| APC Code |
Group Title |
Status Indicator |
Addendum A Payment Rate |
| 0701 |
Sr89 strontium
|
K
|
$XXX.XX
|
| 0702 |
Inj, human-lans, per i.u
|
G
|
$XXX.XX
|
| 0703 |
Inj daxibotulinumtoxina-lanm
|
G
|
$XXX.XX
|
| 0704 |
Inj, aflibercept hd, 1 mg
|
G
|
$XXX.XX
|
| 0705 |
Inj avacincaptad pegol 0.1mg
|
G
|
$XXX.XX
|
| 0706 |
Inj talquetamab-tgvs 0.25 mg
|
G
|
$XXX.XX
|
| 0707 |
Cantharidin top, applicator
|
G
|
$XXX.XX
|
| 0708 |
Inj, elranatamab-bcmm, 1 mg
|
G
|
$XXX.XX
|
| 0709 |
Flortaucipir inj 1 millicuri
|
G
|
$XXX.XX
|
| 0710 |
Inj velmanase alfa-tycv 1 mg
|
G
|
$XXX.XX
|
| 0711 |
Inj, artesunate, 1mg
|
K
|
$XXX.XX
|
| 0713 |
Inj roctavian ml 2x10^13vc g
|
G
|
$XXX.XX
|
| 0714 |
Inj delandistrogene mox rokl
|
G
|
$XXX.XX
|
| 0715 |
Pegunigalsidase alfa-iwxj
|
G
|
$XXX.XX
|
| 0716 |
Vyjuvek 5x10^9pfu/ml, 0.1 ml
|
G
|
$XXX.XX
|
| 0717 |
Instill adstiladrin, tx dose
|
G
|
$XXX.XX
|
| 0718 |
Inj, carmustine (accord)
|
K
|
$XXX.XX
|
| 0719 |
Inj cyclophos avyxa 5mg
|
G
|
$XXX.XX
|
| 0720 |
Inj glofitamab gxbm, 2.5 mg
|
G
|
$XXX.XX
|
| 0721 |
Inj ronzanolixizum-noli 1 mg
|
G
|
$XXX.XX
|
| 0722 |
Dexmedetomidine film, 1 mcg
|
K
|
$XXX.XX
|
| 0723 |
Inj efgart-alfa 2mg hya-qvfc
|
K
|
$XXX.XX
|
| 0725 |
Inj secukinumab intrav 1mg
|
G
|
$XXX.XX
|
| 0726 |
Dexrazoxane HCl injection
|
K
|
$XXX.XX
|
| 0727 |
Inj, adzynma, 10 iu
|
G
|
$XXX.XX
|
| 0728 |
Inj, mirikizumab-mrkz, 1 mg
|
G
|
$XXX.XX
|
| 0729 |
Inj, motixafortide, 0.25 mg
|
G
|
$XXX.XX
|
| 0730 |
Inj melphalan (hepzato) 1 mg
|
G
|
$XXX.XX
|
| 0731 |
Sargramostim injection
|
K
|
$XXX.XX
|
| 0732 |
Inj, brixadi, 7 days or less
|
G
|
$XXX.XX
|
| 0733 |
Inj brixadi, more than 7 day
|
G
|
$XXX.XX
|
| 0734 |
Inj, levothyroxine, freskabi
|
K
|
$XXX.XX
|
| 0735 |
Inj, levothyroxine, hikma
|
K
|
$XXX.XX
|
| 0736 |
Amphotericin b liposome inj
|
K
|
$XXX.XX
|
| 0737 |
Inj, cipaglucosidase, 5 mg
|
G
|
$XXX.XX
|
| 0738 |
Rasburicase
|
K
|
$XXX.XX
|
| 0739 |
Inj, rykindo, 0.5 mg
|
K
|
$XXX.XX
|
| 0740 |
Inj hydroxocobalamin iv 25mg
|
K
|
$XXX.XX
|
| 0741 |
Inj cyclophos dr reddys 5 mg
|
K
|
$XXX.XX
|
| 0742 |
Anacaulase-bcdb 8.8% gel 1 g
|
G
|
$XXX.XX
|
| 0743 |
Inj, cyclophosphamide, nos
|
K
|
$XXX.XX
|
| 0744 |
Inst tauro 1.35mg/hep 100u
|
G
|
$XXX.XX
|
| 0745 |
Inj, toripalimab-tpzi, 1 mg
|
G
|
$XXX.XX
|
| 0746 |
Inj, betibeglogene autotemce
|
G
|
$XXX.XX
|
| 0748 |
Inj, lovotibeglogene autotem
|
G
|
$XXX.XX
|
| 0749 |
Inj travoprost intra impl
|
G
|
$XXX.XX
|
| 0750 |
Inj, nithiodote, 3mg / 125mg
|
K
|
$XXX.XX
|
| 0752 |
Dactinomycin injection
|
K
|
$XXX.XX
|
| 0753 |
Inj cefazolin (wg crit care)
|
K
|
$XXX.XX
|
| 0754 |
Daptomycin (xellia) unrefrig
|
K
|
$XXX.XX
|
| 0755 |
Oral methotrexate (jylamvo)
|
K
|
$XXX.XX
|
| 0756 |
Oral methotrexate (xatmep)
|
K
|
$XXX.XX
|
| 0757 |
Docetaxel (docivyx), 1 mg
|
G
|
$XXX.XX
|
| 0759 |
Naltrexone, depot form
|
K
|
$XXX.XX
|
| 0760 |
Tc-99m graphite crucible
|
G
|
$XXX.XX
|
| 0761 |
Inj, focinvez, 1mg
|
G
|
$XXX.XX
|
| 0762 |
Bupivacaine implant, 1 mg
|
K1
|
$XXX.XX
|
| 0763 |
Inj, bupivacaine liposome
|
K1
|
$XXX.XX
|
| 0764 |
Ketorolac tromethamine inj
|
K1
|
$XXX.XX
|
| 0765 |
Inj, donanemab-azbt, 2 mg
|
G
|
$XXX.XX
|
| 0766 |
Tc99m exametazime
|
K
|
$XXX.XX
|
| 0767 |
Inj, nogapendekin pmln 1 mcg
|
G
|
$XXX.XX
|
| 0768 |
Inj, tarlatamab-dlle, 1 mg
|
G
|
$XXX.XX
|
| 0769 |
In111 ibritumomab, dx
|
K
|
$XXX.XX
|
| 0770 |
In111 oxyquinoline
|
K
|
$XXX.XX
|
| 0771 |
In111 pentetate
|
K
|
$XXX.XX
|
| 0772 |
Inj, pegulicianine, 1 mg
|
G
|
$XXX.XX
|
| 0773 |
Inj, beqvez, per tx dose
|
G
|
$XXX.XX
|
| 0774 |
Tc99m bicisate
|
K
|
$XXX.XX
|
| 0775 |
Technetium tc99m arcitumomab
|
K
|
$XXX.XX
|
| 0776 |
Technetium tc-99m auto wbc
|
K
|
$XXX.XX
|
| 0777 |
Indium in-111 auto wbc
|
K
|
$XXX.XX
|
| 0778 |
Inj, vasopressin (baxter)
|
G
|
$XXX.XX
|
| 0779 |
Indium in-111 pentetreotide
|
K
|
$XXX.XX
|
| 0780 |
Iodine i-123 iobenguane
|
K
|
$XXX.XX
|
| 0781 |
Iodine i-123 ioflupane
|
K
|
$XXX.XX
|
| 0782 |
Inj, pemrydi rtu, 10 mg
|
G
|
$XXX.XX
|
| 0784 |
Inj, tyenne, 1 mg
|
G
|
$XXX.XX
|
| 0785 |
Inj, cyclophosphamd, sandoz
|
K
|
$XXX.XX
|
| 0786 |
Inj, tofidence, 1 mg
|
G
|
$XXX.XX
|
| 0788 |
Inj cefazolin sodium, hikma
|
K
|
$XXX.XX
|
| 0789 |
Inj daptomycin (xellia)
|
K
|
$XXX.XX
|
| 0790 |
Inj, methylpred acetate 1 mg
|
K
|
$XXX.XX
|
| 0792 |
Inj, glycopyrrolate, 0.1 mg
|
K
|
$XXX.XX
|
| 0793 |
Inj glycopyrrolate fres kabi
|
K
|
$XXX.XX
|
| 0794 |
Inj, bumetanide, 0.5 mg
|
K
|
$XXX.XX
|
| 0795 |
Inj, lidocaine in d5w, 1 mg
|
K
|
$XXX.XX
|
| 0796 |
Inj meropenem (wg crit care)
|
K
|
$XXX.XX
|
| 0797 |
Inj, immphentiv, 20 mcg
|
K
|
$XXX.XX
|
| 0798 |
Inj, sezaby, 1 mg
|
K
|
$XXX.XX
|
| 0799 |
Inj fluphenazine hcl 1.25 mg
|
K
|
$XXX.XX
|
| 0800 |
Leuprolide acetate
|
K
|
$XXX.XX
|
| 0801 |
Inj, methylpred sod succ 5mg
|
K
|
$XXX.XX
|
| 0803 |
Hydroxocobalamin im 10mcg
|
K
|
$XXX.XX
|
| 0804 |
Capecitabine, oral, 50 mg
|
K
|
$XXX.XX
|
| 0805 |
Hiv prep, inj, cabotegravir
|
K
|
$XXX.XX
|
| 0806 |
Hiv prep, ftc/tdf 200/300mg
|
K
|
$XXX.XX
|
| 0807 |
Aldesleukin injection
|
K
|
$XXX.XX
|
| 0808 |
Hiv prep, ftc/taf 200/25mg
|
K
|
$XXX.XX
|
| 0810 |
Goserelin acetate implant
|
K
|
$XXX.XX
|
| 0811 |
Inj, nypozi, 1 mcg
|
G
|
$XXX.XX
|
| 0812 |
Carmustine injection
|
K
|
$XXX.XX
|
| 0813 |
Injection, imetelstat, 1 mg
|
G
|
$XXX.XX
|
| 0814 |
Inj, magtrace per study dose
|
G
|
$XXX.XX
|
| 0815 |
Inj, palonosetron (posfrea)
|
G
|
$XXX.XX
|
| 0816 |
Inj, tislelizumab-jsgr
|
G
|
$XXX.XX
|
| 0817 |
Inj, adalimumab, 1 mg
|
K
|
$XXX.XX
|
| 0818 |
Inj, crovalimab-akkz, 10 mg
|
K
|
$XXX.XX
|
| 0819 |
Inj, alyglo, 500 mg
|
K
|
$XXX.XX
|
| 0820 |
Daunorubicin injection
|
K
|
$XXX.XX
|
| 0822 |
Inj, romiplostim 1 microgram
|
K
|
$XXX.XX
|
| 0824 |
Inj, exagamglogene autotem
|
K
|
$XXX.XX
|
| 0825 |
Nelarabine injection
|
K
|
$XXX.XX
|
| 0826 |
Inj adalimumab-fkjp, 1 mg
|
K
|
$XXX.XX
|
| 0827 |
Floxuridine injection
|
K
|
$XXX.XX
|
| 0828 |
Inj adalimumab-aaty, 1 mg
|
K
|
$XXX.XX
|
| 0829 |
Inj adalimumab-ryvk, 1 mg
|
K
|
$XXX.XX
|
| 0830 |
Inj adalimumab-adbm, 1 mg
|
K
|
$XXX.XX
|
| 0833 |
Inj, idacio, 1 mg
|
K
|
$XXX.XX
|
| 0834 |
Inj, abrilada, 1 mg
|
K
|
$XXX.XX
|
| 0840 |
Inj melpha hydroch nos 50 mg
|
K
|
$XXX.XX
|
| 0843 |
Pegaspargase injection
|
K
|
$XXX.XX
|
| 0844 |
Pentostatin injection
|
K
|
$XXX.XX
|
| 0851 |
Thiotepa injection
|
K
|
$XXX.XX
|
| 0856 |
Porfimer sodium injection
|
K
|
$XXX.XX
|
| 0858 |
Inj cladribine
|
K
|
$XXX.XX
|
| 0864 |
Mitoxantrone hydrochl
|
K
|
$XXX.XX
|
| 0874 |
Synvisc or synvisc-one
|
K
|
$XXX.XX
|
| 0875 |
Euflexxa inj per dose
|
K
|
$XXX.XX
|
| 0877 |
Orthovisc inj per dose
|
K
|
$XXX.XX
|
| 0887 |
Azathioprine parenteral
|
K
|
$XXX.XX
|
| 0890 |
Lymphocyte immune globulin
|
K
|
$XXX.XX
|
| 0901 |
Alpha 1 proteinase inhibitor
|
K
|
$XXX.XX
|
| 0902 |
Injection,onabotulinumtoxinA
|
K
|
$XXX.XX
|
| 0903 |
Cytomegalovirus imm IV /vial
|
K
|
$XXX.XX
|
| 0925 |
Factor viii
|
K
|
$XXX.XX
|
| 0927 |
Factor viii recombinant
|
K
|
$XXX.XX
|
| 0928 |
Factor ix complex
|
K
|
$XXX.XX
|
| 0929 |
Anti-inhibitor
|
K
|
$XXX.XX
|
| 0931 |
Factor IX non-recombinant
|
K
|
$XXX.XX
|
| 0932 |
Factor ix recombinant nos
|
K
|
$XXX.XX
|
| 0943 |
Octagam injection
|
K
|
$XXX.XX
|
| 0944 |
Gammagard liquid injection
|
K
|
$XXX.XX
|
| 0946 |
Hepagam b im injection
|
K
|
$XXX.XX
|
| 0947 |
Flebogamma injection
|
K
|
$XXX.XX
|
| 0948 |
Gamunex-C/Gammaked
|
K
|
$XXX.XX
|
| 0963 |
Albumin (human), 5%, 250 ml
