FEBRUARY 2006 PROSTHESES LIST
GAP PERMITTED PROSTHESES
Billing
Product Name Sponsor Minimum Benefit Maximum Benefit Gap
Code
AC022 Flyer RX Coronary Stent System Atrium Australia-Pacific Rim Pty Ltd $750.00 $1,450.00 $700.00
AD281 Micronail intramedullary radial fixation Advanced Surgical Technologies $1,620.00 $1,930.00 $310.00
AD282 Micronail intramedullary radial fixation Advanced Surgical Technologies $220.00 $268.00 $48.00
AD286 BFH Total, A-class Advanced Surgical Technologies $3,300.00 $3,740.00 $440.00
AD305 Micronail Intramedullary Radial Fixation Advanced Surgical Technologies $250.00 $292.00 $42.00
AL017 Alcon AcrySof ReSTOR PC Diffractive IOL Model SA60D3 Alcon Laboratories (Aust.) Pty Ltd $750.00 $950.00 $200.00
AL022 Alcon AcrySof ReSTOR PC Diffractive IOL Natural Model Alcon Laboratories (Aust.) Pty Ltd $790.00 $1,040.00 $250.00
SN60D3
AL023 Alcon AcrySof Toric PC IOL Models Alcon Laboratories (Aust.) Pty Ltd $540.00 $690.00 $150.00
AO002 Sensar AR40 Monofocal Acrylic IOL, Sensar OptiEdge AR40e Advanced Medical Optics Australia Pty $310.00 $360.00 $50.00
Foldable Acrylic IOL Ltd
AO003 Intraocular Lens: Allergan AMO Duralens Posterior Chamber IOL Advanced Medical Optics Australia Pty $150.00 $190.00 $40.00
Model PS42ANB, PS53ANB, PS60ANB, PS59NB, PS60AMB Ltd
AO004 Intraocular Lens: Allergan AMO Array Multifocal UV Absorbing Advanced Medical Optics Australia Pty $320.00 $360.00 $40.00
Silicone Posterior Chamber IOL Model SA-40N Ltd
AO006 Clariflex, Model CLRFLXB Posterior Chamber Intraocular Lens Advanced Medical Optics Australia Pty $310.00 $360.00 $50.00
Ltd
AO011 Anterior Chamber IOL; Pharmacia Heparin Surface Modified AC Advanced Medical Optics Australia Pty $190.00 $200.00 $10.00
IOL Model 352C Ltd
AO014 Tecnis TM Intraocular Lens Advanced Medical Optics Australia Pty $350.00 $400.00 $50.00
Ltd
AO016 Verisyse AC IOL Advanced Medical Optics Australia Pty $653.40 $700.00 $46.60
Ltd
AO017 Verisyse AC IOL Advanced Medical Optics Australia Pty $653.40 $700.00 $46.60
Ltd
AO018 Verisyse AC IOL Advanced Medical Optics Australia Pty $853.40 $1,400.00 $546.60
Ltd
AO019 Verisyse AC IOL Advanced Medical Optics Australia Pty $150.00 $400.00 $250.00
Ltd
AO020 ReZoom Acrylic Multifocal Intraocular Lens Advanced Medical Optics Australia Pty $320.00 $420.00 $100.00
Ltd
AO022 Posterior Chamber IOL; Pharmacia Heparin Surface Modified AC Advanced Medical Optics Australia Pty $190.00 $200.00 $10.00
IOL Model 352C Ltd
Pg 1
FEBRUARY 2006 PROSTHESES LIST
GAP PERMITTED PROSTHESES
Billing
Product Name Sponsor Minimum Benefit Maximum Benefit Gap
Code
AO023 Tecnis Multifocal Intraocular Lens Advanced Medical Optics Australia Pty $750.00 $950.00 $200.00
Ltd
AS111 IVS Tunneller System Auto Suture Company, Australia T/A $540.00 $636.00 $96.00
Tyco Healthcare Pty Ltd
AS119 DST Series* EEA* Circular Stapler Auto Suture Company, Australia T/A $790.00 $864.00 $74.00
