		Addendum C. - Proposed HCPCS Codes Payable Under the 2026 OPPS by APC										
		CPT codes and descriptions only are copyright 2025 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2025 American Dental Association. All Rights Reserved.										
		"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	HCPCS	Group Title	Short Descriptor	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		
0701	A9600		Sr89 strontium						20.000%			
0702		"Inj, human-lans, per i.u"		G		$1.546	.	$0.31	20.000%	$0.31		
0702	J7165		"Inj, human-lans, per i.u"						20.000%			
0703		Inj daxibotulinumtoxina-lanm		G		$2.992	.	$0.60	20.000%	$0.60		
0703	J0589		Inj daxibotulinumtoxina-lan						20.000%			
0704		"Inj, aflibercept hd, 1 mg"		G		$321.176	.	$64.24	20.000%	$64.24		
0704	J0177		"Inj, aflibercept hd, 1 mg"						20.000%			
0705		Inj avacincaptad pegol 0.1mg		G		$107.444	.	$21.49	20.000%	$21.49		
0705	J2782		Inj avacincaptad pegol 0.1m						20.000%			
0706		Inj talquetamab-tgvs 0.25 mg		G		$69.997	.	$14.00	19.851%	$13.90		IRA-adjusted coinsurance
0706	J3055		Inj talquetamab-tgvs 0.25 m						19.851%			
0707		"Cantharidin top, applicator"		G		$682.257	.	$136.46	20.000%	$136.46		
0707	J7354		"Cantharidin top, applicator"						20.000%			
0708		"Inj, elranatamab-bcmm, 1 mg"		G		$182.980	.	$36.60	20.000%	$36.60		
0708	J1323		"Inj, elranatamab-bcmm, 1 mg"						20.000%			
0709		Flortaucipir inj 1 millicuri		G		"$3,710.000"		$742.00	20.000%	$742.00		
0709	A9601		Flortaucipir inj 1 millicur						20.000%			
0710		Inj velmanase alfa-tycv 1 mg		G		$444.976	.	$89.00	19.679%	$87.57		IRA-adjusted coinsurance
0710	J0217		Inj velmanase alfa-tycv 1 m						19.679%			
0711		"Inj, artesunate, 1mg"		K		$51.829	.	$10.37	20.000%	$10.37		
0711	J0391		"Inj, artesunate, 1mg"						20.000%			
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."
0713	J1412		Inj roctavian ml 2x10^13vc						20.000%			
0714		Inj delandistrogene mox rokl		G		"$3,322,473.300"	.	"$664,494.66"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
0714	J1413		Inj delandistrogene mox rok						20.000%			
0715		Pegunigalsidase alfa-iwxj		G		$226.927	.	$45.39	19.817%	$44.98		IRA-adjusted coinsurance
0715	J2508		Pegunigalsidase alfa-iwxj						19.817%			
0716		"Vyjuvek 5x10^9pfu/ml, 0.1 ml"		G		"$1,016.669"	.	$203.34	20.000%	$203.34		
0716	J3401		"Vyjuvek 5x10^9pfu/ml, 0.1 m"						20.000%			
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."
0717	J9029		"Instill adstiladrin, tx dos"						20.000%			
0718		"Inj, carmustine (accord)"		K		$259.700	.	$51.94	20.000%	$51.94		
0718	J9052		"Inj, carmustine (accord)"						20.000%			
0719		Inj cyclophos avyxa 5mg		G		$9.053	.	$1.82	20.000%	$1.82		
0719	J9072		Inj cyclophos avyxa 5mg						20.000%			
0720		"Inj glofitamab gxbm, 2.5 mg"		G		"$2,772.798"	.	$554.56	20.000%	$554.56		
0720	J9286		"Inj glofitamab gxbm, 2.5 mg"						20.000%			
0721		Inj ronzanolixizum-noli 1 mg		G		$22.842	.	$4.57	20.000%	$4.57		
0721	J9333		Inj ronzanolixizum-noli 1 m						20.000%			
0723		Inj efgart-alfa 2mg hya-qvfc		K		$33.371	.	$6.68	20.000%	$6.68		
0723	J9334		Inj efgart-alfa 2mg hya-qvf						20.000%			
0725		Inj secukinumab intrav 1mg		G		$17.728	.	$3.55	20.000%	$3.55		
0725	J3247		Inj secukinumab intrav 1mg						20.000%			
0726		Dexrazoxane HCl injection		K		$80.956	.	$16.20	20.000%	$16.20		
0726	J1190		Dexrazoxane hcl injection						20.000%			
0727		"Inj, adzynma, 10 iu"		G		$34.516	.	$6.91	20.000%	$6.91		
0727	J7171		"Inj, adzynma, 10 iu"						20.000%			
0728		"Inj, mirikizumab-mrkz, 1 mg"		G		$47.566	.	$9.52	14.952%	$7.12		IRA-adjusted coinsurance
0728	J2267		"Inj, mirikizumab-mrkz, 1 mg"						14.952%			
0729		"Inj, motixafortide, 0.25 mg"		G		$25.218	.	$5.05	20.000%	$5.05		
0729	J2277		"Inj, motixafortide, 0.25 mg"						20.000%			
0731		Sargramostim injection		K		$59.883	.	$11.98	19.955%	$11.95		IRA-adjusted coinsurance
0731	J2820		Sargramostim injection						19.955%			
0732		"Inj, brixadi, 7 days or less"		G		$425.404	.	$85.09	19.491%	$82.92		IRA-adjusted coinsurance
0732	J0577		"Inj, brixadi, 7 days or les"						19.491%			
0733		"Inj brixadi, more than 7 day"		G		"$1,701.615"	.	$340.33	19.491%	$331.67		IRA-adjusted coinsurance
0733	J0578		"Inj brixadi, more than 7 da"						19.491%			
0734		"Inj, levothyroxine, freskabi"		K		$6.398	.	$1.28	20.000%	$1.28		
0734	J0651		"Inj, levothyroxine, freskab"						20.000%			
0736		Amphotericin b liposome inj		K		$23.307	.	$4.67	20.000%	$4.67		
0736	J0289		Amphotericin b liposome inj						20.000%			
0737		"Inj, cipaglucosidase, 5 mg"		G		$89.846	.	$17.97	20.000%	$17.97		
0737	J1203		"Inj, cipaglucosidase, 5 mg"						20.000%			
0738		Rasburicase		K		$370.456	.	$74.10	20.000%	$74.10		
0738	J2783		Rasburicase						20.000%			
0739		"Inj, rykindo, 0.5 mg"		K		$13.029	.	$2.61	20.000%	$2.61		
0739	J2801		"Inj, rykindo, 0.5 mg"						20.000%			
0741		Inj cyclophosphamd (ingenus)		K		$1.762	.	$0.36	20.000%	$0.36		
0741	J9073		Inj cyclophos dr reddys 5 m						20.000%			
0743		"Inj, cyclophosphamide, nos"		K		$0.799	.	$0.16	20.000%	$0.16		
0743	J9075		"Inj, cyclophosphamide, nos"						20.000%			
0744		Inst tauro 1.35mg/hep 100u		G		$8.593	.	$1.72	20.000%	$1.72		
0744	J0911		Inst tauro 1.35mg/hep 100u						20.000%			
0745		"Inj, toripalimab-tpzi, 1 mg"		G		$39.096	.	$7.82	20.000%	$7.82		
0745	J3263		"Inj, toripalimab-tpzi, 1 mg"						20.000%			
0746		"Inj, betibeglogene autotemce"		G		"$2,948,213.330"	.	"$589,642.67"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
0746	J3393		"Inj, betibeglogene autotemc"						20.000%			
0747		"Inj, zolbetuximab-clzb, 2 mg"		G		$33.557	.	$6.72	20.000%	$6.72		
0747	J1326		"Inj, zolbetuximab-clzb, 2 m"						20.000%			
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."
0748	J3394		"Inj, lovotibeglogene autote"						20.000%			
0749		Inj travoprost intra impl		G		$194.411	.	$38.89	20.000%	$38.89		
0749	J7355		Inj travoprost intra impl						20.000%			
0750		"Inj, nithiodote, 3mg / 125mg"		K		$2.166	.	$0.44	20.000%	$0.44		
0750	J0211		"Inj, nithiodote, 3mg / 125m"						20.000%			
0752		Dactinomycin injection		K		$288.796	.	$57.76	20.000%	$57.76		
0752	J9120		Dactinomycin injection						20.000%			
0755		Oral methotrexate (jylamvo)		K		$18.968	.	$3.80	20.000%	$3.80		
0755	J8611		Oral methotrexate (jylamvo)						20.000%			
0756		Oral methotrexate (xatmep)		K		$20.710	.	$4.15	20.000%	$4.15		
0756	J8612		Oral methotrexate (xatmep)						20.000%			
0757		"Docetaxel (docivyx), 1 mg"		G		$51.620	.	$10.33	20.000%	$10.33		
0757	J9172		"Docetaxel (docivyx), 1 mg"						20.000%			
0759		"Naltrexone, depot form"		K		$4.123	.	$0.83	20.000%	$0.83		
0759	J2315		"Naltrexone, depot form"						20.000%			
0760		Tc-99m graphite crucible		G		$328.600		$0.00	0.000%	$0.00		
0760	A9506		Tc-99m graphite crucible						0.000%			
0761		"Inj, focinvez, 1mg"		G		$3.021	.	$0.61	20.000%	$0.61		
0761	J1434		"Inj, focinvez, 1mg"						20.000%			
0763		"Inj, bupivacaine liposome"		K1		$1.421	.	$0.29	20.000%	$0.29		
0763	J0666		"Inj, bupivacaine liposome"						20.000%			
0764		Ketorolac tromethamine inj		K1		$0.501	.	$0.11	20.000%	$0.11		
0764	J1885		Ketorolac tromethamine inj						20.000%			
0765		"Inj, donanemab-azbt, 2 mg"		G		$4.181	.	$0.84	20.000%	$0.84		
0765	J0175		"Inj, donanemab-azbt, 2 mg"						20.000%			
0767		"Inj, nogapendekin pmln 1 mcg"		G		$94.581	.	$18.92	20.000%	$18.92		
0767	J9028		"Inj, nogapendekin pmln, 1mc"						20.000%			
0768		"Inj, tarlatamab-dlle, 1 mg"		G		"$1,570.765"	.	$314.16	20.000%	$314.16		
0768	J9026		"Inj, tarlatamab-dlle, 1 mg"						20.000%			
0770		In111 oxyquinoline		K		$911.310	.	$182.27	20.000%	$182.27		
0770	A9547		In111 oxyquinoline						20.000%			
0771		In111 pentetate		K		$764.790	.	$152.96	20.000%	$152.96		
0771	A9548		In111 pentetate						20.000%			
0772		"Inj, pegulicianine, 1 mg"		G		$37.508		$0.00	0.000%	$0.00		
0772	A9615		"Inj, pegulicianine, 1 mg"						0.000%			
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."
0773	J1414		"Inj, beqvez, per tx dose"						20.000%			
0774		Tc99m bicisate		K		$821.850	.	$164.37	20.000%	$164.37		
0774	A9557		Tc99m bicisate						20.000%			
0776		Technetium tc-99m auto wbc		K		$958.220	.	$191.65	20.000%	$191.65		
0776	A9569		Technetium tc-99m auto wbc						20.000%			
0777		Indium in-111 auto wbc		K		"$1,073.130"	.	$214.63	20.000%	$214.63		
0777	A9570		Indium in-111 auto wbc						20.000%			
0778		"Inj, vasopressin (baxter)"		G		$3.501	.	$0.71	20.000%	$0.71		
0778	J2601		"Inj, vasopressin (baxter)"						20.000%			
0779		Indium in-111 pentetreotide		K		"$2,027.500"	.	$405.50	20.000%	$405.50		
0779	A9572		Indium in-111 pentetreotide						20.000%			
0780		Iodine i-123 iobenguane		K		"$2,418.900"	.	$483.78	20.000%	$483.78		
0780	A9582		Iodine i-123 iobenguane						20.000%			
0781		Iodine i-123 ioflupane		K		"$1,410.500"	.	$282.10	20.000%	$282.10		
0781	A9584		Iodine i-123 ioflupane						20.000%			
0782		"Inj, pemrydi rtu, 10 mg"		G		$81.057	.	$16.22	20.000%	$16.22		
0782	J9324		"Inj, pemrydi rtu, 10 mg"						20.000%			
0784		"Inj, tyenne, 1 mg"		G		$4.065	.	$0.82	20.000%	$0.82		8% of reference add-on applied
0784	Q5135		"Inj, tyenne, 1 mg"						20.000%			
0785		"Inj, cyclophosphamd, sandoz"		K		$4.344	.	$0.87	20.000%	$0.87		
0785	J9074		"Inj, cyclophosphamd, sandoz"						20.000%			
0786		"Inj, tofidence, 1 mg"		G		$5.971	.	$1.20	20.000%	$1.20		8% of reference add-on applied
0786	Q5133		"Inj, tofidence, 1 mg"						20.000%			
0798		"Inj, sezaby, 1 mg"		K		$1.056	.	$0.22	20.000%	$0.22		
0798	J2561		"Inj, sezaby, 1 mg"						20.000%			
0800		Leuprolide acetate		K		"$1,670.296"	.	$334.06	18.892%	$315.56		IRA-adjusted coinsurance
0800	J1950		Leuprolide acetate /3.75 mg						18.892%			
0802		Etoposide oral 50 mg		K		$76.456	.	$15.30	20.000%	$15.30		
0802	J8560		Etoposide oral 50 mg						20.000%			
0804		"Capecitabine, oral, 50 mg"		K		$0.065	.	$0.02	20.000%	$0.02		
0804	J8522		"Capecitabine, oral, 50 mg"						20.000%			
0805	J0739		"Hiv prep, inj, cabotegravir"			$6.887			0.000%			
0805		"Hiv prep, inj, cabotegravir"		K			$0.00	$0.00	0.000%	#N/A		
0806		"Hiv prep, ftc/tdf 200/300mg"		K		$1.277	$0.00	$0.00	0.000%	$0.00		
0806	J0750		"Hiv prep, ftc/tdf 200/300mg"						0.000%			
0807		Aldesleukin injection		K		"$5,301.260"	.	"$1,060.26"	20.000%	"$1,060.26"		
0807	J9015		Aldesleukin injection						20.000%			
0808		"Hiv prep, ftc/taf 200/25mg"		K		$71.272	$0.00	$0.00	0.000%	$0.00		
0808	J0751		"Hiv prep, ftc/taf 200/25mg"						0.000%			
0811		"Inj, nypozi, 1 mcg"		G		$0.535	.	$0.11	20.000%	$0.11		
0811	Q5148		"Inj, nypozi 1 mcg"						20.000%			
0812		Carmustine injection		K		$145.597	.	$29.12	20.000%	$29.12		
0812	J9050		Carmustine injection						20.000%			
0813		"Injection, imetelstat, 1 mg"		G		$55.510	.	$11.11	20.000%	$11.11		
0813	J0870		"Injection, imetelstat, 1 mg"						20.000%			
0814		"Inj, magtrace per study dose"		G		"$1,137.959"		$0.00	0.000%	$0.00		
0814	A9697		"Inj, magtrace per study dos"						0.000%			
0815		"Inj, palonosetron (posfrea)"		G		$59.905	.	$11.99	20.000%	$11.99		
0815	J2468		"Inj, palonosetron (posfrea)"						20.000%			
0816		"Inj, tislelizumab-jsgr"		G		$56.279	.	$11.26	20.000%	$11.26		
0816	J9329		"Inj, tislelizumab-jsgr"						20.000%			
0818		"Inj, crovalimab-akkz, 10 mg"		K		$551.512	.	$110.31	20.000%	$110.31		
0818	J1307		"Inj, crovalimab-akkz, 10 mg"						20.000%			
0819		"Inj, alyglo, 500 mg"		K		$138.111	.	$27.63	20.000%	$27.63		
0819	J1552		"Inj, alyglo, 500 mg"						20.000%			
0821		Indigotindisulfonate sod 1mg		G		$9.956	$0.00	$0.00	0.000%	$0.00		
0821	J9220		Indigotindisulfonate sod 1m						0.000%			
0822		"Inj, romiplostim 1 microgram"		K		$10.516	.	$2.11	18.888%	$1.99		IRA-adjusted coinsurance
0822	J2802		"Inj, romiplostim 1 microgra"						18.888%			
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."
0824	J3392		"Inj, exagamglogene autotem"						20.000%			
0825		Nelarabine injection		K		$63.184	.	$12.64	20.000%	$12.64		
0825	J9261		Nelarabine injection						20.000%			
0827		Floxuridine injection		K		"$3,988.333"	.	$797.67	20.000%	$797.67		
0827	J9200		Floxuridine injection						20.000%			
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."
0831	Q2058		Obecbtge autol up to 400 mi						20.000%			
0835		"Datopotamab deruxtecan, 1 mg"		G		$50.378	.	$10.08	20.000%	$10.08		
0835	C9174		"Datopotamab deruxtecan, 1 m"						20.000%			
0837		"Inj, treosulfan, 50 mg"		G		$31.415	.	$6.29	20.000%	$6.29		
0837	C9175		"Inj, treosulfan, 50 mg"						20.000%			
0839		Inj axatilimab-csfr 0.1 mg		G		$54.075	.	$10.82	20.000%	$10.82		
0839	J9038		Inj axatilimab-csfr 0.1 mg						20.000%			
0840		Inj melpha hydroch nos 50 mg		K		$157.102	.	$31.43	20.000%	$31.43		
0840	J9245		Inj melpha hydroch nos 50 m						20.000%			
0841		"Inj, docetaxel (beizray) 1mg"		G		$52.470	.	$10.50	20.000%	$10.50		
0841	J9174		"Inj, docetaxel (beizray) 1m"						20.000%			
0842		"Inj, melphalan (apotex) 1 mg"		G		$64.778	.	$12.96	20.000%	$12.96		
0842	J9249		"Inj, melphalan (apotex) 1 m"						20.000%			
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."
0843	J9266		Pegaspargase injection						19.208%			
0844		Pentostatin injection		K		"$2,673.431"	.	$534.69	17.794%	$475.72		IRA-adjusted coinsurance
0844	J9268		Pentostatin injection						17.794%			
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."
0845	J3391		"Inj, atidarsagene autotemce"						20.000%			
0846		"Inj, eculizumab-aeeb, 2 mg"		G		$41.486	.	$8.30	20.000%	$8.30		
0846	Q5152		"Inj, eculizumab-aeeb, 2 mg"						20.000%			
0847		Inj thiotepa nos 1 mg		K		$12.236	.	$2.45	20.000%	$2.45		
0847	J9342		Inj thiotepa nos 1 mg						20.000%			
0848		Inj nivolumab 2 mg hyaluron		G		$26.736	.	$5.35	20.000%	$5.35		
0848	J9289		Inj nivolumab 2 mg hyaluron						20.000%			
0852		"Inj, eculizumab-aagh, 2 mg"		K		$31.353	.	$6.28	20.000%	$6.28		
0852	Q5151		"Inj, eculizumab-aagh, 2 mg"						20.000%			
0853		Inj zenocutuzumab-zbco 1 mg		G		$32.617	.	$6.53	20.000%	$6.53		
0853	J9382		Inj zenocutuzumab-zbco 1 mg						20.000%			
0854		In111 capromab		K		"$1,545.730"	.	$309.15	20.000%	$309.15		
0854	A9507		In111 capromab						20.000%			
0860		"I131 iodobenguate, dx"		K		$805.900	.	$161.18	20.000%	$161.18		
0860	A9508		"I131 iodobenguate, dx"						20.000%			
0861		"I125 serum albumin, dx"		K		$469.060	.	$93.82	20.000%	$93.82		
0861	A9532		"I125 serum albumin, dx"						20.000%			
0862		Cr51 chromate		K		"$1,717.620"	.	$343.53	20.000%	$343.53		
0862	A9553		Cr51 chromate						20.000%			
0863		"I125 iothalamate, dx"		K		$435.170	.	$87.04	20.000%	$87.04		
0863	A9554		"I125 iothalamate, dx"						20.000%			
0864		Mitoxantrone hydrochl		K		$27.693	.	$5.54	20.000%	$5.54		
0864	J9293		Mitoxantrone hydrochl / 5 m						20.000%			
0865		"Inj, hercessi, 10 mg"		K		$76.181		$15.24	20.000%	$15.24		
0865	Q5146		"Inj, hercessi, 10 mg"						20.000%			
0866		"Inj, sod thiosulfate (hope)"		K		$0.984	.	$0.20	20.000%	$0.20		
0866	J0209		"Inj, sod thiosulfate (hope)"						20.000%			
0870		Inj. calaspargase pegol-mknl		K		$76.527	.	$15.31	20.000%	$15.31		
0870	J9118		Inj. calaspargase pegol-mkn						20.000%			
0871		Inj pemetrexed (bluepoint)		K		$10.000	.	$2.00	20.000%	$2.12		
0871	J9322		Inj pemetrexed (bluepoint)						20.000%			
0872		"Inj. denosumab-bbdz, 1 mg"		K		$27.538	.	$5.51	20.000%	$5.51		
0872	Q5136		"Inj. denosumab-bbdz, 1 mg"						20.000%			
0874		Synvisc or synvisc-one		K		$9.252	.	$1.86	20.000%	$1.86		
0874	J7325		Synvisc or synvisc-one						20.000%			
0875		Euflexxa inj per dose		K		$126.409	.	$25.29	20.000%	$25.29		
0875	J7323		Euflexxa inj per dose						20.000%			
0877		Orthovisc inj per dose		K		$125.299	.	$25.06	20.000%	$25.06		
0877	J7324		Orthovisc inj per dose						20.000%			
0887		Azathioprine parenteral		K		$224.969	.	$45.00	20.000%	$45.00		
0887	J7501		Azathioprine parenteral						20.000%			
0890		Lymphocyte immune globulin		K		"$4,376.290"	.	$875.26	13.028%	$570.15		IRA-adjusted coinsurance
0890	J7504		Lymphocyte immune globulin						13.028%			
0901		Alpha 1 proteinase inhibitor		K		$5.160	.	$1.04	20.000%	$1.04		
0901	J0256		Alpha 1 proteinase inhibito						20.000%			
0902		"Injection,onabotulinumtoxinA"		K		$6.478	.	$1.30	20.000%	$1.30		
0902	J0585		"Injection,onabotulinumtoxin"						20.000%			
0903		Cytomegalovirus imm IV /vial		K		"$1,812.007"	.	$362.41	20.000%	$362.41		
0903	J0850		Cytomegalovirus imm iv /via						20.000%			
0925		Factor viii		K		$1.116	.	$0.23	20.000%	$0.23		
0925	J7190		Factor viii						20.000%			
0927		Factor viii recombinant		K		$1.558	.	$0.32	20.000%	$0.32		
0927	J7192		Factor viii recombinant nos						20.000%			
0928		Factor ix complex		K		$1.656	.	$0.34	20.000%	$0.34		
0928	J7194		Factor ix complex						20.000%			
0929		Anti-inhibitor		K		$2.397	.	$0.48	20.000%	$0.48		
0929	J7198		Anti-inhibitor						20.000%			
0931		Factor IX non-recombinant		K		$1.377	.	$0.28	20.000%	$0.28		
0931	J7193		Factor ix non-recombinant						20.000%			
0932		Factor ix recombinant nos		K		$1.848	.	$0.37	20.000%	$0.37		
0932	J7195		Factor ix recombinant nos						20.000%			
0943		Octagam injection		K		$48.055	.	$9.62	20.000%	$9.62		
0943	J1568		Octagam injection						20.000%			
0944		Gammagard liquid injection		K		$45.129	.	$9.03	20.000%	$9.03		
0944	J1569		Gammagard liquid injection						20.000%			
0946		Hepagam b im injection		K		$65.146	.	$13.03	20.000%	$13.03		
0946	J1571		Hepagam b im injection						20.000%			
0947		Flebogamma injection		K		$55.760	.	$11.16	20.000%	$11.16		
0947	J1572		Flebogamma injection						20.000%			
0948		Gamunex-C/Gammaked		K		$48.345	.	$9.67	20.000%	$9.67		
0948	J1561		Gamunex-c/gammaked						20.000%			
0961		"Albumin (human),5%, 50ml"		K		$10.615	.	$2.13	20.000%	$2.13		
0961	P9041		"Albumin (human),5%, 50ml"						20.000%			
0963		"Albumin (human), 5%, 250 ml"		K		$53.077	.	$10.62	20.000%	$10.62		
0963	P9045		"Albumin (human), 5%, 250 ml"						20.000%			
0964		"Albumin (human), 25%, 20 ml"		K		$21.231	.	$4.25	20.000%	$4.25		
0964	P9046		"Albumin (human), 25%, 20 ml"						20.000%			
0965		"Albumin (human), 25%, 50ml"		K		$53.077	.	$10.62	20.000%	$10.62		
0965	P9047		"Albumin (human), 25%, 50ml"						20.000%			
1064		"I131 iodide cap, rx"		K		$23.130	.	$4.63	20.000%	$4.63		
1064	A9517		"I131 iodide cap, rx"						20.000%			
1138		"Hepagam b intravenous, inj"		K		$65.146	.	$13.03	20.000%	$13.03		
1138	J1573		"Hepagam b intravenous, inj"						20.000%			
1139		Protein c concentrate		K		$15.024	.	$3.01	20.000%	$3.01		
1139	J2724		Protein c concentrate						20.000%			
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."
1142	J9226		Supprelin la implant						20.000%			
1150		"I131 iodide sol, rx"		K		$20.880	.	$4.18	20.000%	$4.18		
1150	A9530		"I131 iodide sol, rx"						20.000%			
1168		"Inj, temsirolimus"		K		$30.317	.	$6.07	20.000%	$6.07		
1168	J9330		Temsirolimus injection						20.000%			
1178		Busulfan injection		K		$1.456	.	$0.30	20.000%	$0.30		
1178	J0594		Busulfan injection						20.000%			
1203		Verteporfin injection		K		$11.519	.	$2.31	20.000%	$2.31		
1203	J3396		Verteporfin injection						20.000%			
1207		"Octreotide injection, depot"		K		$204.592	.	$40.92	20.000%	$40.92		
1207	J2353		"Octreotide injection, depot"						20.000%			
1213		Antihemophilic viii/vwf comp		K		$1.198	.	$0.24	20.000%	$0.24		
1213	J7186		Antihemophilic viii/vwf com						20.000%			
1214		Inj IVIG privigen 500 mg		K		$49.179	.	$9.84	20.000%	$9.84		
1214	J1459		Inj ivig privigen 500 mg						20.000%			
1232		Mitomycin injection		K		$25.602	.	$5.13	20.000%	$5.13		
1232	J9280		Mitomycin injection						20.000%			
1235		Valrubicin injection		K		"$1,444.550"	.	$288.91	20.000%	$288.91		
1235	J9357		Valrubicin injection						20.000%			
1237		Inj iron dextran		K		$17.233	.	$3.45	20.000%	$3.45		
1237	J1750		Inj iron dextran						20.000%			
1238		Topotecan oral		K		$124.900	.	$24.98	20.000%	$24.98		
1238	J8705		Topotecan oral						20.000%			
1253		Triamcinolone a inj prs-free		G		$25.016	.	$5.01	20.000%	$5.01		
1253	J3300		Triamcinolone a inj prs-fre						20.000%			
1263		Antithrombin iii injection		K		$3.943	.	$0.79	20.000%	$0.79		
1263	J7197		Antithrombin iii injection						20.000%			
1268		Xyntha inj		K		$1.490	.	$0.30	20.000%	$0.30		
1268	J7185		Xyntha inj						20.000%			
1274		Edetate calcium disodium inj		K		"$6,460.026"	.	"$1,292.01"	20.000%	"$1,292.01"		
1274	J0600		Edetate calcium disodium in						20.000%			
1281		Bevacizumab injection		K		$1.818	.	$0.37	20.000%	$0.37		
1281	C9257		Bevacizumab injection						20.000%			
1289		AbobotulinumtoxinA		K		$9.044	.	$1.81	20.000%	$1.81		
1289	J0586		Abobotulinumtoxina						20.000%			
1295		Sm 153 lexidronam		K		"$4,314.910"	.	$862.99	20.000%	$862.99		
1295	A9604		Sm 153 lexidronam						20.000%			
1296		Degarelix injection		K		$4.357	.	$0.88	20.000%	$0.88		
1296	J9155		Degarelix injection						20.000%			
1297		"Ferumoxytol, non-esrd"		K		$0.328	.	$0.07	20.000%	$0.07		
1297	Q0138		"Ferumoxytol, non-esrd"						20.000%			
1311		Canakinumab injection		K		$136.557	.	$27.32	20.000%	$27.32		
1311	J0638		Canakinumab injection						20.000%			
1312		Hizentra injection		K		$13.644	.	$2.73	19.870%	$2.72		IRA-adjusted coinsurance
1312	J1559		Hizentra injection						19.870%			
1327		Imiglucerase injection		K		$43.141	.	$8.63	20.000%	$8.63		
1327	J1786		Imuglucerase injection						20.000%			
1340		"Collagenase, clost hist inj"		K		$73.375	.	$14.68	17.894%	$13.13		IRA-adjusted coinsurance
1340	J0775		"Collagenase, clost hist inj"						17.894%			
1352		Wilate injection		K		$1.279	.	$0.26	20.000%	$0.26		
1352	J7183		Wilate injection						20.000%			
1353		Belimumab injection		K		$54.968	.	$11.00	20.000%	$11.00		
1353	J0490		Belimumab injection						20.000%			
1413		Lumizyme injection		K		$201.566	.	$40.32	20.000%	$40.32		
1413	J0221		Lumizyme injection						20.000%			
1415		Glassia injection		K		$5.448	.	$1.09	20.000%	$1.09		
1415	J0257		Glassia injection						20.000%			
1416		Factor xiii anti-hem factor		K		$10.477	.	$2.10	20.000%	$2.10		
1416	J7180		Factor xiii anti-hem factor						20.000%			
1417		Gel-one		K		$538.480	.	$107.70	20.000%	$107.70		
1417	J7326		Gel-one						20.000%			
1420		Aflibercept injection		K		$795.861	.	$159.18	20.000%	$159.18		
1420	J0178		Aflibercept injection						20.000%			
1421		Imported lipodox inj		K		$528.860	.	$105.78	20.000%	$105.78		
1421	Q2049		Imported lipodox inj						20.000%			
1426		Eribulin mesylate injection		K		$118.749	.	$23.75	20.000%	$23.75		
1426	J9179		Eribulin mesylate injection						20.000%			
1441		Dom nonHEU Tc99m add-on/dose		K		$10.000	.	$2.00	20.000%	$2.00		
1441	C917X		Dom nonHEU Tc99m add-on/dos						20.000%			
1446		Visualization adjunct		K		$7.584	.	$1.52	20.000%	$1.52		
1446	Q9968		Visualization adjunct						20.000%			
1458		Phentolaine mesylate inj		K		$449.299	.	$89.86	20.000%	$89.86		
1458	J2760		Phentolaine mesylate inj						20.000%			
1464		Factor viii (porcine)		K		$190.000	.	$38.00	20.000%	$38.00		
1464	J7191		Factor viii (porcine)						20.000%			
1467		Factor ix recombinan rixubis		K		$1.632	.	$0.33	20.000%	$0.33		
1467	J7200		Factor ix recombinan rixubi						20.000%			
1468		"Inj, abilify maintena, 1 mg"		K		$7.033	.	$1.41	20.000%	$1.41		
1468	J0401		"Inj, abilify maintena, 1 mg"						20.000%			
1469		Inj filgrastim excl biosimil		K		$0.983	.	$0.20	20.000%	$0.20		
1469	J1442		Inj filgrastim excl biosimi						20.000%			
1471		"Injection, Pertuzumab, 1 mg"		K		$16.229	.	$3.25	20.000%	$3.25		
1471	J9306		"Injection, pertuzumab, 1 mg"						20.000%			
1474		Certolizumab pegol inj 1mg		K		$3.984	.	$0.80	20.000%	$0.80		
1474	J0717		Certolizumab pegol inj 1mg						20.000%			
1475		Golimumab for iv use 1mg		K		$10.769	.	$2.16	20.000%	$2.16		
1475	J1602		Golimumab for iv use 1mg						20.000%			
1476		Obinutuzumab inj		K		$75.212	.	$15.05	20.000%	$15.05		
1476	J9301		Obinutuzumab inj						20.000%			
1478		Inj human fibrinogen con nos		K		$1.484	.	$0.30	20.000%	$0.30		
1478	J7178		Inj human fibrinogen con no						20.000%			
1480		"Elosulfase alfa, injection"		K		$293.935	.	$58.79	20.000%	$58.79		
1480	J1322		"Elosulfase alfa, injection"						20.000%			
1482		"Darbepoetin alfa, esrd use"		K		$2.918	.	$0.59	20.000%	$0.59		
1482	J0882		"Darbepoetin alfa, esrd use"						20.000%			
1485		"Ferumoxytol, esrd use"		K		$0.328	.	$0.07	20.000%	$0.07		
1485	Q0139		"Ferumoxytol, esrd use"						20.000%			
1486		Factor ix fc fusion recomb		K		$3.545	.	$0.71	20.000%	$0.71		
1486	J7201		Factor ix alprolix recomb						20.000%			
1488		"Injection, ramucirumab"		K		$73.368	.	$14.68	20.000%	$14.68		
1488	J9308		"Injection, ramucirumab"						20.000%			
1489		Inj vedolizumab iv 1 mg		K		$21.162	.	$4.24	20.000%	$4.24		
1489	J3380		Inj vedolizumab iv 1 mg						20.000%			
1490		Inj pembrolizumab		K		$59.349	.	$11.87	20.000%	$11.87		
1490	J9271		Inj pembrolizumab						20.000%			
1505		New Technology - Level 5 ($301 - $400)		S		$350.50	.	$70.10	0.000%			
1505	0693T		Compre ful bdy 3d mtn alys						0.000%			
1505	0733T		Rem r-t mtn nrehab ther spl						0.000%			
1506		New Technology - Level 6 ($401 - $500)		S		$450.50	.	$90.10	0.000%			
1506	M0249		Adm tocilizu covid-19 1st				$0.00	$0.00	0.000%	$0.00		
1506	M0250		Adm tocilizu covid-19 2nd				$0.00	$0.00	0.000%	$0.00		
1506	M0224		Pemivibart infusion						0.000%			
1508		New Technology - Level 8 ($601 - $700)		S		$650.50	.	$130.10	0.000%			
1508	0721T		Quan ct tiss charac w/o ct						0.000%			
1508	0722T		Quan ct tiss charac w/ct						0.000%			
1508	0877T		Augmnt alys ch ct ild w/o c						0.000%			
1508	0878T		Augmnt alys ch ct ild w/ct						0.000%			
1508	G0138		Iv cipaglucosidase alfa-atg						0.000%			
1511		New Technology - Level 11 ($901 - $1000)		S		$950.50	.	$190.10	0.000%			
1511	0648T		Quan mr tis wo mri 1orgn						0.000%			
1511	0649T		Quan mr tiss w/mri 1orgn						0.000%			
1511	0697T		Quan mr tis wo mri mlt orgn						0.000%			
1511	0698T		Quan mr tiss w/mri mlt orgn						0.000%			
1511	0723T		Qmrcp w/o dx mri sm anat se						0.000%			
1511	0724T		Qmrcp w/dx mri same anatomy						0.000%			
1511	0889T		Prsnlz trgt dvl arhfcmrigtb						0.000%			
1511	75XX6		Quan&char c athrosclrtc pla						0.000%			
1512		New Technology - Level 12 ($1001 - $1100)		S		"$1,050.50"	.	$210.10	0.000%			
1512	G2082		Visit esketamine 56m or les						0.000%			
1514		New Technology - Level 14 ($1201- $1300)		S		"$1,250.50"	.	$250.10	0.000%			
1514	G0562		Complex simulation w/pet-ct						0.000%			
1517		New Technology - Level 17 ($1501-$1600)		S		"$1,550.50"	.	$310.10	0.000%			
1517	9XX01		Mchnl sclp cool meas fitg						0.000%			
1517	G2083		"Visit esketamine, > 56m"						0.000%			
1519		New Technology - Level 19 ($1701-$1800)		S		"$1,750.50"	.	$350.10	0.000%			
1519	78432		Myocrd img pet 2rtracer						0.000%			
1521		New Technology - Level 21 ($1901-$2000)		S		"$1,950.50"	.	$390.10	0.000%			
1521	0890T		Arhfcmrigtbs 1st tx day						0.000%			
1522		New Technology - Level 22 ($2001-$2500)		S		"$2,250.50"	.	$450.10	0.000%			
1522	78431		Myocrd img pet rst&strs ct						0.000%			
1522	78433		Myocrd img pet 2rtracer ct						0.000%			
1522	0891T		Arhfcmrigtbs sbsq tx day						0.000%			
1525		New Technology - Level 25 ($3501-$4000)		S		"$3,750.50"	.	$750.10	0.000%			
1525	0892T		Arhfcmrigtbs sbsq per tx da						0.000%			
1525	G0563		Sbrt w/positron emission de						0.000%			
1532		New Technology - Level 32 ($7001-$7500)		S		"$7,250.50"	.	"$1,450.10"	0.000%			
1532	15013		Prepj skn cll ssp agrft 1st						0.000%			
1532	C8002		"Prep skin cell susp, automt"						0.000%			
1534		New Technology - Level 34 ($8001-$8500)		S		"$8,250.50"	.	"$1,650.10"	0.000%			
1534	C9780		Insert cv cath inf & sup ap						0.000%			
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."
1537	C9792		Blind/nonblind trans atrial						0.000%			
1551		New Technology - Level 14 ($1201- $1300)		T		"$1,250.50"	.	$250.10	0.000%			
1551	C9791		Mri hyperpolarized xenon129						0.000%			
1553		New Technology - Level 16 ($1401 - $1500)		T		"$1,450.50"	.	$290.10	0.000%			
1553	C9789		Instill pharm renal pelvis						0.000%			
1561		New Technology - Level 24 ($3001-$3500)		T		"$3,250.50"	.	$650.10	0.000%			
1561	0446T		Insj impltbl glucose sensor						0.000%			
1561	0448T		Remvl insj impltbl gluc sen						0.000%			
1563		New Technology - Level 26 ($4001-$4500)		T		"$4,250.50"	.	$850.10	0.000%			
1563	0810T		Subrta njx rx agt w/vtrc						0.000%			
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."
1576	0888T		Histotripsy mal renal tissu						0.000%			
1576	C8005		Pef bronch ablt 3d nav ebus						0.000%			
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."
1577	0956T		Prt crn ch cr&tun elt s-scl						0.000%			
1577	0960T		Rpl s-sclp eltr ra rcvr&tlm						0.000%			
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."
1579	0620T		Evasc ven artlz tibl/prnl v						0.000%			
1579	0686T		Histotripsy mal hepatcel ti						0.000%			
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."
1580	33276		Insj phrnc nrv stim sys						0.000%			
1580	64XX5		1st opn implt bat modulj sy						0.000%			
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."
1590	C9782		Blind myocar trpl bon marro						0.000%			
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."
1592	C9760		Non-blind interatrial shunt						0.000%			
1609		"Rho(D) immune globulin h, sd"		K		$32.507	.	$6.51	20.000%	$6.51		
1609	J2792		"Rho(d) immune globulin h, s"						20.000%			
1613		Trastuzumab injection		K		$75.692	.	$15.14	20.000%	$15.14		
1613	J9355		Inj trastuzumab excl biosim						20.000%			
1630		"Hep b ig, im"		K		$143.215	.	$28.65	20.000%	$28.65		
1630	90371		Hep b ig im						20.000%			
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."
1643	A9543		"Y90 ibritumomab, rx"						20.000%			
1656		Factor viii fc fusion recomb		K		$2.320	.	$0.47	20.000%	$0.47		
1656	J7205		Factor viii fc fusion recom						20.000%			
1658		"Injection, belinostat, 10mg"		K		$50.919	.	$10.19	20.000%	$10.19		
1658	J9032		"Injection, belinostat, 10mg"						20.000%			
1660		"Injection, oritavancin"		K		$28.525	.	$5.71	20.000%	$5.71		
1660	J2407		"Injection, oritavancin"						20.000%			
1662		Inj tedizolid phosphate		K		$1.801	.	$0.37	20.000%	$0.37		
1662	J3090		Inj tedizolid phosphate						20.000%			
1664		Florbetapir f18		K		"$1,881.870"	.	$376.38	20.000%	$376.38		
1664	A9586		Florbetapir f18						20.000%			
1670		Tetanus immune globulin inj		K		$575.760	.	$115.16	20.000%	$115.16		
1670	J1670		Tetanus immune globulin inj						20.000%			
1675		P32 na phosphate		K		$179.120	.	$35.83	20.000%	$35.83		
1675	A9563		P32 na phosphate						20.000%			
1683		Basiliximab		K		"$4,687.658"	.	$937.54	20.000%	$937.54		
1683	J0480		Basiliximab						20.000%			
1685		"Darbepoetin alfa, non-esrd"		K		$2.918	.	$0.59	20.000%	$0.59		
1685	J0881		"Darbepoetin alfa, non-esrd"						20.000%			
1686		"Epoetin alfa, non-esrd"		K		$7.080	.	$1.42	20.000%	$1.42		
1686	J0885		"Epoetin alfa, non-esrd"						20.000%			
1688		Ethanolamine oleate		K		$497.700	.	$99.54	20.000%	$99.54		
1688	J1430		Ethanolamine oleate 100 mg						20.000%			
1689		Fomepizole		K		$6.155	.	$1.24	20.000%	$1.24		
1689	J1451		"Fomepizole, 15 mg"						20.000%			
1690		Hemin		K		$33.073	.	$6.62	19.297%	$6.39		IRA-adjusted coinsurance
1690	J1640		"Hemin, 1 mg"						19.297%			
1696		Palifermin injection		K		$33.991	.	$6.80	16.991%	$5.78		IRA-adjusted coinsurance
1696	J2425		Palifermin injection						16.991%			
1701		Treprostinil injection		K		$56.834	.	$11.37	20.000%	$11.37		
1701	J3285		Treprostinil injection						20.000%			
1704		"Humate-P, inj"		K		$1.446	.	$0.29	20.000%	$0.29		
1704	J7187		"Humate-p, inj"						20.000%			
1705		Factor viia recomb novoseven		K		$2.526	.	$0.51	20.000%	$0.51		
1705	J7189		Factor viia recomb novoseve						20.000%			
1710		Clofarabine injection		K		$16.006	.	$3.21	20.000%	$3.21		
1710	J9027		Clofarabine injection						20.000%			
1712		Paclitaxel protein bound		K		$13.064	.	$2.62	20.000%	$2.62		
1712	J9264		Paclitaxel protein bound						20.000%			
1744		Zidovudine		K		$1.513	.	$0.31	20.000%	$0.31		
1744	J3485		Zidovudine						20.000%			
1745		Radium ra223 dichloride ther		K		$169.057	.	$33.82	20.000%	$33.82		
1745	A9606		Radium ra223 dichloride the						20.000%			
1746		Factor xiii recomb a-subunit		K		$17.336	.	$3.47	20.000%	$3.47		
1746	J7181		Factor xiii recomb a-subuni						20.000%			
1747		Monovisc inj per dose		K		$663.641	.	$132.73	20.000%	$132.73		
1747	J7327		Monovisc inj per dose						20.000%			
1748		Inj tbo filgrastim 1 microg		K		$0.366	.	$0.08	20.000%	$0.08		
1748	J1447		Inj tbo filgrastim 1 microg						20.000%			
1809		"Injection, alemtuzumab"		K		"$2,441.493"	.	$488.30	20.000%	$488.30		
1809	J0202		"Injection, alemtuzumab"						20.000%			
1822		"Injection, zarxio"		K		$0.333	.	$0.07	20.000%	$0.07		8% of reference add-on applied
1822	Q5101		"Injection, zarxio"						20.000%			
1823		"Injection, dalbavancin"		K		$15.567	.	$3.12	20.000%	$3.12		
1823	J0875		"Injection, dalbavancin"						20.000%			
1824		Ceftaroline fosamil inj		K		$3.991	.	$0.80	20.000%	$0.80		
1824	J0712		Ceftaroline fosamil inj						20.000%			
1825		Ceftazidime and avibactam		K		$100.496	.	$20.10	20.000%	$20.10		
1825	J0714		Ceftazidime and avibactam						20.000%			
1826		Hyqvia 100mg immuneglobulin		K		$17.565	.	$3.52	20.000%	$3.52		
1826	J1575		Hyqvia 100mg immuneglobulin						20.000%			
1827		Factor viii recomb obizur		K		$3.229	.	$0.65	20.000%	$0.65		
1827	J7188		Factor viii recomb obizur						20.000%			
1829		Penicillin g benzathine inj		K		$26.984	.	$5.40	13.590%	$3.67		IRA-adjusted coinsurance
1829	J0561		Penicillin g benzathine inj						13.590%			
1831		Chloramphenicol sodium injec		K		$51.569	.	$10.32	20.000%	$10.32		
1831	J0720		Chloramphenicol sodium inje						20.000%			
1832		Dimethyl sulfoxide 50% 50 ml		K		$714.724	.	$142.95	20.000%	$142.95		
1832	J1212		Dimethyl sulfoxide 50% 50 m						20.000%			
1844		Factor viii pegylated recomb		K		$2.102	.	$0.43	20.000%	$0.43		
1844	J7207		Factor viii pegylated recom						20.000%			
1846		Factor viii nuwiq recomb 1iu		K		$1.193	.	$0.24	20.000%	$0.24		
1846	J7209		Factor viii nuwiq recomb 1i						20.000%			
1847		"Injection, inflectra"		K		$15.912	.	$3.19	20.000%	$3.19		8% of reference add-on applied
1847	Q5103		"Injection, inflectra"						20.000%			
1848		Artiss fibrin sealant		K		$133.135	.	$26.63	20.000%	$26.63		
1848	C9250		Artiss fibrin sealant						20.000%			
1850		Gamma globulin 1 cc inj		K		$48.885	.	$9.78	20.000%	$9.78		
1850	J1460		Gamma globulin 1 cc inj						20.000%			
1851		Gamma globulin > 10 cc inj		K		$488.853	.	$97.78	20.000%	$97.78		
1851	J1560		Gamma globulin > 10 cc inj						20.000%			
1853		Minocycline hydrochloride		K		$2.592	.	$0.52	18.632%	$0.49		IRA-adjusted coinsurance
1853	J2265		Minocycline hydrochloride						18.632%			
1854		Pentobarbital sodium inj		K		$64.144	.	$12.83	20.000%	$12.83		
1854	J2515		Pentobarbital sodium inj						20.000%			
1856		Factor viii recomb novoeight		K		$1.397	.	$0.28	20.000%	$0.28		
1856	J7182		Factor viii recomb novoeigh						20.000%			
1857		"Inj, factor x, (human), 1iu"		K		$9.533	.	$1.91	20.000%	$1.91		
1857	J7175		"Inj, factor x, (human), 1iu"						20.000%			
1859		Argatroban nonesrd use 1mg		K		$0.950	.	$0.19	20.000%	$0.19		
1859	J0883		Argatroban nonesrd use 1mg						20.000%			
1861		"Inj., bendeka 1 mg"		K		$13.581	.	$2.72	20.000%	$2.72		
1861	J9034		"Inj., bendeka 1 mg"						20.000%			
2041		"Cath, bladed, vasc prep"		H								
2041	C1600		"Cath, bladed, vasc prep"									
2042		"Endo, single, pulmonary"		H								
2042	C1601		"Endo, single, pulmonary"									
2043		Orth/matrx/bn fill drug-elut		H								
2043	C1602		Orth/matrx/bn fill drug-elu									
2044		"Ret dev, laser, ivc filter"		H								
2044	C1603		"Ret dev, laser, ivc filter"									
2045		"Grft, trnsmurl/trnsvens byps"		H								
2045	C1604		"Grft, trnsmurl/trnsvens byp"									
2046		"Pmkr, dual, leadless"		H								
2046	C1605		"Pmkr, dual, leadless"									
2047		"Adapter, us to endoscope"		H								
2047	C1606		"Adapter, us to endoscope"									
2048		Pump elastomc non-opioid dev		H1								
2048	C9804		Pump elastomc non-opioid de									
2049		"Suprt dev, a-v fistula, imp"		H								
2049	C8000		"Suprt dev, a-v fistula, imp"									
2050		Cath coronary drug-delivery		H								
2050	C9610		Cath coronary drug-delivery									
2051		Cath renal denerv radiofreq		H								
2051	C1735		Cath renal denerv radiofreq									
2052		Cath renal denerv ultrasnd		H								
2052	C1736		Cath renal denerv ultrasnd									
2053		Si&pelvis fusn&fixn dev		H								
2053	C1737		Si&pelvis fusn&fixn dev									
2054		Power endo us-guid bx dev		H								
2054	C1738		Power endo us-guid bx dev									
2055		"Tissue marker, detectable"		H								
2055	C1739		"Tissue marker, detectable"									
2056		Pump perist non-opioid dev		H1								
2056	C9806		Pump perist non-opioid dev									
2057		Nerve stim non-opioid dev		H1								
2057	C9807		Nerve stim non-opioid dev									
2058		Cryo probe non-opioid dev		H1								
2058	C9808		Cryo probe non-opioid dev									
2059		Cryo needle non-opioid dev		H1								
2059	C9809		Cryo needle non-opioid dev									
2060		Cold therapy non-opioid dev		H1								
2060	C9XX0		Cold therapy non-opioid dev									
2062		"Inj zanidatamab-hrii, 2 mg"		G		$25.122	.	$5.03	20.000%	$5.03		
2062	J9276		"Inj zanidatamab-hrii, 2 mg"						20.000%			
2064		"Inj marstacim-hncq, 0.5 mg"		G		$52.788	.	$10.56	20.000%	$10.56		
2064	J7172		"Inj marstacim-hncq, 0.5 mg"						20.000%			
2065		"Flurpiridaz f18, diag, 1 mci"		G		$515.000	.	$103.00	20.000%	$103.00		
2065	A9611		"Flurpiridaz f18, diag, 1 mc"						20.000%			
2066		Inj bortezomib boruzu 0.1 mg		G		$26.265	.	$5.26	20.000%	$5.26		
2066	J9054		Inj bortezomib boruzu 0.1 m						20.000%			
2067		Afamitresgene autoleucel		G		"$770,620.000"	.	"$154,124.00"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
2067	Q2057		Afamitresgene autoleucel						20.000%			
2068		"Inj, aflibercept-ayyh, 1 mg"		G		$795.861	.	$159.18	20.000%	$159.18		
2068	Q5147		"Inj, aflibercept-ayyh, 1 mg"						20.000%			
2069		"Inj, testosterone, azmiro"		K		$1.288	.	$0.26	20.000%	$0.26		
2069	J1072		"Inj, testosterone, azmiro"						20.000%			
2070		"Inj, eculizumab, 2 mg"		K		$44.809	.	$8.97	20.000%	$8.97		
2070	J1299		"Inj, eculizumab, 2 mg"						20.000%			
2071		Inj ocrelizumab 1mg hya-ocsq		K		$45.187	.	$9.04	20.000%	$9.04		
2071	J2351		Inj ocrelizumab 1mg hya-ocs						20.000%			
2072		"Inj, erzofri, 1 mg"		K		$17.150	.	$3.43	20.000%	$3.43		
2072	J2428		"Inj, erzofri, 1 mg"						20.000%			
2073		Inj atezolizumb 5mg hya-tqjs		K		$30.876	.	$6.18	20.000%	$6.18		
2073	J9024		Inj atezolizumb 5mg hya-tqj						20.000%			
2075		Inj acetaminoph 10mg/ibu 3mg		G		$0.218	$0.00	$0.00	0.000%	$0.00		
2075	J0138		Inj acetaminoph 10mg/ibu 3m						0.000%			
2076		"Inj, pemetrexed dipotassium"		G		$81.370	.	$16.28	20.000%	$16.28		
2076	J9292		"Inj, pemetrexed dipotassium"						20.000%			
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."