|
K
|
$XXX.XX
|
| 0964 |
Albumin (human), 25%, 20 ml
|
K
|
$XXX.XX
|
| 1015 |
Injection glatiramer acetate
|
K
|
$XXX.XX
|
| 1064 |
I131 iodide cap, rx
|
K
|
$XXX.XX
|
| 1138 |
Hepagam b intravenous, inj
|
K
|
$XXX.XX
|
| 1139 |
Protein c concentrate
|
K
|
$XXX.XX
|
| 1142 |
Supprelin LA implant
|
K
|
$XXX.XX
|
| 1150 |
I131 iodide sol, rx
|
K
|
$XXX.XX
|
| 1168 |
Inj, temsirolimus
|
K
|
$XXX.XX
|
| 1178 |
Busulfan injection
|
K
|
$XXX.XX
|
| 1203 |
Verteporfin injection
|
K
|
$XXX.XX
|
| 1207 |
Octreotide injection, depot
|
K
|
$XXX.XX
|
| 1213 |
Antihemophilic viii/vwf comp
|
K
|
$XXX.XX
|
| 1214 |
Inj IVIG privigen 500 mg
|
K
|
$XXX.XX
|
| 1232 |
Mitomycin injection
|
K
|
$XXX.XX
|
| 1235 |
Valrubicin injection
|
K
|
$XXX.XX
|
| 1237 |
Inj iron dextran
|
K
|
$XXX.XX
|
| 1253 |
Triamcinolone a inj prs-free
|
G
|
$XXX.XX
|
| 1263 |
Antithrombin iii injection
|
K
|
$XXX.XX
|
| 1268 |
Xyntha inj
|
K
|
$XXX.XX
|
| 1274 |
Edetate calcium disodium inj
|
K
|
$XXX.XX
|
| 1281 |
Bevacizumab injection
|
K
|
$XXX.XX
|
| 1289 |
AbobotulinumtoxinA
|
K
|
$XXX.XX
|
| 1295 |
Sm 153 lexidronam
|
K
|
$XXX.XX
|
| 1296 |
Degarelix injection
|
K
|
$XXX.XX
|
| 1297 |
Ferumoxytol, non-esrd
|
K
|
$XXX.XX
|
| 1311 |
Canakinumab injection
|
K
|
$XXX.XX
|
| 1312 |
Hizentra injection
|
K
|
$XXX.XX
|
| 1327 |
Imiglucerase injection
|
K
|
$XXX.XX
|
| 1331 |
Olanzapine long-acting inj
|
K
|
$XXX.XX
|
| 1340 |
Collagenase, clost hist inj
|
K
|
$XXX.XX
|
| 1352 |
Wilate injection
|
K
|
$XXX.XX
|
| 1353 |
Belimumab injection
|
K
|
$XXX.XX
|
| 1413 |
Lumizyme injection
|
K
|
$XXX.XX
|
| 1415 |
Glassia injection
|
K
|
$XXX.XX
|
| 1416 |
Factor xiii anti-hem factor
|
K
|
$XXX.XX
|
| 1417 |
Gel-one
|
K
|
$XXX.XX
|
| 1420 |
Aflibercept injection
|
K
|
$XXX.XX
|
| 1421 |
Imported lipodox inj
|
K
|
$XXX.XX
|
| 1426 |
Eribulin mesylate injection
|
K
|
$XXX.XX
|
| 1431 |
Centruroides immune f(ab)
|
K
|
$XXX.XX
|
| 1433 |
Calcitonin salmon injection
|
K
|
$XXX.XX
|
| 1440 |
Inj desmopressin acetate
|
K
|
$XXX.XX
|
| 1442 |
Non-HEU TC-99M add-on/dose
|
K
|
$XXX.XX
|
| 1443 |
Icatibant injection
|
K
|
$XXX.XX
|
| 1446 |
Visualization adjunct
|
K
|
$XXX.XX
|
| 1458 |
Phentolaine mesylate inj
|
K
|
$XXX.XX
|
| 1468 |
Inj, abilify maintena, 1 mg
|
K
|
$XXX.XX
|
| 1469 |
Inj filgrastim excl biosimil
|
K
|
$XXX.XX
|
| 1471 |
Injection, Pertuzumab, 1 mg
|
K
|
$XXX.XX
|
| 1472 |
Inj beta interferon im 1 mcg
|
K
|
$XXX.XX
|
| 1474 |
Certolizumab pegol inj 1mg
|
K
|
$XXX.XX
|
| 1475 |
Golimumab for iv use 1mg
|
K
|
$XXX.XX
|
| 1476 |
Obinutuzumab inj
|
K
|
$XXX.XX
|
| 1478 |
Inj human fibrinogen con nos
|
K
|
$XXX.XX
|
| 1480 |
Elosulfase alfa, injection
|
K
|
$XXX.XX
|
| 1482 |
Darbepoetin alfa, esrd use
|
K
|
$XXX.XX
|
| 1485 |
Ferumoxytol, esrd use
|
K
|
$XXX.XX
|
| 1486 |
Factor ix fc fusion recomb
|
K
|
$XXX.XX
|
| 1488 |
Injection, ramucirumab
|
K
|
$XXX.XX
|
| 1489 |
Inj vedolizumab iv 1 mg
|
K
|
$XXX.XX
|
| 1490 |
Inj pembrolizumab
|
K
|
$XXX.XX
|
| 1491 |
New Technology - Level 1A ($0-$10)
|
S
|
$XXX.XX
|
| 1492 |
New Technology - Level 1B ($11-$20)
|
S
|
$XXX.XX
|
| 1493 |
New Technology - Level 1C ($21-$30)
|
S
|
$XXX.XX
|
| 1494 |
New Technology - Level 1D ($31-$40)
|
S
|
$XXX.XX
|
| 1495 |
New Technology - Level 1E ($41-$50)
|
S
|
$XXX.XX
|
| 1496 |
New Technology - Level 1A ($0-$10)
|
T
|
$XXX.XX
|
| 1497 |
New Technology - Level 1B ($11-$20)
|
T
|
$XXX.XX
|
| 1498 |
New Technology - Level 1C ($21-$30)
|
T
|
$XXX.XX
|
| 1499 |
New Technology - Level 1D ($31-$40)
|
T
|
$XXX.XX
|
| 1500 |
New Technology - Level 1E ($41-$50)
|
T
|
$XXX.XX
|
| 1502 |
New Technology - Level 2 ($51 - $100)
|
S
|
$XXX.XX
|
| 1503 |
New Technology - Level 3 ($101 - $200)
|
S
|
$XXX.XX
|
| 1504 |
New Technology - Level 4 ($201 - $300)
|
S
|
$XXX.XX
|
| 1505 |
New Technology - Level 5 ($301 - $400)
|
S
|
$XXX.XX
|
| 1506 |
New Technology - Level 6 ($401 - $500)
|
S
|
$XXX.XX
|
| 1507 |
New Technology - Level 7 ($501 - $600)
|
S
|
$XXX.XX
|
| 1508 |
New Technology - Level 8 ($601 - $700)
|
S
|
$XXX.XX
|
| 1509 |
New Technology - Level 9 ($701 - $800)
|
S
|
$XXX.XX
|
| 1510 |
New Technology - Level 10 ($801 - $900)
|
S
|
$XXX.XX
|
| 1511 |
New Technology - Level 11 ($901 - $1000)
|
S
|
$XXX.XX
|
| 1512 |
New Technology - Level 12 ($1001 - $1100)
|
S
|
$XXX.XX
|
| 1513 |
New Technology - Level 13 ($1101 - $1200)
|
S
|
$XXX.XX
|
| 1514 |
New Technology - Level 14 ($1201- $1300)
|
S
|
$XXX.XX
|
| 1515 |
New Technology - Level 15 ($1301 - $1400)
|
S
|
$XXX.XX
|
| 1516 |
New Technology - Level 16 ($1401 - $1500)
|
S
|
$XXX.XX
|
| 1517 |
New Technology - Level 17 ($1501-$1600)
|
S
|
$XXX.XX
|
| 1518 |
New Technology - Level 18 ($1601-$1700)
|
S
|
$XXX.XX
|
| 1519 |
New Technology - Level 19 ($1701-$1800)
|
S
|
$XXX.XX
|
| 1520 |
New Technology - Level 20 ($1801-$1900)
|
S
|
$XXX.XX
|
| 1521 |
New Technology - Level 21 ($1901-$2000)
|
S
|
$XXX.XX
|
| 1522 |
New Technology - Level 22 ($2001-$2500)
|
S
|
$XXX.XX
|
| 1523 |
New Technology - Level 23 ($2501-$3000)
|
S
|
$XXX.XX
|
| 1524 |
New Technology - Level 24 ($3001-$3500)
|
S
|
$XXX.XX
|
| 1525 |
New Technology - Level 25 ($3501-$4000)
|
S
|
$XXX.XX
|
| 1526 |
New Technology - Level 26 ($4001-$4500)
|
S
|
$XXX.XX
|
| 1527 |
New Technology - Level 27 ($4501-$5000)
|
S
|
$XXX.XX
|
| 1528 |
New Technology - Level 28 ($5001-$5500)
|
S
|
$XXX.XX
|
| 1529 |
New Technology - Level 29 ($5501-$6000)
|
S
|
$XXX.XX
|
| 1530 |
New Technology - Level 30 ($6001-$6500)
|
S
|
$XXX.XX
|
| 1531 |
New Technology - Level 31 ($6501-$7000)
|
S
|
$XXX.XX
|
| 1532 |
New Technology - Level 32 ($7001-$7500)
|
S
|
$XXX.XX
|
| 1533 |
New Technology - Level 33 ($7501-$8000)
|
S
|
$XXX.XX
|
| 1534 |
New Technology - Level 34 ($8001-$8500)
|
S
|
$XXX.XX
|
| 1535 |
New Technology - Level 35 ($8501-$9000)
|
S
|
$XXX.XX
|
| 1536 |
New Technology - Level 36 ($9001-$9500)
|
S
|
$XXX.XX
|
| 1537 |
New Technology - Level 37 ($9501-$10000)
|
S
|
$XXX.XX
|
| 1539 |
New Technology - Level 2 ($51 - $100)
|
T
|
$XXX.XX
|
| 1540 |
New Technology - Level 3 ($101 - $200)
|
T
|
$XXX.XX
|
| 1541 |
New Technology - Level 4 ($201 - $300)
|
T
|
$XXX.XX
|
| 1542 |
New Technology - Level 5 ($301 - $400)
|
T
|
$XXX.XX
|
| 1543 |
New Technology - Level 6 ($401 - $500)
|
T
|
$XXX.XX
|
| 1544 |
New Technology - Level 7 ($501 - $600)
|
T
|
$XXX.XX
|
| 1545 |
New Technology - Level 8 ($601 - $700)
|
T
|
$XXX.XX
|
| 1546 |
New Technology - Level 9 ($701 - $800)
|
T
|
$XXX.XX
|
| 1547 |
New Technology - Level 10 ($801 - $900)
|
T
|
$XXX.XX
|
| 1548 |
New Technology - Level 11 ($901 - $1000)
|
T
|
$XXX.XX
|
| 1549 |
New Technology - Level 12 ($1001 - $1100)
|
T
|
$XXX.XX
|
| 1550 |
New Technology - Level 13 ($1101 - $1200)
|
T
|
$XXX.XX
|
| 1551 |
New Technology - Level 14 ($1201- $1300)
|
T
|
$XXX.XX
|
| 1552 |
New Technology - Level 15 ($1301 - $1400)
|
T
|
$XXX.XX
|
| 1553 |
New Technology - Level 16 ($1401 - $1500)
|
T
|
$XXX.XX
|
| 1554 |
New Technology - Level 17 ($1501-$1600)
|
T
|
$XXX.XX
|
| 1555 |
New Technology - Level 18 ($1601-$1700)
|
T
|
$XXX.XX
|
| 1556 |
New Technology - Level 19 ($1701-$1800)
|
T
|
$XXX.XX
|
| 1557 |
New Technology - Level 20 ($1801-$1900)
|
T
|
$XXX.XX
|
| 1558 |
New Technology - Level 21 ($1901-$2000)
|
T
|
$XXX.XX
|
| 1559 |
New Technology - Level 22 ($2001-$2500)
|
T
|
$XXX.XX
|
| 1560 |
New Technology - Level 23 ($2501-$3000)
|
T
|
$XXX.XX
|
| 1561 |
New Technology - Level 24 ($3001-$3500)
|
T
|
$XXX.XX
|
