	Addendum A.-Final OPPS APCs for CY 2020																																																																																																																																																																																																																											
 APC  	Group Title	SI	Relative Weight 	Payment Rate	National Unadjusted Copayment 	Minimum Unadjusted Copayment 	"Note: Actual copayments would be lower due to the cap on copayments at the Inpatient Deductible of $1,364.00"																																																																																																																																																																																																																					
0701	Sr89 strontium	K		"$2,045.702"	.	$409.15																																																																																																																																																																																																																						
0726	Dexrazoxane HCl injection	K		$194.341	.	$38.87																																																																																																																																																																																																																						
0731	Sargramostim injection	K		$43.442	.	$8.69																																																																																																																																																																																																																						
0736	Amphotericin b liposome inj	K		$26.087	.	$5.22																																																																																																																																																																																																																						
0738	Rasburicase	K		$289.815	.	$57.97																																																																																																																																																																																																																						
0751	Mechlorethamine hcl inj	K		$328.290	.	$65.66																																																																																																																																																																																																																						
0752	Dactinomycin injection	K		"$1,098.200"	.	$219.64																																																																																																																																																																																																																						
0759	"Naltrexone, depot form"	K		$3.247	.	$0.65																																																																																																																																																																																																																						
0800	Leuprolide acetate	K		"$1,269.227"	.	$253.85																																																																																																																																																																																																																						
0802	Etoposide oral	K		$75.355	.	$15.08																																																																																																																																																																																																																						
0807	Aldesleukin injection	K		"$4,964.616"	.	$992.93																																																																																																																																																																																																																						
0810	Goserelin acetate implant	K		$497.719	.	$99.55																																																																																																																																																																																																																						
0812	Carmustine injection	K		"$3,039.006"	.	$607.81																																																																																																																																																																																																																						
0820	Daunorubicin injection	K		$46.740	.	$9.35																																																																																																																																																																																																																						
0823	Docetaxel injection	K		$0.865	.	$0.18																																																																																																																																																																																																																						
0825	Nelarabine injection	K		$152.479	.	$30.50																																																																																																																																																																																																																						
0836	Interferon alfa-2b inj	K		$34.239	.	$6.85																																																																																																																																																																																																																						
0840	Inj melphalan hydrochl	K		$610.875	.	$122.18																																																																																																																																																																																																																						
0843	Pegaspargase injection	K		"$17,566.886"	.	"$3,513.38"	#																																																																																																																																																																																																																					
0844	Pentostatin injection	K		"$1,968.606"	.	$393.73																																																																																																																																																																																																																						
0850	Streptozocin injection	K		$349.701	.	$69.95																																																																																																																																																																																																																						
0851	Thiotepa injection	K		$404.280	.	$80.86																																																																																																																																																																																																																						
0856	Porfimer sodium injection	K		"$21,397.867"	.	"$4,279.58"	#																																																																																																																																																																																																																					
0858	Inj cladribine	K		$18.999	.	$3.80																																																																																																																																																																																																																						
0864	Mitoxantrone hydrochl	K		$27.385	.	$5.48																																																																																																																																																																																																																						
0874	Synvisc or synvisc-one	K		$11.412	.	$2.29																																																																																																																																																																																																																						
0875	Euflexxa inj per dose	K		$145.079	.	$29.02																																																																																																																																																																																																																						
0877	Orthovisc inj per dose	K		$143.397	.	$28.68																																																																																																																																																																																																																						
0887	Azathioprine parenteral	K		$238.188	.	$47.64																																																																																																																																																																																																																						
0890	Lymphocyte immune globulin	K		"$2,066.023"	.	$413.21																																																																																																																																																																																																																						
0901	Alpha 1 proteinase inhibitor	K		$4.550	.	$0.91																																																																																																																																																																																																																						
0902	"Injection,onabotulinumtoxinA"	K		$6.123	.	$1.23																																																																																																																																																																																																																						
0903	Cytomegalovirus imm IV /vial	K		"$1,129.154"	.	$225.84																																																																																																																																																																																																																						
0910	Interferon beta-1b / .25 MG	K		$386.238	.	$77.25																																																																																																																																																																																																																						
0925	Factor viii	K		$1.069	.	$0.22																																																																																																																																																																																																																						
0927	Factor viii recombinant	K		$1.254	.	$0.26																																																																																																																																																																																																																						
0928	Factor ix complex	K		$1.469	.	$0.30																																																																																																																																																																																																																						
0929	Anti-inhibitor	K		$1.897	.	$0.38																																																																																																																																																																																																																						
0931	Factor IX non-recombinant	K		$1.149	.	$0.23																																																																																																																																																																																																																						
0932	Factor ix recombinant nos	K		$1.502	.	$0.31																																																																																																																																																																																																																						
0943	Octagam injection	K		$35.683	.	$7.14																																																																																																																																																																																																																						
0944	Gammagard liquid injection	K		$37.468	.	$7.50																																																																																																																																																																																																																						
0946	Hepagam b im injection	K		$60.057	.	$12.02																																																																																																																																																																																																																						
0947	Flebogamma injection	K		$35.585	.	$7.12																																																																																																																																																																																																																						
0948	Gamunex-C/Gammaked	K		$39.140	.	$7.83																																																																																																																																																																																																																						
0961	"Albumin (human),5%, 50ml"	K		$10.490	.	$2.10																																																																																																																																																																																																																						
0963	"Albumin (human), 5%, 250 ml"	K		$52.450	.	$10.49																																																																																																																																																																																																																						
0964	"Albumin (human), 25%, 20 ml"	K		$20.980	.	$4.20																																																																																																																																																																																																																						
0965	"Albumin (human), 25%, 50ml"	K		$52.450	.	$10.49																																																																																																																																																																																																																						
1015	Injection glatiramer acetate	K		$163.404	.	$32.69																																																																																																																																																																																																																						
1064	"I131 iodide cap, rx"	K		$20.760	.	$4.16																																																																																																																																																																																																																						
1083	Adalimumab injection	K		"$1,371.138"	.	$274.23																																																																																																																																																																																																																						
1138	"Hepagam b intravenous, inj"	K		$60.057	.	$12.02																																																																																																																																																																																																																						
1139	Protein c concentrate	K		$15.097	.	$3.02																																																																																																																																																																																																																						
1142	Supprelin LA implant	K		"$36,647.599"	.	"$7,329.52"	#																																																																																																																																																																																																																					
1150	"I131 iodide sol, rx"	K		$13.570	.	$2.72																																																																																																																																																																																																																						
1166	Cytarabine liposome inj	K		$81.420	.	$16.29																																																																																																																																																																																																																						
1168	"Inj, temsirolimus"	K		$53.135	.	$10.63																																																																																																																																																																																																																						
1178	Busulfan injection	K		$4.579	.	$0.92																																																																																																																																																																																																																						
1203	Verteporfin injection	K		$11.078	.	$2.22																																																																																																																																																																																																																						
1207	"Octreotide injection, depot"	K		$206.565	.	$41.32																																																																																																																																																																																																																						
1213	Antihemophilic viii/vwf comp	K		$1.059	.	$0.22																																																																																																																																																																																																																						
1214	Inj IVIG privigen 500 mg	K		$40.122	.	$8.03																																																																																																																																																																																																																						
1232	Mitomycin injection	K		$87.749	.	$17.55																																																																																																																																																																																																																						
1235	Valrubicin injection	K		"$1,438.588"	.	$287.72																																																																																																																																																																																																																						
1236	Inj levoleucovorin nos 0.5mg	K		$0.576	.	$0.12																																																																																																																																																																																																																						
1237	Inj iron dextran	K		$14.407	.	$2.89																																																																																																																																																																																																																						
1263	Antithrombin iii injection	K		$3.319	.	$0.67																																																																																																																																																																																																																						
1268	Xyntha inj	K		$1.266	.	$0.26																																																																																																																																																																																																																						
1274	Edetate calcium disodium inj	K 		"$5,594.422"	.	"$1,118.89"																																																																																																																																																																																																																						
1281	Bevacizumab injection	K		$2.030	.	$0.41																																																																																																																																																																																																																						
1289	AbobotulinumtoxinA	K		$8.432	.	$1.69																																																																																																																																																																																																																						
1295	Sm 153 lexidronam	K		"$16,040.561"	.	"$3,208.12"	#																																																																																																																																																																																																																					
1296	Degarelix injection	K		$3.965	.	$0.80																																																																																																																																																																																																																						
1297	"Ferumoxytol, non-esrd"	K		$0.997	.	$0.20																																																																																																																																																																																																																						
1311	Canakinumab injection	K		$111.013	.	$22.21																																																																																																																																																																																																																						
1312	Hizentra injection	K		$10.437	.	$2.09																																																																																																																																																																																																																						
1327	Imiglucerase injection	K		$42.937	.	$8.59																																																																																																																																																																																																																						
1340	"Collagenase, clost hist inj"	K		$48.760	.	$9.76																																																																																																																																																																																																																						
1341	Amobarbital 125 MG inj	K		$56.620	.	$11.33																																																																																																																																																																																																																						
1352	Wilate injection	K		$0.971	.	$0.20																																																																																																																																																																																																																						
1353	Belimumab injection	K		$44.824	.	$8.97																																																																																																																																																																																																																						
1408	Cyclophosphamide 100 MG inj	K		$34.139	.	$6.83																																																																																																																																																																																																																						
1413	Lumizyme injection	K		$171.046	.	$34.21																																																																																																																																																																																																																						
1415	Glassia injection	K		$4.823	.	$0.97																																																																																																																																																																																																																						
1416	Factor xiii anti-hem factor	K		$8.469	.	$1.70																																																																																																																																																																																																																						
1417	Gel-one	K		"$1,166.000"	.	$233.20																																																																																																																																																																																																																						
1420	Aflibercept injection	K		$952.473	.	$190.50																																																																																																																																																																																																																						
1421	Imported lipodox inj	K		$470.400	.	$94.08																																																																																																																																																																																																																						
1426	Eribulin mesylate injection	K		$114.274	.	$22.86																																																																																																																																																																																																																						
1431	Centruroides immune f(ab)	K		"$4,822.428"	.	$964.49																																																																																																																																																																																																																						
1433	Calcitonin salmon injection	K		"$2,661.047"	.	$532.21																																																																																																																																																																																																																						
1440	Inj desmopressin acetate	K		$12.143	.	$2.43																																																																																																																																																																																																																						
1442	Non-HEU TC-99M add-on/dose	K		$10.000	.	$2.00																																																																																																																																																																																																																						
1443	Icatibant injection	K		$377.080	.	$75.42																																																																																																																																																																																																																						
1446	Visualization adjunct	K		$6.401	.	$1.29																																																																																																																																																																																																																						
1458	Phentolaine mesylate inj	K		$377.567	.	$75.52																																																																																																																																																																																																																						