2616	C2616		"Brachytx, non-str,yttrium-9"						0.000%			
2632		Iodine I-125 sodium iodide		U	4.3733	$401.24	.	$80.25	0.000%			
2632	A9527		Iodine i-125 sodium iodide						0.000%			
2634		"Brachytx, non-str, HA, I-125"		U	2.0301	$186.26	.	$37.26	0.000%			
2634	C2634		"Brachytx, non-str, ha, i-12"						0.000%			
2635		"Brachytx, non-str, HA, P-103"		U	1.1747	$107.78	.	$21.56	0.000%			
2635	C2635		"Brachytx, non-str, ha, p-10"						0.000%			
2636		"Brachy linear, non-str,P-103"		U	0.9669	$88.71	.	$17.75	0.000%			
2636	C2636		"Brachy linear, non-str,p-10"						0.000%			
2638		"Brachytx, stranded, I-125"		U	0.381	$34.96	.	$7.00	0.000%			
2638	C2638		"Brachytx, stranded, i-125"						0.000%			
2639		"Brachytx, non-stranded,I-125"		U	0.4096	$37.58	.	$7.52	0.000%			
2639	C2639		"Brachytx, non-stranded,i-12"						0.000%			
2640		"Brachytx, stranded, P-103"		U	0.9735	$89.32	.	$17.87	0.000%			
2640	C2640		"Brachytx, stranded, p-103"						0.000%			
2641		"Brachytx, non-stranded,P-103"		U	0.7561	$69.37	.	$13.88	0.000%			
2641	C2641		"Brachytx, non-stranded,p-10"						0.000%			
2642		"Brachytx, stranded, C-131"		U	1.2853	$117.92	.	$23.59	0.000%			
2642	C2642		"Brachytx, stranded, c-131"						0.000%			
2643		"Brachytx, non-stranded,C-131"		U	1.0907	$100.07	.	$20.02	0.000%			
2643	C2643		"Brachytx, non-stranded,c-13"						0.000%			
2645		"Brachytx, non-str, Gold-198"		U	5.2421	$480.95	.	$96.19	0.000%			
2645	C1716		"Brachytx, non-str, gold-198"						0.000%			
2646		"Brachytx, non-str, HDR Ir-192"		U	3.9045	$358.23	.	$71.65	0.000%			
2646	C1717		"Brachytx, non-str,hdr ir-19"						0.000%			
2647		"Brachytx, NS, Non-HDRIr-192"		U	9.8273	$901.63	.	$180.33	0.000%			
2647	C1719		"Brachytx, ns, non-hdrir-192"						0.000%			
2648		"Brachytx planar, p-103"		U	0.0511	$4.69	.	$0.94	0.000%			
2648	C2645		"Brachytx planar, p-103"						0.000%			
2698		"Brachytx, stranded, NOS"		U	0.381	$34.96	.	$7.00	0.000%			
2698	C2698		"Brachytx, stranded, nos"						0.000%			
2699		"Brachytx, non-stranded, NOS"		U	0.4096	$37.58	.	$7.52	0.000%			
2699	C2699		"Brachytx, non-stranded, nos"						0.000%			
2731		"Immune globulin, powder"		K		$81.011	.	$16.21	20.000%	$16.21		
2731	J1566		"Immune globulin, powder"						20.000%			
5012		Clinic Visits and Related Services		V	1.4624	$134.17	.	$26.84	0.000%			
5012	G0402		Initial preventive exam				$0.00	$0.00	0.000%	$0.00		
5012	92002		Intrm oph exam new patient						0.000%			
5012	92004		Compre oph exam new pt 1/>						0.000%			
5012	92012		Intrm oph exam est patient						0.000%			
5012	92014		Compre oph exam est pt 1/>						0.000%			
5012	95250		Cont gluc mntr phys/qhp eqp						0.000%			
5012	98975		Rem ther mntr 1st set-up&ed						0.000%			
5012	99453		Rem mntr physiol param setu						0.000%			
5012	99460		Init nb em per day hosp						0.000%			
5012	99463		Same day nb discharge						0.000%			
5012	99495		Transj care mgmt mod f2f 14						0.000%			
5012	99496		Transj care mgmt high f2f 7						0.000%			
5012	0811T		Rem mlt day uroflow setup						0.000%			
5012	0982T		Rem mntr impl ivc snr set-u						0.000%			
5012	D0120		Periodic oral evaluation						0.000%			
5012	D0140		Limit oral eval problm focu						0.000%			
5012	D0150		Comprehensve oral evaluatio						0.000%			
5012	D0160		Extensv oral eval prob focu						0.000%			
5012	D0170		"Re-eval,est pt,problem focu"						0.000%			
5012	D0171		Re-eval post-op visit						0.000%			
5012	D0180		Comp periodontal evaluation						0.000%			
5012	D0191		Assessment of a patient						0.000%			
5012	D1110		Dental prophylaxis adult						0.000%			
5012	D4921		Gingival irrigation per qua						0.000%			
5012	G0245		Initial foot exam pt lops						0.000%			
5012	G0246		Followup eval of foot pt lo						0.000%			
5012	G0248		Demonstrate use home inr mo						0.000%			
5012	G0249		Provide inr test mater/equi						0.000%			
5012	G0463		Hospital outpt clinic visit						0.000%			
5012	G0552		Supply of digital device						0.000%			
5012	G0553		Monthly tx for dmht 20mins						0.000%			
5012	X465T		Rem mntr s-scl eeg sys setu						0.000%			
5021		Level 1 Type A ED Visits		V	0.9614	$88.21	.	$17.65	0.000%			
5021	99281		Emr dpt vst mayx req phy/qh						0.000%			
5022		Level 2 Type A ED Visits		V	1.7539	$160.92	.	$32.19	0.000%			
5022	99282		Emergency dept visit sf mdm						0.000%			
5023		Level 3 Type A ED Visits		V	3.1121	$285.53	.	$57.11	0.000%			
5023	99283		Emergency dept visit low md						0.000%			
5024		Level 4 Type A ED Visits		V	4.773	$437.91	.	$87.59	0.000%			
5024	90945		Dialysis one evaluation						0.000%			
5024	99284		Emergency dept visit mod md						0.000%			
5024	G0175		"Opps service,sched team con"						0.000%			
5025		Level 5 Type A ED Visits		V	6.8477	$628.26	.	$125.66	0.000%			
5025	99285		Emergency dept visit hi mdm						0.000%			
5025	G0379		Direct refer hospital obser						0.000%			
5031		Level 1 Type B ED Visits		V	0.8678	$79.62	.	$15.93	0.000%			
5031	G0380		Lev 1 hosp type b ed visit						0.000%			
5032		Level 2 Type B ED Visits		V	1.1278	$103.47	.	$20.70	0.000%			
5032	G0381		Lev 2 hosp type b ed visit						0.000%			
5033		Level 3 Type B ED Visits		V	2.0804	$190.87	.	$38.18	0.000%			
5033	G0382		Lev 3 hosp type b ed visit						0.000%			
5034		Level 4 Type B ED Visits		V	3.162	$290.10	.	$58.02	0.000%			
5034	G0383		Lev 4 hosp type b ed visit						0.000%			
5035		Level 5 Type B ED Visits		V	4.6553	$427.11	.	$85.43	0.000%			
5035	G0384		Lev 5 hosp type b ed visit						0.000%			
5041		Critical Care		S	9.5018	$871.76	.	$174.36	0.000%			
5041	99291		Critical care first hour						0.000%			
5045		Trauma Response with Critical Care		S	15.0186	"$1,377.91"	.	$275.59	0.000%			
5045	G0390		Trauma respons w/hosp criti						0.000%			
5051		Level 1 Skin Procedures		T	2.2201	$203.69	.	$40.74	0.000%			
5051	10040		Extraction						0.000%			
5051	10060		I&d abscess simple/single						0.000%			
5051	11055		Paring/cutg b9 hyprker les						0.000%			
5051	11056		Parng/cutg b9 hyprkr les 2-						0.000%			
5051	11057		Parng/cutg b9 hyprkr les >4						0.000%			
5051	11200		Rmvl skin tags up to&inc 15						0.000%			
5051	11301		Shave skin lesion 0.6-1.0 c						0.000%			
5051	11302		Shave skin lesion 1.1-2.0 c						0.000%			
5051	11305		Shave skin lesion 0.5 cm/<						0.000%			
5051	11306		Shave skin lesion 0.6-1.0 c						0.000%			
5051	11307		Shave skin lesion 1.1-2.0 c						0.000%			
5051	11310		Shave skin lesion 0.5 cm/<						0.000%			
5051	11311		Shave skin lesion 0.6-1.0 c						0.000%			
5051	11730		Removal of nail plate						0.000%			
5051	11900		Inject skin lesions </w 7						0.000%			
5051	11901		Inject skin lesions >7						0.000%			
5051	11950		Tx contour defects 1 cc/<						0.000%			
5051	12001		Rpr s/n/ax/gen/trnk 2.5cm/<						0.000%			
5051	12002		Rpr s/n/ax/gen/trnk2.6-7.5c						0.000%			
5051	12004		Rpr s/n/ax/gen/trk7.6-12.5c						0.000%			
5051	12007		Rpr s/n/ax/gen/trnk >30.0 c						0.000%			
5051	12011		Rpr f/e/e/n/l/m 2.5 cm/<						0.000%			
5051	12013		Rpr f/e/e/n/l/m 2.6-5.0 cm						0.000%			
5051	12014		Rpr f/e/e/n/l/m 5.1-7.5 cm						0.000%			
5051	12015		Rpr f/e/e/n/l/m 7.6-12.5 cm						0.000%			
5051	12018		Rpr f/e/e/n/l/m >30.0 cm						0.000%			
5051	15786		Abrasion lesion single						0.000%			
5051	16000		Initial treatment of burn(s						0.000%			
5051	16020		Dress/debrid p-thick burn s						0.000%			
5051	16025		Dress/debrid p-thick burn m						0.000%			
5051	17000		Destruct premalg lesion						0.000%			
5051	17110		Destruct b9 lesion 1-14						0.000%			
5051	17111		Destruct lesion 15 or more						0.000%			
5051	17250		Chem caut of granltj tissue						0.000%			
5051	17260		Dstrj mal les t/a/l 0.5 cm/						0.000%			
5051	17261		Dstrj mal les t/a/l .6-1.0c						0.000%			
5051	17262		Dstrj mal les t/a/l 1.1-2.0						0.000%			
5051	17263		Dstrj mal les t/a/l 2.1-3.0						0.000%			
5051	17270		Dstr mal les s/n/h/f/g .5 /						0.000%			
5051	17271		Dstr mal les s/n/h/f/g 0.6-						0.000%			
5051	17272		Dstr mal les s/n/h/f/g 1.1-						0.000%			
5051	17280		Dstr mal ls f/e/e/n/l/m .5/						0.000%			
5051	17281		Dstr mal ls f/e/e/n/l/m .6-						0.000%			
5051	17282		Dstr mal ls f/e/e/n/l/m1.1-						0.000%			
5051	17360		Chemical exfoliation acne						0.000%			
5051	17999		Unlistd px skn muc memb sub						0.000%			
5051	26010		Drainage of finger abscess						0.000%			
5051	46916		Cryosurgery anal lesion(s)						0.000%			
5051	54056		Cryosurgery penis lesion(s)						0.000%			
5051	69220		Clean out mastoid cavity						0.000%			
5051	96567		Pdt dstr prmlg les skn						0.000%			
5051	96573		Pdt dstr prmlg les phys/qhp						0.000%			
5051	96574		Dbrdmt prmlg les w/pdt						0.000%			
5051	96920		Excimer lsr psriasis<250sqc						0.000%			
5051	96921		Excimer lsr psriasis 250-50						0.000%			
5051	96999		Unlisted spec derm svc/px						0.000%			
5051	97597		Dbrdmt opn wnd 1st 20 cm/<						0.000%			
5051	97602		Wound(s) care non-selective						0.000%			
5051	97605		Neg prs wnd ther dme<=50sqc						0.000%			
5051	97610		Low frequency non-thermal u						0.000%			
5051	0447T		Rmvl impltbl glucose sensor						0.000%			
5051	0512T		Esw integ wnd hlg 1st wnd						0.000%			
5051	0906T		Coms ther 1st appl<=50 sq c						0.000%			
5051	G0247		Routine footcare pt w lops						0.000%			
5052		Level 2 Skin Procedures		T	4.5193	$414.63	.	$82.93	0.000%			
5052	10021		Fna bx w/o img gdn 1st les						0.000%			
5052	10061		I&d abscess comp/multiple						0.000%			
5052	10120		Inc&rmvl fb subq tiss smpl						0.000%			
5052	10160		Pnxr aspir absc hmtma bulla						0.000%			
5052	11000		Dbrdmt ecz/infected skin<10						0.000%			
5052	11042		Dbrdmt subq tis 1st 20sqcm/						0.000%			
5052	11102		Tangntl bx skin single les						0.000%			
5052	11104		Punch bx skin single lesion						0.000%			
5052	11300		Shave skin lesion 0.5 cm/<						0.000%			
5052	11303		Shave skin lesion >2.0 cm						0.000%			
5052	11308		Shave skin lesion >2.0 cm						0.000%			
5052	11312		Shave skin lesion 1.1-2.0 c						0.000%			
5052	11313		Shave skin lesion >2.0 cm						0.000%			
5052	11401		Exc tr-ext b9+marg 0.6-1 cm						0.000%			
5052	11602		Exc tr-ext mal+marg 1.1-2 c						0.000%			
5052	11750		Removal of nail bed						0.000%			
5052	11765		Excision of nail fold toe						0.000%			
5052	12005		Rpr s/n/a/gen/trk12.6-20.0c						0.000%			
5052	12006		Rpr s/n/a/gen/trk20.1-30.0c						0.000%			
5052	12016		Rpr fe/e/en/l/m 12.6-20.0 c						0.000%			
5052	12017		Rpr fe/e/en/l/m 20.1-30.0 c						0.000%			
5052	12021		Tx supfc wnd dehsn w/packin						0.000%			
5052	12031		Intmd rpr s/a/t/ext 2.5 cm/						0.000%			
5052	12032		Intmd rpr s/a/t/ext 2.6-7.5						0.000%			
5052	12034		Intmd rpr s/tr/ext 7.6-12.5						0.000%			
5052	12035		Intmd rpr s/a/t/ext 12.6-20						0.000%			
5052	12041		Intmd rpr n-hf/genit 2.5cm/						0.000%			
5052	12042		Intmd rpr n-hf/genit2.6-7.5						0.000%			
5052	12051		Intmd rpr face/mm 2.5 cm/<						0.000%			
5052	12052		Intmd rpr face/mm 2.6-5.0 c						0.000%			
5052	12053		Intmd rpr face/mm 5.1-7.5 c						0.000%			
5052	12054		Intmd rpr face/mm 7.6-12.5c						0.000%			
5052	12055		Intmd rpr face/mm 12.6-20 c						0.000%			
5052	12056		Intmd rpr face/mm 20.1-30.0						0.000%			
5052	12057		Intmd rpr face/mm >30.0 cm						0.000%			
5052	13120		Cmplx rpr s/a/l 1.1-2.5 cm						0.000%			
5052	13121		Cmplx rpr s/a/l 2.6-7.5 cm						0.000%			
5052	13131		Cmplx rpr f/c/c/m/n/ax/g/h/						0.000%			
5052	13132		Cmplx rpr f/c/c/m/n/ax/g/h/						0.000%			
5052	15004		Wound prep f/n/hf/g						0.000%			
5052	15775		Hair trnspl 1-15 punch grft						0.000%			
5052	15776		Hair trnspl >15 punch graft						0.000%			
5052	15783		Dermabrasion suprfl any sit						0.000%			
5052	15788		Chemical peel facial epidrm						0.000%			
5052	15793		Chemical peel nonfacial drm						0.000%			
5052	16030		Dress/debrid p-thick burn l						0.000%			
5052	16035		Incision of burn scab initi						0.000%			
5052	17004		Destroy premal lesions 15/>						0.000%			
5052	17106		Destruction of skin lesions						0.000%			
5052	17264		Dstrj mal les t/a/l 3.1-4.0						0.000%			
5052	17266		Dstrj mal les t/a/l >4.0 cm						0.000%			
5052	17273		Dstr mal les s/n/h/f/g 2.1-						0.000%			
5052	17274		Dstr mal les s/n/h/f/g 3.1-						0.000%			
5052	17276		Dstr mal les s/n/h/f/g >4.0						0.000%			
5052	17283		Dstr mal ls f/e/e/n/l/m2.1-						0.000%			
5052	36468		Njx sclrsnt spider veins						0.000%			
5052	36470		Njx sclrsnt 1 incmptnt vein						0.000%			
5052	36471		Njx sclrsnt mlt incmptnt vn						0.000%			
5052	46900		Destruction anal lesion(s)						0.000%			
5052	54050		Destruction penis lesion(s)						0.000%			
5052	96913		Photochemotx sev dermatoses						0.000%			
5052	96922		Excimer lsr psriasis>500sqc						0.000%			
5052	97606		Neg prs wnd ther dme>50 sqc						0.000%			
5052	97607		Neg prs wnd thr ndme<=50sqc						0.000%			
5052	97608		Neg prs wnd ther ndme>50sqc						0.000%			
5052	0973T		Slctv nzmtc dbrdmt t/a/l 1s						0.000%			
5052	0975T		Slctv nzmtc dbrdmt s/n/hf 1						0.000%			
5053		Level 3 Skin Procedures		T	8.1377	$746.61	.	$149.33	0.000%			
5053	11043		Dbrdmt musc&/fsca 1st 20/<						0.000%			
5053	11106		Incal bx skn single les						0.000%			
5053	11760		Repair of nail bed						0.000%			
5053	11920		Correct skin color 6.0 cm/<						0.000%			
5053	11921		Correct skn color 6.1-20.0c						0.000%			
5053	11951		Tx contour defects 1.1-5.0c						0.000%			
5053	11952		Tx contour defects 5.1-10cc						0.000%			
5053	11954		Tx contour defects >10.0 cc						0.000%			
5053	12020		Tx supfc wnd dehsn smpl cls						0.000%			
5053	12036		Intmd rpr s/a/t/ext 20.1-30						0.000%			
5053	12044		Intmd rpr n-hf/genit7.6-12.						0.000%			
5053	12045		Intmd rpr n-hf/genit12.6-20						0.000%			
5053	12046		Intmd rpr n-hf/genit20.1-30						0.000%			
5053	13100		Cmplx rpr trunk 1.1-2.5 cm						0.000%			
5053	13101		Cmplx rpr trunk 2.6-7.5 cm						0.000%			
5053	13151		Cmplx rpr e/n/e/l 1.1-2.5 c						0.000%			
5053	13152		Cmplx rpr e/n/e/l 2.6-7.5 c						0.000%			
5053	15002		Wound prep trk/arm/leg						0.000%			
5053	15050		Pinch graft up to 2 cm diam						0.000%			
5053	15271		Skin sub graft trnk/arm/leg						0.000%			
5053	15275		Skin sub graft face/nk/hf/g						0.000%			
5053	15789		Chemical peel facial dermal						0.000%			
5053	15792		Chem peel nonfacial epidrm						0.000%			
5053	15852		Dressing change not for bur						0.000%			
5053	17107		Destruction of skin lesions						0.000%			
5053	17284		Dstr mal ls f/e/e/n/l/m3.1-						0.000%			
5053	17286		Dstr mal ls f/e/e/n/l/m>4.0						0.000%			
5053	17311		Mohs 1 stage h/n/hf/g						0.000%			
5053	17313		Mohs 1 stage t/a/l						0.000%			
5053	17380		Electrolysis epilation ea 3						0.000%			
5053	20910		Remove cartilage for graft						0.000%			
5053	0419T		Dstrj neurofibroma xtnsv						0.000%			
5053	0420T		Dstrj neurofibroma xtnsv						0.000%			
5053	0479T		Fxjl abl lsr 1st 100 sq cm						0.000%			
5054		Level 4 Skin Procedures		T	23.2972	"$2,137.45"	.	$427.49	0.000%			
5054	11762		Reconstruction of nail bed						0.000%			
5054	12037		Intmd rpr s/tr/ext >30.0 cm						0.000%			
5054	12047		Intmd rpr n-hf/genit >30.0c						0.000%			
5054	14000		Tis trnfr trunk 10 sq cm/<						0.000%			
5054	14001		Tis trnfr trunk 10.1-30sqcm						0.000%			
5054	14020		Tis trnfr s/a/l 10 sq cm/<						0.000%			
5054	14021		Tis trnfr s/a/l 10.1-30 sqc						0.000%			
5054	14040		Tis trnfr f/c/c/m/n/a/g/h/f						0.000%			
5054	14041		Tis trnfr f/c/c/m/n/a/g/h/f						0.000%			
5054	14060		Tis trnfr e/n/e/l 10 sq cm/						0.000%			
5054	14061		Tis trnfr e/n/e/l10.1-30sqc						0.000%			
5054	14350		Filleted finger/toe flap						0.000%			
5054	15011		Hrv skn cll ssp agrft 1st 2						0.000%			
5054	15015		App skn cl ssp agrft t/a/l						0.000%			
5054	15017		App skn cll ssp f/n/g/hf 1s						0.000%			
5054	15040		Harvest cultured skin graft						0.000%			
5054	15100		Splt agrft t/a/l 1st 100sqc						0.000%			
5054	15110		Epidrm agrft t/a/l 1st 100						0.000%			
5054	15115		Epdrm agrft f/s/n/h/f/g/m 1						0.000%			
5054	15130		Drm agrft t/a/l 1st 100 sqc						0.000%			
5054	15150		Tis cltr skn agrft t/a/l 1s						0.000%			
5054	15200		Fth/gft fr trnk 20 sq cm/<						0.000%			
5054	15220		Fth/gft fr s/a/l 20 sq cm/<						0.000%			
5054	15240		Fth/gft f/c/c/m/n/ax/g/h/f2						0.000%			
5054	15260		Fth/gft fr n/e/e/l 20 sqcm/						0.000%			
5054	15273		Skin sub grft t/arm/lg chil						0.000%			
5054	15277		Skn sub grft f/n/hf/g child						0.000%			
5054	15570		Skin pedicle flap trunk						0.000%			
5054	15574		Pedcle fh/ch/ch/m/n/ax/g/h/						0.000%			
5054	15576		Pedicle e/n/e/l/ntroral						0.000%			
5054	15610		Delay flap arms/legs						0.000%			
5054	15620		Delay flap f/c/c/n/ax/g/h/f						0.000%			
5054	15630		Delay flap eye/nos/ear/lip						0.000%			
5054	15650		Transfer skin pedicle flap						0.000%			
5054	15736		Muscle-skin graft arm						0.000%			
5054	15740		Island pedicle flap graft						0.000%			
5054	15760		Composite skin graft						0.000%			
5054	15773		Grfg autol fat lipo 25 cc/<						0.000%			
5054	15820		Blepharoplasty lower eyelid						0.000%			
5054	15821		Blepharp lwr eyelid fat pad						0.000%			
5054	15822		Blepharoplasty upper eyelid						0.000%			
5054	15823		Blepharp upr eyelid xcsv sk						0.000%			
5054	15824		Rhytidectomy forehead						0.000%			
5054	15842		Nerve palsy microsurg graft						0.000%			
5054	15851		Removal sutr/staple req ane						0.000%			
5054	15878		Suction lipectomy upr extre						0.000%			
5054	15936		Exc sac pr ulc prep mus fla						0.000%			
5054	15937		Exc sac pr ulc prep mus ost						0.000%			
5054	15945		Exc isch pr ulc skn flp ost						0.000%			
5054	15946		Exc isch pr ulc prep mus fl						0.000%			
5054	15952		Exc trchntr pr ulc flp clsr						0.000%			
5054	15956		Exc trchntr pr ulc prep fla						0.000%			
5054	17108		Destruction of skin lesions						0.000%			
5054	20101		Expl pentrg wound chest						0.000%			
5054	20102		Expl pentrg wnd abd/flnk/bk						0.000%			
5054	20920		Removal of fascia for graft						0.000%			
5054	20922		Removal of fascia for graft						0.000%			
5054	23921		Disarticulation sho sec cls						0.000%			
5054	25929		Amputation follow-up surger						0.000%			
5054	33222		Relocation pocket pacemaker						0.000%			
5054	33223		Relocate pocket for defib						0.000%			
5054	36465		Njx noncmpnd sclrsnt 1 vein						0.000%			
5054	36466		Njx noncmpnd sclrsnt mlt vn						0.000%			
5054	43887		Remove gastric port open						0.000%			
5054	46910		Destruction anal lesion(s)						0.000%			
5054	54055		Destruction penis lesion(s)						0.000%			
5054	54057		Laser surg penis lesion(s)						0.000%			
5054	54060		Excision of penis lesion(s)						0.000%			
5054	54065		Destruction penis lesion(s)						0.000%			
5054	56501		Destroy vulva lesions sim						0.000%			
5054	56515		Destroy vulva lesion/s comp						0.000%			
5054	0416T		Reloc skin pocket pls gen						0.000%			
5054	0862T		Rlcj pg wcs lv battery only						0.000%			
5054	0863T		Rlcj pg wcs lv trnsmtr only						0.000%			
5054	0925T		Rlcj skin pocket ccm-d pg						0.000%			
5054	G0429		Dermal filler injection(s)						0.000%			
5054	G0460		Autolog prp not diab ulcer						0.000%			
5054	G0465		Autolog prp diab wound ulce						0.000%			
5055		Level 5 Skin Procedures		T	39.8919	"$3,659.96"	.	$732.00	0.000%			
5055	11960		Insert tissue expander(s)						0.000%			
5055	13160		Sec clsr surg wnd/dehsn xtn						0.000%			
5055	14301		Tis trnfr any 30.1-60 sq cm						0.000%			
5055	15120		Splt agrft f/s/n/h/f/g/m 1s						0.000%			
5055	15135		Drm agrft f/s/n/h/f/g/m 1st						0.000%			
5055	15155		Tis cltr agrft f/s/n/h/f/g						0.000%			
5055	15572		Skin pedicle flap arms/legs						0.000%			
5055	15600		Delay flap trunk						0.000%			
5055	15730		Mdfc flap w/prsrv vasc pedc						0.000%			
5055	15731		Forehead flap w/vasc pedicl						0.000%			
5055	15733		Musc myoq/fscq flp h&n pedc						0.000%			
5055	15734		Muscle-skin graft trunk						0.000%			
5055	15738		Muscle-skin graft leg						0.000%			
5055	15750		Neurovascular pedicle flap						0.000%			
5055	15769		Grfg autol soft tiss dir ex						0.000%			
5055	15770		Derma-fat-fascia graft						0.000%			
5055	15771		Grfg autol fat lipo 50 cc/<						0.000%			
5055	15825		Rhytdct nck pltysml tghtg						0.000%			
5055	15826		Rhytidectomy glblr frn line						0.000%			
5055	15828		Rhytidectomy cheek chn & nc						0.000%			
5055	15829		Rhytidectomy smas flap						0.000%			
5055	15840		Nerve palsy fascial graft						0.000%			
5055	15841		Nerve palsy muscle graft						0.000%			
5055	15845		Skin and muscle repair face						0.000%			
5055	15876		Suction lipectomy head&neck						0.000%			
5055	15877		Suction lipectomy trunk						0.000%			
5055	15879		Suction lipectomy lwr extre						0.000%			
5055	15922		Exc coccygl pr ulc flap cls						0.000%			
5055	15934		Exc sacral pr ulc skn flap						0.000%			
5055	15935		Exc sac pr ulc skn flp ostc						0.000%			
5055	15944		Exc isch pr ulc skn flp cls						0.000%			
5055	15953		Exc trchntr pr ulc flp ostc						0.000%			
5055	15958		Exc trchntr pr ulc prep ost						0.000%			
5055	20912		Remove cartilage for graft						0.000%			
5055	43886		Revise gastric port open						0.000%			
5055	43888		Change gastric port open						0.000%			
5055	44312		Revision of ileostomy						0.000%			
5055	44314		Revision of ileostomy						0.000%			
5055	44340		Revision of colostomy						0.000%			
5055	44345		Revision of colostomy						0.000%			
5055	44346		Revision of colostomy						0.000%			
5055	0717T		Adrc ther prtl rc tear						0.000%			
5055	0718T		Adrc ther prtl rc tear njx						0.000%			
5061		Hyperbaric Oxygen		S	1.556	$142.76	.	$28.56	0.000%			
5061	G0277		"Hbot, full body chamber, 30"						0.000%			
5071		Level 1 Excision/ Biopsy/ Incision and Drainage		T	7.9601	$730.32	.	$146.07	0.000%			
5071	10005		Fna bx w/us gdn 1st les						0.000%			
5071	10007		Fna bx w/fluor gdn 1st les						0.000%			
5071	10009		Fna bx w/ct gdn 1st les						0.000%			
5071	10011		Fna bx w/mr gdn 1st les						0.000%			
5071	10030		Img gid flu coll drg sft ti						0.000%			
5071	10035		Plmt sft tiss loclzj dev 1s						0.000%			
5071	10080		I&d pilonidal cyst simple						0.000%			
5071	10081		I&d pilonidal cyst comp						0.000%			
5071	11010		Debride skin at fx site						0.000%			
5071	11011		Debride skin musc at fx sit						0.000%			
5071	11400		Exc tr-ext b9+marg 0.5 cm<						0.000%			
5071	11402		Exc tr-ext b9+marg 1.1-2 cm						0.000%			
5071	11403		Exc tr-ext b9+marg 2.1-3cm						0.000%			
5071	11421		Exc h-f-nk-sp b9+marg 0.6-1						0.000%			
5071	11440		Exc face-mm b9+marg 0.5 cm/						0.000%			
5071	11441		Exc face-mm b9+marg 0.6-1 c						0.000%			
5071	11442		Exc face-mm b9+marg 1.1-2 c						0.000%			
5071	11600		Exc tr-ext mal+marg 0.5 cm/						0.000%			
5071	11601		Exc tr-ext mal+marg 0.6-1 c						0.000%			
5071	11603		Exc tr-ext mal+marg 2.1-3 c						0.000%			
5071	11604		Exc tr-ext mal+marg 3.1-4 c						0.000%			
5071	11621		Exc s/n/h/f/g mal+mrg 0.6-1						0.000%			
5071	11622		Exc s/n/h/f/g mal+mrg 1.1-2						0.000%			
5071	11640		Exc f/e/e/n/l mal+mrg 0.5cm						0.000%			
5071	11641		Exc f/e/e/n/l mal+mrg 0.6-1						0.000%			
5071	11642		Exc f/e/e/n/l mal+mrg 1.1-2						0.000%			
5071	11755		Biopsy nail unit						0.000%			
5071	11976		Remove contraceptive capsul						0.000%			
5071	15781		Dermabrasion segmental face						0.000%			
5071	15999		Unlisted px exc pressure ul						0.000%			
5071	19000		Puncture aspir cyst breast						0.000%			
5071	19283		Perq dev breast 1st strtctc						0.000%			
5071	19285		Perq dev breast 1st us imag						0.000%			
5071	19287		Perq dev breast 1st mr guid						0.000%			
5071	20615		Treatment of bone cyst						0.000%			
5071	20950		Fluid pressure muscle						0.000%			
5071	21725		Revision of neck muscle						0.000%			
5071	28190		Removal of foot foreign bod						0.000%			
5071	33286		Rmvl subq car rhythm mntr						0.000%			
5071	35226		Repair blood vessel dir lxt						0.000%			
5071	40800		Drainage of mouth lesion						0.000%			
5071	42400		Biopsy of salivary gland						0.000%			
5071	47399		Unlisted procedure liver						0.000%			
5071	48999		Unlisted procedure pancreas						0.000%			
5071	50390		Drainage of kidney lesion						0.000%			
5071	55000		Drainage of hydrocele						0.000%			
5071	60100		Biopsy of thyroid						0.000%			
5071	60300		Aspir/inj thyroid cyst						0.000%			
5071	62267		Interdiscal perq aspir dx						0.000%			
5071	69000		Drg xtrnl ear absc/hem smpl						0.000%			
5071	69020		Drg xtrnl aud canal abscess						0.000%			
5071	D7510		I&d absc intraoral soft tis						0.000%			
5071	D7511		Incision/drain abscess intr						0.000%			
5071	D7520		I&d abscess extraoral						0.000%			
5071	D7521		Incision/drain abscess extr						0.000%			
5072		Level 2 Excision/ Biopsy/ Incision and Drainage		J1	18.4444	"$1,692.22"	.	$338.45	0.000%			
5072	10121		Inc&rmvl fb subq tiss comp						0.000%			
5072	10140		I&d hmtma seroma/fluid coll						0.000%			
5072	11044		Dbrdmt bone 1st 20 sq cm/<						0.000%			
5072	11404		Exc tr-ext b9+marg 3.1-4 cm						0.000%			
5072	11406		Exc tr-ext b9+marg >4.0 cm						0.000%			
5072	11420		Exc h-f-nk-sp b9+marg 0.5/<						0.000%			
5072	11422		Exc h-f-nk-sp b9+marg 1.1-2						0.000%			
5072	11423		Exc h-f-nk-sp b9+marg 2.1-3						0.000%			
5072	11424		Exc h-f-nk-sp b9+marg 3.1-4						0.000%			
5072	11443		Exc face-mm b9+marg 2.1-3 c						0.000%			
5072	11444		Exc face-mm b9+marg 3.1-4 c						0.000%			
5072	11606		Exc tr-ext mal+marg >4 cm						0.000%			
5072	11620		Exc h-f-nk-sp mal+marg 0.5/						0.000%			
5072	11623		Exc s/n/h/f/g mal+mrg 2.1-3						0.000%			
5072	11624		Exc s/n/h/f/g mal+mrg 3.1-4						0.000%			
5072	11643		Exc f/e/e/n/l mal+mrg 2.1-3						0.000%			
5072	11644		Exc f/e/e/n/l mal+mrg 3.1-4						0.000%			
5072	15950		Exc trchntr pr ulc prim sut						0.000%			
5072	19020		Mastotomy expl drg absc dp						0.000%			
5072	19081		Bx breast 1st lesion strtct						0.000%			
5072	19083		Bx breast 1st lesion us ima						0.000%			
5072	19085		Bx breast 1st lesion mr ima						0.000%			
5072	19100		Bx breast percut w/o image						0.000%			
5072	19281		Perq device breast 1st imag						0.000%			
5072	20103		Expl pentrg wound extremity						0.000%			
5072	20200		Muscle biopsy superficial						0.000%			
5072	20206		Biopsy muscle perq needle						0.000%			
5072	20220		Bone biopsy trocar/ndl supf						0.000%			
5072	20225		Bone biopsy trocar/ndl deep						0.000%			
5072	20520		Removal of foreign body						0.000%			
5072	20670		Removal implant superficial						0.000%			
5072	21011		Exc face les sc <2 cm						0.000%			
5072	21012		Exc face les sbq 2 cm/>						0.000%			
5072	21013		Exc face tum deep < 2 cm						0.000%			
5072	21550		Biopsy of neck/chest						0.000%			
5072	21555		Exc neck les sc < 3 cm						0.000%			
5072	21920		Biopsy soft tissue of back						0.000%			
5072	21925		Biopsy soft tissue of back						0.000%			
5072	21930		Exc back les sc < 3 cm						0.000%			
5072	21931		Exc back les sc 3 cm/>						0.000%			
5072	22902		Exc abd les sc < 3 cm						0.000%			
5072	23065		Biopsy shoulder tissues						0.000%			
5072	23071		Exc shoulder les sc 3 cm/>						0.000%			
5072	23075		Exc shoulder les sc < 3 cm						0.000%			
5072	23330		Remove shoulder foreign bod						0.000%			
5072	23931		I&d upr a/e bursa						0.000%			
5072	24065		Biopsy arm/elbow soft tissu						0.000%			
5072	24075		Exc arm/elbow les sc < 3 cm						0.000%			
5072	24200		Rmvl fb upper arm/elbw subq						0.000%			
5072	25065		Biopsy forearm soft tissues						0.000%			
5072	25071		Exc forearm les sc 3 cm/>						0.000%			
5072	25075		Exc forearm les sc < 3 cm						0.000%			
5072	25076		Exc forearm tum deep < 3 cm						0.000%			
5072	26011		Drainage of finger abscess						0.000%			
5072	26111		Exc hand les sc 1.5 cm/>						0.000%			
5072	26113		Exc hand tum deep 1.5 cm/>						0.000%			
5072	26115		Exc hand les sc < 1.5 cm						0.000%			
5072	26116		Exc hand tum deep < 1.5 cm						0.000%			
5072	26320		Removal of implant from han						0.000%			
5072	27040		Biopsy of soft tissues						0.000%			
5072	27041		Biopsy of soft tissues						0.000%			
5072	27323		Biopsy thigh soft tissues						0.000%			
5072	27327		Exc thigh/knee les sc < 3 c						0.000%			
5072	27613		Biopsy lower leg soft tissu						0.000%			
5072	27618		Exc leg/ankle tum < 3 cm						0.000%			
5072	28001		Drainage of bursa of foot						0.000%			
5072	28043		Exc foot/toe tum sc < 1.5 c						0.000%			
5072	28192		Removal of foot foreign bod						0.000%			
5072	28193		Removal of foot foreign bod						0.000%			
5072	32400		Needle biopsy chest lining						0.000%			
5072	32408		Core ndl bx lng/med perq						0.000%			
5072	37609		Ligation/bx temporal artery						0.000%			
5072	38220		Dx bone marrow aspirations						0.000%			
5072	38221		Dx bone marrow biopsies						0.000%			
5072	38505		Needle biopsy lymph nodes						0.000%			
5072	41108		Biopsy of floor of mouth						0.000%			
5072	47000		Needle biopsy of liver perq						0.000%			
5072	48102		Needle biopsy pancreas						0.000%			
5072	49180		Biopsy abdominal mass						0.000%			
5072	49185		Sclerotx fluid collection						0.000%			
5072	49405		Image cath fluid colxn visc						0.000%			
5072	49406		Image cath fluid peri/retro						0.000%			
5072	49407		Image cath fluid trns/vgnl						0.000%			
5072	50200		Renal biopsy perq						0.000%			
5072	54015		Drain penis lesion						0.000%			
5072	54100		Biopsy of penis						0.000%			
5072	54800		Biopsy of epididymis						0.000%			
5072	55100		Drainage of scrotum abscess						0.000%			
5072	60660		Abltj 1/+thyr ndul 1lobe pr						0.000%			
5072	62269		Needle biopsy spinal cord						0.000%			
5072	69005		Drg xtrnl ear absc/hem comp						0.000%			
5072	69205		Clear outer ear canal						0.000%			
5072	0673T		Abltj b9 thyr ndul perq las						0.000%			
5072	0959T		Rmv/rplc magnet coil assem						0.000%			
5073		Level 3 Excision/ Biopsy/ Incision and Drainage		J1	32.3758	"$2,970.38"	.	$594.08	0.000%			
5073	10180		I&d complex po wound infctj						0.000%			
5073	11012		Deb skin bone at fx site						0.000%			
5073	11426		Exc h-f-nk-sp b9+marg >4 cm						0.000%			
5073	11446		Exc face-mm b9+marg >4 cm						0.000%			
5073	11450		Exc skn hdrdnt ax smpl/ntrm						0.000%			
5073	11451		Exc skn hdrdnt ax complex						0.000%			
5073	11462		Exc skn hdrdnt ing smpl/ntr						0.000%			
5073	11463		Exc skn hdrdnt ing complex						0.000%			
5073	11470		Exc skn h/p/p/u smpl/ntrm						0.000%			
5073	11471		Exc skn h/p/p/u complex						0.000%			
5073	11626		Exc s/n/h/f/g mal+mrg >4 cm						0.000%			
5073	11646		Exc f/e/e/n/l mal+mrg >4 cm						0.000%			
5073	11770		Remove pilonidal cyst simpl						0.000%			
5073	11771		Remove pilonidal cyst exten						0.000%			
5073	11772		Remove pilonidal cyst compl						0.000%			
5073	11971		Rmvl tis xpndr wo insj impl						0.000%			
5073	15780		Dermabrasion total face						0.000%			
5073	15782		Dermabrasion other than fac						0.000%			
5073	15832		Exc excessive skin thigh						0.000%			
5073	15833		Exc excessive skin leg						0.000%			
5073	15834		Exc excessive skin hip						0.000%			
5073	15835		Exc excessive skin buttock						0.000%			
5073	15836		Exc excessive skin arm						0.000%			
5073	15837		Exc excsv skin forearm/hand						0.000%			
5073	15838		Exc excsv submental fat pad						0.000%			
5073	15839		Exc excessive skn other are						0.000%			
5073	15920		Exc coccygl pr ulc prim sut						0.000%			
5073	15931		Exc sacral pr ulc prim sutr						0.000%			
5073	15933		Exc sac pr ulc prim str ost						0.000%			
5073	15940		Exc ischial pr ulc prim sut						0.000%			
5073	15941		Exc isch pr ulc prm sut ost						0.000%			
5073	15951		Exc trchntr pr ulc ostc						0.000%			
5073	20205		Deep muscle biopsy						0.000%			
5073	20240		Bone biopsy open superficia						0.000%			
5073	20245		Bone biopsy open deep						0.000%			
5073	20525		Removal of foreign body						0.000%			
5073	20680		Removal of implant deep						0.000%			
5073	21014		Exc face tum deep 2 cm/>						0.000%			
5073	21015		Resect face/scalp tum < 2 c						0.000%			
5073	21016		Resect face/scalp tum 2 cm/						0.000%			
5073	21501		I&d dp absc/hmtma sft ts nc						0.000%			
5073	21552		Exc neck les sc 3 cm/>						0.000%			
5073	21554		Exc neck tum deep 5 cm/>						0.000%			
5073	21556		Exc neck tum deep < 5 cm						0.000%			
5073	21557		Resect neck thorax tumor<5c						0.000%			
5073	21558		Resect neck tumor 5 cm/>						0.000%			
5073	21601		Exc chest wall tumor w/ribs						0.000%			
5073	21932		Exc back tum deep < 5 cm						0.000%			
5073	21933		Exc back tum deep 5 cm/>						0.000%			
5073	21935		Resect back tum < 5 cm						0.000%			
5073	21936		Resect back tum 5 cm/>						0.000%			
5073	22900		Exc abdl tum deep < 5 cm						0.000%			
5073	22901		Exc abdl tum deep 5 cm/>						0.000%			
5073	22903		Exc abd les sc 3 cm/>						0.000%			
5073	22904		Radical resect abd tumor<5c						0.000%			
5073	22905		Rad resect abd tumor 5 cm/>						0.000%			
5073	23000		Removal of calcium deposits						0.000%			
5073	23030		Drain shoulder lesion						0.000%			
5073	23031		Drain shoulder bursa						0.000%			
5073	23066		Biopsy shoulder tissues						0.000%			
5073	23073		Exc shoulder tum deep 5 cm/						0.000%			
5073	23076		Exc shoulder tum deep < 5 c						0.000%			
5073	23077		Resect shoulder tumor < 5 c						0.000%			
5073	23078		Resect shoulder tumor 5 cm/						0.000%			
5073	23333		Remove shoulder fb deep						0.000%			
5073	23334		Shoulder prosthesis removal						0.000%			
5073	23335		Shoulder prosthesis removal						0.000%			
5073	23930		I&d upr a/e dp absc/hmtma						0.000%			
5073	24066		Biopsy arm/elbow soft tissu						0.000%			
5073	24071		Exc arm/elbow les sc 3 cm/>						0.000%			
5073	24073		Ex arm/elbow tum deep 5 cm/						0.000%			
5073	24076		Ex arm/elbow tum deep < 5 c						0.000%			
5073	24077		Rad rescj tum tiss a/e <5cm						0.000%			
5073	24079		Rad rescj tum tiss a/e 5 cm						0.000%			
5073	24201		Rmvl fb upper arm/elbw deep						0.000%			
5073	25066		Biopsy forearm soft tissues						0.000%			
5073	25073		Exc forearm tum deep 3 cm/>						0.000%			
5073	25077		Resect forearm/wrist tum<3c						0.000%			
5073	25078		Resect forarm/wrist tum 3cm						0.000%			
5073	26117		Rad resect hand tumor < 3 c						0.000%			
5073	26118		Rad resect hand tumor 3 cm/						0.000%			
5073	27043		Exc hip pelvis les sc 3 cm/						0.000%			
5073	27045		Exc hip/pelv tum deep 5 cm/						0.000%			
5073	27047		Exc hip/pelvis les sc < 3 c						0.000%			
5073	27048		Exc hip/pelv tum deep < 5 c						0.000%			
5073	27049		Resect hip/pelv tum < 5 cm						0.000%			
5073	27059		Resect hip/pelv tum 5 cm/>						0.000%			
5073	27086		Remove hip foreign body						0.000%			
5073	27301		Drain thigh/knee lesion						0.000%			
5073	27324		Biopsy thigh soft tissues						0.000%			
5073	27328		Exc thigh/knee tum deep <5c						0.000%			
5073	27329		Resect thigh/knee tum < 5 c						0.000%			
5073	27337		Exc thigh/knee les sc 3 cm/						0.000%			
5073	27339		Exc thigh/knee tum dep 5cm/						0.000%			
5073	27364		Resect thigh/knee tum 5 cm/						0.000%			
5073	27372		Removal of foreign body						0.000%			
5073	27603		Drain lower leg lesion						0.000%			
5073	27614		Biopsy lower leg soft tissu						0.000%			
5073	27615		Resect leg/ankle tum < 5 cm						0.000%			
5073	27616		Resect leg/ankle tum 5 cm/>						0.000%			
5073	27619		Exc leg/ankle tum deep <5 c						0.000%			
5073	27632		Exc leg/ankle les sc 3 cm/>						0.000%			
5073	27634		Exc leg/ankle tum dep 5 cm/						0.000%			
5073	28039		Exc foot/toe tum sc 1.5 cm/						0.000%			
5073	28041		Exc foot/toe tum dep 1.5cm/						0.000%			
5073	28045		Exc foot/toe tum deep <1.5c						0.000%			
5073	28046		Resect foot/toe tumor < 3 c						0.000%			
5073	28047		Resect foot/toe tumor 3 cm/						0.000%			
5073	38222		Dx bone marrow bx & aspir						0.000%			
5073	38300		Drainage lymph node lesion						0.000%			
5073	38305		Drainage lymph node lesion						0.000%			
5073	51080		Drainage of bladder abscess						0.000%			
5073	54105		Biopsy of penis						0.000%			
5073	54115		Treatment of penis lesion						0.000%			
5073	54500		Biopsy of testis						0.000%			
5073	57022		I&d vaginal hematoma ob/pp						0.000%			
5073	57023		I&d vaginal hematoma non-ob						0.000%			
5073	69110		Remove external ear partial						0.000%			
5073	69145		Remove ear canal lesion(s)						0.000%			
5091		Level 1 Breast/Lymphatic Surgery and Related Procedures		J1	44.1344	"$4,049.20"	.	$809.84	0.000%			
5091	19101		Biopsy of breast open						0.000%			
5091	19105		Cryosurg ablate fa each						0.000%			
5091	19110		Nipple exploration						0.000%			
5091	19112		Excise breast duct fistula						0.000%			
5091	19120		Removal of breast lesion						0.000%			
5091	19125		Excision breast lesion						0.000%			
5091	19300		Mastectomy for gynecomastia						0.000%			
5091	19301		Partial mastectomy						0.000%			
5091	19328		Rmvl intact breast implant						0.000%			
5091	19330		Rmvl ruptured breast implan						0.000%			
5091	19350		Nipple/areola reconstructio						0.000%			
5091	19355		Correct inverted nipple(s)						0.000%			
5091	19370		Revj peri-implt capsule brs						0.000%			
5091	19371		Peri-implt capslc brst comp						0.000%			
5091	19396		Design custom breast implan						0.000%			
5091	19499		Unlisted procedure breast						0.000%			
5091	38308		Incision of lymph channels						0.000%			
5091	38500		Biopsy/removal lymph nodes						0.000%			
5091	38510		Biopsy/removal lymph nodes						0.000%			
5091	38520		Biopsy/removal lymph nodes						0.000%			
5091	38525		Biopsy/removal lymph nodes						0.000%			
5091	38530		Biopsy/removal lymph nodes						0.000%			
5091	38531		Open bx/exc inguinofem node						0.000%			
5091	38550		Removal neck/armpit lesion						0.000%			
5091	0581T		Abltj mal brst tum perq crt						0.000%			
5091	0970T		Ablt b9 brst tum perq lsr e						0.000%			
5091	0971T		Ablt mal brst tum pq lsr un						0.000%			
5091	X476T		Lymphovenous bypass per xtr						0.000%			
5092		Level 2 Breast/Lymphatic Surgery and Related Procedures		J1	82.4046	"$7,560.37"	.	"$1,512.08"	0.000%			
5092	15830		Exc excessive skin abdomen						0.000%			
5092	19298		Place breast rad tube/caths						0.000%			
5092	19302		P-mastectomy w/ln removal						0.000%			
5092	19303		Mast simple complete						0.000%			
5092	19307		Mast mod rad						0.000%			
5092	19316		Mastopexy						0.000%			
5092	19318		Breast reduction						0.000%			
5092	19340		Insj breast implt sm d mast						0.000%			
5092	19380		Revj reconstructed breast						0.000%			
5092	38555		Removal neck/armpit lesion						0.000%			
5092	38562		Removal pelvic lymph nodes						0.000%			
5092	38700		Removal of lymph nodes neck						0.000%			
5092	38720		Removal of lymph nodes neck						0.000%			
5092	38760		Remove groin lymph nodes						0.000%			
5093		Level 3 Breast/Lymphatic Surgery and Related Procedures		J1	71.6713	"$6,575.63"	.	"$1,315.13"	0.000%			
5093	19296		Place po breast cath for ra						0.000%			
5093	19325		Breast augmentation w/implt						0.000%			
5093	19342		Insj/rplcmt brst implt sep						0.000%			
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."
5094	19357		Tiss xpndr plmt brst rcnstj						0.000%			
5101		Level 1 Strapping and Cast Application		T	1.7833	$163.61	.	$32.73	0.000%			
5101	29044		Application of body cast						0.000%			
5101	29085		Apply hand/wrist cast						0.000%			
5101	29086		Apply finger cast						0.000%			
5101	29105		Apply long arm splint						0.000%			
5101	29200		Strapping thorax						0.000%			
5101	29440		Addition of walker to cast						0.000%			
5101	29450		Application of leg cast						0.000%			
5101	29505		Application long leg splint						0.000%			
5101	29515		Application lower leg splin						0.000%			
5101	29540		Strapping of ankle and/or f						0.000%			
5101	29580		Strapping unna boot						0.000%			
5101	29581		Apply multlay comprs lwr le						0.000%			
5101	29584		Appl multlay comprs arm/han						0.000%			
5101	29720		Repair of body cast						0.000%			
5101	29730		Windowing of cast						0.000%			
5101	29799		Unlisted px casting/strpg						0.000%			
5102		Level 2 Strapping and Cast Application		T	3.0819	$282.76	.	$56.56	0.000%			
5102	26775		Treat finger dislocation						0.000%			
5102	28665		Treat toe dislocation						0.000%			
5102	29000		Application of body cast						0.000%			
5102	29010		Application of body cast						0.000%			
5102	29015		Application of body cast						0.000%			
5102	29035		Application of body cast						0.000%			
5102	29040		Application of body cast						0.000%			
5102	29046		Application of body cast						0.000%			
5102	29049		Application of figure eight						0.000%			
5102	29055		Application of shoulder cas						0.000%			
5102	29058		Application of shoulder cas						0.000%			
5102	29065		Application of long arm cas						0.000%			
5102	29075		Application of forearm cast						0.000%			
5102	29305		Application of hip cast						0.000%			
5102	29325		Application of hip casts						0.000%			
5102	29345		Application of long leg cas						0.000%			
5102	29355		Application of long leg cas						0.000%			
5102	29358		Apply long leg cast brace						0.000%			
5102	29365		Application of long leg cas						0.000%			
5102	29405		Apply short leg cast						0.000%			
5102	29425		Apply short leg cast						0.000%			
5102	29435		Apply short leg cast						0.000%			
5102	29445		Apply rigid leg cast						0.000%			
5102	29700		Removal/revision of cast						0.000%			
5102	29705		Removal/revision of cast						0.000%			
5102	29710		Removal/revision of cast						0.000%			
5102	29740		Wedging of cast						0.000%			
5102	29750		Wedging of clubfoot cast						0.000%			
5111		Level 1 Musculoskeletal Procedures		T	2.7746	$254.56	.	$50.92	0.000%			
5111	20999		Unlisted px muscskel genera						0.000%			
5111	21480		Cltx tmprmand dislc 1st/sbs						0.000%			
5111	21820		Treat sternum fracture						0.000%			
5111	22310		Closed tx vert fx w/o manj						0.000%			
5111	22899		Unlisted procedure spine						0.000%			
5111	22999		Unlisted px abdomen muscske						0.000%			
5111	23500		Cltx clavicular fx w/o mnpj						0.000%			
5111	23525		Cltx strnclav dislc w/mnpj						0.000%			
5111	23540		Cltx acromclav dislc wo mnp						0.000%			
5111	23545		Cltx acromclav dislc w/mnpj						0.000%			
5111	23570		Cltx scapular fx w/o mnpj						0.000%			
5111	23600		Cltx prox humrl fx w/o mnpj						0.000%			
5111	23620		Cltx gr hmrl tbrs fx wo mnp						0.000%			
5111	23650		Cltx sho dslc w/mnpj wo ane						0.000%			
5111	23929		Unlisted procedure shoulder						0.000%			
5111	24500		Treat humerus fracture						0.000%			
5111	24530		Treat humerus fracture						0.000%			
5111	24560		Treat humerus fracture						0.000%			
5111	24576		Treat humerus fracture						0.000%			
5111	24600		Treat elbow dislocation						0.000%			
5111	24640		Treat elbow dislocation						0.000%			
5111	24650		Treat radius fracture						0.000%			
5111	24670		Treat ulnar fracture						0.000%			
5111	24999		Unlisted px humerus/elbow						0.000%			
5111	25500		Cltx rdl shft fx w/o mnpj						0.000%			
5111	25530		Cltx ulnar shft fx w/o mnpj						0.000%			
5111	25535		Cltx ulnar shft fx w/mnpj						0.000%			
5111	25560		Cltx rdl&uln shft fx wo mnp						0.000%			
5111	25600		Cltx dst rdl fx/ephys sep w						0.000%			
5111	25622		Cltx carpl scphd fx w/o mnp						0.000%			
5111	25630		Cltx carpl fx w/o mnpj ea b						0.000%			
5111	25650		Cltx ulnar styloid fracture						0.000%			
5111	25660		Cltx rdcrpl/ntrcrpl dislc 1						0.000%			
5111	25675		Cltx dstl rad/uln dislc mnp						0.000%			
5111	25680		Cltx trns-scphprlnr fx mnpj						0.000%			
5111	25999		Unlisted px forearm/wrist						0.000%			
5111	26341		Manipulat palm cord post in						0.000%			
5111	26600		Treat metacarpal fracture						0.000%			
5111	26605		Treat metacarpal fracture						0.000%			
5111	26641		Treat thumb dislocation						0.000%			
5111	26670		Treat hand dislocation						0.000%			
5111	26700		Treat knuckle dislocation						0.000%			
5111	26720		Treat finger fracture each						0.000%			
5111	26725		Treat finger fracture each						0.000%			
5111	26740		Treat finger fracture each						0.000%			
5111	26750		Treat finger fracture each						0.000%			
5111	26755		Treat finger fracture each						0.000%			
5111	26770		Treat finger dislocation						0.000%			
5111	26989		Unlisted px hands/fingers						0.000%			
5111	27197		Clsd tx pelvic ring fx						0.000%			
5111	27198		Clsd tx pelvic ring fx						0.000%			
5111	27200		Treat tail bone fracture						0.000%			
5111	27220		Treat hip socket fracture						0.000%			
5111	27222		Treat hip socket fracture						0.000%			
5111	27230		Treat thigh fracture						0.000%			
5111	27246		Treat thigh fracture						0.000%			
5111	27250		Treat hip dislocation						0.000%			
5111	27256		Treat hip dislocation						0.000%			
5111	27265		Treat hip dislocation						0.000%			
5111	27299		Unlisted px pelvis/hip join						0.000%			
5111	27500		Treatment of thigh fracture						0.000%			
5111	27501		Treatment of thigh fracture						0.000%			
5111	27508		Treatment of thigh fracture						0.000%			
5111	27516		Treat thigh fx growth plate						0.000%			
5111	27520		Treat kneecap fracture						0.000%			
5111	27530		Treat knee fracture						0.000%			
5111	27538		Treat knee fracture(s)						0.000%			
5111	27550		Treat knee dislocation						0.000%			
5111	27560		Treat kneecap dislocation						0.000%			
5111	27562		Treat kneecap dislocation						0.000%			
5111	27599		Unlisted px femur/knee						0.000%			
5111	27750		Treatment of tibia fracture						0.000%			
5111	27760		Cltx medial ankle fx						0.000%			
5111	27767		Cltx post ankle fx						0.000%			
5111	27780		Treatment of fibula fractur						0.000%			
5111	27786		Treatment of ankle fracture						0.000%			
5111	27788		Treatment of ankle fracture						0.000%			
5111	27808		Treatment of ankle fracture						0.000%			
5111	27816		Treatment of ankle fracture						0.000%			
5111	27824		Treat lower leg fracture						0.000%			
5111	27830		Treat lower leg dislocation						0.000%			
5111	27840		Treat ankle dislocation						0.000%			
5111	27899		Unlisted px leg/ankle						0.000%			
5111	28400		Treatment of heel fracture						0.000%			
5111	28405		Treatment of heel fracture						0.000%			
5111	28430		Treatment of ankle fracture						0.000%			
5111	28450		Treat midfoot fracture each						0.000%			
5111	28470		Treat metatarsal fracture						0.000%			
5111	28475		Treat metatarsal fracture						0.000%			
5111	28490		Treat big toe fracture						0.000%			
5111	28495		Treat big toe fracture						0.000%			
5111	28510		Treatment of toe fracture						0.000%			
5111	28515		Treatment of toe fracture						0.000%			
5111	28530		Treat sesamoid bone fractur						0.000%			
5111	28540		Treat foot dislocation						0.000%			
5111	28570		Treat foot dislocation						0.000%			
5111	28600		Treat foot dislocation						0.000%			
5111	28605		Treat foot dislocation						0.000%			
5111	28630		Treat toe dislocation						0.000%			
5111	28660		Treat toe dislocation						0.000%			
5111	28899		Unlisted px foot/toes						0.000%			
5111	29999		Unlisted px arthroscopy						0.000%			
5111	0101T		Esw muscskel sys nos						0.000%			
5112		Level 2 Musculoskeletal Procedures		J1	18.0927	"$1,659.95"	.	$331.99	0.000%			
5112	20660		Apply rem fixation device						0.000%			
5112	20661		Application halo cranial						0.000%			
5112	20662		Application halo pelvic						0.000%			
5112	20664		Appl halo cranial 6+pins						0.000%			
5112	20694		Rmvl ext fixj sys under ane						0.000%			
5112	20697		App mltpln uni xtrnl fix xc						0.000%			
5112	20816		Replantation digit complete						0.000%			
5112	20822		Replantation digit complete						0.000%			
5112	20824		Replantation thumb complete						0.000%			
5112	20827		Replantation thumb complete						0.000%			
5112	21813		Treatment of rib fracture						0.000%			
5112	22505		Manipulation of spine						0.000%			
5112	23035		Drain shoulder bone lesion						0.000%			
5112	23505		Cltx clavicular fx w/mnpj						0.000%			
5112	23520		Cltx strnclav dislc w/o mnp						0.000%			
5112	23575		Cltx scap fx w/mnpj +-tract						0.000%			
5112	23605		Cltx prx hmrl fx mnpj+-trac						0.000%			
5112	23625		Cltx gr hmrl tbrs fx w/mnpj						0.000%			
5112	23655		Cltx sho dslc w/mnpj w/anes						0.000%			
5112	23665		Cltx sho dslc fx gr hmrl tb						0.000%			
5112	23675		Cltx sho dislc neck fx mnpj						0.000%			
5112	23700		Mnpj anes sho jt fixj aprat						0.000%			
5112	24300		Mnpj elbow under anes						0.000%			
5112	24505		Treat humerus fracture						0.000%			
5112	24535		Treat humerus fracture						0.000%			
5112	24565		Treat humerus fracture						0.000%			
5112	24566		Treat humerus fracture						0.000%			
5112	24577		Treat humerus fracture						0.000%			
5112	24605		Treat elbow dislocation						0.000%			
5112	24620		Treat elbow fracture						0.000%			
5112	24655		Treat radius fracture						0.000%			
5112	24675		Treat ulnar fracture						0.000%			
5112	25000		Incision of tendon sheath						0.000%			
5112	25020		Decompress forearm 1 space						0.000%			
5112	25025		Decompress forearm 2 spaces						0.000%			
5112	25031		Drainage of forearm bursa						0.000%			
5112	25110		Remove wrist tendon lesion						0.000%			
5112	25111		Remove wrist tendon lesion						0.000%			
5112	25112		Reremove wrist tendon lesio						0.000%			
5112	25115		Remove wrist/forearm lesion						0.000%			
5112	25118		Excise wrist tendon sheath						0.000%			
5112	25125		Remove/graft forearm lesion						0.000%			
5112	25248		Remove forearm foreign body						0.000%			
5112	25250		Removal of wrist prosthesis						0.000%			
5112	25259		Manipulate wrist w/anesthes						0.000%			
5112	25505		Cltx rdl shft fx w/mnpj						0.000%			
5112	25520		Cltx rdl shft fx&dislc						0.000%			
5112	25565		Cltx rdl&uln shft fx w/mnpj						0.000%			
5112	25605		Cltx dst rdl fx/ephys sep w						0.000%			
5112	25624		Cltx carpl scphd fx w/mnpj						0.000%			
5112	25635		Cltx carpl fx w/mnpj ea b1						0.000%			
5112	25690		Cltx lunate dislc w/mnpj						0.000%			
5112	25922		Amputate hand at wrist						0.000%			
5112	26034		Treat hand bone lesion						0.000%			
5112	26040		Release palm contracture						0.000%			
5112	26055		Incise finger tendon sheath						0.000%			
5112	26060		Incision of finger tendon						0.000%			
5112	26070		Explore/treat hand joint						0.000%			
5112	26080		Explore/treat finger joint						0.000%			
5112	26110		Biopsy finger joint lining						0.000%			
5112	26140		Revise finger joint each						0.000%			
5112	26145		Tendon excision palm/finger						0.000%			
5112	26160		Remove tendon sheath lesion						0.000%			
5112	26170		Removal of palm tendon each						0.000%			
5112	26180		Removal of finger tendon						0.000%			
5112	26185		Remove finger bone						0.000%			
5112	26200		Remove hand bone lesion						0.000%			
5112	26210		Removal of finger lesion						0.000%			
5112	26235		Partial removal finger bone						0.000%			
5112	26236		Partial removal finger bone						0.000%			
5112	26262		Resect distal finger tumor						0.000%			
5112	26340		Manipulate finger w/anesth						0.000%			
5112	26410		Repair hand tendon						0.000%			
5112	26418		Repair finger tendon						0.000%			
5112	26432		Repair finger tendon						0.000%			
5112	26440		Release palm/finger tendon						0.000%			
5112	26455		Incision of finger tendon						0.000%			
5112	26460		Incise hand/finger tendon						0.000%			
5112	26474		Fusion of finger tendons						0.000%			
5112	26525		Release finger contracture						0.000%			
5112	26560		Repair of web finger						0.000%			
5112	26590		Repair finger deformity						0.000%			
5112	26645		Treat thumb fracture						0.000%			
5112	26675		Treat hand dislocation						0.000%			
5112	26705		Treat knuckle dislocation						0.000%			
5112	26742		Treat finger fracture each						0.000%			
5112	26991		Drainage of pelvis bursa						0.000%			
5112	27000		Incision of hip tendon						0.000%			
5112	27050		Biopsy of sacroiliac joint						0.000%			
5112	27052		Biopsy of hip joint						0.000%			
5112	27057		Buttock fasciotomy w/dbrdmt						0.000%			
5112	27232		Treat thigh fracture						0.000%			
5112	27238		Treat thigh fracture						0.000%			
5112	27240		Treat thigh fracture						0.000%			
5112	27252		Treat hip dislocation						0.000%			
5112	27257		Treat hip dislocation						0.000%			
5112	27266		Treat hip dislocation						0.000%			
5112	27268		Cltx thigh fx w/mnpj						0.000%			
5112	27275		Manipulation of hip joint						0.000%			
5112	27498		Decompression of thigh/knee						0.000%			
5112	27502		Treatment of thigh fracture						0.000%			
5112	27503		Treatment of thigh fracture						0.000%			
5112	27510		Treatment of thigh fracture						0.000%			
5112	27517		Treat thigh fx growth plate						0.000%			
5112	27552		Treat knee dislocation						0.000%			
5112	27570		Fixation of knee joint						0.000%			
5112	27605		Incision of achilles tendon						0.000%			
5112	27752		Treatment of tibia fracture						0.000%			
5112	27762		Cltx med ankle fx w/mnpj						0.000%			
5112	27768		Cltx post ankle fx w/mnpj						0.000%			
5112	27781		Treatment of fibula fractur						0.000%			
5112	27810		Treatment of ankle fracture						0.000%			
5112	27818		Treatment of ankle fracture						0.000%			
5112	27825		Treat lower leg fracture						0.000%			
5112	27842		Treat ankle dislocation						0.000%			
5112	28002		Treatment of foot infection						0.000%			
5112	28010		Incision of toe tendon						0.000%			
5112	28011		Incision of toe tendons						0.000%			
5112	28024		Exploration of toe joint						0.000%			
5112	28080		Removal of foot lesion						0.000%			
5112	28090		Removal of foot lesion						0.000%			
5112	28092		Removal of toe lesions						0.000%			
5112	28108		Removal of toe lesions						0.000%			
5112	28175		Resect phalanx of toe tumor						0.000%			
5112	28220		Release of foot tendon						0.000%			
5112	28230		Incision of foot tendon(s)						0.000%			
5112	28232		Incision of toe tendon						0.000%			
5112	28234		Incision of foot tendon						0.000%			
5112	28261		Revision of foot tendon						0.000%			
5112	28264		Release of midfoot joint						0.000%			
5112	28272		Release of toe joint each						0.000%			
5112	28345		Repair webbed toe(s)						0.000%			
5112	28435		Treatment of ankle fracture						0.000%			
5112	28455		Treat midfoot fracture each						0.000%			
5112	28546		Treat foot dislocation						0.000%			
5112	28635		Treat toe dislocation						0.000%			
5112	28890		Hi enrgy eswt plantar fasci						0.000%			
5112	29848		Wrist endoscopy/surgery						0.000%			
5112	29850		Knee arthroscopy/surgery						0.000%			
5112	29851		Knee arthroscopy/surgery						0.000%			
5112	29902		Mcp joint arthroscopy surg						0.000%			
5112	0957T		Rev s-sclp eltr ra rcvr&tlm						0.000%			
5113		Level 3 Musculoskeletal Procedures		J1	36.8099	"$3,377.20"	.	$675.44	0.000%			
5113	20150		Excision epiphyseal bar						0.000%			
5113	20250		Biopsy vrt bdy open thoraci						0.000%			
5113	20555		Place ndl musc/tis for rt						0.000%			
5113	20650		Insert and remove bone pin						0.000%			
5113	20663		Application halo femoral						0.000%			
5113	21336		Open tx septal fx w/wo stab						0.000%			
5113	21502		I&d dp abs/hmtm nck rib ost						0.000%			
5113	21510		Inc deep opng b1 crtx thora						0.000%			
5113	21610		Partial removal of rib						0.000%			
5113	21620		Partial removal of sternum						0.000%			
5113	21627		Sternal debridement						0.000%			
5113	21720		Revision of neck muscle						0.000%			
5113	21742		Repair stern/nuss w/o scope						0.000%			
5113	21743		Repair sternum/nuss w/scope						0.000%			
5113	22315		Closed tx vert fx w/manj						0.000%			
5113	22510		Perq cervicothoracic inject						0.000%			
5113	22511		Perq lumbosacral injection						0.000%			
5113	23020		Release shoulder joint						0.000%			
5113	23040		Exploratory shoulder surger						0.000%			
5113	23044		Exploratory shoulder surger						0.000%			
5113	23100		Biopsy of shoulder joint						0.000%			
5113	23101		Shoulder joint surgery						0.000%			
5113	23106		Incision of collarbone join						0.000%			
5113	23120		Claviculectomy partial						0.000%			
5113	23125		Claviculectomy total						0.000%			
5113	23130		Acromp/acromionectomy prtl						0.000%			
5113	23140		Removal of bone lesion						0.000%			
5113	23145		Removal of bone lesion						0.000%			
5113	23150		Removal of humerus lesion						0.000%			
5113	23170		Remove collar bone lesion						0.000%			
5113	23172		Remove shoulder blade lesio						0.000%			
5113	23190		Partial removal of scapula						0.000%			
5113	23935		Inc dp opn b1 crtx hum/elbw						0.000%			
5113	24000		Arthrt elbw expl drg/rmvl f						0.000%			
5113	24006		Arthrt elbw capsl exc rls						0.000%			
5113	24100		Arthrt elbw synovial bx onl						0.000%			
5113	24101		Arthrt elbw jt expl bx rmvl						0.000%			
5113	24102		Arthrt elbow w/synovectomy						0.000%			
5113	24105		Excision olecranon bursa						0.000%			
5113	24110		Exc/curtg b1 cst/b9 tum hum						0.000%			
5113	24120		Exc/crtg b1 cst/b9 tum rds						0.000%			
5113	24125		Exc/crtg b1 cst/tum rds agr						0.000%			
5113	24130		Excision radial head						0.000%			
5113	24136		Sequestrectomy radial h/n						0.000%			
5113	24140		Partial exc bone humerus						0.000%			
5113	24147		Prtl exc bone olecrn proces						0.000%			
5113	24155		Resection of elbow joint						0.000%			
5113	24160		Rmvl prosthhumrl&ulnar cmpn						0.000%			
5113	24164		Removal prosth radial head						0.000%			
5113	24305		Tendon lngth upr a/e ea tdn						0.000%			
5113	24310		Tnot opn elbw to sho ea tdn						0.000%			
5113	24332		Tenolysis triceps						0.000%			
5113	24343		Repr elbow lat ligmnt w/tis						0.000%			
5113	24357		Repair elbow perc						0.000%			
5113	24358		Repair elbow w/deb open						0.000%			
5113	24359		Repair elbow deb/attch open						0.000%			
5113	24470		Revision of elbow joint						0.000%			
5113	24925		Amputation follow-up surger						0.000%			
5113	25001		Incise flexor carpi radiali						0.000%			
5113	25023		Decompress forearm 1 space						0.000%			
5113	25024		Decompress forearm 2 spaces						0.000%			
5113	25028		Drainage of forearm lesion						0.000%			
5113	25040		Explore/treat wrist joint						0.000%			
5113	25085		Incision of wrist capsule						0.000%			
5113	25100		Biopsy of wrist joint						0.000%			
5113	25101		Explore/treat wrist joint						0.000%			
5113	25105		Remove wrist joint lining						0.000%			
5113	25107		Remove wrist joint cartilag						0.000%			
5113	25109		Excise tendon forearm/wrist						0.000%			
5113	25116		Remove wrist/forearm lesion						0.000%			
5113	25119		Partial removal of ulna						0.000%			
5113	25120		Removal of forearm lesion						0.000%			
5113	25126		Remove/graft forearm lesion						0.000%			
5113	25130		Removal of wrist lesion						0.000%			
5113	25145		Remove forearm bone lesion						0.000%			
5113	25150		Partial removal of ulna						0.000%			
5113	25151		Partial removal of radius						0.000%			
5113	25210		Removal of wrist bone						0.000%			
5113	25215		Removal of wrist bones						0.000%			
5113	25230		Partial removal of radius						0.000%			
5113	25240		Partial removal of ulna						0.000%			
5113	25251		Removal of wrist prosthesis						0.000%			
5113	25260		Repair forearm tendon/muscl						0.000%			
5113	25265		Repair forearm tendon/muscl						0.000%			
5113	25270		Repair forearm tendon/muscl						0.000%			
5113	25272		Repair forearm tendon/muscl						0.000%			
5113	25274		Repair forearm tendon/muscl						0.000%			
5113	25275		Repair forearm tendon sheat						0.000%			
5113	25280		Revise wrist/forearm tendon						0.000%			
5113	25290		Incise wrist/forearm tendon						0.000%			
5113	25295		Release wrist/forearm tendo						0.000%			
5113	25300		Fusion of tendons at wrist						0.000%			
5113	25301		Fusion of tendons at wrist						0.000%			
5113	25310		Transplant forearm tendon						0.000%			
5113	25312		Transplant forearm tendon						0.000%			
5113	25332		Revise wrist joint						0.000%			
5113	25335		Centralization wrist on uln						0.000%			
5113	25355		Revision of radius						0.000%			
5113	25370		Revise radius or ulna						0.000%			
5113	25375		Revise radius & ulna						0.000%			
5113	25394		Repair carpal bone shorten						0.000%			
5113	25426		Repair/graft radius & ulna						0.000%			
5113	25430		Vasc graft into carpal bone						0.000%			
5113	25447		Arthrp ntrcrp/crp/mtcr ntrp						0.000%			
5113	25448		Arthrp ntrcrpl/crp/mtcrp ss						0.000%			
5113	25450		Epiphysl arrst dstl rds/uln						0.000%			
5113	25455		Epiphysl arrst dstl rds&uln						0.000%			
5113	25492		Prophylactic tx radius&ulna						0.000%			
5113	25606		Perq skel fixj dstl rdl fx						0.000%			
5113	25645		Optx crpl fx oth/thn scph e						0.000%			
5113	25651		Perq skel fix ulnar styld f						0.000%			
5113	25671		Perq skel fix rad/uln dislc						0.000%			
5113	25907		Amputation follow-up surger						0.000%			
5113	25920		Amputate hand at wrist						0.000%			
5113	25924		Amputation follow-up surger						0.000%			
5113	25927		Amputation of hand						0.000%			
5113	25931		Amputation follow-up surger						0.000%			
5113	26020		Drain hand tendon sheath						0.000%			
5113	26025		Drainage of palm bursa						0.000%			
5113	26030		Drainage of palm bursas						0.000%			
5113	26035		Decompress fingers/hand						0.000%			
5113	26037		Decompress fingers/hand						0.000%			
5113	26045		Release palm contracture						0.000%			
5113	26075		Explore/treat finger joint						0.000%			
5113	26100		Biopsy hand joint lining						0.000%			
5113	26105		Biopsy finger joint lining						0.000%			
5113	26121		Release palm contracture						0.000%			
5113	26123		Release palm contracture						0.000%			
5113	26130		Remove wrist joint lining						0.000%			
5113	26135		Revise finger joint each						0.000%			
5113	26215		Remove/graft finger lesion						0.000%			
5113	26230		Partial removal of hand bon						0.000%			
5113	26250		Extensive hand surgery						0.000%			
5113	26260		Resect prox finger tumor						0.000%			
5113	26350		Repair finger/hand tendon						0.000%			
5113	26356		Repair finger/hand tendon						0.000%			
5113	26357		Repair finger/hand tendon						0.000%			
5113	26370		Repair finger/hand tendon						0.000%			
5113	26373		Repair finger/hand tendon						0.000%			
5113	26412		Repair/graft hand tendon						0.000%			
5113	26415		Excision hand/finger tendon						0.000%			
5113	26416		Graft hand or finger tendon						0.000%			
5113	26420		Repair/graft finger tendon						0.000%			
5113	26426		Repair finger/hand tendon						0.000%			
5113	26428		Repair/graft finger tendon						0.000%			
5113	26433		Repair finger tendon						0.000%			
5113	26434		Repair/graft finger tendon						0.000%			
5113	26437		Realignment of tendons						0.000%			
5113	26442		Release palm & finger tendo						0.000%			
5113	26445		Release hand/finger tendon						0.000%			
5113	26449		Release forearm/hand tendon						0.000%			
5113	26450		Incision of palm tendon						0.000%			
5113	26471		Fusion of finger tendons						0.000%			
5113	26476		Tendon lengthening						0.000%			
5113	26477		Tendon shortening						0.000%			
5113	26478		Lengthening of hand tendon						0.000%			
5113	26479		Shortening of hand tendon						0.000%			
5113	26480		Transplant hand tendon						0.000%			
5113	26483		Transplant/graft hand tendo						0.000%			
5113	26485		Transplant palm tendon						0.000%			
5113	26489		Transplant/graft palm tendo						0.000%			
5113	26490		Revise thumb tendon						0.000%			
5113	26492		Tendon transfer with graft						0.000%			
5113	26494		Hand tendon/muscle transfer						0.000%			
5113	26496		Revise thumb tendon						0.000%			
5113	26497		Finger tendon transfer						0.000%			
5113	26498		Finger tendon transfer						0.000%			
5113	26499		Revision of finger						0.000%			
5113	26502		Hand tendon reconstruction						0.000%			
5113	26508		Release thumb contracture						0.000%			
5113	26510		Thumb tendon transfer						0.000%			
5113	26516		Fusion of knuckle joint						0.000%			
5113	26517		Fusion of knuckle joints						0.000%			
5113	26520		Release knuckle contracture						0.000%			
5113	26535		Revise finger joint						0.000%			
5113	26540		Repair hand joint						0.000%			
5113	26541		Repair hand joint with graf						0.000%			
5113	26542		Repair hand joint with graf						0.000%			
5113	26545		Reconstruct finger joint						0.000%			
5113	26548		Reconstruct finger joint						0.000%			
5113	26550		Pollicization digit						0.000%			
5113	26561		Repair of web finger						0.000%			
5113	26562		Repair of web finger						0.000%			
5113	26565		Correct metacarpal flaw						0.000%			
5113	26567		Correct finger deformity						0.000%			
5113	26580		Repair cleft hand						0.000%			
5113	26587		Reconstruct extra finger						0.000%			
5113	26591		Repair muscles of hand						0.000%			
5113	26593		Release muscles of hand						0.000%			
5113	26596		Excision constricting tissu						0.000%			
5113	26607		Treat metacarpal fracture						0.000%			
5113	26608		Treat metacarpal fracture						0.000%			
5113	26615		Treat metacarpal fracture						0.000%			
5113	26650		Treat thumb fracture						0.000%			
5113	26665		Treat thumb fracture						0.000%			
5113	26676		Pin hand dislocation						0.000%			
5113	26685		Treat hand dislocation						0.000%			
5113	26686		Treat hand dislocation						0.000%			
5113	26706		Pin knuckle dislocation						0.000%			
5113	26715		Treat knuckle dislocation						0.000%			
5113	26727		Treat finger fracture each						0.000%			
5113	26735		Treat finger fracture each						0.000%			
5113	26746		Treat finger fracture each						0.000%			
5113	26756		Pin finger fracture each						0.000%			
5113	26765		Treat finger fracture each						0.000%			
5113	26776		Pin finger dislocation						0.000%			
5113	26785		Treat finger dislocation						0.000%			
5113	26860		Fusion of finger joint						0.000%			
5113	26862		Fusion/graft of finger join						0.000%			
5113	26910		Amputate metacarpal bone						0.000%			
5113	26951		Amputation of finger/thumb						0.000%			
5113	26952		Amputation of finger/thumb						0.000%			
5113	26990		Drainage of pelvis lesion						0.000%			
5113	26992		Drainage of bone lesion						0.000%			
5113	27001		Incision of hip tendon						0.000%			
5113	27005		Incision of hip tendon						0.000%			
5113	27006		Incision of hip tendons						0.000%			
5113	27025		Incision of hip/thigh fasci						0.000%			
5113	27035		Denervation of hip joint						0.000%			
5113	27054		Removal of hip joint lining						0.000%			
5113	27062		Remove femur lesion/bursa						0.000%			
5113	27066		Remove hip bone les deep						0.000%			
5113	27070		Part remove hip bone super						0.000%			
5113	27071		Part removal hip bone deep						0.000%			
5113	27080		Removal of tail bone						0.000%			
5113	27087		Remove hip foreign body						0.000%			
5113	27097		Revision of hip tendon						0.000%			
5113	27098		Transfer tendon to pelvis						0.000%			
5113	27105		Transfer of spinal muscle						0.000%			
5113	27111		Transfer of iliopsoas muscl						0.000%			
5113	27175		Treat slipped epiphysis						0.000%			
5113	27176		Treat slipped epiphysis						0.000%			
5113	27177		Treat slipped epiphysis						0.000%			
5113	27178		Treat slipped epiphysis						0.000%			
5113	27185		Revision of femur epiphysis						0.000%			
5113	27202		Treat tail bone fracture						0.000%			
5113	27253		Treat hip dislocation						0.000%			
5113	27254		Treat hip dislocation						0.000%			
5113	27258		Treat hip dislocation						0.000%			
5113	27259		Treat hip dislocation						0.000%			
5113	27267		Cltx thigh fx						0.000%			
5113	27282		Arthrodesis symphysis pubis						0.000%			
5113	27303		Drainage of bone lesion						0.000%			
5113	27305		Incise thigh tendon & fasci						0.000%			
5113	27306		Incision of thigh tendon						0.000%			
5113	27307		Incision of thigh tendons						0.000%			
5113	27310		Exploration of knee joint						0.000%			
5113	27330		Biopsy knee joint lining						0.000%			
5113	27331		Explore/treat knee joint						0.000%			
5113	27332		Removal of knee cartilage						0.000%			
5113	27333		Removal of knee cartilage						0.000%			
5113	27334		Remove knee joint lining						0.000%			
5113	27340		Removal of kneecap bursa						0.000%			
5113	27345		Removal of knee cyst						0.000%			
5113	27347		Remove knee cyst						0.000%			
5113	27355		Remove femur lesion						0.000%			
5113	27360		Partial removal leg bone(s)						0.000%			
5113	27365		Resect femur/knee tumor						0.000%			
5113	27390		Incision of thigh tendon						0.000%			
5113	27391		Incision of thigh tendons						0.000%			
5113	27392		Incision of thigh tendons						0.000%			
5113	27395		Lengthening of thigh tendon						0.000%			
5113	27425		Lat retinacular release ope						0.000%			
5113	27435		Incision of knee joint						0.000%			
5113	27496		Decompression of thigh/knee						0.000%			
5113	27497		Decompression of thigh/knee						0.000%			
5113	27532		Treat knee fracture						0.000%			
5113	27590		Amputate leg at thigh						0.000%			
5113	27591		Amputate leg at thigh						0.000%			
5113	27592		Amputate leg at thigh						0.000%			
5113	27594		Amputation follow-up surger						0.000%			
5113	27596		Amputation follow-up surger						0.000%			
5113	27598		Amputate lower leg at knee						0.000%			
5113	27600		Decompression of lower leg						0.000%			
5113	27601		Decompression of lower leg						0.000%			
5113	27602		Decompression of lower leg						0.000%			
5113	27604		Drain lower leg bursa						0.000%			
5113	27606		Incision of achilles tendon						0.000%			
5113	27607		Treat lower leg bone lesion						0.000%			
5113	27610		Explore/treat ankle joint						0.000%			
5113	27612		Exploration of ankle joint						0.000%			
5113	27620		Explore/treat ankle joint						0.000%			
5113	27625		Remove ankle joint lining						0.000%			
5113	27626		Remove ankle joint lining						0.000%			
5113	27630		Removal of tendon lesion						0.000%			
5113	27635		Remove lower leg bone lesio						0.000%			
5113	27640		Partial removal of tibia						0.000%			
5113	27641		Partial removal of fibula						0.000%			
5113	27645		Resect tibia tumor						0.000%			
5113	27646		Resect fibula tumor						0.000%			
5113	27647		Resect talus/calcaneus tum						0.000%			
5113	27656		Repair leg fascia defect						0.000%			
5113	27658		Repair of leg tendon each						0.000%			
5113	27675		Repair lower leg tendons						0.000%			
5113	27680		Release of lower leg tendon						0.000%			
5113	27681		Release of lower leg tendon						0.000%			
5113	27685		Revision of lower leg tendo						0.000%			
5113	27686		Revise lower leg tendons						0.000%			
5113	27687		Revision of calf tendon						0.000%			
5113	27704		Removal of ankle implant						0.000%			
5113	27707		Osteotomy fibula						0.000%			
5113	27727		Repair of lower leg						0.000%			
5113	27730		Repair of tibia epiphysis						0.000%			
5113	27732		Repair of fibula epiphysis						0.000%			
5113	27734		Repair lower leg epiphyses						0.000%			
5113	27740		Repair of leg epiphyses						0.000%			
5113	27742		Repair of leg epiphyses						0.000%			
5113	27831		Treat lower leg dislocation						0.000%			
5113	27860		Fixation of ankle joint						0.000%			
5113	27881		Amputation of lower leg						0.000%			
5113	27882		Amputation of lower leg						0.000%			
5113	27884		Amputation follow-up surger						0.000%			
5113	27886		Amputation follow-up surger						0.000%			
5113	27888		Amputation of foot at ankle						0.000%			
5113	27892		Decompression of leg						0.000%			
5113	27894		Decompression of leg						0.000%			
5113	28003		Treatment of foot infection						0.000%			
5113	28005		Treat foot bone lesion						0.000%			
5113	28008		Incision of foot fascia						0.000%			
5113	28020		Exploration of foot joint						0.000%			
5113	28022		Exploration of foot joint						0.000%			
5113	28050		Biopsy of foot joint lining						0.000%			
5113	28052		Biopsy of foot joint lining						0.000%			
5113	28054		Biopsy of toe joint lining						0.000%			
5113	28060		Partial removal foot fascia						0.000%			
5113	28062		Removal of foot fascia						0.000%			
5113	28072		Removal of foot joint linin						0.000%			
5113	28086		Excise foot tendon sheath						0.000%			
5113	28088		Excise foot tendon sheath						0.000%			