| 1562 |
New Technology - Level 25 ($3501-$4000)
|
T
|
$XXX.XX
|
| 1563 |
New Technology - Level 26 ($4001-$4500)
|
T
|
$XXX.XX
|
| 1564 |
New Technology - Level 27 ($4501-$5000)
|
T
|
$XXX.XX
|
| 1565 |
New Technology - Level 28 ($5001-$5500)
|
T
|
$XXX.XX
|
| 1566 |
New Technology - Level 29 ($5501-$6000)
|
T
|
$XXX.XX
|
| 1567 |
New Technology - Level 30 ($6001-$6500)
|
T
|
$XXX.XX
|
| 1568 |
New Technology - Level 31 ($6501-$7000)
|
T
|
$XXX.XX
|
| 1569 |
New Technology - Level 32 ($7001-$7500)
|
T
|
$XXX.XX
|
| 1570 |
New Technology - Level 33 ($7501-$8000)
|
T
|
$XXX.XX
|
| 1571 |
New Technology - Level 34 ($8001-$8500)
|
T
|
$XXX.XX
|
| 1572 |
New Technology - Level 35 ($8501-$9000)
|
T
|
$XXX.XX
|
| 1573 |
New Technology - Level 36 ($9001-$9500)
|
T
|
$XXX.XX
|
| 1574 |
New Technology - Level 37 ($9501-$10000)
|
T
|
$XXX.XX
|
| 1575 |
New Technology - Level 38 ($10,001-$15,000)
|
S
|
$XXX.XX
|
| 1576 |
New Technology - Level 39 ($15,001-$20,000)
|
S
|
$XXX.XX
|
| 1577 |
New Technology - Level 40 ($20,001-$25,000)
|
S
|
$XXX.XX
|
| 1578 |
New Technology - Level 41 ($25,001-$30,000)
|
S
|
$XXX.XX
|
| 1579 |
New Technology - Level 42 ($30,001-$40,000)
|
S
|
$XXX.XX
|
| 1580 |
New Technology - Level 43 ($40,001-$50,000)
|
S
|
$XXX.XX
|
| 1581 |
New Technology - Level 44 ($50,001-$60,000)
|
S
|
$XXX.XX
|
| 1582 |
New Technology - Level 45 ($60,001-$70,000)
|
S
|
$XXX.XX
|
| 1583 |
New Technology - Level 46 ($70,001-$80,000)
|
S
|
$XXX.XX
|
| 1584 |
New Technology - Level 47 ($80,001-$90,000)
|
S
|
$XXX.XX
|
| 1585 |
New Technology - Level 48 ($90,001-$100,000)
|
S
|
$XXX.XX
|
| 1589 |
New Technology - Level 38 ($10,001-$15,000)
|
T
|
$XXX.XX
|
| 1590 |
New Technology - Level 39 ($15,001-$20,000)
|
T
|
$XXX.XX
|
| 1591 |
New Technology - Level 40 ($20,001-$25,000)
|
T
|
$XXX.XX
|
| 1592 |
New Technology - Level 41 ($25,001-$30,000)
|
T
|
$XXX.XX
|
| 1593 |
New Technology - Level 42 ($30,001-$40,000)
|
T
|
$XXX.XX
|
| 1594 |
New Technology - Level 43 ($40,001-$50,000)
|
T
|
$XXX.XX
|
| 1595 |
New Technology - Level 44 ($50,001-$60,000)
|
T
|
$XXX.XX
|
| 1596 |
New Technology - Level 45 ($60,001-$70,000)
|
T
|
$XXX.XX
|
| 1597 |
New Technology - Level 46 ($70,001-$80,000)
|
T
|
$XXX.XX
|
| 1598 |
New Technology - Level 47 ($80,001-$90,000)
|
T
|
$XXX.XX
|
| 1599 |
New Technology - Level 48 ($90,001-$100,000)
|
T
|
$XXX.XX
|
| 1608 |
Etanercept injection
|
K
|
$XXX.XX
|
| 1609 |
Rho(D) immune globulin h, sd
|
K
|
$XXX.XX
|
| 1613 |
Trastuzumab injection
|
K
|
$XXX.XX
|
| 1630 |
Hep b ig, im
|
K
|
$XXX.XX
|
| 1643 |
Y90 ibritumomab, rx
|
K
|
$XXX.XX
|
| 1656 |
Factor viii fc fusion recomb
|
K
|
$XXX.XX
|
| 1658 |
Injection, belinostat, 10mg
|
K
|
$XXX.XX
|
| 1660 |
Injection, oritavancin
|
K
|
$XXX.XX
|
| 1662 |
Inj tedizolid phosphate
|
K
|
$XXX.XX
|
| 1664 |
Florbetapir f18
|
K
|
$XXX.XX
|
| 1670 |
Tetanus immune globulin inj
|
K
|
$XXX.XX
|
| 1675 |
P32 na phosphate
|
K
|
$XXX.XX
|
| 1683 |
Basiliximab
|
K
|
$XXX.XX
|
| 1685 |
Darbepoetin alfa, non-esrd
|
K
|
$XXX.XX
|
| 1686 |
Epoetin alfa, non-esrd
|
K
|
$XXX.XX
|
| 1687 |
Digoxin immune fab (ovine)
|
K
|
$XXX.XX
|
| 1688 |
Ethanolamine oleate
|
K
|
$XXX.XX
|
| 1689 |
Fomepizole
|
K
|
$XXX.XX
|
| 1690 |
Hemin
|
K
|
$XXX.XX
|
| 1694 |
Ziconotide injection
|
K
|
$XXX.XX
|
| 1696 |
Palifermin injection
|
K
|
$XXX.XX
|
| 1700 |
Inj secretin synthetic human
|
K
|
$XXX.XX
|
| 1701 |
Treprostinil injection
|
K
|
$XXX.XX
|
| 1704 |
Humate-P, inj
|
K
|
$XXX.XX
|
| 1705 |
Factor viia recomb novoseven
|
K
|
$XXX.XX
|
| 1710 |
Clofarabine injection
|
K
|
$XXX.XX
|
| 1712 |
Paclitaxel protein bound
|
K
|
$XXX.XX
|
| 1745 |
Radium ra223 dichloride ther
|
K
|
$XXX.XX
|
| 1746 |
Factor xiii recomb a-subunit
|
K
|
$XXX.XX
|
| 1747 |
Monovisc inj per dose
|
K
|
$XXX.XX
|
| 1748 |
Inj tbo filgrastim 1 microg
|
K
|
$XXX.XX
|
| 1761 |
Rolapitant, oral, 1mg
|
K
|
$XXX.XX
|
| 1809 |
Injection, alemtuzumab
|
K
|
$XXX.XX
|
| 1822 |
Injection, zarxio
|
K
|
$XXX.XX
|
| 1823 |
Injection, dalbavancin
|
K
|
$XXX.XX
|
| 1824 |
Ceftaroline fosamil inj
|
K
|
$XXX.XX
|
| 1825 |
Ceftazidime and avibactam
|
K
|
$XXX.XX
|
| 1826 |
Hyqvia 100mg immuneglobulin
|
K
|
$XXX.XX
|
| 1827 |
Factor viii recomb obizur
|
K
|
$XXX.XX
|
| 1829 |
Penicillin g benzathine inj
|
K
|
$XXX.XX
|
| 1832 |
Dimethyl sulfoxide 50% 50 ml
|
K
|
$XXX.XX
|
| 1836 |
Penicillin g procaine inj
|
K
|
$XXX.XX
|
| 1844 |
Factor viii pegylated recomb
|
K
|
$XXX.XX
|
| 1846 |
Factor viii nuwiq recomb 1iu
|
K
|
$XXX.XX
|
| 1847 |
Injection, inflectra
|
K
|
$XXX.XX
|
| 1848 |
Artiss fibrin sealant
|
K
|
$XXX.XX
|
| 1849 |
Foscarnet sodium injection
|
K
|
$XXX.XX
|
| 1850 |
Gamma globulin 1 cc inj
|
K
|
$XXX.XX
|
| 1851 |
Gamma globulin > 10 cc inj
|
K
|
$XXX.XX
|
| 1852 |
Interferon beta-1a inj
|
K
|
$XXX.XX
|
| 1853 |
Minocycline hydrochloride
|
K
|
$XXX.XX
|
| 1856 |
Factor viii recomb novoeight
|
K
|
$XXX.XX
|
| 1857 |
Inj, factor x, (human), 1iu
|
K
|
$XXX.XX
|
| 1859 |
Argatroban nonesrd use 1mg
|
K
|
$XXX.XX
|
| 1861 |
Inj., bendeka 1 mg
|
K
|
$XXX.XX
|
| 1901 |
New Technology - Level 49 ($100,001-$115,000)
|
S
|
$XXX.XX
|
| 1902 |
New Technology - Level 49 ($100,001-$115,000)
|
T
|
$XXX.XX
|
| 1903 |
New Technology - Level 50 ($115,001-$130,000)
|
S
|
$XXX.XX
|
| 1904 |
New Technology - Level 50 ($115,001-$130,000)
|
T
|
$XXX.XX
|
| 1905 |
New Technology - Level 51 ($130,001-$145,000)
|
S
|
$XXX.XX
|
| 1906 |
New Technology - Level 51 ($130,001-$145,000)
|
T
|
$XXX.XX
|
| 1907 |
New Technology - Level 52 ($145,001-$160,000)
|
S
|
$XXX.XX
|
| 1908 |
New Technology - Level 52 ($145,001-$160,000)
|
T
|
$XXX.XX
|
| 2038 |
Gen, neuro, clo loop, rechg
|
H
|
$XXX.XX
|
| 2039 |
Gen, neuro, imp led, ex cntr
|
H
|
$XXX.XX
|
| 2040 |
Endo, single, urinary tract
|
H
|
$XXX.XX
|
| 2041 |
Cath, bladed, vasc prep
|
H
|
$XXX.XX
|
| 2042 |
Endo, single, pulmonary
|
H
|
$XXX.XX
|
| 2043 |
Orth/matrx/bn fill drug-elut
|
H
|
$XXX.XX
|
| 2044 |
Ret dev, laser, ivc filter
|
H
|
$XXX.XX
|
| 2045 |
Grft, trnsmurl/trnsvens byps
|
H
|
$XXX.XX
|
| 2046 |
Pmkr, dual, leadless
|
H
|
$XXX.XX
|
| 2047 |
Adapter, us to endoscope
|
H
|
$XXX.XX
|
| 2048 |
Pump elastomc non-opioid dev
|
H1
|
$XXX.XX
|
| 2049 |
Suprt dev, a-v fistula, imp
|
H
|
$XXX.XX
|
| 2050 |
Cath coronary drug-delivery
|
H
|
$XXX.XX
|
| 2051 |
Cath renal denerv radiofreq
|
H
|
$XXX.XX
|
| 2052 |
Cath renal denerv ultrasnd
|
H
|
$XXX.XX
|
| 2053 |
Si&pelvis fusn&fixn dev
|
H
|
$XXX.XX
|
| 2054 |
Power endo us-guid bx dev
|
H
|
$XXX.XX
|
| 2055 |
Tissue marker, detectable
|
H
|
$XXX.XX
|
| 2056 |
Pump perist non-opioid dev
|
H1
|
$XXX.XX
|
| 2057 |
Nerve stim non-opioid dev
|
H1
|
$XXX.XX
|
| 2058 |
Cryo probe non-opioid dev
|
H1
|
$XXX.XX
|
| 2059 |
Cryo needle non-opioid dev
|
H1
|
$XXX.XX
|
| 2061 |
Obecabtagene car pos t
|
G
|
$XXX.XX
|
| 2062 |
Inj zanidatamab, 2 mg
|
G
|
$XXX.XX
|
| 2063 |
Inj zolbetuximab, 1 mg
|
G
|
$XXX.XX
|
| 2064 |
Inj marstacimab, 0.5 mg
|
G
|
$XXX.XX
|
| 2065 |
Flurpiridaz f18, diag, 1 mci
|
G
|
$XXX.XX
|
| 2066 |
Inj bortezomib boruzu 0.1 mg
|
G
|
$XXX.XX
|
| 2067 |
Afamitresgene autoleucel
|
G
|
$XXX.XX
|
| 2068 |
Inj, aflibercept-ayyh, 1 mg
|
G
|
$XXX.XX
|
| 2069 |
Inj, testosterone, azmiro
|
K
|
$XXX.XX
|
| 2070 |
Inj, eculizumab, 2 mg
|
K
|
$XXX.XX
|
| 2071 |
Inj ocrelizumab 1mg hya-ocsq
|
K
|
$XXX.XX
|
| 2072 |
Inj, erzofri, 1 mg
|
K
|
$XXX.XX
|
| 2073 |
Inj atezolizumb 5mg hya-tqjs
|
K
|
$XXX.XX
|
| 2075 |
