PART B - Human Tissue List

PART B - Human Tissue List CARDIO-THORACIC Billing Code Facility Minimum Benefit Maximum Benefit Aortic Valved Conduit Patch QHV09 Queensland Heart Valve Bank $4,706.00 Arterial Graft/Conduit SHV03 Sydney Heart Valve Bank, Darlinghurst NSW $987.00 Heart Valve - Aortic QHV01 Queensland Heart Valve Bank $4,706.00 RPH01 Royal Perth Hospital $3,833.00 SHV01 Sydney Heart Valve Bank, Darlinghurst NSW $5,350.00 TBV01 Donor Tissue Bank of Victoria $5,923.00 Heart Valve - Pulmonary QHV02 Queensland Heart Valve Bank $4,706.00 RPH02 Royal Perth Hospital $3,833.00 SHV02 Sydney Heart Valve Bank, Darlinghurst NSW $5,350.00 TBV02 Donor Tissue Bank of Victoria $5,923.00 Mitral Valve Patch QHV03 Queensland Heart Valve Bank $985.00 Pericardium TBV50 Donor Tissue Bank of Victoria $440.00 Pericardium Patch QHV05 Queensland Heart Valve Bank $985.00 Pulmonary Conduit TBV03 Donor Tissue Bank of Victoria $909.00 Pulmonary Conduit - Large QHV07 Queensland Heart Valve Bank $985.00 Pulmonary Conduit - Small QHV06 Queensland Heart Valve Bank $985.00 Pulmonary Valved Conduit For Patch use QHV08 Queensland Heart Valve Bank $4,706.00

of 17 CARDIO-THORACIC Billing Code Facility Minimum Benefit Maximum Benefit Tricuspid Valve Patch QHV04 Queensland Heart Valve Bank $985.00

of 17 OPHTHALMIC Billing Code Facility Minimum Benefit Maximum Benefit Amnion Corneal Graft AUB01 Australian Biotechnologies $800.00 Cornea LEM01 Lions Eye Bank - Melbourne $1,747.00 LEN01 Lions NSW Eye Bank $1,000.00 LEW01 The Lions Eye Bank of WA $2,000.00 QEB01 Queensland Eye Bank $1,345.00 SAE01 The Eye Bank of SA $840.00 TBV04 Donor Tissue Bank of Victoria $800.00 Cornea For Lamellar LEN03 Lions NSW Eye Bank $600.00 Cornea for Sclera LEM02 Lions Eye Bank - Melbourne $150.00 LEN02 Lions NSW Eye Bank $150.00 SAE02 The Eye Bank of SA $60.00 Human Amniotic Membrane for Transplantation LEM03 Lions Eye Bank - Melbourne $770.00 SCLERA LEW02 The Lions Eye Bank of WA $200.00 QEB02 Queensland Eye Bank $230.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit Achilles Tendon NBB01 New South Wales Bone Bank $1,560.00 PBT01 Perth Bone & Tissue Bank $2,000.00 QBB01 Queensland Bone Bank $1,560.00 TBV05 Donor Tissue Bank of Victoria $904.00 Achilles Tendon with Bone Plug NBB02 New South Wales Bone Bank $1,900.00 TBV06 Donor Tissue Bank of Victoria $1,841.00 Anterior Cruciate Ligament Unit PBT02 Perth Bone & Tissue Bank $1,700.00 Autologous Chondrocyte Transplantation MTE01 Mercy Tissue Engineering Pty Ltd $9,996.00 MTE03 Mercy Tissue Engineering Pty Ltd $11,349.00 MUA01 Monash University, Dept of Surgery, Alfred Hospital, Tissue Culture Laboratory $8,694.43 MVS22 Institute of Medical & Veterinary Science, SA $9,538.00 VAP01 Verigen Australia Pty Ltd $9,556.00 Autologous Chondrocytes MTE02 Mercy Tissue Engineering Pty Ltd $2,509.00 VAP03 Verigen Australia Pty Ltd $2,593.00 Autologous Chondrocytes Implant and Matrix ORT01 Orthogen Australia Pty Ltd $11,400.00 Autologous Skull Flap MVS23 Institute of Medical & Veterinary Science, SA $1,396.00 Bone - Chips/cubes 40cc TBV09 Donor Tissue Bank of Victoria $874.00 Bone - Chips/cubes 80cc TBV10 Donor Tissue Bank of Victoria $1,663.00 Bone Plug/Dowel - Cancellous PBT03 Perth Bone & Tissue Bank $500.00 TBV07 Donor Tissue Bank of Victoria $610.