|
9141
|
OTHER
|
Inj Onase Abepar-xioi Tre
|
1
|
1
|
—
|
—
|
$4,299,505.20
|
$4,299,505.20
|
$4,299,505.20
|
2024-10-01
|
|
Q2042
|
HCPCS
|
Tisagenlecleucel, Up To 600 Million Car-positive Viable T Cells, Including Leuka…
|
4
|
1
|
—
|
—
|
$1,369,371.65
|
$1,369,371.65
|
$1,369,371.65
|
2024-10-01
|
|
Q2056
|
HCPCS
|
Ciltacabtagene Autoleucel, Up To 100 Million Autologous B-cell Maturation Antige…
|
4
|
1
|
—
|
—
|
$1,328,128.35
|
$1,328,128.35
|
$1,328,128.35
|
2024-10-01
|
|
Q2041
|
HCPCS
|
Axicabtagene Ciloleucel, Up To 200 Million Autologous Anti-cd19 Car Positive Via…
|
4
|
1
|
—
|
—
|
$1,279,600.63
|
$1,279,600.63
|
$1,279,600.63
|
2024-10-01
|
|
Q2053
|
HCPCS
|
Brexucabtagene Autoleucel, Up To 200 Million Autologous Anti-cd19 Car Positive V…
|
4
|
1
|
—
|
—
|
$1,175,752.00
|
$1,175,752.00
|
$1,175,752.00
|
2024-10-01
|
|
9194
|
OTHER
|
Tisagenlecleucel Car-pos
|
1
|
1
|
—
|
—
|
$952,547.22
|
$952,547.22
|
$952,547.22
|
2024-10-01
|
|
9498
|
OTHER
|
Ciltacabtagene Car-pos T
|
1
|
1
|
—
|
—
|
$948,822.12
|
$948,822.12
|
$948,822.12
|
2024-10-01
|
|
9422
|
OTHER
|
Idecabtagene Vicleucel Ca
|
1
|
1
|
—
|
—
|
$947,857.68
|
$947,857.68
|
$947,857.68
|
2024-10-01
|
|
9413
|
OTHER
|
Lisocabtagene Car Pos T
|
1
|
1
|
—
|
—
|
$930,106.98
|
$930,106.98
|
$930,106.98
|
2024-10-01
|
|
9035
|
OTHER
|
Axicabtagene Ciloleucel C
|
1
|
1
|
—
|
—
|
$881,020.80
|
$881,020.80
|
$881,020.80
|
2024-10-01
|
|
9391
|
OTHER
|
Brexucabtagene Car Pos T
|
1
|
1
|
—
|
—
|
$828,954.72
|
$828,954.72
|
$828,954.72
|
2024-10-01
|
|
1907
|
OTHER
|
New Technology - Level 52
|
1
|
1
|
—
|
—
|
$274,500.90
|
$274,500.90
|
$274,500.90
|
2024-10-01
|
|
1908
|
OTHER
|
New Technology - Level 52
|
1
|
1
|
—
|
—
|
$274,500.90
|
$274,500.90
|
$274,500.90
|
2024-10-01
|
|
1906
|
OTHER
|
New Technology - Level 51
|
1
|
1
|
—
|
—
|
$247,500.90
|
$247,500.90
|
$247,500.90
|
2024-10-01
|
|
1905
|
OTHER
|
New Technology - Level 51
|
1
|
1
|
—
|
—
|
$247,500.90
|
$247,500.90
|
$247,500.90
|
2024-10-01
|
|
1904
|
OTHER
|
New Technology - Level 50
|
1
|
1
|
—
|
—
|
$220,500.90
|
$220,500.90
|
$220,500.90
|
2024-10-01
|
|
1903
|
OTHER
|
New Technology - Level 50
|
1
|
1
|
—
|
—
|
$220,500.90
|
$220,500.90
|
$220,500.90
|
2024-10-01
|
|
1902
|
OTHER
|
New Technology - Level 49
|
1
|
1
|
—
|
—
|
$193,500.90
|
$193,500.90
|
$193,500.90
|
2024-10-01
|
|
1901
|
OTHER
|
New Technology - Level 49
|
1
|
1
|
—
|
—
|
$193,500.90
|
$193,500.90
|
$193,500.90
|
2024-10-01
|
|
1599
|
OTHER
|
New Technology - Level 48
|
1
|
1
|
—
|
—
|
$171,000.90
|
$171,000.90
|
$171,000.90
|
2024-10-01
|
|
1585
|
OTHER
|
New Technology - Level 48
|
1
|
1
|
—
|
—
|
$171,000.90
|
$171,000.90
|
$171,000.90
|
2024-10-01
|
|
J9029
|
HCPCS
|
Intravesical Instillation, Nadofaragene Firadenovec-vncg, Per Therapeutic Dose
|
4
|
1
|
—
|
—
|
$166,116.65
|
$166,116.65
|
$166,116.65
|
2024-10-01
|
|
516430
|
CDM
|
Kit Implnt Hrtmt 3 Kit
|
41
|
18
|
$374,970.83
|
$374,970.83
|
$68,844.64
|
$337,473.75
|
$160,937.48
|
2024-10-01
|
|
1598
|
OTHER
|
New Technology - Level 47
|
1
|
1
|
—
|
—
|
$153,000.90
|
$153,000.90
|
$153,000.90
|
2024-10-01
|
|
1584
|
OTHER
|
New Technology - Level 47
|
1
|
1
|
—
|
—
|
$153,000.90
|
$153,000.90
|
$153,000.90
|
2024-10-01
|
|
Q2043
|
HCPCS
|
Sipuleucel-t, Minimum Of 50 Million Autologous Cd54+ Cells Activated With Pap-gm…
|
4
|
1
|
—
|
—
|
$145,223.54
|
$145,223.54
|
$145,223.54
|
2024-10-01
|
|
456896
|
CDM
|
Device Vntrc Asst Hrtmt
|
41
|
18
|
$326,401.50
|
$326,401.50
|
$59,927.32
|
$293,761.35
|
$140,091.52
|
2024-10-01
|
|
1583
|
OTHER
|
New Technology - Level 46
|
1
|
1
|
—
|
—
|
$135,000.90
|
$135,000.90
|
$135,000.90
|
2024-10-01
|
|
1597
|
OTHER
|
New Technology - Level 46
|
1
|
1
|
—
|
—
|
$135,000.90
|
$135,000.90
|
$135,000.90
|
2024-10-01
|
|
494847
|
CDM
|
Syst Imp Hrtmt2 Lft Vent
|
41
|
18
|
$307,657.85
|
$307,657.85
|
$56,485.98
|
$276,892.06
|
$132,046.75
|
2024-10-01
|
|
C9293
|
HCPCS
|
Glucarpidase 1000 U Inj
|
31
|
17
|
$284,911.28
|
$284,911.28
|
$52,309.71
|
$256,420.15
|
$125,360.96
|
2024-10-01
|
|
J9999
|
HCPCS
|
Carmustine Wafers 8/box
|
31
|
17
|
$282,764.06
|
$282,764.06
|
$51,915.48
|
$254,487.65
|
$124,416.19
|
2024-10-01
|
|
216
|
MS_DRG
|
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza…
|
9
|
8
|
—
|
—
|
$26,869.21
|
$120,739.50
|
$118,439.70
|