1466	"Inj, vincristine sul lip 1mg"	K		"$3,080.040"	.	$616.01																																																																																																																																																																																																																						
1467	Factor ix recombinan rixubis	K		$1.323	.	$0.27																																																																																																																																																																																																																						
1468	Inj Aripiprazole Ext Rel 1mg	K		$5.704	.	$1.15																																																																																																																																																																																																																						
1469	Inj filgrastim excl biosimil	K		$0.964	.	$0.20																																																																																																																																																																																																																						
1471	"Injection, Pertuzumab, 1 mg"	K		$12.290	.	$2.46																																																																																																																																																																																																																						
1472	Inj beta interferon im 1 mcg	K		$53.583	.	$10.72																																																																																																																																																																																																																						
1474	Certolizumab pegol inj 1mg	K		$8.023	.	$1.61																																																																																																																																																																																																																						
1475	Golimumab for iv use 1mg	K		$21.580	.	$4.32																																																																																																																																																																																																																						
1476	Obinutuzumab inj	K		$62.864	.	$12.58																																																																																																																																																																																																																						
1478	Inj human fibrinogen con nos	K		$1.197	.	$0.24																																																																																																																																																																																																																						
1480	"Elosulfase alfa, injection"	K		$241.453	.	$48.30																																																																																																																																																																																																																						
1482	"	Darbepoetin alfa, esrd use"	K		$3.852	.	$0.78																																																																																																																																																																																																																						
1485	"	Ferumoxytol, esrd use"	K		$0.997	.	$0.20																																																																																																																																																																																																																						
1486	Factor ix fc fusion recomb	K		$3.110	.	$0.63																																																																																																																																																																																																																						
1488	"Injection, ramucirumab"	K		$58.419	.	$11.69																																																																																																																																																																																																																						
1489	"Injection, vedolizumab"	K		$19.864	.	$3.98																																																																																																																																																																																																																						
1490	Inj pembrolizumab	K		$49.389	.	$9.88																																																																																																																																																																																																																						
1491	New Technology  - Level 1A ($0-$10)	S		$5.00	.	$1.00																																																																																																																																																																																																																						
1492	New Technology  - Level 1B ($11-$20)	S		$15.50	.	$3.10																																																																																																																																																																																																																						
1493	New Technology  - Level 1C ($21-$30)	S		$25.50	.	$5.10																																																																																																																																																																																																																						
1494	New Technology  - Level 1D ($31-$40)	S		$35.50	.	$7.10																																																																																																																																																																																																																						
1495	New Technology  - Level 1E ($41-$50)	S		$45.50	.	$9.10																																																																																																																																																																																																																						
1496	New Technology  - Level 1A ($0-$10)	T		$5.00	.	$1.00																																																																																																																																																																																																																						
1497	New Technology  - Level 1B ($11-$20)	T		$15.50	.	$3.10																																																																																																																																																																																																																						
1498	New Technology  - Level 1C ($21-$30)	T		$25.50	.	$5.10																																																																																																																																																																																																																						
1499	New Technology  - Level 1D ($31-$40)	T		$35.50	.	$7.10																																																																																																																																																																																																																						
1500	New Technology  - Level 1E ($41-$50)	T		$45.50	.	$9.10																																																																																																																																																																																																																						
1502	New Technology - Level 2 ($51 - $100)	S		$75.50	.	$15.10																																																																																																																																																																																																																						
1503	New Technology - Level 3 ($101 - $200)	S		$150.50	.	$30.10																																																																																																																																																																																																																						
1504	New Technology - Level 4 ($201 - $300)	S		$250.50	.	$50.10																																																																																																																																																																																																																						
1505	New Technology - Level 5 ($301 - $400)	S		$350.50	.	$70.10																																																																																																																																																																																																																						
1506	New Technology - Level 6 ($401 - $500)	S		$450.50	.	$90.10																																																																																																																																																																																																																						
1507	New Technology - Level 7 ($501 - $600)	S		$550.50	.	$110.10																																																																																																																																																																																																																						
1508	New Technology - Level 8 ($601 - $700)	S		$650.50	.	$130.10																																																																																																																																																																																																																						
1509	New Technology - Level 9 ($701 - $800)	S		$750.50	.	$150.10																																																																																																																																																																																																																						
1510	New Technology - Level 10 ($801 - $900)	S		$850.50	.	$170.10																																																																																																																																																																																																																						
1511	New Technology - Level 11 ($901 - $1000)	S		$950.50	.	$190.10																																																																																																																																																																																																																						
1512	New Technology - Level 12 ($1001 - $1100)	S		"$1,050.50"	.	$210.10																																																																																																																																																																																																																						
1513	New Technology - Level 13 ($1101 - $1200)	S		"$1,150.50"	.	$230.10																																																																																																																																																																																																																						
1514	New Technology - Level 14 ($1201- $1300)	S		"$1,250.50"	.	$250.10																																																																																																																																																																																																																						
1515	New Technology - Level 15 ($1301 - $1400)	S		"$1,350.50"	.	$270.10																																																																																																																																																																																																																						
1516	New Technology - Level 16  ($1401 - $1500)	S		"$1,450.50"	.	$290.10																																																																																																																																																																																																																						
1517	New Technology - Level 17 ($1501-$1600)	S		"$1,550.50"	.	$310.10																																																																																																																																																																																																																						
1518	New Technology - Level 18 ($1601-$1700)	S		"$1,650.50"	.	$330.10																																																																																																																																																																																																																						
1519	New Technology - Level 19 ($1701-$1800)	S		"$1,750.50"	.	$350.10																																																																																																																																																																																																																						
1520	New Technology - Level 20 ($1801-$1900)	S		"$1,850.50"	.	$370.10																																																																																																																																																																																																																						
1521	New Technology - Level 21 ($1901-$2000)	S		"$1,950.50"	.	$390.10																																																																																																																																																																																																																						
1522	New Technology - Level 22 ($2001-$2500)	S		"$2,250.50"	.	$450.10																																																																																																																																																																																																																						
1523	New Technology - Level 23 ($2501-$3000)	S		"$2,750.50"	.	$550.10																																																																																																																																																																																																																						
1524	New Technology - Level 24 ($3001-$3500)	S		"$3,250.50"	.	$650.10																																																																																																																																																																																																																						
1525	New Technology - Level 25 ($3501-$4000)	S		"$3,750.50"	.	$750.10																																																																																																																																																																																																																						
1526	New Technology - Level 26 ($4001-$4500)	S		"$4,250.50"	.	$850.10																																																																																																																																																																																																																						
1527	New Technology - Level 27 ($4501-$5000)	S		"$4,750.50"	.	$950.10																																																																																																																																																																																																																						
1528	New Technology - Level 28 ($5001-$5500)	S		"$5,250.50"	.	"$1,050.10"																																																																																																																																																																																																																						
1529	New Technology - Level 29 ($5501-$6000)	S		"$5,750.50"	.	"$1,150.10"																																																																																																																																																																																																																						
1530	New Technology - Level 30 ($6001-$6500)	S		"$6,250.50"	.	"$1,250.10"																																																																																																																																																																																																																						
1531	New Technology - Level 31 ($6501-$7000)	S		"$6,750.50"	.	"$1,350.10"																																																																																																																																																																																																																						
1532	New Technology - Level 32 ($7001-$7500)	S		"$7,250.50"	.	"$1,450.10"	#																																																																																																																																																																																																																					
1533	New Technology - Level 33 ($7501-$8000)	S		"$7,750.50"	.	"$1,550.10"	#																																																																																																																																																																																																																					
1534	New Technology - Level 34 ($8001-$8500)	S		"$8,250.50"	.	"$1,650.10"	#																																																																																																																																																																																																																					
1535	New Technology - Level 35 ($8501-$9000)	S		"$8,750.50"	.	"$1,750.10"	#																																																																																																																																																																																																																					
1536	New Technology - Level 36 ($9001-$9500)	S		"$9,250.50"	.	"$1,850.10"	#																																																																																																																																																																																																																					
1537	New Technology - Level 37 ($9501-$10000)	S		"$9,750.50"	.	"$1,950.10"	#																																																																																																																																																																																																																					
1539	New Technology - Level 2 ($51 - $100)	T		$75.50	.	$15.10																																																																																																																																																																																																																						
1540	New Technology - Level 3 ($101 - $200)	T		$150.50	.	$30.10																																																																																																																																																																																																																						
1541	New Technology - Level 4 ($201 - $300)	T		$250.50	.	$50.10																																																																																																																																																																																																																						
1542	New Technology - Level 5 ($301 - $400)	T		$350.50	.	$70.10																																																																																																																																																																																																																						
1543	New Technology - Level 6 ($401 - $500)	T		$450.50	.	$90.10																																																																																																																																																																																																																						
1544	New Technology - Level 7 ($501 - $600)	T		$550.50	.	$110.10																																																																																																																																																																																																																						
1545	New Technology - Level 8 ($601 - $700)	T		$650.50	.	$130.10																																																																																																																																																																																																																						
1546	New Technology - Level 9 ($701 - $800)	T		$750.50	.	$150.10																																																																																																																																																																																																																						
1547	New Technology - Level 10 ($801 - $900)	T		$850.50	.	$170.10																																																																																																																																																																																																																						
1548	New Technology - Level 11 ($901 - $1000)	T		$950.50	.	$190.10																																																																																																																																																																																																																						
1549	New Technology - Level 12 ($1001 - $1100)	T		"$1,050.50"	.	$210.10																																																																																																																																																																																																																						
1550	New Technology - Level 13 ($1101 - $1200)	T		"$1,150.50"	.	$230.10																																																																																																																																																																																																																						
1551	New Technology - Level 14 ($1201- $1300)	T		"$1,250.50"	.	$250.10																																																																																																																																																																																																																						
1552	New Technology - Level 15 ($1301 - $1400)	T		"$1,350.50"	.	$270.10																																																																																																																																																																																																																						
1553	New Technology - Level 16 ($1401 - $1500)	T		"$1,450.50"	.	$290.10																																																																																																																																																																																																																						
1554	New Technology - Level 17 ($1501-$1600)	T		"$1,550.50"	.	$310.10																																																																																																																																																																																																																						
1555	New Technology - Level 18 ($1601-$1700)	T		"$1,650.50"	.	$330.10																																																																																																																																																																																																																						
1556	New Technology - Level 19 ($1701-$1800)	T		"$1,750.50"	.	$350.10																																																																																																																																																																																																																						
1557	New Technology - Level 20 ($1801-$1900)	T		"$1,850.50"	.	$370.10																																																																																																																																																																																																																						
1558	New Technology - Level 21 ($1901-$2000)	T		"$1,950.50"	.	$390.10																																																																																																																																																																																																																						
1559	New Technology - Level 22 ($2001-$2500)	T		"$2,250.50"	.	$450.10																																																																																																																																																																																																																						
1560	New Technology - Level 23 ($2501-$3000)	T		"$2,750.50"	.	$550.10																																																																																																																																																																																																																						
1561	New Technology - Level 24 ($3001-$3500)	T		"$3,250.50"	.	$650.10																																																																																																																																																																																																																						
1562	New Technology - Level 25 ($3501-$4000)	T		"$3,750.50"	.	$750.10																																																																																																																																																																																																																						
1563	New Technology - Level 26 ($4001-$4500)	T		"$4,250.50"	.	$850.10																																																																																																																																																																																																																						
1564	New Technology - Level 27 ($4501-$5000)	T		"$4,750.50"	.	$950.10																																																																																																																																																																																																																						
1565	New Technology - Level 28 ($5001-$5500)	T		"$5,250.50"	.	"$1,050.10"																																																																																																																																																																																																																						
1566	New Technology - Level 29 ($5501-$6000)	T		"$5,750.50"	.	"$1,150.10"																																																																																																																																																																																																																						
1567	New Technology - Level 30 ($6001-$6500)	T		"$6,250.50"	.	"$1,250.10"																																																																																																																																																																																																																						
1568	New Technology - Level 31 ($6501-$7000)	T		"$6,750.50"	.	"$1,350.10"																																																																																																																																																																																																																						
1569	New Technology - Level 32 ($7001-$7500)	T		"$7,250.50"	.	"$1,450.10"	#																																																																																																																																																																																																																					
