********************************************************************************************** Hospital Name - Lourdes Hospital; Hospital File Date - 12/31/2023; Version - v1; Hospital Location - 1530 Lone Oak Rd., Paducah, KY, 42003; Hospital Financial Aid Policy - Payment plans are available and/or a patient can be put on a sliding scale which would allow a percentage of assistance depending on their eligibility.; Hospital License - ********************************************************************************************** Code,Procedure_Description,NDC,rev_code,IP_Price,OP_Price,Self_pay_IP,Self_pay_OP,AETNA_BETTER_HEALTH_OF_KENTUCKY_4329001_IP,AETNA_BETTER_HEALTH_OF_KENTUCKY_4329001_OP,AETNA_MEDICARE_ADVANTAGE_PPO_103002_IP,AETNA_MEDICARE_ADVANTAGE_PPO_103002_OP,AETNA_NAP_CHOICE_POS_II_3004025_IP,AETNA_NAP_CHOICE_POS_II_3004025_OP,ANTHEM_BCBS_BSMH_EMPLOYEES_OH_KY_3123085_IP,ANTHEM_BCBS_BSMH_EMPLOYEES_OH_KY_3123085_OP,ANTHEM_BCBS_FEDERAL_3123012_IP,ANTHEM_BCBS_FEDERAL_3123012_OP,ANTHEM_KY_MEDICAID_4205001_IP,ANTHEM_KY_MEDICAID_4205001_OP,ANTHEM_MEDIBLUE_DUAL_ADVANTAGE_1006007_IP,ANTHEM_MEDIBLUE_DUAL_ADVANTAGE_1006007_OP,ANTHEM_MEDIBLUE_ESSENTIAL_PLUS_1005001_IP,ANTHEM_MEDIBLUE_ESSENTIAL_PLUS_1005001_OP,ANTHEM_PATHWAY_X_HMO_ACA_3123027_IP,ANTHEM_PATHWAY_X_HMO_ACA_3123027_OP,BCBS_KY_3123005_IP,BCBS_KY_3123005_OP,BCBS_OH_PPO_3123016_IP,BCBS_OH_PPO_3123016_OP,BCBS_OUT_OF_STATE_3123021_IP,BCBS_OUT_OF_STATE_3123021_OP,CIGNA_3020001_IP,CIGNA_3020001_OP,HUMANA_CHOICE_PPO_MEDICARE_101003_IP,HUMANA_CHOICE_PPO_MEDICARE_101003_OP,HUMANA_MEDICAID_KY_4198001_IP,HUMANA_MEDICAID_KY_4198001_OP,UMR_3113004_IP,UMR_3113004_OP,UNITED_HEALTHCARE_CHOICE_PLU_3112014_IP,UNITED_HEALTHCARE_CHOICE_PLU_3112014_OP,UNITED_HEALTHCARE_COMMUNITY_PLAN_OF_KY_3519005_IP,UNITED_HEALTHCARE_COMMUNITY_PLAN_OF_KY_3519005_OP,UNITEDHEALTHCARE_DUAL_COMPLETE_1011006_IP,UNITEDHEALTHCARE_DUAL_COMPLETE_1011006_OP,WELLCARE_MEDICARE_1009002_IP,WELLCARE_MEDICARE_1009002_OP,WELLCARE_OF_KENTUCKY_2009003_IP,WELLCARE_OF_KENTUCKY_2009003_OP,Min_IP,Max_IP,Min_OP,Max_OP,Notes,Billing_Class CPT 0001A,HC Imm Admin Sarscov2 30mcg/0.3ml Dil Recon 1st Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,39.22,N/A,70.25,N/A,41.48,N/A,90.69,N/A,17.08,N/A,37.49,N/A,37.49,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,70.25,N/A,37.49,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,37.49,N/A,39.22,N/A,122.00,73.20,73.20,17.08,122.00,,Hospital CPT 0004A,HC Imm Admn Sarscov2 30mcg/0.3ml Bst Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,39.22,N/A,63.34,N/A,37.40,N/A,90.69,N/A,15.40,N/A,37.49,N/A,37.49,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,63.34,N/A,37.49,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,37.49,N/A,39.22,N/A,110.00,66.00,66.00,15.40,110.00,,Hospital 00100,PR Anesthesia Salivary Glands With Biopsy,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,40827.87,N/A,24496.72,N/A,5715.90,N/A,5043.96,N/A,23507.36,N/A,13881.47,N/A,11681.54,N/A,5715.90,N/A,4821.94,N/A,4821.94,N/A,7271.97,N/A,11681.54,N/A,11681.54,N/A,11681.54,N/A,23507.38,N/A,4821.94,N/A,5715.90,N/A,5963.00,N/A,5963.00,N/A,5715.90,N/A,4821.94,N/A,5043.96,N/A,1388.81,N/A,N/A,1388.81,24496.72,,Hospital 00102,PR Anesthesia Cleft Lip Involving Plastic Repair,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,76507.40,N/A,45904.44,N/A,10711.03,N/A,5129.50,N/A,44050.84,N/A,26010.21,N/A,11709.46,N/A,10711.03,N/A,4821.94,N/A,4821.94,N/A,7289.36,N/A,11709.46,N/A,11709.46,N/A,11709.46,N/A,44050.82,N/A,4821.94,N/A,10711.03,N/A,8944.50,N/A,8944.50,N/A,10711.03,N/A,4821.94,N/A,5129.50,N/A,2215.13,N/A,N/A,2215.13,45904.44,,Hospital 00124,Anesthesia for Ear Exam,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,8435.90,N/A,5061.54,N/A,1181.02,N/A,1354.15,N/A,4856.71,N/A,2868.21,N/A,3279.11,N/A,1181.02,N/A,1354.15,N/A,1354.15,N/A,2041.31,N/A,3279.11,N/A,3279.11,N/A,3279.11,N/A,4856.72,N/A,1354.15,N/A,1181.02,N/A,1871.00,N/A,1871.00,N/A,1181.02,N/A,1354.15,N/A,1354.15,N/A,1489.57,N/A,N/A,1181.02,5061.54,,Hospital 00144,"Anesth,Corneal Transplant",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,49298.50,N/A,29579.10,N/A,6902.84,N/A,3577.00,N/A,28381.85,N/A,16761.50,N/A,13266.78,N/A,6902.84,N/A,3608.17,N/A,3608.17,N/A,8253.97,N/A,13266.78,N/A,13266.78,N/A,13266.78,N/A,28381.84,N/A,3608.17,N/A,6902.84,N/A,5963.00,N/A,5963.00,N/A,6902.84,N/A,3608.17,N/A,3577.00,N/A,1241.67,N/A,N/A,1241.67,29579.10,,Hospital 00148,Anesthesia for Eye Exam,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,5585.00,N/A,3351.00,N/A,781.90,N/A,1899.46,N/A,3214.85,N/A,1898.90,N/A,4627.53,N/A,781.90,N/A,1909.23,N/A,1909.23,N/A,2880.73,N/A,4627.53,N/A,4627.53,N/A,4627.53,N/A,3214.85,N/A,1909.23,N/A,781.90,N/A,3397.00,N/A,3397.00,N/A,781.90,N/A,1909.23,N/A,1899.46,N/A,145.29,N/A,N/A,145.29,4627.53,,Hospital 00170,"Anesth,Procedure on Mouth",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,31117.17,11532.50,18670.30,6919.50,6443.15,1614.55,7917.20,4821.94,14520.17,6638.92,10579.84,3921.05,14659.07,11532.50,6641.68,1614.55,80366.00,4821.94,80366.00,4821.94,9124.93,7268.13,14659.07,11532.50,14659.07,11532.50,14659.07,11532.50,14520.17,6638.92,7887.55,4821.94,6641.68,1614.55,17440.63,3397.00,17440.63,3397.00,1741.14,1614.55,3010.42,4821.94,7917.20,4821.94,7106.60,5304.13,1741.14,80366.00,1614.55,11532.50,,Hospital 00192,"Anesth,Radical Facial Bone Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,89588.93,N/A,53753.36,N/A,12525.32,N/A,5043.96,N/A,51455.08,N/A,30341.89,N/A,11736.46,N/A,12525.32,N/A,4821.94,N/A,4821.94,N/A,7306.46,N/A,11736.46,N/A,11736.46,N/A,11736.46,N/A,51455.12,N/A,4821.94,N/A,12525.32,N/A,5963.00,N/A,5963.00,N/A,12525.32,N/A,4821.94,N/A,5043.96,N/A,1534.64,N/A,N/A,1534.64,53753.36,,Hospital 00211,"Anesth, Intracranial Hematoma Evacuation",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,36692.37,N/A,22015.42,N/A,5136.93,N/A,2052.96,N/A,20914.49,N/A,12475.39,N/A,29428.51,N/A,5136.93,N/A,2052.96,N/A,2052.96,N/A,18319.27,N/A,29428.51,N/A,29428.51,N/A,29428.51,N/A,20914.49,N/A,2052.96,N/A,5136.93,N/A,2464.50,N/A,2464.50,N/A,5136.93,N/A,2052.96,N/A,2052.96,N/A,2258.26,N/A,N/A,2052.96,29428.51,,Hospital 00215,"Anesth, Cranioplasty",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,91225.33,N/A,54735.20,N/A,12633.71,N/A,6281.32,N/A,51699.62,N/A,31014.58,N/A,7972.82,N/A,12633.71,N/A,6281.19,N/A,6281.19,N/A,5216.41,N/A,7972.82,N/A,7972.82,N/A,7972.82,N/A,51699.66,N/A,6301.31,N/A,12633.71,N/A,1643.00,N/A,1643.00,N/A,12633.71,N/A,6281.19,N/A,6281.32,N/A,1594.47,N/A,N/A,1594.47,54735.20,,Hospital CPT 0022A,HC Imm Admin Sarscov2 5x10/.5ml 2nd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,122.00,N/A,70.25,N/A,41.48,N/A,17.08,N/A,17.08,N/A,122.00,N/A,122.00,N/A,10.61,N/A,17.08,N/A,17.08,N/A,17.08,N/A,70.25,N/A,122.00,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,122.00,N/A,122.00,N/A,122.00,73.20,73.20,10.61,122.00,,Hospital 00326,PR Anesthesia Larynx & Trachea Children <1 Year,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,31560.37,N/A,18936.22,N/A,4418.45,N/A,5943.56,N/A,18170.78,N/A,10730.52,N/A,13524.39,N/A,4418.45,N/A,5587.18,N/A,5587.18,N/A,8419.20,N/A,13524.39,N/A,13524.39,N/A,13524.39,N/A,18170.78,N/A,5587.18,N/A,4418.45,N/A,5095.50,N/A,5095.50,N/A,4418.45,N/A,5587.18,N/A,5943.56,N/A,579.95,N/A,N/A,579.95,18936.22,,Hospital 0034U,HC So Tpmt Nudt15 Genes,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,491168.27,6735.00,294700.96,4041.00,N/A,1036.08,N/A,563.97,N/A,3878.01,N/A,2289.90,N/A,1877.91,N/A,1036.08,N/A,1052.30,N/A,1052.30,N/A,1169.03,N/A,1877.91,N/A,1877.91,N/A,1877.91,N/A,3878.01,N/A,1052.30,N/A,1036.08,N/A,1431.00,N/A,1431.00,N/A,1036.08,N/A,1052.30,N/A,563.97,N/A,620.37,294700.96,294700.96,563.97,4041.00,,Hospital 00472,"Anesth,Chest Wall Repair",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,60490.10,N/A,36294.06,N/A,8054.74,N/A,8700.33,N/A,28205.12,N/A,20566.63,N/A,16969.95,N/A,8302.92,N/A,277066.00,N/A,277066.00,N/A,10563.40,N/A,16969.95,N/A,16969.95,N/A,16969.95,N/A,28205.12,N/A,8670.68,N/A,8302.92,N/A,20190.01,N/A,20190.01,N/A,2585.29,N/A,8670.68,N/A,8700.33,N/A,8884.13,N/A,2585.29,277066.00,N/A,N/A,,Hospital 00528,"Anesth,Mediastinoscopy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,50676.27,30182.40,30405.76,18109.44,7562.36,4225.54,4832.50,4923.50,18987.64,17376.95,N/A,10262.02,17205.41,11425.09,7795.37,4225.54,9211.52,4706.78,9211.52,4706.78,10709.97,7112.35,17205.41,11425.09,17205.41,11425.09,17205.41,11425.09,18987.64,17376.96,9211.52,4706.78,7795.37,4225.54,20470.14,5963.00,20470.14,5963.00,N/A,4225.54,9211.52,4706.78,9270.82,4923.50,8341.04,989.60,4832.50,30405.76,989.60,18109.44,,Hospital 00530,"Anesth,Pacemaker Insertion",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,47216.82,57588.93,28330.09,34553.36,10141.65,7994.38,12262.69,9428.31,34603.03,32848.75,16053.71,19580.23,23970.97,22623.69,10454.13,7994.38,12262.69,9327.29,12262.69,9327.29,14921.73,14083.69,23970.97,22623.69,23970.97,22623.69,23970.97,22623.69,34603.03,32848.75,12262.69,9327.29,10454.13,7994.38,27451.88,12375.50,27451.88,12375.50,N/A,7994.38,12262.69,9327.29,12262.69,9428.31,11185.92,543.16,10141.65,34603.03,543.16,34553.36,,Hospital 00534,"Anesth,Cardioverter/Defib",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,154345.03,156768.30,92607.02,94060.98,10193.39,21899.93,12323.90,29279.92,85074.99,89034.32,51537.55,53301.22,70209.79,70122.77,10507.47,21899.93,562.00,28966.21,562.00,28966.21,43707.08,43652.78,70209.79,70122.77,70209.79,70122.77,70209.79,70122.77,85074.99,89034.32,12323.90,28966.21,10507.47,21899.93,27591.95,29766.00,27591.95,29766.00,4900.75,21899.93,12323.90,28966.21,12323.90,29279.92,11242.99,474.29,562.00,92607.02,474.29,94060.98,,Hospital 00539,"Anesth,Tracheobronchial Reconstruct",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,269968.82,N/A,161981.29,N/A,N/A,N/A,13990.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13990.82,N/A,13990.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13990.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13990.82,N/A,13990.82,N/A,N/A,N/A,13990.82,161981.29,N/A,N/A,,Hospital CPT 0053A,HC IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 3rd,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,110.00,N/A,63.34,N/A,37.40,N/A,15.40,N/A,15.40,N/A,110.00,N/A,110.00,N/A,9.57,N/A,15.40,N/A,15.40,N/A,15.40,N/A,63.34,N/A,110.00,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,110.00,N/A,110.00,N/A,110.00,66.00,66.00,9.57,110.00,,Hospital 0054T,Bone Surgery Using Computer,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62618.60,N/A,37571.16,N/A,8699.56,N/A,11951.69,N/A,35701.10,N/A,21290.34,N/A,30187.53,N/A,8699.56,N/A,11951.69,N/A,11951.69,N/A,19013.17,N/A,30187.53,N/A,30187.53,N/A,30187.53,N/A,N/A,N/A,11977.96,N/A,9047.48,N/A,N/A,N/A,11923.50,N/A,8699.56,N/A,11951.69,N/A,11951.69,N/A,13146.85,N/A,N/A,8699.56,37571.16,,Hospital 0055T,Bone Surgery Using Computer,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,70473.57,76024.67,42284.14,45614.80,10199.26,10637.62,12330.85,11831.30,37501.00,43353.51,23961.02,25848.37,23204.73,29169.93,10513.52,10637.62,562.00,11933.08,562.00,11933.08,14444.40,18354.85,23204.73,29169.93,23204.73,29169.93,23204.73,29169.93,37501.00,43353.52,12330.85,11956.02,10513.52,10637.62,27607.84,12507.25,27607.84,12507.25,N/A,10637.62,12330.85,11933.08,12330.85,11831.30,11249.46,1778.88,562.00,42284.14,1778.88,45614.80,,Hospital 00566,"Anesth,Direct Cabg W/O Pump Oxygenator",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,219255.20,N/A,131553.12,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76596.93,131553.12,N/A,N/A,,Hospital 00567,"Anesth, Direct Cabg W Pump Oxygenator",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,231765.73,N/A,139059.44,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9658.67,139059.44,N/A,N/A,,Hospital 00640,"Anesth,Closed Manipulation, Spine C/T/L",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,16473.10,N/A,9883.86,N/A,2292.82,N/A,1368.82,N/A,6817.29,N/A,5600.86,N/A,3291.70,N/A,2292.82,N/A,1354.15,N/A,1354.15,N/A,2049.15,N/A,3291.70,N/A,3291.70,N/A,3291.70,N/A,6787.06,N/A,1354.15,N/A,2292.82,N/A,1871.00,N/A,1871.00,N/A,2292.82,N/A,1354.15,N/A,1368.82,N/A,441.07,N/A,N/A,441.07,9883.86,,Hospital 0064U,HC Antibody Treponema Pallidum Total & Rpr Ia Qual,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,34199.02,1581.00,20519.41,948.60,6943.01,203.01,4210.67,208.58,16315.16,910.33,11627.67,537.54,16267.45,167.44,7156.93,203.01,2810.00,208.58,2810.00,208.58,10126.97,155.61,16267.45,167.44,16267.45,167.44,16267.45,167.44,16315.16,910.33,4210.67,208.58,7156.93,203.01,18793.66,203.01,18793.66,203.01,6085.60,203.01,8478.86,208.58,4210.67,208.58,6707.72,223.32,2810.00,20519.41,155.61,948.60,,Hospital CPT 0072A,HC Imm Admn Sarscov2 10mcg/0.2ml Tris-Sucrose 2nd,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,110.00,N/A,63.34,N/A,37.40,N/A,15.40,N/A,15.40,N/A,110.00,N/A,110.00,N/A,9.57,N/A,15.40,N/A,15.40,N/A,15.40,N/A,63.34,N/A,110.00,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,110.00,N/A,110.00,N/A,110.00,66.00,66.00,9.57,110.00,,Hospital 00790,"Anesth,Surg Upper Abdomen",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,48314.77,30554.52,28988.86,18332.71,6961.68,4267.93,8530.60,4706.78,15688.71,7923.00,16427.03,10388.53,15838.79,11410.17,7176.18,4267.93,8500.95,4706.78,8500.95,4706.78,9859.28,7103.06,15838.79,11410.17,15838.79,11410.17,15838.79,11410.17,15688.71,7923.00,8500.95,4706.78,7176.18,4267.93,18844.20,7897.00,18844.20,7897.00,5177.46,4267.93,8500.95,4706.78,8530.60,4706.78,7678.51,5177.46,5177.46,28988.86,4267.93,18332.71,,Hospital 00810,"Anesth,Intestine,Scope,Low",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,24242.60,N/A,14545.56,N/A,3381.08,N/A,4265.28,N/A,7619.54,N/A,8242.48,N/A,7692.43,N/A,3485.26,N/A,4265.28,N/A,4265.28,N/A,4788.36,N/A,7692.43,N/A,7692.43,N/A,7692.43,N/A,7619.54,N/A,4265.28,N/A,3485.26,N/A,9152.07,N/A,9152.07,N/A,N/A,N/A,4265.28,N/A,4265.28,N/A,3729.23,N/A,3381.08,14545.56,N/A,N/A,,Hospital CPT 0081A,HC Imm Admn Sarscov2 3 Mcg/0.2 Ml 1st Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital 00844,"Anesth,Abd-Perineal Resection",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,91784.58,N/A,55070.75,N/A,670.82,N/A,13367.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,670.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,670.82,N/A,30920.37,N/A,30920.37,N/A,670.82,N/A,N/A,N/A,N/A,N/A,670.82,N/A,670.82,55070.75,N/A,N/A,,Hospital 00872,"Anesth,Kid Stone Destruct+Water Bath",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,20932.20,N/A,12559.32,N/A,2930.51,N/A,2971.66,N/A,12051.09,N/A,7116.95,N/A,7018.14,N/A,2930.51,N/A,2894.35,N/A,2894.35,N/A,4368.92,N/A,7018.14,N/A,7018.14,N/A,7018.14,N/A,12051.09,N/A,2894.35,N/A,2930.51,N/A,11845.50,N/A,11845.50,N/A,2930.51,N/A,2894.35,N/A,2971.66,N/A,599.95,N/A,N/A,599.95,12559.32,,Hospital 00880,"Anesth,Major Low Abd Vessel Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,261025.43,126911.92,156615.26,76147.15,30201.68,17749.19,20493.69,10201.42,143877.22,72785.20,88748.65,43150.05,90889.06,23233.43,26404.00,17749.19,562.00,9589.98,562.00,9589.98,56590.32,14463.26,90889.06,23233.43,90889.06,23233.43,90889.06,23233.43,143877.22,72785.20,20493.69,9589.98,26404.00,17749.19,123726.06,15608.50,123726.06,15608.50,23548.49,17749.19,20493.69,9589.98,20493.69,10201.42,28252.28,978.21,562.00,156615.26,978.21,76147.15,,Hospital 00906,"Anesth,Removal of Vulva",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,21069.50,N/A,12641.70,N/A,2949.74,N/A,2606.39,N/A,12128.82,N/A,7163.64,N/A,6194.53,N/A,2949.74,N/A,2553.29,N/A,2553.29,N/A,3856.21,N/A,6194.53,N/A,6194.53,N/A,6194.53,N/A,12128.82,N/A,2553.29,N/A,2949.74,N/A,3397.00,N/A,3397.00,N/A,2949.74,N/A,2553.29,N/A,2606.39,N/A,680.94,N/A,N/A,680.94,12641.70,,Hospital 00912,"Anesth,Xurethral Bladder Tumor Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,47863.22,20916.03,28717.93,12549.62,5750.19,2928.25,4596.79,2894.35,13404.55,12035.38,16273.50,7111.46,13082.47,7168.06,5927.36,2928.25,1124.00,2894.35,1124.00,2894.35,8143.53,4462.24,13082.47,7168.06,13082.47,7168.06,13082.47,7168.06,13404.55,12035.39,7067.82,2894.35,5927.36,2928.25,15564.88,3397.00,15564.88,3397.00,N/A,2928.25,7067.82,2894.35,7067.82,2894.35,6342.28,3183.79,1124.00,28717.93,2894.35,12549.62,,Hospital 00920,"Anesth,Male Genitalia Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,47939.20,22443.00,28763.52,13465.80,6623.46,3142.03,8160.16,2894.35,14926.52,12919.32,16299.33,7630.62,15069.30,7045.08,6827.55,3142.03,100036.00,2894.35,100036.00,2894.35,9380.29,4385.69,15069.30,7045.08,15069.30,7045.08,15069.30,7045.08,14926.52,12919.31,8100.86,2894.35,6827.55,3142.03,17928.70,3397.00,17928.70,3397.00,2964.74,3142.03,8100.86,2894.35,8160.16,2894.35,7305.47,3183.79,2964.74,100036.00,2894.35,13465.80,,Hospital 00926,"Anesth,Radical Remv Testis,Inguinal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,28035.00,N/A,16821.00,N/A,3924.89,N/A,3345.78,N/A,16139.17,N/A,9531.89,N/A,7790.43,N/A,3924.89,N/A,3198.50,N/A,3198.50,N/A,4849.70,N/A,7790.43,N/A,7790.43,N/A,7790.43,N/A,16139.19,N/A,3198.50,N/A,3924.89,N/A,4562.00,N/A,4562.00,N/A,3924.89,N/A,3198.50,N/A,3345.78,N/A,1185.00,N/A,N/A,1185.00,16821.00,,Hospital 00938,"Anesth,Insert Penis Prosthesis",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,88626.07,105083.83,53175.64,63050.30,7689.32,14711.74,9361.72,18213.89,43303.20,59784.17,30132.87,35610.19,17494.27,42170.64,7926.24,14711.74,1686.00,17412.16,1686.00,17412.16,10889.78,26255.65,17494.27,42170.64,17494.27,42170.64,17494.27,42170.64,43303.20,59784.17,9361.72,17412.16,7926.24,14711.74,20813.82,19618.50,20813.82,19618.50,N/A,14711.74,9361.72,17412.16,9361.72,18213.89,8481.08,1673.97,1686.00,53175.64,1673.97,63050.30,,Hospital CPT 0094A,HC Adm Sarscov2 50 Mcg/0.5 Ml Booster,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital 0097U,HC GI Pthgn Mult Rev Trans & Amp Prb Tech 22 Trgt,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,89030.77,N/A,53418.46,N/A,N/A,N/A,9884.16,N/A,18450.35,N/A,30270.46,N/A,N/A,N/A,8174.80,N/A,4496.00,N/A,9977.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18450.35,N/A,9646.96,N/A,8174.80,N/A,21466.50,N/A,21466.50,N/A,N/A,N/A,9646.96,N/A,9646.96,N/A,8747.03,N/A,4496.00,53418.46,N/A,N/A,,Hospital 0100U,HC Respirpthgn Mult Rev Trans & Amp Prb Tech 21 Trgt,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,170277.30,N/A,102166.38,N/A,N/A,N/A,13053.99,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13053.99,N/A,13053.99,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13053.99,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12668.10,N/A,13053.99,N/A,N/A,N/A,12668.10,102166.38,N/A,N/A,,Hospital CPT 0111A,HC Imm Admn Sarscov2 25 Mcg/0.25 Ml 1st Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital 01150,"Anesth,Radical Pelvic Tumor Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,42335.90,N/A,25401.54,N/A,5918.19,N/A,2811.81,N/A,24345.66,N/A,14394.22,N/A,15187.21,N/A,5918.19,N/A,2688.04,N/A,2688.04,N/A,9454.31,N/A,15187.21,N/A,15187.21,N/A,15187.21,N/A,24345.68,N/A,2688.04,N/A,5918.19,N/A,5383.50,N/A,5383.50,N/A,5918.19,N/A,2688.04,N/A,2811.81,N/A,3093.11,N/A,N/A,2688.04,25401.54,,Hospital 01170,"Anesth,Pubis,Sacroiliac Closed Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,52599.40,N/A,31559.64,N/A,7359.25,N/A,2412.76,N/A,30273.08,N/A,17883.80,N/A,5705.15,N/A,7359.25,N/A,2332.78,N/A,2332.78,N/A,3551.56,N/A,5705.15,N/A,5705.15,N/A,5705.15,N/A,30273.08,N/A,2332.78,N/A,7359.25,N/A,3397.00,N/A,3397.00,N/A,7359.25,N/A,2332.78,N/A,2412.76,N/A,451.73,N/A,N/A,451.73,31559.64,,Hospital 01215,"Anesth,Revise Total Hip Arthroplasty",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,100735.18,154062.13,60441.11,92437.28,15935.58,21537.88,19264.86,7568.25,39209.64,88030.79,N/A,52381.13,N/A,31342.12,16426.58,21537.88,8436.67,7565.76,8436.67,7565.76,N/A,19993.21,N/A,31342.12,N/A,31342.12,N/A,31342.12,39209.64,88030.80,8436.67,7576.58,16426.58,21537.88,43135.17,12375.50,43135.17,12375.50,N/A,21537.88,19116.61,7565.76,19264.86,7568.25,17576.44,2891.46,8436.67,60441.11,2891.46,92437.28,,Hospital 01232,"Anesth,Amputation of Femur",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,321889.82,N/A,193133.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,193133.89,193133.89,N/A,N/A,,Hospital 01320,"Anesth,Knee Area Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,44533.10,31958.83,26719.86,19175.30,7332.44,4466.74,6398.45,6248.31,16524.24,18398.01,15141.25,10866.00,16682.31,14513.25,7558.36,4466.74,97788.00,5973.28,97788.00,5973.28,10384.35,9034.78,16682.31,14513.25,16682.31,14513.25,16682.31,14513.25,16524.24,18398.02,8939.53,5973.28,7558.36,4466.74,19847.78,5277.50,19847.78,5277.50,N/A,4466.74,8939.53,5973.28,8969.18,6248.31,8087.45,718.62,6398.45,97788.00,718.62,19175.30,,Hospital 01380,"Anesth,Knee Joint,Closed Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,9835.70,N/A,5901.42,N/A,1363.43,N/A,372.22,N/A,5658.96,N/A,3344.14,N/A,1749.05,N/A,1363.43,N/A,372.22,N/A,372.22,N/A,1087.96,N/A,1749.05,N/A,1749.05,N/A,1749.05,N/A,5658.98,N/A,372.22,N/A,1363.43,N/A,2806.50,N/A,2806.50,N/A,1363.43,N/A,372.22,N/A,372.22,N/A,409.44,N/A,N/A,372.22,5901.42,,Hospital 01392,"Anesth,Upper Leg,Open Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,66769.00,45542.02,40061.40,27325.21,8054.74,6367.01,9912.59,6248.31,18905.25,26130.24,22701.46,15484.27,18325.66,14610.93,8302.92,6367.01,177030.00,5973.28,177030.00,5973.28,11407.29,9128.64,18325.66,14610.93,18325.66,14610.93,18325.66,14610.93,18905.25,26130.25,9793.99,5973.28,8302.92,6367.01,21802.96,7897.00,21802.96,7897.00,N/A,6367.01,9793.99,5973.28,9912.59,6248.31,8884.13,824.38,8054.74,177030.00,824.38,27325.21,,Hospital 01484,"Anesth,Lower Leg Bone Revision",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,74385.50,N/A,44631.30,N/A,10413.96,N/A,6248.31,N/A,42518.18,N/A,25291.07,N/A,14546.00,N/A,10413.96,N/A,5973.28,N/A,5973.28,N/A,9081.88,N/A,14546.00,N/A,14546.00,N/A,14546.00,N/A,42518.19,N/A,5973.28,N/A,10413.96,N/A,6226.50,N/A,6226.50,N/A,10413.96,N/A,5973.28,N/A,6248.31,N/A,796.82,N/A,N/A,796.82,44631.30,,Hospital 0151U,Nfct Ds Bct/Vir Respir Trc Nfctj Dna/Rna 33 Trgt,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 01520,"Anesth,Lower Leg Vein Surg,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,37594.88,N/A,22556.93,N/A,5263.58,N/A,2813.99,N/A,21645.25,N/A,12782.24,N/A,6539.60,N/A,5263.58,N/A,2690.13,N/A,2690.13,N/A,4071.03,N/A,6539.60,N/A,6539.60,N/A,6539.60,N/A,21645.26,N/A,2690.13,N/A,5263.58,N/A,6843.00,N/A,6843.00,N/A,5263.58,N/A,2690.13,N/A,2813.99,N/A,357.79,N/A,N/A,357.79,22556.93,,Hospital 0152U,HC So Nfct Ds Dna Untrgt Ngnrj Seq,N/A,0309 - LABORATORY - OTHER LABORATORY,124143.03,5575.00,74485.82,3345.00,33091.94,3535.16,21742.91,2211.53,N/A,3210.08,26407.69,1895.50,26407.69,2211.53,33091.94,3535.16,21742.91,2211.53,21742.91,2211.53,26407.69,1376.67,26407.69,2211.53,26407.69,2211.53,26407.69,2211.53,N/A,3210.08,21742.91,2211.53,33091.94,824.00,N/A,2205.96,N/A,2205.96,33091.94,2471.96,21742.91,2211.53,21742.91,2211.53,33091.94,87.75,21742.91,74485.82,87.75,3535.16,,Hospital 01620,"Anesth,Shoulder,Closed Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,25250.50,10365.60,15150.30,6219.36,4594.18,1441.48,5700.32,1295.43,10353.35,5964.29,8585.17,3524.30,10452.38,3185.59,4735.73,1441.48,562.00,1295.43,562.00,1295.43,6506.37,1983.09,10452.38,3185.59,10452.38,3185.59,10452.38,3185.59,10353.35,5964.29,5700.32,1295.43,4735.73,1441.48,12435.73,2586.50,12435.73,2586.50,2426.03,1441.48,5700.32,1295.43,5700.32,1295.43,5067.23,1424.97,562.00,15150.30,1295.43,6219.36,,Hospital 01650,"Anesth,Shoulder Artery Surg,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,37239.20,N/A,22343.52,N/A,5146.83,N/A,4691.68,N/A,21341.31,N/A,12661.32,N/A,11335.32,N/A,5146.83,N/A,4641.41,N/A,4641.41,N/A,7056.44,N/A,11335.32,N/A,11335.32,N/A,11335.32,N/A,21341.32,N/A,4641.41,N/A,5146.83,N/A,8612.50,N/A,8612.50,N/A,5146.83,N/A,4641.41,N/A,4691.68,N/A,1072.49,N/A,N/A,1072.49,22343.52,,Hospital 01714,"Anesth,Upperarm Tendon Revisn Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,42846.85,N/A,25708.11,N/A,5998.57,N/A,6354.28,N/A,24646.72,N/A,14567.93,N/A,14504.37,N/A,5998.57,N/A,5973.28,N/A,5973.28,N/A,9032.71,N/A,14504.37,N/A,14504.37,N/A,14504.37,N/A,24646.72,N/A,5973.28,N/A,5998.57,N/A,6678.50,N/A,6678.50,N/A,5998.57,N/A,5973.28,N/A,6354.28,N/A,881.33,N/A,N/A,881.33,25708.11,,Hospital 01716,"Anesth,Biceps Tendon Repair",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,25273.80,N/A,15164.28,N/A,3530.49,N/A,5973.28,N/A,11735.00,N/A,8593.09,N/A,14581.07,N/A,3538.33,N/A,5973.28,N/A,5973.28,N/A,9076.99,N/A,14581.07,N/A,14581.07,N/A,14581.07,N/A,11735.00,N/A,5973.28,N/A,3538.33,N/A,8601.75,N/A,8601.75,N/A,3538.33,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,3530.49,15164.28,,Hospital 01756,"Anesth,Radical Humerus Surg",N/A,N/A,N/A,90594.90,N/A,54356.94,N/A,12683.29,N/A,6354.28,N/A,52116.19,N/A,30802.27,N/A,14960.15,N/A,12683.29,N/A,5973.28,N/A,5973.28,N/A,9312.97,N/A,14960.15,N/A,14960.15,N/A,14960.15,N/A,52116.19,N/A,5973.28,N/A,12683.29,N/A,5277.50,N/A,5277.50,N/A,12683.29,N/A,5973.28,N/A,6354.28,N/A,1323.56,N/A,N/A,1323.56,54356.94,,Hospital 01758,"Anesth,Humeral Lesion Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,17967.50,N/A,10780.50,N/A,2508.96,N/A,2440.19,N/A,10343.63,N/A,6108.95,N/A,5666.90,N/A,2508.96,N/A,2332.78,N/A,2332.78,N/A,3527.76,N/A,5666.90,N/A,5666.90,N/A,5666.90,N/A,10343.64,N/A,2332.78,N/A,2508.96,N/A,3397.00,N/A,3397.00,N/A,2508.96,N/A,2332.78,N/A,2440.19,N/A,1174.17,N/A,N/A,1174.17,10780.50,,Hospital 01770,"Anesth,Upperarm Artery Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,28286.40,N/A,16971.84,N/A,3942.26,N/A,2790.22,N/A,16284.61,N/A,9617.38,N/A,6536.47,N/A,3942.26,N/A,2697.99,N/A,2697.99,N/A,4069.08,N/A,6536.47,N/A,6536.47,N/A,6536.47,N/A,16284.61,N/A,2697.99,N/A,3942.26,N/A,4562.00,N/A,4562.00,N/A,3942.26,N/A,2697.99,N/A,2790.22,N/A,410.52,N/A,N/A,410.52,16971.84,,Hospital 01832,"Anesth,Wrist Replacement",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,99858.93,N/A,59915.36,N/A,13980.25,N/A,19753.77,N/A,56709.47,N/A,33952.04,N/A,48523.98,N/A,13980.25,N/A,19924.58,N/A,19924.58,N/A,30403.13,N/A,48523.98,N/A,48523.98,N/A,48523.98,N/A,53825.84,N/A,19947.52,N/A,13980.25,N/A,11660.00,N/A,11660.00,N/A,13980.25,N/A,19924.58,N/A,19753.77,N/A,1532.69,N/A,N/A,1532.69,59915.36,,Hospital 01842,"Anesth,Lower Arm Embolectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,65568.30,N/A,39340.98,N/A,10970.65,N/A,13243.35,N/A,24723.24,N/A,22293.22,N/A,24959.74,N/A,11308.67,N/A,13243.35,N/A,13243.35,N/A,15536.86,N/A,24959.74,N/A,24959.74,N/A,24959.74,N/A,24723.24,N/A,13243.35,N/A,11308.67,N/A,29695.86,N/A,29695.86,N/A,2921.16,N/A,13243.35,N/A,13243.35,N/A,12100.28,N/A,2921.16,39340.98,N/A,N/A,,Hospital 01844,"Anesth,Lower Arm,Vasc Shunt Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,68454.78,29045.48,41072.87,17427.29,17655.99,4048.72,21151.77,4641.41,42683.46,16720.60,23274.63,9875.46,41732.01,11308.16,18200.01,4048.72,562.00,4641.41,562.00,4641.41,25977.84,7039.54,41732.01,11308.16,41732.01,11308.16,41732.01,11308.16,42683.46,16720.60,21151.77,4641.41,18200.01,4048.72,47792.07,7897.00,47792.07,7897.00,N/A,4048.72,21151.77,4641.41,21151.77,4641.41,19474.01,5105.55,562.00,47792.07,4048.72,17427.29,,Hospital 01930,"Anesth,Inter Rad,Venous/Lymph Sys,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,43550.68,N/A,26130.41,N/A,6024.43,N/A,1343.59,N/A,25065.06,N/A,14807.24,N/A,3384.11,N/A,6024.43,N/A,1343.59,N/A,1343.59,N/A,2106.58,N/A,3384.11,N/A,3384.11,N/A,3384.11,N/A,25065.07,N/A,1343.59,N/A,6024.43,N/A,790.50,N/A,790.50,N/A,6024.43,N/A,1343.59,N/A,1343.59,N/A,1477.95,N/A,N/A,790.50,26130.41,,Hospital 01933,"Anesth,Inter Rad,Intracranial",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,22304.92,N/A,13382.95,N/A,3111.88,N/A,9586.05,N/A,12836.79,N/A,7583.66,N/A,22304.92,N/A,3111.88,N/A,9586.05,N/A,9586.05,N/A,14470.85,N/A,22304.92,N/A,22304.92,N/A,22304.92,N/A,12836.79,N/A,9586.05,N/A,3111.88,N/A,11660.00,N/A,11660.00,N/A,3111.88,N/A,9586.05,N/A,9586.05,N/A,10544.65,N/A,N/A,3111.88,22304.92,,Hospital 01938,Anes Perq Img Njx Drg/Aspir Px Spi/Sp Lmbr/Sac,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,8631.90,N/A,5179.14,N/A,1208.47,N/A,765.62,N/A,4968.68,N/A,2934.85,N/A,1883.99,N/A,1208.47,N/A,769.55,N/A,769.55,N/A,1172.82,N/A,1883.99,N/A,1883.99,N/A,1883.99,N/A,4968.68,N/A,769.55,N/A,1208.47,N/A,1694.50,N/A,1694.50,N/A,1208.47,N/A,769.55,N/A,765.62,N/A,171.79,N/A,N/A,171.79,5179.14,,Hospital 01941,Anes Perq Img Neuromd/Ntrvrt Px Spi/Sp Crv/Thrc,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,92364.07,38045.70,55418.44,22827.42,12530.49,5326.40,14584.00,6168.00,28549.09,21779.68,31403.78,12935.54,28623.90,14427.93,12916.58,5326.40,246156.00,5963.54,246156.00,5963.54,17817.71,8981.65,28623.90,14427.93,28623.90,14427.93,28623.90,14427.93,28549.09,21779.68,14435.75,5963.54,12916.58,5326.40,34055.30,7897.00,34055.30,7897.00,N/A,5326.40,14435.75,5963.54,14584.00,6168.00,13820.74,480.19,12530.49,246156.00,480.19,22827.42,,Hospital 01952,"Anesth,Burn Tx, 4-9% Tbsa",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,6178.00,N/A,3706.80,N/A,864.92,N/A,762.91,N/A,3556.17,N/A,2100.52,N/A,1871.95,N/A,864.92,N/A,769.55,N/A,769.55,N/A,1165.33,N/A,1871.95,N/A,1871.95,N/A,1871.95,N/A,3556.17,N/A,769.55,N/A,864.92,N/A,1431.00,N/A,1431.00,N/A,864.92,N/A,769.55,N/A,762.91,N/A,88.25,N/A,N/A,88.25,3706.80,,Hospital 01962,"Anesth,Urg Hysterectomy Fol Delivery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,56683.12,44354.92,34009.87,26612.95,6244.71,6200.86,7652.80,6542.02,14072.95,25476.54,19272.26,15080.67,14207.57,15194.48,6437.12,6200.86,562.00,6254.06,562.00,6254.06,8843.88,9458.86,14207.57,15194.48,14207.57,15194.48,14207.57,15194.48,14072.95,25476.56,7652.80,6254.06,6437.12,6200.86,16903.46,9384.50,16903.46,9384.50,2522.30,6200.86,7652.80,6254.06,7652.80,6542.02,6887.72,2719.57,562.00,34009.87,2719.57,26612.95,,Hospital 01999,Unlisted Anesth Procedure,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,34734.42,N/A,20840.65,N/A,4862.82,N/A,196.32,N/A,19999.35,N/A,11809.71,N/A,466.92,N/A,4862.82,N/A,187.68,N/A,187.68,N/A,290.67,N/A,466.92,N/A,466.92,N/A,466.92,N/A,19999.35,N/A,187.68,N/A,4862.82,N/A,527.00,N/A,527.00,N/A,4862.82,N/A,187.68,N/A,196.32,N/A,37.68,N/A,N/A,37.68,20840.65,,Hospital 0232T,Inject Platelet Rich Plasma W/Img Harvest/Preparatoin,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24469.17,N/A,14681.50,N/A,3419.86,N/A,2780.20,N/A,14082.52,N/A,8319.51,N/A,6521.02,N/A,3419.86,N/A,2688.04,N/A,2688.04,N/A,4059.46,N/A,6521.02,N/A,6521.02,N/A,6521.02,N/A,14082.53,N/A,2688.04,N/A,3419.86,N/A,3660.50,N/A,3660.50,N/A,3419.86,N/A,2688.04,N/A,2780.20,N/A,389.45,N/A,N/A,389.45,14681.50,,Hospital 0237T,"HC Transluminal Peripheral Atherectomy, Brachiocephal and Branches, Ea",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,82898.30,N/A,49738.98,N/A,11601.94,N/A,9959.28,N/A,47630.78,N/A,28185.41,N/A,23235.68,N/A,11601.94,N/A,9586.05,N/A,9586.05,N/A,14464.65,N/A,23235.68,N/A,23235.68,N/A,23235.68,N/A,47630.78,N/A,9586.05,N/A,11601.94,N/A,17621.75,N/A,17621.75,N/A,11601.94,N/A,9586.05,N/A,9959.28,N/A,654.87,N/A,N/A,654.87,49738.98,,Hospital 0308T,Insj Oc Tlscp Prosth Rmvl Crystalline/Io Lens,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51311.43,N/A,30786.86,N/A,7183.60,N/A,958.50,N/A,29484.21,N/A,17445.89,N/A,39542.68,N/A,7183.60,N/A,16335.98,N/A,16335.98,N/A,24616.09,N/A,39542.68,N/A,39542.68,N/A,39542.68,N/A,29484.23,N/A,16335.98,N/A,7183.60,N/A,40081.50,N/A,40081.50,N/A,7183.60,N/A,16335.98,N/A,958.50,N/A,916.74,N/A,N/A,916.74,40081.50,,Hospital 0408T,HC Insj/Rplc Car Modulj Sys Pls Gen Transvns Eltrd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,196634.52,N/A,117980.71,N/A,27528.83,N/A,35022.96,N/A,111581.73,N/A,66855.74,N/A,86382.26,N/A,27528.83,N/A,29823.61,N/A,29823.61,N/A,53756.87,N/A,86382.26,N/A,86382.26,N/A,86382.26,N/A,111581.73,N/A,29823.61,N/A,27528.83,N/A,29766.00,N/A,29766.00,N/A,27528.83,N/A,29823.61,N/A,35022.96,N/A,16.85,N/A,N/A,16.85,117980.71,,Hospital 0439T,HC Myocard Contrast Perfusion Echo,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,N/A,6336.00,N/A,3801.60,N/A,887.04,N/A,466.48,N/A,3648.27,N/A,2154.24,N/A,1099.02,N/A,887.04,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,3648.27,N/A,454.35,N/A,887.04,N/A,3396.09,N/A,3396.09,N/A,887.04,N/A,454.35,N/A,466.48,N/A,128.65,N/A,N/A,128.65,3801.60,,Hospital 0440T,Abltj Perc Cryoabltj Img Gdn Uxtr/Perph Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65750.20,N/A,39450.12,N/A,9196.17,N/A,5043.96,N/A,37834.85,N/A,22355.09,N/A,11719.48,N/A,9196.17,N/A,4821.94,N/A,4821.94,N/A,7295.59,N/A,11719.48,N/A,11719.48,N/A,11719.48,N/A,37834.87,N/A,4821.94,N/A,9196.17,N/A,9793.75,N/A,9793.75,N/A,9196.17,N/A,4821.94,N/A,5043.96,N/A,1982.08,N/A,N/A,1982.08,39450.12,,Hospital 0442T,HC Abltj Perc Cryoabltj Img Gdn Nrv Plex/Trncl Nrv,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,210609.72,73660.10,126365.83,44196.06,N/A,10312.42,N/A,5654.82,81215.45,42409.59,N/A,25044.43,N/A,13547.27,N/A,10312.42,N/A,5579.57,N/A,5579.57,N/A,8433.43,N/A,13547.27,N/A,13547.27,N/A,13547.27,81215.45,42409.62,N/A,5579.57,N/A,10312.42,81215.45,5963.00,81215.45,5963.00,N/A,10312.42,N/A,5579.57,N/A,5654.82,N/A,N/A,81215.45,126365.83,5579.57,44196.06,,Hospital 0449T,Insj Aqueous Drain Dev W/O Eo Rsvr Initial Dev,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24610.68,N/A,14766.41,N/A,3445.50,N/A,3774.30,N/A,14008.59,N/A,8367.64,N/A,10923.57,N/A,3445.50,N/A,3608.17,N/A,3608.17,N/A,6800.12,N/A,10923.57,N/A,10923.57,N/A,10923.57,N/A,14008.60,N/A,3608.17,N/A,3445.50,N/A,5963.00,N/A,5963.00,N/A,3445.50,N/A,3608.17,N/A,3774.30,N/A,N/A,N/A,N/A,3445.50,14766.41,,Hospital 0466T,Insrt Ch Wall Respir Eltrd/Ra & Conj Pulse Gen,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,121859.30,N/A,73115.58,N/A,17042.80,N/A,26799.01,N/A,68868.05,N/A,41432.14,N/A,64160.22,N/A,17042.80,N/A,26511.88,N/A,26511.88,N/A,39940.98,N/A,64160.22,N/A,64160.22,N/A,64160.22,N/A,68868.05,N/A,26511.88,N/A,17042.80,N/A,29766.00,N/A,29766.00,N/A,17042.80,N/A,26511.88,N/A,26799.01,N/A,700.99,N/A,N/A,700.99,73115.58,,Hospital 0499T,Cysto W/Dil & Urtl Rx Del F/Urtl Strix/Stenosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28068.53,N/A,16841.12,N/A,3929.58,N/A,3027.62,N/A,16159.91,N/A,9543.30,N/A,7027.43,N/A,3929.58,N/A,2894.35,N/A,2894.35,N/A,4374.71,N/A,7027.43,N/A,7027.43,N/A,7027.43,N/A,16159.91,N/A,2894.35,N/A,3929.58,N/A,3397.00,N/A,3397.00,N/A,3929.58,N/A,2894.35,N/A,3027.62,N/A,21.15,N/A,N/A,21.15,16841.12,,Hospital 0538T,HC Cart-T Therapy Prepj Bld Drv T Lmphcyt F/Trans,N/A,0872 - CELL/GENE THERAPY - SPECIAL PROCESSING & STORAGE PRIOR TO TRANSPORT,N/A,3823.00,N/A,2293.80,N/A,539.60,N/A,109.68,N/A,2201.30,N/A,1299.82,N/A,701.50,N/A,539.60,N/A,104.85,N/A,104.85,N/A,436.20,N/A,701.50,N/A,701.50,N/A,701.50,N/A,2201.30,N/A,104.85,N/A,539.60,N/A,32.80,N/A,32.80,N/A,539.60,N/A,104.85,N/A,109.68,N/A,94.28,N/A,N/A,32.80,2293.80,,Hospital CPT 0569T,HC Ttvr Perc Approach Initial Prosthesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,15495.00,15495.00,9297.00,9297.00,N/A,2169.30,N/A,15495.00,N/A,8922.02,N/A,5268.30,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,14434.61,N/A,15495.00,N/A,15495.00,N/A,15495.00,N/A,8922.02,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,15495.00,9297.00,9297.00,2169.30,15495.00,,Hospital 0623,"Dressing,Plurogel, 20g, Tube",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2183.90,N/A,1310.34,N/A,N/A,N/A,540.00,N/A,N/A,N/A,742.53,N/A,576.20,N/A,305.75,N/A,540.00,N/A,540.00,N/A,568.17,N/A,576.20,N/A,576.20,N/A,576.20,N/A,1257.49,N/A,540.00,N/A,N/A,N/A,98.57,N/A,98.57,N/A,N/A,N/A,540.00,N/A,540.00,N/A,N/A,N/A,N/A,98.57,1310.34,,Hospital 0644T,HC Tcat Rmvl/Debulk Icar Mass Suction Device Perq,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,183287.25,N/A,109972.35,N/A,35169.69,N/A,31950.32,N/A,N/A,N/A,66047.71,N/A,66047.71,N/A,35169.69,N/A,31950.32,N/A,31950.32,N/A,66047.71,N/A,66047.71,N/A,66047.71,N/A,66047.71,N/A,N/A,N/A,31950.32,N/A,35169.69,N/A,N/A,N/A,N/A,N/A,35169.69,N/A,31950.32,N/A,31950.32,N/A,35169.69,N/A,31950.32,109972.35,N/A,N/A,,Hospital CPT 10009,HC Fna Bx W/CT Gdn 1st Les,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1352.00,1352.00,811.20,811.20,N/A,189.28,N/A,613.03,N/A,778.48,N/A,459.68,N/A,1352.00,N/A,189.28,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1352.00,N/A,1352.00,N/A,1352.00,N/A,778.48,N/A,586.05,N/A,189.28,N/A,1431.00,N/A,1431.00,N/A,189.28,N/A,586.05,N/A,613.03,N/A,118.43,811.20,811.20,118.43,1431.00,,Hospital CPT 10010,HC Fna Bx W/CT Gdn Ea Addl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1352.00,1352.00,811.20,811.20,N/A,189.28,N/A,77.35,N/A,778.48,N/A,459.68,N/A,656.70,N/A,189.28,N/A,77.35,N/A,77.35,N/A,408.80,N/A,656.70,N/A,656.70,N/A,656.70,N/A,778.48,N/A,77.35,N/A,189.28,N/A,1352.00,N/A,1352.00,N/A,189.28,N/A,77.35,N/A,77.35,N/A,85.09,811.20,811.20,77.35,1352.00,,Hospital CPT 10180,"HC I&D Complex,Post OP Wound",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8217.00,8217.00,4930.20,4930.20,N/A,1150.38,N/A,2472.12,N/A,4731.35,N/A,2793.78,N/A,5642.81,N/A,1150.38,N/A,2332.78,N/A,2332.78,N/A,3512.76,N/A,5642.81,N/A,5642.81,N/A,5642.81,N/A,4731.35,N/A,2332.78,N/A,1150.38,N/A,3397.00,N/A,3397.00,N/A,1150.38,N/A,2332.78,N/A,2472.12,N/A,184.67,4930.20,4930.20,184.67,5642.81,,Hospital CPT 10180,HC Comlex Drainage Wound,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,8217.00,8217.00,4930.20,4930.20,N/A,1150.38,N/A,2472.12,N/A,4731.35,N/A,2793.78,N/A,5642.81,N/A,1150.38,N/A,2332.78,N/A,2332.78,N/A,3512.76,N/A,5642.81,N/A,5642.81,N/A,5642.81,N/A,4731.35,N/A,2332.78,N/A,1150.38,N/A,8217.00,N/A,8217.00,N/A,1150.38,N/A,2332.78,N/A,2472.12,N/A,184.67,4930.20,4930.20,184.67,8217.00,,Hospital CPT 11000,"HC Debrd Eczema/Infect Skin,>10%",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1631.00,1631.00,978.60,978.60,N/A,228.34,N/A,27.01,N/A,939.13,N/A,554.54,N/A,161.28,N/A,228.34,N/A,27.01,N/A,27.01,N/A,100.40,N/A,161.28,N/A,161.28,N/A,161.28,N/A,939.13,N/A,27.01,N/A,228.34,N/A,1631.00,N/A,1631.00,N/A,228.34,N/A,27.01,N/A,27.01,N/A,29.71,978.60,978.60,27.01,1631.00,,Hospital CPT 11000,HC Debride Infected Skin,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1631.00,1631.00,978.60,978.60,N/A,228.34,N/A,27.01,N/A,939.13,N/A,554.54,N/A,161.28,N/A,228.34,N/A,27.01,N/A,27.01,N/A,100.40,N/A,161.28,N/A,161.28,N/A,161.28,N/A,939.13,N/A,27.01,N/A,228.34,N/A,1631.00,N/A,1631.00,N/A,228.34,N/A,27.01,N/A,27.01,N/A,29.71,978.60,978.60,27.01,1631.00,,Hospital 11004,Dbrdmt Skn Subq T/M/F Necro Infctj Gent&PR,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71205.17,N/A,42723.10,N/A,9920.21,N/A,2746.07,N/A,40673.88,N/A,24209.80,N/A,19857.63,N/A,9920.21,N/A,2690.13,N/A,2690.13,N/A,12361.71,N/A,19857.63,N/A,19857.63,N/A,19857.63,N/A,40673.89,N/A,2690.13,N/A,9920.21,N/A,3103.25,N/A,3103.25,N/A,9920.21,N/A,2690.13,N/A,2746.07,N/A,3456.08,N/A,N/A,2690.13,42723.10,,Hospital CPT 11012,HC Deb Skin Bone at Fx Site,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7767.00,7767.00,4660.20,4660.20,N/A,1087.38,N/A,397.30,N/A,4472.24,N/A,2640.78,N/A,1823.37,N/A,1087.38,N/A,397.30,N/A,397.30,N/A,1135.05,N/A,1823.37,N/A,1823.37,N/A,1823.37,N/A,4472.24,N/A,397.30,N/A,1087.38,N/A,7767.00,N/A,7767.00,N/A,1087.38,N/A,397.30,N/A,397.30,N/A,437.03,4660.20,4660.20,397.30,7767.00,,Hospital CPT 11012,Dbrdmt Fx&/Dislc Subq T/M/F Bone,N/A,N/A,1173.00,1173.00,703.80,703.80,N/A,164.22,N/A,397.30,N/A,1173.00,N/A,398.82,N/A,1173.00,N/A,164.22,N/A,397.30,N/A,397.30,N/A,1135.05,N/A,1173.00,N/A,1173.00,N/A,1173.00,N/A,1173.00,N/A,397.30,N/A,164.22,N/A,1173.00,N/A,1173.00,N/A,164.22,N/A,397.30,N/A,397.30,N/A,437.03,703.80,703.80,164.22,1173.00,,Hospital CPT 11044,HC Debride Skin Sub Musc Bone,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,8040.00,8040.00,4824.00,4824.00,N/A,1125.60,N/A,1354.15,N/A,4629.43,N/A,2733.60,N/A,3275.59,N/A,1125.60,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,4629.43,N/A,1354.15,N/A,1125.60,N/A,8040.00,N/A,8040.00,N/A,1125.60,N/A,1354.15,N/A,1354.15,N/A,1489.57,4824.00,4824.00,1125.60,8040.00,,Hospital CPT 11044,Debridement Bone Muscle &/Fascia 20 Sq Cm/<,N/A,N/A,521.00,521.00,312.60,312.60,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,N/A,521.00,312.60,312.60,312.60,521.00,,Hospital CPT 11044,"HC Debrid,Bone,1st 20sqcm or Less",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8040.00,8040.00,4824.00,4824.00,N/A,1125.60,N/A,1354.15,N/A,4629.43,N/A,2733.60,N/A,3275.59,N/A,1125.60,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,4629.43,N/A,1354.15,N/A,1125.60,N/A,1431.00,N/A,1431.00,N/A,1125.60,N/A,1354.15,N/A,1354.15,N/A,1489.57,4824.00,4824.00,1125.60,4824.00,,Hospital CPT 11046,"HC Debrid,Musc/Fasc,Ea Add 20sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2292.00,2292.00,1375.20,1375.20,N/A,320.88,N/A,2292.00,N/A,1319.73,N/A,779.28,N/A,2292.00,N/A,320.88,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,1319.73,N/A,2292.00,N/A,320.88,N/A,527.00,N/A,527.00,N/A,320.88,N/A,2292.00,N/A,53.40,N/A,58.74,1375.20,1375.20,53.40,2292.00,,Hospital CPT 11047,"HC Debrid,Bone Ea Addl 20sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7118.00,7118.00,4270.80,4270.80,N/A,996.52,N/A,7118.00,N/A,4098.54,N/A,2420.12,N/A,7118.00,N/A,996.52,N/A,7118.00,N/A,7118.00,N/A,7118.00,N/A,7118.00,N/A,7118.00,N/A,7118.00,N/A,4098.54,N/A,7118.00,N/A,996.52,N/A,527.00,N/A,527.00,N/A,996.52,N/A,7118.00,N/A,93.37,N/A,102.71,4270.80,4270.80,93.37,7118.00,,Hospital CPT 11055,HC Paring of Callus Single,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,763.00,763.00,457.80,457.80,N/A,106.82,N/A,172.81,N/A,439.34,N/A,259.42,N/A,394.46,N/A,106.82,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,439.34,N/A,163.07,N/A,106.82,N/A,527.00,N/A,527.00,N/A,106.82,N/A,163.07,N/A,173.47,N/A,17.23,457.80,457.80,17.23,527.00,,Hospital CPT 11055,HC Trim Skin Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,763.00,763.00,457.80,457.80,N/A,106.82,N/A,172.81,N/A,439.34,N/A,259.42,N/A,394.46,N/A,106.82,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,439.34,N/A,163.07,N/A,106.82,N/A,763.00,N/A,763.00,N/A,106.82,N/A,163.07,N/A,173.47,N/A,17.23,457.80,457.80,17.23,763.00,,Hospital CPT 11057,HC Paring of Callus > 4 Lesions,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,734.00,734.00,440.40,440.40,N/A,102.76,N/A,172.81,N/A,422.64,N/A,249.56,N/A,394.46,N/A,102.76,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,422.64,N/A,163.07,N/A,102.76,N/A,527.00,N/A,527.00,N/A,102.76,N/A,163.07,N/A,172.81,N/A,30.95,440.40,440.40,30.95,527.00,,Hospital CPT 11106,HC Incisional Biopsy Skin Single Lesion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,555.96,N/A,723.78,N/A,427.38,N/A,1257.00,N/A,175.98,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,723.78,N/A,524.62,N/A,175.98,N/A,1431.00,N/A,1431.00,N/A,175.98,N/A,524.62,N/A,524.62,N/A,577.08,754.20,754.20,175.98,1431.00,,Hospital CPT 11106,HC Incisional Biopsy Skin Single Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,555.96,N/A,723.78,N/A,427.38,N/A,1257.00,N/A,175.98,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,723.78,N/A,524.62,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,175.98,N/A,524.62,N/A,524.62,N/A,577.08,754.20,754.20,175.98,1257.00,,Hospital CPT 11107,HC Incisional Biopsy Skin Ea Sep/Additional Lesion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,1257.00,N/A,723.78,N/A,427.38,N/A,1257.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,723.78,N/A,1257.00,N/A,175.98,N/A,527.00,N/A,527.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,32.68,754.20,754.20,32.68,1257.00,,Hospital CPT 11107,HC Incisional Biopsy Skin Ea Sep/Additional Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,763.00,763.00,457.80,457.80,N/A,106.82,N/A,763.00,N/A,439.34,N/A,259.42,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,439.34,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,32.68,457.80,457.80,32.68,763.00,,Hospital 11313,HC Shave Lesion Face Dia >2.0 Cm,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,933.00,N/A,559.80,N/A,130.62,N/A,350.01,N/A,537.22,N/A,317.22,N/A,N/A,N/A,130.62,N/A,336.90,N/A,336.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,537.22,N/A,336.90,N/A,130.62,N/A,500.09,N/A,500.09,N/A,130.62,N/A,336.90,N/A,350.01,N/A,101.02,N/A,N/A,101.02,559.80,,Hospital CPT 11440,HC Exc Face-Mm B9+Marg 0.5 Cm/<,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,97.53,N/A,1017.44,N/A,600.78,N/A,396.03,N/A,247.38,N/A,97.53,N/A,97.53,N/A,246.53,N/A,396.03,N/A,396.03,N/A,396.03,N/A,1017.44,N/A,97.53,N/A,247.38,N/A,1767.00,N/A,1767.00,N/A,247.38,N/A,97.53,N/A,97.53,N/A,107.28,1060.20,1060.20,97.53,1767.00,,Hospital 11450,Excision Hidradenitis Axillary Smpl/Intrm Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19316.80,N/A,11590.08,N/A,2704.36,N/A,2381.29,N/A,11115.82,N/A,6567.72,N/A,5670.99,N/A,2704.36,N/A,2332.78,N/A,2332.78,N/A,3530.30,N/A,5670.99,N/A,5670.99,N/A,5670.99,N/A,11115.82,N/A,2332.78,N/A,2704.36,N/A,3397.00,N/A,3397.00,N/A,2704.36,N/A,2332.78,N/A,2381.29,N/A,305.29,N/A,N/A,305.29,11590.08,,Hospital 11463,Excision Hidradenitis Inguinal Complex Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25803.20,N/A,15481.92,N/A,3612.45,N/A,2381.29,N/A,14851.29,N/A,8773.10,N/A,5666.17,N/A,3612.45,N/A,2332.78,N/A,2332.78,N/A,3527.31,N/A,5666.17,N/A,5666.17,N/A,5666.17,N/A,14851.28,N/A,2332.78,N/A,3612.45,N/A,5095.50,N/A,5095.50,N/A,3612.45,N/A,2332.78,N/A,2381.29,N/A,605.47,N/A,N/A,605.47,15481.92,,Hospital CPT 11470,Excision H/P/P/U Simple/Intermediate Repair,N/A,N/A,756.00,756.00,453.60,453.60,N/A,105.84,N/A,270.58,N/A,756.00,N/A,257.04,N/A,756.00,N/A,105.84,N/A,270.58,N/A,270.58,N/A,756.00,N/A,756.00,N/A,756.00,N/A,756.00,N/A,756.00,N/A,270.58,N/A,105.84,N/A,756.00,N/A,756.00,N/A,105.84,N/A,270.58,N/A,270.58,N/A,297.64,453.60,453.60,105.84,756.00,,Hospital 11471,Excision H/P/P/U Complex Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14784.27,N/A,8870.56,N/A,2070.83,N/A,2308.46,N/A,8510.82,N/A,5026.64,N/A,5628.49,N/A,2070.83,N/A,2320.33,N/A,2320.33,N/A,3503.85,N/A,5628.49,N/A,5628.49,N/A,5628.49,N/A,8464.76,N/A,2320.33,N/A,2070.83,N/A,5095.50,N/A,5095.50,N/A,2070.83,N/A,2320.33,N/A,2308.46,N/A,943.04,N/A,N/A,943.04,8870.56,,Hospital 11600,Excision Mal Lesion Trunk/Arm/Leg 0.5 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10319.10,N/A,6191.46,N/A,1445.71,N/A,1842.07,N/A,5940.34,N/A,3508.49,N/A,4495.45,N/A,1445.71,N/A,1851.54,N/A,1851.54,N/A,2798.49,N/A,4495.45,N/A,4495.45,N/A,4495.45,N/A,5940.34,N/A,1851.54,N/A,1445.71,N/A,2586.50,N/A,2586.50,N/A,1445.71,N/A,1851.54,N/A,1842.07,N/A,854.43,N/A,N/A,854.43,6191.46,,Hospital 11601,HC Exc Malig Lesion <=0.5 Trunk Arms or Legs,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,12282.30,N/A,7369.38,N/A,1719.52,N/A,902.47,N/A,7072.15,N/A,4175.98,N/A,2052.11,N/A,1719.52,N/A,848.36,N/A,848.36,N/A,1277.48,N/A,2052.11,N/A,2052.11,N/A,2052.11,N/A,7072.15,N/A,848.36,N/A,1719.52,N/A,1694.50,N/A,1694.50,N/A,1719.52,N/A,848.36,N/A,902.47,N/A,508.02,N/A,N/A,508.02,7369.38,,Hospital 11602,HC Exc Mal Les Tk Am Lg 1.1-2.0cm,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,11750.50,N/A,7050.30,N/A,1645.07,N/A,340.55,N/A,6765.26,N/A,3995.17,N/A,822.95,N/A,1645.07,N/A,336.90,N/A,336.90,N/A,512.30,N/A,822.95,N/A,822.95,N/A,822.95,N/A,6765.27,N/A,336.90,N/A,1645.07,N/A,527.00,N/A,527.00,N/A,1645.07,N/A,336.90,N/A,340.55,N/A,199.80,N/A,N/A,199.80,7050.30,,Hospital 11604,Excision Mal Lesion Trunk/Arm/Leg 3.1-4.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15762.40,N/A,9457.44,N/A,2206.73,N/A,789.23,N/A,9073.97,N/A,5359.21,N/A,1873.28,N/A,2206.73,N/A,754.50,N/A,754.50,N/A,1166.16,N/A,1873.28,N/A,1873.28,N/A,1873.28,N/A,9073.97,N/A,754.50,N/A,2206.73,N/A,1694.50,N/A,1694.50,N/A,2206.73,N/A,754.50,N/A,789.23,N/A,448.39,N/A,N/A,448.39,9457.44,,Hospital 11900,HC Inject Skin Lesions 100 1st 100,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2939.00,2939.00,1763.40,1763.40,N/A,411.46,N/A,1600.15,N/A,1692.28,N/A,999.26,N/A,2939.00,N/A,411.46,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,2939.00,N/A,2939.00,N/A,2939.00,N/A,1692.28,N/A,1558.52,N/A,411.46,N/A,1871.00,N/A,1871.00,N/A,411.46,N/A,1558.52,N/A,1600.15,N/A,238.11,1763.40,1763.40,238.11,2939.00,,Hospital 15572,Frmj Direct/Tube Pedicle W/WO Tr Scalp Arms/Legs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56078.27,N/A,33646.96,N/A,7835.64,N/A,3202.87,N/A,32013.11,N/A,19051.05,N/A,14601.76,N/A,7835.64,N/A,5973.28,N/A,5973.28,N/A,9089.86,N/A,14601.76,N/A,14601.76,N/A,14601.76,N/A,32013.13,N/A,5973.28,N/A,7835.64,N/A,10435.25,N/A,10435.25,N/A,7835.64,N/A,5973.28,N/A,3202.87,N/A,3472.32,N/A,N/A,3202.87,33646.96,,Hospital 15574,Frmj Dir/Tube Pedcl W/Wotr Fh/Ch/Ch/M/N/Ax/G/H/F,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21704.00,N/A,13022.40,N/A,3038.56,N/A,5043.96,N/A,12494.64,N/A,7379.37,N/A,11724.27,N/A,3038.56,N/A,4821.94,N/A,4821.94,N/A,7298.58,N/A,11724.27,N/A,11724.27,N/A,11724.27,N/A,12494.66,N/A,4821.94,N/A,3038.56,N/A,6898.50,N/A,6898.50,N/A,3038.56,N/A,4821.94,N/A,5043.96,N/A,1253.04,N/A,N/A,1253.04,13022.40,,Hospital 15576,Frmj Direct/Tubed Pedicle W/Wotr E/N/E/L/Ntroral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43956.48,N/A,26373.89,N/A,6153.93,N/A,4922.21,N/A,25172.63,N/A,14945.21,N/A,12378.42,N/A,6153.93,N/A,4821.94,N/A,4821.94,N/A,7705.80,N/A,12378.42,N/A,12378.42,N/A,12378.42,N/A,25172.64,N/A,4821.94,N/A,6153.93,N/A,5563.25,N/A,5563.25,N/A,6153.93,N/A,4821.94,N/A,4922.21,N/A,2750.52,N/A,N/A,2750.52,26373.89,,Hospital CPT 15731,Forehead Flap W/Preservation Vascular Pedicle,N/A,N/A,1861.00,1861.00,1116.60,1116.60,N/A,260.54,N/A,945.27,N/A,1861.00,N/A,632.74,N/A,1861.00,N/A,260.54,N/A,945.27,N/A,945.27,N/A,1861.00,N/A,1861.00,N/A,1861.00,N/A,1861.00,N/A,1861.00,N/A,945.27,N/A,260.54,N/A,1861.00,N/A,1861.00,N/A,260.54,N/A,945.27,N/A,945.27,N/A,1039.80,1116.60,1116.60,260.54,1861.00,,Hospital 15738,Musc Myocutaneous/Fasciocutaneous Flap Lxtr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24343.60,N/A,14606.16,N/A,3412.44,N/A,1444.46,N/A,14012.86,N/A,8276.83,N/A,3310.38,N/A,3412.44,N/A,1358.08,N/A,1358.08,N/A,2060.77,N/A,3310.38,N/A,3310.38,N/A,3310.38,N/A,14012.87,N/A,1358.08,N/A,3412.44,N/A,5497.50,N/A,5497.50,N/A,3412.44,N/A,1358.08,N/A,1444.46,N/A,1773.70,N/A,N/A,1358.08,14606.16,,Hospital 15819,Cervicoplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57377.60,N/A,34426.56,N/A,8029.99,N/A,5159.17,N/A,33034.16,N/A,19508.38,N/A,12595.93,N/A,8029.99,N/A,5185.70,N/A,5185.70,N/A,7841.20,N/A,12595.93,N/A,12595.93,N/A,12595.93,N/A,33034.17,N/A,5185.70,N/A,8029.99,N/A,7310.75,N/A,7310.75,N/A,8029.99,N/A,5185.70,N/A,5159.17,N/A,840.17,N/A,N/A,840.17,34426.56,,Hospital 15826,Rhytidectomy Glabellar Frown Lines,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39716.20,N/A,23829.72,N/A,5560.27,N/A,1440.53,N/A,22863.42,N/A,13503.51,N/A,3317.65,N/A,5560.27,N/A,1354.15,N/A,1354.15,N/A,2065.30,N/A,3317.65,N/A,3317.65,N/A,3317.65,N/A,22863.42,N/A,1354.15,N/A,5560.27,N/A,5277.50,N/A,5277.50,N/A,5560.27,N/A,1354.15,N/A,1440.53,N/A,5456.18,N/A,N/A,1354.15,23829.72,,Hospital 15829,Rhytidectomy Smas Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58823.47,N/A,35294.08,N/A,8235.30,N/A,N/A,N/A,33843.67,N/A,19999.98,N/A,14385.45,N/A,8235.30,N/A,5875.25,N/A,5875.25,N/A,8955.19,N/A,14385.45,N/A,14385.45,N/A,14385.45,N/A,33843.72,N/A,5875.25,N/A,8235.30,N/A,7983.50,N/A,7983.50,N/A,8235.30,N/A,5875.25,N/A,N/A,N/A,N/A,N/A,N/A,5875.25,35294.08,,Hospital CPT 15830,Excision Skin Abd Infraumbilical Panniculectomy,N/A,N/A,4000.00,4000.00,2400.00,2400.00,N/A,560.00,N/A,1114.98,N/A,4000.00,N/A,1360.00,N/A,3328.83,N/A,560.00,N/A,1114.98,N/A,1114.98,N/A,2072.20,N/A,3328.83,N/A,3328.83,N/A,3328.83,N/A,4000.00,N/A,1114.98,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,560.00,N/A,1114.98,N/A,1114.98,N/A,1226.48,2400.00,2400.00,560.00,4000.00,,Hospital 15832,Excision Excessive Skin & Subq Tissue Thigh,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64716.87,N/A,38830.12,N/A,9060.18,N/A,5709.23,N/A,37249.89,N/A,22003.75,N/A,13112.89,N/A,9060.18,N/A,5366.90,N/A,5366.90,N/A,8163.02,N/A,13112.89,N/A,13112.89,N/A,13112.89,N/A,37249.88,N/A,5366.90,N/A,9060.18,N/A,8129.25,N/A,8129.25,N/A,9060.18,N/A,5366.90,N/A,5709.23,N/A,2965.05,N/A,N/A,2965.05,38830.12,,Hospital 15839,Excision Excessive Skin & Subq Tissue Other Area,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39237.57,N/A,23542.54,N/A,5491.42,N/A,5942.72,N/A,22363.63,N/A,13340.77,N/A,14494.87,N/A,5491.42,N/A,5973.28,N/A,5973.28,N/A,9023.33,N/A,14494.87,N/A,14494.87,N/A,14494.87,N/A,22363.63,N/A,5973.28,N/A,5491.42,N/A,9412.25,N/A,9412.25,N/A,5491.42,N/A,5973.28,N/A,5942.72,N/A,1436.24,N/A,N/A,1436.24,23542.54,,Hospital 15850,Removal Sutures Under Anesthesia Same Surgeon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15949.80,N/A,9569.88,N/A,2232.97,N/A,N/A,N/A,9183.70,N/A,5422.93,N/A,1305.59,N/A,2232.97,N/A,N/A,N/A,N/A,N/A,811.33,N/A,1305.59,N/A,1305.59,N/A,1305.59,N/A,9183.70,N/A,N/A,N/A,2232.97,N/A,N/A,N/A,N/A,N/A,2232.97,N/A,N/A,N/A,N/A,N/A,1544.28,N/A,N/A,811.33,9569.88,,Hospital 15852,Dressing Change Under Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,4286.93,N/A,2572.16,N/A,600.17,N/A,578.72,N/A,2468.42,N/A,1457.56,N/A,1269.02,N/A,600.17,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,2468.42,N/A,524.62,N/A,600.17,N/A,527.00,N/A,527.00,N/A,600.17,N/A,524.62,N/A,45.15,N/A,49.67,N/A,N/A,45.15,2572.16,,Hospital 15878,Suction Assisted Lipectomy Upper Extremity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54798.60,N/A,32879.16,N/A,7668.94,N/A,5934.44,N/A,31547.62,N/A,18631.52,N/A,14507.90,N/A,7668.94,N/A,5964.96,N/A,5964.96,N/A,9031.44,N/A,14507.90,N/A,14507.90,N/A,14507.90,N/A,31547.62,N/A,5964.96,N/A,7668.94,N/A,7310.75,N/A,7310.75,N/A,7668.94,N/A,5964.96,N/A,5934.44,N/A,9.47,N/A,N/A,9.47,32879.16,,Hospital 15879,Suction Assisted Lipectomy Lower Extremity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41982.97,N/A,25189.78,N/A,5781.08,N/A,29.60,N/A,24149.77,N/A,14274.21,N/A,10803.71,N/A,5781.08,N/A,4406.44,N/A,4406.44,N/A,6725.51,N/A,10803.71,N/A,10803.71,N/A,10803.71,N/A,24149.81,N/A,4406.44,N/A,5781.08,N/A,6843.00,N/A,6843.00,N/A,5781.08,N/A,4406.44,N/A,29.60,N/A,32.57,N/A,N/A,29.60,25189.78,,Hospital 15936,Exc Sac PR Ulc Prepj Musc/Myoq Flap/Skn Grf Clsr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38432.90,N/A,23059.74,N/A,5414.58,N/A,1686.43,N/A,22102.35,N/A,13067.17,N/A,3915.83,N/A,5414.58,N/A,1633.00,N/A,1633.00,N/A,2446.07,N/A,3915.83,N/A,3915.83,N/A,3915.83,N/A,22102.34,N/A,1633.00,N/A,5414.58,N/A,1871.00,N/A,1871.00,N/A,5414.58,N/A,1633.00,N/A,1686.43,N/A,1061.08,N/A,N/A,1061.08,23059.74,,Hospital 17004,HC Destruction Benign Lesion 15+,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,625.00,N/A,375.00,N/A,87.50,N/A,472.68,N/A,359.88,N/A,212.50,N/A,N/A,N/A,87.50,N/A,446.04,N/A,446.