Price Transparencybeta Hospital negotiated rates

Hospital facility prices. What the hospital charges for the facility side of care — the surgeon’s and anesthesiologist’s fees are billed separately and are not included. How we scope prices →

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Hospital

GOOD SAMARITAN HOSPITAL

San Jose, CA · CCN 050380 · Rates published

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You selected 93350 (CPT)

ECHO STRESS

This hospital’s price: $4,052 across 23 payers · range $68-$8,103

Source: https://core.secure.ehc.com/src/util/json-detail-price-list/62-1763090_good-samaritan-hospital_standardcharges.json · observed 2024-10-01

This is the facility’s filed rate for this code. The comparison board’s estimate also adds the surgeon and anesthesia fees, so it is usually higher.

33,966 distinct procedures filed
46 distinct payers
1,064,647 rate rows
2024-10-01 last MRF observed · ⚠ 24 mo old
Data quality

1,009,469 of 1,064,647 rate rows are consumer-grade (94.8%)

55,178 rows are marked excluded from the consumer medians — these stay visible in the raw drill-down with the same reason shown here, so nothing is silently hidden.

Excluded — reasonRows
template filing: same amount across many unrelated codes — excluded 27,510
per-diem day rate — not a per-procedure price 14,604
percent-of-billed methodology on a DRG bundle — not comparable to case rates; shown as context only 9,207
no usable negotiated amount (only an out-of-band fallback) — excluded from medians 2,346
below 25% of the Medicare reference for this code — likely a mislabeled per-diem or placeholder; excluded from medians 694
percent-of-charges filed in the dollar field — excluded from medians 621
placeholder amount (≤ $0.02) — excluded from medians 150
below 25% of the Medicare reference for this DRG — likely a mislabeled per-diem; excluded from rankings 28
exceeds 10× this hospital's gross charge — excluded from medians 18

⚠ Possibly outdated The most recent machine-readable file we have for this hospital is 24 months old. CMS requires hospitals to refresh these files at least annually, so newer rates may exist that we haven't ingested yet. The prices below are exactly as last filed.

Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://core.secure.ehc.com/src/util/json-detail-price-list/62-1763090_good-samaritan-hospital_standardcharges.json
Found on page https://goodsamsanjose.com/about/legal-information/pricing-transparency-cms-required-file-of-standard-charges.dot
Discovered viaDiscovered by HANK
Last fetch not_modified · 2026-10-11
Content fingerprint c32032bd82954b73… · 647,621,834 bytes · first seen 2026-05-14

Top 50 most expensive offerings

Outliers are flagged where this hospital's filed rate is ≥2× or ≤0.5× the national median for the same code.

