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PLA Codes

Laboratory Fee Schedule

2019
2018

Physician Fee Schedule

2019
2018

OPPS Fee Schedule

2019-April
2019-January

ASC Fee Schedule

2019-April
2019-January

APC Codes

2019-April
2019-January

DRG Codes

2019
2018

ASP Drug Pricing Files

April 2019
January 2019


CMS Transmittals



--

Addendum A.- OPPS APCs effective October 2018

APC Code
Group Title
Status Indicator
Addendum A Payment Rate
0701
Sr89 strontium
K
$XXX.XX
0726
Dexrazoxane HCl injection
K
$XXX.XX
0731
Sargramostim injection
K
$XXX.XX
0736
Amphotericin b liposome inj
K
$XXX.XX
0738
Rasburicase
K
$XXX.XX
0751
Mechlorethamine hcl inj
K
$XXX.XX
0752
Dactinomycin injection
K
$XXX.XX
0759
Naltrexone, depot form
K
$XXX.XX
0800
Leuprolide acetate
K
$XXX.XX
0802
Etoposide oral
K
$XXX.XX
0807
Aldesleukin injection
K
$XXX.XX
0809
Bcg live intravesical vac
K
$XXX.XX
0810
Goserelin acetate implant
K
$XXX.XX
0812
Carmustine injection
K
$XXX.XX
0820
Daunorubicin injection
K
$XXX.XX
0823
Docetaxel injection
K
$XXX.XX
0825
Nelarabine injection
K
$XXX.XX
0832
Idarubicin hcl injection
K
$XXX.XX
0836
Interferon alfa-2b inj
K
$XXX.XX
0840
Inj melphalan hydrochl
K
$XXX.XX
0843
Pegaspargase injection
K
$XXX.XX
0844
Pentostatin injection
K
$XXX.XX
0849
Rituximab injection
K
$XXX.XX
0850
Streptozocin injection
K
$XXX.XX
0851
Thiotepa injection
K
$XXX.XX
0856
Porfimer sodium injection
K
$XXX.XX
0858
Inj cladribine
K
$XXX.XX
0864
Mitoxantrone hydrochl
K
$XXX.XX
0868
Oral aprepitant
K
$XXX.XX
0873
Hyalgan supartz visco-3 dose
K
$XXX.XX
0874
Synvisc or synvisc-one
K
$XXX.XX
0875
Euflexxa inj per dose
K
$XXX.XX
0877
Orthovisc inj per dose
K
$XXX.XX
0887
Azathioprine parenteral
K
$XXX.XX
0890
Lymphocyte immune globulin
K
$XXX.XX
0901
Alpha 1 proteinase inhibitor
K
$XXX.XX
0902
Injection,onabotulinumtoxinA
K
$XXX.XX
0903
Cytomegalovirus imm IV /vial
K
$XXX.XX
0910
Interferon beta-1b / .25 MG
K
$XXX.XX
0925
Factor viii
K
$XXX.XX
0927
Factor viii recombinant
K
$XXX.XX
0928
Factor ix complex
K
$XXX.XX
0929
Anti-inhibitor
K
$XXX.XX
0931
Factor IX non-recombinant
K
$XXX.XX
0932
Factor ix recombinant nos
K
$XXX.XX
0943
Octagam injection
K
$XXX.XX
0944
Gammagard liquid injection
K
$XXX.XX
0946
Hepagam b im injection
K
$XXX.XX
0947
Flebogamma injection
K
$XXX.XX
0948
Gamunex-C/Gammaked
K
$XXX.XX
0961
Albumin (human),5%, 50ml
K
$XXX.XX
0963
Albumin (human), 5%, 250 ml
K
$XXX.XX
0964
Albumin (human), 25%, 20 ml
K
$XXX.XX
0965
Albumin (human), 25%, 50ml
K
$XXX.XX
1015
Injection glatiramer acetate
K
$XXX.XX
1052
Injection, voriconazole
K
$XXX.XX
1064
I131 iodide cap, rx
K
$XXX.XX
1083
Adalimumab injection
K
$XXX.XX
1138
Hepagam b intravenous, inj
K
$XXX.XX
1139
Protein c concentrate
K
$XXX.XX
1142
Supprelin LA implant
K
$XXX.XX
1150
I131 iodide sol, rx
K
$XXX.XX
1166
Cytarabine liposome inj
K
$XXX.XX
1168
Inj, temsirolimus
K
$XXX.XX
1178
Busulfan injection
K
$XXX.XX
1203
Verteporfin injection
K
$XXX.XX
1207
Octreotide injection, depot
K
$XXX.XX
1213
Antihemophilic viii/vwf comp
K
$XXX.XX
1214
Inj IVIG privigen 500 mg
K
$XXX.XX
1232
Mitomycin injection
K
$XXX.XX
1235
Valrubicin injection
K
$XXX.XX
1236
Levoleucovorin injection
K
$XXX.XX
1237
Inj iron dextran
K
$XXX.XX
1238
Topotecan oral
K
$XXX.XX
1253
Triamcinolone A inj PRS-free
K
$XXX.XX
1263
Antithrombin iii injection
K
$XXX.XX
1268
Xyntha inj
K
$XXX.XX
1274
Edetate calcium disodium inj
K
$XXX.XX
1280
Corticotropin injection
K
$XXX.XX
1281
Bevacizumab injection
K
$XXX.XX
1289
AbobotulinumtoxinA
K
$XXX.XX
1291
Rilonacept injection
K
$XXX.XX
1295
Sm 153 lexidronam
K
$XXX.XX
1296
Degarelix injection
K
$XXX.XX
1297
Ferumoxytol, non-esrd
K
$XXX.XX
1311
Canakinumab injection
K
$XXX.XX
1312
Hizentra injection
K
$XXX.XX
1327
Imiglucerase injection
K
$XXX.XX
1340
Collagenase, clost hist inj
K
$XXX.XX
1341
Amobarbital 125 MG inj
K
$XXX.XX
1352
Wilate injection
K
$XXX.XX
1353
Belimumab injection
K
$XXX.XX
1408
Cyclophosphamide 100 MG inj
K
$XXX.XX
1413
Lumizyme injection
K
$XXX.XX
1415
Glassia injection
K
$XXX.XX
1416
Factor xiii anti-hem factor
K
$XXX.XX
1417
Gel-one
K
$XXX.XX
1420
Aflibercept injection
K
$XXX.XX
1426