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,359.88,N/A,446.04,N/A,87.50,N/A,335.00,N/A,335.00,N/A,87.50,N/A,446.04,N/A,472.68,N/A,100.58,N/A,N/A,87.50,472.68,,Hospital 17106,Destruction Cutaneous Vasc Proliferative <10cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15886.90,N/A,9532.14,N/A,2216.14,N/A,1416.50,N/A,9145.81,N/A,5401.54,N/A,3298.84,N/A,2216.14,N/A,1354.15,N/A,1354.15,N/A,2053.60,N/A,3298.84,N/A,3298.84,N/A,3298.84,N/A,9145.81,N/A,1354.15,N/A,2216.14,N/A,1694.50,N/A,1694.50,N/A,2216.14,N/A,1354.15,N/A,1416.50,N/A,376.36,N/A,N/A,376.36,9532.14,,Hospital CPT 17250,HC Chem Cautery Granulatn Tissue,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,564.00,564.00,338.40,338.40,N/A,78.96,N/A,35.22,N/A,324.75,N/A,191.76,N/A,394.46,N/A,78.96,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,324.75,N/A,163.07,N/A,78.96,N/A,564.00,N/A,564.00,N/A,78.96,N/A,163.07,N/A,35.22,N/A,38.74,338.40,338.40,35.22,564.00,,Hospital CPT 17250,HC Wound Cautery-Chemical,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1105.00,1105.00,663.00,663.00,N/A,154.70,N/A,35.22,N/A,636.26,N/A,375.70,N/A,394.46,N/A,154.70,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,636.26,N/A,163.07,N/A,154.70,N/A,527.00,N/A,527.00,N/A,154.70,N/A,163.07,N/A,35.22,N/A,38.74,663.00,663.00,35.22,663.00,,Hospital 17260,HC Dest Malignant Lesion T/a/L 0.5 Cm/<,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,416.00,N/A,249.60,N/A,58.24,N/A,115.66,N/A,239.54,N/A,141.44,N/A,N/A,N/A,58.24,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,239.54,N/A,109.14,N/A,58.24,N/A,222.98,N/A,222.98,N/A,58.24,N/A,109.14,N/A,115.66,N/A,72.79,N/A,N/A,58.24,249.60,,Hospital 17311,Mohs Micrographic H/N/H/F/G 1st Stage 5 Blocks,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11622.83,N/A,6973.70,N/A,1627.19,N/A,825.05,N/A,6685.20,N/A,3948.36,N/A,1929.98,N/A,1627.19,N/A,786.93,N/A,786.93,N/A,1201.44,N/A,1929.98,N/A,1929.98,N/A,1929.98,N/A,6685.21,N/A,786.93,N/A,1627.19,N/A,790.50,N/A,790.50,N/A,1627.19,N/A,786.93,N/A,655.92,N/A,721.51,N/A,N/A,655.92,6973.70,,Hospital CPT 19000,HC Puncture Aspir Cyst-Breast,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1266.00,1266.00,759.60,759.60,N/A,177.24,N/A,586.05,N/A,728.96,N/A,430.44,N/A,1266.00,N/A,177.24,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1266.00,N/A,1266.00,N/A,1266.00,N/A,728.96,N/A,586.05,N/A,177.24,N/A,1431.00,N/A,1431.00,N/A,177.24,N/A,586.05,N/A,586.05,N/A,644.65,759.60,759.60,177.24,1431.00,,Hospital CPT 19001,HC Punc Asp Cyst Brs @ Eadd Cys,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,906.00,906.00,543.60,543.60,N/A,126.84,N/A,906.00,N/A,521.67,N/A,308.04,N/A,906.00,N/A,126.84,N/A,906.00,N/A,906.00,N/A,906.00,N/A,906.00,N/A,906.00,N/A,906.00,N/A,521.67,N/A,906.00,N/A,126.84,N/A,527.00,N/A,527.00,N/A,126.84,N/A,906.00,N/A,906.00,N/A,22.53,543.60,543.60,22.53,906.00,,Hospital CPT 19001,HC Puncture Ea Add Breast Cyst,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,906.00,906.00,543.60,543.60,N/A,126.84,N/A,906.00,N/A,521.67,N/A,308.04,N/A,906.00,N/A,126.84,N/A,906.00,N/A,906.00,N/A,906.00,N/A,906.00,N/A,906.00,N/A,906.00,N/A,521.67,N/A,906.00,N/A,126.84,N/A,527.00,N/A,527.00,N/A,126.84,N/A,906.00,N/A,906.00,N/A,22.53,543.60,543.60,22.53,906.00,,Hospital CPT 19020,HC I&D Breast Abscess Deep,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,8691.00,8691.00,5214.60,5214.60,N/A,1216.74,N/A,296.05,N/A,5004.28,N/A,2954.94,N/A,1306.77,N/A,1216.74,N/A,296.05,N/A,296.05,N/A,813.46,N/A,1306.77,N/A,1306.77,N/A,1306.77,N/A,5004.28,N/A,296.05,N/A,1216.74,N/A,8691.00,N/A,8691.00,N/A,1216.74,N/A,296.05,N/A,296.05,N/A,325.66,5214.60,5214.60,296.05,8691.00,,Hospital CPT 19020,Mastotomy W/Exploration/Drainage Abscess Deep,N/A,N/A,796.00,796.00,477.60,477.60,N/A,111.44,N/A,296.05,N/A,796.00,N/A,270.64,N/A,796.00,N/A,111.44,N/A,296.05,N/A,296.05,N/A,796.00,N/A,796.00,N/A,796.00,N/A,796.00,N/A,796.00,N/A,296.05,N/A,111.44,N/A,796.00,N/A,796.00,N/A,111.44,N/A,296.05,N/A,296.05,N/A,325.66,477.60,477.60,111.44,796.00,,Hospital 19030,HC Injection for Ductogram,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,3264.50,N/A,1958.70,N/A,457.03,N/A,215.26,N/A,1878.75,N/A,1109.93,N/A,542.47,N/A,457.03,N/A,210.88,N/A,210.88,N/A,337.69,N/A,542.47,N/A,542.47,N/A,542.47,N/A,1878.75,N/A,210.88,N/A,457.03,N/A,527.00,N/A,527.00,N/A,457.03,N/A,210.88,N/A,215.26,N/A,168.17,N/A,N/A,168.17,1958.70,,Hospital CPT 19081,HC Bx Breast 1st Lesion Strtctc,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,9519.00,9519.00,5711.40,5711.40,N/A,1332.66,N/A,1354.15,N/A,5481.04,N/A,3236.46,N/A,3275.59,N/A,1332.66,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,5481.04,N/A,1354.15,N/A,1332.66,N/A,5102.18,N/A,5102.18,N/A,1332.66,N/A,1354.15,N/A,1354.15,N/A,1489.57,5711.40,5711.40,1332.66,5711.40,,Hospital CPT 19081,HC Bx Breast 1st Lesion Strtctc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9519.00,9519.00,5711.40,5711.40,N/A,1332.66,N/A,1354.15,N/A,5481.04,N/A,3236.46,N/A,3275.59,N/A,1332.66,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,5481.04,N/A,1354.15,N/A,1332.66,N/A,1871.00,N/A,1871.00,N/A,1332.66,N/A,1354.15,N/A,1354.15,N/A,1489.57,5711.40,5711.40,1332.66,5711.40,,Hospital 19085,HC Bx Breast 1st Les MR Image,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,N/A,10630.90,N/A,6378.54,N/A,1488.33,N/A,1495.28,N/A,2506.74,N/A,3050.45,N/A,3603.95,N/A,1488.33,N/A,1432.93,N/A,1432.93,N/A,2243.53,N/A,3603.95,N/A,3603.95,N/A,3603.95,N/A,2506.74,N/A,1432.93,N/A,1488.33,N/A,1704.27,N/A,1704.27,N/A,1488.33,N/A,1432.93,N/A,1495.28,N/A,493.96,N/A,N/A,493.96,6378.54,,Hospital CPT 19282,HC Perq Device Breast Add Image,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1599.00,1439.00,959.40,863.40,N/A,201.46,N/A,1439.00,N/A,828.58,N/A,489.26,N/A,1439.00,N/A,201.46,N/A,1439.00,N/A,1439.00,N/A,1439.00,N/A,1439.00,N/A,1439.00,N/A,1439.00,N/A,828.58,N/A,1439.00,N/A,201.46,N/A,527.00,N/A,527.00,N/A,201.46,N/A,1439.00,N/A,1439.00,N/A,52.81,959.40,959.40,52.81,1439.00,,Hospital CPT 19286,HC Perq Dev Breast Add US Image,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1190.00,1190.00,714.00,714.00,N/A,166.60,N/A,1190.00,N/A,685.20,N/A,404.60,N/A,1190.00,N/A,166.60,N/A,1190.00,N/A,1190.00,N/A,1190.00,N/A,1190.00,N/A,1190.00,N/A,1190.00,N/A,685.20,N/A,1190.00,N/A,166.60,N/A,637.84,N/A,637.84,N/A,166.60,N/A,1190.00,N/A,1190.00,N/A,45.44,714.00,714.00,45.44,1190.00,,Hospital 19298,Plmt Radthx Brachytx Brst Following Prtl Mast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68100.58,N/A,40860.35,N/A,9527.20,N/A,7031.63,N/A,39065.24,N/A,23154.19,N/A,18375.67,N/A,9527.20,N/A,7031.63,N/A,7031.63,N/A,11549.63,N/A,18375.67,N/A,18375.67,N/A,18375.67,N/A,39065.24,N/A,7042.40,N/A,9527.20,N/A,17785.25,N/A,17785.25,N/A,9527.20,N/A,7031.63,N/A,7031.63,N/A,7734.79,N/A,N/A,7031.63,40860.35,,Hospital 19328,Removal Intact Breast Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29296.95,N/A,17578.17,N/A,4101.58,N/A,1295.82,N/A,16857.71,N/A,9960.96,N/A,13034.81,N/A,4101.58,N/A,5366.90,N/A,5366.90,N/A,8114.41,N/A,13034.81,N/A,13034.81,N/A,13034.81,N/A,16857.73,N/A,5366.90,N/A,4101.58,N/A,7983.50,N/A,7983.50,N/A,4101.58,N/A,5366.90,N/A,1295.82,N/A,1425.40,N/A,N/A,1295.82,17578.17,,Hospital 19340,Insertion Breast Implant Same Day of Mastectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,160957.93,113390.10,96574.76,68034.06,10791.12,15874.64,9799.67,8224.56,88720.01,64802.38,54725.69,38552.63,18336.58,20889.20,8307.87,15874.64,562.00,7951.94,562.00,7951.94,11414.09,13003.91,18336.58,20889.20,18336.58,20889.20,18336.58,20889.20,88720.01,64802.39,9799.67,7951.94,8307.87,15874.64,21815.95,12369.25,21815.95,12369.25,6056.69,15874.64,9799.67,7951.94,9799.67,8224.56,8889.42,2372.09,562.00,96574.76,2372.09,68034.06,,Hospital CPT 19342,Insj/Rplcmt Breast Implant Sep Day Mastectomy,N/A,N/A,1835.00,1835.00,1101.00,1101.00,N/A,256.90,N/A,721.93,N/A,1835.00,N/A,623.90,N/A,1835.00,N/A,256.90,N/A,721.93,N/A,721.93,N/A,1344.06,N/A,1835.00,N/A,1835.00,N/A,1835.00,N/A,1835.00,N/A,721.93,N/A,256.90,N/A,1835.00,N/A,1835.00,N/A,256.90,N/A,721.93,N/A,721.93,N/A,794.12,1101.00,1101.00,256.90,1835.00,,Hospital 19367,Breast Reconstruction Single Pedicled Tram Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,90532.50,N/A,54319.50,N/A,12669.05,N/A,5550.90,N/A,51927.10,N/A,30781.03,N/A,28313.81,N/A,12669.05,N/A,5366.90,N/A,5366.90,N/A,17994.12,N/A,28313.81,N/A,28313.81,N/A,28313.81,N/A,51927.08,N/A,5366.90,N/A,12669.05,N/A,16077.25,N/A,16077.25,N/A,12669.05,N/A,5366.90,N/A,5550.90,N/A,3937.60,N/A,N/A,3937.60,54319.50,,Hospital 19371,Peri-Implant Capsulectomy Breast Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38009.48,N/A,22805.69,N/A,5321.32,N/A,7951.94,N/A,21849.91,N/A,12923.22,N/A,19385.54,N/A,5321.32,N/A,7951.94,N/A,7951.94,N/A,12067.86,N/A,19385.54,N/A,19385.54,N/A,19385.54,N/A,21849.92,N/A,7951.94,N/A,5321.32,N/A,12986.00,N/A,12986.00,N/A,5321.32,N/A,7951.94,N/A,7951.94,N/A,8747.13,N/A,N/A,5321.32,22805.69,,Hospital CPT 20205,HC Deep Muscle Biopsy,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7224.00,7224.00,4334.40,4334.40,N/A,1011.36,N/A,2440.19,N/A,4159.58,N/A,2456.16,N/A,5642.81,N/A,1011.36,N/A,2332.78,N/A,2332.78,N/A,3512.76,N/A,5642.81,N/A,5642.81,N/A,5642.81,N/A,4159.58,N/A,2332.78,N/A,1011.36,N/A,1871.00,N/A,1871.00,N/A,1011.36,N/A,2332.78,N/A,2440.19,N/A,161.24,4334.40,4334.40,161.24,5642.81,,Hospital 20250,Biopsy Vertebral Body Open Thoracic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,105466.52,N/A,63279.91,N/A,14765.31,N/A,6354.28,N/A,60455.34,N/A,35858.61,N/A,14475.26,N/A,14765.31,N/A,8076.58,N/A,8076.58,N/A,9011.13,N/A,14475.26,N/A,14475.26,N/A,14475.26,N/A,60455.34,N/A,8076.58,N/A,14765.31,N/A,8244.00,N/A,8244.00,N/A,14765.31,N/A,8076.58,N/A,6354.28,N/A,1326.10,N/A,N/A,1326.10,63279.91,,Hospital 20500,HC Inj Sinus Tract Therapeutic,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,2825.00,N/A,1695.00,N/A,381.96,N/A,1267.12,N/A,1626.58,N/A,960.50,N/A,2825.00,N/A,381.96,N/A,1253.55,N/A,1253.55,N/A,1889.54,N/A,2825.00,N/A,2825.00,N/A,2825.00,N/A,1626.58,N/A,1253.55,N/A,381.96,N/A,1871.00,N/A,1871.00,N/A,381.96,N/A,1253.55,N/A,1267.12,N/A,141.39,N/A,N/A,141.39,2825.00,,Hospital CPT 20520,HC Removal of Foreign Body Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1698.00,1698.00,1018.80,1018.80,N/A,237.72,N/A,139.04,N/A,977.71,N/A,577.32,N/A,602.22,N/A,237.72,N/A,139.04,N/A,139.04,N/A,374.88,N/A,602.22,N/A,602.22,N/A,602.22,N/A,977.71,N/A,139.04,N/A,237.72,N/A,1698.00,N/A,1698.00,N/A,237.72,N/A,139.04,N/A,139.04,N/A,152.94,1018.80,1018.80,139.04,1698.00,,Hospital CPT 20526,"HC Carpal Tunnel Inj, Pmc",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,754.00,754.00,452.40,452.40,N/A,105.56,N/A,245.53,N/A,434.15,N/A,256.36,N/A,593.92,N/A,105.56,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,434.15,N/A,245.53,N/A,105.56,N/A,404.14,N/A,404.14,N/A,105.56,N/A,245.53,N/A,245.53,N/A,270.08,452.40,452.40,105.56,593.92,,Hospital CPT 20550,HC Tendon Sheath Inj,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1309.00,1309.00,785.40,785.40,N/A,183.26,N/A,245.53,N/A,753.72,N/A,445.06,N/A,593.92,N/A,183.26,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,753.72,N/A,245.53,N/A,183.26,N/A,701.62,N/A,701.62,N/A,183.26,N/A,245.53,N/A,245.53,N/A,270.08,785.40,785.40,183.26,785.40,,Hospital CPT 20550,Injection 1 Tendon Sheath/Ligament Aponeurosis,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,95.00,95.00,57.00,57.00,N/A,13.30,N/A,245.53,N/A,54.70,N/A,32.30,N/A,95.00,N/A,13.30,N/A,245.53,N/A,245.53,N/A,95.00,N/A,95.00,N/A,95.00,N/A,95.00,N/A,54.70,N/A,245.53,N/A,13.30,N/A,95.00,N/A,95.00,N/A,13.30,N/A,245.53,N/A,245.53,N/A,270.08,57.00,57.00,13.30,270.08,,Hospital CPT 20550,HC Inj Tendon Sheath/Ligamnt,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1309.00,1309.00,785.40,785.40,N/A,183.26,N/A,245.53,N/A,753.72,N/A,445.06,N/A,593.92,N/A,183.26,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,753.72,N/A,245.53,N/A,183.26,N/A,1309.00,N/A,1309.00,N/A,183.26,N/A,245.53,N/A,245.53,N/A,270.08,785.40,785.40,183.26,1309.00,,Hospital 20551,HC Inj Tendon Origin/Insertion,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,12171.73,N/A,7303.04,N/A,1704.04,N/A,370.75,N/A,6988.77,N/A,4138.39,N/A,3261.13,N/A,1704.04,N/A,1295.43,N/A,1295.43,N/A,2030.11,N/A,3261.13,N/A,3261.13,N/A,3261.13,N/A,6988.78,N/A,1295.43,N/A,1704.04,N/A,3660.50,N/A,3660.50,N/A,1704.04,N/A,1295.43,N/A,370.75,N/A,407.84,N/A,N/A,370.75,7303.04,,Hospital CPT 20552,HC Trigger Point 1 or 2 Muscles,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1232.00,1232.00,739.20,739.20,N/A,172.48,N/A,260.19,N/A,709.39,N/A,418.88,N/A,593.92,N/A,172.48,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,709.39,N/A,245.53,N/A,172.48,N/A,660.35,N/A,660.35,N/A,172.48,N/A,245.53,N/A,260.19,N/A,39.86,739.20,739.20,39.86,739.20,,Hospital CPT 20552,HC Inj Trigger Points 1-2 Musc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1232.00,1232.00,739.20,739.20,N/A,172.48,N/A,260.19,N/A,709.39,N/A,418.88,N/A,593.92,N/A,172.48,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,709.39,N/A,245.53,N/A,172.48,N/A,1232.00,N/A,1232.00,N/A,172.48,N/A,245.53,N/A,260.19,N/A,39.86,739.20,739.20,39.86,1232.00,,Hospital CPT 20560,HC Needle Insertion W/O Injection 1 or 2 Muscles,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,22.54,N/A,63.34,N/A,37.40,N/A,54.51,N/A,15.40,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,63.34,N/A,22.54,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,22.54,N/A,22.54,N/A,24.79,66.00,66.00,15.40,66.00,,Hospital CPT 20606,HC Drain/Inj Joint/Bursa Med Joint W/US,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1590.00,1590.00,954.00,954.00,N/A,222.60,N/A,581.86,N/A,915.52,N/A,540.60,N/A,1407.47,N/A,222.60,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,915.52,N/A,581.86,N/A,222.60,N/A,852.24,N/A,852.24,N/A,222.60,N/A,581.86,N/A,581.86,N/A,640.05,954.00,954.00,222.60,1407.47,,Hospital CPT 20611,HC Large Joint Injection W/ US,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1747.00,1747.00,1048.20,1048.20,N/A,244.58,N/A,245.53,N/A,1005.92,N/A,593.98,N/A,593.92,N/A,244.58,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1005.92,N/A,245.53,N/A,244.58,N/A,936.39,N/A,936.39,N/A,244.58,N/A,245.53,N/A,245.53,N/A,270.08,1048.20,1048.20,244.58,1048.20,,Hospital CPT 20611,HC Drain/Inj Joint/Bursa W/US,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1747.00,1747.00,1048.20,1048.20,N/A,244.58,N/A,245.53,N/A,1005.92,N/A,593.98,N/A,593.92,N/A,244.58,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1005.92,N/A,245.53,N/A,244.58,N/A,527.00,N/A,527.00,N/A,244.58,N/A,245.53,N/A,245.53,N/A,270.08,1048.20,1048.20,244.58,1048.20,,Hospital 20615,HC Treatment of Bone Cyst,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,11183.10,N/A,6709.86,N/A,1555.35,N/A,872.49,N/A,3770.64,N/A,3802.25,N/A,2156.82,N/A,1555.35,N/A,876.98,N/A,876.98,N/A,1342.67,N/A,2156.82,N/A,2156.82,N/A,2156.82,N/A,3770.64,N/A,876.98,N/A,1555.35,N/A,2146.50,N/A,2146.50,N/A,1555.35,N/A,876.98,N/A,872.49,N/A,440.16,N/A,N/A,440.16,6709.86,,Hospital CPT 20680,Removal Implant Deep,N/A,N/A,1033.00,1033.00,619.80,619.80,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,N/A,1033.00,619.80,619.80,619.80,1033.00,,Hospital 20690,Application Uniplane External Fixation System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,87264.25,74992.43,52358.55,44995.46,10076.03,10459.50,12185.08,11910.55,25495.68,43079.06,29669.84,25497.42,22924.37,28593.77,10386.49,10459.50,1686.00,11782.94,1686.00,11782.94,14269.88,17800.17,22924.37,28593.77,22924.37,28593.77,22924.37,28593.77,25495.68,43018.61,12185.08,11782.94,10386.49,10459.50,27274.27,5635.25,27274.27,5635.25,254.83,10459.50,12185.08,11782.94,12185.08,11910.55,11113.55,1194.52,254.83,52358.55,1194.52,44995.46,,Hospital 20902,Bone Graft Any Donor Area Major/Large,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,97138.22,N/A,58282.93,N/A,13599.37,N/A,14992.70,N/A,55538.88,N/A,33027.00,N/A,29774.67,N/A,13599.37,N/A,13647.65,N/A,13647.65,N/A,18533.96,N/A,29774.67,N/A,29774.67,N/A,29774.67,N/A,55538.87,N/A,13647.65,N/A,13599.37,N/A,10535.75,N/A,10535.75,N/A,13599.37,N/A,13647.65,N/A,14992.70,N/A,1246.07,N/A,N/A,1246.07,58282.93,,Hospital 20912,Cartilage Graft Nasal Septum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40133.43,N/A,24080.06,N/A,5618.68,N/A,1402.32,N/A,23104.86,N/A,13645.37,N/A,10681.92,N/A,5618.68,N/A,4406.44,N/A,4406.44,N/A,6649.70,N/A,10681.92,N/A,10681.92,N/A,10681.92,N/A,23104.85,N/A,4406.44,N/A,5618.68,N/A,6843.00,N/A,6843.00,N/A,5618.68,N/A,4406.44,N/A,1402.32,N/A,1542.56,N/A,N/A,1402.32,24080.06,,Hospital 20926,Remv Tissue for Graft Othr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,84840.42,N/A,50904.25,N/A,11877.64,N/A,6178.06,N/A,48612.75,N/A,28795.02,N/A,15424.94,N/A,11877.64,N/A,5973.28,N/A,5973.28,N/A,9602.31,N/A,15424.94,N/A,15424.94,N/A,15424.94,N/A,48612.75,N/A,5973.28,N/A,11877.64,N/A,8944.50,N/A,8944.50,N/A,11877.64,N/A,5973.28,N/A,6178.06,N/A,584.61,N/A,N/A,584.61,50904.25,,Hospital 20931,Allograft for Spine Surgery Only Structural,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,88832.87,54267.23,53299.72,32560.34,16382.62,7568.97,18700.42,11782.94,47810.35,31039.72,30203.18,18450.83,37062.76,28536.89,16887.40,7568.97,11933.08,11782.94,11933.08,11782.94,23070.70,17764.77,37062.76,28536.89,37062.76,28536.89,37062.76,28536.89,47810.35,31039.71,18641.12,11782.94,16887.40,7568.97,44095.43,13336.25,44095.43,13336.25,N/A,7568.97,18641.12,11782.94,18700.42,11782.94,18069.51,12961.23,11933.08,53299.72,7568.97,32560.34,,Hospital 20936,Autograft Spine Surgery Local From Same Incision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,154035.30,67133.20,92421.18,40279.92,14881.62,9372.31,17868.86,11782.94,84904.26,38457.80,52372.00,22825.26,45707.94,28590.87,15340.14,9372.31,562.00,11782.94,562.00,11782.94,28452.13,17798.36,45707.94,28590.87,45707.94,28590.87,45707.94,28590.87,84904.26,38457.79,17868.86,11782.94,15340.14,9372.31,54381.04,12019.00,54381.04,12019.00,15340.14,9372.31,17868.86,11782.94,17868.86,11782.94,16413.95,12961.23,562.00,92421.18,9372.31,40279.92,,Hospital 20937,Autograft Spine Surgery Morselized Sep Incision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,141690.28,102949.57,85014.17,61769.74,25542.16,14389.17,30480.71,11933.08,78099.68,58809.21,48174.70,35002.86,58111.96,29164.58,26329.16,14389.17,562.00,11933.08,562.00,11933.08,36173.34,18351.52,58111.96,29164.58,58111.96,29164.58,58111.96,29164.58,78099.68,58068.18,30480.71,11956.02,26329.16,14389.17,69138.72,12369.25,69138.72,12369.25,2688.70,14389.17,30480.71,11933.08,30480.71,11933.08,28172.20,13126.38,562.00,85014.17,11933.08,61769.74,,Hospital 20962,Bone Grf W/Mvasc Anast Oth/Thn Iliac Crest/Metar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27178.28,N/A,16306.97,N/A,3746.84,N/A,6132.82,N/A,15639.49,N/A,9240.62,N/A,27178.29,N/A,3746.84,N/A,5973.28,N/A,5973.28,N/A,17995.14,N/A,27178.29,N/A,27178.29,N/A,27178.29,N/A,15639.49,N/A,5973.28,N/A,3746.84,N/A,8601.75,N/A,8601.75,N/A,3746.84,N/A,5973.28,N/A,6132.82,N/A,3813.07,N/A,N/A,3746.84,27178.29,,Hospital 20970,Free Ostq Flap W/Mvasc Anastomosis Iliac Crest,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,192276.92,N/A,115366.15,N/A,16384.53,N/A,16152.22,N/A,105983.03,N/A,65374.14,N/A,66950.82,N/A,13069.98,N/A,527156.00,N/A,527156.00,N/A,41685.63,N/A,66950.82,N/A,66950.82,N/A,66950.82,N/A,105983.03,N/A,16122.57,N/A,13069.98,N/A,26741.44,N/A,26741.44,N/A,11531.24,N/A,16122.57,N/A,16152.22,N/A,13984.88,N/A,11531.24,527156.00,N/A,N/A,,Hospital 20974,HC Electrical Stimulation Bone Healing Noninvasive,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,194.00,N/A,116.40,N/A,27.16,N/A,46.24,N/A,111.71,N/A,65.96,N/A,N/A,N/A,27.16,N/A,46.24,N/A,46.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,111.71,N/A,46.24,N/A,27.16,N/A,103.98,N/A,103.98,N/A,27.16,N/A,46.24,N/A,46.24,N/A,50.86,N/A,N/A,27.16,116.40,,Hospital 20985,Cptr-Asst Surgical Navigation Image-Less,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,91440.93,66522.47,54864.56,39913.48,10199.26,9298.47,11792.13,11951.38,48846.06,37946.75,31087.20,22617.65,23204.73,30214.80,10513.52,9298.47,562.00,11951.38,562.00,11951.38,14444.40,19030.14,23204.73,30214.80,23204.73,30214.80,23204.73,30214.80,48846.06,37946.77,12330.85,11977.96,10513.52,9298.47,27607.84,12507.25,27607.84,12507.25,10513.52,9298.47,12330.85,11951.38,12330.85,11951.38,11249.46,13146.51,562.00,54864.56,9298.47,39913.48,,Hospital 21011,Excision Tumor Soft Tiss Face/Scalp Subq <2cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14443.60,N/A,8666.16,N/A,2022.10,N/A,1382.32,N/A,8314.50,N/A,4910.82,N/A,3290.87,N/A,2022.10,N/A,1354.15,N/A,1354.15,N/A,2048.63,N/A,3290.87,N/A,3290.87,N/A,3290.87,N/A,8242.52,N/A,1354.15,N/A,2022.10,N/A,1694.50,N/A,1694.50,N/A,2022.10,N/A,1354.15,N/A,1382.32,N/A,462.17,N/A,N/A,462.17,8666.16,,Hospital 21016,Rad Resection Tumor Soft Tiss Face/Scalp 2 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23172.00,N/A,13903.20,N/A,3244.08,N/A,2381.29,N/A,13340.59,N/A,7878.48,N/A,5658.45,N/A,3244.08,N/A,2332.78,N/A,2332.78,N/A,3522.49,N/A,5658.45,N/A,5658.45,N/A,5658.45,N/A,13340.59,N/A,2332.78,N/A,3244.08,N/A,3397.00,N/A,3397.00,N/A,3244.08,N/A,2332.78,N/A,2381.29,N/A,1096.57,N/A,N/A,1096.57,13903.20,,Hospital 21031,Excision Torus Mandibularis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38051.92,N/A,22831.15,N/A,5327.27,N/A,2622.61,N/A,21878.81,N/A,12937.64,N/A,6273.89,N/A,5327.27,N/A,2569.18,N/A,2569.18,N/A,3905.63,N/A,6273.89,N/A,6273.89,N/A,6273.89,N/A,21878.82,N/A,2569.18,N/A,5327.27,N/A,5095.50,N/A,5095.50,N/A,5327.27,N/A,2569.18,N/A,2622.61,N/A,322.25,N/A,N/A,322.25,22831.15,,Hospital 21040,Excision Benign Tumor/Cyst Mandible Encl & Curt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30037.90,N/A,18022.74,N/A,4205.31,N/A,2733.05,N/A,17295.05,N/A,10212.89,N/A,6217.36,N/A,4205.31,N/A,2569.18,N/A,2569.18,N/A,3870.43,N/A,6217.36,N/A,6217.36,N/A,6217.36,N/A,17295.05,N/A,2569.18,N/A,4205.31,N/A,3660.50,N/A,3660.50,N/A,4205.31,N/A,2569.18,N/A,2733.05,N/A,420.71,N/A,N/A,420.71,18022.74,,Hospital CPT 21110,HC Appl Interdental Fixation Dev,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4149.00,4149.00,2489.40,2489.40,N/A,580.86,N/A,677.72,N/A,2388.99,N/A,1410.66,N/A,2381.13,N/A,580.86,N/A,677.72,N/A,677.72,N/A,1482.25,N/A,2381.13,N/A,2381.13,N/A,2381.13,N/A,2388.99,N/A,677.72,N/A,580.86,N/A,4149.00,N/A,4149.00,N/A,580.86,N/A,677.72,N/A,677.72,N/A,745.49,2489.40,2489.40,580.86,4149.00,,Hospital 21123,Geniop Sliding Agmntj W/Interposal Bone Grafts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,117268.18,N/A,70360.91,N/A,16402.86,N/A,8780.63,N/A,67143.27,N/A,39871.17,N/A,23401.13,N/A,16402.86,N/A,8752.88,N/A,8752.88,N/A,14567.66,N/A,23401.13,N/A,23401.13,N/A,23401.13,N/A,67143.27,N/A,8752.88,N/A,16402.86,N/A,10435.25,N/A,10435.25,N/A,16402.86,N/A,8752.88,N/A,8780.63,N/A,5855.22,N/A,N/A,5855.22,70360.91,,Hospital 21181,Rcnstj Contouring Benign Tumor Crnl Bones Xtrc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35593.48,N/A,21356.09,N/A,4965.67,N/A,5043.96,N/A,20493.63,N/A,12101.79,N/A,11689.55,N/A,4965.67,N/A,4821.94,N/A,4821.94,N/A,7276.94,N/A,11689.55,N/A,11689.55,N/A,11689.55,N/A,20493.63,N/A,4821.94,N/A,4965.67,N/A,3397.00,N/A,3397.00,N/A,4965.67,N/A,4821.94,N/A,5043.96,N/A,998.38,N/A,N/A,998.38,21356.09,,Hospital 21209,Osteoplasty Facial Bones Reduction,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49609.57,N/A,29765.74,N/A,6940.19,N/A,4922.21,N/A,28419.81,N/A,16867.25,N/A,11673.92,N/A,6940.19,N/A,4821.94,N/A,4821.94,N/A,7267.23,N/A,11673.92,N/A,11673.92,N/A,11673.92,N/A,28419.81,N/A,4821.94,N/A,6940.19,N/A,5963.00,N/A,5963.00,N/A,6940.19,N/A,4821.94,N/A,4922.21,N/A,1056.33,N/A,N/A,1056.33,29765.74,,Hospital 21210,Graft Bone Nasal/Maxillary/Malar Areas,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,96784.58,N/A,58070.75,N/A,13524.67,N/A,5043.96,N/A,55493.90,N/A,32906.75,N/A,11894.34,N/A,13524.67,N/A,7329.27,N/A,7329.27,N/A,7408.08,N/A,11894.34,N/A,11894.34,N/A,11894.34,N/A,55493.93,N/A,7329.27,N/A,13524.67,N/A,6226.50,N/A,6226.50,N/A,13524.67,N/A,7329.27,N/A,5043.96,N/A,833.01,N/A,N/A,833.01,58070.75,,Hospital 21249,Rcnstj Mandible/Maxl Endosteal Implant Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63681.50,N/A,38208.90,N/A,8907.38,N/A,5043.96,N/A,36664.38,N/A,21651.71,N/A,11699.77,N/A,8907.38,N/A,4821.94,N/A,4821.94,N/A,7283.32,N/A,11699.77,N/A,11699.77,N/A,11699.77,N/A,36664.39,N/A,4821.94,N/A,8907.38,N/A,5963.00,N/A,5963.00,N/A,8907.38,N/A,4821.94,N/A,5043.96,N/A,1179.85,N/A,N/A,1179.85,38208.90,,Hospital 21330,Open Tx Nasal Fx Comp W/Int&/Xtrnl Skeletal Fi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23912.37,N/A,14347.42,N/A,3347.73,N/A,675.27,N/A,13758.23,N/A,8061.85,N/A,11731.42,N/A,3347.73,N/A,4821.94,N/A,4821.94,N/A,7303.03,N/A,11731.42,N/A,11731.42,N/A,11731.42,N/A,13758.25,N/A,4821.94,N/A,3347.73,N/A,5944.75,N/A,5944.75,N/A,3347.73,N/A,4821.94,N/A,675.27,N/A,742.80,N/A,N/A,675.27,14347.42,,Hospital 21345,Closed Tx Nasomaxillary Complex Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26304.88,N/A,15782.93,N/A,3682.70,N/A,1267.12,N/A,15073.75,N/A,8943.67,N/A,3078.25,N/A,3682.70,N/A,1253.55,N/A,1253.55,N/A,1916.25,N/A,3078.25,N/A,3078.25,N/A,3078.25,N/A,15073.76,N/A,1253.55,N/A,3682.70,N/A,1871.00,N/A,1871.00,N/A,3682.70,N/A,1253.55,N/A,1267.12,N/A,668.00,N/A,N/A,668.00,15782.93,,Hospital 21355,Percutaneous Tx Malar Area Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17604.60,N/A,10562.76,N/A,2464.64,N/A,2597.00,N/A,10134.86,N/A,5590.86,N/A,6222.48,N/A,2464.64,N/A,2569.18,N/A,2569.18,N/A,3873.62,N/A,6222.48,N/A,6222.48,N/A,6222.48,N/A,10134.86,N/A,2569.18,N/A,2464.64,N/A,5963.00,N/A,5963.00,N/A,2464.64,N/A,2569.18,N/A,2597.00,N/A,342.08,N/A,N/A,342.08,10562.76,,Hospital 21387,Open Tx Orbital Floor Blowout Fx Combined Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82447.82,N/A,49468.69,N/A,11534.71,N/A,5043.96,N/A,47381.26,N/A,28032.29,N/A,11767.41,N/A,11534.71,N/A,4821.94,N/A,4821.94,N/A,7325.43,N/A,11767.41,N/A,11767.41,N/A,11767.41,N/A,47099.71,N/A,4821.94,N/A,11534.71,N/A,5963.00,N/A,5963.00,N/A,11534.71,N/A,4821.94,N/A,5043.96,N/A,884.24,N/A,N/A,884.24,49468.69,,Hospital 21401,Closed Tx Fx Orbit Except Blowout W/Manipulation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10723.90,N/A,6434.34,N/A,1501.35,N/A,1242.72,N/A,6171.56,N/A,3646.13,N/A,3063.20,N/A,1501.35,N/A,1253.55,N/A,1253.55,N/A,1906.89,N/A,3063.20,N/A,3063.20,N/A,3063.20,N/A,6171.57,N/A,1253.55,N/A,1501.35,N/A,1871.00,N/A,1871.00,N/A,1501.35,N/A,1253.55,N/A,1242.72,N/A,337.82,N/A,N/A,337.82,6434.34,,Hospital 21406,Open Tx Fx Orbit Except Blowout W/O Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44529.90,N/A,26717.94,N/A,6234.18,N/A,5043.96,N/A,25558.55,N/A,15140.17,N/A,11695.34,N/A,6234.18,N/A,4821.94,N/A,4821.94,N/A,7280.57,N/A,11695.34,N/A,11695.34,N/A,11695.34,N/A,25495.22,N/A,4821.94,N/A,6234.18,N/A,8944.50,N/A,8944.50,N/A,6234.18,N/A,4821.94,N/A,5043.96,N/A,1779.54,N/A,N/A,1779.54,26717.94,,Hospital 21421,Closed Tx Palatal/Maxillary Fx W/Fixation/Splint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20043.80,N/A,12026.28,N/A,2835.07,N/A,2687.47,N/A,11538.06,N/A,6814.89,N/A,6257.63,N/A,2835.07,N/A,2569.18,N/A,2569.18,N/A,3895.50,N/A,6257.63,N/A,6257.63,N/A,6257.63,N/A,11538.06,N/A,2569.18,N/A,2835.07,N/A,5563.25,N/A,5563.25,N/A,2835.07,N/A,2569.18,N/A,2687.47,N/A,843.70,N/A,N/A,843.70,12026.28,,Hospital 21432,Open Tx Craniofacial Sep W/Wiring&/Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,88809.37,N/A,53285.62,N/A,12433.30,N/A,6513.88,N/A,50946.38,N/A,30195.18,N/A,17914.91,N/A,12433.30,N/A,6493.40,N/A,6493.40,N/A,11152.39,N/A,17914.91,N/A,17914.91,N/A,17914.91,N/A,50946.38,N/A,6493.40,N/A,12433.30,N/A,6898.50,N/A,6898.50,N/A,12433.30,N/A,6493.40,N/A,6513.88,N/A,850.47,N/A,N/A,850.47,53285.62,,Hospital 21453,Closed Tx Mandibular Fx W/Interdental Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31193.08,N/A,18715.85,N/A,4367.03,N/A,4874.16,N/A,17808.92,N/A,10605.66,N/A,11684.80,N/A,4367.03,N/A,4821.94,N/A,4821.94,N/A,7274.01,N/A,11684.80,N/A,11684.80,N/A,11684.80,N/A,17778.69,N/A,4821.94,N/A,4367.03,N/A,5963.00,N/A,5963.00,N/A,4367.03,N/A,4821.94,N/A,4874.16,N/A,961.62,N/A,N/A,961.62,18715.85,,Hospital 21470,Optx Comp Mandibular Fx Mlt Appr W/Int Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43807.78,N/A,26284.67,N/A,6162.02,N/A,5129.50,N/A,25106.61,N/A,14894.66,N/A,11713.06,N/A,6162.02,N/A,4821.94,N/A,4821.94,N/A,7291.59,N/A,11713.06,N/A,11713.06,N/A,11713.06,N/A,24737.52,N/A,4821.94,N/A,6162.02,N/A,8944.50,N/A,8944.50,N/A,6162.02,N/A,4821.94,N/A,5129.50,N/A,1317.13,N/A,N/A,1317.13,26284.67,,Hospital 21499,Unlisted Musculoskeletal Procedure Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17660.30,N/A,10596.18,N/A,2476.35,N/A,1440.53,N/A,10163.64,N/A,6004.50,N/A,3301.70,N/A,2476.35,N/A,1354.15,N/A,1354.15,N/A,2055.37,N/A,3301.70,N/A,3301.70,N/A,3301.70,N/A,10163.64,N/A,1354.15,N/A,2476.35,N/A,2266.25,N/A,2266.25,N/A,2476.35,N/A,1354.15,N/A,1440.53,N/A,598.18,N/A,N/A,598.18,10596.18,,Hospital CPT 21552,Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,N/A,N/A,894.00,894.00,536.40,536.40,N/A,125.16,N/A,428.14,N/A,894.00,N/A,303.96,N/A,894.00,N/A,125.16,N/A,428.14,N/A,428.14,N/A,794.40,N/A,894.00,N/A,894.00,N/A,894.00,N/A,894.00,N/A,428.14,N/A,125.16,N/A,894.00,N/A,894.00,N/A,125.16,N/A,428.14,N/A,428.14,N/A,470.95,536.40,536.40,125.16,894.00,,Hospital CPT 21556,Exc Tumor Soft Tiss Neck/Thorax Subfascial <5cm,N/A,N/A,1057.00,1057.00,634.20,634.20,N/A,147.98,N/A,507.72,N/A,1057.00,N/A,359.38,N/A,1057.00,N/A,147.98,N/A,507.72,N/A,507.72,N/A,943.57,N/A,1057.00,N/A,1057.00,N/A,1057.00,N/A,1057.00,N/A,507.72,N/A,147.98,N/A,1057.00,N/A,1057.00,N/A,147.98,N/A,507.72,N/A,507.72,N/A,558.49,634.20,634.20,147.98,1057.00,,Hospital 21601,Excision Chest Wall Tumor Including Ribs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22325.30,N/A,13395.18,N/A,3125.54,N/A,2440.19,N/A,12854.22,N/A,7590.60,N/A,5651.51,N/A,3125.54,N/A,2332.78,N/A,2332.78,N/A,3518.17,N/A,5651.51,N/A,5651.51,N/A,5651.51,N/A,12854.24,N/A,2332.78,N/A,3125.54,N/A,3397.00,N/A,3397.00,N/A,3125.54,N/A,2332.78,N/A,2440.19,N/A,1412.51,N/A,N/A,1412.51,13395.18,,Hospital 21920,Biopsy Soft Tissue Back/Flank Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19014.40,N/A,11408.64,N/A,2653.16,N/A,1416.50,N/A,10947.38,N/A,6464.90,N/A,3286.54,N/A,2653.16,N/A,1354.15,N/A,1354.15,N/A,2045.94,N/A,3286.54,N/A,3286.54,N/A,3286.54,N/A,10947.37,N/A,1354.15,N/A,2653.16,N/A,1431.00,N/A,1431.00,N/A,2653.16,N/A,1354.15,N/A,1416.50,N/A,369.25,N/A,N/A,369.25,11408.64,,Hospital 22102,Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Lmbr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48281.67,N/A,28969.00,N/A,6759.46,N/A,6248.31,N/A,27796.58,N/A,16415.78,N/A,14565.46,N/A,6759.46,N/A,5973.28,N/A,5973.28,N/A,9067.27,N/A,14565.46,N/A,14565.46,N/A,14565.46,N/A,27796.58,N/A,5973.28,N/A,6759.46,N/A,7897.00,N/A,7897.00,N/A,6759.46,N/A,5973.28,N/A,6248.31,N/A,832.79,N/A,N/A,832.79,28969.00,,Hospital 22327,Optx&/Rdctj Vrt Fx&/Dislc Pst 1 Vrt Sgm Th,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,426949.93,N/A,256169.96,N/A,26160.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,26160.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,26160.89,N/A,N/A,N/A,N/A,N/A,26160.89,N/A,N/A,N/A,N/A,N/A,26160.89,N/A,26160.89,256169.96,N/A,N/A,,Hospital 22585,Arthrd Ant Ntrbd Min Dsc Ea Addl Interspace,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,351473.97,72426.42,210884.38,43455.85,47947.37,10106.25,43110.40,11932.77,193732.45,41381.43,119501.14,24624.98,122383.23,29150.74,43500.73,10106.25,43051.10,11932.77,43051.10,11932.77,76199.55,18342.90,122383.23,29150.74,122383.23,29150.74,122383.23,29150.74,193732.45,41381.47,43051.10,11956.02,43500.73,10087.35,242662.12,13819.75,242662.12,13819.75,39358.89,10106.25,43051.10,11932.77,43110.40,11932.77,46545.78,13126.04,39358.89,242662.12,10087.35,43455.85,,Hospital 22586,Arthrodesis Presacral Ntrbdy Dsc W/Instrmj L5-S1,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,251515.32,N/A,150909.19,N/A,35212.13,N/A,14741.77,N/A,142306.89,N/A,85515.20,N/A,97047.16,N/A,35212.13,N/A,14741.00,N/A,14741.00,N/A,60413.75,N/A,97047.16,N/A,97047.16,N/A,97047.16,N/A,142306.90,N/A,14741.00,N/A,35212.13,N/A,17621.75,N/A,17621.75,N/A,35212.13,N/A,14741.00,N/A,14741.77,N/A,4112.56,N/A,N/A,4112.56,150909.19,,Hospital 22612,Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,140568.75,123322.82,84341.25,73993.69,20090.18,17213.95,24031.30,2932.13,77481.50,69914.52,47793.38,41929.76,45707.94,48716.64,20709.19,17213.95,24031.30,19943.19,24031.30,19943.19,28452.13,30547.91,45707.94,48716.64,45707.94,48716.64,45707.94,48716.64,77481.50,69914.54,24031.30,19969.46,20709.19,17213.95,54381.04,10309.75,54381.04,10309.75,2492.66,17213.95,24031.30,19943.19,24031.30,2932.13,22158.84,3219.22,2492.66,84341.25,2932.13,73993.69,,Hospital 22632,Arthrodesis Posterior Interbody 1 Ntrspc Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,177012.18,N/A,106207.31,N/A,24752.35,N/A,20138.73,N/A,100660.92,N/A,60184.16,N/A,48987.36,N/A,24752.35,N/A,19924.58,N/A,19924.58,N/A,30691.56,N/A,48987.36,N/A,48987.36,N/A,48987.36,N/A,97777.44,N/A,19947.52,N/A,24752.35,N/A,20531.21,N/A,14072.75,N/A,N/A,N/A,19924.58,N/A,20358.75,N/A,4349.45,N/A,N/A,4349.45,106207.31,,Hospital 22633,Arthrodesis Combined Tq 1ntrspc Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,167793.63,151582.67,100676.18,90949.60,32492.64,21180.64,38732.41,3619.72,92487.85,85872.30,57049.83,51229.73,73925.25,48496.15,33493.80,21180.64,134880.00,19924.58,134880.00,19924.58,46016.75,30385.79,73925.25,48496.15,73925.25,48496.15,73925.25,48496.15,92487.85,85872.32,38702.76,19947.52,33493.80,21180.64,87952.60,19049.75,87952.60,19049.75,7251.57,21180.64,38702.76,19924.58,38732.41,3619.72,35838.36,3981.70,7251.57,134880.00,3619.72,90949.60,,Hospital 22843,Posterior Segmental Instrumentation 7-12 Vrt Seg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,182159.40,N/A,109295.64,N/A,25448.49,N/A,3399.84,N/A,103345.25,N/A,61934.19,N/A,49774.75,N/A,25448.49,N/A,19924.58,N/A,19924.58,N/A,31181.74,N/A,49774.75,N/A,49774.75,N/A,49774.75,N/A,103345.27,N/A,19947.52,N/A,25448.49,N/A,19049.75,N/A,19049.75,N/A,25448.49,N/A,19924.58,N/A,3399.84,N/A,3733.71,N/A,N/A,3399.84,109295.64,,Hospital 22854,Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74280.03,N/A,44568.02,N/A,10283.64,N/A,11960.59,N/A,42429.82,N/A,24796.22,N/A,29162.06,N/A,10283.64,N/A,11960.59,N/A,11960.59,N/A,18349.95,N/A,29162.06,N/A,29162.06,N/A,29162.06,N/A,42429.89,N/A,11983.53,N/A,10283.64,N/A,13336.25,N/A,13336.25,N/A,10283.64,N/A,11960.59,N/A,11960.59,N/A,13156.64,N/A,N/A,10283.64,44568.02,,Hospital 22856,Total Disc Arthrp Ant Single Interspace Cervical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,153822.68,75813.62,92293.61,45488.17,19885.86,10613.90,21854.89,21427.27,84787.06,43064.19,52299.71,25776.62,43534.21,47927.18,20498.58,10613.90,21825.24,19774.44,21825.24,19774.44,27099.03,29835.60,43534.21,47927.18,43534.21,47927.18,43534.21,47927.18,84787.06,43064.20,21825.24,19774.44,20498.58,10613.90,51794.84,8160.50,51794.84,8160.50,4809.44,10613.90,21825.24,19774.44,21854.89,21427.27,21933.48,2295.92,4809.44,92293.61,2295.92,47927.18,,Hospital 22859,Insj Biomchn Dev Ntrvrt Disc Space W/O Arthrd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,143396.82,N/A,86038.09,N/A,19874.41,N/A,20354.11,N/A,81673.21,N/A,48754.94,N/A,48553.14,N/A,19874.41,N/A,19942.88,N/A,19942.88,N/A,30446.11,N/A,48553.14,N/A,48553.14,N/A,48553.14,N/A,81171.72,N/A,19969.46,N/A,19874.41,N/A,19049.75,N/A,19049.75,N/A,19874.41,N/A,19942.88,N/A,20354.11,N/A,3068.77,N/A,N/A,3068.77,86038.09,,Hospital CPT 22902,Exc Tumor Soft Tissue Abdominal Wall Subq <3cm,N/A,N/A,785.00,785.00,471.00,471.00,N/A,109.90,N/A,317.75,N/A,785.00,N/A,266.90,N/A,785.00,N/A,109.90,N/A,317.75,N/A,317.75,N/A,785.00,N/A,785.00,N/A,785.00,N/A,785.00,N/A,785.00,N/A,317.75,N/A,109.90,N/A,785.00,N/A,785.00,N/A,109.90,N/A,317.75,N/A,317.75,N/A,349.53,471.00,471.00,109.90,785.00,,Hospital 22999,Unlisted Px Abdomen Musculoskeletal System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,84217.13,67523.30,50530.28,40513.98,8404.69,9383.82,10207.96,1131.21,23655.46,38828.86,28633.83,22957.91,19121.84,13138.45,8663.66,9383.82,562.00,5366.90,562.00,5366.90,11902.90,8178.92,19121.84,13138.45,19121.84,13138.45,19121.84,13138.45,23655.46,38828.90,10207.96,5366.90,8663.66,9383.82,22750.22,6358.25,22750.22,6358.25,N/A,9383.82,10207.96,5366.90,10207.96,1131.21,9270.11,1244.34,562.00,50530.28,1131.21,40513.98,,Hospital 23000,Removal Subdeltoid Calcareous Deposits Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,73712.90,N/A,44227.74,N/A,12576.90,N/A,15143.47,N/A,41824.62,N/A,24969.29,N/A,28614.19,N/A,12964.42,N/A,562.00,N/A,562.00,N/A,17811.67,N/A,28614.19,N/A,28614.19,N/A,28614.19,N/A,41824.62,N/A,15143.47,N/A,12964.42,N/A,34043.74,N/A,34043.74,N/A,N/A,N/A,15143.47,N/A,15143.47,N/A,13871.93,N/A,562.00,44227.74,N/A,N/A,,Hospital 23031,I&D Shoulder Infected Bursa,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26702.30,N/A,16021.38,N/A,3642.82,N/A,2440.19,N/A,15373.10,N/A,9039.00,N/A,5696.22,N/A,3642.82,N/A,2332.78,N/A,2332.78,N/A,3546.01,N/A,5696.22,N/A,5696.22,N/A,5696.22,N/A,15366.93,N/A,2332.78,N/A,3642.82,N/A,3397.00,N/A,3397.00,N/A,3642.82,N/A,2332.78,N/A,2440.19,N/A,310.40,N/A,N/A,310.40,16021.38,,Hospital 23065,Biopsy Soft Tissue Shoulder Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27310.30,N/A,16386.18,N/A,3737.55,N/A,1416.50,N/A,15721.67,N/A,9285.51,N/A,3334.77,N/A,3737.55,N/A,1354.15,N/A,1354.15,N/A,2075.95,N/A,3334.77,N/A,3334.77,N/A,3334.77,N/A,15721.68,N/A,1354.15,N/A,3737.55,N/A,1431.00,N/A,1431.00,N/A,3737.55,N/A,1354.15,N/A,1416.50,N/A,265.29,N/A,N/A,265.29,16386.18,,Hospital 23071,Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17288.63,N/A,10373.18,N/A,2418.57,N/A,435.24,N/A,9950.04,N/A,5878.14,N/A,3305.92,N/A,2418.57,N/A,1354.15,N/A,1354.15,N/A,2058.00,N/A,3305.92,N/A,3305.92,N/A,3305.92,N/A,9950.05,N/A,1354.15,N/A,2418.57,N/A,3397.00,N/A,3397.00,N/A,2418.57,N/A,1354.15,N/A,435.24,N/A,478.77,N/A,N/A,435.24,10373.18,,Hospital 23075,Excision Tumor Soft Tissue Shoulder Subq <3cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12256.30,N/A,7353.78,N/A,1715.90,N/A,1368.82,N/A,7054.44,N/A,4167.15,N/A,3304.13,N/A,1715.90,N/A,1354.15,N/A,1354.15,N/A,2056.88,N/A,3304.13,N/A,3304.13,N/A,3304.13,N/A,6993.98,N/A,1354.15,N/A,1715.90,N/A,4800.25,N/A,4800.25,N/A,1715.90,N/A,1354.15,N/A,1368.82,N/A,1266.23,N/A,N/A,1266.23,7353.78,,Hospital 23076,Exc Tumor Soft Tiss Shoulder Subfasc <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11993.90,N/A,7196.34,N/A,1679.15,N/A,2440.19,N/A,6904.80,N/A,4077.93,N/A,5658.92,N/A,1679.15,N/A,2332.78,N/A,2332.78,N/A,3522.79,N/A,5658.92,N/A,5658.92,N/A,5658.92,N/A,6904.80,N/A,2332.78,N/A,1679.15,N/A,1871.00,N/A,1871.00,N/A,1679.15,N/A,2332.78,N/A,2440.19,N/A,599.66,N/A,N/A,599.66,7196.34,,Hospital 23125,Claviculectomy Total,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31695.70,N/A,19017.42,N/A,4437.41,N/A,1468.92,N/A,11735.00,N/A,10776.54,N/A,6614.45,N/A,4437.41,N/A,2688.04,N/A,2688.04,N/A,4117.61,N/A,6614.45,N/A,6614.45,N/A,6614.45,N/A,11735.00,N/A,2688.04,N/A,4437.41,N/A,10535.75,N/A,10535.75,N/A,4437.41,N/A,2688.04,N/A,1468.92,N/A,1615.82,N/A,N/A,1468.92,19017.42,,Hospital 23140,Exc/Curtg Bone Cyst/Benign Tumor Clav/Scapula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22589.50,N/A,13553.70,N/A,3152.83,N/A,2688.04,N/A,13001.43,N/A,7680.43,N/A,6592.15,N/A,3152.83,N/A,2688.04,N/A,2688.04,N/A,4103.74,N/A,6592.15,N/A,6592.15,N/A,6592.15,N/A,13001.44,N/A,2688.04,N/A,3152.83,N/A,4112.50,N/A,4112.50,N/A,3152.83,N/A,2688.04,N/A,2688.04,N/A,2956.85,N/A,N/A,2688.04,13553.70,,Hospital 23156,Exc/Curtg Bone Cyst/Benign Tum Prox Hum W/Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35395.10,N/A,21237.06,N/A,4891.11,N/A,6248.31,N/A,20352.16,N/A,12034.33,N/A,14468.73,N/A,4891.11,N/A,5973.28,N/A,5973.28,N/A,9007.06,N/A,14468.73,N/A,14468.73,N/A,14468.73,N/A,20352.15,N/A,5973.28,N/A,4891.11,N/A,5277.50,N/A,5277.50,N/A,4891.11,N/A,5973.28,N/A,6248.31,N/A,1078.22,N/A,N/A,1078.22,21237.06,,Hospital 23190,Ostectomy Scapula Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34893.00,N/A,20935.80,N/A,4885.03,N/A,2811.81,N/A,20089.49,N/A,11863.62,N/A,6521.37,N/A,4885.03,N/A,2688.04,N/A,2688.04,N/A,4059.68,N/A,6521.37,N/A,6521.37,N/A,6521.37,N/A,20089.48,N/A,2688.04,N/A,4885.03,N/A,5277.50,N/A,4562.00,N/A,4885.03,N/A,2688.04,N/A,2811.81,N/A,697.33,N/A,N/A,697.33,20935.80,,Hospital 23333,Removal Shoulder Foreign Body Deep Subfascial/Im,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9782.40,N/A,5869.44,N/A,1370.85,N/A,2358.04,N/A,5630.28,N/A,3326.01,N/A,5665.50,N/A,1370.85,N/A,2332.78,N/A,2332.78,N/A,3526.89,N/A,5665.50,N/A,5665.50,N/A,5665.50,N/A,5630.28,N/A,2332.78,N/A,1370.85,N/A,1431.00,N/A,1431.00,N/A,1370.85,N/A,2332.78,N/A,2358.04,N/A,497.64,N/A,N/A,497.64,5869.44,,Hospital 23335,Prosthesis Removal Humeral and Glenoid Component,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68445.83,N/A,41067.50,N/A,9510.90,N/A,6248.31,N/A,11735.00,N/A,23271.59,N/A,21194.24,N/A,9510.90,N/A,5973.28,N/A,5973.28,N/A,13193.70,N/A,21194.24,N/A,21194.24,N/A,21194.24,N/A,11735.00,N/A,5973.28,N/A,9510.90,N/A,12694.75,N/A,12694.75,N/A,9510.90,N/A,5973.28,N/A,6248.31,N/A,2587.16,N/A,N/A,2587.16,41067.50,,Hospital 23395,Muscle Transfer Shoulder/Upper Arm Single,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,97009.88,N/A,58205.93,N/A,13581.39,N/A,12534.51,N/A,55342.42,N/A,32983.37,N/A,29082.36,N/A,13581.39,N/A,11782.94,N/A,11782.94,N/A,18104.34,N/A,29082.36,N/A,29082.36,N/A,29082.36,N/A,55342.42,N/A,11782.94,N/A,13581.39,N/A,14999.25,N/A,14999.25,N/A,13581.39,N/A,11782.94,N/A,12534.51,N/A,2927.96,N/A,N/A,2927.96,58205.93,,Hospital CPT 23412,Open Repair of Rotator Cuff Chronic,N/A,N/A,1697.00,1697.00,1018.20,1018.20,N/A,237.58,N/A,812.34,N/A,1697.00,N/A,576.98,N/A,1697.00,N/A,237.58,N/A,812.34,N/A,812.34,N/A,1511.97,N/A,1697.00,N/A,1697.00,N/A,1697.00,N/A,1697.00,N/A,812.34,N/A,237.58,N/A,1697.00,N/A,1697.00,N/A,237.58,N/A,812.34,N/A,812.34,N/A,893.57,1018.20,1018.20,237.58,1697.00,,Hospital 23415,Coracoacromial Ligament Releas W/Woacromioplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34427.57,N/A,20656.54,N/A,4819.86,N/A,6248.31,N/A,11735.00,N/A,11705.37,N/A,14501.32,N/A,4819.86,N/A,5973.28,N/A,5973.28,N/A,9027.33,N/A,14501.32,N/A,14501.32,N/A,14501.32,N/A,11735.00,N/A,5973.28,N/A,4819.86,N/A,9384.50,N/A,9384.50,N/A,4819.86,N/A,5973.28,N/A,6248.31,N/A,1978.91,N/A,N/A,1978.91,20656.54,,Hospital 23455,Capsulorrhaphy Anterior W/Labral Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54744.22,N/A,32846.53,N/A,7664.20,N/A,1010.37,N/A,31278.63,N/A,18612.78,N/A,14516.60,N/A,7664.20,N/A,5973.28,N/A,5973.28,N/A,9036.86,N/A,14516.60,N/A,14516.60,N/A,14516.60,N/A,31278.66,N/A,5973.28,N/A,7664.20,N/A,8612.50,N/A,8612.50,N/A,7664.20,N/A,5973.28,N/A,1010.37,N/A,1111.41,N/A,N/A,1010.37,32846.53,,Hospital 23462,Capsulorrhaphy Anterior W/Coracoid Process Tr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61984.48,N/A,37190.69,N/A,8677.82,N/A,6248.31,N/A,35646.81,N/A,21074.71,N/A,14944.23,N/A,8677.82,N/A,5973.28,N/A,5973.28,N/A,9310.07,N/A,14944.23,N/A,14944.23,N/A,14944.23,N/A,35646.82,N/A,5973.28,N/A,8677.82,N/A,7256.25,N/A,7256.25,N/A,8677.82,N/A,5973.28,N/A,6248.31,N/A,1945.65,N/A,N/A,1945.65,37190.69,,Hospital 23466,Capsulorrhaphy Glenohumrl Jt Multi-Dirional Ins,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49134.43,N/A,29480.66,N/A,6878.81,N/A,6472.55,N/A,11735.00,N/A,16705.71,N/A,14577.10,N/A,6878.81,N/A,5973.28,N/A,5973.28,N/A,9074.52,N/A,14577.10,N/A,14577.10,N/A,14577.10,N/A,11735.00,N/A,5973.28,N/A,6878.81,N/A,13336.25,N/A,13336.25,N/A,6878.81,N/A,5973.28,N/A,6472.55,N/A,2932.91,N/A,N/A,2932.91,29480.66,,Hospital CPT 23540,HC Treat Clavicle Disloc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,222.93,N/A,327.05,N/A,193.12,N/A,568.00,N/A,79.52,N/A,222.93,N/A,222.93,N/A,427.15,N/A,568.00,N/A,568.00,N/A,568.00,N/A,327.05,N/A,222.93,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,222.93,N/A,222.93,N/A,245.22,340.80,340.80,79.52,568.00,,Hospital 23552,Optx Acromclav Dislc Acute/Chronic W/Fascial Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74193.80,N/A,44516.28,N/A,10387.13,N/A,6248.31,N/A,11735.00,N/A,25225.88,N/A,14626.90,N/A,10387.13,N/A,5973.28,N/A,5973.28,N/A,9114.85,N/A,14626.90,N/A,14626.90,N/A,14626.90,N/A,11735.00,N/A,5973.28,N/A,10387.13,N/A,10535.75,N/A,10535.75,N/A,10387.13,N/A,5973.28,N/A,6248.31,N/A,1319.77,N/A,N/A,1319.77,44516.28,,Hospital 23660,Open Tx Acute Shoulder Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59646.30,N/A,35787.78,N/A,8350.48,N/A,1197.53,N/A,33922.55,N/A,20264.44,N/A,14512.72,N/A,8350.48,N/A,5973.28,N/A,5973.28,N/A,9034.44,N/A,14512.72,N/A,14512.72,N/A,14512.72,N/A,33922.54,N/A,5973.28,N/A,8350.48,N/A,10535.75,N/A,10535.75,N/A,8350.48,N/A,5973.28,N/A,1197.53,N/A,1317.28,N/A,N/A,1197.53,35787.78,,Hospital 23670,Optx Sho Dislc W/Fx Gr Humeral Tubrst Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34607.65,N/A,20764.59,N/A,4845.07,N/A,6248.31,N/A,19913.51,N/A,11766.60,N/A,14459.05,N/A,4845.07,N/A,5973.28,N/A,5973.28,N/A,9001.04,N/A,14459.05,N/A,14459.05,N/A,14459.05,N/A,19913.51,N/A,5973.28,N/A,4845.07,N/A,8612.50,N/A,8612.50,N/A,4845.07,N/A,5973.28,N/A,6248.31,N/A,978.98,N/A,N/A,978.98,20764.59,,Hospital 23700,Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10365.60,N/A,6219.36,N/A,1441.48,N/A,1295.43,N/A,5964.29,N/A,3524.30,N/A,3185.59,N/A,1441.48,N/A,1295.43,N/A,1295.43,N/A,1983.09,N/A,3185.59,N/A,3185.59,N/A,3185.59,N/A,5964.29,N/A,1295.43,N/A,1441.48,N/A,2586.50,N/A,2586.50,N/A,1441.48,N/A,1295.43,N/A,1295.43,N/A,1424.97,N/A,N/A,1295.43,6219.36,,Hospital CPT 23930,HC Drain Arm Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,6533.00,6533.00,3919.80,3919.80,N/A,914.62,N/A,205.12,N/A,3761.70,N/A,2221.22,N/A,1004.01,N/A,914.62,N/A,205.12,N/A,205.12,N/A,625.00,N/A,1004.01,N/A,1004.01,N/A,1004.01,N/A,3761.70,N/A,205.12,N/A,914.62,N/A,6533.00,N/A,6533.00,N/A,914.62,N/A,205.12,N/A,205.12,N/A,225.63,3919.80,3919.80,205.12,6533.00,,Hospital CPT 24071,Exc Tumor Soft Tissue Upper Arm/Elbow Subq 3cm/>,N/A,N/A,811.00,811.00,486.60,486.60,N/A,113.54,N/A,388.15,N/A,811.00,N/A,275.74,N/A,811.00,N/A,113.54,N/A,388.15,N/A,388.15,N/A,719.59,N/A,811.00,N/A,811.00,N/A,811.00,N/A,811.00,N/A,388.15,N/A,113.54,N/A,811.00,N/A,811.00,N/A,113.54,N/A,388.15,N/A,388.15,N/A,426.97,486.60,486.60,113.54,811.00,,Hospital 24101,Arthrt Elbow W/Jt Expl W/Wobx W/O Rmvl Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27184.55,N/A,16310.73,N/A,3805.84,N/A,578.23,N/A,15645.73,N/A,9242.75,N/A,6568.77,N/A,3805.84,N/A,2688.04,N/A,2688.04,N/A,4089.18,N/A,6568.77,N/A,6568.77,N/A,6568.77,N/A,15645.74,N/A,2688.04,N/A,3805.84,N/A,5277.50,N/A,5277.50,N/A,3805.84,N/A,2688.04,N/A,578.23,N/A,636.06,N/A,N/A,578.23,16310.73,,Hospital 24105,Excision Olecranon Bursa,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19482.50,N/A,11689.50,N/A,2727.55,N/A,2759.84,N/A,11215.44,N/A,6624.06,N/A,6533.87,N/A,2727.55,N/A,2688.04,N/A,2688.04,N/A,4067.46,N/A,6533.87,N/A,6533.87,N/A,6533.87,N/A,11215.44,N/A,2688.04,N/A,2727.55,N/A,4112.50,N/A,4112.50,N/A,2727.55,N/A,2688.04,N/A,2759.84,N/A,470.11,N/A,N/A,470.11,11689.50,,Hospital 24115,Exc/Curtg Bone Cyst/Benign Tumor Humerus W/Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,103029.10,N/A,61817.46,N/A,14371.70,N/A,12495.32,N/A,58898.08,N/A,35029.89,N/A,30046.82,N/A,14371.70,N/A,11932.77,N/A,11932.77,N/A,18900.72,N/A,30046.82,N/A,30046.82,N/A,30046.82,N/A,58898.08,N/A,11956.02,N/A,14371.70,N/A,14298.75,N/A,14298.75,N/A,14371.70,N/A,11952.78,N/A,12495.32,N/A,2855.22,N/A,N/A,2855.22,61817.46,,Hospital 24130,Excision Radial Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,107192.93,N/A,64315.76,N/A,14958.72,N/A,19753.77,N/A,60977.03,N/A,36445.59,N/A,48499.39,N/A,14958.72,N/A,19924.58,N/A,19924.58,N/A,30387.78,N/A,48499.39,N/A,48499.39,N/A,48499.39,N/A,59535.24,N/A,19947.52,N/A,14958.72,N/A,14790.25,N/A,14790.25,N/A,14958.72,N/A,19924.58,N/A,19753.77,N/A,3165.12,N/A,N/A,3165.12,64315.76,,Hospital 24147,Partial Excision Bone Olecranon Process,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27402.67,N/A,16441.60,N/A,3836.37,N/A,6262.60,N/A,15686.74,N/A,9316.90,N/A,14511.52,N/A,3836.37,N/A,5973.28,N/A,5973.28,N/A,9033.69,N/A,14511.52,N/A,14511.52,N/A,14511.52,N/A,15686.77,N/A,5973.28,N/A,3836.37,N/A,8601.75,N/A,8601.75,N/A,3836.37,N/A,5973.28,N/A,1398.68,N/A,1538.55,N/A,N/A,1398.68,16441.60,,Hospital 24164,Prosthesis Removal Radial Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17228.70,N/A,10337.22,N/A,2392.78,N/A,2664.83,N/A,9917.48,N/A,5791.62,N/A,6542.82,N/A,2392.78,N/A,2688.04,N/A,2688.04,N/A,4073.04,N/A,6542.82,N/A,6542.82,N/A,6542.82,N/A,9917.48,N/A,2688.04,N/A,2392.78,N/A,4562.00,N/A,4562.00,N/A,2392.78,N/A,2688.04,N/A,2664.83,N/A,834.39,N/A,N/A,834.39,10337.22,,Hospital 24201,Removal Foreign Body Upper Arm/Elbow Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26708.60,N/A,16025.16,N/A,3734.79,N/A,2481.57,N/A,15375.23,N/A,9080.93,N/A,5667.72,N/A,3734.79,N/A,2332.78,N/A,2332.78,N/A,3528.27,N/A,5667.72,N/A,5667.72,N/A,5667.72,N/A,15375.23,N/A,2332.78,N/A,3734.79,N/A,1871.00,N/A,1871.00,N/A,3734.79,N/A,2332.78,N/A,2481.57,N/A,392.51,N/A,N/A,392.51,16025.16,,Hospital 24305,Tendon Lengthening Upper Arm/Elbow Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24026.20,N/A,14415.72,N/A,3363.66,N/A,2811.81,N/A,13832.47,N/A,8168.91,N/A,6533.44,N/A,3363.66,N/A,2688.04,N/A,2688.04,N/A,4067.19,N/A,6533.44,N/A,6533.44,N/A,6533.44,N/A,13832.46,N/A,2688.04,N/A,3363.66,N/A,7109.75,N/A,7109.75,N/A,3363.66,N/A,2688.04,N/A,2811.81,N/A,1231.75,N/A,N/A,1231.75,14415.72,,Hospital 24343,Repair Lateral Collateral Ligament Elbow,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,71626.02,51191.12,42975.61,30714.67,7332.44,7166.76,12475.31,12027.98,25642.41,29386.68,24352.85,17404.99,16682.31,28556.30,7558.36,7166.76,162418.00,11782.94,162418.00,11782.94,10384.35,17776.84,16682.31,28556.30,16682.31,28556.30,16682.31,28556.30,25642.41,29386.68,8217.00,11782.94,7558.36,7166.76,19847.78,14298.75,19847.78,14298.75,N/A,7166.76,8217.00,11782.94,8246.65,12027.98,8087.45,1621.11,7332.44,162418.00,1621.11,30714.67,,Hospital 24360,Arthroplasty Elbow W/Membrane,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28693.00,N/A,17215.80,N/A,4018.89,N/A,6330.07,N/A,16519.36,N/A,9755.63,N/A,14475.51,N/A,4018.89,N/A,5973.28,N/A,5973.28,N/A,9011.28,N/A,14475.51,N/A,14475.51,N/A,14475.51,N/A,16519.37,N/A,5973.28,N/A,4018.89,N/A,8510.75,N/A,8510.75,N/A,4018.89,N/A,5973.28,N/A,6330.07,N/A,2428.47,N/A,N/A,2428.47,17215.80,,Hospital 24362,Arthrp Elbow W/Implt&Fsca Lata Ligament Rcnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59496.70,N/A,35698.02,N/A,8317.26,N/A,11681.16,N/A,33929.85,N/A,20228.87,N/A,28545.68,N/A,8317.26,N/A,11782.94,N/A,11782.94,N/A,17770.24,N/A,28545.68,N/A,28545.68,N/A,28545.68,N/A,33929.85,N/A,11782.94,N/A,8317.26,N/A,6898.50,N/A,6898.50,N/A,8317.26,N/A,11782.94,N/A,11681.16,N/A,1939.01,N/A,N/A,1939.01,35698.02,,Hospital 24371,Revis Elbow Arthrplsty Humeral&Ulna Compnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83380.30,N/A,50028.18,N/A,11663.44,N/A,1791.57,N/A,47522.53,N/A,28349.30,N/A,47935.88,N/A,11663.44,N/A,19774.44,N/A,19774.44,N/A,29841.00,N/A,47935.88,N/A,47935.88,N/A,47935.88,N/A,47522.53,N/A,19774.44,N/A,11663.44,N/A,12375.50,N/A,12375.50,N/A,11663.44,N/A,19774.44,N/A,1791.57,N/A,1970.73,N/A,N/A,1791.57,50028.18,,Hospital 24430,Repair Non/Malunion Humerus W/O Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56866.50,N/A,34119.90,N/A,7917.57,N/A,11933.08,N/A,32521.31,N/A,19334.61,N/A,29125.30,N/A,7917.57,N/A,11933.08,N/A,11933.08,N/A,18327.07,N/A,29125.30,N/A,29125.30,N/A,29125.30,N/A,32265.13,N/A,11956.02,N/A,7917.57,N/A,8612.50,N/A,8612.50,N/A,7917.57,N/A,11933.08,N/A,11933.08,N/A,13126.38,N/A,N/A,7917.57,34119.90,,Hospital CPT 24505,HC Clsd Tx Hum Shaft Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,431.53,N/A,979.44,N/A,578.34,N/A,1438.68,N/A,238.14,N/A,431.53,N/A,431.53,N/A,895.58,N/A,1438.68,N/A,1438.68,N/A,1438.68,N/A,979.44,N/A,431.53,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,431.53,N/A,431.53,N/A,474.68,1020.60,1020.60,238.14,1701.00,,Hospital 24515,Optx Humeral Shft Fx W/Plate/Screws W/Wocerclage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32690.72,N/A,19614.43,N/A,4576.71,N/A,11782.94,N/A,18711.21,N/A,11114.85,N/A,28518.25,N/A,4576.71,N/A,11782.94,N/A,11782.94,N/A,17753.16,N/A,28518.25,N/A,28518.25,N/A,28518.25,N/A,18711.20,N/A,11782.94,N/A,4576.71,N/A,7897.00,N/A,7897.00,N/A,4576.71,N/A,11782.94,N/A,11782.94,N/A,12961.23,N/A,N/A,4576.71,28518.25,,Hospital 24545,Open Tx Humeral Supracondylar Fracture W/O Xtn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58439.93,N/A,35063.96,N/A,8180.31,N/A,12997.98,N/A,33333.43,N/A,19775.19,N/A,28578.64,N/A,8180.31,N/A,11782.94,N/A,11782.94,N/A,17790.76,N/A,28578.64,N/A,28578.64,N/A,28578.64,N/A,33333.44,N/A,11782.94,N/A,8180.31,N/A,7897.00,N/A,7897.00,N/A,8180.31,N/A,11782.94,N/A,913.36,N/A,1004.70,N/A,N/A,913.36,35063.96,,Hospital CPT 24565,HC ED Clsd Tx Hum Epicndyl Fx Man,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,470.47,N/A,979.44,N/A,578.34,N/A,1544.88,N/A,238.14,N/A,470.47,N/A,470.47,N/A,961.69,N/A,1544.88,N/A,1544.88,N/A,1544.88,N/A,979.44,N/A,470.47,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,470.47,N/A,470.47,N/A,517.52,1020.60,1020.60,238.14,1701.00,,Hospital 24575,Open Tx Humeral Epicondylar Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38915.47,N/A,23349.28,N/A,5448.17,N/A,782.73,N/A,22345.29,N/A,13230.99,N/A,28532.26,N/A,5448.17,N/A,11782.94,N/A,11782.94,N/A,17761.87,N/A,28532.26,N/A,28532.26,N/A,28532.26,N/A,22345.30,N/A,11782.94,N/A,5448.17,N/A,8612.50,N/A,8612.50,N/A,5448.17,N/A,11782.94,N/A,782.73,N/A,861.01,N/A,N/A,782.73,28532.26,,Hospital 24587,Optx Priarticular Fx&/Dislc Elbw W/Implt Arthr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,96918.93,N/A,58151.36,N/A,10557.21,N/A,12060.69,N/A,48316.64,N/A,32952.43,N/A,24019.12,N/A,10882.50,N/A,166352.00,N/A,166352.00,N/A,14951.35,N/A,24019.12,N/A,24019.12,N/A,24019.12,N/A,48316.64,N/A,12754.28,N/A,10882.50,N/A,28576.76,N/A,28576.76,N/A,N/A,N/A,12754.28,N/A,12783.93,N/A,11644.28,N/A,10557.21,166352.00,N/A,N/A,,Hospital 24665,Open Tx Radial Head/Neck Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54769.05,N/A,32861.43,N/A,7667.68,N/A,1723.37,N/A,31290.04,N/A,18621.46,N/A,28553.96,N/A,7667.68,N/A,11782.94,N/A,11782.94,N/A,17775.37,N/A,28553.96,N/A,28553.96,N/A,28553.96,N/A,31290.06,N/A,11782.94,N/A,7667.68,N/A,12203.25,N/A,12203.25,N/A,7667.68,N/A,11782.94,N/A,1723.37,N/A,1895.70,N/A,N/A,1723.37,32861.43,,Hospital CPT 24999,HC Unlisted Procedure Humerus/Elbow,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,518.00,518.00,310.80,310.80,N/A,72.52,N/A,518.00,N/A,298.26,N/A,176.12,N/A,72.52,N/A,72.52,N/A,518.00,N/A,518.00,N/A,45.07,N/A,72.52,N/A,72.52,N/A,72.52,N/A,298.26,N/A,518.00,N/A,72.52,N/A,518.00,N/A,518.00,N/A,72.52,N/A,518.00,N/A,518.00,N/A,518.00,310.80,310.80,45.07,518.00,,Hospital HCPCS 2500000003,CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,00338-1123-04,0250 - PHARMACY - GENERAL CLASSIFICATION,580.50,580.50,348.30,348.30,N/A,81.27,N/A,580.50,N/A,334.25,N/A,197.37,N/A,81.27,N/A,81.27,N/A,580.50,N/A,580.50,N/A,50.50,N/A,81.27,N/A,81.27,N/A,81.27,N/A,334.25,N/A,580.50,N/A,81.27,N/A,311.15,N/A,311.15,N/A,81.27,N/A,580.50,N/A,580.50,N/A,580.50,348.30,348.30,50.50,580.50,,Hospital HCPCS 2500000003,POTASSIUM ACETATE 2 MEQ/ML IV SOLN,00409-8183-01,0250 - PHARMACY - GENERAL CLASSIFICATION,23.40,23.40,14.04,14.04,N/A,3.28,N/A,23.40,N/A,13.47,N/A,7.96,N/A,3.28,N/A,3.28,N/A,23.40,N/A,23.40,N/A,2.04,N/A,3.28,N/A,3.28,N/A,3.28,N/A,13.47,N/A,23.40,N/A,3.28,N/A,12.54,N/A,12.54,N/A,3.28,N/A,23.40,N/A,23.40,N/A,23.40,14.04,14.04,2.04,23.40,,Hospital HCPCS 2500000003,SODIUM BICARBONATE 8.4 % IV SOLN,00409-6625-22,0250 - PHARMACY - GENERAL CLASSIFICATION,36.70,36.70,22.02,22.02,N/A,5.14,N/A,36.70,N/A,21.13,N/A,12.48,N/A,5.14,N/A,5.14,N/A,36.70,N/A,36.70,N/A,3.19,N/A,5.14,N/A,5.14,N/A,5.14,N/A,21.13,N/A,36.70,N/A,5.14,N/A,19.67,N/A,19.67,N/A,5.14,N/A,36.70,N/A,36.70,N/A,36.70,22.02,22.02,3.19,36.70,,Hospital HCPCS 2500000003,LACTATED RINGERS IR SOLN,00338-0137-27,0250 - PHARMACY - GENERAL CLASSIFICATION,121.50,121.50,72.90,72.90,N/A,17.01,N/A,121.50,N/A,69.96,N/A,41.31,N/A,17.01,N/A,17.01,N/A,121.50,N/A,121.50,N/A,10.57,N/A,17.01,N/A,17.01,N/A,17.01,N/A,69.96,N/A,121.50,N/A,17.01,N/A,65.12,N/A,65.12,N/A,17.01,N/A,121.50,N/A,121.50,N/A,121.50,72.90,72.90,10.57,121.50,,Hospital HCPCS 2500000003,NEOMYCIN-POLYMYXIN B GU 40-200000 IR SOLN,39822-1220-01,0250 - PHARMACY - GENERAL CLASSIFICATION,837.00,837.00,502.20,502.20,N/A,117.18,N/A,837.00,N/A,481.94,N/A,284.58,N/A,117.18,N/A,117.18,N/A,837.00,N/A,837.00,N/A,72.82,N/A,117.18,N/A,117.18,N/A,117.18,N/A,481.94,N/A,837.00,N/A,117.18,N/A,448.63,N/A,448.63,N/A,117.18,N/A,837.00,N/A,837.00,N/A,837.00,502.20,502.20,72.82,837.