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

TRISTAR SUMMIT MEDICAL CENTER

Hermitage, TN · CCN 440150 · Rates published

62,369 distinct procedures filed
42 distinct payers
930,224 rate rows
2026-07-30 last MRF observed
Data quality

855,190 of 930,224 rate rows are consumer-grade (91.9%)

75,034 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
no usable negotiated amount (only an out-of-band fallback) — excluded from medians 34,885
per-diem day rate — not a per-procedure price 23,360
percent-of-billed methodology on a DRG bundle — not comparable to case rates; shown as context only 11,578
exceeds 10× this hospital's gross charge — excluded from medians 4,421
below 25% of the Medicare reference for this DRG — likely a mislabeled per-diem; excluded from rankings 433
placeholder amount (≤ $0.02) — excluded from medians 247
below 25% of the Medicare reference for this code — likely a mislabeled per-diem or placeholder; excluded from medians 65
percent-of-charges filed in the dollar field — excluded from medians 44
template filing: same amount across many unrelated codes — excluded 1
Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://stctrprodsnsvc00455826e6.blob.core.windows.net/pt-final-posting-files/62-1113737_TRISTAR-SUMMIT-MEDICAL-CENTER_standardcharges.json?si=pt-json-access-policy&spr=https&sv=2024-11-04&sr=c&sig=o5IofreS%2F7ETlsnhPakPWCwHVVUZRobywQ5wUKGjVuQ%3D
Found on page https://www.tristarhealth.com/patient-resources/patient-financial-resources/pricing-transparency-cms-required-file-of-standard-charges
Discovered viaCMS hospital list
Last fetch Latest re-check couldn't be parsed — showing last good data · 2026-10-10

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
J1411
HCPCS 		Injection, Etranacogene Dezaparvovec-drlb, Per Therapeutic Dose 1 $4,200,000.00 $4,200,000.00 $4,200,000.00 nat. median
$3,685,267
1.1× median
J1413
HCPCS 		Injection, Delandistrogene Moxeparvovec-rokl, Per Therapeutic Dose 1 $3,840,000.00 $3,840,000.00 $3,840,000.00 nat. median
$3,325,455
1.2× median
9138
OTHER 		Inj, Hemgenix, Per Tx Dos 17 $3,232,152.00 $4,223,835.00 $3,709,629.00 nat. median
$3,765,001
1.0× median
773
OTHER 		Inj, Beqvez, Per Tx Dose 17 $3,172,400.00 $4,145,750.00 $3,641,050.00 nat. median
$3,677,100
1.0× median
714
OTHER 		Inj Delandistrogene Mox R 20 $4,496.74 $4,888,418.85 $3,358,709.55 nat. median
$3,391,964
1.0× median
748
OTHER 		Inj, Lovotibeglogene Auto 20 $7,417.36 $4,830,420.00 $3,318,860.00 nat. median
$3,351,720
1.0× median
746
OTHER 		Inj, Betibeglogene Autote 20 $6,588.09 $4,362,960.00 $2,997,680.00 nat. median
$3,001,835
1.0× median
9141
OTHER 		Inj Onase Abepar-xioi Tre 20 $2,101,980.32 $3,511,262.58 $2,436,386.28 nat. median
$2,508,045
1.0× median
Q2042
HCPCS 		Tisagenlecleucel, Up To 600 Million Car-positive Viable T Cells, Including Leuka… 1 $1,387,149.28 $1,387,149.28 $1,387,149.28 nat. median
$621,313
outlier · 2.2×
Q2056
HCPCS 		Ciltacabtagene Autoleucel, Up To 100 Million Autologous B-cell Maturation Antige… 2 $620,118.79 $1,345,370.55 $1,345,370.55 nat. median
$599,737
outlier · 2.2×
Q2055
HCPCS 		Idecabtagene Vicleucel, Up To 510 Million Autologous B-cell Maturation Antigen (… 2 $591,090.52 $1,334,154.50 $1,334,154.50 nat. median
$574,037
outlier · 2.3×
Q2054
HCPCS 		Lisocabtagene Maraleucel, Up To 110 Million Autologous Anti-cd19 Car-positive Vi… 2 $579,352.98 $1,315,434.06 $1,315,434.06 nat. median
$579,571
outlier · 2.3×
Q2041
HCPCS 		Axicabtagene Ciloleucel, Up To 200 Million Autologous Anti-cd19 Car Positive Via… 2 $549,504.00 $1,296,212.81 $1,296,212.81 nat. median
$562,501
outlier · 2.3×
Q2053
HCPCS 		Brexucabtagene Autoleucel, Up To 200 Million Autologous Anti-cd19 Car Positive V… 2 $549,504.00 $1,191,016.00 $1,191,016.00 nat. median
$513,770
outlier · 2.3×
9194
OTHER 		Tisagenlecleucel Car-pos 20 $465,689.75 $777,913.56 $539,776.76 nat. median
$555,653
1.0× median
9498
OTHER 		Ciltacabtagene Car-pos T 20 $463,868.59 $774,871.40 $537,665.86 nat. median
$553,480
1.0× median
9422
OTHER 		Idecabtagene Vicleucel Ca 20 $463,397.09 $774,083.77 $537,119.35 nat. median
$552,917
1.0× median
9413
OTHER 		Lisocabtagene Car Pos T 20 $454,718.97 $759,587.37 $527,060.62 nat. median
$542,562
1.0× median
9035
OTHER 		Axicabtagene Ciloleucel C 20 $430,721.28 $719,500.32 $499,245.12 nat. median
$513,929
1.0× median
9391
OTHER 		Brexucabtagene Car Pos T 20 $405,266.75 $676,979.69 $469,741.01 nat. median
$483,557
1.0× median
18
MS_DRG 		Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 26 $1,854.72 $910,889.88 $268,234.70 nat. median
$168,055
1.6× median
1
MS_DRG 		Heart Transplant Or Implant Of Heart Assist System With Mcc 27 $2,253.12 $680,359.39 $202,566.29 nat. median
$186,516
1.1× median
J7330
HCPCS 		Autologous Cultured Chondrocytes, Implant 2 $87,248.40 $192,914.70 $192,914.70 nat. median
$92,809
outlier · 2.1×
A9543
HCPCS 		Yttrium Y-90 Ibritumomab Tiuxetan, Therapeutic, Per Treatment Dose, Up To 40 Mil… 3 $74,124.43 $173,512.94 $173,512.94 nat. median
$65,477
outlier · 2.7×
927
MS_DRG 		Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft 27 $2,253.12 $573,024.23 $169,108.76 nat. median
$131,925
1.3× median
J9029
HCPCS 		Intravesical Instillation, Nadofaragene Firadenovec-vncg, Per Therapeutic Dose 3 $72,000.00 $168,273.22 $168,273.22 nat. median
$66,211
outlier · 2.5×
3
