is used on all

                                                                            Biotronik coronary stents producedso far

                 Boston Scientific Australia Pty Ltd

BS069           Liberte Coronary Stent System                    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 &

                 Imaxeon Pty Ltd

IX001           Amazonia CroCo                                    Balloon expandable intracoronary cobalt            Lengths:  8mm, 12mm, 16mm,    $1,248.00

                                                                            chromium stent premounted onto a rapid           20mm, 24mm, 28mm, 32, 36,

                                                                            exchange delivery catheter                            and 40mm.  Diameters: 

                                                                                                                                      2.25mm, 2.5mm, 2.75mm,

                                                                                                                                      3.0mm, 3.5mm, 4.0mm, 4.50

                                                                                                                                      and 5.00 mm in all lengths

                 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

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 8 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

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

                                                                             a balloon delivery system

JJ670            Presillion CoCr Coronary Stent on RX           Cobalt Chromium, bare metal coronary             Stent Length (mm) x Stent          $1,248.00

                   System                                                                                                           Diameter (mm) 8 x 2.50, 2.75,

                                                                                                                                      3.0, 3.50, 4.0; 12 x 2.50, 2.75,

                                                                                                                                      3.0, 3.50, 4.0; 17 x 2.50, 2.75,

                                                                                                                                      3.0, 3.50, 4.0; 24 x 2.75, 3.0,

                                                                                                                                      3.50, 4.0; 33 x 2.75, 3.0, 3.50,

                 Medtronic Australasia Pty Ltd

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

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

                                                                                                                                      Micro-Driver Stent: diameter

                                                                                                                                      (2.25 - 2.75mm), length (8 -

MC932          Driver Sprint Coronary Stent System             Cobalt Alloy                                            Diameter: 2.25 - 4.5 mm;           $1,248.00

                                                                                                                                      Length: 8-30mm

MC956          Integrity Coronary Stent System                  Cobalt Alloy Coronary Stent                         Diameter: 2.25 - 4.5mm; Length:  $1,248.00

                                                                                                                                       8 - 30mm

                 OrbusNeich  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

NM004          Blazer Coronary Stent Delivery System          L605 Cobalt Chromium alloy balloon               Expanded Stent Diameter 2.5 to   $1,248.00

                                                                            expandable vascular prosthesis                      4.0mm, Stent Length 9 to 33mm

                 Terumo Corporation Australia

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

                                                                                                                                      Length 8mm - 30mm length

     Sub-Group 3: Bare metal stents for specific indications

            a, b

                 Abbott Australasia Pty Ltd

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

            c.3

                 Imaxeon Pty Ltd

IX003           Minvasys Nile Delta Coronary Stent              Balloon expandable Amazonia                       Nile Delta 2.50mm diameter x     $1,248.00

                                                                            intracoronary cobalt chromium stent                 8mm length; Nile Delta 3.00mm

                                                                            premounted onto a rapid exchange                   diameter x 8mm length

                                                                            delivery catheter with tapered balloon.

Prostheses List by Category, Groups and Sponsor                                                                                                               Page 9 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            C1

                 Abbott Australasia Pty Ltd

AY027          Multilink Coronary Stent System -                316L Stainless steel stent                             Length 1.5 - 8.0mm                 $2,200.00

            C2

                 Imaxeon Pty Ltd

IX002           Nile CroCo                                           Intracoronary stent pre-mounted on two            Diameter : 2.50 - 3.50mm.  MB   $1,750.00

                                                                            rapid exchange delivery systems for                 and 2.00-3.00mm SB

                                                                            bifurcation lesions treatment                          Lengths 18 mm and 24 mm

Group 13: Special Purpose Percutaneous Cardiovascular Devices

     Sub-Group 1: Intracardiac Defect Occluders

            a

                 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

ME187          AMPLATZER Duct Occluder II                  Self expandable multiple Nitinol wire               Waist diameter 3-6mm, Nominal $10,200.00

                                                                            mesh PDA occlusion device                         length 4-6mm

                 Pacing Importers Pty Ltd - Life Systems

PI020            'STARflex Rapid Transport Plus System        The STARFlex Rapid Transport Plus               23mm, 28mm, 33mm and         $10,200.00

                                                                            System consists of two primary

                                                                            components: 1) The device, a permanent

                                                                            implant, which is constructed primarily of

                                                                             a metal MP35N framework to which

                                                                            polyester fabric is attached, and 2) The

                                                                            delivery catheter, a Pebax based catheter

                                                                            designed specifically to facilitate

                                                                            attachment, loading, delivery and

                                                                            deployment of the device to the defect.

                                                                            The device and delivery catheter can be

                                                                            packaged separately or pre-attached as a

                 St. Jude Medical Australia Pty Ltd

SJ091            Premere PFO Closure System                     Percutaneous, transcatheter, self-                    Left Atrial Anchor diameter       $10,036.00

                                                                            expanding, dual anchor, occlusion and              20mm, 25mm and 30mm

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 10 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 W L Gore & Associates

GT223           Helex 1.5 Septal Occluder                          The GORE HELEX Septal Occluder                Diameters: 15, 20, 25, 30 and    $10,200.00

                                                                            consists of an implantable endoprosthesis          35mm

                                                                            and a catheter delivery system.  The

                                                                            Occluder is comprised of a nickel-

                                                                            titanium (Nitinol) wire frame covered

                                                                            with expanded polytetrafluoroethylene

                                                                            (ePTFE).  The ePTFE is treated with

     Sub-Group 3: Vascular Occlusion Devices

                 Denward Dell Pty Ltd TA Surimex

DW001          Nit-Occlud PDA Occlusion System              Nitinol spiral coil and delivery system for          Distal x Proximal Coil Diameter: $1,900.00

                                                                            transcatheter occlusion of PDA                      4x4mm, 5x4mm, 6x5mm,

                                                                                                                                      10x6mm, 12x6mm, 14x6mm;

                                                                                                                                      Introducer Sheath: 4F, 5F;

                                                                                                                                      Length Introducer: 85cm,

                                                                                                                                      105cm; Coil Length

                                                                                                                                      configurated +-0.5mm: 3.5mm,

DW002          Nit-Occlud PDA Occlusion System              Nitinol spiral coil and delivery system for          Distal x Proximal Coil Diameter: $1,650.00

                   (Medium)                                             transcatheter occlusion of PDA                      7 x 6mm, 9 x 6mm, 11 x 6mm,

                                                                                                                                      12 x 6mm, 14 x 6mm;

                                                                                                                                      Introducer Sheath:  5F; Length

                                                                                                                                      Introducer: 85cm, 105cm; Coil

                                                                                                                                      Length configurated +-0.5mm:

Group 14: Implantable Cardiac Event Recorders

                 Medtronic Australasia Pty Ltd

MC763          Reveal XT                                            Reveal XT Insertable Cardiac Monitor              61 x 19 x 8 mm with a volume     $3,900.00

                                                                                                                                      of 9cc

MC768          Reveal DX                                           Insertable Cardiac Monitor                           61 x 19 x 8 mm with a volume     $3,900.00

                                                                                                                                      of 9cc

                 St. Jude Medical Australia Pty Ltd

SJ152            SJM Confirm Model DM2102                    Implantable cardiac monitor with atrial              6.5cc, 12g                            $3,900.00  Temporary Listing

                                                                            fibrillation monitoring.

SJ159            SJM Confirm Model DM2100                    Implantable cardiac monitor                          6.5cc, 12g                            $3,900.00  Temporary Listing

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 11 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

Group 15: Endovascular Therapeutic Devices

     Sub- Group 2: Embolic Protection Devices

                 St. Jude Medical Australia Pty Ltd

SJ127            Proxis Embolic Protection System -               Proximal embolic protection device and             6F and 7F                            $2,100.00

                   Long Sheath                                          delivery system

Group 2 - Cardiothoracic Tissue Valves

                 Edwards Lifesciences Pty Ltd

EL032           Baxter Edwards Prima Plus Stentless             Edwards Prima Plus. Porcine Valve;                19mm-29mm                         $4,841.00

                   Bioprosthesis Model 2500P Prosthetic           Woven Polyester Cloth.

                   Heart Valve

     Group 2a - Stented

                 Medtronic Australasia Pty Ltd

MC950          Mosaic Ultra Cinch II                               Small Aortic Root Bioprosthesis                    19mm - 29mm                       $4,445.00  $5,650.00

MC962          Mosaic Cinch II                                     Aortic Bioprosthesis                                  19mm -29mm                        $4,445.00  $5,345.00

                 St. Jude Medical Australia Pty Ltd

SJ141            SJM Epic Supra Valve                             triple composite Bioprosthetic heart valve          Tissue Annulus Diameter - 19-    $4,445.00

                                                                            for supra-annular placement in the aortic            23mm

                                                                                                                                      Total Height - 14-16mm

SJ156            SJM Epic Valve                                     Triple composite bioprosthetic heart valve          Aortic valve 21-29mm tissue       $4,445.00

                                                                                                                                      annulus diameter

                                                                                                                                      14-20 total height

                                                                                                                                      Mitral Valves 25-33mm tissue

                                                                                                                                      annulus diameter

                                                                                                                                      15-20mm total height

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 12 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            (p)

                 St. Jude Medical Australia Pty Ltd

SJ069            St Jude Medical Biocor Porcine                   St Jude Medical Biocor Porcine                      Aortic Valves - Tissue Annulus   $4,445.00

                   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-

SJ136            SJM Biocor Heart Valve                           Stented Porcine tissue valve                          Aortic Valves - Tissue Annulus   $4,445.00

                                                                                                                                      Diameter - 21 - 29mm             

                                                                                                                                                                                   

                                                                                                                                                       Mitral Valves -

                                                                                                                                      Tissue Annulus Diameter - 25-

                                                                                                                                      35mm

SJ192            Epic Flexfit                                           Triple-composite Bioprosthetic heart                Aortic Valves 21-29mm tissue     $4,445.00

                                                                                                                                      annulus diameter, 14-20mm total

                                                                                                                                       height. Mitral Valves 25-33mm

                                                                                                                                      tissue annulus diameter, 15-

                                                                                                                                      20mm total height.

SJ201            Epic FlexFit Supra                                  Triple-composite Bioprosthetic heart                Tissue Annulus Diameter -         $4,445.00

                                                                            valve for supra-annular placement in the            19mm-23mm. Total Height

                                                                            aortic position

            B (Bovine), E (Equine), P (Porcine)

                 Edwards Lifesciences Pty Ltd

EL030           CE Supra Annular Aortic Valve Model          Carpentier-Edwards SAV Bioprosthesis.           19mm-33mm                         $4,445.00

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

                   Bioprosthesis Model 6650 Mitral Valve         Alloy; Silicone Rubber,

                 Medtronic Australasia Pty Ltd

MC701          Mosaic Cinch, Aortic, Mitral                      Models 305cxx, 310cxx                              19mm - 35mm                       $4,445.00  $5,345.00

MC771          Mosaic Ultra                                         Small Aortic Root Bioprosthesis                    19mm-29mm                         $4,445.00  $5,650.00

     Group 2b - Stented, pericardial

                 Edwards Lifesciences Pty Ltd

EL056           Magna Mitral                                        Carpentier-Edwards PERIMOUNT                 25, 27, 29, 31 and 33mm           $5,000.00  $5,690.00

                                                                            Magna Mitral Bioprosthesis, Model

                 Sorin Group

SA130           Mitroflow                                            Pericardial Bioprosthesis                             19-27mm                             $5,000.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 13 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            (p)  Pericardial

                 Edwards Lifesciences Pty Ltd

EL058           Magna Ease                                          Carpentier - Edwards PERIMOUNT               19, 21, 23, 25, 27 and 29mm      $5,000.00  $6,100.00

                                                                            Magna Ease Bioprosthesis, Model

            B (Bovine), E (Equine), P (Porcine)

                 Edwards Lifesciences Pty Ltd

EL031           Carpentier-Edwards Perimount                    Carpentier-Edwards Pericardial                      Models 2900/6900 19-33mm,     $5,000.00

