Hospital

MAINEHEALTH WALDO HOSPITAL

Belfast, ME · CCN 201312 · Rates published

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You selected 27447 (CPT)

TOTAL KNEE ARTHROPLASTY

This hospital’s price: $63,218 across 1 payer

Source: https://sthpiprd.blob.core.windows.net/machine-readable-files/7977/010238552-1841397932_mainehealth_standardcharges.csv · observed 2025-09-09

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.

10,093 distinct procedures filed

9 distinct payers

525,970 rate rows

2025-09-09 last MRF observed

Data quality

186,798 of 525,970 rate rows are consumer-grade (35.5%)

339,172 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 — reason	Rows
professional (physician) fee — not the facility price	338,662
exceeds 10× this hospital's gross charge — excluded from medians	242
placeholder amount (≤ $0.02) — excluded from medians	162
percent-of-charges filed in the dollar field — excluded from medians	52
per-diem day rate — not a per-procedure price	40
below 25% of the Medicare reference for this code — likely a mislabeled per-diem or placeholder; excluded from medians	10
no usable negotiated amount (only an out-of-band fallback) — excluded from medians	4

Data source & audit trail ↓ Download audit trail (JSON)

Source MRF file	https://sthpiprd.blob.core.windows.net/machine-readable-files/7977/010238552-1841397932_mainehealth_standardcharges.csv
Found on page	https://search.hospitalpriceindex.com/hpi2/machineReadable/waldocountygeneralhospital/7977
Discovered via	Discovered by HANK
Last fetch	not_modified · 2026-08-11
Content fingerprint	bb6248fbc775f768… · 99,203,824 bytes · first seen 2026-05-09