2024-10-01
|
|
1643
|
OTHER
|
Y90 Ibritumomab, Rx
|
1
|
1
|
—
|
—
|
$117,857.84
|
$117,857.84
|
$117,857.84
|
2024-10-01
|
|
1596
|
OTHER
|
New Technology - Level 45
|
1
|
1
|
—
|
—
|
$117,000.90
|
$117,000.90
|
$117,000.90
|
2024-10-01
|
|
1582
|
OTHER
|
New Technology - Level 45
|
1
|
1
|
—
|
—
|
$117,000.90
|
$117,000.90
|
$117,000.90
|
2024-10-01
|
|
717
|
OTHER
|
Instill Adstiladrin, Tx D
|
1
|
1
|
—
|
—
|
$114,038.59
|
$114,038.59
|
$114,038.59
|
2024-10-01
|
|
J9226
|
HCPCS
|
Histrelin Implant (supprelin La), 50 Mg
|
4
|
1
|
—
|
—
|
$110,645.59
|
$110,645.59
|
$110,645.59
|
2024-10-01
|
|
9273
|
OTHER
|
Sipuleucel-t Auto Cd54+
|
1
|
1
|
—
|
—
|
$99,027.41
|
$99,027.41
|
$99,027.41
|
2024-10-01
|
|
1581
|
OTHER
|
New Technology - Level 44
|
1
|
1
|
—
|
—
|
$99,000.90
|
$99,000.90
|
$99,000.90
|
2024-10-01
|
|
1595
|
OTHER
|
New Technology - Level 44
|
1
|
1
|
—
|
—
|
$99,000.90
|
$99,000.90
|
$99,000.90
|
2024-10-01
|
|
5244
|
OTHER
|
Level 4 Blood Product Exc
|
1
|
1
|
—
|
—
|
$93,719.11
|
$93,719.11
|
$93,719.11
|
2024-10-01
|
|
1142
|
OTHER
|
Supprelin La Implant
|
1
|
1
|
—
|
—
|
$81,630.38
|
$81,630.38
|
$81,630.38
|
2024-10-01
|
|
1580
|
OTHER
|
New Technology - Level 43
|
1
|
1
|
—
|
—
|
$81,000.90
|
$81,000.90
|
$81,000.90
|
2024-10-01
|
|
1594
|
OTHER
|
New Technology - Level 43
|
1
|
1
|
—
|
—
|
$81,000.90
|
$81,000.90
|
$81,000.90
|
2024-10-01
|
|
231
|
MS_DRG
|
Coronary Bypass With Ptca With Mcc
|
9
|
8
|
—
|
—
|
$30,575.45
|
$80,599.05
|
$79,063.83
|
2024-10-01
|
|
275
|
MS_DRG
|
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc
|
9
|
8
|
—
|
—
|
$21,886.98
|
$79,317.00
|
$77,806.20
|
2024-10-01
|
|
456
|
MS_DRG
|
Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Ex…
|
9
|
8
|
—
|
—
|
$16,815.50
|
$79,170.00
|
$77,662.00
|
2024-10-01
|
|
233
|
MS_DRG
|
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc
|
9
|
8
|
—
|
—
|
$24,182.02
|
$73,903.20
|
$72,495.52
|
2024-10-01
|
|
219
|
MS_DRG
|
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheter…
|
9
|
8
|
—
|
—
|
$19,646.03
|
$72,303.00
|
$70,925.80
|
2024-10-01
|
|
266
|
MS_DRG
|
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc
|
9
|
8
|
—
|
—
|
$20,973.67
|
$69,328.35
|
$68,007.81
|
2024-10-01
|
|
457
|
MS_DRG
|
Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Ex…
|
9
|
8
|
—
|
—
|
$13,894.64
|
$65,121.00
|
$63,880.60
|
2024-10-01
|
|
450
|
MS_DRG
|
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-made Anatomically
|
8
|
7
|
—
|
—
|
$61,653.00
|
$64,735.65
|
$63,502.59
|
2024-10-01
|
|
1593
|
OTHER
|
New Technology - Level 42
|
1
|
1
|
—
|
—
|
$63,000.90
|
$63,000.90
|
$63,000.90
|
2024-10-01
|
|
1579
|
OTHER
|
New Technology - Level 42
|
1
|
1
|
—
|
—
|
$63,000.90
|
$63,000.90
|
$63,000.90
|
2024-10-01
|
|
270
|
MS_DRG
|
Other Major Cardiovascular Procedures With Mcc
|
9
|
8
|
—
|
—
|
$15,467.31
|
$63,540.75
|
$62,330.45
|
2024-10-01
|
|
447
|
MS_DRG
|
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-made Anatomicall…
|
8
|
7
|
—
|
—
|
$57,603.00
|
$60,483.15
|
$59,331.09
|
2024-10-01
|
|
218
|
MS_DRG
|
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza…
|
9
|
8
|
—
|
—
|
$18,149.90
|
$60,051.60
|
$58,907.76
|
2024-10-01
|
|
217
|
MS_DRG
|
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza…
|
9
|
8
|
—
|
—
|
$23,434.49
|
$60,051.60
|
$58,907.76
|
2024-10-01
|
|
551981
|
CDM
|
Pump Heart 21fr 85mm
|
42
|
19
|
$136,815.00
|
$136,815.00
|
$25,119.23
|
$123,133.50
|
$58,721.00
|
2024-10-01
|
|
276
|
MS_DRG
|
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator
|
9
|
8
|
—
|
—
|
$20,254.54
|
$59,845.80
|
$58,705.88
|
2024-10-01
|
|
268
|
MS_DRG
|
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc
|
9
|
8
|
—
|
—
|
$24,532.25
|
$58,950.15
|
$57,827.29
|
2024-10-01
|
|
5166
|
OTHER
|
Cochlear Implant Procedur
|
1
|
1
|
—
|
—
|
$57,512.52
|
$57,512.52
|
$57,512.52
|
2024-10-01
|
|
5232
|
OTHER
|
Level 2 Icd And Similar P
|
1
|
1
|
—
|
—
|
$56,422.76
|
$56,422.76
|
$56,422.76
|
2024-10-01
|
|
A9543
|
HCPCS
|
Y90 Ibritum Tiu Tx 40mci
|
32
|
18
|
$133,686.05
|
$133,686.05
|
$24,544.76
|
$120,317.44
|
$56,148.14
|
2024-10-01
|
|
232
|
MS_DRG
|
Coronary Bypass With Ptca Without Mcc
|
9
|
8
|
—
|
—
|
$21,207.07
|
$56,866.95
|
$55,783.77
|
2024-10-01
|
|
234
|
MS_DRG
|
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc
|
9
|
8
|
—
|
—
|
$15,336.68
|
$56,379.75
|
$55,305.85
|
2024-10-01
|
|
463214
|
CDM
|
Valve Xt Sapien 26mm Ta
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
463211
|
CDM
|
Valve 29mm Sapien Xt Trn
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
469507
|
CDM
|
Valve 29mm Thv
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
463212
|
CDM
|
Valve 29mm Sapien Xt Trn
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
485943
|
CDM
|
Valve Heart W/cert 29a
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
463209
|
CDM
|
Valve 23mm Sapien Xt Trn
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
441862
|
CDM
|
Valve Pulm 26mm Sapien R
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
451502
|
CDM
|
Valve Heart Sapien Trans
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
485646
|
CDM
|
Valve Hrt W Cert Sys 26a
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
463210
|
CDM
|
Valve 26mm Sapien Xt Trn
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
457579
|
CDM
|
Valve Hrt Sapien 26mm As
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
463213
|
CDM
|
Valve Xt Sapien 23mm Ta
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
451503
|
CDM
|
Valve Heart Sapien Trans
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
441861
|
CDM
|
Valve Pulm 23mm Sapien R
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
496433
|
CDM
|
Valve Ao 9000tfx 23mm
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
457578
|
CDM
|
Valve Hrt Sapien 23mm As
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
469504
|
CDM
|
Valve 23mm Thv
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
485939
|
CDM
|
Valve Hrt W/cert Sys 20a
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
485942
|
CDM
|
Valve Hrt W/cert Sys 23a
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
469508
|
CDM
|
Valve Aor 20mm Edwrd Sap
|
41
|
18
|
$127,042.50
|
$127,042.50
|
$23,325.00
|
$114,338.25
|
$54,526.64
|
2024-10-01
|
|
329
|
MS_DRG
|
Major Small And Large Bowel Procedures With Mcc
|
9
|
8
|
—
|
—
|
$11,473.03
|
$55,307.70
|
$54,254.22
|
2024-10-01
|
|
J2350
|
HCPCS
|
Ocrelizumab 300 Mg Inj
|
35
|
17
|
$139,200.48
|
$139,200.48
|
$157.62
|
$125,280.43
|
$53,870.59
|
2024-10-01
|
|
5465
|
OTHER
|
Level 5 Neurostimulator A
|
1
|
1
|
—
|
—
|
$53,255.32
|
$53,255.32
|
$53,255.32
|
2024-10-01
|
|
544809
|
CDM
|
Valve Tavr 25mm
|
41
|
18
|
$123,133.50
|
$123,133.50
|
$22,607.31
|
$110,820.15
|
$52,848.90
|
2024-10-01
|
|
J9266
|
HCPCS
|
Pegaspargase Singl Vial
|
35
|
17
|
$115,974.63
|
$115,974.63
|
$21,292.94
|
$104,377.17
|
$52,304.56
|
2024-10-01
|
|
235
|
MS_DRG
|
Coronary Bypass Without Cardiac Catheterization With Mcc
|
9
|
8
|
—
|
—
|
$15,897.86
|
$53,034.45
|
$52,024.27
|
2024-10-01
|
|
487218
|
CDM
|
Valve Tavr 34mm
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
487214
|
CDM
|
Valve Aor Evolut Pro 23m
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
575013
|
CDM
|
Valve Tavr 23mm
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
547223
|
CDM
|
Valve Mitral 36.5x52.5mm
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
547229
|
CDM
|
Valve Mitral 46.5x39.5mm
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
547215
|
CDM
|
Valve Mitral 29m
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
777080
|
CDM
|
Valve Tavor Aor 29mm
|
41
|
18
|
$117,270.00
|
$117,270.00
|
$21,530.77
|
$105,543.00
|
$50,332.28
|
2024-10-01
|
|
5200
|
OTHER
|
Implantation Wireless Pa
|
1
|
1
|
—
|
—
|
$49,846.45
|
$49,846.45
|
$49,846.45
|
2024-10-01
|
|
1592
|
OTHER
|
New Technology - Level 41
|
1
|
1
|
—
|
—
|
$49,500.90
|
$49,500.90
|
$49,500.90
|
2024-10-01
|
|
1578
|
OTHER
|
New Technology - Level 41
|
1
|
1
|
—
|
—
|
$49,500.90
|
$49,500.90
|
$49,500.90
|
2024-10-01
|
|
843
|
OTHER
|
Pegaspargase Injection
|
1
|
1
|
—
|
—
|
$48,726.95
|
$48,726.95
|
$48,726.95
|
2024-10-01
|
|
220
|
MS_DRG
|
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheter…
|
9
|
8
|
—
|
—
|
$13,934.67
|
$49,449.75
|
$48,507.85
|
2024-10-01
|
|
277
|
MS_DRG
|
Cardiac Defibrillator Implant Without Mcc
|
9
|
8
|
—
|
—
|
$13,166.59
|
$49,245.00
|
$48,307.00
|
2024-10-01
|
|
264
|
MS_DRG
|
Other Circulatory System O.r. Procedures
|
9
|
8
|
—
|
—
|
$9,575.28
|
$48,552.00
|
$47,627.20
|
2024-10-01
|
|
326
|
MS_DRG
|