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

                   2900/6900  Carpentier-Edwards                   Pericardium; Elgiloy Alloy; Silicone

                   Perimount Plus Pericardial Bioprosthesis        Rubber, Polytetrafluoroethylene

                    Mitral - Model 6900P

EL039           Edwards Perimount Magna Model 3000         Carpentier-Edwards Perimount Magna             19MM Aortic Pericardial Tissue $5,000.00  $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

     Group 2c - Non-Stented

                 Medtronic Australasia Pty Ltd

MC015          Freestyle bioprosthesis                             Models 995xx, 995MSxx                            19 - 35mm                            $5,110.00  $5,350.00

                 St. Jude Medical Australia Pty Ltd

SJ038            St Jude Medical Toronto SPV Valve             Tissue Heart Valves, Bioimplant                    TSPV: 21 - 29mm, Bioimplant    $4,900.00

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

                   Bioimplant Heart Valve                                                                                       Mitral: 27-32mm

            e

                 Advanced Biomedical Pty Ltd

AB070          ATS 3f Aortic Bioprosthesis (EQUINE)        Model 1000 - EQUINE Pericardium                19 - 29 mm                           $5,000.00

                                                                            Bioprostheseis (non stented)

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 14 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

Group 2: Dual Chamber ICD's

     Generation 3

                 Guidant Australia Pty Ltd

GU149          Vitality 2 DR - Model T165                       Dual Chamber ICD                                    30cc; 82g                            $43,680.00

GU150          Vitality 2 EL DR - Model T167                   Dual Chamber ICD                                    30cc; 82g                            $43,680.00

                 Sorin Group

SA140           OVATIO DR 6550                                 Titanium dual chamber ICD, 29 cc                  29cc                                  $43,680.00

            a

                 Boston Scientific Australia Pty Ltd

BS128           Confient RF HE                                     Dual chamber ICD, high energy with RF          44cc, 87.5g                         $45,760.00

                 Sorin Group

SA147           Paradym DR 8550                                  Dual Chamber, High Energy, Implantable          Weight: 90 grams; Volume:       $45,760.00

                                                                            Cardioverter Defibrillator with rate                  32.6cc; Dimensions: 58.4 x 73.4

                 St. Jude Medical Australia Pty Ltd

SJ115            Atlas II+ DR V-268                                Dual Chamber Cardioverter Defibrillator           39cc, 78g                            $45,760.00

SJ123            Current DR 2107                                    Dual Chamber Cardio-verter Defibrillator          39cc 78g                            $45,760.00

            A,C,D

                 Medtronic Australasia Pty Ltd

MC721          Virtuoso                                              DR ModelImplantable Cardioverter                 37cc, 68g                            $45,760.00

                                                                            Defibrillator, Dual Chamber

MC938          Virtuoso II                                           DR Model - Implantable Cardioverter               37cc, 68g                            $45,760.00

                                                                            Defibrillator, Dual Chamber

            A,D

                 Biotronik Australia Pty Ltd

BT086           Lumax 340 DR-T                                   ICD-DR 34 J with bidirectional Home              One Size Only                      $45,760.00  $48,760.00

                                                                            Monitoring. Dual chamber

BT101           Lumax 540 DR-T                                   High Energy, Dual-Chamber ICD                   Diamensions: 66*55*13mm,     $45,760.00  $48,760.00

                                                                            (Implantable Cardiac Defibrillator) with            Volume/Weight: 37.2cc/92g

                                                                            Advanced Patient Management Via unique

                                                                             Home Monitoring Technology

                                                                            incorporating Automatic Ventricular

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 15 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 Boston Scientific Australia Pty Ltd

BS135           Teligen 100 DR DF-1/IS-1                        Dual chamber ICD, high energy with RF          31.5cc, 9.9mm                      $45,760.00

                 St. Jude Medical Australia Pty Ltd

SJ120            Current DR RF 2207                               Dual Chamber Cardioverter Defibrillator           80g, 42cc                            $45,760.00

                                                                            with RF Telemetry

SJ144            AnalyST DR Model CD2217-36                 Dual Chamber cardioverter defibrillator             80g, 42cm                           $45,760.00  $47,760.00

                                                                            with RF telemetry and ST Segment

            A,D,E

                 Boston Scientific Australia Pty Ltd

BS134           TELIGEN 100 HE DR 4-SITE                    Dual Chamber ICD, high energy with RF          31.55cc, 9.9mm                    $46,510.00

            c

                 Guidant Australia Pty Ltd

GU157          Vitality AVT - Model A155                       Dual Chamber ICD with atrial therapies            30cc                                  $43,680.00

            D

                 Biotronik Australia Pty Ltd

BT091           Lumax 300 DR-T                                   ICD-DR with bidirectional Home                   One size only                       $43,680.00  $46,680.00

                 St. Jude Medical Australia Pty Ltd

SJ215            AnalyST DR CD2217-30                          Dual chamber cardioverter defribillator             74g, 38cc                            $43,680.00  $45,680.00

                                                                            with RF telemetry and ST segment

     Generation 4

            a, d, e

                 St. Jude Medical Australia Pty Ltd

SJ235            AnalyST Accel DR CD2219-36Q                Dual chamber cardioverter defibrillator             80g, 41cc                            $47,880.00

                                                                            with RF telemetry and ST segment

                                                                            monitoring and SJ4 connector

SJ239            Current Accel DR CD2215-36Q                  Dual Chamber Cardioverter Defibrillator           80g, 41cc                            $47,880.00

                                                                            with RF Telemetry and SJ4 connector

            A,C,D

                 Medtronic Australasia Pty Ltd

MC814          Secura DR                                            Fully Automatic, Wireless Implantable              37cc                                  $47,130.00

                                                                            cardioverter defibrillator with high energy

                                                                             capability and therapies for ventricular

                                                                            and atrial tachyarrhythmia

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 16 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            A,D

                 St. Jude Medical Australia Pty Ltd

SJ143            AnalyST Accel DR CD2219-36                  Dual Chamber cardioverter defibrillator             80g, 42cc                            $47,130.00  $48,480.00

                                                                            with RF telemetry and ST Segment

SJ153            Current Accel DR RF CD2215-36                Dual Chamber Cardioverter Defibrillator           80g, 42cc                            $47,130.00  $48,480.00

                                                                            with RF Telemetry

            D

                 St. Jude Medical Australia Pty Ltd

SJ214            Current Accel DR RF CD2215-30                Dual chamber cardioverter defribillator             74g, 38cc                            $46,030.00

                                                                            with RF telemetry

SJ217            AnalyST Accel DR CD2219-30                  Dual Chamber cardioverter defibrillator             74g, 38cc                            $46,030.00

                                                                            with RF telemetry and ST segment

Group 3 - Cardiothoracic Valve Conduits

     Group 3a - Mechanical Valve

                 Advanced Biomedical Pty Ltd

AB001          ATS Medical open pivot aortic valved            Pyrolythic Carbon, Double Velour                  21- 33mm                            $6,950.00

                   graft model 502AG                                 Polyester, Titanium

                 Medtronic Australasia Pty Ltd

MC198          Medtronic Hall rotatable aortic valved            Titanium, pyrolite, dacron                            20 - 33mm                            $6,950.00

                   collagen impregnated conduit Model

                 Sorin Group

SA128           CarboSeal Ascending Aortic Prosthesis,         Mechanical Conduit                                   AP 21-33mm, CP 21 - 33mm     $6,950.00

                   sterile, CarboSeal Ascending Aortic

                   Prosthesis with Handle Model AP21,

                   Model AP23, Model AP25, Model AP27,

                    Model AP29, Model AP31, Model

                   AP33, Carboseal Valsalva

                 St. Jude Medical Australia Pty Ltd

SJ036            St Jude Medical Coated Aortic Valved           Coated Aortic Valved Graft                          21mm - 33mm                       $6,950.00

SJ104            SJM Masters Series Aortic Valved               St Jude Medical Mechanical Heart Valve           Annulus Diameter 19-29mm       $6,950.00

                   Prosthesis - VAVGJ                                sewn into the base of a woven polyester

                                                                            fibre graft which has been impregnated

                                                                            with bovine-derived gelatin

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 17 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     Group 3b - Tissue Valve, stented porcine

                 Medtronic Australasia Pty Ltd

MC012          Medtronic Hancock Valved Conduit              Porcine bioprosthesis, dacron                        12, 14, 16, 18, 20, 22, 25,          $5,900.00  $6,800.00

                   Model 100/150

Group 3: ICD's with CRT

     Generation 2

                 Boston Scientific Australia Pty Ltd

BS129           LIVIAN CRT-D                                    CRT-D with RF                                       40cc, 79.5g, 14.5mm              $45,760.00

                 Guidant Australia Pty Ltd

GU147          Contak Renewal 4 CRT-D Model H190,         CRT-D                                                  One Size only                      $45,760.00

                   Model H195

                 Sorin Group

SA138           OVATIO CRT-D 6750                            Titanium, dual chamber ICD with CRT             30cc                                  $45,760.00

            a

                 Boston Scientific Australia Pty Ltd

BS130           LIVIAN CRT-D HE                                CRT-D, high energy with RF                        44cc, 87.5g, 14.5mm              $47,840.00

                 Guidant Australia Pty Ltd

GU144          Contak Renewal 4 HE CRT-D Model            CRT-D high energy                                   One size only                       $47,840.00

                   H197, Model H199

                 Sorin Group

SA145           PARADYM CRT-D 8750                         Implantable Cardioverter Defibrillator               34cc,  94 grams;  61.8 x 73.4 x   $47,840.00

                                                                            with Cardiac Resynchronisation therapy,           11mm

                                                                            High Energy

                 St. Jude Medical Australia Pty Ltd

SJ109            Atlas II+ HF V-367                                 Cardiac Resynchronisation Therapy                 41cc, 79g                            $47,840.00

                                                                            Defibrillator with V-V Timing

                                                                            Programmability

SJ117            Promote CRT-D 3107                              Cardiac Resynchronisation Therapy                 41cc, 80g                            $47,840.00

                                                                            Defibrillator

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 18 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            A,C

                 Guidant Australia Pty Ltd

GU155          Contak Renewal 4 AVT HE CRT - D -          Implantable Cardioverter Defibrillator               40cc; 89g                            $47,840.00

                   Model M177, M179                                with cardiac resynchronisation Therapy

            A,C,D

                 Medtronic Australasia Pty Ltd

MC720          Concerto CRT-D                                    Implantable Cardioverter Defibrillator               38cc                                  $47,840.00  $50,000.00

                                                                            with Cardiac Resynchronisation Therapy

MC937          Concerto II                                           Fully automatic, wireless implantable               38cc                                  $50,000.00

                                                                            cardioverter defibrillator with Cardiac

                                                                            Resynchronisation Therapy (CRT), and

                                                                            therapies for ventricular and atrial

                                                                            tachyarrhythmia.