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit Bone Plug/Dowel - Tricortical TBV08 Donor Tissue Bank of Victoria $673.00 Cancellous Bone Matrix (CBM) - 40cc TBV52 Victorian Institute of Forensic Medicine $556.00 Cancellous Bone Matrix (CBM) - 80cc TBV53 Victorian Institute of Forensic Medicine $1,110.00 Cancellous Crunch - 15cc NBB62 New South Wales Bone Bank $795.00 Cancellous Crunch - 30cc NBB61 New South Wales Bone Bank $1,450.00 Cancellous Crunch - 60cc NBB60 New South Wales Bone Bank $2,200.00 Cartilage (costal) segments PBT11 Perth Bone & Tissue Bank $300.00 QBB12 Queensland Bone Bank $200.00 TBV17 Donor Tissue Bank of Victoria $350.00 Cortical Struts (Freeze Dried) 1 strut QBB02 Queensland Bone Bank $600.00 Cortical Struts (1 strut) TBV14 Donor Tissue Bank of Victoria $685.00 Cortical Struts (2 struts) TBV13 Donor Tissue Bank of Victoria $1,370.00 Cortical Struts 10-15cm PBT06 Perth Bone & Tissue Bank $1,550.00 Cortical Struts>15 - 20cm PBT07 Perth Bone & Tissue Bank $1,950.00 Cortical struts>20cm PBT48 Perth Bone & Tissue Bank $2,200.00 Cortico - Cancellous Freeze Dried 20g

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit QBB03 Queensland Bone Bank $1,740.00 Cortico-Cancellous Crunch (40/60) - 15cc NBB65 New South Wales Bone Bank $795.00 Cortico-Cancellous Crunch (40/60) - 30cc NBB64 New South Wales Bone Bank $1,450.00 Cortico-Cancellous Crunch (40/60) - 60cc NBB63 New South Wales Bone Bank $2,200.00 Disc - Freeze Dried QBB04 Queensland Bone Bank $650.00 Dowel Plug NBB05 New South Wales Bone Bank $1,080.00 QBB13 Queensland Bone Bank $1,080.00 Elbow - joint QBB14 Queensland Bone Bank $2,100.00 TBV18 Donor Tissue Bank of Victoria $4,710.00 Fascia Lata TBV21 Donor Tissue Bank of Victoria $724.00 Fascia Lata - Large (15cm x 10cm) PBT15 Perth Bone & Tissue Bank $1,400.00 Fascia Lata - Small (>10cm x >5cm) NBB09 New South Wales Bone Bank $800.00 Fascia Lata - Small (10cm x 5cm) PBT16 Perth Bone & Tissue Bank $800.00 Fascia Lata (per sq cm) NBB08 New South Wales Bone Bank $4.00 QBB11 Queensland Bone Bank $5.00 Femoral Condyle PBT21 Perth Bone & Tissue Bank $1,900.00 Femoral Head ACT01 ACT Bone Bank $1,638.00 Page 6 of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit APH01 The Avenue Private Hospital Prahan Victoria $1,131.00 CSA01 Central Sydney Area Health t/a Rachel Forster Bone Bank $802.00 DHR01 The Douglas Hocking Research Institute - Bone Bank $1,060.00 HBB01 The Hobart Private Hospital Bone Bank $1,400.00 LPH01 Lingard Private Hospital $1,103.00 MMH01 Mater Misericordiae Hospital North Sydney $400.00 MVS05 Institute of Medical & Veterinary Science, SA $1,595.00 NBB16 New South Wales Bone Bank $1,750.00 PBT22 Perth Bone & Tissue Bank $1,900.00 QBB27 Queensland Bone Bank $1,775.00 RNB01 The Royal Newcastle Hospital Bone Bank $1,619.00 SVN01 St Vincent's Private Hospital (NSW) $731.00 TBV26 Donor Tissue Bank of Victoria $2,113.00 Femoral Head - Half (Freeze Dried) QBB29 Queensland Bone Bank $500.00 Femoral Head - Whole (Freeze Dried) QBB28 Queensland Bone Bank $800.00 Femoral Rings NBB17 New South Wales Bone Bank $1,400.00 PBT24 Perth Bone & Tissue Bank $1,400.00 QBB30 Queensland Bone Bank $1,260.00 Femoral Rings - (Freeze Dried) QBB31 Queensland Bone Bank $650.00 Femur - > 15cm QBB19 Queensland Bone Bank $1,460.00 Femur - Cortical Portions < 15cm QBB17 Queensland Bone Bank $1,560.00 Femur - Cortical portions> 1/3 QBB18 Queensland Bone Bank $1,100.00 Femur - Distal (shaft & condyles) MVS02 Institute of Medical & Veterinary Science, SA $2,290.00 Page 7 