5113	28100		Removal of ankle/heel lesio						0.000%			
5113	28104		Removal of foot lesion						0.000%			
5113	28110		Part removal of metatarsal						0.000%			
5113	28111		Part removal of metatarsal						0.000%			
5113	28112		Part removal of metatarsal						0.000%			
5113	28113		Part removal of metatarsal						0.000%			
5113	28114		Removal of metatarsal heads						0.000%			
5113	28116		Revision of foot						0.000%			
5113	28118		Removal of heel bone						0.000%			
5113	28119		Removal of heel spur						0.000%			
5113	28120		Part removal of ankle/heel						0.000%			
5113	28122		Partial removal of foot bon						0.000%			
5113	28124		Partial removal of toe						0.000%			
5113	28126		Partial removal of toe						0.000%			
5113	28140		Removal of metatarsal						0.000%			
5113	28150		Removal of toe						0.000%			
5113	28153		Partial removal of toe						0.000%			
5113	28160		Partial removal of toe						0.000%			
5113	28171		Resect tarsal tumor						0.000%			
5113	28173		Resect metatarsal tumor						0.000%			
5113	28200		Repair of foot tendon						0.000%			
5113	28208		Repair of foot tendon						0.000%			
5113	28222		Release of foot tendons						0.000%			
5113	28225		Release of foot tendon						0.000%			
5113	28226		Release of foot tendons						0.000%			
5113	28240		Release of big toe						0.000%			
5113	28250		Revision of foot fascia						0.000%			
5113	28260		Release of midfoot joint						0.000%			
5113	28270		Release of foot contracture						0.000%			
5113	28280		Fusion of toes						0.000%			
5113	28285		Repair of hammertoe						0.000%			
5113	28286		Repair of hammertoe						0.000%			
5113	28288		Partial removal of foot bon						0.000%			
5113	28289		Corrj halux rigdus w/o impl						0.000%			
5113	28292		Cor hlx vlgs rsc prx phlx b						0.000%			
5113	28295		Cor hlx vlgs prx mtar osteo						0.000%			
5113	28296		Cor hlx vlgs dstl mtar oste						0.000%			
5113	28308		Incision of metatarsal						0.000%			
5113	28312		Revision of toe						0.000%			
5113	28313		Repair deformity of toe						0.000%			
5113	28315		Removal of sesamoid bone						0.000%			
5113	28340		Resect enlarged toe tissue						0.000%			
5113	28341		Resect enlarged toe						0.000%			
5113	28344		Repair extra toe(s)						0.000%			
5113	28476		Treat metatarsal fracture						0.000%			
5113	28496		Treat big toe fracture						0.000%			
5113	28505		Treat big toe fracture						0.000%			
5113	28525		Treat toe fracture						0.000%			
5113	28545		Treat foot dislocation						0.000%			
5113	28575		Treat foot dislocation						0.000%			
5113	28606		Treat foot dislocation						0.000%			
5113	28636		Treat toe dislocation						0.000%			
5113	28645		Repair toe dislocation						0.000%			
5113	28666		Treat toe dislocation						0.000%			
5113	28675		Repair of toe dislocation						0.000%			
5113	28800		Amputation of midfoot						0.000%			
5113	28805		Amputation thru metatarsal						0.000%			
5113	28810		Amputation toe & metatarsal						0.000%			
5113	28820		Amputation of toe						0.000%			
5113	28825		Partial amputation of toe						0.000%			
5113	29800		Jaw arthroscopy/surgery						0.000%			
5113	29804		Jaw arthroscopy/surgery						0.000%			
5113	29805		Sho arthrs dx +- synovial b						0.000%			
5113	29819		Sho arthrs srg rmvl loose/f						0.000%			
5113	29821		Sho arthrs srg compl synvct						0.000%			
5113	29822		Sho arthrs srg lmtd dbrdmt						0.000%			
5113	29823		Sho arthrs srg xtnsv dbrdmt						0.000%			
5113	29824		Sho arthrs srg dstl clavicl						0.000%			
5113	29825		Sho arthrs srg lss&rescj ad						0.000%			
5113	29830		Elbow arthroscopy						0.000%			
5113	29834		Elbow arthroscopy/surgery						0.000%			
5113	29835		Elbow arthroscopy/surgery						0.000%			
5113	29837		Elbow arthroscopy/surgery						0.000%			
5113	29838		Elbow arthroscopy/surgery						0.000%			
5113	29840		Wrist arthroscopy						0.000%			
5113	29843		Wrist arthroscopy/surgery						0.000%			
5113	29844		Wrist arthroscopy/surgery						0.000%			
5113	29845		Wrist arthroscopy/surgery						0.000%			
5113	29846		Wrist arthroscopy/surgery						0.000%			
5113	29863		Hip arthr0 w/synovectomy						0.000%			
5113	29870		Knee arthroscopy dx						0.000%			
5113	29871		Knee arthroscopy/drainage						0.000%			
5113	29873		Knee arthroscopy/surgery						0.000%			
5113	29874		Knee arthroscopy/surgery						0.000%			
5113	29875		Knee arthroscopy/surgery						0.000%			
5113	29876		Knee arthroscopy/surgery						0.000%			
5113	29877		Knee arthroscopy/surgery						0.000%			
5113	29879		Knee arthroscopy/surgery						0.000%			
5113	29880		Knee arthroscopy/surgery						0.000%			
5113	29881		Knee arthroscopy/surgery						0.000%			
5113	29882		Knee arthroscopy/surgery						0.000%			
5113	29883		Knee arthroscopy/surgery						0.000%			
5113	29884		Knee arthroscopy/surgery						0.000%			
5113	29886		Knee arthroscopy/surgery						0.000%			
5113	29891		Ankle arthroscopy/surgery						0.000%			
5113	29893		Scope plantar fasciotomy						0.000%			
5113	29894		Ankle arthroscopy/surgery						0.000%			
5113	29895		Ankle arthroscopy/surgery						0.000%			
5113	29897		Ankle arthroscopy/surgery						0.000%			
5113	29898		Ankle arthroscopy/surgery						0.000%			
5113	29900		Mcp joint arthroscopy dx						0.000%			
5113	29901		Mcp joint arthroscopy surg						0.000%			
5113	29904		Subtalar arthro w/fb rmvl						0.000%			
5113	29906		Subtalar arthro w/deb						0.000%			
5113	61892		Rmv sk-mnt crnl nstm pg/rcv						0.000%			
5113	64821		Sympathectomy radial artery						0.000%			
5113	64822		Sympathectomy ulnar artery						0.000%			
5113	64823		Sympathectomy supfc palmar						0.000%			
5113	69726		Rmv ntr oi implt skl prq es						0.000%			
5113	69727		Rmv ntr oi imp sk tc esp<10						0.000%			
5113	69728		Rmv ntr oi imp sk tc>=100						0.000%			
5113	0102T		Esw phy anes lat hmrl epcnd						0.000%			
5113	0510T		Rmvl sinus tarsi implant						0.000%			
5113	0707T		Njx b1 sub mtrl sbchdrl dfc						0.000%			
5113	0869T		Njx b1 sub mtrl hw fixj aug						0.000%			
5113	0958T		Rmv s-sclp eltr ra rcvr&tlm						0.000%			
5113	D7874		Tmj arthroscopy disc reposi						0.000%			
5113	G0415		Open tx post pelvic fxcture						0.000%			
5114		Level 4 Musculoskeletal Procedures		J1	82.1157	"$7,533.87"	.	"$1,506.78"	0.000%			
5114	11970		Rplcmt tiss xpndr perm impl						0.000%			
5114	20251		Biopsy vrt bdy open lmbr/cr						0.000%			
5114	20690		Appl unipln uni ext fixj sy						0.000%			
5114	20693		Adjmt/revj ext fixj sys ane						0.000%			
5114	20900		Removal of bone for graft						0.000%			
5114	20902		Removal of bone for graft						0.000%			
5114	20924		Removal of tendon for graft						0.000%			
5114	20955		Fibula bone graft microvasc						0.000%			
5114	20956		Iliac bone graft microvasc						0.000%			
5114	20957		Mt bone graft microvasc						0.000%			
5114	20962		Other bone graft microvasc						0.000%			
5114	20969		Bone/skin graft microvasc						0.000%			
5114	20970		Bone/skin graft iliac crest						0.000%			
5114	20972		Bone/skin graft metatarsal						0.000%			
5114	20973		Bone/skin graft great toe						0.000%			
5114	20983		Ablate bone tumor(s) perq						0.000%			
5114	21600		Partial removal of rib						0.000%			
5114	21602		Exc ch wal tum w/o lymphade						0.000%			
5114	21603		Exc ch wal tum w/lymphadec						0.000%			
5114	21615		Removal of rib						0.000%			
5114	21616		Removal of rib and nerves						0.000%			
5114	21630		Radical resection sternum						0.000%			
5114	21700		Revision of neck muscle						0.000%			
5114	21705		Revision of neck muscle/rib						0.000%			
5114	21740		Reconstruction of sternum						0.000%			
5114	21750		Repair of sternum separatio						0.000%			
5114	21811		Optx of rib fx w/fixj scope						0.000%			
5114	21812		Treatment of rib fracture						0.000%			
5114	21825		Treat sternum fracture						0.000%			
5114	22010		I&d p-spine c/t/cerv-thor						0.000%			
5114	22015		I&d abscess p-spine l/s/ls						0.000%			
5114	22100		Remove part of neck vertebr						0.000%			
5114	22101		Remove part thorax vertebra						0.000%			
5114	22102		Remove part lumbar vertebra						0.000%			
5114	22110		Remove part of neck vertebr						0.000%			
5114	22112		Remove part thorax vertebra						0.000%			
5114	22114		Remove part lumbar vertebra						0.000%			
5114	22206		Incis spine 3 column thorac						0.000%			
5114	22207		Incis spine 3 column lumbar						0.000%			
5114	22210		Incis 1 vertebral seg cerv						0.000%			
5114	22212		Incis 1 vertebral seg thora						0.000%			
5114	22214		Incis 1 vertebral seg lumba						0.000%			
5114	22220		Osteot dsc ant 1 vrt sgm cr						0.000%			
5114	22222		Osteot dsc ant 1vrt sgm thr						0.000%			
5114	22224		Osteot dsc ant 1vrt sgm lmb						0.000%			
5114	22513		Perq vertebral augmentation						0.000%			
5114	22514		Perq vertebral augmentation						0.000%			
5114	22830		Exploration of spinal fusio						0.000%			
5114	22850		Remove spine fixation devic						0.000%			
5114	22852		Remove spine fixation devic						0.000%			
5114	22855		Removal anterior instrmj						0.000%			
5114	22864		Rmvl tot arthrp 1ntrspc crv						0.000%			
5114	22865		Rmvl tot arthrp 1ntrspc lmb						0.000%			
5114	23105		Remove shoulder joint linin						0.000%			
5114	23107		Explore treat shoulder join						0.000%			
5114	23146		Removal of bone lesion						0.000%			
5114	23155		Removal of humerus lesion						0.000%			
5114	23156		Removal of humerus lesion						0.000%			
5114	23174		Remove humerus lesion						0.000%			
5114	23180		Remove collar bone lesion						0.000%			
5114	23182		Remove shoulder blade lesio						0.000%			
5114	23184		Remove humerus lesion						0.000%			
5114	23195		Removal of head of humerus						0.000%			
5114	23200		Resect clavicle tumor						0.000%			
5114	23210		Resect scapula tumor						0.000%			
5114	23220		Resect prox humerus tumor						0.000%			
5114	23395		Muscle transfer shoulder/ar						0.000%			
5114	23397		Muscle transfers						0.000%			
5114	23400		Fixation of shoulder blade						0.000%			
5114	23405		Incision of tendon & muscle						0.000%			
5114	23406		Incise tendon(s) & muscle(s						0.000%			
5114	23410		Repair rotator cuff acute						0.000%			
5114	23412		Repair rotator cuff chronic						0.000%			
5114	23415		Release of shoulder ligamen						0.000%			
5114	23420		Repair of shoulder						0.000%			
5114	23430		Repair biceps tendon						0.000%			
5114	23440		Remove/transplant tendon						0.000%			
5114	23450		Repair shoulder capsule						0.000%			
5114	23455		Repair shoulder capsule						0.000%			
5114	23460		Repair shoulder capsule						0.000%			
5114	23462		Repair shoulder capsule						0.000%			
5114	23465		Repair shoulder capsule						0.000%			
5114	23466		Repair shoulder capsule						0.000%			
5114	23480		Revision of collar bone						0.000%			
5114	23490		Reinforce clavicle						0.000%			
5114	23515		Optx clavicular fx w/int fi						0.000%			
5114	23530		Optx strnclav dislc aqt/chr						0.000%			
5114	23532		Optx strclv dslc aq/chrn gr						0.000%			
5114	23550		Optx acromclv dislc aqt/chr						0.000%			
5114	23552		Optx acrclv dslc aq/chrn gr						0.000%			
5114	23585		Optx scapular fx w/int fixj						0.000%			
5114	23630		Optx gr hmrl tbrs fx int fi						0.000%			
5114	23660		Optx acute shoulder dislc						0.000%			
5114	23670		Optx sho dislc fx						0.000%			
5114	23800		Arthrodesis glenohumeral jt						0.000%			
5114	24115		Exc/crtg b1 cst/tum hum agr						0.000%			
5114	24116		Exc/crtg b1 cst/tum hum alg						0.000%			
5114	24126		Exc/crtg b1 cst/tum rds alg						0.000%			
5114	24134		Sequestrectomy shft/dstl hu						0.000%			
5114	24138		Sequestrectomy olecrn proce						0.000%			
5114	24145		Prtl exc bone radial h/n						0.000%			
5114	24149		Radical resection of elbow						0.000%			
5114	24150		Rad rescj tum dstl/shft hum						0.000%			
5114	24152		Rad resection tum radial h/						0.000%			
5114	24301		Musc/tdn transfer upr a/e 1						0.000%			
5114	24320		Tenoplasty elbow to sho 1						0.000%			
5114	24330		Flexor-plasty elbow						0.000%			
5114	24331		Flexor-plasty elbw w/advmnt						0.000%			
5114	24340		Tenodesis biceps tdn at elb						0.000%			
5114	24341		Rpr tdn/musc upr a/e each						0.000%			
5114	24342		Repair of ruptured tendon						0.000%			
5114	24344		Reconstruct elbow lat ligmn						0.000%			
5114	24345		Repr elbw med ligmnt w/tiss						0.000%			
5114	24360		Reconstruct elbow joint						0.000%			
5114	24400		Revision of humerus						0.000%			
5114	24420		Revision of humerus						0.000%			
5114	24495		Decompression of forearm						0.000%			
5114	24538		Treat humerus fracture						0.000%			
5114	24582		Treat humerus fracture						0.000%			
5114	24615		Treat elbow dislocation						0.000%			
5114	24635		Treat elbow fracture						0.000%			
5114	24665		Treat radius fracture						0.000%			
5114	24685		Treat ulnar fracture						0.000%			
5114	24800		Fusion of elbow joint						0.000%			
5114	24930		Amputation follow-up surger						0.000%			
5114	24935		Revision of amputation						0.000%			
5114	25035		Treat forearm bone lesion						0.000%			
5114	25135		Remove & graft wrist lesion						0.000%			
5114	25136		Remove & graft wrist lesion						0.000%			
5114	25170		Resect radius/ulnar tumor						0.000%			
5114	25263		Repair forearm tendon/muscl						0.000%			
5114	25315		Revise palsy hand tendon(s)						0.000%			
5114	25316		Revise palsy hand tendon(s)						0.000%			
5114	25320		Repair/revise wrist joint						0.000%			
5114	25337		Reconstruct ulna/radioulnar						0.000%			
5114	25350		Revision of radius						0.000%			
5114	25360		Revision of ulna						0.000%			
5114	25390		Shorten radius or ulna						0.000%			
5114	25392		Shorten radius & ulna						0.000%			
5114	25393		Lengthen radius & ulna						0.000%			
5114	25400		Repair radius or ulna						0.000%			
5114	25405		Repair/graft radius or ulna						0.000%			
5114	25415		Repair radius & ulna						0.000%			
5114	25420		Repair/graft radius & ulna						0.000%			
5114	25425		Repair/graft radius or ulna						0.000%			
5114	25431		Repair nonunion carpal bone						0.000%			
5114	25440		Repair nonu scphd carpl b1						0.000%			
5114	25443		Arthrp prostc dstl scph crp						0.000%			
5114	25445		Arthrp w/prostc trapezium						0.000%			
5114	25449		Revj arthrp wrist joint						0.000%			
5114	25490		Prophylactic tx radius						0.000%			
5114	25515		Optx radial shaft fracture						0.000%			
5114	25525		Optx rdl shft fx&cltx rad/u						0.000%			
5114	25526		Optx rdl shft fx&dstl rad/u						0.000%			
5114	25545		Optx ulnar shft fx int fixj						0.000%			
5114	25574		Optx rdl&uln shft fx rds/ul						0.000%			
5114	25575		Optx rdl&uln shft fx rds&ul						0.000%			
5114	25607		Optx dst rd xartc fx/epi se						0.000%			
5114	25608		Optx dst rd xart fx/epi sep						0.000%			
5114	25609		Optx dst rd xart fx/ep sep3						0.000%			
5114	25628		Optx carpl scphd fx int fix						0.000%			
5114	25652		Optx ulnar styloid fracture						0.000%			
5114	25670		Optx rdcrpl/ntrcrpl dislc 1						0.000%			
5114	25676		Optx rad/uln dislc aqt/chrn						0.000%			
5114	25685		Optx trns-scphprlnr fx disl						0.000%			
5114	25695		Optx lunate dislocation						0.000%			
5114	25800		Arthrd wrist complete wo gr						0.000%			
5114	25805		Arthrd wrist w/sliding graf						0.000%			
5114	25820		Arthrd wrist lmtd w/o b1 gr						0.000%			
5114	25825		Arthrd wrist with autograft						0.000%			
5114	25830		Arthrd dst rad/ul jt sgm rs						0.000%			
5114	25900		Amputation of forearm						0.000%			
5114	25905		Amputation of forearm						0.000%			
5114	25909		Amputation follow-up surger						0.000%			
5114	25915		Amputation of forearm						0.000%			
5114	26205		Remove/graft bone lesion						0.000%			
5114	26352		Repair/graft hand tendon						0.000%			
5114	26358		Repair/graft hand tendon						0.000%			
5114	26372		Repair/graft hand tendon						0.000%			
5114	26390		Revise hand/finger tendon						0.000%			
5114	26392		Repair/graft hand tendon						0.000%			
5114	26500		Hand tendon reconstruction						0.000%			
5114	26518		Fusion of knuckle joints						0.000%			
5114	26530		Revise knuckle joint						0.000%			
5114	26531		Revise knuckle with implant						0.000%			
5114	26536		Revise/implant finger joint						0.000%			
5114	26546		Repair nonunion hand						0.000%			
5114	26551		Great toe-hand transfer						0.000%			
5114	26553		Single transfer toe-hand						0.000%			
5114	26554		Double transfer toe-hand						0.000%			
5114	26555		Positional change of finger						0.000%			
5114	26556		Toe joint transfer						0.000%			
5114	26568		Lengthen metacarpal/finger						0.000%			
5114	26820		Thumb fusion with graft						0.000%			
5114	26841		Fusion of thumb						0.000%			
5114	26842		Thumb fusion with graft						0.000%			
5114	26843		Fusion of hand joint						0.000%			
5114	26844		Fusion/graft of hand joint						0.000%			
5114	26850		Fusion of knuckle						0.000%			
5114	26852		Fusion of knuckle with graf						0.000%			
5114	27003		Incision of hip tendon						0.000%			
5114	27027		Buttock fasciotomy						0.000%			
5114	27030		Drainage of hip joint						0.000%			
5114	27033		Exploration of hip joint						0.000%			
5114	27036		Excision of hip joint/muscl						0.000%			
5114	27060		Removal of ischial bursa						0.000%			
5114	27065		Remove hip bone les super						0.000%			
5114	27067		Remove/graft hip bone lesio						0.000%			
5114	27075		Resect hip tumor						0.000%			
5114	27076		Resect hip tum incl acetabu						0.000%			
5114	27077		Resect hip tum w/innom bone						0.000%			
5114	27078		Rsect hip tum incl femur						0.000%			
5114	27090		Removal of hip prosthesis						0.000%			
5114	27100		Transfer of abdominal muscl						0.000%			
5114	27110		Transfer of iliopsoas muscl						0.000%			
5114	27122		Reconstruction of hip socke						0.000%			
5114	27140		Transplant femur ridge						0.000%			
5114	27146		Incision of hip bone						0.000%			
5114	27147		Revision of hip bone						0.000%			
5114	27151		Incision of hip bones						0.000%			
5114	27156		Revision of hip bones						0.000%			
5114	27158		Revision of pelvis						0.000%			
5114	27161		Incision of neck of femur						0.000%			
5114	27165		Incision/fixation of femur						0.000%			
5114	27170		Repair/graft femur head/nec						0.000%			
5114	27179		Revise head/neck of femur						0.000%			
5114	27181		Treat slipped epiphysis						0.000%			
5114	27187		Reinforce hip bones						0.000%			
5114	27226		Treat hip wall fracture						0.000%			
5114	27227		Treat hip fracture(s)						0.000%			
5114	27228		Treat hip fracture(s)						0.000%			
5114	27235		Treat thigh fracture						0.000%			
5114	27236		Treat thigh fracture						0.000%			
5114	27244		Treat thigh fracture						0.000%			
5114	27245		Treat thigh fracture						0.000%			
5114	27248		Treat thigh fracture						0.000%			
5114	27269		Optx thigh fx						0.000%			
5114	27335		Remove knee joint lining						0.000%			
5114	27350		Removal of kneecap						0.000%			
5114	27357		Remove femur lesion/graft						0.000%			
5114	27380		Repair of kneecap tendon						0.000%			
5114	27381		Repair/graft kneecap tendon						0.000%			
5114	27385		Repair of thigh muscle						0.000%			
5114	27386		Repair/graft of thigh muscl						0.000%			
5114	27393		Lengthening of thigh tendon						0.000%			
5114	27394		Lengthening of thigh tendon						0.000%			
5114	27396		Transplant of thigh tendon						0.000%			
5114	27397		Transplants of thigh tendon						0.000%			
5114	27400		Revise thigh muscles/tendon						0.000%			
5114	27403		Repair of knee cartilage						0.000%			
5114	27405		Repair of knee ligament						0.000%			
5114	27407		Repair of knee ligament						0.000%			
5114	27409		Repair of knee ligaments						0.000%			
5114	27412		Autochondrocyte implant kne						0.000%			
5114	27416		Osteochondral knee autograf						0.000%			
5114	27418		Repair degenerated kneecap						0.000%			
5114	27420		Revision of unstable kneeca						0.000%			
5114	27422		Revision of unstable kneeca						0.000%			
5114	27424		Revision/removal of kneecap						0.000%			
5114	27427		Reconstruction knee						0.000%			
5114	27430		Revision of thigh muscles						0.000%			
5114	27437		Revise kneecap						0.000%			
5114	27448		Incision of thigh						0.000%			
5114	27450		Incision of thigh						0.000%			
5114	27454		Realignment of thigh bone						0.000%			
5114	27455		Realignment of knee						0.000%			
5114	27457		Realignment of knee						0.000%			
5114	27465		Shortening of thigh bone						0.000%			
5114	27466		Lengthening of thigh bone						0.000%			
5114	27470		Repair of thigh						0.000%			
5114	27472		Repair/graft of thigh						0.000%			
5114	27475		Surgery to stop leg growth						0.000%			
5114	27477		Surgery to stop leg growth						0.000%			
5114	27479		Surgery to stop leg growth						0.000%			
5114	27485		Surgery to stop leg growth						0.000%			
5114	27495		Reinforce thigh						0.000%			
5114	27499		Decompression of thigh/knee						0.000%			
5114	27506		Treatment of thigh fracture						0.000%			
5114	27507		Treatment of thigh fracture						0.000%			
5114	27509		Treatment of thigh fracture						0.000%			
5114	27511		Treatment of thigh fracture						0.000%			
5114	27513		Treatment of thigh fracture						0.000%			
5114	27514		Treatment of thigh fracture						0.000%			
5114	27519		Treat thigh fx growth plate						0.000%			
5114	27524		Treat kneecap fracture						0.000%			
5114	27535		Treat knee fracture						0.000%			
5114	27536		Treat knee fracture						0.000%			
5114	27540		Treat knee fracture						0.000%			
5114	27556		Treat knee dislocation						0.000%			
5114	27557		Treat knee dislocation						0.000%			
5114	27558		Treat knee dislocation						0.000%			
5114	27566		Treat kneecap dislocation						0.000%			
5114	27637		Remove/graft leg bone lesio						0.000%			
5114	27638		Remove/graft leg bone lesio						0.000%			
5114	27650		Repair achilles tendon						0.000%			
5114	27652		Repair/graft achilles tendo						0.000%			
5114	27654		Repair of achilles tendon						0.000%			
5114	27659		Repair of leg tendon each						0.000%			
5114	27664		Repair of leg tendon each						0.000%			
5114	27665		Repair of leg tendon each						0.000%			
5114	27676		Repair lower leg tendons						0.000%			
5114	27690		Revise lower leg tendon						0.000%			
5114	27691		Revise lower leg tendon						0.000%			
5114	27695		Repair of ankle ligament						0.000%			
5114	27696		Repair of ankle ligaments						0.000%			
5114	27698		Repair of ankle ligament						0.000%			
5114	27700		Revision of ankle joint						0.000%			
5114	27705		Osteotomy tibia						0.000%			
5114	27720		Repair of tibia						0.000%			
5114	27722		Repair/graft of tibia						0.000%			
5114	27724		Repair/graft of tibia						0.000%			
5114	27725		Repair of lower leg						0.000%			
5114	27726		Repair fibula nonunion						0.000%			
5114	27745		Reinforce tibia						0.000%			
5114	27756		Treatment of tibia fracture						0.000%			
5114	27766		Optx medial ankle fx						0.000%			
5114	27769		Optx post ankle fx						0.000%			
5114	27784		Treatment of fibula fractur						0.000%			
5114	27792		Treatment of ankle fracture						0.000%			
5114	27814		Treatment of ankle fracture						0.000%			
5114	27822		Treatment of ankle fracture						0.000%			
5114	27823		Treatment of ankle fracture						0.000%			
5114	27826		Treat lower leg fracture						0.000%			
5114	27829		Treat lower leg joint						0.000%			
5114	27832		Treat lower leg dislocation						0.000%			
5114	27846		Treat ankle dislocation						0.000%			
5114	27848		Treat ankle dislocation						0.000%			
5114	27880		Amputation of lower leg						0.000%			
5114	27889		Ankle disarticulation						0.000%			
5114	27893		Decompression of leg						0.000%			
5114	28070		Removal of foot joint linin						0.000%			
5114	28102		Remove/graft foot lesion						0.000%			
5114	28103		Remove/graft foot lesion						0.000%			
5114	28106		Remove/graft foot lesion						0.000%			
5114	28107		Remove/graft foot lesion						0.000%			
5114	28130		Removal of ankle bone						0.000%			
5114	28202		Repair/graft of foot tendon						0.000%			
5114	28210		Repair/graft of foot tendon						0.000%			
5114	28238		Revision of foot tendon						0.000%			
5114	28262		Revision of foot and ankle						0.000%			
5114	28291		Corrj halux rigdus w/implt						0.000%			
5114	28298		Cor hlx vlgs prx phlx osteo						0.000%			
5114	28299		Cor hlx vlgs double osteot						0.000%			
5114	28300		Incision of heel bone						0.000%			
5114	28302		Incision of ankle bone						0.000%			
5114	28304		Incision of midfoot bones						0.000%			
5114	28305		Incise/graft midfoot bones						0.000%			
5114	28306		Incision of metatarsal						0.000%			
5114	28307		Incision of metatarsal						0.000%			
5114	28309		Incision of metatarsals						0.000%			
5114	28310		Revision of big toe						0.000%			
5114	28322		Repair of metatarsals						0.000%			
5114	28360		Reconstruct cleft foot						0.000%			
5114	28406		Treatment of heel fracture						0.000%			
5114	28415		Treat heel fracture						0.000%			
5114	28436		Treatment of ankle fracture						0.000%			
5114	28445		Treat ankle fracture						0.000%			
5114	28446		Osteochondral talus autogrf						0.000%			
5114	28456		Treat midfoot fracture						0.000%			
5114	28465		Treat midfoot fracture each						0.000%			
5114	28485		Treat metatarsal fracture						0.000%			
5114	28531		Treat sesamoid bone fractur						0.000%			
5114	28555		Repair foot dislocation						0.000%			
5114	28576		Treat foot dislocation						0.000%			
5114	28585		Repair foot dislocation						0.000%			
5114	28615		Repair foot dislocation						0.000%			
5114	28740		Fusion of foot bones						0.000%			
5114	28750		Fusion of big toe joint						0.000%			
5114	28755		Fusion of big toe joint						0.000%			
5114	28760		Fusion of big toe joint						0.000%			
5114	29806		Sho arthrs srg capsulorraph						0.000%			
5114	29807		Sho arthrs srg rpr slap les						0.000%			
5114	29820		Sho arthrs srg prtl synvct						0.000%			
5114	29827		Sho arthrs srg rt8tr cuf rp						0.000%			
5114	29828		Sho arthrs srg bicp tenodsi						0.000%			
5114	29836		Elbow arthroscopy/surgery						0.000%			
5114	29847		Wrist arthroscopy/surgery						0.000%			
5114	29855		Tibial arthroscopy/surgery						0.000%			
5114	29860		Hip arthroscopy dx						0.000%			
5114	29861		Hip arthro w/fb removal						0.000%			
5114	29862		Hip arthr0 w/debridement						0.000%			
5114	29866		Autgrft implnt knee w/scope						0.000%			
5114	29868		Meniscal trnspl knee w/scpe						0.000%			
5114	29885		Knee arthroscopy/surgery						0.000%			
5114	29887		Knee arthroscopy/surgery						0.000%			
5114	29888		Knee arthroscopy/surgery						0.000%			
5114	29892		Ankle arthroscopy/surgery						0.000%			
5114	29899		Ankle arthroscopy/surgery						0.000%			
5114	29905		Subtalar arthro w/exc						0.000%			
5114	29914		Hip arthro w/femoroplasty						0.000%			
5114	29915		Hip arthro acetabuloplasty						0.000%			
5114	29916		Hip arthro w/labral repair						0.000%			
5114	62351		Implant spinal canal cath						0.000%			
5114	62380		Ndsc dcmprn 1 ntrspc lumbar						0.000%			
5114	63001		Remove spine lamina 1/2 crv						0.000%			
5114	63003		Remove spine lamina 1/2 thr						0.000%			
5114	63005		Remove spine lamina 1/2 lmb						0.000%			
5114	63011		Remove spine lamina 1/2 scr						0.000%			
5114	63012		Remove lamina/facets lumbar						0.000%			
5114	63015		Remove spine lamina >2 crvc						0.000%			
5114	63016		Remove spine lamina >2 thrc						0.000%			
5114	63017		Remove spine lamina >2 lmbr						0.000%			
5114	63020		Neck spine disk surgery						0.000%			
5114	63030		Low back disk surgery						0.000%			
5114	63040		Laminotomy single cervical						0.000%			
5114	63042		Laminotomy single lumbar						0.000%			
5114	63045		Lam facetec & foramot crv						0.000%			
5114	63046		Lam facetec & foramot thrc						0.000%			
5114	63047		Lam facetec & foramot lumba						0.000%			
5114	63055		Decompress spinal cord thrc						0.000%			
5114	63056		Decompress spinal cord lmbr						0.000%			
5114	63064		Decompress spinal cord thrc						0.000%			
5114	63075		Neck spine disk surgery						0.000%			
5114	63265		Excise intraspinl lesion cr						0.000%			
5114	63266		Excise intrspinl lesion thr						0.000%			
5114	63267		Excise intrspinl lesion lmb						0.000%			
5114	63268		Excise intrspinl lesion scr						0.000%			
5114	69717		Rplcmt oi implt skl prq esp						0.000%			
5114	0200T		Perq sacral augmt unilat in						0.000%			
5114	0201T		Perq sacral augmt bilat inj						0.000%			
5114	0221T		Plmt post facet implt lumb						0.000%			
5114	0274T		Prq lamot/lam dcmpr crv/thr						0.000%			
5114	0335T		Insj sinus tarsi implant						0.000%			
5114	0511T		Rmvl&rinsj sinus tarsi impl						0.000%			
5114	0594T		Osteot hum xtrnl lngth dev						0.000%			
5114	27XX0		Osteot femur imed lngth dev						0.000%			
5114	27XX1		Osteot tibia imed lngth dev						0.000%			
5114	62XX0		Dcmprn prq rmv lig flv 1lmb						0.000%			
5114	G0276		Pild/placebo control clin t						0.000%			
5114	G0412		Open tx iliac spine uni/bil						0.000%			
5114	G0413		Pelvic ring fracture uni/bi						0.000%			
5114	G0414		Pelvic ring fx treat int fi						0.000%			
5114	X459T		Arthrp 1st crp/mtcrpl prost						0.000%			
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."
5115	20692		Appl mltpln uni ext fixj sy						0.000%			
5115	20982		Ablate bone tumor(s) perq						0.000%			
5115	22318		Treat odontoid fx w/o graft						0.000%			
5115	22319		Treat odontoid fx w/graft						0.000%			
5115	22325		Treat spine fracture						0.000%			
5115	22326		Treat neck spine fracture						0.000%			
5115	22327		Treat thorax spine fracture						0.000%			
5115	22532		Arthrd lat xtrcvtry tq thrc						0.000%			
5115	22548		Arthrd ant toral/xoral c1-c						0.000%			
5115	22551		Arthrd ant ntrbdy cervical						0.000%			
5115	22554		Arthrd ant ntrbd min dsc cr						0.000%			
5115	22590		Arthrd pst tq craniocervica						0.000%			
5115	22595		Arthrd pst tq atlas-axis						0.000%			
5115	22849		Reinsert spinal fixation						0.000%			
5115	22869		Insj stablj dev w/o dcmprn						0.000%			
5115	23470		Reconstruct shoulder joint						0.000%			
5115	23473		Revis reconst shoulder join						0.000%			
5115	23474		Revis reconst shoulder join						0.000%			
5115	23485		Revision of collar bone						0.000%			
5115	23491		Reinforce shoulder bones						0.000%			
5115	23615		Optx prox humrl fx w/int fi						0.000%			
5115	23680		Optx sho dislc neck fx fixj						0.000%			
5115	23802		Arthrd glenohumeral jt w/gr						0.000%			
5115	23900		Interthoracoscplr amputatio						0.000%			
5115	23920		Disarticulation shoulder						0.000%			
5115	24346		Reconstruct elbow med ligmn						0.000%			
5115	24362		Reconstruct elbow joint						0.000%			
5115	24365		Reconstruct head of radius						0.000%			
5115	24366		Reconstruct head of radius						0.000%			
5115	24370		Revise reconst elbow joint						0.000%			
5115	24410		Revision of humerus						0.000%			
5115	24430		Repair of humerus						0.000%			
5115	24435		Repair humerus with graft						0.000%			
5115	24498		Reinforce humerus						0.000%			
5115	24515		Treat humerus fracture						0.000%			
5115	24516		Treat humerus fracture						0.000%			
5115	24545		Treat humerus fracture						0.000%			
5115	24546		Treat humerus fracture						0.000%			
5115	24575		Treat humerus fracture						0.000%			
5115	24579		Treat humerus fracture						0.000%			
5115	24586		Treat elbow fracture						0.000%			
5115	24587		Treat elbow fracture						0.000%			
5115	24666		Treat radius fracture						0.000%			
5115	24802		Fusion/graft of elbow joint						0.000%			
5115	24900		Amputation of upper arm						0.000%			
5115	24920		Amputation of upper arm						0.000%			
5115	24931		Amputate upper arm & implan						0.000%			
5115	24940		Revision of upper arm						0.000%			
5115	25365		Revise radius & ulna						0.000%			
5115	25391		Lengthen radius or ulna						0.000%			
5115	25441		Arthrp w/prostc dstl rds						0.000%			
5115	25444		Arthrp w/prostc lunate						0.000%			
5115	25491		Prophylactic tx ulna						0.000%			
5115	25810		Arthrd wrst iliac/oth agrft						0.000%			
5115	27091		Removal of hip prosthesis						0.000%			
5115	27120		Reconstruction of hip socke						0.000%			
5115	27125		Partial hip replacement						0.000%			
5115	27130		Total hip arthroplasty						0.000%			
5115	27132		Total hip arthroplasty						0.000%			
5115	27134		Revise hip joint replacemen						0.000%			
5115	27137		Revise hip joint replacemen						0.000%			
5115	27138		Revise hip joint replacemen						0.000%			
5115	27284		Arthrodesis hip joint						0.000%			
5115	27286		Arthrd hip jt sbtrchc osteo						0.000%			
5115	27356		Remove femur lesion/graft						0.000%			
5115	27415		Osteochondral knee allograf						0.000%			
5115	27428		Reconstruction knee						0.000%			
5115	27429		Reconstruction knee						0.000%			
5115	27438		Revise kneecap with implant						0.000%			
5115	27440		Revision of knee joint						0.000%			
5115	27441		Revision of knee joint						0.000%			
5115	27442		Revision of knee joint						0.000%			
5115	27443		Revision of knee joint						0.000%			
5115	27446		Revision of knee joint						0.000%			
5115	27447		Total knee arthroplasty						0.000%			
5115	27486		Revise/replace knee joint						0.000%			
5115	27487		Revise/replace knee joint						0.000%			
5115	27488		Removal of knee prosthesis						0.000%			
5115	27580		Fusion of knee						0.000%			
5115	27709		Osteotomy tibia & fibula						0.000%			
5115	27712		Osteot mlt relignmt imed ro						0.000%			
5115	27715		Ostpl tibfib lngth/shrt						0.000%			
5115	27758		Treatment of tibia fracture						0.000%			
5115	27759		Treatment of tibia fracture						0.000%			
5115	27827		Treat lower leg fracture						0.000%			
5115	27828		Treat lower leg fracture						0.000%			
5115	27870		Fusion of ankle joint open						0.000%			
5115	27871		Fusion of tibiofibular join						0.000%			
5115	28297		Cor hlx vlgs jt arthrd						0.000%			
5115	28320		Repair of foot bones						0.000%			
5115	28420		Treat/graft heel fracture						0.000%			
5115	28715		Arthrodesis triple						0.000%			
5115	28725		Arthrodesis subtalar						0.000%			
5115	28730		Fusion of foot bones						0.000%			
5115	28735		Fusion of foot bones						0.000%			
5115	28737		Revision of foot bones						0.000%			
5115	29856		Tibial arthroscopy/surgery						0.000%			
5115	29867		Allgrft implnt knee w/scope						0.000%			
5115	29889		Knee arthroscopy/surgery						0.000%			
5115	29907		Subtalar arthro w/fusion						0.000%			
5115	64628		Trml dstrj ios bvn 1st 2 l/						0.000%			
5115	69714		Impl oi implt skull perq es						0.000%			
5115	69716		Impl oi implt sk tc esp<100						0.000%			
5115	69719		Rplcm oi implt sk tc esp<10						0.000%			
5115	69729		Impl oi implt sk tc esp>=10						0.000%			
5115	69730		Rplc oi implt sk tc esp>=10						0.000%			
5115	0202T		Post vert arthrplst 1 lumba						0.000%			
5115	0219T		Plmt post facet implt cerv						0.000%			
5115	0220T		Plmt post facet implt thor						0.000%			
5115	0627T		Perq njx algc fluor lmbr 1s						0.000%			
5115	0629T		Perq njx algc ct lmbr 1st						0.000%			
5115	0737T		Xenograft impltj artclr sur						0.000%			
5115	C9734		"U/s trtmt, not leiomyomata"						0.000%			
5115	C9757		Spine device implant surger						0.000%			
5115	C9781		Arthro/shoul surg; w/spacer						0.000%			
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."
5116	20802		Replantation arm complete						0.000%			
5116	20805		Replant forearm complete						0.000%			
5116	20808		Replantation hand complete						0.000%			
5116	20838		Replantation foot complete						0.000%			
5116	22533		Arthrd lat xtrcvtry tq lmbr						0.000%			
5116	22556		Arthrd ant ntrbd min dsc th						0.000%			
5116	22586		Arthrd pre-sac ntrbdy l5-s1						0.000%			
5116	22600		Arthrd pst tq 1ntrspc crv						0.000%			
5116	22610		Arthrd pst tq 1ntrspc thrc						0.000%			
5116	22612		Arthrd pst tq 1ntrspc lumba						0.000%			
5116	22800		Arthrd pst dfrm<6 vrt sgm						0.000%			
5116	22802		Arthrd pst dfrm 7-12 vrt sg						0.000%			
5116	22804		Arthrd pst dfrm 13+ vrt sgm						0.000%			
5116	22808		Arthrd ant dfrm 2-3 vrt sgm						0.000%			
5116	22810		Arthrd ant dfrm 4-7 vrt sgm						0.000%			
5116	22812		Arthrd ant dfrm 8+ vrt sgm						0.000%			
5116	22818		Kyphectomy 1-2 segments						0.000%			
5116	22819		Kyphectomy 3 or more						0.000%			
5116	22836		Ant thrc vrt body tethrg <7						0.000%			
5116	22837		Ant thrc vrt body tethrg 8+						0.000%			
5116	22838		Rev rplc/rmv thrc vrt tethr						0.000%			
5116	22856		Tot disc arthrp 1ntrspc crv						0.000%			
5116	22857		Tot disc arthrp 1ntrspc lmb						0.000%			
5116	22861		Rev rplcm arthrp 1ntrspc cr						0.000%			
5116	22862		Rev rplcm rthrp 1ntrspc lmb						0.000%			
5116	22867		Insj stablj dev w/dcmprn						0.000%			
5116	23472		Reconstruct shoulder joint						0.000%			
5116	23616		Optx prx hmrl fx fix rpr rp						0.000%			
5116	24361		Reconstruct elbow joint						0.000%			
5116	24363		Replace elbow joint						0.000%			
5116	24371		Revise reconst elbow joint						0.000%			
5116	25442		Arthrp w/prostc dstl ulna						0.000%			
5116	25446		Arthrp w/prostc dst rds&crp						0.000%			
5116	27278		Arthrd si jt plmt iartic de						0.000%			
5116	27279		Arthrd si jt plmt tartclr d						0.000%			
5116	27280		Arthr si jt opn b1grf instr						0.000%			
5116	27290		Amputation of leg at hip						0.000%			
5116	27295		Amputation of leg at hip						0.000%			
5116	27703		Reconstruction ankle joint						0.000%			
5116	28705		Arthrodesis pantalar						0.000%			
5116	0656T		Ant lmbr vrt bdy teth <7 se						0.000%			
5116	0657T		Ant lmbr vrt bdy teth 8+ se						0.000%			
5116	0790T		Revj rplcmt/rmvl vrt tethrg						0.000%			
5116	C8003		Imp extar knee shck absrb						0.000%			
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."
5117	20696		App mltpln uni xtrnl fix 1s						0.000%			
5117	21243		Reconstruction of jaw joint						0.000%			
5117	22558		Arthrd ant ntrbd min dsc lu						0.000%			
5117	22630		Arthrd pst tq 1ntrspc lum						0.000%			
5117	22633		Arthrd cmbn 1ntrspc lumbar						0.000%			
5117	27702		Reconstruct ankle joint						0.000%			
5151		Level 1 Airway Endoscopy		T	2.2087	$202.64	.	$40.53	0.000%			
5151	31231		Nasal endoscopy dx						0.000%			
5151	31505		Diagnostic laryngoscopy						0.000%			
5151	31511		Remove foreign body larynx						0.000%			
5151	31575		Diagnostic laryngoscopy						0.000%			
5151	31899		Unlisted px trachea bronchi						0.000%			
5151	92511		Nasopharyngoscopy						0.000%			
5152		Level 2 Airway Endoscopy		T	4.3182	$396.18	.	$79.24	0.000%			
5152	31233		Nsl/sins ndsc dx max sinusc						0.000%			
5152	31513		Injection into vocal cord						0.000%			
5152	31515		Laryngoscopy for aspiration						0.000%			
5152	31520		Dx laryngoscopy newborn						0.000%			
5152	31577		Largsc w/rmvl foreign bdy(s						0.000%			
5152	31579		Laryngoscopy telescopic						0.000%			
5152	31646		Brnchsc w/ther aspir sbsq						0.000%			
5152	31717		Bronchial brush biopsy						0.000%			
5153		Level 3 Airway Endoscopy		J1	19.8269	"$1,819.06"	.	$363.82	0.000%			
5153	31235		Nsl/sins ndsc dx sphn sinus						0.000%			
5153	31237		Nsl/sins ndsc surg bx polyp						0.000%			
5153	31238		Nsl/sins ndsc srg nsl hemrr						0.000%			
5153	31240		Nsl/sns ndsc cnch bull resc						0.000%			
5153	31241		Nsl/sns ndsc lig sphnptn ar						0.000%			
5153	31525		Dx laryngoscopy excl nb						0.000%			
5153	31526		Dx laryngoscopy w/oper scop						0.000%			
5153	31530		Laryngoscopy w/fb removal						0.000%			
5153	31573		Largsc w/ther injection						0.000%			
5153	31574		Largsc w/njx augmentation						0.000%			
5153	31576		Laryngoscopy with biopsy						0.000%			
5153	31622		Dx bronchoscope/wash						0.000%			
5153	31623		Dx bronchoscope/brush						0.000%			
5153	31624		Dx bronchoscope/lavage						0.000%			
5153	31625		Bronchoscopy w/biopsy(s)						0.000%			
5153	31635		Bronchoscopy w/fb removal						0.000%			
5153	31643		Diag bronchoscope/catheter						0.000%			
5153	31645		Brnchsc w/ther aspir 1st						0.000%			
5153	31649		Bronchial valve remov addl						0.000%			
5153	31730		Intro windpipe wire/tube						0.000%			
5153	42975		Dise eval slp do brth flx d						0.000%			
5154		Level 4 Airway Endoscopy		J1	41.9117	"$3,845.27"	.	$769.06	0.000%			
5154	31239		Nsl/sinus endoscopy surg dc						0.000%			
5154	31256		Exploration maxillary sinus						0.000%			
5154	31510		Laryngoscopy with biopsy						0.000%			
5154	31512		Removal of larynx lesion						0.000%			
5154	31527		Laryngoscopy for treatment						0.000%			
5154	31528		Laryngoscopy and dilation						0.000%			
5154	31529		Laryngoscopy and dilation						0.000%			
5154	31531		Laryngoscopy w/fb & op scop						0.000%			
5154	31535		Laryngoscopy w/biopsy						0.000%			
5154	31536		Laryngoscopy w/bx & op scop						0.000%			
5154	31540		Laryngoscopy w/exc of tumor						0.000%			
5154	31541		Larynscop w/tumr exc + scop						0.000%			
5154	31545		Remove vc lesion w/scope						0.000%			
5154	31570		Laryngoscope w/vc inj						0.000%			
5154	31571		Laryngoscop w/vc inj + scop						0.000%			
5154	31572		Largsc w/laser dstrj les						0.000%			
5154	31578		Largsc w/removal lesion						0.000%			
5154	31628		Bronchoscopy/lung bx each						0.000%			
5154	31629		Bronchoscopy/needle bx each						0.000%			
5154	31630		Bronchoscopy dilate/fx repr						0.000%			
5154	31640		Bronchoscopy w/tumor excise						0.000%			
5154	31641		Bronchoscopy treat blockage						0.000%			
5154	31648		Bronchial valve remov init						0.000%			
5154	31652		Bronch ebus samplng 1/2 nod						0.000%			
5154	31653		Bronch ebus samplng 3/> nod						0.000%			
5155		Level 5 Airway Endoscopy		J1	79.2246	"$7,268.62"	.	"$1,453.73"	0.000%			
5155	31253		Nsl/sins ndsc total						0.000%			
5155	31254		Nsl/sins ndsc w/prtl ethmdc						0.000%			
5155	31255		Nsl/sins ndsc w/tot ethmdct						0.000%			
5155	31257		Nsl/sins ndsc tot w/sphendt						0.000%			
5155	31259		Nsl/sins ndsc sphn tiss rmv						0.000%			
5155	31267		Endoscopy maxillary sinus						0.000%			
5155	31276		Nsl/sins ndsc frnt tiss rmv						0.000%			
5155	31287		Nasal/sinus endoscopy surg						0.000%			
5155	31288		Nasal/sinus endoscopy surg						0.000%			
5155	31292		Nsl/sins ndsc med/inf dcmpr						0.000%			
5155	31293		Nsl/sins ndsc med&inf dcmpr						0.000%			
5155	31294		Nsl/sins ndsc surg on dcmpr						0.000%			
5155	31295		Nsl/sins ndsc surg max sins						0.000%			
5155	31296		Nsl/sins ndsc surg frnt sin						0.000%			
5155	31297		Nsl/sins ndsc surg sphn sin						0.000%			
5155	31298		Nsl/sins ndsc surg frnt&sph						0.000%			
5155	31546		Remove vc lesion scope/graf						0.000%			
5155	31560		Laryngoscop w/arytenoidecto						0.000%			
5155	31561		Larynscop remve cart + scop						0.000%			
5155	31626		Bronchoscopy w/markers						0.000%			
5155	31631		Bronchoscopy dilate w/stent						0.000%			
5155	31634		Bronch w/balloon occlusion						0.000%			
5155	31636		Bronchoscopy bronch stents						0.000%			
5155	31638		Bronchoscopy revise stent						0.000%			
5155	31647		Bronchial valve init insert						0.000%			
5155	31660		Bronch thermoplsty 1 lobe						0.000%			
5155	31661		Bronch thermoplsty 2/> lobe						0.000%			
5161		Level 1 ENT Procedures		T	2.6708	$245.04	.	$49.01	0.000%			
5161	21085		Impres&prep oral surg splin						0.000%			
5161	21089		Unlisted maxlfcl prosth px						0.000%			
5161	21299		Unlisted cranfcl&maxlfcl px						0.000%			
5161	21499		Unlisted muscskel px head						0.000%			
5161	21899		Unlisted px neck/thorax						0.000%			
5161	30000		Drainage of nose lesion						0.000%			
5161	30906		Repeat control of nosebleed						0.000%			
5161	30999		Unlisted procedure nose						0.000%			
5161	31000		Irrigation maxillary sinus						0.000%			
5161	31299		Unlisted px accessory sinus						0.000%			
5161	31500		Insert emergency airway						0.000%			
5161	31502		Change of windpipe airway						0.000%			
5161	31599		Unlisted procedure larynx						0.000%			
5161	31605		Emer tracheostomy cthyr mem						0.000%			
5161	40490		Biopsy of lip						0.000%			
5161	40799		Unlisted procedure lips						0.000%			
5161	40830		Repair mouth laceration						0.000%			
5161	40899		Unlisted px vestibule mouth						0.000%			
5161	41005		Drainage of mouth lesion						0.000%			
5161	41251		Repair tongue laceration						0.000%			
5161	41252		Repair tongue laceration						0.000%			
5161	41599		Unlisted px tongue flr mout						0.000%			
5161	41899		Unlisted px dentalvlr strux						0.000%			
5161	42000		Drainage mouth roof lesion						0.000%			
5161	42299		Unlisted px palate uvula						0.000%			
5161	42699		Unlisted px salivry glnd/du						0.000%			
5161	42700		Drainage of tonsil abscess						0.000%			
5161	42970		Control nose/throat bleedin						0.000%			
5161	42999		Unlisted px phrnx adnd/tnsl						0.000%			
5161	69100		Biopsy of external ear						0.000%			
5161	69399		Unlisted px external ear						0.000%			
5161	69420		Incision of eardrum						0.000%			
5161	69799		Unlisted px middle ear						0.000%			
5161	69949		Unlisted px inner ear						0.000%			
5161	69979		Unlisted px temporal bone						0.000%			
5161	D4999		Unspecified periodontal pro						0.000%			
5162		Level 2 ENT Procedures		T	5.9527	$546.14	.	$109.23	0.000%			
5162	20100		Expl pentrg wound neck						0.000%			
5162	21400		Closed tx orbit w/o manipul						0.000%			
5162	21450		Cltx mndblr fx w/o mnpj						0.000%			
5162	30020		Drainage of nose lesion						0.000%			
5162	30200		Injection treatment of nose						0.000%			
5162	30560		Lysis intranasal synechia						0.000%			
5162	31615		Trcheobrnchsc est trachs in						0.000%			
5162	40650		Rpr lip fth vermilion only						0.000%			
5162	40652		Rpr lip fth<half ver height						0.000%			
5162	40801		Drainage of mouth lesion						0.000%			
5162	40805		Removal foreign body mouth						0.000%			
5162	40806		Incision of lip fold						0.000%			
5162	40808		Biopsy of mouth lesion						0.000%			
5162	40818		Excise oral mucosa for graf						0.000%			
5162	40831		Repair mouth laceration						0.000%			
5162	41000		Drainage of mouth lesion						0.000%			
5162	41009		Drainage of mouth lesion						0.000%			
5162	41015		Drainage of mouth lesion						0.000%			
5162	41100		Biopsy of tongue						0.000%			
5162	42180		Repair lac palate<2 cm						0.000%			
5162	42280		Preparation palate mold						0.000%			
5162	42310		Drainage of salivary gland						0.000%			
5162	42320		Drainage of salivary gland						0.000%			
5162	42660		Dilation of salivary duct						0.000%			
5162	42960		Control throat bleeding						0.000%			
5162	69222		Clean out mastoid cavity						0.000%			
5162	69433		Create eardrum opening						0.000%			
5162	92502		Ear and throat examination						0.000%			
5163		Level 3 ENT Procedures		J1	17.3299	"$1,589.97"	.	$318.00	0.000%			
5163	20500		Injection of sinus tract						0.000%			
5163	21073		Mnpj of tmj w/anesth						0.000%			
5163	21076		Impres&prep surg obt prosth						0.000%			
5163	21110		Interdental fixation						0.000%			
5163	21295		Revision of jaw muscle/bone						0.000%			
5163	21315		Clsd tx nsl fx mnpj wo stbl						0.000%			
5163	21345		Closed tx nose/jaw fx						0.000%			
5163	21401		Closed tx orbit w/manipulj						0.000%			
5163	21451		Cltx mndblr fx w/mnpj						0.000%			
5163	21485		Cltx tmprmand dislc comp						0.000%			
5163	21497		Interdental wirg oth/thn fx						0.000%			
5163	30100		Intranasal biopsy						0.000%			
5163	30110		Removal of nose polyp(s)						0.000%			
5163	30124		Removal of nose lesion						0.000%			
5163	30210		Nasal sinus therapy						0.000%			
5163	30220		Insert nasal septal button						0.000%			
5163	30320		Remove nasal foreign body						0.000%			
5163	30801		Ablate inf turbinate superf						0.000%			
5163	30802		Ablate inf turbinate submuc						0.000%			
5163	31002		Irrigation sphenoid sinus						0.000%			
5163	31201		Removal of ethmoid sinus						0.000%			
5163	31603		Emer tracheostomy ttrach						0.000%			
5163	40654		Rpr lip fth>1half ver ht/cp						0.000%			
5163	40812		Excise/repair mouth lesion						0.000%			
5163	40819		Excise lip or cheek fold						0.000%			
5163	41006		Drainage of mouth lesion						0.000%			
5163	41007		Drainage of mouth lesion						0.000%			
5163	41010		Incision of tongue fold						0.000%			
5163	41018		Drainage of mouth lesion						0.000%			
5163	41115		Excision of tongue fold						0.000%			
5163	41805		Removal foreign body gum						0.000%			
5163	41806		Removal foreign body jawbon						0.000%			
5163	41821		Excision of gum flap						0.000%			
5163	41822		Excision of gum lesion						0.000%			
5163	41828		Excision of gum lesion						0.000%			
5163	41850		Treatment of gum lesion						0.000%			
5163	41870		Periodontal mucosal graftin						0.000%			
5163	42100		Biopsy roof of mouth						0.000%			
5163	42300		Drainage of salivary gland						0.000%			
5163	42405		Biopsy of salivary gland						0.000%			
5163	42650		Dilation of salivary duct						0.000%			
5163	42800		Biopsy of throat						0.000%			
5163	42900		Repair throat wound						0.000%			
5163	42955		Surgical opening of throat						0.000%			
5163	43020		Incision of esophagus						0.000%			
5163	60000		Drain thyroid/tongue cyst						0.000%			
5163	69105		Biopsy of external ear cana						0.000%			
5163	69436		Create eardrum opening						0.000%			
5163	69540		Excision aural polyp						0.000%			
5163	69610		Tympanic membrane repair						0.000%			
5163	69700		Close mastoid fistula						0.000%			
5163	69801		Incise inner ear						0.000%			
5163	0583T		Tmpst auto tube dlvr sys						0.000%			
5163	C9727		Insert palate implants						0.000%			
5163	D4231		Ana crown exp 1-3 per quad						0.000%			
5163	D4241		Gngvl flap w rootplan 1-3 t						0.000%			
5163	D4245		Apically positioned flap						0.000%			
5163	D4266		Guided tiss regen resorble						0.000%			
5163	D4267		Guided tiss regen nonresorb						0.000%			
5163	D4270		Pedicle soft tissue graft p						0.000%			
5163	D4273		Auto tissue graft 1st tooth						0.000%			
5163	D4275		Non-auto graft 1st tooth						0.000%			
5163	D4276		Con tissue w pedicle graft						0.000%			
5163	D4277		Soft tissue graft firsttoot						0.000%			
5163	D7210		Rem imp tooth w mucoper flp						0.000%			
5163	D7251		Coronectomy						0.000%			
5163	D7310		Alveoplasty w/ extraction						0.000%			
5163	D7311		Alveoloplasty w/extract 1-3						0.000%			
5163	D7320		Alveoplasty w/o extraction						0.000%			
5163	D7321		Alveoloplasty not w/extract						0.000%			
5163	D7410		Rad exc lesion up to 1.25 c						0.000%			
5163	D7411		Excision benign lesion>1.25						0.000%			
5163	D7412		Excision benign lesion comp						0.000%			
5163	D7413		Excision malig lesion<=1.25						0.000%			
5163	D7414		Excision malig lesion>1.25c						0.000%			
5163	D7415		Excision malig les complica						0.000%			
5164		Level 4 ENT Procedures		J1	37.0827	"$3,402.23"	.	$680.45	0.000%			
5164	21010		Incision of jaw joint						0.000%			
5164	21029		Contour of face bone lesion						0.000%			
5164	21031		Remove exostosis mandible						0.000%			
5164	21032		Remove exostosis maxilla						0.000%			
5164	21040		Excise mandible lesion						0.000%			
5164	21079		Impres&prep intrm obt prost						0.000%			
5164	21080		Impres&prep def obt prosth						0.000%			
5164	21082		Impres&prep paltl aug prost						0.000%			
5164	21083		Impres&prep paltl lft prost						0.000%			
5164	21084		Impres&prep sp aid prosth						0.000%			
5164	21086		Impres&prep auricular prost						0.000%			
5164	21088		Impres&prep facial prosth						0.000%			
5164	21121		Geniop sldg osteot 1						0.000%			
5164	21123		Geniop sldg augmentation						0.000%			
5164	21137		Rdctj forehead cntrg only						0.000%			
5164	21280		Medial canthopexy						0.000%			
5164	21282		Lateral canthopexy						0.000%			
5164	21296		Revision of jaw muscle/bone						0.000%			
5164	21320		Clsd tx nsl fx w/mnpj&stabl						0.000%			
5164	21325		Open tx nose fx uncomplicat						0.000%			
5164	21335		Open tx nose & septal fx						0.000%			
5164	21337		Closed tx septal&nose fx						0.000%			
5164	21340		Perq tx nasoethmoid fx						0.000%			
5164	21355		Perq tx malar fracture						0.000%			
5164	21421		Cltx palatal/max fx wire fi						0.000%			
5164	21440		Cltx mndblr/max alv ridge f						0.000%			
5164	21490		Optx tmprmand dislocation						0.000%			
5164	30115		Removal of nose polyp(s)						0.000%			
5164	30117		Removal of intranasal lesio						0.000%			
5164	30118		Removal of intranasal lesio						0.000%			
5164	30120		Revision of nose						0.000%			
5164	30130		Excise inferior turbinate						0.000%			
5164	30140		Resect inferior turbinate						0.000%			
5164	30310		Remove nasal foreign body						0.000%			
5164	30520		Repair of nasal septum						0.000%			
5164	30630		Repair nasal septum defect						0.000%			
5164	30930		Ther fx nasal inf turbinate						0.000%			
5164	31020		Exploration maxillary sinus						0.000%			
5164	31205		Removal of ethmoid sinus						0.000%			
5164	31300		Removal of larynx lesion						0.000%			
5164	31600		Planned tracheostomy						0.000%			
5164	31611		Constj trachesophgl fstl						0.000%			
5164	31612		Perq trchl pnxr ttrach aspi						0.000%			
5164	31613		Tracheostoma revj simple						0.000%			
5164	31820		Closure of windpipe lesion						0.000%			
5164	31825		Repair of windpipe defect						0.000%			
5164	31830		Revise windpipe scar						0.000%			
5164	40500		Partial excision of lip						0.000%			
5164	40510		Partial excision of lip						0.000%			
5164	40520		Partial excision of lip						0.000%			
5164	40525		Reconstruct lip with flap						0.000%			
5164	40530		Partial removal of lip						0.000%			
5164	40720		Repair cleft lip/nasal						0.000%			
5164	40810		Excision of mouth lesion						0.000%			
5164	40814		Excise/repair mouth lesion						0.000%			
5164	40816		Excision of mouth lesion						0.000%			
5164	40820		Treatment of mouth lesion						0.000%			
5164	41008		Drainage of mouth lesion						0.000%			
5164	41017		Drainage of mouth lesion						0.000%			
5164	41105		Biopsy of tongue						0.000%			
5164	41110		Excision of tongue lesion						0.000%			
5164	41112		Excision of tongue lesion						0.000%			
5164	41113		Excision of tongue lesion						0.000%			
5164	41114		Excision of tongue lesion						0.000%			
5164	41116		Excision of mouth lesion						0.000%			
5164	41510		Tongue to lip surgery						0.000%			
5164	41520		Reconstruction tongue fold						0.000%			
5164	41530		Tongue base vol reduction						0.000%			
5164	41820		Excision gum each quadrant						0.000%			
5164	41825		Excision of gum lesion						0.000%			
5164	41826		Excision of gum lesion						0.000%			
5164	41830		Removal of gum tissue						0.000%			
5164	41872		Gingivoplasty each quadrant						0.000%			
5164	41874		Alveoloplasty each quadrant						0.000%			
5164	42104		Excision lesion mouth roof						0.000%			
5164	42106		Excision lesion mouth roof						0.000%			
5164	42140		Excision of uvula						0.000%			
5164	42160		Treatment mouth roof lesion						0.000%			
5164	42205		Reconstruct cleft palate						0.000%			
5164	42305		Drainage of salivary gland						0.000%			
5164	42330		Removal of salivary stone						0.000%			
5164	42335		Removal of salivary stone						0.000%			
5164	42340		Removal of salivary stone						0.000%			
5164	42408		Excision of salivary cyst						0.000%			
5164	42409		Drainage of salivary cyst						0.000%			
5164	42510		Parotid duct diversion						0.000%			
5164	42600		Closure of salivary fistula						0.000%			
5164	42665		Ligation of salivary duct						0.000%			
5164	42720		Drainage of throat abscess						0.000%			
5164	42804		Biopsy of upper nose/throat						0.000%			
5164	42806		Biopsy of upper nose/throat						0.000%			
5164	42808		Excise pharynx lesion						0.000%			
5164	42810		Excision of neck cyst						0.000%			
5164	42821		Remove tonsils and adenoids						0.000%			
5164	42826		Removal of tonsils						0.000%			
5164	42830		Removal of adenoids						0.000%			
5164	42831		Removal of adenoids						0.000%			
5164	42835		Removal of adenoids						0.000%			
5164	42836		Removal of adenoids						0.000%			
5164	42860		Excision of tonsil tags						0.000%			
5164	42962		Control throat bleeding						0.000%			
5164	42972		Control nose/throat bleedin						0.000%			
5164	43420		Repair esophagus opening						0.000%			
5164	61330		Dcmprn orbit only transcrnl						0.000%			
5164	62000		Treat skull fracture						0.000%			
5164	69300		Revise external ear						0.000%			
5164	69421		Incision of eardrum						0.000%			
5164	69424		Remove ventilating tube						0.000%			
5164	69440		Exploration of middle ear						0.000%			
5164	69450		Eardrum revision						0.000%			
5164	69620		Myringoplasty						0.000%			
5164	69650		Stapes mobilization						0.000%			
5164	69666		Repair middle ear structure						0.000%			
5164	69667		Repair middle ear structure						0.000%			
5164	69676		Remove middle ear nerve						0.000%			
5164	69711		Remove/repair hearing aid						0.000%			
5164	69915		Incise inner ear nerve						0.000%			
5164	0964T		I&cust prep jaw xpnsj 1arch						0.000%			
5164	0965T		I&cst prp jw xpn dl arch no						0.000%			
5164	0966T		I&cst prp jw xpn dl arch fx						0.000%			
5164	D4210		Gingivectomy/plasty 4 or mo						0.000%			
5164	D4211		Gingivectomy/plasty 1 to 3						0.000%			
5164	D4212		Gingivectomy/plasty rest						0.000%			
5164	D4230		Ana crown exp 4 or> per qua						0.000%			
5164	D4240		Gingival flap proc w/ plani						0.000%			
5164	D4261		Osseous surg 1 to 3 teeth						0.000%			
5164	D7440		Malig tumor exc to 1.25 cm						0.000%			
5164	D7441		Malig tumor > 1.25 cm						0.000%			
5164	D7450		Rem odontogen cyst to 1.25c						0.000%			
5164	D7451		Rem odontogen cyst > 1.25 c						0.000%			
5164	D7471		Rem exostosis any site						0.000%			
5164	D7670		Closd rductn splint alveolu						0.000%			
5164	D7771		Alveolus clsd reduc stblz t						0.000%			
5164	G0330		Facility svs dental rehab						0.000%			
5165		Level 5 ENT Procedures		J1	67.3832	"$6,182.21"	.	"$1,236.45"	0.000%			
5165	21025		Excision of bone lower jaw						0.000%			
5165	21026		Excision of facial bone(s)						0.000%			
5165	21030		Excise max/zygoma b9 tumor						0.000%			
5165	21034		Excise max/zygoma mal tumor						0.000%			
5165	21044		Removal of jaw bone lesion						0.000%			
5165	21045		Extensive jaw surgery						0.000%			
5165	21046		Remove mandible cyst comple						0.000%			
5165	21047		Excise lwr jaw cyst w/repai						0.000%			
5165	21048		Remove maxilla cyst complex						0.000%			
5165	21049		Excis uppr jaw cyst w/repai						0.000%			
5165	21050		Removal of jaw joint						0.000%			
5165	21060		Remove jaw joint cartilage						0.000%			
5165	21070		Remove coronoid process						0.000%			
5165	21077		Impres&prep orbital prosth						0.000%			
5165	21081		Impres&prep mndbl res prost						0.000%			
5165	21087		Impres&prep nasal prosth						0.000%			
5165	21100		Maxillofacial fixation						0.000%			
5165	21120		Genioplasty augmentation						0.000%			
5165	21122		Geniop sldg osteot 2/>						0.000%			
5165	21125		Augmentation mndblr prostc						0.000%			
5165	21127		Augmentation mndblr b1 grf						0.000%			
5165	21138		Rdctj forehead cntrg&prostc						0.000%			
5165	21139		Rdctj forehead cntrg&setbac						0.000%			
5165	21141		Lefort i-1 piece w/o graft						0.000%			
5165	21142		Lefort i-2 piece w/o graft						0.000%			
5165	21143		Lefort i-3/> piece w/o graf						0.000%			
5165	21145		Lefort i-1 piece w/ graft						0.000%			
5165	21146		Lefort i-2 piece w/ graft						0.000%			
5165	21147		Lefort i-3/> piece w/ graft						0.000%			
5165	21150		Lefort ii anterior intrusio						0.000%			
5165	21151		Lefort ii w/bone grafts						0.000%			
5165	21154		Lefort iii w/o lefort i						0.000%			
5165	21155		Lefort iii w/ lefort i						0.000%			
5165	21159		Lefort iii w/fhdw/o lefort						0.000%			
5165	21160		Lefort iii w/fhd w/ lefort						0.000%			
5165	21172		Reconstruct orbit/forehead						0.000%			
5165	21175		Reconstruct orbit/forehead						0.000%			
5165	21179		Reconstruct entire forehead						0.000%			
5165	21180		Reconstruct entire forehead						0.000%			
5165	21181		Contour cranial bone lesion						0.000%			
5165	21182		Reconstruct cranial bone						0.000%			
5165	21183		Reconstruct cranial bone						0.000%			
5165	21184		Reconstruct cranial bone						0.000%			
5165	21188		Reconstruction of midface						0.000%			
5165	21193		Reconst lwr jaw w/o graft						0.000%			
5165	21194		Reconst lwr jaw w/graft						0.000%			
5165	21195		Reconst lwr jaw w/o fixatio						0.000%			
5165	21196		Reconst lwr jaw w/fixation						0.000%			
5165	21198		Reconstr lwr jaw segment						0.000%			
5165	21199		Reconstr lwr jaw w/advance						0.000%			
5165	21206		Reconstruct upper jaw bone						0.000%			
5165	21208		Augmentation of facial bone						0.000%			
5165	21209		Reduction of facial bones						0.000%			
5165	21210		Face bone graft						0.000%			
5165	21215		Lower jaw bone graft						0.000%			
5165	21230		Rib cartilage graft						0.000%			
5165	21235		Ear cartilage graft						0.000%			
5165	21240		Reconstruction of jaw joint						0.000%			
5165	21242		Reconstruction of jaw joint						0.000%			
5165	21244		Reconstruction of lower jaw						0.000%			
5165	21245		Reconstruction of jaw						0.000%			
5165	21246		Reconstruction of jaw						0.000%			
5165	21247		Reconstruct lower jaw bone						0.000%			
5165	21248		Reconstruction of jaw						0.000%			
5165	21249		Reconstruction of jaw						0.000%			
5165	21255		Reconstruct lower jaw bone						0.000%			
5165	21256		Reconstruction of orbit						0.000%			
5165	21260		Revise eye sockets						0.000%			
5165	21261		Revise eye sockets						0.000%			
5165	21263		Revise eye sockets						0.000%			
5165	21267		Revise eye sockets						0.000%			
5165	21268		Revise eye sockets						0.000%			
5165	21270		Augmentation cheek bone						0.000%			
5165	21275		Revision orbitofacial bones						0.000%			
5165	21330		Open tx nose fx w/skele fix						0.000%			
5165	21338		Open nasoethmoid fx w/o fix						0.000%			
5165	21339		Open nasoethmoid fx w/ fixj						0.000%			
5165	21343		Open tx dprsd front sinus f						0.000%			
5165	21344		Open tx compl front sinus f						0.000%			
5165	21346		Opn tx nasomax fx w/fixj						0.000%			
5165	21347		Opn tx nasomax fx multple						0.000%			
5165	21348		Opn tx nasomax fx w/graft						0.000%			
5165	21356		Opn tx dprsd zygomatic arch						0.000%			
5165	21360		Opn tx dprsd malar fracture						0.000%			
5165	21365		Opn tx complx malar fx						0.000%			
5165	21366		Opn tx complx malar w/grft						0.000%			
5165	21385		Opn tx orbit fx transantral						0.000%			
5165	21386		Opn tx orbit fx periorbital						0.000%			
5165	21387		Opn tx orbit fx combined						0.000%			
5165	21390		Opn tx orbit periorbtl impl						0.000%			
5165	21395		Opn tx orbit periorbt w/grf						0.000%			
5165	21406		Opn tx orbit fx w/o implant						0.000%			
5165	21407		Opn tx orbit fx w/implant						0.000%			
5165	21408		Opn tx orbit fx w/bone grft						0.000%			
5165	21422		Optx palatal/max fracture						0.000%			
5165	21423		Optx palatal/max fx comp						0.000%			
5165	21431		Cltx craniofacial separatio						0.000%			
5165	21432		Optx cranfcl sep w/wiring						0.000%			
5165	21433		Optx cranfcl sep comp mlt						0.000%			
5165	21435		Optx crnfc sep comp int&/xt						0.000%			
5165	21436		Optx crnfcl sep comp mlt in						0.000%			
5165	21445		Optx mndblr/max alv ridge f						0.000%			
5165	21452		Perq tx mndblr fx xtrnl fix						0.000%			
5165	21453		Cltx mndblr fx ntrdntl fixj						0.000%			
5165	21454		Optx mndblr fx xtrnl fixj						0.000%			
5165	21461		Optx mndblr fx wo ntrdntl						0.000%			
5165	21462		Optx mndblr fx w/ntrdntl						0.000%			
5165	21465		Optx mndblr cndylr fx						0.000%			
5165	21470		Optx complicated mndblr fx						0.000%			
5165	21685		Hyoid myotomy & suspension						0.000%			
5165	30125		Removal of nose lesion						0.000%			
5165	30150		Rhinectomy partial						0.000%			
5165	30160		Rhinectomy total						0.000%			
5165	30400		Reconstruction of nose						0.000%			
5165	30410		Reconstruction of nose						0.000%			
5165	30420		Reconstruction of nose						0.000%			
5165	30430		Revision of nose						0.000%			
5165	30435		Revision of nose						0.000%			
5165	30450		Revision of nose						0.000%			
5165	30460		Revision of nose						0.000%			
5165	30462		Revision of nose						0.000%			
5165	30465		Repair nasal stenosis						0.000%			
5165	30468		Rpr nsl vlv collapse w/impl						0.000%			
5165	30469		Rpr nsl vlv collapse w/rmdl						0.000%			
5165	30540		Rpr choanal atresia ntranas						0.000%			
5165	30545		Rpr choanal atresia trsnplt						0.000%			
5165	30580		Repair upper jaw fistula						0.000%			
5165	30600		Repair mouth/nose fistula						0.000%			
5165	30620		Intranasal reconstruction						0.000%			
5165	31030		Exploration maxillary sinus						0.000%			
5165	31032		Explore sinus remove polyps						0.000%			
5165	31040		Exploration behind upper ja						0.000%			
5165	31050		Exploration sphenoid sinus						0.000%			
5165	31051		Sphenoid sinus surgery						0.000%			
5165	31070		Exploration of frontal sinu						0.000%			
5165	31075		Exploration of frontal sinu						0.000%			
5165	31080		Removal of frontal sinus						0.000%			
5165	31081		Removal of frontal sinus						0.000%			
5165	31084		Removal of frontal sinus						0.000%			
5165	31085		Removal of frontal sinus						0.000%			
5165	31086		Removal of frontal sinus						0.000%			
5165	31087		Removal of frontal sinus						0.000%			
5165	31090		Exploration of sinuses						0.000%			
5165	31200		Removal of ethmoid sinus						0.000%			
5165	31242		Nsl/sinus ndsc rf abltj pnn						0.000%			
5165	31243		Nsl/sinus ndsc cryoabltj pn						0.000%			
5165	31400		Revision of larynx						0.000%			
5165	31420		Epiglottidectomy						0.000%			
5165	31551		Laryngoplasty laryngeal ste						0.000%			
5165	31552		Laryngoplasty laryngeal ste						0.000%			
5165	31553		Laryngoplasty laryngeal ste						0.000%			
5165	31554		Laryngoplasty laryngeal ste						0.000%			
5165	31580		Laryngoplasty laryngeal web						0.000%			
5165	31584		Laryngoplasty fx rdctj fixj						0.000%			
5165	31587		Laryngoplasty cricoid split						0.000%			
5165	31590		Reinnervate larynx						0.000%			
5165	31591		Laryngoplasty medialization						0.000%			
5165	31592		Cricotracheal resection						0.000%			
5165	31601		Planned tracheostomy<2 yrs						0.000%			
5165	31610		Tracheostomy fenest skin fl						0.000%			
5165	31614		Tracheostoma revj complex						0.000%			
5165	31750		Tracheoplasty cervical						0.000%			
5165	31755		Trachplsty trchphryngl fstl						0.000%			
5165	31785		Remove windpipe lesion						0.000%			
5165	40527		Reconstruct lip with flap						0.000%			
5165	40700		Repair cleft lip/nasal						0.000%			
5165	40701		Repair cleft lip/nasal						0.000%			
5165	40702		Repair cleft lip/nasal						0.000%			
5165	40761		Repair cleft lip/nasal						0.000%			
5165	40840		Reconstruction of mouth						0.000%			
5165	40842		Reconstruction of mouth						0.000%			
5165	40843		Reconstruction of mouth						0.000%			
5165	40844		Reconstruction of mouth						0.000%			
5165	40845		Reconstruction of mouth						0.000%			
5165	41016		Drainage of mouth lesion						0.000%			
5165	41019		Place needles h&n for rt						0.000%			
5165	41120		Partial removal of tongue						0.000%			
5165	41512		Tongue suspension						0.000%			
5165	41823		Excision of gum lesion						0.000%			
5165	41827		Excision of gum lesion						0.000%			
5165	42107		Excision lesion mouth roof						0.000%			
5165	42120		Remove palate/lesion						0.000%			
5165	42145		Repair palate pharynx/uvula						0.000%			
5165	42182		Repair palate						0.000%			
5165	42200		Reconstruct cleft palate						0.000%			
5165	42210		Reconstruct cleft palate						0.000%			
5165	42215		Reconstruct cleft palate						0.000%			
5165	42220		Reconstruct cleft palate						0.000%			
5165	42225		Reconstruct cleft palate						0.000%			
5165	42226		Lengthening of palate						0.000%			
5165	42227		Lengthening of palate						0.000%			
5165	42235		Repair palate						0.000%			
5165	42260		Repair nose to lip fistula						0.000%			
5165	42281		Insertion palate prosthesis						0.000%			
5165	42410		Excise parotid gland/lesion						0.000%			
5165	42415		Excise parotid gland/lesion						0.000%			
5165	42420		Excise parotid gland/lesion						0.000%			
5165	42425		Excise parotid gland/lesion						0.000%			
5165	42440		Excise submaxillary gland						0.000%			
5165	42450		Excise sublingual gland						0.000%			
5165	42500		Repair salivary duct						0.000%			
5165	42505		Repair salivary duct						0.000%			
5165	42507		Parotid duct diversion						0.000%			
5165	42509		Parotid duct diversion						0.000%			
5165	42725		Drainage of throat abscess						0.000%			
5165	42815		Excision of neck cyst						0.000%			
5165	42820		Remove tonsils and adenoids						0.000%			
5165	42825		Removal of tonsils						0.000%			
5165	42842		Extensive surgery of throat						0.000%			
5165	42844		Extensive surgery of throat						0.000%			
5165	42870		Excision of lingual tonsil						0.000%			
5165	42890		Limited pharyngectomy						0.000%			
5165	42892		Revision of pharyngeal wall						0.000%			
5165	42950		Reconstruction of throat						0.000%			
5165	43030		Cricopharyngeal myotomy						0.000%			
5165	43130		Removal of esophagus pouch						0.000%			
5165	43180		Esophagoscopy rigid trnso						0.000%			
5165	60252		Removal of thyroid						0.000%			
5165	60260		Repeat thyroid surgery						0.000%			
5165	60271		Removal of thyroid						0.000%			
5165	60500		Explore parathyroid glands						0.000%			
5165	60502		Re-explore parathyroids						0.000%			
5165	60520		Removal of thymus gland						0.000%			
5165	69120		Removal of external ear						0.000%			
5165	69140		Remove ear canal lesion(s)						0.000%			
5165	69150		Extensive ear canal surgery						0.000%			
5165	69310		Rebuild outer ear canal						0.000%			
5165	69320		Rebuild outer ear canal						0.000%			
5165	69501		Mastoidectomy						0.000%			
5165	69502		Mastoidectomy						0.000%			
5165	69505		Remove mastoid structures						0.000%			
5165	69511		Extensive mastoid surgery						0.000%			
5165	69530		Extensive mastoid surgery						0.000%			
5165	69550		Exc aurl glomus tum trnscan						0.000%			
5165	69552		Exc aurl glomus tum trnsmst						0.000%			
5165	69601		Revj mstdc rsltg compl mstd						0.000%			
5165	69602		Rev mstdc rslt mod rad mstd						0.000%			
5165	69603		Revj mstdc rsltg rad mstdc						0.000%			
5165	69604		Revj mstdc rsltg tympanplst						0.000%			
5165	69631		Repair eardrum structures						0.000%			
5165	69632		Rebuild eardrum structures						0.000%			
5165	69633		Rebuild eardrum structures						0.000%			
5165	69635		Repair eardrum structures						0.000%			
5165	69636		Rebuild eardrum structures						0.000%			
5165	69637		Rebuild eardrum structures						0.000%			
5165	69641		Revise middle ear & mastoid						0.000%			
5165	69642		Revise middle ear & mastoid						0.000%			
5165	69643		Revise middle ear & mastoid						0.000%			
5165	69644		Revise middle ear & mastoid						0.000%			
5165	69645		Revise middle ear & mastoid						0.000%			
5165	69646		Revise middle ear & mastoid						0.000%			
5165	69660		Revise middle ear bone						0.000%			
5165	69661		Revise middle ear bone						0.000%			
5165	69662		Revise middle ear bone						0.000%			
5165	69670		Remove mastoid air cells						0.000%			
5165	69705		Nps surg dilat eust tube un						0.000%			
5165	69706		Nps surg dilat eust tube bi						0.000%			
5165	69720		Release facial nerve						0.000%			
5165	69725		Release facial nerve						0.000%			
5165	69740		Repair facial nerve						0.000%			
5165	69745		Repair facial nerve						0.000%			
5165	69805		Explore inner ear						0.000%			
5165	69806		Explore inner ear						0.000%			
5165	69905		Remove inner ear						0.000%			
5165	69910		Remove inner ear & mastoid						0.000%			
5165	69955		Release facial nerve						0.000%			
5165	69960		Release inner ear canal						0.000%			
5165	69970		Remove inner ear lesion						0.000%			
5165	D4260		Osseous surgery 4 or more						0.000%			
5165	D7340		Vestibuloplasty ridge exten						0.000%			
5165	D7350		Vestibuloplasty exten graft						0.000%			
5165	D7485		Surg reduct osseoustuberosi						0.000%			
5165	D7671		Alveolus open reduction						0.000%			
5165	D7770		Open reduc compd alveolus f						0.000%			
5165	D7950		Mandible graft						0.000%			
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."