            A,D

                 Biotronik Australia Pty Ltd

BT089           Lumax 340 HF-T                                    CRT-D 34 J with bidirectional Home               One Size Only                      $47,840.00  $53,000.00

                                                                            Monitoring

BT102           Lumax 540 HF-T                                    High Energy, Three Chamber ICD                  Diamensions: 66*59*13 mm,    $47,840.00  $53,000.00

                                                                            (Implantable Cardiac Defibrillator) with            Volume/Weight: 39.8cc/94g

                                                                            Advanced Patient Management Via unique

                                                                             Home Monitoring Technology

                                                                            incorporating Automatic RV/LV

                                                                            Threshold Monitoring and Extended

                 Boston Scientific Australia Pty Ltd

BS139           COGNIS 100 HE (DF-1/IS-1 & DF-            CRT-D high energy with RF                         32.5cc, 9.9mm                      $47,840.00

                 St. Jude Medical Australia Pty Ltd

SJ128            Promote RF CRT-D 3213                          Cardiac Resynchronisation Therapy                 43cc, 82g                            $47,840.00  $49,840.00

                                                                            Defibrillator with RF Telemetry

            A,D,E

                 Boston Scientific Australia Pty Ltd

BS138           COGNIS 100 HE 4-SITE                          CRT-D high energy with RF IS4                    32cc, 9.9mm                        $48,590.00

            c

                 Guidant Australia Pty Ltd

GU154          Contak Renewal 4 AVT CRT -D -                Implantable Cardioverter Defibrillator               37cc; 89g                            $45,760.00

                   Model M170 and M175                            with Cardiac Resynchronisation Therapy

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 19 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            D

                 Biotronik Australia Pty Ltd

BT088           Lumax 300 HF-T                                    CRT-D with bidirectional Home                     One size only                       $45,760.00  $48,760.00

     Generation 3

            a, d, e

                 St. Jude Medical Australia Pty Ltd

SJ236            Promote Accel CD3215-36Q                      Cardiac Resynchronisation Therapy                 82g, 43cc                            $52,750.00

                                                                            Defibrillator with RF Telemetry and SJ4

                                                                            connector

            A,C,D

                 Medtronic Australasia Pty Ltd

MC812          Consulta CRT-D                                    Fully Automatic, Wireless Implantable              38cc                                  $52,000.00

                                                                            cardioverter defibrillator with cardiac

                                                                            resynchronization therapy (CRT), and

                                                                            therapies for ventricular and atrial

                                                                            tachyarrhythmia

            A,D

                 St. Jude Medical Australia Pty Ltd

SJ150            Promote Accel RF CD3215-36                    Cardiac Resynchronisation Therapy                 82g, 43cc                            $52,000.00

                                                                            Defibrillator with RF Telemetry

            D

                 St. Jude Medical Australia Pty Ltd

SJ145            Promote Accel CD3215-30                        Cardiac Resyncronisation Therapy                  76g, 39cc                            $49,760.00

                                                                            Defibrillator with RF Telemetry

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 20 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

Group 4 - Cardiothoracic Atrio-Ventricular Rings and Bands

     Group 4a - Ring, Standard

                 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;               Ring. Composition: Elgiloy Bands;

                   Classic Annuloplasty Ring-Tricuspid             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;

                 Medtronic Australasia Pty Ltd

MC005          Medtronic Duran Annuloplasty Ring;            Annuloplasty Devices - Models 610R &           Model 610R 25-35mm & Model $2,200.00

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

                   Ancore Chordal Model 620RG

                 Sorin Group

SA127           AnnuloFlo Annuloplasty System                 Annuloflex Ring or AnnuloFlo Ring               26-36mm                             $2,200.00

                 St. Jude Medical Australia Pty Ltd

SJ035            SJM Tailor Annuloplasty Ring                    Fully Flexible                                          25mm - 35mm                       $2,200.00

     Group 4b - Ring, with modification

                 Edwards Lifesciences Pty Ltd

EL049           Edwards Etlogix Annuloplasty Ring              Titanium/silicon/dacron polyester                    24mm/26mm/28mm/30mm/32m  $2,400.00

                                                                            cloth/plastic template Mitral valve annular          m/34mmd

                                                                            repair device designed specifically for

                                                                            patients with Ischemic Mitral regurgitation

EL057           Geoform                                              Geoform annuloplasty ring Model 4200            26, 28, 30 and 32mm               $2,400.00

                                                                            with Holder

                 Medtronic Australasia Pty Ltd

MC745          CG Future Composite Ring                        Semi-rigid mitral annuloplasty ring, with           24, 26, 28, 30, 32, 34, 36 &        $2,400.00

                                                                            anterior flexibility

MC844          Profile 3D Annuloplasty Ring                     3D, rigid annuloplasty ring with                     Diameter (mm) 24 - 40mm         $2,400.00

                                                                            physiologic mitral valve shape

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 21 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 St. Jude Medical Australia Pty Ltd

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

SJ195            Attune Flexible Adjustable Annuloplasty        Flexible annuloplasty ring                            25mm - 43mm                       $2,200.00

                   Ring

     Group 4c - Band, Standard

                 Edwards Lifesciences Pty Ltd

EL050           Edwards MC3 Tricuspid Annuloplasty           Annuloplasty Ring,                                    26mm to 36mm in 2mm            $2,400.00

                   System                                                titanium/silicone/polyester velour

                                                                            cloth/plastic template

     Group 4d - Band, with modification

                 Medtronic Australasia Pty Ltd

MC709          Posterior Annuloplasty Band;  Colvin -          Annuloplasty - Model 610B & 620B               Model 610B: 25-35mm; Models $2,200.00

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

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

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

                                                                            includes-band, malleable handle, template

                                                                            with suture markers, sizers

                 Reid Healthcare

RH002          Kalangos Mitral Ring                               KALANGOS Mitral Ring is intended for          Diameter 16mm - 36mm, Height  $2,200.00  $2,500.00

                                                                            heart valve repair. Each device is                      10.62mm - 24.61mm

                                                                            characterized by a resorbable polymeric             Thickness 1.3mm - 1.5mm

                                                                            curved segment, processed in poly-1,4-

                                                                            dioxanone, moulded around a PVDF

                                                                            suture itself ended by swaged stainless

                                                                            steel needles. These three constituents are

                                                                             assembled in such a way that they

                                                                            cannot be shared or dismounted after

                                                                            assembly without irremediably destroying

                                                                             the device. For these reasons,

                                                                            KALANGOS Mitral Ring should be

                                                                            considered as a single device. Each

                                                                            extremity of the polymeric segment is

                                                                            terminated by a sharp end prolonged by

                                                                            the PVDF suture with a swaged stainless

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 22 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

RH003          Kalangos Tricuspid Ring                           KALANGOS Tricuspid Ring is intended          TRK16 5.10 Radius 1 (mm)        $2,200.00  $2,500.00

                                                                            for heart valve repair. Each device is                9.31 Radius 2 (mm) 3.1 Radius

                                                                            characterized by a resorbable polymeric             3 (mm) 5.44 Height (mm) 1.30

                                                                            curved segment, processed in poly-1,4-            Thickness (mm)

                                                                            dioxanone, moulded around a PVDF               TRK18 6.1 Radius 1 (mm)

                                                                            suture itself ended by swaged stainless             10.44 Radius 2 (mm) 4.1 Radius

                                                                            steel needles. These three constituents are          3 (mm) 7.98 Height (mm) 1.30

                                                                             assembled in such a way that they                  Thickness (mm)

                                                                            cannot be shared or dismounted after                TRK20 7.1 Radius 1 (mm) 8.92

                                                                            assembly without irremediably destroying         Radius 2 (mm) 5.1 Radius 3

                                                                             the device. For these reasons,                        (mm) 8.96 Height (mm) 1.30

                                                                            KALANGOS Tricuspid Ring should be            Thickness (mm)

                                                                            considered as a single device. Each                  TRK22 8.1 Radius 1 (mm) 9.27

                                                                            extremity of the polymeric segment is               Radius 2 (mm) 6.1 Radius 3

                                                                            terminated by a sharp end prolonged by            (mm) 10.05 Height (mm) 1.30

                                                                            the PVDF suture with a swaged stainless          Thickness (mm)

                                                                            steel needle on both sides.                            TRK24 9.1 Radius 1 (mm)

                                                                                                                                      11.21 Radius 2 (mm) 7.1 Radius

                                                                                                                                       3 (mm) 10.97 Height (mm)

                                                                                                                                      1.30 Thickness (mm)

                                                                                                                                      TRK26 10 Radius 1 (mm) 11.21

                                                                                                                                       Radius 2 (mm) 8 Radius 3

                                                                                                                                      (mm) 10.37 Height (mm) 1.50

                                                                                                                                      Thickness (mm)

                                                                                                                                      TRK28 10.5 Radius 1 (mm)

                                                                                                                                      16.71 Radius 2 (mm) 9 Radius 3

                                                                                                                                       (mm) 11.02 Height (mm) 1.50

                                                                                                                                      Thickness (mm)

                                                                                                                                      TRK30 12 Radius 1 (mm) 11.9

                                                                                                                                      Radius 2 (mm) 10 Radius 3

                                                                                                                                      (mm) 12.83 Height (mm) 1.50

                                                                                                                                      Thickness (mm)

                                                                                                                                      TRK32 13 Radius 1 (mm) 15.45

                                                                                                                                       Radius 2 (mm) 11 Radius 3

                                                                                                                                      (mm) 13.15 Height (mm) 1.50

                                                                                                                                      Thickness (mm)

                                                                                                                                      TRK34 14 Radius 1 (mm) 16.25

                                                                                                                                       Radius 2 (mm) 12 Radius 3

                                                                                                                                      (mm) 13.5 Height (mm) 1.50

                                                                                                                                      Thickness (mm)

                                                                                                                                      TRK36 15 Radius 1 (mm) 15.85

                                                                                                                                       Radius 2 (mm) 13 Radius 3

                                                                                                                                      (mm) 16.09 Height (mm) 1.50

                                                                                                                                      Thickness (mm)

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 23 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 St. Jude Medical Australia Pty Ltd

SJ088            SJM Tailor Annuloplasty Band                   Flexible double-velour, polyester fabric            25 - 35mm                            $2,200.00

Group 4: Single Chamber Pacemakers

     Generation 1

                 St. Jude Medical Australia Pty Ltd

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

     Generation 2

                 St. Jude Medical Australia Pty Ltd

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

     Generation 3

                 Biotronik Australia Pty Ltd

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

                                                                            SSIR pacemaker

BT080           Cylos VR                                             single chamber dual sensor rate responsive        one size only                         $5,928.00

BT106           Cylos 990 SR                                        Single-chamber pacemaker with Closed            57 x 39 x 6mm / 27g                $5,928.00

                                                                            Loop Stimulation (CLS)

BT109           Entovis SR                                           Fully automatic, extended longevity,                53 x 39 x 6.5W x H x D [mm],    $5,928.00

                                                                            single cFully automatic, extended                    Size 1 [cm3],  25 Mass[g]

                                                                            longevity, single chamber pacemaker with

                                                                             Closed Loop Stimulation.

BT113           Evia SR                                               Fully automatic, extended longevity,                53 x 39 x 6.5 W x H x D [mm],   $5,928.00

                                                                            single chamber pacemaker with Closed             Size 10[cm3], 25 Mass [g]

                                                                            Loop Stimulation.

                 Boston Scientific Australia Pty Ltd

BS124           Insignia AVT 1192                                 Single chamber rate responsive                      10cc, 23.4g                           $5,928.00

BS145           Altrua 20 SR                                         Single chamber rate responsive                      10cc - 15cc                           $5,928.00

BS147           Altrua 40 SR                                         Single chamber rate responsive                      10cc - 15cc                           $5,928.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 24 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

BS149           Altrua 50 SR                                         Single chamber rate responsive                      10cc - 15cc                           $5,928.00

BS152           Altrua 60 SR                                         Single chamber rate responsive                      10cc - 15cc                           $5,928.00

                 Guidant Australia Pty Ltd

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

GU139          Insignia Ultra SR Model 1190                     Single Chamber Rate Responsive                    One size only                        $5,928.00

                 Medtronic Australasia Pty Ltd

MC728          Adapta Pacemaker                                   SR PacemakerModels ADSR01,                    9.7 - 11.0cc21.5 - 22.5g            $5,928.00

                                                                            ADSR06, ADSR03

                 Sorin Group

SA137           Symphony SR                                       Titanium                                                one size only                         $5,928.00

SA142           Reply™ SR                                          Single chamber permenent pacemaker               37 x 41.5 x 6.1mm                  $5,928.00

                                                                            with rate response modulation                       19 Grams

                                                                                                                                      7.5 cm3

SA143           ESPRIT SR                                          Single Chamber Permanent Pacemaker             Dimensions: 37.4 x 41.5 x         $5,928.00

                                                                            with Rate Response Modulation                     6.1mm Weight : 19grams.