MS_DRG 		Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 28 $2,253.12 $517,646.48 $154,360.23 nat. median
$145,435
1.1× median
001
OTHER 		Heart Transplant Or Implant Of Heart Assist System With Mcc 1 $152,420.78 $152,420.78 $152,420.78 nat. median
$177,883
0.9× median
Q2043
HCPCS 		Sipuleucel-t, Minimum Of 50 Million Autologous Cd54+ Cells Activated With Pap-gm… 3 $65,321.65 $147,108.87 $147,108.87 nat. median
$63,499
outlier · 2.3×
1907
OTHER 		New Technology - Level 52 20 $123,322.14 $206,004.04 $142,941.58 nat. median
$149,948
1.0× median
1908
OTHER 		New Technology - Level 52 20 $123,322.14 $206,004.04 $142,941.58 nat. median
$149,948
1.0× median
1905
OTHER 		New Technology - Level 51 20 $111,192.14 $185,741.41 $128,881.79 nat. median
$135,199
1.0× median
1906
OTHER 		New Technology - Level 51 20 $111,192.14 $185,741.41 $128,881.79 nat. median
$135,199
1.0× median
018
OTHER 		Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 1 $125,769.64 $125,769.64 $125,769.64 nat. median
$149,977
0.8× median
A9699
HCPCS 		Radiopharmaceutical, Therapeutic, Not Otherwise Classified 1 $123,321.96 $123,321.96 $123,321.96 nat. median
$7,098
outlier · 17.4×
J9226
HCPCS 		Histrelin Implant (supprelin La), 50 Mg 3 $54,500.39 $117,019.36 $117,019.36 nat. median
$57,036
outlier · 2.1×
1903
OTHER 		New Technology - Level 50 20 $99,062.13 $165,478.78 $114,822.01 nat. median
$3,015
outlier · 38.1×
1904
OTHER 		New Technology - Level 50 20 $99,062.13 $165,478.78 $114,822.01 nat. median
$3,015
outlier · 38.1×
003
OTHER 		Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 1 $102,091.46 $102,091.46 $102,091.46 nat. median
$119,739
0.9× median
Q0480
HCPCS 		Driver For Use With Pneumatic Ventricular Assist Device, Replacement Only 20 $87,999.91 $146,999.85 $101,999.90 nat. median
$108,243
0.9× median
4
MS_DRG 		Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 28 $2,253.12 $341,288.41 $101,120.15 nat. median
$97,418
1.0× median
1901
OTHER 		New Technology - Level 49 20 $86,932.13 $145,216.17 $100,762.24 nat. median
$3,015
outlier · 33.4×
1902
OTHER 		New Technology - Level 49 20 $86,932.13 $145,216.17 $100,762.24 nat. median
$3,015
outlier · 33.4×
14
MS_DRG 		Allogeneic Bone Marrow Transplant 27 $1,854.72 $316,452.24 $93,833.49 nat. median
$72,715
1.3× median
7
MS_DRG 		Lung Transplant 27 $2,253.12 $315,655.12 $93,599.64 nat. median
$70,649
1.3× median
K1007
HCPCS 		Bilateral Hip, Knee, Ankle, Foot Device, Powered, Includes Pelvic Component, Sin… 20 $80,108.07 $133,816.89 $92,852.54 nat. median
$95,583
1.0× median
1599
OTHER 		New Technology - Level 48 20 $76,823.79 $128,330.65 $89,045.76 nat. median
$93,410
1.0× median
1585
OTHER 		New Technology - Level 48 20 $76,823.79 $128,330.65 $89,045.76 nat. median
$93,410
1.0× median
30230X3
OTHER 		Transfusion Of Allogeneic Unrelated Cord Blood Stem Cells Into Peripheral Vein,… 1 $83,298.00 $83,298.00 $83,298.00 nat. median
$413,419
outlier · 0.2×
30233Y2
OTHER 		Transfusion Of Allogeneic Related Hematopoietic Stem Cells Into Peripheral Vein,… 1 $83,298.00 $83,298.00 $83,298.00 nat. median
$413,419
outlier · 0.2×

Other procedures at this hospital

Browse this hospital's 62,369 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
             
369754 CDM Coil Embol Neuro 4x2mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
425229 CDM Coil Embl 4.5mm 3mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
423118 CDM Coil Emb Neuro 6x3mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
425896 CDM Coil Embl 6mm 2mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
425050 CDM Coil Embl 5mm 2mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
423421 CDM Coil Embz .017 4.5mm 2mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
423119 CDM Coil Embol Neuro 7x3mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
365432 CDM Device Endo Sng 5x3mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
423239 CDM Coil Emb Neuro 6x4.6mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
425364 CDM Coil Emb Neuro 6x4mm 24 20 $65,988.00 $65,988.00 $9,898.20 $59,389.20 $32,994.00 2024-10-01
25 MS_DRG Craniotomy And Endovascular Intracranial Procedures With Mcc 58 28 — — $2,253.12 $108,021.16 $33,002.63 2024-10-01
B0903 HCPCS Other Orthopedic; M > 24.15 & M < 34.35 3 1 — — $33,146.27 $33,146.27 $33,146.27 2024-10-01
B1003 HCPCS Amputation, Lower Extremity; M < 36.25 3 1 — — $33,333.58 $33,333.58 $33,333.58 2024-10-01
C0704 HCPCS Fracture Of Lower Extremity; M < 28.15 3 1 — — $33,387.36 $33,387.36 $33,387.36 2024-10-01
D1903 HCPCS Guillian Barre; M < 18.05 3 1 — — $33,411.47 $33,411.47 $33,411.47 2024-10-01
418562 CDM Sys Endo Sng Lyr 6x3mm 24 20 $67,200.50 $67,200.50 $10,080.08 $60,480.45 $33,600.25 2024-10-01
418561 CDM System Endo Sng Lyr 6mmx 24 20 $67,200.50 $67,200.50 $10,080.08 $60,480.45 $33,600.25 2024-10-01
650 MS_DRG Kidney Transplant With Hemodialysis With Mcc 49 27 — — $2,253.12 $111,282.09 $33,638.94 2024-10-01
163 MS_DRG Major Chest Procedures With Mcc 58 28 — — $2,253.12 $111,327.98 $33,652.40 2024-10-01
417957 CDM Device Embl 5x25mm Pipln 24 20 $67,313.00 $67,313.00 $10,096.95 $60,581.70 $33,656.50 2024-10-01
329 MS_DRG Major Small And Large Bowel Procedures With Mcc 55 25 — — $10,181.00 $110,912.51 $33,859.24 2024-10-01
B0503 HCPCS Nontraumatic Spinal Cord Injury; M > 31.25 & M < 4 3 1 — — $33,865.83 $33,865.83 $33,865.83 2024-10-01