Code Description Payers Min $ Max $ Avg median vs national
J3393
HCPCS 		Injection, Betibeglogene Autotemcel, Per Treatment 1 $4,897,200.00 $4,897,200.00 $4,897,200.00 nat. median
$2,994,107
1.6× median
J3399
HCPCS 		Injection, Onasemnogene Abeparvovec-xioi, Per Treatment, Up To 5x10°15 Vector Ge… 1 $3,884,946.48 $3,884,946.48 $3,884,946.48 nat. median
$2,467,386
1.6× median
09138
OTHER 		Inj, Hemgenix, Per Tx Dos 2 $3,672,900.00 $3,672,900.00 $3,672,900.00 nat. median
$3,574,709
1.0× median
9138
OTHER 		Inj, Hemgenix, Per Tx Dos 19 $3,672,900.00 $4,774,770.00 $3,672,900.00 nat. median
$3,758,972
1.0× median
773
OTHER 		Inj, Beqvez, Per Tx Dose 20 $3,605,000.00 $4,686,500.00 $3,605,000.00 nat. median
$3,672,053
1.0× median
00773
OTHER 		Inj, Beqvez, Per Tx Dose 2 $3,605,000.00 $3,605,000.00 $3,605,000.00 nat. median
$3,496,850
1.0× median
00714
OTHER 		Inj Delandistrogene Mox R 2 $3,325,455.00 $3,325,455.00 $3,325,455.00 nat. median
$3,228,024
1.0× median
714
OTHER 		Inj Delandistrogene Mox R 21 $9,629.20 $4,323,091.50 $3,325,455.00 nat. median
$3,325,455
1.0× median
00748
OTHER 		Inj, Lovotibeglogene Auto 2 $3,286,000.00 $3,286,000.00 $3,286,000.00 nat. median
$3,187,420
1.0× median
748
OTHER 		Inj, Lovotibeglogene Auto 21 $15,883.34 $4,271,800.00 $3,286,000.00 nat. median
$3,252,508
1.0× median
00746
OTHER 		Inj, Betibeglogene Autote 2 $2,968,000.00 $2,968,000.00 $2,968,000.00 nat. median
$2,878,960
1.0× median
746
OTHER 		Inj, Betibeglogene Autote 21 $14,107.56 $3,858,400.00 $2,968,000.00 nat. median
$2,939,969
1.0× median
9141
OTHER 		Inj Onase Abepar-xioi Tre 20 $2,388,614.00 $4,299,505.20 $2,388,614.00 nat. median
$2,588,981
0.9× median
09141
OTHER 		Inj Onase Abepar-xioi Tre 2 $2,388,614.00 $2,388,614.00 $2,388,614.00 nat. median
$2,511,312
1.0× median
09194
OTHER 		Tisagenlecleucel Car-pos 2 $529,192.90 $529,192.90 $529,192.90 nat. median
$549,535
1.0× median
9194
OTHER 		Tisagenlecleucel Car-pos 20 $529,192.90 $952,547.22 $529,192.90 nat. median
$577,163
0.9× median
09498
OTHER 		Ciltacabtagene Car-pos T 2 $527,123.40 $527,123.40 $527,123.40 nat. median
$570,020
0.9× median
9498
OTHER 		Ciltacabtagene Car-pos T 20 $527,123.40 $948,822.12 $527,123.40 nat. median
$587,650
0.9× median
9422
OTHER 		Idecabtagene Vicleucel Ca 20 $526,587.60 $947,857.68 $526,587.60 nat. median
$563,449
0.9× median
09422
OTHER 		Idecabtagene Vicleucel Ca 2 $526,587.60 $526,587.60 $526,587.60 nat. median
$541,339
1.0× median
9413
OTHER 		Lisocabtagene Car Pos T 20 $516,726.10 $930,106.98 $516,726.10 nat. median
$562,201
0.9× median
09413
OTHER 		Lisocabtagene Car Pos T 2 $516,726.10 $516,726.10 $516,726.10 nat. median
$545,335
0.9× median
Q2056
HCPCS 		Ciltacabtagene Autoleucel, Up To 100 Million Autologous B-cell Maturation Antige… 5 $84,532.00 $1,929,210.60 $507,496.00 nat. median
$646,415
0.8× median
09035
OTHER 		Axicabtagene Ciloleucel C 2 $489,456.00 $489,456.00 $489,456.00 nat. median
$516,226
0.9× median
9035
OTHER 		Axicabtagene Ciloleucel C 21 $489,456.00 $881,020.80 $489,456.00 nat. median
$533,230
0.9× median
Q2055
HCPCS 		Idecabtagene Vicleucel, Up To 510 Million Autologous B-cell Maturation Antigen (… 5 $96,938.00 $1,913,127.21 $484,690.00 nat. median
$622,450
0.8× median
Q2054
HCPCS 		Lisocabtagene Maraleucel, Up To 110 Million Autologous Anti-cd19 Car-positive Vi… 5 $94,770.00 $1,886,282.80 $474,061.00 nat. median
$640,950
0.7× median
09391
OTHER 		Brexucabtagene Car Pos T 2 $460,530.40 $460,530.40 $460,530.40 nat. median
$474,767
1.0× median
9391
OTHER 		Brexucabtagene Car Pos T 20 $460,530.40 $828,954.72 $460,530.40 nat. median
$492,768
0.9× median
Q2041
HCPCS 		Axicabtagene Ciloleucel, Up To 200 Million Autologous Anti-cd19 Car Positive Via… 5 $89,888.00 $1,858,720.26 $459,381.00 nat. median
$608,239
0.8× median
Q2053
HCPCS 		Brexucabtagene Autoleucel, Up To 200 Million Autologous Anti-cd19 Car Positive V… 5 $89,888.00 $1,707,872.00 $449,440.00 nat. median
$591,721
0.8× median
18
MS_DRG 		Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 23 $374,380.74 $703,457.88 $415,978.60 nat. median
$359,454
1.2× median
5834
APR_DRG 		Neonate With Ecmo 5 $369,399.28 $894,514.19 $380,824.00 nat. median
$307,206
1.2× median
5833
APR_DRG 		Neonate With Ecmo 5 $321,698.56 $544,976.31 $331,648.00 nat. median
$244,017
1.4× median
001
OTHER 		Heart Transplant Or Implant Of Heart Assist System With Mcc 2 $326,389.90 $326,389.90 $326,389.90 nat. median
$214,523
1.5× median
104
APR_DRG 		Head Trauma With Deep Coma 1 $324,518.90 $324,518.90 $324,518.90 nat. median
$42,757
outlier · 7.6×
1
MS_DRG 		Heart Transplant Or Implant Of Heart Assist System With Mcc 24 $8,580.00 $455,676.00 $310,775.60 nat. median
$249,036
1.2× median
Q2042
HCPCS 		Tisagenlecleucel, Up To 600 Million Car-positive Viable T Cells, Including Leuka… 5 $2,127.00 $1,989,119.73 $305,968.40 nat. median
$739,258
outlier · 0.4×
5884
APR_DRG 		Neonate Birth Weight < 1500 Grams With Major Procedure 5 $275,524.62 $816,134.21 $284,046.00 nat. median
$247,214
1.1× median
018
OTHER 		Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 2 $269,319.80 $269,319.80 $269,319.80 nat. median
$297,123
0.9× median
1614
APR_DRG 		Implantable Heart Assist Systems 5 $254,132.24 $697,651.10 $261,992.00 nat. median
$202,993
1.3× median
927
MS_DRG 		Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft 24 $8,580.00 $443,235.00 $261,793.00 nat. median
$198,418
1.3× median
24
APR_DRG 		Heart And/or Lung Transplant 5 $246,197.64 $645,038.48 $253,812.00 nat. median
$241,437
1.1× median
3
MS_DRG 		Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 25 $7,700.00 $588,627.00 $236,521.30 nat. median
$190,559
1.2× median
01908
OTHER 		New Technology - Level 52 2 $229,049.70 $229,049.70 $229,049.70 nat. median
$89,692
outlier · 2.6×
1908
OTHER 		New Technology - Level 52 21 $229,049.70 $412,289.46 $229,049.70 nat. median
$155,563
1.5× median
1907
OTHER 		New Technology - Level 52 21 $229,049.70 $412,289.46 $229,049.70 nat. median
$155,833
1.5× median
01907
OTHER 		New Technology - Level 52 2 $229,049.70 $229,049.70 $229,049.70 nat. median
$89,692
outlier · 2.6×
003
OTHER 		Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 2 $218,616.00 $218,616.00 $218,616.00 nat. median
$165,355
1.3× median
5832
APR_DRG 		Neonate With Ecmo 5 $201,874.46 $221,844.30 $208,118.00 nat. median
$159,249
1.3× median

Other procedures at this hospital

Browse this hospital's 33,966 published procedures. Use the slice to choose what to show, then sort or filter any column.