1570	New Technology - Level 33 ($7501-$8000)	T		"$7,750.50"	.	"$1,550.10"	#																																																																																																																																																																																																																					
1571	New Technology - Level 34 ($8001-$8500)	T		"$8,250.50"	.	"$1,650.10"	#																																																																																																																																																																																																																					
1572	New Technology - Level 35 ($8501-$9000)	T		"$8,750.50"	.	"$1,750.10"	#																																																																																																																																																																																																																					
1573	New Technology - Level 36 ($9001-$9500)	T		"$9,250.50"	.	"$1,850.10"	#																																																																																																																																																																																																																					
1574	New Technology - Level 37 ($9501-$10000)	T		"$9,750.50"	.	"$1,950.10"	#																																																																																																																																																																																																																					
1575	"New Technology - Level 38 ($10,001-$15,000)"	S		"$12,500.50"	.	"$2,500.10"	#																																																																																																																																																																																																																					
1576	"New Technology - Level 39 ($15,001-$20,000)"	S		"$17,500.50"	.	"$3,500.10"	#																																																																																																																																																																																																																					
1577	"New Technology - Level 40 ($20,001-$25,000)"	S		"$22,500.50"	.	"$4,500.10"	#																																																																																																																																																																																																																					
1578	"New Technology - Level 41 ($25,001-$30,000)"	S		"$27,500.50"	.	"$5,500.10"	#																																																																																																																																																																																																																					
1579	"New Technology - Level 42 ($30,001-$40,000)"	S		"$35,000.50"	.	"$7,000.10"	#																																																																																																																																																																																																																					
1580	"New Technology - Level 43 ($40,001-$50,000)"	S		"$45,000.50"	.	"$9,000.10"	#																																																																																																																																																																																																																					
1581	"New Technology - Level 44 ($50,001-$60,000)"	S		"$55,000.50"	.	"$11,000.10"	#																																																																																																																																																																																																																					
1582	"New Technology - Level 45 ($60,001-$70,000)"	S		"$65,000.50"	.	"$13,000.10"	#																																																																																																																																																																																																																					
1583	"New Technology - Level 46 ($70,001-$80,000)"	S		"$75,000.50"	.	"$15,000.10"	#																																																																																																																																																																																																																					
1584	"New Technology - Level 47 ($80,001-$90,000)"	S		"$85,000.50"	.	"$17,000.10"	#																																																																																																																																																																																																																					
1585	"New Technology - Level 48 ($90,001-$100,000)"	S		"$95,000.50"	.	"$19,000.10"	#																																																																																																																																																																																																																					
1589	"New Technology - Level 38 ($10,001-$15,000)"	T		"$12,500.50"	.	"$2,500.10"	#																																																																																																																																																																																																																					
1590	"New Technology - Level 39 ($15,001-$20,000)"	T		"$17,500.50"	.	"$3,500.10"	#																																																																																																																																																																																																																					
1591	"New Technology - Level 40 ($20,001-$25,000)"	T		"$22,500.50"	.	"$4,500.10"	#																																																																																																																																																																																																																					
1592	"New Technology - Level 41 ($25,001-$30,000)"	T		"$27,500.50"	.	"$5,500.10"	#																																																																																																																																																																																																																					
1593	"New Technology - Level 42 ($30,001-$40,000)"	T		"$35,000.50"	.	"$7,000.10"	#																																																																																																																																																																																																																					
1594	"New Technology - Level 43 ($40,001-$50,000)"	T		"$45,000.50"	.	"$9,000.10"	#																																																																																																																																																																																																																					
1595	"New Technology - Level 44 ($50,001-$60,000)"	T		"$55,000.50"	.	"$11,000.10"	#																																																																																																																																																																																																																					
1596	"New Technology - Level 45 ($60,001-$70,000)"	T		"$65,000.50"	.	"$13,000.10"	#																																																																																																																																																																																																																					
1597	"New Technology - Level 46 ($70,001-$80,000)"	T		"$75,000.50"	.	"$15,000.10"	#																																																																																																																																																																																																																					
1598	"New Technology - Level 47 ($80,001-$90,000)"	T		"$85,000.50"	.	"$17,000.10"	#																																																																																																																																																																																																																					
1599	"New Technology - Level 48 ($90,001-$100,000)"	T		"$95,000.50"	.	"$19,000.10"	#																																																																																																																																																																																																																					
1607	Eptifibatide injection	K		$4.286	.	$0.86																																																																																																																																																																																																																						
1608	Etanercept injection	K		$685.563	.	$137.12																																																																																																																																																																																																																						
1609	"Rho(D) immune globulin h, sd"	K		$29.784	.	$5.96																																																																																																																																																																																																																						
1613	Trastuzumab injection	K		$106.622	.	$21.33																																																																																																																																																																																																																						
1630	"Hep b ig, im"	K		$110.667	.	$22.14																																																																																																																																																																																																																						
1643	"Y90 ibritumomab, rx"	K		"$42,472.671"	.	"$8,494.54"	#																																																																																																																																																																																																																					
1656	Factor viii fc fusion recomb	K		$2.080	.	$0.42																																																																																																																																																																																																																						
1658	"Injection, belinostat, 10mg"	K		$40.070	.	$8.02																																																																																																																																																																																																																						
1660	"Injection, oritavancin"	K		$23.780	.	$4.76																																																																																																																																																																																																																						
1662	Inj tedizolid phosphate	K		$1.489	.	$0.30																																																																																																																																																																																																																						
1670	Tetanus immune globulin inj	K		$432.663	.	$86.54																																																																																																																																																																																																																						
1675	P32 Na phosphate	K		$730.030	.	$146.01																																																																																																																																																																																																																						
1683	Basiliximab	K		"$3,799.932"	.	$759.99																																																																																																																																																																																																																						
1684	Corticorelin ovine triflutal	K		$9.040	.	$1.81																																																																																																																																																																																																																						
1685	"Darbepoetin alfa, non-esrd"	K		$3.852	.	$0.78																																																																																																																																																																																																																						
1686	"Epoetin alfa, non-esrd"	K		$11.031	.	$2.21																																																																																																																																																																																																																						
1687	Digoxin immune fab (ovine)	K		"$3,780.193"	.	$756.04																																																																																																																																																																																																																						
1688	Ethanolamine oleate	K		$444.099	.	$88.82																																																																																																																																																																																																																						
1689	Fomepizole	K		$8.541	.	$1.71																																																																																																																																																																																																																						
1690	Hemin	K		$23.719	.	$4.75																																																																																																																																																																																																																						
1694	Ziconotide injection	K		$7.914	.	$1.59																																																																																																																																																																																																																						
1695	Nesiritide injection	K		$74.801	.	$14.97																																																																																																																																																																																																																						
1696	Palifermin injection	K		$21.275	.	$4.26																																																																																																																																																																																																																						
1700	Inj secretin synthetic human	K		$34.781	.	$6.96																																																																																																																																																																																																																						
1701	Treprostinil injection	K		$63.853	.	$12.78																																																																																																																																																																																																																						
1704	"Humate-P, inj"	K		$1.159	.	$0.24																																																																																																																																																																																																																						
1705	Factor viia	K		$2.150	.	$0.43																																																																																																																																																																																																																						
1709	Azacitidine injection	K		$1.161	.	$0.24																																																																																																																																																																																																																						
1710	Clofarabine injection	K		$61.690	.	$12.34																																																																																																																																																																																																																						
1711	Vantas implant	K		"$4,085.605"	.	$817.13																																																																																																																																																																																																																						
1712	Paclitaxel protein bound	K		$12.513	.	$2.51																																																																																																																																																																																																																						
1739	"Pegademase bovine, 25 iu"	K		$367.961	.	$73.60																																																																																																																																																																																																																						
1745	Radium ra223 dichloride ther	K		$138.815	.	$27.77																																																																																																																																																																																																																						
1746	Factor xiii recomb a-subunit	K		$15.519	.	$3.11																																																																																																																																																																																																																						
1747	Monovisc inj per dose	K		$769.506	.	$153.91																																																																																																																																																																																																																						
1748	Inj tbo filgrastim 1 microg	K		$0.566	.	$0.12																																																																																																																																																																																																																						
1761	"Rolapitant, oral, 1mg"	K		$2.118	.	$0.43																																																																																																																																																																																																																						
1809	"Injection, alemtuzumab"	K		"$1,917.042"	.	$383.41																																																																																																																																																																																																																						
1822	"Injection, zarxio"	K		$0.573	.	$0.12																																																																																																																																																																																																																						
1823	"Injection, dalbavancin"	K		$14.945	.	$2.99																																																																																																																																																																																																																						
1824	"	Ceftaroline fosamil inj"	K		$3.190	.	$0.64																																																																																																																																																																																																																						
1825	Ceftazidime and avibactam	K		$92.052	.	$18.42																																																																																																																																																																																																																						
1826	Hyqvia 100mg immuneglobulin	K		$14.556	.	$2.92																																																																																																																																																																																																																						
1827	Factor viii recomb obizur	K		$3.178	.	$0.64																																																																																																																																																																																																																						
1829	"	Penicillin g benzathine inj"	K		$13.820	.	$2.77																																																																																																																																																																																																																						
1832	Dimethyl sulfoxide 50% 50 ml	K		$586.511	.	$117.31																																																																																																																																																																																																																						
1844	Factor viii pegylated recomb	K		$1.741	.	$0.35																																																																																																																																																																																																																						
1846	Factor viii nuwiq recomb 1iu	K		$1.240	.	$0.25																																																																																																																																																																																																																						
1847	"Injection, inflectra"	G		$49.247	.	$9.85																																																																																																																																																																																																																						
1848	Artiss fibrin sealant	K		$164.845	.	$32.97																																																																																																																																																																																																																						
1849	Foscarnet sodium injection	K		$82.268	.	$16.46																																																																																																																																																																																																																						
1850	Gamma globulin 1 cc inj	K		$39.909	.	$7.99																																																																																																																																																																																																																						
1851	Gamma globulin > 10 cc inj	K		$399.090	.	$79.82																																																																																																																																																																																																																						
1852	Interferon beta-1a inj	K		"$2,785.970"	.	$557.20																																																																																																																																																																																																																						
1853	Minocycline hydrochloride	K		$1.811	.	$0.37																																																																																																																																																																																																																						
1854	Pentobarbital sodium inj	K		$37.015	.	$7.41																																																																																																																																																																																																																						
1856	Factor viii recomb novoeight	K		$1.307	.	$0.27																																																																																																																																																																																																																						
1857	"Inj, factor x, (human), 1iu"	K		$7.513	.	$1.51																																																																																																																																																																																																																						
1859	Argatroban nonesrd use 1mg	K		$1.194	.	$0.24																																																																																																																																																																																																																						
1861	"Inj., bendeka 1 mg"	K		$22.849	.	$4.57																																																																																																																																																																																																																						
1862	Gelsyn-3 injection 0.1 mg	G		$2.177	.	$0.44																																																																																																																																																																																																																						
1901	"New Technology - Level 49 ($100,001-$115,000)"	S		"$107,500.50"	.	"$21,500.10"	#																																																																																																																																																																																																																					
1902	"New Technology - Level 49 ($100,001-$115,000)"	T		"$107,500.50"	.	"$21,500.10"	#																																																																																																																																																																																																																					
1903	"New Technology - Level 50 ($115,001-$130,000)"	S		"$122,500.50"	.	"$24,500.10"	#																																																																																																																																																																																																																					
1904	"New Technology - Level 50 ($115,001-$130,000)"	T		"$122,500.50"	.	"$24,500.10"	#																																																																																																																																																																																																																					
1905	"New Technology - Level 51 ($130,001-$145,000)"	S		"$137,500.50"	.	"$27,500.10"	#																																																																																																																																																																																																																					
1906	"New Technology - Level 51 ($130,001-$145,000)"	T		"$137,500.50"	.	"$27,500.10"	#																																																																																																																																																																																																																					
1907	"New Technology - Level 52 ($145,001-$160,000)"	S		"$152,500.50"	.	"$30,500.10"	#																																																																																																																																																																																																																					
1908	"New Technology - Level 52 ($145,001-$160,000)"	T		"$152,500.50"	.	"$30,500.10"	#																																																																																																																																																																																																																					