                 St. Jude Medical Australia Pty Ltd

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

                   implantable pacemaker                              adaptive pacing device

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

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

SJ105            Zephyr SR 5620                                     Single Chamber Rate-Responsive                   8cc, 17g                               $5,928.00

SJ131            Zephyr XL SR 5626                                Single-Chamber Rate-Responsive                   23.5g and 10.4cc                    $5,928.00

SJ205            Accent SR PM 1110                                Single Chamber Rate Responsive                    18g, 9.5cc                            $5,928.00

            a

                 St. Jude Medical Australia Pty Ltd

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

                   2525T Pacemaker

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 25 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            D

                 Biotronik Australia Pty Ltd

BT108           Entovis SR-T                                        Fully automatic, extended longevity,                53 x 39 x 6.5 W x H x D [mm],   $5,928.00  $8,928.00

                                                                            single chamber pacemaker with Closed             Size 11 [cm3], 24 mass[g]

                                                                            Loop Stimulation & BIOTRONIK Home

                                                                            Monitoring

BT110           Evia SR-T                                            Fully automatic, extended longevity,                53 x 39 x 6.5 W x H x D [mm],   $5,928.00  $8,928.00

                                                                            single chamber pacemaker with Closed             Size 11 [cm3], 24 Mass [g]

                                                                            Loop Stimulation & BIOTRONIK Home

                                                                            Monitoring

                 St. Jude Medical Australia Pty Ltd

SJ200            Accent SR RF PM1210                            Single Chamber Pacemaker with RF                23g, 12.8cc                           $5,928.00  $7,928.00

Group 5 - Cardiothoracic Membranes and Patches

     Group 5a - Tissue

                 Advanced Biomedical Pty Ltd

AB066          Supple Peri-Guard (10 x 16cm)                   Model No PC1016SN - 10 x 16 Bovine            10 x 16cm                              $760.00

                                                                            pericardium patch

AB067          Supple Peri-Guard (8 x 14cm)                     Nodel No PC0814SN - 8 x 14 Bovine              8 x 14cm                                $700.00

                                                                            pericardium patch

AB068          Supple Peri-Guard (6 x 8cm)                      Model No PC0608SN -6 x 8cm Bovine            6 x 8cm                                 $610.00

                                                                            pericardium patch

AB069          Supple Peri-Guard (4 x 4cm)                      Model No PC0404SN - 4 x 4cm Bovine           4 x 4cm                                 $350.00

                                                                            pericardium patch

                 Edwards Lifesciences Pty Ltd

EL033           Baxter Augmentation / Substitution               Edwards Pericardial Patch. Bovine                  10cm x 16cm                           $760.00

                   Material, Human or Animal Origin,               Pericardium.

                   Sterile Pericardial Patch.

     Group 5b - Synthetic, Cardiovascular

                 Tag Medical

TM040          Repel - CV                                           Bioresorbable Adhesion Barrier                     18cmx13.5cmx137 microns          $550.00

                 W L Gore & Associates

GT117           Gore-Tex - Cardiovascular Patch                  ePTFE                                                   0.4mm Thickness 2 x 9cm            $240.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 26 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

GT118           Gore-Tex - Cardiovascular Patch                  ePTFE                                                   0.4mm - 3 x 6cm                       $280.00

                                                                                                                                      0.6mm - 2.5cm x 15cm & 5cm

                                                                                                                                      x 7.5cm

GT120           Gore-Tex  Cardiovascular Patch                   ePTFE                                                   0.6mm Thickness 5 x 15cm          $521.00

GT121           Gore-Tex Cardiovascular Patch                   ePTFE                                                   0.6mm Thickness 10 x 15cm         $945.00

GT126           Acuseal Cardiovascular Patch Vascular          ePTFE                                                   0.5mm Thickness 1 x 9cm; 0.8       $223.00

                                                                                                                                      x 7.5cm

GT127           Acuseal Cardiovascular Patch Cardiac            ePTFE                                                   0.5mm Thickness 3 x 6cm & 5       $270.00

                                                                                                                                      x 7.5cm

     Group 5c - Synthetic, Non-cardiovascular

                 W L Gore & Associates

GT122           Preclude Pericardial Membrane                    ePTFE                                                   0.1mm Thickness 6 x 12cm          $360.00

GT123           Preclude Pericardial Membrane                    ePTFE                                                   0.1mm Thickness 8 x 16cm          $643.00

GT124           Preclude Pericardial Membrane                    ePTFE                                                   0.1mm Thickness 12 x 12cm         $748.00

GT125           Preclude Pericardial Membrane                    ePTFE                                                   0.1mm Thickness 15 x 20cm      $1,455.00

Group 5: Dual Chamber Pacemakers

     Generation 1

                 Boston Scientific Australia Pty Ltd

BS123           Insignia AVT 882                                   Dual chamber VDD pacemaker                      10.0cc, 23.5g                         $5,200.00

BS150           Altrua 50 VDD                                      Dual chamber VDD pacemaker                      10cc - 15cc                           $5,200.00

                 St. Jude Medical Australia Pty Ltd

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

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

     Generation 2

                 Medtronic Australasia Pty Ltd

MC713          Adapta Pacemaker                                   VDDR PacemakerModels ADVDD01             11.1cc23.6g                          $6,760.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 27 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 St. Jude Medical Australia Pty Ltd

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

                   implantable pacemaker                              adaptive pacing device with extended

                                                                            longevity

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

     Generation 3

                 Biotronik Australia Pty Ltd

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

BT104           Cylos 990 DR                                       Dual-chamber pacemaker with Closed              57* 43* 6mm/28g                   $9,360.00

                                                                            Loop Stimulation (CLS)

BT105           Cylos 990 DR-T                                     Dual-chamber pacemaker with Closed              57*43*6mm/28g                    $9,360.00  $12,360.00

                                                                            Loop Stimulation (CLS) and Biotronik

                                                                            Home Monitoring Technology

                 Boston Scientific Australia Pty Ltd

BS126           Insignia AVT 1292                                 Dual chamber rate responsive pacemaker           10.8cc, 25.4g                         $9,360.00

BS144           Altrua 20 DR                                        Dual chamber rate responsive pacemaker           10cc - 15cc                           $9,360.00

BS146           Altrua 40 DR                                        Dual chamber rate responsive pacemaker           10cc - 15cc                           $9,360.00

BS148           Altrua 50 DR                                        Dual chamber rate responsive pacemaker           10cc - 15cc                           $9,360.00

BS151           Altrua 60 DR                                        Dual chamber rate responsive pacemaker           10cc - 15cc                           $9,360.00

                 Guidant Australia Pty Ltd

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

GU140          Insignia Ultra DR Model 1291                    Dual Chamber Rate Responsive                     One size only                        $9,360.00

GU141          Insignia Ultra DR Model 1290                    Dual Chamber Rate Responsive                     One size only                        $9,360.00

                 Sorin Group

SA136           Symphony DR 2550                                Active Implantable pacemaker                       1 size only                            $9,360.00

SA141           Reply™ DR                                          Dual Chamber permanent Pacemaker               8cc, Weight: 20grams,              $9,360.00

                                                                            with Rate Response Modulation                     Dimensions:41.2 x 41.5 x

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 28 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

SA144           ESPRIT DR                                          Dual Chamber Permanent Pacemaker               8cc, Weight: 20grams,              $9,360.00

                                                                            with Rate Response Modulation                     Dimensions:41.2 x 41.5 x

                 St. Jude Medical Australia Pty Ltd

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

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

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 8ccADx XL DR

                                                                                                                                      5386: 44x52x6mm, 23.5g and

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

            b

                 Medtronic Australasia Pty Ltd

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

                                                                            chamber pacemaker with Anti-

                                                                            Tachycardia functions: DDDRP

MC935          EnRhythm MRI SureScan                         Model EMDR01, MRI Conditional, Rate          13cc, 22g                            $11,440.00

                                                                            Responsive Dual Chamber Pacemaker

                                                                            with Anti-Tachycardia functions and

            D

                 Biotronik Australia Pty Ltd

BT071           Philos II DR-T                                       Dual Chamber Rate Responsive with               One size only                        $9,360.00  $12,360.00

                                                                            Home Monitoring

BT079           Cylos DR-T                                          Dual chamber dual sensor rate responsive          one size                               $9,360.00  $12,360.00

                                                                             with home monitoring system option

     Generation 4

                 Biotronik Australia Pty Ltd

BT111           Entovis DR                                           Fully automatic, extended longevity, Dual          53 x 43 x 6.5W x H x D [mm], $11,440.00

                                                                            Chamber Pacemaker with Closed Loop             Size 11 [cm3], 26 Mass [g]

                                                                            stimulation & Vp Suppression

BT112           Evia DR                                              Fully automatic, extended longevity, Dual          53 x 43 x 6.5 W x H x D [mm], $11,440.00

                                                                            Chamber Pacemaker with Closed Loop             Size 11 [cm3], 26 Mass [g]

                                                                            stimulation & Vp Suppression.

                 Medtronic Australasia Pty Ltd

MC726          Adapta Pacemaker                                   DR PacemakerModels ADDR01,                   11.1-14.2cc23.6g-31.3g           $11,440.00

                                                                            ADDRS1, ADDRL1, ADDR06, ADDR03

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 29 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 St. Jude Medical Australia Pty Ltd

SJ103            Zephyr XL DR 5826 and DR 5820               Dual Chamber Rate-Responsive                     5826 - 23.5g, 11cc and 5820 -    $11,440.00

                                                                                                                                      18g, 8.5cc

SJ193            Accent DR PM 2112                               Dual Chamber Pacemaker                            19g, 10.5cc                         $11,440.00

            b

                 Medtronic Australasia Pty Ltd

MC933          Advisa DR MRI SureScan                         Model A3DR01 Digital dual chamber              13cc, 22g                            $11,780.00

                                                                            pacemaker with SureScan Technology

                                                                            (OAE-DDDR) MR Conditional with MVP

                                                                             Mode, Complete Capture Management

                                                                            Diagnostic (ACM, RVCM), AT/AF Suite

                                                                            Diagnostics and Therapies, OptiVol Fluid

                                                                            Status Monitoring, and Therapy Guide

MC934          Advisa DR                                           Model A5DR01 Digital dual chamber              13cc, 22g                            $11,780.00

                                                                            pacemaker (OAE-DDDR)  MVP mode

                                                                            with Complete Capture Management

                                                                            Diagnostic (ACM, RVCM)  AT/AF Suite

                                                                            Diagnostics and Therapies, OptiVol Fluid

                                                                            Status Monitoring, and Therapy Guide

            D

                 Biotronik Australia Pty Ltd

BT114           Evia DR-T                                            Fully automatic, extended longevity, Dual          53 x 44.5 x 6.5 W x H x D       $11,440.00  $14,440.00

                                                                            Chamber Pacemaker with Closed Loop             [mm], Size 12 [cm3], 25 Mass

                                                                            stimulation, Vp Suppression and

                                                                            BIOTRONIK Home Monitoring

BT115           Entovis DR-T                                        Fully automatic, extended longevity, Dual          53 x 44.5 x 6.5 W x H x D       $11,440.00  $14,440.00

                                                                            Chamber Pacemaker with Closed Loop             [mm], Size 12 [cm3], 25 Mass

                                                                            stimulation, Vp Suppression and

                                                                            BIOTRONIK Home Monitoring

                 St. Jude Medical Australia Pty Ltd

SJ196            Accent DR RF PM2212                            Dual chamber Pacemaker with RF                   236, 12.8cc                         $11,440.00  $13,440.00

Group 6 - Cardiothoracic Assisted Anastomic Devices

                 Medtronic Australasia Pty Ltd

MC680          Spyder                                                Proximal Anastomotic Device                       6-clip assembly                        $590.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 30 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

Group 6: CRT Pacemakers

     Generation 2

                 Guidant Australia Pty Ltd

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

                   H140, Model H145

                 Medtronic Australasia Pty Ltd

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

                   Pacemaker Model 8042

                 St. Jude Medical Australia Pty Ltd

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

            D

                 Biotronik Australia Pty Ltd

BT085           Stratos LV-T                                         Multiprogrammable Biventricular DDDRV        One size only                       $12,480.00  $15,480.00