Slice
Sortable, filterable data table. Use the column headers to sort, the filter row to narrow results.
Code Type Description Rate rows Payers Gross Cash Min $ Max $ Avg median Last observed
             
J3393 HCPCS Injection, Betibeglogene Autotemcel, Per Treatment 1 1 — — $4,897,200.00 $4,897,200.00 $4,897,200.00 2024-10-01
J3399 HCPCS Injection, Onasemnogene Abeparvovec-xioi, Per Treatment, Up To 5x10°15 Vector Ge… 1 1 — — $3,884,946.48 $3,884,946.48 $3,884,946.48 2024-10-01
9138 OTHER Inj, Hemgenix, Per Tx Dos 27 19 — — $3,672,900.00 $4,774,770.00 $3,672,900.00 2024-10-01
09138 OTHER Inj, Hemgenix, Per Tx Dos 2 2 — — $3,672,900.00 $3,672,900.00 $3,672,900.00 2024-10-01
773 OTHER Inj, Beqvez, Per Tx Dose 28 20 — — $3,605,000.00 $4,686,500.00 $3,605,000.00 2024-10-01
00773 OTHER Inj, Beqvez, Per Tx Dose 2 2 — — $3,605,000.00 $3,605,000.00 $3,605,000.00 2024-10-01
714 OTHER Inj Delandistrogene Mox R 30 21 — — $9,629.20 $4,323,091.50 $3,325,455.00 2024-10-01
00714 OTHER Inj Delandistrogene Mox R 2 2 — — $3,325,455.00 $3,325,455.00 $3,325,455.00 2024-10-01
00748 OTHER Inj, Lovotibeglogene Auto 2 2 — — $3,286,000.00 $3,286,000.00 $3,286,000.00 2024-10-01
748 OTHER Inj, Lovotibeglogene Auto 30 21 — — $15,883.34 $4,271,800.00 $3,286,000.00 2024-10-01
00746 OTHER Inj, Betibeglogene Autote 2 2 — — $2,968,000.00 $2,968,000.00 $2,968,000.00 2024-10-01
746 OTHER Inj, Betibeglogene Autote 30 21 — — $14,107.56 $3,858,400.00 $2,968,000.00 2024-10-01
9141 OTHER Inj Onase Abepar-xioi Tre 28 20 — — $2,388,614.00 $4,299,505.20 $2,388,614.00 2024-10-01
09141 OTHER Inj Onase Abepar-xioi Tre 2 2 — — $2,388,614.00 $2,388,614.00 $2,388,614.00 2024-10-01
9194 OTHER Tisagenlecleucel Car-pos 28 20 — — $529,192.90 $952,547.22 $529,192.90 2024-10-01
09194 OTHER Tisagenlecleucel Car-pos 2 2 — — $529,192.90 $529,192.90 $529,192.90 2024-10-01
09498 OTHER Ciltacabtagene Car-pos T 2 2 — — $527,123.40 $527,123.40 $527,123.40 2024-10-01
9498 OTHER Ciltacabtagene Car-pos T 28 20 — — $527,123.40 $948,822.12 $527,123.40 2024-10-01
09422 OTHER Idecabtagene Vicleucel Ca 2 2 — — $526,587.60 $526,587.60 $526,587.60 2024-10-01
9422 OTHER Idecabtagene Vicleucel Ca 28 20 — — $526,587.60 $947,857.68 $526,587.60 2024-10-01
9413 OTHER Lisocabtagene Car Pos T 28 20 — — $516,726.10 $930,106.98 $516,726.10 2024-10-01
09413 OTHER Lisocabtagene Car Pos T 2 2 — — $516,726.10 $516,726.10 $516,726.10 2024-10-01
Q2056 HCPCS Ciltacabtagene Autoleucel, Up To 100 Million Autologous B-cell Maturation Antige… 6 5 — — $84,532.00 $1,929,210.60 $507,496.00 2024-10-01
09035 OTHER Axicabtagene Ciloleucel C 2 2 — — $489,456.00 $489,456.00 $489,456.00 2024-10-01
9035 OTHER Axicabtagene Ciloleucel C 29 21 — — $489,456.00 $881,020.80 $489,456.00 2024-10-01
Q2055 HCPCS Idecabtagene Vicleucel, Up To 510 Million Autologous B-cell Maturation Antigen (… 6 5 — — $96,938.00 $1,913,127.21 $484,690.00 2024-10-01
Q2054 HCPCS Lisocabtagene Maraleucel, Up To 110 Million Autologous Anti-cd19 Car-positive Vi… 6 5 — — $94,770.00 $1,886,282.80 $474,061.00 2024-10-01
9391 OTHER Brexucabtagene Car Pos T 28 20 — — $460,530.40 $828,954.72 $460,530.40 2024-10-01
09391 OTHER Brexucabtagene Car Pos T 2 2 — — $460,530.40 $460,530.40 $460,530.40 2024-10-01
Q2041 HCPCS Axicabtagene Ciloleucel, Up To 200 Million Autologous Anti-cd19 Car Positive Via… 6 5 — — $89,888.00 $1,858,720.26 $459,381.00 2024-10-01
Q2053 HCPCS Brexucabtagene Autoleucel, Up To 200 Million Autologous Anti-cd19 Car Positive V… 6 5 — — $89,888.00 $1,707,872.00 $449,440.00 2024-10-01
18 MS_DRG Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 33 23 — — $374,380.74 $703,457.88 $415,978.60 2024-10-01
5834 APR_DRG Neonate With Ecmo 5 5 — — $369,399.28 $894,514.19 $380,824.00 2024-10-01
5833 APR_DRG Neonate With Ecmo 5 5 — — $321,698.56 $544,976.31 $331,648.00 2024-10-01
001 OTHER Heart Transplant Or Implant Of Heart Assist System With Mcc 2 2 — — $326,389.90 $326,389.90 $326,389.90 2024-10-01
104 APR_DRG Head Trauma With Deep Coma 1 1 — — $324,518.90 $324,518.90 $324,518.90 2024-10-01
1 MS_DRG Heart Transplant Or Implant Of Heart Assist System With Mcc 35 24 — — $8,580.00 $455,676.00 $310,775.60 2024-10-01
Q2042 HCPCS Tisagenlecleucel, Up To 600 Million Car-positive Viable T Cells, Including Leuka… 8 5 — — $2,127.00 $1,989,119.73 $305,968.40 2024-10-01
5884 APR_DRG Neonate Birth Weight < 1500 Grams With Major Procedure 5 5 — — $275,524.62 $816,134.21 $284,046.00 2024-10-01
018 OTHER Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 2 2 — — $269,319.80 $269,319.80 $269,319.80 2024-10-01
1614 APR_DRG Implantable Heart Assist Systems 5 5 — — $254,132.24 $697,651.10 $261,992.00 2024-10-01
927 MS_DRG Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft 34 24 — — $8,580.00 $443,235.00 $261,793.00 2024-10-01
24 APR_DRG Heart And/or Lung Transplant 5 5 — — $246,197.64 $645,038.48 $253,812.00 2024-10-01
3 MS_DRG Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 38 25 — — $7,700.00 $588,627.00 $236,521.30 2024-10-01