2024	"Generator, CCM, implant"	H 			.	.																																																																																																																																																																																																																						
2025	"Cath, pressure,valve-occlu"	H 			.	.																																																																																																																																																																																																																						
2026	"Orth/devic/drug bn/bn,tis/bn "	H 			.	.																																																																																																																																																																																																																						
2027	"Probe, robotic, water-jet"	H 			.	.																																																																																																																																																																																																																						
2028	Iris prosthesis	H 			.	.																																																																																																																																																																																																																						
2616	"Brachytx, non-str,Yttrium-90"	U	211.5476	"$17,089.66"	.	"$3,417.94"	#																																																																																																																																																																																																																					
2632	Iodine I-125 sodium iodide	U	0.3870	$31.26	.	$6.26																																																																																																																																																																																																																						
2634	"Brachytx, non-str, HA, I-125"	U	2.2515	$181.89	.	$36.38																																																																																																																																																																																																																						
2635	"Brachytx, non-str, HA, P-103"	U	0.6978	$56.37	.	$11.28																																																																																																																																																																																																																						
2636	"Brachy linear, non-str,P-103"	U	0.4460	$36.03	.	$7.21																																																																																																																																																																																																																						
2638	"Brachytx, stranded, I-125"	U	0.4276	$34.54	.	$6.91																																																																																																																																																																																																																						
2639	"Brachytx, non-stranded,I-125"	U	0.4411	$35.63	.	$7.13																																																																																																																																																																																																																						
2640	"Brachytx, stranded, P-103"	U	1.0347	$83.59	.	$16.72																																																																																																																																																																																																																						
2641	"Brachytx, non-stranded,P-103"	U	0.8589	$69.39	.	$13.88																																																																																																																																																																																																																						
2642	"Brachytx, stranded, C-131"	U	0.9495	$76.70	.	$15.34																																																																																																																																																																																																																						
2643	"Brachytx, non-stranded,C-131"	U	1.1847	$95.70	.	$19.14																																																																																																																																																																																																																						
2645	"Brachytx, non-str, Gold-198"	U	1.4414	$116.44	.	$23.29																																																																																																																																																																																																																						
2646	"Brachytx, non-str, HDR Ir-192"	U	3.9857	$321.98	.	$64.40																																																																																																																																																																																																																						
2647	"Brachytx, NS, Non-HDRIr-192"	U	0.7794	$62.96	.	$12.60																																																																																																																																																																																																																						
2648	"Brachytx planar, p-103"	U	0.0581	$4.69	.	$0.94																																																																																																																																																																																																																						
2698	"Brachytx, stranded, NOS"	U	0.4276	$34.54	.	$6.91																																																																																																																																																																																																																						
2699	"Brachytx, non-stranded, NOS"	U	0.4411	$35.63	.	$7.13																																																																																																																																																																																																																						
2731	"Immune globulin, powder"	K		$61.203	.	$12.25																																																																																																																																																																																																																						
2770	Quinupristin/dalfopristin	K		$417.490	.	$83.50																																																																																																																																																																																																																						
2993	"Gen, neuro, trans sen/stim"	H			.	.																																																																																																																																																																																																																						
4001	Echo guidance radiotherapy	S		$86.62	.	$17.32																																																																																																																																																																																																																						
4002	Stereoscopic x-ray guidance 	S		$55.58	.	$11.12																																																																																																																																																																																																																						
4003	"Radiation treatment delivery, MeV <= 5; simple "	S		$189.83	.	$37.97																																																																																																																																																																																																																						
4004	"Radiation treatment delivery, 6-10 MeV; simple "	S		$143.64	.	$28.73																																																																																																																																																																																																																						
4005	"Radiation treatment delivery, 11-19 MeV; simple "	S		$143.64	.	$28.73																																																																																																																																																																																																																						
4006	"Radiation treatment delivery, MeV>=20; simple "	S		$143.64	.	$28.73																																																																																																																																																																																																																						
4007	"Radiation treatment delivery, MeV<=5; intermediate"	S		$269.59	.	$53.92																																																																																																																																																																																																																						
4008	"Radiation treatment delivery, 6-10 MeV; intermediate "	S		$198.13	.	$39.63																																																																																																																																																																																																																						
4009	"Radiation treatment delivery, 11-19 MeV; intermediate"	S		$196.69	.	$39.34																																																																																																																																																																																																																						
4010	"Radiation treatment delivery, MeV >=20; intermediate"	S		$196.69	.	$39.34																																																																																																																																																																																																																						
4011	"Radiation treatment delivery, MeV<=5; complex"	S		$266.34	.	$53.27																																																																																																																																																																																																																						
4012	"Radiation treatment delivery, 6-10 MeV; complex"	S		$262.73	.	$52.55																																																																																																																																																																																																																						
4013	"Radiation treatment delivery, 11-19 MeV; complex"	S		$263.09	.	$52.62																																																																																																																																																																																																																						
4014	"Radiation treatment delivery, MeV >=20; complex"	S		$263.09	.	$52.62																																																																																																																																																																																																																						
4015	Radiation tx delivery imrt	S		$369.92	.	$73.98																																																																																																																																																																																																																						
4016	Delivery comp imrt	S		$368.47	.	$73.69																																																																																																																																																																																																																						
5012	Clinic Visits and Related Services	V	1.4349	$115.92	.	$23.19																																																																																																																																																																																																																						
5021	Level 1 Type A ED Visits	V	0.8617	$69.61	.	$13.93																																																																																																																																																																																																																						
5022	Level 2 Type A ED Visits	V	1.5838	$127.95	.	$25.59																																																																																																																																																																																																																						
5023	Level 3 Type A ED Visits	V	2.7643	$223.31	.	$44.67																																																																																																																																																																																																																						
5024	Level 4 Type A ED Visits	V	4.3542	$351.75	.	$70.35																																																																																																																																																																																																																						
5025	Level 5 Type A ED Visits	V	6.2445	$504.46	.	$100.90																																																																																																																																																																																																																						
5031	Level 1 Type B ED Visits	V	0.8177	$66.06	.	$13.22																																																																																																																																																																																																																						
5032	Level 2 Type B ED Visits	V	1.1188	$90.38	.	$18.08																																																																																																																																																																																																																						
5033	Level 3 Type B ED Visits	V	1.9536	$157.82	.	$31.57																																																																																																																																																																																																																						
5034	Level 4 Type B ED Visits	V	2.5118	$202.91	.	$40.59																																																																																																																																																																																																																						
5035	Level 5 Type B ED Visits	V	3.8243	$308.94	.	$61.79																																																																																																																																																																																																																						
5041	Critical Care	S	8.2514	$666.58	.	$133.32																																																																																																																																																																																																																						
5045	Trauma Response with Critical Care	S	11.0301	$891.06	.	$178.22																																																																																																																																																																																																																						
5051	Level 1 Skin Procedures	T	2.1627	$174.71	.	$34.95																																																																																																																																																																																																																						
5052	Level 2 Skin Procedures	T	3.9547	$319.48	.	$63.90																																																																																																																																																																																																																						
5053	Level 3 Skin Procedures	T	6.1518	$496.97	.	$99.40																																																																																																																																																																																																																						
5054	Level 4 Skin Procedures	T	20.0852	"$1,622.56"	.	$324.52																																																																																																																																																																																																																						
5055	Level 5 Skin Procedures	T	36.8508	"$2,976.96"	.	$595.40																																																																																																																																																																																																																						
5061	Hyperbaric Oxygen	S	1.4241	$115.04	.	$23.01																																																																																																																																																																																																																						
5071	Level 1 Excision/ Biopsy/ Incision and Drainage	T	7.5503	$609.94	.	$121.99																																																																																																																																																																																																																						
5072	Level 2 Excision/ Biopsy/ Incision and Drainage	J1	16.9891	"$1,372.45"	.	$274.49																																																																																																																																																																																																																						
5073	Level 3 Excision/ Biopsy/ Incision and Drainage	J1	28.7016	"$2,318.63"	.	$463.73																																																																																																																																																																																																																						
5091	Level 1 Breast/Lymphatic Surgery and Related Procedures	J1	37.4977	"$3,029.21"	.	$605.85																																																																																																																																																																																																																						
5092	Level 2 Breast/Lymphatic Surgery and Related Procedures	J1	64.8236	"$5,236.71"	.	"$1,047.35"																																																																																																																																																																																																																						
5093	Level 3 Breast/Lymphatic Surgery and Related Procedures	J1	100.6964	"$8,134.66"	.	"$1,626.94"	#																																																																																																																																																																																																																					
5094	Level 4 Breast/Lymphatic Surgery and Related Procedures	J1	171.4670	"$13,851.79"	.	"$2,770.36"	#																																																																																																																																																																																																																					
5101	Level 1 Strapping and Cast Application	T	1.6553	$133.72	.	$26.75																																																																																																																																																																																																																						
5102	Level 2 Strapping and Cast Application	T	2.8445	$229.79	.	$45.96																																																																																																																																																																																																																						
5111	Level 1 Musculoskeletal Procedures	T	2.6691	$215.62	.	$43.13																																																																																																																																																																																																																						
5112	Level 2 Musculoskeletal Procedures	J1	16.7761	"$1,355.24"	.	$271.05																																																																																																																																																																																																																						
5113	Level 3 Musculoskeletal Procedures	J1	33.8823	"$2,737.15"	.	$547.43																																																																																																																																																																																																																						
5114	Level 4 Musculoskeletal Procedures	J1	74.0404	"$5,981.28"	.	"$1,196.26"																																																																																																																																																																																																																						
5115	Level 5 Musculoskeletal Procedures	J1	147.2988	"$11,899.39"	.	"$2,379.88"	#																																																																																																																																																																																																																					
5116	Level 6 Musculoskeletal Procedures	J1	197.3696	"$15,944.31"	.	"$3,188.87"	#																																																																																																																																																																																																																					
5151	Level 1 Airway Endoscopy	T	1.9377	$156.54	.	$31.31																																																																																																																																																																																																																						
5152	Level 2 Airway Endoscopy	T	4.6773	$377.85	.	$75.57																																																																																																																																																																																																																						
5153	Level 3 Airway Endoscopy	J1	17.7071	"$1,430.45"	.	$286.09																																																																																																																																																																																																																						
5154	Level 4 Airway Endoscopy	J1	36.3510	"$2,936.58"	.	$587.32																																																																																																																																																																																																																						
5155	Level 5 Airway Endoscopy	J1	67.3370	"$5,439.75"	.	"$1,087.95"																																																																																																																																																																																																																						
5161	Level 1 ENT Procedures	T	2.5205	$203.62	.	$40.73																																																																																																																																																																																																																						
5162	Level 2 ENT Procedures	T	5.4673	$441.67	.	$88.34																																																																																																																																																																																																																						
5163	Level 3 ENT Procedures	J1	16.7012	"$1,349.19"	.	$269.84																																																																																																																																																																																																																						
5164	Level 4 ENT Procedures	J1	32.4198	"$2,619.00"	.	$523.80																																																																																																																																																																																																																						
5165	Level 5 ENT Procedures	J1	60.0365	"$4,849.99"	.	$970.00																																																																																																																																																																																																																						
5166	Cochlear Implant Procedure	J1	409.7919	"$33,104.63"	"$7,683.79"	"$6,620.93"	#																																																																																																																																																																																																																					
5181	Level 1 Vascular Procedures	T	7.8040	$630.44	.	$126.09																																																																																																																																																																																																																						
5182	Level 2 Vascular Procedures	J1	20.1890	"$1,630.95"	.	$326.19																																																																																																																																																																																																																						
5183	Level 3 Vascular Procedures	J1	34.3010	"$2,770.97"	.	$554.20																																																																																																																																																																																																																						
5184	Level 4 Vascular Procedures	J1	56.8885	"$4,595.68"	.	$919.14																																																																																																																																																																																																																						
5191	Level 1 Endovascular Procedures	J1	35.2747	"$2,849.63"	$864.64	$569.93																																																																																																																																																																																																																						
5192	Level 2 Endovascular Procedures	J1	61.3161	"$4,953.36"	.	$990.68																																																																																																																																																																																																																						
5193	Level 3 Endovascular Procedures	J1	122.6403	"$9,907.37"	.	"$1,981.48"	#																																																																																																																																																																																																																					
5194	Level 4 Endovascular Procedures	J1	197.2940	"$15,938.20"	.	"$3,187.64"	#																																																																																																																																																																																																																					