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
Q2057 HCPCS	Afamitresgene Autoleucel	1	$849,762.67	$849,762.67	$849,762.67	nat. median $809,151 1.1× median
Q2042 HCPCS	Tisagenlecleucel Car-pos T	1	$637,718.51	$637,718.51	$637,718.51	nat. median $691,418 0.9× median
Q2056 HCPCS	Ciltacabtagene Car-pos T	1	$610,210.84	$610,210.84	$610,210.84	nat. median $631,793 1.0× median
Q2054 HCPCS	Lisocabtagene Mara Car Pos T	1	$597,261.64	$597,261.64	$597,261.64	nat. median $624,417 1.0× median
Q2055 HCPCS	Idecabtagene Vicleucel Car	1	$596,847.89	$596,847.89	$596,847.89	nat. median $610,161 1.0× median
Q2041 HCPCS	Axicabtagene Ciloleucel Car+	1	$587,823.43	$587,823.43	$587,823.43	nat. median $588,565 1.0× median
J9355 HCPCS	Trastuzumab 150 Mg/7.15ml IV (wet Solr Vial)	9	$236.78	$579,975.97	$547,991.09	nat. median $544 outlier · 1008.2×
Q2053 HCPCS	Brexucabtagene Car Pos T	1	$540,014.24	$540,014.24	$540,014.24	nat. median $577,541 0.9× median
Q2058 HCPCS	Obecbtge Autol Up To 400 Mil	1	$298,142.51	$298,142.51	$298,142.51	nat. median $302,242 1.0× median
38240 CPT	Transplt Allo Hct/donor	1	$290,581.32	$290,581.32	$290,581.32	nat. median $13,835 outlier · 21.0×
A9543 HCPCS	Y90 Ibritumomab, Rx	1	$198,557.73	$198,557.73	$198,557.73	nat. median $63,643 outlier · 3.1×
J9029 HCPCS	Instill Adstiladrin, Tx Dose	1	$192,561.72	$192,561.72	$192,561.72	nat. median $69,291 outlier · 2.8×
0571T CPT	Insj/rplcmt Icds Ss Eltrd	1	$157,526.70	$157,526.70	$157,526.70	nat. median $32,069 outlier · 4.9×
33249 CPT	Insj/rplcmt Defib W/lead(s)	1	$157,526.70	$157,526.70	$157,526.70	nat. median $31,420 outlier · 5.0×
0408T CPT	Insj/rplc Cardiac Modulj Sys	1	$157,526.70	$157,526.70	$157,526.70	nat. median $32,062 outlier · 4.9×
33270 CPT	Ins/rep Subq Defibrillator	1	$157,526.70	$157,526.70	$157,526.70	nat. median $31,963 outlier · 4.9×
33231 CPT	Insrt Pulse Gen W/mult Leads	1	$157,526.70	$157,526.70	$157,526.70	nat. median $29,955 outlier · 5.3×
33264 CPT	Rmvl & Rplcmt Dfb Gen Mlt Ld	1	$157,526.70	$157,526.70	$157,526.70	nat. median $31,464 outlier · 5.0×
0915T CPT	Insj Perm Ccm-d Sys Pg&eltrd	1	$157,526.70	$157,526.70	$157,526.70	nat. median $32,635 outlier · 4.8×
69930 CPT	Implant Cochlear Device	1	$156,279.93	$156,279.93	$156,279.93	nat. median $29,361 outlier · 5.3×
61886 CPT	Implant Neurostim Arrays	1	$149,724.49	$149,724.49	$149,724.49	nat. median $27,176 outlier · 5.5×
0268T CPT	Commercial Fee Schedule	1	$149,724.49	$149,724.49	$149,724.49	nat. median $29,816 outlier · 5.0×
64582 CPT	Opn Mpltj Hpglsl Nstm Ary Pg	1	$149,724.49	$149,724.49	$149,724.49	nat. median $28,070 outlier · 5.3×
0674T CPT	Laps Insj Nw/rpcmt Prm Isdss	1	$149,724.49	$149,724.49	$149,724.49	nat. median $29,473 outlier · 5.1×
63685 CPT	Ins/rplc Spi Npg/rcvr Pocket	1	$149,724.49	$149,724.49	$149,724.49	nat. median $21,025 outlier · 7.1×