of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit PBT17 Perth Bone & Tissue Bank $2,900.00 TBV22 Donor Tissue Bank of Victoria $3,460.00 Femur - Distal Half NBB10 New South Wales Bone Bank $2,370.00 Femur - Distal half > 15cm QBB20 Queensland Bone Bank $2,370.00 Femur - Distal third NBB11 New South Wales Bone Bank $1,144.00 Femur - Distal third < 15cm QBB21 Queensland Bone Bank $2,270.00 Femur - Entire MVS03 Institute of Medical & Veterinary Science, SA $2,290.00 NBB12 New South Wales Bone Bank $5,539.00 PBT18 Perth Bone & Tissue Bank $4,900.00 QBB22 Queensland Bone Bank $3,685.00 TBV23 Donor Tissue Bank of Victoria $5,794.00 Femur - Hemicondyle NBB59 New South Wales Bone Bank $2,000.00 Femur - Middle third NBB13 New South Wales Bone Bank $2,250.00 QBB23 Queensland Bone Bank $1,865.00 TBV24 Donor Tissue Bank of Victoria $1,887.00 Femur - Proximal (shaft, trochanter, neck) MVS04 Institute of Medical & Veterinary Science, SA $2,290.00 PBT20 Perth Bone & Tissue Bank $2,900.00 TBV25 Donor Tissue Bank of Victoria $3,434.00 Femur - Proximal half NBB15 New South Wales Bone Bank $2,570.00 Femur - Proximal half > 15cm QBB25 Queensland Bone Bank $2,570.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit Femur - Proximal third NBB14 New South Wales Bone Bank $1,040.00 Femur - Proximal third < 15cm QBB24 Queensland Bone Bank $2,120.00 Femur - Segment NBB56 New South Wales Bone Bank $1,500.00 Femur - Shaft Half NBB57 New South Wales Bone Bank $2,200.00 Femur - Shaft Third NBB55 New South Wales Bone Bank $1,500.00 Femur - Trochanter Milled QBB26 Queensland Bone Bank $800.00 Femur- 1 Condyle only TBV46 Donor Tissue Bank of Victoria $1,065.00 Femur-Proximal(Shaft, trochanter, neck and head) TBV51 Donor Tissue Bank of Victoria $3,332.00 Fibula - Entire MVS07 Institute of Medical & Veterinary Science, SA $2,290.00 NBB18 New South Wales Bone Bank $3,200.00 PBT25 Perth Bone & Tissue Bank $2,100.00 QBB32 Queensland Bone Bank $2,220.00 TBV27 Donor Tissue Bank of Victoria $6,041.00 Fibula - Segment NBB54 New South Wales Bone Bank $1,925.00 Fibula - Segment (12cm) MVS14 Institute of Medical & Veterinary Science, SA $2,290.00 NBB20 New South Wales Bone Bank $1,881.00 TBV29 Donor Tissue Bank of Victoria $932.00 Fibula - Segment (6cm) MVS13 Institute of Medical & Veterinary Science, SA $2,290.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit NBB19 New South Wales Bone Bank $1,300.00 TBV28 Donor Tissue Bank of Victoria $610.00 Fibula - Shaft TBV30 Donor Tissue Bank of Victoria $1,968.00 Fibula segment (prox / distal) PBT28 Perth Bone & Tissue Bank $1,200.00 Fibular Strut < 10cm: QBB06 Queensland Bone Bank $1,210.00 Fibular Strut > 10cm: QBB07 Queensland Bone Bank $1,335.00 Freeze Dried Milled Bone <30gm PBT37 Perth Bone & Tissue Bank $750.00 Freeze Dried Milled Bone 30 - 50gm PBT38 Perth Bone & Tissue Bank $900.00 Freeze-dried Cancellous Cubes (6) QBB09 Queensland Bone Bank $1,335.00 Freeze-Dried Cancellous Strips (2) QBB10 Queensland Bone Bank $650.00 Hemipelvis - Acetabulum NBB21 New South Wales Bone Bank $2,568.00 PBT29 Perth Bone & Tissue Bank $2,400.00 QBB33 Queensland Bone Bank $2,320.00 TBV31 Donor Tissue Bank of Victoria $2,686.00 Hemipelvis - Complete MVS08 Institute of Medical & Veterinary Science, SA $2,290.00 NBB24 New South Wales Bone Bank $5,825.00 PBT30 Perth Bone & Tissue Bank $4,500.00 QBB37 Queensland Bone Bank $3,685.00 TBV32 Donor Tissue Bank of Victoria $6,093.00 Hemipelvis - IIliac crest