5200	Implantation Wireless PA Pressure Monitor	J1	353.0198	"$28,518.35"	.	"$5,703.67"	#																																																																																																																																																																																																																					
5211	Level 1 Electrophysiologic Procedures	J1	12.2233	$987.45	.	$197.49																																																																																																																																																																																																																						
5212	Level 2 Electrophysiologic Procedures	J1	72.8493	"$5,885.06"	.	"$1,177.02"																																																																																																																																																																																																																						
5213	Level 3 Electrophysiologic Procedures	J1	252.9337	"$20,433.00"	.	"$4,086.60"	#																																																																																																																																																																																																																					
5221	Level1 Pacemaker and Similar Procedures	T	36.9340	"$2,983.68"	.	$596.74																																																																																																																																																																																																																						
5222	Level 2 Pacemaker and Similar Procedures	J1	94.5856	"$7,641.00"	.	"$1,528.20"	#																																																																																																																																																																																																																					
5223	Level 3 Pacemaker and Similar Procedures	J1	126.8914	"$10,250.79"	.	"$2,050.16"	#																																																																																																																																																																																																																					
5224	Level 4 Pacemaker and Similar Procedures	J1	226.6684	"$18,311.18"	.	"$3,662.24"	#																																																																																																																																																																																																																					
5231	Level 1 ICD and Similar Procedures	J1	281.1245	"$22,710.36"	.	"$4,542.08"	#																																																																																																																																																																																																																					
5232	Level 2 ICD and Similar Procedures	J1	399.5722	"$32,279.04"	.	"$6,455.81"	#																																																																																																																																																																																																																					
5241	Level 1 Blood Product Exchange and Related Services	S	4.8029	$388.00	.	$77.60																																																																																																																																																																																																																						
5242	Level 2 Blood Product Exchange and Related Services	S	16.3828	"$1,323.47"	.	$264.70																																																																																																																																																																																																																						
5243	Level 3 Blood Product Exchange and Related Services	S	47.2610	"$3,817.93"	.	$763.59																																																																																																																																																																																																																						
5244	Level 4 Blood Product Exchange and Related Services	J1	463.3555	"$37,431.71"	.	"$7,486.35"	#																																																																																																																																																																																																																					
5301	Level 1 Upper GI Procedures	T	9.7276	$785.83	.	$157.17																																																																																																																																																																																																																						
5302	Level 2 Upper GI Procedures 	J1	19.2764	"$1,557.22"	.	$311.45																																																																																																																																																																																																																						
5303	Level 3 Upper GI Procedures	J1	37.1206	"$2,998.75"	.	$599.75																																																																																																																																																																																																																						
5311	Level 1 Lower GI Procedures 	T	9.4548	$763.80	.	$152.76																																																																																																																																																																																																																						
5312	Level 2 Lower GI Procedures 	T	12.4295	"$1,004.10"	.	$200.82																																																																																																																																																																																																																						
5313	Level 3 Lower GI Procedures 	J1	29.0147	"$2,343.92"	.	$468.79																																																																																																																																																																																																																						
5331	Complex GI Procedures	J1	59.1738	"$4,780.30"	.	$956.06																																																																																																																																																																																																																						
5341	Abdominal/Peritoneal/Biliary and Related Procedures	J1	38.4853	"$3,109.00"	.	$621.80																																																																																																																																																																																																																						
5361	Level 1 Laparoscopy and Related Services	J1	59.8283	"$4,833.17"	.	$966.64																																																																																																																																																																																																																						
5362	Level 2 Laparoscopy and Related Services	J1	104.1317	"$8,412.18"	.	"$1,682.44"	#																																																																																																																																																																																																																					
5371	Level 1 Urology and Related Services	T	2.9074	$234.87	.	$46.98																																																																																																																																																																																																																						
5372	Level 2 Urology and Related Services	T	6.8884	$556.47	.	$111.30																																																																																																																																																																																																																						
5373	Level 3 Urology and Related Services	J1	21.9270	"$1,771.35"	.	$354.27																																																																																																																																																																																																																						
5374	Level 4 Urology and Related Services	J1	37.3614	"$3,018.20"	.	$603.64																																																																																																																																																																																																																						
5375	Level 5 Urology and Related Services	J1	52.3761	"$4,231.15"	.	$846.23																																																																																																																																																																																																																						
5376	Level 6 Urology and Related Services	J1	99.8593	"$8,067.03"	.	"$1,613.41"	#																																																																																																																																																																																																																					
5377	Level 7 Urology and Related Services	J1	217.5184	"$17,572.01"	.	"$3,514.41"	#																																																																																																																																																																																																																					
5401	Dialysis	S	7.9219	$639.96	.	$128.00																																																																																																																																																																																																																						
5411	Level 1 Gynecologic Procedures	T	2.0552	$166.03	.	$33.21																																																																																																																																																																																																																						
5412	Level 2 Gynecologic Procedures	T	3.3508	$270.69	.	$54.14																																																																																																																																																																																																																						
5413	Level 3 Gynecologic Procedures	T	7.9024	$638.39	.	$127.68																																																																																																																																																																																																																						
5414	Level 4 Gynecologic Procedures	J1	30.9198	"$2,497.83"	.	$499.57																																																																																																																																																																																																																						
5415	Level 5 Gynecologic Procedures	J1	52.8702	"$4,271.07"	$902.82	$854.22																																																																																																																																																																																																																						
5416	Level 6 Gynecologic Procedures	J1	82.9725	"$6,702.85"	"$1,405.70"	"$1,340.57"	#																																																																																																																																																																																																																					
5431	Level 1 Nerve Procedures	J1	21.2809	"$1,719.16"	.	$343.84																																																																																																																																																																																																																						
5432	Level 2 Nerve Procedures	J1	68.1867	"$5,508.39"	.	"$1,101.68"																																																																																																																																																																																																																						
5441	Level 1 Nerve Injections	T	3.2400	$261.74	.	$52.35																																																																																																																																																																																																																						
5442	Level 2 Nerve Injections	T	7.7364	$624.98	.	$125.00																																																																																																																																																																																																																						
5443	Level 3 Nerve Injections	T	10.0510	$811.96	.	$162.40																																																																																																																																																																																																																						
5461	Level 1 Neurostimulator and Related Procedures	J1	38.9699	"$3,148.14"	.	$629.63																																																																																																																																																																																																																						
5462	Level 2 Neurostimulator and Related Procedures	J1	76.5800	"$6,186.44"	.	"$1,237.29"																																																																																																																																																																																																																						
5463	Level 3 Neurostimulator and Related Procedures	J1	238.6273	"$19,277.27"	.	"$3,855.46"	#																																																																																																																																																																																																																					
5464	Level 4 Neurostimulator and Related Procedures	J1	360.4117	"$29,115.50"	.	"$5,823.10"	#																																																																																																																																																																																																																					
5471	Implantation of Drug Infusion Device	J1	204.4291	"$16,514.60"	.	"$3,302.92"	#																																																																																																																																																																																																																					
5481	Laser Eye Procedures	T	6.2744	$506.87	$101.51	$101.38																																																																																																																																																																																																																						
5491	Level 1 Intraocular Procedures	J1	25.0252	"$2,021.64"	.	$404.33																																																																																																																																																																																																																						
5492	Level 2 Intraocular Procedures	J1	47.2606	"$3,817.90"	.	$763.58																																																																																																																																																																																																																						
5493	Level 3 Intraocular Procedures	J1	76.7308	"$6,198.62"	.	"$1,239.73"																																																																																																																																																																																																																						
5494	Level 4 Intraocular Procedures	J1	159.3718	"$12,874.69"	.	"$2,574.94"	#																																																																																																																																																																																																																					
5495	Level 5 Intraocular Procedures	J1	255.9085	"$20,673.31"	.	"$4,134.67"	#																																																																																																																																																																																																																					
5501	"Level 1 Extraocular, Repair, and Plastic Eye Procedures"	T	3.3479	$270.46	.	$54.10																																																																																																																																																																																																																						
5502	"Level 2 Extraocular, Repair, and Plastic Eye Procedures"	T	9.9881	$806.88	.	$161.38																																																																																																																																																																																																																						
5503	"Level 3 Extraocular, Repair, and Plastic Eye Procedures"	J1	23.9526	"$1,934.99"	.	$387.00																																																																																																																																																																																																																						
5504	"Level 4 Extraocular, Repair, and Plastic Eye Procedures"	J1	38.7046	"$3,126.71"	.	$625.35																																																																																																																																																																																																																						
5521	Level 1 Imaging without Contrast	S	0.9878	$79.80	.	$15.96																																																																																																																																																																																																																						
5522	Level 2 Imaging without Contrast	S	1.3873	$112.07	.	$22.42																																																																																																																																																																																																																						
5523	Level 3 Imaging without Contrast	S	2.8844	$233.01	.	$46.61																																																																																																																																																																																																																						
5524	Level 4 Imaging without Contrast	S	5.9607	$481.53	.	$96.31																																																																																																																																																																																																																						
5571	Level 1 Imaging with Contrast	S	2.2554	$182.20	.	$36.44																																																																																																																																																																																																																						
5572	Level 2 Imaging with Contrast	S	4.7263	$381.81	.	$76.37																																																																																																																																																																																																																						
5573	Level 3 Imaging with Contrast	S	8.4267	$680.74	.	$136.15																																																																																																																																																																																																																						
5591	Level 1 Nuclear Medicine and Related Services 	S	4.5564	$368.08	.	$73.62																																																																																																																																																																																																																						
5592	Level 2 Nuclear Medicine and Related Services	S	5.8419	$471.93	.	$94.39																																																																																																																																																																																																																						
5593	Level 3 Nuclear Medicine and Related Services 	S	15.7463	"$1,272.05"	.	$254.41																																																																																																																																																																																																																						
5594	Level 4 Nuclear Medicine and Related Services	S	17.8625	"$1,443.00"	.	$288.60																																																																																																																																																																																																																						
5611	Level 1 Therapeutic Radiation Treatment Preparation	S	1.5669	$126.58	$32.03	$25.32																																																																																																																																																																																																																						
5612	Level 2 Therapeutic Radiation Treatment Preparation	S	4.1484	$335.12	.	$67.03																																																																																																																																																																																																																						
5613	Level 3 Therapeutic Radiation Treatment Preparation	S	15.4140	"$1,245.20"	.	$249.04																																																																																																																																																																																																																						
5621	Level 1 Radiation Therapy	S	1.5188	$122.69	.	$24.54																																																																																																																																																																																																																						
5622	Level 2 Radiation Therapy	S	2.9255	$236.33	.	$47.27																																																																																																																																																																																																																						
5623	Level 3 Radiation Therapy	S	6.6693	$538.77	.	$107.76																																																																																																																																																																																																																						
5624	Level 4 Radiation Therapy	S	9.1657	$740.44	.	$148.09																																																																																																																																																																																																																						
5625	Level 5 Radiation Therapy	S	15.4315	"$1,246.62"	.	$249.33																																																																																																																																																																																																																						
5626	Level 6 Radiation Therapy	S 	21.8887	"$1,768.26"	.	$353.66																																																																																																																																																																																																																						
5627	Level 7 Radiation Therapy	J1	98.3057	"$7,941.53"	.	"$1,588.31"	#																																																																																																																																																																																																																					
5661	Therapeutic Nuclear Medicine	S	2.9384	$237.38	.	$47.48																																																																																																																																																																																																																						
5671	Level 1 Pathology	S	0.6123	$49.46	.	$9.90																																																																																																																																																																																																																						
5672	Level 2 Pathology	S	1.7761	$143.48	.	$28.70																																																																																																																																																																																																																						
5673	Level 3 Pathology	S	3.5078	$283.37	.	$56.68																																																																																																																																																																																																																						
5674	Level 4 Pathology	S	7.7754	$628.13	.	$125.63																																																																																																																																																																																																																						
5691	Level 1 Drug Administration	S	0.4717	$38.11	.	$7.63																																																																																																																																																																																																																						
5692	Level 2 Drug Administration	S	0.7484	$60.46	.	$12.10																																																																																																																																																																																																																						
5693	Level 3 Drug Administration	S	2.2742	$183.72	.	$36.75																																																																																																																																																																																																																						
5694	Level 4 Drug Administration	S	3.8320	$309.56	.	$61.92																																																																																																																																																																																																																						
5721	Level1 Diagnostic Tests and Related Services	S	1.7124	$138.33	.	$27.67																																																																																																																																																																																																																						
5722	Level 2 Diagnostic Tests and Related Services	S	3.1327	$253.07	.	$50.62																																																																																																																																																																																																																						
5723	Level 3 Diagnostic Tests and Related Services	S	6.0105	$485.55	.	$97.11																																																																																																																																																																																																																						
5724	Level 4 Diagnostic Tests and Related Services	S	11.2503	$908.84	.	$181.77																																																																																																																																																																																																																						