01907 OTHER New Technology - Level 52 2 2 — — $229,049.70 $229,049.70 $229,049.70 2024-10-01
1908 OTHER New Technology - Level 52 29 21 — — $229,049.70 $412,289.46 $229,049.70 2024-10-01
01908 OTHER New Technology - Level 52 2 2 — — $229,049.70 $229,049.70 $229,049.70 2024-10-01
1907 OTHER New Technology - Level 52 29 21 — — $229,049.70 $412,289.46 $229,049.70 2024-10-01
003 OTHER Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 2 2 — — $218,616.00 $218,616.00 $218,616.00 2024-10-01
5832 APR_DRG Neonate With Ecmo 5 5 — — $201,874.46 $221,844.30 $208,118.00 2024-10-01
01906 OTHER New Technology - Level 51 2 2 — — $206,520.20 $206,520.20 $206,520.20 2024-10-01
1906 OTHER New Technology - Level 51 29 21 — — $206,520.20 $371,736.36 $206,520.20 2024-10-01
1905 OTHER New Technology - Level 51 29 21 — — $206,520.20 $371,736.36 $206,520.20 2024-10-01
01905 OTHER New Technology - Level 51 2 2 — — $206,520.20 $206,520.20 $206,520.20 2024-10-01
1613 APR_DRG Implantable Heart Assist Systems 5 5 — — $192,573.13 $274,082.74 $198,529.00 2024-10-01
114 APR_DRG Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 4 4 — — $191,244.23 $197,159.00 $196,173.21 2024-10-01
6304 APR_DRG Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure 5 5 — — $187,273.05 $293,732.66 $193,065.00 2024-10-01
8414 APR_DRG Extensive Third Degree Burns With Skin Graft 5 5 — — $182,521.99 $575,460.46 $188,167.00 2024-10-01
5934 APR_DRG Neonate Birth Weight 750-999 Grams Without Major Procedure 5 5 — — $181,126.16 $573,987.75 $186,728.00 2024-10-01
5914 APR_DRG Neonate Birth Weight 500-749 Grams Without Major Procedure 5 5 — — $179,320.02 $717,077.88 $184,866.00 2024-10-01
01904 OTHER New Technology - Level 50 2 2 — — $183,990.80 $183,990.80 $183,990.80 2024-10-01
1903 OTHER New Technology - Level 50 29 21 — — $183,990.80 $331,183.44 $183,990.80 2024-10-01
01903 OTHER New Technology - Level 50 2 2 — — $183,990.80 $183,990.80 $183,990.80 2024-10-01
1904 OTHER New Technology - Level 50 29 21 — — $183,990.80 $331,183.44 $183,990.80 2024-10-01
5883 APR_DRG Neonate Birth Weight < 1500 Grams With Major Procedure 5 5 — — $176,713.63 $548,089.95 $182,179.00 2024-10-01
6314 APR_DRG Neonate Birth Weight > 2499 Grams With Other Major Procedure 5 5 — — $176,162.67 $261,480.56 $181,611.00 2024-10-01
6094 APR_DRG Neonate Birth Weight 1500-2499 Grams With Major Procedure 5 5 — — $174,148.95 $422,500.73 $179,535.00 2024-10-01
5882 APR_DRG Neonate Birth Weight < 1500 Grams With Major Procedure 5 5 — — $172,013.98 $244,683.38 $177,334.00 2024-10-01
94 APR_DRG Extracorporeal Membrane Oxygenation (ecmo) 5 5 — — $164,038.64 $461,258.18 $169,112.00 2024-10-01
5831 APR_DRG Neonate With Ecmo 5 5 — — $140,491.43 $168,537.00 $166,851.63 2024-10-01
44 APR_DRG Tracheostomy With Mv >96 Hours With Extensive Procedure 5 5 — — $161,004.48 $470,616.26 $165,984.00 2024-10-01
74 APR_DRG Allogeneic Bone Marrow Transplant 5 5 — — $159,389.43 $489,153.92 $164,319.00 2024-10-01
01902 OTHER New Technology - Level 49 2 2 — — $161,461.50 $161,461.50 $161,461.50 2024-10-01
1902 OTHER New Technology - Level 49 29 21 — — $161,461.50 $290,630.70 $161,461.50 2024-10-01
1901 OTHER New Technology - Level 49 29 21 — — $161,461.50 $290,630.70 $161,461.50 2024-10-01
01901 OTHER New Technology - Level 49 2 2 — — $161,461.50 $161,461.50 $161,461.50 2024-10-01
23 APR_DRG Heart And/or Lung Transplant 5 5 — — $155,819.83 $418,274.83 $160,639.00 2024-10-01
14 APR_DRG Liver Transplant And/or Intestinal Transplant 5 5 — — $154,521.97 $483,723.07 $159,301.00 2024-10-01
1612 APR_DRG Implantable Heart Assist Systems 5 5 — — $154,432.73 $171,899.03 $159,209.00 2024-10-01
4 MS_DRG Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 38 25 — — $7,700.00 $363,881.00 $156,040.00 2024-10-01
004 OTHER Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 2 2 — — $153,714.20 $153,714.20 $153,714.20 2024-10-01
1611 APR_DRG Implantable Heart Assist Systems 5 5 — — $131,589.92 $151,430.00 $149,915.70 2024-10-01
14 MS_DRG Allogeneic Bone Marrow Transplant 33 23 — — $130,235.40 $217,838.17 $144,706.00 2024-10-01
7 MS_DRG Lung Transplant 34 24 — — $8,580.00 $237,578.47 $144,342.20 2024-10-01
014 OTHER Allogeneic Bone Marrow Transplant 2 2 — — $142,826.90 $142,826.90 $142,826.90 2024-10-01
01599 OTHER New Technology - Level 48 2 2 — — $142,687.00 $142,687.00 $142,687.00 2024-10-01
01585 OTHER New Technology - Level 48 2 2 — — $142,687.00 $142,687.00 $142,687.00 2024-10-01
1585 OTHER New Technology - Level 48 29 21 — — $142,687.00 $256,836.60 $142,687.00 2024-10-01
1599 OTHER New Technology - Level 48 29 21 — — $142,687.00 $256,836.60 $142,687.00 2024-10-01
6034 APR_DRG Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition 5 5 — — $135,870.81 $396,870.70 $140,073.00 2024-10-01
651 OTHER Kidney Transplant With Hemodialysis Without Mcc 2 2 — — $139,092.60 $139,092.60 $139,092.60 2024-10-01