Eribulin mesylate injection
K
$XXX.XX
1431
Centruroides immune f(ab)
K
$XXX.XX
1433
Calcitonin salmon injection
K
$XXX.XX
1440
Inj desmopressin acetate
K
$XXX.XX
1442
Non-HEU TC-99M add-on/dose
K
$XXX.XX
1443
Icatibant injection
K
$XXX.XX
1446
Visualization adjunct
K
$XXX.XX
1458
Phentolaine mesylate inj
K
$XXX.XX
1466
Inj, vincristine sul lip 1mg
K
$XXX.XX
1467
Factor ix recombinan rixubis
K
$XXX.XX
1468
Inj Aripiprazole Ext Rel 1mg
K
$XXX.XX
1469
Inj filgrastim excl biosimil
K
$XXX.XX
1471
Injection, Pertuzumab, 1 mg
K
$XXX.XX
1472
Inj beta interferon im 1 mcg
K
$XXX.XX
1474
Certolizumab pegol inj 1mg
K
$XXX.XX
1475
Golimumab for iv use 1mg
K
$XXX.XX
1476
Obinutuzumab inj
K
$XXX.XX
1478
Human fibrinogen conc inj
K
$XXX.XX
1480
Elosulfase alfa, injection
K
$XXX.XX
1482
Darbepoetin alfa, esrd use
K
$XXX.XX
1484
Pentazocine injection
K
$XXX.XX
1485
Ferumoxytol, esrd use
K
$XXX.XX
1486
Factor ix fc fusion recomb
K
$XXX.XX
1488
Injection, ramucirumab
K
$XXX.XX
1489
Injection, vedolizumab
K
$XXX.XX
1490
Inj pembrolizumab
K
$XXX.XX
1491
New Technology - Level 1A (0-10)
S
$XXX.XX
1492
New Technology - Level 1B (11-20)
S
$XXX.XX
1493
New Technology - Level 1C (21-30)
S
$XXX.XX
1494
New Technology - Level 1D (31-40)
S
$XXX.XX
1495
New Technology - Level 1E (41-50)
S
$XXX.XX
1496
New Technology - Level 1A (0-10)
T
$XXX.XX
1497
New Technology - Level 1B (11-20)
T
$XXX.XX
1498
New Technology - Level 1C (21-30)
T
$XXX.XX
1499
New Technology - Level 1D (31-40)
T
$XXX.XX
1500
New Technology - Level 1E (41-50)
T
$XXX.XX
1502
New Technology - Level 2 (51 - 100)
S
$XXX.XX
1503
New Technology - Level 3 (101 - 200)
S
$XXX.XX
1504
New Technology - Level 4 (201 - 300)
S
$XXX.XX
1505
New Technology - Level 5 (301 - 400)
S
$XXX.XX
1506
New Technology - Level 6 (401 - 500)
S
$XXX.XX
1507
New Technology - Level 7 (501 - 600)
S
$XXX.XX
1508
New Technology - Level 8 (601 - 700)
S
$XXX.XX
1509
New Technology - Level 9 (701 - 800)
S
$XXX.XX
1510
New Technology - Level 10 (801 - 900)
S
$XXX.XX
1511
New Technology - Level 11 (901 - 1000)
S
$XXX.XX
1512
New Technology - Level 12 (1001 - 1100)
S
$XXX.XX
1513
New Technology - Level 13 (1101 - 1200)
S
$XXX.XX
1514
New Technology - Level 14 (1201- 1300)
S
$XXX.XX
1515
New Technology - Level 15 (1301 - 1400)
S
$XXX.XX
1516
New Technology - Level 16 (1401 - 1500)
S
$XXX.XX
1517
New Technology - Level 17 (1501-1600)
S
$XXX.XX
1518
New Technology - Level 18 (1601-1700)
S
$XXX.XX
1519
New Technology - Level 19 (1701-1800)
S
$XXX.XX
1520
New Technology - Level 20 (1801-1900)
S
$XXX.XX
1521
New Technology - Level 21 (1901-2000)
S
$XXX.XX
1522
New Technology - Level 22 (2001-2500)
S
$XXX.XX
1523
New Technology - Level 23 (2501-3000)
S
$XXX.XX
1524
New Technology - Level 24 (3001-3500)
S
$XXX.XX
1525
New Technology - Level 25 (3501-4000)
S
$XXX.XX
1526
New Technology - Level 26 (4001-4500)
S
$XXX.XX
1527
New Technology - Level 27 (4501-5000)
S
$XXX.XX
1528
New Technology - Level 28 (5001-5500)
S
$XXX.XX
1529
New Technology - Level 29 (5501-6000)
S
$XXX.XX
1530
New Technology - Level 30 (6001-6500)
S
$XXX.XX
1531
New Technology - Level 31 (6501-7000)
S
$XXX.XX
1532
New Technology - Level 32 (7001-7500)
S
$XXX.XX
1533
New Technology - Level 33 (7501-8000)
S
$XXX.XX
1534
New Technology - Level 34 (8001-8500)
S
$XXX.XX
1535
New Technology - Level 35 (8501-9000)
S
$XXX.XX
1536
New Technology - Level 36 (9001-9500)
S
$XXX.XX
1537
New Technology - Level 37 (9501-10000)
S
$XXX.XX
1539
New Technology - Level 2 (51 - 100)
T
$XXX.XX
1540
New Technology - Level 3 (101 - 200)
T
$XXX.XX
1541
New Technology - Level 4 (201 - 300)
T
$XXX.XX
1542
New Technology - Level 5 (301 - 400)
T
$XXX.XX
1543
New Technology - Level 6 (401 - 500)
T
$XXX.XX
1544
New Technology - Level 7 (501 - 600)
T
$XXX.XX
1545
New Technology - Level 8 (601 - 700)
T
$XXX.XX
1546
New Technology - Level 9 (701 - 800)
T
$XXX.XX
1547
New Technology - Level 10 (801 - 900)
T
$XXX.XX
1548
New Technology - Level 11 (901 - 1000)
T
$XXX.XX
1549
New Technology - Level 12 (1001 - 1100)
T
$XXX.XX
1550
New Technology - Level 13 (1101 - 1200)
T
$XXX.XX
1551
New Technology - Level 14 (1201- 1300)
T
$XXX.XX
1552