B1803 HCPCS Major Multiple Trauma With Brain Or Spinal Cord In 3 1 — — $33,893.65 $33,893.65 $33,893.65 2024-10-01
602566 CDM Tacth Impl Wrls Pa Snsr 27 22 $96,560.71 $96,560.71 $14,484.11 $86,904.64 $33,989.37 2024-10-01
B1503 HCPCS Pulmonary; M > 29.15 & M < 39.05 3 1 — — $34,060.56 $34,060.56 $34,060.56 2024-10-01
L8701 HCPCS Powered Upper Extremity Range Of Motion Assist Device, Elbow, Wrist, Hand With S… 30 20 — — $29,463.19 $49,216.92 $34,150.52 2024-10-01
823 MS_DRG Lymphoma And Non-acute Leukemia With Other Procedures With Mcc 56 28 — — $2,253.12 $234,521.98 $34,150.60 2024-10-01
221 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheter… 55 25 — — $19,699.08 $110,927.01 $34,192.30 2024-10-01
C1504 HCPCS Pulmonary; M < 29.15 3 1 — — $34,234.88 $34,234.88 $34,234.88 2024-10-01
A0205 HCPCS Traumatic Brain Injury; M > 28.75 & M < 40.65 3 1 — — $34,462.99 $34,462.99 $34,462.99 2024-10-01
C0604 HCPCS Neurological; M < 25.85 3 1 — — $34,577.97 $34,577.97 $34,577.97 2024-10-01
B0303 HCPCS Nontraumatic Brain Injury; M > 26.15 & M < 35.05 3 1 — — $34,583.54 $34,583.54 $34,583.54 2024-10-01
277 MS_DRG Cardiac Defibrillator Implant Without Mcc 55 25 — — $19,956.03 $157,103.00 $34,625.13 2024-10-01
981 MS_DRG Extensive O.r. Procedures Unrelated To Principal Diagnosis With Mcc 58 28 — — $2,253.12 $114,840.12 $34,682.83 2024-10-01
422423 CDM Device 17 Sng Sphr 5 .0 24 20 $69,461.00 $69,461.00 $10,419.15 $62,514.90 $34,730.50 2024-10-01
826 MS_DRG Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.r. 56 28 — — $2,253.12 $241,075.40 $34,830.94 2024-10-01
423 OTHER Other Hepatobiliary Or Pancreas O.r. Procedures With Mcc 1 1 — — $34,992.05 $34,992.05 $34,992.05 2024-10-01
267 MS_DRG Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc 55 25 — — $20,179.95 $118,359.00 $35,002.31 2024-10-01
799 MS_DRG Splenic Procedures With Mcc 55 25 — — $10,181.00 $114,844.95 $35,024.28 2024-10-01
B1603 HCPCS Pain Syndrome: M < 26.75 3 1 — — $35,138.05 $35,138.05 $35,138.05 2024-10-01
A0405 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A < 63.5 3 1 — — $35,256.74 $35,256.74 $35,256.74 2024-10-01
C1004 HCPCS Amputation, Lower Extremity; M=39-45 3 1 — — $35,293.83 $35,293.83 $35,293.83 2024-10-01
B0703 HCPCS Fracture Of Lower Extremity; M > 28.15 & M < 34.15 3 1 — — $35,330.92 $35,330.92 $35,330.92 2024-10-01
6 MS_DRG Liver Transplant Without Mcc 48 27 — — $2,253.12 $117,125.18 $35,353.23 2024-10-01
A0105 HCPCS Stroke; M > 34.25 & M < 38.85 3 1 — — $35,792.70 $35,792.70 $35,792.70 2024-10-01
C1903 HCPCS Guillian Barre; M < 18.05 3 1 — — $35,805.68 $35,805.68 $35,805.68 2024-10-01
834 OTHER Acute Leukemia With Mcc 1 1 — — $35,809.91 $35,809.91 $35,809.91 2024-10-01
245 MS_DRG Aicd Generator Procedures 58 28 — — $2,253.12 $118,033.41 $35,968.91 2024-10-01
471 MS_DRG Cervical Spinal Fusion With Mcc 55 25 — — $20,834.54 $108,607.38 $36,104.96 2024-10-01
B0403 HCPCS Traumatic Spinal Cord Injury; M > 16.05 & M < 30.3 3 1 — — $36,198.85 $36,198.85 $36,198.85 2024-10-01
853 MS_DRG Infectious And Parasitic Diseases With O.r. Procedures With Mcc 58 28 — — $2,253.12 $120,811.23 $36,434.68 2024-10-01
414726 CDM Set Vntrc 17.4x13.8in 36 27 $112,375.00 $112,375.00 $15,000.00 $101,137.50 $36,465.69 2024-10-01
957 OTHER Other O.r. Procedures For Multiple Significant Trauma With Mcc 1 1 — — $36,470.11 $36,470.11 $36,470.11 2024-10-01
837 MS_DRG Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemot… 58 28 — — $1,854.72 $120,939.25 $36,472.24 2024-10-01
D0205 HCPCS Traumatic Brain Injury; M > 28.75 & M < 40.65 3 1 — — $36,604.99 $36,604.99 $36,604.99 2024-10-01
B1703 HCPCS Maj Mult Trauma No Brain Or Spinal Cord Injury; M 3 1 — — $36,608.70 $36,608.70 $36,608.70 2024-10-01
228 MS_DRG Other Cardiothoracic Procedures With Mcc 58 28 — — $2,253.12 $120,361.95 $36,658.77 2024-10-01
239 MS_DRG Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc 58 28 — — $2,253.12 $121,656.66 $36,682.72 2024-10-01
278 MS_DRG Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures 58 28 — — $2,253.12 $120,845.05 $36,801.90 2024-10-01
B0603 HCPCS Neurological; M > 25.85 & M < 37.35 3 1 — — $36,827.54 $36,827.54 $36,827.54 2024-10-01
956 OTHER Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma 1 1 — — $36,906.30 $36,906.30 $36,906.30 2024-10-01
421205 CDM Graft Evas 40x40x10cm 24 20 $74,114.00 $74,114.00 $11,117.10 $66,702.60 $37,057.00 2024-10-01
B1804 HCPCS Major Multiple Trauma With Brain Or Spinal Code In 3 1 — — $37,064.92 $37,064.92 $37,064.92 2024-10-01
B1103 HCPCS Amputation, Non-lower Extremity; M=12-37 3 1 — — $37,194.74 $37,194.74 $37,194.74 2024-10-01
466 MS_DRG Revision Of Hip Or Knee Replacement With Mcc 58 28 — — $2,253.12 $123,052.82 $37,274.15 2024-10-01
326 MS_DRG Stomach, Esophageal And Duodenal Procedures With Mcc 55 25 — — $10,181.00 $122,676.00 $37,344.35 2024-10-01
019 OTHER Simultaneous Pancreas And Kidney Transplant With Hemodialysis 1 1 — — $37,502.26 $37,502.26 $37,502.26 2024-10-01
D0105 HCPCS Stroke; M > 34.25 & M < 38.85 3 1 — — $37,556.37 $37,556.37 $37,556.37 2024-10-01
C2624 HCPCS Sensor Artery Impl Systm 50 25 $87,402.00 $87,402.00 $12,632.85 $78,661.80 $37,670.26 2024-10-01
450 MS_DRG Single Level Spinal Fusion Except Cervical With Mcc Or Custom-made Anatomically 51 25 — — $21,031.00 $124,391.00 $37,852.45 2024-10-01