Inj acetaminoph 10mg/ibu 3mg
|
G
|
$XXX.XX
|
| 2076 |
Inj, pemetrexed (avyxa) 10mg
|
G
|
$XXX.XX
|
| 2616 |
Brachytx, non-str,Yttrium-90
|
U
|
$XXX.XX
|
| 2632 |
Iodine I-125 sodium iodide
|
U
|
$XXX.XX
|
| 2634 |
Brachytx, non-str, HA, I-125
|
U
|
$XXX.XX
|
| 2635 |
Brachytx, non-str, HA, P-103
|
U
|
$XXX.XX
|
| 2636 |
Brachy linear, non-str,P-103
|
U
|
$XXX.XX
|
| 2638 |
Brachytx, stranded, I-125
|
U
|
$XXX.XX
|
| 2639 |
Brachytx, non-stranded,I-125
|
U
|
$XXX.XX
|
| 2640 |
Brachytx, stranded, P-103
|
U
|
$XXX.XX
|
| 2641 |
Brachytx, non-stranded,P-103
|
U
|
$XXX.XX
|
| 2642 |
Brachytx, stranded, C-131
|
U
|
$XXX.XX
|
| 2643 |
Brachytx, non-stranded,C-131
|
U
|
$XXX.XX
|
| 2645 |
Brachytx, non-str, Gold-198
|
U
|
$XXX.XX
|
| 2646 |
Brachytx, non-str, HDR Ir-192
|
U
|
$XXX.XX
|
| 2647 |
Brachytx, NS, Non-HDRIr-192
|
U
|
$XXX.XX
|
| 2648 |
Brachytx planar, p-103
|
U
|
$XXX.XX
|
| 2698 |
Brachytx, stranded, NOS
|
U
|
$XXX.XX
|
| 2699 |
Brachytx, non-stranded, NOS
|
U
|
$XXX.XX
|
| 2731 |
Immune globulin, powder
|
K
|
$XXX.XX
|
| 2770 |
Quinupristin/dalfopristin
|
K
|
$XXX.XX
|
| 4001 |
Echo guidance radiotherapy
|
S
|
$XXX.XX
|
| 4002 |
Stereoscopic x-ray guidance
|
S
|
$XXX.XX
|
| 4003 |
Radiation treatment delivery, MeV <= 5; simple
|
S
|
$XXX.XX
|
| 4004 |
Radiation treatment delivery, 6-10 MeV; simple
|
S
|
$XXX.XX
|
| 4005 |
Radiation treatment delivery, 11-19 MeV; simple
|
S
|
$XXX.XX
|
| 4006 |
Radiation treatment delivery, MeV>=20; simple
|
S
|
$XXX.XX
|
| 4007 |
Radiation treatment delivery, MeV<=5; intermediate
|
S
|
$XXX.XX
|
| 4008 |
Radiation treatment delivery, 6-10 MeV; intermediate
|
S
|
$XXX.XX
|
| 4009 |
Radiation treatment delivery, 11-19 MeV; intermediate
|
S
|
$XXX.XX
|
| 4010 |
Radiation treatment delivery, MeV >=20; intermediate
|
S
|
$XXX.XX
|
| 4011 |
Radiation treatment delivery, MeV<=5; complex
|
S
|
$XXX.XX
|
| 4012 |
Radiation treatment delivery, 6-10 MeV; complex
|
S
|
$XXX.XX
|
| 4013 |
Radiation treatment delivery, 11-19 MeV; complex
|
S
|
$XXX.XX
|
| 4014 |
Radiation treatment delivery, MeV >=20; complex
|
S
|
$XXX.XX
|
| 4015 |
Radiation tx delivery imrt
|
S
|
$XXX.XX
|
| 4016 |
Delivery comp imrt
|
S
|
$XXX.XX
|
| 5012 |
Clinic Visits and Related Services
|
V
|
$XXX.XX
|
| 5021 |
Level 1 Type A ED Visits
|
V
|
$XXX.XX
|
| 5022 |
Level 2 Type A ED Visits
|
V
|
$XXX.XX
|
| 5023 |
Level 3 Type A ED Visits
|
V
|
$XXX.XX
|
| 5024 |
Level 4 Type A ED Visits
|
V
|
$XXX.XX
|
| 5025 |
Level 5 Type A ED Visits
|
V
|
$XXX.XX
|
| 5031 |
Level 1 Type B ED Visits
|
V
|
$XXX.XX
|
| 5032 |
Level 2 Type B ED Visits
|
V
|
$XXX.XX
|
| 5033 |
Level 3 Type B ED Visits
|
V
|
$XXX.XX
|
| 5034 |
Level 4 Type B ED Visits
|
V
|
$XXX.XX
|
| 5035 |
Level 5 Type B ED Visits
|
V
|
$XXX.XX
|
| 5041 |
Critical Care
|
S
|
$XXX.XX
|
| 5045 |
Trauma Response with Critical Care
|
S
|
$XXX.XX
|
| 5051 |
Level 1 Skin Procedures
|
T
|
$XXX.XX
|
| 5052 |
Level 2 Skin Procedures
|
T
|
$XXX.XX
|
| 5053 |
Level 3 Skin Procedures
|
T
|
$XXX.XX
|
| 5054 |
Level 4 Skin Procedures
|
T
|
$XXX.XX
|
| 5055 |
Level 5 Skin Procedures
|
T
|
$XXX.XX
|
| 5061 |
Hyperbaric Oxygen
|
S
|
$XXX.XX
|
| 5071 |
Level 1 Excision/ Biopsy/ Incision and Drainage
|
T
|
$XXX.XX
|
| 5072 |
Level 2 Excision/ Biopsy/ Incision and Drainage
|
J1
|
$XXX.XX
|
| 5073 |
Level 3 Excision/ Biopsy/ Incision and Drainage
|
J1
|
$XXX.XX
|
| 5091 |
Level 1 Breast/Lymphatic Surgery and Related Procedures
|
J1
|
$XXX.XX
|
| 5092 |
Level 2 Breast/Lymphatic Surgery and Related Procedures
|
J1
|
$XXX.XX
|
| 5093 |
Level 3 Breast/Lymphatic Surgery and Related Procedures
|
J1
|
$XXX.XX
|
| 5094 |
Level 4 Breast/Lymphatic Surgery and Related Procedures
|
J1
|
$XXX.XX
|
| 5101 |
Level 1 Strapping and Cast Application
|
T
|
$XXX.XX
|
| 5102 |
Level 2 Strapping and Cast Application
|
T
|
$XXX.XX
|
| 5111 |
Level 1 Musculoskeletal Procedures
|
T
|
$XXX.XX
|
| 5112 |
Level 2 Musculoskeletal Procedures
|
J1
|
$XXX.XX
|
| 5113 |
Level 3 Musculoskeletal Procedures
|
J1
|
$XXX.XX
|
| 5114 |
Level 4 Musculoskeletal Procedures
|
J1
|
$XXX.XX
|
| 5115 |
Level 5 Musculoskeletal Procedures
|
J1
|
$XXX.XX
|
| 5116 |
Level 6 Musculoskeletal Procedures
|
J1
|
$XXX.XX
|
| 5151 |
Level 1 Airway Endoscopy
|
T
|
$XXX.XX
|
| 5152 |
Level 2 Airway Endoscopy
|
T
|
$XXX.XX
|
| 5153 |
Level 3 Airway Endoscopy
|
J1
|
$XXX.XX
|
| 5154 |
Level 4 Airway Endoscopy
|
J1
|
$XXX.XX
|
| 5155 |
Level 5 Airway Endoscopy
|
J1
|
$XXX.XX
|
| 5161 |
Level 1 ENT Procedures
|
T
|
$XXX.XX
|
| 5162 |
Level 2 ENT Procedures
|
T
|
$XXX.XX
|
| 5163 |
Level 3 ENT Procedures
|
J1
|
$XXX.XX
|
| 5164 |
Level 4 ENT Procedures
|
J1
|
$XXX.XX
|
| 5165 |
Level 5 ENT Procedures
|
J1
|
$XXX.XX
|
| 5166 |
Cochlear Implant Procedure
|
J1
|
$XXX.XX
|
| 5181 |
Level 1 Vascular Procedures
|
T
|
$XXX.XX
|
| 5182 |
Level 2 Vascular Procedures
|
J1
|
$XXX.XX
|
| 5183 |
Level 3 Vascular Procedures
|
J1
|
$XXX.XX
|
| 5184 |
Level 4 Vascular Procedures
|
J1
|
$XXX.XX
|
| 5191 |
Level 1 Endovascular Procedures
|
J1
|
$XXX.XX
|
| 5192 |
Level 2 Endovascular Procedures
|
J1
|
$XXX.XX
|
| 5193 |
Level 3 Endovascular Procedures
|
J1
|
$XXX.XX
|
| 5194 |
Level 4 Endovascular Procedures
|
J1
|
$XXX.XX
|
| 5200 |
Implantation Wireless PA Pressure Monitor
|
J1
|
$XXX.XX
|
| 5211 |
Level 1 Electrophysiologic Procedures
|
J1
|
$XXX.XX
|
| 5212 |
Level 2 Electrophysiologic Procedures
|
J1
|
$XXX.XX
|
| 5213 |
Level 3 Electrophysiologic Procedures
|
J1
|
$XXX.XX
|
| 5221 |
Level 1 Pacemaker and Similar Procedures
|
T
|
$XXX.XX
|
| 5222 |
Level 2 Pacemaker and Similar Procedures
|
J1
|
$XXX.XX
|
| 5223 |
Level 3 Pacemaker and Similar Procedures
|
J1
|
$XXX.XX
|
| 5224 |
Level 4 Pacemaker and Similar Procedures
|
J1
|
$XXX.XX
|
| 5231 |
Level 1 ICD and Similar Procedures
|
J1
|
$XXX.XX
|
| 5232 |
Level 2 ICD and Similar Procedures
|
J1
|
$XXX.XX
|
| 5241 |
Level 1 Blood Product Exchange and Related Services
|
S
|
$XXX.XX
|
| 5242 |
Level 2 Blood Product Exchange and Related Services
|
S
|
$XXX.XX
|
| 5243 |
Level 3 Blood Product Exchange and Related Services
|
S
|
$XXX.XX
|
| 5244 |
Level 4 Blood Product Exchange and Related Services
|
J1
|
$XXX.XX
|
| 5301 |
Level 1 Upper GI Procedures
|
T
|
$XXX.XX
|
| 5302 |
Level 2 Upper GI Procedures
|
J1
|
$XXX.XX
|
| 5303 |
Level 3 Upper GI Procedures
|
J1
|
$XXX.XX
|
| 5311 |
Level 1 Lower GI Procedures
|
T
|
$XXX.XX
|
| 5312 |
Level 2 Lower GI Procedures
|
T
|
$XXX.XX
|
| 5313 |
Level 3 Lower GI Procedures
|
J1
|
$XXX.XX
|
| 5331 |
Complex GI Procedures
|
J1
|
$XXX.XX
|
| 5341 |
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures
|
J1
|
$XXX.XX
|
| 5342 |
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures
|
J1
|
$XXX.XX
|
| 5361 |
Level 1 Laparoscopy and Related Services
|
J1
|
$XXX.XX
|
| 5362 |
Level 2 Laparoscopy and Related Services
|
J1
|
$XXX.XX
|
| 5371 |
Level 1 Urology and Related Services
|
T
|
$XXX.XX
|
| 5372 |
Level 2 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5373 |
Level 3 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5374 |
Level 4 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5375 |
Level 5 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5376 |
Level 6 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5377 |
Level 7 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5378 |
Level 8 Urology and Related Services
|
J1
|
$XXX.XX
|
| 5401 |
Dialysis
|
S
|
$XXX.XX
|
| 5411 |
Level 1 Gynecologic Procedures
|
T
|
$XXX.XX
