| 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
|
| 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
|
| 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
|
| 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
|
| 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
|
| 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 |
Inj levoleucovorin nos 0.5mg
|
K
|
$XXX.XX
|
| 1237 |
Inj iron dextran
|
K
|
$XXX.XX
|
| 1263 |
Antithrombin iii injection
|
K
|
$XXX.XX
|
| 1268 |
Xyntha inj
|
K
|
$XXX.XX
|
| 1274 |
Edetate calcium disodium inj
|
K
|
$XXX.XX
|
| 1281 |
Bevacizumab injection
|
K
|
$XXX.XX
|
| 1289 |
AbobotulinumtoxinA
|
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
|
| 1421 |
Imported lipodox inj
|
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 |
Inj human fibrinogen con nos
|
K
|
$XXX.XX
|
| 1480 |
Elosulfase alfa, injection
|
K
|
$XXX.XX
|
| 1482 |
Darbepoetin alfa, esrd use
|
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
|
| 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
|
| 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
|
| 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
|
| 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
|
K
|
$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
|
| 1829 |
Penicillin g benzathine inj
|
K
|
$XXX.XX
|
| 1832 |
Dimethyl sulfoxide 50% 50 ml
|
K
|
$XXX.XX
|
| 1844 |
Factor viii pegylated recomb
|
K
|
$XXX.XX
|
| 1846 |
Factor viii nuwiq recomb 1iu
|
K
|
$XXX.XX
|
| 1847 |
Injection, inflectra
|
K
|
$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
|
| 1859 |
Argatroban nonesrd use 1mg
|
K
|
$XXX.XX
|
| 1861 |
Inj., bendeka 1 mg
|
K
|
$XXX.XX
|
| 1862 |
Gelsyn-3 injection 0.1 mg
|
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
|
| 2024 |
Generator, CCM, implant
|
H
|
$XXX.XX
|
| 2025 |
Cath, pressure,valve-occlu
|
H
|
$XXX.XX
|
| 2026 |
Orth/devic/drug bn/bn,tis/bn
|
H
|
$XXX.XX
|
| 2027 |
Probe, robotic, water-jet
|
H
|
$XXX.XX
|
| 2028 |
Iris prosthesis
|
H
|
$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
|
| 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
|
| 2993 |
Gen, neuro, trans sen/stim
|
H
|
$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
|
J1
|
$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
|
J1
|
$XXX.XX
|
| 5183 |
Level 3 Vascular Procedures
|
J1
|
$XXX.XX
|
| 5184 |
Level 4 Vascular Procedures
|
J1
|
$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
|
J1
|
$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 |
Level 1 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
|
| 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
|
| 9006 |
Tacrolimus injection
|
K
|
$XXX.XX
|
| 9012 |
Arsenic trioxide injection
|
K
|
$XXX.XX
|
| 9014 |
Inj., cerliponase alfa 1 mg
|
G
|
$XXX.XX
|
| 9015 |
Inj., haegarda 10 units
|
G
|
$XXX.XX
|
| 9016 |
Inj., triptorelin xr 3.75 mg
|
G
|
$XXX.XX
|
| 9018 |
Inj, rimabotulinumtoxinB
|
K
|
$XXX.XX
|
| 9024 |
Amphotericin b lipid complex
|
K
|
$XXX.XX
|
| 9028 |
Inj inotuzumab ozogam 0.1 mg
|
G
|
$XXX.XX
|
| 9029 |
Inj., guselkumab, 1 mg
|
G
|
$XXX.XX
|
| 9030 |
Inj., copanlisib, 1 mg
|
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.