A0505 HCPCS Nontraumatic Spinal Cord Injury; M > 23.75 & M < 2 3 1 — — $37,886.48 $37,886.48 $37,886.48 2024-10-01
B0104 HCPCS Stroke; M > 38.85 & M < 44.45 3 1 — — $37,897.61 $37,897.61 $37,897.61 2024-10-01
231 OTHER Coronary Bypass With Ptca With Mcc 1 1 — — $38,073.28 $38,073.28 $38,073.28 2024-10-01
270 MS_DRG Other Major Cardiovascular Procedures With Mcc 55 25 — — $21,031.00 $123,982.78 $38,097.82 2024-10-01
B0204 HCPCS Traumatic Brain Injury; M > 40.65 & M < 44.25 3 1 — — $38,199.90 $38,199.90 $38,199.90 2024-10-01
B0805 HCPCS Replacement Of Lower Extremity Joint; M > 22.05 & 3 1 — — $38,227.72 $38,227.72 $38,227.72 2024-10-01
021 OTHER Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc 1 1 — — $38,446.92 $38,446.92 $38,446.92 2024-10-01
L2006 HCPCS Knee Ankle Foot Device, Any Material, Single Or Double Upright, Swing And Stance… 30 20 — — $33,177.32 $55,421.21 $38,455.53 2024-10-01
B1203 HCPCS Osteoarthritis; M < 30.75 3 1 — — $38,619.03 $38,619.03 $38,619.03 2024-10-01
455 MS_DRG Combined Anterior And Posterior Spinal Fusion Without Cc/mcc 7 4 — — $2,253.12 $47,985.75 $38,705.46 2024-10-01
D0405 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A < 63.5 3 1 — — $38,800.77 $38,800.77 $38,800.77 2024-10-01
L7180 HCPCS Electronic Elbow, Microprocessor Sequential Control Of Elbow And Terminal Device… 30 20 — — $33,694.76 $56,285.57 $39,055.29 2024-10-01
234 MS_DRG Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc 55 25 — — $21,031.00 $128,502.18 $39,070.43 2024-10-01
B2004 HCPCS Miscellaneous; M < 27.85 3 1 — — $39,080.81 $39,080.81 $39,080.81 2024-10-01
576 MS_DRG Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc 58 28 — — $2,253.12 $130,313.81 $39,222.62 2024-10-01
11 MS_DRG Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc 58 28 — — $2,253.12 $130,330.72 $39,227.59 2024-10-01
220 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheter… 55 25 — — $21,031.00 $127,932.13 $39,279.24 2024-10-01
8 MS_DRG Simultaneous Pancreas And Kidney Transplant 48 27 — — $2,253.12 $131,422.52 $39,547.91 2024-10-01
463 MS_DRG Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective 58 28 — — $2,253.12 $130,453.91 $39,648.67 2024-10-01
B1304 HCPCS Rheumatoid, Other Arthritis; M=12-35 3 1 — — $39,716.92 $39,716.92 $39,716.92 2024-10-01
B0904 HCPCS Other Orthopedic; M < 24.15 3 1 — — $39,716.92 $39,716.92 $39,716.92 2024-10-01
B1404 HCPCS Cardiac; M < 31.15 3 1 — — $39,794.81 $39,794.81 $39,794.81 2024-10-01
405 MS_DRG Pancreas, Liver And Shunt Procedures With Mcc 55 25 — — $10,181.00 $131,123.00 $39,846.90 2024-10-01
326066 CDM Revsc Tib/per Ath Addl 27 22 $113,353.53 $113,353.53 $15,000.00 $102,018.18 $39,900.44 2024-10-01
C0405 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A < 63.5 3 1 — — $39,970.99 $39,970.99 $39,970.99 2024-10-01
B0304 HCPCS Nontraumatic Brain Injury; M < 26.15 3 1 — — $40,097.10 $40,097.10 $40,097.10 2024-10-01
430 MS_DRG Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc 51 25 — — $21,031.00 $132,130.27 $40,145.31 2024-10-01
834 MS_DRG Acute Leukemia With Mcc 58 28 — — $1,854.72 $133,502.27 $40,158.08 2024-10-01
B0504 HCPCS Nontraumatic Spinal Cord Injury; M > 29.25 & M < 3 3 1 — — $40,256.59 $40,256.59 $40,256.59 2024-10-01
C0205 HCPCS Traumatic Brain Injury; M > 28.75 & M < 40.65 3 1 — — $40,301.10 $40,301.10 $40,301.10 2024-10-01
428 MS_DRG Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Wit… 51 25 — — $21,031.00 $132,978.11 $40,396.50 2024-10-01
B1204 HCPCS Osteoarthritis; M=39-47 3 1 — — $40,497.68 $40,497.68 $40,497.68 2024-10-01
21 MS_DRG Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc 58 28 — — $2,253.12 $133,511.93 $40,554.65 2024-10-01
A0106 HCPCS Stroke; M > 30.05 & M < 34.25 3 1 — — $40,709.10 $40,709.10 $40,709.10 2024-10-01
653 MS_DRG Major Bladder Procedures With Mcc 55 25 — — $10,181.00 $134,644.80 $40,890.28 2024-10-01
C1882 HCPCS Crt-d Crd 5.37x8.08x0.99 304 17 $61,350.50 $61,350.50 $9,584.06 $97,973.10 $41,051.32 2024-10-01
C0105 HCPCS Stroke; M > 34.25 & M < 38.85 3 1 — — $41,098.55 $41,098.55 $41,098.55 2024-10-01
D0505 HCPCS Nontraumatic Spinal Cord Injury; M > 23.75 & M < 2 3 1 — — $41,113.39 $41,113.39 $41,113.39 2024-10-01
B2005 HCPCS Miscellaneous; M=12-32 And A Tm81 3 1 — — $41,193.13 $41,193.13 $41,193.13 2024-10-01
B1704 HCPCS Major Multiple Trauma,no Brain Or Spinal Cord Inju 3 1 — — $41,436.08 $41,436.08 $41,436.08 2024-10-01
23 MS_DRG Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Wi… 58 28 — — $2,253.12 $137,797.03 $41,824.18 2024-10-01
217 OTHER Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza… 1 1 — — $42,177.37 $42,177.37 $42,177.37 2024-10-01
B1504 HCPCS Pulmonary; M < 29.15 3 1 — — $42,179.75 $42,179.75 $42,179.75 2024-10-01
1594 OTHER New Technology - Level 43 30 20 — — $36,390.43 $60,788.56 $42,179.82 2024-10-01
1580 OTHER New Technology - Level 43 30 20 — — $36,390.43 $60,788.56 $42,179.82 2024-10-01
820 MS_DRG Lymphoma And Leukemia With Major O.r. Procedures With Mcc 56 28 — — $2,253.12 $314,996.79 $42,248.69 2024-10-01
216 OTHER Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza… 1 1 — — $42,413.21 $42,413.21 $42,413.21 2024-10-01
457 MS_DRG Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Ex… 55 25 — — $24,617.96 $128,329.78 $42,478.08 2024-10-01
B1004 HCPCS Amputation, Lower Extremity; M=39-45 3 1 — — $42,674.91 $42,674.91 $42,674.91 2024-10-01