J7330 HCPCS Autologous Cultured Chondrocytes, Implant 6 3 — — $95,681.68 $276,632.40 $135,036.37 2024-10-01
6024 APR_DRG Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other… 5 5 — — $130,697.80 $429,555.34 $134,740.00 2024-10-01
C1832 HCPCS Device Cell Harvest 30 22 $266,274.00 $266,274.00 $39,941.10 $266,274.00 $133,137.00 2024-10-01
C1721 HCPCS Icd 63x82.6mm 2 Chmbr 76 14 $195,409.50 $195,409.50 $39,562.36 $266,274.00 $132,173.55 2024-10-01
3024 APR_DRG Knee Joint Replacement 1 1 — — $130,841.55 $130,841.55 $130,841.55 2024-10-01
3014 APR_DRG Hip Joint Replacement 1 1 — — $129,382.57 $129,382.57 $129,382.57 2024-10-01
5464 APR_DRG Other O.r. Proc For Obstetric Diagnoses Except Delivery Diagnoses 1 1 — — $129,156.00 $129,156.00 $129,156.00 2024-10-01
01598 OTHER New Technology - Level 47 2 2 — — $127,667.40 $127,667.40 $127,667.40 2024-10-01
1584 OTHER New Technology - Level 47 29 21 — — $127,667.40 $229,801.32 $127,667.40 2024-10-01
01584 OTHER New Technology - Level 47 2 2 — — $127,667.40 $127,667.40 $127,667.40 2024-10-01
1598 OTHER New Technology - Level 47 29 21 — — $127,667.40 $229,801.32 $127,667.40 2024-10-01
64 APR_DRG Pancreas Transplant 5 5 — — $123,117.25 $479,747.77 $126,925.00 2024-10-01
A9699 HCPCS Radiopharmaceutical, Therapeutic, Not Otherwise Classified 2 1 — — $76,785.37 $176,839.04 $126,812.21 2024-10-01
5933 APR_DRG Neonate Birth Weight 750-999 Grams Without Major Procedure 5 5 — — $121,999.81 $372,253.38 $125,773.00 2024-10-01
J9999 HCPCS Carmustine Wafers 8/box 19 15 $205,734.00 $205,734.00 $30,860.10 $205,734.00 $123,440.40 2024-10-01
007 OTHER Lung Transplant 2 2 — — $123,233.70 $123,233.70 $123,233.70 2024-10-01
002 OTHER Heart Transplant Or Implant Of Heart Assist System Without Mcc 2 2 — — $123,010.10 $123,010.10 $123,010.10 2024-10-01
C2621 HCPCS Crt-p 8 Bdpl Hr-t 38 14 $192,761.00 $192,761.00 $39,161.39 $203,376.00 $122,025.60 2024-10-01
C1722 HCPCS Defib Crd 35ml 68gm 1chm 38 14 $195,409.50 $195,409.50 $40,300.25 $203,376.00 $122,025.60 2024-10-01
2 MS_DRG Heart Transplant Or Implant Of Heart Assist System Without Mcc 35 24 — — $8,580.00 $283,406.00 $121,764.50 2024-10-01
5913 APR_DRG Neonate Birth Weight 500-749 Grams Without Major Procedure 5 5 — — $117,400.07 $445,267.73 $121,031.00 2024-10-01
212 MS_DRG Concomitant Aortic And Mitral Valve Procedures 34 24 — — $8,580.00 $181,114.00 $120,369.00 2024-10-01
C1882 HCPCS Crtd Xt MRI Is1 Df4 76 14 $192,536.50 $192,536.50 $39,562.36 $203,376.00 $120,301.80 2024-10-01
1604 APR_DRG Major Cardiothoracic Repair Of Heart Anomaly 5 5 — — $115,877.17 $290,056.02 $119,461.00 2024-10-01
5881 APR_DRG Neonate Birth Weight < 1500 Grams With Major Procedure 5 5 — — $114,408.59 $169,132.12 $117,947.00 2024-10-01
5 MS_DRG Liver Transplant With Mcc Or Intestinal Transplant 34 24 — — $8,580.00 $222,003.03 $117,673.80 2024-10-01
215 MS_DRG Other Heart Assist System Implant 44 28 — — $7,700.00 $200,520.88 $117,074.20 2024-10-01
426 MS_DRG Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Wit… 32 22 — — $8,580.00 $150,582.90 $115,833.00 2024-10-01
22 APR_DRG Heart And/or Lung Transplant 5 5 — — $112,148.49 $347,732.17 $115,617.00 2024-10-01
54 APR_DRG Tracheostomy With Mv >96 Hours Without Extensive Procedure 5 5 — — $110,547.02 $333,066.82 $113,966.00 2024-10-01
955 OTHER Craniotomy For Multiple Significant Trauma 2 2 — — $113,844.30 $113,844.30 $113,844.30 2024-10-01
A9543 HCPCS Yttrium Y-90 Ibritumomab Tiuxetan, Therapeutic, Per Treatment Dose, Up To 40 Mil… 8 5 — — $61,770.00 $296,127.12 $113,243.61 2024-10-01
01597 OTHER New Technology - Level 46 2 2 — — $112,647.80 $112,647.80 $112,647.80 2024-10-01
1597 OTHER New Technology - Level 46 29 21 — — $112,647.80 $202,766.04 $112,647.80 2024-10-01
1583 OTHER New Technology - Level 46 29 21 — — $112,647.80 $202,766.04 $112,647.80 2024-10-01
01583 OTHER New Technology - Level 46 2 2 — — $112,647.80 $112,647.80 $112,647.80 2024-10-01
C1767 HCPCS Gen Nrstm 1.8x1.3x.27in 76 14 $178,697.00 $178,697.00 $34,256.60 $203,376.00 $110,969.85 2024-10-01
C2616 HCPCS Brachytx Ns Yttrium 90 21 14 $184,011.00 $184,011.00 $31,102.00 $184,011.00 $110,406.60 2024-10-01
C1822 HCPCS Pulse Gen Imp 19 14 $184,011.00 $184,011.00 $39,562.36 $184,011.00 $110,406.60 2024-10-01
C2624 HCPCS System Mntr 2x15mm 4.5cm 19 14 $184,011.00 $184,011.00 $39,562.36 $184,011.00 $110,406.60 2024-10-01
43 APR_DRG Tracheostomy With Mv >96 Hours With Extensive Procedure 5 5 — — $106,413.85 $317,326.98 $109,705.00 2024-10-01
216 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza… 47 29 — — $19,109.00 $247,840.00 $106,670.50 2024-10-01
113 APR_DRG Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 4 4 — — $102,760.83 $105,939.00 $105,409.30 2024-10-01
020 OTHER Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc 2 2 — — $104,922.90 $104,922.90 $104,922.90 2024-10-01
6074 APR_DRG Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other… 5 5 — — $101,597.80 $343,430.75 $104,740.00 2024-10-01