5731	Level 1 Minor Procedures	S	0.2845	$22.98	.	$4.60																																																																																																																																																																																																																						
5732	Level 2 Minor Procedures	S	0.4138	$33.43	.	$6.69																																																																																																																																																																																																																						
5733	Level 3 Minor Procedures	S	0.6809	$55.01	.	$11.01																																																																																																																																																																																																																						
5734	Level 4 Minor Procedures	S	1.3495	$109.02	.	$21.81																																																																																																																																																																																																																						
5735	Level 5 Minor Procedures	S	4.5003	$363.55	.	$72.71																																																																																																																																																																																																																						
5741	Level 1 Electronic Analysis of Devices	S	0.4487	$36.25	.	$7.25																																																																																																																																																																																																																						
5742	Level 2 Electronic Analysis of Devices	S	1.4039	$113.41	.	$22.69																																																																																																																																																																																																																						
5743	Level 3 Electronic Analysis of Devices	S	3.3531	$270.88	.	$54.18																																																																																																																																																																																																																						
5771	Cardiac Rehabilitation	S	1.3619	$110.02	.	$22.01																																																																																																																																																																																																																						
5781	Resuscitation and Cardioversion	S	6.6399	$536.40	.	$107.28																																																																																																																																																																																																																						
5791	Pulmonary Treatment	S	2.2769	$183.94	.	$36.79																																																																																																																																																																																																																						
5801	Ventilation Initiation and Management	S	5.7496	$464.48	.	$92.90																																																																																																																																																																																																																						
5811	Manipulation Therapy	S	0.3035	$24.52	.	$4.91																																																																																																																																																																																																																						
5821	Level 1 Health and Behavior Services	S	0.3382	$27.32	.	$5.47																																																																																																																																																																																																																						
5822	Level 2 Health and Behavior Services	S	0.9721	$78.53	.	$15.71																																																																																																																																																																																																																						
5823	Level 3 Health and Behavior Services	S	1.6259	$131.35	.	$26.27																																																																																																																																																																																																																						
5853	Partial Hospitalization (3 or more services) for CMHCs	P	1.5385	$124.29	.	$24.86																																																																																																																																																																																																																						
5863	Partial Hospitalization (3 or more services) for Hospital-based PHPs	P	2.9540	$238.64	.	$47.73																																																																																																																																																																																																																						
5871	Dental Procedures	S	12.0688	$974.97	.	$195.00																																																																																																																																																																																																																						
5881	Ancillary Outpatient Services When Patient Dies	J1	83.2350	"$6,724.06"	.	"$1,344.82"																																																																																																																																																																																																																						
7000	Amifostine	K		"$1,003.594"	.	$200.72																																																																																																																																																																																																																						
7011	Oprelvekin injection	K		$163.980	.	$32.80																																																																																																																																																																																																																						
7035	Teniposide	K		"$2,645.707"	.	$529.15																																																																																																																																																																																																																						
7041	Tirofiban HCl	K		$6.917	.	$1.39																																																																																																																																																																																																																						
7043	Infliximab not biosimil 10mg	K		$63.285	.	$12.66																																																																																																																																																																																																																						
7046	Doxorubicin inj 10mg	K		$355.070	.	$71.02																																																																																																																																																																																																																						
7048	Alteplase recombinant	K		$87.638	.	$17.53																																																																																																																																																																																																																						
7308	Aminolevulinic acid hcl top	K		$390.979	.	$78.20																																																																																																																																																																																																																						
8004	Ultrasound Composite	S	3.8088	$307.69	.	$61.54																																																																																																																																																																																																																						
8005	CT and CTA without Contrast Composite	S	2.9958	$242.01	.	$48.41																																																																																																																																																																																																																						
8006	CT and CTA with Contrast Composite	S	5.7082	$461.13	.	$92.23																																																																																																																																																																																																																						
8007	MRI and MRA without Contrast Composite	S	6.7231	$543.12	.	$108.63																																																																																																																																																																																																																						
8008	MRI and MRA with Contrast Composite	S	10.7120	$865.36	.	$173.08																																																																																																																																																																																																																						
8010	Mental Health Services Composite	S	2.9540	$238.64	.	$47.73																																																																																																																																																																																																																						
8011	Comprehensive Observation Services	J2	27.2746	"$2,203.35"	.	$440.67																																																																																																																																																																																																																						
9002	Tenecteplase injection	K		$121.825	.	$24.37																																																																																																																																																																																																																						
9003	Palivizumab	K		"$1,205.050"	.	$241.01																																																																																																																																																																																																																						
9006	Tacrolimus injection	K		$211.839	.	$42.37																																																																																																																																																																																																																						
9012	Arsenic trioxide injection	K		$44.314	.	$8.87																																																																																																																																																																																																																						
9014	"Inj., cerliponase alfa 1 mg"	G		$93.506	.	$18.71																																																																																																																																																																																																																						
9015	"Inj., haegarda 10 units"	G		$9.672	.	$1.94																																																																																																																																																																																																																						
9016	"Inj., triptorelin xr 3.75 mg"	G		"$2,897.333"	.	$579.47																																																																																																																																																																																																																						
9018	"Inj, rimabotulinumtoxinB"	K		$11.987	.	$2.40																																																																																																																																																																																																																						
9024	Amphotericin b lipid complex	K		$6.184	.	$1.24																																																																																																																																																																																																																						
9028	Inj inotuzumab ozogam 0.1 mg	G		"$2,270.312"	.	$454.07																																																																																																																																																																																																																						
9029	"Inj., guselkumab, 1 mg"	G		$100.205	.	$20.05																																																																																																																																																																																																																						
9030	"Inj., copanlisib, 1 mg"	G		$79.415	.	$15.89																																																																																																																																																																																																																						
9031	"Inj, etelcalcetide, 0.1 mg"	K		$2.602	.	$0.53																																																																																																																																																																																																																						
9032	Baclofen 10 MG injection	K		$169.513	.	$33.91																																																																																																																																																																																																																						
9033	Cidofovir injection	K		$623.268	.	$124.66																																																																																																																																																																																																																						
9034	"Inj cuvitru, 100 mg"	K		$13.787	.	$2.76																																																																																																																																																																																																																						
9035	Axicabtagene ciloleucel car+ 	G		"$395,380.000"	.	"$79,076.00"	#																																																																																																																																																																																																																					
9036	"Injection, renflexis"	G		$53.395	.	$10.68																																																																																																																																																																																																																						
9038	Inj estrogen conjugate	K		$308.930	.	$61.79																																																																																																																																																																																																																						
9042	Glucagon hydrochloride	K		$199.272	.	$39.86																																																																																																																																																																																																																						
9043	"Inj, afstyla, 1 i.u."	K		$1.355	.	$0.28																																																																																																																																																																																																																						
9044	Ibutilide fumarate injection	K		$278.770	.	$55.76																																																																																																																																																																																																																						
9058	Buprenorphine implant 74.2mg	K		"$1,303.529"	.	$260.71																																																																																																																																																																																																																						
9059	Vonvendi inj 1 iu vwf:rco	K		$1.828	.	$0.37																																																																																																																																																																																																																						
9065	Argatroban esrd dialysis 1mg	K 		$1.194	.	$0.24																																																																																																																																																																																																																						
9067	Lutetium lu 177 dotatat ther	G		$259.170	.	$51.84																																																																																																																																																																																																																						
9070	Inj luxturna 1 billion vec g	G		"$2,923.668"	.	$584.74																																																																																																																																																																																																																						
9071	Capsaicin 8% patch	K		$3.152	.	$0.64																																																																																																																																																																																																																						
9073	Buprenorph xr 100 mg or less	G		"$1,673.362"	.	$334.68																																																																																																																																																																																																																						
9074	"Makena, 10 mg"	K		$22.396	.	$4.48																																																																																																																																																																																																																						
9078	Testosterone undecanoate 1mg	K		$1.466	.	$0.30																																																																																																																																																																																																																						
9079	"Genvisc 850, inj, 1mg"	K		$16.918	.	$3.39																																																																																																																																																																																																																						
9084	Florbetapir f18	G		"$3,028.844"	.	$0.00																																																																																																																																																																																																																						
9085	Inj sulf hexa lipid microsph	G		$19.535	.	$0.00																																																																																																																																																																																																																						
9088	Peng benzathine/procaine inj	K		$10.887	.	$2.18																																																																																																																																																																																																																						
9092	Interferon alfa-2a inj	K		$169.330	.	$33.87																																																																																																																																																																																																																						
9094	Radiesse injection	K		$473.900	.	$94.78																																																																																																																																																																																																																						
9095	"Inj, sculptra, 0.5mg"	K		$3.280	.	$0.66																																																																																																																																																																																																																						
9096	Inj retacrit esrd on dialysi	G		$0.963	.	$0.20																																																																																																																																																																																																																						
9097	Inj retacrit non-esrd use	G		$9.629	.	$1.93																																																																																																																																																																																																																						
9099	"Inj fosnetupitant, palonoset"	G		$416.867	.	$83.38																																																																																																																																																																																																																						
9104	Antithymocyte globuln rabbit	K		$768.555	.	$153.72																																																																																																																																																																																																																						
9108	Thyrotropin injection	K		"$1,695.118"	.	$339.03																																																																																																																																																																																																																						
9119	"Injection, pegfilgrastim 6mg"	K		"$4,432.555"	.	$886.52																																																																																																																																																																																																																						
9120	"Injection, Fulvestrant"	K		$94.874	.	$18.98																																																																																																																																																																																																																						
9122	Triptorelin pamoate	K		$258.739	.	$51.75																																																																																																																																																																																																																						
9124	Daptomycin injection	K		$0.330	.	$0.07																																																																																																																																																																																																																						
9125	"Risperidone, long acting"	K		$10.044	.	$2.01																																																																																																																																																																																																																						
9126	Natalizumab injection	K		$20.242	.	$4.05																																																																																																																																																																																																																						
9131	"Inj, Ado-trastuzumab Emt 1mg"	K		$31.364	.	$6.28																																																																																																																																																																																																																						
9132	"Kcentra, per i.u."	K		$2.002	.	$0.41																																																																																																																																																																																																																						
9133	"Rabies ig, im/sc"	K		$280.644	.	$56.13																																																																																																																																																																																																																						
9134	"Rabies ig, heat treated"	K		$271.374	.	$54.28																																																																																																																																																																																																																						
9135	"Varicella-zoster ig, im"	K		"$1,716.184"	.	$343.24																																																																																																																																																																																																																						
9139	"Rabies vaccine, im"	K		$297.589	.	$59.52																																																																																																																																																																																																																						
9140	"Rabies vaccine, id"	K		$130.010	.	$26.01																																																																																																																																																																																																																						
9171	Factor ix idelvion inj	K		$4.293	.	$0.86																																																																																																																																																																																																																						
9172	"Injection, dexamethasone 9%"	G		$1.185	.	$0.24																																																																																																																																																																																																																						
9173	"Injection, fulphila"	G		$327.413	.	$65.49																																																																																																																																																																																																																						
9174	"Inj, durolane 1 mg"	G		$17.225	.	$3.45																																																																																																																																																																																																																						
9175	Puraply 1 sq cm	G		$89.703	.	$0.00																																																																																																																																																																																																																						
9176	Puraply am 1 sq cm	G		$104.832	.	$0.00																																																																																																																																																																																																																						
9177	Antithrombin recombinant	K		$103.350	.	$20.67																																																																																																																																																																																																																						