D0106 HCPCS Stroke; M > 30.05 & M < 34.25 3 1 — — $42,717.57 $42,717.57 $42,717.57 2024-10-01
335058 CDM Dialysis Circ Thrmb/stnt 27 22 $122,088.27 $122,088.27 $15,000.00 $109,879.44 $42,975.07 2024-10-01
B2102 HCPCS Burns; M=12-45 3 1 — — $42,980.91 $42,980.91 $42,980.91 2024-10-01
235 MS_DRG Coronary Bypass Without Cardiac Catheterization With Mcc 55 25 — — $21,031.00 $142,123.19 $43,105.87 2024-10-01
790 MS_DRG Extreme Immaturity Or Respiratory Distress Syndrome, Neonate 45 25 — — $1,854.72 $132,936.15 $43,121.07 2024-10-01
B0704 HCPCS Fracture Of Lower Extremity; M < 28.15 3 1 — — $43,160.81 $43,160.81 $43,160.81 2024-10-01
C0505 HCPCS Nontraumatic Spinal Cord Injury; M > 23.75 & M < 2 3 1 — — $43,518.73 $43,518.73 $43,518.73 2024-10-01
16 MS_DRG Autologous Bone Marrow Transplant With Cc/mcc 48 27 — — $1,854.72 $145,787.50 $43,762.43 2024-10-01
17 MS_DRG Autologous Bone Marrow Transplant Without Cc/mcc 48 27 — — $1,854.72 $145,787.50 $43,762.43 2024-10-01
215 OTHER Other Heart Assist System Implant 1 1 — — $43,815.62 $43,815.62 $43,815.62 2024-10-01
218 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza… 55 25 — — $21,031.00 $143,700.51 $43,996.21 2024-10-01
28 MS_DRG Spinal Procedures With Mcc 58 28 — — $2,253.12 $146,840.66 $44,071.42 2024-10-01
A5104 HCPCS Expired, Not Orthopedic, Length Of Stay Is 16 Days 3 1 — — $44,201.20 $44,201.20 $44,201.20 2024-10-01
266 MS_DRG Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc 55 25 — — $21,031.00 $157,627.00 $44,294.64 2024-10-01
A0404 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A > 63.5 3 1 — — $44,334.73 $44,334.73 $44,334.73 2024-10-01
461 MS_DRG Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc 58 28 — — $2,253.12 $148,231.99 $44,533.31 2024-10-01
326651 CDM Rem/replace Icd Gen Mult 27 22 $126,864.47 $126,864.47 $15,000.00 $114,178.02 $44,656.29 2024-10-01
326575 CDM Rem/replace Icd Gen Dual 27 22 $126,864.47 $126,864.47 $15,000.00 $114,178.02 $44,656.29 2024-10-01
317 MS_DRG Concomitant Left Atrial Appendage Closure And Cardiac Ablation 51 25 — — $21,031.00 $149,422.83 $44,828.99 2024-10-01
B0405 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A < 63.5 3 1 — — $44,946.73 $44,946.73 $44,946.73 2024-10-01
573 MS_DRG Skin Graft For Skin Ulcer Or Cellulitis With Mcc 54 25 — — $12,000.00 $148,741.66 $45,066.68 2024-10-01
232 MS_DRG Coronary Bypass With Ptca Without Mcc 55 25 — — $21,031.00 $205,689.00 $45,146.55 2024-10-01
326053 CDM Revsc Tib/per St/ath Ini 27 22 $129,211.15 $129,211.15 $15,000.00 $116,290.04 $45,482.32 2024-10-01
A9604 HCPCS Samarium Sm-153 Lexidronam, Therapeutic, Per Treatment Dose, Up To 150 Millicuri… 6 3 — — $19,539.46 $45,738.60 $45,738.60 2024-10-01
276 MS_DRG Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator 55 25 — — $21,031.00 $157,627.00 $45,765.79 2024-10-01
969 MS_DRG HIV With Extensive O.r. Procedures With Mcc 58 28 — — $2,253.12 $152,753.80 $45,806.26 2024-10-01
B0604 HCPCS Neurological; M < 25.85 3 1 — — $46,185.57 $46,185.57 $46,185.57 2024-10-01
1142 OTHER Supprelin La Implant 30 20 — — $39,908.18 $66,664.81 $46,257.21 2024-10-01
B1903 HCPCS Guillian Barre; M < 18.05 3 1 — — $46,575.02 $46,575.02 $46,575.02 2024-10-01
C0106 HCPCS Stroke; M > 30.05 & M < 34.25 3 1 — — $46,745.64 $46,745.64 $46,745.64 2024-10-01
207 MS_DRG Respiratory System Diagnosis With Ventilator Support >96 Hours 58 28 — — $1,854.72 $156,227.29 $46,825.34 2024-10-01
326041 CDM Revsc Tib/per W Ath Init 27 22 $133,438.96 $133,438.96 $15,000.00 $120,095.06 $46,970.51 2024-10-01
453 OTHER Combined Anterior And Posterior Spinal Fusion With Mcc 1 1 — — $47,111.56 $47,111.56 $47,111.56 2024-10-01
005 OTHER Liver Transplant With Mcc Or Intestinal Transplant 1 1 — — $47,219.35 $47,219.35 $47,219.35 2024-10-01
B0105 HCPCS Stroke; M > 34.25 & M < 38.85 3 1 — — $47,389.17 $47,389.17 $47,389.17 2024-10-01
217 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza… 55 25 — — $21,031.00 $155,978.50 $47,669.07 2024-10-01
928 MS_DRG Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/mcc 48 27 — — $2,253.12 $161,319.17 $48,319.24 2024-10-01
L7181 HCPCS Electronic Elbow, Microprocessor Simultaneous Control Of Elbow And Terminal Devi… 30 20 — — $41,793.84 $69,814.71 $48,442.86 2024-10-01
268 MS_DRG Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc 55 25 — — $21,031.00 $161,046.22 $48,712.09 2024-10-01
D0404 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A > 63.5 3 1 — — $48,791.20 $48,791.20 $48,791.20 2024-10-01
5244 OTHER Level 4 Blood Product Exc 30 20 — — $42,104.21 $70,333.16 $48,802.60 2024-10-01
B0205 HCPCS Traumatic Brain Injury; M > 28.75 & M < 40.65 3 1 — — $48,932.15 $48,932.15 $48,932.15 2024-10-01
447 MS_DRG Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-made Anatomicall… 51 25 — — $21,031.00 $161,939.95 $48,976.87 2024-10-01
020 OTHER Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc 1 1 — — $48,997.92 $48,997.92 $48,997.92 2024-10-01
955 MS_DRG Craniotomy For Multiple Significant Trauma 58 28 — — $2,253.12 $164,927.92 $49,862.10 2024-10-01
C0404 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A > 63.5 3 1 — — $50,261.85 $50,261.85 $50,261.85 2024-10-01
870 MS_DRG Septicemia Or Severe Sepsis With Mv >96 Hours 58 28 — — $1,854.72 $168,034.26 $50,289.37 2024-10-01
