	Addendum A.- Proposed OPPS APCs for CY 2026																																						
	Inflation Reduction Act (IRA)-adjusted 3-digit coinsurance percentage may not precisely reflect the copayment amount due to rounding calculations.																																						
	"For the subset of providers to which the 340b remedy offset applies, adjusted OPPS payment rates can be calculated by applying the ratio 0.9805 to payments and copayments associated with status indicators J1, J2, P, Q1, Q2, Q3, R, S, T, U, V"																																						
 APC  	Group Title	SI	Relative Weight 	Payment Rate 	National Unadjusted Copayment	Minimum Unadjusted Copayment	IRA Coinsurance percentage 	Adjusted Beneficiary Copayment	Drug and Device Pass-Through Expiration during Calendar Year	Note																													
0701	Sr89 strontium	K		"$4,146.335"	.	$829.27	20.000%	$829.27																															
0702	"Inj, human-lans, per i.u"	G		$1.546	.	$0.31	20.000%	$0.31																															
0703	Inj daxibotulinumtoxina-lanm	G		$2.992	.	$0.60	20.000%	$0.60																															
0704	"Inj, aflibercept hd, 1 mg"	G		$321.176	.	$64.24	20.000%	$64.24																															
0705	Inj avacincaptad pegol 0.1mg	G		$107.444	.	$21.49	20.000%	$21.49																															
0706	Inj talquetamab-tgvs 0.25 mg	G		$69.997	.	$14.00	19.851%	$13.90		IRA-adjusted coinsurance																													
0707	"Cantharidin top, applicator"	G		$682.257	.	$136.46	20.000%	$136.46																															
0708	"Inj, elranatamab-bcmm, 1 mg"	G		$182.980	.	$36.60	20.000%	$36.60																															
0709	Flortaucipir inj 1 millicuri	G		"$3,710.000"	.	$0.00	20.000%	$742.00																															
0710	Inj velmanase alfa-tycv 1 mg	G		$444.976	.	$89.00	19.679%	$87.57		IRA-adjusted coinsurance																													
0711	"Inj, artesunate, 1mg"	K		$51.829	.	$10.37	20.000%	$10.37																															
0713	Inj roctavian ml 2x10^13vc g	G		"$12,007.813"	.	"$2,401.57"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0714	Inj delandistrogene mox rokl	G		"$3,322,473.295"	.	"$664,494.66"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0715	Pegunigalsidase alfa-iwxj	G		$226.927	.	$45.39	19.817%	$44.98		IRA-adjusted coinsurance																													
0716	"Vyjuvek 5x10^9pfu/ml, 0.1 ml"	G		"$1,016.669"	.	$203.34	20.000%	$203.34																															
0717	"Instill adstiladrin, tx dose"	G		"$63,235.607"	.	"$12,647.13"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0718	"Inj, carmustine (accord)"	K		$259.700	.	$51.94	20.000%	$51.94																															
0719	Inj cyclophos avyxa 5mg	G 		$9.053	.	$1.82	20.000%	$1.82																															
0720	"Inj glofitamab gxbm, 2.5 mg"	G		"$2,772.798"	.	$554.56	20.000%	$554.56																															
0721	Inj ronzanolixizum-noli 1 mg	G		$22.842	.	$4.57	20.000%	$4.57																															
0723	Inj efgart-alfa 2mg hya-qvfc	K		$33.371	.	$6.68	20.000%	$6.68																															
0725	Inj secukinumab intrav 1mg	G		$17.728	.	$3.55	20.000%	$3.55																															
0726	Dexrazoxane HCl injection	K		$80.956	.	$16.20	20.000%	$16.20																															
0727	"Inj, adzynma, 10 iu"	G		$34.516	.	$6.91	20.000%	$6.91																															
0728	"Inj, mirikizumab-mrkz, 1 mg"	G		$47.566	.	$9.52	14.952%	$7.12		IRA-adjusted coinsurance																													
0729	"Inj, motixafortide, 0.25 mg"	G		$25.218	.	$5.05	20.000%	$5.05																															
0731	Sargramostim injection	K		$59.883	.	$11.98	19.955%	$11.95		IRA-adjusted coinsurance																													
0732	"Inj, brixadi, 7 days or less"	G		$425.404	.	$85.09	19.491%	$82.92		IRA-adjusted coinsurance																													
0733	"Inj brixadi, more than 7 day"	G		"$1,701.615"	.	$340.33	19.491%	$331.67		IRA-adjusted coinsurance																													
0734	"Inj, levothyroxine, freskabi"	K		$6.398	.	$1.28	20.000%	$1.28																															
0736	Amphotericin b liposome inj	K		$23.307	.	$4.67	20.000%	$4.67																															
0737	"Inj, cipaglucosidase, 5 mg"	G		$89.846	.	$17.97	20.000%	$17.97																															
0738	Rasburicase	K		$370.456	.	$74.10	20.000%	$74.10																															
0739	"Inj, rykindo, 0.5 mg"	K		$13.029	.	$2.61	20.000%	$2.61																															
0741	Inj cyclophosphamd (ingenus)	K		$1.762	.	$0.36	20.000%	$0.36																															
0743	"Inj, cyclophosphamide, nos"	K		$0.799	.	$0.16	20.000%	$0.16																															
0744	Inst tauro 1.35mg/hep 100u 	G		$8.593	.	$1.72	20.000%	$1.72																															
0745	"Inj, toripalimab-tpzi, 1 mg"	G		$39.096	.	$7.82	20.000%	$7.82																															
0746	"Inj, betibeglogene autotemce"	G		"$2,948,213.333"	.	"$589,642.67"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0747	"Inj, zolbetuximab-clzb, 2 mg"	G		$33.557	.	$6.72	20.000%	$6.72																															
0748	"Inj, lovotibeglogene autotem"	G		"$3,286,000.000"	.	"$657,200.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0749	Inj travoprost intra impl	G		$194.411	.	$38.89	20.000%	$38.89																															
0750	"Inj, nithiodote, 3mg / 125mg"	K		$2.166	.	$0.44	20.000%	$0.44																															
0752	Dactinomycin injection	K		$288.796	.	$57.76	20.000%	$57.76																															
0755	Oral methotrexate (jylamvo)	K		$18.968	.	$3.80	20.000%	$3.80																															
0756	Oral methotrexate (xatmep)	K		$20.710	.	$4.15	20.000%	$4.15																															
0757	"Docetaxel (docivyx), 1 mg"	G		$51.620	.	$10.33	20.000%	$10.33																															
0759	"Naltrexone, depot form"	K		$4.123	.	$0.83	20.000%	$0.83																															
0760	Tc-99m graphite crucible	G		$328.600	.	$0.00	0.000%	$0.00																															
0761	"Inj, focinvez, 1mg"	G		$3.021	.	$0.61	20.000%	$0.61																															
0763	"Inj, bupivacaine liposome"	K1		$1.421	.	$0.29	20.000%	$0.29																															
0764	Ketorolac tromethamine inj	K1		$0.501	.	$0.11	20.000%	$0.11																															
0765	"Inj, donanemab-azbt, 2 mg"	G		$4.181	.	$0.84	20.000%	$0.84																															
0767	"Inj, nogapendekin pmln 1 mcg"	G		$94.581	.	$18.92	20.000%	$18.92																															
0768	"Inj, tarlatamab-dlle, 1 mg "	G		"$1,570.765"	.	$314.16	20.000%	$314.16																															
0770	In111 oxyquinoline	K		$911.310	.	$182.27	20.000%	$182.27																															
0771	In111 pentetate	K		$764.790	.	$152.96	20.000%	$152.96																															
0772	"Inj, pegulicianine, 1 mg "	G		$37.508	.	$0.00	0.000%	$0.00																															
0773	"Inj, beqvez, per tx dose"	G		"$3,710,000.000"	.	"$742,000.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0774	Tc99m bicisate	K		$821.850	.	$164.37	20.000%	$164.37																															
0776	Technetium tc-99m auto wbc	K		$958.220	.	$191.65	20.000%	$191.65																															
0777	Indium in-111 auto wbc	K		"$1,073.130"	.	$214.63	20.000%	$214.63																															
0778	"Inj, vasopressin (baxter) "	G		$3.501	.	$0.71	20.000%	$0.71																															
0779	Indium in-111 pentetreotide	K		"$2,027.500"	.	$405.50	20.000%	$405.50																															
0780	Iodine i-123 iobenguane	K		"$2,418.900"	.	$483.78	20.000%	$483.78																															
0781	Iodine i-123 ioflupane	K		"$1,410.500"	.	$282.10	20.000%	$282.10																															
0782	"Inj, pemrydi rtu, 10 mg"	G		$81.057	.	$16.22	20.000%	$16.22																															
0784	"Inj, tyenne, 1 mg"	G		$4.065	.	$0.82	20.000%	$0.82		8% of reference add-on applied																													
0785	"Inj, cyclophosphamd, sandoz"	K		$4.344	.	$0.87	20.000%	$0.87																															
0786	"Inj, tofidence, 1 mg"	G		$5.971	.	$1.20	20.000%	$1.20		8% of reference add-on applied																													
0798	"Inj, sezaby, 1 mg"	K		$1.056	.	$0.22	20.000%	$0.22																															
0800	Leuprolide acetate	K		"$1,670.296"	.	$334.06	18.892%	$315.56		IRA-adjusted coinsurance																													
0802	Etoposide oral 50 mg	K 		$76.456	.	$15.30	20.000%	$15.30																															
0804	"Capecitabine, oral, 50 mg"	K		$0.065	.	$0.02	20.000%	$0.02																															
0805	"Hiv prep, inj, cabotegravir"	K		$6.887	.	$0.00	0.000%	$0.00																															
0806	"Hiv prep, ftc/tdf 200/300mg "	K		$1.277	.	$0.00	0.000%	$0.00																															
0807	Aldesleukin injection	K		"$5,301.260"	.	"$1,060.26"	20.000%	"$1,060.26"																															
0808	"Hiv prep, ftc/taf 200/25mg "	K		$71.272	.	$0.00	0.000%	$0.00																															
0811	"Inj, nypozi, 1 mcg"	G		$0.535	.	$0.11	20.000%	$0.11																															
0812	Carmustine injection	K		$145.597	.	$29.12	20.000%	$29.12																															
0813	"Injection, imetelstat, 1 mg"	G		$55.510	.	$11.11	20.000%	$11.11																															
0814	"Inj, magtrace per study dose"	G		"$1,137.959"	.	$0.00	0.000%	$0.00																															
0815	"Inj, palonosetron (posfrea)"	G		$59.905	.	$11.99	20.000%	$11.99																															
0816	"Inj, tislelizumab-jsgr"	G		$56.279	.	$11.26	20.000%	$11.26																															
0818	"Inj, crovalimab-akkz, 10 mg"	K 		$551.512	.	$110.31	20.000%	$110.31																															
0819	"Inj, alyglo, 500 mg"	K 		$138.111	.	$27.63	20.000%	$27.63																															
0821	Indigotindisulfonate sod 1mg	G		$9.956	.	$0.00	0.000%	$0.00																															
0822	"Inj, romiplostim 1 microgram"	K		$10.516	.	$2.11	18.888%	$1.99		IRA-adjusted coinsurance																													
0824	"Inj, exagamglogene autotem"	K		"$2,332,000.000"	.	"$466,400.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0825	Nelarabine injection	K		$63.184	.	$12.64	20.000%	$12.64																															
0827	Floxuridine injection	K		"$3,988.333"	.	$797.67	20.000%	$797.67																															
0831	Obecbtge autol up to 400 mil	G		"$270,375.000"	.	"$54,075.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0835	"Datopotamab deruxtecan, 1 mg"	G		$50.378	.	$10.08	20.000%	$10.08																															
0837	"Inj, treosulfan, 50 mg"	G		$31.415	.	$6.29	20.000%	$6.29																															
0839	Inj axatilimab-csfr 0.1 mg	G		$54.075	.	$10.82	20.000%	$10.82																															
0840	Inj melpha hydroch nos 50 mg	K		$157.102	.	$31.43	20.000%	$31.43																															
0841	"Inj, docetaxel (beizray) 1mg"	G		$52.470	.	$10.50	20.000%	$10.50																															
0842	"Inj, melphalan (apotex) 1 mg"	G		$64.778	.	$12.96	20.000%	$12.96																															
0843	Pegaspargase injection	K		"$27,070.534"	.	"$5,414.11"	19.208%	"$1,676.00"		"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
0844	Pentostatin injection	K		"$2,673.431"	.	$534.69	17.794%	$475.72		IRA-adjusted coinsurance																													
0845	"Inj, atidarsagene autotemcel"	K		"$4,377,500.000"	.	"$875,500.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
0846	"Inj, eculizumab-aeeb, 2 mg"	G		$41.486	.	$8.30	20.000%	$8.30																															
0847	Inj thiotepa nos 1 mg	K		$12.236	.	$2.45	20.000%	$2.45																															
0848	Inj nivolumab 2 mg hyaluron	G		$26.736	.	$5.35	20.000%	$5.35																															
0852	"Inj, eculizumab-aagh, 2 mg"	K		$31.353	.	$6.28	20.000%	$6.28																															
0853	Inj zenocutuzumab-zbco 1 mg	G		$32.617	.	$6.53	20.000%	$6.53																															
0854	In111 capromab	K		"$1,545.730"	.	$309.15	20.000%	$309.15																															
0860	"I131 iodobenguate, dx"	K		$805.900	.	$161.18	20.000%	$161.18																															
0861	"I125 serum albumin, dx"	K		$469.060	.	$93.82	20.000%	$93.82																															
0862	Cr51 chromate	K		"$1,717.620"	.	$343.53	20.000%	$343.53																															
0863	"I125 iothalamate, dx"	K		$435.170	.	$87.04	20.000%	$87.04																															
0864	Mitoxantrone hydrochl	K		$27.693	.	$5.54	20.000%	$5.54																															
0865	"Inj, hercessi, 10 mg"	K		$76.181		$15.24	20.000%	$15.24																															
0866	"Inj, sod thiosulfate (hope)"	K		$0.984	.	$0.20	20.000%	$0.20																															
0870	Inj. calaspargase pegol-mknl	K		$76.527	.	$15.31	20.000%	$15.31																															