9178	"Inj., meropenem, vaborbactam"	K		$1.788	.	$0.36																																																																																																																																																																																																																						
9179	"Injection, Aristada Initio"	G		$2.856	.	$0.58																																																																																																																																																																																																																						
9180	"Inj., patisiran, 0.1 mg"	G		$98.322	.	$19.67																																																																																																																																																																																																																						
9181	"Inj., perseris, 0.5 mg"	G		$9.866	.	$1.98																																																																																																																																																																																																																						
9182	"Inj mogamulizumab-kpkc, 1 mg"	G		$200.870	.	$40.18																																																																																																																																																																																																																						
9183	"Inj., plazomicin, 5 mg"	G		$3.219	.	$0.65																																																																																																																																																																																																																						
9186	"Inj., rituximab, 10 mg"	K		$94.667	.	$18.94																																																																																																																																																																																																																						
9187	"Injection, burosumab-twza 1m"	K		$353.210	.	$70.65																																																																																																																																																																																																																						
9188	Inj crotalidae im f(ab')2 eq	K		"$1,264.421"	.	$252.89																																																																																																																																																																																																																						
9189	"Inj., ibalizumab-uiyk, 10 mg"	K		$60.155	.	$12.04																																																																																																																																																																																																																						
9190	"Inj., vestronidase alfa-vjbk"	K		$218.332	.	$43.67																																																																																																																																																																																																																						
9191	"Inj., fibryga, 1 mg"	K		$1.139	.	$0.23																																																																																																																																																																																																																						
9192	"Inj, bortezomib, nos, 0.1 mg"	K		$25.039	.	$5.01																																																																																																																																																																																																																						
9193	Nivestym	G		$0.635	.	$0.13																																																																																																																																																																																																																						
9194	Tisagenlecleucel car-pos t	G		"$441,508.391"	.	"$88,301.68"	#																																																																																																																																																																																																																					
9195	"Injection, udenyca 0.5 mg"	G		$347.056	.	$69.42																																																																																																																																																																																																																						
9196	"Inj, trivisc 1 mg"	K		$7.195	.	$1.44																																																																																																																																																																																																																						
9197	"Inj., fremanezumab-vfrm 1 mg"	G		$2.505	.	$0.51																																																																																																																																																																																																																						
9198	"Inj, coagulation factor Xa"	G		$291.500	.	$58.30																																																																																																																																																																																																																						
9199	"Injection, caplacizumab-yhdp"	G		$683.545	.	$136.71																																																																																																																																																																																																																						
9207	"Inj., velcade 0.1 mg"	K		$44.687	.	$8.94																																																																																																																																																																																																																						
9208	Agalsidase beta injection	K		$183.430	.	$36.69																																																																																																																																																																																																																						
9209	Laronidase injection	K		$32.136	.	$6.43																																																																																																																																																																																																																						
9213	Pemetrexed injection	K		$69.472	.	$13.90																																																																																																																																																																																																																						
9214	Bevacizumab injection	K		$81.182	.	$16.24																																																																																																																																																																																																																						
9215	Cetuximab injection	K		$62.048	.	$12.41																																																																																																																																																																																																																						
9217	Leuprolide acetate suspnsion	K		$224.698	.	$44.94																																																																																																																																																																																																																						
9224	Galsulfase injection	K		$397.922	.	$79.59																																																																																																																																																																																																																						
9225	Fluocinolone acetonide implt	K		$341.615	.	$68.33																																																																																																																																																																																																																						
9228	Tigecycline injection	K		$1.566	.	$0.32																																																																																																																																																																																																																						
9229	Ibandronate sodium injection	K		$43.480	.	$8.70																																																																																																																																																																																																																						
9230	Abatacept injection	K		$54.318	.	$10.87																																																																																																																																																																																																																						
9231	Decitabine injection	K		$7.485	.	$1.50																																																																																																																																																																																																																						
9232	Idursulfase injection	K		$542.887	.	$108.58																																																																																																																																																																																																																						
9233	Ranibizumab injection	K		$352.174	.	$70.44																																																																																																																																																																																																																						
9234	Alglucosidase alfa injection	K		$141.140	.	$28.23																																																																																																																																																																																																																						
9235	Panitumumab injection	K		$119.071	.	$23.82																																																																																																																																																																																																																						
9236	Eculizumab injection	K		$230.479	.	$46.10																																																																																																																																																																																																																						
9237	"Inj, lanreotide acetate"	K		$62.324	.	$12.47																																																																																																																																																																																																																						
9239	Buprenorphine xr over 100 mg	G		"$1,673.362"	.	$334.68																																																																																																																																																																																																																						
9240	"Injection, ixabepilone"	K		$91.065	.	$18.22																																																																																																																																																																																																																						
9242	"Injection, fosaprepitant"	K		$1.969	.	$0.40																																																																																																																																																																																																																						
9243	"Inj., treanda 1 mg"	K		$27.844	.	$5.57																																																																																																																																																																																																																						
9245	Romiplostim injection	K		$74.275	.	$14.86																																																																																																																																																																																																																						
9251	C1 esterase inhibitor inj	K		$57.031	.	$11.41																																																																																																																																																																																																																						
9252	Plerixafor injection	K		$347.712	.	$69.55																																																																																																																																																																																																																						
9253	Temozolomide injection	K		$10.392	.	$2.08																																																																																																																																																																																																																						
9255	Paliperidone palmitate inj	K		$11.630	.	$2.33																																																																																																																																																																																																																						
9256	Dexamethasone intra implant	K		$200.026	.	$40.01																																																																																																																																																																																																																						
9257	"Inj., emicizumab-kxwh 0.5 mg"	G		$47.348	.	$9.47																																																																																																																																																																																																																						
9258	Telavancin injection	K		$5.737	.	$1.15																																																																																																																																																																																																																						
9259	Pralatrexate injection	K		$291.264	.	$58.26																																																																																																																																																																																																																						
9260	Ofatumumab injection	K		$60.093	.	$12.02																																																																																																																																																																																																																						
9261	"Ustekinumab sub cu inj, 1 mg"	K		$191.387	.	$38.28																																																																																																																																																																																																																						
9263	Ecallantide injection	K		$493.743	.	$98.75																																																																																																																																																																																																																						
9264	Tocilizumab injection	K		$4.958	.	$1.00																																																																																																																																																																																																																						
9265	Romidepsin injection	K		$297.586	.	$59.52																																																																																																																																																																																																																						
9269	"C-1 esterase, berinert"	K		$51.305	.	$10.27																																																																																																																																																																																																																						
9270	Gammaplex IVIG	K		$45.824	.	$9.17																																																																																																																																																																																																																						
9271	Velaglucerase alfa	K		$345.522	.	$69.11																																																																																																																																																																																																																						
9272	"Inj, denosumab"	K		$19.276	.	$3.86																																																																																																																																																																																																																						
9273	Sipuleucel-T auto CD54+	K		"$46,374.199"	.	"$9,274.84"	#																																																																																																																																																																																																																					
9274	Crotalidae Poly Immune Fab	K		"$3,285.188"	.	$657.04																																																																																																																																																																																																																						
9276	Cabazitaxel injection	K		$173.666	.	$34.74																																																																																																																																																																																																																						
9278	Incobotulinumtoxin A	K		$5.054	.	$1.02																																																																																																																																																																																																																						
9281	"Injection, pegloticase"	K		"$2,512.548"	.	$502.51																																																																																																																																																																																																																						
9284	Ipilimumab injection	K		$153.128	.	$30.63																																																																																																																																																																																																																						
9286	Belatacept injection	K		$3.776	.	$0.76																																																																																																																																																																																																																						
9287	Brentuximab vedotin inj	K		$162.437	.	$32.49																																																																																																																																																																																																																						
9289	Erwinaze injection	K		$414.825	.	$82.97																																																																																																																																																																																																																						
9294	"Inj, taliglucerase alfa 10 u"	K		$40.084	.	$8.02																																																																																																																																																																																																																						
9295	"Injection, Carfilzomib, 1 mg"	K		$37.599	.	$7.52																																																																																																																																																																																																																						
9296	"Inj, ziv-aflibercept, 1mg"	K		$8.374	.	$1.68																																																																																																																																																																																																																						
9297	"Inj, Omacetaxine Mep, 0.01mg"	K		$3.110	.	$0.63																																																																																																																																																																																																																						
9298	"Inj, Ocriplasmin, 0.125 mg"	K		"$1,046.927"	.	$209.39																																																																																																																																																																																																																						
9299	Inj. jivi 1 iu	G		$2.018	.	$0.41																																																																																																																																																																																																																						
9300	Omalizumab injection	K		$36.778	.	$7.36																																																																																																																																																																																																																						
9301	"Aminolevulinic acid, 10% gel"	G		$1.448	.	$0.29																																																																																																																																																																																																																						
9302	"Inj daunorubicin, cytarabine"	G		$192.306	.	$38.47																																																																																																																																																																																																																						
9304	"Inj., cemiplimab-rwlc, 1 mg"	G		$27.447	.	$5.49																																																																																																																																																																																																																						
9305	"Inj., lumoxiti, 0.01 mg"	G		$22.083	.	$4.42																																																																																																																																																																																																																						
9306	"Inj., tildrakizumab, 1 mg"	G		$136.489	.	$27.30																																																																																																																																																																																																																						
9307	Cocaine hcl nasal solution	G		$0.859	.	$0.18																																																																																																																																																																																																																						
9308	Dexametha opth insert 0.1 mg	G		$151.410	.	$30.29																																																																																																																																																																																																																						
9309	Inj. tagraxofusp-erzs 10 mcg	G		$258.958	.	$51.80																																																																																																																																																																																																																						
9310	"Inj., emapalumab-lzsg, 1 mg"	G		$780.047	.	$156.01																																																																																																																																																																																																																						
9311	"Inj., omadacycline, 1 mg"	G		$3.492	.	$0.70																																																																																																																																																																																																																						
9312	"Inj., ravulizumab-cwvz 10 mg"	G		$226.275	.	$45.26																																																																																																																																																																																																																						
9313	Inj. belrapzo/bendamustine	G		$24.355	.	$4.88																																																																																																																																																																																																																						
9314	"Inj. herceptin hylecta, 10mg"	G		$80.258	.	$16.06																																																																																																																																																																																																																						
9315	"	Diphtheria antitoxin"	K		$12.680	.	$2.54																																																																																																																																																																																																																						
9316	Corticotropin injection	K		"$3,946.500"	.	$789.30																																																																																																																																																																																																																						
9317	Doripenem injection	K		$0.885	.	$0.18																																																																																																																																																																																																																						
9318	Inj hydroxyprogst capoat nos	K		$10.810	.	$2.17																																																																																																																																																																																																																						
9319	Somatropin injection	K		$1.670	.	$0.34																																																																																																																																																																																																																						
9320	Carbidopa levodopa ent 100ml	K		$219.448	.	$43.89																																																																																																																																																																																																																						
9321	Fosphenytoin inj pe	K		$1.725	.	$0.35																																																																																																																																																																																																																						
9322	Bcg live intravesical 1mg	K		$2.821	.	$0.57																																																																																																																																																																																																																						
9324	Phenylep ketorolac opth soln	G		$112.353	.	$22.48																																																																																																																																																																																																																						