                                                                             with Home Monitoring

     Generation 3

                 St. Jude Medical Australia Pty Ltd

SJ194            Anthem PM3112 CRT Pacemaker                Cardiac Resynchronisation Therapy                 21g, 11.5cc                         $13,520.00  $14,560.00

                                                                            Pacemaker

            D

                 St. Jude Medical Australia Pty Ltd

SJ207            Anthem RF PM3212                               CRT Pacemaker with RF telemetry                  25g, 13.7cc                         $13,520.00  $14,560.00

Group 7 - Cardiothoracic Assisted Fixation Devices

     Group 7a Valvular

                 Medtronic Australasia Pty Ltd

MC714          U-Clips (Valve Repair)                             Double Arm, Mitral Valve Repair                   2-packs                                  $510.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 31 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     Group 7b Related to anastomosis

                 Medtronic Australasia Pty Ltd

MC765          U-Clips                                               Nitinol Clips, 8-pack                                  Needle Lengths: 6.5mm -             $336.00

                                                                                                                                      9.5mm, 8-pack

MC772          U-Clips                                               Nitinol Clips, 2-pack                                  Needle Lengths: 6.5mm -               $84.00

                                                                                                                                      9.5mm, 2-Pack

     Group 7c Related to skeletal fixation

            s

                 Advanced Biomedical Pty Ltd

AB074          FLEXIGRIP (Various Sizes)                      Nitinol Sternal Closure Clips - various sizes       20mm - 40mm                           $80.00  $160.00

Group 7: ICD Leads

     Sub -Group 1: Coronary Sinus Leads

                 Medtronic Australasia Pty Ltd

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

                   6937;                                                  6937-58, Model 6937-110; Silicone;

     Sub -Group 2: Subcutaneous Leads

                 Guidant Australia Pty Ltd

GU123          Endotak SQ Array XP Lead Model 0085        Sub-Q Array for high DFT                          70cm                                  $4,680.00

                 Medtronic Australasia Pty Ltd

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

                   Lead Model 6996SQ 41cm, 58cm,

     Sub -Group 5: Transvenous/ Steroid/ Passive  Leads

                 Biotronik Australia Pty Ltd

BT092           Linox TD                                             Fractal and steroid coated passive fixation          65, 74 or 100cm length and 16     $9,360.00

                                                                             quadripolar ICD lead                                 or 18mm electrode spacing

BT093           Linox T                                               Passive fix RV bipolar fractal coated                65, 75cm length                      $9,360.00

                                                                            steroid ICD lead

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 32 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

BT119           Linox SMART TD                                  Linox SMART TD is a family of ICD              Length:  Linox SMART TD       $9,360.00

                                                                            leads with an active fixation helix.  The             65/16 65cm, Linox SMART TD

                                                                            fixation helix is comprised of platinum              65/18 65cm, Linox SMART TD

                                                                                                                                      75/18 75cm; Lead Body

                 Guidant Australia Pty Ltd

GU115          Endotak Reliance Lead                              Passive Dual Coil                                      59cm, 64cm, 90cm                  $9,360.00

GU158          Endotak Reliance SG Passive                      Passive Single Coil wih GORE ePTFE             54cm - 90cm                         $9,360.00

                                                                            covered coils

GU159          Endotak Reliance G Passive                       Passive Dual Coil with GORE ePTFE              54cm - 90cm                         $9,360.00

                                                                            covered coils

                 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

                 Sorin Group

SA148           ISOLINE 2CT                                       Passive fixation, steroid eluting,                     Lead body is 7.8 French            $9,360.00

                                                                            intergrated bipolar, dual shock coil                  diameter whilst 65cm in length

                 St. Jude Medical Australia Pty Ltd

SJ110            Riata ST Transvenous Tachyarrhythmia          Riata ST 7040/41 Passive-Fixation True-          60 - 75cm, 6.3 Fr, 7 Fr              $9,360.00

                    Leads 7040/41/42 and 7050/51/52               Bipolar, Dual-Coil, Steroid-eluting,

                                                                            Endocardial Defibrillation Leads, 7042 -

                                                                            Single Coil, 7050/51 - Integrated Bipolar,

                                                                            Dual Coil, 7052 - Integrated Bipolar,

                                                                            Single Coil

SJ130            Riata ST Optim 7070/1                             Passive Fixation, True bipolar, Dual Coil,          60, 65 and 70cm length, 7Fr       $9,360.00

                                                                            Steroid Eluting, Endocardial Defibrillation         introducer

                                                                            Leads with Optim insulation overlay

SJ158            Durata 7170, 7171                                  Passive fixation, true bipolar, dual coil,             60, 65 and 70cm                     $9,360.00

                                                                            steroid eluting, endocardial defibrillation

                                                                            leads with Optium insulation overlay

            a

                 Boston Scientific Australia Pty Ltd

BS170           Endotak Reliance S 4-SITE                        Passive fixation single coil defibrillation            50-70cm                              $9,360.00

                                                                            leads & 4-SITE connector.

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 33 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

BS180           Endotak Reliance G 4-SITE                        Passive fixation dual coil defibrillation              50-70cm                              $9,360.00

                                                                            leads with ePTFE covered coils & 4-

                                                                            SITE connector

BS181           Endotak Reliance SG 4-SITE                      Passive fixation single coil defibrillation            50-70                                  $9,360.00

                                                                            leads with ePTFE covered coil & 4-SITE

BS183           Endotak Reliance 4-SITE                           Passive fixation dual coil defibrillation              50-70cm                              $9,360.00

                                                                            leads with 4-SITE connector

     Sub -Group 6: Transvenous/ Steroid/ Active Leads

                 Biotronik Australia Pty Ltd

BT084           Linox SD                                             Fractal coated and steroid electrode,                 65, 75cm length, 16, 18mm elec   $9,000.00  $9,360.00

                                                                            active fixation quadrapolar

BT096           Linox S                                               Active fix RV bipolar fractal coated                 65, 75cm length                      $9,000.00  $9,360.00

                                                                            steroid IC lead

BT120           Linox SMART SD                                  Linox SMART SD is a family of ICD              Length:  Linnox SMART SD      $9,000.00

                                                                            leads with an active fixation helix for the           60/16 61.2cm; Linnox SMART

                                                                            therapy of tachycardia arrhythmia.  The             SD 65/16 65cm;  Linnox

                                                                            active fixation helix is comprised of                 SMART SD 65/18 65cm;

                                                                                                                                      Linnox SMART SD 75/18

                 Guidant Australia Pty Ltd

GU163          ENDOTAK RELIANCE G Active               Active Dual Coil with GORE ePTFE               59-90cm                              $9,000.00

                                                                            covered coils

GU164          ENDOTAK RELIANCE SG Active             Active Single coil with GORE ePTFE              59-90cm                              $9,000.00

                                                                            covered coils

                 Medtronic Australasia Pty Ltd

MC208          Medtronic Sprint Quattro Secure Lead            Leads, Defibrillator, Implantable, Silicone,         58-100cm                             $9,000.00

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

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

MC834          Sprint Quattro Secure S                            Model 6935, Active Fixation Single Coil           52 - 100cm                           $9,000.00

                                                                            Defibrillation Lead

                 Sorin Group

SA146           ISOLINE 2CR                                       Active fixation, steroid eluting, integrated          Lead body is 7.8 French            $9,000.00  $9,360.00

                                                                            bipolar, dual coil defibrillation lead                  diameter whilst 65cm in length

                 St. Jude Medical Australia Pty Ltd

SJ074            Riata Transvenous tachyarrhythmia               Tri-polar Active - Fixation, Steroid-                 60cm, 65cm, 8F introducer         $9,000.00  $9,360.00

                   Leads Model 1582                                  Eluting, Single shock Coil

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 34 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

SJ075            Riata Transvenous Tachyarrhythmia              Quadripolar, dual-coil, steroid eluting,              One size only                        $9,000.00  $9,360.00

                   Lead Model 1580, Model 1581                    active fixation tachyarrhythmia leads

SJ081            Riata i Transvenous Tachyarrhythmia             Active fixation leads, Steroid Eluting,               60cm, 65cm, 75cm, 8F              $9,000.00  $9,360.00

                   Leads Model 1590/1591                            Dual Shock Coil Defibrillation Lead

SJ084            Riata i Transvenous Tachyarrhythmia             Active Fixation, Steroid Eluting, Single             60cm, 65cm, 75cm, 8F              $9,000.00  $9,360.00

                   Lead Model 1592                                    Shock Coil Defibrillation Lead

SJ096            Riata ST 7000/7001/7002                          Active-Fixation True-Bipolar, Dual-Coil,           60, 65cm 7F introducer             $9,000.00  $9,360.00

                                                                            (7002 - Single-Coil) Steroid-Eluting

                                                                            Steroid Eluting, Endocardial Defibrillation

SJ122            Riata ST Optim 7020/1/2 and 7030/1             7020/1 - Active fixation, true bipolar,               60, 65 and 75cm length and 7Fr   $9,000.00  $9,360.00

                                                                            7022 - Active fixation, true bipolar -                introducer

                                                                            single coil, 7030/1 - Active fixation,

                                                                            integrated bipolar, dual coil steroid eluting

                                                                             endocardial defibrillation leads with

                                                                            Optim insulation overlay

SJ157            Durata 7120, 7121, 7122, 7130, 7131            Active fixation bipolar, dual-coil/single             60, 65, 75cm                         $9,000.00  $9,360.00

                                                                            coil Steroid-eluting Endocardial

                                                                            Defibrillation Leads

            a

                 Boston Scientific Australia Pty Ltd

BS174           Endotak Reliance SG 4-SITE                      Active fixation single coil defibrillation             50-70cm                              $9,000.00

                                                                            leads with ePTFE covered coil & 4-SITE

BS178           Endotak Reliance 4-SITE                           Active fixation dual coil defibrillation leads        50-70cm                              $9,000.00

                                                                             with 4-SITE connector

BS179           Endotak Reliance S 4-SITE                        Active fixation single coil defibrillation             50-70mm                             $9,000.00

                                                                            leads & 4-SITE connector

BS182           Endotak Reliance G 4-SITE                        Active fixation dual coil defibrillation leads        50-70cm                              $9,000.00

                                                                             with ePTFE covered coils & 4-SITE

                                                                            connector.

                 St. Jude Medical Australia Pty Ltd

SJ230            Durata 7120Q, 7121Q and 7122Q                7120/1Q - Adtive fixation, true bipolar;             52cm, 58cm and 65cm              $9,000.00  $9,360.00

                                                                            7122Q - Active fixation true bipolar -

                                                                            single coil steroid eluting endocardial

                                                                            defibrillation leads with Optim insulation

                                                                            overlay and SJ4 quadripolar lead

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 35 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

SJ233            Riata ST Optim 7020Q, 7021Q, 7022Q          7020/1Q - Active fixation, true bipolar;             52cm, 58cm and 65cm              $9,000.00  $9,360.00

                                                                            7022Q - Active fixation true bipolar -

                                                                            single coil steroid eluting endocardial

                                                                            defibrillation leads with Optim insulation

                                                                            overlay and SJ4 quadripolar lead

     Sub -Group 7: Epicardial Patches

                 Medtronic Australasia Pty Ltd

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

Group 8 - Cardiothoracic Grafts (Proximal Aorta)

     Group 8b Modified Tube

                 Terumo Corporation Australia

TU036           Gelweave Valsalva Graft                           Woven vascular prosthesis, polyester,              Diameter 24 - 34 mm, Overall     $3,320.00

                                                                            gelatin sealed                                           length 18.4 - 19.6cm

     Group 8c Tube with one side branch

                 Terumo Corporation Australia

TU038           Gelweave Graft                                      Straight Thoracic Graft, with antiflo side           20 -34 mm x 20-40 cm             $1,715.00

                                                                            branch, Polyester, woven, gelatin sealed

     Group 8d Tube with multiple side branches (more than 1)

                 Terumo Corporation Australia

TU037           Gelweave Plexus Graft                             Multi Branched, for Aortic Arch                     20 - 34 mm x 40 cm                 $2,150.00

                                                                            reconstruction, Polyester, Woven, gelatin

                                                                            sealed

Group 8: Pacemaker Leads

     Sub-Group 1: Non-transvenous, Bi-Polar, Steroid

                 Boston Scientific Australia Pty Ltd

BS153           Myopore                                              Bipolar sutureless myocardial pacing lead          25-54cm                              $1,716.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 36 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 Medtronic Australasia Pty Ltd

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

                   epicardial lead Model 4968 - ventricle

                 St. Jude Medical Australia Pty Ltd

SJ132            Myodex 1084T                                      Steroid-Eluting Bipolar Sutureless                   35cm and 54cm                      $1,716.00

                                                                            Myocardial Pacing Lead with Titanium

                                                                            Nitride Electrodes

SJ140            Myodex 1084T and FasTac Flex Lead            Steroid -Eluting Bipolar Sutureless                  35cm and 54cm, Lead implant     $1,716.00  $1,966.00

                   Implant Tool                                         Myocardial Pacing Lead with Titanium             tool - 44cm

                                                                            Nitride Electrodes and Lead implant tool

                                                                            with articulating distal end.