64568 CPT	Opn Impltj Crnl Nrv Nea&pg	1	$149,724.49	$149,724.49	$149,724.49	nat. median $27,651 outlier · 5.4×
33287 CPT	Rmv&rplcmt Phrnc Nrv Stim Pg	1	$149,724.49	$149,724.49	$149,724.49	nat. median $29,000 outlier · 5.2×
Q0480 HCPCS	Driver Pneumatic Vad, Rep	1	$142,841.00	$142,841.00	$142,841.00	nat. median $111,503 1.3× median
33289 CPT	Tcat Impl Wrls P-art Prs Snr	1	$139,675.60	$139,675.60	$139,675.60	nat. median $27,692 outlier · 5.0×
J9226 HCPCS	Supprelin La Implant	1	$133,909.89	$133,909.89	$133,909.89	nat. median $55,200 outlier · 2.4×
J9043 HCPCS	Cabazitaxel 60 Mg/6ml IV Soln	9	$653.50	$141,367.55	$133,571.33	nat. median $709 outlier · 188.5×
K1007 HCPCS	Bil Hkaf Pc S/d Micro Sensor	1	$123,348.02	$123,348.02	$123,348.02	nat. median $97,404 1.3× median
93653 CPT	Compre Ep Eval Tx Svt	1	$120,533.44	$120,533.44	$120,533.44	nat. median $26,399 outlier · 4.6×
93654 CPT	Compre Ep Eval Tx Vt	1	$120,533.44	$120,533.44	$120,533.44	nat. median $26,806 outlier · 4.5×
93656 CPT	Compre Ep Eval Abltj Atr Fib	1	$120,533.44	$120,533.44	$120,533.44	nat. median $26,956 outlier · 4.5×
0614T CPT	Rmvl&rplcmt Ss Impl Dfb Pg	1	$110,283.85	$110,283.85	$110,283.85	nat. median $23,432 outlier · 4.7×
0923T CPT	Rmvl&rplcmt Perm Ccm-d Pg	1	$110,283.85	$110,283.85	$110,283.85	nat. median $22,725 outlier · 4.9×
33262 CPT	Rmvl& Replc Pulse Gen 1 Lead	1	$110,283.85	$110,283.85	$110,283.85	nat. median $23,104 outlier · 4.8×
0409T CPT	Insj/rplc Car Modulj Pls Gn	1	$110,283.85	$110,283.85	$110,283.85	nat. median $23,132 outlier · 4.8×
0916T CPT	Insj Perm Ccm-d Sys Pg Only	1	$110,283.85	$110,283.85	$110,283.85	nat. median $23,439 outlier · 4.7×
0515T CPT	Insj Wcs Lv Compl Sys	1	$110,283.85	$110,283.85	$110,283.85	nat. median $22,690 outlier · 4.9×
33263 CPT	Rmvl & Rplcmt Dfb Gen 2 Lead	1	$110,283.85	$110,283.85	$110,283.85	nat. median $23,228 outlier · 4.7×
0414T CPT	Rmvl & Rpl Car Modulj Pls Gn	1	$110,283.85	$110,283.85	$110,283.85	nat. median $23,105 outlier · 4.8×
33240 CPT	Insrt Pulse Gen W/singl Lead	1	$110,283.85	$110,283.85	$110,283.85	nat. median $21,987 outlier · 5.0×
33230 CPT	Insrt Pulse Gen W/dual Leads	1	$110,283.85	$110,283.85	$110,283.85	nat. median $22,374 outlier · 4.9×
61885 CPT	Insrt/redo Neurostim 1 Array	1	$105,361.73	$105,361.73	$105,361.73	nat. median $19,880 outlier · 5.3×
61891 CPT	Rev/rplcmt Sk-mnt Crnl Nstm	1	$105,361.73	$105,361.73	$105,361.73	nat. median $20,661 outlier · 5.1×
63655 CPT	Implant Neuroelectrodes	1	$105,361.73	$105,361.73	$105,361.73	nat. median $18,229 outlier · 5.8×
0817T CPT	Opn Insj/rplcmt Ins Ptn Subf	1	$105,361.73	$105,361.73	$105,361.73	nat. median $21,273 outlier · 5.0×
64590 CPT	Ins/rpl Prph Sac/gstr Npg/r	1	$105,361.73	$105,361.73	$105,361.73	nat. median $17,900 outlier · 5.9×