Stomach, Esophageal And Duodenal Procedures With Mcc
|
9
|
8
|
—
|
—
|
$12,344.42
|
$48,060.60
|
$47,145.16
|
2024-10-01
|
|
488819
|
CDM
|
Set Pump 21fr 5.0
|
42
|
19
|
$109,452.00
|
$109,452.00
|
$20,095.39
|
$98,506.80
|
$46,976.80
|
2024-10-01
|
|
267
|
MS_DRG
|
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc
|
9
|
8
|
—
|
—
|
$14,311.94
|
$46,716.60
|
$45,826.76
|
2024-10-01
|
|
458
|
MS_DRG
|
Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Ex…
|
9
|
8
|
—
|
—
|
$11,953.35
|
$45,874.50
|
$45,000.70
|
2024-10-01
|
|
405
|
MS_DRG
|
Pancreas, Liver And Shunt Procedures With Mcc
|
9
|
8
|
—
|
—
|
$16,873.38
|
$45,340.05
|
$44,476.43
|
2024-10-01
|
|
448
|
MS_DRG
|
Multiple Level Spinal Fusion Except Cervical Without Mcc
|
8
|
7
|
—
|
—
|
$43,020.00
|
$45,171.00
|
$44,310.60
|
2024-10-01
|
|
221
|
MS_DRG
|
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheter…
|
9
|
8
|
—
|
—
|
$13,934.67
|
$44,658.60
|
$43,807.96
|
2024-10-01
|
|
856
|
OTHER
|
Porfimer Sodium Injection
|
1
|
1
|
—
|
—
|
$42,966.25
|
$42,966.25
|
$42,966.25
|
2024-10-01
|
|
252
|
MS_DRG
|
Other Vascular Procedures With Mcc
|
9
|
8
|
—
|
—
|
$10,652.21
|
$43,352.40
|
$42,526.64
|
2024-10-01
|
|
371977
|
CDM
|
Set Vntrc 17.4x13.8in
|
42
|
19
|
$97,725.00
|
$97,725.00
|
$17,942.31
|
$87,952.50
|
$41,943.57
|
2024-10-01
|
|
236
|
MS_DRG
|
Coronary Bypass Without Cardiac Catheterization Without Mcc
|
9
|
8
|
—
|
—
|
$13,445.42
|
$42,552.30
|
$41,741.78
|
2024-10-01
|
|
5213
|
OTHER
|
Level 3 Electrophysiologi
|
1
|
1
|
—
|
—
|
$40,732.54
|
$40,732.54
|
$40,732.54
|
2024-10-01
|
|
1591
|
OTHER
|
New Technology - Level 40
|
1
|
1
|
—
|
—
|
$40,500.90
|
$40,500.90
|
$40,500.90
|
2024-10-01
|
|
1577
|
OTHER
|
New Technology - Level 40
|
1
|
1
|
—
|
—
|
$40,500.90
|
$40,500.90
|
$40,500.90
|
2024-10-01
|
|
5231
|
OTHER
|
Level 1 Icd And Similar P
|
1
|
1
|
—
|
—
|
$40,425.57
|
$40,425.57
|
$40,425.57
|
2024-10-01
|
|
271
|
MS_DRG
|
Other Major Cardiovascular Procedures With Cc
|
9
|
8
|
—
|
—
|
$10,944.84
|
$39,594.45
|
$38,840.27
|
2024-10-01
|
|
544808
|
CDM
|
Valve Tavr 27mm
|
41
|
18
|
$89,907.00
|
$89,907.00
|
$16,506.93
|
$80,916.30
|
$38,588.08
|
2024-10-01
|
|
544807
|
CDM
|
Valve Heart 29 Mm
|
41
|
18
|
$89,907.00
|
$89,907.00
|
$16,506.93
|
$80,916.30
|
$38,588.08
|
2024-10-01
|
|
653
|
MS_DRG
|
Major Bladder Procedures With Mcc
|
9
|
8
|
—
|
—
|
$15,827.27
|
$38,559.15
|
$37,824.69
|
2024-10-01
|
|
5464
|
OTHER
|
Level 4 Neurostimulator A
|
1
|
1
|
—
|
—
|
$37,517.11
|
$37,517.11
|
$37,517.11
|
2024-10-01
|
|
451
|
MS_DRG
|
Single Level Spinal Fusion Except Cervical Without Mcc
|
8
|
7
|
—
|
—
|
$35,937.00
|
$37,733.85
|
$37,015.11
|
2024-10-01
|
|
471
|
MS_DRG
|
Cervical Spinal Fusion With Mcc
|
9
|
8
|
—
|
—
|
$14,188.62
|
$37,666.65
|
$36,949.19
|
2024-10-01
|
|
J3357
|
HCPCS
|
Ustekinumab 45 Mg Sq
|
100
|
18
|
$94,247.81
|
$94,247.81
|
$364.77
|
$177,958.64
|
$36,473.90
|
2024-10-01
|
|
799
|
MS_DRG
|
Splenic Procedures With Mcc
|
9
|
8
|
—
|
—
|
$13,077.07
|
$36,775.20
|
$36,074.72
|
2024-10-01
|
|
273
|
MS_DRG
|
Percutaneous And Other Intracardiac Procedures With Mcc
|
9
|
8
|
—
|
—
|
$12,196.21
|
$36,232.35
|
$35,542.21
|
2024-10-01
|
|
469
|
MS_DRG
|
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc…
|
9
|
8
|
—
|
—
|
$10,924.56
|
$35,731.50
|
$35,050.90
|
2024-10-01
|
|
5378
|
OTHER
|
Level 8 Urology And Relat
|
1
|
1
|
—
|
—
|
$34,595.10
|
$34,595.10
|
$34,595.10
|
2024-10-01
|
|
166
|
MS_DRG
|
Other Respiratory System O.r. Procedures With Mcc
|
9
|
8
|
—
|
—
|
$16,749.24
|
$34,970.25
|
$34,304.15
|
2024-10-01
|
|
573
|
MS_DRG
|
Skin Graft For Skin Ulcer Or Cellulitis With Mcc
|
9
|
8
|
—
|
—
|
$30,880.52
|
$34,660.50
|
$34,000.30
|
2024-10-01
|
|
443520
|
CDM
|
Pump Cath Lv Impella 9fr
|
42
|
19
|
$78,180.00
|
$78,180.00
|
$14,353.85
|
$70,362.00
|
$33,554.86
|
2024-10-01
|
|
5224
|
OTHER
|
Level 4 Pacemaker And Sim
|
1
|
1
|
—
|
—
|
$33,417.63
|
$33,417.63
|
$33,417.63
|
2024-10-01
|
|
772801
|
CDM
|
Kit Impl Neurostim
|
41
|
18
|
$77,320.02
|
$77,320.02
|
$14,195.96
|
$69,588.02
|
$33,185.75
|
2024-10-01
|
|
269
|
MS_DRG
|
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc
|
9
|
8
|
—
|
—
|
$7,489.30
|
$33,671.40
|
$33,030.04
|
2024-10-01
|
|
518
|
MS_DRG
|
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurost…
|
9
|
8
|
—
|
—
|
$11,583.64