|
| 5412 |
Level 2 Gynecologic Procedures
|
T
|
$XXX.XX
|
| 5413 |
Level 3 Gynecologic Procedures
|
T
|
$XXX.XX
|
| 5414 |
Level 4 Gynecologic Procedures
|
J1
|
$XXX.XX
|
| 5415 |
Level 5 Gynecologic Procedures
|
J1
|
$XXX.XX
|
| 5416 |
Level 6 Gynecologic Procedures
|
J1
|
$XXX.XX
|
| 5431 |
Level 1 Nerve Procedures
|
J1
|
$XXX.XX
|
| 5432 |
Level 2 Nerve Procedures
|
J1
|
$XXX.XX
|
| 5441 |
Level 1 Nerve Injections
|
T
|
$XXX.XX
|
| 5442 |
Level 2 Nerve Injections
|
T
|
$XXX.XX
|
| 5443 |
Level 3 Nerve Injections
|
T
|
$XXX.XX
|
| 5461 |
Level 1 Neurostimulator and Related Procedures
|
J1
|
$XXX.XX
|
| 5462 |
Level 2 Neurostimulator and Related Procedures
|
J1
|
$XXX.XX
|
| 5463 |
Level 3 Neurostimulator and Related Procedures
|
J1
|
$XXX.XX
|
| 5464 |
Level 4 Neurostimulator and Related Procedures
|
J1
|
$XXX.XX
|
| 5465 |
Level 5 Neurostimulator and Related Procedures
|
J1
|
$XXX.XX
|
| 5471 |
Implantation of Drug Infusion Device
|
J1
|
$XXX.XX
|
| 5481 |
Laser Eye Procedures
|
T
|
$XXX.XX
|
| 5491 |
Level 1 Intraocular Procedures
|
J1
|
$XXX.XX
|
| 5492 |
Level 2 Intraocular Procedures
|
J1
|
$XXX.XX
|
| 5493 |
Level 3 Intraocular Procedures
|
J1
|
$XXX.XX
|
| 5494 |
Level 4 Intraocular Procedures
|
J1
|
$XXX.XX
|
| 5495 |
Level 5 Intraocular Procedures
|
J1
|
$XXX.XX
|
| 5496 |
Level 6 Intraocular Procedures
|
J1
|
$XXX.XX
|
| 5501 |
Level 1 Extraocular, Repair, and Plastic Eye Procedures
|
T
|
$XXX.XX
|
| 5502 |
Level 2 Extraocular, Repair, and Plastic Eye Procedures
|
T
|
$XXX.XX
|
| 5503 |
Level 3 Extraocular, Repair, and Plastic Eye Procedures
|
J1
|
$XXX.XX
|
| 5504 |
Level 4 Extraocular, Repair, and Plastic Eye Procedures
|
J1
|
$XXX.XX
|
| 5521 |
Level 1 Imaging without Contrast
|
S
|
$XXX.XX
|
| 5522 |
Level 2 Imaging without Contrast
|
S
|
$XXX.XX
|
| 5523 |
Level 3 Imaging without Contrast
|
S
|
$XXX.XX
|
| 5524 |
Level 4 Imaging without Contrast
|
S
|
$XXX.XX
|
| 5571 |
Level 1 Imaging with Contrast
|
S
|
$XXX.XX
|
| 5572 |
Level 2 Imaging with Contrast
|
S
|
$XXX.XX
|
| 5573 |
Level 3 Imaging with Contrast
|
S
|
$XXX.XX
|
| 5591 |
Level 1 Nuclear Medicine and Related Services
|
S
|
$XXX.XX
|
| 5592 |
Level 2 Nuclear Medicine and Related Services
|
S
|
$XXX.XX
|
| 5593 |
Level 3 Nuclear Medicine and Related Services
|
S
|
$XXX.XX
|
| 5594 |
Level 4 Nuclear Medicine and Related Services
|
S
|
$XXX.XX
|
| 5611 |
Level 1 Therapeutic Radiation Treatment Preparation
|
S
|
$XXX.XX
|
| 5612 |
Level 2 Therapeutic Radiation Treatment Preparation
|
S
|
$XXX.XX
|
| 5613 |
Level 3 Therapeutic Radiation Treatment Preparation
|
S
|
$XXX.XX
|
| 5621 |
Level 1 Radiation Therapy
|
S
|
$XXX.XX
|
| 5622 |
Level 2 Radiation Therapy
|
S
|
$XXX.XX
|
| 5623 |
Level 3 Radiation Therapy
|
S
|
$XXX.XX
|
| 5624 |
Level 4 Radiation Therapy
|
S
|
$XXX.XX
|
| 5625 |
Level 5 Radiation Therapy
|
S
|
$XXX.XX
|
| 5626 |
Level 6 Radiation Therapy
|
S
|
$XXX.XX
|
| 5627 |
Level 7 Radiation Therapy
|
J1
|
$XXX.XX
|
| 5661 |
Therapeutic Nuclear Medicine
|
S
|
$XXX.XX
|
| 5671 |
Level 1 Pathology
|
S
|
$XXX.XX
|
| 5672 |
Level 2 Pathology
|
S
|
$XXX.XX
|
| 5673 |
Level 3 Pathology
|
S
|
$XXX.XX
|
| 5674 |
Level 4 Pathology
|
S
|
$XXX.XX
|
| 5691 |
Level 1 Drug Administration
|
S
|
$XXX.XX
|
| 5692 |
Level 2 Drug Administration
|
S
|
$XXX.XX
|
| 5693 |
Level 3 Drug Administration
|
S
|
$XXX.XX
|
| 5694 |
Level 4 Drug Administration
|
S
|
$XXX.XX
|
| 5721 |
Level 1 Diagnostic Tests and Related Services
|
S
|
$XXX.XX
|
| 5722 |
Level 2 Diagnostic Tests and Related Services
|
S
|
$XXX.XX
|
| 5723 |
Level 3 Diagnostic Tests and Related Services
|
S
|
$XXX.XX
|
| 5724 |
Level 4 Diagnostic Tests and Related Services
|
S
|
$XXX.XX
|
| 5731 |
Level 1 Minor Procedures
|
S
|
$XXX.XX
|
| 5732 |
Level 2 Minor Procedures
|
S
|
$XXX.XX
|
| 5733 |
Level 3 Minor Procedures
|
S
|
$XXX.XX
|
| 5734 |
Level 4 Minor Procedures
|
S
|
$XXX.XX
|
| 5735 |
Level 5 Minor Procedures
|
S
|
$XXX.XX
|
| 5741 |
Level 1 Electronic Analysis of Devices
|
S
|
$XXX.XX
|
| 5742 |
Level 2 Electronic Analysis of Devices
|
S
|
$XXX.XX
|
| 5743 |
Level 3 Electronic Analysis of Devices
|
S
|
$XXX.XX
|
| 5771 |
Cardiac Rehabilitation
|
S
|
$XXX.XX
|
| 5781 |
Resuscitation and Cardioversion
|
S
|
$XXX.XX
|
| 5791 |
Pulmonary Treatment
|
S
|
$XXX.XX
|
| 5801 |
Ventilation Initiation and Management
|
S
|
$XXX.XX
|
| 5811 |
Manipulation Therapy
|
S
|
$XXX.XX
|
| 5821 |
Level 1 Health and Behavior Services
|
S
|
$XXX.XX
|
| 5822 |
Level 2 Health and Behavior Services
|
S
|
$XXX.XX
|
| 5823 |
Level 3 Health and Behavior Services
|
S
|
$XXX.XX
|
| 5851 |
Intensive Outpatient (3 services) for CMHCs
|
P
|
$XXX.XX
|
| 5852 |
Intensive Outpatient (4 or more services) for CMHCs
|
P
|
$XXX.XX
|
| 5853 |
Partial Hospitalization (3 services) for CMHCs
|
P
|
$XXX.XX
|
| 5854 |
Partial Hospitalization (4 or more services) for CMHCs
|
P
|
$XXX.XX
|
| 5861 |
Intensive Outpatient (3 services) for Hospital-based IOPs
|
P
|
$XXX.XX
|
| 5862 |
Intensive Outpatient (4 or more services) for Hospital-based IOPs
|
P
|
$XXX.XX
|
| 5863 |
Partial Hospitalization (3 services) for Hospital-based PHPs
|
P
|
$XXX.XX
|
| 5864 |
Partial Hospitalization (4 or more services) for Hospital-based PHPs
|
P
|
$XXX.XX
|
| 5871 |
Dental Procedures
|
T
|
$XXX.XX
|
| 5881 |
Ancillary Outpatient Services When Patient Dies
|
J1
|
$XXX.XX
|
| 7043 |
Infliximab not biosimil 10mg
|
K
|
$XXX.XX
|
| 7046 |
Doxorubicin inj 10mg
|
K
|
$XXX.XX
|
| 7048 |
Alteplase recombinant
|
K
|
$XXX.XX
|
| 7308 |
Aminolevulinic acid hcl top
|
K
|
$XXX.XX
|
| 8004 |
Ultrasound Composite
|
S
|
$XXX.XX
|
| 8005 |
CT and CTA without Contrast Composite
|
S
|
$XXX.XX
|
| 8006 |
CT and CTA with Contrast Composite
|
S
|
$XXX.XX
|
| 8007 |
MRI and MRA without Contrast Composite
|
S
|
$XXX.XX
|
| 8008 |
MRI and MRA with Contrast Composite
|
S
|
$XXX.XX
|
| 8010 |
Mental Health Services Composite
|
S
|
$XXX.XX
|
| 8011 |
Comprehensive Observation Services
|
J2
|
$XXX.XX
|
| 9002 |
Tenecteplase injection
|
K
|
$XXX.XX
|
| 9003 |
Rsv mab im 50mg
|
K
|
$XXX.XX
|
| 9004 |
Injection, inclisiran, 1 mg
|
G
|
$XXX.XX
|
| 9005 |
Reteplase injection
|
K
|
$XXX.XX
|
| 9006 |
Tacrolimus injection
|
K
|
$XXX.XX
|
| 9008 |
Inj tezepelumab-ekko, 1mg
|
G
|
$XXX.XX
|
| 9009 |
Inj, vutrisiran, 1 mg
|
G
|
$XXX.XX
|
| 9010 |
Inj efgartigimod 2mg
|
G
|
$XXX.XX
|
| 9012 |
Arsenic trioxide injection
|
K
|
$XXX.XX
|
| 9013 |
Inj risankizumab-rzaa 1 mg
|
G
|
$XXX.XX
|
| 9016 |
Inj., triptorelin xr 3.75 mg
|
K
|
$XXX.XX
|
| 9017 |
Inj. byooviz, 0.1 mg
|
G
|
$XXX.XX
|
| 9018 |
Inj, rimabotulinumtoxinB
|
K
|
$XXX.XX
|
| 9020 |
Argatroban nonesrd (accord)
|
K
|
$XXX.XX
|
| 9022 |
Argatroban nonesrd (auromed)
|
K
|
$XXX.XX
|
| 9024 |
Amphotericin b lipid complex
|
K
|
$XXX.XX
|
| 9025 |
Inj glucagon hcl, fresenius
|
K
|
$XXX.XX
|
| 9026 |
Inj, bortezomib, dr. reddy’s
|
K
|
$XXX.XX
|
| 9027 |
Inj, bortezomib freseniuskab
|
K
|
$XXX.XX
|
| 9028 |
Inj inotuzumab ozogam 0.1 mg
|
K
|
$XXX.XX
|
| 9029 |
Inj., guselkumab, 1 mg
|
K
|
$XXX.XX
|
| 9030 |
Inj., copanlisib, 1 mg
|
K
|
$XXX.XX
|
| 9032 |
Baclofen 10 MG injection
|
K
|
$XXX.XX
|
| 9033 |
Cidofovir injection
|
K
|
$XXX.XX
|
| 9034 |
Inj cuvitru, 100 mg
|
K
|
$XXX.XX
|
| 9035 |
Axicabtagene ciloleucel car+
|
K
|
$XXX.XX
|
| 9036 |
Injection, renflexis
|
K
|
$XXX.XX
|
| 9038 |
Inj estrogen conjugate
|
K
|
$XXX.XX
|
| 9042 |
Glucagon hydrochloride
|
K
|
$XXX.XX
|
| 9043 |
Inj, afstyla, 1 i.u.