Other procedures at this hospital

Browse this hospital's 10,093 published procedures. Use the slice to choose what to show, then sort or filter any column.

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

Q2057	HCPCS	Afamitresgene Autoleucel	2	1	—	—	$849,762.67	$849,762.67	$849,762.67	2025-09-09
Q2042	HCPCS	Tisagenlecleucel Car-pos T	2	1	—	—	$637,718.51	$637,718.51	$637,718.51	2025-09-09
Q2056	HCPCS	Ciltacabtagene Car-pos T	2	1	—	—	$610,210.84	$610,210.84	$610,210.84	2025-09-09
Q2054	HCPCS	Lisocabtagene Mara Car Pos T	2	1	—	—	$597,261.64	$597,261.64	$597,261.64	2025-09-09
Q2055	HCPCS	Idecabtagene Vicleucel Car	2	1	—	—	$596,847.89	$596,847.89	$596,847.89	2025-09-09
Q2041	HCPCS	Axicabtagene Ciloleucel Car+	2	1	—	—	$587,823.43	$587,823.43	$587,823.43	2025-09-09
J9355	HCPCS	Trastuzumab 150 Mg/7.15ml IV (wet Solr Vial)	68	9	$615,685.74	$615,685.74	$236.78	$579,975.97	$547,991.09	2025-09-09
Q2053	HCPCS	Brexucabtagene Car Pos T	2	1	—	—	$540,014.24	$540,014.24	$540,014.24	2025-09-09
Q2058	HCPCS	Obecbtge Autol Up To 400 Mil	2	1	—	—	$298,142.51	$298,142.51	$298,142.51	2025-09-09
38240	CPT	Transplt Allo Hct/donor	2	1	—	—	$290,581.32	$290,581.32	$290,581.32	2025-09-09
A9543	HCPCS	Y90 Ibritumomab, Rx	2	1	—	—	$198,557.73	$198,557.73	$198,557.73	2025-09-09
J9029	HCPCS	Instill Adstiladrin, Tx Dose	2	1	—	—	$192,561.72	$192,561.72	$192,561.72	2025-09-09
0571T	CPT	Insj/rplcmt Icds Ss Eltrd	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
33249	CPT	Insj/rplcmt Defib W/lead(s)	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
33264	CPT	Rmvl & Rplcmt Dfb Gen Mlt Ld	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
0408T	CPT	Insj/rplc Cardiac Modulj Sys	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
33231	CPT	Insrt Pulse Gen W/mult Leads	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
33270	CPT	Ins/rep Subq Defibrillator	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
0915T	CPT	Insj Perm Ccm-d Sys Pg&eltrd	2	1	—	—	$157,526.70	$157,526.70	$157,526.70	2025-09-09
69930	CPT	Implant Cochlear Device	2	1	—	—	$156,279.93	$156,279.93	$156,279.93	2025-09-09
61886	CPT	Implant Neurostim Arrays	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
64582	CPT	Opn Mpltj Hpglsl Nstm Ary Pg	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
33287	CPT	Rmv&rplcmt Phrnc Nrv Stim Pg	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
64568	CPT	Opn Impltj Crnl Nrv Nea&pg	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
63685	CPT	Ins/rplc Spi Npg/rcvr Pocket	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
0674T	CPT	Laps Insj Nw/rpcmt Prm Isdss	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
0268T	CPT	Commercial Fee Schedule	2	1	—	—	$149,724.49	$149,724.49	$149,724.49	2025-09-09
Q0480	HCPCS	Driver Pneumatic Vad, Rep	2	1	—	—	$142,841.00	$142,841.00	$142,841.00	2025-09-09
33289	CPT	Tcat Impl Wrls P-art Prs Snr	2	1	—	—	$139,675.60	$139,675.60	$139,675.60	2025-09-09
J9226	HCPCS	Supprelin La Implant	2	1	—	—	$133,909.89	$133,909.89	$133,909.89	2025-09-09
J9043	HCPCS	Cabazitaxel 60 Mg/6ml IV Soln	42	9	$150,071.71	$150,071.71	$653.50	$141,367.55	$133,571.33	2025-09-09
K1007	HCPCS	Bil Hkaf Pc S/d Micro Sensor	2	1	—	—	$123,348.02	$123,348.02	$123,348.02	2025-09-09
93653	CPT	Compre Ep Eval Tx Svt	2	1	—	—	$120,533.44	$120,533.44	$120,533.44	2025-09-09
93654	CPT	Compre Ep Eval Tx Vt	2	1	—	—	$120,533.44	$120,533.44	$120,533.44	2025-09-09
93656	CPT	Compre Ep Eval Abltj Atr Fib	2	1	—	—	$120,533.44	$120,533.44	$120,533.44	2025-09-09
33240	CPT	Insrt Pulse Gen W/singl Lead	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
33262	CPT	Rmvl& Replc Pulse Gen 1 Lead	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
0414T	CPT	Rmvl & Rpl Car Modulj Pls Gn	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
0409T	CPT	Insj/rplc Car Modulj Pls Gn	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
0916T	CPT	Insj Perm Ccm-d Sys Pg Only	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
0614T	CPT	Rmvl&rplcmt Ss Impl Dfb Pg	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
33263	CPT	Rmvl & Rplcmt Dfb Gen 2 Lead	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
0923T	CPT	Rmvl&rplcmt Perm Ccm-d Pg	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
0515T	CPT	Insj Wcs Lv Compl Sys	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
33230	CPT	Insrt Pulse Gen W/dual Leads	2	1	—	—	$110,283.85	$110,283.85	$110,283.85	2025-09-09
64580	CPT	Opn Impltj Nea Neuromuscular	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
63655	CPT	Implant Neuroelectrodes	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
0680T	CPT	Insj/rplcmt Pg Only Isdss	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
0816T	CPT	Opn Insj/rplcmt Ins Ptn Subq	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
0817T	CPT	Opn Insj/rplcmt Ins Ptn Subf	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
61891	CPT	Rev/rplcmt Sk-mnt Crnl Nstm	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
64590	CPT	Ins/rpl Prph Sac/gstr Npg/r	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
61885	CPT	Insrt/redo Neurostim 1 Array	2	1	—	—	$105,361.73	$105,361.73	$105,361.73	2025-09-09
54410	CPT	Remove/replace Penis Prosth	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
54405	CPT	Insert Multi-comp Penis Pros	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
53444	CPT	Insert Tandem Cuff	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
54401	CPT	Insert Self-contd Prosthesis	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