|
$33,415.20
|
$32,778.72
|
2024-10-01
|
|
423
|
MS_DRG
|
Other Hepatobiliary Or Pancreas O.r. Procedures With Mcc
|
9
|
8
|
—
|
—
|
$12,498.31
|
$33,292.35
|
$32,658.21
|
2024-10-01
|
|
411
|
MS_DRG
|
Cholecystectomy With C.d.e. With Mcc
|
9
|
8
|
—
|
—
|
$8,079.15
|
$33,128.55
|
$32,497.53
|
2024-10-01
|
|
5116
|
OTHER
|
Level 6 Musculoskeletal P
|
1
|
1
|
—
|
—
|
$31,961.30
|
$31,961.30
|
$31,961.30
|
2024-10-01
|
|
C1822
|
HCPCS
|
Implant Pulse 8.5x15.5in
|
41
|
18
|
$74,271.00
|
$74,271.00
|
$13,636.16
|
$66,843.90
|
$31,877.11
|
2024-10-01
|
|
321
|
MS_DRG
|
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ A…
|
9
|
8
|
—
|
—
|
$7,887.94
|
$32,209.80
|
$31,596.28
|
2024-10-01
|
|
274
|
MS_DRG
|
Percutaneous And Other Intracardiac Procedures Without Mcc
|
9
|
8
|
—
|
—
|
$7,982.60
|
$32,154.15
|
$31,541.69
|
2024-10-01
|
|
514663
|
CDM
|
Cap Endrnt Grft 162698
|
41
|
18
|
$73,489.20
|
$73,489.20
|
$13,492.62
|
$66,140.28
|
$31,541.56
|
2024-10-01
|
|
1590
|
OTHER
|
New Technology - Level 39
|
1
|
1
|
—
|
—
|
$31,500.90
|
$31,500.90
|
$31,500.90
|
2024-10-01
|
|
1576
|
OTHER
|
New Technology - Level 39
|
1
|
1
|
—
|
—
|
$31,500.90
|
$31,500.90
|
$31,500.90
|
2024-10-01
|
|
1295
|
OTHER
|
Sm 153 Lexidronam
|
1
|
1
|
—
|
—
|
$31,067.73
|
$31,067.73
|
$31,067.73
|
2024-10-01
|
|
2616
|
OTHER
|
Brachytx, Non-str,yttrium
|
1
|
1
|
—
|
—
|
$30,918.62
|
$30,918.62
|
$30,918.62
|
2024-10-01
|
|
515
|
MS_DRG
|
Other Musculoskeletal System And Connective Tissue O.r. Procedures With Mcc
|
9
|
8
|
—
|
—
|
$12,691.14
|
$31,434.90
|
$30,836.14
|
2024-10-01
|
|
272
|
MS_DRG
|
Other Major Cardiovascular Procedures Without Cc/mcc
|
9
|
8
|
—
|
—
|
$7,171.52
|
$31,180.80
|
$30,586.88
|
2024-10-01
|
|
5471
|
OTHER
|
Implantation Of Drug Infu
|
1
|
1
|
—
|
—
|
$30,586.28
|
$30,586.28
|
$30,586.28
|
2024-10-01
|
|
903264
|
CDM
|
Ep Generator Subcutaneo
|
42
|
19
|
$71,174.00
|
$71,174.00
|
$13,067.55
|
$64,056.60
|
$30,547.88
|
2024-10-01
|
|
5094
|
OTHER
|
Level 4 Breast/Lymphatic
|
1
|
1
|
—
|
—
|
$30,222.02
|
$30,222.02
|
$30,222.02
|
2024-10-01
|
|
J9119
|
HCPCS
|
Cemiplimab-rwlc 350mginj
|
35
|
17
|
$77,952.26
|
$77,952.26
|
$72.46
|
$70,157.03
|
$30,167.52
|
2024-10-01
|
|
5194
|
OTHER
|
Level 4 Endovascular Proc
|
1
|
1
|
—
|
—
|
$30,073.16
|
$30,073.16
|
$30,073.16
|
2024-10-01
|
|
472
|
MS_DRG
|
Cervical Spinal Fusion With Cc
|
9
|
8
|
—
|
—
|
$7,297.28
|
$30,643.20
|
$30,059.52
|
2024-10-01
|
|
903280
|
CDM
|
Ep Generator Bi-vent 20
|
42
|
19
|
$69,489.00
|
$69,489.00
|
$12,758.18
|
$62,540.10
|
$29,824.68
|
2024-10-01
|
|
5496
|
OTHER
|
Level 6 Intraocular Proce
|
1
|
1
|
—
|
—
|
$29,754.70
|
$29,754.70
|
$29,754.70
|
2024-10-01
|
|
337140
|
CDM
|
Stnt Prox Str24x24x152
|
41
|
18
|
$68,682.11
|
$68,682.11
|
$12,610.04
|
$61,813.90
|
$29,478.36
|
2024-10-01
|
|
406
|
MS_DRG
|
Pancreas, Liver And Shunt Procedures With Cc
|
9
|
8
|
—
|
—
|
$9,531.20
|
$29,692.95
|
$29,127.37
|
2024-10-01
|
|
438918
|
CDM
|
Stent Graft Evas 199mm 3
|
41
|
18
|
$67,527.98
|
$67,527.98
|
$12,398.14
|
$60,775.18
|
$28,983.01
|
2024-10-01
|
|
492
|
MS_DRG
|
Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc
|
9
|
8
|
—
|
—
|
$8,783.95
|
$29,443.05
|
$28,882.23
|
2024-10-01
|
|
480
|
MS_DRG
|
Hip And Femur Procedures Except Major Joint With Mcc
|
9
|
8
|
—
|
—
|
$7,284.84
|
$29,413.65
|
$28,853.39
|
2024-10-01
|
|
J1412
|
HCPCS
|
Injection, Valoctocogene Roxaparvovec-rvox, Per Ml, Containing Nominal 2 X 10°13…
|
4
|
1
|
—
|
—
|
$28,750.78
|
$28,750.78
|
$28,750.78
|
2024-10-01
|
|
773094
|
CDM
|
Device Clsr 12fr 20mm
|
41
|
18
|
$66,453.00
|
$66,453.00
|
$12,200.77
|
$59,807.70
|
$28,521.63
|
2024-10-01
|
|
773098
|
CDM
|
Device Clsr 12f 35mm
|
41
|
18
|
$66,453.00
|
$66,453.00
|
$12,200.77
|
$59,807.70
|
$28,521.63
|
2024-10-01
|
|
773097
|
CDM
|
Device Clsr 12fr 31mm
|
41
|
18
|
$66,453.00
|
$66,453.00
|
$12,200.77
|
$59,807.70
|
$28,521.63
|
2024-10-01
|
|
773095
|
CDM
|
Device Clsr 12fr 24mm
|
41
|
18
|
$66,453.00
|
$66,453.00
|
$12,200.77
|
$59,807.70
|
$28,521.63
|
2024-10-01
|
|
773096
|
CDM
|
Device Clsr 12fr 27mm
|
41
|
18
|
$66,453.00
|
$66,453.00
|
$12,200.77
|
$59,807.70
|
$28,521.63
|
2024-10-01
|
|
337142
|
CDM
|
Stent Evas Cls 150x40x40
|
41
|
18
|
$65,896.94
|
$65,896.94
|
$12,098.68
|
$59,307.25
|
$28,282.97
|
2024-10-01
|
|
337141