|
K
|
$XXX.XX
|
| 9044 |
Ibutilide fumarate injection
|
K
|
$XXX.XX
|
| 9045 |
Idursulfase injection
|
K
|
$XXX.XX
|
| 9046 |
Inj., fibryga, 1 mg
|
K
|
$XXX.XX
|
| 9048 |
Inj, alymsys, 10 mg
|
G
|
$XXX.XX
|
| 9049 |
Inj, oliceridine 0.1 mg
|
G
|
$XXX.XX
|
| 9050 |
Leuprolide inj, camcevi, 1mg
|
G
|
$XXX.XX
|
| 9051 |
Inj, lanreotide, (cipla) 1mg
|
G
|
$XXX.XX
|
| 9052 |
Fluciclovine f-18
|
K
|
$XXX.XX
|
| 9053 |
Fluorodopa f-18 diag per mci
|
G
|
$XXX.XX
|
| 9054 |
Lutetium lu 177 vipivotide
|
G
|
$XXX.XX
|
| 9055 |
Gallium locametz 1 millicuri
|
G
|
$XXX.XX
|
| 9056 |
Gallium ga-68
|
K
|
$XXX.XX
|
| 9057 |
Inj nivol relatlimab 3mg/1mg
|
G
|
$XXX.XX
|
| 9059 |
Vonvendi inj 1 iu vwf:rco
|
K
|
$XXX.XX
|
| 9067 |
Lutetium lu 177 dotatat ther
|
K
|
$XXX.XX
|
| 9068 |
Smallpox&monkeypox vac 0.5ml
|
K
|
$XXX.XX
|
| 9070 |
Inj luxturna 1 billion vec g
|
K
|
$XXX.XX
|
| 9071 |
Capsaicin 8% patch
|
K
|
$XXX.XX
|
| 9073 |
Buprenorph xr 100 mg or less
|
K
|
$XXX.XX
|
| 9074 |
Makena, 10 mg
|
K
|
$XXX.XX
|
| 9075 |
Inj, kovaltry, 1 i.u.
|
K
|
$XXX.XX
|
| 9077 |
Epoetin beta non esrd
|
K
|
$XXX.XX
|
| 9078 |
Testosterone undecanoate 1mg
|
K
|
$XXX.XX
|
| 9079 |
Genvisc 850, inj, 1mg
|
K
|
$XXX.XX
|
| 9080 |
Fludarabine phosphate inj
|
K
|
$XXX.XX
|
| 9087 |
Inj, clevidipine butyrate
|
K
|
$XXX.XX
|
| 9088 |
Peng benzathine/procaine inj
|
K
|
$XXX.XX
|
| 9094 |
Radiesse injection
|
K
|
$XXX.XX
|
| 9095 |
Inj, sculptra, 0.5mg
|
K
|
$XXX.XX
|
| 9096 |
Inj retacrit esrd on dialysi
|
K
|
$XXX.XX
|
| 9097 |
Inj retacrit non-esrd use
|
K
|
$XXX.XX
|
| 9099 |
Inj fosnetupitant, palonoset
|
K
|
$XXX.XX
|
| 9101 |
Vaccinia vrs vac 0.3 ml perq
|
K
|
$XXX.XX
|
| 9102 |
Inj, fulvestrant (teva)
|
K
|
$XXX.XX
|
| 9103 |
Inj, fulvestrant (fresenius)
|
K
|
$XXX.XX
|
| 9104 |
Antithymocyte globuln rabbit
|
K
|
$XXX.XX
|
| 9105 |
Inj pemetrexed (teva) 10mg
|
K
|
$XXX.XX
|
| 9106 |
Inj, bupivacaine (posimir)
|
G
|
$XXX.XX
|
| 9107 |
Inj, aponvie, 1 mg
|
G
|
$XXX.XX
|
| 9108 |
Thyrotropin injection
|
K
|
$XXX.XX
|
| 9109 |
Inj, elahere, 1 mg
|
G
|
$XXX.XX
|
| 9110 |
Inj, tremelimumab-actl, 1 mg
|
G
|
$XXX.XX
|
| 9111 |
Inj teclistamab cqyv 0.5 mg
|
G
|
$XXX.XX
|
| 9112 |
Inj teplizumab mzwv 5 mcg
|
G
|
$XXX.XX
|
| 9113 |
Inj olipudase alfa-rpcp 1mg
|
G
|
$XXX.XX
|
| 9114 |
Inj eflapegrastim-xnst 0.1mg
|
G
|
$XXX.XX
|
| 9115 |
Inj, spesolimab-sbzo, 1 mg
|
G
|
$XXX.XX
|
| 9116 |
Chloroprocaine opht gel, 1mg
|
G
|
$XXX.XX
|
| 9117 |
Inj, cimerli, 0.1 mg
|
G
|
$XXX.XX
|
| 9118 |
Inj, fylnetra, 0.5 mg
|
G
|
$XXX.XX
|
| 9119 |
Inj, pedmark, 100 mg
|
G
|
$XXX.XX
|
| 9120 |
Injection, Fulvestrant
|
K
|
$XXX.XX
|
| 9122 |
Triptorelin pamoate
|
K
|
$XXX.XX
|
| 9123 |
Inj pemetrexed, hospira 10mg
|
K
|
$XXX.XX
|
| 9125 |
Risperidone, long acting
|
K
|
$XXX.XX
|
| 9126 |
Natalizumab injection
|
K
|
$XXX.XX
|
| 9127 |
Inj pemetrexed (accord) 10mg
|
K
|
$XXX.XX
|
| 9129 |
Inj, stimufend, 0.5 mg
|
K
|
$XXX.XX
|
| 9131 |
Inj, Ado-trastuzumab Emt 1mg
|
K
|
$XXX.XX
|
| 9132 |
Prothrombin complex kcentra
|
K
|
$XXX.XX
|
| 9133 |
Rabies ig, im/sc
|
K
|
$XXX.XX
|
| 9134 |
Rabies ig, heat treated
|
K
|
$XXX.XX
|
| 9135 |
Varicella-zoster ig, im
|
K
|
$XXX.XX
|
| 9136 |
Leuprolide depot cipla 7.5mg
|
G
|
$XXX.XX
|
| 9138 |
Inj, hemgenix, per tx dose
|
G
|
$XXX.XX
|
| 9139 |
Rabies vaccine, im
|
K
|
$XXX.XX
|
| 9140 |
Rabies vaccine, id
|
K
|
$XXX.XX
|
| 9141 |
Inj onase abepar-xioi treat
|
K
|
$XXX.XX
|
| 9142 |
Fecal microbiota jslm 1 ml
|
G
|
$XXX.XX
|
| 9144 |
Inj, panzyga, 500 mg
|
K
|
$XXX.XX
|
| 9145 |
Inj, invega hafyera/trinza
|
K
|
$XXX.XX
|
| 9146 |
Inj, ixinity, 1 i.u.