C1895 HCPCS Lead Defib 52cm 190 14 $175,668.50 $175,668.50 $28,613.92 $203,376.00 $104,631.56 2024-10-01
6303 APR_DRG Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure 5 5 — — $101,445.51 $140,783.23 $104,583.00 2024-10-01
C1777 HCPCS Lead Icd Df4 Pf Sc 59cm 247 14 $167,071.00 $167,071.00 $28,359.79 $203,376.00 $104,541.50 2024-10-01
3034 APR_DRG Dorsal And Lumbar Fusion Procedure For Curvature Of Back 5 5 — — $100,655.93 $330,131.69 $103,769.00 2024-10-01
914098 CDM Valve Mitral 33mm 24 16 $195,717.00 $195,717.00 $29,357.55 $195,717.00 $102,751.43 2024-10-01
913648 CDM Valve Mitral 27mm 24 16 $195,717.00 $195,717.00 $29,357.55 $195,717.00 $102,751.43 2024-10-01
914000 CDM Valve Mitral 29mm 24 16 $195,717.00 $195,717.00 $29,357.55 $195,717.00 $102,751.43 2024-10-01
914097 CDM Valve Mitral 31mm 24 16 $195,717.00 $195,717.00 $29,357.55 $195,717.00 $102,751.43 2024-10-01
8424 APR_DRG Burns With Skin Graft Except Extensive Third Degree Burns 5 5 — — $99,626.76 $298,754.99 $102,708.00 2024-10-01
1624 APR_DRG Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis 5 5 — — $99,096.17 $321,721.09 $102,161.00 2024-10-01
850 MS_DRG Acute Leukemia With Other Procedures 32 22 — — $8,580.00 $132,379.26 $101,830.20 2024-10-01
6023 APR_DRG Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other… 5 5 — — $98,732.42 $311,254.18 $101,786.00 2024-10-01
005 OTHER Liver Transplant With Mcc Or Intestinal Transplant 2 2 — — $101,114.30 $101,114.30 $101,114.30 2024-10-01
453 OTHER Combined Anterior And Posterior Spinal Fusion With Mcc 2 2 — — $100,883.50 $100,883.50 $100,883.50 2024-10-01
63 APR_DRG Pancreas Transplant 5 5 — — $97,470.45 $318,394.61 $100,485.00 2024-10-01
Q0480 HCPCS Driver For Use With Pneumatic Ventricular Assist Device, Replacement Only 31 22 — — $99,999.90 $179,999.82 $99,999.90 2024-10-01
460133 CDM Impl Envl Gntr 2.9x3.3in 24 16 $187,443.00 $187,443.00 $28,116.45 $187,443.00 $98,407.57 2024-10-01
B0404 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A > 63.5 1 1 — — $97,832.31 $97,832.31 $97,832.31 2024-10-01
5932 APR_DRG Neonate Birth Weight 750-999 Grams Without Major Procedure 5 5 — — $94,858.24 $226,269.30 $97,792.00 2024-10-01
580508 CDM Ablt Atria X10sv Endo 27 21 $325,964.00 $325,964.00 $48,894.60 $325,964.00 $97,789.20 2024-10-01
1582 OTHER New Technology - Level 45 29 21 — — $97,628.15 $175,730.67 $97,628.15 2024-10-01
01582 OTHER New Technology - Level 45 2 2 — — $97,628.15 $97,628.15 $97,628.15 2024-10-01
01596 OTHER New Technology - Level 45 2 2 — — $97,628.15 $97,628.15 $97,628.15 2024-10-01
1596 OTHER New Technology - Level 45 29 21 — — $97,628.15 $175,730.67 $97,628.15 2024-10-01
B0505 HCPCS Nontraumatic Spinal Cord Injury; M > 23.75 & M < 2 1 1 — — $96,827.54 $96,827.54 $96,827.54 2024-10-01
914689 CDM Device Embl 3mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466382 CDM Kit Impl Crnl Cstm Lg 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
914691 CDM Device Embl 3.75mm 14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
437689 CDM Stnt Thorac 28x28mm 10cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460026 CDM Graft Evas 14cm 26mm 14. 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
914704 CDM Device Embl 5mm 25mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
411116 CDM Device Embl 3.5mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
463946 CDM Device Embl 4.25mmx12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461127 CDM Occluder Cv 25x18mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466534 CDM Graft Evas 18x23x14.5mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
914692 CDM Device Embl 4mm 16mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
914699 CDM Device Embl 4.75mm 14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
468695 CDM Valve Aortic 26mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
468798 CDM Device Embl 25mm 3mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471957 CDM Valve Aortic 25mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
454672 CDM Graft Ostchnd Tochlr Lt 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458085 CDM Implant Cust Cranial Lge 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460654 CDM Device Embl 5x18mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
468623 CDM Graft Evas 10cm 10mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460893 CDM Graft Excluder 16cm 28.5 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
469491 CDM Valve Heart Trnscth 26mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460911 CDM Graft Evas 23x14.5m 12cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471913 CDM Device Embl 5mm 16mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
413087 CDM Device Embl 4.75mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
919971 CDM Stnt Thorac 26x26mm 10cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460976 CDM Graft Evas 14 Cm 28.5 14 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466960 CDM Device Embl 4.25x14mm Pl 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
