OBJECTIVES:  To perform an incremental cost analysis of Diamondback 360 peripheral orbital atherectomy system (OAS) in conjunction with balloon angioplasty (BA) compared to BA alone for the treatment of critical limb ischemia (CLI) in peripheral artery disease (PAD) patients from a US hospital perspective. METHODS:  A deterministic decision tree simulation model was constructed for a hypothetical cohort of 100 PAD-CLI patients with moderate-to-severely calcified below-the-knee lesions undergoing an endovascular revascularization. Clinical (peri-operative and one-year complications) and healthcare utilization (OAS device, balloon(s), and bailout bare metal stenting) data were obtained primarily from the CALCIUM 360° trial and supplemented with a best evidence review of the published literature (BA arm only). Eligible studies were pooled and parameters weighted by sample size. Cost data (2016 dollars) were obtained from 2014 HCUP and published evidence. Incremental cost to the hospital for performing OAS+BA vs. BA was computed by summing cost differences corresponding to differential utilization during the procedure and treating peri- and post-operative complications. One-way, scenario (a composite one-year major adverse event) and probabilistic sensitivity analyses (SA) were performed to gauge the model robustness. RESULTS:  For every 100 revascularizations, the incremental costs to the hospital at one-year were $467,355 lower with OAS+BA compared to BA alone. These savings reflected a reduced need for revascularization in the target lesion (TLR) and/or vessel (TVR) and, amputation, and lower end-of-life care costs, despite higher technology costs upfront. One-way SA demonstrated that the model was most sensitive to: amputation rates and its costs, OAS device cost, TLR/TVR frequency and its costs, and one-year mortality and end-of-life care cost. CONCLUSIONS:  Compared to stand-alone BA, OAS+BA appears to be associated with cost savings of $4,674 per-patient-per-year to a hospital/health system. SA determined that the superior economic value of OAS+BA was robust to the specified parameter value ranges.