9325	"Inj., eravacycline, 1 mg"	K		$0.957	.	$0.20																																																																																																																																																																																																																						
9326	"Inj., lanadelumab-flyo, 1 mg"	K		$76.344	.	$15.27																																																																																																																																																																																																																						
9327	Inj. romosozumab-aqqg 1 mg	G		$8.951	.	$1.80																																																																																																																																																																																																																						
9328	"Inj., yutiq, 0.01 mg"	K		$491.133	.	$98.23																																																																																																																																																																																																																						
9329	Inj mvasi 10 mg	G		$69.772	.	$13.96																																																																																																																																																																																																																						
9330	"Inj., kanjinti, 10 mg"	G		$90.671	.	$18.14																																																																																																																																																																																																																						
9331	"Inj, polatuzumab vedotin 1mg"	G		$110.357	.	$22.08																																																																																																																																																																																																																						
9332	"Injection, lefamulin"	G		$0.704	.	$0.15																																																																																																																																																																																																																						
9333	"Inj, brexanolone"	G		$76.735	.	$15.35																																																																																																																																																																																																																						
9334	"Injection, khapzory, 0.5 mg"	G		$2.040	.	$0.41																																																																																																																																																																																																																						
9335	Oral busulfan	K 		$24.181	.	$4.84																																																																																																																																																																																																																						
9337	"Synojoynt, inj., 1 mg"	K 		$6.129	.	$1.23																																																																																																																																																																																																																						
9338	"Inj., triluron, 1 mg"	K 		$25.184	.	$5.04																																																																																																																																																																																																																						
9339	Iodine i-131 iobenguane 1mci	G		$311.060	.	$62.22																																																																																																																																																																																																																						
9340	"Inj, brolucizumab-dbll, 1 mg"	K 		$317.583	.	$63.52																																																																																																																																																																																																																						
9441	Inj ferric carboxymaltos 1mg	K		$1.097	.	$0.22																																																																																																																																																																																																																						
9445	"Injection, ruconest"	K		$28.219	.	$5.65																																																																																																																																																																																																																						
9448	"Oral netupitant, palonosetro"	K		$245.742	.	$49.15																																																																																																																																																																																																																						
9449	"Injection, blinatumomab"	K		$113.397	.	$22.68																																																																																																																																																																																																																						
9450	Fluocinol acet intravit imp	K		$490.865	.	$98.18																																																																																																																																																																																																																						
9451	"Injection, peramivir"	K		$1.642	.	$0.33																																																																																																																																																																																																																						
9452	Inj ceftolozane tazobactam	K		$5.602	.	$1.13																																																																																																																																																																																																																						
9453	"Injection, nivolumab"	K		$27.805	.	$5.57																																																																																																																																																																																																																						
9454	"Inj, pasireotide long acting"	K		$303.034	.	$60.61																																																																																																																																																																																																																						
9455	"Injection, siltuximab"	K		$103.062	.	$20.62																																																																																																																																																																																																																						
9456	"Injection, isavuconazonium"	K		$0.784	.	$0.16																																																																																																																																																																																																																						
9460	"Injection, cangrelor"	K		$15.378	.	$3.08																																																																																																																																																																																																																						
9462	"Injection, delafloxacin"	G		$0.468	.	$0.10																																																																																																																																																																																																																						
9463	"Inj., aprepitant, 1 mg"	G		$2.170	.	$0.44																																																																																																																																																																																																																						
9464	"Inj., rolapitant, 0.5 mg"	G		$0.939	.	$0.19																																																																																																																																																																																																																						
9466	"Inj., benralizumab, 1 mg"	G		$168.502	.	$33.71																																																																																																																																																																																																																						
9467	"Inj rituximab, hyaluronidase"	G		$43.528	.	$8.71																																																																																																																																																																																																																						
9468	Factor ix recomb gly rebinyn	G		$3.987	.	$0.80																																																																																																																																																																																																																						
9469	Inj triamcinolone ace xr 1mg	G		$18.880	.	$3.78																																																																																																																																																																																																																						
9470	Aripirazole lauroxil 1 mg	K		$2.778	.	$0.56																																																																																																																																																																																																																						
9471	Hymovis injection 1 mg	K		$31.668	.	$6.34																																																																																																																																																																																																																						
9472	Inj talimogene laherparepvec	K		$51.466	.	$10.30																																																																																																																																																																																																																						
9473	"Injection, mepolizumab, 1mg"	K		$29.720	.	$5.95																																																																																																																																																																																																																						
9474	Inj irinotecan liposome 1 mg	K		$49.913	.	$9.99																																																																																																																																																																																																																						
9475	"Injection, necitumumab, 1 mg"	K		$5.744	.	$1.15																																																																																																																																																																																																																						
9476	"Injection, daratumumab 10 mg"	K		$53.948	.	$10.79																																																																																																																																																																																																																						
9477	"Injection, elotuzumab, 1mg"	K		$6.496	.	$1.30																																																																																																																																																																																																																						
9478	Inj sebelipase alfa 1 mg	K		$541.130	.	$108.23																																																																																																																																																																																																																						
9479	"Instill, ciprofloxacin otic"	K		$29.972	.	$6.00																																																																																																																																																																																																																						
9480	Injection trabectedin 0.1mg	K		$312.913	.	$62.59																																																																																																																																																																																																																						
9481	"Injection, reslizumab"	K		$9.616	.	$1.93																																																																																																																																																																																																																						
9482	Sotalol hydrochloride IV	K		$9.985	.	$2.00																																																																																																																																																																																																																						
9483	"Inj, atezolizumab,10 mg"	K		$77.008	.	$15.41																																																																																																																																																																																																																						
9484	"Inj, eteplirsen, 10 mg"	G		$167.364	.	$33.48																																																																																																																																																																																																																						
9485	"Inj, olaratumab, 10 mg"	G		$52.134	.	$10.43																																																																																																																																																																																																																						
9486	"Inj, granisetron, xr, 0.1 mg"	G		$2.744	.	$0.55																																																																																																																																																																																																																						
9487	"Ustekinumab, iv inject,1 mg"	G		$12.037	.	$2.41																																																																																																																																																																																																																						
9488	Conivaptan hcl	G		$31.564	.	$6.32																																																																																																																																																																																																																						
9489	"Inj, nusinersen, 0.1mg"	G		"$1,101.828"	.	$220.37																																																																																																																																																																																																																						
9490	"Inj, bezlotoxumab, 10 mg"	G		$39.829	.	$7.97																																																																																																																																																																																																																						
9491	"Injection, avelumab, 10 mg"	G		$82.969	.	$16.60																																																																																																																																																																																																																						
9492	"Inj., durvalumab, 10 mg"	G		$74.636	.	$14.93																																																																																																																																																																																																																						
9493	"Injection, edaravone, 1 mg"	G		$19.485	.	$3.90																																																																																																																																																																																																																						
9494	"Injection, ocrelizumab"	G		$57.417	.	$11.49																																																																																																																																																																																																																						
9495	Gemtuzumab ozogamicin inj	G		$199.230	.	$39.85																																																																																																																																																																																																																						
9500	"Platelets, irradiated"	R	1.7285	$139.64	.	$27.93																																																																																																																																																																																																																						
9501	Platelet pheres leukoreduced	R	6.1838	$499.55	.	$99.91																																																																																																																																																																																																																						
9502	Platelet pheresis irradiated	R	8.5698	$692.30	.	$138.46																																																																																																																																																																																																																						
9503	Fr frz plasma donor retested	R	0.6187	$49.98	.	$10.00																																																																																																																																																																																																																						
9504	RBC deglycerolized	R	3.9664	$320.42	.	$64.09																																																																																																																																																																																																																						
9505	RBC irradiated	R	2.3618	$190.80	.	$38.16																																																																																																																																																																																																																						
9507	"Platelets, pheresis"	R	4.0105	$323.98	.	$64.80																																																																																																																																																																																																																						
9508	Plasma 1 donor frz w/in 8 hr	R	1.0366	$83.74	.	$16.75																																																																																																																																																																																																																						
9509	"Frozen plasma, pooled, sd"	R	0.9919	$80.13	.	$16.03																																																																																																																																																																																																																						
9510	Whole blood for transfusion	R	1.5744	$127.19	.	$25.44																																																																																																																																																																																																																						
9511	Cryoprecipitate each unit	R	0.6243	$50.43	.	$10.09																																																																																																																																																																																																																						
9512	RBC leukocytes reduced	R	2.3313	$188.33	.	$37.67																																																																																																																																																																																																																						
9513	"Plasma, frz between 8-24hour"	R	0.9396	$75.90	.	$15.18																																																																																																																																																																																																																						
9514	"Plasma protein fract,5%,50ml"	R	0.2281	$18.43	.	$3.69																																																																																																																																																																																																																						
9515	"Platelets, each unit"	R	1.3372	$108.02	.	$21.61																																																																																																																																																																																																																						
9516	Plaelet rich plasma unit	R	1.7481	$141.22	.	$28.25																																																																																																																																																																																																																						
9517	Red blood cells unit	R	1.7299	$139.75	.	$27.95																																																																																																																																																																																																																						
9518	Washed red blood cells unit	R	4.7000	$379.68	.	$75.94																																																																																																																																																																																																																						
9519	"Plasmaprotein fract,5%,250ml"	R	1.3825	$111.68	.	$22.34																																																																																																																																																																																																																						
9520	Blood split unit	R	1.6645	$134.46	.	$26.90																																																																																																																																																																																																																						
9521	Platelets leukoreduced irrad	R	2.6874	$217.10	.	$43.42																																																																																																																																																																																																																						
9522	RBC leukoreduced irradiated	R	3.2523	$262.73	.	$52.55																																																																																																																																																																																																																						
9523	Cryoprecipitatereducedplasma	R	1.1314	$91.40	.	$18.28																																																																																																																																																																																																																						
9524	"Blood, l/r, cmv-neg"	R	2.3283	$188.09	.	$37.62																																																																																																																																																																																																																						
9525	"Platelets, hla-m, l/r, unit"	R	10.5754	$854.32	.	$170.87																																																																																																																																																																																																																						
9526	Platelets leukocytes reduced	R	1.5639	$126.34	.	$25.27																																																																																																																																																																																																																						
9527	"Blood, l/r, froz/degly/wash"	R	3.4793	$281.07	.	$56.22																																																																																																																																																																																																																						
9528	"Plt, aph/pher, l/r, cmv-neg"	R	6.0051	$485.12	.	$97.03																																																																																																																																																																																																																						
9529	"Blood, l/r, irradiated"	R	2.5167	$203.31	.	$40.67																																																																																																																																																																																																																						
9530	Plate pheres leukoredu irrad	R	7.8558	$634.62	.	$126.93																																																																																																																																																																																																																						
9531	"Plt, pher, l/r cmv-neg, irr"	R	6.2164	$502.19	.	$100.44																																																																																																																																																																																																																						
9532	"RBC, frz/deg/wsh, l/r, irrad"	R	2.9909	$241.62	.	$48.33																																																																																																																																																																																																																						
9533	"RBC, l/r, cmv-neg, irrad"	R	3.0548	$246.78	.	$49.36																																																																																																																																																																																																																						
9534	Pathogen reduced plasma pool	R	0.3998	$32.30	.	$6.46																																																																																																																																																																																																																						
9535	Pathogen reduced plasma sing	R	0.9915	$80.10	.	$16.02																																																																																																																																																																																																																						
9536	Platelets pheresis path redu	R	7.5750	$611.94	.	$122.39																																																																																																																																																																																																																						
																																																																																																																																																																																																																												
The addendum A reflects 2019 Inpatient deductible amount. 2020 Deductible will apply when it is available																																																																																																																																																																																																																												