|
K
|
$XXX.XX
|
| 9149 |
Inj ublituximab-xiiy, 1 mg
|
G
|
$XXX.XX
|
| 9150 |
Inj mosunetuzumab-axgb, 1 mg
|
G
|
$XXX.XX
|
| 9154 |
Inj, vivimusta, 1 mg
|
G
|
$XXX.XX
|
| 9155 |
Inj, lenacapavir, 1 mg
|
G
|
$XXX.XX
|
| 9156 |
Inj pemetrexed ditromethamin
|
K
|
$XXX.XX
|
| 9157 |
Inj, lecanemab-irmb, 1 mg
|
G
|
$XXX.XX
|
| 9158 |
Inj, pegcetacoplan, 1mg
|
G
|
$XXX.XX
|
| 9159 |
Inj, vegzelma, 10 mg
|
G
|
$XXX.XX
|
| 9166 |
Inj, fosaprepitant (teva)
|
K
|
$XXX.XX
|
| 9171 |
Factor ix idelvion inj
|
K
|
$XXX.XX
|
| 9173 |
Injection, fulphila
|
K
|
$XXX.XX
|
| 9174 |
Inj, durolane 1 mg
|
K
|
$XXX.XX
|
| 9178 |
Inj., meropenem, vaborbactam
|
K
|
$XXX.XX
|
| 9179 |
Inj., aristada initio, 1 mg
|
K
|
$XXX.XX
|
| 9180 |
Inj., patisiran, 0.1 mg
|
K
|
$XXX.XX
|
| 9181 |
Inj., perseris, 0.5 mg
|
K
|
$XXX.XX
|
| 9182 |
Inj mogamulizumab-kpkc, 1 mg
|
K
|
$XXX.XX
|
| 9183 |
Inj., plazomicin, 5 mg
|
K
|
$XXX.XX
|
| 9186 |
Inj., rituximab, 10 mg
|
K
|
$XXX.XX
|
| 9187 |
Injection, burosumab-twza 1m
|
K
|
$XXX.XX
|
| 9188 |
Inj crotalidae im f(ab')2 eq
|
K
|
$XXX.XX
|
| 9189 |
Inj., ibalizumab-uiyk, 10 mg
|
K
|
$XXX.XX
|
| 9193 |
Nivestym
|
K
|
$XXX.XX
|
| 9194 |
Tisagenlecleucel car-pos t
|
K
|
$XXX.XX
|
| 9195 |
Injection, udenyca 0.5 mg
|
K
|
$XXX.XX
|
| 9196 |
Inj, trivisc 1 mg
|
K
|
$XXX.XX
|
| 9198 |
Inj andexxa, 10 mg
|
K
|
$XXX.XX
|
| 9200 |
Inj, remdesivir, 1 mg
|
K
|
$XXX.XX
|
| 9201 |
Rabies ig ht&sol human im/sc
|
K
|
$XXX.XX
|
| 9202 |
Difelikefalin, esrd on dialy
|
K
|
$XXX.XX
|
| 9203 |
Inj cyclophosphamd auromedic
|
K
|
$XXX.XX
|
| 9204 |
Inj tisotu vedotin-tftv, 1mg
|
K
|
$XXX.XX
|
| 9205 |
Inj lon tesirin-lpyl 0.075mg
|
K
|
$XXX.XX
|
| 9206 |
Inj plasminogen tvmh 1mg
|
K
|
$XXX.XX
|
| 9208 |
Agalsidase beta injection
|
K
|
$XXX.XX
|
| 9209 |
Laronidase injection
|
K
|
$XXX.XX
|
| 9213 |
Inj. pemetrexed nos 10mg
|
K
|
$XXX.XX
|
| 9214 |
Bevacizumab injection
|
K
|
$XXX.XX
|
| 9215 |
Cetuximab injection
|
K
|
$XXX.XX
|
| 9217 |
Leuprolide acetate suspnsion
|
K
|
$XXX.XX
|
| 9219 |
Procainamide hcl injection
|
K
|
$XXX.XX
|
| 9225 |
Fluocinolone acetonide implt
|
K
|
$XXX.XX
|
| 9230 |
Abatacept injection
|
K
|
$XXX.XX
|
| 9233 |
Ranibizumab injection
|
K
|
$XXX.XX
|
| 9235 |
Panitumumab injection
|
K
|
$XXX.XX
|
| 9237 |
Inj, lanreotide acetate
|
K
|
$XXX.XX
|
| 9239 |
Buprenorphine xr over 100 mg
|
K
|
$XXX.XX
|
| 9240 |
Injection, ixabepilone
|
K
|
$XXX.XX
|
| 9241 |
Inj sirolimus prot part 1 mg
|
K
|
$XXX.XX
|
| 9243 |
Inj, bendamustine hcl, 1mg
|
K
|
$XXX.XX
|
| 9246 |
Inj, abilify asimtufii, 1 mg
|
G
|
$XXX.XX
|
| 9247 |
Inj, amisulpride, 1 mg
|
G
|
$XXX.XX
|
| 9250 |
Inj epcoritamab-bysp 0.16 mg
|
G
|
$XXX.XX
|
| 9251 |
C1 esterase inhibitor inj
|
K
|
$XXX.XX
|
| 9252 |
Plerixafor injection
|
K
|
$XXX.XX
|
| 9253 |
Temozolomide injection
|
K
|
$XXX.XX
|
| 9254 |
Flotufolastat f18 diag 1 mci
|
G
|
$XXX.XX
|
| 9255 |
Inj, invega sustenna, 1 mg
|
K
|
$XXX.XX
|
| 9256 |
Dexamethasone intra implant
|
K
|
$XXX.XX
|
| 9257 |
Inj., emicizumab-kxwh 0.5 mg
|
K
|
$XXX.XX
|
| 9258 |
Telavancin injection
|
K
|
$XXX.XX
|
| 9259 |
Pralatrexate injection
|
K
|
$XXX.XX
|
| 9260 |
Ofatumumab injection
|
K
|
$XXX.XX
|
| 9261 |
Ustekinumab sub cu inj, 1 mg
|
K
|
$XXX.XX
|
| 9262 |
Inj tofersen intrathec 1 mg
|
G
|
$XXX.XX
|
| 9263 |
Ecallantide injection
|
K
|
$XXX.XX
|
| 9264 |
Tocilizumab injection
|
K
|
$XXX.XX
|
| 9266 |
Inj, uzedy, 1 mg
|
G
|
$XXX.XX
|
| 9267 |
Inj, rezafungin, 1 mg
|
G
|
$XXX.XX
|
| 9269 |
C-1 esterase, berinert
|
K
|
$XXX.XX
|
| 9270 |
Gammaplex IVIG
|
K
|
$XXX.XX
|
| 9271 |
Velaglucerase alfa
|
K
|
$XXX.XX
|
| 9272 |
Inj, denosumab
|
K
|
$XXX.XX
|
| 9273 |
Sipuleucel-T auto CD54+
|
K
|
$XXX.XX
|
| 9274 |
Crotalidae Poly Immune Fab
|
K
|
$XXX.XX
|
| 9276 |
Cabazitaxel injection
|
K
|
$XXX.XX
|
| 9277 |
Altuviiio per factor viii iu
|
G
|
$XXX.XX
|
| 9278 |
Incobotulinumtoxin A
|
K
|
$XXX.XX
|
| 9280 |
Inj, retifanlimab-dlwr, 1 mg
|
G
|
$XXX.XX
|
| 9281 |
Injection, pegloticase
|
K
|
$XXX.XX
|
| 9284 |
Ipilimumab injection
|
K
|
$XXX.XX
|
| 9285 |
Inj allopurinol sodium 1 mg
|
K
|
$XXX.XX
|
| 9286 |
Belatacept injection
|
K
|
$XXX.XX
|
| 9287 |
Brentuximab vedotin inj
|
K
|
$XXX.XX
|
| 9294 |
Inj, taliglucerase alfa 10 u
|
K
|
$XXX.XX
|
| 9295 |
Injection, Carfilzomib, 1 mg
|
K
|
$XXX.XX
|
| 9296 |
Inj, ziv-aflibercept, 1mg
|
K
|
$XXX.XX
|
| 9297 |
Inj, Omacetaxine Mep, 0.01mg
|
K
|
$XXX.XX
|
| 9299 |
Inj. jivi 1 iu
|
K
|
$XXX.XX
|
| 9300 |
Omalizumab injection
|
K
|
$XXX.XX
|
| 9301 |
Aminolevulinic acid, 10% gel
|
K
|
$XXX.XX
|
| 9302 |
Inj daunorubicin, cytarabine
|
K
|
$XXX.XX
|
| 9304 |
Inj., cemiplimab-rwlc, 1 mg
|
K
|
$XXX.XX
|
| 9305 |
Inj., lumoxiti, 0.01 mg
|
K
|
$XXX.XX
|
| 9306 |
Inj., tildrakizumab, 1 mg
|
K
|
$XXX.XX
|
| 9308 |
Dexametha opth insert 0.1 mg
|
K1
|
$XXX.XX
|
| 9309 |
Inj. tagraxofusp-erzs 10 mcg
|
K
|
$XXX.XX
|
| 9310 |
Inj., emapalumab-lzsg, 1 mg
|
K
|
$XXX.XX
|
| 9311 |
Inj., omadacycline, 1 mg
|
K
|
$XXX.XX
|
| 9312 |
Inj., ravulizumab-cwvz 10 mg
|
K
|
$XXX.XX
|
| 9313 |
Inj. belrapzo/bendamustine
|
K
|
$XXX.XX
|
| 9314 |
Inj. herceptin hylecta, 10mg
|
K
|
$XXX.XX
|
| 9319 |
Somatropin injection
|
K
|
$XXX.XX
|
| 9320 |
Carbidopa levodopa ent 100ml
|
K
|
$XXX.XX
|
| 9323 |
Gallium ga-68 dotatoc
|
K
|
$XXX.XX
|
| 9324 |
Phenylep ketorolac opth soln
|
K1
|
$XXX.XX
|
| 9327 |
Inj. romosozumab-aqqg 1 mg
|
K
|
$XXX.XX
|
| 9328 |
Inj., yutiq, 0.01 mg
|
K
|
$XXX.XX
|
| 9329 |
Inj mvasi 10 mg
|
K
|
$XXX.XX
|
| 9330 |
Inj., kanjinti, 10 mg
|
K
|
$XXX.XX
|
| 9331 |
Inj, polatuzumab vedotin 1mg
|
K
|
$XXX.XX
|
| 9335 |
Oral busulfan
|
K
|
$XXX.XX
|
| 9336 |
Inj truxima 10 mg
|
K
|
$XXX.XX
|
| 9338 |
Inj., triluron, 1 mg
|
K
|
$XXX.XX
|
| 9340 |
Inj, brolucizumab-dbll, 1 mg
|
K
|
$XXX.XX
|
| 9341 |
Inj ogivri 10 mg
|
K
|
$XXX.XX
|
| 9343 |
Inj givosiran 0.5 mg
|
K
|
$XXX.XX
|
| 9345 |
Inj pegfilgrastim-bmez 0.5mg
|
K
|
$XXX.XX
|
| 9346 |
Mometasone sinus sinuva
|
K
|
$XXX.XX
|
| 9347 |
Inj luspatercept-aamt 0.25mg
|
K
|
$XXX.XX
|
| 9348 |
Inj., zirabev, 10 mg
|
K
|
$XXX.XX
|
| 9349 |
Inj herzuma 10 mg
|
K
|
$XXX.XX
|
| 9350 |
Inj., trazimera, 10 mg
|
K
|
$XXX.XX
|
| 9351 |
Inj bimatoprost itc imp 1mcg
|
K
|
$XXX.XX
|
| 9353 |
Inj fam-trastu deru-nxki 1mg
|
K
|
$XXX.XX
|
| 9354 |
Inj recombin esperoct per iu
|
K
|
$XXX.XX
|
| 9355 |
Inj. teprotumumab-trbw 10 mg
|
K
|
$XXX.XX
|
| 9357 |
Inj. eptinezumab-jjmr 1 mg
|
K
|
$XXX.XX
|
| 9358 |
Inj xipere 1 mg
|
K
|
$XXX.XX
|
| 9359 |
Inj crizanlizumab-tmca 5mg
|
K
|
$XXX.XX
|
| 9361 |
Inj. cetirizine hcl 0.5mg
|
K
|
$XXX.XX
|
| 9362 |
Inj imip 4 cilas 4 releb 2mg
|
K
|
$XXX.XX
|
| 9364 |
Inj enfort vedo-ejfv 0.25mg
|
K
|
$XXX.XX
|
| 9366 |
Fiasp for insulin pump use
|
K
|
$XXX.XX
|
| 9367 |
Inj ruxience, 10 mg
|
K
|
$XXX.XX
|
| 9370 |
Fluoroestradiol F 18
|
K
|
$XXX.XX
|
| 9372 |
Inj. xembify, 100 mg
|
K
|
$XXX.XX
|
| 9374 |
Mitomycin instillation
|
K
|
$XXX.XX
|
| 9375 |