326048 CDM Revsc Tib/per Stnt Init 27 22 $144,782.97 $144,782.97 $15,000.00 $130,304.67 $50,963.61 2024-10-01
326021 CDM Revsc Fem/pop W Angiop 27 22 $144,782.97 $144,782.97 $15,000.00 $130,304.67 $50,963.61 2024-10-01
326029 CDM Revsc Fem/pop W Stnt 27 22 $144,782.97 $144,782.97 $15,000.00 $130,304.67 $50,963.61 2024-10-01
326025 CDM Revsc Fem/pop W Atherct 27 22 $144,782.97 $144,782.97 $15,000.00 $130,304.67 $50,963.61 2024-10-01
454 MS_DRG Combined Anterior And Posterior Spinal Fusion With Cc 7 4 — — $2,253.12 $63,725.73 $51,401.39 2024-10-01
1595 OTHER New Technology - Level 44 30 20 — — $44,477.10 $74,296.98 $51,553.00 2024-10-01
1581 OTHER New Technology - Level 44 30 20 — — $44,477.10 $74,296.98 $51,553.00 2024-10-01
427 MS_DRG Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Wit… 51 25 — — $21,031.00 $171,469.10 $51,800.03 2024-10-01
275 MS_DRG Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc 55 25 — — $21,031.00 $241,583.00 $52,070.27 2024-10-01
955 OTHER Craniotomy For Multiple Significant Trauma 1 1 — — $53,164.13 $53,164.13 $53,164.13 2024-10-01
326574 CDM Rem/replace Icd Gen Sgl 27 22 $151,308.71 $151,308.71 $15,000.00 $136,177.84 $53,260.67 2024-10-01
B0106 HCPCS Stroke; M > 30.05 & M < 34.25 3 1 — — $53,900.47 $53,900.47 $53,900.47 2024-10-01
957 MS_DRG Other O.r. Procedures For Multiple Significant Trauma With Mcc 58 28 — — $2,253.12 $180,285.67 $54,412.07 2024-10-01
326033 CDM Revsc Fem/pop W Stnt/ath 27 22 $156,295.40 $156,295.40 $15,000.00 $140,665.86 $55,015.98 2024-10-01
459 MS_DRG Spinal Fusion Except Cervical With Mcc 7 4 — — $2,253.12 $69,101.93 $55,737.85 2024-10-01
B0505 HCPCS Nontraumatic Spinal Cord Injury; M > 23.75 & M < 2 3 1 — — $55,938.61 $55,938.61 $55,938.61 2024-10-01
C1822 HCPCS System Imp Ipg Neuro 19 17 $86,326.00 $86,326.00 $15,892.62 $77,693.40 $56,111.90 2024-10-01
9273 OTHER Sipuleucel-t Auto Cd54+ 30 20 — — $48,413.40 $80,872.39 $56,115.54 2024-10-01
B0404 HCPCS Traumatic Spinal Cord Injury; M < 16.05 & A > 63.5 3 1 — — $56,519.09 $56,519.09 $56,519.09 2024-10-01
219 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheter… 55 25 — — $21,031.00 $186,887.24 $56,915.14 2024-10-01
233 MS_DRG Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc 55 25 — — $21,031.00 $188,790.65 $56,931.80 2024-10-01
19 MS_DRG Simultaneous Pancreas And Kidney Transplant With Hemodialysis 49 27 — — $2,253.12 $191,469.44 $57,164.98 2024-10-01
002 OTHER Heart Transplant Or Implant Of Heart Assist System Without Mcc 1 1 — — $57,444.46 $57,444.46 $57,444.46 2024-10-01
10 MS_DRG Pancreas Transplant 48 27 — — $2,253.12 $192,578.15 $57,490.27 2024-10-01
007 OTHER Lung Transplant 1 1 — — $57,548.86 $57,548.86 $57,548.86 2024-10-01
20 MS_DRG Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc 58 28 — — $2,253.12 $194,701.38 $58,398.06 2024-10-01
429 MS_DRG Combined Anterior And Posterior Cervical Spinal Fusion With Mcc 51 25 — — $21,031.00 $201,452.70 $60,683.11 2024-10-01
1582 OTHER New Technology - Level 45 30 20 — — $52,563.77 $87,805.39 $60,926.19 2024-10-01
1596 OTHER New Technology - Level 45 30 20 — — $52,563.77 $87,805.39 $60,926.19 2024-10-01
456 MS_DRG Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Ex… 55 25 — — $36,326.82 $189,366.36 $62,201.51 2024-10-01
231 MS_DRG Coronary Bypass With Ptca With Mcc 55 25 — — $21,031.00 $205,689.00 $62,236.19 2024-10-01
J9600 HCPCS Injection, Porfimer Sodium, 75 Mg 6 3 — — $26,766.00 $62,320.47 $62,320.47 2024-10-01
312754 CDM Ins Icd Lead/generator 27 22 $180,305.80 $180,305.80 $15,000.00 $162,275.22 $63,467.64 2024-10-01
717 OTHER Instill Adstiladrin, Tx D 31 20 — — $10,776.28 $93,131.51 $63,988.32 2024-10-01
651 OTHER Kidney Transplant With Hemodialysis Without Mcc 1 1 — — $64,954.81 $64,954.81 $64,954.81 2024-10-01
850 MS_DRG Acute Leukemia With Other Procedures 51 25 — — $10,181.00 $222,498.95 $66,268.69 2024-10-01
014 OTHER Allogeneic Bone Marrow Transplant 1 1 — — $66,698.72 $66,698.72 $66,698.72 2024-10-01
1643 OTHER Y90 Ibritumomab, Rx 30 20 — — $57,619.39 $96,250.57 $66,786.12 2024-10-01
L8702 HCPCS Powered Upper Extremity Range Of Motion Assist Device, Elbow, Wrist, Hand, Finge… 30 20 — — $57,967.10 $96,831.40 $67,189.14 2024-10-01
90288 CPT Botulism Immune Globulin, Human, For Intravenous Use 1 1 — — $68,674.05 $68,674.05 $68,674.05 2024-10-01
1597 OTHER New Technology - Level 46 30 20 — — $60,650.44 $101,313.81 $70,299.38 2024-10-01
1583 OTHER New Technology - Level 46 30 20 — — $60,650.44 $101,313.81 $70,299.38 2024-10-01
216 MS_DRG Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheteriza… 55 25 — — $21,031.00 $233,105.41 $70,740.89 2024-10-01
J9266 HCPCS Injection, Pegaspargase, Per Single Dose Vial 6 3 — — $31,521.48 $71,589.38 $71,589.38 2024-10-01
004 OTHER Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 1 1 — — $71,782.97 $71,782.97 $71,782.97 2024-10-01
453 MS_DRG Combined Anterior And Posterior Spinal Fusion With Mcc 7 4 — — $2,253.12 $92,326.93 $74,471.21 2024-10-01
C9150 HCPCS Xenon Xe-129 Hyperpolarized Gas, Diagnostic, Per Study Dose 1 1 — — $74,786.40 $74,786.40 $74,786.40 2024-10-01
426 MS_DRG Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Wit… 51 25 — — $21,031.00 $253,183.05 $76,008.99 2024-10-01
5 MS_DRG Liver Transplant With Mcc Or Intestinal Transplant 48 27 — — $2,253.12 $257,216.93 $76,454.54 2024-10-01
215 MS_DRG Other Heart Assist System Implant 58 28 — — $2,253.12 $422,208.00 $76,814.79 2024-10-01