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 1 % IJ SOLN,00409-4713-32,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,GLYCOPYRROLATE 1 MG/5ML IJ SOLN,63323-0578-05,0250 - PHARMACY - GENERAL CLASSIFICATION,20.20,20.20,12.12,12.12,N/A,2.83,N/A,20.20,N/A,11.63,N/A,6.87,N/A,2.83,N/A,2.83,N/A,20.20,N/A,20.20,N/A,1.76,N/A,2.83,N/A,2.83,N/A,2.83,N/A,11.63,N/A,20.20,N/A,2.83,N/A,10.83,N/A,10.83,N/A,2.83,N/A,20.20,N/A,20.20,N/A,20.20,12.12,12.12,1.76,20.20,,Hospital HCPCS 2500000003,VALPROATE SODIUM 100 MG/ML IV SOLN,63323-0494-05,0250 - PHARMACY - GENERAL CLASSIFICATION,45.30,45.30,27.18,27.18,N/A,6.34,N/A,45.30,N/A,26.08,N/A,15.40,N/A,6.34,N/A,6.34,N/A,45.30,N/A,45.30,N/A,3.94,N/A,6.34,N/A,6.34,N/A,6.34,N/A,26.08,N/A,45.30,N/A,6.34,N/A,24.28,N/A,24.28,N/A,6.34,N/A,45.30,N/A,45.30,N/A,45.30,27.18,27.18,3.94,45.30,,Hospital HCPCS 2500000003,HYDROXOCOBALAMIN 5 G IV SOLR,11704-0370-01,0250 - PHARMACY - GENERAL CLASSIFICATION,3548.10,3548.10,2128.86,2128.86,N/A,496.73,N/A,3548.10,N/A,2043.00,N/A,1206.35,N/A,496.73,N/A,496.73,N/A,3548.10,N/A,3548.10,N/A,308.68,N/A,496.73,N/A,496.73,N/A,496.73,N/A,2043.00,N/A,3548.10,N/A,496.73,N/A,1901.78,N/A,1901.78,N/A,496.73,N/A,3548.10,N/A,3548.10,N/A,3548.10,2128.86,2128.86,308.68,3548.10,,Hospital HCPCS 2500000003,PROPARACAINE HCL 0.5 % OP SOLN,61314-0016-01,0250 - PHARMACY - GENERAL CLASSIFICATION,79.00,79.00,47.40,47.40,N/A,11.06,N/A,79.00,N/A,45.49,N/A,26.86,N/A,11.06,N/A,11.06,N/A,79.00,N/A,79.00,N/A,6.87,N/A,11.06,N/A,11.06,N/A,11.06,N/A,45.49,N/A,79.00,N/A,11.06,N/A,42.34,N/A,42.34,N/A,11.06,N/A,79.00,N/A,79.00,N/A,79.00,47.40,47.40,6.87,79.00,,Hospital HCPCS 2500000003,NAFCILLIN SODIUM 1 G IJ SOLR,63323-0327-10,0250 - PHARMACY - GENERAL CLASSIFICATION,100.50,100.50,60.30,60.30,N/A,14.07,N/A,100.50,N/A,57.87,N/A,34.17,N/A,14.07,N/A,14.07,N/A,100.50,N/A,100.50,N/A,8.74,N/A,14.07,N/A,14.07,N/A,14.07,N/A,57.87,N/A,100.50,N/A,14.07,N/A,53.87,N/A,53.87,N/A,14.07,N/A,100.50,N/A,100.50,N/A,100.50,60.30,60.30,8.74,100.50,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 0.5 % IJ SOLN,63323-0491-57,0250 - PHARMACY - GENERAL CLASSIFICATION,85.10,85.10,51.06,51.06,N/A,11.91,N/A,85.10,N/A,49.00,N/A,28.93,N/A,11.91,N/A,11.91,N/A,85.10,N/A,85.10,N/A,7.40,N/A,11.91,N/A,11.91,N/A,11.91,N/A,49.00,N/A,85.10,N/A,11.91,N/A,45.61,N/A,45.61,N/A,11.91,N/A,85.10,N/A,85.10,N/A,85.10,51.06,51.06,7.40,85.10,,Hospital HCPCS 2500000003,INFUVITE ADULT IV INJ,54643-5649-01,0250 - PHARMACY - GENERAL CLASSIFICATION,78.60,78.60,47.16,47.16,N/A,11.00,N/A,78.60,N/A,45.26,N/A,26.72,N/A,11.00,N/A,11.00,N/A,78.60,N/A,78.60,N/A,6.84,N/A,11.00,N/A,11.00,N/A,11.00,N/A,45.26,N/A,78.60,N/A,11.00,N/A,42.13,N/A,42.13,N/A,11.00,N/A,78.60,N/A,78.60,N/A,78.60,47.16,47.16,6.84,78.60,,Hospital HCPCS 2500000003,NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,36000-0162-01,0250 - PHARMACY - GENERAL CLASSIFICATION,86.10,86.10,51.66,51.66,N/A,12.05,N/A,86.10,N/A,49.58,N/A,29.27,N/A,12.05,N/A,12.05,N/A,86.10,N/A,86.10,N/A,7.49,N/A,12.05,N/A,12.05,N/A,12.05,N/A,49.58,N/A,86.10,N/A,12.05,N/A,46.15,N/A,46.15,N/A,12.05,N/A,86.10,N/A,86.10,N/A,86.10,51.66,51.66,7.49,86.10,,Hospital HCPCS 2500000003,VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,00006-4827-00,0250 - PHARMACY - GENERAL CLASSIFICATION,360.00,360.00,216.00,216.00,N/A,50.40,N/A,360.00,N/A,207.29,N/A,122.40,N/A,50.40,N/A,50.40,N/A,360.00,N/A,360.00,N/A,31.32,N/A,50.40,N/A,50.40,N/A,50.40,N/A,207.29,N/A,360.00,N/A,50.40,N/A,192.96,N/A,192.96,N/A,50.40,N/A,360.00,N/A,360.00,N/A,360.00,216.00,216.00,31.32,360.00,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,00409-3178-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,00409-1638-02,0250 - PHARMACY - GENERAL CLASSIFICATION,286.40,286.40,171.84,171.84,N/A,40.10,N/A,286.40,N/A,164.91,N/A,97.38,N/A,40.10,N/A,40.10,N/A,286.40,N/A,286.40,N/A,24.92,N/A,40.10,N/A,40.10,N/A,40.10,N/A,164.91,N/A,286.40,N/A,40.10,N/A,153.51,N/A,153.51,N/A,40.10,N/A,286.40,N/A,286.40,N/A,286.40,171.84,171.84,24.92,286.40,,Hospital HCPCS 2500000003,VANCOMYCIN HCL 25 MG/ML PO SOLR,65628-0204-05,0250 - PHARMACY - GENERAL CLASSIFICATION,725.00,725.00,435.00,435.00,N/A,101.50,N/A,725.00,N/A,417.46,N/A,246.50,N/A,101.50,N/A,101.50,N/A,725.00,N/A,725.00,N/A,63.08,N/A,101.50,N/A,101.50,N/A,101.50,N/A,417.46,N/A,725.00,N/A,101.50,N/A,388.60,N/A,388.60,N/A,101.50,N/A,725.00,N/A,725.00,N/A,725.00,435.00,435.00,63.08,725.00,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,63323-0482-17,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 1 %-1:200000 IJ SOLN,63323-0487-37,0250 - PHARMACY - GENERAL CLASSIFICATION,23.20,23.20,13.92,13.92,N/A,3.25,N/A,23.20,N/A,13.36,N/A,7.89,N/A,3.25,N/A,3.25,N/A,23.20,N/A,23.20,N/A,2.02,N/A,3.25,N/A,3.25,N/A,3.25,N/A,13.36,N/A,23.20,N/A,3.25,N/A,12.44,N/A,12.44,N/A,3.25,N/A,23.20,N/A,23.20,N/A,23.20,13.92,13.92,2.02,23.20,,Hospital HCPCS 2500000003,CLINIMIX E/DEXTROSE (4.25/10) 4.25 % IV SOLN,00338-1145-03,0250 - PHARMACY - GENERAL CLASSIFICATION,324.00,324.00,194.40,194.40,N/A,45.36,N/A,324.00,N/A,186.56,N/A,110.16,N/A,45.36,N/A,45.36,N/A,324.00,N/A,324.00,N/A,28.19,N/A,45.36,N/A,45.36,N/A,45.36,N/A,186.56,N/A,324.00,N/A,45.36,N/A,173.66,N/A,173.66,N/A,45.36,N/A,324.00,N/A,324.00,N/A,324.00,194.40,194.40,28.19,324.00,,Hospital HCPCS 2500000003,THROMBIN 20000 UNITS EX SOLR,60793-0217-20,0250 - PHARMACY - GENERAL CLASSIFICATION,1920.20,1920.20,1152.12,1152.12,N/A,268.83,N/A,1920.20,N/A,1105.65,N/A,652.87,N/A,268.83,N/A,268.83,N/A,1920.20,N/A,1920.20,N/A,167.06,N/A,268.83,N/A,268.83,N/A,268.83,N/A,1105.65,N/A,1920.20,N/A,268.83,N/A,1029.23,N/A,1029.23,N/A,268.83,N/A,1920.20,N/A,1920.20,N/A,1920.20,1152.12,1152.12,167.06,1920.20,,Hospital HCPCS 2500000003,LIDOCAINE HCL 1 % IJ SOLN,63323-0201-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,CALCIUM CHLORIDE 10 % IV SOLN,00409-1631-40,0250 - PHARMACY - GENERAL CLASSIFICATION,29.10,29.10,17.46,17.46,N/A,4.07,N/A,29.10,N/A,16.76,N/A,9.89,N/A,4.07,N/A,4.07,N/A,29.10,N/A,29.10,N/A,2.53,N/A,4.07,N/A,4.07,N/A,4.07,N/A,16.76,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,4.07,N/A,29.10,N/A,29.10,N/A,29.10,17.46,17.46,2.53,29.10,,Hospital HCPCS 2500000003,BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN,63323-0461-57,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,NITHIODOTE 300MG/10ML&12.5 GM/50ML IV KIT,60267-0812-00,0250 - PHARMACY - GENERAL CLASSIFICATION,2227.50,2227.50,1336.50,1336.50,N/A,311.85,N/A,2227.50,N/A,1282.59,N/A,757.35,N/A,311.85,N/A,311.85,N/A,2227.50,N/A,2227.50,N/A,193.79,N/A,311.85,N/A,311.85,N/A,311.85,N/A,1282.59,N/A,2227.50,N/A,311.85,N/A,1193.94,N/A,1193.94,N/A,311.85,N/A,2227.50,N/A,2227.50,N/A,2227.50,1336.50,1336.50,193.79,2227.50,,Hospital HCPCS 2500000003,NICARDIPINE HCL 2.5 MG/ML IV SOLN,00143-9689-10,0250 - PHARMACY - GENERAL CLASSIFICATION,172.30,172.30,103.38,103.38,N/A,24.12,N/A,172.30,N/A,99.21,N/A,58.58,N/A,24.12,N/A,24.12,N/A,172.30,N/A,172.30,N/A,14.99,N/A,24.12,N/A,24.12,N/A,24.12,N/A,99.21,N/A,172.30,N/A,24.12,N/A,92.35,N/A,92.35,N/A,24.12,N/A,172.30,N/A,172.30,N/A,172.30,103.38,103.38,14.99,172.30,,Hospital HCPCS 2500000003,ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,00942-0641-04,0250 - PHARMACY - GENERAL CLASSIFICATION,67.50,67.50,40.50,40.50,N/A,9.45,N/A,67.50,N/A,38.87,N/A,22.95,N/A,9.45,N/A,9.45,N/A,67.50,N/A,67.50,N/A,5.87,N/A,9.45,N/A,9.45,N/A,9.45,N/A,38.87,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,9.45,N/A,67.50,N/A,67.50,N/A,67.50,40.50,40.50,5.87,67.50,,Hospital HCPCS 2500000003,METHOHEXITAL SODIUM 0.5 G IJ SOLR,42023-0105-01,0250 - PHARMACY - GENERAL CLASSIFICATION,552.40,552.40,331.44,331.44,N/A,77.34,N/A,552.40,N/A,318.07,N/A,187.82,N/A,77.34,N/A,77.34,N/A,552.40,N/A,552.40,N/A,48.06,N/A,77.34,N/A,77.34,N/A,77.34,N/A,318.07,N/A,552.40,N/A,77.34,N/A,296.09,N/A,296.09,N/A,77.34,N/A,552.40,N/A,552.40,N/A,552.40,331.44,331.44,48.06,552.40,,Hospital HCPCS 2500000003,MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,00004-0298-09,0250 - PHARMACY - GENERAL CLASSIFICATION,1457.80,1457.80,874.68,874.68,N/A,204.09,N/A,1457.80,N/A,839.40,N/A,495.65,N/A,204.09,N/A,204.09,N/A,1457.80,N/A,1457.80,N/A,126.83,N/A,204.09,N/A,204.09,N/A,204.09,N/A,839.40,N/A,1457.80,N/A,204.09,N/A,781.38,N/A,781.38,N/A,204.09,N/A,1457.80,N/A,1457.80,N/A,1457.80,874.68,874.68,126.83,1457.80,,Hospital HCPCS 2500000003,DILTIAZEM 5 MG IN DEXTROSE 5% 50 ML INFUSION,09999-9910-13,0250 - PHARMACY - GENERAL CLASSIFICATION,147.80,147.80,88.68,88.68,N/A,20.69,N/A,147.80,N/A,85.10,N/A,50.25,N/A,20.69,N/A,20.69,N/A,147.80,N/A,147.80,N/A,12.86,N/A,20.69,N/A,20.69,N/A,20.69,N/A,85.10,N/A,147.80,N/A,20.69,N/A,79.22,N/A,79.22,N/A,20.69,N/A,147.80,N/A,147.80,N/A,147.80,88.68,88.68,12.86,147.80,,Hospital HCPCS 2500000003,NEOMYCIN-POLYMYXIN B GU 40-200000 IR SOLN,33982-2120-11,0250 - PHARMACY - GENERAL CLASSIFICATION,40.30,40.30,24.18,24.18,N/A,5.64,N/A,40.30,N/A,23.20,N/A,13.70,N/A,5.64,N/A,5.64,N/A,40.30,N/A,40.30,N/A,3.51,N/A,5.64,N/A,5.64,N/A,5.64,N/A,23.20,N/A,40.30,N/A,5.64,N/A,21.60,N/A,21.60,N/A,5.64,N/A,40.30,N/A,40.30,N/A,40.30,24.18,24.18,3.51,40.30,,Hospital HCPCS 2500000003,CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,00517-2502-01,0250 - PHARMACY - GENERAL CLASSIFICATION,87.00,87.00,52.20,52.20,N/A,12.18,N/A,87.00,N/A,50.09,N/A,29.58,N/A,12.18,N/A,12.18,N/A,87.00,N/A,87.00,N/A,7.57,N/A,12.18,N/A,12.18,N/A,12.18,N/A,50.09,N/A,87.00,N/A,12.18,N/A,46.63,N/A,46.63,N/A,12.18,N/A,87.00,N/A,87.00,N/A,87.00,52.20,52.20,7.57,87.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % 20 ML IJ SOLN,00409-4277-02,0250 - PHARMACY - GENERAL CLASSIFICATION,25.70,25.70,15.42,15.42,N/A,3.60,N/A,25.70,N/A,14.80,N/A,8.74,N/A,3.60,N/A,3.60,N/A,25.70,N/A,25.70,N/A,2.24,N/A,3.60,N/A,3.60,N/A,3.60,N/A,14.80,N/A,25.70,N/A,3.60,N/A,13.78,N/A,13.78,N/A,3.60,N/A,25.70,N/A,25.70,N/A,25.70,15.42,15.42,2.24,25.70,,Hospital HCPCS 2500000003,ATRACURIUM BESYLATE 50 MG/5ML IV SOLN,00409-1109-01,0250 - PHARMACY - GENERAL CLASSIFICATION,17.30,17.30,10.38,10.38,N/A,2.42,N/A,17.30,N/A,9.96,N/A,5.88,N/A,2.42,N/A,2.42,N/A,17.30,N/A,17.30,N/A,1.51,N/A,2.42,N/A,2.42,N/A,2.42,N/A,9.96,N/A,17.30,N/A,2.42,N/A,9.27,N/A,9.27,N/A,2.42,N/A,17.30,N/A,17.30,N/A,17.30,10.38,10.38,1.51,17.30,,Hospital HCPCS 2500000003,NAFCILLIN SODIUM 2 G IJ SOLR,63323-0328-20,0250 - PHARMACY - GENERAL CLASSIFICATION,195.10,195.10,117.06,117.06,N/A,27.31,N/A,195.10,N/A,112.34,N/A,66.33,N/A,27.31,N/A,27.31,N/A,195.10,N/A,195.10,N/A,16.97,N/A,27.31,N/A,27.31,N/A,27.31,N/A,112.34,N/A,195.10,N/A,27.31,N/A,104.57,N/A,104.57,N/A,27.31,N/A,195.10,N/A,195.10,N/A,195.10,117.06,117.06,16.97,195.10,,Hospital HCPCS 2500000003,BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN (MIXTURES ONLY),63323-0462-37,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,REMIFENTANIL HCL 2 MG IV SOLR,63323-0724-01,0250 - PHARMACY - GENERAL CLASSIFICATION,868.20,868.20,520.92,520.92,N/A,121.55,N/A,868.20,N/A,499.91,N/A,295.19,N/A,121.55,N/A,121.55,N/A,868.20,N/A,868.20,N/A,75.53,N/A,121.55,N/A,121.55,N/A,121.55,N/A,499.91,N/A,868.20,N/A,121.55,N/A,465.36,N/A,465.36,N/A,121.55,N/A,868.20,N/A,868.20,N/A,868.20,520.92,520.92,75.53,868.20,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,00409-3178-03,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 2 % IJ SOLN,00409-4282-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,DEXMEDETOMIDINE HCL-DEXTROSE 400MCG/100ML -5% IV SOLN,44567-0603-24,0250 - PHARMACY - GENERAL CLASSIFICATION,243.00,243.00,145.80,145.80,N/A,34.02,N/A,243.00,N/A,139.92,N/A,82.62,N/A,34.02,N/A,34.02,N/A,243.00,N/A,243.00,N/A,21.14,N/A,34.02,N/A,34.02,N/A,34.02,N/A,139.92,N/A,243.00,N/A,34.02,N/A,130.25,N/A,130.25,N/A,34.02,N/A,243.00,N/A,243.00,N/A,243.00,145.80,145.80,21.14,243.00,,Hospital HCPCS 2500000003,METHOHEXITAL SODIUM 50 MG/5ML IV SOSY,N/A,0250 - PHARMACY - GENERAL CLASSIFICATION,234.20,234.20,140.52,140.52,N/A,32.79,N/A,234.20,N/A,134.85,N/A,79.63,N/A,32.79,N/A,32.79,N/A,234.20,N/A,234.20,N/A,20.38,N/A,32.79,N/A,32.79,N/A,32.79,N/A,134.85,N/A,234.20,N/A,32.79,N/A,125.53,N/A,125.53,N/A,32.79,N/A,234.20,N/A,234.20,N/A,234.20,140.52,140.52,20.38,234.20,,Hospital HCPCS 2500000003,KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,00338-0803-04,0250 - PHARMACY - GENERAL CLASSIFICATION,67.50,67.50,40.50,40.50,N/A,9.45,N/A,67.50,N/A,38.87,N/A,22.95,N/A,9.45,N/A,9.45,N/A,67.50,N/A,67.50,N/A,5.87,N/A,9.45,N/A,9.45,N/A,9.45,N/A,38.87,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,9.45,N/A,67.50,N/A,67.50,N/A,67.50,40.50,40.50,5.87,67.50,,Hospital HCPCS 2500000003,CLINIMIX E/DEXTROSE (4.25/5) 4.25 % IV SOLN,00338-1144-03,0250 - PHARMACY - GENERAL CLASSIFICATION,290.30,290.30,174.18,174.18,N/A,40.64,N/A,290.30,N/A,167.15,N/A,98.70,N/A,40.64,N/A,40.64,N/A,290.30,N/A,290.30,N/A,25.26,N/A,40.64,N/A,40.64,N/A,40.64,N/A,167.15,N/A,290.30,N/A,40.64,N/A,155.60,N/A,155.60,N/A,40.64,N/A,290.30,N/A,290.30,N/A,290.30,174.18,174.18,25.26,290.30,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,63323-0489-17,0250 - PHARMACY - GENERAL CLASSIFICATION,106.20,106.20,63.72,63.72,N/A,14.87,N/A,106.20,N/A,61.15,N/A,36.11,N/A,14.87,N/A,14.87,N/A,106.20,N/A,106.20,N/A,9.24,N/A,14.87,N/A,14.87,N/A,14.87,N/A,61.15,N/A,106.20,N/A,14.87,N/A,56.92,N/A,56.92,N/A,14.87,N/A,106.20,N/A,106.20,N/A,106.20,63.72,63.72,9.24,106.20,,Hospital HCPCS 2500000003,CLINIMIX E/DEXTROSE (4.25/10) 4.25 % IV SOLN,00338-1115-04,0250 - PHARMACY - GENERAL CLASSIFICATION,553.50,553.50,332.10,332.10,N/A,77.49,N/A,553.50,N/A,318.71,N/A,188.19,N/A,77.49,N/A,77.49,N/A,553.50,N/A,553.50,N/A,48.15,N/A,77.49,N/A,77.49,N/A,77.49,N/A,318.71,N/A,553.50,N/A,77.49,N/A,296.68,N/A,296.68,N/A,77.49,N/A,553.50,N/A,553.50,N/A,553.50,332.10,332.10,48.15,553.50,,Hospital HCPCS 2500000003,CALCIUM ACETATE (PHOS BINDER) 667 MG PO CAPS,00054-0088-13,0250 - PHARMACY - GENERAL CLASSIFICATION,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.88,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.88,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % 20 ML IJ SOLN,63323-0486-27,0250 - PHARMACY - GENERAL CLASSIFICATION,22.60,22.60,13.56,13.56,N/A,3.16,N/A,22.60,N/A,13.01,N/A,7.68,N/A,3.16,N/A,3.16,N/A,22.60,N/A,22.60,N/A,1.97,N/A,3.16,N/A,3.16,N/A,3.16,N/A,13.01,N/A,22.60,N/A,3.16,N/A,12.11,N/A,12.11,N/A,3.16,N/A,22.60,N/A,22.60,N/A,22.60,13.56,13.56,1.97,22.60,,Hospital HCPCS 2500000003,NOREPINEPHRINE-SODIUM CHLORIDE 16-0.9 MG/250ML-% IV SOLN,69374-0315-25,0250 - PHARMACY - GENERAL CLASSIFICATION,148.50,148.50,89.10,89.10,N/A,20.79,N/A,148.50,N/A,85.51,N/A,50.49,N/A,20.79,N/A,20.79,N/A,148.50,N/A,148.50,N/A,12.92,N/A,20.79,N/A,20.79,N/A,20.79,N/A,85.51,N/A,148.50,N/A,20.79,N/A,79.60,N/A,79.60,N/A,20.79,N/A,148.50,N/A,148.50,N/A,148.50,89.10,89.10,12.92,148.50,,Hospital HCPCS 2500000003,ROCURONIUM BROMIDE 50 MG/5ML IV SOLN,39822-4200-01,0250 - PHARMACY - GENERAL CLASSIFICATION,30.40,30.40,18.24,18.24,N/A,4.26,N/A,30.40,N/A,17.50,N/A,10.34,N/A,4.26,N/A,4.26,N/A,30.40,N/A,30.40,N/A,2.64,N/A,4.26,N/A,4.26,N/A,4.26,N/A,17.50,N/A,30.40,N/A,4.26,N/A,16.29,N/A,16.29,N/A,4.26,N/A,30.40,N/A,30.40,N/A,30.40,18.24,18.24,2.64,30.40,,Hospital HCPCS 2500000003,INFUVITE PEDIATRIC IV SOLN,54643-5646-01,0250 - PHARMACY - GENERAL CLASSIFICATION,122.80,122.80,73.68,73.68,N/A,17.19,N/A,122.80,N/A,70.71,N/A,41.75,N/A,17.19,N/A,17.19,N/A,122.80,N/A,122.80,N/A,10.68,N/A,17.19,N/A,17.19,N/A,17.19,N/A,70.71,N/A,122.80,N/A,17.19,N/A,65.82,N/A,65.82,N/A,17.19,N/A,122.80,N/A,122.80,N/A,122.80,73.68,73.68,10.68,122.80,,Hospital HCPCS 2500000003,DANTROLENE SODIUM 20 MG IV SOLR,00143-9297-01,0250 - PHARMACY - GENERAL CLASSIFICATION,478.70,478.70,287.22,287.22,N/A,67.02,N/A,478.70,N/A,275.64,N/A,162.76,N/A,67.02,N/A,67.02,N/A,478.70,N/A,478.70,N/A,41.65,N/A,67.02,N/A,67.02,N/A,67.02,N/A,275.64,N/A,478.70,N/A,67.02,N/A,256.58,N/A,256.58,N/A,67.02,N/A,478.70,N/A,478.70,N/A,478.70,287.22,287.22,41.65,478.70,,Hospital HCPCS 2500000003,BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,00409-3977-03,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LEVALBUTEROL TARTRATE 45 MCG/ACT IN AERO,00591-2927-54,0250 - PHARMACY - GENERAL CLASSIFICATION,132.70,132.70,79.62,79.62,N/A,18.58,N/A,132.70,N/A,76.41,N/A,45.12,N/A,18.58,N/A,18.58,N/A,132.70,N/A,132.70,N/A,11.54,N/A,18.58,N/A,18.58,N/A,18.58,N/A,76.41,N/A,132.70,N/A,18.58,N/A,71.13,N/A,71.13,N/A,18.58,N/A,132.70,N/A,132.70,N/A,132.70,79.62,79.62,11.54,132.70,,Hospital HCPCS 2500000003,FAMOTIDINE (PF) 20 MG/2ML IV SOLN,63323-0739-12,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,CLINIMIX E/DEXTROSE (5/20) 5 % IV SOLN,00338-1125-04,0250 - PHARMACY - GENERAL CLASSIFICATION,594.00,594.00,356.40,356.40,N/A,83.16,N/A,594.00,N/A,342.03,N/A,201.96,N/A,83.16,N/A,83.16,N/A,594.00,N/A,594.00,N/A,51.68,N/A,83.16,N/A,83.16,N/A,83.16,N/A,342.03,N/A,594.00,N/A,83.16,N/A,318.38,N/A,318.38,N/A,83.16,N/A,594.00,N/A,594.00,N/A,594.00,356.40,356.40,51.68,594.00,,Hospital HCPCS 2500000003,TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,64980-0320-05,0250 - PHARMACY - GENERAL CLASSIFICATION,145.10,145.10,87.06,87.06,N/A,20.31,N/A,145.10,N/A,83.55,N/A,49.33,N/A,20.31,N/A,20.31,N/A,145.10,N/A,145.10,N/A,12.62,N/A,20.31,N/A,20.31,N/A,20.31,N/A,83.55,N/A,145.10,N/A,20.31,N/A,77.77,N/A,77.77,N/A,20.31,N/A,145.10,N/A,145.10,N/A,145.10,87.06,87.06,12.62,145.10,,Hospital HCPCS 2500000003,GLYCOPYRROLATE 0.2 MG/ML IJ SOLN,00517-4601-25,0250 - PHARMACY - GENERAL CLASSIFICATION,43.90,43.90,26.34,26.34,N/A,6.15,N/A,43.90,N/A,25.28,N/A,14.93,N/A,6.15,N/A,6.15,N/A,43.90,N/A,43.90,N/A,3.82,N/A,6.15,N/A,6.15,N/A,6.15,N/A,25.28,N/A,43.90,N/A,6.15,N/A,23.53,N/A,23.53,N/A,6.15,N/A,43.90,N/A,43.90,N/A,43.90,26.34,26.34,3.82,43.90,,Hospital HCPCS 2500000003,KETAMINE HCL 50 MG/ML IJ SOLN,09999-9912-85,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,00074-4380-10,0250 - PHARMACY - GENERAL CLASSIFICATION,185.70,185.70,111.42,111.42,N/A,26.00,N/A,185.70,N/A,106.93,N/A,63.14,N/A,26.00,N/A,26.00,N/A,185.70,N/A,185.70,N/A,16.16,N/A,26.00,N/A,26.00,N/A,26.00,N/A,106.93,N/A,185.70,N/A,26.00,N/A,99.54,N/A,99.54,N/A,26.00,N/A,185.70,N/A,185.70,N/A,185.70,111.42,111.42,16.16,185.70,,Hospital HCPCS 2500000003,ACETIC ACID 0.25 % IR SOLN,09999-9910-09,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,METOPROLOL TARTRATE 5 MG/5ML IV SOLN,00143-9660-10,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,KCL-LACTATED RINGERS-D5W 20 MEQ/L IV SOLN,00338-0811-04,0250 - PHARMACY - GENERAL CLASSIFICATION,74.30,74.30,44.58,44.58,N/A,10.40,N/A,74.30,N/A,42.78,N/A,25.26,N/A,10.40,N/A,10.40,N/A,74.30,N/A,74.30,N/A,6.46,N/A,10.40,N/A,10.40,N/A,10.40,N/A,42.78,N/A,74.30,N/A,10.40,N/A,39.82,N/A,39.82,N/A,10.40,N/A,74.30,N/A,74.30,N/A,74.30,44.58,44.58,6.46,74.30,,Hospital HCPCS 2500000003,SODIUM CHLORIDE BACTERIOSTATIC 0.9 % IJ SOLN,00409-1966-05,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,KETAMINE HCL 100 MG/ML IJ SOLN,00409-2051-05,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,B-1 100 MG PO TABS,40985-0211-51,0250 - PHARMACY - GENERAL CLASSIFICATION,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.88,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.88,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),00409-4277-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,CARDIOPLEGIA DEL NIDO FORMULA PF SOLN,09999-9918-43,0250 - PHARMACY - GENERAL CLASSIFICATION,1316.60,1316.60,789.96,789.96,N/A,184.32,N/A,1316.60,N/A,758.10,N/A,447.64,N/A,184.32,N/A,184.32,N/A,1316.60,N/A,1316.60,N/A,114.54,N/A,184.32,N/A,184.32,N/A,184.32,N/A,758.10,N/A,1316.60,N/A,184.32,N/A,705.70,N/A,705.70,N/A,184.32,N/A,1316.60,N/A,1316.60,N/A,1316.60,789.96,789.96,114.54,1316.60,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN,00409-4277-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,DILTIAZEM HCL 100 MG IV SOLR,00409-4350-03,0250 - PHARMACY - GENERAL CLASSIFICATION,77.10,77.10,46.26,46.26,N/A,10.79,N/A,77.10,N/A,44.39,N/A,26.21,N/A,10.79,N/A,10.79,N/A,77.10,N/A,77.10,N/A,6.71,N/A,10.79,N/A,10.79,N/A,10.79,N/A,44.39,N/A,77.10,N/A,10.79,N/A,41.33,N/A,41.33,N/A,10.79,N/A,77.10,N/A,77.10,N/A,77.10,46.26,46.26,6.71,77.10,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN,63323-0202-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,VECURONIUM BROMIDE 20 MG IV SOLR,67457-0475-20,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,00009-0856-05,0250 - PHARMACY - GENERAL CLASSIFICATION,2404.40,2404.40,1442.64,1442.64,N/A,336.62,N/A,2404.40,N/A,1384.45,N/A,817.50,N/A,336.62,N/A,336.62,N/A,2404.40,N/A,2404.40,N/A,209.18,N/A,336.62,N/A,336.62,N/A,336.62,N/A,1384.45,N/A,2404.40,N/A,336.62,N/A,1288.76,N/A,1288.76,N/A,336.62,N/A,2404.40,N/A,2404.40,N/A,2404.40,1442.64,1442.64,209.18,2404.40,,Hospital HCPCS 2500000003,ROCURONIUM BROMIDE 50 MG/5ML IV SOSY,69374-0924-05,0250 - PHARMACY - GENERAL CLASSIFICATION,48.60,48.60,29.16,29.16,N/A,6.80,N/A,48.60,N/A,27.98,N/A,16.52,N/A,6.80,N/A,6.80,N/A,48.60,N/A,48.60,N/A,4.23,N/A,6.80,N/A,6.80,N/A,6.80,N/A,27.98,N/A,48.60,N/A,6.80,N/A,26.05,N/A,26.05,N/A,6.80,N/A,48.60,N/A,48.60,N/A,48.60,29.16,29.16,4.23,48.60,,Hospital HCPCS 2500000003,ROPIV-CLONIDINE-KETOROLAC 123-0.04-15 MG/50ML PA SOSY,69374-0515-50,0250 - PHARMACY - GENERAL CLASSIFICATION,405.00,405.00,243.00,243.00,N/A,56.70,N/A,405.00,N/A,233.20,N/A,137.70,N/A,56.70,N/A,56.70,N/A,405.00,N/A,405.00,N/A,35.24,N/A,56.70,N/A,56.70,N/A,56.70,N/A,233.20,N/A,405.00,N/A,56.70,N/A,217.08,N/A,217.08,N/A,56.70,N/A,405.00,N/A,405.00,N/A,405.00,243.00,243.00,35.24,405.00,,Hospital HCPCS 2500000003,BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,00409-9046-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,KETAMINE HCL 50 MG/5ML IJ SOSY,69374-0982-55,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),63323-0491-57,0250 - PHARMACY - GENERAL CLASSIFICATION,85.10,85.10,51.06,51.06,N/A,11.91,N/A,85.10,N/A,49.00,N/A,28.93,N/A,11.91,N/A,11.91,N/A,85.10,N/A,85.10,N/A,7.40,N/A,11.91,N/A,11.91,N/A,11.91,N/A,49.00,N/A,85.10,N/A,11.91,N/A,45.61,N/A,45.61,N/A,11.91,N/A,85.10,N/A,85.10,N/A,85.10,51.06,51.06,7.40,85.10,,Hospital HCPCS 2500000003,IODINE STRONG 6.9-5 % EX TINC,00395-1207-92,0250 - PHARMACY - GENERAL CLASSIFICATION,45.10,45.10,27.06,27.06,N/A,6.31,N/A,45.10,N/A,25.97,N/A,15.33,N/A,6.31,N/A,6.31,N/A,45.10,N/A,45.10,N/A,3.92,N/A,6.31,N/A,6.31,N/A,6.31,N/A,25.97,N/A,45.10,N/A,6.31,N/A,24.17,N/A,24.17,N/A,6.31,N/A,45.10,N/A,45.10,N/A,45.10,27.06,27.06,3.92,45.10,,Hospital HCPCS 2500000003,NOREPINEPHRINE-SODIUM CHLORIDE 16-0.9 MG/250ML-% IV SOLN (WEIGHT-BASED),69374-0315-25,0250 - PHARMACY - GENERAL CLASSIFICATION,148.50,148.50,89.10,89.10,N/A,20.79,N/A,148.50,N/A,85.51,N/A,50.49,N/A,20.79,N/A,20.79,N/A,148.50,N/A,148.50,N/A,12.92,N/A,20.79,N/A,20.79,N/A,20.79,N/A,85.51,N/A,148.50,N/A,20.79,N/A,79.60,N/A,79.60,N/A,20.79,N/A,148.50,N/A,148.50,N/A,148.50,89.10,89.10,12.92,148.50,,Hospital HCPCS 2500000003,LIDOCAINE HCL 100 MG/5ML IJ SOSY,69374-0949-05,0250 - PHARMACY - GENERAL CLASSIFICATION,16.20,16.20,9.72,9.72,N/A,2.27,N/A,16.20,N/A,9.33,N/A,5.51,N/A,2.27,N/A,2.27,N/A,16.20,N/A,16.20,N/A,1.41,N/A,2.27,N/A,2.27,N/A,2.27,N/A,9.33,N/A,16.20,N/A,2.27,N/A,8.68,N/A,8.68,N/A,2.27,N/A,16.20,N/A,16.20,N/A,16.20,9.72,9.72,1.41,16.20,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),55150-0165-05,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,ANTICOAGULANT SODIUM CITRATE 4% SYRINGE,71266-6641-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,NA HYALUR & NA CHOND-NA HYALUR 0.55-0.5 ML IO KIT,08065-1831-50,0250 - PHARMACY - GENERAL CLASSIFICATION,2253.10,2253.10,1351.86,1351.86,N/A,315.43,N/A,2253.10,N/A,1297.33,N/A,766.05,N/A,315.43,N/A,315.43,N/A,2253.10,N/A,2253.10,N/A,196.02,N/A,315.43,N/A,315.43,N/A,315.43,N/A,1297.33,N/A,2253.10,N/A,315.43,N/A,1207.66,N/A,1207.66,N/A,315.43,N/A,2253.10,N/A,2253.10,N/A,2253.10,1351.86,1351.86,196.02,2253.10,,Hospital HCPCS 2500000003,FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,00338-0519-09,0250 - PHARMACY - GENERAL CLASSIFICATION,126.90,126.90,76.14,76.14,N/A,17.77,N/A,126.90,N/A,73.07,N/A,43.15,N/A,17.77,N/A,17.77,N/A,126.90,N/A,126.90,N/A,11.04,N/A,17.77,N/A,17.77,N/A,17.77,N/A,73.07,N/A,126.90,N/A,17.77,N/A,68.02,N/A,68.02,N/A,17.77,N/A,126.90,N/A,126.90,N/A,126.90,76.14,76.14,11.04,126.90,,Hospital HCPCS 2500000003,VECURONIUM BROMIDE 10 MG IV SOLR,63323-0781-41,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,00781-3040-72,0250 - PHARMACY - GENERAL CLASSIFICATION,34.70,34.70,20.82,20.82,N/A,4.86,N/A,34.70,N/A,19.98,N/A,11.80,N/A,4.86,N/A,4.86,N/A,34.70,N/A,34.70,N/A,3.02,N/A,4.86,N/A,4.86,N/A,4.86,N/A,19.98,N/A,34.70,N/A,4.86,N/A,18.60,N/A,18.60,N/A,4.86,N/A,34.70,N/A,34.70,N/A,34.70,20.82,20.82,3.02,34.70,,Hospital HCPCS 2500000003,DILTIAZEM HCL 25 MG/5ML IV SOLN,00641-6013-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,00409-3182-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 2 % IJ SOLN,63323-0495-07,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 1 % IJ SOLN,63323-0492-37,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,NITROPRUSSIDE SODIUM-NACL 20-0.9 MG/100ML-% IV SOLN,51754-1029-01,0250 - PHARMACY - GENERAL CLASSIFICATION,303.80,303.80,182.28,182.28,N/A,42.53,N/A,303.80,N/A,174.93,N/A,103.29,N/A,42.53,N/A,42.53,N/A,303.80,N/A,303.80,N/A,26.43,N/A,42.53,N/A,42.53,N/A,42.53,N/A,174.93,N/A,303.80,N/A,42.53,N/A,162.84,N/A,162.84,N/A,42.53,N/A,303.80,N/A,303.80,N/A,303.80,182.28,182.28,26.43,303.80,,Hospital HCPCS 2500000003,FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,00338-0519-13,0250 - PHARMACY - GENERAL CLASSIFICATION,126.90,126.90,76.14,76.14,N/A,17.77,N/A,126.90,N/A,73.07,N/A,43.15,N/A,17.77,N/A,17.77,N/A,126.90,N/A,126.90,N/A,11.04,N/A,17.77,N/A,17.77,N/A,17.77,N/A,73.07,N/A,126.90,N/A,17.77,N/A,68.02,N/A,68.02,N/A,17.77,N/A,126.90,N/A,126.90,N/A,126.90,76.14,76.14,11.04,126.90,,Hospital HCPCS 2500000003,ETOMIDATE 2 MG/ML IV SOLN,00409-6695-01,0250 - PHARMACY - GENERAL CLASSIFICATION,19.10,19.10,11.46,11.46,N/A,2.67,N/A,19.10,N/A,11.00,N/A,6.49,N/A,2.67,N/A,2.67,N/A,19.10,N/A,19.10,N/A,1.66,N/A,2.67,N/A,2.67,N/A,2.67,N/A,11.00,N/A,19.10,N/A,2.67,N/A,10.24,N/A,10.24,N/A,2.67,N/A,19.10,N/A,19.10,N/A,19.10,11.46,11.46,1.66,19.10,,Hospital HCPCS 2500000003,POTASSIUM PHOSPHATE 3 MMOL/ML IV SOLN (MIXTURES ONLY),00409-7295-01,0250 - PHARMACY - GENERAL CLASSIFICATION,99.90,99.90,59.94,59.94,N/A,13.99,N/A,99.90,N/A,57.52,N/A,33.97,N/A,13.99,N/A,13.99,N/A,99.90,N/A,99.90,N/A,8.69,N/A,13.99,N/A,13.99,N/A,13.99,N/A,57.52,N/A,99.90,N/A,13.99,N/A,53.55,N/A,53.55,N/A,13.99,N/A,99.90,N/A,99.90,N/A,99.90,59.94,59.94,8.69,99.90,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),00409-4277-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,ETOMIDATE 2 MG/ML IV SOLN,55150-0222-20,0250 - PHARMACY - GENERAL CLASSIFICATION,19.10,19.10,11.46,11.46,N/A,2.67,N/A,19.10,N/A,11.00,N/A,6.49,N/A,2.67,N/A,2.67,N/A,19.10,N/A,19.10,N/A,1.66,N/A,2.67,N/A,2.67,N/A,2.67,N/A,11.00,N/A,19.10,N/A,2.67,N/A,10.24,N/A,10.24,N/A,2.67,N/A,19.10,N/A,19.10,N/A,19.10,11.46,11.46,1.66,19.10,,Hospital HCPCS 2500000003,FAMOTIDINE 40 MG/4ML IV SOLN,00641-6023-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,49281-0752-22,0250 - PHARMACY - GENERAL CLASSIFICATION,63.60,63.60,38.16,38.16,N/A,8.90,N/A,63.60,N/A,36.62,N/A,21.62,N/A,8.90,N/A,8.90,N/A,63.60,N/A,63.60,N/A,5.53,N/A,8.90,N/A,8.90,N/A,8.90,N/A,36.62,N/A,63.60,N/A,8.90,N/A,34.09,N/A,34.09,N/A,8.90,N/A,63.60,N/A,63.60,N/A,63.60,38.16,38.16,5.53,63.60,,Hospital HCPCS 2500000003,SODIUM PHOSPHATES 15 MMOLE/5ML IV SOLN,63323-0170-05,0250 - PHARMACY - GENERAL CLASSIFICATION,109.00,109.00,65.40,65.40,N/A,15.26,N/A,109.00,N/A,62.76,N/A,37.06,N/A,15.26,N/A,15.26,N/A,109.00,N/A,109.00,N/A,9.48,N/A,15.26,N/A,15.26,N/A,15.26,N/A,62.76,N/A,109.00,N/A,15.26,N/A,58.42,N/A,58.42,N/A,15.26,N/A,109.00,N/A,109.00,N/A,109.00,65.40,65.40,9.48,109.00,,Hospital HCPCS 2500000003,KETAMINE HCL 50 MG/ML IJ SOLN,42023-0114-10,0250 - PHARMACY - GENERAL CLASSIFICATION,47.40,47.40,28.44,28.44,N/A,6.64,N/A,47.40,N/A,27.29,N/A,16.12,N/A,6.64,N/A,6.64,N/A,47.40,N/A,47.40,N/A,4.12,N/A,6.64,N/A,6.64,N/A,6.64,N/A,27.29,N/A,47.40,N/A,6.64,N/A,25.41,N/A,25.41,N/A,6.64,N/A,47.40,N/A,47.40,N/A,47.40,28.44,28.44,4.12,47.40,,Hospital HCPCS 2500000003,SODIUM PHOSPHATES 45 MMOLE/15ML IV SOLN,00409-7391-72,0250 - PHARMACY - GENERAL CLASSIFICATION,102.80,102.80,61.68,61.68,N/A,14.39,N/A,102.80,N/A,59.19,N/A,34.95,N/A,14.39,N/A,14.39,N/A,102.80,N/A,102.80,N/A,8.94,N/A,14.39,N/A,14.39,N/A,14.39,N/A,59.19,N/A,102.80,N/A,14.39,N/A,55.10,N/A,55.10,N/A,14.39,N/A,102.80,N/A,102.80,N/A,102.80,61.68,61.68,8.94,102.80,,Hospital HCPCS 2500000003,TRAVASOL 10 % IV SOLN,00264-1933-10,0250 - PHARMACY - GENERAL CLASSIFICATION,1066.50,1066.50,639.90,639.90,N/A,149.31,N/A,1066.50,N/A,614.09,N/A,362.61,N/A,149.31,N/A,149.31,N/A,1066.50,N/A,1066.50,N/A,92.79,N/A,149.31,N/A,149.31,N/A,149.31,N/A,614.09,N/A,1066.50,N/A,149.31,N/A,571.64,N/A,571.64,N/A,149.31,N/A,1066.50,N/A,1066.50,N/A,1066.50,639.90,639.90,92.79,1066.50,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 1 % IJ SOLN,63323-0492-97,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,VERAPAMIL HCL 2.5 MG/ML IV SOLN,51754-0203-01,0250 - PHARMACY - GENERAL CLASSIFICATION,108.60,108.60,65.16,65.16,N/A,15.20,N/A,108.60,N/A,62.53,N/A,36.92,N/A,15.20,N/A,15.20,N/A,108.60,N/A,108.60,N/A,9.45,N/A,15.20,N/A,15.20,N/A,15.20,N/A,62.53,N/A,108.60,N/A,15.20,N/A,58.21,N/A,58.21,N/A,15.20,N/A,108.60,N/A,108.60,N/A,108.60,65.16,65.16,9.45,108.60,,Hospital HCPCS 2500000003,AMIODARONE 450 MG IN DEXTROSE 5% 250 ML INFUSION,09999-9910-08,0250 - PHARMACY - GENERAL CLASSIFICATION,369.60,369.60,221.76,221.76,N/A,51.74,N/A,369.60,N/A,212.82,N/A,125.66,N/A,51.74,N/A,51.74,N/A,369.60,N/A,369.60,N/A,32.16,N/A,51.74,N/A,51.74,N/A,51.74,N/A,212.82,N/A,369.60,N/A,51.74,N/A,198.11,N/A,198.11,N/A,51.74,N/A,369.60,N/A,369.60,N/A,369.60,221.76,221.76,32.16,369.60,,Hospital HCPCS 2500000003,LIDOCAINE HCL 1% INJ (MIXTURES ONLY),00409-4276-02,0250 - PHARMACY - GENERAL CLASSIFICATION,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,11.52,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,11.52,N/A,20.00,N/A,2.80,N/A,10.72,N/A,10.72,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital HCPCS 2500000003,BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,63323-0462-37,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,DILTIAZEM HCL-SODIUM CHLORIDE 125-0.7 MG/125ML-% IV SOLN,69374-0997-15,0250 - PHARMACY - GENERAL CLASSIFICATION,97.10,97.10,58.26,58.26,N/A,13.59,N/A,97.10,N/A,55.91,N/A,33.01,N/A,13.59,N/A,13.59,N/A,97.10,N/A,97.10,N/A,8.45,N/A,13.59,N/A,13.59,N/A,13.59,N/A,55.91,N/A,97.10,N/A,13.59,N/A,52.05,N/A,52.05,N/A,13.59,N/A,97.10,N/A,97.10,N/A,97.10,58.26,58.26,8.45,97.10,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,63323-0489-27,0250 - PHARMACY - GENERAL CLASSIFICATION,106.20,106.20,63.72,63.72,N/A,14.87,N/A,106.20,N/A,61.15,N/A,36.11,N/A,14.87,N/A,14.87,N/A,106.20,N/A,106.20,N/A,9.24,N/A,14.87,N/A,14.87,N/A,14.87,N/A,61.15,N/A,106.20,N/A,14.87,N/A,56.92,N/A,56.92,N/A,14.87,N/A,106.20,N/A,106.20,N/A,106.20,63.72,63.72,9.24,106.20,,Hospital HCPCS 2500000003,POTASSIUM PHOSPHATES 45 MMOLE/15ML IV SOLN,00409-7295-11,0250 - PHARMACY - GENERAL CLASSIFICATION,99.90,99.90,59.94,59.94,N/A,13.99,N/A,99.90,N/A,57.52,N/A,33.97,N/A,13.99,N/A,13.99,N/A,99.90,N/A,99.90,N/A,8.69,N/A,13.99,N/A,13.99,N/A,13.99,N/A,57.52,N/A,99.90,N/A,13.99,N/A,53.55,N/A,53.55,N/A,13.99,N/A,99.90,N/A,99.90,N/A,99.90,59.94,59.94,8.69,99.90,,Hospital HCPCS 2500000003,INDOMETHACIN SODIUM 1 MG IV SOLR,63323-0659-03,0250 - PHARMACY - GENERAL CLASSIFICATION,3570.40,3570.40,2142.24,2142.24,N/A,499.86,N/A,3570.40,N/A,2055.84,N/A,1213.94,N/A,499.86,N/A,499.86,N/A,3570.40,N/A,3570.40,N/A,310.62,N/A,499.86,N/A,499.86,N/A,499.86,N/A,2055.84,N/A,3570.40,N/A,499.86,N/A,1913.73,N/A,1913.73,N/A,499.86,N/A,3570.40,N/A,3570.40,N/A,3570.40,2142.24,2142.24,310.62,3570.40,,Hospital HCPCS 2500000003,ETHACRYNATE SODIUM 50 MG IV SOLR,25010-0210-27,0250 - PHARMACY - GENERAL CLASSIFICATION,33849.00,33849.00,20309.40,20309.40,N/A,4738.86,N/A,33849.00,N/A,19490.25,N/A,11508.66,N/A,4738.86,N/A,4738.86,N/A,33849.00,N/A,33849.00,N/A,2944.86,N/A,4738.86,N/A,4738.86,N/A,4738.86,N/A,19490.25,N/A,33849.00,N/A,4738.86,N/A,18143.06,N/A,18143.06,N/A,4738.86,N/A,33849.00,N/A,33849.00,N/A,33849.00,20309.40,20309.40,2944.86,33849.00,,Hospital HCPCS 2500000003,REMIFENTANIL HCL 5 MG IV SOLR,67457-0198-10,0250 - PHARMACY - GENERAL CLASSIFICATION,1760.60,1760.60,1056.36,1056.36,N/A,246.48,N/A,1760.60,N/A,1013.75,N/A,598.60,N/A,246.48,N/A,246.48,N/A,1760.60,N/A,1760.60,N/A,153.17,N/A,246.48,N/A,246.48,N/A,246.48,N/A,1013.75,N/A,1760.60,N/A,246.48,N/A,943.68,N/A,943.68,N/A,246.48,N/A,1760.60,N/A,1760.60,N/A,1760.60,1056.36,1056.36,153.17,1760.60,,Hospital HCPCS 2500000003,SODIUM PHOSPHATE 3 MMOL/ML IV SOLN (MIXTURES ONLY),63323-0884-01,0250 - PHARMACY - GENERAL CLASSIFICATION,116.10,116.10,69.66,69.66,N/A,16.25,N/A,116.10,N/A,66.85,N/A,39.47,N/A,16.25,N/A,16.25,N/A,116.10,N/A,116.10,N/A,10.10,N/A,16.25,N/A,16.25,N/A,16.25,N/A,66.85,N/A,116.10,N/A,16.25,N/A,62.23,N/A,62.23,N/A,16.25,N/A,116.10,N/A,116.10,N/A,116.10,69.66,69.66,10.10,116.10,,Hospital HCPCS 2500000003,CUPRIC CHLORIDE 0.4 MG/ML IV SOLN,00409-4092-01,0250 - PHARMACY - GENERAL CLASSIFICATION,146.30,146.30,87.78,87.78,N/A,20.48,N/A,146.30,N/A,84.24,N/A,49.74,N/A,20.48,N/A,20.48,N/A,146.30,N/A,146.30,N/A,12.73,N/A,20.48,N/A,20.48,N/A,20.48,N/A,84.24,N/A,146.30,N/A,20.48,N/A,78.42,N/A,78.42,N/A,20.48,N/A,146.30,N/A,146.30,N/A,146.30,87.78,87.78,12.73,146.30,,Hospital HCPCS 2500000003,TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,00517-9302-01,0250 - PHARMACY - GENERAL CLASSIFICATION,135.00,135.00,81.00,81.00,N/A,18.90,N/A,135.00,N/A,77.73,N/A,45.90,N/A,18.90,N/A,18.90,N/A,135.00,N/A,135.00,N/A,11.75,N/A,18.90,N/A,18.90,N/A,18.90,N/A,77.73,N/A,135.00,N/A,18.90,N/A,72.36,N/A,72.36,N/A,18.90,N/A,135.00,N/A,135.00,N/A,135.00,81.00,81.00,11.75,135.00,,Hospital HCPCS 2500000003,SILVER SULFADIAZINE 1 % EX CREA,67877-0124-50,0250 - PHARMACY - GENERAL CLASSIFICATION,27.60,27.60,16.56,16.56,N/A,3.86,N/A,27.60,N/A,15.89,N/A,9.38,N/A,3.86,N/A,3.86,N/A,27.60,N/A,27.60,N/A,2.40,N/A,3.86,N/A,3.86,N/A,3.86,N/A,15.89,N/A,27.60,N/A,3.86,N/A,14.79,N/A,14.79,N/A,3.86,N/A,27.60,N/A,27.60,N/A,27.60,16.56,16.56,2.40,27.60,,Hospital HCPCS 2500000003,METHADONE NEONATAL ORAL SOLUTION 0.1 MG/ML,09999-9900-67,0250 - PHARMACY - GENERAL CLASSIFICATION,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.88,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.88,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 1 % IJ SOLN,00409-4276-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 1% INJ (MIXTURES ONLY),00409-4276-01,0250 - PHARMACY - GENERAL CLASSIFICATION,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,11.52,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,11.52,N/A,20.00,N/A,2.80,N/A,10.72,N/A,10.72,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN,00409-4277-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,AMINOCAPROIC ACID 250 MG/ML IV SOLN,00409-4346-73,0250 - PHARMACY - GENERAL CLASSIFICATION,49.20,49.20,29.52,29.52,N/A,6.89,N/A,49.20,N/A,28.33,N/A,16.73,N/A,6.89,N/A,6.89,N/A,49.20,N/A,49.20,N/A,4.28,N/A,6.89,N/A,6.89,N/A,6.89,N/A,28.33,N/A,49.20,N/A,6.89,N/A,26.37,N/A,26.37,N/A,6.89,N/A,49.20,N/A,49.20,N/A,49.20,29.52,29.52,4.28,49.20,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 2 % IJ SOLN,63323-0495-27,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,00781-6153-95,0250 - PHARMACY - GENERAL CLASSIFICATION,37.40,37.40,22.44,22.44,N/A,5.24,N/A,37.40,N/A,21.53,N/A,12.72,N/A,5.24,N/A,5.24,N/A,37.40,N/A,37.40,N/A,3.25,N/A,5.24,N/A,5.24,N/A,5.24,N/A,21.53,N/A,37.40,N/A,5.24,N/A,20.05,N/A,20.05,N/A,5.24,N/A,37.40,N/A,37.40,N/A,37.40,22.44,22.44,3.25,37.40,,Hospital HCPCS 2500000003,LIDOCAINE HCL 0.5 % IJ SOLN,00409-4275-01,0250 - PHARMACY - GENERAL CLASSIFICATION,29.10,29.10,17.46,17.46,N/A,4.07,N/A,29.10,N/A,16.76,N/A,9.89,N/A,4.07,N/A,4.07,N/A,29.10,N/A,29.10,N/A,2.53,N/A,4.07,N/A,4.07,N/A,4.07,N/A,16.76,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,4.07,N/A,29.10,N/A,29.10,N/A,29.10,17.46,17.46,2.53,29.10,,Hospital HCPCS 2500000003,LIDOCAINE HCL 1% INJ (MIXTURES ONLY),55150-0162-05,0250 - PHARMACY - GENERAL CLASSIFICATION,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,11.52,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,11.52,N/A,20.00,N/A,2.80,N/A,10.72,N/A,10.72,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital HCPCS 2500000003,ABLYSINOL IA SOLN,54288-0105-02,0250 - PHARMACY - GENERAL CLASSIFICATION,1343.30,1343.30,805.98,805.98,N/A,188.06,N/A,1343.30,N/A,773.47,N/A,456.72,N/A,188.06,N/A,188.06,N/A,1343.30,N/A,1343.30,N/A,116.87,N/A,188.06,N/A,188.06,N/A,188.06,N/A,773.47,N/A,1343.30,N/A,188.06,N/A,720.01,N/A,720.01,N/A,188.06,N/A,1343.30,N/A,1343.30,N/A,1343.30,805.98,805.98,116.87,1343.30,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),63323-0495-27,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,TRANEXAMIC ACID 1000 MG/10ML IV SOLN,23155-0166-31,0250 - PHARMACY - GENERAL CLASSIFICATION,81.00,81.00,48.60,48.60,N/A,11.34,N/A,81.00,N/A,46.64,N/A,27.54,N/A,11.34,N/A,11.34,N/A,81.00,N/A,81.00,N/A,7.05,N/A,11.34,N/A,11.34,N/A,11.34,N/A,46.64,N/A,81.00,N/A,11.34,N/A,43.42,N/A,43.42,N/A,11.34,N/A,81.00,N/A,81.00,N/A,81.00,48.60,48.60,7.05,81.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 1 % IJ SOLN,00409-4713-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,00409-3182-21,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,PHENYLEPHRINE HCL 0.5 % NA SOLN,00225-0805-47,0250 - PHARMACY - GENERAL CLASSIFICATION,44.20,44.20,26.52,26.52,N/A,6.19,N/A,44.20,N/A,25.45,N/A,15.03,N/A,6.19,N/A,6.19,N/A,44.20,N/A,44.20,N/A,3.85,N/A,6.19,N/A,6.19,N/A,6.19,N/A,25.45,N/A,44.20,N/A,6.19,N/A,23.69,N/A,23.69,N/A,6.19,N/A,44.20,N/A,44.20,N/A,44.20,26.52,26.52,3.85,44.20,,Hospital HCPCS 2500000003,SODIUM CHLORIDE BACTERIOSTATIC 0.9 % IJ SOLN,00409-1966-07,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,FAMOTIDINE PREMIXED 20-0.9 MG/50ML-% IV SOLN,00338-5197-41,0250 - PHARMACY - GENERAL CLASSIFICATION,55.20,55.20,33.12,33.12,N/A,7.73,N/A,55.20,N/A,31.78,N/A,18.77,N/A,7.73,N/A,7.73,N/A,55.20,N/A,55.20,N/A,4.80,N/A,7.73,N/A,7.73,N/A,7.73,N/A,31.78,N/A,55.20,N/A,7.73,N/A,29.59,N/A,29.59,N/A,7.73,N/A,55.20,N/A,55.20,N/A,55.20,33.12,33.12,4.80,55.20,,Hospital HCPCS 2500000003,SODIUM ACETATE 2 MEQ/ML IV SOLN,00409-7299-73,0250 - PHARMACY - GENERAL CLASSIFICATION,21.60,21.60,12.96,12.96,N/A,3.02,N/A,21.60,N/A,12.44,N/A,7.34,N/A,3.02,N/A,3.02,N/A,21.60,N/A,21.60,N/A,1.88,N/A,3.02,N/A,3.02,N/A,3.02,N/A,12.44,N/A,21.60,N/A,3.02,N/A,11.58,N/A,11.58,N/A,3.02,N/A,21.60,N/A,21.60,N/A,21.60,12.96,12.96,1.88,21.60,,Hospital HCPCS 2500000003,LEVOTHYROXINE SODIUM 100 MCG/5ML IV SOLN,63323-0885-10,0250 - PHARMACY - GENERAL CLASSIFICATION,104.80,104.80,62.88,62.88,N/A,14.67,N/A,104.80,N/A,60.34,N/A,35.63,N/A,14.67,N/A,14.67,N/A,104.80,N/A,104.80,N/A,9.12,N/A,14.67,N/A,14.67,N/A,14.67,N/A,60.34,N/A,104.80,N/A,14.67,N/A,56.17,N/A,56.17,N/A,14.67,N/A,104.80,N/A,104.80,N/A,104.80,62.88,62.88,9.12,104.80,,Hospital HCPCS 2500000003,POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,63323-0321-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL (PF) 4 % IJ SOLN,00409-4283-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,00338-0663-04,0250 - PHARMACY - GENERAL CLASSIFICATION,60.80,60.80,36.48,36.48,N/A,8.51,N/A,60.80,N/A,35.01,N/A,20.67,N/A,8.51,N/A,8.51,N/A,60.80,N/A,60.80,N/A,5.29,N/A,8.51,N/A,8.51,N/A,8.51,N/A,35.01,N/A,60.80,N/A,8.51,N/A,32.59,N/A,32.59,N/A,8.51,N/A,60.80,N/A,60.80,N/A,60.80,36.48,36.48,5.29,60.80,,Hospital HCPCS 2500000003,SECUKINUMAB 150 MG/ML SC SOAJ,00078-0639-68,0250 - PHARMACY - GENERAL CLASSIFICATION,43681.10,43681.10,26208.66,26208.66,N/A,6115.35,N/A,43681.10,N/A,25151.58,N/A,14851.57,N/A,6115.35,N/A,6115.35,N/A,43681.10,N/A,43681.10,N/A,3800.26,N/A,6115.35,N/A,6115.35,N/A,6115.35,N/A,25151.58,N/A,43681.10,N/A,6115.35,N/A,23413.07,N/A,23413.07,N/A,6115.35,N/A,43681.10,N/A,43681.10,N/A,43681.10,26208.66,26208.66,3800.26,43681.10,,Hospital HCPCS 2500000003,ANTICOAGULANT SODIUM CITRATE 4% SYRINGE,69374-0906-05,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,TUMESCENT SOLN (EPI/LIDOCAINE/NABICARB/NACL) 500 ML PREMIX,09999-9916-17,0250 - PHARMACY - GENERAL CLASSIFICATION,334.20,334.20,200.52,200.52,N/A,46.79,N/A,334.20,N/A,192.43,N/A,113.63,N/A,46.79,N/A,46.79,N/A,334.20,N/A,334.20,N/A,29.08,N/A,46.79,N/A,46.79,N/A,46.79,N/A,192.43,N/A,334.20,N/A,46.79,N/A,179.13,N/A,179.13,N/A,46.79,N/A,334.20,N/A,334.20,N/A,334.20,200.52,200.52,29.08,334.20,,Hospital HCPCS 2500000003,EXENATIDE 10 MCG/0.04ML SC SOPN,00310-6524-01,0250 - PHARMACY - GENERAL CLASSIFICATION,3605.30,3605.30,2163.18,2163.18,N/A,504.74,N/A,3605.30,N/A,2075.93,N/A,1225.80,N/A,504.74,N/A,504.74,N/A,3605.30,N/A,3605.30,N/A,313.66,N/A,504.74,N/A,504.74,N/A,504.74,N/A,2075.93,N/A,3605.30,N/A,504.74,N/A,1932.44,N/A,1932.44,N/A,504.74,N/A,3605.30,N/A,3605.30,N/A,3605.30,2163.18,2163.18,313.66,3605.30,,Hospital HCPCS 2500000003,ANTICOAGULANT SODIUM CITRATE 46.7 % VI CONC,23731-6030-03,0250 - PHARMACY - GENERAL CLASSIFICATION,510.30,510.30,306.18,306.18,N/A,71.44,N/A,510.30,N/A,293.83,N/A,173.50,N/A,71.44,N/A,71.44,N/A,510.30,N/A,510.30,N/A,44.40,N/A,71.44,N/A,71.44,N/A,71.44,N/A,293.83,N/A,510.30,N/A,71.44,N/A,273.52,N/A,273.52,N/A,71.44,N/A,510.30,N/A,510.30,N/A,510.30,306.18,306.18,44.40,510.30,,Hospital HCPCS 2500000003,OLANZAPINE 10 MG IM SOLR,00781-3159-72,0250 - PHARMACY - GENERAL CLASSIFICATION,39.30,39.30,23.58,23.58,N/A,5.50,N/A,39.30,N/A,22.63,N/A,13.36,N/A,5.50,N/A,5.50,N/A,39.30,N/A,39.30,N/A,3.42,N/A,5.50,N/A,5.50,N/A,5.50,N/A,22.63,N/A,39.30,N/A,5.50,N/A,21.06,N/A,21.06,N/A,5.50,N/A,39.30,N/A,39.30,N/A,39.30,23.58,23.58,3.42,39.30,,Hospital HCPCS 2500000003,TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,49281-0752-21,0250 - PHARMACY - GENERAL CLASSIFICATION,63.60,63.60,38.16,38.16,N/A,8.90,N/A,63.60,N/A,36.62,N/A,21.62,N/A,8.90,N/A,8.90,N/A,63.60,N/A,63.60,N/A,5.53,N/A,8.90,N/A,8.90,N/A,8.90,N/A,36.62,N/A,63.60,N/A,8.90,N/A,34.09,N/A,34.09,N/A,8.90,N/A,63.60,N/A,63.60,N/A,63.60,38.16,38.16,5.53,63.60,,Hospital HCPCS 2500000003,INSULIN PEN NEEDLE 31G X 5 MM MISC,08290-3201-19,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,DEXTROSE 50 % IV SOLN,00409-7517-66,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,24.00,24.00,N/A,5.60,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,24.00,24.00,3.48,40.00,,Hospital HCPCS 2500000003,BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN (MIXTURES ONLY),00409-1755-50,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN,63323-0486-17,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LEVOTHYROXINE SODIUM 100 MCG IV SOLR,63323-0649-94,0250 - PHARMACY - GENERAL CLASSIFICATION,77.50,77.50,46.50,46.50,N/A,10.85,N/A,77.50,N/A,44.62,N/A,26.35,N/A,10.85,N/A,10.85,N/A,77.50,N/A,77.50,N/A,6.74,N/A,10.85,N/A,10.85,N/A,10.85,N/A,44.62,N/A,77.50,N/A,10.85,N/A,41.54,N/A,41.54,N/A,10.85,N/A,77.50,N/A,77.50,N/A,77.50,46.50,46.50,6.74,77.50,,Hospital HCPCS 2500000003,LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),00409-4282-02,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,00409-1209-01,0250 - PHARMACY - GENERAL CLASSIFICATION,33.30,33.30,19.98,19.98,N/A,4.66,N/A,33.30,N/A,19.17,N/A,11.32,N/A,4.66,N/A,4.66,N/A,33.30,N/A,33.30,N/A,2.90,N/A,4.66,N/A,4.66,N/A,4.66,N/A,19.17,N/A,33.30,N/A,4.66,N/A,17.85,N/A,17.85,N/A,4.66,N/A,33.30,N/A,33.30,N/A,33.30,19.98,19.98,2.90,33.30,,Hospital HCPCS 2500000003,EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN,42023-0216-01,0250 - PHARMACY - GENERAL CLASSIFICATION,196.10,196.10,117.66,117.66,N/A,27.45,N/A,196.10,N/A,112.91,N/A,66.67,N/A,27.45,N/A,27.45,N/A,196.10,N/A,196.10,N/A,17.06,N/A,27.45,N/A,27.45,N/A,27.45,N/A,112.91,N/A,196.10,N/A,27.45,N/A,105.11,N/A,105.11,N/A,27.45,N/A,196.10,N/A,196.10,N/A,196.10,117.66,117.66,17.06,196.10,,Hospital HCPCS 2500000003,TALC 4 G PL AERP,63256-0100-30,0250 - PHARMACY - GENERAL CLASSIFICATION,272.30,272.30,163.38,163.38,N/A,38.12,N/A,272.30,N/A,156.79,N/A,92.58,N/A,38.12,N/A,38.12,N/A,272.30,N/A,272.30,N/A,23.69,N/A,38.12,N/A,38.12,N/A,38.12,N/A,156.79,N/A,272.30,N/A,38.12,N/A,145.95,N/A,145.95,N/A,38.12,N/A,272.30,N/A,272.30,N/A,272.30,163.38,163.38,23.69,272.30,,Hospital HCPCS 2500000003,BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,00409-9042-17,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,REMIFENTANIL HCL 1 MG IV SOLR,63323-0723-01,0250 - PHARMACY - GENERAL CLASSIFICATION,434.10,434.10,260.46,260.46,N/A,60.77,N/A,434.10,N/A,249.95,N/A,147.59,N/A,60.77,N/A,60.77,N/A,434.10,N/A,434.10,N/A,37.77,N/A,60.77,N/A,60.77,N/A,60.77,N/A,249.95,N/A,434.10,N/A,60.77,N/A,232.68,N/A,232.68,N/A,60.77,N/A,434.10,N/A,434.10,N/A,434.10,260.46,260.46,37.77,434.10,,Hospital HCPCS 2500000003,LIDOCAINE HCL 1 % IJ SOLN,00409-4276-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,MANNITOL 20 % IV SOLN,00338-0357-03,0250 - PHARMACY - GENERAL CLASSIFICATION,106.40,106.40,63.84,63.84,N/A,14.90,N/A,106.40,N/A,61.27,N/A,36.18,N/A,14.90,N/A,14.90,N/A,106.40,N/A,106.40,N/A,9.26,N/A,14.90,N/A,14.90,N/A,14.90,N/A,61.27,N/A,106.40,N/A,14.90,N/A,57.03,N/A,57.03,N/A,14.90,N/A,106.40,N/A,106.40,N/A,106.40,63.84,63.84,9.26,106.40,,Hospital HCPCS 2500000003,DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN,00143-9525-01,0250 - PHARMACY - GENERAL CLASSIFICATION,216.00,216.00,129.60,129.60,N/A,30.24,N/A,216.00,N/A,124.37,N/A,73.44,N/A,30.24,N/A,30.24,N/A,216.00,N/A,216.00,N/A,18.79,N/A,30.24,N/A,30.24,N/A,30.24,N/A,124.37,N/A,216.00,N/A,30.24,N/A,115.78,N/A,115.78,N/A,30.24,N/A,216.00,N/A,216.00,N/A,216.00,129.60,129.60,18.79,216.00,,Hospital HCPCS 2500000003,FLUMAZENIL 0.5 MG/5ML IV SOLN,00143-9784-10,0250 - PHARMACY - GENERAL CLASSIFICATION,17.60,17.60,10.56,10.56,N/A,2.46,N/A,17.60,N/A,10.13,N/A,5.98,N/A,2.46,N/A,2.46,N/A,17.60,N/A,17.60,N/A,1.53,N/A,2.46,N/A,2.46,N/A,2.46,N/A,10.13,N/A,17.60,N/A,2.46,N/A,9.43,N/A,9.43,N/A,2.46,N/A,17.60,N/A,17.60,N/A,17.60,10.56,10.56,1.53,17.60,,Hospital HCPCS 2500000003,DOXYCYCLINE HYCLATE 100 MG IV SOLR,67457-0437-00,0250 - PHARMACY - GENERAL CLASSIFICATION,112.60,112.60,67.56,67.56,N/A,15.76,N/A,112.60,N/A,64.84,N/A,38.28,N/A,15.76,N/A,15.76,N/A,112.60,N/A,112.60,N/A,9.80,N/A,15.76,N/A,15.76,N/A,15.76,N/A,64.84,N/A,112.60,N/A,15.76,N/A,60.35,N/A,60.35,N/A,15.76,N/A,112.60,N/A,112.60,N/A,112.60,67.56,67.56,9.80,112.60,,Hospital HCPCS 2500000003,LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,00409-3178-01,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 2500000003,PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,10122-0510-03,0250 - PHARMACY - GENERAL CLASSIFICATION,6771.00,6771.00,4062.60,4062.60,N/A,947.94,N/A,6771.00,N/A,3898.74,N/A,2302.14,N/A,947.94,N/A,947.94,N/A,6771.00,N/A,6771.00,N/A,589.08,N/A,947.94,N/A,947.94,N/A,947.94,N/A,3898.74,N/A,6771.00,N/A,947.94,N/A,3629.26,N/A,3629.26,N/A,947.94,N/A,6771.00,N/A,6771.00,N/A,6771.00,4062.60,4062.60,589.08,6771.00,,Hospital HCPCS 2500000003,THROMBIN 5000 UNITS EX SOLR,60793-0215-05,0250 - PHARMACY - GENERAL CLASSIFICATION,486.90,486.90,292.14,292.14,N/A,68.17,N/A,486.90,N/A,280.36,N/A,165.55,N/A,68.17,N/A,68.17,N/A,486.90,N/A,486.90,N/A,42.36,N/A,68.17,N/A,68.17,N/A,68.17,N/A,280.36,N/A,486.90,N/A,68.17,N/A,260.98,N/A,260.98,N/A,68.17,N/A,486.90,N/A,486.90,N/A,486.90,292.14,292.14,42.36,486.90,,Hospital HCPCS 2500000003,BSS PLUS IO SOLN,00065-0795-15,0250 - PHARMACY - GENERAL CLASSIFICATION,24.20,24.20,14.52,14.52,N/A,3.39,N/A,24.20,N/A,13.93,N/A,8.23,N/A,3.39,N/A,3.39,N/A,24.20,N/A,24.20,N/A,2.11,N/A,3.39,N/A,3.39,N/A,3.39,N/A,13.93,N/A,24.20,N/A,3.39,N/A,12.97,N/A,12.97,N/A,3.39,N/A,24.20,N/A,24.20,N/A,24.20,14.52,14.52,2.11,24.20,,Hospital CPT 25075,Exc Tumor Soft Tissue Forearm &/Wrist Subq <3cm,N/A,N/A,867.00,867.00,520.20,520.20,N/A,121.38,N/A,299.50,N/A,867.00,N/A,294.78,N/A,867.00,N/A,121.38,N/A,299.50,N/A,299.50,N/A,867.00,N/A,867.00,N/A,867.00,N/A,867.00,N/A,867.00,N/A,299.50,N/A,121.38,N/A,867.00,N/A,867.00,N/A,121.38,N/A,299.50,N/A,299.50,N/A,329.45,520.20,520.20,121.38,867.00,,Hospital 25078,Rad Rescj Tum Soft Tissue Forearm&/Wrist 3 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24850.67,N/A,14910.40,N/A,3468.60,N/A,2194.44,N/A,14288.48,N/A,8449.22,N/A,7838.64,N/A,3468.60,N/A,3104.47,N/A,3104.47,N/A,5117.80,N/A,7838.64,N/A,7838.64,N/A,7838.64,N/A,14288.48,N/A,3104.47,N/A,3468.60,N/A,5227.25,N/A,5227.25,N/A,3468.60,N/A,3104.47,N/A,2194.44,N/A,2413.89,N/A,N/A,2194.44,14910.40,,Hospital 25110,Excision Lesion Tendon Sheath Forearm&/Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16691.00,N/A,10014.60,N/A,2336.74,N/A,788.45,N/A,9604.60,N/A,5674.94,N/A,3158.57,N/A,2336.74,N/A,1295.43,N/A,1295.43,N/A,1966.27,N/A,3158.57,N/A,3158.57,N/A,3158.57,N/A,9604.60,N/A,1295.43,N/A,2336.74,N/A,5453.25,N/A,5453.25,N/A,2336.74,N/A,1295.43,N/A,788.45,N/A,867.30,N/A,N/A,788.45,10014.60,,Hospital 25112,Excision Ganglion Wrist Dorsal/Volar Recurrent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18479.87,N/A,11087.92,N/A,2587.19,N/A,370.23,N/A,10637.27,N/A,6283.16,N/A,3151.64,N/A,2587.19,N/A,1295.43,N/A,1295.43,N/A,1961.94,N/A,3151.64,N/A,3151.64,N/A,3151.64,N/A,10637.28,N/A,1295.43,N/A,2587.19,N/A,3397.00,N/A,3397.00,N/A,2587.19,N/A,1295.43,N/A,370.23,N/A,407.25,N/A,N/A,370.23,11087.92,,Hospital 25116,Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12311.10,N/A,7386.66,N/A,1723.56,N/A,2811.81,N/A,7087.36,N/A,4185.78,N/A,6521.36,N/A,1723.56,N/A,2688.04,N/A,2688.04,N/A,4059.66,N/A,6521.36,N/A,6521.36,N/A,6521.36,N/A,7087.36,N/A,2688.04,N/A,1723.56,N/A,3397.00,N/A,3397.00,N/A,1723.56,N/A,2688.04,N/A,2811.81,N/A,658.67,N/A,N/A,658.67,7386.66,,Hospital 25126,Exc/Curtg Cyst/Tumor Radius/Ulna W/Allograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68780.73,N/A,41268.44,N/A,9627.48,N/A,6248.31,N/A,39317.65,N/A,23385.46,N/A,14554.70,N/A,9627.48,N/A,5973.28,N/A,5973.28,N/A,9060.56,N/A,14554.70,N/A,14554.70,N/A,14554.70,N/A,39317.65,N/A,5973.28,N/A,9627.48,N/A,10178.00,N/A,10178.00,N/A,9627.48,N/A,5973.28,N/A,6248.31,N/A,1689.30,N/A,N/A,1689.30,41268.44,,Hospital 25151,Partial Excision Bone Radius,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28976.00,N/A,17385.60,N/A,4041.12,N/A,2811.81,N/A,16677.71,N/A,9851.87,N/A,6633.70,N/A,4041.12,N/A,2688.04,N/A,2688.04,N/A,4131.64,N/A,6633.70,N/A,6633.70,N/A,6633.70,N/A,16677.73,N/A,2688.04,N/A,4041.12,N/A,7109.75,N/A,7109.75,N/A,4041.12,N/A,2688.04,N/A,2811.81,N/A,2037.62,N/A,N/A,2037.62,17385.60,,Hospital 25230,Radical Styloidectomy Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,77288.40,N/A,46373.04,N/A,10820.40,N/A,6248.31,N/A,44361.71,N/A,26278.07,N/A,14492.42,N/A,10820.40,N/A,5973.28,N/A,5973.28,N/A,9021.81,N/A,14492.42,N/A,14492.42,N/A,14492.42,N/A,44361.72,N/A,5973.28,N/A,10820.40,N/A,10178.00,N/A,10178.00,N/A,10820.40,N/A,5973.28,N/A,6248.31,N/A,1206.84,N/A,N/A,1206.84,46373.04,,Hospital 25248,Expl W/Removal Deep Foreign Body Forearm/Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16505.90,N/A,9903.54,N/A,2310.83,N/A,1309.46,N/A,9501.48,N/A,5612.01,N/A,3175.70,N/A,2310.83,N/A,1295.43,N/A,1295.43,N/A,1976.93,N/A,3175.70,N/A,3175.70,N/A,3175.70,N/A,9501.48,N/A,1295.43,N/A,2310.83,N/A,3397.00,N/A,3397.00,N/A,2310.83,N/A,1295.43,N/A,1309.46,N/A,450.46,N/A,N/A,450.46,9903.54,,Hospital 25295,Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40036.32,N/A,24021.79,N/A,5632.65,N/A,1181.60,N/A,22832.07,N/A,13612.35,N/A,6548.83,N/A,5632.65,N/A,2688.04,N/A,2688.04,N/A,4076.77,N/A,6548.83,N/A,6548.83,N/A,6548.83,N/A,22832.08,N/A,2688.04,N/A,5632.65,N/A,4332.50,N/A,4332.50,N/A,5632.65,N/A,2688.04,N/A,1181.60,N/A,1299.76,N/A,N/A,1181.60,24021.79,,Hospital 25312,Tdn Trnsplj/Tr Flxr/Xtnsr F/Arm&/Wrst 1/Tdn Gr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41278.10,N/A,24766.86,N/A,5716.59,N/A,5921.68,N/A,23584.05,N/A,14034.55,N/A,14501.75,N/A,5716.59,N/A,5973.28,N/A,5973.28,N/A,9027.61,N/A,14501.75,N/A,14501.75,N/A,14501.75,N/A,23584.04,N/A,5973.28,N/A,5716.59,N/A,10085.00,N/A,10085.00,N/A,5716.59,N/A,5973.28,N/A,5921.68,N/A,3841.70,N/A,N/A,3841.70,24766.86,,Hospital 25320,Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32251.10,N/A,19350.66,N/A,4515.15,N/A,6132.82,N/A,18543.41,N/A,10965.37,N/A,14492.93,N/A,4515.15,N/A,5973.28,N/A,5973.28,N/A,9022.12,N/A,14492.93,N/A,14492.93,N/A,14492.93,N/A,18543.42,N/A,5973.28,N/A,4515.15,N/A,8601.75,N/A,8601.75,N/A,4515.15,N/A,5973.28,N/A,6132.82,N/A,1615.63,N/A,N/A,1615.63,19350.66,,Hospital 25350,Osteotomy Radius Distal Third,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39698.97,N/A,23819.38,N/A,5557.86,N/A,6248.31,N/A,22763.03,N/A,13497.64,N/A,14523.53,N/A,5557.86,N/A,5973.28,N/A,5973.28,N/A,9043.23,N/A,14523.53,N/A,14523.53,N/A,14523.53,N/A,22763.05,N/A,5973.28,N/A,5557.86,N/A,6678.50,N/A,6678.50,N/A,5557.86,N/A,5973.28,N/A,6248.31,N/A,774.28,N/A,N/A,774.28,23819.38,,Hospital 25441,Arthroplasty W/Prosthetic Rplcmt Distal Radius,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69529.38,N/A,41717.63,N/A,9734.12,N/A,12325.48,N/A,39712.87,N/A,23639.99,N/A,28563.03,N/A,9734.12,N/A,11782.94,N/A,11782.94,N/A,17781.30,N/A,28563.03,N/A,28563.03,N/A,28563.03,N/A,39712.87,N/A,11782.94,N/A,9734.12,N/A,13941.00,N/A,13941.00,N/A,9734.12,N/A,11782.94,N/A,12325.48,N/A,1773.27,N/A,N/A,1773.27,41717.63,,Hospital 25449,Revj Arthrp W/Removal Implant Wrist Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69268.57,N/A,41561.14,N/A,9697.61,N/A,6097.50,N/A,39578.76,N/A,23551.32,N/A,14487.38,N/A,9697.61,N/A,5973.28,N/A,5973.28,N/A,9018.67,N/A,14487.38,N/A,14487.38,N/A,14487.38,N/A,39578.77,N/A,5973.28,N/A,9697.61,N/A,6678.50,N/A,6678.50,N/A,9697.61,N/A,5973.28,N/A,6097.50,N/A,1204.27,N/A,N/A,1204.27,41561.14,,Hospital 25530,HC Treat Fracture of Ulna,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,2353.00,N/A,1411.80,N/A,329.42,N/A,423.79,N/A,1354.86,N/A,800.02,N/A,N/A,N/A,329.42,N/A,419.26,N/A,419.