Tyco Healthcare Pty Ltd
AX020 S2 Nail System Austofix $1,050.00 $1,400.00 $350.00
BT071 Philos II DR-T Biotronik Australia Pty Ltd $9,000.00 $10,000.00 $1,000.00
CR057 AMC Uni Condylar Tibial Component - Bonit Coat Corin Australia Pty Ltd $2,427.00 $2,841.00 $414.00
CR061 AMC Uni Condylar, Cemented Tibial Base Plate Corin Australia Pty Ltd $1,665.00 $2,172.00 $507.00
CS001 Staar foldable silicone intraocular lens: Model AA4203VF; Model ConceptVision Australia Pty Ltd $270.00 $285.00 $15.00
AA4204VF; AA4204VL;
CS005 Staar foldable silicone intraocular lens: KS-3 Model AS310NV ConceptVision Australia Pty Ltd $290.00 $305.00 $15.00
CS006 Staar foldable silicone IOLs: Model KS-1 (AS-110NV) preloaded ConceptVision Australia Pty Ltd $290.00 $305.00 $15.00
Intraocular lens
CS007 Staar foldable silicone IOLs: Models AQ2010V, AQ2017V and ConceptVision Australia Pty Ltd $270.00 $285.00 $15.00
AO2003V
DE253 MicroSil Toric IOL Device Technologies Australia Pty Ltd $500.00 $716.00 $216.00
DE254 MicroSil Toric IOL Device Technologies Australia Pty Ltd $500.00 $958.00 $458.00
DE255 MicroSil Toric IOL Device Technologies Australia Pty Ltd $500.00 $1,537.00 $1,037.00
DE260 ICU Akkomodative® IOL Device Technologies Australia Pty Ltd $650.00 $950.00 $300.00
EG008 Artisan Anterior Chamber Intraocular Lens Emagin Pty Ltd $853.40 $1,286.68 $433.28
EG009 Artisan Anterior Chamber Intraocular Lens Emagin Pty Ltd $150.00 $253.00 $103.00
EG010 Artiflex Anterior Chamber Intraocular Lens Emagin Pty Ltd $723.00 $880.00 $157.00
ET046 Parietene Endotherapeutics Pty Ltd $265.00 $290.00 $25.00
ET047 Parietex Endotherapeutics Pty Ltd $240.00 $297.00 $57.00
ET048 Parietene Endotherapeutics Pty Ltd $380.00 $440.00 $60.00
ET049 Parietex Endotherapeutics Pty Ltd $350.00 $410.00 $60.00
GU158 Endotak Reliance SG Passive Fixation Lead Guidant Australia Pty Ltd $7,200.00 $10,000.00 $2,800.00
GU159 Endotak Reliance G Passive Fixation Lead Guidant Australia Pty Ltd $7,200.00 $10,000.00 $2,800.00
GU163 ENDOTAK RELIANCE G Lead 018 Series Guidant Australia Pty Ltd $7,200.00 $11,000.00 $3,800.00
Pg 2
FEBRUARY 2006 PROSTHESES LIST
GAP PERMITTED PROSTHESES
Billing
Product Name Sponsor Minimum Benefit Maximum Benefit Gap
Code
GU164 ENDOTAK RELIANCE SG Lead 018 Series Guidant Australia Pty Ltd $7,200.00 $11,000.00 $3,800.00
IP010 Cousin Bioring Gastric Band Incision Pty Ltd $3,200.00 $3,750.00 $550.00
IQ001 UltraChoice 1.0 Rollable Thinlens Model PHC001 IQ Medical $360.00 $650.00 $290.00
IQ003 Tetraflex IQ Medical $350.00 $1,200.00 $850.00
IQ004 Softec IQ Medical $350.00 $420.00 $70.00
KA015 Entristar Skin Level Gastrostomy Kits Kendall Australasia Pty Ltd T/A Tyco $170.00 $263.00 $93.00
Healthcare Pty Ltd
KA017 NutriPort Balloon Skin Level Gastrostomy Kit Kendall Australasia Pty Ltd T/A Tyco $115.00 $207.00 $92.00
Healthcare Pty Ltd