|
K
|
$XXX.XX
|
| 9044 |
Ibutilide fumarate injection
|
K
|
$XXX.XX
|
| 9058 |
Buprenorphine implant 74.2mg
|
K
|
$XXX.XX
|
| 9059 |
Vonvendi inj 1 iu vwf:rco
|
K
|
$XXX.XX
|
| 9065 |
Argatroban esrd dialysis 1mg
|
K
|
$XXX.XX
|
| 9067 |
Lutetium lu 177 dotatat ther
|
G
|
$XXX.XX
|
| 9070 |
Inj luxturna 1 billion vec g
|
G
|
$XXX.XX
|
| 9071 |
Capsaicin 8% patch
|
K
|
$XXX.XX
|
| 9073 |
Buprenorph xr 100 mg or less
|
G
|
$XXX.XX
|
| 9074 |
Makena, 10 mg
|
K
|
$XXX.XX
|
| 9078 |
Testosterone undecanoate 1mg
|
K
|
$XXX.XX
|
| 9079 |
Genvisc 850, inj, 1mg
|
K
|
$XXX.XX
|
| 9084 |
Florbetapir f18
|
G
|
$XXX.XX
|
| 9085 |
Inj sulf hexa lipid microsph
|
G
|
$XXX.XX
|
| 9088 |
Peng benzathine/procaine inj
|
K
|
$XXX.XX
|
| 9092 |
Interferon alfa-2a inj
|
K
|
$XXX.XX
|
| 9094 |
Radiesse injection
|
K
|
$XXX.XX
|
| 9095 |
Inj, sculptra, 0.5mg
|
K
|
$XXX.XX
|
| 9096 |
Inj retacrit esrd on dialysi
|
G
|
$XXX.XX
|
| 9097 |
Inj retacrit non-esrd use
|
G
|
$XXX.XX
|
| 9099 |
Inj fosnetupitant, palonoset
|
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
|
| 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
|
K
|
$XXX.XX
|
| 9172 |
Injection, dexamethasone 9%
|
G
|
$XXX.XX
|
| 9173 |
Injection, fulphila
|
G
|
$XXX.XX
|
| 9174 |
Inj, durolane 1 mg
|
G
|
$XXX.XX
|
| 9175 |
Puraply 1 sq cm
|
G
|
$XXX.XX
|
| 9176 |
Puraply am 1 sq cm
|
G
|
$XXX.XX
|
| 9177 |
Antithrombin recombinant
|
K
|
$XXX.XX
|
| 9178 |
Inj., meropenem, vaborbactam
|
K
|
$XXX.XX
|
| 9179 |
Injection, Aristada Initio
|
G
|
$XXX.XX
|
| 9180 |
Inj., patisiran, 0.1 mg
|
G
|
$XXX.XX
|
| 9181 |
Inj., perseris, 0.5 mg
|
G
|
$XXX.XX
|
| 9182 |
Inj mogamulizumab-kpkc, 1 mg
|
G
|
$XXX.XX
|
| 9183 |
Inj., plazomicin, 5 mg
|
G
|
$XXX.XX
|
| 9186 |
Inj., rituximab, 10 mg
|
K
|
$XXX.XX
|
| 9187 |
Injection, burosumab-twza 1m
|
K
|
$XXX.XX
|
| 9188 |
Inj crotalidae im f(ab')2 eq
|
K
|
$XXX.XX
|
| 9189 |
Inj., ibalizumab-uiyk, 10 mg
|
K
|
$XXX.XX
|
| 9190 |
Inj., vestronidase alfa-vjbk
|
K
|
$XXX.XX
|
| 9191 |
Inj., fibryga, 1 mg
|
K
|
$XXX.XX
|
| 9192 |
Inj, bortezomib, nos, 0.1 mg
|
K
|
$XXX.XX
|
| 9193 |
Nivestym
|
G
|
$XXX.XX
|
| 9194 |
Tisagenlecleucel car-pos t
|
G
|
$XXX.XX
|
| 9195 |
Injection, udenyca 0.5 mg
|
G
|
$XXX.XX
|
| 9196 |
Inj, trivisc 1 mg