     Sub-Group 11: Transvenous, Bi-Polar, Passive, Steroid, Left Ventricular

                 Biotronik Australia Pty Ltd

BT095           Corox OTW BP                                     Coronary Sinus bipolar steroid                      77, 87 cm length                     $6,240.00

                 Guidant Australia Pty Ltd

GU138          Easytrak 2, Model 4514, 4515, 4516,             Bipolar, passive fixation                              .                                        $6,240.00

                   4517, 4518, 4519, 4520

GU153          Easytrak 2 Is-1 Lead - Models 4542,             Bipolar, passive fixation                              80 to 100cm                          $6,240.00

                   4543 & 4544

GU156          Easytrak 3 Lead - Models 4521, 4522,           Bipolar, passive fixation                              80 to 100cm                          $6,240.00

                   4523, 4524, 4525, 4526 and 4527

GU162          Easytrak 3 IS-1 Lead                                Bipolar, passive fixation                              Sizes 80 to 100cm                   $6,240.00

GU165          Acuity Steerable Lead                               Bipolar, passive fixation                              80cm, 90cm ,100cm                 $6,240.00

                 Medtronic Australasia Pty Ltd

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

MC811          Attain Ability 4196 LV Lead                      Over the wire dual electrode left                     78, 88, and 103 cm                  $6,240.00

                                                                            ventricular lead

                 St. Jude Medical Australia Pty Ltd

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

SJ126            QuickSite XL 1058T                                Bipolar, Steroid-Eluting, Titanium Nitride          75-86cm                              $6,240.00

                                                                            Coated Electrodes, Guidewire/Stylet-

                                                                            Placed Left Heart Lead with Fast-Pass

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 37 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

SJ139            Quickflex 1156T and XL 1158T                  Bipolar, Steroid-Eluting, Titanium Nitride          Length 75 and 86cm                $6,240.00

                                                                            Coated Elextrodes, Guidewire/Stylet-

                                                                            Placed Left Heart Lead with Fast-PassTM

            a

                 St. Jude Medical Australia Pty Ltd

SJ208            Quick Flex µ 1258T                                4F Bipolar Left Ventricular Pacing Lead           75cm, 86cm, 92cm                  $6,240.00

     Sub-Group 13: Transvenous, Active, Steroid, Left Ventricular

                 Medtronic Australasia Pty Ltd

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

     Sub-Group 2: Non-transvenous, Uni-Polar, Steroid

                 Medtronic Australasia Pty Ltd

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

                   epicardial lead Model 4965 ventricle

     Sub-Group 3: Non-transvenous, Uni-Polar, Non-Steroid

                 Medtronic Australasia Pty Ltd

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

                   Model 5071

     Sub-Group 4: Transvenous, Uni-Polar, Passive, Steroid, Right Ventricular/Atrial

                 Medtronic Australasia Pty Ltd

MC254          CapSure Sense pacemaker lead Models          Titanium Nitride                                       30 - 85cm                             $1,248.00

                 St. Jude Medical Australia Pty Ltd

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

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

     Sub-Group 5: Transvenous, Uni-Polar, Passive, Non-Steroid, Left Ventricular

                 St. Jude Medical Australia Pty Ltd

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

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 38 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     Sub-Group 6: Transvenous, Uni-Polar, Passive, Steroid, Left Ventricular

                 Biotronik Australia Pty Ltd

BT070           Corox OTW UP Steroid                            Coronary Sinus Lead                                  77, 87cm                              $3,120.00

                 Boston Scientific Australia Pty Ltd

BS133           Acuity Spiral                                         Unipolar passive fixation                             80, 90 & 100cm                     $3,120.00

                 Medtronic Australasia Pty Ltd

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

                 St. Jude Medical Australia Pty Ltd

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

     Sub-Group 8: Transvenous, Bi-Polar, Passive, Steroid, Right Ventricular/Atrial

                 Biotronik Australia Pty Ltd

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

BT117           Siello JT                                              The Siello JT is a family of sub 6F,                 Length: Siello T 45 cm; Siello T   $1,248.00

                                                                            steroid-eluting, transvenous, endocardial,           53 cm;  Diameter:  5.6Fr

                                                                            bipolar passive-fixation leads that carries

                                                                            a j-shaped distal end.

BT118           Siello T                                               The Siello T is a family of sub 6F,                   Length:  Siello T 53cm; Siello T   $1,248.00

                                                                            steroid-eluting, transvenous, endocardail,           60cm  Diameter: 5.6Fr

                                                                            bipolar passive-fixation leads that carries

                                                                            a j-shaped distal end.

                 Guidant Australia Pty Ltd

GU009          Fineline II Sterox IROX Lead                     Bipolar passive fixation                               52cm, 58cm                          $1,248.00

GU011          Fineline II Sterox IROX Lead                     Bipolar passive fixation                               52cm, 58cm                          $1,248.00

GU012          Fineline II Sterox IROX Lead                     Bipolar, passive fixation                              45cm, 52cm                          $1,248.00

GU023          Guidant Aust Selute Picotip Steroid               Model 4035, Model 4064                            45cm, 52cm, 59cm                  $1,248.00

                   Eluting Bipolar Lead

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 39 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

                 Medtronic Australasia Pty Ltd

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

MC229          Medtronic Capsure SP Novus Model             Silicone, platinum                                      30-100cm                             $1,180.00

                   5594 Lead 30cm

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

                   5054 Pacing Lead                                   anchoring sleeve, stylet & guide, 1 x vein

                                                                            lifter, 2 x fixation tools, extra stylets

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

                   5554 Pacing Lead                                   anchoring sleeve, stylet & guide, 1 x vein

                                                                            lifter, 2 x fixation tools, extra stylets

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

                 St. Jude Medical Australia Pty Ltd

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

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

SJ146            Isoflex 1944T & 1948T                            Passive-Fixation, Bipolar, Steriod Eluting,         46cm, 52cm, 58cm                  $1,248.00

                                                                            Endocardial Pacing Lead with Optim

                                                                            insulation

            b

                 Guidant Australia Pty Ltd

GU028          Guidant Aust Selute Picotip VDD Lead          VDD bipolar, passive fixation                       .                                        $1,544.00

                 Medtronic Australasia Pty Ltd

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

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 40 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     Sub-Group 9: Transvenous, Bi-Polar, Active, Steroid, Right Ventricular/Atrial

                 Biotronik Australia Pty Ltd

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

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

                                                                            coated and steroid eluting electrode

BT097           Dextrus (marketed by Boston Scientific)         Bipolar, silicone, active fixation, steroid            7Fr, with 45cm, 53cm and          $1,248.00

                                                                            eluting, pacing lead                                    60cm length options

BT116           Siello S                                               The Siello S is a family of sub 6F,                   Length: Siello S45 cm; Siello      $1,248.00

                                                                            steroid-eluting, trasvenous, endocardial,            S53 cm; Siello S 60 cm;

                                                                            bipolar active-fixation leads with an

                                                                            extendable/retractible, electrically active

                                                                            screw.

                 Guidant Australia Pty Ltd

GU013          Fineline II EZ Sterox IROX Lead                 Bipolar, active fixation                                45cm, 52cm, 58cm                  $1,248.00

GU016          Fineline II EZ Sterox IROX Lead                 Bipolar, active fixation                                45cm, 52cm, 58cm                  $1,248.00

GU122          Flextend Lead Models 4086, 4087 &             Bipolar, active fixation                                45,52,59cm                           $1,248.00

                 Medtronic Australasia Pty Ltd

MC008          Medtronic Capsurefix Model 5568                Silicone Polyurethane                                 30 - 85cm                             $1,215.00

                   Pacing Leads

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

                   5076 Pacing Lead                                   anchoring sleeve, stylet & guide, 1 x vein

                                                                            lifter, 2 x fixation tools, extra stylets

MC833          CapSureFix Novus Model 4076 Pacing          Active fixation pacemaker lead                       45 - 85cm                             $1,248.00

MC936          CapSure Fix MRI Pacing Lead                    Model 5086, MRI Conditional                       42, 52, 58 cm                        $1,248.00

                 St. Jude Medical Australia Pty Ltd

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

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

SJ118            OptiSense 1699T/1699TC                         Endocardial, Bi-polar Active-fixation               40-58cm                              $1,248.00

                                                                            Pacing Leads with Optim Insulation

SJ125            Tendril ST 1788T/TC and 1782TC               Endocardial Bipolar Steroid-Eluting Active        40cm, 46cm, 52cm, 58cm, 65cm  $1,248.00

                                                                             Fixation Pacing Leads

SJ129            Tendril ST 1888TC and 1882TC                  Endocardial Bi-polar Steroid-Eluting                46-65cm                              $1,248.00

                                                                            Active Fixation Pacing Leads

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 41 of 866


CARDIO-THORACIC

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

SJ151            OptiSense Model 1999                             Active-Fixation Bipolar, Steroid Eluting,           40, 46 & 52cm                       $1,248.00

                                                                            endocardial, atrial pacing lead with Optim

                                                                            insulation

SJ238            Tendril STS 1988TC and 2088TC                Endocardial Bi-polar Steroid-Eluting                46cm, 52cm and 58cm              $1,248.00

                                                                            Adtive Fixation Pacing Leads

            a

                 Medtronic Australasia Pty Ltd

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

Group 9: Pacemaker/ICD Adaptors

                 Medtronic Australasia Pty Ltd

MC246          DF-I Y-Adaptor/Extender Model 6726           Silicone                                                 Lengths 25cm, 37cm                  $500.00

                   25cm & 37cm

MC778          Oscor Adaptor                                       Adaptor for LV-1 lead to unipolar and              10cm, 17cm and 40cm                $500.00

                                                                            bipolar IS-1

MC832          Adaptor Kit Model 5866-24M, 5866-            Silicone                                                 14cm                                    $500.00

                   40M, 5866-37M, Bipolar Lead Adaptor

                   Kit Model 2872

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 42 of 866


EAR, NOSE & THROAT

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

2.1.2 Cochlear Implants

     2.1.2.4 Cochlear Implants - Implantable Auditory Stimulator - Generation 4

                 Boston Scientific Australia Pty Ltd

BS159           Harmony ™ HiResolution® Bionic Ear          The HiRes 90K with HiFocus 1j Electrode         Straight array (1j).  56.0mm (L) $12,570.00

                   System - HiRes 90K Implant Cochlear            is the implanted component of the                   x 28.0mm (W) x 3.0mm (D)

                   Stimulator with HiFocus 1j Electrode             HiResolution Bionic Ear System. It