New Technology - Level 15 (1301 - 1400)
T
$XXX.XX
1553
New Technology - Level 16 (1401 - 1500)
T
$XXX.XX
1554
New Technology - Level 17 (1501-1600)
T
$XXX.XX
1555
New Technology - Level 18 (1601-1700)
T
$XXX.XX
1556
New Technology - Level 19 (1701-1800)
T
$XXX.XX
1557
New Technology - Level 20 (1801-1900)
T
$XXX.XX
1558
New Technology - Level 21 (1901-2000)
T
$XXX.XX
1559
New Technology - Level 22 (2001-2500)
T
$XXX.XX
1560
New Technology - Level 23 (2501-3000)
T
$XXX.XX
1561
New Technology - Level 24 (3001-3500)
T
$XXX.XX
1562
New Technology - Level 25 (3501-4000)
T
$XXX.XX
1563
New Technology - Level 26 (4001-4500)
T
$XXX.XX
1564
New Technology - Level 27 (4501-5000)
T
$XXX.XX
1565
New Technology - Level 28 (5001-5500)
T
$XXX.XX
1566
New Technology - Level 29 (5501-6000)
T
$XXX.XX
1567
New Technology - Level 30 (6001-6500)
T
$XXX.XX
1568
New Technology - Level 31 (6501-7000)
T
$XXX.XX
1569
New Technology - Level 32 (7001-7500)
T
$XXX.XX
1570
New Technology - Level 33 (7501-8000)
T
$XXX.XX
1571
New Technology - Level 34 (8001-8500)
T
$XXX.XX
1572
New Technology - Level 35 (8501-9000)
T
$XXX.XX
1573
New Technology - Level 36 (9001-9500)
T
$XXX.XX
1574
New Technology - Level 37 (9501-10000)
T
$XXX.XX
1575
New Technology - Level 38 (10,001-15,000)
S
$XXX.XX
1576
New Technology - Level 39 (15,001-20,000)
S
$XXX.XX
1577
New Technology - Level 40 (20,001-25,000)
S
$XXX.XX
1578
New Technology - Level 41 (25,001-30,000)
S
$XXX.XX
1579
New Technology - Level 42 (30,001-40,000)
S
$XXX.XX
1580
New Technology - Level 43 (40,001-50,000)
S
$XXX.XX
1581
New Technology - Level 44 (50,001-60,000)
S
$XXX.XX
1582
New Technology - Level 45 (60,001-70,000)
S
$XXX.XX
1583
New Technology - Level 46 (70,001-80,000)
S
$XXX.XX
1584
New Technology - Level 47 (80,001-90,000)
S
$XXX.XX
1585
New Technology - Level 48 (90,001-100,000)
S
$XXX.XX
1589
New Technology - Level 38 (10,001-15,000)
T
$XXX.XX
1590
New Technology - Level 39 (15,001-20,000)
T
$XXX.XX
1591
New Technology - Level 40 (20,001-25,000)
T
$XXX.XX
1592
New Technology - Level 41 (25,001-30,000)
T
$XXX.XX
1593
New Technology - Level 42 (30,001-40,000)
T
$XXX.XX
1594
New Technology - Level 43 (40,001-50,000)
T
$XXX.XX
1595
New Technology - Level 44 (50,001-60,000)
T
$XXX.XX
1596
New Technology - Level 45 (60,001-70,000)
T
$XXX.XX
1597
New Technology - Level 46 (70,001-80,000)
T
$XXX.XX
1598
New Technology - Level 47 (80,001-90,000)
T
$XXX.XX
1599
New Technology - Level 48 (90,001-100,000)
T
$XXX.XX
1607
Eptifibatide injection
K
$XXX.XX
1608
Etanercept injection
K
$XXX.XX
1609
Rho(D) immune globulin h, sd
K
$XXX.XX
1613
Trastuzumab injection
K
$XXX.XX
1630
Hep b ig, im
K
$XXX.XX
1631
Baclofen intrathecal trial
K
$XXX.XX
1643
Y90 ibritumomab, rx
K
$XXX.XX
1656
Factor viii fc fusion recomb
K
$XXX.XX
1658
Injection, belinostat, 10mg
K
$XXX.XX
1660
Injection, oritavancin
K
$XXX.XX
1662
Inj tedizolid phosphate
K
$XXX.XX
1669
Erythro lactobionate /500 mg
K
$XXX.XX
1670
Tetanus immune globulin inj
K
$XXX.XX
1675
P32 Na phosphate
K
$XXX.XX
1683
Basiliximab
K
$XXX.XX
1684
Corticorelin ovine triflutal
K
$XXX.XX
1685
Darbepoetin alfa, non-esrd
K
$XXX.XX
1686
Epoetin alfa, non-esrd
K
$XXX.XX
1687
Digoxin immune fab (ovine)
K
$XXX.XX
1688
Ethanolamine oleate
K
$XXX.XX
1689
Fomepizole
K
$XXX.XX
1690
Hemin
K
$XXX.XX
1694
Ziconotide injection
K
$XXX.XX
1695
Nesiritide injection
K
$XXX.XX
1696
Palifermin injection
K
$XXX.XX
1697
Pegaptanib sodium injection
K
$XXX.XX
1700
Inj secretin synthetic human
K
$XXX.XX
1701
Treprostinil injection
K
$XXX.XX
1704
Humate-P, inj
K
$XXX.XX
1705
Factor viia
K
$XXX.XX
1709
Azacitidine injection
K
$XXX.XX
1710
Clofarabine injection
K
$XXX.XX
1711
Vantas implant
K
$XXX.XX
1712
Paclitaxel protein bound
K
$XXX.XX
1739
Pegademase bovine, 25 iu
K
$XXX.XX
1743
Nandrolone decanoate 50 mg
K
$XXX.XX
1745
Radium ra223 dichloride ther
K
$XXX.XX
1746
Factor xiii recomb a-subunit
K
$XXX.XX
1747
Monovisc inj per dose
K
$XXX.XX
1748
Inj tbo filgrastim 1 microg
K
$XXX.XX
1761
Rolapitant, oral, 1mg
K
$XXX.XX
1809
Injection, alemtuzumab
K
$XXX.XX
1822
Injection, zarxio
G
$XXX.XX
1823
Injection, dalbavancin
K
$XXX.XX
1824