|
K
|
$XXX.XX
|
| 9197 |
Inj., fremanezumab-vfrm 1 mg
|
G
|
$XXX.XX
|
| 9198 |
Inj, coagulation factor Xa
|
G
|
$XXX.XX
|
| 9199 |
Injection, caplacizumab-yhdp
|
G
|
$XXX.XX
|
| 9207 |
Inj., velcade 0.1 mg
|
K
|
$XXX.XX
|
| 9208 |
Agalsidase beta injection
|
K
|
$XXX.XX
|
| 9209 |
Laronidase injection
|
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
|
| 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
|
| 9299 |
Inj. jivi 1 iu
|
G
|
$XXX.XX
|
| 9300 |
Omalizumab injection
|
K
|
$XXX.XX
|
| 9301 |
Aminolevulinic acid, 10% gel
|
G
|
$XXX.XX
|
| 9302 |
Inj daunorubicin, cytarabine
|
G
|
$XXX.XX
|
| 9304 |
Inj., cemiplimab-rwlc, 1 mg
|
G
|
$XXX.XX
|
| 9305 |
Inj., lumoxiti, 0.01 mg
|
G
|
$XXX.XX
|
| 9306 |
Inj., tildrakizumab, 1 mg
|
G
|
$XXX.XX
|
| 9307 |
Cocaine hcl nasal solution
|
G
|
$XXX.XX
|
| 9308 |
Dexametha opth insert 0.1 mg
|
G
|
$XXX.XX
|
| 9309 |
Inj. tagraxofusp-erzs 10 mcg
|
G
|
$XXX.XX
|
| 9310 |
Inj., emapalumab-lzsg, 1 mg
|
G
|
$XXX.XX
|
| 9311 |
Inj., omadacycline, 1 mg
|
G
|
$XXX.XX
|
| 9312 |
Inj., ravulizumab-cwvz 10 mg
|
G
|
$XXX.XX
|
| 9313 |
Inj. belrapzo/bendamustine
|
G
|
$XXX.XX
|
| 9314 |
Inj. herceptin hylecta, 10mg
|
G
|
$XXX.XX
|
| 9315 |
Diphtheria antitoxin
|
K
|
$XXX.XX
|
| 9316 |
Corticotropin injection
|
K
|
$XXX.XX
|
| 9317 |
Doripenem injection
|
K
|
$XXX.XX
|
| 9318 |
Inj hydroxyprogst capoat nos
|
K
|
$XXX.XX
|
| 9319 |
Somatropin injection
|
K
|
$XXX.XX
|
| 9320 |
Carbidopa levodopa ent 100ml
|
K
|
$XXX.XX
|
| 9321 |
Fosphenytoin inj pe
|
K
|
$XXX.XX
|
| 9322 |
Bcg live intravesical 1mg
|
K
|
$XXX.XX
|
| 9324 |
Phenylep ketorolac opth soln
|
G
|
$XXX.XX
|
| 9325 |
Inj., eravacycline, 1 mg
|
K
|
$XXX.XX
|
| 9326 |
Inj., lanadelumab-flyo, 1 mg
|
K
|
$XXX.XX
|
| 9327 |
Inj. romosozumab-aqqg 1 mg
|
G
|
$XXX.XX
|
| 9328 |
Inj., yutiq, 0.01 mg
|
K
|
$XXX.XX
|
| 9329 |
Inj mvasi 10 mg
|
G
|
$XXX.XX
|
| 9330 |
Inj., kanjinti, 10 mg
|
G
|
$XXX.XX
|
| 9331 |
Inj, polatuzumab vedotin 1mg
|
G
|
$XXX.XX
|
| 9332 |
Injection, lefamulin
|
G
|
$XXX.XX
|
| 9333 |
Inj, brexanolone
|
G
|
$XXX.XX
|
| 9334 |
Injection, khapzory, 0.5 mg
|
G
|
$XXX.XX
|
| 9335 |
Oral busulfan
|
K
|
$XXX.XX
|
| 9336 |
Inj truxima 10 mg
|
G
|
$XXX.XX
|
| 9337 |
Synojoynt, inj., 1 mg
|
G
|
$XXX.XX