5166	69930		Implant cochlear device						0.000%			
5181		Level 1 Vascular Procedures		T	7.0398	$645.88	.	$129.18	0.000%			
5181	32552		Remove lung catheter						0.000%			
5181	32554		Aspirate pleura w/o imaging						0.000%			
5181	32555		Aspirate pleura w/ imaging						0.000%			
5181	32560		Treat pleurodesis w/agent						0.000%			
5181	32561		Lyse chest fibrin init day						0.000%			
5181	32562		Lyse chest fibrin subq day						0.000%			
5181	32960		Therapeutic pneumothorax						0.000%			
5181	32999		Unlisted px lungs & pleura						0.000%			
5181	33999		Unlisted px cardiac surgery						0.000%			
5181	34471		Removal of vein clot						0.000%			
5181	36002		Pseudoaneurysm injection tr						0.000%			
5181	36572		Insj picc rs&i <5 yr						0.000%			
5181	36575		Repair tunneled cv cath						0.000%			
5181	36589		Removal tunneled cv cath						0.000%			
5181	37501		Unlisted vasc endoscopy px						0.000%			
5181	37799		Unlisted px vascular surger						0.000%			
5181	75801		Lymph vessel x-ray arm/leg						0.000%			
5181	75872		Vein x-ray skull epidural						0.000%			
5181	75880		Vein x-ray eye socket						0.000%			
5181	0415T		Repos car modulj tranvns el						0.000%			
5181	0924T		Rpos prv ccm-d trnsvns eltr						0.000%			
5181	X460T		Active thrc irrigation spx						0.000%			
5182		Level 2 Vascular Procedures		J1	17.4627	"$1,602.15"	.	$320.43	0.000%			
5182	32551		Insertion of chest tube						0.000%			
5182	32557		Insert cath pleura w/ image						0.000%			
5182	33016		Pericardiocentesis w/imagin						0.000%			
5182	35180		Rpr cgen av fistula head&nc						0.000%			
5182	36568		Insj picc <5 yr w/o imaging						0.000%			
5182	36569		Insj picc 5 yr+ w/o imaging						0.000%			
5182	36573		Insj picc rs&i 5 yr+						0.000%			
5182	36576		Repair tunneled cv cath						0.000%			
5182	36580		Replace cvad cath						0.000%			
5182	36584		Compl rplcmt picc rs&i						0.000%			
5182	36590		Removal tunneled cv cath						0.000%			
5182	36596		Mech remov tunneled cv cath						0.000%			
5182	36597		Reposition venous catheter						0.000%			
5182	36860		External cannula declotting						0.000%			
5182	36901		Intro cath dialysis circuit						0.000%			
5182	75803		Lymph vessel x-ray arms/leg						0.000%			
5182	75820		Vein x-ray arm/leg						0.000%			
5182	75822		Vein x-ray arms/legs						0.000%			
5182	75827		Vein x-ray chest						0.000%			
5182	93503		Insert/place heart catheter						0.000%			
5183		Level 3 Vascular Procedures		J1	35.4696	"$3,254.23"	.	$650.85	0.000%			
5183	30915		Ligation nasal sinus artery						0.000%			
5183	30920		Ligation upper jaw artery						0.000%			
5183	33215		Reposition pacing-defib lea						0.000%			
5183	33226		Reposition l ventric lead						0.000%			
5183	33275		Tcat rmvl perm ldls pm w/im						0.000%			
5183	34421		Removal of vein clot						0.000%			
5183	34490		Removal of vein clot						0.000%			
5183	34530		Leg vein fusion						0.000%			
5183	35184		Rpr cgen av fistula xtr						0.000%			
5183	35206		Repair blood vessel dir uxt						0.000%			
5183	35207		Rpr bld vsl dir hand finger						0.000%			
5183	35231		Repair blvsl vn grf neck						0.000%			
5183	35261		Rpr blvsl grf oth/thn vn nc						0.000%			
5183	35860		Explore limb vessels						0.000%			
5183	35903		Excision graft extremity						0.000%			
5183	36221		Place cath thoracic aorta						0.000%			
5183	36222		Place cath carotid/inom art						0.000%			
5183	36225		Place cath subclavian art						0.000%			
5183	36251		Ins cath ren art 1st unilat						0.000%			
5183	36252		Ins cath ren art 1st bilat						0.000%			
5183	36254		Ins cath ren art 2nd+ bilat						0.000%			
5183	36473		Endovenous mchnchem 1st vei						0.000%			
5183	36475		Endovenous rf 1st vein						0.000%			
5183	36478		Endovenous laser 1st vein						0.000%			
5183	36555		Insert non-tunnel cv cath						0.000%			
5183	36556		Insert non-tunnel cv cath						0.000%			
5183	36558		Insert tunneled cv cath						0.000%			
5183	36560		Insert tunneled cv cath						0.000%			
5183	36561		Insert tunneled cv cath						0.000%			
5183	36565		Insert tunneled cv cath						0.000%			
5183	36570		Insert picvad cath						0.000%			
5183	36571		Insert picvad cath						0.000%			
5183	36578		Replace tunneled cv cath						0.000%			
5183	36581		Replace tunneled cv cath						0.000%			
5183	36582		Replace tunneled cv cath						0.000%			
5183	36585		Replace picvad cath						0.000%			
5183	36595		Mech remov tunneled cv cath						0.000%			
5183	36640		Insertion catheter artery						0.000%			
5183	36810		Insertion of cannula						0.000%			
5183	36821		Av fusion direct any site						0.000%			
5183	36835		Insertion thomas shunt						0.000%			
5183	37188		Ven mechnl thrmbc repeat tx						0.000%			
5183	37192		Redo endovas vena cava filt						0.000%			
5183	37193		Rem endovas vena cava filte						0.000%			
5183	37197		Remove intrvas foreign body						0.000%			
5183	37212		Thrombolytic venous therapy						0.000%			
5183	37213		Thromblytic art/ven therapy						0.000%			
5183	37214		Cessj therapy cath removal						0.000%			
5183	37565		Ligation int jugular vein						0.000%			
5183	37600		Ligation xtrnl carotid art						0.000%			
5183	37605		Ligation int/com carotid ar						0.000%			
5183	37606		Lig int/com carotid art occ						0.000%			
5183	37607		Lig/banding angioacs av fst						0.000%			
5183	37615		Ligation major artery neck						0.000%			
5183	37650		Ligation of femoral vein						0.000%			
5183	37700		Ligation&div long saph vein						0.000%			
5183	37718		Lig div&strpg short saph vn						0.000%			
5183	37722		Lig div&strpg long saph vei						0.000%			
5183	37735		Lig&div&compl strpg saph vn						0.000%			
5183	37760		Lig prfratr vn radical 1 le						0.000%			
5183	37761		Ligate leg veins open						0.000%			
5183	37765		Stab phleb veins xtr 10-20						0.000%			
5183	37766		Phleb veins - extrem 20+						0.000%			
5183	37780		Revision of leg vein						0.000%			
5183	37785		Ligate/divide/excise vein						0.000%			
5183	49422		Remove tunneled ip cath						0.000%			
5183	49429		Removal of shunt						0.000%			
5183	75600		Contrast exam thoracic aort						0.000%			
5183	75625		Contrast exam abdominl aort						0.000%			
5183	75630		X-ray aorta leg arteries						0.000%			
5183	75710		Artery x-rays arm/leg						0.000%			
5183	75716		Artery x-rays arms/legs						0.000%			
5183	75731		Artery x-rays adrenal gland						0.000%			
5183	75733		Artery x-rays adrenals						0.000%			
5183	75741		Artery x-rays lung						0.000%			
5183	75743		Artery x-rays lungs						0.000%			
5183	75746		Artery x-rays lung						0.000%			
5183	75756		Artery x-rays chest						0.000%			
5183	75805		Lymph vessel x-ray trunk						0.000%			
5183	75807		Lymph vessel x-ray trunk						0.000%			
5183	75810		Vein x-ray spleen/liver						0.000%			
5183	75825		Vein x-ray trunk						0.000%			
5183	75831		Vein x-ray kidney						0.000%			
5183	75833		Vein x-ray kidneys						0.000%			
5183	75840		Vein x-ray adrenal gland						0.000%			
5183	75860		Vein x-ray neck						0.000%			
5183	75870		Vein x-ray skull						0.000%			
5183	75885		Vein x-ray liver w/hemodyna						0.000%			
5183	75887		Vein x-ray liver w/o hemody						0.000%			
5183	75889		Vein x-ray liver w/hemodyna						0.000%			
5183	75891		Vein x-ray liver						0.000%			
5183	75898		Follow-up angiography						0.000%			
5183	93505		Endomyocardial biopsy						0.000%			
5183	0524T		Ev cath dir chem abltj w/im						0.000%			
5183	0798T		Tcat rmv 2chmbr ldls pm cmp						0.000%			
5183	0799T		Tcat rmvl 2chmbr ldls pm ra						0.000%			
5183	0800T		Tcat rmvl 2chmbr ldls pm rv						0.000%			
5183	0824T		Tcat rmv 1chmbr ldls pm ra						0.000%			
5184		Level 4 Vascular Procedures		J1	62.2596	"$5,712.13"	.	"$1,142.43"	0.000%			
5184	34101		Removal of artery clot						0.000%			
5184	34111		Removal of arm artery clot						0.000%			
5184	34201		Removal of artery clot						0.000%			
5184	34203		Removal of leg artery clot						0.000%			
5184	34501		Repair valve femoral vein						0.000%			
5184	34510		Transposition of vein valve						0.000%			
5184	34520		Cross-over vein graft						0.000%			
5184	35011		Repair defect of artery						0.000%			
5184	35045		Repair defect of arm artery						0.000%			
5184	35188		Rpr acq av fistula head&nec						0.000%			
5184	35190		Repair acq av fistula xtr						0.000%			
5184	35201		Repair blood vessel dir nec						0.000%			
5184	35236		Repair blvsl vn grf uxtr						0.000%			
5184	35256		Repair blvsl vn grf lxtr						0.000%			
5184	35266		Rpr blvsl grf oth/th vn uxt						0.000%			
5184	35286		Rpr blvsl grf oth/th vn lxt						0.000%			
5184	35321		Rechanneling of artery						0.000%			
5184	35372		Rechanneling of artery						0.000%			
5184	35800		Explore neck vessels						0.000%			
5184	35875		Removal of clot in graft						0.000%			
5184	35876		Removal of clot in graft						0.000%			
5184	35879		Revise graft w/vein						0.000%			
5184	35881		Revise graft w/vein						0.000%			
5184	35883		Revj fem anast nonautog grf						0.000%			
5184	35884		Revj fem anast autog vn grf						0.000%			
5184	36223		Place cath carotid/inom art						0.000%			
5184	36224		Place cath carotd art						0.000%			
5184	36226		Place cath vertebral art						0.000%			
5184	36253		Ins cath ren art 2nd+ unila						0.000%			
5184	36260		Insertion of infusion pump						0.000%			
5184	36482		Endoven ther chem adhes 1st						0.000%			
5184	36557		Insert tunneled cv cath						0.000%			
5184	36563		Insert tunneled cv cath						0.000%			
5184	36566		Insert tunneled cv cath						0.000%			
5184	36583		Replace tunneled cv cath						0.000%			
5184	36800		Insertion of cannula						0.000%			
5184	36815		Insertion of cannula						0.000%			
5184	36818		Av fuse uppr arm cephalic						0.000%			
5184	36819		Av fuse uppr arm basilic						0.000%			
5184	36820		Av fusion/forearm vein						0.000%			
5184	36825		Artery-vein autograft						0.000%			
5184	36830		Artery-vein nonautograft						0.000%			
5184	36831		Open thrombect av fistula						0.000%			
5184	36832		Av fistula revision open						0.000%			
5184	36833		Av fistula revision						0.000%			
5184	36838		Dist revas ligation hemo						0.000%			
5184	36861		Cannula declotting						0.000%			
5184	37191		Ins endovas vena cava filtr						0.000%			
5184	37200		Transcatheter biopsy						0.000%			
5184	37211		Thrombolytic art therapy						0.000%			
5184	37617		Ligation major artery abd						0.000%			
5184	37619		Ligation of inf vena cava						0.000%			
5184	49419		Insert tun ip cath w/port						0.000%			
5184	75605		Contrast exam thoracic aort						0.000%			
5184	75705		Artery x-rays spine						0.000%			
5184	75726		Artery x-rays abdomen						0.000%			
5184	75736		Artery x-rays pelvis						0.000%			
5184	75893		Venous sampling by catheter						0.000%			
5184	0744T		Insj bioprostc vlv fem vn						0.000%			
5191		Level 1 Endovascular Procedures		J1	36.1748	"$3,318.93"	$863.75	$663.79	0.000%			
5191	93451		Right heart cath						0.000%			
5191	93452		Left hrt cath w/ventrclgrph						0.000%			
5191	93453		R&l hrt cath w/ventriclgrph						0.000%			
5191	93454		Coronary artery angio s&i						0.000%			
5191	93455		Coronary art/grft angio s&i						0.000%			
5191	93456		R hrt coronary artery angio						0.000%			
5191	93457		R hrt art/grft angio						0.000%			
5191	93458		L hrt artery/ventricle angi						0.000%			
5191	93459		L hrt art/grft angio						0.000%			
5191	93460		R&l hrt art/ventricle angio						0.000%			
5191	93461		R&l hrt art/ventricle angio						0.000%			
5191	93593		R hrt cath chd nml nt cnj						0.000%			
5191	93594		R hrt cath chd abnl nt cnj						0.000%			
5191	93595		L hrt cath chd nm/abn nt cn						0.000%			
5191	93596		R&l hrt cath chd nml nt cnj						0.000%			
5191	93597		R&l hrt cath chd abnl nt cn						0.000%			
5191	0933T		Tcat impl wrls l atr prs sn						0.000%			
5192		Level 2 Endovascular Procedures		J1	64.0964	"$5,880.65"	.	"$1,176.13"	0.000%			
5192	36902		Intro cath dialysis circuit						0.000%			
5192	36904		Thrmbc/nfs dialysis circuit						0.000%			
5192	37183		Revision tips						0.000%			
5192	37246		Trluml balo angiop 1st art						0.000%			
5192	37248		Trluml balo angiop 1st vein						0.000%			
5192	92920		Prq trluml c angiop 1art&/b						0.000%			
5192	92986		Revision of aortic valve						0.000%			
5192	0338T		Trnscth renal symp denrv un						0.000%			
5192	0339T		Trnscth renal symp denrv bi						0.000%			
5192	0644T		Tcat rmvl/dblk icar mas per						0.000%			
5192	0913T		Prq tcat ther rx ntrac balo						0.000%			
5192	37X03		Revsc evasc ivt angio cplx						0.000%			
5192	37X10		Revsc evasc fpvt angio sf 1						0.000%			
5192	37X12		Revsc evsc fpvt angio cplx						0.000%			
5192	37XX1		Revsc evasc ivt angio sf 1s						0.000%			
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."
5193	33900		Perq p-art revsc 1 nm nt un						0.000%			
5193	33901		Perq p-art revsc 1 nm nt bi						0.000%			
5193	33903		Perq p-art revsc 1 abnor bi						0.000%			
5193	36903		Intro cath dialysis circuit						0.000%			
5193	36905		Thrmbc/nfs dialysis circuit						0.000%			
5193	37182		Insert hepatic shunt (tips)						0.000%			
5193	37187		Venous mech thrombectomy						0.000%			
5193	37236		Open/perq place stent 1st						0.000%			
5193	37238		Open/perq place stent same						0.000%			
5193	37241		Vasc embolize/occlude venou						0.000%			
5193	37243		Vasc embolize/occlude organ						0.000%			
5193	37244		Vasc embolize/occlude bleed						0.000%			
5193	61623		Endovasc tempory vessel occ						0.000%			
5193	61626		Tcat perm occls/embol noncn						0.000%			
5193	92924		Prq trluml c athrc 1 art&/b						0.000%			
5193	92928		Prq tcat plmt ntrac st 1 le						0.000%			
5193	92937		Prq trluml revsc cab grf 1						0.000%			
5193	92943		Prq trluml revsc ch occ ant						0.000%			
5193	92987		Revision of mitral valve						0.000%			
5193	92990		Revision of pulmonary valve						0.000%			
5193	92997		Pul art balloon repr percut						0.000%			
5193	0234T		Trluml perip athrc renal ar						0.000%			
5193	0236T		Trluml perip athrc abd aort						0.000%			
5193	0237T		Trluml perip athrc brchiocp						0.000%			
5193	0505T		Ev fempop artl revsc						0.000%			
5193	37X05		Revsc evasc ivt stent sf 1s						0.000%			
5193	37X07		Revsc evasc ivt st cplx 1st						0.000%			
5193	37X14		Revsc evsc fpvt stent sf 1s						0.000%			
5193	37X16		Revsc evasc fpvt st cplx 1s						0.000%			
5193	37X27		Revsc evsc tpvt angio sf 1s						0.000%			
5193	37X29		Rvsc evsc tpvt angio cplx 1						0.000%			
5193	37X43		Revsc evasc imvt angio sf 1						0.000%			
5193	37X45		Revsc evsc imvt angio cplx						0.000%			
5193	92X01		Prq tcat plmt ntrac st 2+le						0.000%			
5193	92X02		Prq trl rvs ch occ ant&rtrg						0.000%			
5193	C8004		Sim ang w/prs cath rad emb						0.000%			
5193	C9600		Perc drug-el cor stent sing						0.000%			
5193	C9604		Perc d-e cor revasc t cabg						0.000%			
5193	C9764		Revasc intravasc lithotrips						0.000%			
5193	C9772		Revasc lithotrip tibi/peron						0.000%			
5193	C9783		Blind cor sinus reducer imp						0.000%			
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."
5194	33902		Perq p-art revsc 1 abnor un						0.000%			
5194	36836		Prq av fstl crtj uxtr 1 acs						0.000%			
5194	36837		Prq av fstl crt uxtr sep ac						0.000%			
5194	36906		Thrmbc/nfs dialysis circuit						0.000%			
5194	37184		Prim art m-thrmbc 1st vsl						0.000%			
5194	37242		Vasc embolize/occlude arter						0.000%			
5194	61624		Tcat perm occls/embolj cns						0.000%			
5194	92933		Prq trlml c athrc st angiop						0.000%			
5194	93580		Transcath closure of asd						0.000%			
5194	93581		Transcath closure of vsd						0.000%			
5194	93582		Perq transcath closure pda						0.000%			
5194	93590		Perq transcath cls mitral						0.000%			
5194	93591		Perq transcath cls aortic						0.000%			
5194	0238T		Trluml perip athrc iliac ar						0.000%			
5194	0632T		Perq tcat us abltj nrv p-ar						0.000%			
5194	0645T		Tcat impltj c sins rdctj de						0.000%			
5194	0793T		Prq tcat thrm ablt nrv p-ar						0.000%			
5194	0981T		Tcat impl wrls ivc snr						0.000%			
5194	37X18		Revsc evsc fpvt athrc sf 1s						0.000%			
5194	37X20		Revsc evsc fpvt athrc cplx						0.000%			
5194	37X22		Rvsc evsc fpvt st athrc sf						0.000%			
5194	37X24		Rvsc evsc fpvt st athr cpx						0.000%			
5194	37X31		Revsc evasc tpvt st sf 1st						0.000%			
5194	37X33		Revsc evasc tpvt st cplx 1s						0.000%			
5194	37X35		Revsc evsc tpvt athrc sf 1s						0.000%			
5194	37X37		Revsc evsc tpvt athrc cplx						0.000%			
5194	37X39		Rvsc evsc tpvt st athrc sf						0.000%			
5194	37X41		Rvsc evsc tpvt st athr cpx						0.000%			
5194	C9602		Perc d-e cor stent ather s						0.000%			
5194	C9607		Perc d-e cor revasc chro si						0.000%			
5194	C9765		Revasc intra lithotrip-sten						0.000%			
5194	C9766		Revasc intra lithotrip-athe						0.000%			
5194	C9767		Revasc lithotrip-stent-athe						0.000%			
5194	C9773		Revasc lithotr-stent tib/pe						0.000%			
5194	C9774		Revasc lithotr-ather tib/pe						0.000%			
5194	C9775		Revasc lith-sten-ath tib/pe						0.000%			
5194	C9797		Vasc emb/occ w/prs cath						0.000%			
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."
5200	33289		Tcat impl wrls p-art prs sn						0.000%			
5211		Level 1 Electrophysiologic Procedures		J1	13.4278	"$1,231.96"	.	$246.40	0.000%			
5211	93603		Right ventricular recording						0.000%			
5211	93615		Esophageal recording						0.000%			
5211	93616		Esophageal recording w/pacg						0.000%			
5211	93618		Indctj arrhythmia elec pacg						0.000%			
5211	93642		Ep evl 1/2chmb trnsvns cvdf						0.000%			
5211	0577T		Ephys eval icds ss						0.000%			
5211	0930T		Ephys eval ccm-d ld 1st imp						0.000%			
5211	0931T		Ephys eval ccm-d ld separat						0.000%			
5212		Level 2 Electrophysiologic Procedures		J1	86.8856	"$7,971.49"	.	"$1,594.30"	0.000%			
5212	93600		Bundle of his recording						0.000%			
5212	93602		Intra-atrial recording						0.000%			
5212	93610		Intra-atrial pacing						0.000%			
5212	93612		Intraventricular pacing						0.000%			
5212	93619		Comprehensive ep evaluation						0.000%			
5212	93620		Comp ep evl r at ven pac&re						0.000%			
5212	93624		Ep f-up study pacg&rec						0.000%			
5212	93650		Icar cath abltj av node fun						0.000%			
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."
5213	93653		Compre ep eval tx svt						0.000%			
5213	93654		Compre ep eval tx vt						0.000%			
5213	93656		Compre ep eval abltj atr fi						0.000%			
5221		Level 1 Pacemaker and Similar Procedures		T	42.704	"$3,917.96"	.	$783.60	0.000%			
5221	33218		Repair lead pace-defib one						0.000%			
5221	33220		Repair lead pace-defib dual						0.000%			
5221	33234		Removal of pacemaker system						0.000%			
5221	33235		Removal pacemaker electrode						0.000%			
5221	33241		Remove pulse generator						0.000%			
5221	33244		Remove elctrd transvenously						0.000%			
5221	33272		Rmvl of subq defibrillator						0.000%			
5221	33273		Repos prev impltbl subq dfb						0.000%			
5221	36261		Revision of infusion pump						0.000%			
5221	36262		Removal of infusion pump						0.000%			
5221	0412T		Rmvl cardiac modulj pls gen						0.000%			
5221	0413T		Rmvl car modulj tranvns elt						0.000%			
5221	0518T		Rmvl pg wcs lv battery only						0.000%			
5221	0530T		Removal complete iims						0.000%			
5221	0531T		Removal iims electrode only						0.000%			
5221	0532T		Removal iims implt mntr onl						0.000%			
5221	0573T		Removal ss dfb electrode						0.000%			
5221	0574T		Repos prev ss impl dfb eltr						0.000%			
5221	0580T		Rmvl ss impl dfb pg only						0.000%			
5221	0861T		Rmvl pg wcs lv both compnt						0.000%			
5221	0919T		Rmvl perm ccm-d sys pg only						0.000%			
5221	0920T		Rmvl perm ccm-d sys 1 pac l						0.000%			
5221	0921T		Rmvl perm ccm-d sys 1 dfb l						0.000%			
5221	0922T		Rmvl perm ccm-d sys dual ld						0.000%			
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."
5222	33210		Insert electrd/pm cath sngl						0.000%			
5222	33211		Insert card electrodes dual						0.000%			
5222	33212		Insert pulse gen sngl lead						0.000%			
5222	33216		Insert 1 electrode pm-defib						0.000%			
5222	33217		Insert 2 electrode pm-defib						0.000%			
5222	33227		Remove&replace pm gen singl						0.000%			
5222	33233		Removal of pm generator						0.000%			
5222	33271		Insj subq impltbl dfb elctr						0.000%			
5222	33285		Insj subq car rhythm mntr						0.000%			
5222	0410T		Insj/rplc car modulj atr el						0.000%			
5222	0411T		Insj/rplc car modulj vnt el						0.000%			
5222	0526T		Insj/rplcmt iims eltrd only						0.000%			
5222	0527T		Insj/rplcmt iims implt mntr						0.000%			
5222	0572T		Insertion ss dfb electrode						0.000%			
5222	0917T		Insj perm ccm-d sys 1 lead						0.000%			
5222	0918T		Insj perm ccm-d sys dual ld						0.000%			
5223		Level 3 Pacemaker and Similar Procedures		J1	116.992	"$10,733.67"	.	"$2,146.74"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
5223	33206		Insert heart pm atrial						0.000%			
5223	33207		Insert heart pm ventricular						0.000%			
5223	33208		Insrt heart pm atrial & ven						0.000%			
5223	33213		Insert pulse gen dual leads						0.000%			
5223	33214		Upgrade of pacemaker system						0.000%			
5223	33224		Insert pacing lead & connec						0.000%			
5223	33228		Remv&replc pm gen dual lead						0.000%			
5223	0516T		Insj wcs lv eltrd only						0.000%			
5223	0517T		Insj wcs lv both compnt pg						0.000%			
5223	0519T		Rmv&rplcmt pg wcs lv both						0.000%			
5223	0520T		Rmv&rplcmt pg wcs lv batter						0.000%			
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."
5224	33221		Insert pulse gen mult leads						0.000%			
5224	33229		Remv&replc pm gen mult lead						0.000%			
5224	33274		Tcat insj/rpl perm ldls pm						0.000%			
5224	0525T		Insj/rplcmt compl iims						0.000%			
5224	0795T		Tcat ins 2chmbr ldls pm cmp						0.000%			
5224	0796T		Tcat ins 2chmbr ldls pm ra						0.000%			
5224	0797T		Tcat ins 2chmbr ldls pm rv						0.000%			
5224	0801T		Tcat rmv&rpl 2chmbr ldls pm						0.000%			
5224	0802T		Tcat rmv&rpl2chmb ldls pm r						0.000%			
5224	0803T		Tcat rmv&rpl2chmb ldls pm r						0.000%			
5224	0823T		Tcat ins 1chmbr ldls pm ra						0.000%			
5224	0825T		Tcat rmv&rpl1chmb ldls pm r						0.000%			
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."
5231	33230		Insrt pulse gen w/dual lead						0.000%			
5231	33240		Insrt pulse gen w/singl lea						0.000%			
5231	33262		Rmvl& replc pulse gen 1 lea						0.000%			
5231	33263		Rmvl & rplcmt dfb gen 2 lea						0.000%			
5231	0409T		Insj/rplc car modulj pls gn						0.000%			
5231	0414T		Rmvl & rpl car modulj pls g						0.000%			
5231	0515T		Insj wcs lv compl sys						0.000%			
5231	0614T		Rmvl&rplcmt ss impl dfb pg						0.000%			
5231	0916T		Insj perm ccm-d sys pg only						0.000%			
5231	0923T		Rmvl&rplcmt perm ccm-d pg						0.000%			
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."
5232	33231		Insrt pulse gen w/mult lead						0.000%			
5232	33249		Insj/rplcmt defib w/lead(s)						0.000%			
5232	33264		Rmvl & rplcmt dfb gen mlt l						0.000%			
5232	33270		Ins/rep subq defibrillator						0.000%			
5232	0408T		Insj/rplc cardiac modulj sy						0.000%			
5232	0571T		Insj/rplcmt icds ss eltrd						0.000%			
5232	0915T		Insj perm ccm-d sys pg&eltr						0.000%			
5241		Level 1 Blood Product Exchange and Related Services		S	4.9445	$453.64	.	$90.73	0.000%			
5241	36430		Transfusion bld/bld compnt						0.000%			
5241	36440		Bld push tfuj 2 yr/<						0.000%			
5241	36450		Bld exchange truj newborn						0.000%			
5241	36455		Bld exchange truj oth thn n						0.000%			
5241	36456		Prtl exchange transfuse nb						0.000%			
5241	36460		Intrauterine transfusion ft						0.000%			
5241	36513		Apheresis platelets						0.000%			
5241	38207		Cryopreserve stem cells						0.000%			
5241	38208		Thaw preserved stem cells						0.000%			
5241	38209		Wash harvest stem cells						0.000%			
5241	38210		T-cell depletion of harvest						0.000%			
5241	38211		Tumor cell deplete of harvs						0.000%			
5241	38212		Rbc depletion of harvest						0.000%			
5241	38213		Platelet deplete of harvest						0.000%			
5241	38214		Volume deplete of harvest						0.000%			
5241	38215		Harvest stem cell concentrt						0.000%			
5241	38999		Unlistd px hemic/lymphtc sy						0.000%			
5242		Level 2 Blood Product Exchange and Related Services		S	17.1784	"$1,576.07"	.	$315.22	0.000%			
5242	36511		Apheresis wbc						0.000%			
5242	36512		Apheresis rbc						0.000%			
5242	36514		Apheresis plasma						0.000%			
5242	38206		Harvest auto stem cells						0.000%			
5242	38230		Bone marrow harvest allogen						0.000%			
5242	38241		Transplt autol hct/donor						0.000%			
5242	38242		Transplt allo lymphocytes						0.000%			
5242	38243		Transplj hematopoietic boos						0.000%			
5242	0692T		Therapeutic ultrafiltration						0.000%			
5243		Level 3 Blood Product Exchange and Related Services		S	49.1014	"$4,504.91"	.	$900.99	0.000%			
5243	36516		Apheresis immunoads slctv						0.000%			
5243	36522		Photopheresis						0.000%			
5243	38232		Bone marrow harvest autolog						0.000%			
5243	0263T		Im b1 mrw cel ther cmpl						0.000%			
5243	0264T		Im b1 mrw cel ther xcl hrvs						0.000%			
5243	0265T		Im b1 mrw cel ther hrvst on						0.000%			
5243	0342T		Thxp apheresis w/hdl delip						0.000%			
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."
5244	38240		Transplt allo hct/donor						0.000%			
5301		Level 1 Upper GI Procedures		T	10.2165	$937.33	.	$187.47	0.000%			
5301	40804		Removal foreign body mouth						0.000%			
5301	43197		Esophagoscopy flex dx brush						0.000%			
5301	43198		Esophagosc flex trnsn biops						0.000%			
5301	43200		Esophagoscopy flexible brus						0.000%			
5301	43235		Egd diagnostic brush wash						0.000%			
5301	43236		Uppr gi scope w/submuc inj						0.000%			
5301	43239		Egd biopsy single/multiple						0.000%			
5301	43247		Egd remove foreign body						0.000%			
5301	43248		Egd guide wire insertion						0.000%			
5301	43291		Egd flx trnsorl rmvl balo						0.000%			
5301	43450		Dilate esophagus 1/mult pas						0.000%			
5301	43499		Unlisted procedure esophagu						0.000%			
5301	43510		Surgical opening of stomach						0.000%			
5301	43756		Dx duod intub w/asp spec						0.000%			
5301	43757		Dx duod intub w/asp specs						0.000%			
5301	43831		Gastrostomy open neonatal						0.000%			
5301	43999		Unlisted procedure stomach						0.000%			
5301	44100		Biopsy of bowel						0.000%			
5301	44380		Small bowel endoscopy br/wa						0.000%			
5301	44382		Small bowel endoscopy						0.000%			
5301	44500		Intro gastrointestinal tube						0.000%			
5301	44799		Unlisted px small intestine						0.000%			
5301	47537		Removal biliary drg cath						0.000%			
5301	47999		Unlisted px biliary tract						0.000%			
5301	49082		Abd paracentesis						0.000%			
5301	49083		Abd paracentesis w/imaging						0.000%			
5301	49084		Peritoneal lavage						0.000%			
5301	49450		Replace g/c tube perc						0.000%			
5301	49451		Replace duod/jej tube perc						0.000%			
5301	49452		Replace g-j tube perc						0.000%			
5301	49460		Fix g/colon tube w/device						0.000%			
5301	49999		Unlisted px abd pertm&omn						0.000%			
5301	91110		Gi trc img intral esoph-ile						0.000%			
5301	91111		Gi trc img intral esophagus						0.000%			
5301	91112		Gi wireless capsule measure						0.000%			
5301	0651T		Mag ctrld capsule endoscopy						0.000%			
5301	0813T		Egd vol adjmt bariatric bal						0.000%			
5301	0977T		Upr gi bld detcj snr capsul						0.000%			
5302		Level 2 Upper GI Procedures		J1	21.533	"$1,975.59"	.	$395.12	0.000%			
5302	32556		Insert cath pleura w/o imag						0.000%			
5302	43191		Esophagoscopy rigid trnso d						0.000%			
5302	43192		Esophagoscp rig trnso injec						0.000%			
5302	43193		Esophagoscp rig trnso biops						0.000%			
5302	43194		Esophagoscp rig trnso rem f						0.000%			
5302	43196		Esophagoscp guide wire dila						0.000%			
5302	43201		Esoph scope w/submucous inj						0.000%			
5302	43202		Esophagoscopy flex biopsy						0.000%			
5302	43204		Esoph scope w/sclerosis inj						0.000%			
5302	43205		Esophagus endoscopy/ligatio						0.000%			
5302	43206		Esoph optical endomicroscop						0.000%			
5302	43211		Esophagoscop mucosal resect						0.000%			
5302	43213		Esophagoscopy retro balloon						0.000%			
5302	43214		Esophagosc dilate balloon 3						0.000%			
5302	43215		Esophagoscopy flex remove f						0.000%			
5302	43216		Esophagoscopy lesion remova						0.000%			
5302	43217		Esophagoscopy snare les rem						0.000%			
5302	43220		Esophagoscopy balloon <30mm						0.000%			
5302	43226		Esoph endoscopy dilation						0.000%			
5302	43227		Esophagoscopy control bleed						0.000%			
5302	43231		Esophagoscop ultrasound exa						0.000%			
5302	43232		Esophagoscopy w/us needle b						0.000%			
5302	43233		Egd balloon dil esoph30 mm/						0.000%			
5302	43237		Endoscopic us exam esoph						0.000%			
5302	43238		Egd us fine needle bx/aspir						0.000%			
5302	43241		Egd tube/cath insertion						0.000%			
5302	43242		Egd us fine needle bx/aspir						0.000%			
5302	43243		Egd injection varices						0.000%			
5302	43244		Egd varices ligation						0.000%			
5302	43245		Egd dilate stricture						0.000%			
5302	43246		Egd place gastrostomy tube						0.000%			
5302	43249		Esoph egd dilation <30 mm						0.000%			
5302	43250		Egd cautery tumor polyp						0.000%			
5302	43251		Egd remove lesion snare						0.000%			
5302	43252		Egd optical endomicroscopy						0.000%			
5302	43253		Egd us transmural injxn/mar						0.000%			
5302	43254		Egd endo mucosal resection						0.000%			
5302	43255		Egd control bleeding any						0.000%			
5302	43259		Egd us exam duodenum/jejunu						0.000%			
5302	43263		Ercp sphincter pressure mea						0.000%			
5302	43270		Egd lesion ablation						0.000%			
5302	43275		Ercp remove forgn body duct						0.000%			
5302	43290		Egd flx trnsorl dplmnt balo						0.000%			
5302	43453		Dilate esophagus						0.000%			
5302	43830		Gstrst open wo constj tube						0.000%			
5302	44300		Open bowel to skin						0.000%			
5302	44360		Small bowel endoscopy						0.000%			
5302	44361		Small bowel endoscopy/biops						0.000%			
5302	44363		Small bowel endoscopy						0.000%			
5302	44364		Small bowel endoscopy						0.000%			
5302	44365		Small bowel endoscopy						0.000%			
5302	44366		Small bowel endoscopy						0.000%			
5302	44369		Small bowel endoscopy						0.000%			
5302	44372		Small bowel endoscopy						0.000%			
5302	44373		Small bowel endoscopy						0.000%			
5302	44376		Small bowel endoscopy						0.000%			
5302	44377		Small bowel endoscopy/biops						0.000%			
5302	44378		Small bowel endoscopy						0.000%			
5302	44381		Small bowel endoscopy br/wa						0.000%			
5302	44384		Small bowel endoscopy						0.000%			
5302	49423		Exchange drainage catheter						0.000%			
5302	49436		Embedded ip cath exit-site						0.000%			
5302	49440		Place gastrostomy tube perc						0.000%			
5302	49441		Place duod/jej tube perc						0.000%			
5302	49446		Change g-tube to g-j perc						0.000%			
5302	0647T		Insj gtube perq mag gastrpx						0.000%			
5302	0652T		Egd flx transnasal dx br/wa						0.000%			
5302	0653T		Egd flx transnasal bx 1/mlt						0.000%			
5303		Level 3 Upper GI Procedures		J1	43.6262	"$4,002.57"	.	$800.52	0.000%			
5303	43195		Esophagoscopy rigid balloon						0.000%			
5303	43229		Esophagoscopy lesion ablate						0.000%			
5303	43257		Egd w/thrml txmnt gerd						0.000%			
5303	43260		Ercp w/specimen collection						0.000%			
5303	43261		Endo cholangiopancreatograp						0.000%			
5303	43262		Endo cholangiopancreatograp						0.000%			
5303	43264		Ercp remove duct calculi						0.000%			
5303	43277		Ercp ea duct/ampulla dilate						0.000%			
5303	43278		Ercp lesion ablate w/dilate						0.000%			
5303	43772		Lap rmvl gastr adj device						0.000%			
5303	43774		Lap rmvl gastr adj all part						0.000%			
5303	43840		Repair of stomach lesion						0.000%			
5303	43870		Repair stomach opening						0.000%			
5303	44602		Suture small intestine						0.000%			
5303	0654T		Egd flx transnasal tube/cat						0.000%			
5303	C9777		Esophag muc integ w/eso egd						0.000%			
5303	C9779		Esd endoscopy or colonoscop						0.000%			
5311		Level 1 Lower GI Procedures		T	10.4328	$957.18	.	$191.44	0.000%			
5311	G0104		Ca screen;flexi sigmoidscop				$0.00	$0.00	0.000%	$0.00		
5311	G0105		Colorectal scrn; hi risk in				$0.00	$0.00	0.000%	$0.00		
5311	G0121		Colon ca scrn not hi rsk in				$0.00	$0.00	0.000%	$0.00		
5311	44385		Endoscopy of bowel pouch						0.000%			
5311	44386		Endoscopy bowel pouch/biop						0.000%			
5311	44388		Colonoscopy thru stoma spx						0.000%			
5311	44390		Colonoscopy for foreign bod						0.000%			
5311	44408		Colonoscopy w/decompression						0.000%			
5311	45300		Proctosigmoidoscopy dx						0.000%			
5311	45330		Diagnostic sigmoidoscopy						0.000%			
5311	45331		Sigmoidoscopy and biopsy						0.000%			
5311	45333		Sigmoidoscopy & polypectomy						0.000%			
5311	45335		Sigmoidoscopy w/submuc inj						0.000%			
5311	45337		Sigmoidoscopy & decompress						0.000%			
5311	45341		Sigmoidoscopy w/ultrasound						0.000%			
5311	45378		Diagnostic colonoscopy						0.000%			
5311	45399		Unlisted procedure colon						0.000%			
5311	45520		Treatment of rectal prolaps						0.000%			
5311	45900		Reduction of rectal prolaps						0.000%			
5311	45999		Unlisted procedure rectum						0.000%			
5311	46050		Incision of anal abscess						0.000%			
5311	46221		Ligation of hemorrhoid(s)						0.000%			
5311	46500		Injection into hemorrhoid(s						0.000%			
5311	46608		Anoscopy remove for body						0.000%			
5311	46611		Anoscopy						0.000%			
5311	46942		Treatment of anal fissure						0.000%			
5311	46999		Unlisted procedure anus						0.000%			
5311	91113		Gi trc img intral colon i&r						0.000%			
5311	C9725		Place endorectal app						0.000%			
5311	G0455		Fecal microbiota prep insti						0.000%			
5312		Level 2 Lower GI Procedures		T	13.43	"$1,232.16"	.	$246.44	0.000%			
5312	44389		Colonoscopy with biopsy						0.000%			
5312	44391		Colonoscopy for bleeding						0.000%			
5312	44392		Colonoscopy & polypectomy						0.000%			
5312	44394		Colonoscopy w/snare						0.000%			
5312	44401		Colonoscopy with ablation						0.000%			
5312	44403		Colonoscopy w/resection						0.000%			
5312	44404		Colonoscopy w/injection						0.000%			
5312	44405		Colonoscopy w/dilation						0.000%			
5312	44406		Colonoscopy w/ultrasound						0.000%			
5312	44407		Colonoscopy w/ndl aspir/bx						0.000%			
5312	45000		Drainage of pelvic abscess						0.000%			
5312	45005		Drainage of rectal abscess						0.000%			
5312	45150		Excision of rectal strictur						0.000%			
5312	45303		Proctosigmoidoscopy dilate						0.000%			
5312	45305		Proctosigmoidoscopy w/bx						0.000%			
5312	45309		Proctosigmoidoscopy removal						0.000%			
5312	45315		Proctosigmoidoscopy removal						0.000%			
5312	45317		Proctosigmoidoscopy bleed						0.000%			
5312	45332		Sigmoidoscopy w/fb removal						0.000%			
5312	45334		Sigmoidoscopy for bleeding						0.000%			
5312	45338		Sigmoidoscopy w/tumr remove						0.000%			
5312	45340		Sig w/tndsc balloon dilatio						0.000%			
5312	45342		Sigmoidoscopy w/us guide bx						0.000%			
5312	45346		Sigmoidoscopy w/ablation						0.000%			
5312	45350		Sgmdsc w/band ligation						0.000%			
5312	45379		Colonoscopy w/fb removal						0.000%			
5312	45380		Colonoscopy and biopsy						0.000%			
5312	45381		Colonoscopy submucous njx						0.000%			
5312	45382		Colonoscopy w/control bleed						0.000%			
5312	45384		Colonoscopy w/lesion remova						0.000%			
5312	45385		Colonoscopy w/lesion remova						0.000%			
5312	45386		Colonoscopy w/balloon dilat						0.000%			
5312	45388		Colonoscopy w/ablation						0.000%			
5312	45391		Colonoscopy w/endoscope us						0.000%			
5312	45392		Colonoscopy w/endoscopic fn						0.000%			
5312	45393		Colonoscopy w/decompression						0.000%			
5312	45398		Colonoscopy w/band ligation						0.000%			
5312	45905		Dilation of anal sphincter						0.000%			
5312	45910		Dilation of rectal narrowin						0.000%			
5312	45915		Remove rectal obstruction						0.000%			
5312	46030		Removal anal seton oth mrk						0.000%			
5312	46040		Incision of rectal abscess						0.000%			
5312	46220		Excise anal ext tag/papilla						0.000%			
5312	46320		Removal of hemorrhoid clot						0.000%			
5312	46505		Chemodenervation anal musc						0.000%			
5312	46604		Anoscopy and dilation						0.000%			
5312	46606		Anoscopy and biopsy						0.000%			
5312	46607		Diagnostic anoscopy & biops						0.000%			
5312	46614		Anoscopy control bleeding						0.000%			
5312	46930		Destroy internal hemorrhoid						0.000%			
5312	49442		Place cecostomy tube perc						0.000%			
5312	0963T		Anosc sbmcsl njx bulking ag						0.000%			
5312	0967T		Tranal ins tmp clrc anst de						0.000%			
5313		Level 3 Lower GI Procedures		J1	31.1101	"$2,854.26"	.	$570.86	0.000%			
5313	45020		Drainage of rectal abscess						0.000%			
5313	45100		Biopsy of rectum						0.000%			
5313	45108		Anorectal myomectomy						0.000%			
5313	45160		Excision of rectal lesion						0.000%			
5313	45171		Exc rect tum transanal part						0.000%			
5313	45172		Exc rect tum transanal full						0.000%			
5313	45190		Destruction rectal tumor						0.000%			
5313	45307		Proctosigmoidoscopy fb						0.000%			
5313	45308		Proctosigmoidoscopy removal						0.000%			
5313	45320		Proctosigmoidoscopy ablate						0.000%			
5313	45321		Proctosigmoidoscopy volvul						0.000%			
5313	45349		Sigmoidoscopy w/resection						0.000%			
5313	45390		Colonoscopy w/resection						0.000%			
5313	45500		Repair of rectum						0.000%			
5313	45505		Repair of rectum						0.000%			
5313	45541		Correct rectal prolapse						0.000%			
5313	45560		Repair of rectocele						0.000%			
5313	45990		Surg dx exam anorectal						0.000%			
5313	46020		Placement of seton						0.000%			
5313	46045		Incision of rectal abscess						0.000%			
5313	46060		Incision of rectal abscess						0.000%			
5313	46070		Incision anal septum infant						0.000%			
5313	46080		Incision of anal sphincter						0.000%			
5313	46200		Removal of anal fissure						0.000%			
5313	46230		Removal of anal tags						0.000%			
5313	46250		Remove ext hem groups 2+						0.000%			
5313	46255		Remove int/ext hem 1 group						0.000%			
5313	46257		Remove in/ex hem grp & fiss						0.000%			
5313	46258		Remove in/ex hem grp w/fist						0.000%			
5313	46260		Remove in/ex hem groups 2+						0.000%			
5313	46261		Remove in/ex hem grps & fis						0.000%			
5313	46262		Remove in/ex hem grps w/fis						0.000%			
5313	46270		Remove anal fist subq						0.000%			
5313	46275		Remove anal fist inter						0.000%			
5313	46280		Remove anal fist complex						0.000%			
5313	46285		Remove anal fist 2 stage						0.000%			
5313	46288		Repair anal fistula						0.000%			
5313	46610		Anoscopy remove lesion						0.000%			
5313	46612		Anoscopy remove lesions						0.000%			
5313	46615		Anoscopy						0.000%			
5313	46700		Repair of anal stricture						0.000%			
5313	46706		Repr of anal fistula w/glue						0.000%			
5313	46707		Repair anorectal fist w/plu						0.000%			
5313	46750		Repair of anal sphincter						0.000%			
5313	46753		Reconstruction of anus						0.000%			
5313	46754		Removal of suture from anus						0.000%			
5313	46760		Repair of anal sphincter						0.000%			
5313	46761		Repair of anal sphincter						0.000%			
5313	46917		Laser surgery anal lesions						0.000%			
5313	46922		Excision of anal lesion(s)						0.000%			
5313	46924		Destruction anal lesion(s)						0.000%			
5313	46940		Treatment of anal fissure						0.000%			
5313	46945		Int hrhc lig 1 hroid w/o im						0.000%			
5313	46946		Int hrhc lig 2+hroid w/o im						0.000%			
5313	46947		Hemorrhoidopexy by stapling						0.000%			
5313	46948		Int hrhc tranal dartlzj 2+						0.000%			
5313	C9796		Rpr intst excl anrect fist						0.000%			
5331		Complex GI Procedures		J1	68.4077	"$6,276.20"	.	"$1,255.24"	0.000%			
5331	43212		Esophagoscop stent placemen						0.000%			
5331	43240		Egd w/transmural drain cyst						0.000%			
5331	43265		Ercp lithotripsy calculi						0.000%			
5331	43266		Egd endoscopic stent place						0.000%			
5331	43274		Ercp duct stent placement						0.000%			
5331	43276		Ercp stent exchange w/dilat						0.000%			
5331	43497		Transorl lwr esophgl myotom						0.000%			
5331	44370		Small bowel endoscopy/stent						0.000%			
5331	44379		S bowel endoscope w/stent						0.000%			
5331	44402		Colonoscopy w/stent plcmt						0.000%			
5331	45327		Proctosigmoidoscopy w/stent						0.000%			
5331	45347		Sigmoidoscopy w/plcmt stent						0.000%			
5331	45389		Colonoscopy w/stent plcmt						0.000%			
5331	0184T		Exc rectal tumor endoscopic						0.000%			
5331	0884T		Esphgsc flx 1st tndsc dilat						0.000%			
5331	0885T		Colsc flx 1st tndsc dilat						0.000%			
5331	0886T		Sgmdsc flx 1st tndsc dilat						0.000%			
5341		Level 1 Abdominal/Peritoneal/Biliary and Related Procedures		J1	40.3118	"$3,698.49"	.	$739.70	0.000%			
5341	32550		Insert pleural cath						0.000%			
5341	47490		Incision of gallbladder						0.000%			
5341	47531		Injection for cholangiogram						0.000%			
5341	47532		Injection for cholangiogram						0.000%			
5341	47533		Plmt biliary drainage cath						0.000%			
5341	47534		Plmt biliary drainage cath						0.000%			
5341	47535		Conversion ext bil drg cath						0.000%			
5341	47536		Exchange biliary drg cath						0.000%			
5341	47555		Biliary endoscopy thru skin						0.000%			
5341	49250		Excision of umbilicus						0.000%			
5341	49402		Remove foreign body adbomen						0.000%			
5341	49418		Insert tun ip cath perc						0.000%			
5341	49421		Ins tun ip cath for dial op						0.000%			
5341	49426		Revise abdomen-venous shunt						0.000%			
5341	49492		Rpr ing hern premie blocked						0.000%			
5341	49495		Rpr ing hernia baby reduc						0.000%			
5341	49496		Rpr ing hernia baby blocked						0.000%			
5341	49501		Rpr ing hernia init blocked						0.000%			
5341	49505		Prp i/hern init reduc >5 yr						0.000%			
5341	49507		Prp i/hern init block >5 yr						0.000%			
5341	49520		Rerepair ing hernia reduce						0.000%			
5341	49525		Repair ing hernia sliding						0.000%			
5341	49550		Rpr rem hernia init reduce						0.000%			
5341	49553		Rpr fem hernia init blocked						0.000%			
5341	49555		Rerepair fem hernia reduce						0.000%			
5341	49557		Rerepair fem hernia blocked						0.000%			
5341	49591		Rpr aa hrn 1st < 3 cm rdc						0.000%			
5341	49600		Repair umbilical lesion						0.000%			
5341	49613		Rpr aa hrn rcr < 3 rdc						0.000%			
5341	54530		Removal of testis						0.000%			
5341	54550		Exploration for testis						0.000%			
5341	54640		Orchiopexy ingun/scrot appr						0.000%			
5341	54650		Orchiopexy (fowler-stephens						0.000%			
5341	55040		Removal of hydrocele						0.000%			
5341	55041		Removal of hydroceles						0.000%			
5341	55540		Revise hernia & sperm veins						0.000%			
5342		Level 2 Abdominal/Peritoneal/Biliary and Related Procedures		J1	72.6672	"$6,667.00"	.	"$1,333.40"	0.000%			
5342	44950		Appendectomy						0.000%			
5342	47541		Plmt access bil tree sm bwl						0.000%			
5342	47552		Biliary endo perq dx w/spec						0.000%			
5342	47553		Biliary endoscopy thru skin						0.000%			
5342	49010		Exploration behind abdomen						0.000%			
5342	49255		Removal of omentum						0.000%			
5342	49500		Rpr ing hernia init reduce						0.000%			
5342	49521		Rerepair ing hernia blocked						0.000%			
5342	49593		Rpr aa hrn 1st 3-10 rdc						0.000%			
5342	49595		Rpr aa hrn 1st > 10 rdc						0.000%			
5342	49615		Rpr aa hrn rcr 3-10 rdc						0.000%			
5342	55535		Revise spermatic cord veins						0.000%			
5361		Level 1 Laparoscopy and Related Services		J1	67.8929	"$6,228.97"	.	"$1,245.80"	0.000%			
5361	32601		Thoracoscopy diagnostic						0.000%			
5361	32606		Thoracoscopy w/bx med space						0.000%			
5361	32609		Thoracoscopy w/bx pleura						0.000%			
5361	32998		Ablate pulm tumor perq rf						0.000%			
5361	38129		Unlisted laps px spleen						0.000%			
5361	38542		Explore deep node(s) neck						0.000%			
5361	38570		Laparoscopy lymph node biop						0.000%			
5361	38589		Unlisted laps px lymphtc sy						0.000%			
5361	38740		Remove armpit lymph nodes						0.000%			
5361	38745		Remove armpit lymph nodes						0.000%			
5361	39401		Mediastinoscpy w/medstnl bx						0.000%			
5361	39402		Mediastinoscpy w/lmph nod b						0.000%			
5361	43285		Rmvl esophgl sphnctr dev						0.000%			
5361	43289		Unlisted laps px esoph						0.000%			
5361	43651		Laparoscopy vagus nerve						0.000%			
5361	43652		Laparoscopy vagus nerve						0.000%			
5361	43653		Laparoscopy gastrostomy						0.000%			
5361	43659		Unlisted laps px stomach						0.000%			
5361	43773		Lap replace gastr adj devic						0.000%			
5361	44180		Lap enterolysis						0.000%			
5361	44186		Lap jejunostomy						0.000%			
5361	44238		Unlisted laps px intestine						0.000%			
5361	44970		Laparoscopy appendectomy						0.000%			
5361	44979		Unlisted laps px appendix						0.000%			
5361	45499		Laparoscope proc rectum						0.000%			
5361	47379		Unlisted laps px liver						0.000%			
5361	47382		Percut ablate liver rf						0.000%			
5361	47538		Perq plmt bile duct stent						0.000%			
5361	47539		Perq plmt bile duct stent						0.000%			
5361	47540		Perq plmt bile duct stent						0.000%			
5361	47562		Laparoscopic cholecystectom						0.000%			
5361	47563		Laparo cholecystectomy/grap						0.000%			
5361	47579		Unlisted laps px biliary tr						0.000%			
5361	49320		Diag laparo separate proc						0.000%			
5361	49321		Laparoscopy biopsy						0.000%			
5361	49322		Laparoscopy aspiration						0.000%			
5361	49323		Laparo drain lymphocele						0.000%			
5361	49324		Lap insert tunnel ip cath						0.000%			
5361	49325		Lap revision perm ip cath						0.000%			
5361	49329		Unlstd laps px abd pertm&om						0.000%			
5361	49491		Rpr hern preemie reduc						0.000%			
5361	49540		Repair lumbar hernia						0.000%			
5361	49592		Rpr aa hrn 1st < 3 ncr/strn						0.000%			
5361	49594		Rpr aa hrn 1st 3-10 ncr/str						0.000%			
5361	49614		Rpr aa hrn rcr < 3 ncr/strn						0.000%			
5361	49650		Lap ing hernia repair init						0.000%			
5361	49651		Lap ing hernia repair recur						0.000%			
5361	49659		Unlstd laps px hrnap hrnrph						0.000%			
5361	50549		Unlisted laps px renal						0.000%			
5361	50592		Perc rf ablate renal tumor						0.000%			
5361	50945		Laparoscopy ureterolithotom						0.000%			
5361	50949		Unlisted laps px ureter						0.000%			
5361	51500		Removal of bladder cyst						0.000%			
5361	51990		Laparo urethral suspension						0.000%			
5361	51992		Laparo sling operation						0.000%			
5361	51999		Unlisted laps px bladder						0.000%			
5361	54690		Laparoscopy orchiectomy						0.000%			
5361	54692		Laparoscopy orchiopexy						0.000%			
5361	54699		Unlisted laps px testis						0.000%			
5361	55550		Laparo ligate spermatic vei						0.000%			
5361	55559		Unlstd laps px sprmatic cor						0.000%			
5361	58545		Laparoscopic myomectomy						0.000%			
5361	58550		Laparo-asst vag hysterectom						0.000%			
5361	58578		Unlisted laps px uterus						0.000%			
5361	58660		Laparoscopy lysis						0.000%			
5361	58661		Laparoscopy remove adnexa						0.000%			
5361	58662		Laparoscopy excise lesions						0.000%			
5361	58670		Laparoscopy tubal cautery						0.000%			
5361	58671		Laparoscopy tubal block						0.000%			
5361	58672		Laparoscopy fimbrioplasty						0.000%			
5361	58679		Unlisted laps px ovidct ovr						0.000%			
5361	59150		Treat ectopic pregnancy						0.000%			
5361	59151		Treat ectopic pregnancy						0.000%			
5361	59898		Unlstd laps px mat care&dlv						0.000%			
5361	60200		Remove thyroid lesion						0.000%			
5361	60210		Partial thyroid excision						0.000%			
5361	60212		Partial thyroid excision						0.000%			
5361	60220		Partial removal of thyroid						0.000%			
5361	60225		Partial removal of thyroid						0.000%			
5361	60240		Removal of thyroid						0.000%			
5361	60280		Remove thyroid duct lesion						0.000%			
5361	60281		Remove thyroid duct lesion						0.000%			
5361	60659		Unlisted laps px endoc sys						0.000%			
5361	60699		Unlisted px endocrine syste						0.000%			
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."