Ceftaroline fosamil inj
K
$XXX.XX
1825
Ceftazidime and avibactam
K
$XXX.XX
1826
Hyqvia 100mg immuneglobulin
K
$XXX.XX
1827
Factor viii recomb obizur
K
$XXX.XX
1828
Carbidopa levodopa ent 100ml
K
$XXX.XX
1829
Penicillin g benzathine inj
K
$XXX.XX
1832
Dimethyl sulfoxide 50% 50 ml
K
$XXX.XX
1844
Factor viii pegylated recomb
G
$XXX.XX
1845
Tacrol envarsus ex rel oral
G
$XXX.XX
1846
Factor viii nuwiq recomb 1iu
G
$XXX.XX
1847
Injection, inflectra
G
$XXX.XX
1848
Artiss fibrin sealant
K
$XXX.XX
1849
Foscarnet sodium injection
K
$XXX.XX
1850
Gamma globulin 1 cc inj
K
$XXX.XX
1851
Gamma globulin > 10 cc inj
K
$XXX.XX
1852
Interferon beta-1a inj
K
$XXX.XX
1853
Minocycline hydrochloride
K
$XXX.XX
1854
Pentobarbital sodium inj
K
$XXX.XX
1856
Factor viii recomb novoeight
K
$XXX.XX
1857
Inj, factor x, (human), 1iu
K
$XXX.XX
1858
Leuprolide acetate injeciton
K
$XXX.XX
1859
Argatroban nonesrd use 1mg
K
$XXX.XX
1860
Monoclonal antibodies
K
$XXX.XX
1861
Inj., bendeka 1 mg
G
$XXX.XX
1862
Gelsyn-3 injection 0.1 mg
G
$XXX.XX
1863
Inj diclofenac sodium 0.5mg
K
$XXX.XX
1901
New Technology - Level 49 (100,001-115,000)
S
$XXX.XX
1902
New Technology - Level 49 (100,001-115,000)
T
$XXX.XX
1903
New Technology - Level 50 (115,001-130,000)
S
$XXX.XX
1904
New Technology - Level 50 (115,001-130,000)
T
$XXX.XX
1905
New Technology - Level 51 (130,001-145,000)
S
$XXX.XX
1906
New Technology - Level 51 (130,001-145,000)
T
$XXX.XX
1907
New Technology - Level 52 (145,001-160,000)
S
$XXX.XX
1908
New Technology - Level 52 (145,001-160,000)
T
$XXX.XX
2616
Brachytx, non-str,Yttrium-90
U
$XXX.XX
2632
Iodine I-125 sodium iodide
U
$XXX.XX
2634
Brachytx, non-str, HA, I-125
U
$XXX.XX
2635
Brachytx, non-str, HA, P-103
U
$XXX.XX
2636
Brachy linear, non-str,P-103
U
$XXX.XX
2638
Brachytx, stranded, I-125
U
$XXX.XX
2639
Brachytx, non-stranded,I-125
U
$XXX.XX
2640
Brachytx, stranded, P-103
U
$XXX.XX
2641
Brachytx, non-stranded,P-103
U
$XXX.XX
2642
Brachytx, stranded, C-131
U
$XXX.XX
2643
Brachytx, non-stranded,C-131
U
$XXX.XX
2644
Brachytx cesium-131 chloride
U
$XXX.XX
2645
Brachytx, non-str, Gold-198
U
$XXX.XX
2646
Brachytx, non-str, HDR Ir-192
U
$XXX.XX
2647
Brachytx, NS, Non-HDRIr-192
U
$XXX.XX
2648
Brachytx planar, p-103
U
$XXX.XX
2698
Brachytx, stranded, NOS
U
$XXX.XX
2699
Brachytx, non-stranded, NOS
U
$XXX.XX
2731
Immune globulin, powder
K
$XXX.XX
2770
Quinupristin/dalfopristin
K
$XXX.XX
4001
Echo guidance radiotherapy
S
$XXX.XX
4002
Stereoscopic x-ray guidance
S
$XXX.XX
4003
Radiation treatment delivery, MeV <= 5; simple
S
$XXX.XX
4004
Radiation treatment delivery, 6-10 MeV; simple
S
$XXX.XX
4005
Radiation treatment delivery, 11-19 MeV; simple
S
$XXX.XX
4006
Radiation treatment delivery, MeV>=20; simple
S
$XXX.XX
4007
Radiation treatment delivery, MeV<=5; intermediate
S
$XXX.XX
4008
Radiation treatment delivery, 6-10 MeV; intermediate
S
$XXX.XX
4009
Radiation treatment delivery, 11-19 MeV; intermediate
S
$XXX.XX
4010
Radiation treatment delivery, MeV >=20; intermediate
S
$XXX.XX
4011
Radiation treatment delivery, MeV<=5; complex
S
$XXX.XX
4012
Radiation treatment delivery, 6-10 MeV; complex
S
$XXX.XX
4013
Radiation treatment delivery, 11-19 MeV; complex
S
$XXX.XX
4014
Radiation treatment delivery, MeV >=20; complex
S
$XXX.XX
4015
Radiation tx delivery imrt
S
$XXX.XX
4016
Delivery comp imrt
S
$XXX.XX
5012
Clinic Visits and Related Services
V
$XXX.XX
5021
Level 1 Type A ED Visits
V
$XXX.XX
5022
Level 2 Type A ED Visits
V
$XXX.XX
5023
Level 3 Type A ED Visits
V
$XXX.XX
5024
Level 4 Type A ED Visits
V
$XXX.XX
5025
Level 5 Type A ED Visits
V
$XXX.XX
5031
Level 1 Type B ED Visits
V
$XXX.XX
5032
Level 2 Type B ED Visits
V
$XXX.XX
5033
Level 3 Type B ED Visits
V
$XXX.XX
5034
Level 4 Type B ED Visits
V
$XXX.XX
5035
Level 5 Type B ED Visits
V
$XXX.XX
5041
Critical Care
S
$XXX.XX
5045
Trauma Response with Critical Care
S
$XXX.XX
5051
Level 1 Skin Procedures
T
$XXX.XX
5052
Level 2 Skin Procedures
T
$XXX.XX
5053
Level 3 Skin Procedures
T
$XXX.XX
5054
Level 4 Skin Procedures
T
$XXX.XX
5055
Level 5 Skin Procedures
T
$XXX.XX
5061
Hyperbaric Oxygen
S
$XXX.XX
5071
Level 1 Excision/ Biopsy/ Incision and Drainage
T