                                                                            receives information through an RF

                                                                            transmission coil, processes the

                                                                            information and then sends the resulting

                                                                            signal to an electrode array implanted in

                                                                            the cochlea. It consists of

                                                                            receiving/transmitting coil, Stimulator

                                                                            electrodes and HiFocus 1j Electrode

BS160           Harmony ™ HiResolution® Bionic Ear -        The HiRes 90K with HiFocus Helix                Helix (coiled) electrode array -   $13,570.00

                   HiRes 90K Implant Cochlear Stimulator          Electrode is the implanted component of            56.0mm (L) x 28.0mm (W) x

                   with HiFocus Helix Electrode                     the HiResoulution Bionic Ear System. It            3.0mm (D)

                                                                            receives information through an RF

                                                                            tranmission coil, precesses the

                                                                            information and then sends the resulting

                                                                            signal to an electrode array implanted in

                                                                            the cochlea. It consists of

                                                                            receiving/transmitting coil, Stimulator

                                                                            electronics and HiFocus Helix Electrode

                 Cochlear Limited

CO024          Nucleus Freedom Implant with Straight          Speech processor and accessories - Initial          One size only                       $12,570.00

                   Electrode

                 Pacing Importers Pty Ltd - Life Systems

PI011            Sonata Ti 100 Cochlear Implant                   Cochlear implant, titanium casing, 24               45.7mm length, width at coil      $12,570.00

                                                                            independent current sources, sequential             29.0mm, width at stimulator

                                                                            and parallel stimulation modes up to                 24.8mm, thickness at coil

                                                                            50,074 pulses per sec, 19 or 24 oval-               3.7mm, thickness at stiulator

                                                                            shaped platinium electrodes, different sizes        5.9mm.  Standard Electrode -

                                                                                                                                      length 31.5mm, spacing 2.4mm;

                                                                                                                                       Medium - length: 20.9mm,

                                                                                                                                      Spacing 1.9mm; Compressed

                                                                                                                                      (short) - length 12.1mm, Electro

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 43 of 866


EAR, NOSE & THROAT

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            Electroacoustic, Hybrid Technology

                 Pacing Importers Pty Ltd - Life Systems

PI018            Sonata TI with FLEX EAS electrode             Cochlear Implant with atraumatic                    One size                             $12,570.00

                                                                            electrode specifically designed for partial

                                                                            deafness & hearing preservation surgery

            Hybrid Technology

                 Cochlear Limited

CO043          Nucleus Hybrid L 24 Implant                      A Nucleus Freedom cochlear implant               One size                             $12,570.00  $13,570.00

                                                                            featuring a special 16mm, 22 contact

                                                                            point electrode array

            Perimodiolar

                 Cochlear Limited

CO021          Nucleus Freedom Implant with Contour          Model C124RE (CA), Generation 4                 one size only                        $13,570.00

                   Advance Electrode                                  Cochlear implant with perimodiolar

                                                                            electrode array.  Titanium casing,

                                                                            removable magnet, 22 half-banded

                                                                            platinum electrodes, moulded in a durable

CO046          Cochlear™ Nucleus® CI512 Cochlear           Model CI512, 5th generation cochlear              One Size                            $13,570.00

                   Implants with Contour Advance                   implant with perimodiloar electrode array.

                                                                             Titanium casing, removable magnet, 22

                                                                            half-banded platinum electrodes, moulded

                                                                             in a durable silicone seal.

2.1.3 Speech Processors

     2.1.3.4 Initial - Generation 4

                 Boston Scientific Australia Pty Ltd

BS161           Harmony™ HiResolution® Bionic Ear           The Auria Harmony Processor is an                Sound Processor Size 54 mm    $11,500.00

                   System - Behind The Ear Sound                   external component of the HiRes Bionic            (H) x 13mm (TH) x 21 mm (w).

                   Processor - Auria Harmony Sound               Ear System. This processor is intended to          Headpiece Diameter: 28.1 mm

                   Processor (INITIAL Order)                       deliver HiResolution sound to a cochlear

                                                                            implant by converting sound waves

                                                                            (received via a microphone) into an

                                                                            electrical signal which is then transmitted

                                                                            to the implant via a headpiece. This listing

                                                                             includes sound processor, headpiece,

                                                                            earhooks, powercels, rechargers, cables

                                                                            and essential accessories.

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 44 of 866


EAR, NOSE & THROAT

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

BS164           Harmony™ HiResolution® Bionic Ear           The Platinum Sound Processor is a body           PSP only one size; 2.69' x 2.19" $11,500.00

                   System -Body worn sound processor -           worn component of the HiRes Bionic Ear          x 0.81"                       

                   Platinum Series Processor (PSP)                  System. This processor is intended to               Headpiece cable : options 18, 24,

                   INITIAL Order                                      deliver HiResolution sount to a cochlear             32, 42 and 48 inches

                                                                            implant by converting soundwaves

                                                                            (received via a microphone in the

                                                                            Platinum Headpiece) into an electrical

                                                                            signal that is then transmitted to the

                                                                            implant via the headpiece. This listing

                                                                            consists of the sound processor,

                                                                            headpiece, connecting cables, and

                 Cochlear Limited

CO022          Nucleus Freedom Speech Processor -            Speech processor (modular) and                     One size only                       $11,500.00

CO048          Cochlear™ Nucleus® CP810 Sound             The ear level sound processor of the                One size                             $11,500.00

                   Processor - INITIAL                               Nucleus 5 cochlear implant system with

                                                                            multiple wearing options and a remote

                 Pacing Importers Pty Ltd - Life Systems

PI009            OPUS 2 Speech Processor                         Cochlear implant speech processor, fine            54.0mm x 35.1mm x 8.7mm     $11,500.00

                                                                            structure speech processing, remote

                                                                            control, interface for assistive listening

                                                                            devices according to the international

                                                                            hearing aid standard (initial patient kit)

            Electroacoustic

                 Cochlear Limited

CO044          Freedom Hybrid Sound Processor                The modular sound processor of the                One size                             $12,950.00

                                                                            Cochlear Hybrid system provides dual

                                                                            electrical and acoustic processing within

                                                                            a single device. Acoustic amplication is

                                                                            delivered through the acoustic component

                                                                             and electrical stimuation via the Nucleus

                 Pacing Importers Pty Ltd - Life Systems

PI007            Duet EAS Hearing System                         Cochlear implant speech processor and             Length 53.5mm, width 8.5mm,   $12,950.00

                                                                            accoustic hearing aid combined in one              Height 58.4mm (one size only)

PI019            DUET 2                                              Audio Processor for Electric and                    50.6mm x 8.5mm x 59.7mm     $12,950.00

                                                                            Acoustic Stimulation (2nd Generation

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 45 of 866


EAR, NOSE & THROAT

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     2.1.3.7 Replacement - Generation 3

                 Cochlear Limited

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

     2.1.3.8 Replacement - Generation 4

                 Boston Scientific Australia Pty Ltd

BS162           Harmony™ HiResolution® Bionic Ear           The Auria Harmony Processor is an                Sound Processor - one size 54     $8,050.00

                   System -Behind The Ear Sound                   external component of the HiRes Bionic            mm (H) x 13mm (TH) x 21 mm

                   Processor - Auria Harmony Sound               Ear System. This processor is intended to

                   Processor (REPLACEMENT Order)             deliver HiResolution sound to a cochlear

                                                                            inplant by converting sound waves

                                                                            (received via a microphone) into an

                                                                            electrical signal which is then transmitted

                                                                            to the implant via a headpiece. This listing

                                                                             Processor only.

BS165           Harmony™ HiResolution® Bionic Ear           The Platinum Sound Processor is a body           PSP: one size; 2.69' x 2.19" x      $8,050.00

                   System - Body worn Platinum Sound            worn component of the HiRes Bionic Ear

                   Processor (PSP) REPLACEMENT Order       System. This processor is intended to

                                                                            deliver HiResolution sount to a cochlear

                                                                            implant by converting soundwaves

                                                                            (received via a microphone in the

                                                                            Platinum Headpiece) into an electrical

                                                                            signal that is then transmitted to the

                                                                            implant via the headpiece. This listing

                                                                            comes with the processor only.

                 Cochlear Limited

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

                                                                            REPLACEMENT

CO049          Cochlear™ Nucleus® CP810 Sound             The ear level sound processor of the                One size                              $8,050.00

                   Processor - REPLACEMENT                     Nucleus 5 cochlear implant system with

                                                                            multiple wearing options and a remote

                 Pacing Importers Pty Ltd - Life Systems

PI010            Opus 2 Speech Processor Replacement          Cochlear implant speech processor, fine            54.0mm x 35.1mm x 8.7mm       $8,050.00

                                                                            structure speech processing, remote

                                                                            control, interface for assistive listening

                                                                            devices according to the international

                                                                            hearing aid standard (replacement kit)

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 46 of 866


EAR, NOSE & THROAT

                                                                                                                                                                                     Minimum                                                                                                                                                                                     Maximum

Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

            Electroacoustic

                 Cochlear Limited

CO045          Freedom Hybrid Sound Processor                The modular sound processor of the                One size                              $9,065.00

                   (Replacement)                                        Cochlear Hybrid system provides dual

                                                                            electronic and acoustic processing within

                                                                            a single device. Acoustic amplication is

                                                                            delivered through the acoustic component

                                                                             and electrical stimulation is delivered via

                                                                            the Nucleus Hybrid L24 implant.

2.1.4 Cochlear Implants, Accessory Kit or Item

                 Boston Scientific Australia Pty Ltd

BS163           Harmony ™ HiResolution® Bionic Ear          1x HPwcable; 1x direct connect                     various                                  $500.00

                   System - Behind the Ear Sound                    earhook; 1x standard earhook;

                   Processor Auria Harmony Essential              1x audio cable; 1x monitor

                                                                            earphone.

BS166           Harmony ™ HiResolution® Bionic Ear          1x HP cable; 1x Auxiliary                            various                                  $500.00

                   System - Body worn Sound Processor -         microphone; 1x telephone

                    Platinum Series Processor (PSP)                 adaptor; 1x monitor earphone

                   Essential Accessory Kit

     2.1.4.1 Cochlear Implants - Accessory Kit or Item, Initial

                 Cochlear Limited

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

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

                                                                            clip, battery cover set and accessory case

2.1.5 Implantable Bone Conduction Hearing System

     2.1.5.1 Implantable bone conduction hearing system, Sound processor, Generation 1 - Body

                 Cochlear Limited

CO033          Baha Cordelle II sound processor                 A powerful sound processor for the Baha          One Size                              $6,000.00  To be claimed only for patients

                                                                             hearing system with a bodyworn unit                                                                             with deafness who have

                                                                            and a head worn transducer.  Available in                                                                             problems using air conduction or

                                                                            three colours. Body worn sound                                                                          conventional hearing aids which

                                                                            processor for the Baha hearing system.                                                                            is made worse when a hearing

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 47 of 866


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Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     2.1.5.4 Implantable bone conduction hearing system, Sound processor, Generation 2 - Head

                 Cochlear Limited

CO040          Baha Divino sound processor                     Head worn digital sound processor for             One Size                              $6,000.00

                                                                            the Baha hearing system.  Available in

                                                                            four colours and left and right side

CO041          Baha Intenso sound processor                     Head worn digital sound processor for             One size                              $6,000.00

                                                                            the Baha hearing system.  Available in

                                                                            four colours.

CO047          Cochlear™ Baha® BP100 sound                 Fully programmable head worn sound              One size - 30 x 21 x 12mm        $6,500.00  $6,900.00

                                                                            processor for the Baha implantable bone

                                                                            conduction hearing system

     2.1.5.5 Implantable bone conduction hearing system, Osseointegration abutment

                 Cochlear Limited

CO025          Baha Abutment Snap Coupling                    Titanium abutment delivered with a gold            5.5mm - 9035, 8.5mm - 90410      $895.00

                                                                            screw and holder, individually packaged

                                                                            and sterile.  The 5/5mm is for standard

                                                                            use and the 8.5mm for patients that have

                                                                            persistent regrowth of subcutaneous tissue

CO032          Flange fixture - self tapping fixture with          Self tapping titanium flange fixture with            Self Tapping 4mm and 3mm       $1,930.00

                   pre-mounted abutment                              abutment in two sizes:  3mm and 4mm             with BAHA Abutment

CO050          Baha BA210 Abutment                             Titanium abutments compatible with                5.5mm and 8.5mm                     $895.00

                                                                            hexagonal coupling Baha implants

CO052          Baha BA300 abutment.                             Titanium abutment of the Baha BI300               6mm and 9mm                         $895.00

                                                                            implant system.