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit NBB22 New South Wales Bone Bank $2,321.00 PBT31 Perth Bone & Tissue Bank $1,100.00 QBB34 Queensland Bone Bank $2,060.00 TBV33 Donor Tissue Bank of Victoria $2,428.00 Hemipelvis - Tricortical wedge QBB35 Queensland Bone Bank $1,005.00 Hemipelvis - Tricortical wedge (Freeze Dried) QBB36 Queensland Bone Bank $700.00 Hemipelvis -Tricortical iliac wedge NBB23 New South Wales Bone Bank $1,005.00 PBT32 Perth Bone & Tissue Bank $600.00 TBV34 Donor Tissue Bank of Victoria $920.00 Humeral Head QBB44 Queensland Bone Bank $1,350.00 TBV37 Donor Tissue Bank of Victoria $1,484.00 Humeral Head Addition NBB26 New South Wales Bone Bank $1,419.00 Humerus - Cortical portions/blocks < 10cm QBB38 Queensland Bone Bank $1,110.00 Humerus - Cortical portions/blocks > 10cm QBB39 Queensland Bone Bank $1,330.00 Humerus - Distal MVS19 Institute of Medical & Veterinary Science, SA $2,290.00 TBV49 Donor Tissue Bank of Victoria $1,979.00 Humerus - Distal half NBB25 New South Wales Bone Bank $1,200.00 Humerus - Entire MVS20 Institute of Medical & Veterinary Science, SA $2,290.00 NBB29 New South Wales Bone Bank $2,828.00 QBB43 Queensland Bone Bank $2,570.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit Humerus - Proximal half NBB27 New South Wales Bone Bank $1,658.00 QBB40 Queensland Bone Bank $1,260.00 Humerus - Proximal half with rotator cuff NBB28 New South Wales Bone Bank $2,500.00 QBB41 Queensland Bone Bank $2,245.00 Humerus - Proximal with rotator cuff MVS09 Institute of Medical & Veterinary Science, SA $2,290.00 PBT34 Perth Bone & Tissue Bank $2,500.00 TBV35 Donor Tissue Bank of Victoria $2,336.00 Humerus - Proximal w'out rotator cuff PBT35 Perth Bone & Tissue Bank $1,100.00 QBB42 Queensland Bone Bank $1,260.00 TBV36 Donor Tissue Bank of Victoria $2,485.00 Humerus - Ring NBB53 New South Wales Bone Bank $1,300.00 Humerus - Segment NBB52 New South Wales Bone Bank $1,400.00 Humerus - Shaft Half NBB51 New South Wales Bone Bank $1,500.00 Humerus - Shaft Whole NBB50 New South Wales Bone Bank $2,750.00 Humerus - Whole PBT33 Perth Bone & Tissue Bank $3,000.00 Humerus - Whole with rotator cuff NBB30 New South Wales Bone Bank $2,941.00 Medial Ligament NBB31 New South Wales Bone Bank $1,529.00 TBV38 Donor Tissue Bank of Victoria $1,599.00 Meniscal Graft

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit PBT47 Perth Bone & Tissue Bank $1,800.00 Meniscus QBB05 Queensland Bone Bank $1,160.00 Meniscus with Ligaments TBV39 Donor Tissue Bank of Victoria $1,927.00 Meniscus without Ligaments TBV40 Donor Tissue Bank of Victoria $1,046.00 Milled Bone - 15cc NBB58 New South Wales Bone Bank $720.00 Milled Bone - 30g NBB03 New South Wales Bone Bank $1,050.00 Milled Bone - 40cc TBV11 Donor Tissue Bank of Victoria $1,046.00 TBV15 Donor Tissue Bank of Victoria $760.00 Milled Bone - 60cc QBB45 Queensland Bone Bank $1,675.00 Milled Bone - 60g NBB04 New South Wales Bone Bank $1,675.00 Milled Bone - 60g max QBB46 Queensland Bone Bank $1,200.00 Milled Bone - 80cc TBV12 Donor Tissue Bank of Victoria $1,870.00 TBV16 Donor Tissue Bank of Victoria $1,445.00 Milled Bone <30g PBT08 Perth Bone & Tissue Bank $1,600.00 Milled Bone >50g PBT10 Perth Bone & Tissue Bank $2,350.00 Milled Bone 30 - 50g PBT09 Perth Bone & Tissue Bank $2,050.