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1354.86,N/A,419.26,N/A,329.42,N/A,523.14,N/A,523.14,N/A,329.42,N/A,419.26,N/A,423.79,N/A,364.16,N/A,N/A,329.42,1411.80,,Hospital CPT 25605,HC ED Cltx Distal Radial Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,487.80,N/A,979.44,N/A,578.34,N/A,1549.14,N/A,238.14,N/A,487.80,N/A,487.80,N/A,964.34,N/A,1549.14,N/A,1549.14,N/A,1549.14,N/A,979.44,N/A,487.80,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,487.80,N/A,487.80,N/A,536.58,1020.60,1020.60,238.14,1701.00,,Hospital 25606,Perq Skel Fixj Distal Radial Fx/Epiphysl Sep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20298.22,N/A,12178.93,N/A,2841.76,N/A,639.38,N/A,11681.36,N/A,6901.40,N/A,6534.12,N/A,2841.76,N/A,2688.04,N/A,2688.04,N/A,4067.62,N/A,6534.12,N/A,6534.12,N/A,6534.12,N/A,11681.36,N/A,2688.04,N/A,2841.76,N/A,3397.00,N/A,3397.00,N/A,2841.76,N/A,2688.04,N/A,639.38,N/A,703.32,N/A,N/A,639.38,12178.93,,Hospital CPT 25609,Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag,N/A,N/A,2083.00,2083.00,1249.80,1249.80,N/A,291.62,N/A,1000.02,N/A,2083.00,N/A,708.22,N/A,2083.00,N/A,291.62,N/A,1000.02,N/A,1000.02,N/A,1864.18,N/A,2083.00,N/A,2083.00,N/A,2083.00,N/A,2083.00,N/A,1000.02,N/A,291.62,N/A,2083.00,N/A,2083.00,N/A,291.62,N/A,1000.02,N/A,1000.02,N/A,1100.02,1249.80,1249.80,291.62,2083.00,,Hospital CPT 25624,HC Clsd Tx Navicular Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4030.00,4030.00,2418.00,2418.00,N/A,564.20,N/A,422.56,N/A,2320.47,N/A,1370.20,N/A,1397.88,N/A,564.20,N/A,422.56,N/A,422.56,N/A,870.18,N/A,1397.88,N/A,1397.88,N/A,1397.88,N/A,2320.47,N/A,422.56,N/A,564.20,N/A,4030.00,N/A,4030.00,N/A,564.20,N/A,422.56,N/A,422.56,N/A,464.82,2418.00,2418.00,422.56,4030.00,,Hospital 25628,Open Tx Carpal Scaphoid Navicular Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46576.40,N/A,27945.84,N/A,6520.69,N/A,6248.31,N/A,26797.34,N/A,15835.97,N/A,14469.04,N/A,6520.69,N/A,5973.28,N/A,5973.28,N/A,9007.25,N/A,14469.04,N/A,14469.04,N/A,14469.04,N/A,26797.36,N/A,5973.28,N/A,6520.69,N/A,8612.50,N/A,8612.50,N/A,6520.69,N/A,5973.28,N/A,6248.31,N/A,821.66,N/A,N/A,821.66,27945.84,,Hospital 25635,HC Treat Wrist Bone Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 25671,Prq Skeletal Fixj Distal Radioulnar Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,109781.00,N/A,65868.60,N/A,15322.72,N/A,2425.67,N/A,62485.25,N/A,36291.94,N/A,28563.65,N/A,15322.72,N/A,11782.94,N/A,11782.94,N/A,17781.42,N/A,28563.65,N/A,28563.65,N/A,28563.65,N/A,62485.27,N/A,11782.94,N/A,15322.72,N/A,12694.75,N/A,12694.75,N/A,15322.72,N/A,11782.94,N/A,2425.67,N/A,2668.25,N/A,N/A,2425.67,65868.60,,Hospital CPT 25680,HC Treat Wrist Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,504.22,N/A,327.05,N/A,193.12,N/A,568.00,N/A,79.52,N/A,504.22,N/A,504.22,N/A,568.00,N/A,568.00,N/A,568.00,N/A,568.00,N/A,327.05,N/A,504.22,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,504.22,N/A,504.22,N/A,554.64,340.80,340.80,79.52,568.00,,Hospital 25805,Arthrodesis Wrist W/Sliding Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59274.58,N/A,35564.75,N/A,8298.32,N/A,6334.00,N/A,33856.55,N/A,20153.37,N/A,14496.68,N/A,8298.32,N/A,5977.21,N/A,5977.21,N/A,9024.46,N/A,14496.68,N/A,14496.68,N/A,14496.68,N/A,33856.56,N/A,5977.21,N/A,8298.32,N/A,8612.50,N/A,8612.50,N/A,8298.32,N/A,5977.21,N/A,6334.00,N/A,988.46,N/A,N/A,988.46,35564.75,,Hospital 25825,Arthrodesis Wrist Limited W/Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68392.40,N/A,41035.44,N/A,9558.75,N/A,761.81,N/A,38786.60,N/A,23253.42,N/A,14498.98,N/A,9558.75,N/A,5973.28,N/A,5973.28,N/A,9025.88,N/A,14498.98,N/A,14498.98,N/A,14498.98,N/A,38786.63,N/A,5973.28,N/A,9558.75,N/A,7897.00,N/A,7897.00,N/A,9558.75,N/A,5973.28,N/A,761.81,N/A,838.00,N/A,N/A,761.81,41035.44,,Hospital 26035,Decompression Fingers&/Hand Injection Injury,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15805.70,N/A,9483.42,N/A,2174.85,N/A,2811.81,N/A,9098.98,N/A,5373.94,N/A,6543.53,N/A,2174.85,N/A,2688.04,N/A,2688.04,N/A,4073.46,N/A,6543.53,N/A,6543.53,N/A,6543.53,N/A,9098.98,N/A,2688.04,N/A,2174.85,N/A,2134.50,N/A,2134.50,N/A,2174.85,N/A,2688.04,N/A,2811.81,N/A,1097.82,N/A,N/A,1097.82,9483.42,,Hospital 26070,Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25948.03,N/A,15568.82,N/A,3612.43,N/A,1288.80,N/A,14874.57,N/A,8822.33,N/A,3222.54,N/A,3612.43,N/A,1295.43,N/A,1295.43,N/A,2006.10,N/A,3222.54,N/A,3222.54,N/A,3222.54,N/A,14828.52,N/A,1295.43,N/A,3612.43,N/A,4332.50,N/A,4332.50,N/A,3612.43,N/A,1295.43,N/A,1288.80,N/A,717.89,N/A,N/A,717.89,15568.82,,Hospital CPT 26080,HC Explore/Treat Finger Jnt,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3922.00,3922.00,2353.20,2353.20,N/A,549.08,N/A,377.21,N/A,2258.29,N/A,1333.48,N/A,1133.13,N/A,549.08,N/A,377.21,N/A,377.21,N/A,705.37,N/A,1133.13,N/A,1133.13,N/A,1133.13,N/A,2258.29,N/A,377.21,N/A,549.08,N/A,3922.00,N/A,3922.00,N/A,549.08,N/A,377.21,N/A,377.21,N/A,414.93,2353.20,2353.20,377.21,3922.00,,Hospital 26111,Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11723.08,N/A,7033.85,N/A,1641.24,N/A,424.55,N/A,6746.61,N/A,3985.85,N/A,3288.90,N/A,1641.24,N/A,1354.15,N/A,1354.15,N/A,2047.41,N/A,3288.90,N/A,3288.90,N/A,3288.90,N/A,6746.63,N/A,1354.15,N/A,1641.24,N/A,3397.00,N/A,3397.00,N/A,1641.24,N/A,1354.15,N/A,424.55,N/A,467.01,N/A,N/A,424.55,7033.85,,Hospital 26121,Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17692.40,N/A,10615.44,N/A,2476.94,N/A,2811.81,N/A,10186.54,N/A,6015.42,N/A,6515.06,N/A,2476.94,N/A,2688.04,N/A,2688.04,N/A,4055.75,N/A,6515.06,N/A,6515.06,N/A,6515.06,N/A,10186.55,N/A,2688.04,N/A,2476.94,N/A,4562.00,N/A,4562.00,N/A,2476.94,N/A,2688.04,N/A,2811.81,N/A,656.17,N/A,N/A,656.17,10615.44,,Hospital 26125,Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22027.25,N/A,13216.35,N/A,3083.82,N/A,2965.23,N/A,12672.80,N/A,7489.26,N/A,6563.90,N/A,3083.82,N/A,2688.04,N/A,2688.04,N/A,4086.16,N/A,6563.90,N/A,6563.90,N/A,6563.90,N/A,12672.81,N/A,2688.04,N/A,3083.82,N/A,4957.25,N/A,4957.25,N/A,3083.82,N/A,2688.04,N/A,1310.17,N/A,1441.19,N/A,N/A,1310.17,13216.35,,Hospital 26130,Synovectomy Carpometacarpal Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10584.40,N/A,6350.64,N/A,1481.81,N/A,2759.84,N/A,6093.19,N/A,3598.69,N/A,6518.89,N/A,1481.81,N/A,2688.04,N/A,2688.04,N/A,4058.14,N/A,6518.89,N/A,6518.89,N/A,6518.89,N/A,6092.74,N/A,2688.04,N/A,1481.81,N/A,4332.50,N/A,4332.50,N/A,1481.81,N/A,2688.04,N/A,2759.84,N/A,856.67,N/A,N/A,856.67,6518.89,,Hospital 26140,Synvct Prox Iphal Jt W/Xtnsr Rcnstj Ea Iphal Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10888.53,N/A,6533.12,N/A,1524.40,N/A,1312.90,N/A,6265.70,N/A,3702.11,N/A,3153.83,N/A,1524.40,N/A,1295.43,N/A,1295.43,N/A,1963.32,N/A,3153.83,N/A,3153.83,N/A,3153.83,N/A,6265.71,N/A,1295.43,N/A,1524.40,N/A,2806.50,N/A,2806.50,N/A,1524.40,N/A,1295.43,N/A,780.87,N/A,858.96,N/A,N/A,780.87,6533.12,,Hospital 26373,Rpr/Advmnt Tdn W/Ntc Supfcis Tdn W/O Free Grf Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27700.80,N/A,16620.48,N/A,3878.11,N/A,2811.81,N/A,15948.36,N/A,9418.26,N/A,6538.83,N/A,3878.11,N/A,2688.04,N/A,2688.04,N/A,4074.18,N/A,6538.83,N/A,6538.83,N/A,6538.83,N/A,15948.36,N/A,2688.04,N/A,3878.11,N/A,7983.50,N/A,7983.50,N/A,3878.11,N/A,2688.04,N/A,2811.81,N/A,2470.28,N/A,N/A,2470.28,16620.48,,Hospital 26410,Repair Extensor Tendon Hand W/O Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34667.47,N/A,20800.48,N/A,4837.28,N/A,1547.45,N/A,19791.49,N/A,11786.92,N/A,6572.27,N/A,4837.28,N/A,2688.04,N/A,2688.04,N/A,4091.35,N/A,6572.27,N/A,6572.27,N/A,6572.27,N/A,19791.50,N/A,2688.04,N/A,4837.28,N/A,4800.25,N/A,4800.25,N/A,4837.28,N/A,2688.04,N/A,1547.45,N/A,1702.21,N/A,N/A,1547.45,20800.48,,Hospital 26420,Repair Extensor Tendon Finger W/Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33214.47,N/A,19928.68,N/A,4650.02,N/A,2818.24,N/A,18923.51,N/A,11292.92,N/A,6545.08,N/A,4650.02,N/A,2688.04,N/A,2688.04,N/A,4074.43,N/A,6545.08,N/A,6545.08,N/A,6545.08,N/A,18923.52,N/A,2688.04,N/A,4650.02,N/A,6618.25,N/A,6618.25,N/A,4650.02,N/A,2688.04,N/A,1103.42,N/A,1213.77,N/A,N/A,1103.42,19928.68,,Hospital 26492,Opponensplasty Tdn Tr W/Grf Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14083.50,N/A,8450.10,N/A,1945.24,N/A,2664.83,N/A,8105.77,N/A,4788.39,N/A,6551.53,N/A,1945.24,N/A,2688.04,N/A,2688.04,N/A,4078.45,N/A,6551.53,N/A,6551.53,N/A,6551.53,N/A,8105.77,N/A,2688.04,N/A,1945.24,N/A,6260.50,N/A,6260.50,N/A,1945.24,N/A,2688.04,N/A,2664.83,N/A,1454.31,N/A,N/A,1454.31,8450.10,,Hospital 26540,Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29104.63,N/A,17462.78,N/A,4074.64,N/A,2811.81,N/A,16670.57,N/A,9895.57,N/A,6523.81,N/A,4074.64,N/A,2688.04,N/A,2688.04,N/A,4061.20,N/A,6523.81,N/A,6523.81,N/A,6523.81,N/A,16670.58,N/A,2688.04,N/A,4074.64,N/A,2806.50,N/A,2806.50,N/A,4074.64,N/A,2688.04,N/A,2811.81,N/A,1034.94,N/A,N/A,1034.94,17462.78,,Hospital 26541,Rcnstj Coltrl Ligm Mtcarphlngl 1 W/Tdn/Fscal Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32998.53,N/A,19799.12,N/A,4619.80,N/A,2674.29,N/A,18937.55,N/A,11219.50,N/A,6537.31,N/A,4619.80,N/A,2688.04,N/A,2688.04,N/A,4069.60,N/A,6537.31,N/A,6537.31,N/A,6537.31,N/A,18937.56,N/A,2688.04,N/A,4619.80,N/A,9093.25,N/A,9093.25,N/A,4619.80,N/A,2688.04,N/A,2674.29,N/A,2101.29,N/A,N/A,2101.29,19799.12,,Hospital 26565,Osteotomy Metacarpal Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25784.43,N/A,15470.66,N/A,3609.82,N/A,2811.81,N/A,14845.11,N/A,8766.70,N/A,6526.66,N/A,3609.82,N/A,2688.04,N/A,2688.04,N/A,4062.97,N/A,6526.66,N/A,6526.66,N/A,6526.66,N/A,14813.45,N/A,2688.04,N/A,3609.82,N/A,10535.75,N/A,10535.75,N/A,3609.82,N/A,2688.04,N/A,2811.81,N/A,1494.60,N/A,N/A,1494.60,15470.66,,Hospital 26591,Repair Intrinsic Muscles Hand Each Muscle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,73746.73,N/A,44248.04,N/A,10352.37,N/A,2859.50,N/A,42298.53,N/A,25073.87,N/A,6587.72,N/A,10352.37,N/A,2688.04,N/A,2688.04,N/A,4100.96,N/A,6587.72,N/A,6587.72,N/A,6587.72,N/A,41929.45,N/A,2688.04,N/A,10352.37,N/A,7692.25,N/A,7692.25,N/A,10352.37,N/A,2688.04,N/A,2859.50,N/A,2678.50,N/A,N/A,2678.50,44248.04,,Hospital 26593,Release Intrinsic Muscles Hand Each Muscle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11191.90,N/A,6715.14,N/A,1566.87,N/A,2664.83,N/A,6442.04,N/A,3805.24,N/A,6552.82,N/A,1566.87,N/A,2688.04,N/A,2688.04,N/A,4079.26,N/A,6552.82,N/A,6552.82,N/A,6552.82,N/A,6442.04,N/A,2688.04,N/A,1566.87,N/A,3274.25,N/A,3274.25,N/A,1566.87,N/A,2688.04,N/A,2664.83,N/A,2019.57,N/A,N/A,1566.87,6715.14,,Hospital 26596,Exc Constricting Ring Fngr W/Mlt Z-Plasties,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13691.00,N/A,8214.60,N/A,1916.77,N/A,2664.83,N/A,7881.65,N/A,4654.89,N/A,6524.83,N/A,1916.77,N/A,2688.04,N/A,2688.04,N/A,4061.82,N/A,6524.83,N/A,6524.83,N/A,6524.83,N/A,7881.65,N/A,2688.04,N/A,1916.77,N/A,7310.75,N/A,7310.75,N/A,1916.77,N/A,2688.04,N/A,2664.83,N/A,11196.17,N/A,N/A,1916.77,11196.17,,Hospital CPT 26605,HC Clsd Tx MC Fx Manipulation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,736.00,736.00,441.60,441.60,N/A,103.04,N/A,282.92,N/A,423.79,N/A,250.24,N/A,736.00,N/A,103.04,N/A,282.92,N/A,282.92,N/A,586.66,N/A,736.00,N/A,736.00,N/A,736.00,N/A,423.79,N/A,282.92,N/A,103.04,N/A,736.00,N/A,736.00,N/A,103.04,N/A,282.92,N/A,282.92,N/A,311.21,441.60,441.60,103.04,736.00,,Hospital 26608,Prq Skeletal Fixj Metacarpal Fx Each Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,29708.70,16927.18,17825.22,10156.31,5509.06,2369.81,6782.57,973.69,12415.12,9737.83,10100.96,5755.26,12533.88,6552.72,5678.81,2369.81,6782.57,2688.04,6782.57,2688.04,7802.05,4079.19,12533.88,6552.72,12533.88,6552.72,12533.88,6552.72,12415.12,9737.83,6782.57,2688.04,5678.81,2369.81,14912.19,5453.25,14912.19,5453.25,N/A,2369.81,6782.57,2688.04,6782.57,973.69,6076.32,1071.06,5509.06,17825.22,973.69,10156.31,,Hospital 26650,Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14277.83,N/A,8566.70,N/A,1998.90,N/A,2759.84,N/A,8218.28,N/A,4854.47,N/A,6576.45,N/A,1998.90,N/A,2688.04,N/A,2688.04,N/A,4093.95,N/A,6576.45,N/A,6576.45,N/A,6576.45,N/A,8218.29,N/A,2688.04,N/A,1998.90,N/A,3397.00,N/A,3397.00,N/A,1998.90,N/A,2688.04,N/A,2759.84,N/A,501.74,N/A,N/A,501.74,8566.70,,Hospital 26665,Open Tx Carpometacarpal Fracture Dislocate Thumb,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31344.62,N/A,18806.77,N/A,4388.25,N/A,592.87,N/A,17877.30,N/A,10657.17,N/A,6594.67,N/A,4388.25,N/A,2688.04,N/A,2688.04,N/A,4105.31,N/A,6594.67,N/A,6594.67,N/A,6594.67,N/A,17877.32,N/A,2688.04,N/A,4388.25,N/A,7897.00,N/A,7897.00,N/A,4388.25,N/A,2688.04,N/A,592.87,N/A,652.16,N/A,N/A,592.87,18806.77,,Hospital 26676,Prq Skel Fixj Carpo/Mtcrpl Dislc Thmb Manj Ea Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40378.97,N/A,24227.38,N/A,5653.07,N/A,1510.83,N/A,23102.35,N/A,13728.85,N/A,7443.95,N/A,5653.07,N/A,2688.04,N/A,2688.04,N/A,4633.98,N/A,7443.95,N/A,7443.95,N/A,7443.95,N/A,23102.36,N/A,2688.04,N/A,5653.07,N/A,10444.75,N/A,10444.75,N/A,5653.07,N/A,2688.04,N/A,1510.83,N/A,1661.92,N/A,N/A,1510.83,24227.38,,Hospital 26706,Prq Skel Fixj Metacarpophalangeal Dislc W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14286.70,N/A,8572.02,N/A,2000.14,N/A,2811.81,N/A,8224.71,N/A,4857.48,N/A,6537.59,N/A,2000.14,N/A,2688.04,N/A,2688.04,N/A,4069.77,N/A,6537.59,N/A,6537.59,N/A,6537.59,N/A,8193.05,N/A,2688.04,N/A,2000.14,N/A,2806.50,N/A,2806.50,N/A,2000.14,N/A,2688.04,N/A,2811.81,N/A,957.13,N/A,N/A,957.13,8572.02,,Hospital 26715,Open Treatment Metacarpophalangeal Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18099.80,N/A,10859.88,N/A,2533.97,N/A,2759.84,N/A,10420.57,N/A,6153.93,N/A,6511.25,N/A,2533.97,N/A,2688.04,N/A,2688.04,N/A,4053.38,N/A,6511.25,N/A,6511.25,N/A,6511.25,N/A,10420.57,N/A,2688.04,N/A,2533.97,N/A,4112.50,N/A,4112.50,N/A,2533.97,N/A,2688.04,N/A,2759.84,N/A,670.01,N/A,N/A,670.01,10859.88,,Hospital 26746,Open Tx Articular Fracture Mcp/IP Joint Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35713.50,N/A,21428.10,N/A,5000.91,N/A,2674.29,N/A,20451.05,N/A,12142.58,N/A,6524.26,N/A,5000.91,N/A,2688.04,N/A,2688.04,N/A,4061.47,N/A,6524.26,N/A,6524.26,N/A,6524.26,N/A,20451.05,N/A,2688.04,N/A,5000.91,N/A,4332.50,N/A,4332.50,N/A,5000.91,N/A,2688.04,N/A,2674.29,N/A,1513.23,N/A,N/A,1513.23,21428.10,,Hospital 26785,Open Tx Interphalangeal Joint Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14887.03,N/A,8932.22,N/A,2084.20,N/A,2759.84,N/A,8569.37,N/A,5061.60,N/A,6517.08,N/A,2084.20,N/A,2688.04,N/A,2688.04,N/A,4057.01,N/A,6517.08,N/A,6517.08,N/A,6517.08,N/A,8569.38,N/A,2688.04,N/A,2084.20,N/A,5227.25,N/A,5227.25,N/A,2084.20,N/A,2688.04,N/A,2759.84,N/A,1127.68,N/A,N/A,1127.68,8932.22,,Hospital 26841,Arthrd Carpo/Metacarpal Jt Thumb W/WO Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30442.22,N/A,18265.33,N/A,4261.92,N/A,6248.31,N/A,17459.74,N/A,10350.36,N/A,14500.41,N/A,4261.92,N/A,5973.28,N/A,5973.28,N/A,9026.77,N/A,14500.41,N/A,14500.41,N/A,14500.41,N/A,17459.74,N/A,5973.28,N/A,4261.92,N/A,4562.00,N/A,4562.00,N/A,4261.92,N/A,5973.28,N/A,6248.31,N/A,831.63,N/A,N/A,831.63,18265.33,,Hospital 26852,Arthrodesis Mtcrpl Jt W/WO Int Fixj W/Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81112.68,N/A,48667.61,N/A,11326.27,N/A,6097.50,N/A,46376.40,N/A,27578.33,N/A,14460.18,N/A,11326.27,N/A,5973.28,N/A,5973.28,N/A,9001.74,N/A,14460.18,N/A,14460.18,N/A,14460.18,N/A,46358.18,N/A,5973.28,N/A,11326.27,N/A,5277.50,N/A,5277.50,N/A,11326.27,N/A,5973.28,N/A,6097.50,N/A,1025.99,N/A,N/A,1025.99,48667.61,,Hospital 26861,Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27350.88,N/A,16410.53,N/A,3812.95,N/A,746.54,N/A,15677.62,N/A,9299.31,N/A,14503.89,N/A,3812.95,N/A,5973.28,N/A,5973.28,N/A,9028.96,N/A,14503.89,N/A,14503.89,N/A,14503.89,N/A,15677.63,N/A,5973.28,N/A,3812.95,N/A,5409.25,N/A,5409.25,N/A,3812.95,N/A,5973.28,N/A,746.54,N/A,821.20,N/A,N/A,746.54,16410.53,,Hospital 27025,Fasciotomy Hip/Thigh Any Type,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,111827.53,N/A,67096.52,N/A,15655.85,N/A,12494.23,N/A,11735.00,N/A,38021.34,N/A,43810.57,N/A,15655.85,N/A,11951.69,N/A,11951.69,N/A,27569.49,N/A,43810.57,N/A,43810.57,N/A,43810.57,N/A,11735.00,N/A,11977.96,N/A,15655.85,N/A,13819.75,N/A,13819.75,N/A,15655.85,N/A,11951.69,N/A,12494.23,N/A,6291.65,N/A,N/A,6291.65,67096.52,,Hospital 27027,Decompression Fasciotomy Pelvic Compartment Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,73917.47,N/A,44350.48,N/A,10344.29,N/A,6398.14,N/A,42549.09,N/A,24805.53,N/A,15146.93,N/A,10344.29,N/A,6123.11,N/A,6123.11,N/A,9625.23,N/A,15146.93,N/A,15146.93,N/A,15146.93,N/A,41673.35,N/A,6146.36,N/A,10344.29,N/A,5409.25,N/A,5409.25,N/A,10344.29,N/A,6123.11,N/A,6398.14,N/A,1656.07,N/A,N/A,1656.07,44350.48,,Hospital CPT 27047,Exc Tumor Soft Tissue Pelvis & Hip Subq <3cm,N/A,N/A,822.00,822.00,493.20,493.20,N/A,115.08,N/A,344.12,N/A,822.00,N/A,279.48,N/A,822.00,N/A,115.08,N/A,344.12,N/A,344.12,N/A,822.00,N/A,822.00,N/A,822.00,N/A,822.00,N/A,822.00,N/A,344.12,N/A,115.08,N/A,822.00,N/A,822.00,N/A,115.08,N/A,344.12,N/A,344.12,N/A,378.53,493.20,493.20,115.08,822.00,,Hospital 27062,Excision Trochanteric Bursa/Calcification,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72090.53,N/A,43254.32,N/A,10083.84,N/A,6248.31,N/A,41396.49,N/A,24510.77,N/A,14604.50,N/A,10083.84,N/A,5973.28,N/A,5973.28,N/A,9091.59,N/A,14604.50,N/A,14604.50,N/A,14604.50,N/A,41396.51,N/A,5973.28,N/A,10083.84,N/A,12694.75,N/A,12694.75,N/A,10083.84,N/A,5973.28,N/A,6248.31,N/A,2690.10,N/A,N/A,2690.10,43254.32,,Hospital 27071,Partial Excision Deep Pelvis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39424.00,N/A,23654.40,N/A,5520.53,N/A,4724.91,N/A,22641.65,N/A,13402.47,N/A,23602.69,N/A,5520.53,N/A,4684.23,N/A,4684.23,N/A,14693.14,N/A,23602.69,N/A,23602.69,N/A,23602.69,N/A,22641.65,N/A,4684.23,N/A,5520.53,N/A,10878.50,N/A,10878.50,N/A,5520.53,N/A,4684.23,N/A,4724.91,N/A,1232.64,N/A,N/A,1232.64,23654.40,,Hospital 27080,Coccygectomy Primary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28748.40,N/A,17249.04,N/A,4024.77,N/A,2780.20,N/A,16546.07,N/A,9774.45,N/A,6548.65,N/A,4024.77,N/A,2688.04,N/A,2688.04,N/A,4076.66,N/A,6548.65,N/A,6548.65,N/A,6548.65,N/A,16546.08,N/A,2688.04,N/A,4024.77,N/A,4562.00,N/A,4562.00,N/A,4024.77,N/A,2688.04,N/A,2780.20,N/A,536.54,N/A,N/A,536.54,17249.04,,Hospital 27125,Hemiarthroplasty Hip Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,101389.40,N/A,60833.64,N/A,11591.60,N/A,16802.48,N/A,39839.51,N/A,34472.40,N/A,26569.11,N/A,11948.75,N/A,459716.00,N/A,459716.00,N/A,16538.65,N/A,26569.11,N/A,26569.11,N/A,26569.11,N/A,39839.51,N/A,10076.38,N/A,11948.75,N/A,31610.60,N/A,31610.60,N/A,N/A,N/A,10076.38,N/A,10106.03,N/A,12785.17,N/A,10076.38,459716.00,N/A,N/A,,Hospital 27130,Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,76688.28,62100.82,46012.97,37260.49,10199.26,8657.38,12330.85,11933.08,34283.40,35355.63,26074.02,21114.28,23204.73,29095.54,10513.52,8657.38,562.00,11933.08,562.00,11933.08,14444.40,18308.54,23204.73,29095.54,23204.73,29095.54,23204.73,29095.54,34283.40,35355.68,12330.85,11956.02,10513.52,8657.38,27607.84,11660.00,27607.84,11660.00,3627.14,8657.38,12330.85,11933.08,12330.85,11933.08,11249.46,13126.38,562.00,46012.97,8657.38,37260.49,,Hospital CPT 27200,HC Treat Tail Bone Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,178.38,N/A,327.05,N/A,193.12,N/A,532.32,N/A,79.52,N/A,178.38,N/A,178.38,N/A,331.37,N/A,532.32,N/A,532.32,N/A,532.32,N/A,327.05,N/A,178.38,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,178.38,N/A,178.38,N/A,196.22,340.80,340.80,79.52,568.00,,Hospital 27215,Optx Iliac Tubrst Avls/Wing Fx Fixj if Prfrmd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24261.40,N/A,14556.84,N/A,3397.64,N/A,97.56,N/A,13962.12,N/A,8248.88,N/A,2395.08,N/A,3397.64,N/A,96.52,N/A,96.52,N/A,1488.79,N/A,2395.08,N/A,2395.08,N/A,2395.08,N/A,13962.12,N/A,96.52,N/A,3397.64,N/A,1431.00,N/A,1431.00,N/A,3397.64,N/A,96.52,N/A,97.56,N/A,60.46,N/A,N/A,60.46,14556.84,,Hospital 27236,Optx Fem Fx Prox End Nck Int Fixj/Prostc Rplcmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,67711.42,52891.08,40626.85,31734.65,11308.88,7404.75,12198.40,1138.28,30859.70,30366.64,23021.88,17982.98,26372.49,14499.10,11657.32,7404.75,127574.00,1138.28,127574.00,1138.28,16416.26,9025.97,26372.49,14499.10,26372.49,14499.10,26372.49,14499.10,30859.70,30366.65,12139.10,1138.28,11657.32,7404.75,31376.68,7897.00,31376.68,7897.00,N/A,7404.75,12139.10,1138.28,12198.40,1138.28,12473.33,1252.11,11308.88,127574.00,1138.28,31734.65,,Hospital 27245,Tx Inter/PR/Subtrchntric Fem Fx Imed Impltscrew,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,69774.63,50205.87,41864.78,30123.52,8781.32,7057.75,8636.72,1303.55,26508.50,28753.27,23723.38,17069.99,19978.72,14721.95,9051.89,7057.75,137690.00,1299.94,137690.00,1299.94,12436.29,9164.69,19978.72,14721.95,19978.72,14721.95,19978.72,14721.95,26508.50,28753.28,8607.07,1299.94,9051.89,7057.75,23769.68,5963.00,23769.68,5963.00,N/A,7057.75,8607.07,1299.94,8636.72,1303.55,9685.52,1379.36,8607.07,137690.00,1299.94,30123.52,,Hospital CPT 27246,HC Treat Thigh Fracture,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,368.11,N/A,327.05,N/A,193.12,N/A,568.00,N/A,79.52,N/A,368.11,N/A,368.11,N/A,568.00,N/A,568.00,N/A,568.00,N/A,568.00,N/A,327.05,N/A,368.11,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,368.11,N/A,368.11,N/A,404.92,340.80,340.80,79.52,568.00,,Hospital 27248,Open Treatment Greater Trochanteric Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,55967.27,N/A,33580.36,N/A,7861.99,N/A,11580.55,N/A,31855.73,N/A,19028.87,N/A,25638.20,N/A,8104.23,N/A,1124.00,N/A,1124.00,N/A,15959.18,N/A,25638.20,N/A,25638.20,N/A,25638.20,N/A,31855.73,N/A,11580.55,N/A,8104.23,N/A,30503.06,N/A,30503.06,N/A,N/A,N/A,11580.55,N/A,11580.55,N/A,8671.53,N/A,1124.00,33580.36,N/A,N/A,,Hospital 27266,Cltx Post Hip Arthrp Dislc Req Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,29514.47,6994.10,17708.68,4196.46,4215.42,968.39,1312.90,1305.73,9562.71,4026.78,10034.91,2377.99,9590.66,3147.56,4345.30,968.39,112400.00,1295.43,112400.00,1295.43,5969.96,1959.41,9590.66,3147.56,9590.66,3147.56,9590.66,3147.56,9562.71,4026.77,5252.26,1295.43,4345.30,968.39,11410.49,1871.00,11410.49,1871.00,4345.30,968.39,5252.26,1305.73,5311.56,1305.73,4649.47,1436.30,1312.90,112400.00,968.39,4196.46,,Hospital CPT 27268,HC ED Cl Tx Thigh Fx W/Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4100.00,4100.00,2460.00,2460.00,N/A,574.00,N/A,518.82,N/A,2360.78,N/A,1394.00,N/A,4100.00,N/A,574.00,N/A,518.82,N/A,518.82,N/A,4047.70,N/A,4100.00,N/A,4100.00,N/A,4100.00,N/A,2360.78,N/A,518.82,N/A,574.00,N/A,4100.00,N/A,4100.00,N/A,574.00,N/A,518.82,N/A,518.82,N/A,570.70,2460.00,2460.00,518.82,4100.00,,Hospital 27305,Fasciotomy Iliotibial Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33946.30,N/A,20367.78,N/A,4752.49,N/A,2811.81,N/A,19542.43,N/A,11541.75,N/A,6577.87,N/A,4752.49,N/A,2688.04,N/A,2688.04,N/A,4094.84,N/A,6577.87,N/A,6577.87,N/A,6577.87,N/A,19542.45,N/A,2688.04,N/A,4752.49,N/A,3397.00,N/A,3397.00,N/A,4752.49,N/A,2688.04,N/A,2811.81,N/A,506.15,N/A,N/A,506.15,20367.78,,Hospital 27323,Biopsy Soft Tissue Thigh/Knee Area Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14040.60,N/A,8424.36,N/A,1965.69,N/A,1406.88,N/A,8081.23,N/A,4773.81,N/A,3323.30,N/A,1965.69,N/A,1354.15,N/A,1354.15,N/A,2068.82,N/A,3323.30,N/A,3323.30,N/A,3323.30,N/A,8081.23,N/A,1354.15,N/A,1965.69,N/A,2146.50,N/A,2146.50,N/A,1965.69,N/A,1354.15,N/A,1406.88,N/A,377.28,N/A,N/A,377.28,8424.36,,Hospital 27324,Biopsy Soft Tissue Thigh/Knee Area Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21230.60,N/A,12738.36,N/A,2966.15,N/A,2416.69,N/A,12218.80,N/A,7218.41,N/A,5665.88,N/A,2966.15,N/A,2336.71,N/A,2336.71,N/A,3527.12,N/A,5665.88,N/A,5665.88,N/A,5665.88,N/A,12218.80,N/A,2336.71,N/A,2966.15,N/A,3397.00,N/A,3397.00,N/A,2966.15,N/A,2336.71,N/A,2416.69,N/A,458.37,N/A,N/A,458.37,12738.36,,Hospital CPT 27327,Excision Tumor Soft Tissue Thigh/Knee Subq <3cm,N/A,N/A,838.00,838.00,502.80,502.80,N/A,117.32,N/A,298.77,N/A,838.00,N/A,284.92,N/A,838.00,N/A,117.32,N/A,298.77,N/A,298.77,N/A,838.00,N/A,838.00,N/A,838.00,N/A,838.00,N/A,838.00,N/A,298.77,N/A,117.32,N/A,838.00,N/A,838.00,N/A,117.32,N/A,298.77,N/A,298.77,N/A,328.65,502.80,502.80,117.32,838.00,,Hospital 27328,Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16608.80,N/A,9965.28,N/A,2325.23,N/A,2440.19,N/A,9532.17,N/A,5646.99,N/A,5701.60,N/A,2325.23,N/A,2332.78,N/A,2332.78,N/A,3549.36,N/A,5701.60,N/A,5701.60,N/A,5701.60,N/A,9532.17,N/A,2332.78,N/A,2325.23,N/A,1871.00,N/A,1871.00,N/A,2325.23,N/A,2332.78,N/A,2440.19,N/A,1055.19,N/A,N/A,1055.19,9965.28,,Hospital 27330,Arthrotomy Knee W/Synovial Biopsy Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18990.13,N/A,11394.08,N/A,2606.37,N/A,442.29,N/A,10931.91,N/A,6456.64,N/A,6520.24,N/A,2606.37,N/A,2688.04,N/A,2688.04,N/A,4058.97,N/A,6520.24,N/A,6520.24,N/A,6520.24,N/A,10931.90,N/A,2688.04,N/A,2606.37,N/A,4562.00,N/A,4562.00,N/A,2606.37,N/A,2688.04,N/A,442.29,N/A,486.52,N/A,N/A,442.29,11394.08,,Hospital 27334,Arthrotomy W/Synovectomy Knee Anterior/Posterior,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,46081.50,48906.40,27648.90,29343.84,7809.88,6723.68,7947.02,2811.81,23751.87,28154.32,15667.71,16628.18,23979.07,6609.65,8050.52,6723.68,209626.00,2688.04,209626.00,2688.04,14926.41,4114.65,23979.07,6609.65,23979.07,6609.65,23979.07,6609.65,23751.87,28154.33,7917.37,2688.04,8050.52,6723.68,28529.11,5855.25,28529.11,5855.25,2392.44,6723.68,7917.37,2688.04,7947.02,2811.81,8614.06,1457.98,2392.44,209626.00,1457.98,29343.84,,Hospital 27335,Arthrt W/Synvct Kne Ant&Post W/Pop Area,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17757.80,N/A,10654.68,N/A,2486.09,N/A,6248.31,N/A,7823.00,N/A,6037.65,N/A,14472.78,N/A,2486.09,N/A,5973.28,N/A,5973.28,N/A,9009.58,N/A,14472.78,N/A,14472.78,N/A,14472.78,N/A,7823.00,N/A,5973.28,N/A,2486.09,N/A,6843.00,N/A,6843.00,N/A,2486.09,N/A,5973.28,N/A,6248.31,N/A,1369.74,N/A,N/A,1369.74,14472.78,,Hospital 27339,Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18335.10,N/A,11001.06,N/A,2561.11,N/A,2412.76,N/A,10550.12,N/A,6087.40,N/A,5667.63,N/A,2561.11,N/A,2332.78,N/A,2332.78,N/A,3528.21,N/A,5667.63,N/A,5667.63,N/A,5667.63,N/A,10550.11,N/A,2332.78,N/A,2561.11,N/A,3397.00,N/A,3397.00,N/A,2561.11,N/A,2332.78,N/A,2412.76,N/A,834.05,N/A,N/A,834.05,11001.06,,Hospital 27340,Excision Prepatellar Bursa,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20661.30,N/A,12396.78,N/A,2881.37,N/A,2811.81,N/A,7823.00,N/A,7024.84,N/A,6529.17,N/A,2881.37,N/A,2688.04,N/A,2688.04,N/A,4064.53,N/A,6529.17,N/A,6529.17,N/A,6529.17,N/A,7823.00,N/A,2688.04,N/A,2881.37,N/A,6260.50,N/A,6260.50,N/A,2881.37,N/A,2688.04,N/A,2811.81,N/A,990.04,N/A,N/A,990.04,12396.78,,Hospital 27345,Excision Synovial Cyst Popliteal Space,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26720.10,N/A,16032.06,N/A,3740.82,N/A,2792.70,N/A,7823.00,N/A,9084.84,N/A,6565.99,N/A,3740.82,N/A,2688.04,N/A,2688.04,N/A,4087.45,N/A,6565.99,N/A,6565.99,N/A,6565.99,N/A,7823.00,N/A,2688.04,N/A,3740.82,N/A,6260.50,N/A,6260.50,N/A,3740.82,N/A,2688.04,N/A,2792.70,N/A,1188.16,N/A,N/A,1188.16,16032.06,,Hospital 27358,Excision/Curettage Cyst/Tumor Femur Int Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,137030.48,N/A,82218.29,N/A,19080.09,N/A,9866.61,N/A,78549.32,N/A,46590.38,N/A,6619.90,N/A,19080.09,N/A,9859.62,N/A,9859.62,N/A,4121.00,N/A,6619.90,N/A,6619.90,N/A,6619.90,N/A,78244.16,N/A,9859.62,N/A,19080.09,N/A,4825.50,N/A,4825.50,N/A,19080.09,N/A,9859.62,N/A,9866.61,N/A,1232.59,N/A,N/A,1232.59,82218.29,,Hospital CPT 27369,HC Njx Px Cntrst Kne Arthg Cntrst Enhncd CT/MRI Kne,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,338.00,338.00,202.80,202.80,N/A,47.32,N/A,38.53,N/A,194.62,N/A,114.92,N/A,338.00,N/A,47.32,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,194.62,N/A,338.00,N/A,47.32,N/A,527.00,N/A,527.00,N/A,47.32,N/A,338.00,N/A,38.53,N/A,42.38,202.80,202.80,38.53,527.00,,Hospital 27372,Removal Foreign Body Deep Thigh/Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6412.50,N/A,3847.50,N/A,897.75,N/A,2312.63,N/A,3691.02,N/A,2180.25,N/A,5657.47,N/A,897.75,N/A,2332.78,N/A,2332.78,N/A,3521.88,N/A,5657.47,N/A,5657.47,N/A,5657.47,N/A,3691.02,N/A,2332.78,N/A,897.75,N/A,3397.00,N/A,3397.00,N/A,897.75,N/A,2332.78,N/A,2312.63,N/A,450.00,N/A,N/A,450.00,5657.47,,Hospital CPT 27385,Suture Quadriceps/Hamstring Rupture Primary,N/A,N/A,1133.00,1133.00,679.80,679.80,N/A,158.62,N/A,577.02,N/A,1133.00,N/A,385.22,N/A,1133.00,N/A,158.62,N/A,577.02,N/A,577.02,N/A,1071.44,N/A,1133.00,N/A,1133.00,N/A,1133.00,N/A,1133.00,N/A,577.02,N/A,158.62,N/A,1133.00,N/A,1133.00,N/A,158.62,N/A,577.02,N/A,577.02,N/A,634.72,679.80,679.80,158.62,1133.00,,Hospital 27386,Sutr Quadriceps/Hamstring Musc Rpt Rcnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29710.37,N/A,17826.22,N/A,4159.45,N/A,6248.31,N/A,17105.36,N/A,10101.52,N/A,14502.04,N/A,4159.45,N/A,5973.28,N/A,5973.28,N/A,9027.79,N/A,14502.04,N/A,14502.04,N/A,14502.04,N/A,17105.37,N/A,5973.28,N/A,4159.45,N/A,4562.00,N/A,4562.00,N/A,4159.45,N/A,5973.28,N/A,6248.31,N/A,900.77,N/A,N/A,900.77,17826.22,,Hospital 27392,Tenotomy Open Hamstring Knee Hip Multiple Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,134968.90,N/A,80981.34,N/A,18895.67,N/A,2292.17,N/A,7823.00,N/A,45889.42,N/A,14617.08,N/A,18895.67,N/A,10127.00,N/A,10127.00,N/A,9099.41,N/A,14617.08,N/A,14617.08,N/A,14617.08,N/A,7823.00,N/A,10127.00,N/A,18895.67,N/A,11318.50,N/A,11318.50,N/A,18895.67,N/A,10127.00,N/A,2292.17,N/A,2521.39,N/A,N/A,2292.17,80981.34,,Hospital 27394,Lengthening Hamstring Tendon Multiple 1 Leg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,185655.08,N/A,111393.05,N/A,25893.15,N/A,14473.60,N/A,106725.25,N/A,63122.74,N/A,29073.01,N/A,25893.15,N/A,14457.65,N/A,14457.65,N/A,18294.52,N/A,29073.01,N/A,29073.01,N/A,29073.01,N/A,106153.29,N/A,14480.59,N/A,25893.15,N/A,6843.00,N/A,6843.00,N/A,25893.15,N/A,14457.65,N/A,14473.60,N/A,2213.12,N/A,N/A,2213.12,111393.05,,Hospital 27412,Autologous Chondrocyte Implantation Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82675.38,N/A,49605.23,N/A,11574.56,N/A,2364.92,N/A,47219.71,N/A,28094.27,N/A,14666.71,N/A,11574.56,N/A,5973.28,N/A,5973.28,N/A,9130.31,N/A,14666.71,N/A,14666.71,N/A,14666.71,N/A,47219.73,N/A,5973.28,N/A,11574.56,N/A,10878.50,N/A,10878.50,N/A,11574.56,N/A,5973.28,N/A,2364.92,N/A,2601.41,N/A,N/A,2364.92,49605.23,,Hospital 27420,Rcnstj Dislocating Patella,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65159.92,N/A,39095.95,N/A,9123.52,N/A,6362.14,N/A,37458.32,N/A,22154.38,N/A,14603.65,N/A,9123.52,N/A,5981.14,N/A,5981.14,N/A,9091.06,N/A,14603.65,N/A,14603.65,N/A,14603.65,N/A,37458.32,N/A,5981.14,N/A,9123.52,N/A,10878.50,N/A,10878.50,N/A,9123.52,N/A,5981.14,N/A,6362.14,N/A,1604.06,N/A,N/A,1604.06,39095.95,,Hospital 27428,Ligamentous Reconstruction Knee Intra-Articular,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72245.82,N/A,43347.49,N/A,10104.72,N/A,11782.94,N/A,7823.00,N/A,24563.57,N/A,28673.17,N/A,10104.72,N/A,11782.94,N/A,11782.94,N/A,17849.60,N/A,28673.17,N/A,28673.17,N/A,28673.17,N/A,7823.00,N/A,11782.94,N/A,10104.72,N/A,12986.00,N/A,12986.00,N/A,10104.72,N/A,11782.94,N/A,11782.94,N/A,12961.23,N/A,N/A,7823.00,43347.49,,Hospital 27429,Ligmous Rcnstj Agmntj Kne Intra-Articular Xtr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50615.35,N/A,30369.21,N/A,7070.54,N/A,12997.98,N/A,28851.56,N/A,17208.97,N/A,28543.16,N/A,7070.54,N/A,11782.94,N/A,11782.94,N/A,17768.68,N/A,28543.16,N/A,28543.16,N/A,28543.16,N/A,28851.56,N/A,11782.94,N/A,7070.54,N/A,8612.50,N/A,8612.50,N/A,7070.54,N/A,11782.94,N/A,1338.17,N/A,1382.34,N/A,N/A,1338.17,30369.21,,Hospital 27430,Quadricepsplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52185.42,N/A,31311.25,N/A,7305.94,N/A,6248.31,N/A,29972.92,N/A,17743.04,N/A,14581.66,N/A,7305.94,N/A,5973.28,N/A,5973.28,N/A,9079.41,N/A,14581.66,N/A,14581.66,N/A,14581.66,N/A,29972.93,N/A,5973.28,N/A,7305.94,N/A,5963.00,N/A,5963.00,N/A,7305.94,N/A,5973.28,N/A,6248.31,N/A,779.08,N/A,N/A,779.08,31311.25,,Hospital 27435,Capsulotomy Posterior Capsular Release Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36041.80,N/A,21625.08,N/A,5016.37,N/A,2811.81,N/A,20745.13,N/A,12254.20,N/A,6627.29,N/A,5016.37,N/A,2688.04,N/A,2688.04,N/A,4191.74,N/A,6627.29,N/A,6627.29,N/A,6627.29,N/A,20745.15,N/A,2688.04,N/A,5016.37,N/A,4562.00,N/A,4562.00,N/A,5016.37,N/A,2688.04,N/A,2811.81,N/A,876.54,N/A,N/A,876.54,21625.08,,Hospital 27446,Arthrp Knee Condyle&Plateau Medial/Lat Cmprt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52761.22,N/A,31656.73,N/A,7386.57,N/A,11864.95,N/A,30127.36,N/A,17938.82,N/A,28893.85,N/A,7386.57,N/A,11864.95,N/A,11864.95,N/A,18097.42,N/A,28893.85,N/A,28893.85,N/A,28893.85,N/A,30127.38,N/A,11880.45,N/A,7386.57,N/A,12375.50,N/A,12375.50,N/A,7386.57,N/A,11864.95,N/A,11864.95,N/A,13051.44,N/A,N/A,7386.57,31656.73,,Hospital 27472,Rpr Non/Mal Femur Dstl H/N W/Iliac/Autog Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41230.47,N/A,24738.28,N/A,5473.36,N/A,1313.75,N/A,23632.41,N/A,14018.36,N/A,17611.74,N/A,5473.36,N/A,1295.43,N/A,1295.43,N/A,10963.64,N/A,17611.74,N/A,17611.74,N/A,17611.74,N/A,23632.42,N/A,1295.43,N/A,5473.36,N/A,9300.25,N/A,9300.25,N/A,5473.36,N/A,1299.72,N/A,1313.75,N/A,1739.83,N/A,N/A,1295.43,24738.28,,Hospital 27501,HC Cltx Sprcndylr/Trnscndylr Fem Fx W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,627.00,N/A,376.20,N/A,88.12,N/A,123.00,N/A,361.03,N/A,213.18,N/A,59.95,N/A,88.12,N/A,123.00,N/A,123.00,N/A,37.26,N/A,59.95,N/A,59.95,N/A,59.95,N/A,361.02,N/A,296.08,N/A,88.12,N/A,3.00,N/A,3.00,N/A,88.12,N/A,296.08,N/A,313.76,N/A,525.59,N/A,N/A,3.00,525.59,,Hospital CPT 27510,HC Closed Treatment of Thigh Fracture,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4100.00,4100.00,2460.00,2460.00,N/A,574.00,N/A,649.61,N/A,2360.78,N/A,1394.00,N/A,1952.40,N/A,574.00,N/A,649.61,N/A,649.61,N/A,1215.37,N/A,1952.40,N/A,1952.40,N/A,1952.40,N/A,2360.78,N/A,649.61,N/A,574.00,N/A,4100.00,N/A,4100.00,N/A,574.00,N/A,649.61,N/A,649.61,N/A,714.57,2460.00,2460.00,574.00,4100.00,,Hospital 27524,Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,51412.52,43138.83,30847.51,25883.30,8054.74,6064.23,9793.99,6355.68,29807.21,24774.47,17480.25,14667.21,18325.66,15045.73,8302.92,6064.23,6142.03,6123.11,6142.03,6123.11,11407.29,9562.26,18325.66,15045.73,18325.66,15045.73,18325.66,15045.73,29807.21,24723.86,9793.99,6146.36,8302.92,6064.23,21802.96,8612.50,21802.96,8612.50,N/A,6064.23,9793.99,6123.11,9793.99,6355.68,8884.13,1215.43,6142.03,30847.51,1215.43,25883.30,,Hospital 27530,HC Cltx Tibial Fx Proximal W/O Manipulation,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1444.00,N/A,866.40,N/A,202.16,N/A,299.28,N/A,831.45,N/A,490.96,N/A,485.18,N/A,202.16,N/A,296.08,N/A,296.08,N/A,485.18,N/A,485.18,N/A,485.18,N/A,485.18,N/A,831.45,N/A,296.08,N/A,202.16,N/A,280.33,N/A,280.33,N/A,202.16,N/A,296.08,N/A,299.28,N/A,326.59,N/A,N/A,202.16,866.40,,Hospital CPT 27532,HC Clsd Tx Tibial Fracture,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3384.00,3384.00,2030.40,2030.40,N/A,473.76,N/A,552.55,N/A,1948.51,N/A,1150.56,N/A,1769.07,N/A,473.76,N/A,552.55,N/A,552.55,N/A,1101.25,N/A,1769.07,N/A,1769.07,N/A,1769.07,N/A,1948.51,N/A,552.55,N/A,473.76,N/A,3384.00,N/A,3384.00,N/A,473.76,N/A,552.55,N/A,552.55,N/A,607.81,2030.40,2030.40,473.76,3384.00,,Hospital 27538,HC Treat Knee Fx(S),N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 27540,Open Tx Intercondylar Spine/Tubrst Fracture Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22262.97,N/A,13357.78,N/A,3116.82,N/A,904.35,N/A,12806.08,N/A,7568.56,N/A,14525.20,N/A,3116.82,N/A,904.35,N/A,904.35,N/A,9042.15,N/A,14525.20,N/A,14525.20,N/A,14525.20,N/A,12806.08,N/A,904.35,N/A,3116.82,N/A,5963.00,N/A,5963.00,N/A,3116.82,N/A,904.35,N/A,904.35,N/A,853.52,N/A,N/A,853.52,14525.20,,Hospital CPT 27560,HC Clsd Tx Patella Disloc WO,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,806.00,806.00,483.60,483.60,N/A,112.84,N/A,321.28,N/A,464.09,N/A,274.04,N/A,806.00,N/A,112.84,N/A,321.28,N/A,321.28,N/A,667.26,N/A,806.00,N/A,806.00,N/A,806.00,N/A,464.09,N/A,321.28,N/A,112.84,N/A,806.00,N/A,806.00,N/A,112.84,N/A,321.28,N/A,321.28,N/A,353.41,483.60,483.60,112.84,806.00,,Hospital CPT 27562,HC Clsd Tx Patella Disloc W Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,806.00,806.00,483.60,483.60,N/A,112.84,N/A,466.48,N/A,464.09,N/A,274.04,N/A,806.00,N/A,112.84,N/A,466.48,N/A,466.48,N/A,806.00,N/A,806.00,N/A,806.00,N/A,806.00,N/A,464.09,N/A,466.48,N/A,112.84,N/A,806.00,N/A,806.00,N/A,112.84,N/A,466.48,N/A,466.48,N/A,513.13,483.60,483.60,112.84,806.00,,Hospital 27566,Optx Patellar Dislc W/WO Prtl/Tot Patellectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52965.83,N/A,31779.50,N/A,7415.23,N/A,6248.31,N/A,30422.43,N/A,18008.39,N/A,14936.99,N/A,7415.23,N/A,5973.28,N/A,5973.28,N/A,9298.55,N/A,14936.99,N/A,14936.99,N/A,14936.99,N/A,30422.43,N/A,5973.28,N/A,7415.23,N/A,12203.25,N/A,12203.25,N/A,7415.23,N/A,5973.28,N/A,6248.31,N/A,1783.75,N/A,N/A,1783.75,31779.50,,Hospital 27594,Amp Thigh Thru Femur Sec Closure/Scar Revision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23702.40,N/A,14221.44,N/A,3273.57,N/A,2912.72,N/A,13640.19,N/A,8058.82,N/A,6583.18,N/A,3273.57,N/A,2688.04,N/A,2688.04,N/A,4098.16,N/A,6583.18,N/A,6583.18,N/A,6583.18,N/A,13640.19,N/A,2688.04,N/A,3273.57,N/A,3397.00,N/A,3397.00,N/A,3273.57,N/A,2688.04,N/A,2912.72,N/A,561.72,N/A,N/A,561.72,14221.44,,Hospital 27599,Unlisted Procedure Femur/Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14026.63,N/A,8415.98,N/A,1963.73,N/A,74.61,N/A,8075.17,N/A,4769.06,N/A,1643.83,N/A,1963.73,N/A,675.33,N/A,675.33,N/A,1023.32,N/A,1643.83,N/A,1643.83,N/A,1643.83,N/A,8075.17,N/A,675.33,N/A,1963.73,N/A,1694.50,N/A,1694.50,N/A,1963.73,N/A,675.33,N/A,74.61,N/A,82.07,N/A,N/A,74.61,8415.98,,Hospital 27600,Dcmprn Fasct Leg Ant&/Lat Compartments Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52310.82,N/A,31386.49,N/A,7314.74,N/A,2780.20,N/A,29903.88,N/A,17785.68,N/A,6536.28,N/A,7314.74,N/A,2688.04,N/A,2688.04,N/A,4068.95,N/A,6536.28,N/A,6536.28,N/A,6536.28,N/A,29903.88,N/A,2688.04,N/A,7314.74,N/A,5095.50,N/A,5095.50,N/A,7314.74,N/A,2688.04,N/A,2780.20,N/A,994.54,N/A,N/A,994.54,31386.49,,Hospital 27620,Arthrt Ankle W/Expl W/WO Bx W/WO Rmvl Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31575.93,N/A,18945.56,N/A,4405.31,N/A,1059.84,N/A,18165.25,N/A,10735.82,N/A,6620.44,N/A,4405.31,N/A,2688.04,N/A,2688.04,N/A,4121.36,N/A,6620.44,N/A,6620.44,N/A,6620.44,N/A,18165.27,N/A,2688.04,N/A,4405.31,N/A,7200.75,N/A,7200.75,N/A,4405.31,N/A,2688.04,N/A,1059.84,N/A,1165.82,N/A,N/A,1059.84,18945.56,,Hospital 27632,Excision Tumor Soft Tissue Leg/Ankle Subq 3 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19587.20,N/A,11752.32,N/A,2741.94,N/A,2476.05,N/A,11276.45,N/A,6659.65,N/A,5671.74,N/A,2741.94,N/A,2332.78,N/A,2332.78,N/A,3530.77,N/A,5671.74,N/A,5671.74,N/A,5671.74,N/A,11276.45,N/A,2332.78,N/A,2741.94,N/A,4332.50,N/A,4332.50,N/A,2741.94,N/A,2336.71,N/A,2476.05,N/A,946.81,N/A,N/A,946.81,11752.32,,Hospital 27634,Exc Tumor Soft Tissue Leg/Ankle Subfasc 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16822.70,N/A,10093.62,N/A,2331.33,N/A,2440.19,N/A,9684.75,N/A,5719.71,N/A,5675.99,N/A,2331.33,N/A,2332.78,N/A,2332.78,N/A,3533.41,N/A,5675.99,N/A,5675.99,N/A,5675.99,N/A,9684.76,N/A,2332.78,N/A,2331.33,N/A,3397.00,N/A,3397.00,N/A,2331.33,N/A,2332.78,N/A,2440.19,N/A,768.89,N/A,N/A,768.89,10093.62,,Hospital 27640,Partial Excision Bone Tibia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64386.40,N/A,38631.84,N/A,9008.92,N/A,2859.50,N/A,37066.99,N/A,21891.38,N/A,6555.33,N/A,9008.92,N/A,2688.04,N/A,2688.04,N/A,4080.81,N/A,6555.33,N/A,6555.33,N/A,6555.33,N/A,37067.00,N/A,2688.04,N/A,9008.92,N/A,6618.25,N/A,6618.25,N/A,9008.92,N/A,2688.04,N/A,2859.50,N/A,2059.86,N/A,N/A,2059.86,38631.84,,Hospital 27645,Radical Resection of Tumor Tibia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,92840.87,N/A,55704.52,N/A,12997.72,N/A,6097.50,N/A,53076.54,N/A,31528.91,N/A,28915.41,N/A,12997.72,N/A,5973.28,N/A,5973.28,N/A,18000.40,N/A,28915.41,N/A,28915.41,N/A,28915.41,N/A,53076.53,N/A,5973.28,N/A,12997.72,N/A,12694.75,N/A,12694.75,N/A,12997.72,N/A,5973.28,N/A,6097.50,N/A,2975.27,N/A,N/A,2975.27,55704.52,,Hospital 27646,Radical Resection Tumor Bone Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,70204.47,N/A,42122.68,N/A,9537.23,N/A,11547.70,N/A,22923.94,N/A,23869.52,N/A,21698.53,N/A,9831.09,N/A,11547.70,N/A,11547.70,N/A,13506.83,N/A,21698.53,N/A,21698.53,N/A,21698.53,N/A,22923.94,N/A,11547.70,N/A,9831.09,N/A,25815.83,N/A,25815.83,N/A,86.16,N/A,11547.70,N/A,11547.70,N/A,10519.27,N/A,86.16,42122.68,N/A,N/A,,Hospital 27658,Repair Flexor Tendon Leg Primary W/O Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43031.25,N/A,25818.75,N/A,6013.88,N/A,1067.86,N/A,24561.79,N/A,14630.38,N/A,14484.48,N/A,6013.88,N/A,5973.28,N/A,5973.28,N/A,9016.85,N/A,14484.48,N/A,14484.48,N/A,14484.48,N/A,24561.80,N/A,5973.28,N/A,6013.88,N/A,6618.25,N/A,6618.25,N/A,6013.88,N/A,5973.28,N/A,1067.86,N/A,1174.66,N/A,N/A,1067.86,25818.75,,Hospital CPT 27687,Gastrocnemius Recession,N/A,N/A,1371.00,1371.00,822.60,822.60,N/A,191.94,N/A,432.16,N/A,1371.00,N/A,466.14,N/A,1292.16,N/A,191.94,N/A,432.16,N/A,432.16,N/A,804.37,N/A,1292.16,N/A,1292.16,N/A,1292.16,N/A,1371.00,N/A,432.16,N/A,191.94,N/A,1371.00,N/A,1371.00,N/A,191.94,N/A,432.16,N/A,432.16,N/A,475.38,822.60,822.60,191.94,1371.00,,Hospital 27692,Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47706.27,N/A,28623.76,N/A,6678.87,N/A,5942.72,N/A,27138.89,N/A,16220.11,N/A,14540.81,N/A,6678.87,N/A,5973.28,N/A,5973.28,N/A,9051.93,N/A,14540.81,N/A,14540.81,N/A,14540.81,N/A,27138.89,N/A,5973.28,N/A,6678.87,N/A,9093.25,N/A,9093.25,N/A,6678.87,N/A,5973.28,N/A,5942.72,N/A,3737.03,N/A,N/A,3737.03,28623.76,,Hospital 27695,Rpr Primary Disrupted Ligament Ankle Collateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65607.52,N/A,39364.51,N/A,8972.47,N/A,6248.31,N/A,37595.26,N/A,22306.56,N/A,14575.38,N/A,8972.47,N/A,5973.28,N/A,5973.28,N/A,9077.07,N/A,14575.38,N/A,14575.38,N/A,14575.38,N/A,37595.27,N/A,5973.28,N/A,8972.47,N/A,12986.00,N/A,12986.00,N/A,8972.47,N/A,5973.28,N/A,6248.31,N/A,2428.79,N/A,N/A,2428.79,39364.51,,Hospital 27698,Repair Secondary Disrupted Ligament Ankle Coltrl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50605.73,N/A,30363.44,N/A,7084.81,N/A,1925.61,N/A,28983.12,N/A,17205.94,N/A,14558.68,N/A,7084.81,N/A,5973.28,N/A,5973.28,N/A,9063.05,N/A,14558.68,N/A,14558.68,N/A,14558.68,N/A,28983.13,N/A,5973.28,N/A,7084.81,N/A,11318.50,N/A,11318.50,N/A,7084.81,N/A,5973.28,N/A,1925.61,N/A,2118.17,N/A,N/A,1925.61,30363.44,,Hospital CPT 27752,HC ED Clsd Manip Tibial Shaft Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2538.00,2538.00,1522.80,1522.80,N/A,355.32,N/A,468.63,N/A,1461.38,N/A,862.92,N/A,1532.52,N/A,355.32,N/A,468.63,N/A,468.63,N/A,953.99,N/A,1532.52,N/A,1532.52,N/A,1532.52,N/A,1461.38,N/A,468.63,N/A,355.32,N/A,2538.00,N/A,2538.00,N/A,355.32,N/A,468.63,N/A,468.63,N/A,515.49,1522.80,1522.80,355.32,2538.00,,Hospital 27760,HC Pbb Cltx Medial Ankle Fx,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,314.00,N/A,188.40,N/A,43.96,N/A,198.10,N/A,180.80,N/A,106.76,N/A,N/A,N/A,43.96,N/A,186.94,N/A,186.94,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,180.80,N/A,186.94,N/A,43.96,N/A,168.30,N/A,168.30,N/A,43.96,N/A,186.94,N/A,198.10,N/A,320.76,N/A,N/A,43.96,320.76,,Hospital CPT 27762,HC Cltx Med Ankle Fx W/Mnpj,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2538.00,2538.00,1522.80,1522.80,N/A,355.32,N/A,417.77,N/A,1461.38,N/A,862.92,N/A,1383.81,N/A,355.32,N/A,417.77,N/A,417.77,N/A,861.42,N/A,1383.81,N/A,1383.81,N/A,1383.81,N/A,1461.38,N/A,417.77,N/A,355.32,N/A,2538.00,N/A,2538.00,N/A,355.32,N/A,417.77,N/A,417.77,N/A,459.55,1522.80,1522.80,355.32,2538.00,,Hospital 27766,Open Treatment Medial Malleolus Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86591.97,39277.72,51955.18,23566.63,12673.99,5498.89,15258.32,1274.60,39915.64,22396.53,29441.27,13354.43,28835.08,14482.24,13064.50,5498.89,2248.00,5973.28,2248.00,5973.28,17949.17,9015.47,28835.08,14482.24,28835.08,14482.24,28835.08,14482.24,39915.64,22396.54,15258.32,5973.28,13064.50,5498.89,34306.55,11845.50,34306.55,11845.50,N/A,5498.89,15258.32,5973.28,15258.32,1274.60,13979.01,1402.06,2248.00,51955.18,1274.60,23566.63,,Hospital CPT 27767,Closed Treatment Pst Malleolus Fracture W/O Manj,N/A,N/A,483.00,483.00,289.80,289.80,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,289.80,289.80,289.80,483.00,,Hospital CPT 27786,HC Treat Ankle Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,749.00,749.00,449.40,449.40,N/A,104.86,N/A,198.10,N/A,431.27,N/A,254.66,N/A,452.19,N/A,104.86,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,431.27,N/A,186.94,N/A,104.86,N/A,749.00,N/A,749.00,N/A,104.86,N/A,186.94,N/A,198.10,N/A,301.30,449.40,449.40,104.86,749.00,,Hospital 27792,Open Tx Distal Fibular Fracture Lat Malleolus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,64444.83,24719.17,38666.90,14831.50,10076.03,3460.67,12214.73,5973.28,31727.13,14145.86,21911.25,8404.51,22924.37,14485.83,10386.49,3460.67,42150.00,5973.28,42150.00,5973.28,14269.88,9017.71,22924.37,14485.83,22924.37,14485.83,22924.37,14485.83,31727.13,14145.86,12185.08,5973.28,10386.49,3460.67,27274.27,8612.50,7897.00,8612.50,10386.49,3460.67,12185.08,5973.28,12214.73,5973.28,11113.55,6570.60,7897.00,42150.00,3460.67,14831.50,,Hospital 27814,Open Treatment Bimalleolar Ankle Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,59429.92,49158.48,35657.95,29495.09,10076.03,6882.18,16707.92,5921.68,29972.53,28089.00,20206.18,16713.88,22474.08,14547.99,10386.49,6882.18,234916.00,5973.28,234916.00,5973.28,13989.59,9056.40,22474.08,14547.99,22474.08,14547.99,22474.08,14547.99,29972.53,28089.00,9944.43,5973.28,10386.49,6882.18,26738.55,8970.25,26738.55,8970.25,3585.66,6882.18,9944.43,5973.28,9974.08,5921.68,11113.55,920.91,3585.66,234916.00,920.91,29495.09,,Hospital 27823,Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,190151.82,51393.33,114091.09,30836.00,16544.02,7163.94,24697.24,6037.97,104811.68,29429.48,64651.61,17473.72,66210.86,14527.96,13262.48,7163.94,247280.00,5973.28,247280.00,5973.28,41224.91,9043.93,66210.86,14527.96,66210.86,14527.96,66210.86,14527.96,104811.68,29429.49,12836.00,5973.28,13262.48,7163.94,27440.33,9190.25,27440.33,9190.25,11159.78,7163.94,12836.00,5973.28,12865.65,6037.97,14190.85,1500.04,11159.78,247280.00,1500.04,30836.00,,Hospital 27824,HC Treat Lower Leg Fracture W/O Man,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,477.00,N/A,286.20,N/A,66.78,N/A,313.76,N/A,274.66,N/A,162.18,N/A,N/A,N/A,66.78,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,274.66,N/A,296.08,N/A,66.78,N/A,255.67,N/A,255.67,N/A,66.78,N/A,296.08,N/A,313.76,N/A,318.21,N/A,N/A,66.78,318.21,,Hospital 27826,Open Treatment Fracture Distal Tibia Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34826.18,N/A,20895.71,N/A,4875.67,N/A,6132.82,N/A,19880.97,N/A,11840.90,N/A,14491.98,N/A,4875.67,N/A,5973.28,N/A,5973.28,N/A,9021.54,N/A,14491.98,N/A,14491.98,N/A,14491.98,N/A,19880.98,N/A,5973.28,N/A,4875.67,N/A,7897.00,N/A,7897.00,N/A,4875.67,N/A,5973.28,N/A,6132.82,N/A,896.68,N/A,N/A,896.68,20895.71,,Hospital 27827,Open Treatment Fracture Distal Tibia Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,77492.90,53703.72,46495.74,32222.23,N/A,7518.51,15495.52,12325.48,30188.59,30701.22,N/A,18259.26,28835.08,28565.54,N/A,7518.51,112400.00,11782.94,112400.00,11782.94,N/A,17782.59,28835.08,28565.54,28835.08,28565.54,28835.08,28565.54,30188.59,30701.23,15258.32,11782.94,13064.50,7518.51,34306.55,7897.00,34306.55,7897.00,N/A,7518.51,15258.32,11782.94,15495.52,12325.48,13979.01,1198.40,13064.50,112400.00,1198.40,32222.23,,Hospital 27832,Open Tx Prox Tibfib Joint Dislocate Exc Prox Fib,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,613475.47,N/A,368085.28,N/A,12753.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12753.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12753.42,N/A,N/A,N/A,N/A,N/A,12753.42,N/A,N/A,N/A,N/A,N/A,12753.42,N/A,12753.42,368085.28,N/A,N/A,,Hospital 27842,Cltx Ankle Dislc Req Anes W/WO Prq Skel Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10336.90,N/A,6202.14,N/A,1447.16,N/A,1345.87,N/A,5950.96,N/A,3514.54,N/A,3166.28,N/A,1447.16,N/A,1295.43,N/A,1295.43,N/A,1971.06,N/A,3166.28,N/A,3166.28,N/A,3166.28,N/A,5950.96,N/A,1295.43,N/A,1447.16,N/A,2586.50,N/A,2586.50,N/A,1447.16,N/A,1295.43,N/A,1345.87,N/A,577.89,N/A,N/A,577.89,6202.14,,Hospital 27871,Arthrodesis Tibiofibular Joint Proximal/Distal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,79224.85,135161.43,47534.91,81096.86,10076.03,18922.59,12185.08,15297.01,35147.63,77134.27,26936.46,45954.88,22924.37,31226.29,10386.49,18922.59,12185.08,15803.48,12185.08,15803.48,14269.88,19438.43,22924.37,31226.29,22924.37,31226.29,22924.37,31226.29,35147.63,77004.70,12185.08,15803.48,10386.49,18922.59,27274.27,8612.50,27274.27,8612.50,N/A,18922.59,11933.08,15803.48,12185.08,15297.01,11113.55,808.32,10076.03,47534.91,808.32,81096.86,,Hospital 27884,Amp Leg Thru Tibia&Fibula Sec Closure/Scar Rev,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30875.60,N/A,18525.36,N/A,4322.58,N/A,2811.81,N/A,17775.53,N/A,10497.70,N/A,6552.14,N/A,4322.58,N/A,2688.04,N/A,2688.04,N/A,4078.84,N/A,6552.14,N/A,6552.14,N/A,6552.14,N/A,17775.53,N/A,2688.04,N/A,4322.58,N/A,3397.00,N/A,3397.00,N/A,4322.58,N/A,2688.04,N/A,2811.81,N/A,608.42,N/A,N/A,608.42,18525.36,,Hospital 27889,Ankle Disarticulation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17965.50,N/A,10779.30,N/A,2509.02,N/A,6181.99,N/A,10343.28,N/A,6108.27,N/A,14456.50,N/A,2509.02,N/A,5977.21,N/A,5977.21,N/A,8999.45,N/A,14456.50,N/A,14456.50,N/A,14456.50,N/A,10343.28,N/A,5977.21,N/A,2509.02,N/A,4562.00,N/A,4562.00,N/A,2509.02,N/A,5977.21,N/A,6181.99,N/A,720.84,N/A,N/A,720.84,14456.50,,Hospital 27892,Dcmprn Fasct Leg Ant&/Lat W/Dbrdmt Musc&/Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74745.85,N/A,44847.51,N/A,10464.42,N/A,2859.50,N/A,42673.30,N/A,25413.58,N/A,6531.38,N/A,10464.42,N/A,2688.04,N/A,2688.04,N/A,4065.91,N/A,6531.38,N/A,6531.38,N/A,6531.38,N/A,42673.30,N/A,2688.04,N/A,10464.42,N/A,6260.50,N/A,6260.50,N/A,10464.42,N/A,2688.04,N/A,2859.50,N/A,1088.08,N/A,N/A,1088.08,44847.51,,Hospital 27894,Dcmprn Fasct Leg Ant&/Lat&Pst W/Dbrdmt Mus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,100277.10,N/A,60166.26,N/A,13924.21,N/A,7312.25,N/A,55185.72,N/A,34094.22,N/A,6587.89,N/A,13924.21,N/A,7305.26,N/A,7305.26,N/A,4101.09,N/A,6587.89,N/A,6587.89,N/A,6587.89,N/A,55024.51,N/A,7305.26,N/A,13924.21,N/A,4562.00,N/A,4562.00,N/A,13924.21,N/A,7305.26,N/A,7312.25,N/A,2118.13,N/A,N/A,2118.13,60166.26,,Hospital 27899,Unlisted Procedure Leg/Ankle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64887.82,N/A,38932.69,N/A,9084.31,N/A,1391.61,N/A,37088.43,N/A,22061.86,N/A,14621.37,N/A,9084.31,N/A,5973.28,N/A,5973.28,N/A,9102.09,N/A,14621.37,N/A,14621.37,N/A,14621.37,N/A,37088.45,N/A,5973.28,N/A,9084.31,N/A,12203.25,N/A,12203.25,N/A,9084.31,N/A,5973.28,N/A,1391.61,N/A,1530.77,N/A,N/A,1391.61,38932.69,,Hospital 28001,Incision&Drainage Bursa Foot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16574.58,N/A,9944.75,N/A,2111.07,N/A,208.90,N/A,9531.41,N/A,5635.36,N/A,3348.88,N/A,2111.07,N/A,1354.15,N/A,1354.15,N/A,2084.75,N/A,3348.88,N/A,3348.88,N/A,3348.88,N/A,9531.42,N/A,1354.15,N/A,2111.07,N/A,2586.50,N/A,2586.50,N/A,2111.07,N/A,1354.15,N/A,208.90,N/A,229.81,N/A,N/A,208.90,9944.75,,Hospital CPT 28011,"HC Tenotomy, Percutaneous, Toe; Multiple Tendons",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4532.00,4532.00,2719.20,2719.20,N/A,634.48,N/A,265.72,N/A,2609.53,N/A,1540.88,N/A,886.74,N/A,634.48,N/A,265.72,N/A,265.72,N/A,552.00,N/A,886.74,N/A,886.74,N/A,886.74,N/A,2609.53,N/A,265.72,N/A,634.48,N/A,4532.00,N/A,4532.00,N/A,634.48,N/A,265.72,N/A,265.72,N/A,292.29,2719.20,2719.20,265.72,4532.00,,Hospital 28020,Arthrt W/Expl Drg/Rmvl Loose/FB Ntrtrsl/Tars Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21894.22,N/A,13136.53,N/A,3065.19,N/A,386.71,N/A,12597.25,N/A,7444.03,N/A,6550.85,N/A,3065.19,N/A,2688.04,N/A,2688.04,N/A,4078.02,N/A,6550.85,N/A,6550.85,N/A,6550.85,N/A,12597.27,N/A,2688.04,N/A,3065.19,N/A,3660.50,N/A,3660.50,N/A,3065.19,N/A,2688.04,N/A,386.71,N/A,425.38,N/A,N/A,386.71,13136.53,,Hospital 28039,Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21710.00,N/A,13026.00,N/A,3039.39,N/A,2412.76,N/A,12496.58,N/A,7381.40,N/A,5661.88,N/A,3039.39,N/A,2332.78,N/A,2332.78,N/A,3524.63,N/A,5661.88,N/A,5661.88,N/A,5661.88,N/A,12496.58,N/A,2332.78,N/A,3039.39,N/A,3397.00,N/A,3397.00,N/A,3039.39,N/A,2332.78,N/A,2412.76,N/A,697.94,N/A,N/A,697.94,13026.00,,Hospital CPT 28060,Fasciectomy Plantar Fascia Partial Spx,N/A,N/A,866.00,866.00,519.60,519.60,N/A,121.24,N/A,343.28,N/A,866.00,N/A,294.44,N/A,866.00,N/A,121.24,N/A,343.28,N/A,343.28,N/A,866.00,N/A,866.00,N/A,866.00,N/A,866.00,N/A,866.00,N/A,343.28,N/A,121.24,N/A,866.00,N/A,866.00,N/A,121.24,N/A,343.28,N/A,343.28,N/A,377.61,519.60,519.60,121.24,866.00,,Hospital CPT 28062,Fasciectomy Plantar Fascia Radical Spx,N/A,N/A,974.00,974.00,584.40,584.40,N/A,136.36,N/A,383.41,N/A,974.00,N/A,331.16,N/A,974.00,N/A,136.36,N/A,383.41,N/A,383.41,N/A,974.00,N/A,974.00,N/A,974.00,N/A,974.00,N/A,974.00,N/A,383.41,N/A,136.36,N/A,974.00,N/A,974.00,N/A,136.36,N/A,383.41,N/A,383.41,N/A,421.75,584.40,584.40,136.36,974.00,,Hospital 28070,Synvct Intertarsal/Tarsometatarsal Jt Ea Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22111.10,N/A,13266.66,N/A,3090.44,N/A,6178.06,N/A,12725.47,N/A,7517.77,N/A,14473.96,N/A,3090.44,N/A,5973.28,N/A,5973.28,N/A,9010.32,N/A,14473.96,N/A,14473.96,N/A,14473.96,N/A,12725.48,N/A,5973.28,N/A,3090.44,N/A,3397.00,N/A,3397.00,N/A,3090.44,N/A,5973.28,N/A,6178.06,N/A,373.05,N/A,N/A,373.05,14473.96,,Hospital 28086,Synovectomy Tendon Sheath Foot Flexor,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,112268.22,N/A,67360.93,N/A,15717.56,N/A,8583.68,N/A,63834.54,N/A,38171.19,N/A,14501.52,N/A,15717.56,N/A,8549.30,N/A,8549.30,N/A,9027.47,N/A,14501.52,N/A,14501.52,N/A,14501.52,N/A,63834.55,N/A,8549.30,N/A,15717.56,N/A,7109.75,N/A,7109.75,N/A,15717.56,N/A,8549.30,N/A,8583.68,N/A,1592.54,N/A,N/A,1592.54,67360.93,,Hospital 28102,Exc/Curtg Cst/B9 Tum Talus/Clcns W/Iliac/Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42723.47,N/A,25634.08,N/A,5981.29,N/A,1323.35,N/A,24446.52,N/A,14510.68,N/A,14562.70,N/A,5981.29,N/A,5973.28,N/A,5973.28,N/A,9065.55,N/A,14562.70,N/A,14562.70,N/A,14562.70,N/A,24446.53,N/A,5973.28,N/A,5981.29,N/A,12203.25,N/A,12203.25,N/A,5981.29,N/A,5973.28,N/A,1323.35,N/A,1455.69,N/A,N/A,1323.35,25634.08,,Hospital 28106,Exc/Curtg Cst/B9 Tum Tarsal/Metar W/Iliac/Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13953.20,N/A,8371.92,N/A,1953.45,N/A,408.66,N/A,8028.92,N/A,4744.09,N/A,13953.20,N/A,1953.45,N/A,5973.28,N/A,5973.28,N/A,9020.30,N/A,13953.20,N/A,13953.20,N/A,13953.20,N/A,8028.92,N/A,5973.28,N/A,1953.45,N/A,7897.00,N/A,7897.00,N/A,1953.45,N/A,5973.28,N/A,408.66,N/A,449.53,N/A,N/A,408.66,13953.20,,Hospital 28107,Exc/Curtg Cst/B9 Tum Tarsal/Metar W/Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18331.57,N/A,10998.94,N/A,2558.94,N/A,6248.31,N/A,10512.35,N/A,6232.73,N/A,14464.90,N/A,2558.94,N/A,5973.28,N/A,5973.28,N/A,9004.67,N/A,14464.90,N/A,14464.90,N/A,14464.90,N/A,10512.36,N/A,5973.28,N/A,2558.94,N/A,7897.00,N/A,7897.00,N/A,2558.94,N/A,5973.28,N/A,6248.31,N/A,587.06,N/A,N/A,587.06,14464.90,,Hospital 28110,Ostectomy Prtl 5th Metar Head Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28140.98,N/A,16884.59,N/A,3939.74,N/A,2780.20,N/A,16197.58,N/A,9567.94,N/A,6525.72,N/A,3939.74,N/A,2688.04,N/A,2688.04,N/A,4062.39,N/A,6525.72,N/A,6525.72,N/A,6525.72,N/A,16197.58,N/A,2688.04,N/A,3939.74,N/A,3397.00,N/A,3397.00,N/A,3939.74,N/A,2688.04,N/A,2780.20,N/A,302.87,N/A,N/A,302.87,16884.59,,Hospital 28153,Resection Condyle Distal End Phalanx Each Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18141.30,N/A,10884.78,N/A,2539.78,N/A,2811.81,N/A,10444.84,N/A,6168.04,N/A,6523.87,N/A,2539.78,N/A,2688.04,N/A,2688.04,N/A,4061.23,N/A,6523.87,N/A,6523.87,N/A,6523.87,N/A,10444.85,N/A,2688.04,N/A,2539.78,N/A,3397.00,N/A,3397.00,N/A,2539.78,N/A,2688.04,N/A,2811.81,N/A,275.39,N/A,N/A,275.39,10884.78,,Hospital 28160,Hemiphalangectomy/Interphalangeal Joint Exc Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25358.97,N/A,15215.38,N/A,3438.81,N/A,595.48,N/A,14597.90,N/A,8622.05,N/A,6530.39,N/A,3438.81,N/A,2688.04,N/A,2688.04,N/A,4065.29,N/A,6530.39,N/A,6530.39,N/A,6530.39,N/A,14597.89,N/A,2688.04,N/A,3438.81,N/A,5095.50,N/A,5095.50,N/A,3438.81,N/A,2688.04,N/A,595.48,N/A,655.05,N/A,N/A,595.48,15215.38,,Hospital 28171,Rad Rescj Tumor Tarsal Except Talus/Calcaneus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,102224.18,N/A,61334.51,N/A,14311.96,N/A,7447.55,N/A,57788.00,N/A,34756.21,N/A,6520.86,N/A,14311.96,N/A,7440.57,N/A,7440.57,N/A,4059.36,N/A,6520.86,N/A,6520.86,N/A,6520.86,N/A,57788.00,N/A,7440.57,N/A,14311.96,N/A,4464.25,N/A,4464.25,N/A,14311.96,N/A,7440.57,N/A,7447.55,N/A,1730.10,N/A,N/A,1730.10,61334.51,,Hospital 28192,Removal Foreign Body Foot Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14026.80,N/A,8416.08,N/A,1954.89,N/A,1416.50,N/A,8075.21,N/A,4769.11,N/A,3303.80,N/A,1954.89,N/A,1354.15,N/A,1354.15,N/A,2056.68,N/A,3303.80,N/A,3303.80,N/A,3303.80,N/A,8075.22,N/A,1354.15,N/A,1954.89,N/A,1871.00,N/A,1871.00,N/A,1954.89,N/A,1354.15,N/A,1416.50,N/A,353.91,N/A,N/A,353.91,8416.08,,Hospital 28202,Rpr Tendon Flxr Foot Sec W/Free Graft Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48429.02,N/A,29057.41,N/A,6767.01,N/A,6181.99,N/A,27764.50,N/A,16465.86,N/A,14477.13,N/A,6767.01,N/A,5977.21,N/A,5977.21,N/A,9012.29,N/A,14477.13,N/A,14477.13,N/A,14477.13,N/A,27764.50,N/A,5977.21,N/A,6767.01,N/A,6618.25,N/A,6618.25,N/A,6767.01,N/A,5977.21,N/A,6181.99,N/A,1195.17,N/A,N/A,1195.17,29057.41,,Hospital 28220,Tenolysis Flexor Foot Single Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37486.82,N/A,22492.09,N/A,5248.16,N/A,1339.84,N/A,21546.74,N/A,12745.52,N/A,3188.60,N/A,5248.16,N/A,1295.43,N/A,1295.43,N/A,1984.96,N/A,3188.60,N/A,3188.60,N/A,3188.60,N/A,21546.73,N/A,1295.43,N/A,5248.16,N/A,4244.25,N/A,4244.25,N/A,5248.16,N/A,1295.43,N/A,1339.84,N/A,401.75,N/A,N/A,401.75,22492.09,,Hospital 28230,Tx Opn Tendon Flexor Foot Single/Mult Tendon Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34894.42,N/A,20936.65,N/A,4885.21,N/A,2811.81,N/A,19916.63,N/A,11864.09,N/A,6516.78,N/A,4885.21,N/A,2688.04,N/A,2688.04,N/A,4056.81,N/A,6516.78,N/A,6516.78,N/A,6516.78,N/A,19916.63,N/A,2688.04,N/A,4885.21,N/A,5095.50,N/A,5095.50,N/A,4885.21,N/A,2688.04,N/A,2811.81,N/A,696.86,N/A,N/A,696.86,20936.65,,Hospital 28288,Ostc Prtl Exostc/Condylc Metar Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,28054.20,29335.85,16832.52,17601.51,10053.63,4107.00,12217.86,2780.20,22656.66,16884.30,9538.43,9974.18,22873.39,6522.68,10363.40,4107.00,2770.05,2688.04,2770.05,2688.04,14238.15,4060.49,22873.39,6522.68,22873.39,6522.68,22873.39,6522.68,22656.66,16884.30,12158.56,2688.04,10363.40,4107.00,27213.62,5095.50,27213.62,5095.50,N/A,4107.00,12158.56,2688.04,12217.86,2780.20,11088.83,701.93,2770.05,27213.62,701.93,17601.51,,Hospital CPT 28308,Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea,N/A,N/A,943.00,943.00,565.80,565.80,N/A,132.02,N/A,364.92,N/A,943.00,N/A,320.62,N/A,943.00,N/A,132.02,N/A,364.92,N/A,364.92,N/A,943.00,N/A,943.00,N/A,943.00,N/A,943.00,N/A,943.00,N/A,364.92,N/A,132.02,N/A,943.00,N/A,943.00,N/A,132.02,N/A,364.92,N/A,364.92,N/A,401.41,565.80,565.80,132.02,943.00,,Hospital 28322,Rpr Non/Malunion Metarsal W/WO Bone Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69649.90,N/A,41789.94,N/A,9643.37,N/A,803.17,N/A,39688.37,N/A,23680.72,N/A,14502.77,N/A,9643.37,N/A,5973.28,N/A,5973.28,N/A,9028.25,N/A,14502.77,N/A,14502.77,N/A,14502.77,N/A,39688.38,N/A,5973.28,N/A,9643.37,N/A,4470.25,N/A,4470.25,N/A,9643.37,N/A,5973.28,N/A,803.17,N/A,883.50,N/A,N/A,803.17,41789.94,,Hospital 28344,Reconstruction Toe Polydactyly,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43757.00,N/A,26254.20,N/A,6057.06,N/A,2743.94,N/A,25186.06,N/A,14877.37,N/A,6548.73,N/A,6057.06,N/A,2688.04,N/A,2688.04,N/A,4076.70,N/A,6548.73,N/A,6548.73,N/A,6548.73,N/A,25186.06,N/A,2688.04,N/A,6057.06,N/A,5944.75,N/A,5944.75,N/A,6057.06,N/A,2688.04,N/A,2743.94,N/A,1289.08,N/A,N/A,1289.08,26254.20,,Hospital 28345,Rcnstj Toe Syndactyly W/WO Skin Graft Each Web,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18984.80,N/A,11390.88,N/A,2657.87,N/A,1372.81,N/A,10930.19,N/A,6454.83,N/A,3152.67,N/A,2657.87,N/A,1295.43,N/A,1295.43,N/A,1962.59,N/A,3152.67,N/A,3152.67,N/A,3152.67,N/A,10930.20,N/A,1295.43,N/A,2657.87,N/A,5563.25,N/A,5563.25,N/A,2657.87,N/A,1295.43,N/A,1372.81,N/A,1009.61,N/A,N/A,1009.61,11390.88,,Hospital 28360,Reconstruction Cleft Foot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22566.00,N/A,13539.60,N/A,3159.24,N/A,6589.23,N/A,12986.40,N/A,7669.04,N/A,14460.47,N/A,3159.24,N/A,5973.28,N/A,5973.28,N/A,9001.93,N/A,14460.47,N/A,14460.47,N/A,14460.47,N/A,12986.41,N/A,5973.28,N/A,3159.24,N/A,11845.50,N/A,11845.50,N/A,3159.24,N/A,5973.28,N/A,1044.77,N/A,1149.25,N/A,N/A,1044.77,14460.47,,Hospital 28400,HC Closed Tx Calcaneal Fracture W/O Manipulation,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,2598.63,N/A,1559.18,N/A,363.81,N/A,403.01,N/A,1494.48,N/A,883.53,N/A,18.57,N/A,363.81,N/A,399.81,N/A,399.81,N/A,11.54,N/A,18.57,N/A,18.57,N/A,18.57,N/A,1494.48,N/A,399.81,N/A,363.81,N/A,767.02,N/A,767.02,N/A,363.81,N/A,212.87,N/A,403.01,N/A,286.12,N/A,N/A,11.54,1559.18,,Hospital 28420,Open Treatment Calcaneal Fracture W Bone Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54008.10,47758.32,32404.86,28654.99,9425.21,6686.17,11444.83,12325.48,26744.62,27367.70,18362.75,16237.83,21443.65,28532.34,9715.61,6686.17,128136.00,11782.94,128136.00,11782.94,13348.17,17761.93,21443.65,28532.34,21443.65,28532.34,21443.65,28532.34,26744.62,27367.71,11415.18,11782.94,9715.61,6686.17,25512.59,11845.50,25512.59,11845.50,2911.47,6686.17,11415.18,11782.94,11444.83,12325.48,10395.71,2436.40,2911.47,128136.00,2436.40,28654.99,,Hospital 28430,HC Treat Ankle Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,42524.60,N/A,25514.76,N/A,5953.44,N/A,5942.72,N/A,24356.44,N/A,14458.35,N/A,14528.15,N/A,5953.44,N/A,5973.28,N/A,5973.28,N/A,9045.35,N/A,14528.15,N/A,14528.15,N/A,14528.15,N/A,24356.45,N/A,5973.28,N/A,5953.44,N/A,8970.25,N/A,8970.25,N/A,5953.44,N/A,5973.28,N/A,5942.72,N/A,1018.92,N/A,N/A,1018.92,25514.76,,Hospital