5362	32604		Thoracoscopy wbx sac						0.000%			
5362	32607		Thoracoscopy w/bx infiltrat						0.000%			
5362	32608		Thoracoscopy w/bx nodule						0.000%			
5362	32994		Ablate pulm tumor perq cryb						0.000%			
5362	38120		Laparoscopy splenectomy						0.000%			
5362	38571		Laparoscopy lymphadenectomy						0.000%			
5362	38572		Laparoscopy lymphadenectomy						0.000%			
5362	38573		Laps pelvic lymphadec						0.000%			
5362	43210		Egd esophagogastrc fndoplst						0.000%			
5362	43280		Laparoscopy fundoplasty						0.000%			
5362	43281		Lap paraesophag hern repair						0.000%			
5362	43282		Lap paraesoph her rpr w/mes						0.000%			
5362	43284		Laps esophgl sphnctr agmntj						0.000%			
5362	43648		Lap revise/remv eltrd antru						0.000%			
5362	43770		Lap place gastr adj device						0.000%			
5362	47370		Laparo ablate liver tumor r						0.000%			
5362	47371		Laparo ablate liver cryosur						0.000%			
5362	47383		Perq abltj lvr cryoablation						0.000%			
5362	47554		Biliary endoscopy thru skin						0.000%			
5362	47556		Biliary endoscopy thru skin						0.000%			
5362	47564		Laparo cholecystectomy/expl						0.000%			
5362	50541		Laparo ablate renal cyst						0.000%			
5362	50542		Laparo ablate renal mass						0.000%			
5362	50543		Laparo partial nephrectomy						0.000%			
5362	50544		Laparoscopy pyeloplasty						0.000%			
5362	50593		Perc cryo ablate renal tum						0.000%			
5362	50947		Laparo new ureter/bladder						0.000%			
5362	50948		Laparo new ureter/bladder						0.000%			
5362	55866		Laps surg prst8ect rpbic ra						0.000%			
5362	55867		Laps surg prst8ect smpl sto						0.000%			
5362	57423		Repair paravag defect lap						0.000%			
5362	57425		Laparoscopy surg colpopexy						0.000%			
5362	58541		Lsh uterus 250 g or less						0.000%			
5362	58542		Lsh w/t/o ut 250 g or less						0.000%			
5362	58543		Lsh uterus above 250 g						0.000%			
5362	58544		Lsh w/t/o uterus above 250						0.000%			
5362	58546		Laparo-myomectomy complex						0.000%			
5362	58552		Laparo-vag hyst incl t/o						0.000%			
5362	58553		Laparo-vag hyst complex						0.000%			
5362	58554		Laparo-vag hyst w/t/o compl						0.000%			
5362	58570		Tlh uterus 250 g or less						0.000%			
5362	58571		Tlh w/t/o 250 g or less						0.000%			
5362	58572		Tlh uterus over 250 g						0.000%			
5362	58573		Tlh w/t/o uterus over 250 g						0.000%			
5362	58673		Laparoscopy salpingostomy						0.000%			
5362	58674		Laps abltj uterine fibroids						0.000%			
5362	0600T		Abltj ire 1+tum organ perq						0.000%			
5362	0601T		Ire abltj 1+tumors open						0.000%			
5362	0677T		Laps repos lead isdss 1st l						0.000%			
5362	0679T		Laps rmvl lead isdss						0.000%			
5362	4001X		Abltj ire liver 1+ tum perq						0.000%			
5362	4XX04		Gstr rstcv px trnsorl esg						0.000%			
5362	558X1		Lap srg prst8ct lymph nod b						0.000%			
5362	558X2		Lap srg prst8ct bi pl lmpha						0.000%			
5362	5XX11		Abltj ire prst8 1+ tum perq						0.000%			
5362	C9785		Endo outlet restrict w/tube						0.000%			
5362	C9901		Endo defect closure gi trac						0.000%			
5371		Level 1 Urology and Related Services		T	2.7971	$256.63	.	$51.33	0.000%			
5371	43761		Reposition gastrostomy tube						0.000%			
5371	43762		Rplc gtube no revj trc						0.000%			
5371	43763		Rplc gtube revj gstrst trc						0.000%			
5371	46083		Incise external hemorrhoid						0.000%			
5371	50391		Instll rx agnt into rnal tu						0.000%			
5371	51100		Drain bladder by needle						0.000%			
5371	51700		Irrigation of bladder						0.000%			
5371	51705		Change of bladder tube						0.000%			
5371	51725		Simple cystometrogram						0.000%			
5371	51726		Complex cystometrogram						0.000%			
5371	51785		Anal/urinary muscle study						0.000%			
5371	53454		Tprnl balo cntnc dev adjmt						0.000%			
5371	53600		Dilate urethra stricture						0.000%			
5371	53621		Dilate urethra stricture						0.000%			
5371	53866		Cathj rmvl dev ischmc rmdlg						0.000%			
5371	53899		Unlisted px urinary system						0.000%			
5371	54200		Injection px peyronie ds						0.000%			
5371	54220		Irrg crpra cavrnosa priapis						0.000%			
5371	54231		Dynamic cavernosometry						0.000%			
5371	54235		Njx corpora cavernosa rx ag						0.000%			
5371	54250		Nctrnl pen tmscn&/rgdity ts						0.000%			
5371	54450		Preputial stretching						0.000%			
5371	55899		Unlisted px male genital sy						0.000%			
5371	0864T		Low ntsty eswt corpus cvrns						0.000%			
5372		Level 2 Urology and Related Services		J1	7.7301	$709.21	.	$141.85	0.000%			
5372	50389		Remove renal tube w/fluoro						0.000%			
5372	50396		Measure kidney pressure						0.000%			
5372	50430		Njx px nfrosgrm &/urtrgrm						0.000%			
5372	50431		Njx px nfrosgrm &/urtrgrm						0.000%			
5372	50572		Kidney endoscopy						0.000%			
5372	51710		Change of bladder tube						0.000%			
5372	51720		Treatment of bladder lesion						0.000%			
5372	51727		Cystometrogram w/up						0.000%			
5372	51728		Cystometrogram w/vp						0.000%			
5372	51729		Cystometrogram w/vp&up						0.000%			
5372	52000		Cystourethroscopy						0.000%			
5372	52010		Cystoscopy & duct catheter						0.000%			
5372	52285		Cystoscopy and treatment						0.000%			
5372	53080		Drainage of urinary leakage						0.000%			
5372	53620		Dilate urethra stricture						0.000%			
5372	54160		Circumcision neonate						0.000%			
5372	0596T		Temp fml iu vlv-pmp 1st ins						0.000%			
5372	0597T		Temp fml iu valve-pmp rplcm						0.000%			
5373		Level 3 Urology and Related Services		J1	23.4184	"$2,148.57"	.	$429.72	0.000%			
5373	50020		Drg perirnl/renal absc open						0.000%			
5373	50382		Change ureter stent percut						0.000%			
5373	50384		Remove ureter stent percut						0.000%			
5373	50385		Change stent via transureth						0.000%			
5373	50386		Remove stent via transureth						0.000%			
5373	50387		Change nephroureteral cath						0.000%			
5373	50432		Plmt nephrostomy catheter						0.000%			
5373	50434		Convert nephrostomy cathete						0.000%			
5373	50435		Exchange nephrostomy cath						0.000%			
5373	50688		Change of ureter tube/stent						0.000%			
5373	51040		Incise & drain bladder						0.000%			
5373	51045		Incise bladder/drain ureter						0.000%			
5373	51060		Removal of ureter stone						0.000%			
5373	51102		Drain bl w/cath insertion						0.000%			
5373	52005		Cysto w/urtrl cathj						0.000%			
5373	52204		Cystoscopy w/biopsy(s)						0.000%			
5373	52260		Cystoscopy and treatment						0.000%			
5373	52265		Cystoscopy and treatment						0.000%			
5373	52270		Cystoscopy & revise urethra						0.000%			
5373	52275		Cystoscopy & revise urethra						0.000%			
5373	52276		Cystoscopy and treatment						0.000%			
5373	52281		Cystoscopy and treatment						0.000%			
5373	52283		Cystoscopy and treatment						0.000%			
5373	52287		Cystoscopy chemodenervation						0.000%			
5373	52290		Cystoscopy and treatment						0.000%			
5373	52310		Cystoscopy and treatment						0.000%			
5373	52315		Cystoscopy and treatment						0.000%			
5373	53000		Incision of urethra						0.000%			
5373	53020		Incision of urethra						0.000%			
5373	53025		Incision of urethra						0.000%			
5373	53060		Drainage of urethra abscess						0.000%			
5373	53085		Drainage of urinary leakage						0.000%			
5373	53200		Biopsy of urethra						0.000%			
5373	53265		Treatment of urethra lesion						0.000%			
5373	53665		Dilation of urethra						0.000%			
5373	53855		Insert prost urethral stent						0.000%			
5373	53860		Transurethral rf treatment						0.000%			
5373	54001		Slitting of prepuce						0.000%			
5373	54150		Circumcision w/regionl bloc						0.000%			
5373	54161		Circum 28 days or older						0.000%			
5373	54162		Lysis penil circumic lesion						0.000%			
5373	54163		Repair of circumcision						0.000%			
5373	54164		Frenulotomy of penis						0.000%			
5373	54380		Repair penis						0.000%			
5373	54385		Repair penis						0.000%			
5373	54560		Exploration for testis						0.000%			
5373	54700		Drainage of scrotum						0.000%			
5373	54840		Remove epididymis lesion						0.000%			
5373	54900		Fusion of spermatic ducts						0.000%			
5373	55120		Removal of scrotum lesion						0.000%			
5373	55250		Removal of sperm duct(s)						0.000%			
5373	55600		Vesiculotomy						0.000%			
5373	74485		Dilation urtr/urt rs&i						0.000%			
5374		Level 4 Urology and Related Services		J1	39.5587	"$3,629.39"	.	$725.88	0.000%			
5374	37790		Penile venous occlusion						0.000%			
5374	50433		Plmt nephroureteral cathete						0.000%			
5374	50436		Dilat xst trc ndurlgc px						0.000%			
5374	50437		Dilat xst trc new access rc						0.000%			
5374	50570		Kidney endoscopy						0.000%			
5374	50574		Kidney endoscopy & biopsy						0.000%			
5374	50590		Fragmenting of kidney stone						0.000%			
5374	50693		Plmt ureteral stent prq						0.000%			
5374	50694		Plmt ureteral stent prq						0.000%			
5374	50695		Plmt ureteral stent prq						0.000%			
5374	50727		Revise ureter						0.000%			
5374	50951		Endoscopy of ureter						0.000%			
5374	50953		Endoscopy of ureter						0.000%			
5374	50970		Ureter endoscopy						0.000%			
5374	50972		Ureter endoscopy & catheter						0.000%			
5374	51020		Cystotomy/cystostomy w/fulg						0.000%			
5374	51065		Remove ureter calculus						0.000%			
5374	51520		Removal of bladder lesion						0.000%			
5374	51535		Repair of ureter lesion						0.000%			
5374	51715		Endoscopic injection/implan						0.000%			
5374	51880		Repair of bladder opening						0.000%			
5374	52001		Cysto w/irrg&evac mlt clots						0.000%			
5374	52007		Cysto urtrl cathj brush bx						0.000%			
5374	52214		Cystoscopy and treatment						0.000%			
5374	52224		Cystoscopy and treatment						0.000%			
5374	52234		Cystoscopy and treatment						0.000%			
5374	52235		Cystoscopy and treatment						0.000%			
5374	52250		Cystoscopy and radiotracer						0.000%			
5374	52277		Cystoscopy and treatment						0.000%			
5374	52282		Cystoscopy implant stent						0.000%			
5374	52300		Cystoscopy and treatment						0.000%			
5374	52301		Cystoscopy and treatment						0.000%			
5374	52317		Remove bladder stone						0.000%			
5374	52318		Remove bladder stone						0.000%			
5374	52320		Cystoscopy and treatment						0.000%			
5374	52330		Cystoscopy and treatment						0.000%			
5374	52332		Cystoscopy and treatment						0.000%			
5374	52334		Create passage to kidney						0.000%			
5374	52341		Cysto w/ureter stricture tx						0.000%			
5374	52342		Cysto w/up stricture tx						0.000%			
5374	52343		Cysto w/renal stricture tx						0.000%			
5374	52344		Cysto/uretero stricture tx						0.000%			
5374	52345		Cysto/uretero w/up strictur						0.000%			
5374	52351		Cystouretero & or pyeloscop						0.000%			
5374	52352		Cystouretero w/stone remove						0.000%			
5374	52400		Cystouretero w/congen repr						0.000%			
5374	52402		Cystourethro cut ejacul duc						0.000%			
5374	52450		Incision of prostate						0.000%			
5374	52500		Revision of bladder neck						0.000%			
5374	52640		Relieve bladder contracture						0.000%			
5374	52700		Drainage of prostate absces						0.000%			
5374	53040		Drainage of urethra abscess						0.000%			
5374	53210		Removal of urethra						0.000%			
5374	53220		Treatment of urethra lesion						0.000%			
5374	53240		Surgery for urethra pouch						0.000%			
5374	53250		Removal of urethra gland						0.000%			
5374	53260		Treatment of urethra lesion						0.000%			
5374	53270		Removal of urethra gland						0.000%			
5374	53275		Repair of urethra defect						0.000%			
5374	53450		Revision of urethra						0.000%			
5374	53453		Tprnl balo cntnc dev rmvl e						0.000%			
5374	53460		Revision of urethra						0.000%			
5374	53500		Urethrlys transvag w/ scope						0.000%			
5374	53502		Repair of urethra injury						0.000%			
5374	53605		Dilate urethra stricture						0.000%			
5374	53850		Prostatic microwave thermot						0.000%			
5374	53852		Prostatic rf thermotx						0.000%			
5374	53854		Trurl dstrj prst8 tiss rf w						0.000%			
5374	54000		Slitting of prepuce						0.000%			
5374	54110		Treatment of penis lesion						0.000%			
5374	54120		Partial removal of penis						0.000%			
5374	54300		Revision of penis						0.000%			
5374	54304		Revision of penis						0.000%			
5374	54312		Reconstruction of urethra						0.000%			
5374	54318		Reconstruction of urethra						0.000%			
5374	54322		Reconstruction of urethra						0.000%			
5374	54324		Reconstruction of urethra						0.000%			
5374	54326		Reconstruction of urethra						0.000%			
5374	54328		Revise penis/urethra						0.000%			
5374	54332		Revise penis/urethra						0.000%			
5374	54336		Revise penis/urethra						0.000%			
5374	54340		Rpr hypspad comp simple						0.000%			
5374	54360		Penis plastic surgery						0.000%			
5374	54406		Remove muti-comp penis pros						0.000%			
5374	54415		Remove self-contd penis pro						0.000%			
5374	54420		Revision of penis						0.000%			
5374	54435		Revision of penis						0.000%			
5374	54437		Repair corporeal tear						0.000%			
5374	54440		Repair of penis						0.000%			
5374	54505		Biopsy of testis						0.000%			
5374	54512		Excise lesion testis						0.000%			
5374	54520		Removal of testis						0.000%			
5374	54522		Orchiectomy partial						0.000%			
5374	54535		Extensive testis surgery						0.000%			
5374	54600		Reduce testis torsion						0.000%			
5374	54620		Suspension of testis						0.000%			
5374	54670		Repair testis injury						0.000%			
5374	54680		Relocation of testis(es)						0.000%			
5374	54830		Remove epididymis lesion						0.000%			
5374	54860		Removal of epididymis						0.000%			
5374	54861		Removal of epididymis						0.000%			
5374	54865		Explore epididymis						0.000%			
5374	54901		Fusion of spermatic ducts						0.000%			
5374	55060		Repair of hydrocele						0.000%			
5374	55110		Explore scrotum						0.000%			
5374	55150		Removal of scrotum						0.000%			
5374	55175		Revision of scrotum						0.000%			
5374	55200		Incision of sperm duct						0.000%			
5374	55400		Repair of sperm duct						0.000%			
5374	55500		Removal of hydrocele						0.000%			
5374	55520		Removal of sperm cord lesio						0.000%			
5374	55530		Revise spermatic cord veins						0.000%			
5374	55680		Remove sperm pouch lesion						0.000%			
5374	55705		Bx prst8 any approach nonim						0.000%			
5374	55706		Prostate saturation samplin						0.000%			
5374	55720		Drainage of prostate absces						0.000%			
5374	55725		Drainage of prostate absces						0.000%			
5374	55980		Sex transformation f to m						0.000%			
5374	5XX00		Bx prst8 trct us guided						0.000%			
5374	5XX01		Bx prst8 trct us w/mri fus						0.000%			
5374	5XX02		Bx prst8 tprnl us guided						0.000%			
5374	5XX03		Bx prst8 tprn us w/mri fus						0.000%			
5374	5XX04		Bx prst8 trct mri-us 1st						0.000%			
5374	5XX07		Bx prst8 tprnl mri-us 1st						0.000%			
5375		Level 5 Urology and Related Services		J1	60.1421	"$5,517.86"	.	"$1,103.58"	0.000%			
5375	50551		Kidney endoscopy						0.000%			
5375	50553		Kidney endoscopy						0.000%			
5375	50561		Kidney endoscopy & treatmen						0.000%			
5375	50575		Kidney endoscopy						0.000%			
5375	50580		Kidney endoscopy & treatmen						0.000%			
5375	50955		Ureter endoscopy & biopsy						0.000%			
5375	50957		Ureter endoscopy & treatmen						0.000%			
5375	50961		Ureter endoscopy & treatmen						0.000%			
5375	50974		Ureter endoscopy & biopsy						0.000%			
5375	50976		Ureter endoscopy & treatmen						0.000%			
5375	50980		Ureter endoscopy & treatmen						0.000%			
5375	51050		Removal of bladder stone						0.000%			
5375	52240		Cystoscopy and treatment						0.000%			
5375	52284		Cysto rx balo cath urtl str						0.000%			
5375	52305		Cystoscopy and treatment						0.000%			
5375	52325		Cystoscopy stone removal						0.000%			
5375	52327		Cystoscopy inject material						0.000%			
5375	52346		Cystouretero w/renal strict						0.000%			
5375	52353		Cystouretero w/lithotripsy						0.000%			
5375	52354		Cystouretero w/biopsy						0.000%			
5375	52355		Cystouretero w/excise tumor						0.000%			
5375	52356		Cysto/uretero w/lithotripsy						0.000%			
5375	52601		Prostatectomy (turp)						0.000%			
5375	52630		Remove prostate regrowth						0.000%			
5375	52648		Laser surgery of prostate						0.000%			
5375	52649		Prostate laser enucleation						0.000%			
5375	53010		Incision of urethra						0.000%			
5375	53215		Removal of urethra						0.000%			
5375	53230		Removal of urethra lesion						0.000%			
5375	53235		Removal of urethra lesion						0.000%			
5375	53400		Revise urethra stage 1						0.000%			
5375	53405		Revise urethra stage 2						0.000%			
5375	53410		Reconstruction of urethra						0.000%			
5375	53420		Reconstruct urethra stage 1						0.000%			
5375	53425		Reconstruct urethra stage 2						0.000%			
5375	53430		Reconstruction of urethra						0.000%			
5375	53431		Reconstruct urethra/bladder						0.000%			
5375	53442		Remove/revise male sling						0.000%			
5375	53446		Remove uro sphincter						0.000%			
5375	53505		Repair of urethra injury						0.000%			
5375	53510		Repair of urethra injury						0.000%			
5375	53515		Repair of urethra injury						0.000%			
5375	53520		Repair of urethra defect						0.000%			
5375	54111		Treat penis lesion graft						0.000%			
5375	54205		Njx px peyronie ds exps pla						0.000%			
5375	54308		Reconstruction of urethra						0.000%			
5375	54348		Rpr hypspad comp dsj & urtp						0.000%			
5375	54352		Revj prior hypspad repair						0.000%			
5375	54408		Repair multi-comp penis pro						0.000%			
5375	54660		Revision of testis						0.000%			
5375	55180		Revision of scrotum						0.000%			
5375	55860		Surgical exposure prostate						0.000%			
5375	55874		Tprnl plmt biodegrdabl matr						0.000%			
5375	55875		Transperi needle place pros						0.000%			
5375	0655T		Tprnl focal abltj mal prst8						0.000%			
5375	0714T		Tpla b9 prst8 hyprplsa<50ml						0.000%			
5375	0867T		Tpla b9 prst8 hyprplsa>=50m						0.000%			
5375	5XX08		Bx prst8 in-bore ct/mri bx						0.000%			
5375	5XX09		Bx prst8 in-bore ct/mri 1						0.000%			
5375	C9739		Cystoscopy prostatic imp 1-						0.000%			
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."
5376	50080		Perq nl/pl lithotrp smpl<2c						0.000%			
5376	50081		Perq nl/pl lithotrp cplx>2c						0.000%			
5376	50555		Kidney endoscopy & biopsy						0.000%			
5376	50557		Kidney endoscopy & treatmen						0.000%			
5376	50562		Renal scope w/tumor resect						0.000%			
5376	50576		Kidney endoscopy & treatmen						0.000%			
5376	51860		Repair of bladder wound						0.000%			
5376	53449		Repair uro sphincter						0.000%			
5376	53452		Tprnl balo cntnc dev uni						0.000%			
5376	53865		Cysto insj dev ischmc rmdlg						0.000%			
5376	54112		Treat penis lesion graft						0.000%			
5376	54316		Reconstruction of urethra						0.000%			
5376	54344		Rrp hypspad comp moblj&urtp						0.000%			
5376	55873		Cryoablate prostate						0.000%			
5376	55880		Abltj mal prst8 tiss hifu						0.000%			
5376	0950T		Abltj b9 prst8 tissue hifu						0.000%			
5376	52XX1		Trurl rbtc wtrjt rescj prst						0.000%			
5376	52XX2		Cysto 1st trurl prst8 comis						0.000%			
5376	C9740		Cysto impl 4 or more						0.000%			
5376	C9761		"Cysto, litho, vacuum kidney"						0.000%			
5377		Level 7 Urology and Related Services		J1	148.801	"$13,652.05"	.	"$2,730.41"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
5377	53440		Male sling procedure						0.000%			
5377	53451		Tprnl balo cntnc dev bi						0.000%			
5377	54400		Insert semi-rigid prosthesi						0.000%			
5377	54417		Remv/replc penis pros compl						0.000%			
5377	55882		Ablt trurl prst8 tis trnsdc						0.000%			
5378		Level 8 Urology and Related Services		J1	229.186	"$21,027.13"	.	"$4,205.43"		"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
5378	53444		Insert tandem cuff						0.000%			
5378	53445		Insert uro/ves nck sphincte						0.000%			
5378	53447		Remove/replace ur sphincter						0.000%			
5378	54401		Insert self-contd prosthesi						0.000%			
5378	54405		Insert multi-comp penis pro						0.000%			
5378	54410		Remove/replace penis prosth						0.000%			
5378	54411		Remov/replc penis pros comp						0.000%			
5378	54416		Remv/repl penis contain pro						0.000%			
5401		Dialysis		S	7.8171	$717.20	.	$143.44	0.000%			
5401	90935		Hemodialysis one evaluation						0.000%			
5401	G0257		Unsched dialysis esrd pt ho						0.000%			
5411		Level 1 Gynecologic Procedures		T	2.272	$208.45	.	$41.69	0.000%			
5411	56420		Drainage of gland abscess						0.000%			
5411	56820		Colposcopy vulva						0.000%			
5411	57160		Insert pessary/other device						0.000%			
5411	57170		Fitting of diaphragm/cap						0.000%			
5411	57180		Treat vaginal bleeding						0.000%			
5411	57452		Exam of cervix w/scope						0.000%			
5411	58100		Biopsy of uterus lining						0.000%			
5411	58322		Artificial insemination						0.000%			
5411	58323		Sperm washing						0.000%			
5411	58579		Unlisted hystsc px uterus						0.000%			
5411	58999		Unlisted px fml genital sys						0.000%			
5411	59020		Fetal contract stress test						0.000%			
5411	59025		Fetal non-stress test						0.000%			
5411	59897		Unlisted fetal invas px w/u						0.000%			
5411	59899		Unlisted px mat care&dlvr						0.000%			
5411	99170		Anogenital exam child w ima						0.000%			
5412		Level 2 Gynecologic Procedures		T	3.4214	$313.90	.	$62.78	0.000%			
5412	56405		I & d of vulva/perineum						0.000%			
5412	56821		Colposcopy vulva w/biopsy						0.000%			
5412	57156		Ins vag brachytx device						0.000%			
5412	57420		Exam of vagina w/scope						0.000%			
5412	57454		Bx/curett of cervix w/scope						0.000%			
5412	57455		Biopsy of cervix w/scope						0.000%			
5412	57456		Endocerv curettage w/scope						0.000%			
5412	57511		Cryocautery of cervix						0.000%			
5412	58301		Remove intrauterine device						0.000%			
5412	58321		Artificial insemination						0.000%			
5412	58976		Transfer of embryo						0.000%			
5412	59001		Amniocentesis therapeutic						0.000%			
5412	59012		Fetal cord puncture prenata						0.000%			
5412	59030		Fetal scalp blood sampling						0.000%			
5412	59070		Transabdom amnioinfus w/us						0.000%			
5412	59072		Umbilical cord occlud w/us						0.000%			
5412	59074		Fetal fluid drainage w/us						0.000%			
5412	59076		Fetal shunt placement w/us						0.000%			
5412	59200		Insert cervical dilator						0.000%			
5412	59866		Abortion (mpr)						0.000%			
5413		Level 3 Gynecologic Procedures		T	10.3197	$946.80	.	$189.36	0.000%			
5413	55870		Electroejaculation						0.000%			
5413	56605		Biopsy of vulva/perineum						0.000%			
5413	57100		Biopsy vaginal mucosa simpl						0.000%			
5413	57421		Exam/biopsy of vag w/scope						0.000%			
5413	57500		Biopsy of cervix						0.000%			
5413	57505		Endocervical curettage						0.000%			
5413	58970		Retrieval of oocyte						0.000%			
5413	58974		Embryo transfer intrauterin						0.000%			
5413	59000		Amniocentesis diagnostic						0.000%			
5413	59015		Chorion biopsy						0.000%			
5414		Level 4 Gynecologic Procedures		J1	36.6246	"$3,360.20"	.	$672.04	0.000%			
5414	56440		Mrsplzatn brthlns glnd cst						0.000%			
5414	56441		Lysis of labial adhesions						0.000%			
5414	56442		Hymenotomy						0.000%			
5414	56620		Vulvectomy simple partial						0.000%			
5414	56625		Vulvectomy simple complete						0.000%			
5414	56700		Prtl hymnctmy/revj hymnl rn						0.000%			
5414	56740		Exc bartholins gland/cyst						0.000%			
5414	56800		Plastic repair introitus						0.000%			
5414	56805		Clitoroplasty intersex stat						0.000%			
5414	56810		Perineoplasty rpr per nonob						0.000%			
5414	57000		Colpotomy w/exploration						0.000%			
5414	57010		Colpotomy drg pel abscess						0.000%			
5414	57061		Destruction vag lesions smp						0.000%			
5414	57065		Destruction vag lesion xtns						0.000%			
5414	57105		Biopsy vaginal mucosa xtnsv						0.000%			
5414	57106		Vagnc prtl rmvl vag wall						0.000%			
5414	57107		Vagnc compl rmvl paravag ti						0.000%			
5414	57109		Vagnc bi total pel lymphade						0.000%			
5414	57130		Excision vaginal septum						0.000%			
5414	57135		Excision vaginal cyst/tumor						0.000%			
5414	57200		Repair of vagina						0.000%			
5414	57210		Repair vagina/perineum						0.000%			
5414	57230		Repair of urethral lesion						0.000%			
5414	57287		Revise/remove sling repair						0.000%			
5414	57295		Revise vag graft via vagina						0.000%			
5414	57300		Repair rectum-vagina fistul						0.000%			
5414	57400		Dilation of vagina						0.000%			
5414	57410		Pelvic examination						0.000%			
5414	57415		Remove vaginal foreign body						0.000%			
5414	57460		Bx of cervix w/scope leep						0.000%			
5414	57461		Conz of cervix w/scope leep						0.000%			
5414	57510		Cauterization of cervix						0.000%			
5414	57513		Laser surgery of cervix						0.000%			
5414	57520		Conization of cervix						0.000%			
5414	57522		Conization of cervix						0.000%			
5414	57558		D&c of cervical stump						0.000%			
5414	57700		Revision of cervix						0.000%			
5414	57720		Revision of cervix						0.000%			
5414	57800		Dilation of cervical canal						0.000%			
5414	58120		Dilation and curettage						0.000%			
5414	58145		Myomectomy vag method						0.000%			
5414	58345		Reopen fallopian tube						0.000%			
5414	58555		Hysteroscopy dx sep proc						0.000%			
5414	58558		Hysteroscopy biopsy						0.000%			
5414	58562		Hysteroscopy remove fb						0.000%			
5414	58600		Division of fallopian tube						0.000%			
5414	58615		Occlude fallopian tube(s)						0.000%			
5414	58770		Create new tubal opening						0.000%			
5414	58800		Drainage of ovarian cyst(s)						0.000%			
5414	58805		Drainage of ovarian cyst(s)						0.000%			
5414	58820		Drain ovary abscess open						0.000%			
5414	58900		Biopsy of ovary(s)						0.000%			
5414	59160		D & c after delivery						0.000%			
5414	59300		Episiotomy or vaginal repai						0.000%			
5414	59320		Revision of cervix						0.000%			
5414	59409		Obstetrical care						0.000%			
5414	59412		Antepartum manipulation						0.000%			
5414	59414		Deliver placenta						0.000%			
5414	59612		Vbac delivery only						0.000%			
5414	59812		Treatment of miscarriage						0.000%			
5414	59820		Care of miscarriage						0.000%			
5414	59821		Treatment of miscarriage						0.000%			
5414	59840		Induced abortion d&c						0.000%			
5414	59841		Induced abortion dilat&evac						0.000%			
5414	59870		Evacuate mole of uterus						0.000%			
5414	59871		Remove cerclage suture						0.000%			
5414	0071T		Us leiomyomata ablate <200						0.000%			
5414	0072T		Fcsd us abltj leiomyom>=200						0.000%			
5415		Level 5 Gynecologic Procedures		J1	56.4352	"$5,177.76"	.	"$1,035.56"	0.000%			
5415	51840		Attach bladder/urethra						0.000%			
5415	51845		Repair bladder neck						0.000%			
5415	55920		Place needles pelvic for rt						0.000%			
5415	55970		Sex transformation m to f						0.000%			
5415	56630		Vulvectomy radical partial						0.000%			
5415	57020		Colpocentesis sep px						0.000%			
5415	57120		Colpocleisis le fort type						0.000%			
5415	57155		Insert uteri tandem/ovoids						0.000%			
5415	57220		Revision of urethra						0.000%			
5415	57240		Anterior colporrhaphy						0.000%			
5415	57250		Repair rectum & vagina						0.000%			
5415	57260		Cmbn ant pst colprhy						0.000%			
5415	57265		Cmbn ap colprhy w/ntrcl rpr						0.000%			
5415	57268		Repair of bowel bulge						0.000%			
5415	57284		Repair paravag defect open						0.000%			
5415	57288		Repair bladder defect						0.000%			
5415	57291		Construction of vagina						0.000%			
5415	57292		Construct vagina with graft						0.000%			
5415	57320		Repair bladder-vagina lesio						0.000%			
5415	57335		Repair vagina						0.000%			
5415	57530		Removal of cervix						0.000%			
5415	57550		Removal of residual cervix						0.000%			
5415	57555		Remove cervix/repair vagina						0.000%			
5415	57556		Remove cervix repair bowel						0.000%			
5415	58260		Vaginal hysterectomy						0.000%			
5415	58262		Vag hyst including t/o						0.000%			
5415	58263		Vag hyst w/t/o & vag repair						0.000%			
5415	58270		Vag hyst w/enterocele repai						0.000%			
5415	58291		Vag hyst incl t/o complex						0.000%			
5415	58294		Vag hyst w/enterocele compl						0.000%			
5415	58346		Insert heyman uteri capsule						0.000%			
5415	58350		Reopen fallopian tube						0.000%			
5415	58353		Endometr ablate thermal						0.000%			
5415	58356		Endometrial cryoablation						0.000%			
5415	58559		Hysteroscopy lysis						0.000%			
5415	58560		Hysteroscopy resect septum						0.000%			
5415	58561		Hysteroscopy remove myoma						0.000%			
5415	58563		Hysteroscopy ablation						0.000%			
5415	58565		Hysteroscopy sterilization						0.000%			
5415	58925		Removal of ovarian cyst(s)						0.000%			
5415	59100		Remove uterus lesion						0.000%			
5415	C9778		"Colpopexy, min/inv, ex-peri"						0.000%			
5416		Level 6 Gynecologic Procedures		J1	83.5174	"$7,662.47"	.	"$1,532.50"	0.000%			
5416	57282		Colpopexy extraperitoneal						0.000%			
5416	57283		Colpopexy intraperitoneal						0.000%			
5416	57285		Repair paravag defect vag						0.000%			
5416	57289		Repair bladder & vagina						0.000%			
5416	57310		Repair urethrovaginal lesio						0.000%			
5416	57330		Repair bladder-vagina lesio						0.000%			
5416	57426		Revise prosth vag graft lap						0.000%			
5416	58290		Vag hyst complex						0.000%			
5416	58292		Vag hyst t/o & repair compl						0.000%			
5416	58580		Transcrv abltj utrn fibrd r						0.000%			
5416	58920		Partial removal of ovary(s)						0.000%			
5431		Level 1 Nerve Procedures		J1	21.7971	"$1,999.82"	.	$399.97	0.000%			
5431	27325		Neurectomy hamstring						0.000%			
5431	27326		Neurectomy popliteal						0.000%			
5431	28035		Decompression of tibia nerv						0.000%			
5431	28055		Neurectomy foot						0.000%			
5431	61790		Treat trigeminal nerve						0.000%			
5431	61791		Treat trigeminal tract						0.000%			
5431	62194		Replace/irrigate catheter						0.000%			
5431	62287		Dcmprn pq nuc pul 1/mlt lmb						0.000%			
5431	62292		Njx chemonucleolysis lmbr						0.000%			
5431	62355		Remove spinal canal cathete						0.000%			
5431	63600		Remove spinal cord lesion						0.000%			
5431	63610		Stimulation of spinal cord						0.000%			
5431	63661		Remove spine eltrd perq ara						0.000%			
5431	63746		Removal of spinal shunt						0.000%			
5431	64605		Injection treatment of nerv						0.000%			
5431	64610		Injection treatment of nerv						0.000%			
5431	64624		Dstrj nulyt agt gnclr nrv						0.000%			
5431	64625		Rf abltj nrv nrvtg si jt						0.000%			
5431	64633		Destroy cerv/thor facet jnt						0.000%			
5431	64635		Destroy lumb/sac facet jnt						0.000%			
5431	64702		Revise finger/toe nerve						0.000%			
5431	64704		Revise hand/foot nerve						0.000%			
5431	64708		Revise arm/leg nerve						0.000%			
5431	64712		Revision of sciatic nerve						0.000%			
5431	64713		Revision of arm nerve(s)						0.000%			
5431	64714		Revise low back nerve(s)						0.000%			
5431	64716		Revision of cranial nerve						0.000%			
5431	64718		Revise ulnar nerve at elbow						0.000%			
5431	64719		Revise ulnar nerve at wrist						0.000%			
5431	64721		Carpal tunnel surgery						0.000%			
5431	64722		Relieve pressure on nerve(s						0.000%			
5431	64726		Release foot/toe nerve						0.000%			
5431	64732		Incision of brow nerve						0.000%			
5431	64734		Incision of cheek nerve						0.000%			
5431	64736		Incision of chin nerve						0.000%			
5431	64738		Incision of jaw nerve						0.000%			
5431	64740		Incision of tongue nerve						0.000%			
5431	64742		Incision of facial nerve						0.000%			
5431	64744		Incise nerve back of head						0.000%			
5431	64746		Incise diaphragm nerve						0.000%			
5431	64763		Incise hip/thigh nerve						0.000%			
5431	64766		Incise hip/thigh nerve						0.000%			
5431	64771		Sever cranial nerve						0.000%			
5431	64772		Incision of spinal nerve						0.000%			
5431	64774		Remove skin nerve lesion						0.000%			
5431	64776		Remove digit nerve lesion						0.000%			
5431	64782		Remove limb nerve lesion						0.000%			
5431	64784		Remove nerve lesion						0.000%			
5431	64788		Remove skin nerve lesion						0.000%			
5431	64790		Removal of nerve lesion						0.000%			
5431	64795		Biopsy of nerve						0.000%			
5431	64802		Sympathectomy cervical						0.000%			
5431	64804		Sympathectomy cervicothorac						0.000%			
5431	64820		Sympathectomy digital arter						0.000%			
5431	64831		Repair of digit nerve						0.000%			
5431	64858		Repair sciatic nerve						0.000%			
5431	64861		Repair of arm nerves						0.000%			
5431	72285		Discography cerv/thor spine						0.000%			
5431	72295		X-ray of lower spine disk						0.000%			
5431	0440T		Abltj perc uxtr/perph nrv						0.000%			
5431	0441T		Abltj perc lxtr/perph nrv						0.000%			
5431	647XX		Dcmprn median nrv carpl tun						0.000%			
5432		Level 2 Nerve Procedures		J1	50.9013	"$4,670.04"	.	$934.01	0.000%			
5432	61215		Ins subq rsvr pmp/nfs sys						0.000%			
5432	61720		Incise skull/brain surgery						0.000%			
5432	61770		Incise skull for treatment						0.000%			
5432	62225		Replace/irrigate catheter						0.000%			
5432	62230		Replace/revise brain shunt						0.000%			
5432	62350		Implant spinal canal cath						0.000%			
5432	62365		Remove spine infusion devic						0.000%			
5432	63741		Install spinal shunt						0.000%			
5432	63744		Revision of spinal shunt						0.000%			
5432	64570		Remove vagus n eltrd						0.000%			
5432	64584		Rmvl hpglsl nstim ary pg						0.000%			
5432	64786		Remove sciatic nerve lesion						0.000%			
5432	64792		Removal of nerve lesion						0.000%			
5432	64834		Repair of hand or foot nerv						0.000%			
5432	64835		Repair of hand or foot nerv						0.000%			
5432	64836		Repair of hand or foot nerv						0.000%			
5432	64840		Repair of leg nerve						0.000%			
5432	64856		Repair/transpose nerve						0.000%			
5432	64857		Repair arm/leg nerve						0.000%			
5432	64862		Repair of low back nerves						0.000%			
5432	64864		Repair of facial nerve						0.000%			
5432	64865		Repair of facial nerve						0.000%			
5432	64885		Nerve graft head/neck <4 cm						0.000%			
5432	64886		Nerve graft head/neck >4 cm						0.000%			
5432	64890		Nrv grf 1strnd hnd/foot <4c						0.000%			
5432	64891		Nrv grf 1strnd hnd/foot >4c						0.000%			
5432	64892		Nrv grf 1strnd arm/leg <4cm						0.000%			
5432	64893		Nrv grf 1strnd arm/leg >4 c						0.000%			
5432	64895		Nrv grf mltst hnd/foot <4 c						0.000%			
5432	64896		Nrv grf mltst hnd/foot >4 c						0.000%			
5432	64897		Nrv grf mltst arm/leg <4 cm						0.000%			
5432	64898		Nrv grf mltst arm/leg >4 cm						0.000%			
5432	64905		Nerve pedicle transfer						0.000%			
5432	64907		Nerve pedicle transfer						0.000%			
5432	64910		Nerve repair w/allograft						0.000%			
5432	64911		Neurorraphy w/vein autograf						0.000%			
5432	64912		Nrv rpr w/nrv algrft 1st						0.000%			
5432	0442T		Abltj perc plex/trncl nrv						0.000%			
5432	64XX8		Rmvl bat modulj sys tot sys						0.000%			
5441		Level 1 Nerve Injections		T	3.4053	$312.43	.	$62.49	0.000%			
5441	20526		Ther injection carp tunnel						0.000%			
5441	20527		Inj dupuytren cord w/enzyme						0.000%			
5441	20550		Inj tendon sheath/ligament						0.000%			
5441	20551		Inj tendon origin/insertion						0.000%			
5441	20552		Inj trigger point 1/2 muscl						0.000%			
5441	20553		Inject trigger points 3/>						0.000%			
5441	20600		Drain/inj joint/bursa w/o u						0.000%			
5441	20604		Drain/inj joint/bursa w/us						0.000%			
5441	20605		Drain/inj joint/bursa w/o u						0.000%			
5441	20610		Drain/inj joint/bursa w/o u						0.000%			
5441	20611		Drain/inj joint/bursa w/us						0.000%			
5441	20612		Aspirate/inj ganglion cyst						0.000%			
5441	61050		Remove brain canal fluid						0.000%			
5441	61055		Injection into brain canal						0.000%			
5441	64400		Njx aa&/strd trigeminal nrv						0.000%			
5441	64405		Njx aa&/strd gr ocpl nrv						0.000%			
5441	64408		Njx aa&/strd vagus nrv						0.000%			
5441	64455		Njx aa&/strd pltr com dg nr						0.000%			
5441	64505		N block spenopalatine gangl						0.000%			
5441	64566		Neuroeltrd stim post tibial						0.000%			
5441	64611		Chemodenerv saliv glands						0.000%			
5441	64612		Destroy nerve face muscle						0.000%			
5441	64615		Chemodenerv musc migraine						0.000%			
5441	64616		Chemodenerv musc neck dysto						0.000%			
5441	64632		N block inj common digit						0.000%			
5441	64650		Chemodenerv eccrine glands						0.000%			
5441	64653		Chemodenerv eccrine glands						0.000%			
5441	64999		Unlisted px nervous system						0.000%			
5441	95991		Spin/brain pump refil & mai						0.000%			
5442		Level 2 Nerve Injections		T	7.8904	$723.92	.	$144.79	0.000%			
5442	20606		Drain/inj joint/bursa w/us						0.000%			
5442	61000		Remove cranial cavity fluid						0.000%			
5442	61001		Remove cranial cavity fluid						0.000%			
5442	61026		Injection into brain canal						0.000%			
5442	61070		Brain canal shunt procedure						0.000%			
5442	62270		Dx lmbr spi pnxr						0.000%			
5442	62272		Ther spi pnxr drg csf						0.000%			
5442	62273		Inject epidural patch						0.000%			
5442	62320		Njx interlaminar crv/thrc						0.000%			
5442	62321		Njx interlaminar crv/thrc						0.000%			
5442	62323		Njx interlaminar lmbr/sac						0.000%			
5442	62328		Dx lmbr spi pnxr w/fluor/ct						0.000%			
5442	62329		Ther spi pnxr csf fluor/ct						0.000%			
5442	64418		Njx aa&/strd sprscap nrv						0.000%			
5442	64420		Njx aa&/strd ntrcost nrv 1						0.000%			
5442	64425		Njx aa&/strd ii ih nerves						0.000%			
5442	64435		Njx aa&/strd paracrv nrv						0.000%			
5442	64445		Njx aa&/strd sciatic nrv im						0.000%			
5442	64447		Njx aa&/strd femoral nrv im						0.000%			
5442	64450		Njx aa&/strd other pn/branc						0.000%			
5442	64451		Njx aa&/strd nrv nrvtg si j						0.000%			
5442	64454		Njx aa&/strd gnclr nrv brnc						0.000%			
5442	64461		Pvb thoracic single inj sit						0.000%			
5442	64463		Pvb thoracic cont infusion						0.000%			
5442	64617		Chemodener muscle larynx em						0.000%			
5442	64642		Chemodenerv 1 extremity 1-4						0.000%			
5442	64644		Chemodenerv 1 extrem 5/> mu						0.000%			
5442	64646		Chemodenerv trunk musc 1-5						0.000%			
5442	64647		Chemodenerv trunk musc 6/>						0.000%			
5442	G0260		Inj for sacroiliac jt anest						0.000%			
5443		Level 3 Nerve Injections		T	9.8573	$904.38	.	$180.88	0.000%			
5443	61020		Remove brain cavity fluid						0.000%			
5443	62263		Epidural lysis mult session						0.000%			
5443	62264		Epidural lysis on single da						0.000%			
5443	62268		Drain spinal cord cyst						0.000%			
5443	62280		Treat spinal cord lesion						0.000%			
5443	62281		Treat spinal cord lesion						0.000%			
5443	62282		Treat spinal canal lesion						0.000%			
5443	62294		Injection into spinal arter						0.000%			
5443	62322		Njx interlaminar lmbr/sac						0.000%			
5443	62324		Njx interlaminar crv/thrc						0.000%			
5443	62325		Njx interlaminar crv/thrc						0.000%			
5443	62326		Njx interlaminar lmbr/sac						0.000%			
5443	62327		Njx interlaminar lmbr/sac						0.000%			
5443	64415		Njx aa&/strd brch plxs img						0.000%			
5443	64416		Njx aa&/strd brch pl nfs im						0.000%			
5443	64417		Njx aa&/strd ax nerve img						0.000%			
5443	64421		Njx aa&/strd ntrcost nrv ea						0.000%			
5443	64430		Njx aa&/strd pudendal nerve						0.000%			
5443	64446		Njx aa&/strd sc nrv nfs img						0.000%			
5443	64448		Njx aa&/strd fem nrv nfs im						0.000%			
5443	64449		Njx aa&/strd lmbr plex nfs						0.000%			
5443	64479		Njx aa&/strd tfrm epi c/t 1						0.000%			
5443	64483		Njx aa&/strd tfrm epi l/s 1						0.000%			
5443	64490		Inj paravert f jnt c/t 1 le						0.000%			
5443	64493		Inj paravert f jnt l/s 1 le						0.000%			
5443	64510		N block stellate ganglion						0.000%			
5443	64517		N block inj hypogas plxs						0.000%			
5443	64520		N block lumbar/thoracic						0.000%			
5443	64530		N block inj celiac pelus						0.000%			
5443	64600		Injection treatment of nerv						0.000%			
5443	64620		Injection treatment of nerv						0.000%			
5443	64630		Injection treatment of nerv						0.000%			
5443	64640		Injection treatment of nerv						0.000%			
5443	64680		Injection treatment of nerv						0.000%			
5443	64681		Injection treatment of nerv						0.000%			
5443	0213T		Njx paravert w/us cer/thor						0.000%			
5443	0216T		Njx paravert w/us lumb/sac						0.000%			
5461		Level 1 Neurostimulator and Related Procedures		J1	40.5759	"$3,722.72"	.	$744.55	0.000%			
5461	33278		Rmvl phrnc nrv stim sys						0.000%			
5461	33279		Rmvl phrnc nrv stim transvn						0.000%			
5461	33280		Rmvl phrnc nrv stim pg only						0.000%			
5461	33281		Reposg phrnc nrv stim trnsv						0.000%			
5461	61880		Revise/remove neuroelectrod						0.000%			
5461	63662		Remove spine eltrd plate						0.000%			
5461	63688		Rev/rmv imp sp npg/r dtch c						0.000%			
5461	64585		Rev/rmv perph nstim eltrd r						0.000%			
5461	64595		Rev/rmv prph sac/gstr npg/r						0.000%			
5461	64598		Revj/rmvl nea pn w/int nsti						0.000%			
5461	0588T		Revision/removal isdns ptn						0.000%			
5461	0681T		Rlcj pulse gen only isdss						0.000%			
5461	0682T		Removal pulse gen only isds						0.000%			
5461	0785T		Revj/rmvl nea spi w/nstim						0.000%			
5461	0787T		Revj/rmvl nea sac w/nstim						0.000%			
5461	0818T		Revj/rmvl ins ptn subq						0.000%			
5461	0819T		Revj/rmvl ins ptn subf						0.000%			
5461	64X10		Rmvl bat modulj sys pg only						0.000%			
5461	64XX6		Revj/rplcmt bat mod sys lea						0.000%			
5461	64XX9		Rmvl bat modul sys lead onl						0.000%			
5461	X401T		Revj/rmvl ins ptn subq&subf						0.000%			
5461	X479T		Rev/rmv lw esoph sphnc npg/						0.000%			
5462		Level 2 Neurostimulator and Related Procedures		J1	71.5065	"$6,560.51"	.	"$1,312.11"	0.000%			
5462	63650		Implant neuroelectrodes						0.000%			
5462	63663		Revise spine eltrd perq ara						0.000%			
5462	64555		Implant neuroelectrodes						0.000%			
5462	64561		Implant neuroelectrodes						0.000%			
5462	64581		Opn impltj nea sacral nerve						0.000%			
5462	0587T		Perq impltj/rplcmt isdns pt						0.000%			
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."
5463	33288		Rmv&rplcmt phrnc nrv stim l						0.000%			
5463	43647		Lap impl electrode antrum						0.000%			
5463	61715		Mrgfus strtctc ablt trgt ic						0.000%			
5463	61888		Revise/remove neuroreceiver						0.000%			
5463	63664		Revise spine eltrd plate						0.000%			
5463	64553		Implant neuroelectrodes						0.000%			
5463	64569		Revise/repl vagus n eltrd						0.000%			
5463	64575		Opn impltj nea perph nerve						0.000%			
5463	64583		Rev/rplct hpglsl nstm ary p						0.000%			
5463	64596		Ins/rplcmt prq eltrd ra pn						0.000%			
5463	0675T		Laps insj nw/rpcmt isdss 1l						0.000%			
5463	0784T		Ins/rplmt eltrd ra spi nsti						0.000%			
5463	X448T		Lap rv/rmv eso sph nstm elt						0.000%			
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."
5464	61891		Rev/rplcmt sk-mnt crnl nstm						0.000%			
5464	63655		Implant neuroelectrodes						0.000%			
5464	64580		Opn impltj nea neuromuscula						0.000%			
5464	64590		Ins/rpl prph sac/gstr npg/r						0.000%			
5464	0680T		Insj/rplcmt pg only isdss						0.000%			
5464	0816T		Opn insj/rplcmt ins ptn sub						0.000%			
5464	0817T		Opn insj/rplcmt ins ptn sub						0.000%			
5464	X400T		Opn ins/rplc ins ptn sbq&sb						0.000%			
5464	X447T		Lap srg imp/rpl eso nea&pg/						0.000%			
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."
5465	33287		Rmv&rplcmt phrnc nrv stim p						0.000%			
5465	61885		Insrt/redo neurostim 1 arra						0.000%			
5465	61886		Implant neurostim arrays						0.000%			
5465	63685		Ins/rplc spi npg/rcvr pocke						0.000%			
5465	64568		Opn impltj crnl nrv nea&pg						0.000%			
5465	64582		Opn mpltj hpglsl nstm ary p						0.000%			
5465	0674T		Laps insj nw/rpcmt prm isds						0.000%			
5465	64XX7		Revj/rplcmt bat mod sys pg						0.000%			
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."
5471	62360		Insert spine infusion devic						0.000%			
5471	62361		Implant spine infusion pump						0.000%			
5471	62362		Implant spine infusion pump						0.000%			
5481		Laser Eye Procedures		T	6.0635	$556.31	.	$111.27	0.000%			
5481	65855		Trabeculoplasty laser surg						0.000%			
5481	65860		Severing ads ant sgm laser						0.000%			
5481	66761		Revision of iris						0.000%			
5481	66762		Revision of iris						0.000%			
5481	66770		Removal of inner eye lesion						0.000%			
5481	66821		After cataract laser surger						0.000%			
5481	67031		Laser surgery eye strands						0.000%			
5481	67105		Repair detached retina pc						0.000%			
5481	67145		Proph rta dtchmnt pc						0.000%			
5481	67210		Treatment of retinal lesion						0.000%			
5481	67220		Treatment of choroid lesion						0.000%			
5481	67221		Ocular photodynamic ther						0.000%			
5481	67228		Treatment x10sv retinopathy						0.000%			
5481	67229		Tr retinal les preterm inf						0.000%			
5481	G0186		"Dstry eye lesn,fdr vssl tec"						0.000%			
5491		Level 1 Intraocular Procedures		J1	23.8035	"$2,183.90"	.	$436.78	0.000%			
5491	65235		Remove foreign body from ey						0.000%			
5491	65260		Remove foreign body from ey						0.000%			
5491	65265		Remove foreign body from ey						0.000%			
5491	65286		Repair of eye wound						0.000%			
5491	65800		Drainage of eye						0.000%			
5491	65810		Drainage of eye						0.000%			
5491	65815		Drainage of eye						0.000%			
5491	65850		Trabeculotomy ab externo						0.000%			
5491	65865		Incise inner eye adhesions						0.000%			
5491	65870		Incise inner eye adhesions						0.000%			
5491	65875		Incise inner eye adhesions						0.000%			
5491	65900		Remove eye lesion						0.000%			
5491	65920		Remove implant of eye						0.000%			
5491	65930		Remove blood clot from eye						0.000%			
5491	66020		Injection treatment of eye						0.000%			
5491	66030		Injection treatment of eye						0.000%			
5491	66160		Glaucoma surgery						0.000%			
5491	66170		Glaucoma surgery						0.000%			
5491	66172		Incision of eye						0.000%			
5491	66184		Revision of aqueous shunt						0.000%			
5491	66185		Revise aqueous shunt eye						0.000%			
5491	66500		Incision of iris						0.000%			
5491	66505		Incision of iris						0.000%			
5491	66605		Removal of iris						0.000%			
5491	66625		Removal of iris						0.000%			
5491	66630		Removal of iris						0.000%			
5491	66635		Removal of iris						0.000%			
5491	66680		Repair iris & ciliary body						0.000%			
5491	66682		Repair iris & ciliary body						0.000%			
5491	66700		Destruction ciliary body						0.000%			
5491	66711		Ecp ciliary body destructio						0.000%			
5491	66820		Incision secondary cataract						0.000%			
5491	66825		Reposition intraocular lens						0.000%			
5491	66830		Removal of lens lesion						0.000%			
5491	66840		Removal of lens material						0.000%			
5491	66850		Removal of lens material						0.000%			
5491	66920		Extraction of lens						0.000%			
5491	66940		Extraction of lens						0.000%			
5491	66982		Xcapsl ctrc rmvl cplx wo ec						0.000%			
5491	66983		Cataract surg w/iol 1 stage						0.000%			
5491	66984		Xcapsl ctrc rmvl w/o ecp						0.000%			
5491	66985		Insert lens prosthesis						0.000%			
5491	66986		Exchange lens prosthesis						0.000%			
5491	66999		Unlisted px ant segment eye						0.000%			
5491	67005		Partial removal of eye flui						0.000%			
5491	67010		Partial removal of eye flui						0.000%			
5491	67015		Release of eye fluid						0.000%			
5491	67025		Replace eye fluid						0.000%			
5491	67030		Incise inner eye strands						0.000%			
5491	67101		Repair detached retina crtx						0.000%			
5491	67110		Repair detached retina						0.000%			
5491	67120		Remove eye implant material						0.000%			
5491	67121		Remove eye implant material						0.000%			
5491	67299		Unlisted px posterior segmn						0.000%			
5491	68330		Revise eyelid lining						0.000%			
5491	0699T		Njx pst chmbr eye medicatio						0.000%			
5491	X433T		Ins&sclr fix caps bag prost						0.000%			
5492		Level 2 Intraocular Procedures		J1	46.2509	"$4,243.38"	.	$848.68	0.000%			
5492	65730		Corneal transplant						0.000%			
5492	65755		Corneal transplant						0.000%			
5492	65756		Corneal trnspl endothelial						0.000%			
5492	65785		Impltj ntrstrml crnl rng se						0.000%			
5492	65820		Goniotomy						0.000%			
5492	65880		Incise inner eye adhesions						0.000%			
5492	66150		Glaucoma surgery						0.000%			
5492	66155		Glaucoma surgery						0.000%			
5492	66174		Trluml dil aq o/f can w/o s						0.000%			
5492	66183		Insert ant drainage device						0.000%			
5492	66600		Remove iris and lesion						0.000%			
5492	66852		Removal of lens material						0.000%			
5492	66930		Extraction of lens						0.000%			
5492	66987		Xcapsl ctrc rmvl cplx w/ecp						0.000%			
5492	66988		Xcapsl ctrc rmvl w/ecp						0.000%			
5492	67036		Removal of inner eye fluid						0.000%			
5492	67039		Laser treatment of retina						0.000%			
5492	67040		Laser treatment of retina						0.000%			
5492	67041		Vit for macular pucker						0.000%			
5492	67042		Vit for macular hole						0.000%			
5492	67043		Vit for membrane dissect						0.000%			
5492	67107		Repair detached retina						0.000%			
5492	67108		Repair detached retina						0.000%			
5492	67115		Release encircling material						0.000%			
5492	67255		Reinforce/graft eye wall						0.000%			
5492	0253T		Insert aqueous drain device						0.000%			
5492	0621T		Trabeculostomy interno lase						0.000%			
5492	0660T		Implt ant sgm io nbio rx sy						0.000%			
5492	0661T		Rmvl&rimpltj ant sgm implt						0.000%			
5492	X458T		Mtrz ab ntrno trph scl/tr m						0.000%			
5493		Level 3 Intraocular Procedures		J1	58.7029	"$5,385.81"	.	"$1,077.17"	0.000%			
5493	65280		Repair of eye wound						0.000%			
5493	65285		Repair of eye wound						0.000%			
5493	65710		Corneal transplant						0.000%			
5493	65750		Corneal transplant						0.000%			
5493	65781		Ocular reconst transplant						0.000%			
5493	66175		Trluml dil aq o/f can w/st						0.000%			
5493	66179		Aqueous shunt eye w/o graft						0.000%			
5493	66180		Aqueous shunt eye w/graft						0.000%			
5493	66225		Repair/graft eye lesion						0.000%			
5493	66989		Xcpsl ctrc rmvl cplx insj 1						0.000%			
5493	66991		Xcapsl ctrc rmvl insj 1+						0.000%			
5493	67113		Repair retinal detach cplx						0.000%			
5493	0449T		Insj aqueous drain dev 1st						0.000%			
5493	0671T		Insj ant sgm aq drg dev 1+						0.000%			
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."
5494	65770		Keratoprosthesis						0.000%			
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."
5495	67027		Implant eye drug system						0.000%			
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."