0871	Inj pemetrexed (bluepoint)	K		$10.000	.	$2.00	20.000%	$2.12																															
0872	"Inj. denosumab-bbdz, 1 mg"	K		$27.538	.	$5.51	20.000%	$5.51																															
0874	Synvisc or synvisc-one	K		$9.252	.	$1.86	20.000%	$1.86																															
0875	Euflexxa inj per dose	K		$126.409	.	$25.29	20.000%	$25.29																															
0877	Orthovisc inj per dose	K		$125.299	.	$25.06	20.000%	$25.06																															
0887	Azathioprine parenteral	K		$224.969	.	$45.00	20.000%	$45.00																															
0890	Lymphocyte immune globulin	K		"$4,376.290"	.	$875.26	13.028%	$570.15		IRA-adjusted coinsurance																													
0901	Alpha 1 proteinase inhibitor	K		$5.160	.	$1.04	20.000%	$1.04																															
0902	"Injection,onabotulinumtoxinA"	K		$6.478	.	$1.30	20.000%	$1.30																															
0903	Cytomegalovirus imm IV /vial	K		"$1,812.007"	.	$362.41	20.000%	$362.41																															
0925	Factor viii	K		$1.116	.	$0.23	20.000%	$0.23																															
0927	Factor viii recombinant	K		$1.558	.	$0.32	20.000%	$0.32																															
0928	Factor ix complex	K		$1.656	.	$0.34	20.000%	$0.34																															
0929	Anti-inhibitor	K		$2.397	.	$0.48	20.000%	$0.48																															
0931	Factor IX non-recombinant	K		$1.377	.	$0.28	20.000%	$0.28																															
0932	Factor ix recombinant nos	K		$1.848	.	$0.37	20.000%	$0.37																															
0943	Octagam injection	K		$48.055	.	$9.62	20.000%	$9.62																															
0944	Gammagard liquid injection	K		$45.129	.	$9.03	20.000%	$9.03																															
0946	Hepagam b im injection	K		$65.146	.	$13.03	20.000%	$13.03																															
0947	Flebogamma injection	K		$55.760	.	$11.16	20.000%	$11.16																															
0948	Gamunex-C/Gammaked	K		$48.345	.	$9.67	20.000%	$9.67																															
0961	"Albumin (human),5%, 50ml"	K		$10.615	.	$2.13	20.000%	$2.13																															
0963	"Albumin (human), 5%, 250 ml"	K		$53.077	.	$10.62	20.000%	$10.62																															
0964	"Albumin (human), 25%, 20 ml"	K		$21.231	.	$4.25	20.000%	$4.25																															
0965	"Albumin (human), 25%, 50ml"	K		$53.077	.	$10.62	20.000%	$10.62																															
1064	"I131 iodide cap, rx"	K		$23.130	.	$4.63	20.000%	$4.63																															
1138	"Hepagam b intravenous, inj"	K		$65.146	.	$13.03	20.000%	$13.03																															
1139	Protein c concentrate	K		$15.024	.	$3.01	20.000%	$3.01																															
1142	Supprelin LA implant	K		"$45,212.040"	.	"$9,042.41"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1150	"I131 iodide sol, rx"	K		$20.880	.	$4.18	20.000%	$4.18																															
1168	"Inj, temsirolimus"	K		$30.317	.	$6.07	20.000%	$6.07																															
1178	Busulfan injection	K		$1.456	.	$0.30	20.000%	$0.30																															
1203	Verteporfin injection	K		$11.519	.	$2.31	20.000%	$2.31																															
1207	"Octreotide injection, depot"	K		$204.592	.	$40.92	20.000%	$40.92																															
1213	Antihemophilic viii/vwf comp	K		$1.198	.	$0.24	20.000%	$0.24																															
1214	Inj IVIG privigen 500 mg	K		$49.179	.	$9.84	20.000%	$9.84																															
1232	Mitomycin injection	K		$25.602	.	$5.13	20.000%	$5.13																															
1235	Valrubicin injection	K		"$1,444.550"	.	$288.91	20.000%	$288.91																															
1237	Inj iron dextran	K		$17.233	.	$3.45	20.000%	$3.45																															
1238	Topotecan oral	K		$124.900	.	$24.98	20.000%	$24.98																															
1253	Triamcinolone a inj prs-free	G		$25.016	.	$5.01	20.000%	$5.01																															
1263	Antithrombin iii injection	K		$3.943	.	$0.79	20.000%	$0.79																															
1268	Xyntha inj	K		$1.490	.	$0.30	20.000%	$0.30																															
1274	Edetate calcium disodium inj	K 		"$6,460.026"	.	"$1,292.01"	20.000%	"$1,292.01"																															
1281	Bevacizumab injection	K		$1.818	.	$0.37	20.000%	$0.37																															
1289	AbobotulinumtoxinA	K		$9.044	.	$1.81	20.000%	$1.81																															
1295	Sm 153 lexidronam	K		"$4,314.910"	.	$862.99	20.000%	$862.99																															
1296	Degarelix injection	K		$4.357	.	$0.88	20.000%	$0.88																															
1297	"Ferumoxytol, non-esrd"	K		$0.328	.	$0.07	20.000%	$0.07																															
1311	Canakinumab injection	K		$136.557	.	$27.32	20.000%	$27.32																															
1312	Hizentra injection	K		$13.644	.	$2.73	19.870%	$2.72		IRA-adjusted coinsurance																													
1327	Imiglucerase injection	K		$43.141	.	$8.63	20.000%	$8.63																															
1340	"Collagenase, clost hist inj"	K		$73.375	.	$14.68	17.894%	$13.13		IRA-adjusted coinsurance																													
1352	Wilate injection	K		$1.279	.	$0.26	20.000%	$0.26																															
1353	Belimumab injection	K		$54.968	.	$11.00	20.000%	$11.00																															
1413	Lumizyme injection	K		$201.566	.	$40.32	20.000%	$40.32																															
1415	Glassia injection	K		$5.448	.	$1.09	20.000%	$1.09																															
1416	Factor xiii anti-hem factor	K		$10.477	.	$2.10	20.000%	$2.10																															
1417	Gel-one	K		$538.480	.	$107.70	20.000%	$107.70																															
1420	Aflibercept injection	K		$795.861	.	$159.18	20.000%	$159.18																															
1421	Imported lipodox inj	K		$528.860	.	$105.78	20.000%	$105.78																															
1426	Eribulin mesylate injection	K		$118.749	.	$23.75	20.000%	$23.75																															
1441	Dom nonHEU Tc99m add-on/dose	K 		$10.000	.	$2.00	20.000%	$2.00																															
1446	Visualization adjunct	K		$7.584	.	$1.52	20.000%	$1.52																															
1458	Phentolaine mesylate inj	K		$449.299	.	$89.86	20.000%	$89.86																															
1464	Factor viii (porcine)	K		$190.000	.	$38.00	20.000%	$38.00																															
1467	Factor ix recombinan rixubis	K		$1.632	.	$0.33	20.000%	$0.33																															
1468	"Inj, abilify maintena, 1 mg"	K		$7.033	.	$1.41	20.000%	$1.41																															
1469	Inj filgrastim excl biosimil	K		$0.983	.	$0.20	20.000%	$0.20																															
1471	"Injection, Pertuzumab, 1 mg"	K		$16.229	.	$3.25	20.000%	$3.25																															
1474	Certolizumab pegol inj 1mg	K		$3.984	.	$0.80	20.000%	$0.80																															
1475	Golimumab for iv use 1mg	K		$10.769	.	$2.16	20.000%	$2.16																															
1476	Obinutuzumab inj	K		$75.212	.	$15.05	20.000%	$15.05																															
1478	Inj human fibrinogen con nos	K		$1.484	.	$0.30	20.000%	$0.30																															
1480	"Elosulfase alfa, injection"	K		$293.935	.	$58.79	20.000%	$58.79																															
1482	"	Darbepoetin alfa, esrd use"	K		$2.918	.	$0.59	20.000%	$0.59																															
1485	"	Ferumoxytol, esrd use"	K		$0.328	.	$0.07	20.000%	$0.07																															
1486	Factor ix fc fusion recomb	K		$3.545	.	$0.71	20.000%	$0.71																															
1488	"Injection, ramucirumab"	K		$73.368	.	$14.68	20.000%	$14.68																															
1489	Inj vedolizumab iv 1 mg	K		$21.162	.	$4.24	20.000%	$4.24																															
1490	Inj pembrolizumab	K		$59.349	.	$11.87	20.000%	$11.87																															
1491	New Technology  - Level 1A ($0-$10)	S		$5.00	.	$1.00																																	
1492	New Technology  - Level 1B ($11-$20)	S		$15.50	.	$3.10																																	
1493	New Technology  - Level 1C ($21-$30)	S		$25.50	.	$5.10																																	
1494	New Technology  - Level 1D ($31-$40)	S		$35.50	.	$7.10																																	
1495	New Technology  - Level 1E ($41-$50)	S		$45.50	.	$9.10																																	
1496	New Technology  - Level 1A ($0-$10)	T		$5.00	.	$1.00																																	
1497	New Technology  - Level 1B ($11-$20)	T		$15.50	.	$3.10																																	
1498	New Technology  - Level 1C ($21-$30)	T		$25.50	.	$5.10																																	
1499	New Technology  - Level 1D ($31-$40)	T		$35.50	.	$7.10																																	
1500	New Technology  - Level 1E ($41-$50)	T		$45.50	.	$9.10																																	
1502	New Technology - Level 2 ($51 - $100)	S		$75.50	.	$15.10																																	
1503	New Technology - Level 3 ($101 - $200)	S		$150.50	.	$30.10																																	
1504	New Technology - Level 4 ($201 - $300)	S		$250.50	.	$50.10																																	
1505	New Technology - Level 5 ($301 - $400)	S		$350.50	.	$70.10																																	
1506	New Technology - Level 6 ($401 - $500)	S		$450.50	.	$90.10																																	
1507	New Technology - Level 7 ($501 - $600)	S		$550.50	.	$110.10																																	
1508	New Technology - Level 8 ($601 - $700)	S		$650.50	.	$130.10																																	
1509	New Technology - Level 9 ($701 - $800)	S		$750.50	.	$150.10																																	
1510	New Technology - Level 10 ($801 - $900)	S		$850.50	.	$170.10																																	
1511	New Technology - Level 11 ($901 - $1000)	S		$950.50	.	$190.10																																	
1512	New Technology - Level 12 ($1001 - $1100)	S		"$1,050.50"	.	$210.10																																	
1513	New Technology - Level 13 ($1101 - $1200)	S		"$1,150.50"	.	$230.10																																	
1514	New Technology - Level 14 ($1201- $1300)	S		"$1,250.50"	.	$250.10																																	
1515	New Technology - Level 15 ($1301 - $1400)	S		"$1,350.50"	.	$270.10																																	
1516	New Technology - Level 16  ($1401 - $1500)	S		"$1,450.50"	.	$290.10																																	
1517	New Technology - Level 17 ($1501-$1600)	S		"$1,550.50"	.	$310.10																																	
1518	New Technology - Level 18 ($1601-$1700)	S		"$1,650.50"	.	$330.10																																	
1519	New Technology - Level 19 ($1701-$1800)	S		"$1,750.50"	.	$350.10																																	
1520	New Technology - Level 20 ($1801-$1900)	S		"$1,850.50"	.	$370.10																																	
1521	New Technology - Level 21 ($1901-$2000)	S		"$1,950.50"	.	$390.10																																	
1522	New Technology - Level 22 ($2001-$2500)	S		"$2,250.50"	.	$450.10																																	
1523	New Technology - Level 23 ($2501-$3000)	S		"$2,750.50"	.	$550.10																																	
1524	New Technology - Level 24 ($3001-$3500)	S		"$3,250.50"	.	$650.10																																	
1525	New Technology - Level 25 ($3501-$4000)	S		"$3,750.50"	.	$750.10																																	
1526	New Technology - Level 26 ($4001-$4500)	S		"$4,250.50"	.	$850.10																																	
1527	New Technology - Level 27 ($4501-$5000)	S		"$4,750.50"	.	$950.10																																	
1528	New Technology - Level 28 ($5001-$5500)	S		"$5,250.50"	.	"$1,050.10"																																	
1529	New Technology - Level 29 ($5501-$6000)	S		"$5,750.50"	.	"$1,150.10"																																	
1530	New Technology - Level 30 ($6001-$6500)	S		"$6,250.50"	.	"$1,250.10"																																	
1531	New Technology - Level 31 ($6501-$7000)	S		"$6,750.50"	.	"$1,350.10"																																	
1532	New Technology - Level 32 ($7001-$7500)	S		"$7,250.50"	.	"$1,450.10"																																	
1533	New Technology - Level 33 ($7501-$8000)	S		"$7,750.50"	.	"$1,550.10"																																	
1534	New Technology - Level 34 ($8001-$8500)	S		"$8,250.50"	.	"$1,650.10"																																	
1535	New Technology - Level 35 ($8501-$9000)	S		"$8,750.50"	.	"$1,750.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1536	New Technology - Level 36 ($9001-$9500)	S		"$9,250.50"	.	"$1,850.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1537	New Technology - Level 37 ($9501-$10000)	S		"$9,750.50"	.	"$1,950.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1539	New Technology - Level 2 ($51 - $100)	T		$75.50	.	$15.10																																	
1540	New Technology - Level 3 ($101 - $200)	T		$150.50	.	$30.10																																	
1541	New Technology - Level 4 ($201 - $300)	T		$250.50	.	$50.10																																	