$XXX.XX
5072
Level 2 Excision/ Biopsy/ Incision and Drainage
J1
$XXX.XX
5073
Level 3 Excision/ Biopsy/ Incision and Drainage
J1
$XXX.XX
5091
Level 1 Breast/Lymphatic Surgery and Related Procedures
J1
$XXX.XX
5092
Level 2 Breast/Lymphatic Surgery and Related Procedures
J1
$XXX.XX
5093
Level 3 Breast/Lymphatic Surgery and Related Procedures
J1
$XXX.XX
5094
Level 4 Breast/Lymphatic Surgery and Related Procedures
J1
$XXX.XX
5101
Level 1 Strapping and Cast Application
T
$XXX.XX
5102
Level 2 Strapping and Cast Application
T
$XXX.XX
5111
Level 1 Musculoskeletal Procedures
T
$XXX.XX
5112
Level 2 Musculoskeletal Procedures
J1
$XXX.XX
5113
Level 3 Musculoskeletal Procedures
J1
$XXX.XX
5114
Level 4 Musculoskeletal Procedures
J1
$XXX.XX
5115
Level 5 Musculoskeletal Procedures
J1
$XXX.XX
5116
Level 6 Musculoskeletal Procedures
J1
$XXX.XX
5151
Level 1 Airway Endoscopy
T
$XXX.XX
5152
Level 2 Airway Endoscopy
T
$XXX.XX
5153
Level 3 Airway Endoscopy
J1
$XXX.XX
5154
Level 4 Airway Endoscopy
J1
$XXX.XX
5155
Level 5 Airway Endoscopy
J1
$XXX.XX
5161
Level 1 ENT Procedures
T
$XXX.XX
5162
Level 2 ENT Procedures
T
$XXX.XX
5163
Level 3 ENT Procedures
T
$XXX.XX
5164
Level 4 ENT Procedures
J1
$XXX.XX
5165
Level 5 ENT Procedures
J1
$XXX.XX
5166
Cochlear Implant Procedure
J1
$XXX.XX
5181
Level 1 Vascular Procedures
T
$XXX.XX
5182
Level 2 Vascular Procedures
T
$XXX.XX
5183
Level 3 Vascular Procedures
T
$XXX.XX
5184
Level 4 Vascular Procedures
T
$XXX.XX
5191
Level 1 Endovascular Procedures
J1
$XXX.XX
5192
Level 2 Endovascular Procedures
J1
$XXX.XX
5193
Level 3 Endovascular Procedures
J1
$XXX.XX
5194
Level 4 Endovascular Procedures
J1
$XXX.XX
5200
Implantation Wireless PA Pressure Monitor
J1
$XXX.XX
5211
Level 1 Electrophysiologic Procedures
J1
$XXX.XX
5212
Level 2 Electrophysiologic Procedures
J1
$XXX.XX
5213
Level 3 Electrophysiologic Procedures
J1
$XXX.XX
5221
Level1 Pacemaker and Similar Procedures
T
$XXX.XX
5222
Level 2 Pacemaker and Similar Procedures
J1
$XXX.XX
5223
Level 3 Pacemaker and Similar Procedures
J1
$XXX.XX
5224
Level 4 Pacemaker and Similar Procedures
J1
$XXX.XX
5231
Level 1 ICD and Similar Procedures
J1
$XXX.XX
5232
Level 2 ICD and Similar Procedures
J1
$XXX.XX
5241
Level 1 Blood Product Exchange and Related Services
S
$XXX.XX
5242
Level 2 Blood Product Exchange and Related Services
S
$XXX.XX
5243
Level 3 Blood Product Exchange and Related Services
S
$XXX.XX
5244
Level 4 Blood Product Exchange and Related Services
J1
$XXX.XX
5301
Level 1 Upper GI Procedures
T
$XXX.XX
5302
Level 2 Upper GI Procedures
J1
$XXX.XX
5303
Level 3 Upper GI Procedures
J1
$XXX.XX
5311
Level 1 Lower GI Procedures
T
$XXX.XX
5312
Level 2 Lower GI Procedures
T
$XXX.XX
5313
Level 3 Lower GI Procedures
J1
$XXX.XX
5331
Complex GI Procedures
J1
$XXX.XX
5341
Abdominal/Peritoneal/Biliary and Related Procedures
J1
$XXX.XX
5361
Level 1 Laparoscopy and Related Services
J1
$XXX.XX
5362
Level 2 Laparoscopy and Related Services
J1
$XXX.XX
5371
Level 1 Urology and Related Services
T
$XXX.XX
5372
Level 2 Urology and Related Services
T
$XXX.XX
5373
Level 3 Urology and Related Services
J1
$XXX.XX
5374
Level 4 Urology and Related Services
J1
$XXX.XX
5375
Level 5 Urology and Related Services
J1
$XXX.XX
5376
Level 6 Urology and Related Services
J1
$XXX.XX
5377
Level 7 Urology and Related Services
J1
$XXX.XX
5401
Dialysis
S
$XXX.XX
5411
Level 1 Gynecologic Procedures
T
$XXX.XX
5412
Level 2 Gynecologic Procedures
T
$XXX.XX
5413
Level 3 Gynecologic Procedures
T
$XXX.XX
5414
Level 4 Gynecologic Procedures
J1
$XXX.XX
5415
Level 5 Gynecologic Procedures
J1
$XXX.XX
5416
Level 6 Gynecologic Procedures
J1
$XXX.XX
5431
Level 1 Nerve Procedures
J1
$XXX.XX
5432
Level 2 Nerve Procedures
J1
$XXX.XX
5441
Level 1 Nerve Injections
T
$XXX.XX
5442
Level 2 Nerve Injections
T
$XXX.XX
5443
Level 3 Nerve Injections
T
$XXX.XX
5461
Level 1 Neurostimulator and Related Procedures
T
$XXX.XX
5462
Level 2 Neurostimulator and Related Procedures
J1
$XXX.XX
5463
Level 3 Neurostimulator and Related Procedures
J1
$XXX.XX
5464
Level 4 Neurostimulator and Related Procedures
J1
$XXX.XX
5471
Implantation of Drug Infusion Device
J1
$XXX.XX
5481
Laser Eye Procedures