5496	66683		Implantation iris prosthesi						0.000%			
5496	0308T		Insj ocular telescope prost						0.000%			
5501		"Level 1 Extraocular, Repair, and Plastic Eye Procedures"		T	3.5649	$327.07	.	$65.42	0.000%			
5501	65450		Treatment of corneal lesion						0.000%			
5501	67141		Proph rta dtchmnt crtx dthr						0.000%			
5501	67208		Treatment of retinal lesion						0.000%			
5501	67345		Destroy nerve of eye muscle						0.000%			
5501	67399		Unlisted px extraocular mus						0.000%			
5501	67500		Inject/treat eye socket						0.000%			
5501	67505		Inject/treat eye socket						0.000%			
5501	67515		Inject/treat eye socket						0.000%			
5501	67599		Unlisted procedure orbit						0.000%			
5501	67700		Blepharotomy drg absc eyeli						0.000%			
5501	67800		Remove eyelid lesion						0.000%			
5501	67805		Remove eyelid lesions						0.000%			
5501	67810		Incal bx eyelid skn lid mrg						0.000%			
5501	67825		Revise eyelashes						0.000%			
5501	67938		Remove eyelid foreign body						0.000%			
5501	67999		Unlisted procedure eyelids						0.000%			
5501	68040		Treatment of eyelid lesions						0.000%			
5501	68399		Unlisted px conjunctiva						0.000%			
5501	68440		Snip inc lacrimal punctum						0.000%			
5501	68530		Clearance of tear duct						0.000%			
5501	68705		Revise tear duct opening						0.000%			
5501	68760		Close tear duct opening						0.000%			
5501	68761		Close tear duct opening						0.000%			
5501	68810		Probe nasolacrimal duct						0.000%			
5501	68840		Explore/irrigate tear ducts						0.000%			
5501	68899		Unlisted px lacrimal system						0.000%			
5502		"Level 2 Extraocular, Repair, and Plastic Eye Procedures"		T	11.0691	"$1,015.56"	.	$203.12	0.000%			
5502	65400		Removal of eye lesion						0.000%			
5502	65435		Curette/treat cornea						0.000%			
5502	65772		Correction of astigmatism						0.000%			
5502	65778		Cover eye w/membrane						0.000%			
5502	67710		Severing tarsorrhaphy						0.000%			
5502	67801		Remove eyelid lesions						0.000%			
5502	67830		Revise eyelashes						0.000%			
5502	67840		Remove eyelid lesion						0.000%			
5502	67850		Dstrj lesion lid margin <1c						0.000%			
5502	67875		Closure of eyelid by suture						0.000%			
5502	68020		Incise/drain eyelid lining						0.000%			
5502	68400		I&d lacrimal gland						0.000%			
5503		"Level 3 Extraocular, Repair, and Plastic Eye Procedures"		J1	26.9061	"$2,468.55"	.	$493.71	0.000%			
5503	65125		Revise ocular implant						0.000%			
5503	65270		Repair of eye wound						0.000%			
5503	65272		Repair of eye wound						0.000%			
5503	65410		Biopsy of cornea						0.000%			
5503	65420		Removal of eye lesion						0.000%			
5503	65426		Removal of eye lesion						0.000%			
5503	65436		Curette/treat cornea						0.000%			
5503	65600		Revision of cornea						0.000%			
5503	65775		Correction of astigmatism						0.000%			
5503	66130		Remove eye lesion						0.000%			
5503	66250		Follow-up surgery of eye						0.000%			
5503	66710		Ciliary transsleral therapy						0.000%			
5503	66720		Destruction ciliary body						0.000%			
5503	66740		Destruction ciliary body						0.000%			
5503	67250		Reinforce eye wall						0.000%			
5503	67311		Revise eye muscle						0.000%			
5503	67314		Revise eye muscle						0.000%			
5503	67316		Revise two eye muscles						0.000%			
5503	67318		Revise eye muscle(s)						0.000%			
5503	67343		Release eye tissue						0.000%			
5503	67405		Explore/drain eye socket						0.000%			
5503	67412		Explore/treat eye socket						0.000%			
5503	67413		Explore/treat eye socket						0.000%			
5503	67415		Aspiration orbital contents						0.000%			
5503	67715		Canthotomy						0.000%			
5503	67808		Remove eyelid lesion(s)						0.000%			
5503	67835		Revise eyelashes						0.000%			
5503	67880		Revision of eyelid						0.000%			
5503	67882		Revision of eyelid						0.000%			
5503	67900		Repair brow defect						0.000%			
5503	67901		Repair eyelid defect						0.000%			
5503	67903		Repair eyelid defect						0.000%			
5503	67904		Repair eyelid defect						0.000%			
5503	67908		Repair eyelid defect						0.000%			
5503	67909		Revise eyelid defect						0.000%			
5503	67911		Revise eyelid defect						0.000%			
5503	67912		Correction eyelid w/implant						0.000%			
5503	67914		Repair eyelid defect						0.000%			
5503	67915		Repair eyelid defect						0.000%			
5503	67916		Repair eyelid defect						0.000%			
5503	67917		Repair eyelid defect						0.000%			
5503	67921		Repair eyelid defect						0.000%			
5503	67922		Repair eyelid defect						0.000%			
5503	67923		Repair eyelid defect						0.000%			
5503	67924		Repair eyelid defect						0.000%			
5503	67930		Repair eyelid wound						0.000%			
5503	67935		Repair eyelid wound						0.000%			
5503	67950		Revision of eyelid						0.000%			
5503	67961		Revision of eyelid						0.000%			
5503	67966		Revision of eyelid						0.000%			
5503	67971		Reconstruction of eyelid						0.000%			
5503	67973		Reconstruction of eyelid						0.000%			
5503	67975		Reconstruction of eyelid						0.000%			
5503	68100		Biopsy conjunctiva						0.000%			
5503	68110		Exc les conjunctiva <1 cm						0.000%			
5503	68115		Exc les conjunctiva >1 cm						0.000%			
5503	68130		Exc les conjunctiva adj scl						0.000%			
5503	68135		Destruction les conjunctiva						0.000%			
5503	68320		Revise/graft eyelid lining						0.000%			
5503	68328		Revise/graft eyelid lining						0.000%			
5503	68340		Separate eyelid adhesions						0.000%			
5503	68362		Revise eyelid lining						0.000%			
5503	68371		Harvest eye tissue alograft						0.000%			
5503	68420		I&d lacrimal sac						0.000%			
5503	68510		Biopsy of tear gland						0.000%			
5503	68525		Biopsy of tear sac						0.000%			
5503	68540		Remove tear gland lesion						0.000%			
5503	68700		Repair tear ducts						0.000%			
5503	68770		Close tear system fistula						0.000%			
5503	68811		Probe nasolacrimal duct						0.000%			
5503	68815		Probe nasolacrimal duct						0.000%			
5503	68816		Probe nl duct w/balloon						0.000%			
5503	68841		Insj rx elut implt lac cana						0.000%			
5503	92018		Compl oph exam general anes						0.000%			
5503	92019		Lmtd oph exam general anes						0.000%			
5503	0402T		Colgn crs-link crn&pachymtr						0.000%			
5504		"Level 4 Extraocular, Repair, and Plastic Eye Procedures"		J1	43.3584	"$3,978.00"	.	$795.60	0.000%			
5504	65091		Revise eye						0.000%			
5504	65093		Revise eye with implant						0.000%			
5504	65101		Removal of eye						0.000%			
5504	65103		Remove eye/insert implant						0.000%			
5504	65105		Remove eye/attach implant						0.000%			
5504	65110		Removal of eye						0.000%			
5504	65112		Remove eye/revise socket						0.000%			
5504	65114		Remove eye/revise socket						0.000%			
5504	65130		Insert ocular implant						0.000%			
5504	65135		Insert ocular implant						0.000%			
5504	65140		Attach ocular implant						0.000%			
5504	65150		Revise ocular implant						0.000%			
5504	65155		Reinsert ocular implant						0.000%			
5504	65175		Removal of ocular implant						0.000%			
5504	65275		Repair of eye wound						0.000%			
5504	65290		Repair of eye socket wound						0.000%			
5504	65779		Cover eye w/membrane suture						0.000%			
5504	65780		Ocular reconst transplant						0.000%			
5504	65782		Ocular reconst transplant						0.000%			
5504	67218		Treatment of retinal lesion						0.000%			
5504	67227		Dstrj extensive retinopathy						0.000%			
5504	67312		Revise two eye muscles						0.000%			
5504	67346		Biopsy eye muscle						0.000%			
5504	67400		Explore/biopsy eye socket						0.000%			
5504	67414		Explr/decompress eye socket						0.000%			
5504	67420		Explore/treat eye socket						0.000%			
5504	67430		Explore/treat eye socket						0.000%			
5504	67440		Explore/drain eye socket						0.000%			
5504	67445		Explr/decompress eye socket						0.000%			
5504	67450		Explore/biopsy eye socket						0.000%			
5504	67550		Insert eye socket implant						0.000%			
5504	67560		Revise eye socket implant						0.000%			
5504	67570		Decompress optic nerve						0.000%			
5504	67902		Repair eyelid defect						0.000%			
5504	67906		Repair eyelid defect						0.000%			
5504	67974		Reconstruction of eyelid						0.000%			
5504	68325		Revise/graft eyelid lining						0.000%			
5504	68326		Revise/graft eyelid lining						0.000%			
5504	68335		Revise/graft eyelid lining						0.000%			
5504	68360		Revise eyelid lining						0.000%			
5504	68500		Removal of tear gland						0.000%			
5504	68505		Partial removal tear gland						0.000%			
5504	68520		Removal of tear sac						0.000%			
5504	68550		Remove tear gland lesion						0.000%			
5504	68720		Create tear sac drain						0.000%			
5504	68745		Create tear duct drain						0.000%			
5504	68750		Create tear duct drain						0.000%			
5521		Level 1 Imaging without Contrast		S	0.9743	$89.39	.	$17.88	0.000%			
5521	77078		Ct bone density axial				$0.00	$0.00	0.000%	$0.00		
5521	77081		Dxa bone density appendicul				$0.00	$0.00	0.000%	$0.00		
5521	70030		X-ray eye for foreign body						0.000%			
5521	70100		X-ray exam of jaw <4views						0.000%			
5521	70140		X-ray exam of facial bones						0.000%			
5521	70160		X-ray exam of nasal bones						0.000%			
5521	70190		X-ray exam of eye sockets						0.000%			
5521	70210		X-ray exam of sinuses						0.000%			
5521	70220		X-ray exam of sinuses						0.000%			
5521	70240		X-ray exam pituitary saddle						0.000%			
5521	70300		X-ray exam of teeth						0.000%			
5521	70328		X-ray exam of jaw joint						0.000%			
5521	70330		X-ray exam of jaw joints						0.000%			
5521	70350		X-ray head for orthodontia						0.000%			
5521	70355		Panoramic x-ray of jaws						0.000%			
5521	70360		X-ray exam of neck						0.000%			
5521	70370		Throat x-ray & fluoroscopy						0.000%			
5521	70380		X-ray exam of salivary glan						0.000%			
5521	71045		X-ray exam chest 1 view						0.000%			
5521	71046		X-ray exam chest 2 views						0.000%			
5521	71047		X-ray exam chest 3 views						0.000%			
5521	71100		X-ray exam ribs uni 2 views						0.000%			
5521	71120		X-ray exam breastbone 2/>vw						0.000%			
5521	71130		X-ray strenoclavic jt 3/>vw						0.000%			
5521	72020		X-ray exam of spine 1 view						0.000%			
5521	72040		X-ray exam neck spine 2-3 v						0.000%			
5521	72080		X-ray exam thoracolmb 2/> v						0.000%			
5521	72081		X-ray exam entire spi 1 vw						0.000%			
5521	72220		X-ray exam sacrum tailbone						0.000%			
5521	73000		X-ray exam of collar bone						0.000%			
5521	73020		X-ray exam of shoulder						0.000%			
5521	73030		X-ray exam of shoulder						0.000%			
5521	73050		X-ray exam of shoulders						0.000%			
5521	73060		X-ray exam of humerus						0.000%			
5521	73070		X-ray exam of elbow						0.000%			
5521	73080		X-ray exam of elbow						0.000%			
5521	73090		X-ray exam of forearm						0.000%			
5521	73100		X-ray exam of wrist						0.000%			
5521	73110		X-ray exam of wrist						0.000%			
5521	73130		X-ray exam of hand						0.000%			
5521	73140		X-ray exam of finger(s)						0.000%			
5521	73501		X-ray exam hip uni 1 view						0.000%			
5521	73502		X-ray exam hip uni 2-3 view						0.000%			
5521	73551		X-ray exam of femur 1						0.000%			
5521	73552		X-ray exam of femur 2/>						0.000%			
5521	73560		X-ray exam of knee 1 or 2						0.000%			
5521	73562		X-ray exam of knee 3						0.000%			
5521	73565		X-ray exam of knees						0.000%			
5521	73590		X-ray exam of lower leg						0.000%			
5521	73592		X-ray exam of leg infant						0.000%			
5521	73600		X-ray exam of ankle						0.000%			
5521	73610		X-ray exam of ankle						0.000%			
5521	73620		X-ray exam of foot						0.000%			
5521	73630		X-ray exam of foot						0.000%			
5521	73650		X-ray exam of heel						0.000%			
5521	73660		X-ray exam of toe(s)						0.000%			
5521	74018		Radex abdomen 1 view						0.000%			
5521	75571		Ct hrt w/o dye w/ca test						0.000%			
5521	76010		X-ray nose to rectum						0.000%			
5521	76016		Mr safety deter phys/qhp						0.000%			
5521	76380		Cat scan follow-up study						0.000%			
5521	76390		Mr spectroscopy						0.000%			
5521	76496		Unlisted fluoroscopic px						0.000%			
5521	76497		Unlisted ct procedure						0.000%			
5521	76498		Unlisted mr procedure						0.000%			
5521	76499		Unlisted dx radiographic px						0.000%			
5521	76529		Echo exam of eye						0.000%			
5521	76642		Ultrasound breast limited						0.000%			
5521	76885		Us exam infant hips dynamic						0.000%			
5521	76886		Us exam infant hips static						0.000%			
5521	76999		Echo examination procedure						0.000%			
5521	77071		Mnl appl strs jt radiograph						0.000%			
5521	77086		Vrt fracture assmt via dxa						0.000%			
5521	77090		Tbs techl prep&transmis dat						0.000%			
5521	77091		Tbs techl calculation only						0.000%			
5521	0350T		Rsa lower extr exam						0.000%			
5521	0422T		Tactile breast img uni/bi						0.000%			
5521	0558T		Ct scan f/biomchn ct alys						0.000%			
5521	0689T		Quan us tis charac w/o dx u						0.000%			
5521	0712T		N-nvs artl plaq alys quan						0.000%			
5521	D0220		Intraoral periapical first						0.000%			
5521	D0240		Intraoral occlusal film						0.000%			
5521	D0250		Extraoral 2d project image						0.000%			
5521	D0251		Extraoral posterior image						0.000%			
5521	D0270		Dental bitewing single imag						0.000%			
5521	D0272		Dental bitewings two images						0.000%			
5521	D0321		Other tmj images by report						0.000%			
5521	D0340		2d cephalometric image						0.000%			
5521	D0350		Oral/facial photo images						0.000%			
5521	D0371		Sialoendoscopy capt & inter						0.000%			
5521	D0393		Trtmnt simulation 3d image						0.000%			
5521	D0394		Digital sub 2 or more image						0.000%			
5521	D0395		Fusion 2 or more 3d images						0.000%			
5521	D0701		Pano radio image						0.000%			
5521	D0702		2d cephal radio image						0.000%			
5521	D0703		2d oral/facial photo image						0.000%			
5521	D0705		Extra oral post radio image						0.000%			
5521	D0706		Intraoral occlus radio imag						0.000%			
5521	D0707		Intraoral periap radio imag						0.000%			
5521	D0708		Intraoral bite radio image						0.000%			
5521	D0709		Intraoral comp image captur						0.000%			
5521	G0183		Software meas of cardiac vo						0.000%			
5522		Level 2 Imaging without Contrast		S	1.1707	$107.41	.	$21.49	0.000%			
5522	71271		Ct thorax lung cancer scr c				$0.00	$0.00	0.000%	$0.00		
5522	76706		Us abdl aorta screen aaa				$0.00	$0.00	0.000%	$0.00		
5522	76977		Us bone density measure				$0.00	$0.00	0.000%	$0.00		
5522	77080		Dxa bone density axial				$0.00	$0.00	0.000%	$0.00		
5522	77085		Dxa bone density axl vrt fx				$0.00	$0.00	0.000%	$0.00		
5522	G0130		Single energy x-ray study				$0.00	$0.00	0.000%	$0.00		
5522	70110		X-ray exam of jaw 4/> views						0.000%			
5522	70120		X-ray exam of mastoids						0.000%			
5522	70130		X-ray exam of mastoids						0.000%			
5522	70150		X-ray exam of facial bones						0.000%			
5522	70200		X-ray exam of eye sockets						0.000%			
5522	70250		X-ray exam of skull						0.000%			
5522	70260		X-ray exam of skull						0.000%			
5522	70450		Ct head/brain w/o dye						0.000%			
5522	70480		Ct orbit/ear/fossa w/o dye						0.000%			
5522	70486		Ct maxillofacial w/o dye						0.000%			
5522	70490		Ct soft tissue neck w/o dye						0.000%			
5522	71048		X-ray exam chest 4+ views						0.000%			
5522	71101		X-ray exam unilat ribs/ches						0.000%			
5522	71110		X-ray exam ribs bil 3 views						0.000%			
5522	71111		X-ray exam ribs/chest4/> vw						0.000%			
5522	71250		Ct thorax dx c-						0.000%			
5522	72050		X-ray exam neck spine 4/5vw						0.000%			
5522	72052		X-ray exam neck spine 6/>vw						0.000%			
5522	72070		X-ray exam thorac spine 2vw						0.000%			
5522	72072		X-ray exam thorac spine 3vw						0.000%			
5522	72074		X-ray exam thorac spine4/>v						0.000%			
5522	72082		X-ray exam entire spi 2/3 v						0.000%			
5522	72083		X-ray exam entire spi 4/5 v						0.000%			
5522	72084		X-ray exam entire spi 6/> v						0.000%			
5522	72100		X-ray exam l-s spine 2/3 vw						0.000%			
5522	72110		X-ray exam l-2 spine 4/>vws						0.000%			
5522	72114		X-ray exam l-s spine bendin						0.000%			
5522	72120		X-ray bend only l-s spine						0.000%			
5522	72125		Ct neck spine w/o dye						0.000%			
5522	72128		Ct chest spine w/o dye						0.000%			
5522	72131		Ct lumbar spine w/o dye						0.000%			
5522	72170		X-ray exam of pelvis						0.000%			
5522	72190		X-ray exam of pelvis						0.000%			
5522	72192		Ct pelvis w/o dye						0.000%			
5522	72200		X-ray exam si joints						0.000%			
5522	72202		X-ray exam si joints 3/> vw						0.000%			
5522	73010		X-ray exam of shoulder blad						0.000%			
5522	73092		X-ray exam of arm infant						0.000%			
5522	73120		X-ray exam of hand						0.000%			
5522	73200		Ct upper extremity w/o dye						0.000%			
5522	73503		X-ray exam hip uni 4/> view						0.000%			
5522	73521		X-ray exam hips bi 2 views						0.000%			
5522	73522		X-ray exam hips bi 3-4 view						0.000%			
5522	73523		X-ray exam hips bi 5/> view						0.000%			
5522	73564		X-ray exam knee 4 or more						0.000%			
5522	73700		Ct lower extremity w/o dye						0.000%			
5522	74019		Radex abdomen 2 views						0.000%			
5522	74021		Radex abdomen 3+ views						0.000%			
5522	74022		Radex compl aqt abd series						0.000%			
5522	74150		Ct abdomen w/o contrast						0.000%			
5522	74261		Ct colonography dx						0.000%			
5522	74445		X-ray exam of penis						0.000%			
5522	75809		Nonvascular shunt x-ray						0.000%			
5522	76100		X-ray exam of body section						0.000%			
5522	76120		Cine/video x-rays						0.000%			
5522	76506		Echo exam of head						0.000%			
5522	76511		Oph us dx quan a-scan only						0.000%			
5522	76512		Oph us dx b-scan						0.000%			
5522	76513		Oph us dx ant sgm us uni/bi						0.000%			
5522	76516		Echo exam of eye						0.000%			
5522	76519		Echo exam of eye						0.000%			
5522	76536		Us exam of head and neck						0.000%			
5522	76604		Us exam chest						0.000%			
5522	76641		Ultrasound breast complete						0.000%			
5522	76700		Us exam abdom complete						0.000%			
5522	76705		Echo exam of abdomen						0.000%			
5522	76770		Us exam abdo back wall comp						0.000%			
5522	76775		Us exam abdo back wall lim						0.000%			
5522	76776		Us exam k transpl w/doppler						0.000%			
5522	76800		Us exam spinal canal						0.000%			
5522	76801		Ob us < 14 wks single fetus						0.000%			
5522	76805		Ob us >= 14 wks sngl fetus						0.000%			
5522	76813		Ob us nuchal meas 1 gest						0.000%			
5522	76815		Ob us limited fetus(s)						0.000%			
5522	76816		Ob us follow-up per fetus						0.000%			
5522	76817		Transvaginal us obstetric						0.000%			
5522	76818		Fetal biophys profile w/nst						0.000%			
5522	76819		Fetal biophys profil w/o ns						0.000%			
5522	76820		Umbilical artery echo						0.000%			
5522	76821		Middle cerebral artery echo						0.000%			
5522	76827		Echo exam of fetal heart						0.000%			
5522	76828		Echo exam of fetal heart						0.000%			
5522	76830		Transvaginal us non-ob						0.000%			
5522	76856		Us exam pelvic complete						0.000%			
5522	76857		Us exam pelvic limited						0.000%			
5522	76870		Us exam scrotum						0.000%			
5522	76872		Us transrectal						0.000%			
5522	76873		Echograp trans r pros study						0.000%			
5522	76881		Us compl joint r-t w/img						0.000%			
5522	76882		Us lmtd jt/fcl evl nvasc xt						0.000%			
5522	76883		Us nrv&acc strux 1xtr compr						0.000%			
5522	76981		Use parenchyma						0.000%			
5522	76982		Use 1st target lesion						0.000%			
5522	77072		Bone age studies						0.000%			
5522	77073		Bone length studies						0.000%			
5522	77074		Radex osseous survey lmtd						0.000%			
5522	77075		Radex osseous survey compl						0.000%			
5522	77076		Radex osseous survey infant						0.000%			
5522	77077		Joint survey single view						0.000%			
5522	93882		Extracranial uni/ltd study						0.000%			
5522	93888		Intracranial limited study						0.000%			
5522	93892		Tcd emboli detect w/o inj						0.000%			
5522	93893		Tcd std icr art ven-art shn						0.000%			
5522	93926		Lower extremity study						0.000%			
5522	93931		Upper extremity study						0.000%			
5522	93971		Extremity study						0.000%			
5522	93976		Vascular study						0.000%			
5522	93979		Vascular study						0.000%			
5522	93980		Penile vascular study						0.000%			
5522	93981		Penile vascular study						0.000%			
5522	93986		Dup-scan hemo compl uni std						0.000%			
5522	93990		Doppler flow testing						0.000%			
5522	0348T		Rsa spine exam						0.000%			
5522	0349T		Rsa upper extr exam						0.000%			
5522	0633T		Ct breast w/3d uni c-						0.000%			
5522	0857T		Opto-acoustic img breast un						0.000%			
5522	0946T		Ortho impl mvmt alys pair c						0.000%			
5522	D0322		Dental tomographic survey						0.000%			
5522	D0364		Cone beam ct capt & interp						0.000%			
5522	D0365		Cone beam ct interprete man						0.000%			
5522	D0366		Cone beam ct interprete max						0.000%			
5522	D0367		Cone beam ct interp both ja						0.000%			
5522	D0368		Cone beam ct interprete tmj						0.000%			
5522	D0369		Max mri capture & interpret						0.000%			
5522	D0370		Max ultrasound capt & inter						0.000%			
5522	D0380		Cone beam ct capture limite						0.000%			
5522	D0381		Cone beam ct capt mandible						0.000%			
5522	D0382		Cone beam ct capt maxilla						0.000%			
5522	D0383		Cone beam ct both jaws						0.000%			
5522	D0384		Cone beam ct capture tmj						0.000%			
5522	D0385		Max mri image capture						0.000%			
5522	D0386		Max ultrasound image captur						0.000%			
5523		Level 3 Imaging without Contrast		S	2.6782	$245.72	.	$49.15	0.000%			
5523	74263		Ct colonography screening				$0.00	$0.00	0.000%	$0.00		
5523	49465		Fluoro exam of g/colon tube						0.000%			
5523	70170		X-ray exam of tear duct						0.000%			
5523	70310		X-ray exam of teeth						0.000%			
5523	70320		Full mouth x-ray of teeth						0.000%			
5523	70332		X-ray exam of jaw joint						0.000%			
5523	70336		Magnetic image jaw joint						0.000%			
5523	70371		Speech evaluation complex						0.000%			
5523	70390		X-ray exam of salivary duct						0.000%			
5523	70540		Mri orbit/face/neck w/o dye						0.000%			
5523	70544		Mr angiography head w/o dye						0.000%			
5523	70547		Mr angiography neck w/o dye						0.000%			
5523	70551		Mri brain stem w/o dye						0.000%			
5523	70554		Fmri brain by tech						0.000%			
5523	70555		Fmri brain by phys/psych						0.000%			
5523	71550		Mri chest w/o dye						0.000%			
5523	72141		Mri neck spine w/o dye						0.000%			
5523	72146		Mri chest spine w/o dye						0.000%			
5523	72148		Mri lumbar spine w/o dye						0.000%			
5523	72195		Mri pelvis w/o dye						0.000%			
5523	73218		Mri upper extremity w/o dye						0.000%			
5523	73221		Mri joint upr extrem w/o dy						0.000%			
5523	73718		Mri lower extremity w/o dye						0.000%			
5523	73721		Mri jnt of lwr extre w/o dy						0.000%			
5523	74176		Ct abd & pelvis w/o contras						0.000%			
5523	74181		Mri abdomen w/o contrast						0.000%			
5523	74440		X-ray male genital tract						0.000%			
5523	74450		X-ray urethra/bladder						0.000%			
5523	74455		X-ray urethra/bladder						0.000%			
5523	74712		Mri fetal sngl/1st gestatio						0.000%			
5523	74740		X-ray female genital tract						0.000%			
5523	74775		X-ray exam of perineum						0.000%			
5523	75557		Cardiac mri for morph						0.000%			
5523	76000		Fluoroscopy <1 hr phys/qhp						0.000%			
5523	76017		Mr sfty med physics xm cstm						0.000%			
5523	76391		Mr elastography						0.000%			
5523	76811		Ob us detailed sngl fetus						0.000%			
5523	76826		Echo exam of fetal heart						0.000%			
5523	76831		Echo exam uterus						0.000%			
5523	76975		Gi endoscopic ultrasound						0.000%			
5523	77046		Mri breast c- unilateral						0.000%			
5523	77047		Mri breast c- bilateral						0.000%			
5523	77053		X-ray of mammary duct						0.000%			
5523	77054		X-ray of mammary ducts						0.000%			
5523	77084		Mri bone marrow blood suppl						0.000%			
5523	93307		Tte w/o doppler complete						0.000%			
5523	93308		Tte f-up or lmtd						0.000%			
5523	93880		Extracranial bilat study						0.000%			
5523	93886		Intracranial complete study						0.000%			
5523	93925		Lower extremity study						0.000%			
5523	93930		Upper extremity study						0.000%			
5523	93970		Extremity study						0.000%			
5523	93975		Vascular study						0.000%			
5523	93978		Vascular study						0.000%			
5523	93985		Dup-scan hemo compl bi std						0.000%			
5523	0556T		B1 str & fx rsk assessment						0.000%			
5523	0609T		Mrs disc pain acquisj data						0.000%			
5523	0611T		Mrs disc pain alg alys data						0.000%			
5523	0636T		Ct breast w/3d bi c-						0.000%			
5523	0743T		B1 str & fx rsk vrt fx assm						0.000%			
5523	0865T		Quan mri alys brn w/o dx mr						0.000%			
5523	0866T		Quan mri alys brn w/dx mri						0.000%			
5523	0944T		3d cntr simula trgt lvr les						0.000%			
5523	C8901		"Mra w/o cont, abd"						0.000%			
5523	C8910		"Mra w/o cont, chest"						0.000%			
5523	C8913		"Mra w/o cont, lwr ext"						0.000%			
5523	C8919		"Mra w/o cont, pelvis"						0.000%			
5523	C8932		"Mra, w/o dye, spinal canal"						0.000%			
5523	C8935		"Mra, w/o dye, upper extr"						0.000%			
5523	D0210		Intraor comprehensive serie						0.000%			
5523	D0273		Bitewings - three images						0.000%			
5523	D0274		Bitewings four images						0.000%			
5523	D0277		Vert bitewings 7 to 8 image						0.000%			
5523	D0310		Dental saliography						0.000%			
5523	D0320		Dental tmj arthrogram incl						0.000%			
5523	D0330		Panoramic image						0.000%			
5523	X409T		N-invas assmt car rsk w/o c						0.000%			
5523	X434T		N-invas assmt car rsk w/ct						0.000%			
5524		Level 4 Imaging without Contrast		S	6.1263	$562.07	.	$112.42	0.000%			
5524	70134		X-ray exam of middle ear						0.000%			
5524	70557		Mri brain w/o dye						0.000%			
5524	74190		Peritoneogram rs&i						0.000%			
5524	74470		X-ray exam of kidney lesion						0.000%			
5524	75559		Cardiac mri w/stress img						0.000%			
5524	76080		X-ray exam of fistula						0.000%			
5524	76098		X-ray exam surgical specime						0.000%			
5524	76825		Echo exam of fetal heart						0.000%			
5524	93303		Echo transthoracic						0.000%			
5524	93304		Echo transthoracic						0.000%			
5524	93306		Tte w/doppler complete						0.000%			
5524	93312		Echo transesophageal						0.000%			
5524	93313		Echo transesophageal						0.000%			
5524	93315		Echo transesophageal						0.000%			
5524	93316		Echo transesophageal						0.000%			
5524	93318		Echo transesophageal intrao						0.000%			
5524	93350		Stress tte only						0.000%			
5524	93351		Stress tte complete						0.000%			
5524	C9762		Cardiac mri seg dys strain						0.000%			
5524	C9763		Cardiac mri seg dys stress						0.000%			
5571		Level 1 Imaging with Contrast		S	1.959	$179.73	.	$35.95	0.000%			
5571	70460		Ct head/brain w/dye						0.000%			
5571	70470		Ct head/brain w/o & w/dye						0.000%			
5571	70481		Ct orbit/ear/fossa w/dye						0.000%			
5571	70482		Ct orbit/ear/fossa w/o&w/dy						0.000%			
5571	70487		Ct maxillofacial w/dye						0.000%			
5571	70488		Ct maxillofacial w/o & w/dy						0.000%			
5571	70491		Ct soft tissue neck w/dye						0.000%			
5571	70492		Ct sft tsue nck w/o & w/dye						0.000%			
5571	70496		Ct angiography head						0.000%			
5571	70498		Ct angiography neck						0.000%			
5571	70558		Mri brain w/dye						0.000%			
5571	70559		Mri brain w/o & w/dye						0.000%			
5571	71260		Ct thorax dx c+						0.000%			
5571	71270		Ct thorax dx c-/c+						0.000%			
5571	71275		Ct angiography chest						0.000%			
5571	72127		Ct neck spine w/o & w/dye						0.000%			
5571	72129		Ct chest spine w/dye						0.000%			
5571	72130		Ct chest spine w/o & w/dye						0.000%			
5571	72133		Ct lumbar spine w/o & w/dye						0.000%			
5571	72191		Ct angiograph pelv w/o&w/dy						0.000%			
5571	72193		Ct pelvis w/dye						0.000%			
5571	72194		Ct pelvis w/o & w/dye						0.000%			
5571	73202		Ct uppr extremity w/o&w/dye						0.000%			
5571	73206		Ct angio upr extrm w/o&w/dy						0.000%			
5571	73701		Ct lower extremity w/dye						0.000%			
5571	73702		Ct lwr extremity w/o&w/dye						0.000%			
5571	73706		Ct angio lwr extr w/o&w/dye						0.000%			
5571	74160		Ct abdomen w/contrast						0.000%			
5571	74170		Ct abd wo cntrst flwd cntrs						0.000%			
5571	74175		Cta abdomen w/contrast						0.000%			
5571	74210		X-ray xm phrnx&/crv esoph c						0.000%			
5571	74220		X-ray xm esophagus 1cntrst						0.000%			
5571	74221		X-ray xm esophagus 2cntrst						0.000%			
5571	74230		X-ray xm swlng funcj c+						0.000%			
5571	74240		X-ray xm upr gi trc 1cntrst						0.000%			
5571	74246		X-ray xm upr gi trc 2cntrst						0.000%			
5571	74250		X-ray xm sm int 1cntrst std						0.000%			
5571	74251		X-ray xm sm int 2cntrst std						0.000%			
5571	74262		Ct colonography dx w/dye						0.000%			
5571	74270		X-ray xm colon 1cntrst std						0.000%			
5571	74280		X-ray xm colon 2cntrst std						0.000%			
5571	74283		Ther nma rdctj intus/obstrc						0.000%			
5571	74290		Contrast x-ray gallbladder						0.000%			
5571	74400		Urography iv +-kub tomog						0.000%			
5571	74410		Urography nfs drip&/bolus						0.000%			
5571	74415		Urography nfs drip&/bls w/n						0.000%			
5571	75635		Ct angio abdominal arteries						0.000%			
5571	76978		Us trgt dyn mbubb 1st les						0.000%			
5571	0634T		Ct breast w/3d uni c+						0.000%			
5571	0635T		Ct breast w/3d uni c-/c+						0.000%			
5571	70XX3		Ct cere prfu aly c+wo ct/ct						0.000%			
5571	C8903		"Mri w/cont, breast,  uni"						0.000%			
5572		Level 2 Imaging with Contrast		S	3.9058	$358.35	.	$71.67	0.000%			
5572	70010		Contrast x-ray of brain						0.000%			
5572	70542		Mri orbit/face/neck w/dye						0.000%			
5572	70543		Mri orbt/fac/nck w/o &w/dye						0.000%			
5572	70545		Mr angiography head w/dye						0.000%			
5572	70546		Mr angiograph head w/o&w/dy						0.000%			
5572	70548		Mr angiography neck w/dye						0.000%			
5572	70549		Mr angiograph neck w/o&w/dy						0.000%			
5572	70552		Mri brain stem w/dye						0.000%			
5572	70553		Mri brain stem w/o & w/dye						0.000%			
5572	71552		Mri chest w/o & w/dye						0.000%			
5572	72126		Ct neck spine w/dye						0.000%			
5572	72132		Ct lumbar spine w/dye						0.000%			
5572	72142		Mri neck spine w/dye						0.000%			
5572	72147		Mri chest spine w/dye						0.000%			
5572	72149		Mri lumbar spine w/dye						0.000%			
5572	72156		Mri neck spine w/o & w/dye						0.000%			
5572	72157		Mri chest spine w/o & w/dye						0.000%			
5572	72158		Mri lumbar spine w/o & w/dy						0.000%			
5572	72196		Mri pelvis w/dye						0.000%			
5572	72197		Mri pelvis w/o & w/dye						0.000%			
5572	73040		Contrast x-ray of shoulder						0.000%			
5572	73085		Contrast x-ray of elbow						0.000%			
5572	73115		Contrast x-ray of wrist						0.000%			
5572	73201		Ct upper extremity w/dye						0.000%			
5572	73219		Mri upper extremity w/dye						0.000%			
5572	73220		Mri uppr extremity w/o&w/dy						0.000%			
5572	73223		Mri joint upr extr w/o&w/dy						0.000%			
5572	73525		Contrast x-ray of hip						0.000%			
5572	73580		Contrast x-ray of knee join						0.000%			
5572	73615		Contrast x-ray of ankle						0.000%			
5572	73719		Mri lower extremity w/dye						0.000%			
5572	73720		Mri lwr extremity w/o&w/dye						0.000%			
5572	73723		Mri joint lwr extr w/o&w/dy						0.000%			
5572	74174		Cta abd&plvs w/contrast						0.000%			
5572	74177		Ct abd & pelvis w/contrast						0.000%			
5572	74178		Ct abd&plv wo cntr flwd cnt						0.000%			
5572	74182		Mri abdomen w/contrast						0.000%			
5572	74183		Mri abd w/o cntr flwd cntr						0.000%			
5572	74420		Urography rtrgr +-kub						0.000%			
5572	74425		Urography antegrade rs&i						0.000%			
5572	74430		Contrast x-ray bladder						0.000%			
5572	75561		Cardiac mri for morph w/dye						0.000%			
5572	75572		Ct hrt w/3d image						0.000%			
5572	75573		Ct hrt c+ strux cgen hrt ds						0.000%			
5572	75574		Ct angio hrt w/3d image						0.000%			
5572	0637T		Ct breast w/3d bi c+						0.000%			
5572	0638T		Ct breast w/3d bi c-/c+						0.000%			
5572	70XX1		Cta h&n c+ w/noncontrast im						0.000%			
5572	C8900		"Mra w/cont, abd"						0.000%			
5572	C8902		"Mra w/o fol w/cont, abd"						0.000%			
5572	C8905		"Mri w/o fol w/cont, brst, u"						0.000%			
5572	C8906		"Mri w/cont, breast,  bi"						0.000%			
5572	C8908		"Mri w/o fol w/cont, breast,"						0.000%			
5572	C8909		"Mra w/cont, chest"						0.000%			
5572	C8911		"Mra w/o fol w/cont, chest"						0.000%			
5572	C8912		"Mra w/cont, lwr ext"						0.000%			
5572	C8914		"Mra w/o fol w/cont, lwr ext"						0.000%			
5572	C8918		"Mra w/cont, pelvis"						0.000%			
5572	C8920		"Mra w/o fol w/cont, pelvis"						0.000%			
5572	C8924		"2d tte w or w/o fol w/con,f"						0.000%			
5572	C8931		"Mra, w/dye, spinal canal"						0.000%			
5572	C8933		"Mra, w/o&w/dye, spinal cana"						0.000%			
5572	C8934		"Mra, w/dye, upper extremity"						0.000%			
5572	C8936		"Mra, w/o&w/dye, upper extr"						0.000%			
5572	C9733		Non-ophthalmic fva						0.000%			
5573		Level 3 Imaging with Contrast		S	8.7456	$802.38	.	$160.48	0.000%			
5573	62302		Myelography lumbar injectio						0.000%			
5573	62303		Myelography lumbar injectio						0.000%			
5573	62304		Myelography lumbar injectio						0.000%			
5573	62305		Myelography lumbar injectio						0.000%			
5573	70015		Contrast x-ray of brain						0.000%			
5573	71551		Mri chest w/dye						0.000%			
5573	72240		Myelography neck spine						0.000%			
5573	72255		Myelography thoracic spine						0.000%			
5573	72265		Myelography l-s spine						0.000%			
5573	72270		Myelogphy 2/> spine regions						0.000%			
5573	73222		Mri joint upr extrem w/dye						0.000%			
5573	73722		Mri joint of lwr extr w/dye						0.000%			
5573	75563		Card mri w/stress img & dye						0.000%			
5573	C8921		"Tte w or w/o fol w/cont, co"						0.000%			
5573	C8922		"Tte w or w/o fol w/cont, f/"						0.000%			
5573	C8923		"2d tte w or w/o fol w/con,c"						0.000%			
5573	C8925		"2d tee w or w/o fol w/con,i"						0.000%			
5573	C8926		"Tee w or w/o fol w/cont,con"						0.000%			
5573	C8927		"Tee w or w/o fol w/cont, mo"						0.000%			
5573	C8928		"Tte w or w/o fol w/con,stre"						0.000%			
5573	C8929		"Tte w or wo fol wcon,dopple"						0.000%			
5573	C8930		"Tte w or w/o contr, cont ec"						0.000%			
5591		Level 1 Nuclear Medicine and Related Services		S	4.4589	$409.09	.	$81.82	0.000%			
5591	38792		Ra tracer id of sentinl nod						0.000%			
5591	78012		Thyroid uptake measurement						0.000%			
5591	78013		Thyroid imaging w/blood flo						0.000%			
5591	78014		Thyroid imaging w/blood flo						0.000%			
5591	78015		Thyroid met imaging						0.000%			
5591	78016		Thyroid met imaging/studies						0.000%			
5591	78070		Parathyroid planar imaging						0.000%			
5591	78071		Parathyrd planar w/wo subtr						0.000%			
5591	78099		Unlisted endocrine px dx nu						0.000%			
5591	78102		Bone marrow imaging ltd						0.000%			
5591	78103		Bone marrow imaging mult						0.000%			
5591	78104		Bone marrow imaging body						0.000%			
5591	78120		Red cell mass single						0.000%			
5591	78130		Red cell survival study						0.000%			
5591	78140		Red cell sequestration						0.000%			
5591	78185		Spleen imaging						0.000%			
5591	78191		Platelet survival study						0.000%			
5591	78199		Unlstd hematop ret/endo lym						0.000%			
5591	78215		Lvr&spleen img static only						0.000%			
5591	78216		Lvr&spleen img w/vasc flow						0.000%			
5591	78226		Hepatobiliary system imagin						0.000%			
5591	78230		Salivary gland imaging						0.000%			
5591	78231		Salivary glnd img serial im						0.000%			
5591	78232		Salivary gland function std						0.000%			
5591	78258		Esophageal motility						0.000%			
5591	78261		Gastric mucosa imaging						0.000%			
5591	78262		Gastroesophageal reflux std						0.000%			
5591	78264		Gastric emptying imag study						0.000%			
5591	78265		Gastric emptying imag study						0.000%			
5591	78278		Acute gi blood loss imaging						0.000%			
5591	78282		Gi protein loss exam						0.000%			
5591	78290		Meckels divert exam						0.000%			
5591	78291		Leveen/shunt patency exam						0.000%			
5591	78299		Unlisted gi px dx nuc med						0.000%			
5591	78300		Bone imaging limited area						0.000%			
5591	78305		Bone imaging multiple areas						0.000%			
5591	78306		Bone imaging whole body						0.000%			
5591	78315		Bone imaging 3 phase						0.000%			
5591	78399		Unlisted muscskel px dx nuc						0.000%			
5591	78428		Cardiac shunt imaging						0.000%			
5591	78445		Vascular flow imaging						0.000%			
5591	78458		Ven thrombosis images bilat						0.000%			
5591	78466		Heart infarct image						0.000%			
5591	78472		Gated heart planar single						0.000%			
5591	78473		Gated heart multiple						0.000%			
5591	78494		Heart image spect						0.000%			
5591	78499		Unlisted cv px dx nuc med						0.000%			
5591	78579		Lung ventilation imaging						0.000%			
5591	78580		Lung perfusion imaging						0.000%			
5591	78597		Lung perfusion differential						0.000%			
5591	78599		Unlisted resp px dx nuc med						0.000%			
5591	78600		Brain image < 4 views						0.000%			
5591	78601		Brain image w/flow < 4 view						0.000%			
5591	78660		Nuclear exam of tear flow						0.000%			
5591	78699		Unlisted nrvs sys px dx nuc						0.000%			
5591	78700		Kidney imaging morphol						0.000%			
5591	78701		Kidney imaging with flow						0.000%			
5591	78725		Kidney function study						0.000%			
5591	78740		Ureteral reflux study						0.000%			
5591	78761		Testicular imaging w/flow						0.000%			
5591	78799		Unlisted gu px dx nuc med						0.000%			
5591	78800		Rp loclzj tum 1 area 1 d im						0.000%			
5591	78801		Rp loclzj tum 2+area 1+d im						0.000%			
5591	78808		Iv inj ra drug dx study						0.000%			
5591	78999		Unlisted misc px dx nuc med						0.000%			
5591	G0235		Pet not otherwise specified						0.000%			
5592		Level 2 Nuclear Medicine and Related Services		S	6.0896	$558.70	.	$111.74	0.000%			
5592	78018		Thyroid met imaging body						0.000%			
5592	78072		Parathyrd planar w/spect&ct						0.000%			
5592	78121		Red cell mass multiple						0.000%			
5592	78122		Whl bld volume determinatio						0.000%			
5592	78195		Lymph system imaging						0.000%			
5592	78201		Liver imaging static only						0.000%			
5592	78202		Liver imaging with vasc flo						0.000%			
5592	78227		Hepatobil syst image w/drug						0.000%			
5592	78266		Gastric emptying imag study						0.000%			
5592	78414		Non-imaging heart function						0.000%			
5592	78457		Venous thrombosis imaging						0.000%			
5592	78468		Heart infarct image (ef)						0.000%			
5592	78469		Heart infarct image (3d)						0.000%			
5592	78481		Heart first pass single						0.000%			
5592	78483		Heart first pass multiple						0.000%			
5592	78582		Lung ventilat&perfus imagin						0.000%			
5592	78598		Lung perf&ventilat diferent						0.000%			
5592	78605		Brain image 4+ views						0.000%			
5592	78606		Brain image w/flow 4 + view						0.000%			
5592	78610		Brain flow imaging only						0.000%			
5592	78630		Cerebrospinal fluid scan						0.000%			
5592	78635		Csf ventriculography						0.000%			
5592	78645		Csf shunt evaluation						0.000%			
5592	78707		K flow/funct image w/o drug						0.000%			
5592	78708		K flow/funct image w/drug						0.000%			
5592	78709		K flow/funct image multiple						0.000%			
5592	78802		Rp loclzj tum whbdy 1 d img						0.000%			
5592	78803		Rp loclzj tum spect 1 area						0.000%			
5592	78804		Rp loclzj tum whbdy 2+d img						0.000%			
5593		Level 3 Nuclear Medicine and Related Services		S	14.4181	"$1,322.82"	.	$264.57	0.000%			
5593	78075		Adrenal cortex & medulla im						0.000%			
5593	78110		Plasma volume single						0.000%			
5593	78111		Plasma volume multiple						0.000%			
5593	78451		Ht muscle image spect sing						0.000%			
5593	78452		Ht muscle image spect mult						0.000%			
5593	78453		Ht muscle image planar sing						0.000%			
5593	78454		Ht musc image planar mult						0.000%			
5593	78456		Acute venous thrombus image						0.000%			
5593	78459		Myocrd img pet single study						0.000%			
5593	78650		Csf leakage imaging						0.000%			
5593	78811		Pet image ltd area						0.000%			
5593	78830		Rp loclzj tum spect w/ct 1						0.000%			
5593	78831		Rp loclzj tum spect 2 areas						0.000%			
5593	0331T		Heart symp image plnr						0.000%			
5593	0332T		Heart symp image plnr spect						0.000%			
5594		Level 4 Nuclear Medicine and Related Services		S	16.0402	"$1,471.64"	.	$294.33	0.000%			
5594	78429		Myocrd img pet 1 std w/ct						0.000%			
5594	78430		Myocrd img pet rst/strs w/c						0.000%			
5594	78491		Myocrd img pet 1std rst/str						0.000%			
5594	78492		Myocrd img pet mlt rst&strs						0.000%			
5594	78608		Brain imaging (pet)						0.000%			
5594	78812		Pet image skull-thigh						0.000%			
5594	78813		Pet image full body						0.000%			
5594	78814		Pet image w/ct lmtd						0.000%			
5594	78815		Pet image w/ct skull-thigh						0.000%			
5594	78816		Pet image w/ct full body						0.000%			
5594	78832		Rp loclzj tum spect w/ct 2						0.000%			
5611		Level 1 Therapeutic Radiation Treatment Preparation		S	1.5134	$138.85	$31.05	$27.77	0.000%			
5611	77280		Ther rad simulaj field smpl						0.000%			
5611	77299		Unlisted px ther rad tx pln						0.000%			
5611	77300		Radiation therapy dose plan						0.000%			
5611	77331		Special radiation dosimetry						0.000%			
5611	77332		Radiation treatment aid(s)						0.000%			
5611	77333		Radiation treatment aid(s)						0.000%			
5611	77336		Radiation physics consult						0.000%			
5611	77370		Radiation physics consult						0.000%			
5611	77399		Unlisted px med radj physic						0.000%			
5611	X455T		Alt elec fld dos&dlv sim md						0.000%			
5612		Level 2 Therapeutic Radiation Treatment Preparation		S	4.2026	$385.58	.	$77.12	0.000%			
5612	77285		Ther rad simulaj field intr						0.000%			
5612	77290		Ther rad simulaj field cplx						0.000%			
5612	77306		Telethx isodose plan simple						0.000%			
5612	77307		Telethx isodose plan cplx						0.000%			
5612	77316		Brachytx isodose plan simpl						0.000%			
5612	77317		Brachytx isodose intermed						0.000%			
5612	77318		Brachytx isodose complex						0.000%			
5612	77321		Special teletx port plan						0.000%			
5612	77334		Radiation treatment aid(s)						0.000%			
5612	77338		Design mlc device for imrt						0.000%			
5613		Level 3 Therapeutic Radiation Treatment Preparation		S	15.5969	"$1,430.97"	.	$286.20	0.000%			
5613	32553		Ins mark thor for rt perq						0.000%			
5613	49411		Ins mark abd/pel for rt per						0.000%			
5613	55876		Place rt device/marker pros						0.000%			
5613	77295		3-d radiotherapy plan						0.000%			
5613	77301		Radiotherapy dose plan imrt						0.000%			
5613	C9728		"Place device/marker, non pr"						0.000%			
5621		Level 1 Radiation Therapy		S	1.1768	$107.97	.	$21.60	0.000%			
5621	77402		Radiation tx delivery lvl 1						0.000%			
5621	77789		Apply surf ldr radionuclide						0.000%			
5621	77799		Unlisted px clin brachytx						0.000%			
5621	77X07		Surf radj ther supfc<=150kv						0.000%			
5621	77X08		Surf rad thr orthvlt>150-50						0.000%			
5622		Level 2 Radiation Therapy		S	3.0011	$275.34	.	$55.07	0.000%			
5622	77407		Radiation tx delivery lvl 2						0.000%			
5622	77412		Radiation tx delivery lvl 3						0.000%			
5622	77600		Hyperthermia ext gen supfc						0.000%			
5622	77750		Infuse radioactive material						0.000%			
5622	77767		Hdr rdncl skn surf brachytx						0.000%			
5622	77768		Hdr rdncl skn surf brachytx						0.000%			
5623		Level 3 Radiation Therapy		S	6.5413	$600.14	.	$120.03	0.000%			
5623	77423		Neutron beam tx complex						0.000%			
5623	77470		Special radiation treatment						0.000%			
5623	77520		Proton trmt simple w/o comp						0.000%			
5623	77610		Hyperthermia ntrstl prb 5/<						0.000%			
5623	77615		Hyperthermia ntrstl prb>5						0.000%			
5623	77620		Hyperthermia gen intrcv prb						0.000%			
5623	77761		Apply intrcav radiat simple						0.000%			
5623	77762		Apply intrcav radiat interm						0.000%			
5624		Level 4 Radiation Therapy		S	7.8022	$715.83	.	$143.17	0.000%			
5624	77605		Hyperthermia ext gen deep						0.000%			
5624	77763		Apply intrcav radiat compl						0.000%			
5624	77770		Hdr rdncl ntrstl/icav brcht						0.000%			
5624	77771		Hdr rdncl ntrstl/icav brcht						0.000%			
5624	77772		Hdr rdncl ntrstl/icav brcht						0.000%			
5624	77778		Apply interstit radiat comp						0.000%			
5624	0395T		Hdr elctr ntrst/ntrcv brcht						0.000%			
5625		Level 5 Radiation Therapy		S	14.488	"$1,329.23"	.	$265.85	0.000%			
5625	77522		Proton trmt simple w/comp						0.000%			
5625	77523		Proton trmt intermediate						0.000%			
5625	77525		Proton treatment complex						0.000%			
5626		Level 6 Radiation Therapy		S	20.1241	"$1,846.33"	.	$369.27	0.000%			
5626	77373		Strtctc bdy rad ther tx dlv						0.000%			
5627		Level 7 Radiation Therapy		J1	83.6367	"$7,673.42"	.	"$1,534.69"	0.000%			
5627	77371		Srs multisource						0.000%			
5627	77372		Srs linear based						0.000%			
5627	77424		Io rad tx delivery by x-ray						0.000%			
5627	77425		Io rad tx deliver by elctrn						0.000%			
5661		Therapeutic Nuclear Medicine		S	2.6037	$238.88	.	$47.78	0.000%			
5661	79005		Nuclear rx oral admin						0.000%			
5661	79101		Nuclear rx iv admin						0.000%			
5661	79200		Nuclear rx intracav admin						0.000%			
5661	79300		Nuclr rx interstit colloid						0.000%			
5661	79403		Hematopoietic nuclear tx						0.000%			
5661	79440		Nuclear rx intra-articular						0.000%			
5661	79445		Nuclear rx intra-arterial						0.000%			
5661	79999		Rp therapy unlisted px						0.000%			
5671		Level 1 Pathology		S	0.5847	$53.64	.	$10.73	0.000%			
5671	80503		Path clin consltj sf 5-20						0.000%			
5671	86079		Phys blood bank serv authrj						0.000%			
5671	86850		Rbc antibody screen						0.000%			
5671	88112		Cytopath cell enhance tech						0.000%			
5671	88125		Forensic cytopathology						0.000%			
5671	88162		Cytopath smear other source						0.000%			
5671	88173		Cytopath eval fna report						0.000%			
5671	88182		Cell marker study						0.000%			
5671	88199		Unlisted cytopathology px						0.000%			
5671	88299		Unlisted cytogenetic study						0.000%			
5671	88304		Tissue exam by pathologist						0.000%			
5671	88305		Tissue exam by pathologist						0.000%			
5671	88312		Special stains group 1						0.000%			
5671	88323		Consltj&reprt matrl prep sl						0.000%			
5671	88356		Analysis nerve						0.000%			
5671	88399		Unlisted surgical path px						0.000%			
5671	89230		Collect sweat for test						0.000%			
5671	89240		Unlisted misc path test						0.000%			
5671	89255		Prepare embryo for transfer						0.000%			
5671	89257		Sperm identification						0.000%			
5671	89260		Sperm isolation simple						0.000%			
5671	89261		Sperm isolation complex						0.000%			
5671	89264		Identify sperm tissue						0.000%			
5671	89335		Cryopreserve testicular tis						0.000%			
5671	89353		Thawing cryopresrved sperm						0.000%			
5671	89398		Unlisted reprod med lab pro						0.000%			
5672		Level 2 Pathology		S	1.919	$176.06	.	$35.22	0.000%			
5672	80504		Path clin consltj mod 21-40						0.000%			
5672	80505		Path clin consltj high 41-6						0.000%			
5672	86078		Phys blood bank serv reactj						0.000%			
5672	86860		Rbc antibody elution						0.000%			
5672	86885		Coombs test indirect qual						0.000%			
5672	86886		Coombs test indirect titer						0.000%			
5672	86890		Autologous blood process						0.000%			
5672	86920		Compatibility test spin						0.000%			
5672	86921		Compatibility test incubate						0.000%			
5672	86922		Compatibility test antiglob						0.000%			
5672	86923		Compatibility test electric						0.000%			
5672	86927		Plasma fresh frozen						0.000%			
5672	86930		Frozen blood prep						0.000%			
5672	86931		Frozen blood thaw						0.000%			
5672	86950		Leukacyte transfusion						0.000%			
5672	86960		Vol reduction of blood/prod						0.000%			
5672	86965		Pooling blood platelets						0.000%			
5672	86971		Rbc pretx incubatj w/enzyme						0.000%			
5672	86972		Rbc pretx incubatj w/densit						0.000%			
5672	86977		Rbc serum pretx incubj/inhi						0.000%			
5672	86985		Split blood or products						0.000%			
5672	88120		Cytp urne 3-5 probes ea spe						0.000%			
5672	88121		Cytp urine 3-5 probes cmptr						0.000%			
5672	88172		Cytp dx eval fna 1st ea sit						0.000%			
5672	88325		Consltj compre rvw rec repr						0.000%			
5672	88331		Path consltj surg 1 blk 1sp						0.000%			
5672	88342		Imhchem/imcytchm 1st antb						0.000%			
5672	88346		Imfluor 1st 1antb stain px						0.000%			
5672	88355		M/phmtrc alys skeletal musc						0.000%			
5672	88358		Analysis tumor						0.000%			
5672	88360		Tumor immunohistochem/manua						0.000%			
5672	88365		Insitu hybridization (fish)						0.000%			
5672	88366		Insitu hybridization (fish)						0.000%			
5672	88374		M/phmtrc alys ishquant/semi						0.000%			
5672	88377		M/phmtrc alys ishquant/semi						0.000%			
5672	89049		Chct for mal hyperthermia						0.000%			
5672	89220		Sputum specimen collection						0.000%			
5672	89250		Cultr oocyte/embryo <4 days						0.000%			
5672	89251		Cultr oocyte/embryo <4 days						0.000%			
5672	89253		Embryo hatching						0.000%			
5672	89254		Oocyte identification						0.000%			
5672	89259		Cryopreservation sperm						0.000%			
5672	89268		Insemination of oocytes						0.000%			
5672	89281		Assist oocyte fertilization						0.000%			
5672	89290		Biopsy oocyte polar body <=						0.000%			
5672	89291		Biopsy oocyte polar body						0.000%			
5672	89337		Cryopreservation oocyte(s)						0.000%			
5672	89342		Storage/year embryo(s)						0.000%			
5672	89343		Storage/year sperm/semen						0.000%			
5672	89344		Storage/year reprod tissue						0.000%			
5672	89346		Storage/year oocyte(s)						0.000%			
5672	89352		Thawing cryopresrved embryo						0.000%			
5672	89354		Thaw cryoprsvrd reprod tiss						0.000%			
5672	89356		Thawing cryopresrved oocyte						0.000%			
5673		Level 3 Pathology		S	4.0337	$370.08	.	$74.02	0.000%			
5673	86870		Rbc antibody identification						0.000%			
5673	86902		Blood type antigen donor ea						0.000%			
5673	86905		Blood typing rbc antigens						0.000%			
5673	88184		Flowcytometry/ tc 1 marker						0.000%			
5673	88307		Tissue exam by pathologist						0.000%			
5673	88344		Imhchem/imcytchm ea mlt ant						0.000%			
5673	88361		Tumor immunohistochem/compu						0.000%			
5673	88367		Insitu hybridization auto						0.000%			
5673	88368		Insitu hybridization manual						0.000%			
5673	G0416		"Prostate biopsy, any mthd"						0.000%			
5674		Level 4 Pathology		S	8.9707	$823.03	.	$164.61	0.000%			
5674	85097		Bone marrow interpretation						0.000%			
5674	86891		Autologous blood op salvage						0.000%			
5674	88309		Tissue exam by pathologist						0.000%			
5674	88319		Enzyme histochemistry						0.000%			
5674	88333		Path consltj surg cyto xm 1						0.000%			
5674	88348		Electron microscopy dx						0.000%			
5674	88362		Nerve teasing preparations						0.000%			
5674	89258		Cryopreservation embryo(s)						0.000%			
5674	89272		Extended culture of oocytes						0.000%			
5674	89280		Assist oocyte fertilization						0.000%			
5691		Level 1 Drug Administration		S	0.5213	$47.83	.	$9.57	0.000%			
5691	G0008		Admin influenza virus vac				$0.00	$0.00	0.000%	$0.00		
5691	G0009		Admin pneumococcal vaccine				$0.00	$0.00	0.000%	$0.00		
5691	G0010		Admin hepatitis b vaccine				$0.00	$0.00	0.000%	$0.00		
5691	95115		Immunotherapy one injection						0.000%			
5691	95117		Immunotherapy injections						0.000%			
5691	95144		Antigen therapy services						0.000%			
5691	95145		Antigen therapy services						0.000%			
5691	95146		Antigen therapy services						0.000%			
5691	95165		Antigen therapy services						0.000%			
5691	95170		Antigen therapy services						0.000%			
5691	96361		Hydrate iv infusion add-on						0.000%			
5691	96366		Ther/proph/diag iv inf addo						0.000%			
5691	96370		Sc ther infusion addl hr						0.000%			
5691	96375		Tx/pro/dx inj new drug addo						0.000%			
5691	96377		Applicaton on-body injector						0.000%			
5691	96379		Unl ther/prop/diag inj/inf						0.000%			
5691	96423		Chemo ia infuse each addl h						0.000%			
5691	96549		Unlisted chemotherapy px						0.000%			
5692		Level 2 Drug Administration		S	0.8128	$74.57	.	$14.92	0.000%			
5692	G0012		Injection of hiv prep drug				$0.00	$0.00	0.000%	$0.00		
5692	90471		Immunization admin						0.000%			
5692	90473		Immune admin oral/nasal						0.000%			
5692	95147		Antigen therapy services						0.000%			
5692	95148		Antigen therapy services						0.000%			
5692	95149		Antigen therapy services						0.000%			
5692	96367		Tx/proph/dg addl seq iv inf						0.000%			
5692	96371		Sc ther infusion reset pump						0.000%			
5692	96372		Ther/proph/diag inj sc/im						0.000%			
5692	96401		Chemo anti-neopl sq/im						0.000%			
5692	96402		Chemo hormon antineopl sq/i						0.000%			
5692	96405		Chemo intralesional up to 7						0.000%			
5692	96411		Chemo iv push addl drug						0.000%			
5692	96415		Chemo iv infusion addl hr						0.000%			
5692	96417		Chemo iv infus each addl se						0.000%			
5693		Level 3 Drug Administration		S	2.3596	$216.49	.	$43.30	0.000%			
5693	36598		Inj w/fluor eval cv device						0.000%			
5693	96360		Hydration iv infusion init						0.000%			
5693	96365		Ther/proph/diag iv inf init						0.000%			
5693	96369		Sc ther infusion up to 1 hr						0.000%			
5693	96373		Ther/proph/diag inj ia						0.000%			
5693	96374		Ther/proph/diag inj iv push						0.000%			
5693	96406		Chemo intralesional over 7						0.000%			
5693	96521		Refill/maint portable pump						0.000%			
5693	96522		Refill/maint pump/resvr sys						0.000%			
5693	C8957		"Prolonged iv inf, req pump"						0.000%			
5694		Level 4 Drug Administration		S	3.7224	$341.52	.	$68.31	0.000%			
5694	36593		Declot vascular device						0.000%			
5694	37195		Thrombolytic therapy stroke						0.000%			
5694	38228		Car-t admn autologous						0.000%			
5694	67028		Injection eye drug						0.000%			
5694	67516		Sprchoroidal spc njx rx agt						0.000%			
5694	95990		Spin/brain pump refil & mai						0.000%			
5694	96409		Chemo iv push sngl drug						0.000%			
5694	96413		Chemo iv infusion 1 hr						0.000%			
5694	96416		Chemo prolong infuse w/pump						0.000%			
5694	96420		Chemo ia push tecnique						0.000%			
5694	96422		Chemo ia infusion up to 1 h						0.000%			
5694	96425		Chemotherapy infusion metho						0.000%			
5694	96440		Chmotx admn plrl cav thrcnt						0.000%			
5694	96446		Chemotx admn pertl cav impl						0.000%			
5694	96450		Chemotherapy into cns						0.000%			
5694	96542		Chemotherapy injection						0.000%			
5694	G0498		Chemo extend iv infus w/pum						0.000%			
5721		Level 1 Diagnostic Tests and Related Services		S	1.4484	$132.89	.	$26.58	0.000%			
5721	43755		Dx gastr intub w/asp specs						0.000%			
5721	50686		Measure ureter pressure						0.000%			
5721	51703		Insert bladder cath complex						0.000%			
5721	51784		Anal/urinary muscle study						0.000%			
5721	53660		Dilation of urethra						0.000%			
5721	91200		Liver elastography						0.000%			
5721	91299		Unlisted dx gi procedure						0.000%			
5721	92274		Multifocal erg w/i&r						0.000%			
5721	92517		Vemp test i&r cervical						0.000%			
5721	92518		Vemp test i&r ocular						0.000%			
5721	92537		Caloric vstblr test w/rec						0.000%			
5721	92544		Optokinetic nystagmus test						0.000%			
5721	92546		Sinusoidal rotational test						0.000%			
5721	92553		Audiometry air & bone						0.000%			
5721	92557		Comprehensive hearing test						0.000%			
5721	92570		Acoustic immitance testing						0.000%			
5721	92572		Staggered spondaic word tes						0.000%			
5721	92582		Conditioning play audiometr						0.000%			
5721	92584		Electrocochleography						0.000%			
5721	92601		Cochlear implt f/up exam <7						0.000%			
5721	92602		Reprogram cochlear implt <7						0.000%			
5721	92603		Cochlear implt f/up exam 7/						0.000%			
5721	92604		Reprogram cochlear implt 7/						0.000%			
5721	92620		Auditory function 60 min						0.000%			
5721	92622		Dx aly aud oi snd prcsr 1st						0.000%			
5721	92625		Tinnitus assessment						0.000%			
5721	92626		Eval aud funcj 1st hour						0.000%			
5721	92640		Aud brainstem implt program						0.000%			
5721	93025		Microvolt t-wave assess						0.000%			
5721	93702		Bis xtracell fluid analysis						0.000%			
5721	93740		Temperature gradient studie						0.000%			
5721	93799		Unlisted cv svc/procedure						0.000%			
5721	94011		Spirometry up to 2 yrs old						0.000%			
5721	94150		Vital capacity test						0.000%			
5721	94450		Hypoxia response curve						0.000%			
5721	94680		Exhaled air analysis o2						0.000%			
5721	94728		Airwy resist by oscillometr						0.000%			
5721	94762		Measure blood oxygen level						0.000%			
5721	94775		Ped home apnea rec hk-up						0.000%			
5721	94776		Ped home apnea rec downld						0.000%			
5721	94799		Unlisted pulmonary svc/px						0.000%			
5721	95863		Needle emg 3 extremities						0.000%			
5721	95864		Needle emg 4 extremities						0.000%			
5721	95866		Needle emg hemidiaphragm						0.000%			
5721	95875		Limb exercise test						0.000%			
5721	95921		Autonomic nrv parasym inerv						0.000%			
5721	95937		Neuromuscular junction test						0.000%			
5721	95999		Unlisted neurological dx px						0.000%			
5721	96112		Devel tst phys/qhp 1st hr						0.000%			
5721	0212T		Compre audiometry evaluatio						0.000%			
5721	0278T		Tempr						0.000%			
5721	0464T		Visual ep test for glaucoma						0.000%			
5721	0736T		Colonic lavage 35+l water						0.000%			
5721	0778T		Smmg cncrnt appl imu snr						0.000%			
5721	0783T		Tc auriculr neurostimulatio						0.000%			
5721	0812T		Rem mlt day uroflow dev spl						0.000%			
5721	93XX4		Interrog crtd sins bat ip w						0.000%			
5721	93XX5		Interrog crtd sins bat ip w						0.000%			
5721	C8001		3d anat seg imaging preop						0.000%			
5721	G0566		3d bn img algor drvd fr mri						0.000%			
5722		Level 2 Diagnostic Tests and Related Services		S	2.4103	$221.14	.	$44.23	0.000%			
5722	43753		Tx gastro intub w/asp						0.000%			
5722	43754		Dx gastr intub w/asp spec						0.000%			
5722	51741		Electro-uroflowmetry first						0.000%			
5722	54240		Penile plethysmography						0.000%			
5722	76936		Echo guide for artery repai						0.000%			
5722	90867		Tcranial magn stim tx plan						0.000%			
5722	90868		Tcranial magn stim tx deli						0.000%			
5722	90869		Tcran magn stim redetemine						0.000%			
5722	91037		Esoph imped function test						0.000%			
5722	91065		Breath hydrogen/methane tes						0.000%			
5722	91117		Colon motility 6 hr study						0.000%			
5722	91132		Electrogastrography						0.000%			
5722	92137		Cptrz oph img pst sg rta oc						0.000%			
5722	92235		Fluorescein angrph mltifram						0.000%			
5722	92240		Icg angiography i&r uni/bi						0.000%			
5722	92242		Fluorescein&icg angiography						0.000%			
5722	92273		Full field erg w/i&r						0.000%			
5722	92512		Nasal function studies						0.000%			
5722	92516		Facial nerve function test						0.000%			
5722	92519		Vemp tst i&r cervical&ocula						0.000%			
5722	92538		Caloric vstblr test w/rec						0.000%			
5722	92540		Basic vestibular evaluation						0.000%			
5722	92545		Oscillating tracking test						0.000%			
5722	92550		Tympanometry & reflex thres						0.000%			
5722	92562		Loudness balance test						0.000%			
5722	92579		Visual audiometry (vra)						0.000%			
5722	92587		Evoked auditory test limite						0.000%			
5722	92651		Aep hearing status deter i&						0.000%			
5722	92652		Aep thrshld est mlt freq i&						0.000%			
5722	92653		Aep neurodiagnostic i&r						0.000%			