KG003 Rayner Standard Toric C-Flex Kevin Grundy (IBD) Pty Ltd $510.00 $900.00 $390.00
KG004 Rayner Premium Toric C-Flex Kevin Grundy (IBD) Pty Ltd $510.00 $1,800.00 $1,290.00
LM048 Ascension Radial Head Locking Plate and screws LMT Surgical Pty Ltd $150.00 $175.00 $25.00
LM056 Ascension DRUJ Ulna Head, Implant System LMT Surgical Pty Ltd $2,220.00 $2,500.00 $280.00
LM057 Ascension Radial Head Locking Plate and Screws LMT Surgical Pty Ltd $1,350.00 $1,500.00 $150.00
LV085 Permaclip Replacement Cartridge ConMed Linvatec Australia Pty Ltd $110.00 $120.00 $10.00
LV087 Permaclip Multi-use Reposable Endoscopic Clip Applier ConMed Linvatec Australia Pty Ltd $200.00 $400.00 $200.00
MA421 seleXys Ceramic Inlay Mathys Orthopaedics Pty Ltd $2,400.00 $3,200.00 $800.00
MA452 balanSys UNI Mathys Orthopaedics Pty Ltd $1,600.00 $2,250.00 $650.00
MA453 balanSys UNI Mathys Orthopaedics Pty Ltd $1,600.00 $2,250.00 $650.00
MC691 Restore Rechargeable Neurostimulation System Medtronic Australasia Pty Ltd $19,150.00 $22,000.00 $2,850.00
MC692 Restore Rechargeable Neurostimulation System Medtronic Australasia Pty Ltd $1,000.00 $3,500.00 $2,500.00
MO243 Polarus Proximal Humeral Plate Medical & Optical Instruments $1,450.00 $1,600.00 $150.00
Australia Pty Ltd
OH023 Optetrak Total Knee System Orthotech Pty Ltd $590.00 $1,029.00 $439.00
OH026 Optetrak Total Knee System Orthotech Pty Ltd $735.00 $1,290.00 $555.00
OH056 Optetrak Total Knee System Orthotech Pty Ltd $735.00 $1,039.00 $304.00
OH057 Opetrak Total Knee System Orthotech Pty Ltd $735.00 $1,299.00 $564.00
OH105 Lima Total Hip Replacement System Orthotech Pty Ltd $850.00 $1,850.00 $1,000.00
OH154 Coriolis Orthotech Pty Ltd $850.00 $1,850.00 $1,000.00
OH158 Academia Knee Orthotech Pty Ltd $590.00 $1,029.00 $439.00
OH194 Array Spinal System Orthotech Pty Ltd $700.00 $800.00 $100.00
OH195 Array Spinal System Orthotech Pty Ltd $600.00 $625.00 $25.00
OH196 Array Spinal System Orthotech Pty Ltd $250.00 $350.00 $100.00
OH197 Array Spinal System Orthotech Pty Ltd $950.00 $1,150.00 $200.00
OH198 Array Spinal System Orthotech Pty Ltd $850.00 $1,000.00 $150.00
Pg 3
FEBRUARY 2006 PROSTHESES LIST
GAP PERMITTED PROSTHESES
Billing
Product Name Sponsor Minimum Benefit Maximum Benefit Gap
Code
OH202 Daphne Orthotech Pty Ltd $1,000.00 $1,250.00 $250.00
OH203 Altius Occipito-Cervico-Thoracic (OCT) System Orthotech Pty Ltd $730.00 $825.00 $95.00
OH204 Altius Occipito-Cervico-Thoracic (OCT) System Orthotech Pty Ltd $390.00 $425.00 $35.00
OH207 Altius Occipito-Cervico-Thoracic (OCT) System Orthotech Pty Ltd $450.00 $845.00 $395.00
OH210 Array Spinal System Orthotech Pty Ltd $1,050.00 $1,240.00 $190.00
OH211 Array Spinal System Orthotech Pty Ltd $1,200.00 $1,450.00 $250.00
OH226 Exactech Femoral Stem Orthotech Pty Ltd $2,000.00 $2,100.00 $100.00
OH230 Optetrak Uni Knee Orthotech Pty Ltd $2,079.00 $2,400.00 $321.00