CPT 28435,HC Closed Tx Talus Fx W/Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3988.00,3988.00,2392.80,2392.80,N/A,558.32,N/A,310.30,N/A,2296.29,N/A,1355.92,N/A,1051.02,N/A,558.32,N/A,310.30,N/A,310.30,N/A,654.26,N/A,1051.02,N/A,1051.02,N/A,1051.02,N/A,2296.29,N/A,310.30,N/A,558.32,N/A,3988.00,N/A,3988.00,N/A,558.32,N/A,310.30,N/A,310.30,N/A,341.33,2392.80,2392.80,310.30,3988.00,,Hospital 28436,Prq Skeletal Fixation Talus Fracture W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45166.27,N/A,27099.76,N/A,6323.28,N/A,6037.97,N/A,25890.60,N/A,15356.52,N/A,14526.86,N/A,6323.28,N/A,5973.28,N/A,5973.28,N/A,9043.26,N/A,14526.86,N/A,14526.86,N/A,14526.86,N/A,25843.39,N/A,5973.28,N/A,6323.28,N/A,9953.25,N/A,9953.25,N/A,6323.28,N/A,5973.28,N/A,6037.97,N/A,1286.22,N/A,N/A,1286.22,27099.76,,Hospital 28446,Open Osteochondral Autograft Talus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58577.08,N/A,35146.25,N/A,8185.61,N/A,11910.55,N/A,33421.54,N/A,19916.23,N/A,28601.21,N/A,8185.61,N/A,11782.94,N/A,11782.94,N/A,17804.79,N/A,28601.21,N/A,28601.21,N/A,28601.21,N/A,33421.55,N/A,11782.94,N/A,8185.61,N/A,12986.00,N/A,12986.00,N/A,8185.61,N/A,11782.94,N/A,11910.55,N/A,2935.02,N/A,N/A,2935.02,35146.25,,Hospital 28450,HC Tx Tarsal Bone Fx Xcp Talus&Calcn W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,46028.67,N/A,27617.20,N/A,6444.02,N/A,1602.36,N/A,26240.38,N/A,13182.13,N/A,14510.12,N/A,6444.02,N/A,5973.28,N/A,5973.28,N/A,9032.83,N/A,14510.12,N/A,14510.12,N/A,14510.12,N/A,26240.40,N/A,5973.28,N/A,6444.02,N/A,12203.25,N/A,12203.25,N/A,6444.02,N/A,5973.28,N/A,1602.36,N/A,1762.60,N/A,N/A,1602.36,27617.20,,Hospital 28465,Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63072.23,N/A,37843.34,N/A,8830.11,N/A,6178.06,N/A,36198.44,N/A,21444.55,N/A,14470.29,N/A,8830.11,N/A,5973.28,N/A,5973.28,N/A,9008.03,N/A,14470.29,N/A,14470.29,N/A,14470.29,N/A,36198.43,N/A,5973.28,N/A,8830.11,N/A,13819.75,N/A,13819.75,N/A,8830.11,N/A,5973.28,N/A,6178.06,N/A,3148.82,N/A,N/A,3148.82,37843.34,,Hospital 28490,HC Treat Big Toe Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,477.00,N/A,286.20,N/A,66.78,N/A,313.76,N/A,274.66,N/A,162.18,N/A,N/A,N/A,66.78,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,274.66,N/A,296.08,N/A,66.78,N/A,255.67,N/A,255.67,N/A,66.78,N/A,296.08,N/A,313.76,N/A,179.43,N/A,N/A,66.78,313.76,,Hospital 28496,Prq Skel Fixj Fx Grt Toe Phlx/Phlg W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19821.28,N/A,11892.77,N/A,2766.12,N/A,2811.81,N/A,11410.24,N/A,6739.24,N/A,6530.05,N/A,2766.12,N/A,2688.04,N/A,2688.04,N/A,4065.08,N/A,6530.05,N/A,6530.05,N/A,6530.05,N/A,11410.24,N/A,2688.04,N/A,2766.12,N/A,3397.00,N/A,3397.00,N/A,2766.12,N/A,2688.04,N/A,2811.81,N/A,259.83,N/A,N/A,259.83,11892.77,,Hospital CPT 28515,HC ED Cl Red Fx Phlx Not Grt Toe,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2584.00,2584.00,1550.40,1550.40,N/A,361.76,N/A,133.72,N/A,1487.87,N/A,878.56,N/A,461.19,N/A,361.76,N/A,133.72,N/A,133.72,N/A,287.09,N/A,461.19,N/A,461.19,N/A,461.19,N/A,1487.87,N/A,133.72,N/A,361.76,N/A,2584.00,N/A,2584.00,N/A,361.76,N/A,133.72,N/A,133.72,N/A,147.09,1550.40,1550.40,133.72,2584.00,,Hospital CPT 28570,HC Closed Tx Foot Disloc W/O An,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,633.00,633.00,379.80,379.80,N/A,88.62,N/A,183.70,N/A,364.48,N/A,215.22,N/A,633.00,N/A,88.62,N/A,183.70,N/A,183.70,N/A,411.86,N/A,633.00,N/A,633.00,N/A,633.00,N/A,364.48,N/A,183.70,N/A,88.62,N/A,633.00,N/A,633.00,N/A,88.62,N/A,183.70,N/A,183.70,N/A,202.07,379.80,379.80,88.62,633.00,,Hospital CPT 28600,HC Closed Tx Tarsometatarsal Dislocation W/O Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,686.00,686.00,411.60,411.60,N/A,96.04,N/A,173.59,N/A,395.00,N/A,233.24,N/A,615.30,N/A,96.04,N/A,173.59,N/A,173.59,N/A,383.02,N/A,615.30,N/A,615.30,N/A,615.30,N/A,395.00,N/A,173.59,N/A,96.04,N/A,686.00,N/A,686.00,N/A,96.04,N/A,173.59,N/A,173.59,N/A,190.95,411.60,411.60,96.04,686.00,,Hospital 28715,Arthrodesis Triple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,131059.50,N/A,78635.70,N/A,18346.16,N/A,13148.12,N/A,74587.70,N/A,44560.24,N/A,29123.08,N/A,18346.16,N/A,11933.08,N/A,11933.08,N/A,18325.69,N/A,29123.08,N/A,29123.08,N/A,29123.08,N/A,74349.36,N/A,11956.02,N/A,18346.16,N/A,10535.75,N/A,10535.75,N/A,18346.16,N/A,11933.08,N/A,1683.02,N/A,1851.33,N/A,N/A,1683.02,78635.70,,Hospital 28750,Arthrodesis Great Toe Metatarsophalangeal Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65441.82,N/A,39265.09,N/A,9161.86,N/A,6248.31,N/A,37402.35,N/A,22250.22,N/A,14469.61,N/A,9161.86,N/A,5973.28,N/A,5973.28,N/A,9007.61,N/A,14469.61,N/A,14469.61,N/A,14469.61,N/A,37402.35,N/A,5973.28,N/A,9161.86,N/A,8160.50,N/A,8160.50,N/A,9161.86,N/A,5973.28,N/A,6248.31,N/A,733.57,N/A,N/A,733.57,39265.09,,Hospital 28755,Arthrodesis Great Toe Interphalangeal Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33616.50,N/A,20169.90,N/A,4706.29,N/A,3571.18,N/A,19164.27,N/A,11429.64,N/A,14493.49,N/A,4706.29,N/A,5973.28,N/A,5973.28,N/A,9022.47,N/A,14493.49,N/A,14493.49,N/A,14493.49,N/A,19164.27,N/A,5973.28,N/A,4706.29,N/A,5944.75,N/A,5944.75,N/A,4706.29,N/A,5973.28,N/A,3571.18,N/A,3928.30,N/A,N/A,3571.18,20169.90,,Hospital 28800,Amputation Foot Midtarsal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,165878.43,N/A,99527.06,N/A,23234.06,N/A,13069.24,N/A,94365.58,N/A,56398.65,N/A,35139.97,N/A,23234.06,N/A,13001.42,N/A,13001.42,N/A,21882.08,N/A,35139.97,N/A,35139.97,N/A,35139.97,N/A,94365.58,N/A,13001.42,N/A,23234.06,N/A,10645.75,N/A,10645.75,N/A,23234.06,N/A,13001.42,N/A,13069.24,N/A,2045.35,N/A,N/A,2045.35,99527.06,,Hospital 29085,HC Apply Hand/Wrist Cast,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 29125,HC Splint App Short Arm Stat,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1079.00,1079.00,647.40,647.40,N/A,151.06,N/A,105.99,N/A,621.29,N/A,366.86,N/A,253.64,N/A,151.06,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,621.29,N/A,104.85,N/A,151.06,N/A,1079.00,N/A,1079.00,N/A,151.06,N/A,104.85,N/A,105.99,N/A,41.05,647.40,647.40,41.05,1079.00,,Hospital CPT 29130,HC Finger Splint Application,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1011.00,1011.00,606.60,606.60,N/A,141.54,N/A,105.99,N/A,582.13,N/A,343.74,N/A,253.64,N/A,141.54,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,582.13,N/A,104.85,N/A,141.54,N/A,1011.00,N/A,1011.00,N/A,141.54,N/A,104.85,N/A,105.99,N/A,30.80,606.60,606.60,30.80,1011.00,,Hospital 29131,HC Apply Finger Splint,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,63755.13,1460.00,38253.08,876.00,N/A,204.40,7451.18,110.32,N/A,840.67,N/A,496.40,N/A,N/A,N/A,204.40,7451.18,109.14,7451.18,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,840.67,7451.18,109.14,N/A,204.40,N/A,403.07,N/A,403.07,N/A,204.40,7451.18,109.14,6841.87,110.32,N/A,147.24,6841.87,38253.08,109.14,876.00,,Hospital CPT 29240,HC Shoulder/Clavicle Strap/Splint,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,528.00,528.00,316.80,316.80,N/A,73.92,N/A,17.98,N/A,304.02,N/A,179.52,N/A,84.90,N/A,73.92,N/A,17.98,N/A,17.98,N/A,52.85,N/A,84.90,N/A,84.90,N/A,84.90,N/A,304.02,N/A,17.98,N/A,73.92,N/A,528.00,N/A,528.00,N/A,73.92,N/A,17.98,N/A,17.98,N/A,19.78,316.80,316.80,17.98,528.00,,Hospital CPT 29280,HC Strapping Hand/Finger,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,113.00,113.00,67.80,67.80,N/A,15.82,N/A,19.15,N/A,65.07,N/A,38.42,N/A,84.00,N/A,15.82,N/A,19.15,N/A,19.15,N/A,52.29,N/A,84.00,N/A,84.00,N/A,84.00,N/A,65.07,N/A,19.15,N/A,15.82,N/A,113.00,N/A,113.00,N/A,15.82,N/A,19.15,N/A,19.15,N/A,21.07,67.80,67.80,15.82,113.00,,Hospital CPT 29405,HC Cast Short Leg,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,511.00,511.00,306.60,306.60,N/A,71.54,N/A,218.99,N/A,294.23,N/A,173.74,N/A,511.00,N/A,71.54,N/A,216.65,N/A,216.65,N/A,326.24,N/A,511.00,N/A,511.00,N/A,511.00,N/A,294.23,N/A,216.65,N/A,71.54,N/A,511.00,N/A,511.00,N/A,71.54,N/A,216.65,N/A,224.08,N/A,60.04,306.60,306.60,60.04,511.00,,Hospital CPT 29505,HC Splint App Long Leg,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1201.00,1201.00,720.60,720.60,N/A,168.14,N/A,139.49,N/A,691.54,N/A,408.34,N/A,318.39,N/A,168.14,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,691.54,N/A,131.63,N/A,168.14,N/A,1201.00,N/A,1201.00,N/A,168.14,N/A,131.63,N/A,139.49,N/A,52.89,720.60,720.60,52.89,1201.00,,Hospital 29550,HC Strapping of Toes,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,4232.00,N/A,2539.20,N/A,592.48,N/A,618.98,N/A,2436.79,N/A,1438.88,N/A,N/A,N/A,592.48,N/A,581.86,N/A,581.86,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2436.79,N/A,581.86,N/A,592.48,N/A,2268.35,N/A,2268.35,N/A,592.48,N/A,581.86,N/A,618.98,N/A,56.75,N/A,N/A,56.75,2539.20,,Hospital CPT 29580,HC Application of Paste Boot,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,591.00,591.00,354.60,354.60,N/A,82.74,N/A,131.63,N/A,340.30,N/A,200.94,N/A,318.39,N/A,82.74,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,340.30,N/A,131.63,N/A,82.74,N/A,591.00,N/A,591.00,N/A,82.74,N/A,131.63,N/A,131.63,N/A,144.79,354.60,354.60,82.74,591.00,,Hospital CPT 29580,"HC Compress Wrap,Unna Boot (Uni)",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,591.00,591.00,354.60,354.60,N/A,82.74,N/A,131.63,N/A,340.30,N/A,200.94,N/A,318.39,N/A,82.74,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,340.30,N/A,131.63,N/A,82.74,N/A,527.00,N/A,527.00,N/A,82.74,N/A,131.63,N/A,131.63,N/A,144.79,354.60,354.60,82.74,527.00,,Hospital 29584,HC Appl Mltlayr Compres Sys Uparm Lwarm Hand&Finger,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,N/A,802.00,N/A,481.20,N/A,112.28,N/A,137.69,N/A,461.79,N/A,272.68,N/A,318.39,N/A,112.28,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,461.79,N/A,131.63,N/A,112.28,N/A,429.87,N/A,429.87,N/A,112.28,N/A,131.63,N/A,137.69,N/A,16.95,N/A,N/A,16.95,481.20,,Hospital 29700,HC Remv/Revisn Boot/Body Cast,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,15498.10,N/A,9298.86,N/A,8349.21,N/A,10142.34,N/A,15498.10,N/A,5269.35,N/A,15498.10,N/A,8606.47,N/A,562.00,N/A,562.00,N/A,11824.33,N/A,15498.10,N/A,15498.10,N/A,15498.10,N/A,15498.10,N/A,10142.34,N/A,8606.47,N/A,15498.10,N/A,15498.10,N/A,N/A,N/A,10142.34,N/A,10142.34,N/A,9208.92,N/A,562.00,15498.10,N/A,N/A,,Hospital 29710,HC Remove/Revise Cast,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 29820,Surgical Arthroscopy Shoulder Prtl Synovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52510.03,N/A,31506.02,N/A,7351.39,N/A,6248.31,N/A,11735.00,N/A,17853.39,N/A,15008.05,N/A,7351.39,N/A,5973.28,N/A,5973.28,N/A,9342.79,N/A,15008.05,N/A,15008.05,N/A,15008.05,N/A,11735.00,N/A,5973.28,N/A,7351.39,N/A,13819.75,N/A,13819.75,N/A,7351.39,N/A,5973.28,N/A,6248.31,N/A,3296.89,N/A,N/A,3296.89,31506.02,,Hospital CPT 29823,Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+,N/A,N/A,1229.00,1229.00,737.40,737.40,N/A,172.06,N/A,564.38,N/A,1229.00,N/A,417.86,N/A,1229.00,N/A,172.06,N/A,564.38,N/A,564.38,N/A,1229.00,N/A,1229.00,N/A,1229.00,N/A,1229.00,N/A,1229.00,N/A,564.38,N/A,172.06,N/A,1229.00,N/A,1229.00,N/A,172.06,N/A,564.38,N/A,564.38,N/A,620.82,737.40,737.40,172.06,1229.00,,Hospital CPT 29827,Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr,N/A,N/A,2108.00,2108.00,1264.80,1264.80,N/A,295.12,N/A,1019.84,N/A,2108.00,N/A,716.72,N/A,2108.00,N/A,295.12,N/A,1019.84,N/A,1019.84,N/A,2108.00,N/A,2108.00,N/A,2108.00,N/A,2108.00,N/A,2108.00,N/A,1019.84,N/A,295.12,N/A,2108.00,N/A,2108.00,N/A,295.12,N/A,1019.84,N/A,1019.84,N/A,1121.82,1264.80,1264.80,295.12,2108.00,,Hospital 29843,Arthroscopy Wrist Infection Lavage&Drainage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24201.90,N/A,14521.14,N/A,3388.27,N/A,2859.50,N/A,13927.87,N/A,8228.65,N/A,6525.83,N/A,3388.27,N/A,2688.04,N/A,2688.04,N/A,4062.45,N/A,6525.83,N/A,6525.83,N/A,6525.83,N/A,13927.87,N/A,2688.04,N/A,3388.27,N/A,4562.00,N/A,4562.00,N/A,3388.27,N/A,2688.04,N/A,2859.50,N/A,508.30,N/A,N/A,508.30,14521.14,,Hospital CPT 29848,Ndsc Wrst Surg W/Rls Transvrs Carpl Ligm,N/A,N/A,1012.00,1012.00,607.20,607.20,N/A,141.68,N/A,484.33,N/A,1012.00,N/A,344.08,N/A,1012.00,N/A,141.68,N/A,484.33,N/A,484.33,N/A,906.35,N/A,1012.00,N/A,1012.00,N/A,1012.00,N/A,1012.00,N/A,484.33,N/A,141.68,N/A,1012.00,N/A,1012.00,N/A,141.68,N/A,484.33,N/A,484.33,N/A,532.76,607.20,607.20,141.68,1012.00,,Hospital 29850,Arthroscopy Aid Tx Spine&/Fx Knee W/O Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39073.88,N/A,23444.33,N/A,5470.36,N/A,644.34,N/A,7823.00,N/A,13285.13,N/A,3239.57,N/A,5470.36,N/A,1295.43,N/A,1295.43,N/A,2016.70,N/A,3239.57,N/A,3239.57,N/A,3239.57,N/A,7823.00,N/A,1295.43,N/A,5470.36,N/A,5277.50,N/A,5277.50,N/A,5470.36,N/A,1295.43,N/A,644.34,N/A,708.78,N/A,N/A,644.34,23444.33,,Hospital 29855,Arthrs Aid Tibial Fracture Proximal Unicondylar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38505.87,N/A,23103.52,N/A,5390.81,N/A,6248.31,N/A,7823.00,N/A,13091.99,N/A,14516.23,N/A,5390.81,N/A,5973.28,N/A,5973.28,N/A,9036.64,N/A,14516.23,N/A,14516.23,N/A,14516.23,N/A,7823.00,N/A,5973.28,N/A,5390.81,N/A,10535.75,N/A,10535.75,N/A,5390.81,N/A,5973.28,N/A,6248.31,N/A,1446.59,N/A,N/A,1446.59,23103.52,,Hospital 29856,Arthrs Aid Tibial Fx Prox Unicondylar Bicondylar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,93435.83,N/A,56061.50,N/A,13084.77,N/A,12538.44,N/A,7823.00,N/A,31768.18,N/A,28601.47,N/A,13084.77,N/A,11786.87,N/A,11786.87,N/A,17804.99,N/A,28601.47,N/A,28601.47,N/A,28601.47,N/A,7823.00,N/A,11786.87,N/A,13084.77,N/A,8970.25,N/A,8970.25,N/A,13084.77,N/A,11786.87,N/A,12538.44,N/A,1267.67,N/A,N/A,1267.67,56061.50,,Hospital 29871,Arthroscopy Knee Infection Lavage & Drainage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,51885.70,32919.20,31131.42,19751.52,10970.65,4586.53,13302.65,2811.81,24723.24,7823.00,17641.14,11192.54,24959.74,6611.14,11308.67,4586.53,111276.00,2688.04,111276.00,2688.04,15536.86,4115.56,24959.74,6611.14,24959.74,6611.14,24959.74,6611.14,24723.24,7823.00,13243.35,2688.04,11308.67,4586.53,29695.86,5277.50,29695.86,5277.50,N/A,4586.53,13243.35,2688.04,13302.65,2811.81,12100.28,702.03,10970.65,111276.00,702.03,19751.52,,Hospital CPT 29875,Arthroscopy Knee Synovectomy Limited Spx,N/A,N/A,983.00,983.00,589.80,589.80,N/A,137.62,N/A,471.84,N/A,983.00,N/A,334.22,N/A,983.00,N/A,137.62,N/A,471.84,N/A,471.84,N/A,879.76,N/A,983.00,N/A,983.00,N/A,983.00,N/A,983.00,N/A,471.84,N/A,137.62,N/A,983.00,N/A,983.00,N/A,137.62,N/A,471.84,N/A,471.84,N/A,519.02,589.80,589.80,137.62,983.00,,Hospital 29898,Arthroscopy Ankle Surgical Debridement Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46344.87,N/A,27806.92,N/A,6488.29,N/A,12325.48,N/A,26510.32,N/A,15757.28,N/A,28548.67,N/A,6488.29,N/A,11782.94,N/A,11782.94,N/A,17772.11,N/A,28548.67,N/A,28548.67,N/A,28548.67,N/A,26510.33,N/A,11782.94,N/A,6488.29,N/A,11318.50,N/A,11318.50,N/A,6488.29,N/A,11782.94,N/A,12325.48,N/A,2743.18,N/A,N/A,2743.18,28548.67,,Hospital 29899,Arthroscopy Ankle Surgical W/Ankle Arthrodesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,123000.48,N/A,73800.29,N/A,17217.31,N/A,1310.90,N/A,70465.59,N/A,41820.17,N/A,16048.41,N/A,17217.31,N/A,9184.32,N/A,9184.32,N/A,10186.44,N/A,16048.41,N/A,16048.41,N/A,16048.41,N/A,70465.58,N/A,9390.36,N/A,17217.31,N/A,8970.25,N/A,8970.25,N/A,17217.31,N/A,9367.42,N/A,1310.90,N/A,1441.99,N/A,N/A,1310.90,73800.29,,Hospital CPT 29914,Arthroscopy Hip W/Femoroplasty,N/A,N/A,1985.00,1985.00,1191.00,1191.00,N/A,277.90,N/A,952.82,N/A,1985.00,N/A,674.90,N/A,1985.00,N/A,277.90,N/A,952.82,N/A,952.82,N/A,1763.74,N/A,1985.00,N/A,1985.00,N/A,1985.00,N/A,1985.00,N/A,952.82,N/A,277.90,N/A,1985.00,N/A,1985.00,N/A,277.90,N/A,952.82,N/A,952.82,N/A,1048.10,1191.00,1191.00,277.90,1985.00,,Hospital CPT 29915,Arthroscopy Hip W/Acetabuloplasty,N/A,N/A,2022.00,2022.00,1213.20,1213.20,N/A,283.08,N/A,979.93,N/A,2022.00,N/A,687.48,N/A,2022.00,N/A,283.08,N/A,979.93,N/A,979.93,N/A,1804.51,N/A,2022.00,N/A,2022.00,N/A,2022.00,N/A,2022.00,N/A,979.93,N/A,283.08,N/A,2022.00,N/A,2022.00,N/A,283.08,N/A,979.93,N/A,979.93,N/A,1077.92,1213.20,1213.20,283.08,2022.00,,Hospital CPT 29999,Unlisted Procedure Arthroscopy,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 30100,Biopsy Intranasal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11913.87,N/A,7148.32,N/A,1667.95,N/A,1382.81,N/A,6854.93,N/A,4050.71,N/A,3044.24,N/A,1667.95,N/A,1253.55,N/A,1253.55,N/A,1895.08,N/A,3044.24,N/A,3044.24,N/A,3044.24,N/A,6854.94,N/A,1253.55,N/A,1667.95,N/A,1871.00,N/A,1871.00,N/A,1667.95,N/A,1253.55,N/A,93.69,N/A,103.06,N/A,N/A,93.69,7148.32,,Hospital 30117,Excision/Destruction Intranasal Lesion Int Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30309.13,N/A,18185.48,N/A,4227.09,N/A,1130.67,N/A,17439.55,N/A,10305.10,N/A,11737.07,N/A,4227.09,N/A,4821.94,N/A,4821.94,N/A,7306.55,N/A,11737.07,N/A,11737.07,N/A,11737.07,N/A,17439.59,N/A,4821.94,N/A,4227.09,N/A,8510.75,N/A,8510.75,N/A,4227.09,N/A,4821.94,N/A,1130.67,N/A,1243.75,N/A,N/A,1130.67,18185.48,,Hospital CPT 30130,Excision Inferior Turbinate Partial/Complete,N/A,N/A,735.00,735.00,441.00,441.00,N/A,102.90,N/A,394.27,N/A,735.00,N/A,249.90,N/A,735.00,N/A,102.90,N/A,394.27,N/A,394.27,N/A,727.78,N/A,735.00,N/A,735.00,N/A,735.00,N/A,735.00,N/A,394.27,N/A,102.90,N/A,735.00,N/A,735.00,N/A,102.90,N/A,394.27,N/A,394.27,N/A,433.70,441.00,441.00,102.90,735.00,,Hospital 30150,Rhinectomy Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60590.80,N/A,36354.48,N/A,8482.71,N/A,5043.96,N/A,34884.03,N/A,20600.87,N/A,11737.06,N/A,8482.71,N/A,4821.94,N/A,4821.94,N/A,7306.55,N/A,11737.06,N/A,11737.06,N/A,11737.06,N/A,34884.02,N/A,4821.94,N/A,8482.71,N/A,5963.00,N/A,5963.00,N/A,8482.71,N/A,4821.94,N/A,5043.96,N/A,1810.38,N/A,N/A,1810.38,36354.48,,Hospital CPT 30400,Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti,N/A,N/A,2047.00,2047.00,1228.20,1228.20,N/A,286.58,N/A,1165.65,N/A,2047.00,N/A,695.98,N/A,2047.00,N/A,286.58,N/A,1165.65,N/A,1165.65,N/A,2047.00,N/A,2047.00,N/A,2047.00,N/A,2047.00,N/A,2047.00,N/A,1165.65,N/A,286.58,N/A,2047.00,N/A,2047.00,N/A,286.58,N/A,1165.65,N/A,1165.65,N/A,1282.22,1228.20,1228.20,286.58,2047.00,,Hospital 30410,Rhinp Prim Complete Xtrnl Parts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72460.33,N/A,43476.20,N/A,10217.00,N/A,5043.96,N/A,41719.41,N/A,24636.51,N/A,11704.82,N/A,10217.00,N/A,4821.94,N/A,4821.94,N/A,7286.47,N/A,11704.82,N/A,11704.82,N/A,11704.82,N/A,41719.40,N/A,4821.94,N/A,10217.00,N/A,6898.50,N/A,8510.75,N/A,10217.00,N/A,4821.94,N/A,5043.96,N/A,1801.60,N/A,N/A,1801.60,43476.20,,Hospital 30420,Rhinoplasty Primary W/Major Septal Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37264.58,N/A,22358.75,N/A,5201.43,N/A,5055.49,N/A,21386.40,N/A,12669.96,N/A,11771.25,N/A,5201.43,N/A,4821.94,N/A,4821.94,N/A,7327.81,N/A,11771.25,N/A,11771.25,N/A,11771.25,N/A,21386.42,N/A,4821.94,N/A,5201.43,N/A,5963.00,N/A,5963.00,N/A,5201.43,N/A,4821.94,N/A,1398.22,N/A,1538.04,N/A,N/A,1398.22,22358.75,,Hospital 30435,Rhinoplasty Secondary Intermediate Revision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44886.78,N/A,26932.07,N/A,6284.16,N/A,5055.49,N/A,25747.93,N/A,15261.52,N/A,11826.16,N/A,6284.16,N/A,4821.94,N/A,4821.94,N/A,7362.00,N/A,11826.16,N/A,11826.16,N/A,11826.16,N/A,25747.93,N/A,4821.94,N/A,6284.16,N/A,5963.00,N/A,5963.00,N/A,6284.16,N/A,4821.94,N/A,1272.87,N/A,1400.16,N/A,N/A,1272.87,26932.07,,Hospital 30468,Rpr Nsl Vlv Collapse Subq/Sbmcsl Lat Wall Implt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33370.58,N/A,20022.35,N/A,4671.88,N/A,4780.29,N/A,19102.10,N/A,11346.01,N/A,11683.60,N/A,4671.88,N/A,4821.94,N/A,4821.94,N/A,7273.27,N/A,11683.60,N/A,11683.60,N/A,11683.60,N/A,19102.12,N/A,4821.94,N/A,4671.88,N/A,8510.75,N/A,8510.75,N/A,4671.88,N/A,4821.94,N/A,4780.29,N/A,1102.32,N/A,N/A,1102.32,20022.35,,Hospital 30469,Rpr Nsl Vlv Collapse Lw Nrg Subq/Sbmcsl Rmdlg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38894.63,N/A,23336.78,N/A,5445.24,N/A,940.50,N/A,22389.28,N/A,13193.56,N/A,11696.45,N/A,5445.24,N/A,4821.94,N/A,4821.94,N/A,7281.26,N/A,11696.45,N/A,11696.45,N/A,11696.45,N/A,22389.30,N/A,4821.94,N/A,5445.24,N/A,8510.75,N/A,8510.75,N/A,5445.24,N/A,4821.94,N/A,940.50,N/A,1034.55,N/A,N/A,940.50,23336.78,,Hospital CPT 30520,Septoplasty/Submucous Resecj W/WO Cartilage Grf,N/A,N/A,1211.00,1211.00,726.60,726.60,N/A,169.54,N/A,641.10,N/A,1211.00,N/A,411.74,N/A,1211.00,N/A,169.54,N/A,641.10,N/A,641.10,N/A,1186.52,N/A,1211.00,N/A,1211.00,N/A,1211.00,N/A,1211.00,N/A,641.10,N/A,169.54,N/A,1211.00,N/A,1211.00,N/A,169.54,N/A,641.10,N/A,641.10,N/A,705.21,726.60,726.60,169.54,1211.00,,Hospital 30540,Repair Choanal Atresia Intranasal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,66962.67,N/A,40177.60,N/A,9369.10,N/A,4922.21,N/A,38550.32,N/A,22767.31,N/A,11696.25,N/A,9369.10,N/A,4821.94,N/A,4821.94,N/A,7281.14,N/A,11696.25,N/A,11696.25,N/A,11696.25,N/A,38550.32,N/A,4821.94,N/A,9369.10,N/A,5963.00,N/A,5963.00,N/A,9369.10,N/A,4821.94,N/A,4922.21,N/A,3472.84,N/A,N/A,3472.84,40177.60,,Hospital CPT 30801,Abltj Soft Tis Inferior Turbinates Uni/Bi Supfc,N/A,N/A,392.00,392.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,392.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,375.97,N/A,392.00,N/A,392.00,N/A,392.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,375.97,392.00,,Hospital CPT 30906,HC Repeat Control Nosebleed,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,584.00,584.00,350.40,350.40,N/A,81.76,N/A,130.83,N/A,336.27,N/A,198.56,N/A,584.00,N/A,81.76,N/A,130.83,N/A,130.83,N/A,584.00,N/A,584.00,N/A,584.00,N/A,584.00,N/A,336.27,N/A,130.83,N/A,81.76,N/A,584.00,N/A,584.00,N/A,81.76,N/A,130.83,N/A,130.83,N/A,143.91,350.40,350.40,81.76,584.00,,Hospital 31032,Sinusot Max Antrt Rad W/Rmvl Antroch Polyps,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,45656.57,N/A,27393.94,N/A,4904.12,N/A,5868.94,N/A,10901.55,N/A,14452.56,N/A,11786.04,N/A,5055.22,N/A,5839.29,N/A,5839.29,N/A,7337.02,N/A,11786.04,N/A,11786.04,N/A,11786.04,N/A,10901.55,N/A,5839.29,N/A,5055.22,N/A,13094.19,N/A,13094.19,N/A,N/A,N/A,5839.29,N/A,5868.94,N/A,5409.09,N/A,4904.12,27393.94,N/A,N/A,,Hospital 31201,Ethmoidectomy Intranasal Total,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20296.22,N/A,12177.73,N/A,2841.46,N/A,1813.98,N/A,11679.13,N/A,6854.82,N/A,6235.33,N/A,2841.46,N/A,2569.18,N/A,2569.18,N/A,3881.62,N/A,6235.33,N/A,6235.33,N/A,6235.33,N/A,11679.15,N/A,2569.18,N/A,2841.46,N/A,5944.75,N/A,5944.75,N/A,2841.46,N/A,2569.18,N/A,1813.98,N/A,1995.39,N/A,N/A,1813.98,12177.73,,Hospital 31240,Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58953.07,N/A,35371.84,N/A,8247.03,N/A,5703.37,N/A,33936.04,N/A,20044.02,N/A,13572.59,N/A,8247.03,N/A,5587.18,N/A,5587.18,N/A,8449.22,N/A,13572.59,N/A,13572.59,N/A,13572.59,N/A,33936.04,N/A,5587.18,N/A,8247.03,N/A,7692.25,N/A,7692.25,N/A,8247.03,N/A,5587.18,N/A,5703.37,N/A,1324.52,N/A,N/A,1324.52,35371.84,,Hospital 31241,Nasal/Sinus Ndsc W/Lig Sphenopalatine Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,99129.02,30776.43,59477.41,18465.86,9651.93,4299.85,11713.03,1510.03,36392.43,17719.65,33703.87,10463.99,21959.47,3547.48,9949.32,4299.85,94978.00,1443.56,94978.00,1443.56,13669.26,2212.00,21959.47,3547.48,21959.47,3547.48,21959.47,3547.48,36392.43,17719.67,11683.38,1443.56,9949.32,4299.85,26126.29,3397.00,26126.29,3397.00,238.28,4299.85,11683.38,1443.56,11713.03,1510.03,10645.77,478.07,238.28,94978.00,478.07,18465.86,,Hospital CPT 31253,Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl,N/A,N/A,815.00,815.00,489.00,489.00,N/A,114.10,N/A,481.30,N/A,815.00,N/A,277.10,N/A,815.00,N/A,114.10,N/A,481.30,N/A,481.30,N/A,815.00,N/A,815.00,N/A,815.00,N/A,815.00,N/A,815.00,N/A,481.30,N/A,114.10,N/A,815.00,N/A,815.00,N/A,114.10,N/A,481.30,N/A,481.30,N/A,529.43,489.00,489.00,114.10,815.00,,Hospital CPT 31255,Nasal/Sinus Ndsc W/Total Ethoidectomy,N/A,N/A,802.00,802.00,481.20,481.20,N/A,112.28,N/A,311.45,N/A,802.00,N/A,272.68,N/A,802.00,N/A,112.28,N/A,311.45,N/A,311.45,N/A,577.54,N/A,802.00,N/A,802.00,N/A,802.00,N/A,802.00,N/A,311.45,N/A,112.28,N/A,802.00,N/A,802.00,N/A,112.28,N/A,311.45,N/A,311.45,N/A,342.60,481.20,481.20,112.28,802.00,,Hospital 31288,Nsl/Sinus Ndsc Sphendt Rmvl Tiss Sphenoid Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45374.62,N/A,27224.77,N/A,6352.45,N/A,1290.81,N/A,26105.71,N/A,14745.01,N/A,13660.63,N/A,6352.45,N/A,5587.18,N/A,5587.18,N/A,8504.01,N/A,13660.63,N/A,13660.63,N/A,13660.63,N/A,26105.74,N/A,5587.18,N/A,6352.45,N/A,7692.25,N/A,7692.25,N/A,6352.45,N/A,5587.18,N/A,1290.81,N/A,1419.89,N/A,N/A,1290.81,27224.77,,Hospital 31290,Nasal/Sinus Ndsc Rpr Cerebrsp Fluid Leak Ethmoid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81463.58,N/A,48878.15,N/A,11388.34,N/A,2371.91,N/A,46771.59,N/A,27682.05,N/A,20882.54,N/A,11388.34,N/A,3010.42,N/A,3010.42,N/A,12999.78,N/A,20882.54,N/A,20882.54,N/A,20882.54,N/A,46771.63,N/A,3010.42,N/A,11388.34,N/A,5944.75,N/A,5944.75,N/A,11388.34,N/A,3010.42,N/A,2371.91,N/A,2609.11,N/A,N/A,2371.91,48878.15,,Hospital 31295,Nasal/Sinus Ndsc Surg W/Dilation Maxillary Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50478.93,N/A,30287.36,N/A,7067.07,N/A,5538.92,N/A,28837.82,N/A,17162.85,N/A,13536.69,N/A,7067.07,N/A,5587.18,N/A,5587.18,N/A,8426.86,N/A,13536.69,N/A,13536.69,N/A,13536.69,N/A,28837.83,N/A,5587.18,N/A,7067.07,N/A,7983.50,N/A,7983.50,N/A,7067.07,N/A,5587.18,N/A,5538.92,N/A,1612.77,N/A,N/A,1612.77,30287.36,,Hospital 31513,Laryngoscopy Indirect W/Vocal Cord Injection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41137.95,N/A,24682.77,N/A,5759.31,N/A,3005.77,N/A,23580.78,N/A,13986.89,N/A,7163.82,N/A,5759.31,N/A,2944.53,N/A,2944.53,N/A,4459.63,N/A,7163.82,N/A,7163.82,N/A,7163.82,N/A,23580.78,N/A,2944.53,N/A,5759.31,N/A,2134.50,N/A,2134.50,N/A,5759.31,N/A,2944.53,N/A,3005.77,N/A,329.97,N/A,N/A,329.97,24682.77,,Hospital CPT 31525,HC Dx Laryngoscopy Excl Nb,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4159.00,4159.00,2495.40,2495.40,N/A,582.26,N/A,152.40,N/A,2394.75,N/A,1414.06,N/A,702.12,N/A,582.26,N/A,152.40,N/A,152.40,N/A,437.07,N/A,702.12,N/A,702.12,N/A,702.12,N/A,2394.75,N/A,152.40,N/A,582.26,N/A,4159.00,N/A,4159.00,N/A,582.26,N/A,152.40,N/A,152.40,N/A,167.64,2495.40,2495.40,152.40,4159.00,,Hospital CPT 31525,HC Dx Laryngoscopy Excl Nb,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4159.00,4159.00,2495.40,2495.40,N/A,582.26,N/A,152.40,N/A,2394.75,N/A,1414.06,N/A,702.12,N/A,582.26,N/A,152.40,N/A,152.40,N/A,437.07,N/A,702.12,N/A,702.12,N/A,702.12,N/A,2394.75,N/A,152.40,N/A,582.26,N/A,2229.22,N/A,2229.22,N/A,582.26,N/A,152.40,N/A,152.40,N/A,167.64,2495.40,2495.40,152.40,2495.40,,Hospital 31560,Laryngoscopy Direct Operative W/Arytenoidectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60956.87,70449.90,36574.12,42269.94,10141.65,9862.94,12262.69,5703.37,22855.02,40495.08,20725.34,23952.92,23073.65,13880.22,10454.13,9862.94,12262.69,5587.18,12262.69,5587.18,14362.81,8640.69,23073.65,13880.22,23073.65,13880.22,23073.65,13880.22,22855.02,38592.67,12262.69,5587.18,10454.13,N/A,27451.88,4562.00,27451.88,4562.00,N/A,9862.94,12262.69,5587.18,12262.69,5703.37,11185.92,496.06,10141.65,36574.12,496.06,42269.94,,Hospital 31573,HC Laryngoscopy Flexible Therapeutic Injection Uni,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,60705.97,15683.30,36423.58,9409.98,6443.15,2178.36,7887.55,1459.20,14520.17,8966.48,20640.03,5332.31,14659.07,5119.52,6641.68,2178.36,1443.56,1443.56,1443.56,1443.56,9124.93,3186.98,14659.07,5119.52,14659.07,5119.52,14659.07,5119.52,14520.17,8966.48,7887.55,1443.56,6641.68,2178.36,17440.63,2806.50,17440.63,2806.50,N/A,2178.36,7887.55,1443.56,7887.55,1459.20,7106.60,178.48,1443.56,36423.58,178.48,9409.98,,Hospital CPT 31575,HC Laryngoscopy Flexible Fiberoptic Diagnostic,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,490.00,490.00,294.00,294.00,N/A,68.60,N/A,163.17,N/A,282.14,N/A,166.60,N/A,390.46,N/A,68.60,N/A,161.42,N/A,161.42,N/A,243.07,N/A,390.46,N/A,390.46,N/A,390.46,N/A,282.14,N/A,161.42,N/A,68.60,N/A,490.00,N/A,490.00,N/A,68.60,N/A,161.42,N/A,163.17,N/A,69.66,294.00,294.00,68.60,490.00,,Hospital CPT 31575,HC Laryngosocpy Flex Fiber Dx,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,478.00,478.00,286.80,286.80,N/A,66.92,N/A,163.17,N/A,275.23,N/A,162.52,N/A,390.46,N/A,66.92,N/A,161.42,N/A,161.42,N/A,243.07,N/A,390.46,N/A,390.46,N/A,390.46,N/A,275.23,N/A,161.42,N/A,66.92,N/A,256.21,N/A,256.21,N/A,66.92,N/A,161.42,N/A,163.17,N/A,69.66,286.80,286.80,66.92,390.46,,Hospital 31600,HC Percutaneous Trach Insert,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,504642.78,19297.00,302785.67,11578.20,55050.94,2701.58,88778.28,294.94,449042.43,11111.22,832308.30,6560.98,832308.30,6214.61,55050.94,2701.58,88778.28,2569.18,88778.28,2569.18,832308.30,3868.72,832308.30,6214.61,832308.30,6214.61,832308.30,6214.61,449042.43,11111.22,88778.28,2569.18,55050.94,2701.58,449042.43,3397.00,449042.43,3397.00,55050.94,2701.58,75523.20,2569.18,88778.28,294.94,55050.94,324.43,55050.94,832308.30,294.94,11578.20,,Hospital 31610,Tracheostomy Fenestration W/Skin Flaps,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41618.32,N/A,24970.99,N/A,5826.58,N/A,4922.21,N/A,23871.82,N/A,14150.23,N/A,11685.53,N/A,5826.58,N/A,4821.94,N/A,4821.94,N/A,7274.45,N/A,11685.53,N/A,11685.53,N/A,11685.53,N/A,23871.82,N/A,4821.94,N/A,5826.58,N/A,3397.00,N/A,3397.00,N/A,5826.58,N/A,4821.94,N/A,4922.21,N/A,1038.40,N/A,N/A,1038.40,24970.99,,Hospital 31622,HC Bronchoscopy W or WO Fluoro,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,228560.22,12338.70,137136.13,7403.22,18201.83,1728.47,34487.03,1559.14,74157.47,7101.85,134950.75,4047.94,134950.75,3842.70,18201.83,1728.47,34487.03,1572.73,34487.03,1572.73,134950.75,2392.15,134950.75,3842.70,134950.75,3842.70,134950.75,3842.70,74157.47,7101.86,44818.33,1572.73,18201.83,1728.47,74157.47,3274.25,48184.00,3274.25,18201.83,1728.47,13722.89,1572.73,34487.03,1559.14,18201.83,479.05,13722.89,137136.13,479.05,7403.22,,Hospital 31623,HC Rt Bronch Dx W/Brushing,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,119325.50,28931.10,71595.30,17358.66,2593.58,4050.33,14092.38,3149.03,27716.05,16657.19,N/A,9836.55,N/A,7299.85,2593.58,4050.33,14092.38,3010.42,14092.38,3010.42,N/A,4544.30,N/A,7299.85,N/A,7299.85,N/A,7299.85,27716.05,16657.20,14092.38,3010.42,2593.58,4050.33,27716.05,5965.25,27716.05,5965.25,2593.58,4050.33,12616.71,3010.42,14092.38,3149.03,2593.58,1448.40,2593.58,71595.30,1448.40,17358.66,,Hospital 31628,HC Bronchoscopy W/Bx W/ W/O Fluor,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,203272.27,24748.13,121963.36,14848.88,2184.80,3464.74,10006.80,3010.42,9202.17,14247.35,277500.00,7696.63,277500.00,7310.44,2184.80,3464.74,10006.80,3010.42,10006.80,3010.42,277500.00,4550.89,277500.00,7310.44,277500.00,7310.44,277500.00,7310.44,9202.17,14247.35,10006.80,3010.42,2184.80,3464.74,9202.17,2938.25,9202.17,2938.25,2184.80,3464.74,10006.80,3010.42,10006.80,3010.42,2184.80,3311.46,2184.80,277500.00,2938.25,14848.88,,Hospital 31630,Brnchsc W/Tracheal/Bronchial Dilat/Clsd Rdctj Fx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,35856.23,N/A,21513.74,N/A,4987.11,N/A,207.42,N/A,20639.79,N/A,12191.12,N/A,7295.52,N/A,4987.11,N/A,3010.42,N/A,3010.42,N/A,4541.60,N/A,7295.52,N/A,7295.52,N/A,7295.52,N/A,20639.79,N/A,3010.42,N/A,4987.11,N/A,4562.00,N/A,4562.00,N/A,4987.11,N/A,3010.42,N/A,207.42,N/A,228.17,N/A,N/A,207.42,21513.74,,Hospital 31633,Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,51445.58,N/A,30867.35,N/A,7111.97,N/A,5844.44,N/A,29621.43,N/A,17491.48,N/A,13525.74,N/A,7111.97,N/A,5587.18,N/A,5587.18,N/A,8420.04,N/A,13525.74,N/A,13525.74,N/A,13525.74,N/A,29621.45,N/A,5587.18,N/A,7111.97,N/A,5965.25,N/A,5965.25,N/A,7111.97,N/A,5587.18,N/A,5844.44,N/A,2522.62,N/A,N/A,2522.62,30867.35,,Hospital 31638,Brnchsc Revj Tracheal/Brncl Stent Ins Prev Sess,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,13358.00,N/A,8014.80,N/A,1870.12,N/A,238.49,N/A,7688.50,N/A,4541.72,N/A,13358.00,N/A,1870.12,N/A,5587.18,N/A,5587.18,N/A,8426.34,N/A,13358.00,N/A,13358.00,N/A,13358.00,N/A,7688.50,N/A,5587.18,N/A,1870.12,N/A,4562.00,N/A,4562.00,N/A,1870.12,N/A,5587.18,N/A,238.49,N/A,262.34,N/A,N/A,238.49,13358.00,,Hospital 31640,Bronchoscopy W/Excision Tumor,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,23773.70,N/A,14264.22,N/A,3292.86,N/A,3043.02,N/A,13687.19,N/A,8083.06,N/A,7303.08,N/A,3292.86,N/A,3010.42,N/A,3010.42,N/A,4546.31,N/A,7303.08,N/A,7303.08,N/A,7303.08,N/A,13687.19,N/A,3010.42,N/A,3292.86,N/A,6260.50,N/A,6260.50,N/A,3292.86,N/A,3010.42,N/A,3043.02,N/A,1232.89,N/A,N/A,1232.89,14264.22,,Hospital 31641,Brnchsc W/Dstrj Tum Relief Stenosis Oth/Thn Exc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,59320.48,17715.55,35592.29,10629.33,9651.93,2480.18,11683.38,278.00,21751.40,10190.63,20168.97,6023.28,21959.47,7335.61,9949.32,2480.18,562.00,3010.42,562.00,3010.42,13669.26,4566.56,21959.47,7335.61,21959.47,7335.61,21959.47,7335.61,21751.40,10148.48,11683.38,3010.42,9949.32,2480.18,26126.29,4562.00,26126.29,4562.00,N/A,2480.18,11683.38,3010.42,11683.38,278.00,10645.77,305.80,562.00,35592.29,278.00,10629.33,,Hospital 31648,Brnchsc Removal Bronchial Valve Initial,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,18383.40,N/A,11030.04,N/A,2573.68,N/A,3073.03,N/A,10583.83,N/A,6250.36,N/A,7294.17,N/A,2573.68,N/A,3010.42,N/A,3010.42,N/A,4540.76,N/A,7294.17,N/A,7294.17,N/A,7294.17,N/A,10583.83,N/A,3010.42,N/A,2573.68,N/A,5497.50,N/A,5497.50,N/A,2573.68,N/A,3010.42,N/A,3073.03,N/A,282.12,N/A,N/A,282.12,11030.04,,Hospital 31653,Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,53886.80,27085.83,32332.08,16251.50,4337.56,3760.73,5344.04,3206.37,10385.81,15586.33,18321.51,9209.18,10485.15,7334.01,4471.21,3760.73,3160.25,3014.35,3160.25,3014.35,6526.76,4565.56,10485.15,7334.01,10485.15,7334.01,10485.15,7334.01,10385.81,15586.34,5284.74,3014.35,4471.21,3760.73,12474.72,3397.00,12474.72,3397.00,4322.57,3760.73,5284.74,3014.35,5344.04,3206.37,4784.20,955.95,3160.25,32332.08,955.95,16251.50,,Hospital 31750,Tracheoplasty Cervical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69449.60,N/A,41669.76,N/A,9722.92,N/A,4922.21,N/A,39884.61,N/A,23612.85,N/A,11728.14,N/A,9722.92,N/A,4821.94,N/A,4821.94,N/A,7300.99,N/A,11728.14,N/A,11728.14,N/A,11728.14,N/A,39668.68,N/A,4821.94,N/A,9722.92,N/A,6898.50,N/A,6898.50,N/A,9722.92,N/A,4821.94,N/A,4922.21,N/A,1671.17,N/A,N/A,1671.17,41669.76,,Hospital 31785,Excision Tracheal Tumor/Carcinoma Cervical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47060.12,N/A,28236.07,N/A,6588.42,N/A,4922.21,N/A,27026.32,N/A,16000.45,N/A,11719.76,N/A,6588.42,N/A,4821.94,N/A,4821.94,N/A,7295.78,N/A,11719.76,N/A,11719.76,N/A,11719.76,N/A,27026.32,N/A,4821.94,N/A,6588.42,N/A,3397.00,N/A,3397.00,N/A,6588.42,N/A,4821.94,N/A,4922.21,N/A,1188.64,N/A,N/A,1188.64,28236.07,,Hospital CPT 32554,HC Thoracentesis Without Guidance,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2935.00,2935.00,1761.00,1761.00,N/A,410.90,N/A,86.75,N/A,1689.97,N/A,997.90,N/A,1263.67,N/A,410.90,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1689.97,N/A,522.41,N/A,410.90,N/A,1431.00,N/A,1431.00,N/A,410.90,N/A,522.41,N/A,86.75,N/A,95.43,1761.00,1761.00,86.75,1761.00,,Hospital CPT 32554,HC Thoracentesis WO Imaging,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2935.00,2935.00,1761.00,1761.00,N/A,410.90,N/A,86.75,N/A,1689.97,N/A,997.90,N/A,1263.67,N/A,410.90,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1689.97,N/A,522.41,N/A,410.90,N/A,2935.00,N/A,2935.00,N/A,410.90,N/A,522.41,N/A,86.75,N/A,95.43,1761.00,1761.00,86.75,2935.00,,Hospital CPT 32554,HC Thoracentesis WO Imaging,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2935.00,2935.00,1761.00,1761.00,N/A,410.90,N/A,86.75,N/A,1689.97,N/A,997.90,N/A,1263.67,N/A,410.90,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1689.97,N/A,522.41,N/A,410.90,N/A,1573.16,N/A,1573.16,N/A,410.90,N/A,522.41,N/A,86.75,N/A,95.43,1761.00,1761.00,86.75,1761.00,,Hospital 32561,HC Lyse Chest Fibrin Init Day,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,11004.80,N/A,6602.88,N/A,1540.67,N/A,965.06,N/A,6257.33,N/A,3741.63,N/A,2564.81,N/A,1540.67,N/A,1046.60,N/A,1046.60,N/A,1596.64,N/A,2564.81,N/A,2564.81,N/A,2564.81,N/A,6257.33,N/A,1046.60,N/A,1540.67,N/A,1431.00,N/A,1431.00,N/A,1540.67,N/A,1046.60,N/A,965.06,N/A,89.67,N/A,N/A,89.67,6602.88,,Hospital 32606,Thoracoscopy Dx Mediastinal Space W/Biopsy Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33525.97,N/A,20115.58,N/A,4691.98,N/A,4832.50,N/A,19298.38,N/A,11195.51,N/A,11466.56,N/A,4691.98,N/A,4706.78,N/A,4706.78,N/A,7138.16,N/A,11466.56,N/A,11466.56,N/A,11466.56,N/A,19298.40,N/A,4706.78,N/A,4691.98,N/A,6678.50,N/A,6678.50,N/A,4691.98,N/A,4706.78,N/A,4832.50,N/A,1176.42,N/A,N/A,1176.42,20115.58,,Hospital 32662,Thoracoscopy W/Exc Mediastinal Cyst Tumor/Mass,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25976.17,N/A,15585.70,N/A,3636.67,N/A,1185.73,N/A,14949.73,N/A,8831.90,N/A,12589.24,N/A,3636.67,N/A,1177.08,N/A,1177.08,N/A,7836.76,N/A,12589.24,N/A,12589.24,N/A,12589.24,N/A,14694.66,N/A,1177.08,N/A,3636.67,N/A,1906.50,N/A,1906.50,N/A,3636.67,N/A,1177.08,N/A,1185.73,N/A,1040.04,N/A,N/A,1040.04,15585.70,,Hospital 32994,HC Ablate Pulm Tumor Perq Crybl,N/A,0352 - CT SCAN - BODY SCAN,N/A,48296.90,N/A,28978.14,N/A,6758.01,N/A,4927.79,N/A,27805.67,N/A,16420.95,N/A,11493.46,N/A,6758.01,N/A,4706.78,N/A,4706.78,N/A,7154.90,N/A,11493.46,N/A,11493.46,N/A,11493.46,N/A,27805.69,N/A,4706.78,N/A,6758.01,N/A,7897.00,N/A,7897.00,N/A,6758.01,N/A,4711.07,N/A,4927.79,N/A,534.15,N/A,N/A,534.15,28978.14,,Hospital 33010,HC Pericardiocentesis Intial,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,82996.10,N/A,49797.66,N/A,5869.15,N/A,7208.54,N/A,14352.58,N/A,28218.67,N/A,13872.42,N/A,6049.99,N/A,3934.00,N/A,3934.00,N/A,N/A,N/A,13872.42,N/A,N/A,N/A,13872.42,N/A,14352.58,N/A,7208.54,N/A,6049.99,N/A,15886.89,N/A,15886.89,N/A,N/A,N/A,7208.54,N/A,7208.54,N/A,6473.49,N/A,3934.00,49797.66,N/A,N/A,,Hospital CPT 33016,HC Pericardiocentesis Including Imag Guid When Performed,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2066.00,2066.00,1239.60,1239.60,N/A,289.24,N/A,226.05,N/A,1189.60,N/A,702.44,N/A,2066.00,N/A,289.24,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,2066.00,N/A,2066.00,N/A,2066.00,N/A,1189.60,N/A,1343.59,N/A,289.24,N/A,1431.00,N/A,1431.00,N/A,289.24,N/A,1343.59,N/A,226.05,N/A,248.66,1239.60,1239.60,226.05,2066.00,,Hospital 33202,Insertion Epicardial Electrode Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,115168.77,N/A,69101.26,N/A,26783.53,N/A,31669.99,N/A,63481.02,N/A,39157.38,N/A,65719.37,N/A,27608.78,N/A,31640.34,N/A,31640.34,N/A,40909.77,N/A,65719.37,N/A,65719.37,N/A,65719.37,N/A,62160.95,N/A,31640.34,N/A,27608.78,N/A,75262.72,N/A,75262.72,N/A,N/A,N/A,31640.34,N/A,31669.99,N/A,29541.39,N/A,26783.53,75262.72,N/A,N/A,,Hospital CPT 33212,HC Generator Change Single Chambe,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,8992.00,8992.00,5395.20,5395.20,N/A,1258.88,N/A,308.52,N/A,5177.59,N/A,3057.28,N/A,908.37,N/A,1258.88,N/A,308.52,N/A,308.52,N/A,565.46,N/A,908.37,N/A,908.37,N/A,908.37,N/A,5177.59,N/A,308.52,N/A,1258.88,N/A,8992.00,N/A,8992.00,N/A,1258.88,N/A,308.52,N/A,308.52,N/A,339.37,5395.20,5395.20,308.52,8992.00,,Hospital CPT 33216,HC Replace Atrial/Ventricular Lead,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,20407.00,20407.00,12244.20,12244.20,N/A,2856.98,N/A,7451.14,N/A,11750.35,N/A,6938.38,N/A,17830.58,N/A,2856.98,N/A,7371.31,N/A,7371.31,N/A,11099.88,N/A,17830.58,N/A,17830.58,N/A,17830.58,N/A,11750.35,N/A,7371.31,N/A,2856.98,N/A,7897.00,N/A,7897.00,N/A,2856.98,N/A,7371.31,N/A,355.31,N/A,390.84,12244.20,12244.20,355.31,17830.58,,Hospital CPT 33217,HC Replace Atrial and Vent Lead,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,20407.00,20407.00,12244.20,12244.20,N/A,2856.98,N/A,7987.43,N/A,11750.35,N/A,6938.38,N/A,17830.58,N/A,2856.98,N/A,7371.31,N/A,7371.31,N/A,11099.88,N/A,17830.58,N/A,17830.58,N/A,17830.58,N/A,11750.35,N/A,7371.31,N/A,2856.98,N/A,7897.00,N/A,7897.00,N/A,2856.98,N/A,7371.31,N/A,7987.43,N/A,387.40,12244.20,12244.20,387.40,17830.58,,Hospital CPT 33218,HC Repair Sngl Lead for Sngl Chmb,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4643.00,4643.00,2785.80,2785.80,N/A,650.02,N/A,3106.85,N/A,2673.44,N/A,1578.62,N/A,4643.00,N/A,650.02,N/A,3026.02,N/A,3026.02,N/A,4556.65,N/A,4643.00,N/A,4643.00,N/A,4643.00,N/A,2673.44,N/A,3026.02,N/A,650.02,N/A,4562.00,N/A,4562.00,N/A,650.02,N/A,3026.02,N/A,3106.85,N/A,408.64,2785.80,2785.80,408.64,4643.00,,Hospital CPT 33220,HC Repair 2 Leads for Dual Chambr,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4643.00,4643.00,2785.80,2785.80,N/A,650.02,N/A,360.96,N/A,2673.44,N/A,1578.62,N/A,1064.46,N/A,650.02,N/A,360.96,N/A,360.96,N/A,662.63,N/A,1064.46,N/A,1064.46,N/A,1064.46,N/A,2673.44,N/A,360.96,N/A,650.02,N/A,4643.00,N/A,4643.00,N/A,650.02,N/A,360.96,N/A,360.96,N/A,397.06,2785.80,2785.80,360.96,4643.00,,Hospital CPT 33223,HC Pkt Relocation Icd,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,4292.00,4292.00,2575.20,2575.20,N/A,600.88,N/A,1630.28,N/A,2471.33,N/A,1459.28,N/A,3769.94,N/A,600.88,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,2471.33,N/A,1558.52,N/A,600.88,N/A,2300.51,N/A,2300.51,N/A,600.88,N/A,1558.52,N/A,1630.28,N/A,431.04,2575.20,2575.20,431.04,3769.94,,Hospital CPT 33241,HC Subc Rem of Cd Pulse Generator,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4508.00,4508.00,2704.80,2704.80,N/A,631.12,N/A,3088.95,N/A,2595.71,N/A,1532.72,N/A,4508.00,N/A,631.12,N/A,3026.02,N/A,3026.02,N/A,4508.00,N/A,4508.00,N/A,4508.00,N/A,4508.00,N/A,2595.71,N/A,3026.02,N/A,631.12,N/A,4562.00,N/A,4562.00,N/A,631.12,N/A,3026.02,N/A,3165.36,N/A,225.39,2704.80,2704.80,225.39,4562.00,,Hospital 33272,HC Rmvl of Subq Implantable Defibrillator Electrode,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,154345.03,69079.67,92607.02,41447.80,10193.39,9612.52,12323.90,3165.36,85074.99,39771.85,51537.55,23487.09,70209.79,7433.31,10507.47,9612.52,562.00,3026.02,562.00,3026.02,43707.08,4627.38,70209.79,7433.31,70209.79,7433.31,70209.79,7433.31,85074.99,39771.89,12323.90,3026.02,10507.47,9612.52,27591.95,6843.00,27591.95,6843.00,4900.75,9612.52,12323.90,3026.02,12323.90,3165.36,11242.99,640.84,562.00,92607.02,640.84,41447.80,,Hospital CPT 33285,HC Insertion Subq Cardiac Rhythm Monitor W/Prgrmg,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,20407.00,20407.00,12244.20,12244.20,N/A,2856.98,N/A,7371.31,N/A,11750.35,N/A,6938.38,N/A,17830.58,N/A,2856.98,N/A,7371.31,N/A,7371.31,N/A,11099.88,N/A,17830.58,N/A,17830.58,N/A,17830.58,N/A,11750.35,N/A,7371.31,N/A,2856.98,N/A,11660.00,N/A,11660.00,N/A,2856.98,N/A,7371.31,N/A,7371.31,N/A,8108.44,12244.20,12244.20,2856.98,17830.58,,Hospital CPT 33286,HC Removal Subcutaneous Cardiac Rhythm Monitor,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2164.00,2164.00,1298.40,1298.40,N/A,302.96,N/A,586.05,N/A,1246.03,N/A,735.76,N/A,1417.60,N/A,302.96,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1246.03,N/A,586.05,N/A,302.96,N/A,1431.00,N/A,1431.00,N/A,302.96,N/A,586.05,N/A,586.05,N/A,644.65,1298.40,1298.40,302.96,1431.00,,Hospital CPT 33418,"HC Repair Trnscath Mitral Valve, Initial Prosthesis",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,15495.00,15495.00,9297.00,9297.00,N/A,2169.30,N/A,1724.18,N/A,8922.02,N/A,5268.30,N/A,1263.78,N/A,2169.30,N/A,1724.18,N/A,1724.18,N/A,786.73,N/A,1263.78,N/A,1263.78,N/A,1263.78,N/A,8922.02,N/A,1724.18,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,2169.30,N/A,1724.18,N/A,1724.18,N/A,1896.60,9297.00,9297.00,786.73,15495.00,,Hospital CPT 33419,"HC Repair Trnscath Mitral Valve, Addit Prosthesis",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,8035.00,8035.00,4821.00,4821.00,N/A,1124.90,N/A,407.41,N/A,4626.55,N/A,2731.90,N/A,1197.93,N/A,1124.90,N/A,407.41,N/A,407.41,N/A,745.71,N/A,1197.93,N/A,1197.93,N/A,1197.93,N/A,4626.55,N/A,407.41,N/A,1124.90,N/A,8035.00,N/A,8035.00,N/A,1124.90,N/A,407.41,N/A,407.41,N/A,448.15,4821.00,4821.00,407.41,8035.00,,Hospital 33465,Replacement Tricuspid Valve W/Card Bypass,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,494129.17,N/A,296477.50,N/A,78621.92,N/A,N/A,N/A,272363.99,N/A,N/A,N/A,N/A,N/A,6745.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6745.35,N/A,N/A,N/A,N/A,N/A,6745.35,N/A,N/A,N/A,N/A,N/A,6745.35,N/A,6745.35,296477.50,N/A,N/A,,Hospital 33880,Evasc Rpr Dta Coverage Art Origin 1st Endoprosth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,218561.53,N/A,131136.92,N/A,24248.59,N/A,27251.59,N/A,120471.12,N/A,74310.92,N/A,76103.12,N/A,23515.33,N/A,27251.59,N/A,27251.59,N/A,47384.14,N/A,76103.12,N/A,76103.12,N/A,76103.12,N/A,120471.12,N/A,27251.59,N/A,23515.33,N/A,138067.65,N/A,138067.65,N/A,16125.80,N/A,27251.59,N/A,14009.07,N/A,25161.40,N/A,14009.07,138067.65,N/A,N/A,,Hospital 33901,HC Perq P-Art Revsc St 1st Nml Native Connj Bi,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,138406.77,N/A,83044.06,N/A,17327.79,N/A,20764.09,N/A,76289.81,N/A,47058.30,N/A,N/A,N/A,54065.02,N/A,3372.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76289.81,N/A,N/A,N/A,17861.69,N/A,52934.15,N/A,52934.15,N/A,54065.02,N/A,20764.09,N/A,20764.09,N/A,19112.01,N/A,3372.00,83044.06,N/A,N/A,,Hospital 33947,HC Ecmo/Ecls Initiation Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,893556.58,N/A,536133.95,N/A,N/A,N/A,136920.01,N/A,57156.61,N/A,372140.60,N/A,372140.60,N/A,N/A,N/A,136920.01,N/A,136920.01,N/A,372140.60,N/A,372140.60,N/A,372140.60,N/A,372140.60,N/A,57156.61,N/A,151703.54,N/A,N/A,N/A,57156.61,N/A,57156.61,N/A,N/A,N/A,136920.01,N/A,136920.01,N/A,N/A,N/A,57156.61,536133.95,N/A,N/A,,Hospital 33966,HC Ecmo/Ecls Rmvl Prph Cannula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1303158.07,N/A,781894.84,N/A,137322.81,N/A,173671.32,N/A,423136.78,N/A,894020.97,N/A,894020.97,N/A,137322.81,N/A,173671.32,N/A,173671.32,N/A,894020.97,N/A,894020.97,N/A,894020.97,N/A,894020.97,N/A,423136.78,N/A,173671.32,N/A,137322.81,N/A,423136.78,N/A,423136.78,N/A,137322.81,N/A,173671.32,N/A,173671.32,N/A,137322.81,N/A,137322.81,894020.97,N/A,N/A,,Hospital CPT 33970,"HC Insert Aortic Circulation Assist Device ,Open Approach",N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15302.00,15302.00,9181.20,9181.20,N/A,2142.28,N/A,340.47,N/A,8810.89,N/A,5202.68,N/A,1004.25,N/A,2142.28,N/A,340.47,N/A,340.47,N/A,625.15,N/A,1004.25,N/A,1004.25,N/A,1004.25,N/A,8810.89,N/A,340.47,N/A,2142.28,N/A,15302.00,N/A,15302.00,N/A,2142.28,N/A,340.47,N/A,340.47,N/A,374.52,9181.20,9181.20,340.47,15302.00,,Hospital 33991,HC Insj Perq Vad Trnsptal W/Image Art&Venous Access,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,965957.48,N/A,579574.49,N/A,N/A,N/A,69762.36,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,69762.36,N/A,69762.36,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,69762.36,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,69762.36,N/A,69762.36,N/A,N/A,N/A,69762.36,579574.49,N/A,N/A,,Hospital 33993,HC Resposition Perc Vent Assist Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,702406.45,N/A,421443.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,251474.75,N/A,251474.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,251474.75,N/A,251474.75,N/A,251474.75,N/A,251474.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,251474.75,421443.87,N/A,N/A,,Hospital CPT 33999,HC Unlisted Procedure Cardiac Su,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2280.00,2280.00,1368.00,1368.00,N/A,319.20,N/A,546.46,N/A,1312.82,N/A,775.20,N/A,1263.67,N/A,319.20,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1312.82,N/A,522.41,N/A,319.20,N/A,2280.00,N/A,2280.00,N/A,319.20,N/A,522.41,N/A,546.46,N/A,2280.00,1368.00,1368.00,319.20,2280.00,,Hospital CPT 33999,HC Unlisted Procedure Cardiac Surgery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2280.00,2280.00,1368.00,1368.00,N/A,319.20,N/A,546.46,N/A,1312.82,N/A,775.20,N/A,1263.67,N/A,319.20,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1312.82,N/A,522.41,N/A,319.20,N/A,1431.00,N/A,1431.00,N/A,319.20,N/A,522.41,N/A,546.46,N/A,2280.00,1368.00,1368.00,319.20,2280.00,,Hospital 34101,Emblc/Thrmbc Ax Brach Innominate Subcla Art,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38481.53,N/A,23088.92,N/A,5364.61,N/A,4855.12,N/A,22137.70,N/A,13083.72,N/A,11340.24,N/A,5364.61,N/A,4641.41,N/A,4641.41,N/A,7059.49,N/A,11340.24,N/A,11340.24,N/A,11340.24,N/A,22137.69,N/A,4641.41,N/A,5364.61,N/A,7897.00,N/A,7897.00,N/A,5364.61,N/A,4641.41,N/A,4855.12,N/A,741.17,N/A,N/A,741.17,23088.92,,Hospital 34111,Emblc/Thrmbc W/WO Cath Radial/Ulnar Art Arm Inc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,65568.30,N/A,39340.98,N/A,10970.65,N/A,13243.35,N/A,24723.24,N/A,22293.22,N/A,24959.74,N/A,11308.67,N/A,13243.35,N/A,13243.35,N/A,15536.86,N/A,24959.74,N/A,24959.74,N/A,24959.74,N/A,24723.24,N/A,13243.35,N/A,11308.67,N/A,29695.86,N/A,29695.86,N/A,2921.16,N/A,13243.35,N/A,13243.35,N/A,12100.28,N/A,2921.16,39340.98,N/A,N/A,,Hospital 34201,Emblc/Thrmbc Femoral Popliteal Aorto-Iliac Art,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,141796.90,N/A,85078.14,N/A,19851.56,N/A,10472.07,N/A,81176.28,N/A,48210.94,N/A,13476.22,N/A,19851.56,N/A,10435.06,N/A,10435.06,N/A,8389.18,N/A,13476.22,N/A,13476.22,N/A,13476.22,N/A,81176.28,N/A,10435.06,N/A,19851.56,N/A,8160.50,N/A,8160.50,N/A,19851.56,N/A,10435.06,N/A,10472.07,N/A,1113.87,N/A,N/A,1113.87,85078.14,,Hospital CPT 34705,HC Evac Rpr a-Biiliac Ndgft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,33386.00,33386.00,20031.60,20031.60,N/A,4674.04,N/A,1469.24,N/A,19223.66,N/A,11351.24,N/A,23187.41,N/A,4674.04,N/A,1469.24,N/A,1469.24,N/A,14434.61,N/A,23187.41,N/A,23187.41,N/A,23187.41,N/A,19223.66,N/A,1469.24,N/A,4674.04,N/A,33386.00,N/A,33386.00,N/A,4674.04,N/A,1469.24,N/A,1469.24,N/A,1616.16,20031.60,20031.60,1469.24,33386.00,,Hospital 34706,HC Evasc Rpr a-Biiliac Rpt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,312485.43,N/A,187491.26,N/A,44201.79,N/A,43939.92,N/A,172241.97,N/A,106245.05,N/A,N/A,N/A,40155.18,N/A,43939.92,N/A,43939.92,N/A,N/A,N/A,108807.43,N/A,108807.43,N/A,N/A,N/A,172241.97,N/A,43939.92,N/A,40155.18,N/A,186242.63,N/A,N/A,N/A,N/A,N/A,43939.92,N/A,49499.38,N/A,42966.04,N/A,40155.18,187491.26,N/A,N/A,,Hospital 34707,HC Evasc Rpr Ilio-Iliac Ndgft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,131370.42,N/A,78822.25,N/A,18584.75,N/A,22250.45,N/A,72411.37,N/A,44665.94,N/A,43927.23,N/A,19157.38,N/A,22250.45,N/A,22250.45,N/A,27344.35,N/A,43927.23,N/A,43927.23,N/A,43927.23,N/A,72411.37,N/A,22250.45,N/A,19157.38,N/A,50306.07,N/A,50306.07,N/A,N/A,N/A,22250.45,N/A,22250.45,N/A,20498.40,N/A,18584.75,78822.25,N/A,N/A,,Hospital CPT 34709,HC Plmt Xtn Prosth Evasc Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4253.00,4253.00,2551.80,2551.80,N/A,595.42,N/A,310.80,N/A,2448.88,N/A,1446.02,N/A,4253.00,N/A,595.42,N/A,310.80,N/A,310.80,N/A,4253.00,N/A,4253.00,N/A,4253.00,N/A,4253.00,N/A,2448.88,N/A,310.80,N/A,595.42,N/A,4253.00,N/A,4253.00,N/A,595.42,N/A,310.80,N/A,310.80,N/A,341.88,2551.80,2551.80,310.80,4253.00,,Hospital 34711,HC Dlyd Plmt Xtn Prosth Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,79838.98,N/A,47903.39,N/A,14264.78,N/A,17140.14,N/A,52866.20,N/A,27145.25,N/A,33716.47,N/A,14704.30,N/A,17140.14,N/A,17140.14,N/A,20988.23,N/A,33716.47,N/A,33716.47,N/A,33716.47,N/A,52866.20,N/A,17140.14,N/A,14704.30,N/A,38612.56,N/A,38612.56,N/A,N/A,N/A,17140.14,N/A,17140.14,N/A,15733.60,N/A,14264.78,52866.20,N/A,N/A,,Hospital 34714,Opn Fem Art Expos W/Cndt Crtj Dlvr Evasc Prosth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,218561.53,N/A,131136.92,N/A,24248.59,N/A,27251.59,N/A,120471.12,N/A,74310.92,N/A,76103.12,N/A,23515.33,N/A,27251.59,N/A,27251.59,N/A,47384.14,N/A,N/A,N/A,76103.12,N/A,76103.12,N/A,120471.12,N/A,27251.59,N/A,23515.33,N/A,138067.65,N/A,138067.65,N/A,16125.80,N/A,27251.59,N/A,14009.07,N/A,25161.40,N/A,14009.07,138067.65,N/A,N/A,,Hospital CPT 34812,HC Femoral Art Xpose by Groin Incision Unilat,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4423.00,4423.00,2653.80,2653.80,N/A,619.22,N/A,198.61,N/A,2546.76,N/A,1503.82,N/A,3133.28,N/A,619.22,N/A,198.61,N/A,198.61,N/A,1950.53,N/A,3133.28,N/A,3133.28,N/A,3133.28,N/A,2546.76,N/A,198.61,N/A,619.22,N/A,4423.00,N/A,4423.00,N/A,619.22,N/A,198.61,N/A,198.61,N/A,218.47,2653.80,2653.80,198.61,4423.00,,Hospital 35081,Dir Rpr Aneurysm Abdominal Aorta,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,102567.02,N/A,61540.21,N/A,14294.78,N/A,1485.36,N/A,58999.48,N/A,34872.78,N/A,6619.16,N/A,14294.78,N/A,1471.14,N/A,1471.14,N/A,4120.44,N/A,6619.16,N/A,6619.16,N/A,6619.16,N/A,58999.47,N/A,2303.32,N/A,14294.78,N/A,821.50,N/A,821.50,N/A,14294.78,N/A,1471.14,N/A,1485.36,N/A,2161.04,N/A,N/A,821.50,61540.21,,Hospital 35184,Rpr Congenital Av Fistula Extremities,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44944.60,N/A,26966.76,N/A,6278.11,N/A,2865.65,N/A,25867.33,N/A,15281.17,N/A,6567.82,N/A,6278.11,N/A,2694.06,N/A,2694.06,N/A,4088.58,N/A,6567.82,N/A,6567.82,N/A,6567.82,N/A,25867.33,N/A,2694.06,N/A,6278.11,N/A,4562.00,N/A,4562.00,N/A,6278.11,N/A,2694.06,N/A,2865.65,N/A,1054.65,N/A,N/A,1054.65,26966.76,,Hospital 35302,Teaec W/Graft Superficial Femoral Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,111059.02,N/A,66635.41,N/A,27273.78,N/A,32529.13,N/A,61215.73,N/A,37760.06,N/A,64464.77,N/A,28114.13,N/A,7958.87,N/A,7958.87,N/A,40128.80,N/A,64464.77,N/A,64464.77,N/A,64464.77,N/A,61215.73,N/A,32529.13,N/A,28114.13,N/A,73825.94,N/A,73825.94,N/A,N/A,N/A,32529.13,N/A,32529.13,N/A,30082.12,N/A,7958.87,73825.94,N/A,N/A,,Hospital 35303,Teaec W/Graft Popliteal Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,85490.18,N/A,51294.11,N/A,18584.75,N/A,21503.13,N/A,44022.29,N/A,29066.67,N/A,44946.04,N/A,19157.38,N/A,15512.06,N/A,15512.06,N/A,27978.55,N/A,44946.04,N/A,44946.04,N/A,44946.04,N/A,44022.29,N/A,21443.83,N/A,19157.38,N/A,51472.82,N/A,51472.82,N/A,N/A,N/A,21443.83,N/A,21503.13,N/A,20498.40,N/A,15512.06,51472.82,N/A,N/A,,Hospital 35523,Bypass W/Vein Brachial-Ulnar/-Radial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,47403.70,N/A,28442.22,N/A,14264.78,N/A,17140.14,N/A,32146.83,N/A,16117.26,N/A,33716.47,N/A,14704.30,N/A,562.00,N/A,562.00,N/A,20988.23,N/A,33716.47,N/A,33716.47,N/A,33716.47,N/A,32146.83,N/A,17140.14,N/A,14704.30,N/A,38612.56,N/A,38612.56,N/A,83.74,N/A,17140.14,N/A,17140.14,N/A,15733.60,N/A,83.74,38612.56,N/A,N/A,,Hospital 35556,Bypass W/Vein Femoral-Popliteal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,103635.40,N/A,62181.24,N/A,9754.35,N/A,11198.54,N/A,22432.95,N/A,27471.78,N/A,8623.91,N/A,10054.90,N/A,11139.24,N/A,11139.24,N/A,5536.92,N/A,8623.91,N/A,8623.91,N/A,8623.91,N/A,22432.95,N/A,11139.24,N/A,10054.90,N/A,26129.18,N/A,26129.18,N/A,N/A,N/A,11139.24,N/A,11198.54,N/A,10758.75,N/A,5536.92,62181.24,N/A,N/A,,Hospital 35656,Byp Oth/Thn Vein Femoral-Popliteal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,176902.78,N/A,106141.67,N/A,14940.50,N/A,16447.10,N/A,97508.81,N/A,52186.37,N/A,22794.48,N/A,14704.30,N/A,16387.80,N/A,16387.80,N/A,14386.99,N/A,22794.48,N/A,22794.48,N/A,22794.48,N/A,97508.81,N/A,16387.80,N/A,14704.30,N/A,37639.30,N/A,37639.30,N/A,8843.85,N/A,16387.80,N/A,16447.10,N/A,15733.60,N/A,8843.85,106141.67,N/A,N/A,,Hospital 35665,HC Bypass Graft Other Than Vein Iliofemoral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,308741.75,N/A,185245.05,N/A,38987.93,N/A,28835.49,N/A,170178.45,N/A,104972.20,N/A,107503.88,N/A,34830.16,N/A,28835.49,N/A,28835.49,N/A,66935.21,N/A,107503.88,N/A,107503.88,N/A,107503.88,N/A,170178.45,N/A,28835.49,N/A,34830.16,N/A,185500.02,N/A,185500.02,N/A,N/A,N/A,28256.09,N/A,28835.49,N/A,37268.27,N/A,28256.09,185500.02,N/A,N/A,,Hospital 35703,Exploration N/Flwd Surg Lower Extremity Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35540.40,N/A,21324.24,N/A,4966.21,N/A,483.98,N/A,20457.49,N/A,12083.73,N/A,4050.29,N/A,4966.21,N/A,480.37,N/A,480.37,N/A,2520.76,N/A,4050.29,N/A,4050.29,N/A,4050.29,N/A,20457.49,N/A,480.37,N/A,4966.21,N/A,1643.00,N/A,1643.00,N/A,4966.21,N/A,480.37,N/A,483.98,N/A,490.79,N/A,N/A,480.37,21324.24,,Hospital CPT 36000,HC Place Needle in Vein,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,627.00,627.00,376.20,376.20,N/A,87.78,N/A,627.00,N/A,361.03,N/A,213.18,N/A,627.00,N/A,87.78,N/A,627.00,N/A,627.00,N/A,627.00,N/A,627.00,N/A,627.00,N/A,627.00,N/A,361.03,N/A,627.00,N/A,87.78,N/A,527.00,N/A,527.00,N/A,87.78,N/A,627.00,N/A,627.00,N/A,627.00,376.20,376.20,87.78,627.00,,Hospital Custom 3600000002,HC Surgery Level 2 Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3781.00,3781.00,2268.60,2268.60,N/A,529.34,N/A,3781.00,N/A,2177.10,N/A,1285.54,N/A,529.34,N/A,529.34,N/A,3781.00,N/A,3781.00,N/A,328.95,N/A,529.34,N/A,529.34,N/A,529.34,N/A,2177.10,N/A,3781.00,N/A,529.34,N/A,3781.00,N/A,3781.00,N/A,529.34,N/A,3781.00,N/A,3781.00,N/A,3781.00,2268.60,2268.60,328.95,3781.00,,Hospital Custom 3600000006,HC Surgery Level 6 Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,7815.00,7815.00,4689.00,4689.00,N/A,1094.10,N/A,7815.00,N/A,4499.88,N/A,2657.10,N/A,1094.10,N/A,1094.10,N/A,7815.00,N/A,7815.00,N/A,679.91,N/A,1094.10,N/A,1094.10,N/A,1094.10,N/A,4499.88,N/A,7815.00,N/A,1094.10,N/A,7815.00,N/A,7815.00,N/A,1094.10,N/A,7815.00,N/A,7815.00,N/A,7815.00,4689.00,4689.00,679.91,7815.00,,Hospital Custom 3600000008,HC Surgery Ohs Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4985.00,4985.00,2991.00,2991.00,N/A,697.90,N/A,4985.00,N/A,2870.36,N/A,1694.90,N/A,697.90,N/A,697.90,N/A,4985.00,N/A,4985.00,N/A,433.70,N/A,697.90,N/A,697.90,N/A,697.90,N/A,2870.36,N/A,4985.00,N/A,697.90,N/A,4985.00,N/A,4985.00,N/A,697.90,N/A,4985.00,N/A,4985.00,N/A,4985.00,2991.00,2991.00,433.70,4985.00,,Hospital Custom 3600000017,HC Surgery Hybrid Addl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3171.00,3171.00,1902.60,1902.60,N/A,443.94,N/A,3171.00,N/A,1825.86,N/A,1078.14,N/A,443.94,N/A,443.94,N/A,3171.00,N/A,3171.00,N/A,275.88,N/A,443.94,N/A,443.94,N/A,443.94,N/A,1825.86,N/A,3171.00,N/A,443.94,N/A,3171.00,N/A,3171.00,N/A,443.94,N/A,3171.00,N/A,3171.00,N/A,3171.00,1902.60,1902.60,275.88,3171.00,,Hospital Custom 3600000018,HC Surgery Ohs Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2758.00,2758.00,1654.80,1654.80,N/A,386.12,N/A,2758.00,N/A,1588.06,N/A,937.72,N/A,386.12,N/A,386.12,N/A,2758.00,N/A,2758.00,N/A,239.95,N/A,386.12,N/A,386.12,N/A,386.12,N/A,1588.06,N/A,2758.00,N/A,386.12,N/A,2758.00,N/A,2758.00,N/A,386.12,N/A,2758.00,N/A,2758.00,N/A,2758.00,1654.80,1654.80,239.95,2758.00,,Hospital CPT 36002,HC Inj Thrombin for Aneurysm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,673.00,673.00,403.80,403.80,N/A,94.22,N/A,546.46,N/A,387.51,N/A,228.82,N/A,673.00,N/A,94.22,N/A,522.41,N/A,522.41,N/A,673.00,N/A,673.00,N/A,673.00,N/A,673.00,N/A,387.51,N/A,522.41,N/A,94.22,N/A,1431.00,N/A,1431.00,N/A,94.22,N/A,522.41,N/A,546.46,N/A,109.54,403.80,403.80,94.22,1431.00,,Hospital CPT 36010,HC Place Cath Superior or Inf Vc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2216.00,2216.00,1329.60,1329.60,N/A,310.24,N/A,2216.00,N/A,1275.97,N/A,753.44,N/A,2216.00,N/A,310.24,N/A,2216.00,N/A,2216.00,N/A,2216.00,N/A,2216.00,N/A,2216.00,N/A,2216.00,N/A,1275.97,N/A,2216.00,N/A,310.24,N/A,527.00,N/A,527.00,N/A,310.24,N/A,2216.00,N/A,2216.00,N/A,115.45,1329.60,1329.60,115.45,2216.00,,Hospital Custom 3609008400,HC Sigmoidoscopy Diagnostic,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2197.00,2197.00,1318.20,1318.20,N/A,307.58,N/A,2197.00,N/A,1265.03,N/A,746.98,N/A,307.58,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,191.14,N/A,307.58,N/A,307.58,N/A,307.58,N/A,1265.03,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,2197.00,1318.20,1318.20,191.14,2197.00,,Hospital Custom 3609010300,HC Colonoscopy W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010500,HC Colonoscopy Polypectomy Removal Hot Biopsy/Stoma,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609011100,HC Bronchoscopy Brushings,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609013200,HC Egd W/ Ablation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4500.00,4500.00,2700.00,2700.00,N/A,630.00,N/A,4500.00,N/A,2591.10,N/A,1530.00,N/A,630.