5722	92950		Heart/lung resuscitation cp						0.000%			
5722	93017		Cardiovascular stress test						0.000%			
5722	93923		Upr/lxtr art stdy 3+ lvls						0.000%			
5722	93924		Lwr xtr vasc stdy bilat						0.000%			
5722	94010		Breathing capacity test						0.000%			
5722	94012		Spirmtry w/brnchdil inf-2 y						0.000%			
5722	94015		Patient recorded spirometry						0.000%			
5722	94375		Respiratory flow volume loo						0.000%			
5722	94727		Pulm function test by gas						0.000%			
5722	95700		Eeg cont rec w/vid eeg tech						0.000%			
5722	95705		Eeg w/o vid 2-12 hr unmntr						0.000%			
5722	95706		Eeg wo vid 2-12hr intmt mnt						0.000%			
5722	95707		Eeg w/o vid 2-12hr cont mnt						0.000%			
5722	95711		Veeg 2-12 hr unmonitored						0.000%			
5722	95800		Slp stdy unattended						0.000%			
5722	95806		Sleep study unatt&resp efft						0.000%			
5722	95812		Eeg 41-60 minutes						0.000%			
5722	95813		Eeg extnd mntr 61-119 min						0.000%			
5722	95816		Eeg awake and drowsy						0.000%			
5722	95819		Eeg awake and asleep						0.000%			
5722	95822		Eeg coma or sleep only						0.000%			
5722	95857		Cholinesterase challenge						0.000%			
5722	95867		Ndl emg cranial nrv musc un						0.000%			
5722	95868		Ndl emg cranial nrv musc bi						0.000%			
5722	95869		Ndl emg thrc paraspinal mus						0.000%			
5722	95872		Ndl emg single fiber eltrd						0.000%			
5722	95907		Nvr cndj tst 1-2 studies						0.000%			
5722	95908		Nrv cndj tst 3-4 studies						0.000%			
5722	95909		Nrv cndj tst 5-6 studies						0.000%			
5722	95924		Ans parasymp & symp w/tilt						0.000%			
5722	95925		Somatosensory testing						0.000%			
5722	95926		Somatosensory testing						0.000%			
5722	95927		Somatosensory testing						0.000%			
5722	95930		Visual ep test cns w/i&r						0.000%			
5722	96002		Dynamic surface emg						0.000%			
5722	96116		Nubhvl xm phys/qhp 1st hr						0.000%			
5722	96130		Psycl tst eval phys/qhp 1st						0.000%			
5722	0509T		Pattern erg w/i&r						0.000%			
5722	0598T		R-t fluor wound img 1st sit						0.000%			
5722	0766T		Tc mag stimj pn 1st nerve						0.000%			
5722	0807T		Pulm tiss vntj alys prev ct						0.000%			
5722	0808T		Pulm tiss vntj alys w/ct						0.000%			
5722	91XX1		Rct snsatn tone&cmplianc st						0.000%			
5722	G0303		Pre-op service lvrs 10-15do						0.000%			
5722	G0398		Home sleep test/type 2 port						0.000%			
5722	G0399		Home sleep test/type 3 port						0.000%			
5722	G0400		Home sleep test/type 4 port						0.000%			
5723		Level 3 Diagnostic Tests and Related Services		S	4.1632	$381.96	.	$76.40	0.000%			
5723	76145		Med physic dos eval rad exp						0.000%			
5723	91010		Esophagus motility study						0.000%			
5723	91020		Gastric motility studies						0.000%			
5723	91022		Duodenal motility study						0.000%			
5723	91030		Acid perfusion of esophagus						0.000%			
5723	91034		Gastroesophageal reflux tes						0.000%			
5723	91038		Esoph imped funct test > 1h						0.000%			
5723	91040		Esoph balloon distension ts						0.000%			
5723	92230		Fluorescein angioscopy i&r						0.000%			
5723	92577		Stenger test speech						0.000%			
5723	92588		Evoked auditory tst complet						0.000%			
5723	93229		Remote 30 day ecg tech supp						0.000%			
5723	93660		Tilt table evaluation						0.000%			
5723	94013		Meas lung vol thru 2 yrs						0.000%			
5723	94060		Evaluation of wheezing						0.000%			
5723	94070		Evaluation of wheezing						0.000%			
5723	94621		Cardiopulm exercise testing						0.000%			
5723	94681		O2 uptk exp gas alys w/co2						0.000%			
5723	94726		Pulm funct tst plethysmogra						0.000%			
5723	94772		Breath recording infant						0.000%			
5723	95070		Inhlj brncl challenge tstg						0.000%			
5723	95076		Ingest challenge ini 120 mi						0.000%			
5723	95708		Eeg wo vid ea 12-26hr unmnt						0.000%			
5723	95709		Eeg w/o vid ea 12-26hr intm						0.000%			
5723	95710		Eeg w/o vid ea 12-26hr cont						0.000%			
5723	95712		Veeg 2-12 hr intmt mntr						0.000%			
5723	95713		Veeg 2-12 hr cont mntr						0.000%			
5723	95714		Veeg ea 12-26 hr unmntr						0.000%			
5723	95715		Veeg ea 12-26hr intmt mntr						0.000%			
5723	95807		Sleep study attended						0.000%			
5723	95824		Eeg cerebral death only						0.000%			
5723	95910		Nrv cndj test 7-8 studies						0.000%			
5723	95911		Nrv cndj test 9-10 studies						0.000%			
5723	95912		Nrv cndj test 11-12 studies						0.000%			
5723	95913		Nrv cndj test 13/> studies						0.000%			
5723	95929		C motor evoked lwr limbs						0.000%			
5723	95954		Eeg monitoring/giving drugs						0.000%			
5723	96000		Motion analysis video/3d						0.000%			
5723	96132		Nrpsyc tst eval phys/qhp 1s						0.000%			
5723	0541T		Myocardial imaging mcg						0.000%			
5723	0779T		Gi myoelectrical actv study						0.000%			
5723	0868T		Hi-res gastric ep mapping						0.000%			
5723	91XX2		Anrct mano rct snsatn&balo						0.000%			
5723	G0302		Pre-op service lvrs complet						0.000%			
5723	G0304		Pre-op service lvrs 1-9 dos						0.000%			
5723	G0305		Post op service lvrs min 6						0.000%			
5723	G2000		Blinded conv. tx mdd clin t						0.000%			
5724		Level 4 Diagnostic Tests and Related Services		S	9.5844	$879.34	.	$175.87	0.000%			
5724	51101		Drain bladder by trocar/cat						0.000%			
5724	75580		N-invas est c ffr sw aly ct						0.000%			
5724	90870		Electroconvulsive therapy						0.000%			
5724	91035		G-esoph reflx tst w/electro						0.000%			
5724	95004		Perq tests w/alrgnc xtrcs						0.000%			
5724	95044		Patch/application tests						0.000%			
5724	95716		Veeg ea 12-26hr cont mntr						0.000%			
5724	95782		Polysom <6 yrs 4/> paramtrs						0.000%			
5724	95783		Polysom <6 yrs cpap/bilvl						0.000%			
5724	95805		Multiple sleep latency test						0.000%			
5724	95808		Polysom any age 1-3> param						0.000%			
5724	95810		Polysom 6/> yrs 4/> param						0.000%			
5724	95811		Polysom 6/>yrs cpap 4/> par						0.000%			
5724	95928		C motor evoked uppr limbs						0.000%			
5724	95938		Somatosensory testing						0.000%			
5724	95939		C motor evoked upr&lwr limb						0.000%			
5724	95958		Eeg monitoring/function tes						0.000%			
5724	95961		Electrode stimulation brain						0.000%			
5724	95965		Meg spontaneous						0.000%			
5724	95966		Meg evoked single						0.000%			
5724	96001		Motion test w/ft press meas						0.000%			
5724	0897T		N-invas augmnt arrhyt alys						0.000%			
5724	0898T		N-invas prst8 cancer est ma						0.000%			
5724	64X11		Perq elec nrv field stimj c						0.000%			
5724	C9793		Pre 3d mdl w/ccta and/or mr						0.000%			
5724	G0555		Replacment pt electronic sy						0.000%			
5731		Level 1 Minor Procedures		S	0.3358	$30.81	.	$6.17	0.000%			
5731	Q0091		Obtaining screen pap smear				$0.00	$0.00	0.000%	$0.00		
5731	20560		Ndl insj w/o njx 1 or 2 mus						0.000%			
5731	20561		Ndl insj w/o njx 3+ musc						0.000%			
5731	20979		Us bone stimulation						0.000%			
5731	76014		Mr sfty implt&/fb asmt stf						0.000%			
5731	76514		Echo exam of eye thickness						0.000%			
5731	86077		Phys blood bank serv xmatch						0.000%			
5731	86485		Skin test candida						0.000%			
5731	86486		Skin test unlisted antign e						0.000%			
5731	86580		Tb intradermal test						0.000%			
5731	86976		Rbc serum pretx id dilution						0.000%			
5731	86999		Unlisted transfusion med px						0.000%			
5731	88106		Cytopath fl nongyn filter						0.000%			
5731	88160		Cytopath smear other source						0.000%			
5731	88161		Cytopath smear other source						0.000%			
5731	88300		Surgical path gross						0.000%			
5731	88363		Xm archive tissue molec ana						0.000%			
5731	92499		Unlisted oph svc/procedure						0.000%			
5731	92700		Unlisted orl service/px						0.000%			
5731	93050		Art pressure waveform analy						0.000%			
5731	93291		Interrog dev eval scrms ip						0.000%			
5731	93998		Unlistd noninvas vasc dx st						0.000%			
5731	95017		All tstg perq&iq w/venoms						0.000%			
5731	95027		Iq tsts seql&incrl airborne						0.000%			
5731	95199		Unlisted all/immlg svc/px						0.000%			
5731	96146		Psycl/nrpsyc tst auto resul						0.000%			
5731	97810		Acup 1/> wo estim 1st 15 mi						0.000%			
5731	97813		Acup 1/> w/estim 1st 15 min						0.000%			
5731	99473		Self-meas bp pt educaj/trai						0.000%			
5731	0358T		Bia whole body						0.000%			
5731	0521T		Interrog dev eval wcs ip						0.000%			
5731	0555T		B1 str&fx rsk transmis data						0.000%			
5731	G0117		Glaucoma scrn hgh risk dire						0.000%			
5731	G0237		Therapeutic procd strg endu						0.000%			
5731	G0238		"Oth resp proc, indiv"						0.000%			
5731	G0404		Ekg tracing for initial pre						0.000%			
5731	G0541		No pt prsnt train initial 3						0.000%			
5731	G0543		Group train w/o patient						0.000%			
5731	G2011		Alcohol/sub misuse assess						0.000%			
5731	X473T		Air displacmnt plethysmogra						0.000%			
5732		Level 2 Minor Procedures		S	0.4241	$38.91	.	$7.79	0.000%			
5732	86510		Histoplasmosis skin test						0.000%			
5732	86901		Blood typing serologic rh(d						0.000%			
5732	86906		Bld typing serologic rh phn						0.000%			
5732	86932		Frozen blood freeze/thaw						0.000%			
5732	86945		Blood product/irradiation						0.000%			
5732	88104		Cytopath fl nongyn smears						0.000%			
5732	88108		Cytopath concentrate tech						0.000%			
5732	88302		Tissue exam by pathologist						0.000%			
5732	88321		Consltj&reprt sld prep elsw						0.000%			
5732	92228		Img rta detc/mntr ds phy/qh						0.000%			
5732	92260		Ophthalmodynamometry						0.000%			
5732	92285		External ocular photography						0.000%			
5732	92317		C-lens fitg tech corneosclr						0.000%			
5732	92354		Fitg spect low vis 1system						0.000%			
5732	92355		Fitg spect lw vis cmpnd len						0.000%			
5732	92563		Tone decay hearing test						0.000%			
5732	92567		Tympanometry						0.000%			
5732	92568		Acoustic refl threshold tst						0.000%			
5732	92571		Filtered speech test						0.000%			
5732	92575		Sensorineural acuity lvl ts						0.000%			
5732	92576		Synthetic sentence id test						0.000%			
5732	92596		Ear protector evaluation						0.000%			
5732	93242		Ext ecg>48hr<7d recording						0.000%			
5732	93246		Ext ecg>7d<15d recording						0.000%			
5732	94780		Cars/bd tst inft-12mo 60 mi						0.000%			
5732	95012		Nitric oxide exp gas deter						0.000%			
5732	95018		All tstg perq&iq drugs/biol						0.000%			
5732	95028		Iq tsts allergy delayed rxn						0.000%			
5732	95065		Dir nsl mucous membrane tes						0.000%			
5732	96127		Brief emotional/behav assmt						0.000%			
5732	96900		Actinotherapy uv light						0.000%			
5732	97037		Appl modality 1+lllt po pai						0.000%			
5732	0106T		Touch quant sensory test						0.000%			
5732	0107T		Vibrate quant sensory test						0.000%			
5732	0109T		Heat quant sensory test						0.000%			
5732	0208T		Audiometry air only						0.000%			
5732	0209T		Audiometry air & bone						0.000%			
5732	0210T		Speech audiometry threshold						0.000%			
5732	0211T		Speech audiom thresh & reco						0.000%			
5732	0330T		Tear film img uni/bi w/i&r						0.000%			
5732	0379T		Vis field assmnt tech suppt						0.000%			
5732	0485T		Oct mid ear i&r unilateral						0.000%			
5732	0486T		Oct mid ear i&r bilateral						0.000%			
5732	0640T		Ncntc ifr spctrsc o/t pad 1						0.000%			
5732	77X05		Surf radj ther tx planning						0.000%			
5732	G0118		Glaucoma scrn hgh risk dire						0.000%			
5732	G0239		"Oth resp proc, group"						0.000%			
5732	G0293		"Non-cov surg proc,clin tria"						0.000%			
5732	G0294		"Non-cov proc, clinical tria"						0.000%			
5732	Q0035		Cardiokymography						0.000%			
5733		Level 3 Minor Procedures		S	0.6604	$60.59	.	$12.12	0.000%			
5733	11719		Trim nail(s) any number						0.000%			
5733	11720		Debride nail 1-5						0.000%			
5733	11721		Debride nail 6 or more						0.000%			
5733	17340		Cryotherapy for acne						0.000%			
5733	29131		Application of finger splin						0.000%			
5733	29260		Strapping of elbow or wrist						0.000%			
5733	29280		Strapping of hand or finger						0.000%			
5733	29550		Strapping of toes						0.000%			
5733	51792		Urinary reflex study						0.000%			
5733	51798		Us urine capacity measure						0.000%			
5733	57150		Treat vagina infection						0.000%			
5733	69209		Remove impacted ear wax uni						0.000%			
5733	69210		Remove impacted ear wax uni						0.000%			
5733	76019		Mr safety implt pos&/immobl						0.000%			
5733	86880		Coombs test direct						0.000%			
5733	86904		Blood typing patient serum						0.000%			
5733	86970		Rbc pretx incubatj w/chemic						0.000%			
5733	86978		Rbc pretreatment serum						0.000%			
5733	88329		Path consltj drg surg						0.000%			
5733	92025		Cptrized corneal topography						0.000%			
5733	92060		Sensorimotor examination						0.000%			
5733	92066		Orthop traing supvj phys/qh						0.000%			
5733	92081		Limited visual field xm						0.000%			
5733	92082		Intermediate visual field x						0.000%			
5733	92132		Cptrzd oph dx img ant sgm						0.000%			
5733	92133		Cptrzd oph dx img pst sgm o						0.000%			
5733	92134		Cptrz oph dx img pst sgm rt						0.000%			
5733	92145		Corneal hysteresis deter						0.000%			
5733	92201		Opscpy extnd rta draw uni/b						0.000%			
5733	92202		Opscpy extnd on/mac draw						0.000%			
5733	92227		Img rta detcj/mntr ds staff						0.000%			
5733	92229		Img rta detc/mntr ds poc al						0.000%			
5733	92265		Ndl oculoelectromyography 1						0.000%			
5733	92283		Extnd color vision xm						0.000%			
5733	92326		Replacement of contact lens						0.000%			
5733	92352		Fit aphakia spectcl monofoc						0.000%			
5733	92353		Fit aphakia spectcl multifo						0.000%			
5733	92358		Aphakia prosth service temp						0.000%			
5733	92371		Rpr&refit spct prsth aphaki						0.000%			
5733	92555		Speech threshold audiometry						0.000%			
5733	92556		Speech audiometry complete						0.000%			
5733	92565		Stenger test pure tone						0.000%			
5733	92583		Select picture audiometry						0.000%			
5733	93005		Electrocardiogram tracing						0.000%			
5733	93041		Rhythm ecg tracing						0.000%			
5733	93226		Xtrnl ecg rec<48 hr scan a/						0.000%			
5733	93278		Ecg/signal-averaged						0.000%			
5733	93668		Peripheral vascular rehab						0.000%			
5733	94200		Lung function test (mbc/mvv						0.000%			
5733	94619		Exercise tst brncspsm wo ec						0.000%			
5733	94625		Phy/qhp op pulm rhb w/o mnt						0.000%			
5733	94626		Phy/qhp op pulm rhb w/mntr						0.000%			
5733	94690		O2 uptk exp gas alys rest						0.000%			
5733	95024		Iq tests w/allergenic xtrcs						0.000%			
5733	95052		Photo patch tests						0.000%			
5733	95249		Cont gluc mntr pt prov eqp						0.000%			
5733	95801		Slp stdy unatnd w/anal						0.000%			
5733	95803		Actigraphy testing						0.000%			
5733	95933		Blink reflex test						0.000%			
5733	95981		Io anal gast n-stim subsq						0.000%			
5733	96523		Irrig drug delivery device						0.000%			
5733	96910		Photchmtx tar&uvb/ptrltm&uv						0.000%			
5733	96912		Photochemotherapy puva						0.000%			
5733	0108T		Cool quant sensory test						0.000%			
5733	0347T		Ins bone device for rsa						0.000%			
5733	0506T		Mac pgmt opt dns meas hfp						0.000%			
5733	0507T		Near ifr 2img mibmn glnd i&						0.000%			
5733	0559T		Antmc mdl 3d print 1st cmpn						0.000%			
5733	0561T		Antmc guide 3d print 1st gd						0.000%			
5733	0563T		Evac meibomian glnd heat bi						0.000%			
5733	0658T		Elec impd spectrsc 1+skn le						0.000%			
5733	0716T		Car acous wavfrm rec cad rs						0.000%			
5733	0731T		Augmnt ai-based fcl phnt a/						0.000%			
5733	0740T		Rem auton alg nsln cal setu						0.000%			
5733	0794T		Pt spec alg rx-onc tx optio						0.000%			
5733	0893T		N-invas assmt bld oxygnatio						0.000%			
5733	0904T		Ecg alg 12 ld rdcd trcg onl						0.000%			
5733	G0127		Trim nail(s)						0.000%			
5733	P9100		Pathogen test for platelets						0.000%			
5733	X457T		Raman spectroscopy 1+skn le						0.000%			
5733	X481T		Elec aly npgs esoph sbsq w/						0.000%			
5734		Level 4 Minor Procedures		S	1.4857	$136.31	.	$27.27	0.000%			
5734	11740		Drain blood from under nail						0.000%			
5734	11981		Insertion drug dlvr implant						0.000%			
5734	29125		Apply forearm splint						0.000%			
5734	29126		Apply forearm splint						0.000%			
5734	29130		Application of finger splin						0.000%			
5734	29240		Strapping of shoulder						0.000%			
5734	29520		Strapping of hip						0.000%			
5734	29530		Strapping of knee						0.000%			
5734	30300		Remove nasal foreign body						0.000%			
5734	30901		Control of nosebleed						0.000%			
5734	30903		Control of nosebleed						0.000%			
5734	30905		Control of nosebleed						0.000%			
5734	36420		Venipuncture cutdown < 1 yr						0.000%			
5734	36591		Draw blood off venous devic						0.000%			
5734	36592		Collect blood from picc						0.000%			
5734	36600		Withdrawal of arterial bloo						0.000%			
5734	41800		Drainage of gum lesion						0.000%			
5734	46600		Diagnostic anoscopy spx						0.000%			
5734	51701		Insert bladder catheter						0.000%			
5734	51702		Insert temp bladder cath						0.000%			
5734	51736		Urine flow measurement						0.000%			
5734	53601		Dilate urethra stricture						0.000%			
5734	53661		Dilation of urethra						0.000%			
5734	65205		Remove foreign body from ey						0.000%			
5734	65222		Remove foreign body from ey						0.000%			
5734	67820		Revise eyelashes						0.000%			
5734	69200		Clear outer ear canal						0.000%			
5734	76510		Oph us dx b-scan&quan a-sca						0.000%			
5734	86900		Blood typing serologic abo						0.000%			
5734	88313		Special stains group 2						0.000%			
5734	91133		Electrogastrography w/test						0.000%			
5734	92020		Gonioscopy						0.000%			
5734	92083		Extended visual field xm						0.000%			
5734	92136		Ophthalmic biometry						0.000%			
5734	92250		Fundus photography w/i&r						0.000%			
5734	92270		Electro-oculography w/i&r						0.000%			
5734	92286		Ant sgm img i&r speclr mic						0.000%			
5734	92287		Ant sgm img ir flrscn angrp						0.000%			
5734	92312		Contact lens fitg aphakia o						0.000%			
5734	92313		C-lens fitg corneosclrl len						0.000%			
5734	92315		C-lens fitg tech aphakia 1						0.000%			
5734	92316		C-lens fitg tech aphakia ou						0.000%			
5734	92325		Modification of contact len						0.000%			
5734	92520		Laryngeal function studies						0.000%			
5734	92541		Spontaneous nystagmus test						0.000%			
5734	92542		Positional nystagmus test						0.000%			
5734	92548		Cdp-sot 6 cond w/i&r						0.000%			
5734	92549		Cdp-sot 6 cond w/i&r mct&ad						0.000%			
5734	92552		Pure tone audiometry air						0.000%			
5734	93225		Xtrnl ecg rec<48 hrs rec						0.000%			
5734	93243		Ext ecg>48hr<7d scan a/r						0.000%			
5734	93247		Ext ecg>7d<15d scan a/r						0.000%			
5734	93701		Bioimpedance cv analysis						0.000%			
5734	93786		Ambl bp mntr w/sw rec only						0.000%			
5734	93788		Ambl bp mntr w/sw a/r						0.000%			
5734	93922		Upr/l xtremity art 2 levels						0.000%			
5734	94452		Hast w/report						0.000%			
5734	94453		Hast w/oxygen titrate						0.000%			
5734	94617		Exercise tst brncspsm w/ecg						0.000%			
5734	94618		Pulmonary stress testing						0.000%			
5734	94644		Cbt 1st hour						0.000%			
5734	94667		Chest wall manipulation						0.000%			
5734	94668		Chest wall manipulation						0.000%			
5734	95056		Photo tests						0.000%			
5734	95060		Oph mucous membrane tests						0.000%			
5734	95860		Needle emg 1 extremity						0.000%			
5734	95861		Needle emg 2 extremities						0.000%			
5734	95865		Needle emg larynx						0.000%			
5734	95870		Ndl emg lmtd std musc 1 xtr						0.000%			
5734	95919		Quan puplmtry phy/qhp uni/b						0.000%			
5734	95922		Autonomic nrv adrenrg inerv						0.000%			
5734	95923		Autonomic nrv syst funj tes						0.000%			
5734	95970		Alys npgt w/o prgrmg						0.000%			
5734	96136		Psycl/nrpsyc tst phy/qhp 1s						0.000%			
5734	99195		Phlebotomy						0.000%			
5734	0110T		Nos quant sensory test						0.000%			
5734	0198T		Ocular blood flow measure						0.000%			
5734	0207T		Clear eyelid gland w/heat						0.000%			
5734	0615T		Auto alys binocular eye mvm						0.000%			
5734	0764T		Asstv alg ecg rsk asmt cncr						0.000%			
5734	0765T		Asstv alg ecg rsk asmt prev						0.000%			
5734	0780T		Instlj fecal microbiota ssp						0.000%			
5734	0902T		Qtc ntrvl augmnt alg aly ec						0.000%			
5734	0962T		Asstv alg alys acous&ecg re						0.000%			
5734	G0166		"Extrnl counterpulse, per tx"						0.000%			
5734	X444T		Cptr oph alys monoc eye mvm						0.000%			
5734	X461T		Elec alys s-scl eeg wo prgr						0.000%			
5735		Level 5 Minor Procedures		S	4.9221	$451.59	.	$90.32	0.000%			
5735	11980		Implant hormone pellet(s)						0.000%			
5735	11982		Remove drug implant device						0.000%			
5735	11983		Remove/insert drug implant						0.000%			
5735	15860		Test for blood flow in graf						0.000%			
5735	20665		Rmvl tongs/halo anthr indiv						0.000%			
5735	36425		Venipuncture cutdown 1 yr/>						0.000%			
5735	36680		Insert needle bone cavity						0.000%			
5735	41250		Repair tongue laceration						0.000%			
5735	42809		Remove pharynx foreign body						0.000%			
5735	43752		Nasal/orogastric w/tube plm						0.000%			
5735	46601		Diagnostic anoscopy						0.000%			
5735	65210		Remove foreign body from ey						0.000%			
5735	65220		Remove foreign body from ey						0.000%			
5735	65430		Corneal smear						0.000%			
5735	68200		Treat eyelid by injection						0.000%			
5735	68801		Dilate tear duct opening						0.000%			
5735	86975		Rbc serum pretx incubj drug						0.000%			
5735	92284		Dx dark adaptation exam i&r						0.000%			
5735	92311		Contact lens fitg aphakia 1						0.000%			
5735	93024		Ergonovine provocation test						0.000%			
5735	94014		Patient recorded spirometry						0.000%			
5735	95180		Rapid desensitization						0.000%			
5735	95905		Motor &/ sens nrve cndj tes						0.000%			
5735	96138		Psycl/nrpsyc tech 1st						0.000%			
5735	0232T		Njx platelet plasma						0.000%			
5735	0481T		Njx autol wbc concentrate						0.000%			
5735	0881T		Cryotherapy oral cavity						0.000%			
5735	G0516		"Insert drug del implant, >="						0.000%			
5735	G0517		Remove drug implant						0.000%			
5735	G0518		Remove w insert drug implan						0.000%			
5741		Level 1 Electronic Analysis of Devices		S	0.4144	$38.02	.	$7.61	0.000%			
5741	93260		Prgrmg dev eval impltbl sys						0.000%			
5741	93261		Interrogate subq defib						0.000%			
5741	93264		Rem mntr wrls p-art prs snr						0.000%			
5741	93270		Remote 30 day ecg rev/repor						0.000%			
5741	93279		Prgrmg dev eval pm/ldls pm						0.000%			
5741	93280		Pm device progr eval dual						0.000%			
5741	93281		Pm device progr eval multi						0.000%			
5741	93282		Prgrmg eval implantable dfb						0.000%			
5741	93283		Prgrmg eval implantable dfb						0.000%			
5741	93284		Prgrmg eval implantable dfb						0.000%			
5741	93285		Prgrmg dev eval scrms ip						0.000%			
5741	93288		Interrog evl pm/ldls pm ip						0.000%			
5741	93289		Interrog device eval heart						0.000%			
5741	93290		Interrog dev eval icpms ip						0.000%			
5741	93292		Wcd device interrogate						0.000%			
5741	93293		Pm phone r-strip device eva						0.000%			
5741	93296		Rem interrog evl pm/ids						0.000%			
5741	93297		Rem interrog dev eval icpms						0.000%			
5741	93298		Rem interrog dev eval scrms						0.000%			
5741	95836		Ecog impltd brn npgt <30 d						0.000%			
5741	95976		Alys smpl cn npgt prgrmg						0.000%			
5741	95982		Io ga n-stim subsq w/reprog						0.000%			
5741	98976		Rtm dev sply resp sys 16-30						0.000%			
5741	98977		Rtm dev sply mscskl 16-30 d						0.000%			
5741	98978		Rtm dev sply cbt 16-30 d						0.000%			
5741	99454		Rem mntr physiol param 16-3						0.000%			
5741	0417T		Prgrmg eval cardiac modulj						0.000%			
5741	0418T		Interro eval cardiac modulj						0.000%			
5741	0522T		Prgrmg dev eval wcs ip						0.000%			
5741	0528T		Prgrmg dev eval iims ip						0.000%			
5741	0529T		Interrog dev eval iims ip						0.000%			
5741	0575T		Prgrmg dev eval icds ss ip						0.000%			
5741	0576T		Interrog dev eval icds ss i						0.000%			
5741	0579T		Rem interrog dev icds tech						0.000%			
5741	0650T		Prgrmg dev eval scrms remot						0.000%			
5741	0683T		Prgrmg dev eval isdss ip						0.000%			
5741	0685T		Interrog dev eval isdss ip						0.000%			
5741	0696T		Bdy surf mapg pm/cvdfb f/up						0.000%			
5741	0741T		Rem auton alg nsln data col						0.000%			
5741	0804T		Prgrmg evl ldls pm 2chmbr i						0.000%			
5741	0826T		Prgrmg evl ldls pm 1chmbr i						0.000%			
5741	0926T		Prgrmg dev eval ccm-d ip						0.000%			
5741	0927T		Interrog dev eval ccm-d ip						0.000%			
5741	0929T		Rem interrog dev ccm-d tech						0.000%			
5741	0949T		Rem interrog dev ccm tech						0.000%			
5741	0983T		Rem mntr impl ivc snr phys						0.000%			
5741	98XX4		Rtm dev sply resp sys 2-15						0.000%			
5741	98XX5		Rtm dev sply mscsk sys 2-15						0.000%			
5741	98XX6		Rtm dev sply cbt 2-15 d						0.000%			
5741	99XX4		Rem mntr physiol param 2-15						0.000%			
5741	X482T		Elec alys npgs esoph sbsq w						0.000%			
5742		Level 2 Electronic Analysis of Devices		S	1.0591	$97.17	.	$19.44	0.000%			
5742	76018		Mr safety implant elec prep						0.000%			
5742	93150		Therapy activation ipnss						0.000%			
5742	93151		Interrog&prgrmg ipnss						0.000%			
5742	93153		Interrog w/o prgrmg ipnss						0.000%			
5742	93271		Ecg/monitoring and analysis						0.000%			
5742	93750		Interrogation vad in person						0.000%			
5742	95971		Alys smpl sp/pn npgt w/prgr						0.000%			
5742	95972		Alys cplx sp/pn npgt w/prgr						0.000%			
5742	95977		Alys cplx cn npgt prgrmg						0.000%			
5742	95983		Alys brn npgt prgrmg 15 min						0.000%			
5742	0473T		Reprgrmg io rta eltrd ra						0.000%			
5742	0589T		Elec alys smpl prgrmg iins						0.000%			
5742	0590T		Elec alys cplx prgrmg iins						0.000%			
5742	0788T		Elec aly smp iins sp/sac nr						0.000%			
5742	0789T		Elec aly cpx iins sp/sac nr						0.000%			
5742	X462T		Elec alys s-scl eeg prgr 1s						0.000%			
5743		Level 3 Electronic Analysis of Devices		S	3.4451	$316.08	.	$63.22	0.000%			
5743	62252		Csf shunt reprogram						0.000%			
5743	62367		Analyze spine infus pump						0.000%			
5743	62368		Analyze sp inf pump w/repro						0.000%			
5743	62369		Anal sp inf pmp w/reprg&fil						0.000%			
5743	62370		Anl sp inf pmp w/mdreprg&fi						0.000%			
5743	93152		Interrog&prgrmg ipnss polys						0.000%			
5743	93724		Elec alys antitchycar pm sy						0.000%			
5743	93745		Set-up cardiovert-defibrill						0.000%			
5743	0472T		Prgrmg io rta eltrd ra						0.000%			
5743	0932T		N-invs det hrt fail aug ech						0.000%			
5771		Cardiac Rehabilitation		S	1.4513	$133.15	.	$26.63	0.000%			
5771	93797		Phys/qhp op car rhab wo ecg						0.000%			
5771	93798		Phys/qhp op car rhab w/ecg						0.000%			
5771	G0422		Intens cardiac rehab w/exer						0.000%			
5771	G0423		Intens cardiac rehab no exe						0.000%			
5781		Resuscitation and Cardioversion		S	7.437	$682.32	.	$136.47	0.000%			
5781	92953		Temporary external pacing						0.000%			
5781	92960		Cardioversion electric ext						0.000%			
5781	92961		Cardioversion electric int						0.000%			
5781	99465		Nb resuscitation						0.000%			
5791		Pulmonary Treatment		S	2.4704	$226.65	.	$45.33	0.000%			
5791	31720		Clearance of airways						0.000%			
5791	94610		Surfactant admin thru tube						0.000%			
5791	94640		Airway inhalation treatment						0.000%			
5791	94642		Aerosol inhalation treatmen						0.000%			
5791	94660		Pos airway pressure cpap						0.000%			
5791	94664		Evaluate pt use of inhaler						0.000%			
5791	94669		Mechanical chest wall oscil						0.000%			
5801		Ventilation Initiation and Management		S	7.1217	$653.39	.	$130.68	0.000%			
5801	94002		Vent mgmt inpat init day						0.000%			
5801	94003		Vent mgmt inpat subq day						0.000%			
5811		Manipulation Therapy		S	0.2425	$22.25	.	$4.45	0.000%			
5811	98925		Osteopath manj 1-2 regions						0.000%			
5811	98926		Osteopath manj 3-4 regions						0.000%			
5811	98927		Osteopath manj 5-6 regions						0.000%			
5811	98928		Osteopath manj 7-8 regions						0.000%			
5811	98929		Osteopath manj 9-10 regions						0.000%			
5811	98940		Chiropract manj 1-2 regions						0.000%			
5811	98941		Chiropract manj 3-4 regions						0.000%			
5811	98942		Chiropractic manj 5 regions						0.000%			
5821		Level 1 Health and Behavior Services		S	0.4083	$37.46	.	$7.50	0.000%			
5821	99406		Behav chng smoking 3-10 min				$0.00	$0.00	0.000%	$0.00		
5821	99407		Behav chng smoking > 10 min				$0.00	$0.00	0.000%	$0.00		
5821	G0013		"Hiv prep counsel, clin staf"				$0.00	$0.00	0.000%	$0.00		
5821	G0442		Annual alcohol screen 15 mi				$0.00	$0.00	0.000%	$0.00		
5821	G0444		Depression screen annual				$0.00	$0.00	0.000%	$0.00		
5821	G0446		Intens behave ther cardio d				$0.00	$0.00	0.000%	$0.00		
5821	G0473		Group behave couns 2-10				$0.00	$0.00	0.000%	$0.00		
5821	90899		Unlisted psyc svc/therapy						0.000%			
5821	96160		Pt-focused hlth risk assmt						0.000%			
5821	96161		Caregiver health risk assmt						0.000%			
5821	96164		Hlth bhv ivntj grp 1st 30						0.000%			
5821	96167		Hlth bhv ivntj fam 1st 30						0.000%			
5821	97154		Grp adapt bhv tx by tech						0.000%			
5821	97156		Fam adapt bhv tx gdn phy/qh						0.000%			
5821	97157		Mult fam adapt bhv tx gdn						0.000%			
5821	97158		Grp adapt bhv tx by phy/qhp						0.000%			
5821	99484		Care mgmt svc bhvl hlth con						0.000%			
5821	0362T		Bhv id suprt assmt ea 15 mi						0.000%			
5821	0373T		Adapt bhv tx ea 15 min						0.000%			
5821	C7900		"Hopd mntl hlt, 15-29 min"						0.000%			
5821	C7903		"Hopd mntl hlt, grp"						0.000%			
5821	G0323		Care manage beh svs 20mins						0.000%			
5821	G0396		Alcohol/subs interv 15-30mn						0.000%			
5821	G0537		Risk ascvd tst once pr 12 m						0.000%			
5821	G0556		Adv prim care mgmt lvl 1						0.000%			
5821	G0557		Adv prim care mgmt lvl 2						0.000%			
5821	GPCM3		"Care manage serv, pr cal mo"						0.000%			
5822		Level 2 Health and Behavior Services		S	1.1731	$107.63	.	$21.53	0.000%			
5822	G0101		Ca screen;pelvic/breast exa				$0.00	$0.00	0.000%	$0.00		
5822	G0296		Visit to determ ldct elig				$0.00	$0.00	0.000%	$0.00		
5822	G0443		Brief alcohol misuse counse				$0.00	$0.00	0.000%	$0.00		
5822	G0445		High inten beh couns std 30				$0.00	$0.00	0.000%	$0.00		
5822	G0447		Behavior counsel obesity 15				$0.00	$0.00	0.000%	$0.00		
5822	90853		Group psychotherapy						0.000%			
5822	90880		Hypnotherapy						0.000%			
5822	96156		Hlth bhv assmt/reassessment						0.000%			
5822	97151		Bhv id assmt by phys/qhp						0.000%			
5822	97152		Bhv id suprt assmt by 1 tec						0.000%			
5822	97153		Adaptive behavior tx by tec						0.000%			
5822	99426		Prin care mgmt staff 1st 30						0.000%			
5822	99483		Assmt & care pln pt cog imp						0.000%			
5822	99490		Chrnc care mgmt staff 1st 2						0.000%			
5822	99492		1st psyc collab care mgmt						0.000%			
5822	99493		Sbsq psyc collab care mgmt						0.000%			
5822	99497		Advncd care plan 30 min						0.000%			
5822	C7901		"Hopd mntl hlt, 30-60 min"						0.000%			
5822	G0019		Comm hlth intg svs sdoh 60m						0.000%			
5822	G0023		Pin service 60m per month						0.000%			
5822	G0140		Nav srv peer sup 60 min pr						0.000%			
5822	G0451		Devlopment test interpt&rep						0.000%			
5822	G0538		Ascvd rsk mng clin stf pr m						0.000%			
5822	G0544		Post d/c phone follow up						0.000%			
5822	G0558		Adv prim care mgmt lvl 3						0.000%			
5822	G2214		Init/sub psych care m 1st 3						0.000%			
5822	GPCM1		"Int psych care mng, 1 cal m"						0.000%			
5822	GPCM2		"Subs psych care mng, subs m"						0.000%			
5823		Level 3 Health and Behavior Services		S	1.9103	$175.26	.	$35.06	0.000%			
5823	90791		Psych diagnostic evaluation						0.000%			
5823	90792		Psych diag eval w/med srvcs						0.000%			
5823	90832		Psytx w pt 30 minutes						0.000%			
5823	90834		Psytx w pt 45 minutes						0.000%			
5823	90837		Psytx w pt 60 minutes						0.000%			
5823	90839		Psytx crisis initial 60 min						0.000%			
5823	90845		Psychoanalysis						0.000%			
5823	90846		Family psytx w/o pt 50 min						0.000%			
5823	90847		Family psytx w/pt 50 min						0.000%			
5823	90849		Multiple family group psytx						0.000%			
5823	90865		Narcosynthesis						0.000%			
5823	96158		Hlth bhv ivntj indiv 1st 30						0.000%			
5823	97155		Adapt behavior tx phys/qhp						0.000%			
5823	99487		Cplx chrnc care 1st 60 min						0.000%			
5823	G0397		Alcohol/subs interv >30 min						0.000%			
5823	G2086		Off base opioid tx 70min						0.000%			
5823	G2087		"Off base opioid tx, 60 m"						0.000%			
5871		Dental Procedures		T	9.0843	$833.46	.	$166.70	0.000%			
5871	D0460		Pulp vitality test						0.000%			
5871	D0600		Non-ionizing diag proc						0.000%			
5871	D1510		Space maintainer fxd unilat						0.000%			
5871	D1516		"Fixed bilat space maint, ma"						0.000%			
5871	D1517		"Fixed bilat space maint, ma"						0.000%			
5871	D1520		Remove unilat space maintai						0.000%			
5871	D1526		"Remove bilat space main, ma"						0.000%			
5871	D1527		"Remove bilat space main, ma"						0.000%			
5871	D1551		Recement space maint - max						0.000%			
5871	D1552		Recement space maint - man						0.000%			
5871	D1553		Recement unilat space maint						0.000%			
5871	D1575		"Dist space maint, fixed uni"						0.000%			
5871	D2140		Amalgam one surface permane						0.000%			
5871	D2150		Amalgam two surfaces perman						0.000%			
5871	D2160		Amalgam three surfaces perm						0.000%			
5871	D2161		Amalgam 4 or > surfaces per						0.000%			
5871	D2330		Resin one surface-anterior						0.000%			
5871	D2331		Resin two surfaces-anterior						0.000%			
5871	D2332		Resin three surfaces-anteri						0.000%			
5871	D2335		Resin 4/> surf or w incis a						0.000%			
5871	D2390		Ant resin-based cmpst crown						0.000%			
5871	D2391		Post 1 srfc resinbased cmps						0.000%			
5871	D2392		Post 2 srfc resinbased cmps						0.000%			
5871	D2393		Post 3 srfc resinbased cmps						0.000%			
5871	D2394		Post >=4srfc resinbase cmps						0.000%			
5871	D2410		Dental gold foil one surfac						0.000%			
5871	D2420		Dental gold foil two surfac						0.000%			
5871	D2430		Dental gold foil three surf						0.000%			
5871	D2510		Dental inlay metalic 1 surf						0.000%			
5871	D2520		Dental inlay metallic 2 sur						0.000%			
5871	D2530		Dental inlay metl 3/more su						0.000%			
5871	D2542		Dental onlay metallic 2 sur						0.000%			
5871	D2543		Dental onlay metallic 3 sur						0.000%			
5871	D2544		Dental onlay metl 4/more su						0.000%			
5871	D2610		Inlay porcelain/ceramic 1 s						0.000%			
5871	D2620		Inlay porcelain/ceramic 2 s						0.000%			
5871	D2630		Dental onlay porc 3/more su						0.000%			
5871	D2642		Dental onlay porcelin 2 sur						0.000%			
5871	D2643		Dental onlay porcelin 3 sur						0.000%			
5871	D2644		Dental onlay porc 4/more su						0.000%			
5871	D2650		Inlay composite/resin one s						0.000%			
5871	D2651		Inlay composite/resin two s						0.000%			
5871	D2652		Dental inlay resin 3/mre su						0.000%			
5871	D2662		Dental onlay resin 2 surfac						0.000%			
5871	D2663		Dental onlay resin 3 surfac						0.000%			
5871	D2664		Dental onlay resin 4/mre su						0.000%			
5871	D2710		Crown resin-based indirect						0.000%			
5871	D2712		Crown 3/4 resin-based compo						0.000%			
5871	D2720		Crown resin w/ high noble m						0.000%			
5871	D2721		Crown resin w/ base metal						0.000%			
5871	D2722		Crown resin w/ noble metal						0.000%			
5871	D2740		Crown porcelain/ceramic						0.000%			
5871	D2750		Crown porcelain w/ h noble						0.000%			
5871	D2751		Crown porcelain fused base						0.000%			
5871	D2752		Crown porcelain w/ noble me						0.000%			
5871	D2753		Crown porc fused to titaniu						0.000%			
5871	D2780		Crown 3/4 cast hi noble met						0.000%			
5871	D2781		Crown 3/4 cast base metal						0.000%			
5871	D2782		Crown 3/4 cast noble metal						0.000%			
5871	D2783		Crown 3/4 porcelain/ceramic						0.000%			
5871	D2790		Crown full cast high noble						0.000%			
5871	D2791		Crown full cast base metal						0.000%			
5871	D2792		Crown full cast noble metal						0.000%			
5871	D2794		Crown-titanium						0.000%			
5871	D2799		Interim crown						0.000%			
5871	D2910		Recement inlay onlay or par						0.000%			
5871	D2915		Recement cast or prefab pos						0.000%			
5871	D2920		Re-cement or re-bond crown						0.000%			
5871	D2921		Reattach tooth fragment						0.000%			
5871	D2928		Prefab porc/cer crown perm						0.000%			
5871	D2929		Prefab porc/ceram crown pri						0.000%			
5871	D2930		Prefab stnlss steel crwn pr						0.000%			
5871	D2931		Prefab stnlss steel crown p						0.000%			
5871	D2932		Prefabricated resin crown						0.000%			
5871	D2933		Prefab stainless steel crow						0.000%			
5871	D2934		Prefab steel crown primary						0.000%			
5871	D2940		Place direct restoration						0.000%			
5871	D2949		Restorative foundation						0.000%			
5871	D2950		Core build-up incl any pins						0.000%			
5871	D2951		Tooth pin retention						0.000%			
5871	D2952		Post and core cast + crown						0.000%			
5871	D2954		Prefab post/core + crown						0.000%			
5871	D2957		Each addtnl prefab post						0.000%			
5871	D2960		Labial veneer resin direct						0.000%			
5871	D2961		Labial veneer resin indirec						0.000%			
5871	D2962		Labial veneer porc indirect						0.000%			
5871	D2971		Add proc construct new crow						0.000%			
5871	D2975		Coping						0.000%			
5871	D2980		Crown repair						0.000%			
5871	D2981		Inlay repair						0.000%			
5871	D2982		Onlay repair						0.000%			
5871	D2983		Veneer repair						0.000%			
5871	D2990		Resin infiltration of lesio						0.000%			
5871	D2999		Dental unspec restorative p						0.000%			
5871	D3110		Pulp cap direct						0.000%			
5871	D3120		Pulp cap indirect						0.000%			
5871	D3220		Therapeutic pulpotomy						0.000%			
5871	D3221		Gross pulpal debridement						0.000%			
5871	D3222		Part pulp for apexogenesis						0.000%			
5871	D3230		Pulpal therapy anterior pri						0.000%			
5871	D3240		Pulpal therapy posterior pr						0.000%			
5871	D3310		"End thxpy, anterior tooth"						0.000%			
5871	D3320		"End thxpy, premolar tooth"						0.000%			
5871	D3330		"End thxpy, molar tooth"						0.000%			
5871	D3331		Non-surg tx root canal obs						0.000%			
5871	D3332		Incomplete endodontic tx						0.000%			
5871	D3333		Internal root repair						0.000%			
5871	D3346		Retreat root canal anterior						0.000%			
5871	D3347		Retreat root canal premolar						0.000%			
5871	D3348		Retreat root canal molar						0.000%			
5871	D3351		Apexification/recalc initia						0.000%			
5871	D3352		Apexification/recalc interi						0.000%			
5871	D3353		Apexification/recalc final						0.000%			
5871	D3355		Pulpal regeneration initial						0.000%			
5871	D3356		Pulpal regeneration interim						0.000%			
5871	D3357		Pulpal regeneration complet						0.000%			
5871	D3410		Apicoectomy - anterior						0.000%			
5871	D3421		Root surgery premolar						0.000%			
5871	D3425		Root surgery molar						0.000%			
5871	D3428		Bone graft peri per tooth						0.000%			
5871	D3430		Retrograde filling						0.000%			
5871	D3431		Biological materials						0.000%			
5871	D3432		Guided tissue regeneration						0.000%			
5871	D3450		Root amputation						0.000%			
5871	D3460		Endodontic endosseous impla						0.000%			
5871	D3470		Intentional replantation						0.000%			
5871	D3471		Surg rep root res anterior						0.000%			
5871	D3472		Surg rep root res premolar						0.000%			
5871	D3473		Surg rep root res molar						0.000%			
5871	D3501		Surg exp root surf anterior						0.000%			
5871	D3502		Surg exp root surf premolar						0.000%			
5871	D3503		Surg exp root surf molar						0.000%			
5871	D3910		Isolation- tooth w rubb dam						0.000%			
5871	D3911		Intraorifice barrier						0.000%			
5871	D3920		Tooth splitting						0.000%			
5871	D3921		Decor or submerg erupt toot						0.000%			
5871	D3950		Canal prep/fitting of dowel						0.000%			
5871	D3999		Endodontic procedure						0.000%			
5871	D4249		Crown lengthen hard tissue						0.000%			
5871	D4263		Bone replce graft first sit						0.000%			
5871	D4265		Bio mtrls to aid soft/os re						0.000%			
5871	D4268		Surgical revision procedure						0.000%			
5871	D4274		Mesial/distal wedge proc						0.000%			
5871	D4322		Splint intra-coronal						0.000%			
5871	D4323		Splint extra-coronal						0.000%			
5871	D4341		Periodontal scaling & root						0.000%			
5871	D4342		Periodontal scaling 1-3teet						0.000%			
5871	D4346		Scaling gingiv inflammation						0.000%			
5871	D4355		Full mouth debridement						0.000%			
5871	D4381		Localized delivery antimicr						0.000%			
5871	D4910		Periodontal maint procedure						0.000%			
5871	D4920		Unscheduled dressing change						0.000%			
5871	D5911		Facial moulage sectional						0.000%			
5871	D5912		Facial moulage complete						0.000%			
5871	D5983		Radiation applicator						0.000%			
5871	D5984		Radiation shield						0.000%			
5871	D5985		Radiation cone locator						0.000%			
5871	D5987		Commissure splint						0.000%			
5871	D5988		Surgical splint						0.000%			
5871	D6920		Dental connector bar						0.000%			
5871	D7111		Extraction coronal remnants						0.000%			
5871	D7140		Extraction erupted tooth/ex						0.000%			
5871	D7220		Impact tooth remov soft tis						0.000%			
5871	D7230		Impact tooth remov part bon						0.000%			
5871	D7240		Impact tooth remov comp bon						0.000%			
5871	D7241		Impact tooth rem bony w/com						0.000%			
5871	D7250		Tooth root removal						0.000%			
5871	D7260		Oral antral fistula closure						0.000%			
5871	D7261		Primary closure sinus perf						0.000%			
5871	D7270		Tooth reimplantation						0.000%			
5871	D7272		Tooth transplantation						0.000%			
5871	D7280		Exposure of unerupted tooth						0.000%			
5871	D7291		Transseptal fiberotomy						0.000%			
5871	D7460		Rem nonodonto cyst to 1.25c						0.000%			
5871	D7461		Rem nonodonto cyst > 1.25 c						0.000%			
5871	D7472		Removal of torus palatinus						0.000%			
5871	D7473		Remove torus mandibularis						0.000%			
5871	D7530		Removal fb skin/areolar tis						0.000%			
5871	D7540		Removal of fb reaction						0.000%			
5871	D7550		Removal of sloughed off bon						0.000%			
5871	D7922		Place intra-socket bio dres						0.000%			
5871	D7940		Reshaping bone orthognathic						0.000%			
5871	D9930		Treatment of complications						0.000%			
5871	D9944		"Occ guard, hard, full arch"						0.000%			
5871	D9945		"Occ guard, soft, full arch"						0.000%			
5871	D9946		"Occ guard, hard, part arch"						0.000%			
5871	D9950		Occlusion analysis						0.000%			
5871	D9951		Limited occlusal adjustment						0.000%			
5871	D9952		Complete occlusal adjustmen						0.000%			
6000		PMA Skin Substitute Products		S1	1.3666	$125.38	.	$25.08	0.000%			
6000	Q4101		Apligraf						0.000%			
6000	Q4105		Integra drt or omnigraft						0.000%			
6000	Q4106		Dermagraft						0.000%			
6000	Q4108		Integra matrix						0.000%			
6000	Q4159		Affinity1 square cm						0.000%			
6000	Q4182		"Transcyte, per sq centimete"						0.000%			
6000	Q4238		"Derm-maxx, per sq cm"						0.000%			
6001		510K Skin Substitute Products		S1	1.3666	$125.38	.	$25.08	0.000%			
6001	A2001		"Innovamatrix ac, per sq cm"						0.000%			
6001	A2002		Mirragen adv wnd mat per sq						0.000%			
6001	A2005		"Microlyte matrix, per sq cm"						0.000%			
6001	A2006		Novosorb synpath per sq cm						0.000%			
6001	A2007		"Restrata, per sq cm"						0.000%			
6001	A2008		"Theragenesis, per sq cm"						0.000%			
6001	A2009		"Symphony, per sq cm"						0.000%			
6001	A2010		"Apis, per square centimeter"						0.000%			
6001	A2011		"Supra sdrm, per sq cm"						0.000%			
6001	A2012		"Suprathel, per sq cm"						0.000%			
6001	A2013		"Innovamatrix fs, per sq cm"						0.000%			
6001	A2015		"Phoenix wnd mtrx, per sq cm"						0.000%			
6001	A2016		"Permeaderm b, per sq cm"						0.000%			
6001	A2018		"Permeaderm c, per sq cm"						0.000%			
6001	A2019		Kerecis marigen shld sq cm						0.000%			
6001	A2021		Neomatrix per sq cm						0.000%			
6001	A2022		Innovabrn/innovamatx xl sqc						0.000%			
6001	A2024		Resolve or xenopatch sq cm						0.000%			
6001	A2027		Matriderm per sq cm						0.000%			
6001	C9358		"Surgimend, fetal"						0.000%			
6001	C9360		"Surgimend, neonatal"						0.000%			
6001	C9363		Integra meshed bil wound ma						0.000%			
6001	C9364		"Porcine implant, permacol"						0.000%			
6001	Q4102		Oasis wound matrix						0.000%			
6001	Q4103		Oasis burn matrix						0.000%			
6001	Q4104		Integra bmwd						0.000%			
6001	Q4107		Graftjacket						0.000%			
6001	Q4110		Primatrix						0.000%			
6001	Q4111		Gammagraft						0.000%			
6001	Q4116		Alloderm						0.000%			
6001	Q4117		Hyalomatrix						0.000%			
6001	Q4122		"Dermacell, awm, porous sq c"						0.000%			
6001	Q4124		Oasis tri-layer wound matri						0.000%			
6001	Q4127		Talymed						0.000%			
6001	Q4130		Strattice tm						0.000%			
6001	Q4135		Mediskin						0.000%			
6001	Q4136		Ezderm						0.000%			
6001	Q4146		"Tensix, 1cm"						0.000%			
6001	Q4158		"Kerecis omega3, per sq cm"						0.000%			
6001	Q4161		Bio-connekt per square cm						0.000%			
6001	Q4164		"Helicoll, per square cm"						0.000%			
6001	Q4165		"Keramatrix, kerasorb sq cm"						0.000%			
6001	Q4166		"Cytal, per square centimete"						0.000%			
6001	Q4175		Miroderm						0.000%			
6001	Q4195		Puraply 1 sq cm						0.000%			
6001	Q4196		Puraply am 1 sq cm						0.000%			
6001	Q4197		Puraply xt 1 sq cm						0.000%			
6001	Q4198		Genesis amnio membrane 1sqc						0.000%			
6001	Q4201		Matrion 1 sq cm						0.000%			
6001	Q4203		"Derma-gide, 1 sq cm"						0.000%			
6001	Q4222		"Progenamatrix, per sq cm"						0.000%			
6001	Q4225		"Amnio or derma tl, per sq c"						0.000%			
6001	Q4226		Myown harv prep proc sq cm						0.000%			
6001	Q4232		"Corplex, per sq cm"						0.000%			
6001	Q4276		"Orion, per sq cm"						0.000%			
6001	Q4282		Cygnus dual per sq cm						0.000%			
6001	Q4297		"Emerge matrix, per sq cm"						0.000%			
6002		HCT/P Skin Substitute Products		S1	1.3666	$125.38	.	$25.08	0.000%			
6002	Q4115		Alloskin						0.000%			
6002	Q4121		Theraskin						0.000%			
6002	Q4123		Alloskin						0.000%			
6002	Q4125		Arthroflex						0.000%			
6002	Q4126		Memoderm/derma/tranz/integu						0.000%			
6002	Q4128		Flexhd/allopatchhd/sq cm						0.000%			
6002	Q4132		"Grafix core, grafixpl core"						0.000%			
6002	Q4133		Grafix stravix prime pl sqc						0.000%			
6002	Q4134		Hmatrix						0.000%			
6002	Q4137		Amnioexcel biodexcel 1sq cm						0.000%			
6002	Q4138		"Biodfence dryflex, 1cm"						0.000%			
6002	Q4140		Biodfence 1cm						0.000%			
6002	Q4141		"Alloskin ac, 1 cm"						0.000%			
6002	Q4142		Xcm biologic tiss matrix 1c						0.000%			
6002	Q4143		"Repriza, 1cm"						0.000%			
6002	Q4147		Architect ecm px fx 1 sq cm						0.000%			
6002	Q4148		Neox neox rt or clarix cord						0.000%			
6002	Q4150		Allowrap ds or dry 1 sq cm						0.000%			
6002	Q4151		"Amnioband, guardian 1 sq cm"						0.000%			
6002	Q4152		Dermapure 1 square cm						0.000%			
6002	Q4153		"Dermavest, plurivest sq cm"						0.000%			
6002	Q4154		Biovance 1 square cm						0.000%			
6002	Q4156		Neox 100 or clarix 100						0.000%			
6002	Q4157		Revitalon 1 square cm						0.000%			
6002	Q4160		Nushield 1 square cm						0.000%			
6002	Q4163		"Woundex, bioskin, per sq cm"						0.000%			
6002	Q4167		"Truskin, per sq centimeter"						0.000%			
6002	Q4169		"Artacent wound, per sq cm"						0.000%			
6002	Q4170		"Cygnus, per sq cm"						0.000%			
6002	Q4173		Palingen or palingen xplus						0.000%			
6002	Q4176		"Neopatch or therion, 1 sq c"						0.000%			
6002	Q4178		"Floweramniopatch, per sq cm"						0.000%			
6002	Q4179		"Flowerderm, per sq cm"						0.000%			
6002	Q4180		"Revita, per sq cm"						0.000%			
6002	Q4181		"Amnio wound, per square cm"						0.000%			
6002	Q4183		"Surgigraft, 1 sq cm"						0.000%			
6002	Q4184		Cellesta or duo per sq cm						0.000%			
6002	Q4186		Epifix 1 sq cm						0.000%			
6002	Q4187		Epicord 1 sq cm						0.000%			
6002	Q4188		Amnioarmor 1 sq cm						0.000%			
6002	Q4190		Artacent ac 1 sq cm						0.000%			
6002	Q4191		Restorigin 1 sq cm						0.000%			
6002	Q4193		Coll-e-derm 1 sq cm						0.000%			
6002	Q4194		Novachor 1 sq cm						0.000%			
6002	Q4199		"Cygnus matrix, per sq cm"						0.000%			
6002	Q4200		Skin te 1 sq cm						0.000%			
6002	Q4204		Xwrap 1 sq cm						0.000%			
6002	Q4205		Membrane graft or wrap sq c						0.000%			
6002	Q4208		Novafix per sq cm						0.000%			
6002	Q4209		Surgraft per sq cm						0.000%			
6002	Q4211		Amnion bio or axobio sq cm						0.000%			
6002	Q4214		Cellesta cord per sq cm						0.000%			
6002	Q4216		Artacent cord per sq cm						0.000%			
6002	Q4217		Woundfix biowound plus xplu						0.000%			
6002	Q4218		Surgicord per sq cm						0.000%			
6002	Q4219		Surgigraft dual per sq cm						0.000%			
6002	Q4220		"Bellacell hd, surederm sq c"						0.000%			
6002	Q4221		Amniowrap2 per sq cm						0.000%			
6002	Q4227		Amniocore per sq cm						0.000%			
6002	Q4229		Cogenex amnio memb per sq c						0.000%			
6002	Q4234		"Xcellerate, per sq cm"						0.000%			
6002	Q4235		Amniorepair or altiply sq c						0.000%			
6002	Q4236		Carepatch per sq cm						0.000%			
6002	Q4237		"Cryo-cord, per sq cm"						0.000%			
6002	Q4239		Amnio-maxx or lite per sq c						0.000%			
6002	Q4247		"Amniotext patch, per sq cm"						0.000%			
6002	Q4248		Dermacyte amn mem allo sq c						0.000%			
6002	Q4249		"Amniply, per sq cm"						0.000%			
6002	Q4250		Amnioamp-mp per sq cm						0.000%			
6002	Q4251		"Vim, per square centimeter"						0.000%			
6002	Q4252		"Vendaje, per square centime"						0.000%			
6002	Q4253		Zenith amniotic membrane ps						0.000%			
6002	Q4254		Novafix dl per sq cm						0.000%			
6002	Q4255		"Reguard, topical use per sq"						0.000%			
6002	Q4256		"Mlg complet, per sq cm"						0.000%			
6002	Q4257		"Relese, per sq cm"						0.000%			
6002	Q4258		"Enverse, per sq cm"						0.000%			
6002	Q4259		Celera per sq cm						0.000%			
6002	Q4260		"Signature apatch, per sq cm"						0.000%			
6002	Q4261		"Tag, per square centimeter"						0.000%			
6002	Q4262		"Dual layer impax, per sq cm"						0.000%			
6002	Q4263		"Surgraft tl, per sq cm"						0.000%			
6002	Q4264		"Cocoon membrane, per sq cm"						0.000%			
6002	Q4265		Neostim tl per sq cm						0.000%			
6002	Q4266		Neostim per sq cm						0.000%			
6002	Q4267		Neostim dl per sq cm						0.000%			
6002	Q4268		Surgraft ft per sq cm						0.000%			
6002	Q4269		Surgraft xt per sq cm						0.000%			
6002	Q4270		Complete sl per sq cm						0.000%			
6002	Q4271		Complete ft per sq cm						0.000%			
6002	Q4272		"Esano a, per sq cm"						0.000%			
6002	Q4273		"Esano aaa, per sq cm"						0.000%			
6002	Q4274		"Esano ac, per sq cm"						0.000%			
6002	Q4275		"Esano aca, per sq cm"						0.000%			
6002	Q4278		"Epieffect, per sq cm"						0.000%			
6002	Q4279		"Vendaje ac, per sq cm"						0.000%			
6002	Q4280		Xcell amnio matrix per sq c						0.000%			
6002	Q4281		Barrera slor dl per sq cm						0.000%			
6002	Q4283		"Biovance tri or 3l, sq cm"						0.000%			
6002	Q4284		"Dermabind sl, per sq cm"						0.000%			
6002	Q4285		Nudyn dl or dl mesh pr sq c						0.000%			
6002	Q4286		"Nudyn sl or slw, per sq cm"						0.000%			
6002	Q4287		"Dermabind dl, per sq cm"						0.000%			
6002	Q4288		"Dermabind ch, per sq cm"						0.000%			
6002	Q4289		"Revoshield+ amnio, per sq c"						0.000%			
6002	Q4290		Membrane wrap hydr per sq c						0.000%			
6002	Q4291		"Lamellas xt, per sq cm"						0.000%			
6002	Q4292		"Lamellas, per sq cm"						0.000%			
6002	Q4293		"Acesso dl, per sq cm"						0.000%			
6002	Q4294		"Amnio quad-core, per sq cm"						0.000%			
6002	Q4295		"Amnio tri-core, per sq cm"						0.000%			
6002	Q4296		"Rebound matrix, per sq cm"						0.000%			
6002	Q4298		"Amnicore pro, per sq cm"						0.000%			
6002	Q4299		"Amnicore pro+, per sq cm"						0.000%			
6002	Q4300		"Acesso tl, per sq cm"						0.000%			
6002	Q4301		"Activate matrix, per sq cm"						0.000%			
6002	Q4302		"Complete aca, per sq cm"						0.000%			
6002	Q4303		"Complete aa, per sq cm"						0.000%			
6002	Q4304		"Grafix plus, per sq cm"						0.000%			
6002	Q4305		Amer am ac tri-lay per sq c						0.000%			
6002	Q4306		Americ amnion ac per sq cm						0.000%			
6002	Q4307		"American amnion, per sq cm"						0.000%			
6002	Q4308		"Sanopellis, per sq cm"						0.000%			
6002	Q4309		"Via matrix, per sq cm"						0.000%			
6002	Q4311		"Acesso, per sq cm"						0.000%			
6002	Q4312		"Acesso ac, per sq cm"						0.000%			
6002	Q4313		"Dermabind fm, per sq cm"						0.000%			
6002	Q4314		"Reeva, per sq cm"						0.000%			
6002	Q4315		Regenelink amniotic mem all						0.000%			
6002	Q4316		"Amchoplast, per sq cm"						0.000%			
6002	Q4317		"Vitograft, per sq cm"						0.000%			
6002	Q4318		"E-graft, per sq cm"						0.000%			
6002	Q4319		"Sanograft, per sq cm"						0.000%			
6002	Q4320		"Pellograft, per sq cm"						0.000%			
6002	Q4321		"Renograft, per sq cm"						0.000%			
6002	Q4322		"Caregraft, per sq cm"						0.000%			
6002	Q4323		"Alloply, per sq cm"						0.000%			
6002	Q4324		"Amniotx, per sq cm"						0.000%			
6002	Q4325		"Acapatch, per sq cm"						0.000%			
6002	Q4326		"Woundplus, per sq cm"						0.000%			
6002	Q4327		"Duoamnion, per sq cm"						0.000%			
6002	Q4328		"Most, per sq cm"						0.000%			
6002	Q4329		"Singlay, per sq cm"						0.000%			
6002	Q4330		"Total, per sq cm"						0.000%			
6002	Q4331		"Axolotl graft, per sq cm"						0.000%			
6002	Q4332		"Axolotl dualgraft, per sq c"						0.000%			
6002	Q4333		"Ardeograft, per sq cm"						0.000%			
6002	Q4334		"Amnioplast 1, per sq cm"						0.000%			
6002	Q4335		"Amnioplast 2, per sq cm"						0.000%			
6002	Q4336		"Artecent c, per sq cm"						0.000%			
6002	Q4337		"Artecent trident, per sq cm"						0.000%			
6002	Q4338		"Artacent velos, per sq cm"						0.000%			
6002	Q4339		"Artacent vericlen, per sq c"						0.000%			
6002	Q4340		"Simpligraft, per sq cm"						0.000%			
6002	Q4341		"Simplimax, per sq cm"						0.000%			
6002	Q4342		"Theramend, per sq cm"						0.000%			
6002	Q4343		Dermacyte ac matrx per sq c						0.000%			
6002	Q4344		"Tri membrane wrap, per sq c"						0.000%			
6002	Q4345		Matrix hd allogrft per sq c						0.000%			
6002	Q4346		Shelter dm matrix per sq cm						0.000%			
6002	Q4347		Rampart dl matrix per sq cm						0.000%			
6002	Q4348		Sentry sl matrix per sq cm						0.000%			
6002	Q4349		Mantle dl matrix per sq cm						0.000%			
6002	Q4350		Palisade dm matrix per sq c						0.000%			
6002	Q4351		"Enclose tl matrix, per sq c"						0.000%			
6002	Q4352		"Overlay sl matrix, per sq c"						0.000%			
6002	Q4353		Xceed tl matrix per sq cm						0.000%			
6002	Q4354		Palingen dual-layer sq cm						0.000%			
6002	Q4355		Abio xpl abio xpl hy p sq c						0.000%			
6002	Q4356		Abio mem abio hyd per sq cm						0.000%			
6002	Q4357		"Xwrap plus, per sq cm"						0.000%			
6002	Q4358		"Xwrap dual, per sq cm"						0.000%			
6002	Q4359		"Choriply, per sq cm"						0.000%			
6002	Q4360		Amchoplast fd per sq cm						0.000%			
6002	Q4361		"Epixpress, per sq cm"						0.000%			
6002	Q4362		"Cygnus disk, per sq cm"						0.000%			
6002	Q4363		Am bur mem hydro per sq cm						0.000%			
6002	Q4364		Am bur xp mem xpl hy p sq c						0.000%			
6002	Q4365		Amnio bur dl mem per sq cm						0.000%			
6002	Q4366		Dl amnio bur x-mem per sq c						0.000%			
6002	Q4367		"Amniocore sl, per sq cm"						0.000%			
6002	Q4368		Amchothick per sq cm						0.000%			
6002	Q4369		Amnioplast 3 per sq cm						0.000%			
6002	Q4370		Aeroguard per sq cm						0.000%			
6002	Q4371		Neoguard per sq cm						0.000%			
6002	Q4372		Amchoplast excl per sq cm						0.000%			
6002	Q4373		Membrane wrp lt per sq cm						0.000%			
6002	Q4375		Duograft ac per sq cm						0.000%			
6002	Q4376		Duograft aa per sq cm						0.000%			
6002	Q4377		Trigraft ft per sq cm						0.000%			
6002	Q4378		Renew ft matrix per sq cm						0.000%			
6002	Q4379		Amniodefend ft per sq cm						0.000%			
6002	Q4380		Advograft one per sq cm						0.000%			
6002	Q4382		Advograft dual per sq cm						0.000%			
7043		Infliximab not biosimil 10mg		K		$30.523	.	$6.11	20.000%	$6.11		
7043	J1745		Infliximab not biosimil 10m						20.000%			
7046		Doxorubicin inj 10mg		K		$150.409	.	$30.09	20.000%	$30.09		
7046	Q2050		Doxorubicin inj 10mg						20.000%			
7048		Alteplase recombinant		K		$91.462	.	$18.30	20.000%	$18.30		
7048	J2997		Alteplase recombinant						20.000%			
7308		Aminolevulinic acid hcl top		K		$394.413	.	$78.89	20.000%	$78.89		
7308	J7308		Aminolevulinic acid hcl top						20.000%			
9002		Tenecteplase injection		K		$162.456	.	$32.50	20.000%	$32.50		
9002	J3101		Tenecteplase injection						20.000%			
9003		Rsv mab im 50mg		K		$719.870	.	$143.98	20.000%	$143.98		
9003	90378		Rsv mab im 50mg						20.000%			
9004		"Injection, inclisiran, 1 mg"		K		$12.274	.	$2.46	20.000%	$2.46	*	
9004	J1306		"Injection, inclisiran, 1 mg"						20.000%		*	
9005		Reteplase injection		K		"$2,777.136"	.	$555.43	20.000%	$555.43		
9005	J2993		Reteplase injection						20.000%			
9006		Tacrolimus injection		K		$255.058	.	$51.02	20.000%	$51.02		
9006	J7525		Tacrolimus injection						20.000%			
9007		Inj cutaquig 100 mg		K		$14.335	.	$2.87	20.000%	$2.87		
9007	J1551		Inj cutaquig 100 mg						20.000%			
9008		"Inj tezepelumab-ekko, 1mg"		K		$17.767	.	$3.56	20.000%	$3.56	*	
9008	J2356		"Inj tezepelumab-ekko, 1mg"						20.000%		*	
9009		"Inj, vutrisiran, 1 mg"		K		"$4,956.310"	.	$991.27	20.000%	$991.27	*	
9009	J0225		"Inj, vutrisiran, 1 mg"						20.000%		*	
9010		Inj efgartigimod 2mg		K		$32.375	.	$6.48	20.000%	$6.48	*	
9010	J9332		Inj efgartigimod 2mg						20.000%		*	
9013		Inj risankizumab-rzaa1 mg		K		$14.859	.	$2.98	20.000%	$2.98	*	
9013	J2327		Inj risankizumab-rzaa 1 mg						20.000%		*	
9014		"Inj., cerliponase alfa 1 mg"		K		$245.595	.	$49.12	20.000%	$49.12		
9014	J0567		"Inj., cerliponase alfa 1 mg"						20.000%			
9016		"Inj., triptorelin xr 3.75 mg"		K		"$3,506.041"	.	$701.21	20.000%	$701.21		
9016	J3316		"Inj., triptorelin xr 3.75 m"						20.000%			
9017		"Inj. byooviz, 0.1 mg"		K		$85.569	.	$17.12	20.000%	$17.12	*	8% of reference add-on applied
9017	Q5124		"Inj. byooviz, 0.1 mg"						20.000%		*	
9018		"Inj, rimabotulinumtoxinB"		K		$12.996	.	$2.60	20.000%	$2.60		
9018	J0587		"Inj, rimabotulinumtoxinb"						20.000%			
9020		Argatroban nonesrd (accord)		K		$1.815	.	$0.37	20.000%	$0.37		
9020	J0891		Argatroban nonesrd (accord)						20.000%			
9024		Amphotericin b lipid complex		K		$10.299	.	$2.06	20.000%	$2.06		
9024	J0287		Amphotericin b lipid comple						20.000%			
9025		"Inj glucagon hcl, fresenius"		K		$150.437	.	$30.09	20.000%	$30.09		
9025	J1611		"Inj glucagon hcl, fresenius"						20.000%			
9027		"Inj, bortezomib freseniuskab"		K		$16.500	.	$3.30	20.000%	$3.31		
9027	J9048		"Inj, bortezomib freseniuska"						20.000%			
9028		Inj inotuzumab ozogam 0.1 mg		K		"$2,658.129"	.	$531.63	20.000%	$531.63		
9028	J9229		Inj inotuzumab ozogam 0.1 m						20.000%			
9029		"Inj., guselkumab, 1 mg"		K		$70.427	.	$14.09	20.000%	$14.09		
9029	J1628		"Inj., guselkumab, 1 mg"						20.000%			
9031		"Inj, etelcalcetide, 0.1 mg"		K		$4.373	.	$0.88	20.000%	$0.88		
9031	J0606		"Inj, etelcalcetide, 0.1 mg"						20.000%			
9032		Baclofen 10 MG injection		K		$174.804	.	$34.97	20.000%	$34.97		
9032	J0475		Baclofen 10 mg injection						20.000%			
9033		Cidofovir injection		K		$521.827	.	$104.37	20.000%	$104.37		
9033	J0740		Cidofovir injection						20.000%			
9034		"Inj cuvitru, 100 mg"		K		$16.682	.	$3.34	20.000%	$3.34		
9034	J1555		"Inj cuvitru, 100 mg"						20.000%			
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."