408706 CDM Graft Evas 45x45mm 10cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465236 CDM Graft Evas 16cm 26mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460199 CDM Kit Aor Vlv 14fr 23mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
452272 CDM Graft Evas 12cm 26mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
468799 CDM Device Embl 3.25x20mm Pl 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471758 CDM Valve Aortic 27mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
914688 CDM Device Embl 10mm 2.5mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
462479 CDM Device Embl Pln 4.5x12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465607 CDM Device Embl Pipln 4x18mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465861 CDM Graft Hemi Cndyl Mdl Rt 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
916850 CDM Implant Cranial Peek 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
470779 CDM Valve Aortic 23mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
437690 CDM Graft Evas 34x34x10cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
451457 CDM Coil Embl 4.75x35mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461110 CDM Graft Evs 16cm 26x14.5mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
734682 CDM Graft Bn Fem Condyl Lt 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
454775 CDM Dev Emb Pipeln 5x18mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465237 CDM Graft Evas 17cm 31x14.5 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
918878 CDM Graft Endo Aaa 26x12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
919964 CDM Valve Aortic 21mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
470742 CDM Valve Aortic 29mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461173 CDM Device Embl 12mm 3.75mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458959 CDM Device Embl 12mm 3mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
916380 CDM Device Embl 4mm 14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460913 CDM Graft Evas 10cm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
469985 CDM Dev Embl 14x3.25mm Pipln 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471753 CDM Device Embl 4.5mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466212 CDM Graft Evas 10cm 14.5mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
472017 CDM Device Emb 4.25mm 16mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458226 CDM Graft Evas 31x14.5m 13cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467949 CDM Device Embl 3.75x18mm Pl 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
468694 CDM Valve Aortic 23mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467667 CDM Dev Embl 16x2.75mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
914107 CDM Graft Endo Aaa 32x14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
434394 CDM Pump Pain Infn 20ml 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461128 CDM Occluder Cv 35x18mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461879 CDM Device Embl 5x20mm Pipln 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466546 CDM Device Embl Pip2.75x12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458869 CDM Device Embl 18mm 4.5mm P 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458566 CDM Device Embl 5x35mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467259 CDM Device Embl Pipln 16x4.5 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465431 CDM Dev Embl Pipln 14x3.75mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
469490 CDM Valve Heart Trnscth 23mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
454843 CDM Coil Embl 4.25x20mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
413086 CDM Device Embl 3.75mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
469583 CDM Device Embl 10mm 4.25mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471697 CDM Device Embl 4.25mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
408976 CDM Device Embl 3.25mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471955 CDM Device Embl 3.25mm 16mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
916574 CDM Device Embl 3mm 10mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458565 CDM Device Embl 5x30mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
456952 CDM Implant Cranial Med 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
408845 CDM Device Emb 5mm 14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465928 CDM Graft Hemi Cndyl Mdl Lt 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466377 CDM Device Embl Pipln 16x3.5 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
470937 CDM Device Embl 10mm 4mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471443 CDM Device Embl 4mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