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,391.50,N/A,630.00,N/A,630.00,N/A,630.00,N/A,2591.10,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,4500.00,2700.00,2700.00,391.50,4500.00,,Hospital Custom 3609013300,HC Egd Tube Placement,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4500.00,4500.00,2700.00,2700.00,N/A,630.00,N/A,4500.00,N/A,2591.10,N/A,1530.00,N/A,630.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,391.50,N/A,630.00,N/A,630.00,N/A,630.00,N/A,2591.10,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,4500.00,2700.00,2700.00,391.50,4500.00,,Hospital Custom 3609013400,HC Egd Removal Lesion(S) by Hot Biopsy Forceps,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4500.00,4500.00,2700.00,2700.00,N/A,630.00,N/A,4500.00,N/A,2591.10,N/A,1530.00,N/A,630.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,391.50,N/A,630.00,N/A,630.00,N/A,630.00,N/A,2591.10,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,4500.00,2700.00,2700.00,391.50,4500.00,,Hospital Custom 3609013500,HC Egd Removal Tumor Polyp/Other Lesion Snare Tech,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609014000,HC Enteroscopy Biopsy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3335.00,3335.00,2001.00,2001.00,N/A,466.90,N/A,3335.00,N/A,1920.29,N/A,1133.90,N/A,466.90,N/A,466.90,N/A,3335.00,N/A,3335.00,N/A,290.15,N/A,466.90,N/A,466.90,N/A,466.90,N/A,1920.29,N/A,3335.00,N/A,466.90,N/A,3335.00,N/A,3335.00,N/A,466.90,N/A,3335.00,N/A,3335.00,N/A,3335.00,2001.00,2001.00,290.15,3335.00,,Hospital Custom 3609015200,HC Ercp Remove Calculi/Debris Biliary/Pancreas Duct,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609015600,HC Esophagoscopy Ablation Tumor,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7333.00,7333.00,4399.80,4399.80,N/A,1026.62,N/A,7333.00,N/A,4222.34,N/A,2493.22,N/A,1026.62,N/A,1026.62,N/A,7333.00,N/A,7333.00,N/A,637.97,N/A,1026.62,N/A,1026.62,N/A,1026.62,N/A,4222.34,N/A,7333.00,N/A,1026.62,N/A,7333.00,N/A,7333.00,N/A,1026.62,N/A,7333.00,N/A,7333.00,N/A,7333.00,4399.80,4399.80,637.97,7333.00,,Hospital Custom 3609018800,HC Ercp Dx Collection Specimen Brushing/Washing,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7827.00,7827.00,4696.20,4696.20,N/A,1095.78,N/A,7827.00,N/A,4506.79,N/A,2661.18,N/A,1095.78,N/A,1095.78,N/A,7827.00,N/A,7827.00,N/A,680.95,N/A,1095.78,N/A,1095.78,N/A,1095.78,N/A,4506.79,N/A,7827.00,N/A,1095.78,N/A,7827.00,N/A,7827.00,N/A,1095.78,N/A,7827.00,N/A,7827.00,N/A,7827.00,4696.20,4696.20,680.95,7827.00,,Hospital Custom 3609018900,HC Ercp,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,5598.00,5598.00,3358.80,3358.80,N/A,783.72,N/A,5598.00,N/A,3223.33,N/A,1903.32,N/A,783.72,N/A,783.72,N/A,5598.00,N/A,5598.00,N/A,487.03,N/A,783.72,N/A,783.72,N/A,783.72,N/A,3223.33,N/A,5598.00,N/A,783.72,N/A,5598.00,N/A,5598.00,N/A,783.72,N/A,5598.00,N/A,5598.00,N/A,5598.00,3358.80,3358.80,487.03,5598.00,,Hospital Custom 3609019500,HC Esophagoscopy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3140.00,3140.00,1884.00,1884.00,N/A,439.60,N/A,3140.00,N/A,1808.01,N/A,1067.60,N/A,439.60,N/A,439.60,N/A,3140.00,N/A,3140.00,N/A,273.18,N/A,439.60,N/A,439.60,N/A,439.60,N/A,1808.01,N/A,3140.00,N/A,439.60,N/A,3140.00,N/A,3140.00,N/A,439.60,N/A,3140.00,N/A,3140.00,N/A,3140.00,1884.00,1884.00,273.18,3140.00,,Hospital Custom 3609020700,HC Sigmoidoscopy W/Eus,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3256.00,3256.00,1953.60,1953.60,N/A,455.84,N/A,3256.00,N/A,1874.80,N/A,1107.04,N/A,455.84,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,283.27,N/A,455.84,N/A,455.84,N/A,455.84,N/A,1874.80,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,3256.00,1953.60,1953.60,283.27,3256.00,,Hospital Custom 3609021000,HC Ileoscopy Thru Stoma Dx W/Biopsy or Brushing,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609021200,HC Ileoscopy Thru Stoma W Balloon Dialation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4500.00,4500.00,2700.00,2700.00,N/A,630.00,N/A,4500.00,N/A,2591.10,N/A,1530.00,N/A,630.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,391.50,N/A,630.00,N/A,630.00,N/A,630.00,N/A,2591.10,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,630.00,N/A,4500.00,N/A,4500.00,N/A,4500.00,2700.00,2700.00,391.50,4500.00,,Hospital Custom 3609021600,HC Removal Fecal Impaction or Foreign Body,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2117.00,2117.00,1270.20,1270.20,N/A,296.38,N/A,2117.00,N/A,1218.97,N/A,719.78,N/A,296.38,N/A,296.38,N/A,2117.00,N/A,2117.00,N/A,184.18,N/A,296.38,N/A,296.38,N/A,296.38,N/A,1218.97,N/A,2117.00,N/A,296.38,N/A,2117.00,N/A,2117.00,N/A,296.38,N/A,2117.00,N/A,2117.00,N/A,2117.00,1270.20,1270.20,184.18,2117.00,,Hospital Custom 3609155100,HC Colonoscopy W/ Band Ligation(S),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609155400,HC Add on Computer Assisted Navigation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,6670.00,6670.00,4002.00,4002.00,N/A,933.80,N/A,6670.00,N/A,3840.59,N/A,2267.80,N/A,933.80,N/A,933.80,N/A,6670.00,N/A,6670.00,N/A,580.29,N/A,933.80,N/A,933.80,N/A,933.80,N/A,3840.59,N/A,6670.00,N/A,933.80,N/A,6670.00,N/A,6670.00,N/A,933.80,N/A,6670.00,N/A,6670.00,N/A,6670.00,4002.00,4002.00,580.29,6670.00,,Hospital Custom 3609155500,HC Sigmoidoscopy With Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2291.00,2291.00,1374.60,1374.60,N/A,320.74,N/A,2291.00,N/A,1319.16,N/A,778.94,N/A,320.74,N/A,320.74,N/A,2291.00,N/A,2291.00,N/A,199.32,N/A,320.74,N/A,320.74,N/A,320.74,N/A,1319.16,N/A,2291.00,N/A,320.74,N/A,2291.00,N/A,2291.00,N/A,320.74,N/A,2291.00,N/A,2291.00,N/A,2291.00,1374.60,1374.60,199.32,2291.00,,Hospital 36160,HC Intro Need/Intracath Translum,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,88550.52,N/A,53130.31,N/A,12289.66,N/A,732.06,N/A,50251.45,N/A,30107.18,N/A,23246.61,N/A,12289.66,N/A,9586.05,N/A,9586.05,N/A,14471.45,N/A,23246.61,N/A,23246.61,N/A,23246.61,N/A,50251.46,N/A,9586.05,N/A,12289.66,N/A,11923.50,N/A,11923.50,N/A,12289.66,N/A,9586.05,N/A,732.06,N/A,805.27,N/A,N/A,732.06,53130.31,,Hospital CPT 36217,HC Initial Cath Third Order,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1851.00,1851.00,1110.60,1110.60,N/A,259.14,N/A,1851.00,N/A,1065.81,N/A,629.34,N/A,1851.00,N/A,259.14,N/A,1851.00,N/A,1851.00,N/A,1851.00,N/A,1851.00,N/A,1851.00,N/A,1851.00,N/A,1065.81,N/A,1851.00,N/A,259.14,N/A,527.00,N/A,527.00,N/A,259.14,N/A,1851.00,N/A,1851.00,N/A,344.94,1110.60,1110.60,259.14,1851.00,,Hospital CPT 36224,HC Selective Internal Carotid Imaging Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,17630.00,17630.00,10578.00,10578.00,N/A,2468.20,N/A,4855.12,N/A,10151.35,N/A,5994.20,N/A,11227.17,N/A,2468.20,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,11227.17,N/A,11227.17,N/A,11227.17,N/A,10151.35,N/A,4641.41,N/A,2468.20,N/A,7897.00,N/A,7897.00,N/A,2468.20,N/A,4641.41,N/A,345.57,N/A,380.13,10578.00,10578.00,345.57,11227.17,,Hospital CPT 36245,HC Sel Cath Abd/Pelvic/Le 1st Ord,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3073.00,3073.00,1843.80,1843.80,N/A,430.22,N/A,226.23,N/A,1769.43,N/A,1044.82,N/A,3073.00,N/A,430.22,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,1769.43,N/A,3073.00,N/A,430.22,N/A,527.00,N/A,527.00,N/A,430.22,N/A,3073.00,N/A,226.23,N/A,248.85,1843.80,1843.80,226.23,3073.00,,Hospital CPT 36252,HC Renal Art 1st Order Bil,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,9090.00,9090.00,5454.00,5454.00,N/A,1272.60,N/A,343.27,N/A,5234.02,N/A,3090.60,N/A,6507.21,N/A,1272.60,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5234.02,N/A,2690.13,N/A,1272.60,N/A,4562.00,N/A,4562.00,N/A,1272.60,N/A,2690.13,N/A,343.27,N/A,377.60,5454.00,5454.00,343.27,6507.21,,Hospital CPT 36252,HC Renal Art 1st Order Bil,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9090.00,9090.00,5454.00,5454.00,N/A,1272.60,N/A,343.27,N/A,5234.02,N/A,3090.60,N/A,6507.21,N/A,1272.60,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5234.02,N/A,2690.13,N/A,1272.60,N/A,4562.00,N/A,4562.00,N/A,1272.60,N/A,2690.13,N/A,343.27,N/A,377.60,5454.00,5454.00,343.27,6507.21,,Hospital CPT 36299,HC Vessel Injection Procedure,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,341.00,341.00,204.60,204.60,N/A,47.74,N/A,341.00,N/A,196.35,N/A,115.94,N/A,341.00,N/A,47.74,N/A,341.00,N/A,341.00,N/A,341.00,N/A,341.00,N/A,341.00,N/A,341.00,N/A,196.35,N/A,341.00,N/A,47.74,N/A,527.00,N/A,527.00,N/A,47.74,N/A,341.00,N/A,341.00,N/A,341.00,204.60,204.60,47.74,527.00,,Hospital CPT 36410,HC Midline Placement 3yr or >,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4239.00,4239.00,2543.40,2543.40,N/A,593.46,N/A,4239.00,N/A,2440.82,N/A,1441.26,N/A,4239.00,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,2440.82,N/A,4239.00,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,9.80,2543.40,2543.40,9.80,4239.00,,Hospital CPT 36410,HC Midline Placement 3yr or >,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4239.00,4239.00,2543.40,2543.40,N/A,593.46,N/A,4239.00,N/A,2440.82,N/A,1441.26,N/A,4239.00,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,4239.00,N/A,2440.82,N/A,4239.00,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,9.80,2543.40,2543.40,9.80,4239.00,,Hospital CPT 36415,HC Venipuncture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,36.00,28.00,21.60,16.80,N/A,3.00,N/A,8.57,N/A,16.12,N/A,9.52,N/A,5.00,N/A,3.00,N/A,8.57,N/A,8.57,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,16.12,N/A,8.57,N/A,3.00,N/A,3.00,N/A,3.00,N/A,3.00,N/A,8.57,N/A,8.57,N/A,3.30,21.60,21.60,3.00,16.80,,Hospital 36470,HC Sclerotherapy Single Vein,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,2994.57,N/A,1796.74,N/A,419.24,N/A,525.02,N/A,1724.27,N/A,1018.15,N/A,1222.37,N/A,419.24,N/A,505.35,N/A,505.35,N/A,760.95,N/A,1222.37,N/A,1222.37,N/A,1222.37,N/A,1724.27,N/A,505.35,N/A,419.24,N/A,790.50,N/A,790.50,N/A,419.24,N/A,505.35,N/A,525.02,N/A,105.96,N/A,N/A,105.96,1796.74,,Hospital 36473,Endoven Abltj Incmptnt Vein Mchnchem 1st Vein,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45127.82,N/A,27076.69,N/A,6299.41,N/A,2865.65,N/A,25980.29,N/A,15343.45,N/A,6533.83,N/A,6299.41,N/A,2694.06,N/A,2694.06,N/A,4067.43,N/A,6533.83,N/A,6533.83,N/A,6533.83,N/A,25980.28,N/A,2694.06,N/A,6299.41,N/A,6843.00,N/A,6843.00,N/A,6299.41,N/A,2694.06,N/A,2865.65,N/A,508.12,N/A,N/A,508.12,27076.69,,Hospital CPT 36476,HC Endovenous Rf Vein Add-On,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6794.00,6794.00,4076.40,4076.40,N/A,951.16,N/A,129.67,N/A,3911.99,N/A,2309.96,N/A,789.30,N/A,951.16,N/A,129.67,N/A,129.67,N/A,491.34,N/A,789.30,N/A,789.30,N/A,789.30,N/A,3911.99,N/A,129.67,N/A,951.16,N/A,6794.00,N/A,6794.00,N/A,951.16,N/A,129.67,N/A,129.67,N/A,142.64,4076.40,4076.40,129.67,6794.00,,Hospital 36482,HC Endoven Ther Chem Adhes 1st,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,17576.77,N/A,10546.06,N/A,2460.75,N/A,4822.12,N/A,10120.70,N/A,5976.10,N/A,11227.17,N/A,2460.75,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,11227.17,N/A,11227.17,N/A,11227.17,N/A,10120.70,N/A,4641.41,N/A,2460.75,N/A,7897.00,N/A,7897.00,N/A,2460.75,N/A,4641.41,N/A,4822.12,N/A,190.30,N/A,N/A,190.30,11227.17,,Hospital 36500,HC Venous Sel Blood Sampling,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,37404.32,N/A,22442.59,N/A,5188.32,N/A,4737.93,N/A,21493.53,N/A,12717.47,N/A,11337.42,N/A,5188.32,N/A,4641.41,N/A,4641.41,N/A,7057.77,N/A,11337.42,N/A,11337.42,N/A,11337.42,N/A,21493.54,N/A,4641.41,N/A,5188.32,N/A,922.25,N/A,922.25,N/A,5188.32,N/A,4641.41,N/A,4737.93,N/A,1261.26,N/A,N/A,922.25,22442.59,,Hospital CPT 36511,HC Leukophersis,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",4520.00,4520.00,2712.00,2712.00,N/A,632.80,N/A,104.82,N/A,2602.62,N/A,1536.80,N/A,311.55,N/A,632.80,N/A,104.82,N/A,104.82,N/A,193.94,N/A,311.55,N/A,311.55,N/A,311.55,N/A,2602.62,N/A,104.82,N/A,632.80,N/A,2422.72,N/A,2422.72,N/A,632.80,N/A,104.82,N/A,104.82,N/A,115.30,2712.00,2712.00,104.82,2712.00,,Hospital CPT 36514,HC Therapeutic Plasma Pheresis,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4184.00,4184.00,2510.40,2510.40,N/A,585.76,N/A,1227.99,N/A,2409.15,N/A,1422.56,N/A,2970.41,N/A,585.76,N/A,1227.99,N/A,1227.99,N/A,1849.14,N/A,2970.41,N/A,2970.41,N/A,2970.41,N/A,2409.15,N/A,1227.99,N/A,585.76,N/A,2242.62,N/A,2242.62,N/A,585.76,N/A,1227.99,N/A,1227.99,N/A,1350.79,2510.40,2510.40,585.76,2970.41,,Hospital 36563,HC Cv Cath Plac W/Pump Tun,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,298672.57,N/A,179203.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,179203.54,179203.54,N/A,N/A,,Hospital 36565,HC 2 Cv Cath Plac Tesio,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,135210.85,N/A,81126.51,N/A,17835.24,N/A,21363.81,N/A,74528.22,N/A,45971.69,N/A,42155.67,N/A,N/A,N/A,23525.85,N/A,21363.81,N/A,26241.56,N/A,42155.67,N/A,42155.67,N/A,42155.67,N/A,74528.22,N/A,21363.81,N/A,18384.77,N/A,48277.25,N/A,N/A,N/A,1556.10,N/A,21363.81,N/A,21363.81,N/A,N/A,N/A,1556.10,81126.51,N/A,N/A,,Hospital 36570,HC Picc With Port <5yr,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,198658.20,N/A,119194.92,N/A,15764.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15764.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15764.09,N/A,N/A,N/A,N/A,N/A,15764.09,N/A,N/A,N/A,N/A,N/A,15764.09,N/A,15764.09,119194.92,N/A,N/A,,Hospital CPT 36590,HC Remove Tun Cath Vad W/Port,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5828.00,5828.00,3496.80,3496.80,N/A,815.92,N/A,181.96,N/A,3355.76,N/A,1981.52,N/A,3250.03,N/A,815.92,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,3355.76,N/A,1343.59,N/A,815.92,N/A,1871.00,N/A,1871.00,N/A,815.92,N/A,1343.59,N/A,1405.45,N/A,200.16,3496.80,3496.80,181.96,3496.80,,Hospital CPT 36590,"HC Cath Hold,Rem Vad, With Port",N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,5828.00,5828.00,3496.80,3496.80,N/A,815.92,N/A,181.96,N/A,3355.76,N/A,1981.52,N/A,3250.03,N/A,815.92,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,3355.76,N/A,1343.59,N/A,815.92,N/A,1871.00,N/A,1871.00,N/A,815.92,N/A,1343.59,N/A,1405.45,N/A,200.16,3496.80,3496.80,181.96,3496.80,,Hospital CPT 36591,HC Blood Draw per Port,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,370.00,370.00,222.00,222.00,N/A,51.80,N/A,104.85,N/A,213.05,N/A,N/A,N/A,N/A,N/A,51.80,N/A,104.85,N/A,104.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,213.05,N/A,104.85,N/A,51.80,N/A,198.32,N/A,198.32,N/A,51.80,N/A,104.85,N/A,104.85,N/A,115.34,222.00,222.00,51.80,222.00,,Hospital CPT 36591,HC Blood Draw per Port,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,370.00,370.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,125.80,N/A,370.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,370.00,N/A,370.00,N/A,370.00,N/A,370.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,125.80,370.00,,Hospital CPT 36597,HC Repositioning Vad Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4838.00,4838.00,2902.80,2902.80,N/A,677.32,N/A,1371.53,N/A,2785.72,N/A,1644.92,N/A,3250.03,N/A,677.32,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2785.72,N/A,1343.59,N/A,677.32,N/A,1431.00,N/A,1431.00,N/A,677.32,N/A,1343.59,N/A,1371.53,N/A,63.40,2902.80,2902.80,63.40,3250.03,,Hospital 36800,Insj Cannula Hemo Oth Purpose Spx Vein Vein,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,45648.92,N/A,27389.35,N/A,11109.88,N/A,5642.03,N/A,25805.60,N/A,15520.63,N/A,26269.59,N/A,11452.20,N/A,447352.00,N/A,447352.00,N/A,16352.61,N/A,26269.59,N/A,N/A,N/A,26269.59,N/A,25805.60,N/A,5612.38,N/A,11452.20,N/A,30084.30,N/A,30084.30,N/A,N/A,N/A,5612.38,N/A,5642.03,N/A,12253.85,N/A,5612.38,447352.00,N/A,N/A,,Hospital 36820,Arven Anast Opn F/Arm Vein Trpos,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51974.20,N/A,31184.52,N/A,7186.25,N/A,4737.93,N/A,29923.58,N/A,17671.23,N/A,11260.18,N/A,7186.25,N/A,4641.41,N/A,4641.41,N/A,7009.69,N/A,11260.18,N/A,11260.18,N/A,11260.18,N/A,29923.58,N/A,4641.41,N/A,7186.25,N/A,7897.00,N/A,7897.00,N/A,7186.25,N/A,4641.41,N/A,4737.93,N/A,811.94,N/A,N/A,811.94,31184.52,,Hospital 36830,Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32461.53,N/A,19476.92,N/A,4513.19,N/A,4641.41,N/A,18656.67,N/A,11035.23,N/A,11332.16,N/A,4513.19,N/A,4641.41,N/A,4641.41,N/A,7054.46,N/A,11332.16,N/A,11332.16,N/A,11332.16,N/A,18656.66,N/A,4641.41,N/A,4513.19,N/A,10535.75,N/A,10535.75,N/A,4513.19,N/A,4641.41,N/A,4641.41,N/A,5105.55,N/A,N/A,4513.19,19476.92,,Hospital 36833,Revj Opn Arven Fstl W/Thrmbc Dial Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,115068.15,36193.80,69040.89,21716.28,17835.24,5009.14,21393.46,4691.68,63425.56,20744.87,39123.17,12305.89,42155.67,11320.53,18384.77,5009.14,125326.00,4641.41,125326.00,4641.41,26241.56,7047.22,42155.67,11320.53,42155.67,11320.53,42155.67,11320.53,63425.56,20744.87,21363.81,4641.41,18384.77,5009.14,48277.25,8612.50,48277.25,8612.50,N/A,5009.14,21363.81,4641.41,21393.46,4691.68,19671.71,987.86,17835.24,125326.00,987.86,21716.28,,Hospital CPT 36837,HC Perq Av Fistula Creation Uxtr Sep Access Sites,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,43936.00,43936.00,26361.60,26361.60,N/A,6151.04,N/A,15834.66,N/A,25298.35,N/A,14938.24,N/A,37522.38,N/A,6151.04,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,25298.35,N/A,15512.06,N/A,6151.04,N/A,11660.00,N/A,11660.00,N/A,6151.04,N/A,15512.06,N/A,15834.66,N/A,43936.00,26361.60,26361.60,6151.04,43936.00,,Hospital CPT 36901,HC Intro Cath Dialysis Circuit - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3641.00,3641.00,2184.60,2184.60,N/A,509.74,N/A,1343.59,N/A,2096.49,N/A,1237.94,N/A,3250.03,N/A,509.74,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2096.49,N/A,1343.59,N/A,509.74,N/A,1871.00,N/A,1871.00,N/A,509.74,N/A,1343.59,N/A,1343.59,N/A,1477.95,2184.60,2184.60,509.74,3250.03,,Hospital CPT 36901,HC Intro Cath Dialysis Circuit,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3641.00,3641.00,2184.60,2184.60,N/A,509.74,N/A,1343.59,N/A,2096.49,N/A,1237.94,N/A,3250.03,N/A,509.74,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2096.49,N/A,1343.59,N/A,509.74,N/A,1871.00,N/A,1871.00,N/A,509.74,N/A,1343.59,N/A,1343.59,N/A,1477.95,2184.60,2184.60,509.74,3250.03,,Hospital CPT 36904,HC Thrmbc/Nfs Dialysis Circuit,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9272.00,9272.00,5563.20,5563.20,N/A,1298.08,N/A,353.97,N/A,5338.82,N/A,3152.48,N/A,9272.00,N/A,1298.08,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,9272.00,N/A,9272.00,N/A,9272.00,N/A,5338.82,N/A,4709.71,N/A,1298.08,N/A,7897.00,N/A,7897.00,N/A,1298.08,N/A,4709.71,N/A,353.97,N/A,389.37,5563.20,5563.20,353.97,9272.00,,Hospital CPT 36904,HC Thrmbc/Nfs Dialysis Circuit -Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9272.00,9272.00,5563.20,5563.20,N/A,1298.08,N/A,353.97,N/A,5338.82,N/A,3152.48,N/A,9272.00,N/A,1298.08,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,9272.00,N/A,9272.00,N/A,9272.00,N/A,5338.82,N/A,4709.71,N/A,1298.08,N/A,7897.00,N/A,7897.00,N/A,1298.08,N/A,4709.71,N/A,353.97,N/A,389.37,5563.20,5563.20,353.97,9272.00,,Hospital CPT 36907,HC Balo Angiop Ctr Dialysis Seg,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,9291.00,9291.00,5574.60,5574.60,N/A,1300.74,N/A,9291.00,N/A,5349.76,N/A,3158.94,N/A,9291.00,N/A,1300.74,N/A,9291.00,N/A,9291.00,N/A,9291.00,N/A,9291.00,N/A,9291.00,N/A,9291.00,N/A,5349.76,N/A,9291.00,N/A,1300.74,N/A,4979.98,N/A,4979.98,N/A,1300.74,N/A,9291.00,N/A,9291.00,N/A,154.88,5574.60,5574.60,154.88,9291.00,,Hospital CPT 36907,HC Balo Angiop Ctr Dialysis Seg,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9291.00,8360.00,5574.60,5016.00,N/A,1170.40,N/A,8360.00,N/A,4813.69,N/A,2842.40,N/A,8360.00,N/A,1170.40,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,4813.69,N/A,8360.00,N/A,1170.40,N/A,527.00,N/A,527.00,N/A,1170.40,N/A,8360.00,N/A,8360.00,N/A,154.88,5574.60,5574.60,154.88,8360.00,,Hospital CPT 36908,HC Stent Plmt Ctr Dialysis Seg,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,15699.00,15699.00,9419.40,9419.40,N/A,2197.86,N/A,15699.00,N/A,9039.48,N/A,5337.66,N/A,15699.00,N/A,2197.86,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,9039.48,N/A,15699.00,N/A,2197.86,N/A,527.00,N/A,527.00,N/A,2197.86,N/A,15699.00,N/A,15699.00,N/A,15699.00,9419.40,9419.40,527.00,15699.00,,Hospital CPT 36908,HC Stent Plmt Ctr Dialysis Seg - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15699.00,15699.00,9419.40,9419.40,N/A,2197.86,N/A,15699.00,N/A,9039.48,N/A,5337.66,N/A,15699.00,N/A,2197.86,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,9039.48,N/A,15699.00,N/A,2197.86,N/A,527.00,N/A,527.00,N/A,2197.86,N/A,15699.00,N/A,15699.00,N/A,15699.00,9419.40,9419.40,527.00,15699.00,,Hospital CPT 37197,HC FB Removal Transcath,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5551.00,5551.00,3330.60,3330.60,N/A,777.14,N/A,288.24,N/A,3196.27,N/A,1887.34,N/A,5551.00,N/A,777.14,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5551.00,N/A,5551.00,N/A,5551.00,N/A,3196.27,N/A,2690.13,N/A,777.14,N/A,4562.00,N/A,4562.00,N/A,777.14,N/A,2690.13,N/A,288.24,N/A,317.06,3330.60,3330.60,288.24,5551.00,,Hospital CPT 37197,HC FB Retrieval Percutaneous,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,5551.00,5551.00,3330.60,3330.60,N/A,777.14,N/A,288.24,N/A,3196.27,N/A,1887.34,N/A,5551.00,N/A,777.14,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5551.00,N/A,5551.00,N/A,5551.00,N/A,3196.27,N/A,2690.13,N/A,777.14,N/A,4562.00,N/A,4562.00,N/A,777.14,N/A,2690.13,N/A,288.24,N/A,317.06,3330.60,3330.60,288.24,5551.00,,Hospital 37200,HC Transcatheter Biopsy,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,113542.87,29524.50,68125.72,17714.70,N/A,4136.63,8323.94,4691.68,17604.50,16999.54,60576.47,10038.34,60576.47,11244.83,N/A,4136.63,8323.94,4641.41,8323.94,4641.41,60576.47,7000.13,60576.47,11244.83,60576.47,11244.83,60576.47,11244.83,17604.50,16999.54,8323.94,4641.41,N/A,4136.63,17604.50,8160.50,17604.50,8160.50,N/A,4136.63,8323.94,4641.41,8323.94,4691.68,N/A,734.05,8323.94,68125.72,734.05,17714.70,,Hospital 37217,HC Stent Placemt Retro Carotid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,158673.58,N/A,95204.15,N/A,16129.23,N/A,19345.68,N/A,87460.88,N/A,53949.02,N/A,37790.73,N/A,16626.19,N/A,19345.68,N/A,19345.68,N/A,23525.85,N/A,37790.73,N/A,37790.73,N/A,37790.73,N/A,87460.88,N/A,19345.68,N/A,16626.19,N/A,43659.34,N/A,43659.34,N/A,N/A,N/A,19345.68,N/A,19345.68,N/A,17790.03,N/A,16129.23,95204.15,N/A,N/A,,Hospital CPT 37222,HC Plasty Addl Iliac Ipsilat Vsl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5556.00,5556.00,3333.60,3333.60,N/A,777.84,N/A,5556.00,N/A,3199.14,N/A,1889.04,N/A,5556.00,N/A,777.84,N/A,5556.00,N/A,5556.00,N/A,5556.00,N/A,5556.00,N/A,5556.00,N/A,5556.00,N/A,3199.14,N/A,5556.00,N/A,777.84,N/A,7897.00,N/A,7897.00,N/A,777.84,N/A,5556.00,N/A,5556.00,N/A,196.87,3333.60,3333.60,196.87,7897.00,,Hospital CPT 37224,HC Fem Pop Territory Plasty,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,13663.00,13663.00,8197.80,8197.80,N/A,1912.82,N/A,4709.71,N/A,7867.16,N/A,4645.42,N/A,11392.42,N/A,1912.82,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,11392.42,N/A,11392.42,N/A,11392.42,N/A,7867.16,N/A,4709.71,N/A,1912.82,N/A,7897.00,N/A,7897.00,N/A,1912.82,N/A,4709.71,N/A,4709.71,N/A,5180.69,8197.80,8197.80,1912.82,11392.42,,Hospital CPT 37224,HC Plasty Uni Fempop,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,10518.00,10518.00,6310.80,6310.80,N/A,1472.52,N/A,4709.71,N/A,6056.26,N/A,3576.12,N/A,10518.00,N/A,1472.52,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,10518.00,N/A,10518.00,N/A,10518.00,N/A,6056.26,N/A,4709.71,N/A,1472.52,N/A,7897.00,N/A,7897.00,N/A,1472.52,N/A,4709.71,N/A,4709.71,N/A,5180.69,6310.80,6310.80,1472.52,10518.00,,Hospital CPT 37227,HC Stent W Atherectomy Fem/Pop,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,20567.00,20567.00,12340.20,12340.20,N/A,2879.38,N/A,15926.38,N/A,11842.48,N/A,6992.78,N/A,20567.00,N/A,2879.38,N/A,15512.06,N/A,15512.06,N/A,20567.00,N/A,20567.00,N/A,20567.00,N/A,20567.00,N/A,11842.48,N/A,15512.06,N/A,2879.38,N/A,37100.00,N/A,37100.00,N/A,2879.38,N/A,15512.06,N/A,691.34,N/A,760.47,12340.20,12340.20,691.34,37100.00,,Hospital CPT 37228,HC Plasty Uni Tib/per Initial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,10832.00,10832.00,6499.20,6499.20,N/A,1516.48,N/A,10027.43,N/A,6237.07,N/A,3682.88,N/A,10832.00,N/A,1516.48,N/A,9586.05,N/A,9586.05,N/A,10832.00,N/A,10832.00,N/A,10832.00,N/A,10832.00,N/A,6237.07,N/A,9586.05,N/A,1516.48,N/A,7897.00,N/A,7897.00,N/A,1516.48,N/A,9586.05,N/A,9914.70,N/A,572.50,6499.20,6499.20,572.50,10832.00,,Hospital CPT 37229,HC Atherectomy Tib/Per,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,42944.00,42944.00,25766.40,25766.40,N/A,6012.16,N/A,16226.30,N/A,24727.16,N/A,14600.96,N/A,37522.38,N/A,6012.16,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,24727.16,N/A,15512.06,N/A,6012.16,N/A,11660.00,N/A,11660.00,N/A,6012.16,N/A,15512.06,N/A,16226.30,N/A,736.12,25766.40,25766.40,736.12,37522.38,,Hospital 37234,HC Tib per Terr Addl Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,700603.58,N/A,420362.15,N/A,N/A,N/A,77456.62,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,77456.62,N/A,77456.62,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,77456.62,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,77456.62,N/A,77456.62,N/A,N/A,N/A,77456.62,420362.15,N/A,N/A,,Hospital CPT 37236,HC Stent Place Initial Artery Ang,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,13772.00,13772.00,8263.20,8263.20,N/A,1928.08,N/A,9586.05,N/A,7929.92,N/A,4682.48,N/A,13772.00,N/A,1928.08,N/A,9586.05,N/A,9586.05,N/A,13772.00,N/A,13772.00,N/A,13772.00,N/A,13772.00,N/A,7929.92,N/A,9586.05,N/A,1928.08,N/A,11660.00,N/A,11660.00,N/A,1928.08,N/A,9586.05,N/A,9586.05,N/A,10544.65,8263.20,8263.20,1928.08,13772.00,,Hospital CPT 37237,HC Open/Perq Place Stent Ea Add A,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,14346.00,14346.00,8607.60,8607.60,N/A,2008.44,N/A,14346.00,N/A,8260.43,N/A,4877.64,N/A,14346.00,N/A,2008.44,N/A,14346.00,N/A,14346.00,N/A,14346.00,N/A,14346.00,N/A,14346.00,N/A,14346.00,N/A,8260.43,N/A,14346.00,N/A,2008.44,N/A,7897.00,N/A,7897.00,N/A,2008.44,N/A,14346.00,N/A,14346.00,N/A,223.78,8607.60,8607.60,223.78,14346.00,,Hospital CPT 37238,HC Stent Place Initial Venous Ang,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,15699.00,15699.00,9419.40,9419.40,N/A,2197.86,N/A,10027.43,N/A,9039.48,N/A,5337.66,N/A,15699.00,N/A,2197.86,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,15699.00,N/A,15699.00,N/A,15699.00,N/A,9039.48,N/A,9586.05,N/A,2197.86,N/A,11660.00,N/A,11660.00,N/A,2197.86,N/A,9586.05,N/A,10027.43,N/A,323.64,9419.40,9419.40,323.64,15699.00,,Hospital CPT 37241,HC Embolization Venous Angio,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,21819.00,21819.00,13091.40,13091.40,N/A,3054.66,N/A,414.00,N/A,12563.38,N/A,7418.46,N/A,21819.00,N/A,3054.66,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,21819.00,N/A,21819.00,N/A,21819.00,N/A,12563.38,N/A,9586.05,N/A,3054.66,N/A,11660.00,N/A,11660.00,N/A,3054.66,N/A,9586.05,N/A,414.00,N/A,10544.65,13091.40,13091.40,414.00,21819.00,,Hospital CPT 37246,HC Trluml Balo Angiop 1st Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,11168.00,9842.00,6700.80,5905.20,N/A,1377.88,N/A,4926.57,N/A,5667.02,N/A,3346.28,N/A,9842.00,N/A,1377.88,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,5667.02,N/A,4709.71,N/A,1377.88,N/A,7897.00,N/A,7897.00,N/A,1377.88,N/A,4709.71,N/A,4926.57,N/A,368.03,6700.80,6700.80,368.03,9842.00,,Hospital CPT 37246,HC Trluml Balo Angiop 1st Art - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11168.00,9842.00,6700.80,5905.20,N/A,1377.88,N/A,4926.57,N/A,5667.02,N/A,3346.28,N/A,9842.00,N/A,1377.88,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,5667.02,N/A,4709.71,N/A,1377.88,N/A,7897.00,N/A,7897.00,N/A,1377.88,N/A,4709.71,N/A,4926.57,N/A,368.03,6700.80,6700.80,368.03,9842.00,,Hospital 37565,Ligation Internal Jugular Vein,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43009.18,N/A,25805.51,N/A,5977.81,N/A,2746.07,N/A,24746.00,N/A,14623.11,N/A,6565.25,N/A,5977.81,N/A,2690.13,N/A,2690.13,N/A,4086.99,N/A,6565.25,N/A,6565.25,N/A,6565.25,N/A,24746.00,N/A,2690.13,N/A,5977.81,N/A,1431.00,N/A,1431.00,N/A,5977.81,N/A,2690.13,N/A,2746.07,N/A,787.94,N/A,N/A,787.94,25805.51,,Hospital CPT 37607,HC Ligation of a-V Fistula,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5678.00,5678.00,3406.80,3406.80,N/A,794.92,N/A,357.58,N/A,3269.39,N/A,1930.52,N/A,1057.41,N/A,794.92,N/A,357.58,N/A,357.58,N/A,658.24,N/A,1057.41,N/A,1057.41,N/A,1057.41,N/A,3269.39,N/A,357.58,N/A,794.92,N/A,5678.00,N/A,5678.00,N/A,794.92,N/A,357.58,N/A,357.58,N/A,393.34,3406.80,3406.80,357.58,5678.00,,Hospital 37765,Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32340.32,N/A,19404.19,N/A,4520.18,N/A,2813.99,N/A,18620.31,N/A,10995.72,N/A,6527.98,N/A,4520.18,N/A,2690.13,N/A,2690.13,N/A,4063.79,N/A,6527.98,N/A,6527.98,N/A,6527.98,N/A,18588.64,N/A,2690.13,N/A,4520.18,N/A,6843.00,N/A,6843.00,N/A,4520.18,N/A,2690.13,N/A,2813.99,N/A,595.93,N/A,N/A,595.93,19404.19,,Hospital 38207,HC Cryopreservation & Storage,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,456171.90,21682.62,273703.14,13009.57,N/A,2816.08,52021.50,246.26,145771.72,12371.90,N/A,7372.09,N/A,6004.67,N/A,2816.08,57837.05,2477.81,57837.05,2477.81,N/A,3738.01,N/A,6004.67,N/A,6004.67,N/A,6004.67,145771.72,12371.92,52021.50,2477.81,N/A,2816.08,145771.72,905.15,145771.72,905.15,N/A,2816.08,52021.50,2477.81,52021.50,246.26,N/A,270.90,52021.50,273703.14,246.26,13009.57,,Hospital 38215,HC Allo Semi Auto Buffy,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,440182.20,N/A,264109.32,N/A,94100.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,94100.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,94100.27,N/A,N/A,N/A,N/A,N/A,94100.27,N/A,N/A,N/A,N/A,N/A,94100.27,N/A,94100.27,264109.32,N/A,N/A,,Hospital 38240,HC Allo Cryo Infusion,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,456171.90,108496.00,273703.14,65097.60,N/A,15192.82,52021.50,39902.28,145771.72,62470.48,N/A,36888.64,N/A,92306.99,N/A,15192.82,57837.05,38138.45,57837.05,38138.45,N/A,57462.89,N/A,92306.99,N/A,92306.99,N/A,92306.99,145771.72,62470.49,52021.50,38138.45,N/A,15192.82,145771.72,585.89,145771.72,585.89,N/A,15192.82,52021.50,38146.22,52021.50,39902.28,N/A,409.11,52021.50,273703.14,409.11,92306.99,,Hospital 38500,Bx/Exc Lymph Node Open Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,62091.05,41510.10,37254.63,24906.06,7529.82,5794.83,9202.68,1937.89,16969.05,23840.78,21110.95,14098.14,17131.38,13365.40,7761.82,5794.83,142748.00,5366.90,142748.00,5366.90,10663.88,8558.32,17131.38,13365.40,17131.38,13365.40,17131.38,13365.40,16969.05,23840.80,9173.03,5366.90,7761.82,5794.83,20382.06,7661.50,20382.06,7661.50,N/A,5794.83,5366.90,5366.90,9202.68,1937.89,8305.15,2131.68,5366.90,142748.00,1937.89,24906.06,,Hospital 38520,Bx/Exc Lymph Node Opn Dp Crv Node W/Exc Fat Pad,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13999.58,N/A,8399.75,N/A,1954.26,N/A,479.88,N/A,8055.26,N/A,4759.86,N/A,7540.21,N/A,1954.26,N/A,3104.47,N/A,3104.47,N/A,4693.93,N/A,7540.21,N/A,7540.21,N/A,7540.21,N/A,8055.27,N/A,3104.47,N/A,1954.26,N/A,3397.00,N/A,3397.00,N/A,1954.26,N/A,3104.47,N/A,479.88,N/A,527.87,N/A,N/A,479.88,8399.75,,Hospital 38562,Lmtd Lmphadec Staging Spx Pel&Para-Aortic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,98562.62,N/A,59137.57,N/A,13763.56,N/A,8584.05,N/A,56745.92,N/A,33511.30,N/A,39763.54,N/A,13763.56,N/A,8206.20,N/A,8206.20,N/A,24753.86,N/A,39763.54,N/A,39763.54,N/A,39763.54,N/A,56241.52,N/A,8206.20,N/A,13763.56,N/A,15608.50,N/A,15608.50,N/A,13763.56,N/A,8206.20,N/A,8584.05,N/A,2824.92,N/A,N/A,2824.92,59137.57,,Hospital 38571,Laps Surg Bilateral Total Pelvic Lmphadectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,120771.48,101936.07,72462.89,61161.64,7920.31,14252.56,9634.96,8584.05,66569.25,58658.22,41062.31,34658.26,18019.80,20808.56,8164.35,14252.56,562.00,8206.20,562.00,8206.20,11216.91,12953.71,18019.80,20808.56,18019.80,20808.56,18019.80,20808.56,66569.25,58658.22,9634.96,8206.20,8164.35,14252.56,21439.07,15608.50,21439.07,15608.50,3865.20,14252.56,9634.96,8206.20,9634.96,8584.05,8735.85,2788.62,562.00,72462.89,2788.62,61161.64,,Hospital 38740,Axillary Lymphadenectomy Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30085.78,N/A,18051.47,N/A,4212.02,N/A,5192.14,N/A,17309.15,N/A,10229.17,N/A,11427.01,N/A,4212.02,N/A,4706.78,N/A,4706.78,N/A,7113.54,N/A,11427.01,N/A,11427.01,N/A,11427.01,N/A,17070.79,N/A,4706.78,N/A,4212.02,N/A,7897.00,N/A,7897.00,N/A,4212.02,N/A,4706.78,N/A,890.17,N/A,979.19,N/A,N/A,890.17,18051.47,,Hospital 38900,Intraop Sentinel Lymph Node ID W/Dye Injection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,49813.68,49529.42,29888.21,29717.65,9615.12,6930.01,11669.48,5366.90,21668.45,28286.98,16211.94,16816.54,20025.30,14389.22,9911.38,6930.01,186584.00,5366.90,186584.00,5366.90,12466.13,11971.06,20025.30,14389.22,20025.30,14389.22,20025.30,14389.22,21668.45,28286.98,11639.83,5366.90,9911.38,6930.01,26026.66,11850.25,26026.66,11850.25,9911.38,6930.01,11639.83,5366.90,11669.48,5366.90,10605.18,5903.59,9615.12,186584.00,5366.90,29717.65,,Hospital 39220,Resection Mediastinal Tumor,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60256.53,N/A,36153.92,N/A,8435.89,N/A,5005.51,N/A,34691.90,N/A,20487.21,N/A,23160.15,N/A,8435.89,N/A,4788.79,N/A,4788.79,N/A,14528.06,N/A,23160.15,N/A,23160.15,N/A,23160.15,N/A,34443.76,N/A,4804.29,N/A,8435.89,N/A,8718.50,N/A,8718.50,N/A,8435.89,N/A,4788.79,N/A,5005.51,N/A,2772.98,N/A,N/A,2772.98,36153.92,,Hospital 39501,Repair Laceration Diaphragm Any Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83418.62,N/A,50051.17,N/A,11658.04,N/A,2870.42,N/A,47990.72,N/A,28362.34,N/A,24480.49,N/A,11658.04,N/A,5366.90,N/A,5366.90,N/A,15239.56,N/A,24480.49,N/A,24480.49,N/A,24480.49,N/A,47598.61,N/A,5366.90,N/A,11658.04,N/A,8072.25,N/A,8072.25,N/A,11658.04,N/A,5366.90,N/A,2870.42,N/A,3157.46,N/A,N/A,2870.42,50051.17,,Hospital 40510,Exc Lip Transvrs Wedge Exc W/Prim Clsr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8534.00,N/A,5120.40,N/A,1194.76,N/A,2722.64,N/A,4913.87,N/A,2901.56,N/A,6214.61,N/A,1194.76,N/A,2569.18,N/A,2569.18,N/A,3868.72,N/A,6214.61,N/A,6214.61,N/A,6214.61,N/A,4913.88,N/A,2569.18,N/A,1194.76,N/A,3397.00,N/A,3397.00,N/A,1194.76,N/A,2569.18,N/A,2722.64,N/A,397.46,N/A,N/A,397.46,6214.61,,Hospital 40700,Plstc Rpr Cl Lip/Nsl Dfrm Prim Prtl/Compl Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,33558.07,N/A,20134.84,N/A,4717.40,N/A,5846.09,N/A,10631.05,N/A,11409.74,N/A,10732.75,N/A,4862.76,N/A,5846.09,N/A,5846.09,N/A,6680.89,N/A,10732.75,N/A,10732.75,N/A,10732.75,N/A,10631.05,N/A,5846.09,N/A,4862.76,N/A,12769.29,N/A,12769.29,N/A,49.50,N/A,5846.09,N/A,5846.09,N/A,5203.15,N/A,49.50,20134.84,N/A,N/A,,Hospital CPT 40800,HC I&D Cyst Abscess Mouth Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,840.00,840.00,504.00,504.00,N/A,117.60,N/A,110.66,N/A,483.67,N/A,285.60,N/A,555.45,N/A,117.60,N/A,110.66,N/A,110.66,N/A,345.77,N/A,555.45,N/A,555.45,N/A,555.45,N/A,483.67,N/A,110.66,N/A,117.60,N/A,840.00,N/A,840.00,N/A,117.60,N/A,110.66,N/A,110.66,N/A,121.73,504.00,504.00,110.66,840.00,,Hospital 40801,HC Drain Mouth Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 40805,Rmvl Embedded FB Vestibule Mouth Comp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16956.50,N/A,10173.90,N/A,2373.91,N/A,421.11,N/A,9763.55,N/A,5765.21,N/A,997.86,N/A,2373.91,N/A,412.53,N/A,412.53,N/A,621.19,N/A,997.86,N/A,997.86,N/A,997.86,N/A,9763.55,N/A,412.53,N/A,2373.91,N/A,527.00,N/A,527.00,N/A,2373.91,N/A,412.53,N/A,421.11,N/A,205.38,N/A,N/A,205.38,10173.90,,Hospital 40810,Exc Les Mucosa & Sbmcsl Vestibule Mouth W/O Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14476.20,N/A,8685.72,N/A,2026.66,N/A,2556.03,N/A,8330.82,N/A,4921.90,N/A,6295.52,N/A,2026.66,N/A,2569.18,N/A,2569.18,N/A,3919.10,N/A,6295.52,N/A,6295.52,N/A,6295.52,N/A,8330.82,N/A,2569.18,N/A,2026.66,N/A,1871.00,N/A,1871.00,N/A,2026.66,N/A,2569.18,N/A,2556.03,N/A,159.00,N/A,N/A,159.00,8685.72,,Hospital CPT 41008,HC Intraoral I&D Tongue/Flr Submndblr Space,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7113.00,7113.00,4267.80,4267.80,N/A,995.82,N/A,240.95,N/A,4095.67,N/A,2418.42,N/A,1089.15,N/A,995.82,N/A,240.95,N/A,240.95,N/A,678.00,N/A,1089.15,N/A,1089.15,N/A,1089.15,N/A,4095.67,N/A,240.95,N/A,995.82,N/A,7113.00,N/A,7113.00,N/A,995.82,N/A,240.95,N/A,240.95,N/A,265.05,4267.80,4267.80,240.95,7113.00,,Hospital 41010,HC Incision of Lingual Frenum (Frenotomy),N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,10734.80,13617.92,6440.88,8170.75,7975.79,1906.52,9700.59,530.66,10734.80,7835.11,3649.83,4577.41,5422.15,11676.23,8221.54,1906.52,9700.59,4821.94,9700.59,4821.94,3375.02,7268.67,5422.15,11676.23,5422.15,11676.23,5422.15,11676.23,10734.80,7835.12,9700.59,4821.94,8221.54,1906.52,4160.00,4800.25,4160.00,4800.25,1827.81,1906.52,9700.59,4821.94,9700.59,530.66,8797.05,583.73,1827.81,10734.80,530.66,11676.23,,Hospital 41016,Xtroral I&D Absc Cst/Hmtma Floor Mouth Subment,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14632.60,N/A,8779.56,N/A,2008.62,N/A,4821.94,N/A,8412.99,N/A,4975.09,N/A,11823.30,N/A,2008.62,N/A,4821.94,N/A,4821.94,N/A,7360.12,N/A,11823.30,N/A,11823.30,N/A,11823.30,N/A,8412.99,N/A,4821.94,N/A,2008.62,N/A,4112.50,N/A,4112.50,N/A,2008.62,N/A,4821.94,N/A,4821.94,N/A,5304.13,N/A,N/A,2008.62,11823.30,,Hospital 41100,HC Biopsy Tongue Anter 2/3,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,11737.30,N/A,7042.38,N/A,1635.33,N/A,2984.42,N/A,6757.39,N/A,3990.68,N/A,7291.79,N/A,1635.33,N/A,3010.42,N/A,3010.42,N/A,4539.28,N/A,7291.79,N/A,7291.79,N/A,7291.79,N/A,6757.40,N/A,3010.42,N/A,1635.33,N/A,4464.25,N/A,4464.25,N/A,1635.33,N/A,3010.42,N/A,2984.42,N/A,749.93,N/A,N/A,749.93,7291.79,,Hospital 41105,Biopsy Tongue Posterior One-Third,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15220.32,N/A,9132.19,N/A,2120.36,N/A,437.71,N/A,8757.76,N/A,5174.90,N/A,6235.82,N/A,2120.36,N/A,2569.18,N/A,2569.18,N/A,3881.92,N/A,6235.82,N/A,6235.82,N/A,6235.82,N/A,8757.77,N/A,2569.18,N/A,2120.36,N/A,4464.25,N/A,4464.25,N/A,2120.36,N/A,2569.18,N/A,437.71,N/A,481.49,N/A,N/A,437.71,9132.19,,Hospital 41112,Exc Lesion Tongue W/Clsr Anterior Two-Thirds,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20947.80,N/A,12568.68,N/A,2932.68,N/A,2687.47,N/A,12061.05,N/A,7122.25,N/A,6222.80,N/A,2932.68,N/A,2569.18,N/A,2569.18,N/A,3873.81,N/A,6222.80,N/A,6222.80,N/A,6222.80,N/A,12061.05,N/A,2569.18,N/A,2932.68,N/A,1871.00,N/A,1871.00,N/A,2932.68,N/A,2569.18,N/A,2687.47,N/A,388.66,N/A,N/A,388.66,12568.68,,Hospital 41120,Glossectomy 2.6 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2472.00,2472.00,1483.20,1483.20,N/A,346.08,N/A,198.21,N/A,1423.38,N/A,840.48,N/A,919.26,N/A,346.08,N/A,198.21,N/A,198.21,N/A,572.24,N/A,919.26,N/A,919.26,N/A,919.26,N/A,1423.38,N/A,198.21,N/A,346.08,N/A,2472.00,N/A,2472.00,N/A,346.08,N/A,198.21,N/A,198.21,N/A,218.03,1483.20,1483.20,198.21,2472.00,,Hospital CPT 41520,Frenoplasty Surg Revj Frenum Eg W/Z-Plasty,N/A,N/A,626.00,626.00,375.60,375.60,N/A,87.64,N/A,235.39,N/A,626.00,N/A,212.84,N/A,626.00,N/A,87.64,N/A,235.39,N/A,235.39,N/A,626.00,N/A,626.00,N/A,626.00,N/A,626.00,N/A,626.00,N/A,235.39,N/A,87.64,N/A,626.00,N/A,626.00,N/A,87.64,N/A,235.39,N/A,235.39,N/A,258.93,375.60,375.60,87.64,626.00,,Hospital CPT 41599,HC Tongue and Mouth Surgery,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,589.00,589.00,353.40,353.40,N/A,82.46,N/A,589.00,N/A,339.15,N/A,200.26,N/A,82.46,N/A,82.46,N/A,589.00,N/A,589.00,N/A,51.24,N/A,82.46,N/A,82.46,N/A,82.46,N/A,339.15,N/A,589.00,N/A,82.46,N/A,589.00,N/A,589.00,N/A,82.46,N/A,589.00,N/A,589.00,N/A,589.00,353.40,353.40,51.24,589.00,,Hospital 41820,Gingivectomy Exc Gingiva Each Quadrant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18009.40,N/A,10805.64,N/A,2521.31,N/A,2569.18,N/A,10368.24,N/A,6123.19,N/A,6224.82,N/A,2521.31,N/A,2569.18,N/A,2569.18,N/A,3875.07,N/A,6224.82,N/A,6224.82,N/A,6224.82,N/A,10368.24,N/A,2569.18,N/A,2521.31,N/A,5944.75,N/A,5944.75,N/A,2521.31,N/A,2569.18,N/A,2569.18,N/A,2826.09,N/A,N/A,2521.31,10805.64,,Hospital CPT 42104,Exc Lesion Palate Uvula W/O Closure,N/A,N/A,369.00,369.00,221.40,221.40,N/A,51.66,N/A,126.73,N/A,369.00,N/A,125.46,N/A,369.00,N/A,51.66,N/A,126.73,N/A,126.73,N/A,369.00,N/A,369.00,N/A,369.00,N/A,369.00,N/A,369.00,N/A,126.73,N/A,51.66,N/A,369.00,N/A,369.00,N/A,51.66,N/A,126.73,N/A,126.73,N/A,139.40,221.40,221.40,51.66,369.00,,Hospital 42120,Rescj Palate/Extensive Rescj Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15458.40,N/A,9275.04,N/A,2116.20,N/A,5319.17,N/A,8893.84,N/A,5255.86,N/A,11685.57,N/A,2116.20,N/A,4821.94,N/A,4821.94,N/A,7274.49,N/A,11685.57,N/A,11685.57,N/A,11685.57,N/A,8893.86,N/A,4821.94,N/A,2116.20,N/A,3397.00,N/A,3397.00,N/A,2116.20,N/A,4821.94,N/A,1044.50,N/A,1142.84,N/A,N/A,1044.50,11685.57,,Hospital 42140,Uvulectomy Excision Uvula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29373.50,N/A,17624.10,N/A,4112.29,N/A,2622.61,N/A,16907.58,N/A,9986.99,N/A,6245.85,N/A,4112.29,N/A,2569.18,N/A,2569.18,N/A,3888.16,N/A,6245.85,N/A,6245.85,N/A,6245.85,N/A,16763.63,N/A,2569.18,N/A,4112.29,N/A,2134.50,N/A,2134.50,N/A,4112.29,N/A,2569.18,N/A,2622.61,N/A,259.01,N/A,N/A,259.01,17624.10,,Hospital CPT 42440,Excision Submandibular Submaxillary Gland,N/A,N/A,824.00,824.00,494.40,494.40,N/A,115.36,N/A,396.44,N/A,824.00,N/A,280.16,N/A,824.00,N/A,115.36,N/A,396.44,N/A,396.44,N/A,740.87,N/A,824.00,N/A,824.00,N/A,824.00,N/A,824.00,N/A,396.44,N/A,115.36,N/A,824.00,N/A,824.00,N/A,115.36,N/A,396.44,N/A,396.44,N/A,436.08,494.40,494.40,115.36,824.00,,Hospital 42650,Dilation Salivary Duct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24480.20,N/A,14688.12,N/A,3428.41,N/A,2556.03,N/A,14089.78,N/A,8323.26,N/A,6297.78,N/A,3428.41,N/A,2569.18,N/A,2569.18,N/A,3920.48,N/A,6297.78,N/A,6297.78,N/A,6297.78,N/A,14089.77,N/A,2569.18,N/A,3428.41,N/A,2806.50,N/A,2806.50,N/A,3428.41,N/A,2569.18,N/A,2556.03,N/A,246.63,N/A,N/A,246.63,14688.12,,Hospital 42699,Unlisted Px Salivary Glands/Ducts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14028.07,N/A,8416.84,N/A,1963.92,N/A,186.06,N/A,8072.52,N/A,4622.31,N/A,506.81,N/A,1963.92,N/A,187.68,N/A,187.68,N/A,315.50,N/A,506.81,N/A,506.81,N/A,506.81,N/A,8072.51,N/A,187.68,N/A,1963.92,N/A,527.00,N/A,527.00,N/A,1963.92,N/A,187.68,N/A,186.06,N/A,5.94,N/A,N/A,5.94,8416.84,,Hospital 42800,Biopsy Oropharynx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23842.70,N/A,14305.62,N/A,3338.25,N/A,1279.62,N/A,13726.02,N/A,8106.51,N/A,3046.00,N/A,3338.25,N/A,1253.55,N/A,1253.55,N/A,1896.18,N/A,3046.00,N/A,3046.00,N/A,3046.00,N/A,13726.02,N/A,1253.55,N/A,3338.25,N/A,1431.00,N/A,1431.00,N/A,3338.25,N/A,1253.55,N/A,1279.62,N/A,295.80,N/A,N/A,295.80,14305.62,,Hospital CPT 42809,HC ED Rmvl Foreign Body Pharynx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,416.00,416.00,249.60,249.60,N/A,58.24,N/A,120.48,N/A,239.53,N/A,141.44,N/A,416.00,N/A,58.24,N/A,120.48,N/A,120.48,N/A,354.66,N/A,416.00,N/A,416.00,N/A,416.00,N/A,239.53,N/A,120.48,N/A,58.24,N/A,416.00,N/A,416.00,N/A,58.24,N/A,120.48,N/A,120.48,N/A,132.53,249.60,249.60,58.24,416.00,,Hospital CPT 42830,Adenoidectomy Primary 2nd Prtn W/Rmvl Lesion Snare,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,13915.53,N/A,8349.32,N/A,1948.17,N/A,1645.14,N/A,8012.02,N/A,4731.28,N/A,3815.37,N/A,1948.17,N/A,1572.73,N/A,1572.73,N/A,2375.14,N/A,3815.37,N/A,3815.37,N/A,3815.37,N/A,8012.02,N/A,1572.73,N/A,1948.17,N/A,2806.50,N/A,2806.50,N/A,1948.17,N/A,1572.73,N/A,1645.14,N/A,506.44,N/A,N/A,506.44,8349.32,,Hospital 44369,Enteroscopy > 2nd Prtn Abltj Lesion,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,28413.63,11360.83,17048.18,6816.50,5254.60,1590.52,6511.21,1645.14,11841.67,6541.27,9660.64,3862.68,11954.95,3814.54,5416.50,1590.52,169724.00,1572.73,169724.00,1572.73,7441.68,2374.62,11954.95,3814.54,11954.95,3814.54,11954.95,3814.54,11841.67,6541.28,6481.56,1572.73,5416.50,1590.52,14223.40,1871.00,14223.40,1871.00,N/A,1590.52,1577.11,1572.73,6511.21,1645.14,5795.66,258.42,1577.11,169724.00,258.42,6816.50,,Hospital 44373,Enteroscopy > 2nd Prtn Conv Gstrst Tube,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,12543.90,N/A,7526.34,N/A,1748.60,N/A,1645.14,N/A,7222.47,N/A,4264.92,N/A,3813.60,N/A,1748.60,N/A,1572.73,N/A,1572.73,N/A,2374.04,N/A,3813.60,N/A,3813.60,N/A,3813.60,N/A,7222.48,N/A,1572.73,N/A,1748.60,N/A,1871.00,N/A,1871.00,N/A,1748.60,N/A,1572.73,N/A,1645.14,N/A,234.54,N/A,N/A,234.54,7526.34,,Hospital 44376,Enterosc >2nd Prtn W/Ileum W/WO Collj Spec Spx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8586.80,N/A,5152.08,N/A,1202.15,N/A,1645.14,N/A,4943.73,N/A,2919.51,N/A,3820.45,N/A,1202.15,N/A,1572.73,N/A,1572.73,N/A,2378.30,N/A,3820.45,N/A,3820.45,N/A,3820.45,N/A,4943.73,N/A,1572.73,N/A,1202.15,N/A,1871.00,N/A,1871.00,N/A,1202.15,N/A,1572.73,N/A,1645.14,N/A,299.68,N/A,N/A,299.68,5152.08,,Hospital 44380,Ileoscopy Thru Stoma Dx W/Collj Spec When Prfmd,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10722.40,N/A,6433.44,N/A,1501.14,N/A,1169.69,N/A,6173.77,N/A,3645.62,N/A,2711.06,N/A,1501.14,N/A,1118.20,N/A,1118.20,N/A,1687.68,N/A,2711.06,N/A,2711.06,N/A,2711.06,N/A,6142.10,N/A,1118.20,N/A,1501.14,N/A,2806.50,N/A,2806.50,N/A,1501.14,N/A,1118.20,N/A,1169.69,N/A,236.96,N/A,N/A,236.96,6433.44,,Hospital 44381,Ileoscopy Stoma W/Balloon Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,11599.28,N/A,6959.57,N/A,1623.90,N/A,1564.68,N/A,6677.25,N/A,3943.75,N/A,3828.73,N/A,1623.90,N/A,1572.73,N/A,1572.73,N/A,2383.46,N/A,3828.73,N/A,3828.73,N/A,3828.73,N/A,6677.25,N/A,1572.73,N/A,1623.90,N/A,1871.00,N/A,1871.00,N/A,1623.90,N/A,1572.73,N/A,1564.68,N/A,87.97,N/A,N/A,87.97,6959.57,,Hospital 44385,Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,14298.27,N/A,8578.96,N/A,2001.75,N/A,1174.92,N/A,8210.30,N/A,4861.40,N/A,2722.50,N/A,2001.75,N/A,1123.19,N/A,1123.19,N/A,1694.81,N/A,2722.50,N/A,2722.50,N/A,2722.50,N/A,8210.31,N/A,1123.19,N/A,2001.75,N/A,2806.50,N/A,2806.50,N/A,2001.75,N/A,1123.19,N/A,1174.92,N/A,204.96,N/A,N/A,204.96,8578.96,,Hospital 44388,Colonoscopy Stoma Dx Including Collj Spec Spx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,162222.52,10203.70,97333.51,6122.22,N/A,1428.52,N/A,1113.49,N/A,5874.55,N/A,3469.26,N/A,2731.11,N/A,1428.52,N/A,1123.19,N/A,1123.19,N/A,1700.17,N/A,2731.11,N/A,2731.11,N/A,2731.11,N/A,5874.55,N/A,1123.19,N/A,1428.52,N/A,2806.50,N/A,2806.50,N/A,1428.52,N/A,1123.19,N/A,1113.49,N/A,408.76,97333.51,97333.51,408.76,6122.22,,Hospital 44390,Colonoscopy Stoma W/Rmvl Foreign Body,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10013.10,N/A,6007.86,N/A,1401.83,N/A,795.29,N/A,5763.86,N/A,3404.45,N/A,1832.39,N/A,1401.83,N/A,750.46,N/A,750.46,N/A,1140.70,N/A,1832.39,N/A,1832.39,N/A,1832.39,N/A,5763.86,N/A,750.46,N/A,1401.83,N/A,1871.00,N/A,1871.00,N/A,1401.83,N/A,750.46,N/A,795.29,N/A,231.36,N/A,N/A,231.36,6007.86,,Hospital 44392,Colonoscopy Stoma Rmvl Les by Hot Biopsy Forceps,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,12035.05,N/A,7221.03,N/A,1684.91,N/A,273.87,N/A,6927.07,N/A,4091.92,N/A,3285.56,N/A,1684.91,N/A,1353.14,N/A,1353.14,N/A,2045.33,N/A,3285.56,N/A,3285.56,N/A,3285.56,N/A,6927.08,N/A,1353.14,N/A,1684.91,N/A,2586.50,N/A,2586.50,N/A,1684.91,N/A,1353.14,N/A,273.87,N/A,301.26,N/A,N/A,273.87,7221.03,,Hospital CPT 44500,HC Intro Long Gastro Tube - 15202,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1353.00,1353.00,811.80,811.80,N/A,189.42,N/A,822.34,N/A,779.06,N/A,460.02,N/A,1353.00,N/A,189.42,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1353.00,N/A,1353.00,N/A,1353.00,N/A,779.06,N/A,745.47,N/A,189.42,N/A,1871.00,N/A,1871.00,N/A,189.42,N/A,745.47,N/A,18.85,N/A,20.74,811.80,811.80,18.85,1871.00,,Hospital 44602,Enterorrhaphy Single Perforation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,163843.62,N/A,98306.17,N/A,22671.41,N/A,12205.93,N/A,93304.57,N/A,55706.83,N/A,30997.12,N/A,22671.41,N/A,12169.94,N/A,12169.94,N/A,N/A,N/A,30997.12,N/A,N/A,N/A,30997.12,N/A,93304.59,N/A,12135.12,N/A,22671.41,N/A,12019.00,N/A,12019.00,N/A,22671.41,N/A,12169.94,N/A,12205.93,N/A,6250.30,N/A,N/A,6250.30,98306.17,,Hospital 44640,Closure Intestinal Cutaneous Fistula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,108783.32,N/A,65269.99,N/A,15185.05,N/A,5614.96,N/A,60048.88,N/A,36986.33,N/A,25652.55,N/A,15185.05,N/A,5579.07,N/A,5579.07,N/A,15969.21,N/A,25652.55,N/A,25652.55,N/A,25652.55,N/A,60048.88,N/A,5579.07,N/A,15185.05,N/A,6784.50,N/A,6784.50,N/A,15185.05,N/A,5579.07,N/A,5614.96,N/A,3923.50,N/A,N/A,3923.50,65269.99,,Hospital 44950,Appendectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36845.60,N/A,22107.36,N/A,5161.57,N/A,3465.85,N/A,21200.94,N/A,12527.51,N/A,7843.46,N/A,5161.57,N/A,3198.50,N/A,3198.50,N/A,4882.68,N/A,7843.46,N/A,7843.46,N/A,7843.46,N/A,20837.63,N/A,3198.50,N/A,5161.57,N/A,6843.00,N/A,6843.00,N/A,5161.57,N/A,3198.50,N/A,3465.85,N/A,1702.03,N/A,N/A,1702.03,22107.36,,Hospital 45100,HC Bx Anorectal Wall Anal Apprc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,82106.00,22812.87,49263.60,13687.72,10440.92,3182.44,N/A,623.40,23529.46,13129.57,N/A,7756.38,N/A,5650.53,10762.62,3182.44,4496.00,2320.33,N/A,2320.33,N/A,3517.57,N/A,5650.53,N/A,5650.53,N/A,5650.53,23529.46,13129.58,12616.71,2320.33,10762.62,3182.44,28261.97,2586.50,28261.97,2586.50,N/A,3182.44,12616.71,2326.89,12616.71,623.40,11516.01,685.75,4496.00,49263.60,623.40,13687.72,,Hospital 45300,Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16828.32,N/A,10096.99,N/A,2355.97,N/A,2559.60,N/A,9681.63,N/A,5721.63,N/A,5644.76,N/A,2355.97,N/A,2320.33,N/A,2320.33,N/A,3513.97,N/A,5644.76,N/A,5644.76,N/A,5644.76,N/A,9681.64,N/A,2320.33,N/A,2355.97,N/A,4112.50,N/A,4112.50,N/A,2355.97,N/A,2320.33,N/A,156.36,N/A,172.00,N/A,N/A,156.36,10096.99,,Hospital CPT 45307,HC Proctosigmoidoscopy FB,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4542.00,4542.00,2725.20,2725.20,N/A,635.88,N/A,96.29,N/A,2615.28,N/A,1544.28,N/A,595.65,N/A,635.88,N/A,96.29,N/A,96.29,N/A,370.79,N/A,595.65,N/A,595.65,N/A,595.65,N/A,2615.28,N/A,96.29,N/A,635.88,N/A,4542.00,N/A,4542.00,N/A,635.88,N/A,96.29,N/A,96.29,N/A,105.92,2725.20,2725.20,96.29,4542.00,,Hospital 45309,Proctosgmdsc Rigid Rmvl 1 Lesion Snare Tq,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,15517.52,N/A,9310.51,N/A,2172.45,N/A,1022.94,N/A,8934.46,N/A,5275.96,N/A,2382.57,N/A,2172.45,N/A,977.91,N/A,977.91,N/A,1483.20,N/A,2382.57,N/A,2382.57,N/A,2382.57,N/A,8934.46,N/A,977.91,N/A,2172.45,N/A,1871.00,N/A,1871.00,N/A,2172.45,N/A,977.91,N/A,1022.94,N/A,493.94,N/A,N/A,493.94,9310.51,,Hospital 45317,Proctosgmdsc Rigid Control Bleeding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,7066.62,N/A,4239.97,N/A,989.33,N/A,998.25,N/A,4068.96,N/A,2402.65,N/A,2365.48,N/A,989.33,N/A,977.91,N/A,977.91,N/A,1472.56,N/A,2365.48,N/A,2365.48,N/A,2365.48,N/A,4068.96,N/A,977.91,N/A,989.33,N/A,1871.00,N/A,1871.00,N/A,989.33,N/A,977.91,N/A,998.25,N/A,116.23,N/A,N/A,116.23,4239.97,,Hospital 45330,HC Diagnostic Sigmoidoscopy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,57183.40,5649.70,34310.04,3389.82,7416.72,790.95,9039.24,750.46,16714.19,3251.38,19442.36,1920.89,16874.07,1834.57,7645.25,790.95,2248.00,750.46,2248.00,750.46,10503.72,1142.06,16874.07,1834.57,16874.07,1834.57,16874.07,1834.57,16714.19,3251.38,9039.24,750.46,7645.25,790.95,20075.93,1431.00,20075.93,1431.00,11532.28,790.95,9039.24,750.46,9039.24,750.46,8180.41,825.51,2248.00,34310.04,750.46,3389.82,,Hospital 45332,Sigmoidoscopy Flx W/Rmvl Foreign Body,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 45342,Sigmoidoscopy Flx Tndsc US Gid Ndl Aspir/Bx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,19801.13,N/A,11880.68,N/A,2763.29,N/A,1415.45,N/A,11400.51,N/A,6732.38,N/A,3297.48,N/A,2763.29,N/A,1353.14,N/A,1353.14,N/A,2052.75,N/A,3297.48,N/A,3297.48,N/A,3297.48,N/A,11400.52,N/A,1353.14,N/A,2763.29,N/A,2586.50,N/A,2586.50,N/A,2763.29,N/A,1353.14,N/A,1415.45,N/A,680.00,N/A,N/A,680.00,11880.68,,Hospital 45384,Colsc Flx W/Removal Lesion by Hot Bx Forceps,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,24414.10,5809.70,14648.46,3485.82,4640.05,813.14,5754.58,977.91,10456.74,2552.00,8300.79,1975.30,10556.76,2374.18,4783.02,813.14,1124.00,977.91,1124.00,977.91,6571.34,1477.98,10556.76,2374.18,10556.76,2374.18,10556.76,2374.18,10456.74,2552.00,5754.58,977.91,4783.02,813.14,12559.91,1871.00,12559.91,1871.00,N/A,813.14,5754.58,977.91,5754.58,977.91,5117.83,1075.70,1124.00,14648.46,813.14,3485.82,,Hospital 45393,Colonoscopy Flexible With Decompression,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,33303.70,N/A,19982.22,N/A,8276.66,N/A,10115.81,N/A,18733.54,N/A,11323.26,N/A,18830.56,N/A,8531.68,N/A,196700.00,N/A,196700.00,N/A,11721.58,N/A,18830.56,N/A,18830.56,N/A,18830.56,N/A,18733.54,N/A,10056.51,N/A,8531.68,N/A,22403.66,N/A,1871.00,N/A,N/A,N/A,10056.51,N/A,10115.81,N/A,9128.90,N/A,1871.00,196700.00,N/A,N/A,,Hospital 45400,Laparoscopy Proctopexy Prolapse,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,65590.80,N/A,39354.48,N/A,13098.63,N/A,15790.30,N/A,29767.99,N/A,21364.84,N/A,35648.44,N/A,13502.22,N/A,122516.00,N/A,122516.00,N/A,22191.84,N/A,35648.44,N/A,35648.44,N/A,35648.44,N/A,29767.99,N/A,15760.65,N/A,13502.22,N/A,35455.98,N/A,35455.98,N/A,N/A,N/A,15760.65,N/A,15790.30,N/A,14447.37,N/A,13098.63,122516.00,N/A,N/A,,Hospital 45915,Rmvl Fecal Impaction/FB Spx Under Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35900.30,N/A,21540.18,N/A,3440.30,N/A,1762.07,N/A,7752.99,N/A,12206.10,N/A,7827.15,N/A,3546.30,N/A,1684.52,N/A,1684.52,N/A,4872.22,N/A,7827.15,N/A,7827.15,N/A,7827.15,N/A,7752.99,N/A,4335.33,N/A,3546.30,N/A,9312.36,N/A,9312.36,N/A,1865.65,N/A,4335.33,N/A,1762.07,N/A,3794.54,N/A,1684.52,21540.18,N/A,N/A,,Hospital 45990,Anrct Xm Surg Req Anes General Spi/Edrl Dx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16314.00,N/A,9788.40,N/A,2285.14,N/A,2300.29,N/A,9390.54,N/A,5498.81,N/A,5665.08,N/A,2285.14,N/A,2320.33,N/A,2320.33,N/A,3526.62,N/A,5665.08,N/A,5665.08,N/A,5665.08,N/A,9390.54,N/A,2320.33,N/A,2285.14,N/A,4332.50,N/A,4332.50,N/A,2285.14,N/A,2320.33,N/A,2300.29,N/A,585.51,N/A,N/A,585.51,9788.40,,Hospital CPT 46040,I&D Ischiorectal&/Perirectal Abscess