212 MS_DRG Concomitant Aortic And Mitral Valve Procedures 58 28 — — $2,253.12 $263,122.83 $78,187.26 2024-10-01
1598 OTHER New Technology - Level 47 30 20 — — $68,737.12 $114,822.23 $79,672.57 2024-10-01
1584 OTHER New Technology - Level 47 30 20 — — $68,737.12 $114,822.23 $79,672.57 2024-10-01
2 MS_DRG Heart Transplant Or Implant Of Heart Assist System Without Mcc 52 27 — — $2,253.12 $491,450.00 $79,859.79 2024-10-01
30240G3 OTHER Transfusion Of Allogeneic Unrelated Bone Marrow Into Central Vein, Open Approach… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240U2 OTHER Transfusion Of Allogeneic Related T-cell Depleted Hematopoietic Stem Cells Into … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243G3 OTHER Transfusion Of Allogeneic Unrelated Bone Marrow Into Central Vein, Percutaneous … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233X2 OTHER Transfusion Of Allogeneic Related Cord Blood Stem Cells Into Peripheral Vein, Pe… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230Y3 OTHER Transfusion Of Allogeneic Unrelated Hematopoietic Stem Cells Into Peripheral Vei… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243Y3 OTHER Transfusion Of Allogeneic Unrelated Hematopoietic Stem Cells Into Central Vein, … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233G3 OTHER Transfusion Of Allogeneic Unrelated Bone Marrow Into Peripheral Vein, Percutaneo… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243Y2 OTHER Transfusion Of Allogeneic Related Hematopoietic Stem Cells Into Central Vein, Pe… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243X3 OTHER Transfusion Of Allogeneic Unrelated Cord Blood Stem Cells Into Central Vein, Per… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243X2 OTHER Transfusion Of Allogeneic Related Cord Blood Stem Cells Into Central Vein, Percu… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233U2 OTHER Transfusion Of Allogeneic Related T-cell Depleted Hematopoietic Stem Cells Into … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230U2 OTHER Transfusion Of Allogeneic Related T-cell Depleted Hematopoietic Stem Cells Into … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230G2 OTHER Transfusion Of Allogeneic Related Bone Marrow Into Peripheral Vein, Open Approac… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233U3 OTHER Transfusion Of Allogeneic Unrelated T-cell Depleted Hematopoietic Stem Cells Int… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240X3 OTHER Transfusion Of Allogeneic Unrelated Cord Blood Stem Cells Into Central Vein, Ope… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233Y2 OTHER Transfusion Of Allogeneic Related Hematopoietic Stem Cells Into Peripheral Vein,… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240Y2 OTHER Transfusion Of Allogeneic Related Hematopoietic Stem Cells Into Central Vein, Op… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230Y2 OTHER Transfusion Of Allogeneic Related Hematopoietic Stem Cells Into Peripheral Vein,… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240Y3 OTHER Transfusion Of Allogeneic Unrelated Hematopoietic Stem Cells Into Central Vein, … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240X2 OTHER Transfusion Of Allogeneic Related Cord Blood Stem Cells Into Central Vein, Open … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230G3 OTHER Transfusion Of Allogeneic Unrelated Bone Marrow Into Peripheral Vein, Open Appro… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230X2 OTHER Transfusion Of Allogeneic Related Cord Blood Stem Cells Into Peripheral Vein, Op… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243U3 OTHER Transfusion Of Allogeneic Unrelated T-cell Depleted Hematopoietic Stem Cells Int… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230X3 OTHER Transfusion Of Allogeneic Unrelated Cord Blood Stem Cells Into Peripheral Vein, … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240G2 OTHER Transfusion Of Allogeneic Related Bone Marrow Into Central Vein, Open Approach 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233X3 OTHER Transfusion Of Allogeneic Unrelated Cord Blood Stem Cells Into Peripheral Vein, … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243U2 OTHER Transfusion Of Allogeneic Related T-cell Depleted Hematopoietic Stem Cells Into … 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30243G2 OTHER Transfusion Of Allogeneic Related Bone Marrow Into Central Vein, Percutaneous Ap… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233G2 OTHER Transfusion Of Allogeneic Related Bone Marrow Into Peripheral Vein, Percutaneous… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30240U3 OTHER Transfusion Of Allogeneic Unrelated T-cell Depleted Hematopoietic Stem Cells Int… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30233Y3 OTHER Transfusion Of Allogeneic Unrelated Hamatopoietic Stem Cells Into Peripheral Vei… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
30230U3 OTHER Transfusion Of Allogeneic Unrelated T-cell Depleted Hematopoietic Stem Cells Int… 1 1 — — $83,298.00 $83,298.00 $83,298.00 2024-10-01
1585 OTHER New Technology - Level 48 30 20 — — $76,823.79 $128,330.65 $89,045.76 2024-10-01
1599 OTHER New Technology - Level 48 30 20 — — $76,823.79 $128,330.65 $89,045.76 2024-10-01