Inj., evomela, 1 mg
|
K
|
$XXX.XX
|
| 9376 |
Sacituzumab govitecan-hziy
|
K
|
$XXX.XX
|
| 9377 |
Inj. isatuximab-irfc 10 mg
|
K
|
$XXX.XX
|
| 9378 |
Daratumumab, hyaluronidase
|
K
|
$XXX.XX
|
| 9381 |
Inj. avsola, 10 mg
|
K
|
$XXX.XX
|
| 9382 |
Inj ontruzant 10 mg
|
K
|
$XXX.XX
|
| 9383 |
Copper cu 64 dotatate diag
|
K
|
$XXX.XX
|
| 9385 |
Inj., tafasitamab-cxix
|
K
|
$XXX.XX
|
| 9388 |
Inj. fe derisomaltose 10 mg
|
K
|
$XXX.XX
|
| 9389 |
Inj. lurbinectedin, 0.1 mg
|
K
|
$XXX.XX
|
| 9390 |
Pertuzu, trastuzu, 10 mg
|
K
|
$XXX.XX
|
| 9391 |
Brexucabtagene car pos t
|
K
|
$XXX.XX
|
| 9392 |
Inj. asceniv
|
K
|
$XXX.XX
|
| 9394 |
Inj. inebilizumab-cdon, 1 mg
|
K
|
$XXX.XX
|
| 9396 |
Afamelanotide implant, 1 mg
|
K
|
$XXX.XX
|
| 9398 |
Covid-19 Vaccine Admin Dose 2 of 2, Single Dose Product or Additional Dose
|
S
|
$XXX.XX
|
| 9399 |
Pneumococcal, Influenza, Hepatitis B, and/or Covid-19 Vaccine Home Administration
|
S
|
$XXX.XX
|
| 9406 |
Inj, nyvepria
|
K
|
$XXX.XX
|
| 9407 |
Inj. lumasiran, 0.5 mg
|
K
|
$XXX.XX
|
| 9408 |
Inj. naxitamab-gqgk, 1 mg
|
K
|
$XXX.XX
|
| 9409 |
Gallium ga-68 psma-11 ucsf
|
K
|
$XXX.XX
|
| 9410 |
Gallium ga-68 psma-11, ucla
|
K
|
$XXX.XX
|
| 9411 |
Inj. riabni, 10 mg
|
K
|
$XXX.XX
|
| 9413 |
lisocabtagene car pos t
|
K
|
$XXX.XX
|
| 9414 |
Inj, cabote rilpivir 2mg 3mg
|
K
|
$XXX.XX
|
| 9415 |
Injection, trilaciclib, 1mg
|
K
|
$XXX.XX
|
| 9416 |
Inj, evinacumab-dgnb, 5 mg
|
K
|
$XXX.XX
|
| 9418 |
Inj. margetuximab-cmkb, 5 mg
|
K
|
$XXX.XX
|
| 9419 |
Inj fensolvi 0.25 mg
|
K
|
$XXX.XX
|
| 9421 |
Inj, granisetron, xr, 0.1 mg
|
K
|
$XXX.XX
|
| 9422 |
Idecabtagene vicleucel car
|
K
|
$XXX.XX
|
| 9426 |
Inj, cefiderocol, 10 mg
|
K
|
$XXX.XX
|
| 9427 |
Injection, oritavancin 10 mg
|
K
|
$XXX.XX
|
| 9428 |
Inj romidepsin non-lyo 0.1mg
|
K
|
$XXX.XX
|
| 9429 |
Inj romidepsin lyophil 0.1mg
|
K
|
$XXX.XX
|
| 9430 |
Piflu f-18, dia 1 millicurie
|
K
|
$XXX.XX
|
| 9431 |
Inj, dostarlimab-gxly, 10 mg
|
K
|
$XXX.XX
|
| 9432 |
Inj, amivantamab-vmjw
|
K
|
$XXX.XX
|
| 9433 |
Inj aval alfa-nqpt 4mg
|
K
|
$XXX.XX
|
| 9434 |
Inj anifrolumab-fnia 1mg
|
K
|
$XXX.XX
|
| 9436 |
Inj pegfilgrast ex bio 0.5mg
|
K
|
$XXX.XX
|
| 9437 |
Inj, aspara, rylaze, 0.1 mg
|
K
|
$XXX.XX
|
| 9438 |
Injection, aducanumab-avwa, 2 mg
|
K
|
$XXX.XX
|
| 9439 |
Inj, susvimo 0.1 mg
|
K
|
$XXX.XX
|
| 9440 |
Instill, bupivac and meloxic
|
K1
|
$XXX.XX
|
| 9441 |
Inj ferric carboxymaltos 1mg
|
K
|
$XXX.XX
|
| 9442 |
Inj. pemetrexed, 10 mg
|
K
|
$XXX.XX
|
| 9443 |
Gallium illuccix 1 millicure
|
G
|
$XXX.XX
|
| 9444 |
Inj, sutimlimab-jome, 10 mg
|
G
|
$XXX.XX
|
| 9445 |
Injection, ruconest
|
K
|
$XXX.XX
|
| 9446 |
Inj, tebentafusp-tebn, 1 mcg
|
G
|
$XXX.XX
|
| 9447 |
Inj, releuko 1 mcg
|
G
|
$XXX.XX
|
| 9448 |
Oral netupitant, palonosetro
|
K
|
$XXX.XX
|
| 9449 |
Injection, blinatumomab
|
K
|
$XXX.XX
|
| 9450 |
Fluocinol acet intravit imp
|
K
|
$XXX.XX
|
| 9451 |
Injection, peramivir
|
K
|
$XXX.XX
|
| 9452 |
Inj ceftolozane tazobactam
|
K
|
$XXX.XX
|
| 9453 |
Injection, nivolumab
|
K
|
$XXX.XX
|
| 9454 |
Inj, pasireotide long acting
|
K
|
$XXX.XX
|
| 9455 |
Injection, siltuximab
|
K
|
$XXX.XX
|
| 9456 |
Injection, isavuconazonium
|
K
|
$XXX.XX
|
| 9458 |
Florbetaben f18 diagnostic
|
K
|
$XXX.XX
|
| 9459 |
Flutemetamol f18 diagnostic
|
K
|
$XXX.XX
|
| 9460 |
Injection, cangrelor
|
K
|
$XXX.XX
|
| 9461 |
Choline c-11
|
K
|
$XXX.XX
|
| 9463 |
Inj., aprepitant, 1 mg
|
K
|
$XXX.XX
|
| 9466 |
Inj., benralizumab, 1 mg
|
K
|
$XXX.XX
|
| 9467 |
Inj rituximab, hyaluronidase
|
K
|
$XXX.XX
|
| 9468 |
Factor ix recomb gly rebinyn
|
K
|
$XXX.XX
|
| 9469 |
Inj triamcinolone ace xr 1mg
|
K
|
$XXX.XX
|
| 9470 |
Aripirazole lauroxil 1 mg
|
K
|
$XXX.XX
|
| 9471 |
Hymovis injection 1 mg
|
K
|
$XXX.XX
|
| 9472 |
Inj talimogene laherparepvec
|
K
|
$XXX.XX
|
| 9473 |
Injection, mepolizumab, 1mg
|
K
|
$XXX.XX
|
| 9474 |
Inj irinotecan liposome 1 mg
|
K
|
$XXX.XX
|
| 9475 |
Injection, necitumumab, 1 mg
|
K
|
$XXX.XX
|
| 9476 |
Injection, daratumumab 10 mg
|
K
|
$XXX.XX
|
| 9477 |
Injection, elotuzumab, 1mg
|
K
|
$XXX.XX
|
| 9478 |
Inj sebelipase alfa 1 mg
|
K
|
$XXX.XX
|
| 9480 |
Injection trabectedin 0.1mg
|
K
|
$XXX.XX
|
| 9481 |
Injection, reslizumab
|
K
|
$XXX.XX
|
| 9482 |
Sotalol hydrochloride IV
|
K
|
$XXX.XX
|
| 9483 |
Inj, atezolizumab,10 mg
|
K
|
$XXX.XX
|
| 9487 |
Ustekinumab, iv inject,1 mg
|
K
|
$XXX.XX
|
| 9489 |
Inj, nusinersen, 0.1mg
|
K
|
$XXX.XX
|
| 9490 |
Inj, bezlotoxumab, 10 mg
|
K
|
$XXX.XX
|
| 9491 |
Injection, avelumab, 10 mg
|
K
|
$XXX.XX
|
| 9492 |
Inj., durvalumab, 10 mg
|
K
|
$XXX.XX
|
| 9493 |
Injection, edaravone, 1 mg
|
K
|
$XXX.XX
|
| 9494 |
Injection, ocrelizumab
|
K
|
$XXX.XX
|
| 9495 |
Gemtuzumab ozogamicin inj
|
K
|
$XXX.XX
|
| 9496 |
Inj, faricimab-svoa, 0.1mg
|
G
|
$XXX.XX
|
| 9498 |
Ciltacabtagene car-pos t
|
G
|
$XXX.XX
|
| 9500 |
Platelets, irradiated
|
R
|
$XXX.XX
|
| 9501 |
Platelet pheres leukoreduced
|
R
|
$XXX.XX
|
| 9502 |
Platelet pheresis irradiated
|
R
|
$XXX.XX
|
| 9503 |
Fr frz plasma donor retested
|
R
|
$XXX.XX
|
| 9504 |
RBC deglycerolized
|
R
|
$XXX.XX
|
| 9505 |
RBC irradiated
|
R
|
$XXX.XX
|
| 9507 |
Platelets, pheresis
|
R
|
$XXX.XX
|
| 9508 |
Plasma 1 donor frz w/in 8 hr
|
R
|
$XXX.XX
|
| 9509 |
Frozen plasma, pooled, sd
|
R
|
$XXX.XX
|
| 9510 |
Whole blood for transfusion
|
R
|
$XXX.XX
|
| 9511 |
Cryoprecipitate each unit
|
R
|
$XXX.XX
|
| 9512 |
RBC leukocytes reduced
|
R
|
$XXX.XX
|
| 9513 |
Plasma, frz between 8-24hour
|
R
|
$XXX.XX
|
| 9514 |
Plasma protein fract,5%,50ml
|
R
|
$XXX.XX
|
| 9515 |
Platelets, each unit
|
R
|
$XXX.XX
|
| 9516 |
Plaelet rich plasma unit
|
R
|
$XXX.XX
|
| 9517 |
Red blood cells unit
|
R
|
$XXX.XX
|
| 9518 |
Washed red blood cells unit
|
R
|
$XXX.XX
|
| 9519 |
Plasmaprotein fract,5%,250ml
|
R
|
$XXX.XX
|
| 9520 |
Blood split unit
|
R
|
$XXX.XX
|
| 9521 |
Platelets leukoreduced irrad
|
R
|
$XXX.XX
|
| 9522 |
RBC leukoreduced irradiated
|
R
|
$XXX.XX
|
| 9523 |
Cryoprecipitatereducedplasma
|
R
|
$XXX.XX
|
| 9524 |
Blood, l/r, cmv-neg
|
R
|
$XXX.XX
|
| 9525 |
Platelets, hla-m, l/r, unit
|
R
|
$XXX.XX
|
| 9526 |
Platelets leukocytes reduced
|
R
|
$XXX.XX
|
| 9527 |
Blood, l/r, froz/degly/wash
|
R
|
$XXX.XX
|
| 9528 |
Plt, aph/pher, l/r, cmv-neg
|
R
|
$XXX.XX
|
| 9529 |
Blood, l/r, irradiated
|
R
|
$XXX.XX
|
| 9530 |
Plate pheres leukoredu irrad
|
R
|
$XXX.XX
|
| 9531 |
Plt, pher, l/r cmv-neg, irr
|
R
|
$XXX.XX
|
| 9532 |
RBC, frz/deg/wsh, l/r, irrad
|
R
|
$XXX.XX
|
| 9533 |
RBC, l/r, cmv-neg, irrad
|
R
|
$XXX.XX
|
| 9534 |
Pathogen reduced plasma pool
|
R
|
$XXX.XX
|
| 9535 |
Pathogen reduced plasma sing
|
R
|
$XXX.XX
|
| 9536 |
Platelets pheresis path redu
|
R
|
$XXX.XX
|
| 9537 |
Blood component/product noc
|
R
|
$XXX.XX
|
| 9538 |
Plasma cryo redu path each
|
R
|
$XXX.XX
|
| 9539 |
Cryo fib comp path redu each
|
R
|
$XXX.XX
|
| 9540 |
Covid-19 convalescent plasma
|
R
|
$XXX.XX
|
| 9541 |
Rbc o2 co2 reduced
|
R
|
$XXX.XX
|