     2.1.5.6 Implantable bone conduction hearing system, Cover screw

                 Cochlear Limited

CO028          BAHA - Cover screw unigrip                     Titanium coverscrews, individually                  One size only                           $142.00

                                                                            packaged and delivered sterile.  The cover

                                                                             screws are used to prevent bone

                                                                            overgrowth of the implant.

CO054          Baha Cover Screw conical                         Titanium cover screw of the Baha BI300           One size                                 $142.00

                                                                            implant system used in the two-stage

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Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     2.1.5.7 Implantable bone conduction hearing system, Osseointegration fixture

                 Cochlear Limited

CO030          Self tapping fixture with pre-mounted            Self tapping titanium flange fixture                  Self Tapping 4mm and 3mm       $1,035.00

                   fixture mount                                         premounted with a disposable fixture

                                                                            mount.  Available in two sizes: 3mm and

                                                                            4mm.  Used in two stage surgical

CO051          Baha BI300 implants                                Titanium self-tapping fixture of the Baha           3mm and 4mm                       $1,035.00

                                                                            BI300 implant system with TiObaslt

     2.1.5.8 Implantable bone conduction hearing system, Osseointegration abutment and

                 Cochlear Limited

CO053          Baha BIA300 implants with abutments           Pre-mounted self tapping titanium implant         3mm implant with 6mm             $1,930.00

                                                                             and abutment of the BI300 implant                 abutment, 4mm implant with

                                                                            system, for the Baha FAST surgery.                6mm abutment, 4mm implant

2.1.6 Ossicle/Middle Ear Prosthesis

     2.1.6.1 Ossicle/Middle Ear Prosthesis, Stapes - Metal

                 LMA PacMed Pty Ltd

PM032          K-Piston                                              Gold/Titanium                                          ID 0.4,0.6mm                          $104.00  $222.00

                 Medtronic Australasia Pty Ltd

MC922          Middle Ear Prostheses                              Stapes                                                   0.4 - 1.17mm x 0.9 - 4.0mm x       $104.00  $190.00

                                                                                                                                      4.0 x 10.2mm; 4.0 - 4.75mm

                 Olympus Australia

OL022           Piston: Stapes Prosthesis                           a) Armstrong. Platinum, b) McGee.                 a) 0.6x3.5-0.8x5mm, b)               $104.00

                                                                            Stainless steel, c) Richards.  Teflon &               0.6x3.25-0.8x5.5mm, c)

OL023           Piston: Stapes Prosthesis                           Fisch-Type Platinum or Stainless Steel             0.4mm  x 6mm                         $104.00

            Extra large

                 Medtronic Australasia Pty Ltd

MC918          The Big Easy Piston                                Big Easy Range - MRI Safe, Triple Width         0.4 - 1.17mm x 0.9 - 4.0mm x       $104.00  $350.00

                                                                             Platinum Band, Double Width Platinum           4.0 x 10.2mm; 4.0 - 4.75mm

                                                                            Shaft with Offset Versions

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Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

     2.1.6.2 Ossicle/Middle Ear Prosthesis, Stapes - Non-metal

                 Medtronic Australasia Pty Ltd

MC923          Middle Ear Prostheses                              Stapes                                                   0.4 - 1.17mm x 0.9 - 4.0mm x       $104.00  $190.00

                                                                                                                                      4.0 x 10.2mm; 4.0 - 4.75mm

                 Olympus Australia

OL012           Canal Wall Prosthesis                               Grote, HA                                              Small - Large                           $104.00  $543.00

OL014           Ossicular Prosthesis                                Attic Defect Plate, HA                                7-14mm                                 $104.00  $335.00

OL018           Piston: Stapes Prosthesis                           a) Schuknecht Malleus att Piston.                    a) 0.6x5.5mm-0.8x6.5, b)             $104.00

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

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

                                                                            Schuknecht. Stainless steel, e) Causse.               0.4x3.5-0.5x5mm, e) one size

OL024           Piston: Stapes Prosthesis                           Platinum Fluoroplastic                                0.6x3.5mm - 0.8x5mm                $104.00

OL025           Piston: Stapes Prosthesis                           Platinum Fluoroplastic                                0.6x3mm - 0.8x5.75mm              $104.00

OL075           Piston: Stapes Prosthesis                           Smart: Nitinol/Flouroplastic                          0.5, 0.6, 0.8 x 3.75-4.75mm          $104.00  $535.00

     2.1.6.5 Ossicle/Middle Ear Prosthesis, Middle Ear Bone, Malleus - Metal

                 Medtronic Australasia Pty Ltd

MC924          Middle Ear Prostheses                              Malleus                                                 0.4 - 1.17mm x 0.9 - 4.0mm x       $190.00

                                                                                                                                      4.0 x 10.2mm; 4.0 - 4.75mm

     2.1.6.6 Ossicle/Middle Ear Prosthesis, Middle Ear Bone, Malleus - Non-Metal

                 Medtronic Australasia Pty Ltd

MC919          Prostheses Malleus                                  Hydroxyapatite                                         0.6 - 4.0mm x 2.7 - 5.0mm x         $190.00

                                                                                                                                      1.5 - 10.0mm

     2.1.6.9 Ossicle/Middle Ear Prosthesis, Middle Ear Bone, TORP or PORP

            PORP

                 LMA PacMed Pty Ltd

PM028          Stapes                                                 Bell/Aerial/Angular Prosthesis/Piston  -            1.75 - 7.00mm                         $300.00  $401.00

                                                                            Gold/Titanium

                 Medtronic Australasia Pty Ltd

MC262          Partial Ossicular Reconstruction Implant         Malleus + Incus                                        0.4 - 1.17mm x 2.2 - 8.8mm x       $300.00  $360.00

                                                                                                                                      3.5 - 10.0mm

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Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

MC920          Flex H/A Incus Necrosis Prostheses                                                                        2.5 - 4.0mm x 10.0mm                $300.00  $360.00

MC921          Middle Ear Prostheses                              Malleus+ Incus                                        Small, Medium, Large, 0.6 x 2.2    $300.00  $360.00

                                                                                                                                       x 8.0mm

                 Olympus Australia

OL016           Ossicular Prosthesis - PORP                      Sheehy plastipore, Drum to stapes, Grote          One size only                           $300.00

                                                                            Malleus to stapes, modified, centered or

                                                                            offcentered

OL017           Ossicular Prosthesis - PORP/TORP              Goldenberg Malleable/HA                           One Size Only                         $300.00  $580.00

            TORP

                 Medtronic Australasia Pty Ltd

MC260          Middle Ear Prosthesis                              Total Ossicular Reconstruction Implants           0.6 - 0.8mm x 3.0 - 4.0mm x         $404.00

                                                                                                                                      7.0 - 8.0mm

MC261          Universal Ossicular Reconstruction               Malleus + Incus + Stapes                             0.6 - 1.17mm x 0.3 - 4.0mm x       $404.00

                   Implants - Titanium                                                                                            4.75 - 8.0mm

MC263          Total Ossicular Reconstruction Implant          Malleus + Incus + Stapes                             0.5 - 0.6mm x 3.5 - 6.0mm and      $404.00

                                                                                                                                      One Size Only

                 O R Paradigm Pty Ltd

OS001           ALTO Prosthesis                                    Adjustable Length Titanium Ossicular              Head Size 2.5mm x 3.5mm;          $404.00  $750.00

                                                                            Chain Reconstruction Prosthesis                    Length 2.0mm - 8.0mm; Distal

                                                                                                                                      Diameter 0.8mm - 1.2mm

                 Olympus Australia

OL013           Ossicular Prosthesis Malleus, Incus and         Goldenberg Footplate - HA                          One size only                           $404.00

                   Stapes

OL015           Ossicular Prosthesis Incus                         a) Applebaum HA,  b) Goldenberg HA,            a) small - large, b) one size only,    $404.00

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

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

OL019           Ossicular Prosthesis -TORP                       a) black spanner strut HA, b) black oval            a) one size only, b) 7-10mm, c)      $404.00  $675.00

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

                                                                            universal, HA/fluoroplastic

OL020           Ossicular Prosthesis -TORP                       Fisch plastipore, Causse modified                   One size only                           $404.00

                                                                            plastipore, Shea modified plastipore/

                                                                            fluoroplastic, Austin modified plastipore,

OL021           Ossicular Prosthesis -TORP                       a) Shea malleable, HA/plastipore, b) Shea          a) one size only, b) 4-8mm           $104.00

                                                                            plastipore

OL073           Dornhoffer Prostheses                              Hydroxyapetite head/HAPEX shaft PORP         0.8mm Shaft Dia TORP, 1.3mm    $404.00

                                                                            and TORP                                              Shaft Diameter PORP

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Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

OL074           Ossicular Chain Prosthesis                         Micron adjustable TORP/PORP. Titanium         2-10mm, 2-5mm                       $404.00

2.1.7 Ventilation Tube/Grommet

     2.1.7.10 Ventilation Tube/Grommet, Silicone, Short Term

                 LMA PacMed Pty Ltd

PM090          Tympo Vent                                          Otological ventilation tubes, armstrong             Length 3.8 - 10.0mm                   $20.00

            AB, Medium

                 Medtronic Australasia Pty Ltd

MC279          Medtronic Vent Tubes                              Antimicrobial Ventilation Tube                      1.02 - 1.27mm x 2.7 - 9.1mm         $20.00  $22.00

            Medium

                 Medtronic Australasia Pty Ltd

MC276          Medtronic Vent Tubes                              Silicone                                                 0.76 - 1.27mm x 1.0 - 7.5mm         $20.00

     2.1.7.11 Ventilation Tube/Grommet, Silicone, Medium Term

                 Medtronic Australasia Pty Ltd

MC927          Medtronic Vent Tube                                                                                          1.02 - 1.52mm x 1.3 - 12.0mm        $20.00

                 Olympus Australia

OL027           Ventilation Tube                                     Shepard grommet, fluoroplastic or                   1.02 -1.14mm                            $20.00

                                                                            silicon, vent tube w/wire.

OL032           Ventilation Tube                                     T-Tube Richards Modified Soft Silicon             1.32mm                                   $20.00

OL035           Ventilation Tube                                     Grommet - Sha Mini. Teflon                         0.76mm                                   $20.00

OL036           Ventilation Tube                                     Shah. Teflon, Silicon                                  5.1mm                                    $20.00

OL055           Ventilation Tube                                     Collar Button Silicon                                  1.27mm                                   $20.00

OL058           Ventilation Tube                                     Donaldson Silicon                                     1.14mm                                   $20.00

OL059           Ventilation Tube                                     Donaldson Soft Silicon                               1.14mm                                   $20.00

OL060           Ventilation Tube                                     Donaldson Silicon w/Tab                             1.14mm                                   $20.00

OL061           Ventilation Tube                                     Donaldson Fluoroplastic                              1.14mm                                   $20.00

OL063           Ventilation Tube                                     Duravent Silicon                                       1.27mm                                   $20.00

OL066           Ventilation Tube                                     Shea  w/Tab - Silicone                                0.76mm                                   $20.00

OL067           Ventilation Tube                                     Shea Parasol w/Tab Small Flange -                  1.02mm                                   $20.00

Prostheses List by Category, Groups and Sponsor                                                                                                              Page 52 of 866


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Billing Code   Product Name                                      Description                                            Size                                         Benefit          Benefit                                               Notations

OL068           Ventilation Tube                                     Shea Parasol w/Tab - Silicone                       1.02mm                                   $20.00

OL069           Ventilation Tube                                     Shea Parasol w/Tab - Silicone                       1.52mm                                   $20.00

            AB