Spx,N/A,N/A,928.00,928.00,556.80,556.80,N/A,129.92,N/A,405.48,N/A,928.00,N/A,315.52,N/A,928.00,N/A,129.92,N/A,405.48,N/A,405.48,N/A,928.00,N/A,928.00,N/A,928.00,N/A,928.00,N/A,928.00,N/A,405.48,N/A,129.92,N/A,928.00,N/A,928.00,N/A,129.92,N/A,405.48,N/A,405.48,N/A,446.03,556.80,556.80,129.92,928.00,,Hospital CPT 46040,HC I&D Ischio Perirectal Abs,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7352.00,7352.00,4411.20,4411.20,N/A,1029.28,N/A,405.48,N/A,4233.28,N/A,2499.68,N/A,1552.02,N/A,1029.28,N/A,405.48,N/A,405.48,N/A,966.13,N/A,1552.02,N/A,1552.02,N/A,1552.02,N/A,4233.28,N/A,405.48,N/A,1029.28,N/A,7352.00,N/A,7352.00,N/A,1029.28,N/A,405.48,N/A,405.48,N/A,446.03,4411.20,4411.20,405.48,7352.00,,Hospital CPT 46230,Excision Multiple External Papillae/Tags Anus,N/A,N/A,518.00,518.00,310.80,310.80,N/A,72.52,N/A,164.94,N/A,518.00,N/A,176.12,N/A,518.00,N/A,72.52,N/A,164.94,N/A,164.94,N/A,518.00,N/A,518.00,N/A,518.00,N/A,518.00,N/A,518.00,N/A,164.94,N/A,72.52,N/A,518.00,N/A,518.00,N/A,72.52,N/A,164.94,N/A,164.94,N/A,181.43,310.80,310.80,72.52,518.00,,Hospital 46604,Anoscopy W/Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10779.95,N/A,6467.97,N/A,1509.19,N/A,1011.44,N/A,6203.70,N/A,3665.19,N/A,2375.74,N/A,1509.19,N/A,977.91,N/A,977.91,N/A,1478.94,N/A,2375.74,N/A,2375.74,N/A,2375.74,N/A,6203.70,N/A,977.91,N/A,1509.19,N/A,1871.00,N/A,1871.00,N/A,1509.19,N/A,977.91,N/A,1011.44,N/A,69.67,N/A,N/A,69.67,6467.97,,Hospital CPT 46606,Anoscopy W/Bx Single/Multiple,N/A,N/A,481.00,481.00,288.60,288.60,N/A,67.34,N/A,71.90,N/A,481.00,N/A,163.54,N/A,481.00,N/A,67.34,N/A,71.90,N/A,71.90,N/A,478.10,N/A,481.00,N/A,481.00,N/A,481.00,N/A,481.00,N/A,71.90,N/A,67.34,N/A,481.00,N/A,481.00,N/A,67.34,N/A,71.90,N/A,71.90,N/A,79.09,288.60,288.60,67.34,481.00,,Hospital 46614,Anoscopy Control Bleeding,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64828.22,N/A,38896.93,N/A,9032.88,N/A,2368.59,N/A,37307.16,N/A,21889.24,N/A,5748.20,N/A,9032.88,N/A,2320.33,N/A,2320.33,N/A,3578.36,N/A,5748.20,N/A,5748.20,N/A,5748.20,N/A,37307.17,N/A,2320.33,N/A,9032.88,N/A,5497.50,N/A,5497.50,N/A,9032.88,N/A,2320.33,N/A,2368.59,N/A,546.52,N/A,N/A,546.52,38896.93,,Hospital 46707,HC Repair Anorectal Fistula W/Plug,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52516.97,N/A,31510.18,N/A,7346.70,N/A,486.40,N/A,29745.29,N/A,17855.76,N/A,5677.34,N/A,7346.70,N/A,2320.33,N/A,2320.33,N/A,3534.25,N/A,5677.34,N/A,5677.34,N/A,5677.34,N/A,29745.31,N/A,2320.33,N/A,7346.70,N/A,4562.00,N/A,4562.00,N/A,7346.70,N/A,2320.33,N/A,486.40,N/A,535.04,N/A,N/A,486.40,31510.18,,Hospital 46917,Dstrj Lesion Anus Simple Laser Surg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14817.25,N/A,8890.35,N/A,2074.42,N/A,121.31,N/A,8528.95,N/A,5027.58,N/A,5632.12,N/A,2074.42,N/A,2320.33,N/A,2320.33,N/A,3506.10,N/A,5632.12,N/A,5632.12,N/A,5632.12,N/A,8528.94,N/A,2320.33,N/A,2074.42,N/A,3397.00,N/A,3397.00,N/A,2074.42,N/A,2320.33,N/A,121.31,N/A,133.44,N/A,N/A,121.31,8890.35,,Hospital CPT 46946,Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,N/A,N/A,630.00,630.00,378.00,378.00,N/A,88.20,N/A,363.67,N/A,630.00,N/A,214.20,N/A,630.00,N/A,88.20,N/A,363.67,N/A,363.67,N/A,630.00,N/A,630.00,N/A,630.00,N/A,630.00,N/A,630.00,N/A,363.67,N/A,88.20,N/A,630.00,N/A,630.00,N/A,88.20,N/A,363.67,N/A,363.67,N/A,400.04,378.00,378.00,88.20,630.00,,Hospital 47001,HC Biopsy of Liver; Perc Needle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,166516.18,26975.00,99909.71,16185.00,N/A,3770.30,N/A,4923.50,N/A,11012.00,11284.16,9053.17,11284.16,11413.78,N/A,3770.30,N/A,4706.78,N/A,4706.78,11284.16,7105.29,11284.16,11413.78,11284.16,11413.78,11284.16,11413.78,N/A,11012.00,N/A,4706.78,N/A,3770.30,N/A,8160.50,N/A,8160.50,N/A,3770.30,N/A,4706.78,N/A,4923.50,N/A,1445.68,11284.16,99909.71,1445.68,16185.00,,Hospital 47100,Biopsy Liver Wedge,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26482.57,N/A,15889.54,N/A,3686.46,N/A,1928.84,N/A,7923.00,N/A,9004.07,N/A,14688.61,N/A,3686.46,N/A,4706.78,N/A,4706.78,N/A,9143.95,N/A,14688.61,N/A,14688.61,N/A,14688.61,N/A,7923.00,N/A,4706.78,N/A,3686.46,N/A,9595.50,N/A,9595.50,N/A,3686.46,N/A,4706.78,N/A,1928.84,N/A,2121.73,N/A,N/A,1928.84,15889.54,,Hospital 47420,Choledochot/Ost W/O Sphnctrotomy/Sphnctrop,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44771.68,N/A,26863.01,N/A,6268.03,N/A,2043.02,N/A,25777.16,N/A,15222.37,N/A,9566.73,N/A,6268.03,N/A,2034.95,N/A,2034.95,N/A,5955.47,N/A,9566.73,N/A,9566.73,N/A,9566.73,N/A,25777.15,N/A,2034.95,N/A,6268.03,N/A,2692.50,N/A,2692.50,N/A,6268.03,N/A,2034.95,N/A,2043.02,N/A,1524.24,N/A,N/A,1524.24,26863.01,,Hospital CPT 47533,HC Plmt Biliary Drainage Cath External,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6684.00,6684.00,4010.40,4010.40,N/A,935.76,N/A,254.02,N/A,3848.65,N/A,2272.56,N/A,3199.53,N/A,935.76,N/A,254.02,N/A,254.02,N/A,1991.71,N/A,3199.53,N/A,3199.53,N/A,3199.53,N/A,3848.65,N/A,254.02,N/A,935.76,N/A,6684.00,N/A,6684.00,N/A,935.76,N/A,254.02,N/A,254.02,N/A,279.42,4010.40,4010.40,254.02,6684.00,,Hospital CPT 47538,HC Perq Plmt Bile Duct Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,12640.00,12640.00,7584.00,7584.00,N/A,1769.60,N/A,5192.14,N/A,7278.11,N/A,4297.60,N/A,11385.31,N/A,1769.60,N/A,4706.78,N/A,4706.78,N/A,7087.58,N/A,11385.31,N/A,11385.31,N/A,11385.31,N/A,7278.11,N/A,4706.78,N/A,1769.60,N/A,7897.00,N/A,7897.00,N/A,1769.60,N/A,4706.78,N/A,224.52,N/A,246.97,7584.00,7584.00,224.52,11385.31,,Hospital CPT 47539,HC Perq Plmt Bile Duct Stent W/O Bili Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,12640.00,12640.00,7584.00,7584.00,N/A,1769.60,N/A,405.61,N/A,7278.11,N/A,4297.60,N/A,11417.73,N/A,1769.60,N/A,405.61,N/A,405.61,N/A,7107.54,N/A,11417.73,N/A,11417.73,N/A,11417.73,N/A,7278.11,N/A,405.61,N/A,1769.60,N/A,12640.00,N/A,12640.00,N/A,1769.60,N/A,405.61,N/A,405.61,N/A,446.17,7584.00,7584.00,405.61,12640.00,,Hospital 47554,HC Biliary Endo W/Stone Removal,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,80717.22,N/A,48430.33,N/A,11295.15,N/A,8409.31,N/A,46465.52,N/A,27443.85,N/A,19890.83,N/A,11295.15,N/A,8206.20,N/A,8206.20,N/A,12382.42,N/A,19890.83,N/A,19890.83,N/A,19890.83,N/A,46465.53,N/A,8206.20,N/A,11295.15,N/A,10178.00,N/A,10178.00,N/A,11295.15,N/A,8206.20,N/A,625.96,N/A,688.56,N/A,N/A,625.96,48430.33,,Hospital 47563,Laps Surg Cholecystectomy W/Cholangiography,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,47035.93,32786.87,28221.56,19672.12,8860.80,4590.17,10451.70,4706.78,20542.54,11012.00,15992.22,11147.53,20499.39,12340.70,9133.82,4590.17,262454.00,4706.78,262454.00,4706.78,12760.40,7682.33,20499.39,12340.70,20499.39,12340.70,20499.39,12340.70,20542.54,11012.00,10422.05,4706.78,9133.82,4590.17,24389.16,7897.00,24389.16,7897.00,3696.61,4590.17,10422.05,4706.78,10451.70,4706.78,9773.19,5177.46,3696.61,262454.00,4590.17,19672.12,,Hospital 47564,Laps Surg Cholecstc W/Expl Common Duct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,141408.35,36460.78,84845.01,21876.47,7005.70,5104.51,8500.95,7118.01,77944.28,7923.00,48078.84,12396.67,15838.79,12480.56,7176.18,5104.51,2810.00,6240.00,2810.00,6240.00,9859.28,7768.31,N/A,12480.56,15838.79,12480.56,15838.79,12480.56,77944.28,7923.00,8500.95,6240.00,7176.18,5104.51,18844.20,8160.50,18844.20,8160.50,2639.42,5104.51,8500.95,6240.00,8500.95,7118.01,7678.51,1289.91,2639.42,84845.01,1289.91,21876.47,,Hospital 48102,HC Biopsy of Pancreas Perc Needle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,20238.33,7593.00,12143.00,4555.80,4512.56,1063.02,5633.41,695.16,10169.41,2332.77,6646.97,2581.62,3333.84,1637.79,4651.60,1063.02,78680.00,677.08,78680.00,677.08,2075.38,1019.56,3333.84,1637.79,3333.84,1637.79,3333.84,1637.79,10169.41,2332.77,5603.76,677.08,4651.60,1063.02,12214.80,935.50,12214.80,935.50,4651.60,1063.02,5603.76,677.08,5633.41,695.16,4977.21,321.47,2075.38,78680.00,321.47,4555.80,,Hospital 48153,Pncrtect W/Pancreatojejunostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,146533.12,N/A,87919.87,N/A,18671.96,N/A,N/A,N/A,80769.06,N/A,49821.26,N/A,65869.93,N/A,19247.27,N/A,31344.19,N/A,31344.19,N/A,41002.50,N/A,65869.93,N/A,65869.93,N/A,65869.93,N/A,80769.06,N/A,31344.19,N/A,19247.27,N/A,78368.77,N/A,78368.77,N/A,3535.23,N/A,31344.19,N/A,20214.76,N/A,20594.58,N/A,3535.23,87919.87,N/A,N/A,,Hospital CPT 49000,HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,9939.00,9939.00,5963.40,5963.40,N/A,1391.46,N/A,741.86,N/A,5722.88,N/A,3379.26,N/A,7735.99,N/A,1391.46,N/A,741.86,N/A,741.86,N/A,4815.80,N/A,7735.99,N/A,7735.99,N/A,7735.99,N/A,5722.88,N/A,741.86,N/A,1391.46,N/A,9939.00,N/A,9939.00,N/A,1391.46,N/A,741.86,N/A,741.86,N/A,816.05,5963.40,5963.40,741.86,9939.00,,Hospital 49002,Reopening Recent Laparotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40089.35,N/A,24053.61,N/A,5614.46,N/A,2285.72,N/A,23049.98,N/A,13630.37,N/A,11610.03,N/A,5614.46,N/A,2264.46,N/A,2264.46,N/A,7225.46,N/A,11610.03,N/A,11610.03,N/A,11610.03,N/A,22558.26,N/A,2264.46,N/A,5614.46,N/A,1906.50,N/A,1906.50,N/A,5614.46,N/A,2264.46,N/A,2285.72,N/A,1993.78,N/A,N/A,1906.50,24053.61,,Hospital 49020,HC C T Aspiration Peritoneal Absc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,85001.83,17807.20,51001.10,10684.32,175.64,2493.00,14092.38,4923.50,23529.46,10245.39,28900.63,6054.43,19756.27,17807.20,175.64,2493.00,14092.38,4706.78,14092.38,4706.78,19756.27,11973.66,19756.27,17807.20,19756.27,17807.20,19756.27,17807.20,946.68,10245.39,14092.38,4706.78,175.64,2493.00,946.68,10006.25,946.68,10006.25,175.64,2493.00,14092.38,4706.78,14092.38,4923.50,175.64,2488.03,175.64,51001.10,2488.03,17807.20,,Hospital CPT 49083,HC Abdom Paracentesis Dx/Ther W Imaging Guidance,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7516.00,7516.00,4509.60,4509.60,N/A,1052.24,N/A,745.47,N/A,4327.71,N/A,2555.44,N/A,1803.23,N/A,1052.24,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1803.23,N/A,1803.23,N/A,1803.23,N/A,4327.71,N/A,745.47,N/A,1052.24,N/A,7516.00,N/A,7516.00,N/A,1052.24,N/A,745.47,N/A,745.47,N/A,820.02,4509.60,4509.60,745.47,7516.00,,Hospital CPT 49083,HC Abd Paracentesis W Guide,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7516.00,7516.00,4509.60,4509.60,N/A,1052.24,N/A,745.47,N/A,4327.71,N/A,2555.44,N/A,1803.23,N/A,1052.24,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1803.23,N/A,1803.23,N/A,1803.23,N/A,4327.71,N/A,745.47,N/A,1052.24,N/A,1871.00,N/A,1871.00,N/A,1052.24,N/A,745.47,N/A,745.47,N/A,820.02,4509.60,4509.60,745.47,4509.60,,Hospital 49084,HC Peritoneal Lavage W/WO Imaging Guidance,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,41820.78,N/A,25092.47,N/A,5853.46,N/A,5007.00,N/A,24077.63,N/A,14219.07,N/A,11428.17,N/A,5853.46,N/A,4706.78,N/A,4706.78,N/A,7114.26,N/A,11428.17,N/A,11428.17,N/A,11428.17,N/A,24077.64,N/A,4706.78,N/A,5853.46,N/A,6898.50,N/A,6898.50,N/A,5853.46,N/A,4706.78,N/A,5007.00,N/A,896.49,N/A,N/A,896.49,25092.47,,Hospital CPT 49180,HC Needle Bx Abd/Retroper Mass,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3515.00,3515.00,2109.00,2109.00,N/A,492.10,N/A,80.11,N/A,2023.94,N/A,1195.10,N/A,3275.59,N/A,492.10,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2023.94,N/A,1354.15,N/A,492.10,N/A,1871.00,N/A,1871.00,N/A,492.10,N/A,1354.15,N/A,1416.50,N/A,88.12,2109.00,2109.00,80.11,3275.59,,Hospital 49215,Exc Presac/Sacrococcygeal Tumor,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42335.90,N/A,25401.54,N/A,5918.19,N/A,2811.81,N/A,24345.66,N/A,14394.22,N/A,15187.21,N/A,5918.19,N/A,2688.04,N/A,2688.04,N/A,9454.31,N/A,15187.21,N/A,15187.21,N/A,15187.21,N/A,24345.68,N/A,2688.04,N/A,5918.19,N/A,5383.50,N/A,5383.50,N/A,5918.19,N/A,2688.04,N/A,2811.81,N/A,3093.11,N/A,N/A,2688.04,25401.54,,Hospital 49255,Omntc Epiploectomy Rescj Omentum Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34454.58,N/A,20672.75,N/A,4814.79,N/A,4923.50,N/A,19836.99,N/A,11714.56,N/A,19149.37,N/A,4814.79,N/A,4706.78,N/A,4706.78,N/A,11920.86,N/A,19149.37,N/A,19149.37,N/A,19149.37,N/A,19837.01,N/A,4706.78,N/A,4814.79,N/A,9595.50,N/A,9595.50,N/A,4814.79,N/A,4706.78,N/A,4923.50,N/A,1546.70,N/A,N/A,1546.70,20672.75,,Hospital CPT 49322,Laps Surg W/Aspir Cavity/Cyst Single/Multiple,N/A,N/A,746.00,746.00,447.60,447.60,N/A,104.44,N/A,361.47,N/A,746.00,N/A,253.64,N/A,746.00,N/A,104.44,N/A,361.47,N/A,361.47,N/A,668.47,N/A,746.00,N/A,746.00,N/A,746.00,N/A,746.00,N/A,361.47,N/A,104.44,N/A,746.00,N/A,746.00,N/A,104.44,N/A,361.47,N/A,361.47,N/A,397.62,447.60,447.60,104.44,746.00,,Hospital 49329,Unlisted Laparoscopy Px Abd Pertoneum & Omentum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,66622.97,36711.87,39973.78,22027.12,11346.74,5091.04,13717.89,4923.50,28446.89,21136.05,22651.81,12482.04,25815.40,11429.21,11696.35,5091.04,106780.00,4706.78,106780.00,4706.78,16069.49,7114.89,25815.40,11429.21,25815.40,11429.21,25815.40,11429.21,28446.89,21136.06,13688.24,4706.78,11696.35,5091.04,30713.88,5963.00,30713.88,5963.00,N/A,5091.04,13688.24,4706.78,13717.89,4923.50,12515.10,73.58,11346.74,106780.00,73.58,22027.12,,Hospital 49422,HC Rmvl Perm Intraperitneal Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,103466.43,15829.40,62079.86,9497.64,9699.75,2194.55,N/A,2690.13,N/A,9112.88,26407.69,5382.00,26407.69,6524.93,9699.75,2194.55,N/A,2690.13,N/A,2690.13,26407.69,4061.88,26407.69,6524.93,26407.69,6524.93,26407.69,6524.93,N/A,9112.88,N/A,2690.13,9699.75,2194.55,N/A,4562.00,N/A,4562.00,9699.75,2194.55,N/A,2690.13,N/A,2690.13,9699.75,2959.14,9699.75,62079.86,2194.55,9497.64,,Hospital 49440,HC G Tube Plcmt,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,163013.72,11707.80,97808.23,7024.68,15809.83,1639.09,15579.77,1673.04,18909.39,6739.44,21378.73,3980.65,21378.73,3812.98,15809.83,1639.09,15579.77,1572.73,15579.77,1572.73,21378.73,2373.66,21378.73,3812.98,21378.73,3812.98,21378.73,3812.98,18909.39,6739.44,15579.77,1572.73,15809.83,1639.09,18909.39,1871.00,18909.39,1871.00,6416.04,1639.09,48057.70,1572.73,15579.77,1673.04,15809.83,214.15,6416.04,97808.23,214.15,7024.68,,Hospital 49442,Insert Cecostomy/Other Colonic Tube Percutaneous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10522.90,N/A,6313.74,N/A,1464.16,N/A,977.91,N/A,6057.62,N/A,3577.79,N/A,2386.72,N/A,1464.16,N/A,977.91,N/A,977.91,N/A,1485.78,N/A,2386.72,N/A,2386.72,N/A,2386.72,N/A,6057.62,N/A,977.91,N/A,1464.16,N/A,1871.00,N/A,1871.00,N/A,1464.16,N/A,977.91,N/A,977.91,N/A,1075.70,N/A,N/A,977.91,6313.74,,Hospital CPT 49450,HC Gastrostomy Tube Change W Flouro,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,62.83,N/A,1017.44,N/A,600.78,N/A,1767.00,N/A,247.38,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1767.00,N/A,1767.00,N/A,1767.00,N/A,1017.44,N/A,745.47,N/A,247.38,N/A,1871.00,N/A,1871.00,N/A,247.38,N/A,745.47,N/A,62.83,N/A,69.11,1060.20,1060.20,62.83,1871.00,,Hospital CPT 49450,HC Replace of Peg Tube Flu Guid,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,62.83,N/A,1017.44,N/A,600.78,N/A,1767.00,N/A,247.38,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1767.00,N/A,1767.00,N/A,1767.00,N/A,1017.44,N/A,745.47,N/A,247.38,N/A,1767.00,N/A,1767.00,N/A,247.38,N/A,745.47,N/A,62.83,N/A,69.11,1060.20,1060.20,62.83,1767.00,,Hospital 49521,Rpr Recrt Ingun Hernia Any Age Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34539.75,N/A,20723.85,N/A,4835.57,N/A,692.38,N/A,19827.30,N/A,11743.51,N/A,7807.53,N/A,4835.57,N/A,3198.50,N/A,3198.50,N/A,4860.32,N/A,7807.53,N/A,7807.53,N/A,7807.53,N/A,19827.31,N/A,3198.50,N/A,4835.57,N/A,4562.00,N/A,4562.00,N/A,4835.57,N/A,3198.50,N/A,692.38,N/A,761.62,N/A,N/A,692.38,20723.85,,Hospital 49566,Rpr Recrt Incal/Vnt Hernia Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,49993.92,45075.52,29996.35,27045.31,11346.74,6555.24,14079.13,2729.67,28677.72,25939.97,16495.74,15325.67,11541.98,6722.74,11696.35,6555.24,269198.00,2621.18,269198.00,2621.18,7185.10,4181.79,11541.98,6722.74,11541.98,6722.74,11541.98,6722.74,28677.72,18088.36,14049.48,2621.18,11696.35,6555.24,33086.37,22204.91,33086.37,22204.91,N/A,6555.24,14049.48,2621.18,14079.13,2729.67,12515.10,1973.41,7185.10,269198.00,1973.41,27045.31,,Hospital 49572,Rpr Epigastric Hernia Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32528.60,N/A,19517.16,N/A,4554.02,N/A,524.34,N/A,18690.49,N/A,11059.74,N/A,2538.04,N/A,4554.02,N/A,523.30,N/A,523.30,N/A,1577.30,N/A,2538.04,N/A,2538.04,N/A,2538.04,N/A,18690.50,N/A,523.30,N/A,4554.02,N/A,N/A,N/A,N/A,N/A,4554.02,N/A,523.30,N/A,524.34,N/A,574.97,N/A,N/A,523.30,19517.16,,Hospital 49580,Rpr Umbilical Hernia < 5 Yrs Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17593.40,N/A,10556.04,N/A,2463.08,N/A,322.69,N/A,10129.53,N/A,5981.75,N/A,2100.82,N/A,2463.08,N/A,322.69,N/A,322.69,N/A,1305.51,N/A,2100.82,N/A,2100.82,N/A,2100.82,N/A,10057.55,N/A,322.69,N/A,2463.08,N/A,N/A,N/A,N/A,N/A,2463.08,N/A,322.69,N/A,322.69,N/A,354.96,N/A,N/A,322.69,10556.04,,Hospital 49590,Rpr Spigelian Hernia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44255.55,N/A,26553.33,N/A,6185.98,N/A,1722.30,N/A,25299.08,N/A,15046.89,N/A,2983.59,N/A,6185.98,N/A,1722.30,N/A,1722.30,N/A,1854.25,N/A,2983.59,N/A,2983.59,N/A,2983.59,N/A,25299.09,N/A,1722.30,N/A,6185.98,N/A,N/A,N/A,N/A,N/A,6185.98,N/A,1722.30,N/A,1722.30,N/A,1894.53,N/A,N/A,1722.30,26553.33,,Hospital 49614,Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42217.10,N/A,25330.26,N/A,5910.39,N/A,4706.78,N/A,24190.91,N/A,14353.82,N/A,12327.14,N/A,5910.39,N/A,4706.78,N/A,4706.78,N/A,7673.88,N/A,12327.14,N/A,12327.14,N/A,12327.14,N/A,24190.91,N/A,4706.78,N/A,5910.39,N/A,7897.00,N/A,7897.00,N/A,5910.39,N/A,4706.78,N/A,4706.78,N/A,5177.46,N/A,N/A,4706.78,25330.26,,Hospital 49618,Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60525.77,N/A,36315.46,N/A,8473.60,N/A,6.56,N/A,34592.49,N/A,20578.76,N/A,12377.15,N/A,8473.60,N/A,6.56,N/A,6.56,N/A,7705.01,N/A,12377.15,N/A,12377.15,N/A,12377.15,N/A,34592.51,N/A,6.56,N/A,8473.60,N/A,7897.00,N/A,7897.00,N/A,8473.60,N/A,6.56,N/A,6.56,N/A,N/A,N/A,N/A,6.56,36315.46,,Hospital 49622,Rpr Parastomal Hrna 1st/Recr Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,44981.10,N/A,26988.66,N/A,9346.26,N/A,11351.43,N/A,28890.00,N/A,15293.57,N/A,21264.02,N/A,9634.23,N/A,127574.00,N/A,127574.00,N/A,13236.36,N/A,21264.02,N/A,21264.02,N/A,21264.02,N/A,28890.00,N/A,11321.78,N/A,9634.23,N/A,25298.88,N/A,25298.88,N/A,N/A,N/A,11321.78,N/A,11351.43,N/A,10308.63,N/A,9346.26,127574.00,N/A,N/A,,Hospital 49623,Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39963.68,N/A,23978.21,N/A,5594.92,N/A,3265.02,N/A,22818.42,N/A,13587.65,N/A,7811.35,N/A,5594.92,N/A,3198.50,N/A,3198.50,N/A,4862.71,N/A,7811.35,N/A,7811.35,N/A,7811.35,N/A,22818.42,N/A,3198.50,N/A,5594.92,N/A,4825.50,N/A,4825.50,N/A,5594.92,N/A,3198.50,N/A,3265.02,N/A,1952.25,N/A,N/A,1952.25,23978.21,,Hospital 49651,Laps Surg Rpr Recurrent Inguinal Hernia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42344.35,N/A,25406.61,N/A,5928.21,N/A,543.50,N/A,24189.29,N/A,14397.08,N/A,19884.04,N/A,5928.21,N/A,8206.20,N/A,8206.20,N/A,12378.20,N/A,19884.04,N/A,19884.04,N/A,19884.04,N/A,24189.32,N/A,8206.20,N/A,5928.21,N/A,11845.50,N/A,11845.50,N/A,5928.21,N/A,8206.20,N/A,543.50,N/A,597.85,N/A,N/A,543.50,25406.61,,Hospital 49654,Lap Rpr Hrna Xcpt Incal/Ingun Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49728.00,N/A,29836.80,N/A,6961.93,N/A,816.19,N/A,28613.11,N/A,16907.53,N/A,2879.89,N/A,6961.93,N/A,816.19,N/A,816.19,N/A,1789.72,N/A,2879.89,N/A,2879.89,N/A,2879.89,N/A,28613.13,N/A,816.19,N/A,6961.93,N/A,24535.83,N/A,24535.83,N/A,6961.93,N/A,816.19,N/A,816.19,N/A,897.81,N/A,N/A,816.19,29836.80,,Hospital 49659,Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54893.57,N/A,32936.14,N/A,7685.10,N/A,415.99,N/A,31412.28,N/A,18663.81,N/A,19915.78,N/A,7685.10,N/A,8206.20,N/A,8206.20,N/A,12397.97,N/A,19915.78,N/A,19915.78,N/A,19915.78,N/A,31412.28,N/A,8206.20,N/A,7685.10,N/A,10878.50,N/A,10878.50,N/A,7685.10,N/A,8206.20,N/A,415.99,N/A,457.59,N/A,N/A,415.99,32936.14,,Hospital 49999,HC Abdomen Surgery Procedure,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,35985.70,26861.17,21591.42,16116.70,9568.18,3759.29,11613.95,822.34,23205.90,15440.64,12235.14,9132.54,21768.92,2007.66,9862.99,3759.29,74746.00,745.47,74746.00,745.47,13550.65,1249.61,21768.92,2007.66,21768.92,2007.66,21768.92,2007.66,23205.90,15440.65,11584.30,745.47,9862.99,3759.29,25899.58,1871.00,25899.58,1871.00,N/A,3759.29,11584.30,745.47,11613.95,6.56,10553.40,7.22,9568.18,74746.00,6.56,16116.70,,Hospital 50080,Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,70499.68,64530.12,42299.81,38718.07,5750.19,8989.01,7097.47,8083.61,13213.68,36704.78,23969.90,21940.22,13082.47,18793.33,5927.36,8989.01,125888.00,7727.79,125888.00,7727.79,8143.53,11699.20,13082.47,18793.33,13082.47,18793.33,13082.47,18793.33,13213.68,36704.80,7067.82,7727.79,5927.36,8989.01,15564.88,9093.25,15564.88,9093.25,2633.16,8989.01,7067.82,7727.79,7097.47,8083.61,6342.28,1746.11,2633.16,125888.00,1746.11,38718.07,,Hospital CPT 50200,HC Renal Biopsy Percutaneous,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4981.00,4981.00,2988.60,2988.60,N/A,697.34,N/A,1354.15,N/A,2868.06,N/A,1693.54,N/A,3275.59,N/A,697.34,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2868.06,N/A,1354.15,N/A,697.34,N/A,1871.00,N/A,1871.00,N/A,697.34,N/A,1354.15,N/A,1354.15,N/A,1489.57,2988.60,2988.60,697.34,3275.59,,Hospital 50230,Nephrectomy W/Prtl Ureterect Open Rib Rescj Rad,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51763.12,N/A,31057.87,N/A,7067.22,N/A,1662.55,N/A,29783.86,N/A,17256.02,N/A,11070.86,N/A,7067.22,N/A,1520.81,N/A,1520.81,N/A,6891.83,N/A,11070.86,N/A,11070.86,N/A,11070.86,N/A,29783.91,N/A,1520.81,N/A,7067.22,N/A,1643.00,N/A,1643.00,N/A,7067.22,N/A,1520.81,N/A,1662.55,N/A,1816.57,N/A,N/A,1520.81,31057.87,,Hospital CPT 50387,HC Rem/Rep Ex/in N-U Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4623.00,4623.00,2773.80,2773.80,N/A,647.22,N/A,80.46,N/A,2661.92,N/A,1571.82,N/A,4051.75,N/A,647.22,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,2661.92,N/A,1675.03,N/A,647.22,N/A,1871.00,N/A,1871.00,N/A,647.22,N/A,1675.03,N/A,80.46,N/A,88.51,2773.80,2773.80,80.46,4051.75,,Hospital CPT 50431,"HC Inj Proc Nfrosgrm/Urtrgrm, Complete",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1714.00,1714.00,1028.40,1028.40,N/A,239.96,N/A,576.45,N/A,986.92,N/A,582.76,N/A,1365.97,N/A,239.96,N/A,564.71,N/A,564.71,N/A,850.34,N/A,1365.97,N/A,1365.97,N/A,1365.97,N/A,986.92,N/A,564.71,N/A,239.96,N/A,1431.00,N/A,1431.00,N/A,239.96,N/A,564.71,N/A,61.68,N/A,67.85,1028.40,1028.40,61.68,1431.00,,Hospital 50437,HC Perq Dilation Xst Trc New Access Renal Coltj Sys,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,102459.22,68818.83,61475.53,41291.30,N/A,9561.65,9171.14,8083.61,17329.32,39613.89,34836.13,23391.95,14813.58,18756.64,N/A,9561.65,3372.00,7727.79,3372.00,7727.79,10661.62,11676.37,17127.73,18756.64,17127.73,18756.64,17127.73,18756.64,17329.32,39613.92,9171.14,7727.79,7760.17,9561.65,20377.73,8244.00,20377.73,8244.00,N/A,9561.65,9171.14,7727.79,9171.14,8083.61,8303.39,1948.73,3372.00,61475.53,1948.73,41291.30,,Hospital 50542,Laps Abltj Renal Mass Lesion W/Intraop US,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60092.12,N/A,36055.27,N/A,N/A,N/A,8603.67,N/A,34586.04,N/A,20431.32,N/A,19921.09,N/A,8392.47,N/A,8206.20,N/A,8206.20,N/A,12401.27,N/A,19921.09,N/A,19921.09,N/A,19921.09,N/A,34586.06,N/A,8206.20,N/A,8392.47,N/A,14641.50,N/A,14641.50,N/A,8392.47,N/A,8206.20,N/A,1635.11,N/A,1792.50,N/A,N/A,1635.11,36055.27,,Hospital 50546,Laparoscopy Nephrectomy W/Partial Ureterect,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,105480.75,N/A,63288.45,N/A,14770.27,N/A,1464.31,N/A,60725.35,N/A,35863.45,N/A,12156.33,N/A,14770.27,N/A,1445.64,N/A,1445.64,N/A,7567.54,N/A,12156.33,N/A,12156.33,N/A,12156.33,N/A,60725.36,N/A,1445.64,N/A,14770.27,N/A,1643.00,N/A,1643.00,N/A,14770.27,N/A,1445.64,N/A,1464.31,N/A,1617.54,N/A,N/A,1445.64,63288.45,,Hospital 50593,HC CT Cryo Ablation Renal,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,157635.90,70273.02,94581.54,42163.81,9579.38,9832.54,6216.52,440.25,86888.91,40456.51,53596.21,23892.82,11445.19,19886.64,6513.10,9832.54,6216.52,8206.20,6216.52,8206.20,7124.37,12379.81,11445.19,19886.64,11445.19,19886.64,11445.19,19886.64,86888.91,40456.53,6216.52,8206.20,6513.10,9832.54,13616.92,7897.00,13616.92,7897.00,5476.00,9832.54,6216.52,8206.20,6216.52,440.25,6969.02,484.28,5476.00,94581.54,440.25,42163.81,,Hospital 50684,HC Inj Uretero/Pyelogr Indwell Ca,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,52380.72,13424.17,31428.43,8054.50,5399.17,1877.05,6652.58,1752.16,12167.47,7728.70,17809.44,4564.21,12283.86,4068.04,5565.53,1877.05,6652.58,1675.03,6652.58,1675.03,N/A,2532.43,12283.86,4068.04,12283.86,4068.04,12283.86,4068.04,12167.47,7728.70,6652.58,1675.03,5565.53,1877.05,14614.72,2718.25,14614.72,2718.25,3822.58,1877.05,6652.58,1675.03,6652.58,1752.16,3822.58,438.76,3822.58,31428.43,438.76,8054.50,,Hospital 50705,Ureteral Embolization/Occlusion W/Img Gid Rs&I,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,116753.28,N/A,70051.97,N/A,16332.41,N/A,8220.71,N/A,67199.01,N/A,39696.14,N/A,18795.42,N/A,16332.41,N/A,7727.79,N/A,7727.79,N/A,11700.50,N/A,18795.42,N/A,18795.42,N/A,18795.42,N/A,67199.00,N/A,7727.79,N/A,16332.41,N/A,8510.75,N/A,8510.75,N/A,16332.41,N/A,7727.79,N/A,8220.71,N/A,2333.18,N/A,N/A,2333.18,70051.97,,Hospital 50706,HC Balloon Dilate Urtrl Strx,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,85855.83,23200.08,51513.50,13920.05,7528.22,3209.51,9171.14,2925.70,17425.85,13347.20,29190.99,7888.03,17127.73,7026.82,7760.17,3209.51,562.00,2894.35,562.00,2894.35,10661.62,4374.32,17127.73,7026.82,17127.73,7026.82,17127.73,7026.82,17425.85,13347.20,9171.14,2894.35,7760.17,3209.51,20377.73,5409.25,20377.73,5409.25,29601.09,3209.51,9171.14,2894.35,9171.14,2925.70,8303.39,535.05,562.00,51513.50,535.05,13920.05,,Hospital 50780,Ureteroneocystostomy Anast 1 Ureter Bladder,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,117351.23,N/A,70410.74,N/A,16413.87,N/A,8540.78,N/A,67560.12,N/A,39839.01,N/A,14016.97,N/A,16413.87,N/A,8517.71,N/A,8517.71,N/A,8725.82,N/A,14016.97,N/A,14016.97,N/A,14016.97,N/A,67211.19,N/A,8517.71,N/A,16413.87,N/A,5944.75,N/A,5944.75,N/A,16413.87,N/A,8517.71,N/A,8540.78,N/A,1516.33,N/A,N/A,1516.33,70410.74,,Hospital 50785,Urtroneocstost W/Vesico-Psoas Hitch/Bldr Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,93001.08,N/A,55800.65,N/A,12987.49,N/A,6929.03,N/A,53531.80,N/A,31620.38,N/A,14243.57,N/A,12987.49,N/A,6825.37,N/A,6825.37,N/A,8866.88,N/A,14243.57,N/A,14243.57,N/A,14243.57,N/A,52365.78,N/A,6825.37,N/A,12987.49,N/A,4218.50,N/A,4218.50,N/A,12987.49,N/A,6825.37,N/A,6842.03,N/A,1610.85,N/A,N/A,1610.85,55800.65,,Hospital 50947,Laps Urtroneocstost W/Cstsc&Urtrl Stent Plmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,114321.97,N/A,68593.18,N/A,16003.84,N/A,8571.25,N/A,65800.12,N/A,38869.46,N/A,11470.55,N/A,16003.84,N/A,8533.72,N/A,8533.72,N/A,7140.66,N/A,11470.55,N/A,11470.55,N/A,11470.55,N/A,65627.37,N/A,8533.72,N/A,16003.84,N/A,7897.00,N/A,7897.00,N/A,16003.84,N/A,8533.72,N/A,8571.25,N/A,1523.97,N/A,N/A,1523.97,68593.18,,Hospital 50948,Laps Urtroneocstost W/O Cstsc&Urtrl Stent Plmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,104188.08,N/A,62512.85,N/A,11515.85,N/A,12808.36,N/A,25242.96,N/A,34487.93,N/A,21309.98,N/A,11870.67,N/A,343944.00,N/A,343944.00,N/A,13265.85,N/A,21309.98,N/A,21309.98,N/A,21309.98,N/A,25242.96,N/A,12778.71,N/A,11870.67,N/A,30039.53,N/A,30039.53,N/A,N/A,N/A,12778.71,N/A,12808.36,N/A,12701.62,N/A,11515.85,343944.00,N/A,N/A,,Hospital 50949,Unlisted Laparoscopy Procedure Ureter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,76500.52,N/A,45900.31,N/A,11982.62,N/A,8757.13,N/A,N/A,N/A,26010.17,N/A,27262.13,N/A,12351.83,N/A,8757.13,N/A,159608.00,N/A,16970.04,N/A,27262.13,N/A,27262.13,N/A,27262.13,N/A,27003.82,N/A,14440.47,N/A,12351.83,N/A,32435.13,N/A,32435.13,N/A,N/A,N/A,8356.34,N/A,8757.13,N/A,13216.46,N/A,8356.34,159608.00,N/A,N/A,,Hospital 50953,Ureteral Endoscopy via Ureterost W/WO Dil Ureter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,114094.33,N/A,68456.60,N/A,7528.22,N/A,9200.79,N/A,62888.80,N/A,38792.07,N/A,17127.73,N/A,7760.17,N/A,192766.00,N/A,192766.00,N/A,10661.62,N/A,17127.73,N/A,17127.73,N/A,17127.73,N/A,62888.80,N/A,9171.14,N/A,7760.17,N/A,20377.73,N/A,20377.73,N/A,N/A,N/A,9171.14,N/A,9200.79,N/A,8303.39,N/A,7528.22,192766.00,N/A,N/A,,Hospital 50961,Ureteral Endoscopy via Ureterost W/Rmvl FB/Stone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,114094.33,N/A,68456.60,N/A,7528.22,N/A,9200.79,N/A,62888.80,N/A,38792.07,N/A,17127.73,N/A,7760.17,N/A,192766.00,N/A,192766.00,N/A,10661.62,N/A,17127.73,N/A,17127.73,N/A,17127.73,N/A,62888.80,N/A,9171.14,N/A,7760.17,N/A,20377.73,N/A,20377.73,N/A,N/A,N/A,9171.14,N/A,9200.79,N/A,8303.39,N/A,7528.22,192766.00,N/A,N/A,,Hospital 50980,Ndsc Ureterotomy Rmvl FB/Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 51040,Cystostomy Cystotomy W/Drainage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19290.10,N/A,11574.06,N/A,2700.62,N/A,276.68,N/A,11100.14,N/A,6558.63,N/A,4078.58,N/A,2700.62,N/A,1675.03,N/A,1675.03,N/A,2538.99,N/A,4078.58,N/A,4078.58,N/A,4078.58,N/A,11100.14,N/A,1675.03,N/A,2700.62,N/A,3397.00,N/A,3397.00,N/A,2700.62,N/A,1675.03,N/A,276.68,N/A,304.35,N/A,N/A,276.68,11574.06,,Hospital 51050,Cystolithotomy Cystotomy W/Rmvl Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82725.22,N/A,49635.13,N/A,11474.55,N/A,4334.56,N/A,47623.59,N/A,28126.58,N/A,10325.23,N/A,11474.55,N/A,4246.26,N/A,4246.26,N/A,6427.63,N/A,10325.23,N/A,10325.23,N/A,10325.23,N/A,47623.57,N/A,4246.26,N/A,11474.55,N/A,3397.00,N/A,3397.00,N/A,11474.55,N/A,4246.26,N/A,4334.56,N/A,551.91,N/A,N/A,551.91,49635.13,,Hospital 51102,HC Aspiration of Bladder W/Ins,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,52194.03,15527.30,31316.42,9316.38,6943.01,2155.37,8508.51,1781.87,15646.63,8934.96,17139.57,5279.29,11473.15,4092.46,7156.93,2155.37,41588.00,1675.03,41588.00,1675.03,7142.27,2547.64,11473.15,4092.46,11473.15,4092.46,11473.15,4092.46,15646.63,8934.96,6718.94,1675.03,7156.93,2155.37,18793.66,3397.00,18793.66,3397.00,7156.93,2155.37,8478.86,1675.03,8508.51,1781.87,784.10,179.56,784.10,41588.00,179.56,9316.38,,Hospital 51605,Njx & Placement Chain Contrast&/Urethrocstograpy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17117.42,N/A,10270.45,N/A,2396.44,N/A,N/A,N/A,9854.71,N/A,5819.92,N/A,29.30,N/A,2396.44,N/A,N/A,N/A,N/A,N/A,18.24,N/A,29.30,N/A,29.30,N/A,29.30,N/A,9854.70,N/A,N/A,N/A,2396.44,N/A,527.00,N/A,527.00,N/A,2396.44,N/A,N/A,N/A,N/A,N/A,40.43,N/A,N/A,18.24,10270.45,,Hospital CPT 51701,HC Insert Bladder Catheter Non-Indwelling,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,362.00,362.00,217.20,217.20,N/A,50.68,N/A,111.11,N/A,208.44,N/A,123.08,N/A,253.64,N/A,50.68,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,208.44,N/A,104.85,N/A,50.68,N/A,362.00,N/A,362.00,N/A,50.68,N/A,104.85,N/A,111.54,N/A,27.51,217.20,217.20,27.51,362.00,,Hospital CPT 51701,HC Straight Cath - Residual Urine,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,362.00,362.00,217.20,217.20,N/A,50.68,N/A,111.11,N/A,208.44,N/A,123.08,N/A,253.64,N/A,50.68,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,208.44,N/A,104.85,N/A,50.68,N/A,194.03,N/A,194.03,N/A,50.68,N/A,104.85,N/A,111.54,N/A,27.51,217.20,217.20,27.51,253.64,,Hospital CPT 51703,HC Cath Urethra Complicated,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,740.00,740.00,444.00,444.00,N/A,103.60,N/A,73.75,N/A,426.09,N/A,251.60,N/A,317.67,N/A,103.60,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,426.09,N/A,131.33,N/A,103.60,N/A,740.00,N/A,740.00,N/A,103.60,N/A,131.33,N/A,73.75,N/A,81.13,444.00,444.00,73.75,740.00,,Hospital CPT 51705,HC Cystostomy Tube Change,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,837.00,837.00,502.20,502.20,N/A,117.18,N/A,202.97,N/A,481.94,N/A,284.58,N/A,469.36,N/A,117.18,N/A,194.04,N/A,194.04,N/A,292.18,N/A,469.36,N/A,469.36,N/A,469.36,N/A,481.94,N/A,194.04,N/A,117.18,N/A,448.63,N/A,448.63,N/A,117.18,N/A,194.04,N/A,205.63,N/A,53.93,502.20,502.20,53.93,502.20,,Hospital CPT 51705,HC Change Cystostomy Tube Smpl,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,837.00,837.00,502.20,502.20,N/A,117.18,N/A,202.97,N/A,481.94,N/A,284.58,N/A,469.36,N/A,117.18,N/A,194.04,N/A,194.04,N/A,292.18,N/A,469.36,N/A,469.36,N/A,469.36,N/A,481.94,N/A,194.04,N/A,117.18,N/A,837.00,N/A,837.00,N/A,117.18,N/A,194.04,N/A,205.63,N/A,53.93,502.20,502.20,53.93,837.00,,Hospital 51725,Simple Cystometrogram,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,103097.82,N/A,61858.69,N/A,14431.23,N/A,8729.62,N/A,59359.18,N/A,35053.26,N/A,19877.77,N/A,14431.23,N/A,8206.20,N/A,8206.20,N/A,12374.29,N/A,19877.77,N/A,19877.77,N/A,19877.77,N/A,59359.17,N/A,8206.20,N/A,14431.23,N/A,12203.25,N/A,12203.25,N/A,14431.23,N/A,8206.20,N/A,8729.62,N/A,2929.19,N/A,N/A,2929.19,61858.69,,Hospital 51726,Bladder Pressure Measurement During Filling,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16884.80,N/A,10130.88,N/A,2363.60,N/A,200.69,N/A,9722.27,N/A,5722.54,N/A,469.36,N/A,2363.60,N/A,194.04,N/A,194.04,N/A,292.18,N/A,469.36,N/A,469.36,N/A,469.36,N/A,9722.27,N/A,194.04,N/A,2363.60,N/A,527.00,N/A,527.00,N/A,2363.60,N/A,194.04,N/A,200.69,N/A,222.77,N/A,N/A,194.04,10130.88,,Hospital 51741,HC Complex Uroflometry,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,12704.80,N/A,7622.88,N/A,1745.32,N/A,1732.46,N/A,7315.42,N/A,4319.63,N/A,4051.75,N/A,1745.32,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,7315.42,N/A,1675.03,N/A,1745.32,N/A,2134.50,N/A,2134.50,N/A,1745.32,N/A,1675.03,N/A,1732.46,N/A,195.13,N/A,N/A,195.13,7622.88,,Hospital 51797,Void Pressure Studies Intraabdominal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10116.00,N/A,6069.60,N/A,1416.24,N/A,600.73,N/A,5824.79,N/A,3439.44,N/A,1365.97,N/A,1416.24,N/A,564.71,N/A,564.71,N/A,850.34,N/A,1365.97,N/A,1365.97,N/A,1365.97,N/A,5824.79,N/A,564.71,N/A,1416.24,N/A,1694.50,N/A,1694.50,N/A,1416.24,N/A,564.71,N/A,600.73,N/A,424.07,N/A,N/A,424.07,6069.60,,Hospital 51860,Cystorrhaphy Sutr Bldr Wnd Inj/Rpt Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60973.40,N/A,36584.04,N/A,8481.34,N/A,8584.05,N/A,35091.92,N/A,20730.95,N/A,20034.68,N/A,8481.34,N/A,8206.20,N/A,8206.20,N/A,12471.82,N/A,20034.68,N/A,20034.68,N/A,20034.68,N/A,35091.92,N/A,8206.20,N/A,8481.34,N/A,9595.50,N/A,9595.50,N/A,8481.34,N/A,8206.20,N/A,8584.05,N/A,1984.13,N/A,N/A,1984.13,36584.04,,Hospital 52204,Cystourethroscopy With Biopsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,57811.30,18396.85,34686.78,11038.11,8397.76,2568.47,10199.76,2894.35,18954.83,10575.87,N/A,6254.93,19106.07,7018.46,N/A,2568.47,2248.00,2894.35,2248.00,2894.35,11893.08,4369.12,19106.07,7018.46,19106.07,7018.46,19106.07,7018.46,18954.83,10575.88,10199.76,2894.35,8656.51,2568.47,22731.45,5944.75,22731.45,5944.75,N/A,2568.47,1825.17,2894.35,10199.76,2894.35,9262.46,3183.79,1825.17,34686.78,2568.47,11038.11,,Hospital 52214,Cysto W/Destruction of Lesions,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21438.70,N/A,12863.22,N/A,3002.28,N/A,3086.83,N/A,12341.26,N/A,7289.16,N/A,7033.02,N/A,3002.28,N/A,2902.21,N/A,2902.21,N/A,4378.19,N/A,7033.02,N/A,7033.02,N/A,7033.02,N/A,12341.26,N/A,2902.21,N/A,3002.28,N/A,3397.00,N/A,3397.00,N/A,3002.28,N/A,2902.21,N/A,3086.83,N/A,194.14,N/A,N/A,194.14,12863.22,,Hospital 52275,Cystourethroscopy W/Internal Urethrotomy Male,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9694.48,N/A,5816.69,N/A,1350.87,N/A,1693.17,N/A,5579.18,N/A,3296.13,N/A,4078.45,N/A,1350.87,N/A,1675.03,N/A,1675.03,N/A,2538.90,N/A,4078.45,N/A,4078.45,N/A,4078.45,N/A,5579.18,N/A,1675.03,N/A,1350.87,N/A,5944.75,N/A,5944.75,N/A,1350.87,N/A,1675.03,N/A,1693.17,N/A,417.82,N/A,N/A,417.82,5944.75,,Hospital 52282,Cystourethroscopy Insertion Perm Urethral Stent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,32774.67,16360.98,19664.80,9816.59,7528.22,2290.54,9200.79,2993.58,17279.35,9417.88,11143.38,5562.74,17127.73,7013.73,7760.17,2290.54,107342.00,2894.35,107342.00,2894.35,10661.62,4366.18,17127.73,7013.73,17127.73,7013.73,17127.73,7013.73,17279.35,9417.88,9171.14,2894.35,7760.17,2290.54,20377.73,3397.00,20377.73,3397.00,2364.19,2290.54,9171.14,2894.35,9200.79,2993.58,8303.39,352.52,2364.19,107342.00,352.52,9816.59,,Hospital 52287,HC Cystourethroscopy Inj Chemodenervation of Bladder,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,18662.20,N/A,11197.32,N/A,2612.71,N/A,1781.87,N/A,10633.47,N/A,6345.15,N/A,5672.62,N/A,2612.71,N/A,1675.03,N/A,1675.03,N/A,3531.30,N/A,5672.62,N/A,5672.62,N/A,5672.62,N/A,10633.47,N/A,1675.03,N/A,2612.71,N/A,1871.00,N/A,1871.00,N/A,2612.71,N/A,1675.03,N/A,1781.87,N/A,178.07,N/A,N/A,178.07,11197.32,,Hospital 52301,Cysto W/Resecj Ectopic Ureterocele Uni/Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21945.70,N/A,13167.42,N/A,3072.39,N/A,2993.58,N/A,12628.66,N/A,7461.53,N/A,7022.65,N/A,3072.39,N/A,2894.35,N/A,2894.35,N/A,4371.73,N/A,7022.65,N/A,7022.65,N/A,7022.65,N/A,12628.66,N/A,2894.35,N/A,3072.39,N/A,3397.00,N/A,3397.00,N/A,3072.39,N/A,2894.35,N/A,2993.58,N/A,333.36,N/A,N/A,333.36,13167.42,,Hospital 52317,Litholapaxy Smpl/Sm <2.5 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,57481.98,25724.52,34489.19,15434.71,5111.63,3582.72,6371.74,2894.35,18053.64,14810.29,19543.88,8746.34,11629.67,7015.81,5269.13,3582.72,100598.00,2894.35,100598.00,2894.35,7239.20,4367.47,11629.67,7015.81,11629.67,7015.81,11629.67,7015.81,18053.64,14810.30,6312.44,2894.35,5269.13,3582.72,13836.41,4332.50,13836.41,4332.50,5269.13,3582.72,4246.26,2894.35,6371.74,2894.35,5637.97,3183.79,4246.26,100598.00,2894.35,15434.71,,Hospital 52318,Litholapaxy Comp/Lg > 2.5 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52916.72,36537.68,31750.03,21922.61,4252.23,5045.56,4947.95,524.52,9271.37,20875.23,16060.48,12422.82,7118.07,7065.53,4383.24,5045.56,223114.00,2894.35,223114.00,2894.35,4431.15,4398.42,7118.07,7065.53,7118.07,7065.53,7118.07,7065.53,9271.37,20875.25,4888.65,2894.35,4383.24,5045.56,11136.13,3397.00,11136.13,3397.00,N/A,5045.56,4888.65,2933.61,4947.95,524.52,4690.07,576.98,4252.23,223114.00,524.52,21922.61,,Hospital 52320,Cystourethroscopy W/Rmvl Ureteral Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,28370.38,13568.33,17022.23,8141.00,5750.19,1907.48,2971.66,2869.35,13135.09,7796.98,9645.93,4613.23,12910.13,7043.21,5927.36,1907.48,6656.11,2894.35,6656.11,2894.35,8036.25,4384.52,12910.13,7043.21,12910.13,7043.21,12910.13,7043.21,13135.09,7796.98,6656.11,2894.35,5927.36,1907.48,15359.83,5095.50,15359.83,5095.50,3183.79,1907.48,6656.11,2894.35,6656.11,2869.35,6342.28,501.69,2971.66,17022.23,501.69,8141.00,,Hospital 52327,Cysto W/Suburtric Njx Implt Matrl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25869.25,N/A,15521.55,N/A,3621.70,N/A,4334.56,N/A,14736.06,N/A,8795.55,N/A,10283.65,N/A,3621.70,N/A,4246.26,N/A,4246.26,N/A,6401.77,N/A,10283.65,N/A,10283.65,N/A,10283.65,N/A,14736.06,N/A,4246.26,N/A,3621.70,N/A,5963.00,N/A,5963.00,N/A,3621.70,N/A,4246.26,N/A,4334.56,N/A,277.50,N/A,N/A,277.50,15521.55,,Hospital 52344,Cysto W/Urtroscopy W/Tx Ureteral Stricture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26335.72,N/A,15801.43,N/A,3687.01,N/A,2954.54,N/A,15137.00,N/A,8954.14,N/A,7035.44,N/A,3687.01,N/A,2894.35,N/A,2894.35,N/A,4382.02,N/A,7035.44,N/A,7035.44,N/A,7035.44,N/A,15137.00,N/A,2894.35,N/A,3687.01,N/A,5095.50,N/A,5095.50,N/A,3687.01,N/A,2894.35,N/A,2954.54,N/A,571.94,N/A,N/A,571.94,15801.43,,Hospital 52352,Cysto W/Ureteroscopy W/Rmvl/Manj Stones,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35425.52,21216.43,21255.31,12729.86,5750.19,2957.41,7097.47,2894.35,13192.11,12199.14,12044.68,7211.91,13082.47,7027.29,5927.36,2957.41,153426.00,2894.35,153426.00,2894.35,8143.53,4374.62,13082.47,7027.29,13082.47,7027.29,13082.47,7027.29,13192.11,12199.14,7067.82,2894.35,5927.36,2957.41,15564.88,5095.50,15564.88,5095.50,3056.06,2957.41,7067.82,2894.35,7097.47,2894.35,6342.28,3183.79,3056.06,153426.00,2894.35,12729.86,,Hospital 52630,Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35363.62,23506.28,21218.17,14103.77,7905.37,3283.45,9646.93,759.67,17815.40,13530.46,12023.63,7992.14,17985.82,10299.43,8148.95,3283.45,4246.26,4246.26,4246.26,4246.26,11195.75,6411.59,17985.82,10299.43,17985.82,10299.43,17985.82,10299.43,17815.40,13530.46,9617.28,4246.26,8148.95,3283.45,21398.64,7661.50,21398.64,7661.50,N/A,3283.45,9617.28,4246.26,9646.93,759.67,8719.38,835.64,4246.26,21398.64,759.67,14103.77,,Hospital 52647,Laser Coagulation of Prostate for Urine Flow,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40082.28,N/A,24049.37,N/A,5611.53,N/A,4391.84,N/A,23070.91,N/A,13627.98,N/A,10318.00,N/A,5611.53,N/A,4246.26,N/A,4246.26,N/A,6423.15,N/A,10318.00,N/A,10318.00,N/A,10318.00,N/A,23070.91,N/A,4246.26,N/A,5611.53,N/A,5963.00,N/A,5963.00,N/A,5611.53,N/A,4246.26,N/A,4391.84,N/A,696.61,N/A,N/A,696.61,24049.37,,Hospital 52648,Laser Vaporization of Prostate for Urine Flow,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,42189.58,34786.17,25313.75,20871.70,7905.37,4869.28,9617.28,4334.56,17815.40,20026.43,14344.46,11827.29,17985.82,10296.41,8148.95,4869.28,562.00,4246.26,562.00,4246.26,11195.75,6409.70,17985.82,10296.41,17985.82,10296.41,17985.82,10296.41,17815.40,20026.43,9617.28,4246.26,8148.95,4869.28,21398.64,5963.00,21398.64,5963.00,N/A,4869.28,9617.28,4246.26,9617.28,4334.56,8719.38,736.39,562.00,25313.75,736.39,20871.70,,Hospital 53010,Urethrotomy/Urethrostomy Xt Spx Perineal Urethra,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26817.40,N/A,16090.44,N/A,3743.60,N/A,4395.77,N/A,15435.55,N/A,9117.92,N/A,10297.12,N/A,3743.60,N/A,4250.19,N/A,4250.19,N/A,6410.16,N/A,10297.12,N/A,10297.12,N/A,10297.12,N/A,15435.55,N/A,4250.19,N/A,3743.60,N/A,3397.00,N/A,3397.00,N/A,3743.60,N/A,4250.19,N/A,4395.77,N/A,352.34,N/A,N/A,352.34,16090.44,,Hospital 53025,Meatotomy Cutting Meatus Spx Infant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14089.93,N/A,8453.96,N/A,1972.59,N/A,1847.76,N/A,8110.96,N/A,4784.82,N/A,4056.93,N/A,1972.59,N/A,1675.03,N/A,1675.03,N/A,2525.52,N/A,4056.93,N/A,4056.93,N/A,4056.93,N/A,8110.96,N/A,1675.03,N/A,1972.59,N/A,5095.50,N/A,5095.50,N/A,1972.59,N/A,1675.03,N/A,252.48,N/A,277.73,N/A,N/A,252.48,8453.96,,Hospital 53200,Biopsy Urethra,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14809.90,N/A,8885.94,N/A,2073.38,N/A,1732.46,N/A,8523.07,N/A,5035.36,N/A,4064.45,N/A,2073.38,N/A,1675.03,N/A,1675.03,N/A,2530.19,N/A,4064.45,N/A,4064.45,N/A,4064.45,N/A,8523.07,N/A,1675.03,N/A,2073.38,N/A,3397.00,N/A,3397.00,N/A,2073.38,N/A,1675.03,N/A,1732.46,N/A,182.08,N/A,N/A,182.08,8885.94,,Hospital 53215,Urethrectomy Tot W/Cystost Male,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,101417.20,N/A,60850.32,N/A,14186.44,N/A,7674.27,N/A,58375.31,N/A,34481.84,N/A,10711.75,N/A,14186.44,N/A,7640.41,N/A,7640.41,N/A,6778.70,N/A,10711.75,N/A,10711.75,N/A,10711.75,N/A,57173.04,N/A,7655.91,N/A,14186.44,N/A,6260.50,N/A,6260.50,N/A,14186.44,N/A,7640.41,N/A,7674.27,N/A,2274.41,N/A,N/A,2274.41,60850.32,,Hospital 53230,Exc Urethral Diverticulum Spx Female,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36517.33,N/A,21910.40,N/A,4849.76,N/A,705.24,N/A,21001.16,N/A,12415.89,N/A,10432.84,N/A,4849.76,N/A,4246.26,N/A,4246.26,N/A,6494.63,N/A,10432.84,N/A,10432.84,N/A,10432.84,N/A,21001.13,N/A,4246.26,N/A,4849.76,N/A,4562.00,N/A,4562.00,N/A,4849.76,N/A,4246.26,N/A,705.24,N/A,775.80,N/A,N/A,705.24,21910.40,,Hospital 53265,Exc/Fulguration Urethral Caruncle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17947.67,N/A,10768.60,N/A,2512.68,N/A,210.12,N/A,10328.16,N/A,6086.65,N/A,4073.20,N/A,2512.68,N/A,1675.03,N/A,1675.03,N/A,2535.64,N/A,4073.20,N/A,4073.20,N/A,4073.20,N/A,10328.17,N/A,1675.03,N/A,2512.68,N/A,3397.00,N/A,3397.00,N/A,2512.68,N/A,1675.03,N/A,210.12,N/A,231.14,N/A,N/A,210.12,10768.60,,Hospital 53275,Excision/Fulguration Urethral Prolapse,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23744.80,N/A,14246.88,N/A,3324.93,N/A,3078.97,N/A,13664.85,N/A,8073.23,N/A,7028.24,N/A,3324.93,N/A,2894.35,N/A,2894.35,N/A,4375.21,N/A,7028.24,N/A,7028.24,N/A,7028.24,N/A,13664.85,N/A,2894.35,N/A,3324.93,N/A,3397.00,N/A,3397.00,N/A,3324.93,N/A,2894.35,N/A,3078.97,N/A,319.49,N/A,N/A,319.49,14246.88,,Hospital 53446,Remvl Inflatable Urethral/Bladder Neck Sphincter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33141.87,N/A,19885.12,N/A,4634.18,N/A,617.89,N/A,19070.60,N/A,11268.24,N/A,10344.59,N/A,4634.18,N/A,4246.26,N/A,4246.26,N/A,6439.69,N/A,10344.59,N/A,10344.59,N/A,10344.59,N/A,19070.60,N/A,4246.26,N/A,4634.18,N/A,7897.00,N/A,7897.00,N/A,4634.18,N/A,4246.26,N/A,617.89,N/A,679.68,N/A,N/A,617.89,19885.12,,Hospital 53450,Urethromeatoplasty W/Mucosal Advancement,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11557.70,N/A,6934.62,N/A,1618.08,N/A,3007.04,N/A,6653.69,N/A,3929.62,N/A,7013.86,N/A,1618.08,N/A,2894.35,N/A,2894.35,N/A,4366.26,N/A,7013.86,N/A,7013.86,N/A,7013.86,N/A,6653.70,N/A,2894.35,N/A,1618.08,N/A,4562.00,N/A,4562.00,N/A,1618.08,N/A,2894.35,N/A,3007.04,N/A,429.46,N/A,N/A,429.46,7013.86,,Hospital 53460,Urethromeatoplasty W/Prtl Exc Dstl Urtl Sgm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8322.40,N/A,4993.44,N/A,1165.14,N/A,3007.04,N/A,4790.99,N/A,2825.41,N/A,7011.28,N/A,1165.14,N/A,2894.35,N/A,2894.35,N/A,4364.65,N/A,7011.28,N/A,7011.28,N/A,7011.28,N/A,4791.01,N/A,2894.35,N/A,1165.14,N/A,3397.00,N/A,3397.00,N/A,1165.14,N/A,2894.35,N/A,3007.04,N/A,481.42,N/A,N/A,481.42,7011.28,,Hospital 54001,Slitting Prepuce Dorsal/Lat Spx Xcp Newborn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,43923.40,15008.50,26354.04,9005.10,12867.10,2094.10,15486.76,1675.03,28997.06,8640.48,14933.96,5102.89,29274.44,4065.64,13263.56,2094.10,562.00,1675.03,562.00,1675.03,18222.66,2530.93,29274.44,4065.64,29274.44,4065.64,29274.44,4065.64,28997.06,8640.48,15486.76,1675.03,13263.56,2094.10,34829.28,3397.00,34829.28,3397.00,N/A,2094.10,1690.75,1675.03,15486.76,1675.03,14192.01,1842.53,562.00,34829.28,1675.03,9005.10,,Hospital 54100,Biopsy Penis Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14445.90,N/A,8667.54,N/A,2020.32,N/A,1416.50,N/A,8317.17,N/A,4911.60,N/A,3295.80,N/A,2020.32,N/A,1354.15,N/A,1354.15,N/A,2051.69,N/A,3295.80,N/A,3295.80,N/A,3295.80,N/A,8317.17,N/A,1354.15,N/A,2020.32,N/A,1871.00,N/A,1871.00,N/A,2020.32,N/A,1354.15,N/A,1416.50,N/A,163.58,N/A,N/A,163.58,8667.54,,Hospital 54115,Removal Foreign Body Deep Penile Tissue,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10014.30,N/A,6008.58,N/A,1402.01,N/A,2423.61,N/A,5764.88,N/A,3404.87,N/A,5659.49,N/A,1402.01,N/A,2332.78,N/A,2332.78,N/A,3523.15,N/A,5659.49,N/A,5659.49,N/A,5659.49,N/A,5764.89,N/A,2332.78,N/A,1402.01,N/A,3397.00,N/A,3397.00,N/A,1402.01,N/A,2332.78,N/A,2423.61,N/A,457.72,N/A,N/A,457.72,6008.58,,Hospital 54163,Repair Incomplete Circumcision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16016.97,N/A,9610.18,N/A,2242.37,N/A,1847.76,N/A,9218.51,N/A,5445.77,N/A,4054.94,N/A,2242.37,N/A,1675.03,N/A,1675.03,N/A,2524.27,N/A,4054.94,N/A,4054.94,N/A,4054.94,N/A,9218.51,N/A,1675.03,N/A,2242.37,N/A,3397.00,N/A,3397.00,N/A,2242.37,N/A,1675.03,N/A,206.63,N/A,227.29,N/A,N/A,206.63,9610.18,,Hospital 54164,Frenulotomy Penis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18713.83,N/A,11228.30,N/A,2609.44,N/A,376.15,N/A,10768.00,N/A,6347.40,N/A,4071.54,N/A,2609.44,N/A,1675.03,N/A,1675.03,N/A,2534.61,N/A,4071.54,N/A,4071.54,N/A,4071.54,N/A,10768.01,N/A,1675.03,N/A,2609.44,N/A,5095.50,N/A,5095.50,N/A,2609.44,N/A,1675.03,N/A,376.15,N/A,413.77,N/A,N/A,376.15,11228.30,,Hospital CPT 54220,HC Aspiration of Corpora Cavernos,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1067.00,1067.00,640.20,640.20,N/A,149.38,N/A,127.72,N/A,614.38,N/A,362.78,N/A,615.12,N/A,149.38,N/A,127.72,N/A,127.72,N/A,382.91,N/A,615.12,N/A,615.12,N/A,615.12,N/A,614.38,N/A,127.72,N/A,149.38,N/A,1067.00,N/A,1067.00,N/A,149.38,N/A,127.72,N/A,127.72,N/A,140.49,640.20,640.20,127.72,1067.00,,Hospital 54322,1 Stg Dstl Hypospadias Rpr W/Smpl Meatal Advmnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74396.62,N/A,44637.97,N/A,10415.52,N/A,3078.97,N/A,42834.64,N/A,25294.85,N/A,7004.98,N/A,10415.52,N/A,2894.35,N/A,2894.35,N/A,4360.73,N/A,7004.98,N/A,7004.98,N/A,7004.98,N/A,42834.64,N/A,2894.35,N/A,10415.52,N/A,4562.00,N/A,4562.00,N/A,10415.52,N/A,2894.35,N/A,3078.97,N/A,823.27,N/A,N/A,823.27,44637.97,,Hospital 54400,Insj Penile Prosthesis Non-Inflatable Semi-Rigid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,88626.07,76209.37,53175.64,45725.62,7689.32,10661.80,9361.72,11361.96,43303.20,43250.57,30132.87,25911.18,17494.27,26313.39,7926.24,10661.80,1686.00,10861.83,1686.00,10861.83,10889.78,16381.63,17494.27,26313.39,17494.27,26313.39,17494.27,26313.39,43303.20,43250.57,9361.72,10861.83,7926.24,10661.80,20813.82,11660.00,20813.82,11660.00,N/A,10661.80,9361.72,10861.83,9361.72,11361.96,8481.08,575.61,1686.00,53175.64,575.61,45725.62,,Hospital 54410,Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,110574.60,N/A,66344.76,N/A,15473.28,N/A,18213.89,N/A,62893.19,N/A,37595.37,N/A,42219.57,N/A,15473.28,N/A,17412.16,N/A,17412.16,N/A,26282.48,N/A,42219.57,N/A,42219.57,N/A,42219.57,N/A,62893.21,N/A,17412.16,N/A,15473.28,N/A,16637.00,N/A,16637.00,N/A,15473.28,N/A,17412.16,N/A,18213.89,N/A,921.02,N/A,N/A,921.02,66344.76,,Hospital 54437,Repair of Traumatic Corporeal Tear(S),N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34454.93,N/A,20672.96,N/A,4823.70,N/A,947.66,N/A,19819.55,N/A,11714.68,N/A,7121.35,N/A,4823.70,N/A,2894.35,N/A,2894.35,N/A,4433.18,N/A,7121.35,N/A,7121.35,N/A,7121.35,N/A,19430.33,N/A,2894.35,N/A,4823.70,N/A,4112.50,N/A,4112.50,N/A,4823.70,N/A,2894.35,N/A,947.66,N/A,1042.43,N/A,N/A,947.66,20672.96,,Hospital 54512,Exc Xtrparenchymal Lesion Testis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21152.20,N/A,12691.32,N/A,2961.30,N/A,2954.54,N/A,12173.96,N/A,7191.74,N/A,7040.48,N/A,2961.30,N/A,2894.35,N/A,2894.35,N/A,4382.84,N/A,7040.48,N/A,7040.48,N/A,7040.48,N/A,12030.01,N/A,2894.35,N/A,2961.30,N/A,3397.00,N/A,3397.00,N/A,2961.30,N/A,2894.35,N/A,2954.54,N/A,598.48,N/A,N/A,598.48,12691.32,,Hospital 54522,Orchiectomy Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25676.00,N/A,15405.60,N/A,3594.62,N/A,3345.78,N/A,14780.84,N/A,8729.82,N/A,7805.29,N/A,3594.62,N/A,3198.50,N/A,3198.50,N/A,4858.93,N/A,7805.29,N/A,7805.29,N/A,7805.29,N/A,14780.84,N/A,3198.50,N/A,3594.62,N/A,6260.50,N/A,6260.50,N/A,3594.62,N/A,3198.50,N/A,3345.78,N/A,1108.29,N/A,N/A,1108.29,15405.60,,Hospital 54535,Orchiectomy Radical Tumor W/Abdominal Expl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36442.20,N/A,21865.32,N/A,5101.91,N/A,3027.62,N/A,20975.44,N/A,12390.34,N/A,7139.84,N/A,5101.91,N/A,2894.35,N/A,2894.35,N/A,4444.68,N/A,7139.84,N/A,7139.84,N/A,7139.84,N/A,20975.45,N/A,2894.35,N/A,5101.91,N/A,4562.00,N/A,4562.00,N/A,5101.91,N/A,2894.35,N/A,3027.62,N/A,816.52,N/A,N/A,816.52,21865.32,,Hospital 54640,Orchiopexy Inguinal or Scrotal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22064.25,N/A,13238.55,N/A,3089.00,N/A,414.91,N/A,12682.92,N/A,7501.59,N/A,7856.02,N/A,3089.00,N/A,3198.50,N/A,3198.50,N/A,4890.50,N/A,7856.02,N/A,7856.02,N/A,7856.02,N/A,12682.94,N/A,3198.50,N/A,3089.00,N/A,6843.00,N/A,6843.00,N/A,3089.00,N/A,3198.50,N/A,414.91,N/A,456.40,N/A,N/A,414.91,13238.55,,Hospital 54692,Laparoscopy Orchiopexy Intra-Abdominal Testis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33996.20,N/A,20397.72,N/A,4759.47,N/A,5007.00,N/A,19574.08,N/A,11558.71,N/A,11389.20,N/A,4759.47,N/A,4706.78,N/A,4706.78,N/A,7089.99,N/A,11389.20,N/A,11389.20,N/A,11389.20,N/A,19574.07,N/A,4706.78,N/A,4759.47,N/A,7897.00,N/A,7897.00,N/A,4759.47,N/A,4706.78,N/A,5007.00,N/A,797.63,N/A,N/A,797.63,20397.72,,Hospital CPT 54700,HC Incis/Drain Scrotum/Testis Epididym,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,6044.00,6044.00,3626.40,3626.40,N/A,846.16,N/A,203.03,N/A,3480.14,N/A,2054.96,N/A,603.81,N/A,846.16,N/A,203.03,N/A,203.03,N/A,375.87,N/A,603.81,N/A,603.81,N/A,603.81,N/A,3480.14,N/A,203.03,N/A,846.16,N/A,6044.00,N/A,6044.00,N/A,846.16,N/A,203.03,N/A,203.03,N/A,223.33,3626.40,3626.40,203.03,6044.00,,Hospital 55060,Rpr Tunica Vaginalis Hydrocele Bottle Type,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22443.00,N/A,13465.80,N/A,3142.03,N/A,2894.35,N/A,12919.32,N/A,7630.62,N/A,7045.08,N/A,3142.03,N/A,2894.35,N/A,2894.35,N/A,4385.69,N/A,7045.08,N/A,7045.08,N/A,7045.08,N/A,12919.31,N/A,2894.35,N/A,3142.03,N/A,3397.00,N/A,3397.00,N/A,3142.03,N/A,2894.35,N/A,2894.35,N/A,3183.79,N/A,N/A,2894.35,13465.80,,Hospital 55110,Scrotal Exploration,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19925.48,N/A,11955.29,N/A,2732.70,N/A,676.29,N/A,11462.23,N/A,6774.41,N/A,7115.24,N/A,2732.70,N/A,2894.35,N/A,2894.35,N/A,4429.37,N/A,7115.24,N/A,7115.24,N/A,7115.24,N/A,11462.25,N/A,2894.35,N/A,2732.70,N/A,4470.25,N/A,4470.25,N/A,2732.70,N/A,2894.35,N/A,676.29,N/A,743.93,N/A,N/A,676.29,11955.29,,Hospital 55120,Removal Foreign Body Scrotum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24525.20,N/A,14715.12,N/A,3379.82,N/A,1666.46,N/A,14117.39,N/A,8338.58,N/A,4148.18,N/A,3379.82,N/A,1675.03,N/A,1675.03,N/A,2582.31,N/A,4148.18,N/A,4148.18,N/A,4148.18,N/A,13036.05,N/A,1675.03,N/A,3379.82,N/A,3397.00,N/A,3397.00,N/A,3379.82,N/A,1675.03,N/A,1666.46,N/A,560.40,N/A,N/A,560.40,14715.12,,Hospital 55500,Exc Hydrocele Sprmatic Cord Uni Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17529.28,N/A,10517.57,N/A,2454.11,N/A,375.69,N/A,10082.95,N/A,5959.70,N/A,7085.68,N/A,2454.11,N/A,2894.35,N/A,2894.35,N/A,4410.98,N/A,7085.68,N/A,7085.68,N/A,7085.68,N/A,10082.97,N/A,2894.35,N/A,2454.11,N/A,4562.00,N/A,4562.00,N/A,2454.11,N/A,2894.35,N/A,375.69,N/A,413.26,N/A,N/A,375.69,10517.57,,Hospital 55520,Exc Lesion Spermatic Cord Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,33049.50,28408.15,19829.70,17044.89,5879.29,3966.64,6922.52,948.76,13626.56,16279.37,11236.83,9658.77,13404.10,7811.01,6060.44,3966.64,6892.87,3198.50,6892.87,3198.50,8343.74,4862.49,13404.10,7811.01,13404.10,7811.01,13404.10,7811.01,13626.56,16279.38,6892.87,3198.50,6060.44,3966.64,15947.54,6260.50,15947.54,6260.50,2964.74,3966.64,6892.87,3198.50,6922.52,948.76,6484.67,1043.65,2964.74,19829.70,948.76,17044.89,,Hospital 55550,Laps Ligation Spermatic Veins Varicocele,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32995.82,N/A,19797.49,N/A,4595.49,N/A,4923.50,N/A,18997.91,N/A,11189.26,N/A,11406.34,N/A,4595.49,N/A,4706.78,N/A,4706.78,N/A,7100.68,N/A,11406.34,N/A,11406.34,N/A,11406.34,N/A,18997.91,N/A,4706.78,N/A,4595.49,N/A,7897.00,N/A,7897.00,N/A,4595.49,N/A,4706.78,N/A,4923.50,N/A,485.41,N/A,N/A,485.41,19797.49,,Hospital 55705,Biopsy Prostate Incisional Any Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15242.30,N/A,9145.38,N/A,2111.63,N/A,3082.90,N/A,8774.14,N/A,5182.38,N/A,7017.87,N/A,2111.63,N/A,2894.35,N/A,2894.35,N/A,4368.76,N/A,7017.87,N/A,7017.87,N/A,7017.87,N/A,8774.15,N/A,2894.35,N/A,2111.63,N/A,1871.00,N/A,1871.00,N/A,2111.63,N/A,2898.28,N/A,3082.90,N/A,738.58,N/A,N/A,738.58,9145.38,,Hospital 55831,Prostatectomy Retropubic Subtotal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86324.45,N/A,51794.67,N/A,11250.71,N/A,12491.08,N/A,26379.39,N/A,29350.31,N/A,24695.15,N/A,11597.37,N/A,561438.00,N/A,561438.00,N/A,15372.16,N/A,24695.15,N/A,24695.15,N/A,24695.15,N/A,26379.39,N/A,12461.43,N/A,11597.37,N/A,30453.96,N/A,29381.07,N/A,N/A,N/A,12461.43,N/A,12491.08,N/A,12409.18,N/A,11250.71,561438.00,N/A,N/A,,Hospital 56441,Lysis Labial Adhesions,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9858.80,N/A,5915.28,N/A,1380.23,N/A,2531.24,N/A,5675.92,N/A,3351.99,N/A,6184.59,N/A,1380.23,N/A,2553.29,N/A,2553.29,N/A,3850.02,N/A,6184.59,N/A,6184.59,N/A,6184.59,N/A,5675.93,N/A,2553.29,N/A,1380.23,N/A,3397.00,N/A,3397.00,N/A,1380.23,N/A,2553.29,N/A,2531.24,N/A,162.07,N/A,N/A,162.07,6184.59,,Hospital 56501,"HC Destruct of Lesions, Vulva Les",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,19386.43,N/A,11631.86,N/A,2697.50,N/A,134.81,N/A,11156.62,N/A,6461.71,N/A,3789.05,N/A,2697.50,N/A,1558.52,N/A,1558.52,N/A,2358.76,N/A,3789.05,N/A,3789.05,N/A,3789.05,N/A,11156.62,N/A,1558.52,N/A,2697.50,N/A,1871.00,N/A,1871.00,N/A,2697.50,N/A,1558.52,N/A,134.81,N/A,148.29,N/A,N/A,134.81,11631.86,,Hospital 56633,Vulvectomy Radical Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,85228.10,N/A,51136.86,N/A,11912.85,N/A,3247.41,N/A,48919.66,N/A,28977.54,N/A,18623.77,N/A,11912.85,N/A,6311.41,N/A,6311.41,N/A,11593.93,N/A,18623.77,N/A,18623.77,N/A,18623.77,N/A,48919.66,N/A,6311.41,N/A,11912.85,N/A,14072.75,N/A,14072.75,N/A,11912.85,N/A,6311.41,N/A,3247.41,N/A,3399.61,N/A,N/A,3247.41,51136.86,,Hospital 56810,Perineoplasty Rpr Perineum Nonobstetrical Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15774.90,N/A,9464.94,N/A,2153.25,N/A,2670.86,N/A,9081.64,N/A,5363.46,N/A,6191.45,N/A,2153.25,N/A,2553.29,N/A,2553.29,N/A,3854.30,N/A,6191.45,N/A,6191.45,N/A,6191.45,N/A,9081.64,N/A,2553.29,N/A,2153.25,N/A,3397.00,N/A,3397.00,N/A,2153.25,N/A,2553.29,N/A,2670.86,N/A,320.98,N/A,N/A,320.98,9464.94,,Hospital 56820,HC Exam of Vulva W/Scope,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,2789.00,N/A,1673.40,N/A,390.46,N/A,171.12,N/A,1605.91,N/A,948.26,N/A,N/A,N/A,390.46,N/A,160.86,N/A,160.86,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1605.91,N/A,160.86,N/A,390.46,N/A,1494.90,N/A,1494.90,N/A,390.46,N/A,160.86,N/A,171.12,N/A,89.45,N/A,N/A,89.45,1673.40,,Hospital 