|
CDM
|
Stnt Clsweb Tpr42x38x150
|
41
|
18
|
$65,896.94
|
$65,896.94
|
$12,098.68
|
$59,307.25
|
$28,282.97
|
2024-10-01
|
|
337145
|
CDM
|
Stnt Clsweb Tpr44x40x150
|
41
|
18
|
$65,896.94
|
$65,896.94
|
$12,098.68
|
$59,307.25
|
$28,282.97
|
2024-10-01
|
|
495
|
MS_DRG
|
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Wit…
|
9
|
8
|
—
|
—
|
$11,300.48
|
$28,711.20
|
$28,164.32
|
2024-10-01
|
|
510
|
MS_DRG
|
Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc
|
9
|
8
|
—
|
—
|
$9,951.75
|
$28,625.10
|
$28,079.86
|
2024-10-01
|
|
J2327
|
HCPCS
|
Risankizu-rzaa 600mg Inj
|
35
|
17
|
$72,508.18
|
$72,508.18
|
$39.21
|
$65,257.36
|
$28,060.67
|
2024-10-01
|
|
656
|
MS_DRG
|
Kidney And Ureter Procedures For Neoplasm With Mcc
|
9
|
8
|
—
|
—
|
$7,163.95
|
$28,600.95
|
$28,056.17
|
2024-10-01
|
|
253
|
MS_DRG
|
Other Vascular Procedures With Cc
|
9
|
8
|
—
|
—
|
$7,666.72
|
$28,503.30
|
$27,960.38
|
2024-10-01
|
|
242
|
MS_DRG
|
Permanent Cardiac Pacemaker Implant With Mcc
|
9
|
8
|
—
|
—
|
$11,216.10
|
$28,467.60
|
$27,925.36
|
2024-10-01
|
|
709
|
MS_DRG
|
Penis Procedures With Cc/mcc
|
9
|
8
|
—
|
—
|
$5,488.51
|
$28,247.10
|
$27,709.06
|
2024-10-01
|
|
314
|
MS_DRG
|
Other Circulatory System Diagnoses With Mcc
|
9
|
8
|
—
|
—
|
$7,191.54
|
$27,754.65
|
$27,225.99
|
2024-10-01
|
|
903642
|
CDM
|
MRI Biv Icd Generator
|
41
|
18
|
$63,231.00
|
$63,231.00
|
$11,609.21
|
$56,907.90
|
$27,138.75
|
2024-10-01
|
|
5495
|
OTHER
|
Level 5 Intraocular Proce
|
1
|
1
|
—
|
—
|
$27,069.16
|
$27,069.16
|
$27,069.16
|
2024-10-01
|
|
418030
|
CDM
|
Stent Graft Evas 161mm 2
|
41
|
18
|
$63,032.63
|
$63,032.63
|
$11,572.79
|
$56,729.37
|
$27,053.60
|
2024-10-01
|
|
421752
|
CDM
|
Stent Aaa 40x40x159mm Ta
|
41
|
18
|
$63,032.63
|
$63,032.63
|
$11,572.79
|
$56,729.37
|
$27,053.60
|
2024-10-01
|
|
430213
|
CDM
|
Stent Grf Mn Prx Thr 38m
|
41
|
18
|
$63,032.63
|
$63,032.63
|
$11,572.79
|
$56,729.37
|
$27,053.60
|
2024-10-01
|
|
483
|
MS_DRG
|
Major Joint Or Limb Reattachment Procedures Of Upper Extremities
|
9
|
8
|
—
|
—
|
$8,510.79
|
$27,298.95
|
$26,778.97
|
2024-10-01
|
|
143
|
MS_DRG
|
Other Ear, Nose, Mouth And Throat O.r. Procedures With Mcc
|
9
|
8
|
—
|
—
|
$6,859.42
|
$26,824.35
|
$26,313.41
|
2024-10-01
|
|
414
|
MS_DRG
|
Cholecystectomy Except By Laparoscope Without C.d.e. With Mcc
|
9
|
8
|
—
|
—
|
$10,370.95
|
$26,528.25
|
$26,022.95
|
2024-10-01
|
|
534224
|
CDM
|
Device Embl 25mm 5mm Pip
|
41
|
18
|
$60,511.32
|
$60,511.32
|
$11,109.88
|
$54,460.19
|
$25,971.46
|
2024-10-01
|
|
336176
|
CDM
|
Device Embl 5x35mm
|
41
|
18
|
$60,511.32
|
$60,511.32
|
$11,109.88
|
$54,460.19
|
$25,971.46
|
2024-10-01
|
|
336178
|
CDM
|
Device Embl 4x30mm
|
41
|
18
|
$60,511.32
|
$60,511.32
|
$11,109.88
|
$54,460.19
|
$25,971.46
|
2024-10-01
|
|
322980
|
CDM
|
Device Embl Pln 30x4.25
|
41
|
18
|
$60,511.32
|
$60,511.32
|
$11,109.88
|
$54,460.19
|
$25,971.46
|
2024-10-01
|
|
534130
|
CDM
|
Device Embl 25mm 3.5mm P
|
41
|
18
|
$60,511.32
|
$60,511.32
|
$11,109.88
|
$54,460.19
|
$25,971.46
|
2024-10-01
|
|
551864
|
CDM
|
Device Embl Ped25x4.75mm
|
41
|
18
|
$60,511.32
|
$60,511.32
|
$11,109.88
|
$54,460.19
|
$25,971.46
|
2024-10-01
|
|
337143
|
CDM
|
Stent Gft Vlnt 100x46x46
|
41
|
18
|
$60,326.62
|
$60,326.62
|
$11,075.97
|
$54,293.96
|
$25,892.19
|
2024-10-01
|
|
337144
|
CDM
|
Stnt Distal Str40x40x107
|
41
|
18
|
$60,326.62
|
$60,326.62
|
$11,075.97
|
$54,293.96
|
$25,892.19
|
2024-10-01
|
|
C1767
|
HCPCS
|
Gwire Vasc .018in 200cm
|
740
|
19
|
$61,566.75
|
$61,566.75
|
$926.26
|
$130,444.11
|
$25,868.59
|
2024-10-01
|
|
522
|
MS_DRG
|
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc
|
9
|
8
|
—
|
—
|
$6,493.50
|
$26,361.30
|
$25,859.18
|
2024-10-01
|
|
521
|
MS_DRG
|
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc
|
9
|
8
|
—
|
—
|
$11,023.27
|
$26,361.30
|
$25,859.18
|
2024-10-01
|
|
583
|
MS_DRG
|
Mastectomy For Malignancy Without Cc/mcc
|
9
|
8
|
—
|
—
|
$6,680.12
|
$26,164.95
|
$25,666.57
|
2024-10-01
|
|
582
|
MS_DRG
|
Mastectomy For Malignancy With Cc/mcc
|
9
|
8
|
—
|
—
|
$7,296.74
|
$26,164.95
|
$25,666.57
|
2024-10-01
|
|
432587
|
CDM
|
Graft Evas 12cm 26mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482282
|
CDM
|
Graft Excldr 12x23x15.5
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432593
|
CDM
|