54416	CPT	Remv/repl Penis Contain Pros	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
54411	CPT	Remov/replc Penis Pros Comp	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
53447	CPT	Remove/replace Ur Sphincter	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
53445	CPT	Insert Uro/ves Nck Sphincter	2	1	—	—	$98,896.76	$98,896.76	$98,896.76	2025-09-09
0525T	CPT	Insj/rplcmt Compl Iims	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0797T	CPT	Tcat Ins 2chmbr Ldls Pm Rv	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0803T	CPT	Tcat Rmv&rpl2chmb Ldls Pm Rv	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0802T	CPT	Tcat Rmv&rpl2chmb Ldls Pm Ra	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0796T	CPT	Tcat Ins 2chmbr Ldls Pm Ra	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0825T	CPT	Tcat Rmv&rpl1chmb Ldls Pm Ra	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0795T	CPT	Tcat Ins 2chmbr Ldls Pm Cmpl	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0823T	CPT	Tcat Ins 1chmbr Ldls Pm Ra	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
33274	CPT	Tcat Insj/rpl Perm Ldls Pm	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
33229	CPT	Remv&replc Pm Gen Mult Leads	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
33221	CPT	Insert Pulse Gen Mult Leads	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
0801T	CPT	Tcat Rmv&rpl 2chmbr Ldls Pm	2	1	—	—	$93,701.48	$93,701.48	$93,701.48	2025-09-09
C8003	HCPCS	Imp Extar Knee Shck Absrb	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
22856	CPT	Tot Disc Arthrp 1ntrspc Crv	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
22867	CPT	Insj Stablj Dev W/dcmprn	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
24361	CPT	Reconstruct Elbow Joint	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
22612	CPT	Arthrd Pst Tq 1ntrspc Lumbar	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
24371	CPT	Revise Reconst Elbow Joint	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
23472	CPT	Reconstruct Shoulder Joint	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
25442	CPT	Arthrp W/prostc Dstl Ulna	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
27279	CPT	Arthrd Si Jt Plmt Tartclr Dv	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
25446	CPT	Arthrp W/prostc Dst Rds&crps	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
27278	CPT	Arthrd Si Jt Plmt Iartic Dev	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
23616	CPT	Optx Prx Hmrl Fx Fix Rpr Rpl	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
21243	CPT	Reconstruction Of Jaw Joint	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
28705	CPT	Arthrodesis Pantalar	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
20696	CPT	App Mltpln Uni Xtrnl Fix 1st	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
22633	CPT	Arthrd Cmbn 1ntrspc Lumbar	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
27702	CPT	Reconstruct Ankle Joint	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
24363	CPT	Replace Elbow Joint	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
22630	CPT	Arthrd Pst Tq 1ntrspc Lum	2	1	—	—	$90,354.97	$90,354.97	$90,354.97	2025-09-09
L8702	HCPCS	Ewhf S/d Uprt Micro Sensor	2	1	—	—	$89,256.06	$89,256.06	$89,256.06	2025-09-09
C9765	HCPCS	Revasc Intra Lithotrip-stent	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
0793T	CPT	Prq Tcat Thrm Ablt Nrv P-art	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9767	HCPCS	Revasc Lithotrip-stent-ather	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9766	HCPCS	Revasc Intra Lithotrip-ather	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
0238T	CPT	Trluml Perip Athrc Iliac Art	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
93590	CPT	Perq Transcath Cls Mitral	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
93582	CPT	Perq Transcath Closure Pda	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9602	HCPCS	Perc D-e Cor Stent Ather S	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37242	CPT	Vasc Embolize/occlude Artery	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37231	CPT	Commercial Fee Schedule	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
0645T	CPT	Tcat Impltj C Sins Rdctj Dev	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9774	HCPCS	Revasc Lithotr-ather Tib/per	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37225	CPT	Commercial Fee Schedule	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37227	CPT	Commercial Fee Schedule	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
36906	CPT	Thrmbc/nfs Dialysis Circuit	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37184	CPT	Prim Art M-thrmbc 1st Vsl	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37229	CPT	Commercial Fee Schedule	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
36836	CPT	Prq Av Fstl Crtj Uxtr 1 Acs	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
36837	CPT	Prq Av Fstl Crt Uxtr Sep Acs	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
37230	CPT	Commercial Fee Schedule	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
33902	CPT	Perq P-art Revsc 1 Abnor Uni	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9775	HCPCS	Revasc Lith-sten-ath Tib/per	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9607	HCPCS	Perc D-e Cor Revasc Chro Sin	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9797	HCPCS	Vasc Emb/occ W/prs Cath	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