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit Patella NBB32 New South Wales Bone Bank $875.00 QBB47 Queensland Bone Bank $750.00 TBV41 Donor Tissue Bank of Victoria $915.00 Patella tendon QBB48 Queensland Bone Bank $1,715.00 Patella Tendon and Patella TBV42 Donor Tissue Bank of Victoria $1,927.00 Patella tendon with Bone Plugs NBB33 New South Wales Bone Bank $1,357.00 Patellar unit whole with tibial block PBT40 Perth Bone & Tissue Bank $2,100.00 Primary MACI plus 1/2 VAP02 Verigen Australia Pty Ltd $10,891.00 Proximal Third Tibia with - Patella Tendon QBB08 Queensland Bone Bank $2,370.00 Radius MVS18 Institute of Medical & Veterinary Science, SA $2,290.00 NBB06 New South Wales Bone Bank $2,673.00 PBT13 Perth Bone & Tissue Bank $1,800.00 QBB15 Queensland Bone Bank $1,865.00 TBV19 Donor Tissue Bank of Victoria $2,796.00 Radius - Ring NBB49 New South Wales Bone Bank $1,680.00 Radius - Segment NBB48 New South Wales Bone Bank $1,925.00 Radius - Shaft NBB47 New South Wales Bone Bank $2,750.00 Rib (5cm) MVS21 Institute of Medical & Veterinary Science, SA $382.00

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit PBT41 Perth Bone & Tissue Bank $300.00 TBV43 Donor Tissue Bank of Victoria $437.00 Scaphoid QBB49 Queensland Bone Bank $900.00 Shaft - Femur / Tibia Middle third PBT19 Perth Bone & Tissue Bank $2,500.00 Tibia - Condyles only TBV47 Donor Tissue Bank of Victoria $1,491.00 Tibia - Cortical < 15cm QBB50 Queensland Bone Bank $1,275.00 Tibia - Cortical > 15 cm QBB51 Queensland Bone Bank $1,560.00 Tibia - Distal MVS17 Institute of Medical & Veterinary Science, SA $2,290.00 TBV48 Donor Tissue Bank of Victoria $1,922.00 Tibia - Middle third seg NBB34 New South Wales Bone Bank $1,400.00 QBB53 Queensland Bone Bank $900.00 Tibia - Plateau (prox 1/3) NBB35 New South Wales Bone Bank $2,065.00 Tibia - Proximal third < 15cm QBB54 Queensland Bone Bank $2,065.00 Tibia - Proximal with Patella Tendon NBB46 New South Wales Bone Bank $3,647.00 Tibia - Proximal: without Patella PBT45 Perth Bone & Tissue Bank $2,300.00 Tibia - Proximal: 16-25cm TBV45 Donor Tissue Bank of Victoria $2,215.00 Tibia - Proximal: 7-15cm TBV44 Donor Tissue Bank of Victoria $2,299.00 Page 15 of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit Tibia - Proximal: half MVS11 Institute of Medical & Veterinary Science, SA $2,290.00 NBB36 New South Wales Bone Bank $2,290.00 Tibia - Proximal: with Patella & Tendon PBT44 Perth Bone & Tissue Bank $2,900.00 Tibia - Ring NBB45 New South Wales Bone Bank $1,300.00 Tibia - Shaft Half NBB43 New South Wales Bone Bank $2,200.00 Tibia - Shaft Third NBB42 New South Wales Bone Bank $2,065.00 Tibia - Shaft Whole NBB41 New South Wales Bone Bank $2,750.00 Tibia - Strut QBB52 Queensland Bone Bank $400.00 Tibia - Whole MVS16 Institute of Medical & Veterinary Science, SA $2,290.00 NBB37 New South Wales Bone Bank $3,685.00 QBB55 Queensland Bone Bank $3,685.00 Tibia - Whole with Patella Tendon NBB44 New South Wales Bone Bank $5,042.00 Tibialis Tendon PBT46 Perth Bone & Tissue Bank $1,450.00 Ulna MVS15 Institute of Medical & Veterinary Science, SA $2,290.00 NBB07 New South Wales Bone Bank $2,464.00 PBT14 Perth Bone & Tissue Bank $1,500.00 QBB16 Queensland Bone Bank $1,865.00 TBV20 Donor Tissue Bank of Victoria $2,577.00 Ulna - Ring

of 17 ORTHOPAEDIC Billing Code Facility Minimum Benefit Maximum Benefit NBB40 New South Wales Bone Bank $1,680.00 Ulna - Segment NBB39 New South Wales Bone Bank $1,925.00 Ulna - Shaft NBB38 New South Wales Bone Bank $2,200.00