1542	New Technology - Level 5 ($301 - $400)	T		$350.50	.	$70.10																																	
1543	New Technology - Level 6 ($401 - $500)	T		$450.50	.	$90.10																																	
1544	New Technology - Level 7 ($501 - $600)	T		$550.50	.	$110.10																																	
1545	New Technology - Level 8 ($601 - $700)	T		$650.50	.	$130.10																																	
1546	New Technology - Level 9 ($701 - $800)	T		$750.50	.	$150.10																																	
1547	New Technology - Level 10 ($801 - $900)	T		$850.50	.	$170.10																																	
1548	New Technology - Level 11 ($901 - $1000)	T		$950.50	.	$190.10																																	
1549	New Technology - Level 12 ($1001 - $1100)	T		"$1,050.50"	.	$210.10																																	
1550	New Technology - Level 13 ($1101 - $1200)	T		"$1,150.50"	.	$230.10																																	
1551	New Technology - Level 14 ($1201- $1300)	T		"$1,250.50"	.	$250.10																																	
1552	New Technology - Level 15 ($1301 - $1400)	T		"$1,350.50"	.	$270.10																																	
1553	New Technology - Level 16 ($1401 - $1500)	T		"$1,450.50"	.	$290.10																																	
1554	New Technology - Level 17 ($1501-$1600)	T		"$1,550.50"	.	$310.10																																	
1555	New Technology - Level 18 ($1601-$1700)	T		"$1,650.50"	.	$330.10																																	
1556	New Technology - Level 19 ($1701-$1800)	T		"$1,750.50"	.	$350.10																																	
1557	New Technology - Level 20 ($1801-$1900)	T		"$1,850.50"	.	$370.10																																	
1558	New Technology - Level 21 ($1901-$2000)	T		"$1,950.50"	.	$390.10																																	
1559	New Technology - Level 22 ($2001-$2500)	T		"$2,250.50"	.	$450.10																																	
1560	New Technology - Level 23 ($2501-$3000)	T		"$2,750.50"	.	$550.10																																	
1561	New Technology - Level 24 ($3001-$3500)	T		"$3,250.50"	.	$650.10																																	
1562	New Technology - Level 25 ($3501-$4000)	T		"$3,750.50"	.	$750.10																																	
1563	New Technology - Level 26 ($4001-$4500)	T		"$4,250.50"	.	$850.10																																	
1564	New Technology - Level 27 ($4501-$5000)	T		"$4,750.50"	.	$950.10																																	
1565	New Technology - Level 28 ($5001-$5500)	T		"$5,250.50"	.	"$1,050.10"																																	
1566	New Technology - Level 29 ($5501-$6000)	T		"$5,750.50"	.	"$1,150.10"																																	
1567	New Technology - Level 30 ($6001-$6500)	T		"$6,250.50"	.	"$1,250.10"																																	
1568	New Technology - Level 31 ($6501-$7000)	T		"$6,750.50"	.	"$1,350.10"																																	
1569	New Technology - Level 32 ($7001-$7500)	T		"$7,250.50"	.	"$1,450.10"																																	
1570	New Technology - Level 33 ($7501-$8000)	T		"$7,750.50"	.	"$1,550.10"																																	
1571	New Technology - Level 34 ($8001-$8500)	T		"$8,250.50"	.	"$1,650.10"																																	
1572	New Technology - Level 35 ($8501-$9000)	T		"$8,750.50"	.	"$1,750.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1573	New Technology - Level 36 ($9001-$9500)	T		"$9,250.50"	.	"$1,850.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1574	New Technology - Level 37 ($9501-$10000)	T		"$9,750.50"	.	"$1,950.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1575	"New Technology - Level 38 ($10,001-$15,000)"	S		"$12,500.50"	.	"$2,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1576	"New Technology - Level 39 ($15,001-$20,000)"	S		"$17,500.50"	.	"$3,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1577	"New Technology - Level 40 ($20,001-$25,000)"	S		"$22,500.50"	.	"$4,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1578	"New Technology - Level 41 ($25,001-$30,000)"	S		"$27,500.50"	.	"$5,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1579	"New Technology - Level 42 ($30,001-$40,000)"	S		"$35,000.50"	.	"$7,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1580	"New Technology - Level 43 ($40,001-$50,000)"	S		"$45,000.50"	.	"$9,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1581	"New Technology - Level 44 ($50,001-$60,000)"	S		"$55,000.50"	.	"$11,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1582	"New Technology - Level 45 ($60,001-$70,000)"	S		"$65,000.50"	.	"$13,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1583	"New Technology - Level 46 ($70,001-$80,000)"	S		"$75,000.50"	.	"$15,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1584	"New Technology - Level 47 ($80,001-$90,000)"	S		"$85,000.50"	.	"$17,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1585	"New Technology - Level 48 ($90,001-$100,000)"	S		"$95,000.50"	.	"$19,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1589	"New Technology - Level 38 ($10,001-$15,000)"	T		"$12,500.50"	.	"$2,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1590	"New Technology - Level 39 ($15,001-$20,000)"	T		"$17,500.50"	.	"$3,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1591	"New Technology - Level 40 ($20,001-$25,000)"	T		"$22,500.50"	.	"$4,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1592	"New Technology - Level 41 ($25,001-$30,000)"	T		"$27,500.50"	.	"$5,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1593	"New Technology - Level 42 ($30,001-$40,000)"	T		"$35,000.50"	.	"$7,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1594	"New Technology - Level 43 ($40,001-$50,000)"	T		"$45,000.50"	.	"$9,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1595	"New Technology - Level 44 ($50,001-$60,000)"	T		"$55,000.50"	.	"$11,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1596	"New Technology - Level 45 ($60,001-$70,000)"	T		"$65,000.50"	.	"$13,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1597	"New Technology - Level 46 ($70,001-$80,000)"	T		"$75,000.50"	.	"$15,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1598	"New Technology - Level 47 ($80,001-$90,000)"	T		"$85,000.50"	.	"$17,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1599	"New Technology - Level 48 ($90,001-$100,000)"	T		"$95,000.50"	.	"$19,000.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1609	"Rho(D) immune globulin h, sd"	K		$32.507	.	$6.51	20.000%	$6.51																															
1613	Trastuzumab injection	K		$75.692	.	$15.14	20.000%	$15.14																															
1630	"Hep b ig, im"	K		$143.215	.	$28.65	20.000%	$28.65																															
1643	"Y90 ibritumomab, rx"	K		"$56,824.549"	.	"$11,364.91"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1656	Factor viii fc fusion recomb	K		$2.320	.	$0.47	20.000%	$0.47																															
1658	"Injection, belinostat, 10mg"	K		$50.919	.	$10.19	20.000%	$10.19																															
1660	"Injection, oritavancin"	K		$28.525	.	$5.71	20.000%	$5.71																															
1662	Inj tedizolid phosphate	K		$1.801	.	$0.37	20.000%	$0.37																															
1664	Florbetapir f18	K		"$1,881.870"	.	$376.38	20.000%	$376.38																															
1670	Tetanus immune globulin inj	K		$575.760	.	$115.16	20.000%	$115.16																															
1675	P32 na phosphate	K		$179.120	.	$35.83	20.000%	$35.83																															
1683	Basiliximab	K		"$4,687.658"	.	$937.54	20.000%	$937.54																															
1685	"Darbepoetin alfa, non-esrd"	K		$2.918	.	$0.59	20.000%	$0.59																															
1686	"Epoetin alfa, non-esrd"	K		$7.080	.	$1.42	20.000%	$1.42																															
1688	Ethanolamine oleate	K		$497.700	.	$99.54	20.000%	$99.54																															
1689	Fomepizole	K		$6.155	.	$1.24	20.000%	$1.24																															
1690	Hemin	K		$33.073	.	$6.62	19.297%	$6.39		IRA-adjusted coinsurance																													
1696	Palifermin injection	K		$33.991	.	$6.80	16.991%	$5.78		IRA-adjusted coinsurance																													
1701	Treprostinil injection	K		$56.834	.	$11.37	20.000%	$11.37																															
1704	"Humate-P, inj"	K		$1.446	.	$0.29	20.000%	$0.29																															
1705	Factor viia recomb novoseven	K		$2.526	.	$0.51	20.000%	$0.51																															
1710	Clofarabine injection	K		$16.006	.	$3.21	20.000%	$3.21																															
1712	Paclitaxel protein bound	K		$13.064	.	$2.62	20.000%	$2.62																															
1744	Zidovudine	K		$1.513	.	$0.31	20.000%	$0.31																															
1745	Radium ra223 dichloride ther	K		$169.057	.	$33.82	20.000%	$33.82																															
1746	Factor xiii recomb a-subunit	K		$17.336	.	$3.47	20.000%	$3.47																															
1747	Monovisc inj per dose	K		$663.641	.	$132.73	20.000%	$132.73																															
1748	Inj tbo filgrastim 1 microg	K		$0.366	.	$0.08	20.000%	$0.08																															
1809	"Injection, alemtuzumab"	K		"$2,441.493"	.	$488.30	20.000%	$488.30																															
1822	"Injection, zarxio"	K		$0.333	.	$0.07	20.000%	$0.07		8% of reference add-on applied																													
1823	"Injection, dalbavancin"	K		$15.567	.	$3.12	20.000%	$3.12																															
1824	"	Ceftaroline fosamil inj"	K		$3.991	.	$0.80	20.000%	$0.80																															
1825	Ceftazidime and avibactam	K		$100.496	.	$20.10	20.000%	$20.10																															
1826	Hyqvia 100mg immuneglobulin	K		$17.565	.	$3.52	20.000%	$3.52																															
1827	Factor viii recomb obizur	K		$3.229	.	$0.65	20.000%	$0.65																															
1829	"	Penicillin g benzathine inj"	K		$26.984	.	$5.40	13.590%	$3.67		IRA-adjusted coinsurance																													
1831	Chloramphenicol sodium injec	K		$51.569	.	$10.32	20.000%	$10.32																															
1832	Dimethyl sulfoxide 50% 50 ml	K		$714.724	.	$142.95	20.000%	$142.95																															
1844	Factor viii pegylated recomb	K		$2.102	.	$0.43	20.000%	$0.43																															
1846	Factor viii nuwiq recomb 1iu	K		$1.193	.	$0.24	20.000%	$0.24																															
1847	"Injection, inflectra"	K		$15.912	.	$3.19	20.000%	$3.19		8% of reference add-on applied																													
1848	Artiss fibrin sealant	K		$133.135	.	$26.63	20.000%	$26.63																															
1850	Gamma globulin 1 cc inj	K		$48.885	.	$9.78	20.000%	$9.78																															
1851	Gamma globulin > 10 cc inj	K		$488.853	.	$97.78	20.000%	$97.78																															
1853	Minocycline hydrochloride	K		$2.592	.	$0.52	18.632%	$0.49		IRA-adjusted coinsurance																													
1854	Pentobarbital sodium inj	K		$64.144	.	$12.83	20.000%	$12.83																															
1856	Factor viii recomb novoeight	K		$1.397	.	$0.28	20.000%	$0.28																															
1857	"Inj, factor x, (human), 1iu"	K		$9.533	.	$1.91	20.000%	$1.91																															
1859	Argatroban nonesrd use 1mg	K		$0.950	.	$0.19	20.000%	$0.19																															
1861	"Inj., bendeka 1 mg"	K		$13.581	.	$2.72	20.000%	$2.72																															
1901	"New Technology - Level 49 ($100,001-$115,000)"	S		"$107,500.50"	.	"$21,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1902	"New Technology - Level 49 ($100,001-$115,000)"	T		"$107,500.50"	.	"$21,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1903	"New Technology - Level 50 ($115,001-$130,000)"	S		"$122,500.50"	.	"$24,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1904	"New Technology - Level 50 ($115,001-$130,000)"	T		"$122,500.50"	.	"$24,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1905	"New Technology - Level 51 ($130,001-$145,000)"	S		"$137,500.50"	.	"$27,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1906	"New Technology - Level 51 ($130,001-$145,000)"	T		"$137,500.50"	.	"$27,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1907	"New Technology - Level 52 ($145,001-$160,000)"	S		"$152,500.50"	.	"$30,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
1908	"New Technology - Level 52 ($145,001-$160,000)"	T		"$152,500.50"	.	"$30,500.10"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
2041	"Cath, bladed, vasc prep"	H 			.	.																																	
2042	"Endo, single, pulmonary"	H 			.	.																																	
2043	Orth/matrx/bn fill drug-elut	H 			.	.																																	
2044	"Ret dev, laser, ivc filter"	H 			.	.																																	
2045	"Grft, trnsmurl/trnsvens byps"	H 			.	.																																	