0981T	CPT	Tcat Impl Wrls Ivc Snr	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
92933	CPT	Prq Trlml C Athrc St Angiop1	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
93580	CPT	Transcath Closure Of Asd	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
93581	CPT	Transcath Closure Of Vsd	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
C9773	HCPCS	Revasc Lithotr-stent Tib/per	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
93591	CPT	Perq Transcath Cls Aortic	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
0632T	CPT	Perq Tcat US Abltj Nrv P-art	2	1	—	—	$88,225.93	$88,225.93	$88,225.93	2025-09-09
62362	CPT	Implant Spine Infusion Pump	2	1	—	—	$86,837.43	$86,837.43	$86,837.43	2025-09-09
62360	CPT	Insert Spine Infusion Device	2	1	—	—	$86,837.43	$86,837.43	$86,837.43	2025-09-09
62361	CPT	Implant Spine Infusion Pump	2	1	—	—	$86,837.43	$86,837.43	$86,837.43	2025-09-09
C2616	HCPCS	Brachytx, Non-str,yttrium-90	2	1	—	—	$85,908.77	$85,908.77	$85,908.77	2025-09-09
19357	CPT	Tiss Xpndr Plmt Brst Rcnstj	2	1	—	—	$85,482.53	$85,482.53	$85,482.53	2025-09-09
J9228	HCPCS	Ipilimumab 5 Mg/ml IV Soln (combined)	42	9	$92,780.74	$92,780.74	$536.09	$87,399.46	$82,579.50	2025-09-09
J9266	HCPCS	Pegaspargase Injection	2	1	—	—	$81,922.56	$81,922.56	$81,922.56	2025-09-09
66683	CPT	Implantation Iris Prosthesis	2	1	—	—	$80,658.15	$80,658.15	$80,658.15	2025-09-09
0308T	CPT	Insj Ocular Telescope Prosth	2	1	—	—	$80,658.15	$80,658.15	$80,658.15	2025-09-09
67027	CPT	Implant Eye Drug System	2	1	—	—	$75,491.30	$75,491.30	$75,491.30	2025-09-09
J9600	HCPCS	Porfimer Sodium Injection	2	1	—	—	$71,315.79	$71,315.79	$71,315.79	2025-09-09
65770	CPT	Keratoprosthesis	2	1	—	—	$70,207.00	$70,207.00	$70,207.00	2025-09-09
81416	CPT	Exome Sequence Analysis	2	1	—	—	$66,163.20	$66,163.20	$66,163.20	2025-09-09
54417	CPT	Remv/replc Penis Pros Compl	2	1	—	—	$63,835.08	$63,835.08	$63,835.08	2025-09-09
54400	CPT	Insert Semi-rigid Prosthesis	2	1	—	—	$63,835.08	$63,835.08	$63,835.08	2025-09-09
55882	CPT	Ablt Trurl Prst8 Tis Trnsdcr	2	1	—	—	$63,835.08	$63,835.08	$63,835.08	2025-09-09
53451	CPT	Tprnl Balo Cntnc Dev Bi	2	1	—	—	$63,835.08	$63,835.08	$63,835.08	2025-09-09
53440	CPT	Male Sling Procedure	2	1	—	—	$63,835.08	$63,835.08	$63,835.08	2025-09-09
L7181	HCPCS	Electronic Elbo Simultaneous	2	1	—	—	$63,531.52	$63,531.52	$63,531.52	2025-09-09
24545	CPT	Optx Hum Fx Wo Ntrcndylr Xtn	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23680	CPT	Optx Sho Dislc Neck Fx Fixj	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27827	CPT	Treat Lower Leg Fracture	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
20692	CPT	Appl Mltpln Uni Ext Fixj Sys	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
25810	CPT	Arthrd Wrst Iliac/oth Agrft	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24575	CPT	Optx Humeral Epcndylr Fx	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
0629T	CPT	Perq Njx Algc CT Lmbr 1st	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23802	CPT	Arthrd Glenohumeral Jt W/grf	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24365	CPT	Reconstruct Head Of Radius	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24410	CPT	Mlt Osteot Rlgnm Imed Rd Hum	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24515	CPT	Optx Humrl Shft Fx Plate/scr	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
22551	CPT	Arthrd Ant Ntrbdy Cervical	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28737	CPT	Revision Of Foot Bones	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23470	CPT	Reconstruct Shoulder Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24586	CPT	Optx Partclr Fx&/dislc Elbow	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24587	CPT	Optx Partclr Fx&/dslc Elbw W	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24362	CPT	Reconstruct Elbow Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
C9734	HCPCS	U/s Trtmt, Not Leiomyomata	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
25491	CPT	Prophylactic Tx Ulna	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27356	CPT	Remove Femur Lesion/graft	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
69729	CPT	Impl Oi Implt Sk Tc Esp>=100	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
69719	CPT	Rplcm Oi Implt Sk Tc Esp<100	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24430	CPT	Rpr Non/mal Humerus Wo Graft	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24516	CPT	Tx Humrl Shaft Fx Imed Implt	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
69730	CPT	Rplc Oi Implt Sk Tc Esp>=100	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
25441	CPT	Arthrp W/prostc Dstl Rds	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
20982	CPT	Ablate Bone Tumor(s) Perq	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23485	CPT	Revision Of Collar Bone	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24435	CPT	Rpr Non/mal Hum With Agrft	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23615	CPT	Optx Prox Humrl Fx W/int Fix	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24346	CPT	Reconstruct Elbow Med Ligmnt	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
25444	CPT	Arthrp W/prostc Lunate	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
22554	CPT	Arthrd Ant Ntrbd Min Dsc Crv	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27429	CPT	Reconstruction Knee	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24546	CPT	Optx Hum Fx W/ntrcndylr Xtn	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27871	CPT	Fusion Of Tibiofibular Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27442	CPT	Revision Of Knee Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27441	CPT	Revision Of Knee Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