412999 CDM Device Embl 2.75mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460201 CDM Kit Aor Vlv 14fr 29mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458428 CDM Device Embl16x3.75mm Pip 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461887 CDM Device Embl 14mm 2.5mm P 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460198 CDM Kit Aor Vlv 14fr 20mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461869 CDM Spacer Spn 36x28x15-9.9 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
452402 CDM Coil Embl 4.75x16mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
464914 CDM Device Embl 14x3.5mm Pl 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
713900 CDM Graft Bn Hemi Condrl Rt 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
411781 CDM Graft Endo Aaa 28.5x12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461126 CDM Occluder Cv 18x18mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466774 CDM Device Embl Pipln 14x4mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471698 CDM Device Embl 4.25mm 14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460200 CDM Kit Aor Vlv 14fr 26mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465480 CDM Graft Evas 14cm 35mm 14. 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467113 CDM Valve Aortic 19mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467535 CDM Graft Evas 14.5mm 12cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461131 CDM Device Embl 4x12mm Pline 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471130 CDM Device Embl Piplin 4mmx2 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460977 CDM Graft Evas 16cm 35mm 14. 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
729378 CDM Pump Infs 10ml DRG Dlv 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
915331 CDM Device Embl 4mm 10mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
734632 CDM Graft Evas 12cm 28.5mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461544 CDM Device Embl Pl 4.75x14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
915600 CDM Device Embl 4.5mm 14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
435427 CDM Pump Pain Infn 148gm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
464804 CDM Graft Evas 16cm 23mm 12m 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
457874 CDM Dev Embl 18x3.5mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467258 CDM Device Embl Flx 4.5x14mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
457284 CDM Graft Evas 26x14.5m 12cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461825 CDM Device Embl 16x4.25mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
467488 CDM Dev Embl Ped 12x3.25mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
461871 CDM Graft Evas 18cm28.5x12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458911 CDM Graft Evas 18cm 28.5mm 1 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
471451 CDM Device Embl 4.75mm 16mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
466039 CDM Device Embl Pl 4.75x20mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
468693 CDM Valve Aortic 20mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
460494 CDM Graft Evas 12cm 26x12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465641 CDM Device Embl 16mm 4mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
918337 CDM Device Embl 2.5mm 12mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
457281 CDM Graft Evas 26x14.5m 18cm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
469489 CDM Valve Heart Trnscth 20mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
465384 CDM Graft Bn Fem Condyl Rt 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
450025 CDM Graft Bn L/l Dist Fem 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
700770 CDM Graft Bn Fem Hemi Cndyl 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
458429 CDM Device Embl Ped25x4.75mm 24 16 $184,011.00 $184,011.00 $27,601.65 $184,011.00 $96,605.77 2024-10-01
4404 APR_DRG Kidney Transplant 5 5 — — $93,408.09 $294,518.79 $96,297.00 2024-10-01
456094 CDM Cage Xpnd Frtfy 28x36x20 24 16 $181,862.00 $181,862.00 $27,279.30 $181,862.00 $95,477.55 2024-10-01
457096 CDM Endplate Spnl 26-32x20mm 24 16 $181,862.00 $181,862.00 $27,279.30 $181,862.00 $95,477.55 2024-10-01
724876 CDM Cage Spn 31-44mm 16mm 24 16 $181,469.00 $181,469.00 $27,220.35 $181,469.00 $95,271.23 2024-10-01
734468 CDM Cage Spn 17-22mm 13mm 24 16 $181,469.00 $181,469.00 $27,220.35 $181,469.00 $95,271.23 2024-10-01
471725 CDM Graft Drms Ptch 16x20cm 24 16 $181,459.00 $181,459.00 $27,218.85 $181,459.00 $95,265.98 2024-10-01
21 APR_DRG Heart And/or Lung Transplant 5 5 — — $92,196.56 $305,984.68 $95,048.00 2024-10-01
723419 CDM Graft Evas 18cm 28.5mm 24 16 $179,598.00 $179,598.00 $26,939.70 $179,598.00 $94,288.95 2024-10-01
722835 CDM Graft Evas 14cm 28.5mm 24 16 $179,598.00 $179,598.00 $26,939.70 $179,598.00 $94,288.95 2024-10-01
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