2046	"Pmkr, dual, leadless"	H 			.	.																																	
2047	"Adapter, us to endoscope"	H 			.	.																																	
2048	Pump elastomc non-opioid dev	H1			.	.																																	
2049	"Suprt dev, a-v fistula, imp"	H 			.	.																																	
2050	Cath coronary drug-delivery	H 			.	.																																	
2051	Cath renal denerv radiofreq	H 			.	.																																	
2052	Cath renal denerv ultrasnd	H 			.	.																																	
2053	Si&pelvis fusn&fixn dev	H 			.	.																																	
2054	Power endo us-guid bx dev	H 			.	.																																	
2055	"Tissue marker, detectable"	H 			.	.																																	
2056	Pump perist non-opioid dev	H1			.	.																																	
2057	Nerve stim non-opioid dev	H1			.	.																																	
2058	Cryo probe non-opioid dev	H1			.	.																																	
2059	Cryo needle non-opioid dev	H1			.	.																																	
2060	Cold therapy non-opioid dev	H1			.	.																																	
2062	"Inj zanidatamab-hrii, 2 mg"	G 		$25.122	.	$5.03	20.000%	$5.03																															
2064	"Inj marstacim-hncq, 0.5 mg"	G 		$52.788	.	$10.56	20.000%	$10.56																															
2065	"Flurpiridaz f18, diag, 1 mci"	G 		$515.000	.	$103.00	20.000%	$103.00																															
2066	Inj bortezomib boruzu 0.1 mg	G 		$26.265	.	$5.26	20.000%	$5.26																															
2067	Afamitresgene autoleucel	G 		"$770,620.000"	.	"$154,124.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
2068	"Inj, aflibercept-ayyh, 1 mg"	G 		$795.861	.	$159.18	20.000%	$159.18																															
2069	"Inj, testosterone, azmiro"	K		$1.288	.	$0.26	20.000%	$0.26																															
2070	"Inj, eculizumab, 2 mg"	K		$44.809	.	$8.97	20.000%	$8.97																															
2071	Inj ocrelizumab 1mg hya-ocsq	K		$45.187	.	$9.04	20.000%	$9.04																															
2072	"Inj, erzofri, 1 mg"	K		$17.150	.	$3.43	20.000%	$3.43																															
2073	Inj atezolizumb 5mg hya-tqjs	K		$30.876	.	$6.18	20.000%	$6.18																															
2075	Inj acetaminoph 10mg/ibu 3mg	G 		$0.218	.	$0.00	0.000%	$0.00																															
2076	"Inj, pemetrexed dipotassium"	G 		$81.370	.	$16.28	20.000%	$16.28																															
2616	"Brachytx, non-str,Yttrium-90"	U	196.2286	"$18,003.39"	.	"$3,600.68"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
2632	Iodine I-125 sodium iodide	U	4.3733	$401.24	.	$80.25																																	
2634	"Brachytx, non-str, HA, I-125"	U	2.0301	$186.26	.	$37.26																																	
2635	"Brachytx, non-str, HA, P-103"	U	1.1747	$107.78	.	$21.56																																	
2636	"Brachy linear, non-str,P-103"	U	0.9669	$88.71	.	$17.75																																	
2638	"Brachytx, stranded, I-125"	U	0.3810	$34.96	.	$7.00																																	
2639	"Brachytx, non-stranded,I-125"	U	0.4096	$37.58	.	$7.52																																	
2640	"Brachytx, stranded, P-103"	U	0.9735	$89.32	.	$17.87																																	
2641	"Brachytx, non-stranded,P-103"	U	0.7561	$69.37	.	$13.88																																	
2642	"Brachytx, stranded, C-131"	U	1.2853	$117.92	.	$23.59																																	
2643	"Brachytx, non-stranded,C-131"	U	1.0907	$100.07	.	$20.02																																	
2645	"Brachytx, non-str, Gold-198"	U	5.2421	$480.95	.	$96.19																																	
2646	"Brachytx, non-str, HDR Ir-192"	U	3.9045	$358.23	.	$71.65																																	
2647	"Brachytx, NS, Non-HDRIr-192"	U	9.8273	$901.63	.	$180.33																																	
2648	"Brachytx planar, p-103"	U	0.0511	$4.69	.	$0.94																																	
2698	"Brachytx, stranded, NOS"	U	0.3810	$34.96	.	$7.00																																	
2699	"Brachytx, non-stranded, NOS"	U	0.4096	$37.58	.	$7.52																																	
2731	"Immune globulin, powder"	K		$81.011	.	$16.21	20.000%	$16.21																															
5012	Clinic Visits and Related Services	V	1.4624	$134.17	.	$26.84																																	
5021	Level 1 Type A ED Visits	V	0.9614	$88.21	.	$17.65																																	
5022	Level 2 Type A ED Visits	V	1.7539	$160.92	.	$32.19																																	
5023	Level 3 Type A ED Visits	V	3.1121	$285.53	.	$57.11																																	
5024	Level 4 Type A ED Visits	V	4.7730	$437.91	.	$87.59																																	
5025	Level 5 Type A ED Visits	V	6.8477	$628.26	.	$125.66																																	
5031	Level 1 Type B ED Visits	V	0.8678	$79.62	.	$15.93																																	
5032	Level 2 Type B ED Visits	V	1.1278	$103.47	.	$20.70																																	
5033	Level 3 Type B ED Visits	V	2.0804	$190.87	.	$38.18																																	
5034	Level 4 Type B ED Visits	V	3.1620	$290.10	.	$58.02																																	
5035	Level 5 Type B ED Visits	V	4.6553	$427.11	.	$85.43																																	
5041	Critical Care	S	9.5018	$871.76	.	$174.36																																	
5045	Trauma Response with Critical Care	S	15.0186	"$1,377.91"	.	$275.59																																	
5051	Level 1 Skin Procedures	T	2.2201	$203.69	.	$40.74																																	
5052	Level 2 Skin Procedures	T	4.5193	$414.63	.	$82.93																																	
5053	Level 3 Skin Procedures	T	8.1377	$746.61	.	$149.33																																	
5054	Level 4 Skin Procedures	T	23.2972	"$2,137.45"	.	$427.49																																	
5055	Level 5 Skin Procedures	T	39.8919	"$3,659.96"	.	$732.00																																	
5061	Hyperbaric Oxygen	S	1.5560	$142.76	.	$28.56																																	
5071	Level 1 Excision/ Biopsy/ Incision and Drainage	T	7.9601	$730.32	.	$146.07																																	
5072	Level 2 Excision/ Biopsy/ Incision and Drainage	J1	18.4444	"$1,692.22"	.	$338.45																																	
5073	Level 3 Excision/ Biopsy/ Incision and Drainage	J1	32.3758	"$2,970.38"	.	$594.08																																	
5091	Level 1 Breast/Lymphatic Surgery and Related Procedures	J1	44.1344	"$4,049.20"	.	$809.84																																	
5092	Level 2 Breast/Lymphatic Surgery and Related Procedures	J1	82.4046	"$7,560.37"	.	"$1,512.08"																																	
5093	Level 3 Breast/Lymphatic Surgery and Related Procedures	J1	71.6713	"$6,575.63"	.	"$1,315.13"																																	
5094	Level 4 Breast/Lymphatic Surgery and Related Procedures	J1	153.3717	"$14,071.39"	.	"$2,814.28"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5101	Level 1 Strapping and Cast Application	T	1.7833	$163.61	.	$32.73																																	
5102	Level 2 Strapping and Cast Application	T	3.0819	$282.76	.	$56.56																																	
5111	Level 1 Musculoskeletal Procedures	T	2.7746	$254.56	.	$50.92																																	
5112	Level 2 Musculoskeletal Procedures	J1	18.0927	"$1,659.95"	.	$331.99																																	
5113	Level 3 Musculoskeletal Procedures	J1	36.8099	"$3,377.20"	.	$675.44																																	
5114	Level 4 Musculoskeletal Procedures	J1	82.1157	"$7,533.87"	.	"$1,506.78"																																	
5115	Level 5 Musculoskeletal Procedures	J1	144.4665	"$13,254.37"	.	"$2,650.88"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5116	Level 6 Musculoskeletal Procedures	J1	196.8108	"$18,056.80"	.	"$3,611.36"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5117	Level 7 Musculoskeletal Procedures	J1	303.5689	"$27,851.54"	.	"$5,570.31"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5151	Level 1 Airway Endoscopy	T	2.2087	$202.64	.	$40.53																																	
5152	Level 2 Airway Endoscopy	T	4.3182	$396.18	.	$79.24																																	
5153	Level 3 Airway Endoscopy	J1	19.8269	"$1,819.06"	.	$363.82																																	
5154	Level 4 Airway Endoscopy	J1	41.9117	"$3,845.27"	.	$769.06																																	
5155	Level 5 Airway Endoscopy	J1	79.2246	"$7,268.62"	.	"$1,453.73"																																	
5161	Level 1 ENT Procedures	T	2.6708	$245.04	.	$49.01																																	
5162	Level 2 ENT Procedures	T	5.9527	$546.14	.	$109.23																																	
5163	Level 3 ENT Procedures	J1	17.3299	"$1,589.97"	.	$318.00																																	
5164	Level 4 ENT Procedures	J1	37.0827	"$3,402.23"	.	$680.45																																	
5165	Level 5 ENT Procedures	J1	67.3832	"$6,182.21"	.	"$1,236.45"																																	
5166	Cochlear Implant Procedure	J1	362.0825	"$33,219.98"	"$6,942.79"	"$6,644.00"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5181	Level 1 Vascular Procedures	T	7.0398	$645.88	.	$129.18																																	
5182	Level 2 Vascular Procedures	J1	17.4627	"$1,602.15"	.	$320.43																																	
5183	Level 3 Vascular Procedures	J1	35.4696	"$3,254.23"	.	$650.85																																	
5184	Level 4 Vascular Procedures	J1	62.2596	"$5,712.13"	.	"$1,142.43"																																	
5191	Level 1 Endovascular Procedures	J1	36.1748	"$3,318.93"	$863.75	$663.79																																	
5192	Level 2 Endovascular Procedures	J1	64.0964	"$5,880.65"	.	"$1,176.13"																																	
5193	Level 3 Endovascular Procedures	J1	129.4179	"$11,873.70"	.	"$2,374.74"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5194	Level 4 Endovascular Procedures	J1	204.8167	"$18,791.32"	.	"$3,758.27"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5200	Implantation Wireless PA Pressure Monitor	J1	321.5225	"$29,498.72"	.	"$5,899.75"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5211	Level 1 Electrophysiologic Procedures	J1	13.4278	"$1,231.96"	.	$246.40																																	
5212	Level 2 Electrophysiologic Procedures	J1	86.8856	"$7,971.49"	.	"$1,594.30"																																	
5213	Level 3 Electrophysiologic Procedures	J1	293.5828	"$26,935.34"	.	"$5,387.07"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5221	Level 1 Pacemaker and Similar Procedures	T	42.7040	"$3,917.96"	.	$783.60																																	
5222	Level 2 Pacemaker and Similar Procedures	J1	92.4158	"$8,478.87"	.	"$1,695.78"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5223	Level 3 Pacemaker and Similar Procedures	J1	116.9920	"$10,733.67"	.	"$2,146.74"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5224	Level 4 Pacemaker and Similar Procedures	J1	216.6214	"$19,874.36"	.	"$3,974.88"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5231	Level 1 ICD and Similar Procedures	J1	250.8301	"$23,012.91"	.	"$4,602.59"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5232	Level 2 ICD and Similar Procedures	J1	352.3684	"$32,328.74"	.	"$6,465.75"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5241	Level 1 Blood Product Exchange and Related Services	S	4.9445	$453.64	.	$90.73																																	
5242	Level 2 Blood Product Exchange and Related Services	S	17.1784	"$1,576.07"	.	$315.22																																	
5243	Level 3 Blood Product Exchange and Related Services	S	49.1014	"$4,504.91"	.	$900.99																																	
5244	Level 4 Blood Product Exchange and Related Services	J1	698.8867	"$64,120.76"	.	"$12,824.16"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5301	Level 1 Upper GI Procedures	T	10.2165	$937.33	.	$187.47																																	
5302	Level 2 Upper GI Procedures 	J1	21.5330	"$1,975.59"	.	$395.12																																	
5303	Level 3 Upper GI Procedures	J1	43.6262	"$4,002.57"	.	$800.52																																	
5311	Level 1 Lower GI Procedures 	T	10.4328	$957.18	.	$191.44																																	
5312	Level 2 Lower GI Procedures 	T	13.4300	"$1,232.16"	.	$246.44																																	
5313	Level 3 Lower GI Procedures 	J1	31.1101	"$2,854.26"	.	$570.86																																	
5331	Complex GI Procedures	J1	68.4077	"$6,276.20"	.	"$1,255.24"																																	
