			"Proposed Costs for Hospital Outpatient Services, by Low Volume HCPCS code for CY 2026"									
HCPCS	SI	APC 	Payment Rate 	Single Frequency 	Total Frequency	Minimum Cost 	Maximum Cost 	Median Cost 	Mean Cost	Geometric Mean Cost 	CV 	Deleted Code Used in APC Costs
0041A	S	9397		34	34	$9.32 	$236.89 	$44.71 	$63.06 	$48.65 	83.187	
0308T	J1	5496	"$16,645.08 "	3	3	"$2,332.74 "	"$25,903.49 "	"$3,788.00 "	"$10,674.74 "	"$6,117.09 "	123.736	
0620T	S	1579	"$35,000.50 "	30	30	"$7,855.36 "	"$102,123.20 "	"$38,411.50 "	"$39,144.47 "	"$35,157.97 "	45.461	
0625T	S	1511		113	113	$3.47 	"$2,220.97 "	$3.51 	$243.24 	$13.21 	254.807	YES
0648T	S	1511	$950.50 	445	111002	$19.67 	"$1,341.59 "	$220.04 	$249.44 	$190.11 	74.036	
0686T	S	1576	"$35,000.50 "	97	97	"$2,528.01 "	"$175,433.50 "	"$20,577.77 "	"$32,307.41 "	"$21,264.91 "	109.476	
0698T	S	1511	$950.50 	137	137	$17.49 	$800.00 	$777.16 	$600.88 	$422.93 	50.196	
0721T	S	1508	$650.50 	11	11	$30.24 	$121.46 	$30.24 	$48.58 	$40.90 	74.695	
0722T	S	1508	$650.50 	489	489	$30.24 	$132.65 	$60.67 	$61.05 	$60.47 	15.759	
0810T	T	1563	"$4,250.50 "	42	181754.21	"$1,696.72 "	"$8,407.55 "	"$4,000.73 "	"$4,327.48 "	"$4,040.48 "	37.907	
0888T	S	1576	"$17,500.50 "	6	6	"$2,062.49 "	"$7,799.74 "	"$6,741.27 "	"$5,475.17 "	"$4,772.64 "	47.912	
0890T	S	1525	"$1,950.50 "	12	12	"$1,009.25 "	"$3,267.83 "	"$1,009.25 "	"$1,950.33 "	"$1,646.67 "	59.631	
0891T	S	1525	"$2,250.50 "	39	39	"$1,009.25 "	"$3,910.98 "	"$1,009.25 "	"$2,010.25 "	"$1,692.08 "	57.607	
0892T	S	1525	"$3,750.50 "	3	3	"$3,267.83 "	"$3,267.83 "	"$3,267.83 "	"$3,267.83 "	"$3,267.83 "	0.000	
38240	J1	5244	"$64,120.76 "	246	254	"$10,095.23 "	"$275,497.30 "	"$61,454.32 "	"$65,119.18 "	"$58,572.91 "	46.178	
65770	J1	5494	"$14,408.18 "	212	214	"$5,605.11 "	"$30,947.15 "	"$13,886.42 "	"$14,632.53 "	"$13,893.29 "	32.422	
66683	J1	5496	"$16,645.08 "	24	25	"$5,824.72 "	"$29,738.10 "	"$17,120.71 "	"$16,151.02 "	"$15,040.69 "	35.137	
67027	J1	5495	"$14,285.37 "	247	249	"$1,412.74 "	"$81,245.97 "	"$13,013.22 "	"$14,507.81 "	"$9,965.06 "	79.608	
78432	S	1519	"$1,750.50 "	64	64	$899.64 	"$3,821.72 "	"$1,364.24 "	"$1,737.16 "	"$1,591.81 "	46.495	
78433	S	1521	"$2,250.50 "	5365	5384	$617.64 	"$5,843.52 "	"$1,912.92 "	"$2,125.35 "	"$1,975.62 "	39.668	
C9760	T	1592	"$27,500.50 "	2	2	"$10,474.70 "	"$10,692.01 "	"$10,583.35 "	"$10,583.36 "	"$10,582.80 "	1.452	
C9780	S	1534	"$8,250.50 "	7	7	"$4,871.13 "	"$15,676.67 "	"$13,197.72 "	"$10,830.99 "	"$9,788.43 "	43.181	
C9782	T	1590	"$17,500.50 "	3	3	"$13,260.23 "	"$21,809.32 "	"$21,534.28 "	"$18,867.94 "	"$18,398.17 "	25.749	
C9791	T	1551	"$1,250.50 "	4	4	"$1,064.15 "	"$1,639.13 "	"$1,566.94 "	"$1,459.29 "	"$1,437.80 "	18.644	
C9794	S	1521		16	16	$598.52 	"$2,282.40 "	"$1,203.20 "	"$1,241.82 "	"$1,121.78 "	44.963	YES
C9795	S	1525		28	28	"$1,625.76 "	"$6,856.67 "	"$2,915.04 "	"$3,606.25 "	"$3,348.95 "	40.793	YES
DEATH	J1	5881		352	354	$467.15 	"$177,607.50 "	"$8,756.72 "	"$14,166.82 "	"$8,385.41 "	117.009	
M0201	S	9399	$36.85 	1016	1036	$6.88 	$31.22 	$9.11 	$11.47 	$10.61 	48.000	
M0221	S	1504		1192	1227	$12.02 	"$4,222.56 "	$189.87 	$299.64 	$192.75 	96.293	
M0222	S	1505		71999	72912	$25.10 	"$4,021.36 "	$300.76 	$456.90 	$318.92 	104.573	
M0223	S	1507		431	467	"$1,302.19 "	"$1,302.19 "	"$1,302.19 "	"$1,302.19 "	"$1,302.19 "	0.000	
M0241	S	1509		1	1	$520.30 	$520.30 	$520.30 	$520.30 	$520.30 		
M0244	S	1509		1296	1298	$61.28 	"$4,365.65 "	$582.56 	$831.59 	$614.58 	69.297	
M0246	S	1509		7	7	$131.20 	"$1,334.45 "	$190.91 	$528.53 	$345.06 	97.587	
M0248	S	1509		286	290	$276.84 	"$1,560.59 "	"$1,302.19 "	$949.51 	$840.76 	43.932	