69716	CPT	Impl Oi Implt Sk Tc Esp<100	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24498	CPT	Proph Tx W/wo Mthylmthcrylt	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24366	CPT	Reconstruct Head Of Radius	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23491	CPT	Reinforce Shoulder Bones	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24370	CPT	Revise Reconst Elbow Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
64628	CPT	Trml Dstrj Ios Bvn 1st 2 L/s	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
0627T	CPT	Perq Njx Algc Fluor Lmbr 1st	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
25391	CPT	Lengthen Radius Or Ulna	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
C9781	HCPCS	Arthro/shoul Surg; W/spacer	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
25365	CPT	Revise Radius & Ulna	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
0737T	CPT	Xenograft Impltj Artclr Surf	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
22869	CPT	Insj Stablj Dev Without Dcmprn	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
29907	CPT	Subtalar Arthro W/fusion	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27447	CPT	Total Knee Arthroplasty	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28735	CPT	Fusion Of Foot Bones	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28730	CPT	Fusion Of Foot Bones	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
29856	CPT	Tibial Arthroscopy/surgery	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28715	CPT	Arthrodesis Triple	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
23473	CPT	Revis Reconst Shoulder Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28420	CPT	Optx Calcaneal Fx W/bone Grf	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28725	CPT	Arthrodesis Subtalar	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28297	CPT	Cor Hlx Vlgs Jt Arthrd	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27828	CPT	Treat Lower Leg Fracture	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
28320	CPT	Repair Of Foot Bones	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27759	CPT	Treatment Of Tibia Fracture	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27130	CPT	Total Hip Arthroplasty	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
29867	CPT	Allgrft Implnt Knee W/scope	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
C9757	HCPCS	Spine Device Implant Surgery	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24802	CPT	Arthrd Elbow Jt Autog Graft	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27446	CPT	Revision Of Knee Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27709	CPT	Osteotomy Tibia & Fibula	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27443	CPT	Revision Of Knee Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24666	CPT	Optx Radial Head/nck Fx Rplc	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27758	CPT	Treatment Of Tibia Fracture	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
69714	CPT	Impl Oi Implt Skull Perq Esp	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27438	CPT	Revise Kneecap With Implant	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
24579	CPT	Optx Humrl Cndylr Fracture	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27440	CPT	Revision Of Knee Joint	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27415	CPT	Osteochondral Knee Allograft	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27428	CPT	Reconstruction Knee	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
29889	CPT	Arthrs Aid Pcl Rpr/agmntj	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
27870	CPT	Fusion Of Ankle Joint Open	2	1	—	—	$63,217.96	$63,217.96	$63,217.96	2025-09-09
Q2043	HCPCS	Sipuleucel-t Auto Cd54+	2	1	—	—	$61,691.62	$61,691.62	$61,691.62	2025-09-09
61715	CPT	Mrgfus Strtctc Ablt Trgt Icr	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
0675T	CPT	Laps Insj Nw/rpcmt Isdss 1ld	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
64569	CPT	Revise/repl Vagus N Eltrd	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
61888	CPT	Revise/remove Neuroreceiver	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
64575	CPT	Opn Impltj Nea Perph Nerve	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
63664	CPT	Revise Spine Eltrd Plate	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
64553	CPT	Implant Neuroelectrodes	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
43647	CPT	Lap Impl Electrode Antrum	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
33288	CPT	Rmv&rplcmt Phrnc Nrv Stim Ld	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
64596	CPT	Ins/rplcmt Prq Eltrd Ra Pn 1	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
64583	CPT	Rev/rplct Hpglsl Nstm Ary Pg	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
0784T	CPT	Ins/rplmt Eltrd Ra Spi Nstim	2	1	—	—	$61,269.81	$61,269.81	$61,269.81	2025-09-09
L7180	HCPCS	Electronic Elbow Sequential	2	1	—	—	$57,646.84	$57,646.84	$57,646.84	2025-09-09
61626	CPT	Tcat Perm Occls/embol Noncns	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
61623	CPT	Evasc Temp Balo Artl Occ H/n	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
0237T	CPT	Trluml Perip Athrc Brchiocph	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