T
$XXX.XX
5491
Level 1 Intraocular Procedures
J1
$XXX.XX
5492
Level 2 Intraocular Procedures
J1
$XXX.XX
5493
Level 3 Intraocular Procedures
J1
$XXX.XX
5494
Level 4 Intraocular Procedures
J1
$XXX.XX
5495
Level 5 Intraocular Procedures
J1
$XXX.XX
5501
Level 1 Extraocular, Repair, and Plastic Eye Procedures
T
$XXX.XX
5502
Level 2 Extraocular, Repair, and Plastic Eye Procedures
T
$XXX.XX
5503
Level 3 Extraocular, Repair, and Plastic Eye Procedures
J1
$XXX.XX
5504
Level 4 Extraocular, Repair, and Plastic Eye Procedures
J1
$XXX.XX
5521
Level 1 Imaging without Contrast
S
$XXX.XX
5522
Level 2 Imaging without Contrast
S
$XXX.XX
5523
Level 3 Imaging without Contrast
S
$XXX.XX
5524
Level 4 Imaging without Contrast
S
$XXX.XX
5571
Level 1 Imaging with Contrast
S
$XXX.XX
5572
Level 2 Imaging with Contrast
S
$XXX.XX
5573
Level 3 Imaging with Contrast
S
$XXX.XX
5591
Level 1 Nuclear Medicine and Related Services
S
$XXX.XX
5592
Level 2 Nuclear Medicine and Related Services
S
$XXX.XX
5593
Level 3 Nuclear Medicine and Related Services
S
$XXX.XX
5594
Level 4 Nuclear Medicine and Related Services
S
$XXX.XX
5611
Level 1 Therapeutic Radiation Treatment Preparation
S
$XXX.XX
5612
Level 2 Therapeutic Radiation Treatment Preparation
S
$XXX.XX
5613
Level 3 Therapeutic Radiation Treatment Preparation
S
$XXX.XX
5621
Level 1 Radiation Therapy
S
$XXX.XX
5622
Level 2 Radiation Therapy
S
$XXX.XX
5623
Level 3 Radiation Therapy
S
$XXX.XX
5624
Level 4 Radiation Therapy
S
$XXX.XX
5625
Level 5 Radiation Therapy
S
$XXX.XX
5626
Level 6 Radiation Therapy
S
$XXX.XX
5627
Level 7 Radiation Therapy
J1
$XXX.XX
5661
Therapeutic Nuclear Medicine
S
$XXX.XX
5671
Level 1 Pathology
S
$XXX.XX
5672
Level 2 Pathology
S
$XXX.XX
5673
Level 3 Pathology
S
$XXX.XX
5674
Level 4 Pathology
S
$XXX.XX
5691
Level 1 Drug Administration
S
$XXX.XX
5692
Level 2 Drug Administration
S
$XXX.XX
5693
Level 3 Drug Administration
S
$XXX.XX
5694
Level 4 Drug Administration
S
$XXX.XX
5721
Level1 Diagnostic Tests and Related Services
S
$XXX.XX
5722
Level 2 Diagnostic Tests and Related Services
S
$XXX.XX
5723
Level 3 Diagnostic Tests and Related Services
S
$XXX.XX
5724
Level 4 Diagnostic Tests and Related Services
S
$XXX.XX
5731
Level 1 Minor Procedures
S
$XXX.XX
5732
Level 2 Minor Procedures
S
$XXX.XX
5733
Level 3 Minor Procedures
S
$XXX.XX
5734
Level 4 Minor Procedures
S
$XXX.XX
5735
Level 5 Minor Procedures
S
$XXX.XX
5741
Level 1 Electronic Analysis of Devices
S
$XXX.XX
5742
Level 2 Electronic Analysis of Devices
S
$XXX.XX
5743
Level 3 Electronic Analysis of Devices
S
$XXX.XX
5771
Cardiac Rehabilitation
S
$XXX.XX
5781
Resuscitation and Cardioversion
S
$XXX.XX
5791
Pulmonary Treatment
S
$XXX.XX
5801
Ventilation Initiation and Management
S
$XXX.XX
5811
Manipulation Therapy
S
$XXX.XX
5821
Level 1 Health and Behavior Services
S
$XXX.XX
5822
Level 2 Health and Behavior Services
S
$XXX.XX
5823
Level 3 Health and Behavior Services
S
$XXX.XX
5853
Partial Hospitalization (3 or more services) for CMHCs
P
$XXX.XX
5863
Partial Hospitalization (3 or more services) for Hospital-based PHPs
P
$XXX.XX
5871
Dental Procedures
S
$XXX.XX
5881
Ancillary Outpatient Services When Patient Dies
J1
$XXX.XX
7000
Amifostine
K
$XXX.XX
7011
Oprelvekin injection
K
$XXX.XX
7034
Somatropin injection
K
$XXX.XX
7035
Teniposide
K
$XXX.XX
7041
Tirofiban HCl
K
$XXX.XX
7043
Infliximab not biosimil 10mg
K
$XXX.XX
7046
Doxorubicin inj 10mg
K
$XXX.XX
7048
Alteplase recombinant
K
$XXX.XX
7308
Aminolevulinic acid hcl top
K
$XXX.XX
8004
Ultrasound Composite
S
$XXX.XX
8005
CT and CTA without Contrast Composite
S
$XXX.XX
8006
CT and CTA with Contrast Composite
S
$XXX.XX
8007
MRI and MRA without Contrast Composite
S
$XXX.XX
8008
MRI and MRA with Contrast Composite
S
$XXX.XX
8010
Mental Health Services Composite
S
$XXX.XX
8011
Comprehensive Observation Services
J2
$XXX.XX
9002
Tenecteplase injection
K
$XXX.XX
9003
Palivizumab
K
$XXX.XX
9005
Reteplase injection
K
$XXX.XX
9006
Tacrolimus injection
K
$XXX.XX
9012
Arsenic trioxide injection
K
$XXX.XX
9014
Injection, cerliponase alfa
G
$XXX.XX
9015
C-1 esterase, haegarda
G
$XXX.XX
9016
Inj, triptorelin ext rel
G
$XXX.XX
9018