Graft Evas 18cm 26mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432589
|
CDM
|
Graft Evas 16cm 26mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432588
|
CDM
|
Graft Evas 14cm 26mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
399606
|
CDM
|
Stent Grft Main C3 28mmx
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432594
|
CDM
|
Graft Evas 12cm 28.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
421811
|
CDM
|
Graft Evas 16cm 26mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
478737
|
CDM
|
Graft Evas 10cm 14.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
456456
|
CDM
|
Graft Evas 18cm 35mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432586
|
CDM
|
Graft Evas 18cm 23mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432582
|
CDM
|
Graft Evas 12cm 23mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432584
|
CDM
|
Graft Evas 12cm 23x14.5m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432590
|
CDM
|
Graft Evas 18cm 26mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432583
|
CDM
|
Graft Evas 14cm 23mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432585
|
CDM
|
Graft Evas 16cm 23mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
474099
|
CDM
|
Graft Evas 14 Cm 28.5 14
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
474489
|
CDM
|
Graft Evas 18cm 28.5mm 1
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
459377
|
CDM
|
Graft Evas 15cm 31x14.5
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
473999
|
CDM
|
Graft Evas 18x23x14.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482289
|
CDM
|
Graft Evs 18cm 26x14.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
467555
|
CDM
|
Graft Evas 12cm 26x14.5
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482284
|
CDM
|
Graft Evas 16cm 23mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432592
|
CDM
|
Stent Excluder Gore C3 D
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
476296
|
CDM
|
Graft Evas 16cm 23mm 12m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
430572
|
CDM
|
Graft Evas 15cm 31mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
477230
|
CDM
|
Graft Evs 16cm 26x14.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432599
|
CDM
|
Graft Evas 12cm 28.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
477365
|
CDM
|
Graft Evas 14cm 35mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432591
|
CDM
|
Graft Evas 12cm 26mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482290
|
CDM
|
Graft Excluder 14cm 28.5
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
476831
|
CDM
|
Graft Evas 10cm 12mm Aaa
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
429502
|
CDM
|
Stnt/gft Eprsth 17cm 31m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
429513
|
CDM
|
Graft Evas 18cm 28.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
428598
|
CDM
|
Graft Evas 13cm 31mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
423167
|
CDM
|
Graft Excluder Stent Trk
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
429542
|
CDM
|
Graft Evas 14cm 23x14.5m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482331
|
CDM
|
Graft Evas 10cm 10mm Gor
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482334
|
CDM
|
Graft Evas 16cm 35mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482285
|
CDM
|
Graft Evas 14cm 26mm 12m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482281
|
CDM
|
Graft Evas 18cm 23mm 12m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482292
|
CDM
|
Graft Evas 18cm 28.5mm 1
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432597
|
CDM
|
Graft Evas 16cm 28.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
429860
|
CDM
|
Graft Evas 18cm 23mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
480996
|
CDM
|
Graft Evas 12cm 28.5mm 1
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
472352
|
CDM
|
Stent Gft Ilic 14cm 23mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
473744
|
CDM
|
Graft Excluder 16cm 28.5
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432598
|
CDM
|
Graft Evas 16cm 28.5mm 1
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
420304
|
CDM
|
Stent Aaa Exldr C3 23x12
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
479246
|
CDM
|
Graft Evas 26x12mm 12cm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
476745