OH231 Optetrak Uni Knee Orthotech Pty Ltd $1,325.00 $1,800.00 $475.00
OH232 Exactech Femoral Stem Orthotech Pty Ltd $4,850.00 $5,000.00 $150.00
OH235 Optetrak RBK Orthotech Pty Ltd $1,350.00 $1,500.00 $150.00
PL008 PLUS Hip Joint Prosthesis System Plus Orthopedics Australia Pty Ltd $3,450.00 $4,294.00 $844.00
PL026 PLUS Hip Joint Prostheses System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,500.00 $385.00
PL054 Plus Hip Joint Prosthesis System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,500.00 $385.00
PL055 Plus Hip Joint Prosthesis System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,700.00 $585.00
PL062 PLUS Hip Joint Prostheses System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,500.00 $385.00
PL063 PLUS Hip Joint Prostheses System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,700.00 $585.00
PL069 Plus Knee Joint Prostheses System Plus Orthopedics Australia Pty Ltd $2,050.00 $2,500.00 $450.00
PL080 Plus Hip Joint Prostheses System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,700.00 $585.00
PL112 PLUS Hip Joint Prosthesis System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,500.00 $385.00
PL113 PLUS Hip Joint Prosthesis System Plus Orthopedics Australia Pty Ltd $1,115.00 $1,700.00 $585.00
PL124 Proxy Plus Cementless Hip Plus Orthopedics Australia Pty Ltd $3,450.00 $3,950.00 $500.00
PL126 Reko Reconstruction Cage Plus Orthopedics Australia Pty Ltd $2,200.00 $2,700.00 $500.00
SE001 SIR-Spheres including Delivery Apparatus Sirtex Medical Limited $7,222.00 $8,014.00 $792.00
SJ033 Aescula LV Model 1055K St. Jude Medical Australia Pty Ltd $2,630.00 $3,200.00 $570.00
SO028 IOLTECH Intraocular Lens: Model Bigbag Spectrum Ophthalmics $310.00 $450.00 $140.00
SO030 IOLTECH Intraocular Lens: Model ACOR Spectrum Ophthalmics $500.00 $680.00 $180.00
SO031 IOLTECH Intraocular Lens, Model Stabibag, Model XL Stabi Spectrum Ophthalmics $310.00 $340.00 $30.00
SO032 IOLTECH Intraocular Lens, Model Stabibag RTU, Model XL Stabi Spectrum Ophthalmics $330.00 $360.00 $30.00
RTU
TB304 HemiCAP Contoured Articular Knee System Taylor Bryant Pty Ltd $2,600.00 $3,900.00 $1,300.00
TE035 Eurosilicone Cristilline Paragel Mammary Implants Technology For Life Pty Ltd $735.00 $780.00 $45.00
ZI291 NexGen Prolong Articulating Surface Zimmer $1,100.00 $1,350.00 $250.00
Pg 4
FEBRUARY 2006 PROSTHESES LIST
GAP PERMITTED PROSTHESES
Billing
Product Name Sponsor Minimum Benefit Maximum Benefit Gap
Code
ZI379 PFM Hip series Zimmer $3,516.00 $4,686.00 $1,170.00
ZI450 Natural Knee PE Insert Zimmer $1,100.00 $1,350.00 $250.00
ZI454 Natural Knee Patella Zimmer $500.00 $1,100.00 $600.00
ZI494 Zimmer Uni-Compartmental High Flex Knee Zimmer $2,079.00 $2,500.00 $421.00
ZI516 Trabecular Metal Femoral Cone Augments Zimmer $6,000.00 $8,150.00 $2,150.00
ZY001 Carbostent Zynergy Medical Pty Limited $750.00 $1,425.00 $675.00
Pg 5