Inj, rimabotulinumtoxinB
K
$XXX.XX
9019
Caspofungin acetate
K
$XXX.XX
9024
Amphotericin b lipid complex
K
$XXX.XX
9028
Inj. inotuzumab ozogamicin
G
$XXX.XX
9029
Injection, guselkumab
G
$XXX.XX
9030
Inj copanlisib
G
$XXX.XX
9031
Inj, etelcalcetide, 0.1 mg
K
$XXX.XX
9032
Baclofen 10 MG injection
K
$XXX.XX
9033
Cidofovir injection
K
$XXX.XX
9034
Inj cuvitru, 100 mg
K
$XXX.XX
9035
Axicabtagene ciloleucel car+
G
$XXX.XX
9036
Injection, renflexis
G
$XXX.XX
9038
Inj estrogen conjugate
K
$XXX.XX
9042
Glucagon hydrochloride
K
$XXX.XX
9043
Inj, afstyla, 1 i.u.
G
$XXX.XX
9044
Ibutilide fumarate injection
K
$XXX.XX
9052
Fluciciovine F-18
G
$XXX.XX
9056
Gallium Ga-68
G
$XXX.XX
9058
Buprenorphine implant 74.2mg
G
$XXX.XX
9059
Vonvendi inj 1 iu vwf:rco
G
$XXX.XX
9064
Aripiprazole injection
K
$XXX.XX
9065
Argatroban esrd dialysis 1mg
K
$XXX.XX
9066
Inj dihydroergotamine mesylt
K
$XXX.XX
9067
Lutetium Lu 177 dotatate, tx
G
$XXX.XX
9070
Voretigene neparvovec-rzyl
G
$XXX.XX
9071
Capsaicin 8% patch
K
$XXX.XX
9072
Fosphenytoin inj pe
K
$XXX.XX
9073
Buprenorph xr 100 mg or less
G
$XXX.XX
9074
Makena, 10 mg
K
$XXX.XX
9075
Inj, kovaltry, 1 i.u.
K
$XXX.XX
9076
Dimecaprol injection
K
$XXX.XX
9077
Epoetin beta non esrd
K
$XXX.XX
9078
Testosterone undecanoate 1mg
K
$XXX.XX
9079
Genvisc 850, inj, 1mg
K
$XXX.XX
9080
Fludarabine phosphate inj
K
$XXX.XX
9081
Tisagenlecleucel car-pos t
G
$XXX.XX
9082
Puraply or puraply am
G
$XXX.XX
9083
Inj, phenylephrine ketorolac
G
$XXX.XX
9084
Florbetapir f18
G
$XXX.XX
9085
Inj sulf hexa lipid microsph
G
$XXX.XX
9096
Inj Retacrit esrd on dialysi
G
$XXX.XX
9097
Inj Retacrit non-esrd use
G
$XXX.XX
9099
Inj, akynzeo
G
$XXX.XX
9104
Antithymocyte globuln rabbit
K
$XXX.XX
9108
Thyrotropin injection
K
$XXX.XX
9119
Injection, pegfilgrastim 6mg
K
$XXX.XX
9120
Injection, Fulvestrant
K
$XXX.XX
9122
Triptorelin pamoate
K
$XXX.XX
9124
Daptomycin injection
K
$XXX.XX
9125
Risperidone, long acting
K
$XXX.XX
9126
Natalizumab injection
K
$XXX.XX
9130
Inj, Imm Glob Bivigam, 500mg
K
$XXX.XX
9131
Inj, Ado-trastuzumab Emt 1mg
K
$XXX.XX
9132
Kcentra, per i.u.
K
$XXX.XX
9133
Rabies ig, im/sc
K
$XXX.XX
9134
Rabies ig, heat treated
K
$XXX.XX
9135
Varicella-zoster ig, im
K
$XXX.XX
9139
Rabies vaccine, im
K
$XXX.XX
9140
Rabies vaccine, id
K
$XXX.XX
9171
Factor ix idelvion inj
G
$XXX.XX
9172
Injection, dexamethasone 9%
G
$XXX.XX
9173
Injection, fulphila
K
$XXX.XX
9207
Bortezomib injection
K
$XXX.XX
9208
Agalsidase beta injection
K
$XXX.XX
9209
Laronidase injection
K
$XXX.XX
9210
Palonosetron hcl
K
$XXX.XX
9213
Pemetrexed injection
K
$XXX.XX
9214
Bevacizumab injection
K
$XXX.XX
9215
Cetuximab injection
K
$XXX.XX
9217
Leuprolide acetate suspnsion
K
$XXX.XX
9224
Galsulfase injection
K
$XXX.XX
9225
Fluocinolone acetonide implt
K
$XXX.XX
9228
Tigecycline injection
K
$XXX.XX
9229
Ibandronate sodium injection
K
$XXX.XX
9230
Abatacept injection
K
$XXX.XX
9231
Decitabine injection
K
$XXX.XX
9232
Idursulfase injection
K
$XXX.XX
9233
Ranibizumab injection
K
$XXX.XX
9234
Alglucosidase alfa injection
K
$XXX.XX
9235
Panitumumab injection
K
$XXX.XX
9236
Eculizumab injection
K
$XXX.XX
9237
Inj, lanreotide acetate
K
$XXX.XX
9239
Buprenorphine xr over 100 mg
G
$XXX.XX
9240
Injection, ixabepilone
K
$XXX.XX
9242
Injection, fosaprepitant
K
$XXX.XX
9243
Inj., treanda 1 mg
K
$XXX.XX
9245
Romiplostim injection
K
$XXX.XX
9251
C1 esterase inhibitor inj
K
$XXX.XX
9252
Plerixafor injection
K
$XXX.XX
9253
Temozolomide injection
K
$XXX.XX
9255
Paliperidone palmitate inj
K
$XXX.XX
9256
Dexamethasone intra implant
K
$XXX.XX
9257
Inj. emicizumab-kxwh, 0.5 mg
G
$XXX.XX
9258
Telavancin injection
K
$XXX.XX
9259
Pralatrexate injection
K
$XXX.XX
9260
Ofatumumab injection
K
$XXX.XX
9261
Ustekinumab sub cu inj, 1 mg
K
$XXX.XX
9263
Ecallantide injection
K
$XXX.XX
9264
Tocilizumab injection
K
$XXX.XX
9265
Romidepsin injection
K
$XXX.XX
9269
C-1 esterase, berinert
K
$XXX.XX
9270
Gammaplex IVIG
K
$XXX.XX
9271
Velaglucerase alfa
K
$XXX.XX
9272
Inj, denosumab
K
$XXX.XX
9273
Sipuleucel-T auto CD54+
K
$XXX.XX
9274
Crotalidae Poly Immune Fab
K
$XXX.XX
9276
Cabazitaxel injection
K
$XXX.XX
9278
Incobotulinumtoxin A
K
$XXX.XX
9281