K1007 HCPCS Bilateral Hip, Knee, Ankle, Foot Device, Powered, Includes Pelvic Component, Sin… 30 20 — — $80,108.07 $133,816.89 $92,852.54 2024-10-01
7 MS_DRG Lung Transplant 48 27 — — $2,253.12 $315,655.12 $93,599.64 2024-10-01
14 MS_DRG Allogeneic Bone Marrow Transplant 49 27 — — $1,854.72 $316,452.24 $93,833.49 2024-10-01
1901 OTHER New Technology - Level 49 30 20 — — $86,932.13 $145,216.17 $100,762.24 2024-10-01
1902 OTHER New Technology - Level 49 30 20 — — $86,932.13 $145,216.17 $100,762.24 2024-10-01
4 MS_DRG Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 58 28 — — $2,253.12 $341,288.41 $101,120.15 2024-10-01
Q0480 HCPCS Driver For Use With Pneumatic Ventricular Assist Device, Replacement Only 30 20 — — $87,999.91 $146,999.85 $101,999.90 2024-10-01
003 OTHER Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 1 1 — — $102,091.46 $102,091.46 $102,091.46 2024-10-01
1904 OTHER New Technology - Level 50 30 20 — — $99,062.13 $165,478.78 $114,822.01 2024-10-01
1903 OTHER New Technology - Level 50 30 20 — — $99,062.13 $165,478.78 $114,822.01 2024-10-01
J9226 HCPCS Histrelin Implant (supprelin La), 50 Mg 6 3 — — $54,500.39 $117,019.36 $117,019.36 2024-10-01
A9699 HCPCS Radiopharmaceutical, Therapeutic, Not Otherwise Classified 4 1 — — $123,321.96 $123,321.96 $123,321.96 2024-10-01
018 OTHER Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 1 1 — — $125,769.64 $125,769.64 $125,769.64 2024-10-01
1905 OTHER New Technology - Level 51 30 20 — — $111,192.14 $185,741.41 $128,881.79 2024-10-01
1906 OTHER New Technology - Level 51 30 20 — — $111,192.14 $185,741.41 $128,881.79 2024-10-01
1908 OTHER New Technology - Level 52 30 20 — — $123,322.14 $206,004.04 $142,941.58 2024-10-01
1907 OTHER New Technology - Level 52 30 20 — — $123,322.14 $206,004.04 $142,941.58 2024-10-01
Q2043 HCPCS Sipuleucel-t, Minimum Of 50 Million Autologous Cd54+ Cells Activated With Pap-gm… 6 3 — — $65,321.65 $147,108.87 $147,108.87 2024-10-01
001 OTHER Heart Transplant Or Implant Of Heart Assist System With Mcc 1 1 — — $152,420.78 $152,420.78 $152,420.78 2024-10-01
3 MS_DRG Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth… 58 28 — — $2,253.12 $517,646.48 $154,360.23 2024-10-01
J9029 HCPCS Intravesical Instillation, Nadofaragene Firadenovec-vncg, Per Therapeutic Dose 6 3 — — $72,000.00 $168,273.22 $168,273.22 2024-10-01
927 MS_DRG Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft 48 27 — — $2,253.12 $573,024.23 $169,108.76 2024-10-01
A9543 HCPCS Yttrium Y-90 Ibritumomab Tiuxetan, Therapeutic, Per Treatment Dose, Up To 40 Mil… 6 3 — — $74,124.43 $173,512.94 $173,512.94 2024-10-01
J7330 HCPCS Autologous Cultured Chondrocytes, Implant 5 2 — — $87,248.40 $192,914.70 $192,914.70 2024-10-01
1 MS_DRG Heart Transplant Or Implant Of Heart Assist System With Mcc 52 27 — — $2,253.12 $680,359.39 $202,566.29 2024-10-01
18 MS_DRG Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies 47 26 — — $1,854.72 $910,889.88 $268,234.70 2024-10-01
9391 OTHER Brexucabtagene Car Pos T 30 20 — — $405,266.75 $676,979.69 $469,741.01 2024-10-01
9035 OTHER Axicabtagene Ciloleucel C 30 20 — — $430,721.28 $719,500.32 $499,245.12 2024-10-01
9413 OTHER Lisocabtagene Car Pos T 30 20 — — $454,718.97 $759,587.37 $527,060.62 2024-10-01
9422 OTHER Idecabtagene Vicleucel Ca 30 20 — — $463,397.09 $774,083.77 $537,119.35 2024-10-01
9498 OTHER Ciltacabtagene Car-pos T 30 20 — — $463,868.59 $774,871.40 $537,665.86 2024-10-01
9194 OTHER Tisagenlecleucel Car-pos 30 20 — — $465,689.75 $777,913.56 $539,776.76 2024-10-01
Q2053 HCPCS Brexucabtagene Autoleucel, Up To 200 Million Autologous Anti-cd19 Car Positive V… 5 2 — — $549,504.00 $1,191,016.00 $1,191,016.00 2024-10-01
Q2041 HCPCS Axicabtagene Ciloleucel, Up To 200 Million Autologous Anti-cd19 Car Positive Via… 5 2 — — $549,504.00 $1,296,212.81 $1,296,212.81 2024-10-01
Q2054 HCPCS Lisocabtagene Maraleucel, Up To 110 Million Autologous Anti-cd19 Car-positive Vi… 5 2 — — $579,352.98 $1,315,434.06 $1,315,434.06 2024-10-01
Q2055 HCPCS Idecabtagene Vicleucel, Up To 510 Million Autologous B-cell Maturation Antigen (… 5 2 — — $591,090.52 $1,334,154.50 $1,334,154.50 2024-10-01
Q2056 HCPCS Ciltacabtagene Autoleucel, Up To 100 Million Autologous B-cell Maturation Antige… 5 2 — — $620,118.79 $1,345,370.55 $1,345,370.55 2024-10-01
Q2042 HCPCS Tisagenlecleucel, Up To 600 Million Car-positive Viable T Cells, Including Leuka… 4 1 — — $1,387,149.28 $1,387,149.28 $1,387,149.28 2024-10-01
9141 OTHER Inj Onase Abepar-xioi Tre 30 20 — — $2,101,980.32 $3,511,262.58 $2,436,386.28 2024-10-01
746 OTHER Inj, Betibeglogene Autote 31 20 — — $6,588.09 $4,362,960.00 $2,997,680.00 2024-10-01
748 OTHER Inj, Lovotibeglogene Auto 31 20 — — $7,417.36 $4,830,420.00 $3,318,860.00 2024-10-01
714 OTHER Inj Delandistrogene Mox R 31 20 — — $4,496.74 $4,888,418.85 $3,358,709.55 2024-10-01
773 OTHER Inj, Beqvez, Per Tx Dose 27 17 — — $3,172,400.00 $4,145,750.00 $3,641,050.00 2024-10-01
9138 OTHER Inj, Hemgenix, Per Tx Dos 27 17 — — $3,232,152.00 $4,223,835.00 $3,709,629.00 2024-10-01
J1413 HCPCS Injection, Delandistrogene Moxeparvovec-rokl, Per Therapeutic Dose 1 1 — — $3,840,000.00 $3,840,000.00 $3,840,000.00 2024-10-01
J1411 HCPCS Injection, Etranacogene Dezaparvovec-drlb, Per Therapeutic Dose 1 1 — — $4,200,000.00 $4,200,000.00 $4,200,000.00 2024-10-01
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