5341	Level 1 Abdominal/Peritoneal/Biliary and Related Procedures	J1	40.3118	"$3,698.49"	.	$739.70																																	
5342	Level 2 Abdominal/Peritoneal/Biliary and Related Procedures	J1	72.6672	"$6,667.00"	.	"$1,333.40"																																	
5361	Level 1 Laparoscopy and Related Services	J1	67.8929	"$6,228.97"	.	"$1,245.80"																																	
5362	Level 2 Laparoscopy and Related Services	J1	119.5298	"$10,966.50"	.	"$2,193.30"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5371	Level 1 Urology and Related Services	T	2.7971	$256.63	.	$51.33																																	
5372	Level 2 Urology and Related Services	J1	7.7301	$709.21	.	$141.85																																	
5373	Level 3 Urology and Related Services	J1	23.4184	"$2,148.57"	.	$429.72																																	
5374	Level 4 Urology and Related Services	J1	39.5587	"$3,629.39"	.	$725.88																																	
5375	Level 5 Urology and Related Services	J1	60.1421	"$5,517.86"	.	"$1,103.58"																																	
5376	Level 6 Urology and Related Services	J1	106.4348	"$9,765.07"	.	"$1,953.02"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5377	Level 7 Urology and Related Services	J1	148.8010	"$13,652.05"	.	"$2,730.41"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5378	Level 8 Urology and Related Services	J1	229.1860	"$21,027.13"	.	"$4,205.43"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5401	Dialysis	S	7.8171	$717.20	.	$143.44																																	
5411	Level 1 Gynecologic Procedures	T	2.2720	$208.45	.	$41.69																																	
5412	Level 2 Gynecologic Procedures	T	3.4214	$313.90	.	$62.78																																	
5413	Level 3 Gynecologic Procedures	T	10.3197	$946.80	.	$189.36																																	
5414	Level 4 Gynecologic Procedures	J1	36.6246	"$3,360.20"	.	$672.04																																	
5415	Level 5 Gynecologic Procedures	J1	56.4352	"$5,177.76"	.	"$1,035.56"																																	
5416	Level 6 Gynecologic Procedures	J1	83.5174	"$7,662.47"	.	"$1,532.50"																																	
5431	Level 1 Nerve Procedures	J1	21.7971	"$1,999.82"	.	$399.97																																	
5432	Level 2 Nerve Procedures	J1	50.9013	"$4,670.04"	.	$934.01																																	
5441	Level 1 Nerve Injections	T	3.4053	$312.43	.	$62.49																																	
5442	Level 2 Nerve Injections	T	7.8904	$723.92	.	$144.79																																	
5443	Level 3 Nerve Injections	T	9.8573	$904.38	.	$180.88																																	
5461	Level 1 Neurostimulator and Related Procedures	J1	40.5759	"$3,722.72"	.	$744.55																																	
5462	Level 2 Neurostimulator and Related Procedures	J1	71.5065	"$6,560.51"	.	"$1,312.11"																																	
5463	Level 3 Neurostimulator and Related Procedures	J1	127.5619	"$11,703.42"	.	"$2,340.69"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5464	Level 4 Neurostimulator and Related Procedures	J1	219.3716	"$20,126.69"	.	"$4,025.34"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5465	Level 5 Neurostimulator and Related Procedures	J1	346.0783	"$31,751.65"	.	"$6,350.33"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5471	Implantation of Drug Infusion Device	J1	201.6739	"$18,502.98"	.	"$3,700.60"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5481	Laser Eye Procedures	T	6.0635	$556.31	.	$111.27																																	
5491	Level 1 Intraocular Procedures	J1	23.8035	"$2,183.90"	.	$436.78																																	
5492	Level 2 Intraocular Procedures	J1	46.2509	"$4,243.38"	.	$848.68																																	
5493	Level 3 Intraocular Procedures	J1	58.7029	"$5,385.81"	.	"$1,077.17"																																	
5494	Level 4 Intraocular Procedures	J1	157.0425	"$14,408.18"	.	"$2,881.64"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5495	Level 5 Intraocular Procedures	J1	155.7039	"$14,285.37"	.	"$2,857.08"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5496	Level 6 Intraocular Procedures	J1	181.4237	"$16,645.08"	.	"$3,329.02"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
5501	"Level 1 Extraocular, Repair, and Plastic Eye Procedures"	T	3.5649	$327.07	.	$65.42																																	
5502	"Level 2 Extraocular, Repair, and Plastic Eye Procedures"	T	11.0691	"$1,015.56"	.	$203.12																																	
5503	"Level 3 Extraocular, Repair, and Plastic Eye Procedures"	J1	26.9061	"$2,468.55"	.	$493.71																																	
5504	"Level 4 Extraocular, Repair, and Plastic Eye Procedures"	J1	43.3584	"$3,978.00"	.	$795.60																																	
5521	Level 1 Imaging without Contrast	S	0.9743	$89.39	.	$17.88																																	
5522	Level 2 Imaging without Contrast	S	1.1707	$107.41	.	$21.49																																	
5523	Level 3 Imaging without Contrast	S	2.6782	$245.72	.	$49.15																																	
5524	Level 4 Imaging without Contrast	S	6.1263	$562.07	.	$112.42																																	
5571	Level 1 Imaging with Contrast	S	1.9590	$179.73	.	$35.95																																	
5572	Level 2 Imaging with Contrast	S	3.9058	$358.35	.	$71.67																																	
5573	Level 3 Imaging with Contrast	S	8.7456	$802.38	.	$160.48																																	
5591	Level 1 Nuclear Medicine and Related Services 	S	4.4589	$409.09	.	$81.82																																	
5592	Level 2 Nuclear Medicine and Related Services	S	6.0896	$558.70	.	$111.74																																	
5593	Level 3 Nuclear Medicine and Related Services 	S	14.4181	"$1,322.82"	.	$264.57																																	
5594	Level 4 Nuclear Medicine and Related Services	S	16.0402	"$1,471.64"	.	$294.33																																	
5611	Level 1 Therapeutic Radiation Treatment Preparation	S	1.5134	$138.85	$31.05	$27.77																																	
5612	Level 2 Therapeutic Radiation Treatment Preparation	S	4.2026	$385.58	.	$77.12																																	
5613	Level 3 Therapeutic Radiation Treatment Preparation	S	15.5969	"$1,430.97"	.	$286.20																																	
5621	Level 1 Radiation Therapy	S	1.1768	$107.97	.	$21.60																																	
5622	Level 2 Radiation Therapy	S	3.0011	$275.34	.	$55.07																																	
5623	Level 3 Radiation Therapy	S	6.5413	$600.14	.	$120.03																																	
5624	Level 4 Radiation Therapy	S	7.8022	$715.83	.	$143.17																																	
5625	Level 5 Radiation Therapy	S	14.4880	"$1,329.23"	.	$265.85																																	
5626	Level 6 Radiation Therapy	S 	20.1241	"$1,846.33"	.	$369.27																																	
5627	Level 7 Radiation Therapy	J1	83.6367	"$7,673.42"	.	"$1,534.69"																																	
5661	Therapeutic Nuclear Medicine	S	2.6037	$238.88	.	$47.78																																	
5671	Level 1 Pathology	S	0.5847	$53.64	.	$10.73																																	
5672	Level 2 Pathology	S	1.9190	$176.06	.	$35.22																																	
5673	Level 3 Pathology	S	4.0337	$370.08	.	$74.02																																	
5674	Level 4 Pathology	S	8.9707	$823.03	.	$164.61																																	
5691	Level 1 Drug Administration	S	0.5213	$47.83	.	$9.57																																	
5692	Level 2 Drug Administration	S	0.8128	$74.57	.	$14.92																																	
5693	Level 3 Drug Administration	S	2.3596	$216.49	.	$43.30																																	
5694	Level 4 Drug Administration	S	3.7224	$341.52	.	$68.31																																	
5721	Level 1 Diagnostic Tests and Related Services	S	1.4484	$132.89	.	$26.58																																	
5722	Level 2 Diagnostic Tests and Related Services	S	2.4103	$221.14	.	$44.23																																	
5723	Level 3 Diagnostic Tests and Related Services	S	4.1632	$381.96	.	$76.40																																	
5724	Level 4 Diagnostic Tests and Related Services	S	9.5844	$879.34	.	$175.87																																	
5731	Level 1 Minor Procedures	S	0.3358	$30.81	.	$6.17																																	
5732	Level 2 Minor Procedures	S	0.4241	$38.91	.	$7.79																																	
5733	Level 3 Minor Procedures	S	0.6604	$60.59	.	$12.12																																	
5734	Level 4 Minor Procedures	S	1.4857	$136.31	.	$27.27																																	
5735	Level 5 Minor Procedures	S	4.9221	$451.59	.	$90.32																																	
5741	Level 1 Electronic Analysis of Devices	S	0.4144	$38.02	.	$7.61																																	
5742	Level 2 Electronic Analysis of Devices	S	1.0591	$97.17	.	$19.44																																	
5743	Level 3 Electronic Analysis of Devices	S	3.4451	$316.08	.	$63.22																																	
5771	Cardiac Rehabilitation	S	1.4513	$133.15	.	$26.63																																	
5781	Resuscitation and Cardioversion	S	7.4370	$682.32	.	$136.47																																	
5791	Pulmonary Treatment	S	2.4704	$226.65	.	$45.33																																	
5801	Ventilation Initiation and Management	S	7.1217	$653.39	.	$130.68																																	
5811	Manipulation Therapy	S	0.2425	$22.25	.	$4.45																																	
5821	Level 1 Health and Behavior Services	S	0.4083	$37.46	.	$7.50																																	
5822	Level 2 Health and Behavior Services	S	1.1731	$107.63	.	$21.53																																	
5823	Level 3 Health and Behavior Services	S	1.9103	$175.26	.	$35.06																																	
5851	Intensive Outpatient (3 services) for CMHCs	P	1.4634	$134.26	.	$26.86																																	
5852	Intensive Outpatient (4 or more services) for CMHCs	P	1.8227	$167.23	.	$33.45																																	
5853	Partial Hospitalization (3 services) for CMHCs	P	1.4634	$134.26	.	$26.86																																	
5854	Partial Hospitalization (4 or more services) for CMHCs	P	1.8227	$167.23	.	$33.45																																	
5861	Intensive Outpatient (3 services) for Hospital-based IOPs	P	3.6586	$335.67	.	$67.14																																	
5862	Intensive Outpatient (4 or more services) for Hospital-based IOPs	P	4.5570	$418.09	.	$83.62																																	
5863	Partial Hospitalization (3 services) for Hospital-based PHPs	P	3.6586	$335.67	.	$67.14																																	
5864	Partial Hospitalization (4 or more services) for Hospital-based PHPs	P	4.5570	$418.09	.	$83.62																																	
5871	Dental Procedures	T	9.0843	$833.46	.	$166.70																																	
5881	Ancillary Outpatient Services When Patient Dies	J1	152.0443	"$13,949.61"	.	"$2,789.93"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
6000	PMA Skin Substitute Products	S1	1.3666	$125.38	.	$25.08																																	
6001	510K Skin Substitute Products	S1	1.3666	$125.38	.	$25.08																																	
6002	HCT/P Skin Substitute Products	S1	1.3666	$125.38	.	$25.08																																	
7043	Infliximab not biosimil 10mg	K		$30.523	.	$6.11	20.000%	$6.11																															
7046	Doxorubicin inj 10mg	K		$150.409	.	$30.09	20.000%	$30.09																															
7048	Alteplase recombinant	K		$91.462	.	$18.30	20.000%	$18.30																															
7308	Aminolevulinic acid hcl top	K		$394.413	.	$78.89	20.000%	$78.89																															
8004	Ultrasound Composite	S	3.3033	$303.07	.	$60.62																																	
8005	CT and CTA without Contrast Composite	S	2.4641	$226.07	.	$45.22																																	
8006	CT and CTA with Contrast Composite	S	4.7866	$439.16	.	$87.84																																	
8007	MRI and MRA without Contrast Composite	S	5.9369	$544.69	.	$108.94																																	
8008	MRI and MRA with Contrast Composite	S	9.5367	$874.96	.	$175.00																																	
8010	Mental Health Services Composite	S	4.5570	$418.09	.	$83.62																																	
8011	Comprehensive Observation Services	J2	29.2989	"$2,688.09"	.	$537.62																																	
9002	Tenecteplase injection	K		$162.456	.	$32.50	20.000%	$32.50																															