0236T	CPT	Trluml Perip Athrc Abd Aorta	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92924	CPT	Prq Trluml C Athrc 1 Art&/br	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
0234T	CPT	Trluml Perip Athrc Renal Art	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
C9600	HCPCS	Perc Drug-el Cor Stent Sing	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92987	CPT	Revision Of Mitral Valve	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92943	CPT	Prq Trluml Revsc Ch Occ Ant	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92990	CPT	Revision Of Pulmonary Valve	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92997	CPT	Pul Art Balloon Repr Percut	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
C9783	HCPCS	Blind Cor Sinus Reducer Impl	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
C8004	HCPCS	Sim Ang W/prs Cath Rad Emb	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37243	CPT	Vasc Embolize/occlude Organ	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37244	CPT	Vasc Embolize/occlude Bleed	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37241	CPT	Vasc Embolize/occlude Venous	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37236	CPT	Open/perq Place Stent 1st	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37226	CPT	Commercial Fee Schedule	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37228	CPT	Commercial Fee Schedule	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37238	CPT	Open/perq Place Stent Same	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
36905	CPT	Thrmbc/nfs Dialysis Circuit	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
36903	CPT	Intro Cath Dialysis Circuit	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37187	CPT	Venous Mech Thrombectomy	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
C9604	HCPCS	Perc D-e Cor Revasc T Cabg S	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
33900	CPT	Perq P-art Revsc 1 Nm Nt Uni	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
33901	CPT	Perq P-art Revsc 1 Nm Nt Bi	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
33903	CPT	Perq P-art Revsc 1 Abnor Bi	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
37221	CPT	Commercial Fee Schedule	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
C9772	HCPCS	Revasc Lithotrip Tibi/perone	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
0505T	CPT	Ev Fempop Artl Revsc	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92928	CPT	Prq Tcat Plmt Ntrac St 1 Les	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
C9764	HCPCS	Revasc Intravasc Lithotripsy	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
92937	CPT	Prq Trluml Revsc Cab Grf 1	2	1	—	—	$55,719.09	$55,719.09	$55,719.09	2025-09-09
J9229	HCPCS	Inotuzumab Ozogamicin 0.9 Mg IV Solr	42	9	$59,856.32	$59,856.32	$7,941.66	$56,384.65	$53,275.11	2025-09-09
A9604	HCPCS	Sm 153 Lexidronam	2	1	—	—	$52,340.50	$52,340.50	$52,340.50	2025-09-09
0517T	CPT	Insj Wcs Lv Both Compnt Pg	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
0519T	CPT	Rmv&rplcmt Pg Wcs Lv Both	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
0516T	CPT	Insj Wcs Lv Eltrd Only	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
0520T	CPT	Rmv&rplcmt Pg Wcs Lv Battery	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33224	CPT	Insert Pacing Lead & Connect	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33228	CPT	Remv&replc Pm Gen Dual Lead	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33213	CPT	Insert Pulse Gen Dual Leads	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33208	CPT	Insrt Heart Pm Atrial & Vent	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33214	CPT	Upgrade Of Pacemaker System	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33207	CPT	Insert Heart Pm Ventricular	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
33206	CPT	Insert Heart Pm Atrial	2	1	—	—	$51,418.82	$51,418.82	$51,418.82	2025-09-09
58674	CPT	Laps Abltj Uterine Fibroids	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58573	CPT	Tlh W/t/o Uterus Over 250 G	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58673	CPT	Laparoscopy Salpingostomy	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58571	CPT	Tlh W/t/o 250 G Or Less	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58572	CPT	Tlh Uterus Over 250 G	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58552	CPT	Laparo-vag Hyst Incl T/o	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58546	CPT	Laparo-myomectomy Complex	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58553	CPT	Laparo-vag Hyst Complex	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58543	CPT	Lsh Uterus Above 250 G	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58544	CPT	Lsh W/t/o Uterus Above 250 G	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58554	CPT	Laparo-vag Hyst W/t/o Compl	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58541	CPT	Lsh Uterus 250 G Or Less	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
0677T	CPT	Laps Repos Lead Isdss 1st Ld	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58542	CPT	Lsh W/t/o Ut 250 G Or Less	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
58570	CPT	Tlh Uterus 250 G Or Less	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
57423	CPT	Repair Paravag Defect Lap	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09
57425	CPT	Laparoscopy Surg Colpopexy	2	1	—	—	$51,152.98	$51,152.98	$51,152.98	2025-09-09

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