9035	Q2041		Axicabtagene ciloleucel car						18.977%			
9036		"Injection, renflexis"		K		$27.845	.	$5.57	20.000%	$5.57		8% of reference add-on applied
9036	Q5104		"Injection, renflexis"						20.000%			
9038		Inj estrogen conjugate		K		$382.887	.	$76.58	20.000%	$76.58		
9038	J1410		Inj estrogen conjugate 25 m						20.000%			
9042		Glucagon hydrochloride		K		$190.763	.	$38.16	20.000%	$38.16		
9042	J1610		Glucagon hydrochloride/1 mg						20.000%			
9043		"Inj, afstyla, 1 i.u."		K		$1.514	.	$0.31	20.000%	$0.31		
9043	J7210		"Inj, afstyla, 1 i.u."						20.000%			
9044		Ibutilide fumarate injection		K		$186.771	.	$37.36	20.000%	$37.36		
9044	J1742		Ibutilide fumarate injectio						20.000%			
9045		Idursulfase injection		K		$542.574	.	$108.52	20.000%	$108.52		
9045	J1743		Idursulfase injection						20.000%			
9046		"Inj., fibryga, 1 mg"		K		$1.101	.	$0.23	20.000%	$0.23		
9046	J7177		"Inj., fibryga, 1 mg"						20.000%			
9048		"Inj, alymsys, 10 mg"		K		$46.054	.	$9.22	20.000%	$9.22	*	8% of reference add-on applied
9048	Q5126		Inj alymsys 10 mg						20.000%		*	
9050		"Leuprolide inj, camcevi, 1mg"		K		$52.378	.	$10.48	20.000%	$10.48	*	
9050	J1952		"Leuprolide inj, camcevi, 1m"						20.000%		*	
9051		"Inj, lanreotide, (cipla) 1mg"		K		$25.422	.	$5.09	20.000%	$5.09	*	
9051	J1932		"Inj, lanreotide, (cipla) 1m"						20.000%		*	
9052		Fluciclovine f-18		K		$329.370	.	$65.88	20.000%	$65.88		
9052	A9588		Fluciclovine f-18						20.000%			
9053		Fluorodopa f-18 diag per mci		K		$862.660	.	$174.26	20.000%	$174.26	*	
9053	A9602		Fluorodopa f-18 diag per mc						20.000%		*	
9054		Lutetium lu 177 vipivotide		K		$240.201	.	$48.05	20.000%	$48.05	*	
9054	A9607		Lutetium lu 177 vipivotide						20.000%		*	
9055		Gallium locametz 1 millicuri		K		$341.950	.	$68.39	20.000%	$68.39	*	
9055	A9800		Gallium locametz 1 millicur						20.000%		*	
9056		Gallium ga-68		K		$49.230	.	$9.85	20.000%	$9.85		
9056	A9587		Gallium ga-68						20.000%			
9057		Inj nivol relatlimab 3mg/1mg		K		$194.077	.	$38.82	20.000%	$38.82	*	
9057	J9298		Inj nivol relatlimab 3mg/1m						20.000%		*	
9059		Vonvendi inj 1 iu vwf:rco		K		$1.831	.	$0.37	20.000%	$0.37		
9059	J7179		Vonvendi inj 1 iu vwf:rco						20.000%			
9063		Rh ig minidose im		K		$31.630	.	$6.33	20.000%	$6.33		
9063	90385		Rh ig minidose im						20.000%			
9067		Lutetium lu 177 dotatat ther		K		$296.249	.	$59.25	20.000%	$59.25		
9067	A9513		Lutetium lu 177 dotatat the						20.000%			
9068		Smallpox&monkeypox vac 0.5ml		K		$0.010			0.000%			
9068	90611		Smallpox&monkeypox vac 0.5m				$0.00	$0.00	0.000%	$0.00		
9070		Inj luxturna 1 billion vec g		K		"$3,146.258"	.	$629.26	20.000%	$629.26		
9070	J3398		Inj luxturna 1 billion vec						20.000%			
9071		Capsaicin 8% patch		K		$3.377	.	$0.68	20.000%	$0.68		
9071	J7336		Capsaicin 8% patch						20.000%			
9073		Buprenorph xr 100 mg or less		K		"$1,925.231"	.	$385.05	20.000%	$385.05		
9073	Q9991		Buprenorph xr 100 mg or les						20.000%			
9075		"Inj, kovaltry, 1 i.u."		K		$1.486	.	$0.30	20.000%	$0.30		
9075	J7211		"Inj, kovaltry, 1 i.u."						20.000%			
9078		Testosterone undecanoate 1mg		K		$2.022	.	$0.41	18.704%	$0.38		IRA-adjusted coinsurance
9078	J3145		Testosterone undecanoate 1m						18.704%			
9079		"Genvisc 850, inj, 1mg"		K		$6.314	.	$1.27	20.000%	$1.27		
9079	J7320		"Genvisc 850, inj, 1mg"						20.000%			
9088		Peng benzathine/procaine inj		K		$17.368	.	$3.48	16.732%	$2.91		IRA-adjusted coinsurance
9088	J0558		Peng benzathine/procaine in						16.732%			
9094		Radiesse injection		K		$333.420	.	$66.69	20.000%	$66.69		
9094	Q2026		Radiesse injection						20.000%			
9095		"Inj, sculptra, 0.5mg"		K		$1.000	.	$0.20	20.000%	$0.20		
9095	Q2028		"Inj, sculptra, 0.5mg"						20.000%			
9097		Inj retacrit non-esrd use		K		$7.070	.	$1.42	20.000%	$1.42		8% of reference add-on applied
9097	Q5106		Inj retacrit non-esrd use						20.000%			
9099		"Inj fosnetupitant, palonoset"		K		$632.875	.	$126.58	20.000%	$126.58		
9099	J1454		"Inj fosnetupitant, palonose"						20.000%			
9101		Vaccinia vrs vac 0.3 ml perq		K		$0.010			0.000%			
9101	90622		Vaccinia vrs vac 0.3 ml per				$0.00	$0.00	0.000%	$0.00		
9102		"Inj, fulvestrant (teva)"		K		$46.210	.	$9.25	20.000%	$9.25		
9102	J9393		"Inj, fulvestrant (teva)"						20.000%			
9104		Antithymocyte globuln rabbit		K		$939.346	.	$187.87	20.000%	$187.87		
9104	J7511		Antithymocyte globuln rabbi						20.000%			
9105		Inj pemetrexed (teva) 10mg		K		$8.370	.	$1.68	20.000%	$1.68		
9105	J9314		Inj pemetrexed (teva) 10mg						20.000%			
9107		"Inj, aponvie, 1 mg"		G		$1.863		$0.00	0.000%	$0.00		
9107	C9145		"Inj, aponvie, 1 mg"						0.000%			
9108		Thyrotropin injection		K		"$2,078.711"	.	$415.75	20.000%	$415.75		
9108	J3240		Thyrotropin injection						20.000%			
9109		"Inj, elahere, 1 mg"		G		$68.074	.	$13.62	20.000%	$13.62		
9109	J9063		"Inj, elahere, 1 mg"						20.000%			
9110		"Inj, tremelimumab-actl, 1 mg"		G		$138.244	.	$27.65	20.000%	$27.65		
9110	J9347		"Inj, tremelimumab-actl, 1 m"						20.000%			
9111		Inj teclistamab cqyv 0.5 mg		G		$32.419	.	$6.49	20.000%	$6.49		
9111	J9380		Inj teclistamab cqyv 0.5 mg						20.000%			
9112		Inj teplizumab mzwv 5 mcg		G		$37.307	.	$7.47	20.000%	$7.47		
9112	J9381		Inj teplizumab mzwv 5 mcg						20.000%			
9113		Inj olipudase alfa-rpcp 1mg		G		$381.237	.	$76.25	20.000%	$76.25		
9113	J0218		Inj olipudase alfa-rpcp 1mg						20.000%			
9114		Inj eflapegrastim-xnst 0.1mg		G		$22.608	.	$4.53	20.000%	$4.53		
9114	J1449		Inj eflapegrastim-xnst 0.1m						20.000%			
9115		"Inj, spesolimab-sbzo, 1 mg"		G		$61.428	.	$12.29	20.000%	$12.29		
9115	J1747		"Inj, spesolimab-sbzo, 1 mg"						20.000%			
9116		"Chloroprocaine opht gel, 1mg"		G		$0.604		$0.00	0.000%	$0.00		
9116	J2403		"Chloroprocaine opht gel, 1m"						0.000%			
9117		"Inj, cimerli, 0.1 mg"		G		$146.761	.	$29.36	20.000%	$29.36		
9117	Q5128		"Inj, cimerli, 0.1 mg"						20.000%			
9118		"Inj, fylnetra, 0.5 mg"		G		$164.154	.	$32.84	20.000%	$32.84		
9118	Q5130		"Inj, fylnetra, 0.5 mg"						20.000%			
9119		"Inj, pedmark, 100 mg"		G		$95.397	.	$19.08	20.000%	$19.08		
9119	J0208		"Inj, pedmark, 100 mg"						20.000%			
9122		Triptorelin pamoate		K		$471.625	.	$94.33	20.000%	$94.33		
9122	J3315		Triptorelin pamoate						20.000%			
9123		"Inj pemetrexed, hospira 10mg"		K		$3.860	.	$0.78	20.000%	$0.78		
9123	J9294		"Inj pemetrexed, hospira 10m"						20.000%			
9125		"Risperidone, long acting"		K		$10.499	.	$2.10	20.000%	$2.10		
9125	J2794		"Inj risperdal consta, 0.5 m"						20.000%			
9126		Natalizumab injection		K		$24.368	.	$4.88	20.000%	$4.88		
9126	J2323		Natalizumab injection						20.000%			
9127		Inj pemetrexed (accord) 10mg		K		$9.736	.	$1.95	20.000%	$1.95		
9127	J9296		Inj pemetrexed (accord) 10m						20.000%			
9129		"Inj, stimufend, 0.5 mg"		K		$251.245	.	$50.25	20.000%	$50.25		
9129	Q5127		"Inj, stimufend, 0.5 mg"						20.000%			
9130		"Inj, imm glob bivigam, 500mg"		K		$77.298	.	$15.46	20.000%	$15.46		
9130	J1556		"Inj, imm glob bivigam, 500m"						20.000%			
9131		"Inj, Ado-trastuzumab Emt 1mg"		K		$41.105	.	$8.23	20.000%	$8.23		
9131	J9354		"Inj, ado-trastuzumab emt 1m"						20.000%			
9132		Prothrombin complex kcentra		K		$2.176	.	$0.44	20.000%	$0.44		
9132	J7168		Prothrombin complex kcentra						20.000%			
9133		"Rabies ig, im/sc"		K		$289.914	.	$57.99	20.000%	$57.99		
9133	90375		Rabies ig im/sc						20.000%			
9134		"Rabies ig, heat treated"		K		$347.320	.	$69.47	20.000%	$69.47		
9134	90376		Rabies ig heat treated						20.000%			
9135		"Varicella-zoster ig, im"		K		"$2,254.245"	.	$450.85	20.000%	$450.85		
9135	90396		Varicella-zoster ig im						20.000%			
9136		Inj leu acet lutr dpt 7.5 mg		G		$220.743	.	$44.15	20.000%	$44.15		
9136	J1954		Inj leu acet lutr dpt 7.5 m						20.000%			
9138		"Inj, hemgenix, per tx dose"		G		"$3,685,266.670"	.	"$737,053.34"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
9138	J1411		"Inj, hemgenix, per tx dose"						20.000%			
9139		"Rabies vaccine, im"		K		$317.673	.	$63.54	20.000%	$63.54		
9139	90675		Rabies vaccine im						20.000%			
9140		"Rabies vaccine, id"		K		$264.470	.	$52.90	20.000%	$52.90		
9140	90676		Rabies vaccine id						20.000%			
9141		Inj onase abepar-xioi treat		K		"$2,423,131.230"	.	"$484,626.25"	20.000%	"$1,676.00"		"Copayments capped at inpatient deductible of $1,676.00."
9141	J3399		Inj onase abepar-xioi treat						20.000%			
9142		Fecalmicrobiota jslm 1 ml		G		$63.934	.	$12.79	20.000%	$12.79		
9142	J1440		Fecal microbiota jslm 1 ml						20.000%			
9144		"Inj, panzyga, 500 mg"		K		$70.432	.	$14.09	20.000%	$14.09		
9144	J1576		"Inj, panzyga, 500 mg"						20.000%			
9145		"Inj, invega hafyera/trinza"		K		$12.672	.	$2.54	20.000%	$2.54		
9145	J2427		"Inj, invega hafyera/trinza"						20.000%			
9146		"Inj, ixinity, 1 i.u."		K		$1.923	.	$0.39	20.000%	$0.39		
9146	J7213		"Inj, ixinity, 1 i.u."						20.000%			
9149		"Inj ublituximab-xiiy, 1 mg"		G		$68.655	.	$13.74	20.000%	$13.74		
9149	J2329		"Inj ublituximab-xiiy, 1 mg"						20.000%			
9150		"Inj mosunetuzumab-axgb, 1 mg"		G		$640.956	.	$128.20	20.000%	$128.20		
9150	J9350		"Inj mosunetuzumab-axgb, 1 m"						20.000%			
9154		"Inj, vivimusta, 1 mg"		G		$27.243	.	$5.45	20.000%	$5.45		
9154	J9056		"Inj, vivimusta, 1 mg"						20.000%			
9155		"Inj, lenacapavir, 1 mg"		G		$22.030	.	$4.41	20.000%	$4.41		
9155	J1961		"Inj, lenacapavir, 1 mg"						20.000%			
9156		Inj pemetrexed ditromethamin		K		$10.343	.	$2.07	20.000%	$2.07		
9156	J9323		Inj pemetrexed ditromethami						20.000%			
9157		"Inj, lecanemab-irmb, 1 mg"		G		$1.330	.	$0.27	20.000%	$0.27		
9157	J0174		"Inj, lecanemab-irmb, 1 mg"						20.000%			
9158		"Inj, pegcetacoplan, 1mg"		G		$143.989	.	$28.80	20.000%	$28.80		
9158	J2781		"Inj, pegcetacoplan, 1mg"						20.000%			
9159		"Inj, vegzelma, 10 mg"		G		$48.080	.	$9.62	20.000%	$9.62		8% of reference add-on applied
9159	Q5129		"Inj, vegzelma, 10 mg"						20.000%			
9166		"Inj, fosaprepitant (teva)"		K		$1.214	.	$0.25	6.600%	$0.09		IRA-adjusted coinsurance
9166	J1456		"Inj, fosaprepitant (teva)"						6.600%			
9171		Factor ix idelvion inj		K		$5.183	.	$1.04	20.000%	$1.04		
9171	J7202		Factor ix idelvion inj						20.000%			
9173		"Injection, fulphila"		K		$112.895	.	$22.58	20.000%	$22.58		
9173	Q5108		"Injection, fulphila"						20.000%			
9174		"Inj, durolane 1 mg"		K		$6.931	.	$1.39	20.000%	$1.39		
9174	J7318		"Inj, durolane 1 mg"						20.000%			
9178		"Inj., meropenem, vaborbactam"		K		$2.112	.	$0.43	20.000%	$0.43		
9178	J2186		"Inj., meropenem, vaborbacta"						20.000%			
9179		"Inj., aristada initio, 1 mg"		K		$3.143	.	$0.63	20.000%	$0.63		
9179	J1943		"Inj., aristada initio, 1 mg"						20.000%			
9180		"Inj., patisiran, 0.1 mg"		K		$99.039	.	$19.81	20.000%	$19.81		
9180	J0222		"Inj., patisiran, 0.1 mg"						20.000%			
9181		"Inj., perseris, 0.5 mg"		K		$12.154	.	$2.44	20.000%	$2.44		
9181	J2798		"Inj., perseris, 0.5 mg"						20.000%			
9182		"Inj mogamulizumab-kpkc, 1 mg"		K		$243.625	.	$48.73	20.000%	$48.73		
9182	J9204		"Inj mogamulizumab-kpkc, 1 m"						20.000%			
9183		"Inj., plazomicin, 5 mg"		K		$3.574	.	$0.72	20.000%	$0.72		
9183	J0291		"Inj., plazomicin, 5 mg"						20.000%			
9186		"Inj., rituximab, 10 mg"		K		$76.433	.	$15.29	20.000%	$15.29		
9186	J9312		"Inj., rituximab, 10 mg"						20.000%			
9187		"Injection, burosumab-twza 1m"		K		$469.742	.	$93.95	18.960%	$89.07		IRA-adjusted coinsurance
9187	J0584		"Injection, burosumab-twza 1"						18.960%			
9189		"Inj., ibalizumab-uiyk, 10 mg"		K		$76.950	.	$15.39	20.000%	$15.39		
9189	J1746		"Inj., ibalizumab-uiyk, 10 m"						20.000%			
9193		Nivestym		K		$0.287	.	$0.06	20.000%	$0.06		8% of reference add-on applied
9193	Q5110		Nivestym						20.000%			
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."
9194	Q2042		Tisagenlecleucel car-pos t						17.740%			
9195		"Injection, udenyca 0.5 mg"		K		$163.604	.	$32.73	20.000%	$32.73		
9195	Q5111		"Injection, udenyca 0.5 mg"						20.000%			
9196		"Inj, trivisc 1 mg"		K		$5.586	.	$1.12	20.000%	$1.12		
9196	J7329		"Inj, trivisc 1 mg"						20.000%			
9198		"Inj andexxa, 10 mg"		K		$131.738	.	$26.35	20.000%	$26.35		
9198	J7169		"Inj andexxa, 10 mg"						20.000%			
9199		"Injection, caplacizumab-yhdp"		K		$825.999	.	$165.20	20.000%	$165.20		
9199	C9047		"Injection, caplacizumab-yhd"						20.000%			
9200		"Inj, remdesivir, 1 mg"		K		$6.354	.	$1.28	20.000%	$1.28	*	
9200	J0248		"Inj, remdesivir, 1 mg"						20.000%		*	
9201		Rabies ig ht&sol human im/sc		K		$241.148	.	$48.23	20.000%	$48.23		
9201	90377		Rabies ig ht&sol human im/s						20.000%			
9203		Inj cyclophosphamd auromedic		K		$0.869	.	$0.18	20.000%	$0.18		
9203	J9071		Inj cyclophosphamd auromedi						20.000%			
9204		"Inj tisotu vedotin-tftv, 1mg"		K		$188.651	.	$37.74	18.869%	$35.60	*	IRA-adjusted coinsurance
9204	J9273		"Inj tisotu vedotin-tftv, 1m"						18.869%		*	
9205		Inj lon tesirin-lpyl 0.075mg		K		$211.995	.	$42.40	20.000%	$42.40		
9205	J9359		Inj lon tesirin-lpyl 0.075m						20.000%			
9206		Inj plasminogen tvmh 1mg		K		$32.383	.	$6.48	20.000%	$6.48	*	
9206	J2998		Inj plasminogen tvmh 1mg						20.000%		*	
9208		Agalsidase beta injection		K		$222.839	.	$44.57	20.000%	$44.57		
9208	J0180		Agalsidase beta injection						20.000%			
9209		Laronidase injection		K		$38.605	.	$7.73	20.000%	$7.73		
9209	J1931		Laronidase injection						20.000%			
9213		Inj. pemetrexed nos 10mg		K		$3.771	.	$0.76	20.000%	$0.76		
9213	J9305		Inj. pemetrexed nos 10mg						20.000%			
9214		Bevacizumab injection		K		$72.728	.	$14.55	20.000%	$14.55		
9214	J9035		Bevacizumab injection						20.000%			
9215		Cetuximab injection		K		$77.524	.	$15.51	20.000%	$15.51		
9215	J9055		Cetuximab injection						20.000%			
9217		Leuprolide acetate suspnsion		K		$172.288	.	$34.46	20.000%	$34.46		
9217	J9217		Leuprolide acetate suspnsio						20.000%			
9219		Procainamide hcl injection		K		$284.337	.	$56.87	20.000%	$56.87		
9219	J2690		Procainamide hcl injection						20.000%			
9224		Galsulfase injection		K		$484.877	.	$96.98	20.000%	$96.98		
9224	J1458		Galsulfase injection						20.000%			
9225		Fluocinolone acetonide implt		K		$340.036	.	$68.01	20.000%	$68.01		
9225	J7311		"Inj., retisert, 0.01 mg"						20.000%			
9230		Abatacept injection		K		$43.377	.	$8.68	20.000%	$8.68		
9230	J0129		Abatacept injection						20.000%			
9233		Ranibizumab injection		K		$90.414	.	$18.09	20.000%	$18.09		
9233	J2778		Ranibizumab injection						20.000%			
9235		Panitumumab injection		K		$164.923	.	$32.99	18.817%	$31.04		IRA-adjusted coinsurance
9235	J9303		Panitumumab injection						18.817%			
9237		"Inj, lanreotide acetate"		K		$39.551	.	$7.92	20.000%	$7.92		
9237	J1930		Lanreotide injection						20.000%			
9239		Buprenorphine xr over 100 mg		K		"$1,925.231"	.	$385.05	20.000%	$385.05		
9239	Q9992		Buprenorphine xr over 100 m						20.000%			
9240		"Injection, ixabepilone"		K		$136.207	.	$27.25	19.861%	$27.06		IRA-adjusted coinsurance
9240	J9207		Ixabepilone injection						19.861%			
9241		Inj sirolimus prot part 1 mg		K		$80.931	.	$16.19	20.000%	$16.19	*	IRA-adjusted coinsurance
9241	J9331		Inj sirolimus prot part 1 m						20.000%		*	
9243		"Inj, bendamustine hcl, 1mg"		K		$1.240	.	$0.25	20.000%	$0.25		
9243	J9033		"Inj, bendamustine hcl, 1mg"						20.000%			
9246		"Inj, abilify asimtufii, 1 mg"		G		$5.872	.	$1.18	20.000%	$1.18		
9246	J0402		"Inj, abilify asimtufii, 1 m"						20.000%			
9247		"Inj, amisulpride, 1 mg"		G		$9.114		$0.00	0.000%	$0.00		
9247	J0184		"Inj, amisulpride, 1 mg"						0.000%			
9250		Inj epcoritamab-bysp 0.16 mg		G		$54.861	.	$10.98	20.000%	$10.98		
9250	J9321		Inj epcoritamab-bysp 0.16 m						20.000%			
9251		C1 esterase inhibitor inj		K		$63.877	.	$12.78	20.000%	$12.78		
9251	J0598		"C-1 esterase, cinryze"						20.000%			
9252		Plerixafor injection		K		$24.976	.	$5.00	20.000%	$5.00		
9252	J2562		Plerixafor injection						20.000%			
9253		Temozolomide injection		K		$10.406	.	$2.09	20.000%	$2.09		
9253	J9328		Temozolomide injection						20.000%			
9254		Flotufolastat f18 diag 1 mci		G		$651.668		$130.34	20.000%	$130.34		
9254	A9608		Flotufolastat f18 diag 1 mc						20.000%			
9255		"Inj, invega sustenna, 1 mg"		K		$14.739	.	$2.95	20.000%	$2.95		
9255	J2426		"Inj, invega sustenna, 1 mg"						20.000%			
9256		Dexamethasone intra implant		K		$205.236	.	$41.05	20.000%	$41.05		
9256	J7312		Dexamethasone intra implant						20.000%			
9257		"Inj., emicizumab-kxwh 0.5 mg"		K		$51.984	.	$10.40	20.000%	$10.40		
9257	J7170		"Inj., emicizumab-kxwh 0.5 m"						20.000%			
9258		Telavancin injection		K		$7.090	.	$1.42	20.000%	$1.42		
9258	J3095		Telavancin injection						20.000%			
9259		Pralatrexate injection		K		$373.768	.	$74.76	20.000%	$74.76		
9259	J9307		Pralatrexate injection						20.000%			
9260		Ofatumumab injection		K		$62.234	.	$12.45	20.000%	$12.45		
9260	J9302		Ofatumumab injection						20.000%			
9262		Inj tofersen intrathec 1 mg		G		$155.337	.	$31.07	20.000%	$31.07		
9262	J1304		Inj tofersen intrathec 1 mg						20.000%			
9263		Ecallantide injection		K		$564.641	.	$112.93	20.000%	$112.93		
9263	J1290		Ecallantide injection						20.000%			
9264		Tocilizumab injection		K		$5.881	.	$1.18	20.000%	$1.18		
9264	J3262		Tocilizumab injection						20.000%			
9266		"Inj, uzedy, 1 mg"		G		$24.622	.	$4.93	20.000%	$4.93		
9266	J2799		"Inj, uzedy, 1 mg"						20.000%			
9267		"Inj, rezafungin, 1 mg"		G		$10.418	.	$2.09	19.942%	$2.08		IRA-adjusted coinsurance
9267	J0349		"Inj, rezafungin, 1 mg"						19.942%			
9268		Inj. acthar gel to 40 units		K		"$3,893.429"	.	$778.69	20.000%	$778.69		
9268	J0801		Inj. acthar gel to 40 units						20.000%			
9269		"C-1 esterase, berinert"		K		$72.267	.	$14.46	19.201%	$13.88		IRA-adjusted coinsurance
9269	J0597		"C-1 esterase, berinert"						19.201%			
9270		Gammaplex IVIG		K		$57.476	.	$11.50	20.000%	$11.50		
9270	J1557		Gammaplex injection						20.000%			
9271		Velaglucerase alfa		K		$374.360	.	$74.88	20.000%	$74.88		
9271	J3385		Velaglucerase alfa						20.000%			
9272		"Inj, denosumab"		K		$27.809	.	$5.57	18.201%	$5.07		IRA-adjusted coinsurance
9272	J0897		Denosumab injection						18.201%			
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."
9273	Q2043		Sipuleucel-t auto cd54+						20.000%			
9275		"Inj. (ani), up to 40 units"		K		"$3,445.584"	.	$689.12	20.000%	$689.12		
9275	J0802		"Inj. (ani), up to 40 units"						20.000%			
9276		Cabazitaxel injection		K		$221.705	.	$44.35	20.000%	$44.35		
9276	J9043		Cabazitaxel injection						20.000%			
9277		Altuviiio per factor viii iu		G		$4.596	.	$0.92	20.000%	$0.92		
9277	J7214		Altuviiio per factor viii i						20.000%			
9278		Incobotulinumtoxin A		K		$5.330	.	$1.07	20.000%	$1.07		
9278	J0588		Incobotulinumtoxin a						20.000%			
9280		"Inj, retifanlimab-dlwr, 1 mg"		G		$29.736	.	$5.95	20.000%	$5.95		
9280	J9345		"Inj, retifanlimab-dlwr, 1 m"						20.000%			
9281		"Injection, pegloticase"		K		"$3,565.318"	.	$713.07	19.634%	$700.02		IRA-adjusted coinsurance
9281	J2507		Pegloticase injection						19.634%			
9284		Ipilimumab injection		K		$180.215	.	$36.05	20.000%	$36.05		
9284	J9228		Ipilimumab injection						20.000%			
9285		Inj allopurinol sodium 1 mg		K		$4.450	.	$0.89	20.000%	$0.89		
9285	J0206		Inj allopurinol sodium 1 mg						20.000%			
9286		Belatacept injection		K		$3.891	.	$0.78	20.000%	$0.78		
9286	J0485		Belatacept injection						20.000%			
9287		Brentuximab vedotin inj		K		$248.930	.	$49.79	18.340%	$45.66		IRA-adjusted coinsurance
9287	J9042		Brentuximab vedotin inj						18.340%			
9294		"Inj, taliglucerase alfa 10 u"		K		$40.642	.	$8.13	20.000%	$8.13		
9294	J3060		"Inj, taliglucerase alfa 10"						20.000%			
9295		"Injection, Carfilzomib, 1 mg"		K		$51.847	.	$10.37	18.845%	$9.78		IRA-adjusted coinsurance
9295	J9047		"Injection, carfilzomib, 1 m"						18.845%			
9296		"Inj, ziv-aflibercept, 1mg"		K		$8.298	.	$1.66	20.000%	$1.66		
9296	J9400		"Inj, ziv-aflibercept, 1mg"						20.000%			
9299		Inj. jivi 1 iu		K		$2.450	.	$0.49	20.000%	$0.50		
9299	J7208		Inj. jivi 1 iu						20.000%			
9300		Omalizumab injection		K		$40.117	.	$8.03	20.000%	$8.03		
9300	J2357		Omalizumab injection						20.000%			
9301		"Aminolevulinic acid, 10% gel"		K		$1.783	.	$0.36	20.000%	$0.36		
9301	J7345		"Aminolevulinic acid, 10% ge"						20.000%			
9302		"Inj daunorubicin, cytarabine"		K		$249.021	.	$49.81	19.656%	$48.95		IRA-adjusted coinsurance
9302	J9153		"Inj daunorubicin, cytarabin"						19.656%			
9304		"Inj., cemiplimab-rwlc, 1 mg"		K		$28.921	.	$5.79	20.000%	$5.79		
9304	J9119		"Inj., cemiplimab-rwlc, 1 mg"						20.000%			
9305		"Inj., lumoxiti, 0.01 mg"		K		$23.394	.	$4.68	20.000%	$4.68		
9305	J9313		"Inj., lumoxiti, 0.01 mg"						20.000%			
9306		"Inj., tildrakizumab, 1 mg"		K		$131.462	.	$26.30	20.000%	$26.30		
9306	J3245		"Inj., tildrakizumab, 1 mg"						20.000%			
9308		Dexametha opth insert 0.1 mg		K1		$110.680	.	$22.14	20.000%	$22.14		
9308	J1096		Dexametha opth insert 0.1 m						20.000%			
9309		Inj. tagraxofusp-erzs 10 mcg		K		$338.532	.	$67.71	20.000%	$67.71		
9309	J9269		Inj. tagraxofusp-erzs 10 mc						20.000%			
9310		"Inj., emapalumab-lzsg, 1 mg"		K		$381.503	.	$76.31	20.000%	$76.31		
9310	J9210		"Inj., emapalumab-lzsg, 1 mg"						20.000%			
9311		"Inj., omadacycline, 1 mg"		K		$3.866	.	$0.78	20.000%	$0.78		
9311	J0121		"Inj., omadacycline, 1 mg"						20.000%			
9312		"Inj., ravulizumab-cwvz 10 mg"		K		$220.317	.	$44.07	20.000%	$44.07		
9312	J1303		"Inj., ravulizumab-cwvz 10 m"						20.000%			
9313		Inj. belrapzo/bendamustine		K		$14.196	.	$2.84	20.000%	$2.84		
9313	J9036		Inj. belrapzo/bendamustine						20.000%			
9314		"Inj. herceptin hylecta, 10mg"		K		$62.916	.	$12.59	20.000%	$12.59		
9314	J9356		"Inj. herceptin hylecta, 10m"						20.000%			
9320		Carbidopa levodopa ent 100ml		K		$235.772	.	$47.16	20.000%	$47.16		
9320	J7340		Carbidopa levodopa ent 100m						20.000%			
9322		Bcg live intravesical 1mg		K		$3.139	.	$0.63	20.000%	$0.63		
9322	J9030		Bcg live intravesical 1mg						20.000%			
9323		Gallium ga-68 dotatoc		K		$3.600	.	$0.72	20.000%	$0.72		
9323	C9067		Gallium ga-68 dotatoc						20.000%			
9324		Phenylep ketorolac opth soln		K1		$98.072	.	$19.62	20.000%	$19.62		
9324	J1097		Phenylep ketorolac opth sol						20.000%			
9325		"Inj., eravacycline, 1 mg"		K		$1.206	.	$0.25	20.000%	$0.25		
9325	J0122		"Inj., eravacycline, 1 mg"						20.000%			
9326		"Inj., lanadelumab-flyo, 1 mg"		K		$84.802	.	$16.97	20.000%	$16.97		
9326	J0593		"Inj., lanadelumab-flyo, 1 m"						20.000%			
9327		Inj. romosozumab-aqqg 1 mg		K		$11.494	.	$2.30	19.541%	$2.25		IRA-adjusted coinsurance
9327	J3111		Inj. romosozumab-aqqg 1 mg						19.541%			
9328		"Inj., yutiq, 0.01 mg"		K		$524.568	.	$104.92	20.000%	$104.92		
9328	J7314		"Inj., yutiq, 0.01 mg"						20.000%			
9329		Inj mvasi 10 mg		K		$29.824	.	$5.97	20.000%	$5.97		8% of reference add-on applied
9329	Q5107		Inj mvasi 10 mg						20.000%			
9330		"Inj., kanjinti, 10 mg"		K		$27.905	.	$5.59	20.000%	$5.59		
9330	Q5117		"Inj., kanjinti, 10 mg"						20.000%			
9331		"Inj, polatuzumab vedotin 1mg"		K		$132.725	.	$26.55	20.000%	$26.55		
9331	J9309		"Inj, polatuzumab vedotin 1m"						20.000%			
9336		Inj truxima 10 mg		K		$34.759	.	$6.96	20.000%	$6.96		8% of reference add-on applied
9336	Q5115		Inj truxima 10 mg						20.000%			
9338		"Inj., triluron, 1 mg"		K		$10.281	.	$2.06	20.000%	$2.06		
9338	J7332		"Inj., triluron, 1 mg"						20.000%			
9340		"Inj, brolucizumab-dbll, 1 mg"		K		$339.988	.	$68.00	20.000%	$68.00		
9340	J0179		"Inj, brolucizumab-dbll, 1 m"						20.000%			
9341		Inj  ogivri 10 mg		K		$46.816	.	$9.37	20.000%	$9.37		8% of reference add-on applied
9341	Q5114		Inj ogivri 10 mg						20.000%			
9343		Inj givosiran 0.5 mg		K		$116.471	.	$23.30	20.000%	$23.30		
9343	J0223		Inj givosiran 0.5 mg						20.000%			
9345		Inj pegfilgrastim-bmez 0.5mg		K		$24.711	.	$4.95	20.000%	$4.95		
9345	Q5120		Inj pegfilgrastim-bmez 0.5m						20.000%			
9346		Mometasone sinus sinuva		K		$11.345	.	$2.27	20.000%	$2.27		
9346	J7402		Mometasone sinus sinuva						20.000%			
9347		Inj luspatercept-aamt 0.25mg		K		$41.243	.	$8.25	20.000%	$8.25		
9347	J0896		Inj luspatercept-aamt 0.25m						20.000%			
9348		"Inj., zirabev, 10 mg"		K		$26.943	.	$5.39	20.000%	$5.39		8% of reference add-on applied
9348	Q5118		"Inj., zirabev, 10 mg"						20.000%			
9349		Inj herzuma 10 mg		K		$73.905	.	$14.79	20.000%	$14.79		8% of reference add-on applied
9349	Q5113		Inj herzuma 10 mg						20.000%			
9350		"Inj., trazimera, 10 mg"		K		$24.931	.	$4.99	20.000%	$4.99		8% of reference add-on applied
9350	Q5116		"Inj., trazimera, 10 mg"						20.000%			
9351		Inj bimatoprost itc imp 1mcg		K		$209.907	.	$41.99	20.000%	$41.99		
9351	J7351		Inj bimatoprost itc imp1mcg						20.000%			
9353		Inj fam-trastu deru-nxki 1mg		K		$28.901	.	$5.79	20.000%	$5.79		
9353	J9358		Inj fam-trastu deru-nxki 1m						20.000%			
9354		Inj recombin esperoct per iu		K		$2.138	.	$0.43	20.000%	$0.43		
9354	J7204		Inj recombin esperoct per i						20.000%			
9355		Inj. teprotumumab-trbw 10 mg		K		$352.563	.	$70.52	20.000%	$70.52		
9355	J3241		Inj. teprotumumab-trbw 10 m						20.000%			
9357		Inj. eptinezumab-jjmr 1 mg		K		$19.321	.	$3.87	19.491%	$3.77		IRA-adjusted coinsurance
9357	J3032		Inj. eptinezumab-jjmr 1 mg						19.491%			
9358		Inj xipere 1 mg		K		$48.231	.	$9.65	20.000%	$9.65	*	
9358	J3299		Inj xipere 1 mg						20.000%		*	
9359		Inj crizanlizumab-tmca 5mg		K		$129.502	.	$25.91	20.000%	$25.91		
9359	J0791		Inj crizanlizumab-tmca 5mg						20.000%			
9364		Inj enfort vedo-ejfv 0.25mg		K		$36.642	.	$7.33	19.143%	$7.02		IRA-adjusted coinsurance
9364	J9177		Inj enfort vedo-ejfv 0.25mg						19.143%			
9367		"Inj ruxience, 10 mg"		K		$24.943	.	$4.99	20.000%	$4.99		8% of reference add-on applied
9367	Q5119		"Inj ruxience, 10 mg"						20.000%			
9370		Fluoroestradiol F 18		K		$463.200	.	$92.64	20.000%	$92.64		
9370	A9591		Fluoroestradiol f 18						20.000%			
9372		"Inj. xembify, 100 mg"		K		$14.283	.	$2.86	20.000%	$2.86		
9372	J1558		"Inj. xembify, 100 mg"						20.000%			
9374		Mitomycin instillation		K		$312.995	.	$62.60	20.000%	$62.60		
9374	J9281		Mitomycin instillation						20.000%			
9375		"Inj., evomela, 1 mg"		K		$18.498	.	$3.70	20.000%	$3.70		
9375	J9246		"Inj., evomela, 1 mg"						20.000%			
9376		Sacituzumab govitecan-hziy		K		$35.800	.	$7.16	20.000%	$7.16		
9376	J9317		Sacituzumab govitecan-hziy						20.000%			
9377		Inj. isatuximab-irfc 10 mg		K		$78.855	.	$15.78	20.000%	$15.78		
9377	J9227		Inj. isatuximab-irfc 10 mg						20.000%			
9378		"Daratumumab, hyaluronidase"		K		$52.992	.	$10.60	20.000%	$10.60		
9378	J9144		"Daratumumab, hyaluronidase"						20.000%			
9381		"Inj. avsola, 10 mg"		K		$19.749	.	$3.95	20.000%	$3.95		8% of reference add-on applied
9381	Q5121		"Inj. avsola, 10 mg"						20.000%			
9382		Inj ontruzant 10 mg		K		$28.740	.	$5.75	20.000%	$5.75		8% of reference add-on applied
9382	Q5112		Inj ontruzant 10 mg						20.000%			
9385		"Inj., tafasitamab-cxix"		K		$13.925	.	$2.79	20.000%	$2.79		
9385	J9349		"Inj., tafasitamab-cxix"						20.000%			
9388		Inj. fe derisomaltose 10 mg		K		$20.826	.	$4.17	20.000%	$4.17		
9388	J1437		Inj. fe derisomaltose 10 mg						20.000%			
9389		"Inj. lurbinectedin, 0.1 mg"		K		$205.036	.	$41.01	20.000%	$41.01		
9389	J9223		"Inj. lurbinectedin, 0.1 mg"						20.000%			
9390		"Pertuzu, trastuzu, 10 mg"		K		$62.993	.	$12.60	20.000%	$12.60		
9390	J9316		"Pertuzu, trastuzu, 10 mg"						20.000%			
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."
9391	Q2053		Brexucabtagene car pos t						19.498%			
9392		Inj. asceniv		K		$496.683	.	$99.34	20.000%	$99.34		
9392	J1554		Inj. asceniv						20.000%			
9394		"Inj. inebilizumab-cdon, 1 mg"		K		$484.403	.	$96.89	20.000%	$96.89		
9394	J1823		"Inj. inebilizumab-cdon, 1 m"						20.000%			
9395		Factor viia recomb sevenfact		K		$2.385	.	$0.48	20.000%	$0.48		
9395	J7212		Factor viia recomb sevenfac						20.000%			
9396		"Afamelanotide implant, 1 mg"		K		"$2,873.329"	.	$574.67	20.000%	$574.67		
9396	J7352		"Afamelanotide implant, 1 mg"						20.000%			
9398		Covid-19 Vaccine Administration		S	0.4525	$41.52			0.000%			
9398	90480		Admn sarscov2 vac 1/only cm						0.000%			
9399		"Pneumococcal, Influenza, Hepatitis B, and/or Covid-19 Vaccine Home Administratio"		S	0.4016	$36.85			0.000%	$0.00		
9399	M0201		Pne flu hepb cov home admin						0.000%			
9406		"Inj, nyvepria"		K		$134.252	.	$26.86	20.000%	$26.86		
9406	Q5122		"Inj, nyvepria"						20.000%			
9407		"Inj. lumasiran, 0.5 mg"		K		$318.852	.	$63.78	20.000%	$63.78		
9407	J0224		"Inj. lumasiran, 0.5 mg"						20.000%			
9408		"Inj. naxitamab-gqgk, 1 mg"		K		$641.829	.	$128.37	20.000%	$128.37		
9408	J9348		"Inj. naxitamab-gqgk, 1 mg"						20.000%			
9409		Gallium ga-68 psma-11 ucsf		K		$559.370	.	$111.88	20.000%	$111.88		
9409	A9593		Gallium ga-68 psma-11 ucsf						20.000%			
9410		"Gallium ga-68 psma-11, ucla"		K		$363.510	.	$72.71	20.000%	$72.71		
9410	A9594		"Gallium ga-68 psma-11, ucla"						20.000%			
9411		"Inj. riabni, 10 mg"		K		$33.087	.	$6.62	20.000%	$6.62		8% of reference add-on applied
9411	Q5123		"Inj. riabni, 10 mg"						20.000%			
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."
9413	Q2054		Lisocabtagene mara car pos						19.475%			
9414		"Inj, cabote rilpivir 2mg 3mg"		K		$23.132	.	$4.63	20.000%	$4.63		
9414	J0741		"Inj, cabote rilpivir 2mg 3m"						20.000%			
9415		"Injection, trilaciclib, 1mg"		K		$5.388	.	$1.08	20.000%	$1.08		
9415	J1448		"Injection, trilaciclib, 1mg"						20.000%			
9416		"Inj, evinacumab-dgnb, 5 mg"		K		$186.306	.	$37.27	20.000%	$37.27		
9416	J1305		"Inj, evinacumab-dgnb, 5mg"						20.000%			
9418		"Inj. margetuximab-cmkb, 5 mg"		K		$48.530	.	$9.71	20.000%	$9.71		
9418	J9353		"Inj. margetuximab-cmkb, 5 m"						20.000%			
9419		Inj fensolvi 0.25 mg		K		$134.256	.	$26.86	20.000%	$26.86		
9419	J1951		Inj fensolvi 0.25 mg						20.000%			
9420		Eptifibatide injection		K		$6.360	.	$1.28	20.000%	$1.28		
9420	J1327		Eptifibatide injection						20.000%			
9421		"Inj, granisetron, xr, 0.1 mg"		K		$5.286	.	$1.06	20.000%	$1.06		
9421	J1627		"Inj, granisetron, xr, 0.1 m"						20.000%			
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."
9422	Q2055		Idecabtagene vicleucel car						19.490%			
9426		"Inj, cefiderocol, 10 mg"		K		$2.282	.	$0.46	20.000%	$0.46		
9426	J0699		"Inj, cefiderocol, 10 mg"						20.000%			
9427		"Injection, oritavancin 10 mg"		K		$42.765	.	$8.56	20.000%	$8.56		
9427	J2406		"Injection, oritavancin 10 m"						20.000%			
9428		Inj romidepsin non-lyo 0.1mg		K		$28.517	.	$5.71	20.000%	$5.71		
9428	J9318		Inj romidepsin non-lyo 0.1m						20.000%			
9429		Inj romidepsin lyophil 0.1mg		K		$31.541	.	$6.31	20.000%	$6.31		
9429	J9319		Inj romidepsin lyophil 0.1m						20.000%			
9430		"Piflu f-18, dia 1 millicurie"		K		$347.360	.	$69.48	20.000%	$69.48		
9430	A9595		"Piflu f-18, dia 1 millicuri"						20.000%			
9431		"Inj, dostarlimab-gxly, 10 mg"		K		$240.135	.	$48.03	20.000%	$48.03		
9431	J9272		"Inj, dostarlimab-gxly, 10 m"						20.000%			
9432		"Inj, amivantamab-vmjw"		K		$21.507	.	$4.31	19.252%	$4.15		IRA-adjusted coinsurance
9432	J9061		"Inj, amivantamab-vmjw"						19.252%			
9433		Inj aval alfa-nqpt 4mg		K		$77.817	.	$15.57	20.000%	$15.57		
9433	J0219		Inj aval alfa-nqpt 4mg						20.000%			
9434		Inj anifrolumab-fnia 1mg		K		$17.777	.	$3.56	20.000%	$3.56		
9434	J0491		Inj anifrolumab-fnia 1mg						20.000%			
9436		Inj pegfilgrast ex bio 0.5mg		K		$19.981	.	$4.00	20.000%	$4.00		
9436	J2506		Inj pegfilgrast ex bio 0.5m						20.000%			
9437		"Inj, aspara, rylaze, 0.1 mg"		K		$54.378	.	$10.88	19.533%	$10.63		IRA-adjusted coinsurance
9437	J9021		"Inj, aspara, rylaze, 0.1 mg"						19.533%			
9438		"Injection, aducanumab-avwa, 2 mg"		K		$5.978	.	$1.20	20.000%	$1.20		
9438	J0172		"Inj, aducanumab-avwa, 2 mg"						20.000%			
9439		"Inj, susvimo 0.1 mg"		K		$79.737	.	$15.95	20.000%	$15.95	*	
9439	J2779		"Inj, susvimo 0.1 mg"						20.000%		*	
9440		"Instill, bupivac and meloxic"		K1		$0.773		$0.16	20.000%	$0.16		
9440	C9088		"Instill, bupivac and meloxi"						20.000%			
9441		Inj ferric carboxymaltos 1mg		K		$1.127	.	$0.23	20.000%	$0.23		
9441	J1439		Inj ferric carboxymaltos 1m						20.000%			
9442		"Inj. pemetrexed, 10 mg"		K		$46.350	.	$9.27	20.000%	$9.28	*	
9442	J9304		"Inj. pemetrexed, 10 mg"						20.000%		*	
9443		Gallium illuccix 1 millicure		K		$485.510	.	$97.11	20.000%	$97.11	*	
9443	A9596		Gallium illuccix 1 millicur						20.000%		*	
9444		"Inj, sutimlimab-jome, 10 mg"		K		$18.127	.	$3.63	20.000%	$3.63	*	
9444	J1302		"Inj, sutimlimab-jome, 10 mg"						20.000%		*	
9445		"Injection, ruconest"		K		$34.750	.	$6.95	20.000%	$6.95		
9445	J0596		"Injection, ruconest"						20.000%			
9446		"Inj, tebentafusp-tebn, 1 mcg"		K		$214.756	.	$42.96	20.000%	$42.96	*	
9446	J9274		"Inj, tebentafusp-tebn, 1 mc"						20.000%		*	
9447		"Inj, releuko 1 mcg"		K		$0.425	.	$0.09	20.000%	$0.09	*	8% of reference add-on applied
9447	Q5125		"Inj, releuko 1 mcg"						20.000%		*	
9448		"Oral netupitant, palonosetro"		K		$409.009	.	$81.81	18.671%	$76.37		IRA-adjusted coinsurance
9448	J8655		"Oral netupitant, palonosetr"						18.671%			
9449		"Injection, blinatumomab"		K		$152.276	.	$30.46	19.380%	$29.52		IRA-adjusted coinsurance
9449	J9039		"Injection, blinatumomab"						19.380%			
9450		Fluocinol acet intravit imp		K		$490.765	.	$98.16	20.000%	$98.16		
9450	J7313		"Inj., iluvien, 0.01 mg"						20.000%			
9451		"Injection, peramivir"		K		$1.678	.	$0.34	20.000%	$0.34		
9451	J2547		"Injection, peramivir"						20.000%			
9452		Inj ceftolozane tazobactam		K		$8.041	.	$1.61	19.921%	$1.61		IRA-adjusted coinsurance
9452	J0695		Inj ceftolozane tazobactam						19.921%			
9453		"Injection, nivolumab"		K		$32.352	.	$6.48	20.000%	$6.48		
9453	J9299		"Injection, nivolumab"						20.000%			
9454		"Inj, pasireotide long acting"		K		$526.942	.	$105.39	16.095%	$84.82		IRA-adjusted coinsurance
9454	J2502		"Inj, pasireotide long actin"						16.095%			
9455		"Injection, siltuximab"		K		$163.366	.	$32.68	18.012%	$29.43		IRA-adjusted coinsurance
9455	J2860		"Injection, siltuximab"						18.012%			
9456		"Injection, isavuconazonium"		K		$0.988	.	$0.20	19.860%	$0.20		IRA-adjusted coinsurance
9456	J1833		"Injection, isavuconazonium"						19.860%			
9458		Florbetaben f18 diagnostic		K		"$1,577.130"	.	$315.43	20.000%	$315.43		
9458	Q9983		Florbetaben f18 diagnostic						20.000%			
9459		Flutemetamol f18 diagnostic		K		"$1,962.950"	.	$392.59	20.000%	$392.59		
9459	Q9982		Flutemetamol f18 diagnostic						20.000%			
9460		"Injection, cangrelor"		K		$18.714	.	$3.75	20.000%	$3.75		
9460	C9460		"Injection, cangrelor"						20.000%			
9461		Choline c-11		K		"$2,062.940"	.	$412.59	20.000%	$412.59		
9461	A9515		Choline c-11						20.000%			
9463		"Inj., aprepitant, 1 mg"		K		$1.710	.	$0.35	20.000%	$0.35		
9463	J0185		"Inj., aprepitant, 1 mg"						20.000%			
9466		"Inj., benralizumab, 1 mg"		K		$163.300	.	$32.66	20.000%	$32.67		
9466	J0517		"Inj., benralizumab, 1 mg"						20.000%			
9467		"Inj rituximab, hyaluronidase"		K		$37.526	.	$7.51	20.000%	$7.51		
9467	J9311		"Inj rituximab, hyaluronidas"						20.000%			
9468		Factor ix recomb gly rebinyn		K		$4.320	.	$0.87	20.000%	$0.87		
9468	J7203		Factor ix recomb gly rebiny						20.000%			
9469		Inj triamcinolone ace xr 1mg		K		$18.007	.	$3.61	20.000%	$3.61		
9469	J3304		Inj triamcinolone ace xr 1m						20.000%			
9470		Aripirazole lauroxil 1 mg		K		$3.259	.	$0.66	20.000%	$0.66		
9470	J1944		Aripiprazole lauroxil 1 mg						20.000%			
9471		Hymovis injection 1 mg		K		$17.503	.	$3.51	20.000%	$3.51		
9471	J7322		Hymovis injection 1 mg						20.000%			
9472		Inj talimogene laherparepvec		K		$70.376	.	$14.08	19.381%	$13.64		IRA-adjusted coinsurance
9472	J9325		Inj talimogene laherparepve						19.381%			
9473		"Injection, mepolizumab, 1mg"		K		$30.540	.	$6.11	20.000%	$6.11		
9473	J2182		"Injection, mepolizumab, 1mg"						20.000%			
9474		Inj irinotecan liposome 1 mg		K		$65.278	.	$13.06	20.000%	$13.06		
9474	J9205		Inj irinotecan liposome 1 m						20.000%			
9475		"Injection, necitumumab, 1 mg"		K		$5.731	.	$1.15	20.000%	$1.15		
9475	J9295		"Injection, necitumumab, 1 m"						20.000%			
9476		"Injection, daratumumab 10 mg"		K		$67.625	.	$13.53	20.000%	$13.53		
9476	J9145		"Injection, daratumumab 10 m"						20.000%			
9477		"Injection, elotuzumab, 1mg"		K		$7.732	.	$1.55	20.000%	$1.55		
9477	J9176		"Injection, elotuzumab, 1mg"						20.000%			
9478		Inj sebelipase alfa 1 mg		K		$538.699	.	$107.74	20.000%	$107.74		
9478	J2840		Inj sebelipase alfa 1 mg						20.000%			
9480		Injection trabectedin 0.1mg		K		$363.832	.	$72.77	20.000%	$72.77		
9480	J9352		Injection trabectedin 0.1mg						20.000%			
9481		"Injection, reslizumab"		K		$10.494	.	$2.10	20.000%	$2.10		
9481	J2786		"Injection, reslizumab, 1mg"						20.000%			
9483		"Inj, atezolizumab,10 mg"		K		$89.394	.	$17.88	20.000%	$17.88		
9483	J9022		"Inj, atezolizumab,10 mg"						20.000%			
9487		"Ustekinumab, iv inject,1 mg"		K		$12.808	.	$2.57	20.000%	$2.57		
9487	J3358		"Ustekinumab, iv inject, 1 m"						20.000%			
9489		"Inj, nusinersen, 0.1mg"		K		"$1,248.600"	.	$249.72	20.000%	$249.72		
9489	J2326		"Inj, nusinersen, 0.1mg"						20.000%			
9490		"Inj, bezlotoxumab, 10 mg"		K		$39.869	.	$7.98	20.000%	$7.98		
9490	J0565		"Inj, bezlotoxumab, 10 mg"						20.000%			
9491		"Injection, avelumab, 10 mg"		K		$97.137	.	$19.43	20.000%	$19.43		
9491	J9023		"Injection, avelumab, 10 mg"						20.000%			
9492		"Inj., durvalumab, 10 mg"		K		$83.868	.	$16.78	20.000%	$16.78		
9492	J9173		"Inj., durvalumab, 10 mg"						20.000%			
9493		"Injection, edaravone, 1 mg"		K		$20.405	.	$4.09	20.000%	$4.09		
9493	J1301		"Injection, edaravone, 1 mg"						20.000%			
9494		"Injection, ocrelizumab"		K		$57.807	.	$11.57	20.000%	$11.57		
9494	J2350		"Injection, ocrelizumab, 1 m"						20.000%			
9495		Gemtuzumab ozogamicin inj		K		$233.119	.	$46.63	20.000%	$46.63		
9495	J9203		Gemtuzumab ozogamicin 0.1 m						20.000%			
9496		"Inj, faricimab-svoa, 0.1mg"		K		$34.722	.	$6.95	20.000%	$6.95	*	
9496	J2777		"Inj, faricimab-svoa, 0.1mg"						20.000%		*	
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."
9498	Q2056		Ciltacabtagene car-pos t						18.987%		*	
9500		"Platelets, irradiated"		R	4.2766	$392.37	.	$78.48	0.000%			
9500	P9032		"Platelets, irradiated"						0.000%			
9501		Platelet pheres leukoreduced		R	5.5124	$505.75	.	$101.15	0.000%			
9501	P9035		Platelet pheres leukoreduce						0.000%			
9502		Platelet pheresis irradiated		R	10.111	$927.65	.	$185.53	0.000%			
9502	P9036		Platelet pheresis irradiate						0.000%			
9503		Fr frz plasma donor retested		R	0.6113	$56.08	.	$11.22	0.000%			
9503	P9060		Fr frz plasma donor reteste						0.000%			
9504		RBC deglycerolized		R	3.1687	$290.72	.	$58.15	0.000%			
9504	P9039		Rbc deglycerolized						0.000%			
9505		RBC irradiated		R	1.6189	$148.53	.	$29.71	0.000%			
9505	P9038		Rbc irradiated						0.000%			
9507		"Platelets, pheresis"		R	3.5658	$327.15	.	$65.43	0.000%			
9507	P9034		"Platelets, pheresis"						0.000%			
9508		Plasma 1 donor frz w/in 8 hr		R	0.9323	$85.54	.	$17.11	0.000%			
9508	P9017		Plasma 1 donor frz w/in 8 h						0.000%			
9509		"Frozen plasma, pooled, sd"		R	0.4955	$45.46	.	$9.10	0.000%			
9509	P9023		"Frozen plasma, pooled, sd"						0.000%			
9510		Whole blood for transfusion		R	1.9797	$181.63	.	$36.33	0.000%			
9510	P9010		Whole blood for transfusion						0.000%			
9511		Cryoprecipitate each unit		R	0.7786	$71.43	.	$14.29	0.000%			
9511	P9012		Cryoprecipitate each unit						0.000%			
9512		RBC leukocytes reduced		R	2.0402	$187.18	.	$37.44	0.000%			
9512	P9016		Rbc leukocytes reduced						0.000%			
9513		"Plasma, frz between 8-24hour"		R	0.8204	$75.27	.	$15.06	0.000%			
9513	P9059		"Plasma, frz between 8-24hou"						0.000%			
9514		"Plasma protein fract,5%,50ml"		R	0.0877	$8.05	.	$1.61	0.000%			
9514	P9043		"Plasma protein fract,5%,50m"						0.000%			
9515		"Platelets, each unit"		R	0.7577	$69.52	.	$13.91	0.000%			
9515	P9019		"Platelets, each unit"						0.000%			
9516		Plaelet rich plasma unit		R	6.0539	$555.43	.	$111.09	0.000%			
9516	P9020		Plaelet rich plasma unit						0.000%			
9517		Red blood cells unit		R	1.7057	$156.49	.	$31.30	0.000%			
9517	P9021		Red blood cells unit						0.000%			
9518		Washed red blood cells unit		R	4.2015	$385.48	.	$77.10	0.000%			
9518	P9022		Washed red blood cells unit						0.000%			
9519		"Plasmaprotein fract,5%,250ml"		R	0.4048	$37.14	.	$7.43	0.000%			
9519	P9048		"Plasmaprotein fract,5%,250m"						0.000%			
9520		Blood split unit		R	1.6218	$148.80	.	$29.76	0.000%			
9520	P9011		Blood split unit						0.000%			
9521		Platelets leukoreduced irrad		R	2.0664	$189.59	.	$37.92	0.000%			
9521	P9033		Platelets leukoreduced irra						0.000%			
9522		RBC leukoreduced irradiated		R	2.8809	$264.31	.	$52.87	0.000%			
9522	P9040		Rbc leukoreduced irradiated						0.000%			
9523		Cryoprecipitatereducedplasma		R	1.1642	$106.81	.	$21.37	0.000%			
9523	P9044		Cryoprecipitatereducedplasm						0.000%			
9524		"Blood, l/r, cmv-neg"		R	1.6059	$147.34	.	$29.47	0.000%			
9524	P9051		"Blood, l/r, cmv-neg"						0.000%			
9525		"Platelets, hla-m, l/r, unit"		R	7.7737	$713.21	.	$142.65	0.000%			
9525	P9052		"Platelets, hla-m, l/r, unit"						0.000%			
9526		Platelets leukocytes reduced		R	1.6597	$152.27	.	$30.46	0.000%			
9526	P9031		Platelets leukocytes reduce						0.000%			
9527		"Blood, l/r, froz/degly/wash"		R	2.6312	$241.40	.	$48.28	0.000%			
9527	P9054		"Blood, l/r, froz/degly/wash"						0.000%			
9528		"Plt, aph/pher, l/r, cmv-neg"		R	2.4201	$222.04	.	$44.41	0.000%			
9528	P9055		"Plt, aph/pher, l/r, cmv-neg"						0.000%			
9529		"Blood, l/r, irradiated"		R	0.9286	$85.20	.	$17.04	0.000%			
9529	P9056		"Blood, l/r, irradiated"						0.000%			
9530		Plate pheres leukoredu irrad		R	7.5106	$689.08	.	$137.82	0.000%			
9530	P9037		Plate pheres leukoredu irra						0.000%			
9531		"Plt, pher, l/r cmv-neg, irr"		R	5.0042	$459.12	.	$91.83	0.000%			
9531	P9053		"Plt, pher, l/r cmv-neg, irr"						0.000%			
9532		"RBC, frz/deg/wsh, l/r, irrad"		R	4.7421	$435.07	.	$87.02	0.000%			
9532	P9057		"Rbc, frz/deg/wsh, l/r, irra"						0.000%			
9533		"RBC, l/r, cmv-neg, irrad"		R	2.7075	$248.41	.	$49.69	0.000%			
9533	P9058		"Rbc, l/r, cmv-neg, irrad"						0.000%			
9534		Pathogen reduced plasma pool		R	0.653	$59.91	.	$11.99	0.000%			
9534	P9070		Pathogen reduced plasma poo						0.000%			
9535		Pathogen reduced plasma sing		R	3.163	$290.20	.	$58.04	0.000%			
9535	P9071		Pathogen reduced plasma sin						0.000%			
9536		Platelets pheresis path redu		R	6.7374	$618.14	.	$123.63	0.000%			
9536	P9073		Platelets pheresis path red						0.000%			
9537		Blood component/product noc		R	0.4048	$37.14	.	$7.43	0.000%			
9537	P9099		Blood component/product noc						0.000%			
9538		Plasma cryo redu path each		R	1.4813	$135.90	.	$27.18	0.000%			
9538	P9025		Plasma cryo redu path each						0.000%			
9539		Cryo fib comp path redu each		R	5.6713	$520.32	.	$104.07	0.000%			
9539	P9026		Cryo fib comp path redu eac						0.000%			
9540		Covid-19 convalescent plasma		R	7.5336	$691.19	.	$138.24	0.000%			
9540	C9507		Covid-19 convalescent plasm						0.000%			
9541		Rbc o2 co2 reduced		R	5.5124	$505.75	.	$101.15	0.000%			
9541	P9027		Rbc o2 co2 reduced						0.000%			