9003	Rsv mab im 50mg	K		$719.870	.	$143.98	20.000%	$143.98																															
9004	"Injection, inclisiran, 1 mg"	K		$12.274	.	$2.46	20.000%	$2.46	*																														
9005	Reteplase injection	K		"$2,777.136"	.	$555.43	20.000%	$555.43																															
9006	Tacrolimus injection	K		$255.058	.	$51.02	20.000%	$51.02																															
9007	Inj cutaquig 100 mg	K		$14.335	.	$2.87	20.000%	$2.87																															
9008	"Inj tezepelumab-ekko, 1mg"	K		$17.767	.	$3.56	20.000%	$3.56	*																														
9009	"Inj, vutrisiran, 1 mg"	K		"$4,956.310"	.	$991.27	20.000%	$991.27	*																														
9010	Inj efgartigimod 2mg	K		$32.375	.	$6.48	20.000%	$6.48	*																														
9013	Inj risankizumab-rzaa1 mg	K		$14.859	.	$2.98	20.000%	$2.98	*																														
9014	"Inj., cerliponase alfa 1 mg"	K		$245.595	.	$49.12	20.000%	$49.12																															
9016	"Inj., triptorelin xr 3.75 mg"	K		"$3,506.041"	.	$701.21	20.000%	$701.21																															
9017	"Inj. byooviz, 0.1 mg"	K		$85.569	.	$17.12	20.000%	$17.12	*	8% of reference add-on applied																													
9018	"Inj, rimabotulinumtoxinB"	K		$12.996	.	$2.60	20.000%	$2.60																															
9020	Argatroban nonesrd (accord)	K		$1.815	.	$0.37	20.000%	$0.37																															
9024	Amphotericin b lipid complex	K		$10.299	.	$2.06	20.000%	$2.06																															
9025	"Inj glucagon hcl, fresenius"	K		$150.437	.	$30.09	20.000%	$30.09																															
9027	"Inj, bortezomib freseniuskab"	K		$16.500	.	$3.30	20.000%	$3.31																															
9028	Inj inotuzumab ozogam 0.1 mg	K		"$2,658.129"	.	$531.63	20.000%	$531.63																															
9029	"Inj., guselkumab, 1 mg"	K		$70.427	.	$14.09	20.000%	$14.09																															
9031	"Inj, etelcalcetide, 0.1 mg"	K 		$4.373	.	$0.88	20.000%	$0.88																															
9032	Baclofen 10 MG injection	K		$174.804	.	$34.97	20.000%	$34.97																															
9033	Cidofovir injection	K		$521.827	.	$104.37	20.000%	$104.37																															
9034	"Inj cuvitru, 100 mg"	K		$16.682	.	$3.34	20.000%	$3.34																															
9035	Axicabtagene ciloleucel car+ 	K		"$502,840.728"	.	"$100,568.15"	18.977%	"$1,676.00"		"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
9036	"Injection, renflexis"	K		$27.845	.	$5.57	20.000%	$5.57		8% of reference add-on applied																													
9038	Inj estrogen conjugate	K		$382.887	.	$76.58	20.000%	$76.58																															
9042	Glucagon hydrochloride	K		$190.763	.	$38.16	20.000%	$38.16																															
9043	"Inj, afstyla, 1 i.u."	K		$1.514	.	$0.31	20.000%	$0.31																															
9044	Ibutilide fumarate injection	K		$186.771	.	$37.36	20.000%	$37.36																															
9045	Idursulfase injection	K		$542.574	.	$108.52	20.000%	$108.52																															
9046	"Inj., fibryga, 1 mg"	K		$1.101	.	$0.23	20.000%	$0.23																															
9048	"Inj, alymsys, 10 mg"	K		$46.054	.	$9.22	20.000%	$9.22	*	8% of reference add-on applied																													
9050	"Leuprolide inj, camcevi, 1mg"	K		$52.378	.	$10.48	20.000%	$10.48	*																														
9051	"Inj, lanreotide, (cipla) 1mg"	K		$25.422	.	$5.09	20.000%	$5.09	*																														
9052	Fluciclovine f-18	K		$329.370	.	$65.88	20.000%	$65.88																															
9053	Fluorodopa f-18 diag per mci	K		$862.660	.	$174.26	20.000%	$174.26	*																														
9054	Lutetium lu 177 vipivotide	K		$240.201	.	$48.05	20.000%	$48.05	*																														
9055	Gallium locametz 1 millicuri	K		$341.950	.	$68.39	20.000%	$68.39	*																														
9056	Gallium ga-68	K		$49.230	.	$9.85	20.000%	$9.85																															
9057	Inj nivol relatlimab 3mg/1mg	K		$194.077	.	$38.82	20.000%	$38.82	*																														
9059	Vonvendi inj 1 iu vwf:rco	K		$1.831	.	$0.37	20.000%	$0.37																															
9063	Rh ig minidose im	K		$31.630	.	$6.33	20.000%	$6.33																															
9067	Lutetium lu 177 dotatat ther	K 		$296.249	.	$59.25	20.000%	$59.25																															
9068	Smallpox&monkeypox vac 0.5ml	K 		$0.010	.	$0.00	0.000%	$0.00																															
9070	Inj luxturna 1 billion vec g	K 		"$3,146.258"	.	$629.26	20.000%	$629.26																															
9071	Capsaicin 8% patch	K		$3.377	.	$0.68	20.000%	$0.68																															
9073	Buprenorph xr 100 mg or less	K 		"$1,925.231"	.	$385.05	20.000%	$385.05																															
9075	"Inj, kovaltry, 1 i.u."	K		$1.486	.	$0.30	20.000%	$0.30																															
9078	Testosterone undecanoate 1mg	K		$2.022	.	$0.41	18.704%	$0.38		IRA-adjusted coinsurance																													
9079	"Genvisc 850, inj, 1mg"	K		$6.314	.	$1.27	20.000%	$1.27																															
9088	Peng benzathine/procaine inj	K		$17.368	.	$3.48	16.732%	$2.91		IRA-adjusted coinsurance																													
9094	Radiesse injection	K		$333.420	.	$66.69	20.000%	$66.69																															
9095	"Inj, sculptra, 0.5mg"	K		$1.000	.	$0.20	20.000%	$0.20																															
9097	Inj retacrit non-esrd use	K		$7.070	.	$1.42	20.000%	$1.42		8% of reference add-on applied																													
9099	"Inj fosnetupitant, palonoset"	K		$632.875	.	$126.58	20.000%	$126.58																															
9101	Vaccinia vrs vac 0.3 ml perq	K		$0.010	.	$0.00	0.000%	$0.00																															
9102	"Inj, fulvestrant (teva)"	K		$46.210	.	$9.25	20.000%	$9.25																															
9104	Antithymocyte globuln rabbit	K		$939.346	.	$187.87	20.000%	$187.87																															
9105	Inj pemetrexed (teva) 10mg	K		$8.370	.	$1.68	20.000%	$1.68																															
9107	"Inj, aponvie, 1 mg"	G		$1.863	.	$0.00	0.000%	$0.00																															
9108	Thyrotropin injection	K		"$2,078.711"	.	$415.75	20.000%	$415.75																															
9109	"Inj, elahere, 1 mg"	G		$68.074	.	$13.62	20.000%	$13.62																															
9110	"Inj, tremelimumab-actl, 1 mg"	G		$138.244	.	$27.65	20.000%	$27.65																															
9111	Inj teclistamab cqyv 0.5 mg	G		$32.419	.	$6.49	20.000%	$6.49																															
9112	Inj teplizumab mzwv 5 mcg	G		$37.307	.	$7.47	20.000%	$7.47																															
9113	Inj olipudase alfa-rpcp 1mg	G		$381.237	.	$76.25	20.000%	$76.25																															
9114	Inj eflapegrastim-xnst 0.1mg	G		$22.608	.	$4.53	20.000%	$4.53																															
9115	"Inj, spesolimab-sbzo, 1 mg"	G		$61.428	.	$12.29	20.000%	$12.29																															
9116	"Chloroprocaine opht gel, 1mg"	G		$0.604	.	$0.00	0.000%	$0.00																															
9117	"Inj, cimerli, 0.1 mg"	G		$146.761	.	$29.36	20.000%	$29.36																															
9118	"Inj, fylnetra, 0.5 mg"	G		$164.154	.	$32.84	20.000%	$32.84																															
9119	"Inj, pedmark, 100 mg"	G		$95.397	.	$19.08	20.000%	$19.08																															
9122	Triptorelin pamoate	K		$471.625	.	$94.33	20.000%	$94.33																															
9123	"Inj pemetrexed, hospira 10mg"	K		$3.860	.	$0.78	20.000%	$0.78																															
9125	"Risperidone, long acting"	K		$10.499	.	$2.10	20.000%	$2.10																															
9126	Natalizumab injection	K		$24.368	.	$4.88	20.000%	$4.88																															
9127	Inj pemetrexed (accord) 10mg	K		$9.736	.	$1.95	20.000%	$1.95																															
9129	"Inj, stimufend, 0.5 mg"	K		$251.245	.	$50.25	20.000%	$50.25																															
9130	"Inj, imm glob bivigam, 500mg"	K		$77.298	.	$15.46	20.000%	$15.46																															
9131	"Inj, Ado-trastuzumab Emt 1mg"	K		$41.105	.	$8.23	20.000%	$8.23																															
9132	Prothrombin complex kcentra	K		$2.176	.	$0.44	20.000%	$0.44																															
9133	"Rabies ig, im/sc"	K		$289.914	.	$57.99	20.000%	$57.99																															
9134	"Rabies ig, heat treated"	K		$347.320	.	$69.47	20.000%	$69.47																															
9135	"Varicella-zoster ig, im"	K		"$2,254.245"	.	$450.85	20.000%	$450.85																															
9136	Inj leu acet lutr dpt 7.5 mg	G 		$220.743	.	$44.15	20.000%	$44.15																															
9138	"Inj, hemgenix, per tx dose"	G 		"$3,685,266.667"	.	"$737,053.34"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
9139	"Rabies vaccine, im"	K		$317.673	.	$63.54	20.000%	$63.54																															
9140	"Rabies vaccine, id"	K		$264.470	.	$52.90	20.000%	$52.90																															
9141	Inj onase abepar-xioi treat	K		"$2,423,131.231"	.	"$484,626.25"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
9142	Fecalmicrobiota jslm 1 ml	G		$63.934	.	$12.79	20.000%	$12.79																															
9144	"Inj, panzyga, 500 mg"	K		$70.432	.	$14.09	20.000%	$14.09																															
9145	"Inj, invega hafyera/trinza"	K		$12.672	.	$2.54	20.000%	$2.54																															
9146	"Inj, ixinity, 1 i.u."	K		$1.923	.	$0.39	20.000%	$0.39																															
9149	"Inj ublituximab-xiiy, 1 mg"	G		$68.655	.	$13.74	20.000%	$13.74																															
9150	"Inj mosunetuzumab-axgb, 1 mg"	G		$640.956	.	$128.20	20.000%	$128.20																															
9154	"Inj, vivimusta, 1 mg"	G		$27.243	.	$5.45	20.000%	$5.45																															
9155	"Inj, lenacapavir, 1 mg"	G		$22.030	.	$4.41	20.000%	$4.41																															
9156	Inj pemetrexed ditromethamin	K		$10.343	.	$2.07	20.000%	$2.07																															
9157	"Inj, lecanemab-irmb, 1 mg"	G 		$1.330	.	$0.27	20.000%	$0.27																															
9158	"Inj, pegcetacoplan, 1mg"	G 		$143.989	.	$28.80	20.000%	$28.80																															
9159	"Inj, vegzelma, 10 mg"	G 		$48.080	.	$9.62	20.000%	$9.62		8% of reference add-on applied																													
9166	"Inj, fosaprepitant (teva)"	K		$1.214	.	$0.25	6.600%	$0.09		IRA-adjusted coinsurance																													
9171	Factor ix idelvion inj	K		$5.183	.	$1.04	20.000%	$1.04																															
9173	"Injection, fulphila"	K 		$112.895	.	$22.58	20.000%	$22.58																															
9174	"Inj, durolane 1 mg"	K		$6.931	.	$1.39	20.000%	$1.39																															
9178	"Inj., meropenem, vaborbactam"	K		$2.112	.	$0.43	20.000%	$0.43																															
9179	"Inj., aristada initio, 1 mg"	K 		$3.143	.	$0.63	20.000%	$0.63																															
9180	"Inj., patisiran, 0.1 mg"	K 		$99.039	.	$19.81	20.000%	$19.81																															
9181	"Inj., perseris, 0.5 mg"	K 		$12.154	.	$2.44	20.000%	$2.44																															
9182	"Inj mogamulizumab-kpkc, 1 mg"	K 		$243.625	.	$48.73	20.000%	$48.73																															
9183	"Inj., plazomicin, 5 mg"	K 		$3.574	.	$0.72	20.000%	$0.72																															
9186	"Inj., rituximab, 10 mg"	K		$76.433	.	$15.29	20.000%	$15.29																															
9187	"Injection, burosumab-twza 1m"	K		$469.742	.	$93.95	18.960%	$89.07		IRA-adjusted coinsurance																													
9189	"Inj., ibalizumab-uiyk, 10 mg"	K		$76.950	.	$15.39	20.000%	$15.39																															
9193	Nivestym	K		$0.287	.	$0.06	20.000%	$0.06		8% of reference add-on applied																													
9194	Tisagenlecleucel car-pos t	K		"$578,771.123"	.	"$115,754.23"	17.740%	"$1,676.00"		"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
9195	"Injection, udenyca 0.5 mg"	K 		$163.604	.	$32.73	20.000%	$32.73																															
9196	"Inj, trivisc 1 mg"	K		$5.586	.	$1.12	20.000%	$1.12																															
9198	"Inj andexxa, 10 mg"	K 		$131.738	.	$26.35	20.000%	$26.35																															
9199	"Injection, caplacizumab-yhdp"	K 		$825.999	.	$165.20	20.000%	$165.20																															
9200	"Inj, remdesivir, 1 mg"	K 		$6.354	.	$1.28	20.000%	$1.28	*																														