Injection, pegloticase
K
$XXX.XX
9284
Ipilimumab injection
K
$XXX.XX
9286
Belatacept injection
K
$XXX.XX
9287
Brentuximab vedotin inj
K
$XXX.XX
9289
Erwinaze injection
K
$XXX.XX
9293
Injection, glucarpidase
K
$XXX.XX
9294
Inj, taliglucerase alfa 10 u
K
$XXX.XX
9295
Injection, Carfilzomib, 1 mg
K
$XXX.XX
9296
Inj, ziv-aflibercept, 1mg
K
$XXX.XX
9297
Inj, Omacetaxine Mep, 0.01mg
K
$XXX.XX
9298
Inj, Ocriplasmin, 0.125 mg
K
$XXX.XX
9300
Omalizumab injection
K
$XXX.XX
9301
Aminolevulinic acid, 10% gel
G
$XXX.XX
9302
Inj, daunorubicin-cytarabine
G
$XXX.XX
9441
Inj ferric carboxymaltos 1mg
K
$XXX.XX
9445
Injection, ruconest
K
$XXX.XX
9448
Netupitant palonosetron oral
K
$XXX.XX
9449
Injection, blinatumomab
K
$XXX.XX
9450
Fluocinol acet intravit imp
K
$XXX.XX
9451
Injection, peramivir
K
$XXX.XX
9452
Inj ceftolozane tazobactam
K
$XXX.XX
9453
Injection, nivolumab
K
$XXX.XX
9454
Inj, pasireotide long acting
K
$XXX.XX
9455
Injection, siltuximab
K
$XXX.XX
9456
Injection, isavuconazonium
K
$XXX.XX
9458
Florbetaben f18 diagnostic
G
$XXX.XX
9459
Flutemetamol f18 diagnostic
G
$XXX.XX
9460
Injection, cangrelor
G
$XXX.XX
9461
Choline c-11, diagnostic, per study dose up to 20 millicuries
G
$XXX.XX
9462
Injection, delafloxacin
G
$XXX.XX
9463
Injection, aprepitant
G
$XXX.XX
9464
Injection, rolapitant
G
$XXX.XX
9465
Injection, Durolane
G
$XXX.XX
9466
Injection, benralizumab
G
$XXX.XX
9467
Inj rituximab hyaluronidase
G
$XXX.XX
9468
Inj, factor ix, Rebinyn
G
$XXX.XX
9469
Inj., triamcinolone ext rel
G
$XXX.XX
9470
Aripiprazole lauroxil 1mg
G
$XXX.XX
9471
Hymovis injection 1 mg
G
$XXX.XX
9472
Inj talimogene laherparepvec
G
$XXX.XX
9473
Injection, mepolizumab, 1mg
G
$XXX.XX
9474
Inj irinotecan liposome 1 mg
G
$XXX.XX
9475
Injection, necitumumab, 1 mg
G
$XXX.XX
9476
Injection, daratumumab 10 mg
G
$XXX.XX
9477
Injection, elotuzumab, 1mg
G
$XXX.XX
9478
Inj sebelipase alfa 1 mg
G
$XXX.XX
9479
Instill, ciprofloxacin otic
G
$XXX.XX
9480
Injection trabectedin 0.1mg
G
$XXX.XX
9481
Injection, reslizumab
G
$XXX.XX
9482
Sotalol hydrochloride IV
G
$XXX.XX
9483
Inj, atezolizumab,10 mg
G
$XXX.XX
9484
Inj, eteplirsen, 10 mg
G
$XXX.XX
9485
Inj, olaratumab, 10 mg
G
$XXX.XX
9486
Inj, granisetron, xr, 0.1 mg
G
$XXX.XX
9487
Ustekinumab, iv inject,1 mg
G
$XXX.XX
9488
Conivaptan hcl
G
$XXX.XX
9489
Inj, nusinersen, 0.1mg
G
$XXX.XX
9490
Inj, bezlotoxumab, 10 mg
G
$XXX.XX
9491
Injection, avelumab, 10 mg
G
$XXX.XX
9492
Injection, durvalumab
G
$XXX.XX
9493
Injection, edaravone
G
$XXX.XX
9494
Injection, ocrelizumab
G
$XXX.XX
9495
Gemtuzumab ozogamicin inj
G
$XXX.XX
9497
Loxapine, inhalation powder
K
$XXX.XX
9500
Platelets, irradiated
R
$XXX.XX
9501
Platelet pheres leukoreduced
R
$XXX.XX
9502
Platelet pheresis irradiated
R
$XXX.XX
9503
Fr frz plasma donor retested
R
$XXX.XX
9504
RBC deglycerolized
R
$XXX.XX
9505
RBC irradiated
R
$XXX.XX
9507
Platelets, pheresis
R
$XXX.XX
9508
Plasma 1 donor frz w/in 8 hr
R
$XXX.XX
9509
Frozen plasma, pooled, sd
R
$XXX.XX
9510
Whole blood for transfusion
R
$XXX.XX
9511
Cryoprecipitate each unit
R
$XXX.XX
9512
RBC leukocytes reduced
R
$XXX.XX
9513
Plasma, frz between 8-24hour
R
$XXX.XX
9514
Plasma protein fract,5%,50ml
R
$XXX.XX
9515
Platelets, each unit
R
$XXX.XX
9516
Plaelet rich plasma unit
R
$XXX.XX
9517
Red blood cells unit
R
$XXX.XX
9518
Washed red blood cells unit
R
$XXX.XX
9519
Plasmaprotein fract,5%,250ml
R
$XXX.XX
9520
Blood split unit
R
$XXX.XX
9521
Platelets leukoreduced irrad
R
$XXX.XX
9522
RBC leukoreduced irradiated
R
$XXX.XX
9523
Cryoprecipitatereducedplasma
R
$XXX.XX
9524
Blood, l/r, cmv-neg
R
$XXX.XX
9525
Platelets, hla-m, l/r, unit
R
$XXX.XX
9526
Platelets leukocytes reduced
R
$XXX.XX
9527
Blood, l/r, froz/degly/wash
R
$XXX.XX
9528
Plt, aph/pher, l/r, cmv-neg
R
$XXX.XX
9529
Blood, l/r, irradiated
R
$XXX.XX
9530
Plate pheres leukoredu irrad
R
$XXX.XX
9531
Plt, pher, l/r cmv-neg, irr
R
$XXX.XX
9532
RBC, frz/deg/wsh, l/r, irrad
R
$XXX.XX
9533
RBC, l/r, cmv-neg, irrad
R
$XXX.XX
9534
Pathogen reduced plasma pool
R
$XXX.XX
9535
Pathogen reduced plasma sing
R
$XXX.XX
9536
Platelets, pathogen reduced
R
$XXX.XX



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