|
| 9338 |
Inj., triluron, 1 mg
|
K
|
$XXX.XX
|
| 9339 |
Iodine i-131 iobenguane 1mci
|
G
|
$XXX.XX
|
| 9340 |
Inj, brolucizumab-dbll, 1 mg
|
G
|
$XXX.XX
|
| 9341 |
Inj ogivri 10 mg
|
G
|
$XXX.XX
|
| 9342 |
Inj, crizanlizumab-tmca
|
G
|
$XXX.XX
|
| 9343 |
Injection, givosiran
|
G
|
$XXX.XX
|
| 9344 |
Inj cetirizine hydrochloride
|
G
|
$XXX.XX
|
| 9345 |
Injection,pegfilgrastim-bmez
|
G
|
$XXX.XX
|
| 9348 |
Inj., zirabev, 10 mg
|
K
|
$XXX.XX
|
| 9441 |
Inj ferric carboxymaltos 1mg
|
K
|
$XXX.XX
|
| 9445 |
Injection, ruconest
|
K
|
$XXX.XX
|
| 9448 |
Oral netupitant, palonosetro
|
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
|
K
|
$XXX.XX
|
| 9462 |
Injection, delafloxacin
|
G
|
$XXX.XX
|
| 9463 |
Inj., aprepitant, 1 mg
|
G
|
$XXX.XX
|
| 9464 |
Inj., rolapitant, 0.5 mg
|
G
|
$XXX.XX
|
| 9466 |
Inj., benralizumab, 1 mg
|
G
|
$XXX.XX
|
| 9467 |
Inj rituximab, hyaluronidase
|
G
|
$XXX.XX
|
| 9468 |
Factor ix recomb gly rebinyn
|
G
|
$XXX.XX
|
| 9469 |
Inj triamcinolone ace xr 1mg
|
G
|
$XXX.XX
|
| 9470 |
Aripirazole lauroxil 1 mg
|
K
|
$XXX.XX
|
| 9471 |
Hymovis injection 1 mg
|
K
|
$XXX.XX
|
| 9472 |
Inj talimogene laherparepvec
|
K
|
$XXX.XX
|
| 9473 |
Injection, mepolizumab, 1mg
|
K
|
$XXX.XX
|
| 9474 |
Inj irinotecan liposome 1 mg
|
K
|
$XXX.XX
|
| 9475 |
Injection, necitumumab, 1 mg
|
K
|
$XXX.XX
|
| 9476 |
Injection, daratumumab 10 mg
|
K
|
$XXX.XX
|
| 9477 |
Injection, elotuzumab, 1mg
|
K
|
$XXX.XX
|
| 9478 |
Inj sebelipase alfa 1 mg
|
K
|
$XXX.XX
|
| 9479 |
Instill, ciprofloxacin otic
|
K
|
$XXX.XX
|
| 9480 |
Injection trabectedin 0.1mg
|
K
|
$XXX.XX
|
| 9481 |
Injection, reslizumab
|
K
|
$XXX.XX
|
| 9482 |
Sotalol hydrochloride IV
|
K
|
$XXX.XX
|
| 9483 |
Inj, atezolizumab,10 mg
|
K
|
$XXX.XX
|
| 9484 |
Inj, eteplirsen, 10 mg
|
K
|
$XXX.XX
|
| 9485 |
Inj, olaratumab, 10 mg
|
K
|
$XXX.XX
|
| 9487 |
Ustekinumab, iv inject,1 mg
|
K
|
$XXX.XX
|
| 9488 |
Conivaptan hcl
|
K
|
$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 |
Inj., durvalumab, 10 mg
|
G
|
$XXX.XX
|
| 9493 |
Injection, edaravone, 1 mg
|
G
|
$XXX.XX
|
| 9494 |
Injection, ocrelizumab
|
G
|
$XXX.XX
|
| 9495 |
Gemtuzumab ozogamicin inj
|
G
|
$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 pheresis path redu
|
R
|
$XXX.XX
|