9201	Rabies ig ht&sol human im/sc	K		$241.148	.	$48.23	20.000%	$48.23																															
9203	Inj cyclophosphamd auromedic	K 		$0.869	.	$0.18	20.000%	$0.18																															
9204	"Inj tisotu vedotin-tftv, 1mg"	K 		$188.651	.	$37.74	18.869%	$35.60	*	IRA-adjusted coinsurance																													
9205	Inj lon tesirin-lpyl 0.075mg	K		$211.995	.	$42.40	20.000%	$42.40																															
9206	Inj plasminogen tvmh 1mg	K		$32.383	.	$6.48	20.000%	$6.48	*																														
9208	Agalsidase beta injection	K		$222.839	.	$44.57	20.000%	$44.57																															
9209	Laronidase injection	K		$38.605	.	$7.73	20.000%	$7.73																															
9213	Inj. pemetrexed nos 10mg	K		$3.771	.	$0.76	20.000%	$0.76																															
9214	Bevacizumab injection	K		$72.728	.	$14.55	20.000%	$14.55																															
9215	Cetuximab injection	K		$77.524	.	$15.51	20.000%	$15.51																															
9217	Leuprolide acetate suspnsion	K		$172.288	.	$34.46	20.000%	$34.46																															
9219	Procainamide hcl injection	K		$284.337	.	$56.87	20.000%	$56.87																															
9224	Galsulfase injection	K		$484.877	.	$96.98	20.000%	$96.98																															
9225	Fluocinolone acetonide implt	K		$340.036	.	$68.01	20.000%	$68.01																															
9230	Abatacept injection	K		$43.377	.	$8.68	20.000%	$8.68																															
9233	Ranibizumab injection	K		$90.414	.	$18.09	20.000%	$18.09																															
9235	Panitumumab injection	K		$164.923	.	$32.99	18.817%	$31.04		IRA-adjusted coinsurance																													
9237	"Inj, lanreotide acetate"	K		$39.551	.	$7.92	20.000%	$7.92																															
9239	Buprenorphine xr over 100 mg	K		"$1,925.231"	.	$385.05	20.000%	$385.05																															
9240	"Injection, ixabepilone"	K		$136.207	.	$27.25	19.861%	$27.06		IRA-adjusted coinsurance																													
9241	Inj sirolimus prot part 1 mg	K		$80.931	.	$16.19	20.000%	$16.19	*	IRA-adjusted coinsurance																													
9243	"Inj, bendamustine hcl, 1mg"	K		$1.240	.	$0.25	20.000%	$0.25																															
9246	"Inj, abilify asimtufii, 1 mg"	G		$5.872	.	$1.18	20.000%	$1.18																															
9247	"Inj, amisulpride, 1 mg"	G		$9.114	.	$0.00	0.000%	$0.00																															
9250	Inj epcoritamab-bysp 0.16 mg	G		$54.861	.	$10.98	20.000%	$10.98																															
9251	C1 esterase inhibitor inj	K		$63.877	.	$12.78	20.000%	$12.78																															
9252	Plerixafor injection	K		$24.976	.	$5.00	20.000%	$5.00																															
9253	Temozolomide injection	K		$10.406	.	$2.09	20.000%	$2.09																															
9254	Flotufolastat f18 diag 1 mci	G		$651.668	.	$130.34	20.000%	$130.34																															
9255	"Inj, invega sustenna, 1 mg"	K		$14.739	.	$2.95	20.000%	$2.95																															
9256	Dexamethasone intra implant	K		$205.236	.	$41.05	20.000%	$41.05																															
9257	"Inj., emicizumab-kxwh 0.5 mg"	K		$51.984	.	$10.40	20.000%	$10.40																															
9258	Telavancin injection	K		$7.090	.	$1.42	20.000%	$1.42																															
9259	Pralatrexate injection	K		$373.768	.	$74.76	20.000%	$74.76																															
9260	Ofatumumab injection	K		$62.234	.	$12.45	20.000%	$12.45																															
9262	Inj tofersen intrathec 1 mg	G		$155.337	.	$31.07	20.000%	$31.07																															
9263	Ecallantide injection	K		$564.641	.	$112.93	20.000%	$112.93																															
9264	Tocilizumab injection	K		$5.881	.	$1.18	20.000%	$1.18																															
9266	"Inj, uzedy, 1 mg"	G		$24.622	.	$4.93	20.000%	$4.93																															
9267	"Inj, rezafungin, 1 mg"	G		$10.418	.	$2.09	19.942%	$2.08		IRA-adjusted coinsurance																													
9268	Inj. acthar gel to 40 units	K		"$3,893.429"	.	$778.69	20.000%	$778.69																															
9269	"C-1 esterase, berinert"	K		$72.267	.	$14.46	19.201%	$13.88		IRA-adjusted coinsurance																													
9270	Gammaplex IVIG	K		$57.476	.	$11.50	20.000%	$11.50																															
9271	Velaglucerase alfa	K		$374.360	.	$74.88	20.000%	$74.88																															
9272	"Inj, denosumab"	K		$27.809	.	$5.57	18.201%	$5.07		IRA-adjusted coinsurance																													
9273	Sipuleucel-T auto CD54+	K		"$57,017.103"	.	"$11,403.43"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."																													
9275	"Inj. (ani), up to 40 units"	K		"$3,445.584"	.	$689.12	20.000%	$689.12																															
9276	Cabazitaxel injection	K		$221.705	.	$44.35	20.000%	$44.35																															
9277	Altuviiio per factor viii iu	G		$4.596	.	$0.92	20.000%	$0.92																															
9278	Incobotulinumtoxin A	K		$5.330	.	$1.07	20.000%	$1.07																															
9280	"Inj, retifanlimab-dlwr, 1 mg"	G		$29.736	.	$5.95	20.000%	$5.95																															
9281	"Injection, pegloticase"	K		"$3,565.318"	.	$713.07	19.634%	$700.02		IRA-adjusted coinsurance																													
9284	Ipilimumab injection	K		$180.215	.	$36.05	20.000%	$36.05																															
9285	Inj allopurinol sodium 1 mg	K		$4.450	.	$0.89	20.000%	$0.89																															
9286	Belatacept injection	K		$3.891	.	$0.78	20.000%	$0.78																															
9287	Brentuximab vedotin inj	K		$248.930	.	$49.79	18.340%	$45.66		IRA-adjusted coinsurance																													
9294	"Inj, taliglucerase alfa 10 u"	K		$40.642	.	$8.13	20.000%	$8.13																															
9295	"Injection, Carfilzomib, 1 mg"	K		$51.847	.	$10.37	18.845%	$9.78		IRA-adjusted coinsurance																													
9296	"Inj, ziv-aflibercept, 1mg"	K		$8.298	.	$1.66	20.000%	$1.66																															
9299	Inj. jivi 1 iu	K		$2.450	.	$0.49	20.000%	$0.50																															
9300	Omalizumab injection	K		$40.117	.	$8.03	20.000%	$8.03																															
9301	"Aminolevulinic acid, 10% gel"	K		$1.783	.	$0.36	20.000%	$0.36																															
9302	"Inj daunorubicin, cytarabine"	K		$249.021	.	$49.81	19.656%	$48.95		IRA-adjusted coinsurance																													
9304	"Inj., cemiplimab-rwlc, 1 mg"	K		$28.921	.	$5.79	20.000%	$5.79																															
9305	"Inj., lumoxiti, 0.01 mg"	K		$23.394	.	$4.68	20.000%	$4.68																															
9306	"Inj., tildrakizumab, 1 mg"	K 		$131.462	.	$26.30	20.000%	$26.30																															
9308	Dexametha opth insert 0.1 mg	K1 		$110.680	.	$22.14	20.000%	$22.14																															
9309	Inj. tagraxofusp-erzs 10 mcg	K		$338.532	.	$67.71	20.000%	$67.71																															
9310	"Inj., emapalumab-lzsg, 1 mg"	K		$381.503	.	$76.31	20.000%	$76.31																															
9311	"Inj., omadacycline, 1 mg"	K 		$3.866	.	$0.78	20.000%	$0.78																															
9312	"Inj., ravulizumab-cwvz 10 mg"	K 		$220.317	.	$44.07	20.000%	$44.07																															
9313	Inj. belrapzo/bendamustine	K 		$14.196	.	$2.84	20.000%	$2.84																															
9314	"Inj. herceptin hylecta, 10mg"	K 		$62.916	.	$12.59	20.000%	$12.59																															
9320	Carbidopa levodopa ent 100ml	K		$235.772	.	$47.16	20.000%	$47.16																															
9322	Bcg live intravesical 1mg	K 		$3.139	.	$0.63	20.000%	$0.63																															
9323	Gallium ga-68 dotatoc	K		$3.600	.	$0.72	20.000%	$0.72																															
9324	Phenylep ketorolac opth soln	K1 		$98.072	.	$19.62	20.000%	$19.62																															
9325	"Inj., eravacycline, 1 mg"	K 		$1.206	.	$0.25	20.000%	$0.25																															
9326	"Inj., lanadelumab-flyo, 1 mg"	K 		$84.802	.	$16.97	20.000%	$16.97																															
9327	Inj. romosozumab-aqqg 1 mg	K 		$11.494	.	$2.30	19.541%	$2.25		IRA-adjusted coinsurance																													
9328	"Inj., yutiq, 0.01 mg"	K		$524.568	.	$104.92	20.000%	$104.92																															
9329	Inj mvasi 10 mg	K		$29.824	.	$5.97	20.000%	$5.97		8% of reference add-on applied																													
9330	"Inj., kanjinti, 10 mg"	K		$27.905	.	$5.59	20.000%	$5.59																															
9331	"Inj, polatuzumab vedotin 1mg"	K 		$132.725	.	$26.55	20.000%	$26.55																															
9336	Inj truxima 10 mg	K 		$34.759	.	$6.96	20.000%	$6.96		8% of reference add-on applied																													
9338	"Inj., triluron, 1 mg"	K 		$10.281	.	$2.06	20.000%	$2.06																															
9340	"Inj, brolucizumab-dbll, 1 mg"	K 		$339.988	.	$68.00	20.000%	$68.00																															
9341	Inj  ogivri 10 mg	K 		$46.816	.	$9.37	20.000%	$9.37		8% of reference add-on applied																													
9343	Inj givosiran 0.5 mg	K 		$116.471	.	$23.30	20.000%	$23.30																															
9345	Inj pegfilgrastim-bmez 0.5mg	K 		$24.711	.	$4.95	20.000%	$4.95																															
9346	Mometasone sinus sinuva	K 		$11.345	.	$2.27	20.000%	$2.27																															
9347	Inj luspatercept-aamt 0.25mg	K 		$41.243	.	$8.25	20.000%	$8.25																															
9348	"Inj., zirabev, 10 mg"	K 		$26.943	.	$5.39	20.000%	$5.39		8% of reference add-on applied																													
9349	Inj herzuma 10 mg	K		$73.905	.	$14.79	20.000%	$14.79		8% of reference add-on applied																													
9350	"Inj., trazimera, 10 mg"	K		$24.931	.	$4.99	20.000%	$4.99		8% of reference add-on applied																													
9351	Inj bimatoprost itc imp 1mcg	K 		$209.907	.	$41.99	20.000%	$41.99																															
9353	Inj fam-trastu deru-nxki 1mg	K 		$28.901	.	$5.79	20.000%	$5.79																															
9354	Inj recombin esperoct per iu	K 		$2.138	.	$0.43	20.000%	$0.43																															
9355	Inj. teprotumumab-trbw 10 mg	K 		$352.563	.	$70.52	20.000%	$70.52																															
9357	Inj. eptinezumab-jjmr 1 mg	K 		$19.321	.	$3.87	19.491%	$3.77		IRA-adjusted coinsurance																													
9358	Inj xipere 1 mg	K 		$48.231	.	$9.65	20.000%	$9.65	*																														
9359	Inj crizanlizumab-tmca 5mg	K 		$129.502	.	$25.91	20.000%	$25.91																															
9364	Inj enfort vedo-ejfv 0.25mg	K		$36.642	.	$7.33	19.143%	$7.02		IRA-adjusted coinsurance																													
9367	"Inj ruxience, 10 mg"	K		$24.943	.	$4.99	20.000%	$4.99		8% of reference add-on applied																													
9370	Fluoroestradiol F 18	K		$463.200	.	$92.64	20.000%	$92.64																															
9372	"Inj. xembify, 100 mg"	K 		$14.283	.	$2.86	20.000%	$2.86																															
9374	Mitomycin instillation	K		$312.995	.	$62.60	20.000%	$62.60																															
9375	"Inj., evomela, 1 mg"	K		$18.498	.	$3.70	20.000%	$3.70																															
9376	Sacituzumab govitecan-hziy	K		$35.800	.	$7.16	20.000%	$7.16																															
9377	Inj. isatuximab-irfc 10 mg	K		$78.855	.	$15.78	20.000%	$15.78																															
9378	"Daratumumab, hyaluronidase"	K		$52.992	.	$10.60	20.000%	$10.60																															
9381	"Inj. avsola, 10 mg"	K		$19.749	.	$3.95	20.000%	$3.95		8% of reference add-on applied																													
9382	Inj ontruzant 10 mg	K		$28.740	.	$5.75	20.000%	$5.75		8% of reference add-on applied																													
9385	"Inj., tafasitamab-cxix"	K 		$13.925	.	$2.79	20.000%	$2.79																															
9388	Inj. fe derisomaltose 10 mg	K 		$20.826	.	$4.17	20.000%	$4.17																															
9389	"Inj. lurbinectedin, 0.1 mg"	K 		$205.036	.	$41.01	20.000%	$41.01																															
9390	"Pertuzu, trastuzu, 10 mg"	K 		$62.993	.	$12.60	20.000%	$12.60																															
9391	Brexucabtagene car pos t	K 		"$489,399.157"	.	"$97,879.84"	19.498%	"$1,676.00"		"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
9392	Inj. asceniv	K		$496.683	.	$99.34	20.000%	$99.34																															