|
CDM
|
Graft Evas 12cm 23mm 12m
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482288
|
CDM
|
Graft Evas 14cm 26mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
468315
|
CDM
|
Graft Evas 13cm 31mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
459060
|
CDM
|
Graft Evas 17cm 31x14.5
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
432595
|
CDM
|
Graft Evas 14cm 28.5mm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
482291
|
CDM
|
Graft Evas 28.5x12m 16cm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
468669
|
CDM
|
Graft Evas 14cm 23mm 14.
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
479247
|
CDM
|
Graft Evas 28.5x12m 12cm
|
41
|
18
|
$59,480.25
|
$59,480.25
|
$10,920.57
|
$53,532.22
|
$25,528.92
|
2024-10-01
|
|
500
|
MS_DRG
|
Soft Tissue Procedures With Mcc
|
9
|
8
|
—
|
—
|
$9,031.14
|
$26,009.55
|
$25,514.13
|
2024-10-01
|
|
421602
|
CDM
|
Graft Evas 166mm 28x13mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
368334
|
CDM
|
Graft Evas 145mm 28x20mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421627
|
CDM
|
Stent Graft End Main 25m
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421615
|
CDM
|
Graft Evas 145mm 28x13mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421625
|
CDM
|
Stent Graft End Main 25x
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421617
|
CDM
|
Graft Evas 124mm 28x13mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421593
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421596
|
CDM
|
Stnet Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421589
|
CDM
|
Graft Evas 166mm 20x36mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421586
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421591
|
CDM
|
Graft Evas 145mm 32mm 16
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421619
|
CDM
|
Graft Evas Endurant Stnt
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421681
|
CDM
|
Graft Evas 28mm 16mm End
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421590
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421584
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421582
|
CDM
|
Graft Evas 166mm 23x16mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421585
|
CDM
|
Graft Evas 145mm 23x13mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421992
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421620
|
CDM
|
Graft Evas 145mm 36mm 16
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421470
|
CDM
|
Graft Evas 145mm 25mm 16
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421622
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421682
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421581
|
CDM
|
Stent Graft Endurant Mai
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421342
|
CDM
|
Graft Evas 145mm 28mm 16
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421624
|
CDM
|
Graft Endur Main 32mmx20
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421687
|
CDM
|
Graft Vasc Aaa 32x16x166
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
421686
|
CDM
|
Graft Evas 166mm 25x13mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
449767
|
CDM
|
Graft Evas 124mm 32-20mm
|
41
|
18
|
$59,361.23
|
$59,361.23
|
$10,898.72
|
$53,425.11
|
$25,477.84
|
2024-10-01
|
|
495512
|
CDM
|
Kit Nucleus 7 Processor
|
42
|
19
|
$59,185.13
|
$59,185.13
|
$10,866.39
|
$53,266.62
|
$25,402.26
|
2024-10-01
|
|
495522
|
CDM
|
Kit Nucleus 6 Processor
|
42
|
19
|
$59,185.13
|
$59,185.13
|
$10,866.39
|
$53,266.62
|
$25,402.26
|
2024-10-01
|
|
545183
|
CDM
|
Device Embl 3mm 4mm Web
|
41
|
18
|
$58,439.55
|
$58,439.55
|
$10,729.50
|
$52,595.60
|
$25,082.25
|
2024-10-01
|
|
545195
|
CDM
|
Coil Emb Endo Sn Ly 8mm
|
41
|
18
|
$58,439.55
|
$58,439.55
|
$10,729.50
|
$52,595.60
|
$25,082.25
|
2024-10-01
|
|
545198
|
CDM
|
Coil Emb Endo Sn Ly 8mmx
|
41
|
18
|
$58,439.55
|
$58,439.55
|
$10,729.50
|
$52,595.60
|
$25,082.25
|
2024-10-01
|
|
545213
|
CDM
|
Coil Emb Endo Sn Ly Sphr
|
41
|
18
|
$58,439.55
|
$58,439.55
|
$10,729.50
|
$52,595.60
|
$25,082.25
|
2024-10-01
|
|
J9228
|
HCPCS
|
Ipilimumab 1 Mg Inj
|
97
|
17
|
$64,258.47
|
$64,258.47
|
$218.48
|
$231,329.80
|
$24,868.03
|
2024-10-01
|
|
574
|
MS_DRG
|
Skin Graft For Skin Ulcer Or Cellulitis With Cc
|
9
|
8
|
—
|
—
|
$8,633.30
|
$25,292.40
|
$24,810.64
|
2024-10-01
|