9394	"Inj. inebilizumab-cdon, 1 mg"	K 		$484.403	.	$96.89	20.000%	$96.89																															
9395	Factor viia recomb sevenfact	K		$2.385	.	$0.48	20.000%	$0.48																															
9396	"Afamelanotide implant, 1 mg"	K		"$2,873.329"	.	$574.67	20.000%	$574.67																															
9398	Covid-19 Vaccine Administration 	S	0.4525	$41.52	.	$0.00																																	
9399	"Pneumococcal, Influenza, Hepatitis B, and/or Covid-19 Vaccine Home Administration"	S	0.4016	$36.85	.	$0.00																																	
9406	"Inj, nyvepria"	K 		$134.252	.	$26.86	20.000%	$26.86																															
9407	"Inj. lumasiran, 0.5 mg"	K 		$318.852	.	$63.78	20.000%	$63.78																															
9408	"Inj. naxitamab-gqgk, 1 mg"	K 		$641.829	.	$128.37	20.000%	$128.37																															
9409	Gallium ga-68 psma-11 ucsf	K		$559.370	.	$111.88	20.000%	$111.88																															
9410	"Gallium ga-68 psma-11, ucla"	K		$363.510	.	$72.71	20.000%	$72.71																															
9411	"Inj. riabni, 10 mg"	K 		$33.087	.	$6.62	20.000%	$6.62		8% of reference add-on applied																													
9413	lisocabtagene car pos t	K		"$516,442.285"	.	"$103,288.46"	19.475%	"$1,676.00"		"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
9414	"Inj, cabote rilpivir 2mg 3mg"	K		$23.132	.	$4.63	20.000%	$4.63																															
9415	"Injection, trilaciclib, 1mg"	K		$5.388	.	$1.08	20.000%	$1.08																															
9416	"Inj, evinacumab-dgnb, 5 mg"	K		$186.306	.	$37.27	20.000%	$37.27																															
9418	"Inj. margetuximab-cmkb, 5 mg"	K		$48.530	.	$9.71	20.000%	$9.71																															
9419	Inj fensolvi 0.25 mg	K		$134.256	.	$26.86	20.000%	$26.86																															
9420	Eptifibatide injection	K		$6.360	.	$1.28	20.000%	$1.28																															
9421	"Inj, granisetron, xr, 0.1 mg"	K		$5.286	.	$1.06	20.000%	$1.06																															
9422	Idecabtagene vicleucel car	K		"$527,622.462"	.	"$105,524.50"	19.490%	"$1,676.00"		"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
9426	"Inj, cefiderocol, 10 mg"	K		$2.282	.	$0.46	20.000%	$0.46																															
9427	"Injection, oritavancin 10 mg"	K		$42.765	.	$8.56	20.000%	$8.56																															
9428	Inj romidepsin non-lyo 0.1mg	K		$28.517	.	$5.71	20.000%	$5.71																															
9429	Inj romidepsin lyophil 0.1mg	K		$31.541	.	$6.31	20.000%	$6.31																															
9430	"Piflu f-18, dia 1 millicurie"	K		$347.360	.	$69.48	20.000%	$69.48																															
9431	"Inj, dostarlimab-gxly, 10 mg"	K		$240.135	.	$48.03	20.000%	$48.03																															
9432	"Inj, amivantamab-vmjw"	K		$21.507	.	$4.31	19.252%	$4.15		IRA-adjusted coinsurance																													
9433	Inj aval alfa-nqpt 4mg	K		$77.817	.	$15.57	20.000%	$15.57																															
9434	Inj anifrolumab-fnia 1mg	K		$17.777	.	$3.56	20.000%	$3.56																															
9436	Inj pegfilgrast ex bio 0.5mg	K		$19.981	.	$4.00	20.000%	$4.00																															
9437	"Inj, aspara, rylaze, 0.1 mg"	K		$54.378	.	$10.88	19.533%	$10.63		IRA-adjusted coinsurance																													
9438	"Injection, aducanumab-avwa, 2 mg"	K		$5.978	.	$1.20	20.000%	$1.20																															
9439	"Inj, susvimo 0.1 mg"	K		$79.737	.	$15.95	20.000%	$15.95	*																														
9440	"Instill, bupivac and meloxic"	K1 		$0.773	.	$0.16	20.000%	$0.16																															
9441	Inj ferric carboxymaltos 1mg	K		$1.127	.	$0.23	20.000%	$0.23																															
9442	"Inj. pemetrexed, 10 mg"	K 		$46.350	.	$9.27	20.000%	$9.28	*																														
9443	Gallium illuccix 1 millicure	K 		$485.510	.	$97.11	20.000%	$97.11	*																														
9444	"Inj, sutimlimab-jome, 10 mg"	K 		$18.127	.	$3.63	20.000%	$3.63	*																														
9445	"Injection, ruconest"	K		$34.750	.	$6.95	20.000%	$6.95																															
9446	"Inj, tebentafusp-tebn, 1 mcg"	K 		$214.756	.	$42.96	20.000%	$42.96	*																														
9447	"Inj, releuko 1 mcg"	K 		$0.425	.	$0.09	20.000%	$0.09	*	8% of reference add-on applied																													
9448	"Oral netupitant, palonosetro"	K		$409.009	.	$81.81	18.671%	$76.37		IRA-adjusted coinsurance																													
9449	"Injection, blinatumomab"	K		$152.276	.	$30.46	19.380%	$29.52		IRA-adjusted coinsurance																													
9450	Fluocinol acet intravit imp	K		$490.765	.	$98.16	20.000%	$98.16																															
9451	"Injection, peramivir"	K		$1.678	.	$0.34	20.000%	$0.34																															
9452	Inj ceftolozane tazobactam	K		$8.041	.	$1.61	19.921%	$1.61		IRA-adjusted coinsurance																													
9453	"Injection, nivolumab"	K		$32.352	.	$6.48	20.000%	$6.48																															
9454	"Inj, pasireotide long acting"	K		$526.942	.	$105.39	16.095%	$84.82		IRA-adjusted coinsurance																													
9455	"Injection, siltuximab"	K		$163.366	.	$32.68	18.012%	$29.43		IRA-adjusted coinsurance																													
9456	"Injection, isavuconazonium"	K		$0.988	.	$0.20	19.860%	$0.20		IRA-adjusted coinsurance																													
9458	Florbetaben f18 diagnostic	K		"$1,577.130"	.	$315.43	20.000%	$315.43																															
9459	Flutemetamol f18 diagnostic	K		"$1,962.950"	.	$392.59	20.000%	$392.59																															
9460	"Injection, cangrelor"	K		$18.714	.	$3.75	20.000%	$3.75																															
9461	Choline c-11	K		"$2,062.940"	.	$412.59	20.000%	$412.59																															
9463	"Inj., aprepitant, 1 mg"	K		$1.710	.	$0.35	20.000%	$0.35																															
9466	"Inj., benralizumab, 1 mg"	K		$163.300	.	$32.66	20.000%	$32.67																															
9467	"Inj rituximab, hyaluronidase"	K		$37.526	.	$7.51	20.000%	$7.51																															
9468	Factor ix recomb gly rebinyn	K		$4.320	.	$0.87	20.000%	$0.87																															
9469	Inj triamcinolone ace xr 1mg	K		$18.007	.	$3.61	20.000%	$3.61																															
9470	Aripirazole lauroxil 1 mg	K		$3.259	.	$0.66	20.000%	$0.66																															
9471	Hymovis injection 1 mg	K		$17.503	.	$3.51	20.000%	$3.51																															
9472	Inj talimogene laherparepvec	K		$70.376	.	$14.08	19.381%	$13.64		IRA-adjusted coinsurance																													
9473	"Injection, mepolizumab, 1mg"	K		$30.540	.	$6.11	20.000%	$6.11																															
9474	Inj irinotecan liposome 1 mg	K		$65.278	.	$13.06	20.000%	$13.06																															
9475	"Injection, necitumumab, 1 mg"	K		$5.731	.	$1.15	20.000%	$1.15																															
9476	"Injection, daratumumab 10 mg"	K		$67.625	.	$13.53	20.000%	$13.53																															
9477	"Injection, elotuzumab, 1mg"	K		$7.732	.	$1.55	20.000%	$1.55																															
9478	Inj sebelipase alfa 1 mg	K		$538.699	.	$107.74	20.000%	$107.74																															
9480	Injection trabectedin 0.1mg	K		$363.832	.	$72.77	20.000%	$72.77																															
9481	"Injection, reslizumab"	K		$10.494	.	$2.10	20.000%	$2.10																															
9483	"Inj, atezolizumab,10 mg"	K		$89.394	.	$17.88	20.000%	$17.88																															
9487	"Ustekinumab, iv inject,1 mg"	K 		$12.808	.	$2.57	20.000%	$2.57																															
9489	"Inj, nusinersen, 0.1mg"	K 		"$1,248.600"	.	$249.72	20.000%	$249.72																															
9490	"Inj, bezlotoxumab, 10 mg"	K 		$39.869	.	$7.98	20.000%	$7.98																															
9491	"Injection, avelumab, 10 mg"	K 		$97.137	.	$19.43	20.000%	$19.43																															
9492	"Inj., durvalumab, 10 mg"	K 		$83.868	.	$16.78	20.000%	$16.78																															
9493	"Injection, edaravone, 1 mg"	K 		$20.405	.	$4.09	20.000%	$4.09																															
9494	"Injection, ocrelizumab"	K 		$57.807	.	$11.57	20.000%	$11.57																															
9495	Gemtuzumab ozogamicin inj	K 		$233.119	.	$46.63	20.000%	$46.63																															
9496	"Inj, faricimab-svoa, 0.1mg"	K 		$34.722	.	$6.95	20.000%	$6.95	*																														
9498	Ciltacabtagene car-pos t	K 		"$553,169.299"	.	"$110,633.86"	18.987%	"$1,676.00"	*	"IRA-adjusted coinsurance;Copayments capped at inpatient deductible of $1,676.00."																													
9500	"Platelets, irradiated"	R	4.2766	$392.37	.	$78.48																																	
9501	Platelet pheres leukoreduced	R	5.5124	$505.75	.	$101.15																																	
9502	Platelet pheresis irradiated	R	10.1110	$927.65	.	$185.53																																	
9503	Fr frz plasma donor retested	R	0.6113	$56.08	.	$11.22																																	
9504	RBC deglycerolized	R	3.1687	$290.72	.	$58.15																																	
9505	RBC irradiated	R	1.6189	$148.53	.	$29.71																																	
9507	"Platelets, pheresis"	R	3.5658	$327.15	.	$65.43																																	
9508	Plasma 1 donor frz w/in 8 hr	R	0.9323	$85.54	.	$17.11																																	
9509	"Frozen plasma, pooled, sd"	R	0.4955	$45.46	.	$9.10																																	
9510	Whole blood for transfusion	R	1.9797	$181.63	.	$36.33																																	
9511	Cryoprecipitate each unit	R	0.7786	$71.43	.	$14.29																																	
9512	RBC leukocytes reduced	R	2.0402	$187.18	.	$37.44																																	
9513	"Plasma, frz between 8-24hour"	R	0.8204	$75.27	.	$15.06																																	
9514	"Plasma protein fract,5%,50ml"	R	0.0877	$8.05	.	$1.61																																	
9515	"Platelets, each unit"	R	0.7577	$69.52	.	$13.91																																	
9516	Plaelet rich plasma unit	R	6.0539	$555.43	.	$111.09																																	
9517	Red blood cells unit	R	1.7057	$156.49	.	$31.30																																	
9518	Washed red blood cells unit	R	4.2015	$385.48	.	$77.10																																	
9519	"Plasmaprotein fract,5%,250ml"	R	0.4048	$37.14	.	$7.43																																	
9520	Blood split unit	R	1.6218	$148.80	.	$29.76																																	
9521	Platelets leukoreduced irrad	R	2.0664	$189.59	.	$37.92																																	
9522	RBC leukoreduced irradiated	R	2.8809	$264.31	.	$52.87																																	
9523	Cryoprecipitatereducedplasma	R	1.1642	$106.81	.	$21.37																																	
9524	"Blood, l/r, cmv-neg"	R	1.6059	$147.34	.	$29.47																																	
9525	"Platelets, hla-m, l/r, unit"	R	7.7737	$713.21	.	$142.65																																	
9526	Platelets leukocytes reduced	R	1.6597	$152.27	.	$30.46																																	
9527	"Blood, l/r, froz/degly/wash"	R	2.6312	$241.40	.	$48.28																																	
9528	"Plt, aph/pher, l/r, cmv-neg"	R	2.4201	$222.04	.	$44.41																																	
9529	"Blood, l/r, irradiated"	R	0.9286	$85.20	.	$17.04																																	
9530	Plate pheres leukoredu irrad	R	7.5106	$689.08	.	$137.82																																	
9531	"Plt, pher, l/r cmv-neg, irr"	R	5.0042	$459.12	.	$91.83																																	
9532	"RBC, frz/deg/wsh, l/r, irrad"	R	4.7421	$435.07	.	$87.02																																	
9533	"RBC, l/r, cmv-neg, irrad"	R	2.7075	$248.41	.	$49.69																																	
9534	Pathogen reduced plasma pool	R	0.6530	$59.91	.	$11.99																																	
9535	Pathogen reduced plasma sing	R	3.1630	$290.20	.	$58.04																																	
9536	Platelets pheresis path redu	R	6.7374	$618.14	.	$123.63																																	
9537	Blood component/product noc	R	0.4048	$37.14	.	$7.43																																	
9538	Plasma cryo redu path each	R	1.4813	$135.90	.	$27.18																																	
9539	Cryo fib comp path redu each	R	5.6713	$520.32	.	$104.07																																	
9540	Covid-19 convalescent plasma	R	7.5336	$691.19	.	$138.24																																	
9541	Rbc o2 co2 reduced	R	5.5124	$505.75	.	$101.15																																	