57106,Vaginectomy Partial Removal Vaginal Wall,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44232.90,N/A,26539.74,N/A,6175.44,N/A,4452.67,N/A,25413.49,N/A,15039.19,N/A,10162.21,N/A,6175.44,N/A,4185.69,N/A,4185.69,N/A,6326.17,N/A,10162.21,N/A,10162.21,N/A,10162.21,N/A,25413.50,N/A,4185.69,N/A,6175.44,N/A,6260.50,N/A,6260.50,N/A,6175.44,N/A,4185.69,N/A,4452.67,N/A,1450.53,N/A,N/A,1450.53,26539.74,,Hospital 57111,Vaginectomy Compl Rmvl Vag Wall & Paravag Tiss,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31302.28,N/A,18781.37,N/A,4382.33,N/A,4297.49,N/A,17949.62,N/A,10642.78,N/A,20286.65,N/A,4382.33,N/A,4185.69,N/A,4185.69,N/A,12628.83,N/A,20286.65,N/A,20286.65,N/A,20286.65,N/A,17949.61,N/A,4185.69,N/A,4382.33,N/A,7983.50,N/A,7983.50,N/A,4382.33,N/A,4185.69,N/A,4297.49,N/A,2629.53,N/A,N/A,2629.53,20286.65,,Hospital 57130,Excision Vaginal Septum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50199.22,N/A,30119.53,N/A,6963.72,N/A,4923.50,N/A,28901.49,N/A,16989.32,N/A,11468.60,N/A,6963.72,N/A,4706.78,N/A,4706.78,N/A,7139.42,N/A,11468.60,N/A,11468.60,N/A,11468.60,N/A,28901.50,N/A,4706.78,N/A,6963.72,N/A,10444.75,N/A,10444.75,N/A,6963.72,N/A,4706.78,N/A,4923.50,N/A,1143.41,N/A,N/A,1143.41,30119.53,,Hospital CPT 57135,Excision Vaginal Cyst/Tumor,N/A,N/A,410.00,410.00,246.00,246.00,N/A,57.40,N/A,179.74,N/A,410.00,N/A,139.40,N/A,410.00,N/A,57.40,N/A,179.74,N/A,179.74,N/A,410.00,N/A,410.00,N/A,410.00,N/A,410.00,N/A,410.00,N/A,179.74,N/A,57.40,N/A,410.00,N/A,410.00,N/A,57.40,N/A,179.74,N/A,179.74,N/A,197.71,246.00,246.00,57.40,410.00,,Hospital 57150,Irrigation Vagina&/Appl Medicament Tx Disease,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39457.62,N/A,23674.57,N/A,5544.83,N/A,142.00,N/A,22714.36,N/A,13180.57,N/A,457.68,N/A,5544.83,N/A,142.00,N/A,142.00,N/A,284.91,N/A,457.68,N/A,457.68,N/A,457.68,N/A,22714.35,N/A,142.00,N/A,5544.83,N/A,527.00,N/A,527.00,N/A,5544.83,N/A,142.00,N/A,142.00,N/A,266.20,N/A,N/A,142.00,23674.57,,Hospital 57220,Plastic Urethral Sphincter Vaginal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68476.50,N/A,41085.90,N/A,9579.60,N/A,4378.42,N/A,39426.26,N/A,23282.02,N/A,10178.87,N/A,9579.60,N/A,4185.69,N/A,4185.69,N/A,6336.54,N/A,10178.87,N/A,10178.87,N/A,10178.87,N/A,38921.90,N/A,4185.69,N/A,9579.60,N/A,5963.00,N/A,5963.00,N/A,9579.60,N/A,4185.69,N/A,4378.42,N/A,429.70,N/A,N/A,429.70,41085.90,,Hospital 57230,Plastic Repair Urethrocele,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26497.93,N/A,15898.76,N/A,3700.84,N/A,4378.42,N/A,15202.88,N/A,9009.28,N/A,10147.42,N/A,3700.84,N/A,4185.69,N/A,4185.69,N/A,6316.97,N/A,10147.42,N/A,10147.42,N/A,10147.42,N/A,15202.88,N/A,4185.69,N/A,3700.84,N/A,7661.50,N/A,7661.50,N/A,3700.84,N/A,4185.69,N/A,4378.42,N/A,1240.60,N/A,N/A,1240.60,15898.76,,Hospital 57288,Sling Operation Stress Incontinence,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,89917.42,38762.23,53950.45,23257.34,5750.19,5426.70,4923.50,4378.42,15640.97,22258.32,30571.92,13179.15,12910.13,10278.55,5927.36,5426.70,239974.00,4185.69,239974.00,4185.69,8036.25,6398.59,12910.13,10278.55,12910.13,10278.55,12910.13,10278.55,15640.97,22258.33,6648.07,4185.69,5927.36,5426.70,15359.83,8244.00,15359.83,8244.00,N/A,5426.70,6648.07,4185.69,6677.72,4378.42,6342.28,1443.45,4923.50,239974.00,1443.45,23257.34,,Hospital 57295,Revj/Rmvl Prosthetic Vaginal Graft Vaginal App,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20935.20,N/A,12561.12,N/A,2930.93,N/A,2670.86,N/A,12052.98,N/A,7117.97,N/A,6201.26,N/A,2930.93,N/A,2553.29,N/A,2553.29,N/A,3860.41,N/A,6201.26,N/A,6201.26,N/A,6201.26,N/A,12052.99,N/A,2553.29,N/A,2930.93,N/A,3397.00,N/A,3397.00,N/A,2930.93,N/A,2553.29,N/A,2670.86,N/A,531.99,N/A,N/A,531.99,12561.12,,Hospital 57320,Closure Vesicovaginal Fistula Vaginal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22429.75,N/A,13457.85,N/A,3123.58,N/A,604.66,N/A,12905.10,N/A,7610.56,N/A,10165.55,N/A,3123.58,N/A,4185.69,N/A,4185.69,N/A,6328.25,N/A,10165.55,N/A,10165.55,N/A,10165.55,N/A,12905.10,N/A,4185.69,N/A,3123.58,N/A,4562.00,N/A,4562.00,N/A,3123.58,N/A,4185.69,N/A,604.66,N/A,665.13,N/A,N/A,604.66,13457.85,,Hospital 57415,Removal Impacted Vag FB Spx W/Anes Oth/Thn Local,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15482.10,N/A,9289.26,N/A,2167.50,N/A,2716.15,N/A,8911.57,N/A,5263.92,N/A,6196.99,N/A,2167.50,N/A,2553.29,N/A,2553.29,N/A,3857.75,N/A,6196.99,N/A,6196.99,N/A,6196.99,N/A,8911.56,N/A,2553.29,N/A,2167.50,N/A,4112.50,N/A,4112.50,N/A,2167.50,N/A,2553.29,N/A,2716.15,N/A,270.19,N/A,N/A,270.19,9289.26,,Hospital 57421,Colposcopy Entire Vagina W/Vagina/Cervix Bx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17557.10,N/A,10534.26,N/A,2457.99,N/A,675.78,N/A,10097.06,N/A,5969.41,N/A,1636.46,N/A,2457.99,N/A,635.26,N/A,635.26,N/A,1018.73,N/A,1636.46,N/A,1636.46,N/A,1636.46,N/A,10097.06,N/A,635.26,N/A,2457.99,N/A,1431.00,N/A,1431.00,N/A,2457.99,N/A,635.26,N/A,675.78,N/A,290.54,N/A,N/A,290.54,10534.26,,Hospital 57423,Paravaginal Defect Repair Laparoscopic Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48712.13,N/A,29227.28,N/A,6763.97,N/A,8164.21,N/A,28040.74,N/A,16560.06,N/A,19966.73,N/A,6763.97,N/A,8206.20,N/A,8206.20,N/A,12429.69,N/A,19966.73,N/A,19966.73,N/A,19966.73,N/A,28040.73,N/A,8206.20,N/A,6763.97,N/A,13819.75,N/A,13819.75,N/A,6763.97,N/A,8206.20,N/A,8164.21,N/A,3414.41,N/A,N/A,3414.41,29227.28,,Hospital 57500,HC Biopsy of Cervix,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,18279.62,N/A,10967.77,N/A,2542.56,N/A,362.77,N/A,10519.24,N/A,6199.34,N/A,6213.86,N/A,2542.56,N/A,2553.29,N/A,2553.29,N/A,3868.24,N/A,6213.86,N/A,6213.86,N/A,6213.86,N/A,10519.25,N/A,2553.29,N/A,2542.56,N/A,4112.50,N/A,4112.50,N/A,2542.56,N/A,2553.29,N/A,362.77,N/A,399.05,N/A,N/A,362.77,10967.77,,Hospital CPT 57520,Conization Cervix W/WO D&C Rpr Knife/Laser,N/A,N/A,584.00,584.00,350.40,350.40,N/A,81.76,N/A,282.92,N/A,584.00,N/A,198.56,N/A,584.00,N/A,81.76,N/A,282.92,N/A,282.92,N/A,584.00,N/A,584.00,N/A,584.00,N/A,584.00,N/A,584.00,N/A,282.92,N/A,81.76,N/A,584.00,N/A,584.00,N/A,81.76,N/A,282.92,N/A,282.92,N/A,311.21,350.40,350.40,81.76,584.00,,Hospital 57530,Trachelectomy Cervicectomy Amp Cervix Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,177691.37,N/A,106614.82,N/A,24875.67,N/A,12958.07,N/A,101931.23,N/A,60415.06,N/A,11440.21,N/A,24875.67,N/A,12937.90,N/A,12937.90,N/A,7121.76,N/A,11440.21,N/A,11440.21,N/A,11440.21,N/A,101931.22,N/A,12937.90,N/A,24875.67,N/A,10063.25,N/A,10063.25,N/A,24875.67,N/A,12937.90,N/A,12958.07,N/A,1459.01,N/A,N/A,1459.01,106614.82,,Hospital 57556,Exc Crv Stump Vag Appr W/Rpr Ntrcl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,126095.52,N/A,75657.31,N/A,17646.49,N/A,9854.84,N/A,72370.08,N/A,42872.48,N/A,19909.63,N/A,17646.49,N/A,9789.41,N/A,9789.41,N/A,12394.12,N/A,19909.63,N/A,19909.63,N/A,19909.63,N/A,72370.07,N/A,9789.41,N/A,17646.49,N/A,12019.00,N/A,12019.00,N/A,17646.49,N/A,9789.41,N/A,9854.84,N/A,2090.50,N/A,N/A,2090.50,75657.31,,Hospital 58262,Vag Hyst 250 Gm/< W/Rmvl Tube&/Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48771.05,44473.63,29262.63,26684.18,6244.71,6223.29,7682.45,4460.53,14249.03,25519.14,16582.16,15121.04,14207.57,10236.91,6437.12,6223.29,145558.00,4193.55,145558.00,4193.55,8843.88,6372.69,14207.57,10236.91,14207.57,10236.91,14207.57,10236.91,14249.03,25519.15,7652.80,4193.55,6437.12,6223.29,16903.46,8244.00,6843.00,8244.00,N/A,6223.29,7652.80,4193.55,7682.45,4460.53,6887.72,2066.97,6244.71,145558.00,2066.97,26684.18,,Hospital CPT 58350,Chromotubation Oviduct W/Materials,N/A,N/A,258.00,258.00,154.80,154.80,N/A,36.12,N/A,90.55,N/A,258.00,N/A,87.72,N/A,258.00,N/A,36.12,N/A,90.55,N/A,90.55,N/A,258.00,N/A,258.00,N/A,258.00,N/A,258.00,N/A,258.00,N/A,90.55,N/A,36.12,N/A,258.00,N/A,258.00,N/A,36.12,N/A,90.55,N/A,90.55,N/A,99.61,154.80,154.80,36.12,258.00,,Hospital 58542,Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,53051.08,66694.32,31830.65,40016.59,6244.71,9296.27,8135.31,2661.49,17234.57,38117.73,18037.36,22676.07,14207.57,19912.75,6437.12,9296.27,65192.00,8206.20,65192.00,8206.20,8843.88,12396.08,14207.57,19912.75,14207.57,19912.75,14207.57,19912.75,17234.57,38117.74,7652.80,8206.20,6437.12,9296.27,16903.46,13336.25,16903.46,13336.25,N/A,9296.27,7652.80,8206.20,7682.45,2661.49,6887.72,2927.64,6244.71,65192.00,2661.49,40016.59,,Hospital CPT 58545,Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,N/A,N/A,1799.00,1799.00,1079.40,1079.40,N/A,251.86,N/A,872.64,N/A,1799.00,N/A,611.66,N/A,1799.00,N/A,251.86,N/A,872.64,N/A,872.64,N/A,1617.26,N/A,1799.00,N/A,1799.00,N/A,1799.00,N/A,1799.00,N/A,872.64,N/A,251.86,N/A,1799.00,N/A,1799.00,N/A,251.86,N/A,872.64,N/A,872.64,N/A,959.90,1079.40,1079.40,251.86,1799.00,,Hospital 58555,Hysteroscopy Diagnostic Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26029.70,N/A,15617.82,N/A,3598.14,N/A,2670.86,N/A,14736.95,N/A,8850.09,N/A,6349.74,N/A,3598.14,N/A,2553.29,N/A,2553.29,N/A,4016.86,N/A,6349.74,N/A,6349.74,N/A,6349.74,N/A,14983.40,N/A,2553.29,N/A,3598.14,N/A,5095.50,N/A,5095.50,N/A,3598.14,N/A,2553.29,N/A,2670.86,N/A,768.94,N/A,N/A,768.94,15617.82,,Hospital 58559,Hysteroscopy Lysis Intrauterine Adhesions,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27424.63,N/A,16454.78,N/A,3801.81,N/A,4388.43,N/A,15782.15,N/A,9324.37,N/A,10155.85,N/A,3801.81,N/A,4185.69,N/A,4185.69,N/A,6322.20,N/A,10155.85,N/A,10155.85,N/A,10155.85,N/A,15782.16,N/A,4185.69,N/A,3801.81,N/A,3397.00,N/A,3397.00,N/A,3801.81,N/A,4185.69,N/A,291.62,N/A,320.78,N/A,N/A,291.62,16454.78,,Hospital CPT 58560,Hysteroscopy Div/Rescj Intrauterine Septum,N/A,N/A,636.00,636.00,381.60,381.60,N/A,89.04,N/A,302.26,N/A,636.00,N/A,216.24,N/A,636.00,N/A,89.04,N/A,302.26,N/A,302.26,N/A,559.84,N/A,636.00,N/A,636.00,N/A,636.00,N/A,636.00,N/A,302.26,N/A,89.04,N/A,636.00,N/A,636.00,N/A,89.04,N/A,302.26,N/A,302.26,N/A,332.49,381.60,381.60,89.04,636.00,,Hospital 58565,Hysteroscopy Bi Tube Occlusion W/Perm Implnts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34793.85,N/A,20876.31,N/A,4871.14,N/A,4435.71,N/A,20029.73,N/A,11829.91,N/A,10172.42,N/A,4871.14,N/A,4185.69,N/A,4185.69,N/A,6332.54,N/A,10172.42,N/A,10172.42,N/A,10172.42,N/A,20029.73,N/A,4185.69,N/A,4871.14,N/A,8244.00,N/A,8244.00,N/A,4871.14,N/A,4185.69,N/A,4435.71,N/A,746.79,N/A,N/A,746.79,20876.31,,Hospital CPT 58578,Unlisted Laparoscopy Procedure Uterus,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 58579,Unlisted Hysteroscopy Procedure Uterus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8921.60,N/A,5352.96,N/A,1249.02,N/A,159.47,N/A,5135.22,N/A,3033.34,N/A,408.50,N/A,1249.02,N/A,160.86,N/A,160.86,N/A,254.29,N/A,408.50,N/A,408.50,N/A,408.50,N/A,5109.31,N/A,160.86,N/A,1249.02,N/A,527.00,N/A,527.00,N/A,1249.02,N/A,160.86,N/A,159.47,N/A,1763.51,N/A,N/A,159.47,5352.96,,Hospital CPT 58662,Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,N/A,N/A,1415.00,1415.00,849.00,849.00,N/A,198.10,N/A,688.20,N/A,1415.00,N/A,481.10,N/A,1415.00,N/A,198.10,N/A,688.20,N/A,688.20,N/A,1276.79,N/A,1415.00,N/A,1415.00,N/A,1415.00,N/A,1415.00,N/A,688.20,N/A,198.10,N/A,1415.00,N/A,1415.00,N/A,198.10,N/A,688.20,N/A,688.20,N/A,757.02,849.00,849.00,198.10,1415.00,,Hospital 58720,Salpingo-Oophorectomy Compl/Prtl Uni/Bi Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22133.08,N/A,13279.85,N/A,3098.62,N/A,1020.99,N/A,12740.34,N/A,7520.83,N/A,10904.10,N/A,3098.62,N/A,1023.51,N/A,1023.51,N/A,6788.02,N/A,10904.10,N/A,10904.10,N/A,10904.10,N/A,12740.36,N/A,1023.51,N/A,3098.62,N/A,5963.00,N/A,5963.00,N/A,3098.62,N/A,1023.51,N/A,1020.99,N/A,1002.99,N/A,N/A,1002.99,13279.85,,Hospital 58800,Drainage Ovarian Cyst Uni/Bi Spx Vaginal Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43321.77,N/A,25993.06,N/A,6034.87,N/A,5007.00,N/A,24937.85,N/A,14729.39,N/A,11469.07,N/A,6034.87,N/A,4706.78,N/A,4706.78,N/A,7139.71,N/A,11469.07,N/A,11469.07,N/A,11469.07,N/A,24937.86,N/A,4706.78,N/A,6034.87,N/A,7661.50,N/A,7661.50,N/A,6034.87,N/A,4706.78,N/A,5007.00,N/A,767.46,N/A,N/A,767.46,25993.06,,Hospital 58825,Transposition Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 58940,Oophorectomy Partial/Total Uni/Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 59001,"HC Amniocentesis,Ther Amniotic Fluid Reduct",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1572.00,1572.00,943.20,943.20,N/A,220.08,N/A,170.22,N/A,905.16,N/A,534.48,N/A,510.60,N/A,220.08,N/A,170.22,N/A,170.22,N/A,317.85,N/A,510.60,N/A,510.60,N/A,510.60,N/A,905.16,N/A,170.22,N/A,220.08,N/A,1572.00,N/A,1572.00,N/A,220.08,N/A,170.22,N/A,170.22,N/A,187.24,943.20,943.20,170.22,1572.00,,Hospital 59120,Tx Ectopic Pregnancy Abdominal/Vaginal Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72309.08,N/A,43385.45,N/A,10064.76,N/A,2469.95,N/A,41625.70,N/A,24585.08,N/A,22864.26,N/A,10064.76,N/A,2453.34,N/A,2453.34,N/A,14232.76,N/A,22864.26,N/A,22864.26,N/A,22864.26,N/A,38232.51,N/A,2453.34,N/A,10064.76,N/A,6260.50,N/A,6260.50,N/A,10064.76,N/A,2453.34,N/A,2469.95,N/A,2135.00,N/A,N/A,2135.00,43385.45,,Hospital 59140,Tx Ectopic Pregnancy Cervical W/Evacuation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31037.80,N/A,18622.68,N/A,4356.06,N/A,917.69,N/A,17864.31,N/A,10552.86,N/A,11580.77,N/A,4356.06,N/A,897.15,N/A,897.15,N/A,7209.01,N/A,11580.77,N/A,11580.77,N/A,11580.77,N/A,17457.22,N/A,897.15,N/A,4356.06,N/A,1643.00,N/A,1643.00,N/A,4356.06,N/A,897.15,N/A,917.69,N/A,761.46,N/A,N/A,761.46,18622.68,,Hospital 59150,Laps Tx Ectopic Preg W/O Salping&/Oophorectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28783.40,N/A,17270.04,N/A,3987.52,N/A,815.27,N/A,16565.06,N/A,9786.36,N/A,11442.66,N/A,3987.52,N/A,4706.78,N/A,4706.78,N/A,7123.29,N/A,11442.66,N/A,11442.66,N/A,11442.66,N/A,16565.05,N/A,4706.78,N/A,3987.52,N/A,7897.00,N/A,7897.00,N/A,3987.52,N/A,4706.78,N/A,815.27,N/A,890.68,N/A,N/A,815.27,17270.04,,Hospital 59160,Curettage Postpartum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52273.70,N/A,31364.22,N/A,8862.41,N/A,10779.06,N/A,19972.15,N/A,17773.06,N/A,20163.20,N/A,9135.47,N/A,186584.00,N/A,186584.00,N/A,12551.12,N/A,20163.20,N/A,20163.20,N/A,N/A,N/A,19972.15,N/A,10749.41,N/A,9135.47,N/A,23989.17,N/A,23989.17,N/A,2733.65,N/A,10749.41,N/A,10779.06,N/A,9774.95,N/A,2733.65,186584.00,N/A,N/A,,Hospital 59325,Cerclage Cervix Pregnancy Abdominal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47282.35,N/A,28369.41,N/A,6586.87,N/A,993.32,N/A,27104.46,N/A,16076.00,N/A,21547.20,N/A,6586.87,N/A,4706.78,N/A,4706.78,N/A,13413.55,N/A,21547.20,N/A,21547.20,N/A,21547.20,N/A,27104.46,N/A,4706.78,N/A,6586.87,N/A,8718.50,N/A,8718.50,N/A,6586.87,N/A,4706.78,N/A,993.32,N/A,1092.66,N/A,N/A,993.32,28369.41,,Hospital 59410,Vaginal Delivery Only W/Postpartum Care,N/A,N/A,21272.30,N/A,12763.38,N/A,3722.50,N/A,4669.17,N/A,8388.95,N/A,7232.58,N/A,4696.00,N/A,3837.19,N/A,4669.17,N/A,4669.17,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,8388.95,N/A,4669.17,N/A,3837.19,N/A,10076.23,N/A,10076.23,N/A,5033.29,N/A,4669.17,N/A,4669.17,N/A,4105.80,N/A,2923.00,12763.38,N/A,N/A,,Hospital 59612,Vaginal Delivery After Cesarean Delivery,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,12452.00,N/A,7471.20,N/A,3722.50,N/A,4669.17,N/A,8388.95,N/A,4233.68,N/A,4696.00,N/A,3837.19,N/A,4669.17,N/A,4669.17,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,8388.95,N/A,4669.17,N/A,3837.19,N/A,10076.23,N/A,10076.23,N/A,N/A,N/A,4669.17,N/A,4669.17,N/A,4105.80,N/A,2923.00,10076.23,N/A,N/A,,Hospital CPT 59812,Tx Incomplete Abortion Any Trimester Surgical,N/A,N/A,600.00,600.00,360.00,360.00,N/A,84.00,N/A,294.35,N/A,600.00,N/A,204.00,N/A,600.00,N/A,84.00,N/A,294.35,N/A,294.35,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,294.35,N/A,84.00,N/A,600.00,N/A,600.00,N/A,84.00,N/A,294.35,N/A,294.35,N/A,323.79,360.00,360.00,84.00,600.00,,Hospital CPT 59812,HC Treatment of Miscarriage,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,6840.00,6840.00,4104.00,4104.00,N/A,957.60,N/A,294.35,N/A,3938.47,N/A,2325.60,N/A,1031.40,N/A,957.60,N/A,294.35,N/A,294.35,N/A,642.05,N/A,1031.40,N/A,1031.40,N/A,1031.40,N/A,3938.47,N/A,294.35,N/A,957.60,N/A,6840.00,N/A,6840.00,N/A,957.60,N/A,294.35,N/A,294.35,N/A,323.79,4104.00,4104.00,294.35,6840.00,,Hospital 59841,Induced Abortion Dilation & Evacuation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31821.50,N/A,19092.90,N/A,4454.53,N/A,2716.15,N/A,18131.12,N/A,10819.30,N/A,8963.92,N/A,4454.53,N/A,2553.29,N/A,2553.29,N/A,5580.19,N/A,8963.92,N/A,8963.92,N/A,8963.92,N/A,18131.12,N/A,2553.29,N/A,4454.53,N/A,3660.50,N/A,3660.50,N/A,4454.53,N/A,2553.29,N/A,2716.15,N/A,534.99,N/A,N/A,534.99,19092.90,,Hospital CPT 60100,HC Biopsy Thyroid Perc Needle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2976.00,2976.00,1785.60,1785.60,N/A,416.64,N/A,586.05,N/A,1713.58,N/A,1011.84,N/A,1417.60,N/A,416.64,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1713.58,N/A,586.05,N/A,416.64,N/A,1431.00,N/A,1431.00,N/A,416.64,N/A,586.05,N/A,586.05,N/A,644.65,1785.60,1785.60,416.64,1785.60,,Hospital CPT 60100,HC Bx Throid Perc Core Needle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3697.00,3697.00,2218.20,2218.20,N/A,517.58,N/A,586.05,N/A,2128.73,N/A,1256.98,N/A,1417.60,N/A,517.58,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,2128.73,N/A,586.05,N/A,517.58,N/A,1431.00,N/A,1431.00,N/A,517.58,N/A,586.05,N/A,586.05,N/A,644.65,2218.20,2218.20,517.58,2218.20,,Hospital 60210,Prtl Thyroid Lobectomy Uni W/WO Isthmusectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34052.78,N/A,20431.67,N/A,4717.49,N/A,5100.19,N/A,19602.99,N/A,11577.94,N/A,11457.70,N/A,4717.49,N/A,4706.78,N/A,4706.78,N/A,7132.64,N/A,11457.70,N/A,11457.70,N/A,11457.70,N/A,19373.27,N/A,4706.78,N/A,4717.49,N/A,7897.00,N/A,7897.00,N/A,4717.49,N/A,4706.78,N/A,5100.19,N/A,1022.88,N/A,N/A,1022.88,20431.67,,Hospital 60300,HC Aspir/Inj Thyroid Cyst,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,45441.50,3890.00,27264.90,2334.00,4108.72,544.60,5185.35,598.23,9259.34,2239.85,15450.11,992.80,9347.92,1417.60,4235.32,544.60,77556.00,586.05,77556.00,586.05,5818.86,882.49,9347.92,1417.60,9347.92,1417.60,9347.92,1417.60,9259.34,1681.33,5126.05,586.05,4235.32,544.60,11121.69,1431.00,11121.69,1431.00,N/A,544.60,5126.05,586.05,5185.35,598.23,4531.79,197.13,4108.72,77556.00,197.13,2334.00,,Hospital 61020,Ventricular Puncture Previous Burr Hole W/O Njx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,41419.68,N/A,24851.81,N/A,12489.41,N/A,15039.99,N/A,28851.52,N/A,14082.69,N/A,29262.66,N/A,12874.23,N/A,1245.43,N/A,1245.43,N/A,18216.88,N/A,29262.66,N/A,29262.66,N/A,29262.66,N/A,28851.52,N/A,15039.99,N/A,12874.23,N/A,33806.93,N/A,33806.93,N/A,N/A,N/A,15039.99,N/A,15039.99,N/A,13775.43,N/A,1245.43,33806.93,N/A,N/A,,Hospital 61343,Crnec Suboccipital Crv Lam Dcmprn Medulla & Cord,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39153.12,N/A,23491.87,N/A,5449.76,N/A,2198.92,N/A,22537.85,N/A,13312.07,N/A,14774.55,N/A,5449.76,N/A,2194.09,N/A,2194.09,N/A,9197.43,N/A,14774.55,N/A,14774.55,N/A,14774.55,N/A,22537.86,N/A,2194.09,N/A,5449.76,N/A,1643.00,N/A,1643.00,N/A,5449.76,N/A,2194.09,N/A,2198.92,N/A,2332.31,N/A,N/A,1643.00,23491.87,,Hospital 61581,Craniofacial Ant Cranial Fossa W/Orbital Exntj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87316.58,N/A,52389.95,N/A,12206.88,N/A,5844.44,N/A,50215.42,N/A,29687.63,N/A,42469.19,N/A,12206.88,N/A,5587.18,N/A,5587.18,N/A,26438.79,N/A,42469.19,N/A,42469.19,N/A,42469.19,N/A,50215.44,N/A,5587.18,N/A,12206.88,N/A,6728.25,N/A,6728.25,N/A,12206.88,N/A,5587.18,N/A,5844.44,N/A,7439.99,N/A,N/A,5587.18,52389.95,,Hospital 61600,Resect Base Ant Cran Fossa/Extradurl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87316.58,N/A,52389.95,N/A,12206.88,N/A,5844.44,N/A,50215.42,N/A,29687.63,N/A,42469.19,N/A,12206.88,N/A,5587.18,N/A,5587.18,N/A,26438.79,N/A,42469.19,N/A,42469.19,N/A,42469.19,N/A,50215.44,N/A,5587.18,N/A,12206.88,N/A,6728.25,N/A,6728.25,N/A,12206.88,N/A,5587.18,N/A,5844.44,N/A,7439.99,N/A,N/A,5587.18,52389.95,,Hospital 61605,Resect Infratemp Fossa/Extradurl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,56143.73,N/A,33686.24,N/A,6443.15,N/A,7917.20,N/A,14606.19,N/A,19088.87,N/A,14659.07,N/A,6641.68,N/A,129822.00,N/A,129822.00,N/A,9124.93,N/A,14659.07,N/A,14659.07,N/A,14659.07,N/A,29664.72,N/A,7887.55,N/A,6641.68,N/A,17440.63,N/A,17440.63,N/A,N/A,N/A,7887.55,N/A,7917.20,N/A,7106.60,N/A,6443.15,129822.00,N/A,N/A,,Hospital 61630,HC Intracranial Angioplasty,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,130961.93,N/A,78577.16,N/A,30574.84,N/A,36434.11,N/A,72186.22,N/A,44527.07,N/A,71636.77,N/A,31516.91,N/A,1124.00,N/A,1124.00,N/A,44596.02,N/A,71636.77,N/A,71636.77,N/A,71636.77,N/A,72186.22,N/A,36434.11,N/A,31516.91,N/A,82761.42,N/A,82761.42,N/A,813.39,N/A,36434.11,N/A,36434.11,N/A,33723.09,N/A,813.39,82761.42,N/A,N/A,,Hospital 61635,HC Intracran Angioplsty W/Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,150919.92,69108.22,90551.95,41464.93,21335.28,9543.99,15511.31,2460.18,83187.06,39656.10,51312.78,23496.81,49988.50,17674.39,21992.66,9543.99,25504.18,5125.81,25504.18,5125.81,31119.33,11192.80,49988.50,17674.39,49988.50,17674.39,49988.50,17674.39,83187.06,37110.49,25504.18,5136.89,21992.66,9543.99,57751.34,1906.50,57751.34,1906.50,4302.04,9543.99,25504.18,2308.61,25504.18,5143.49,23532.14,2340.63,4302.04,90551.95,1906.50,41464.93,,Hospital 61640,HC Dilate Ic Vasospasm Initial Vessel,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,147349.12,N/A,88409.47,N/A,30574.84,N/A,36434.11,N/A,81218.83,N/A,50098.70,N/A,71636.77,N/A,31516.91,N/A,36434.11,N/A,36434.11,N/A,44596.02,N/A,71636.77,N/A,N/A,N/A,71636.77,N/A,81218.83,N/A,36434.11,N/A,31516.91,N/A,82761.42,N/A,82761.42,N/A,3677.86,N/A,36434.11,N/A,36434.11,N/A,33723.09,N/A,3677.86,88409.47,N/A,N/A,,Hospital 61645,HC Perq Art M-Thrombect &/Nfs,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,197068.20,N/A,118240.92,N/A,21227.07,N/A,29497.98,N/A,92195.30,N/A,90660.63,N/A,90660.63,N/A,21227.07,N/A,27301.19,N/A,29960.99,N/A,90660.63,N/A,90660.63,N/A,80023.99,N/A,90660.63,N/A,92195.30,N/A,27677.91,N/A,21227.07,N/A,92195.30,N/A,92195.30,N/A,41860.55,N/A,31322.10,N/A,31322.10,N/A,21227.07,N/A,21227.07,118240.92,N/A,N/A,,Hospital 61867,HC Implant Neuroelectrd W/Record 1st Array,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,167545.75,N/A,100527.45,N/A,13312.01,N/A,16013.07,N/A,92351.22,N/A,56965.56,N/A,31190.00,N/A,13722.18,N/A,562.00,N/A,562.00,N/A,19416.71,N/A,31190.00,N/A,31190.00,N/A,31190.00,N/A,92351.22,N/A,16013.07,N/A,13722.18,N/A,36033.58,N/A,36033.58,N/A,7208.24,N/A,16013.07,N/A,16013.07,N/A,14682.73,N/A,562.00,100527.45,N/A,N/A,,Hospital 61880,Revise/Remove Intracran Neuroelec,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48240.03,N/A,28944.02,N/A,13312.01,N/A,16042.72,N/A,33449.16,N/A,16401.62,N/A,31190.00,N/A,13722.18,N/A,10793.67,N/A,10793.67,N/A,19416.71,N/A,31190.00,N/A,31190.00,N/A,31190.00,N/A,33449.16,N/A,16013.07,N/A,13722.18,N/A,36033.58,N/A,36033.58,N/A,N/A,N/A,16013.07,N/A,16042.72,N/A,14682.73,N/A,10793.67,36033.58,N/A,N/A,,Hospital 61885,"Imp Stim,Cranial,Subq,1 Array",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,197545.32,N/A,118527.19,N/A,27656.35,N/A,19429.23,N/A,111275.61,N/A,67165.41,N/A,47028.92,N/A,27656.35,N/A,19429.23,N/A,19429.23,N/A,29276.41,N/A,47028.92,N/A,47028.92,N/A,47028.92,N/A,111265.27,N/A,19429.23,N/A,27656.35,N/A,37100.00,N/A,37100.00,N/A,27656.35,N/A,19429.23,N/A,19429.23,N/A,21372.15,N/A,N/A,19429.23,118527.19,,Hospital 62140,"Repair Skull Defect,Up to 5cm",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34084.20,N/A,20450.52,N/A,4768.30,N/A,1457.12,N/A,19616.87,N/A,11588.63,N/A,9076.22,N/A,4768.30,N/A,1454.06,N/A,1454.06,N/A,5898.72,N/A,9076.22,N/A,9076.22,N/A,9076.22,N/A,19203.21,N/A,1474.70,N/A,4768.30,N/A,1643.00,N/A,1643.00,N/A,4768.30,N/A,1454.06,N/A,1457.12,N/A,1433.42,N/A,N/A,1433.42,20450.52,,Hospital 62225,Replace/Irrigate Ventric Cath,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68704.57,N/A,41222.74,N/A,9594.44,N/A,5935.46,N/A,39531.71,N/A,23359.55,N/A,13576.43,N/A,9594.44,N/A,5579.57,N/A,5579.57,N/A,8451.59,N/A,13576.43,N/A,13576.43,N/A,13576.43,N/A,39531.70,N/A,5579.57,N/A,9594.44,N/A,1871.00,N/A,1871.00,N/A,9594.44,N/A,5579.57,N/A,5935.46,N/A,568.28,N/A,N/A,568.28,41222.74,,Hospital CPT 62264,HC Lysis One Day,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,5685.00,5685.00,3411.00,3411.00,N/A,795.90,N/A,234.42,N/A,3273.42,N/A,1932.90,N/A,1226.67,N/A,795.90,N/A,234.42,N/A,234.42,N/A,763.60,N/A,1226.67,N/A,1226.67,N/A,1226.67,N/A,3273.42,N/A,234.42,N/A,795.90,N/A,3047.16,N/A,3047.16,N/A,795.90,N/A,234.42,N/A,234.42,N/A,257.86,3411.00,3411.00,234.42,3411.00,,Hospital 62267,HC CT Perc Asp Disc Para Vent Tis,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,73598.10,6115.90,44158.86,3669.54,7830.58,846.31,8668.08,592.39,33475.10,3520.90,30420.60,2079.41,30420.60,1422.81,7830.58,846.31,15123.39,586.05,15123.39,586.05,30420.60,885.72,30420.60,1422.81,30420.60,1422.81,30420.60,1422.81,33475.10,3508.87,15123.39,586.05,7830.58,846.31,33475.10,1431.00,33475.10,1431.00,7830.58,846.31,15123.39,586.05,15123.39,592.39,7830.58,288.13,7830.58,44158.86,288.13,3669.54,,Hospital CPT 62273,HC Epidural Blood Patch - Anes,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,3270.00,3270.00,1962.00,1962.00,N/A,457.80,N/A,108.98,N/A,1882.87,N/A,1111.80,N/A,1407.47,N/A,457.80,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1882.87,N/A,581.86,N/A,457.80,N/A,1752.72,N/A,1752.72,N/A,457.80,N/A,581.86,N/A,108.98,N/A,119.88,1962.00,1962.00,108.98,1962.00,,Hospital CPT 62273,HC Blood Patch,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3270.00,3270.00,1962.00,1962.00,N/A,457.80,N/A,108.98,N/A,1882.87,N/A,1111.80,N/A,1407.47,N/A,457.80,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1882.87,N/A,581.86,N/A,457.80,N/A,3270.00,N/A,3270.00,N/A,457.80,N/A,581.86,N/A,108.98,N/A,119.88,1962.00,1962.00,108.98,3270.00,,Hospital CPT 62273,HC Epidural Blood Patch,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3270.00,3270.00,1962.00,1962.00,N/A,457.80,N/A,108.98,N/A,1882.87,N/A,1111.80,N/A,1407.47,N/A,457.80,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1882.87,N/A,581.86,N/A,457.80,N/A,1752.72,N/A,1752.72,N/A,457.80,N/A,581.86,N/A,108.98,N/A,119.88,1962.00,1962.00,108.98,1962.00,,Hospital CPT 62273,HC Inject Epidural Blood/Clot Patch,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3270.00,3270.00,1962.00,1962.00,N/A,457.80,N/A,108.98,N/A,1882.87,N/A,1111.80,N/A,1407.47,N/A,457.80,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1882.87,N/A,581.86,N/A,457.80,N/A,1431.00,N/A,1431.00,N/A,457.80,N/A,581.86,N/A,108.98,N/A,119.88,1962.00,1962.00,108.98,1962.00,,Hospital CPT 62321,HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,581.86,N/A,1402.65,N/A,828.24,N/A,1407.47,N/A,341.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1402.65,N/A,581.86,N/A,341.04,N/A,1305.70,N/A,1305.70,N/A,341.04,N/A,581.86,N/A,581.86,N/A,640.05,1461.60,1461.60,341.04,1461.60,,Hospital CPT 62321,HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,581.86,N/A,1402.65,N/A,828.24,N/A,1407.47,N/A,341.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1402.65,N/A,581.86,N/A,341.04,N/A,1431.00,N/A,1431.00,N/A,341.04,N/A,581.86,N/A,581.86,N/A,640.05,1461.60,1461.60,341.04,1461.60,,Hospital 62361,"Insert Infusn Pump,Nonprogram",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,70444.32,N/A,42266.59,N/A,9853.34,N/A,16000.41,N/A,39958.12,N/A,23951.07,N/A,37093.48,N/A,9853.34,N/A,15296.11,N/A,15296.11,N/A,23091.40,N/A,37093.48,N/A,37093.48,N/A,37093.48,N/A,39958.12,N/A,15296.11,N/A,9853.34,N/A,37100.00,N/A,37100.00,N/A,9853.34,N/A,15296.11,N/A,16000.41,N/A,457.84,N/A,N/A,457.84,42266.59,,Hospital 62362,"Insert Infusn Pump,Programmable",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76775.28,N/A,46065.17,N/A,10748.54,N/A,15704.66,N/A,43554.90,N/A,26103.60,N/A,37031.44,N/A,10748.54,N/A,15296.11,N/A,15296.11,N/A,23052.79,N/A,37031.44,N/A,37031.44,N/A,37031.44,N/A,43554.90,N/A,15296.11,N/A,10748.54,N/A,40081.50,N/A,40081.50,N/A,10748.54,N/A,15296.11,N/A,15704.66,N/A,820.33,N/A,N/A,820.33,46065.17,,Hospital 62365,Remove Infusn Device/Pump,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16212.00,N/A,9727.20,N/A,2269.68,N/A,5728.60,N/A,9332.90,N/A,5512.08,N/A,13527.18,N/A,2269.68,N/A,5579.57,N/A,5579.57,N/A,8420.92,N/A,13527.18,N/A,13527.18,N/A,13527.18,N/A,9332.91,N/A,5579.57,N/A,2269.68,N/A,7897.00,N/A,7897.00,N/A,2269.68,N/A,5579.57,N/A,5728.60,N/A,308.19,N/A,N/A,308.19,13527.18,,Hospital CPT 62368,HC Reprogramming Implanted Pump,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1160.00,1160.00,696.00,696.00,N/A,162.40,N/A,33.88,N/A,667.93,N/A,394.40,N/A,124.89,N/A,162.40,N/A,33.88,N/A,33.88,N/A,77.74,N/A,124.89,N/A,124.89,N/A,124.89,N/A,667.93,N/A,33.88,N/A,162.40,N/A,621.76,N/A,621.76,N/A,162.40,N/A,33.88,N/A,33.88,N/A,37.27,696.00,696.00,33.88,696.00,,Hospital CPT 62369,HC Analysis Pump W/Reprg & Refill,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,957.00,957.00,574.20,574.20,N/A,133.98,N/A,265.76,N/A,551.04,N/A,325.38,N/A,604.32,N/A,133.98,N/A,249.83,N/A,249.83,N/A,376.20,N/A,604.32,N/A,604.32,N/A,604.32,N/A,551.04,N/A,249.83,N/A,133.98,N/A,512.95,N/A,512.95,N/A,133.98,N/A,249.83,N/A,265.76,N/A,37.60,574.20,574.20,37.60,604.32,,Hospital 62370,Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23141.63,N/A,13884.98,N/A,3238.01,N/A,5551.02,N/A,13275.65,N/A,7868.16,N/A,13535.48,N/A,3238.01,N/A,5579.57,N/A,5579.57,N/A,8426.09,N/A,13535.48,N/A,13535.48,N/A,13535.48,N/A,13275.64,N/A,5579.57,N/A,3238.01,N/A,6226.50,N/A,6226.50,N/A,3238.01,N/A,5579.57,N/A,5551.02,N/A,479.70,N/A,N/A,479.70,13884.98,,Hospital 63003,"Laminectomy,Thoracic",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,105328.32,231032.97,63196.99,138619.78,N/A,32343.36,6458.17,29245.74,24035.58,130349.96,N/A,78551.21,N/A,64180.30,N/A,32343.36,6458.17,26511.88,6458.17,26511.88,N/A,39953.48,N/A,64180.30,N/A,64180.30,N/A,64180.30,N/A,130349.98,6458.17,26511.88,N/A,32343.36,N/A,44904.25,N/A,44904.25,N/A,32343.36,6458.17,26511.88,6458.17,2318.83,N/A,2550.71,6458.17,63196.99,2318.83,138619.78,,Hospital 63045,"Laminec/Facetect/Foramin,Cervical",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,93856.33,53155.38,56313.80,31893.23,N/A,7441.75,6421.39,6354.28,23563.12,30601.94,31911.16,18072.83,23788.52,14510.47,10994.13,7441.75,6421.39,5973.28,6421.39,5973.28,37747.22,9033.05,37747.22,14510.47,37747.22,14510.47,37747.22,14510.47,N/A,30601.94,12039.36,5973.28,N/A,2534.47,N/A,7897.00,28302.40,7897.00,N/A,7441.75,6123.11,5973.28,12187.61,6354.28,N/A,1346.19,6123.11,56313.80,1346.19,31893.23,,Hospital 63047,"Laminec/Facetect/Foramin,Lumbar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60141.45,29444.37,36084.87,17666.62,3562.37,4122.00,6421.39,5973.28,24450.34,16950.99,20448.10,10011.09,24684.23,14488.91,11183.84,4122.00,6123.11,5973.28,6123.11,5973.28,15365.36,9019.62,24684.23,14488.91,24684.23,14488.91,24684.23,14488.91,24450.34,16951.00,13100.10,5973.28,3562.37,4122.00,29368.07,7897.00,29368.07,7897.00,3562.37,4122.00,13100.10,5973.28,13100.10,5973.28,3562.37,6570.60,3562.37,36084.87,4122.00,17666.62,,Hospital 63057,"Xpedicul Decompress Cord,Addnl Sgmt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,66694.73,N/A,40016.84,N/A,7894.17,N/A,7862.12,N/A,16085.44,N/A,22676.21,N/A,16239.31,N/A,8137.40,N/A,637870.00,N/A,637870.00,N/A,10108.59,N/A,16239.31,N/A,16239.31,N/A,16239.31,N/A,16085.44,N/A,7832.47,N/A,8137.40,N/A,19320.72,N/A,19320.72,N/A,N/A,N/A,7832.47,N/A,7862.12,N/A,8707.02,N/A,7832.47,637870.00,N/A,N/A,,Hospital 63081,"Remv Vert Body,Cerv,One Sgmt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61453.83,N/A,36872.30,N/A,8537.51,N/A,12060.69,N/A,35082.02,N/A,20894.34,N/A,46699.04,N/A,8537.51,N/A,11933.08,N/A,N/A,N/A,29267.08,N/A,46699.04,N/A,46699.04,N/A,46699.04,N/A,35082.10,N/A,11956.02,N/A,8537.51,N/A,13819.75,N/A,13819.75,N/A,8537.51,N/A,11933.08,N/A,12060.69,N/A,4674.16,N/A,N/A,4674.16,46699.04,,Hospital 63267,"Excis Intrasp Lesn,Xdural,Lumbar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54051.62,39239.22,32430.97,23543.53,7894.17,5493.49,9604.05,6248.31,17790.16,22584.06,18377.56,13341.33,17960.33,14635.57,8137.40,5493.49,562.00,5973.28,562.00,5973.28,11179.89,9110.93,17960.33,14635.57,17960.33,14635.57,17960.33,14635.57,17790.16,22584.08,9604.05,5973.28,8137.40,5493.49,21368.31,3397.00,21368.31,3397.00,8137.40,5493.49,9604.05,5973.28,9604.05,6248.31,8707.02,1453.70,562.00,32430.97,1453.70,23543.53,,Hospital 63275,"Bx/Excis Spinal Tumor,Xdural,Cerv",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52581.23,N/A,31548.74,N/A,12489.41,N/A,15039.99,N/A,28145.91,N/A,17877.61,N/A,29262.66,N/A,12874.23,N/A,2060.65,N/A,2060.65,N/A,18216.88,N/A,29262.66,N/A,29262.66,N/A,29262.66,N/A,28145.91,N/A,15039.99,N/A,12874.23,N/A,33806.93,N/A,33806.93,N/A,N/A,N/A,15039.99,N/A,15039.99,N/A,13775.43,N/A,2060.65,33806.93,N/A,N/A,,Hospital HCPCS 6360000002,IMMUNE GLOBULIN (FLEBOGAMMA) 10%,61953-0005-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4764.60,4764.60,2858.76,2858.76,N/A,667.04,N/A,1122.33,N/A,2678.66,N/A,1619.96,N/A,2098.94,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,1306.61,N/A,2098.94,N/A,2098.94,N/A,2098.94,N/A,2678.66,N/A,1122.33,N/A,667.04,N/A,2553.83,N/A,2553.83,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,4764.60,2858.76,2858.76,667.04,4764.60,,Hospital HCPCS 6360000002,SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,89130-4444-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1067.50,1067.50,640.50,640.50,N/A,149.45,N/A,1067.50,N/A,600.15,N/A,362.95,N/A,197.07,N/A,149.45,N/A,1067.50,N/A,1067.50,N/A,122.68,N/A,197.07,N/A,197.07,N/A,197.07,N/A,600.15,N/A,1067.50,N/A,149.45,N/A,572.18,N/A,572.18,N/A,149.45,N/A,1067.50,N/A,1067.50,N/A,1067.50,640.50,640.50,122.68,1067.50,,Hospital HCPCS 6360000002,COAGULATION FACTOR IX (RECOMB) 3000 UNITS IV KIT,58394-0637-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20115.00,20115.00,12069.00,12069.00,N/A,2816.10,N/A,20115.00,N/A,11308.65,N/A,6839.10,N/A,12665.10,N/A,2816.10,N/A,20115.00,N/A,20115.00,N/A,7884.15,N/A,12665.10,N/A,12665.10,N/A,12665.10,N/A,11308.65,N/A,20115.00,N/A,2816.10,N/A,10781.64,N/A,10781.64,N/A,2816.10,N/A,20115.00,N/A,20115.00,N/A,20115.00,12069.00,12069.00,2816.10,20115.00,,Hospital HCPCS 6360000002,TERIPARATIDE (RECOMBINANT) 600 MCG/2.4ML SC SOPN,00002-8400-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),41252.80,41252.80,24751.68,24751.68,N/A,5775.39,N/A,41252.80,N/A,23192.32,N/A,14025.95,N/A,5775.39,N/A,5775.39,N/A,41252.80,N/A,41252.80,N/A,3588.99,N/A,5775.39,N/A,5775.39,N/A,5775.39,N/A,23192.32,N/A,41252.80,N/A,5775.39,N/A,22111.50,N/A,22111.50,N/A,5775.39,N/A,41252.80,N/A,41252.80,N/A,41252.80,24751.68,24751.68,3588.99,41252.80,,Hospital HCPCS 6360000002,COAGULATION FACTOR IX (RECOMB) 250 UNITS IV KIT,58394-0633-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1676.30,1676.30,1005.78,1005.78,N/A,234.68,N/A,1676.30,N/A,942.42,N/A,569.94,N/A,1055.43,N/A,234.68,N/A,1676.30,N/A,1676.30,N/A,657.01,N/A,1055.43,N/A,1055.43,N/A,1055.43,N/A,942.42,N/A,1676.30,N/A,234.68,N/A,898.50,N/A,898.50,N/A,234.68,N/A,1676.30,N/A,1676.30,N/A,1676.30,1005.78,1005.78,234.68,1676.30,,Hospital HCPCS 6360000002,IMMUNE GLOBULIN (FLEBOGAMMA) 10%,61953-0005-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4764.60,4764.60,2858.76,2858.76,N/A,667.04,N/A,1122.33,N/A,2678.66,N/A,1619.96,N/A,2098.94,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,1306.61,N/A,2098.94,N/A,2098.94,N/A,2098.94,N/A,2678.66,N/A,1122.33,N/A,667.04,N/A,2553.83,N/A,2553.83,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,4764.60,2858.76,2858.76,667.04,4764.60,,Hospital HCPCS 6360000002,IMMUNE GLOBULIN (FLEBOGAMMA) 10%,61953-0005-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4764.60,4764.60,2858.76,2858.76,N/A,667.04,N/A,1122.33,N/A,2678.66,N/A,1619.96,N/A,2098.94,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,1306.61,N/A,2098.94,N/A,2098.94,N/A,2098.94,N/A,2678.66,N/A,1122.33,N/A,667.04,N/A,2553.83,N/A,2553.83,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,4764.60,2858.76,2858.76,667.04,4764.60,,Hospital 63664,"Revision Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,112759.77,N/A,67655.86,N/A,15786.78,N/A,11486.07,N/A,64517.14,N/A,38338.32,N/A,26207.69,N/A,15786.78,N/A,10797.60,N/A,10797.60,N/A,16314.79,N/A,26207.69,N/A,26207.69,N/A,26207.69,N/A,64517.15,N/A,10797.60,N/A,15786.78,N/A,7897.00,N/A,7897.00,N/A,15786.78,N/A,10797.60,N/A,11486.07,N/A,929.90,N/A,N/A,929.90,67655.86,,Hospital 63685,Implant Neurostim/Receiver,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,223936.50,148563.33,134361.90,89138.00,22245.33,20785.30,12697.49,26515.81,123433.80,83950.21,76138.41,50511.55,77974.69,64318.02,18692.82,20785.30,562.00,26515.81,562.00,26515.81,48549.43,40039.21,77974.69,64318.02,77974.69,64318.02,77974.69,64318.02,123433.80,83950.21,12697.49,26515.81,18692.82,20785.30,136888.70,42930.00,136888.70,42930.00,17065.34,20785.30,12697.49,26515.81,12697.49,26515.81,20001.32,29167.39,562.00,136888.70,20785.30,89138.00,,Hospital 63746,Removal of Spinal Shunt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68871.17,N/A,41322.70,N/A,9565.30,N/A,1876.91,N/A,39617.92,N/A,23416.20,N/A,4572.92,N/A,9565.30,N/A,1773.37,N/A,1773.37,N/A,3042.75,N/A,4572.92,N/A,4572.92,N/A,4572.92,N/A,38541.18,N/A,1796.31,N/A,9565.30,N/A,3397.00,N/A,3397.00,N/A,9565.30,N/A,1773.37,N/A,1876.91,N/A,1084.27,N/A,N/A,1084.27,41322.70,,Hospital CPT 64416,HC Peripheral Block - Brachial Plexus Continuous W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2409.00,2409.00,1445.40,1445.40,N/A,337.26,N/A,804.99,N/A,1387.10,N/A,819.06,N/A,1861.48,N/A,337.26,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1387.10,N/A,769.55,N/A,337.26,N/A,1431.00,N/A,1431.00,N/A,337.26,N/A,769.55,N/A,804.99,N/A,68.73,1445.40,1445.40,68.73,1861.48,,Hospital CPT 64421,HC N Block Inj Intercost Mlt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2418.00,2418.00,1450.80,1450.80,N/A,338.52,N/A,769.55,N/A,1392.28,N/A,822.12,N/A,1861.48,N/A,338.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1392.28,N/A,769.55,N/A,338.52,N/A,1431.00,N/A,1431.00,N/A,338.52,N/A,769.55,N/A,769.55,N/A,846.51,1450.80,1450.80,338.52,1861.48,,Hospital CPT 64421,HC N Block Inj Intercost Mlt,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2418.00,2418.00,1450.80,1450.80,N/A,338.52,N/A,769.55,N/A,1392.28,N/A,822.12,N/A,1861.48,N/A,338.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1392.28,N/A,769.55,N/A,338.52,N/A,1296.05,N/A,1296.05,N/A,338.52,N/A,769.55,N/A,769.55,N/A,846.51,1450.80,1450.80,338.52,1861.48,,Hospital CPT 64446,HC Peripheral Block - Sciatic Continuous W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3950.00,3950.00,2370.00,2370.00,N/A,553.00,N/A,806.83,N/A,2274.41,N/A,1343.00,N/A,1861.48,N/A,553.00,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2274.41,N/A,769.55,N/A,553.00,N/A,1431.00,N/A,1431.00,N/A,553.00,N/A,769.55,N/A,57.73,N/A,63.50,2370.00,2370.00,57.73,2370.00,,Hospital CPT 64461,HC Pvb Thoracic Single Inj Site,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,885.00,885.00,531.00,531.00,N/A,123.90,N/A,597.41,N/A,509.58,N/A,300.90,N/A,885.00,N/A,123.90,N/A,581.86,N/A,581.86,N/A,876.18,N/A,885.00,N/A,885.00,N/A,885.00,N/A,509.58,N/A,581.86,N/A,123.90,N/A,1431.00,N/A,1431.00,N/A,123.90,N/A,581.86,N/A,597.41,N/A,84.54,531.00,531.00,84.54,1431.00,,Hospital 64480,HC Inj a/S Transforaminal C/D Add,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9515.50,6035.00,5709.30,3621.00,5123.90,846.98,6326.96,765.62,9515.50,3474.21,3235.27,2051.90,9515.50,1870.40,5281.78,846.98,1686.00,769.55,1686.00,769.55,7256.58,1164.35,9515.50,1870.40,9515.50,1870.40,9515.50,1870.40,9515.50,3474.21,6326.96,769.55,5281.78,846.98,9515.50,1694.50,9515.50,1694.50,5071.13,846.98,6326.96,769.55,6326.96,765.62,5651.50,210.33,1686.00,9515.50,210.33,3621.00,,Hospital CPT 64484,"HC Trans, Esb, L/S, Ea Addit",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2688.00,2688.00,1612.80,1612.80,N/A,376.32,N/A,2688.00,N/A,1547.75,N/A,913.92,N/A,2688.00,N/A,376.32,N/A,2688.00,N/A,2688.00,N/A,2688.00,N/A,2688.00,N/A,2688.00,N/A,2688.00,N/A,1547.75,N/A,2688.00,N/A,376.32,N/A,1440.77,N/A,1440.77,N/A,376.32,N/A,2688.00,N/A,2688.00,N/A,54.78,1612.80,1612.80,54.78,2688.00,,Hospital CPT 64487,HC Peripheral Block - Tap Unilateral Infusion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1107.00,1107.00,664.20,664.20,N/A,154.98,N/A,62.48,N/A,637.41,N/A,376.38,N/A,596.85,N/A,154.98,N/A,62.48,N/A,62.48,N/A,371.54,N/A,596.85,N/A,596.85,N/A,596.85,N/A,637.41,N/A,62.48,N/A,154.98,N/A,1107.00,N/A,1107.00,N/A,154.98,N/A,62.48,N/A,62.48,N/A,68.73,664.20,664.20,62.48,1107.00,,Hospital CPT 64491,"HC Facet Inj, C/T 2nd Level",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,3568.00,N/A,2054.45,N/A,1213.12,N/A,3568.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,2054.45,N/A,3568.00,N/A,499.52,N/A,1912.45,N/A,1912.45,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,2140.80,2140.80,499.52,3568.00,,Hospital CPT 64491,HC N Block Paravert Thoracic 2nd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,3568.00,N/A,2054.45,N/A,1213.12,N/A,3568.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,2054.45,N/A,3568.00,N/A,499.52,N/A,527.00,N/A,527.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,2140.80,2140.80,499.52,3568.00,,Hospital CPT 64495,"HC Facet Jnt,L/S,3rd & Ea Add",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,3568.00,N/A,2054.45,N/A,1213.12,N/A,3568.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,2054.45,N/A,3568.00,N/A,499.52,N/A,1912.45,N/A,1912.45,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,55.11,2140.80,2140.80,55.11,3568.00,,Hospital CPT 64495,HC N Block Paravert Lumbar 3+,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,3568.00,N/A,2054.45,N/A,1213.12,N/A,3568.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,2054.45,N/A,3568.00,N/A,499.52,N/A,527.00,N/A,527.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,55.11,2140.80,2140.80,55.11,3568.00,,Hospital 64505,HC Injection Anes Agent Sphenopalatine Ganglion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,29754.80,N/A,17852.88,N/A,4441.07,N/A,5519.19,N/A,N/A,N/A,10116.63,N/A,10405.42,N/A,4621.96,N/A,5519.19,N/A,5519.19,N/A,6477.68,N/A,10405.42,N/A,10405.42,N/A,10405.42,N/A,10354.12,N/A,5519.19,N/A,4577.91,N/A,12021.30,N/A,12021.30,N/A,4621.96,N/A,5519.19,N/A,5519.19,N/A,4898.36,N/A,4441.07,17852.88,N/A,N/A,,Hospital CPT 64520,HC N Block Lumbar/Thoracic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,818.64,N/A,1402.65,N/A,828.24,N/A,1861.48,N/A,341.04,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1402.65,N/A,769.55,N/A,341.04,N/A,1431.00,N/A,1431.00,N/A,341.04,N/A,769.55,N/A,818.64,N/A,88.25,1461.60,1461.60,88.25,1861.48,,Hospital 64590,Implant Neurostim/Receiver,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87497.65,N/A,52498.59,N/A,12229.38,N/A,19639.65,N/A,49418.80,N/A,29749.20,N/A,47043.63,N/A,12229.38,N/A,19429.23,N/A,19429.23,N/A,29285.57,N/A,47043.63,N/A,47043.63,N/A,47043.63,N/A,49388.57,N/A,19429.23,N/A,12229.38,N/A,41048.50,N/A,41048.50,N/A,12229.38,N/A,19429.23,N/A,19639.65,N/A,508.60,N/A,N/A,508.60,52498.59,,Hospital 64595,Revise/Remove Neurostim/Receiver,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54222.42,24439.12,32533.45,14663.47,8843.20,3410.98,10756.34,260.71,19928.87,14055.94,18435.62,8309.30,20119.50,7211.43,9115.67,3410.98,146682.00,2932.78,146682.00,2932.78,12523.92,4489.25,20119.50,7211.43,20119.50,7211.43,20119.50,7211.43,19928.87,14055.96,10726.69,2932.78,9115.67,3410.98,23937.19,6843.00,23937.19,6843.00,4707.19,3410.98,10726.69,2932.78,10756.34,260.71,9753.77,286.79,4707.19,146682.00,260.71,14663.47,,Hospital CPT 64600,HC Injection Treatment of Nerve,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2351.00,2351.00,1410.60,1410.60,N/A,329.14,N/A,765.62,N/A,1353.71,N/A,799.34,N/A,1861.48,N/A,329.14,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1353.71,N/A,769.55,N/A,329.14,N/A,1431.00,N/A,1431.00,N/A,329.14,N/A,769.55,N/A,765.62,N/A,239.95,1410.60,1410.60,239.95,1861.48,,Hospital CPT 64612,"HC Botox, Facial Nerve",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1024.00,1024.00,614.40,614.40,N/A,143.36,N/A,245.53,N/A,589.62,N/A,348.16,N/A,593.92,N/A,143.36,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,589.62,N/A,245.53,N/A,143.36,N/A,548.86,N/A,548.86,N/A,143.36,N/A,245.53,N/A,245.53,N/A,270.08,614.40,614.40,143.36,614.40,,Hospital CPT 64615,HC Chemodenerv Musc Migraine,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,754.00,754.00,452.40,452.40,N/A,105.56,N/A,245.53,N/A,434.15,N/A,256.36,N/A,593.92,N/A,105.56,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,434.15,N/A,245.53,N/A,105.56,N/A,404.14,N/A,404.14,N/A,105.56,N/A,245.53,N/A,245.53,N/A,270.08,452.40,452.40,105.56,593.92,,Hospital CPT 64616,HC Destr Botox -Neck Muscl Unilat,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,245.53,N/A,884.43,N/A,522.24,N/A,593.92,N/A,215.04,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,884.43,N/A,245.53,N/A,215.04,N/A,823.30,N/A,823.30,N/A,215.04,N/A,245.53,N/A,245.53,N/A,270.08,921.60,921.60,215.04,921.60,,Hospital 64625,HC Radiofrequency Abltj Nrv Nrvtg Si Jt W/Img Gdn,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,10644.40,N/A,6386.64,N/A,1490.21,N/A,1656.99,N/A,6128.71,N/A,3619.10,N/A,3929.09,N/A,1490.21,N/A,1623.23,N/A,1623.23,N/A,2445.93,N/A,3929.09,N/A,3929.09,N/A,3929.09,N/A,6128.71,N/A,1623.23,N/A,1490.21,N/A,3397.00,N/A,3397.00,N/A,1490.21,N/A,1623.23,N/A,1656.99,N/A,219.01,N/A,N/A,219.01,6386.64,,Hospital 64630,Destruct by Neuro Agent; Pudendal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12714.40,N/A,7628.64,N/A,1780.01,N/A,785.56,N/A,7320.25,N/A,4322.89,N/A,1864.85,N/A,1780.01,N/A,769.55,N/A,769.55,N/A,1160.91,N/A,1864.85,N/A,1864.85,N/A,1864.85,N/A,7320.26,N/A,769.55,N/A,1780.01,N/A,1431.00,N/A,1431.00,N/A,1780.01,N/A,769.55,N/A,785.56,N/A,203.57,N/A,N/A,203.57,7628.64,,Hospital CPT 64643,"HC Dest Botox-Ea Add Ext,1-4 Musc",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,765.00,765.00,459.00,459.00,N/A,107.10,N/A,765.00,N/A,440.49,N/A,260.10,N/A,765.00,N/A,107.10,N/A,765.00,N/A,765.00,N/A,765.00,N/A,765.00,N/A,765.00,N/A,765.00,N/A,440.49,N/A,765.00,N/A,107.10,N/A,410.04,N/A,410.04,N/A,107.10,N/A,765.00,N/A,765.00,N/A,765.00,459.00,459.00,107.10,765.00,,Hospital CPT 64644,"HC Dest Botox-1 Extrm,5 or > Musc",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1749.00,1749.00,1049.40,1049.40,N/A,244.86,N/A,581.86,N/A,1007.07,N/A,594.66,N/A,1407.47,N/A,244.86,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1007.07,N/A,581.86,N/A,244.86,N/A,937.46,N/A,937.46,N/A,244.86,N/A,581.86,N/A,581.86,N/A,640.05,1049.40,1049.40,244.86,1407.47,,Hospital CPT 64647,HC Dest Botox -Trunk 6 or > Muscl,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,581.86,N/A,884.43,N/A,522.24,N/A,1407.47,N/A,215.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,884.43,N/A,581.86,N/A,215.04,N/A,823.30,N/A,823.30,N/A,215.04,N/A,581.86,N/A,581.86,N/A,640.05,921.60,921.60,215.04,1407.47,,Hospital 64702,Revise/Repair Finger/Toe Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10780.20,N/A,6468.12,N/A,1509.22,N/A,1666.59,N/A,6204.68,N/A,3665.25,N/A,3957.29,N/A,1509.22,N/A,1623.23,N/A,1623.23,N/A,2463.49,N/A,3957.29,N/A,3957.29,N/A,3957.29,N/A,6204.68,N/A,1623.23,N/A,1509.22,N/A,5563.25,N/A,5563.25,N/A,1509.22,N/A,1623.23,N/A,1666.59,N/A,3217.42,N/A,N/A,1509.22,6468.12,,Hospital 64708,"Neuroplasty Other Arm/Leg Nerve,Open",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29166.40,N/A,17499.84,N/A,4036.89,N/A,1697.97,N/A,16791.29,N/A,9916.58,N/A,3985.99,N/A,4036.89,N/A,1623.23,N/A,1623.23,N/A,2481.36,N/A,3985.99,N/A,3985.99,N/A,3985.99,N/A,16791.29,N/A,1623.23,N/A,4036.89,N/A,3397.00,N/A,3397.00,N/A,4036.89,N/A,1623.23,N/A,1697.97,N/A,541.07,N/A,N/A,541.07,17499.84,,Hospital 64713,"Neuroplasty Brachial Plexus,Open",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38838.30,N/A,23302.98,N/A,5429.35,N/A,1697.97,N/A,22360.16,N/A,13205.03,N/A,3986.63,N/A,5429.35,N/A,1623.23,N/A,1623.23,N/A,2481.74,N/A,3986.63,N/A,3986.63,N/A,3986.63,N/A,22360.18,N/A,1623.23,N/A,5429.35,N/A,3397.00,N/A,3397.00,N/A,5429.35,N/A,1623.23,N/A,1697.97,N/A,837.43,N/A,N/A,837.43,23302.98,,Hospital CPT 64718,Neuroplasty &/Transposition Ulnar Nerve Elbow,N/A,N/A,1170.00,1170.00,702.00,702.00,N/A,163.80,N/A,567.92,N/A,1170.00,N/A,397.80,N/A,1170.00,N/A,163.80,N/A,567.92,N/A,567.92,N/A,1063.58,N/A,1170.00,N/A,1170.00,N/A,1170.00,N/A,1170.00,N/A,567.92,N/A,163.80,N/A,1170.00,N/A,1170.00,N/A,163.80,N/A,567.92,N/A,567.92,N/A,624.71,702.00,702.00,163.80,1170.00,,Hospital 64719,Revise Ulnar Nerve at Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42854.67,N/A,25712.80,N/A,5999.66,N/A,2664.83,N/A,24481.19,N/A,14570.61,N/A,6556.70,N/A,5999.66,N/A,2688.04,N/A,2688.04,N/A,4081.68,N/A,6556.70,N/A,6556.70,N/A,6556.70,N/A,24429.38,N/A,2688.04,N/A,5999.66,N/A,7109.75,N/A,7109.75,N/A,5999.66,N/A,2688.04,N/A,2664.83,N/A,2287.02,N/A,N/A,2287.02,25712.80,,Hospital 64776,Excise Digital Neuroma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45048.72,N/A,27029.23,N/A,6306.82,N/A,12325.48,N/A,25606.10,N/A,15316.57,N/A,28531.97,N/A,6306.82,N/A,11782.94,N/A,11782.94,N/A,17761.70,N/A,28531.97,N/A,28531.97,N/A,28531.97,N/A,25606.12,N/A,11782.94,N/A,6306.82,N/A,9595.50,N/A,9595.50,N/A,6306.82,N/A,11782.94,N/A,12325.48,N/A,1191.40,N/A,N/A,1191.40,28531.97,,Hospital 64784,Excise Major Peripheral Neuroma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30320.77,N/A,18192.46,N/A,4244.92,N/A,1339.38,N/A,17395.53,N/A,10309.06,N/A,11432.09,N/A,4244.92,N/A,4706.78,N/A,4706.78,N/A,7116.69,N/A,11432.09,N/A,11432.09,N/A,11432.09,N/A,17395.52,N/A,4706.78,N/A,4244.92,N/A,9727.25,N/A,9727.25,N/A,4244.92,N/A,4706.78,N/A,1339.38,N/A,1473.32,N/A,N/A,1339.38,18192.46,,Hospital CPT 64831,Suture Digital Nerve Hand/Foot 1 Nerve,N/A,N/A,1364.00,1364.00,818.40,818.40,N/A,190.96,N/A,657.37,N/A,1364.00,N/A,463.76,N/A,1364.00,N/A,190.96,N/A,657.37,N/A,657.37,N/A,1226.31,N/A,1364.00,N/A,1364.00,N/A,1364.00,N/A,1364.00,N/A,657.37,N/A,190.96,N/A,1364.00,N/A,1364.00,N/A,190.96,N/A,657.37,N/A,657.37,N/A,723.11,818.40,818.40,190.96,1364.00,,Hospital 64890,"Nerve Graft,Hand/Foot,One,=<4cm",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,133141.13,N/A,79884.68,N/A,18639.77,N/A,9965.26,N/A,75526.40,N/A,45267.99,N/A,13540.27,N/A,18639.77,N/A,9950.76,N/A,9950.76,N/A,8429.09,N/A,13540.27,N/A,13540.27,N/A,13540.27,N/A,75382.45,N/A,9950.76,N/A,18639.77,N/A,7661.50,N/A,7661.50,N/A,18639.77,N/A,9950.76,N/A,9965.26,N/A,1657.59,N/A,N/A,1657.59,79884.68,,Hospital 64905,"Nerve Pedicle Xfer,First Stage",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29319.88,N/A,17591.93,N/A,4104.78,N/A,5531.37,N/A,16706.32,N/A,9968.77,N/A,13557.79,N/A,4104.78,N/A,5579.57,N/A,5579.57,N/A,8439.98,N/A,13557.79,N/A,13557.79,N/A,13557.79,N/A,16706.32,N/A,5579.57,N/A,4104.78,N/A,8244.00,N/A,8244.00,N/A,4104.78,N/A,5579.57,N/A,5531.37,N/A,1779.09,N/A,N/A,1779.09,17591.93,,Hospital 64911,Neurorraphy W/Vein Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83515.02,N/A,50109.01,N/A,11683.23,N/A,5836.48,N/A,47729.71,N/A,28395.11,N/A,13518.60,N/A,11683.23,N/A,5579.57,N/A,5579.57,N/A,8415.58,N/A,13518.60,N/A,13518.60,N/A,13518.60,N/A,47729.72,N/A,5579.57,N/A,11683.23,N/A,5963.00,N/A,5963.00,N/A,11683.23,N/A,5579.57,N/A,5836.48,N/A,1110.85,N/A,N/A,1110.85,50109.01,,Hospital 65280,"Repair Cornea Lac,Perf,No Uveal",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 65400,Excis Cornea Lesn,N/A,N/A,1138.00,1138.00,682.80,682.80,N/A,159.32,N/A,557.64,N/A,1138.00,N/A,386.92,N/A,1138.00,N/A,159.32,N/A,557.64,N/A,557.64,N/A,1138.00,N/A,1138.00,N/A,1138.00,N/A,1138.00,N/A,1138.00,N/A,557.64,N/A,159.32,N/A,1138.00,N/A,1138.00,N/A,159.32,N/A,557.64,N/A,557.64,N/A,613.40,682.80,682.80,159.32,1138.00,,Hospital CPT 65420,Excis Pterygium,N/A,N/A,884.00,884.00,530.40,530.40,N/A,123.76,N/A,349.47,N/A,884.00,N/A,300.56,N/A,884.00,N/A,123.76,N/A,349.47,N/A,349.47,N/A,884.00,N/A,884.00,N/A,884.00,N/A,884.00,N/A,884.00,N/A,349.47,N/A,123.76,N/A,884.00,N/A,884.00,N/A,123.76,N/A,349.47,N/A,349.47,N/A,384.42,530.40,530.40,123.76,884.00,,Hospital 65435,HC Curette/Treat Cornea,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 65800,Paracentsis Ant Chamb Eye Aspir Aqueous Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32015.25,N/A,19209.15,N/A,4476.46,N/A,1887.49,N/A,18423.84,N/A,10885.18,N/A,8768.86,N/A,4476.46,N/A,3608.17,N/A,3608.17,N/A,5458.79,N/A,8768.86,N/A,8768.86,N/A,8768.86,N/A,18423.85,N/A,3608.17,N/A,4476.46,N/A,7793.25,N/A,7793.25,N/A,4476.46,N/A,3608.17,N/A,1887.49,N/A,2076.25,N/A,N/A,1887.49,19209.15,,Hospital 65810,"Drain Ant Chmbr,Remv Vitreous",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14753.40,N/A,8852.04,N/A,2065.48,N/A,1940.08,N/A,8493.75,N/A,5016.16,N/A,4733.71,N/A,2065.48,N/A,1950.06,N/A,1950.06,N/A,2946.83,N/A,4733.71,N/A,4733.71,N/A,4733.71,N/A,8493.75,N/A,1950.06,N/A,2065.48,N/A,3397.00,N/A,3397.00,N/A,2065.48,N/A,1950.06,N/A,1940.08,N/A,472.27,N/A,N/A,472.27,8852.04,,Hospital 65815,"Drain Ant Chmbr,Remv Blood",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5819.10,N/A,3491.46,N/A,814.67,N/A,2039.85,N/A,3350.36,N/A,1978.49,N/A,4720.09,N/A,814.67,N/A,1950.06,N/A,1950.06,N/A,2938.34,N/A,4720.09,N/A,4720.09,N/A,4720.09,N/A,3350.35,N/A,1950.06,N/A,814.67,N/A,3397.00,N/A,3397.00,N/A,814.67,N/A,1950.06,N/A,2039.85,N/A,484.73,N/A,N/A,484.73,4720.09,,Hospital 65860,"Incise Inner Eye Adhesns,Laser",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32054.80,N/A,19232.88,N/A,4477.18,N/A,1200.46,N/A,18455.12,N/A,10898.63,N/A,8731.79,N/A,4477.18,N/A,3608.17,N/A,3608.17,N/A,5435.71,N/A,8731.79,N/A,8731.79,N/A,8731.79,N/A,18455.12,N/A,3608.17,N/A,4477.18,N/A,6678.50,N/A,6678.50,N/A,4477.18,N/A,3608.17,N/A,1200.46,N/A,1320.51,N/A,N/A,1200.46,19232.88,,Hospital 65920,"Remvl,Implant Material,Ant Segment,Eye",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12676.30,N/A,7605.78,N/A,1774.69,N/A,2039.85,N/A,7296.06,N/A,4309.95,N/A,4794.21,N/A,1774.69,N/A,1950.06,N/A,1950.06,N/A,2984.49,N/A,4794.21,N/A,4794.21,N/A,4794.21,N/A,7296.07,N/A,1950.06,N/A,1774.69,N/A,5095.50,N/A,5095.50,N/A,1774.69,N/A,1950.06,N/A,2039.85,N/A,1208.56,N/A,N/A,1208.56,7605.78,,Hospital 66175,"Transluminal Dilation Aqueous Canal, W Retention Device/Stent",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39994.93,N/A,23996.96,N/A,5598.79,N/A,1557.76,N/A,22819.66,N/A,13598.28,N/A,8740.38,N/A,5598.79,N/A,3608.17,N/A,3608.17,N/A,5441.07,N/A,8740.38,N/A,8740.38,N/A,8740.38,N/A,22819.66,N/A,3608.17,N/A,5598.79,N/A,7661.50,N/A,7661.50,N/A,5598.79,N/A,3608.17,N/A,1557.76,N/A,1575.93,N/A,N/A,1557.76,23996.96,,Hospital 66183,Insert Anter Drainage Dev W/O Extraoc Reservoir,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22626.52,N/A,13575.91,N/A,3167.71,N/A,3589.71,N/A,12824.01,N/A,7693.02,N/A,8730.03,N/A,3167.71,N/A,3608.17,N/A,3608.17,N/A,5434.61,N/A,8730.03,N/A,8730.03,N/A,8730.03,N/A,12824.01,N/A,3608.17,N/A,3167.71,N/A,7661.50,N/A,7661.50,N/A,3167.71,N/A,3608.17,N/A,3589.71,N/A,1606.76,N/A,N/A,1606.76,13575.91,,Hospital 66184,Revj Shunt Extraocular Reservoir W/O Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18615.38,N/A,11169.23,N/A,2606.15,N/A,2039.85,N/A,10593.02,N/A,6329.23,N/A,4789.14,N/A,2606.15,N/A,1950.06,N/A,1950.06,N/A,2981.32,N/A,4789.14,N/A,4789.14,N/A,4789.14,N/A,10593.03,N/A,1950.06,N/A,2606.15,N/A,3397.00,N/A,3397.00,N/A,2606.15,N/A,1950.06,N/A,2039.85,N/A,805.13,N/A,N/A,805.13,11169.23,,Hospital 66680,Repair Iris/Ciliary Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11125.20,N/A,6675.12,N/A,1557.53,N/A,2151.15,N/A,6401.83,N/A,3782.57,N/A,4724.57,N/A,1557.53,N/A,1950.06,N/A,1950.06,N/A,2941.13,N/A,4724.57,N/A,4724.57,N/A,4724.57,N/A,6401.85,N/A,1950.06,N/A,1557.53,N/A,3397.00,N/A,3397.00,N/A,1557.53,N/A,1950.06,N/A,483.84,N/A,532.22,N/A,N/A,483.84,6675.12,,Hospital 66762,Iridoplasty by Photocoag,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6135.80,N/A,3681.48,N/A,859.02,N/A,528.73,N/A,3533.00,N/A,2086.17,N/A,1159.41,N/A,859.02,N/A,479.31,N/A,479.31,N/A,721.75,N/A,1159.41,N/A,1159.41,N/A,1159.41,N/A,3533.00,N/A,479.31,N/A,859.02,N/A,1431.00,N/A,1431.00,N/A,859.02,N/A,479.31,N/A,393.09,N/A,432.40,N/A,N/A,393.09,3681.48,,Hospital 66825,Reposition Intraocular Lens W Incis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27422.27,N/A,16453.36,N/A,3828.63,N/A,1615.07,N/A,15782.42,N/A,9323.57,N/A,8772.89,N/A,3828.63,N/A,3608.17,N/A,3608.17,N/A,5461.30,N/A,8772.89,N/A,8772.89,N/A,8772.89,N/A,15782.42,N/A,3608.17,N/A,3828.63,N/A,7661.50,N/A,7661.50,N/A,3828.63,N/A,3608.17,N/A,1615.07,N/A,1776.58,N/A,N/A,1615.07,16453.36,,Hospital 66840,Rmvl Lens Material Aspir Tq 1/> Stages,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11657.30,N/A,6994.38,N/A,1632.02,N/A,2039.85,N/A,6712.13,N/A,3963.48,N/A,4717.91,N/A,1632.02,N/A,1950.06,N/A,1950.06,N/A,2936.99,N/A,4717.91,N/A,4717.91,N/A,4717.91,N/A,6712.14,N/A,1950.06,N/A,1632.02,N/A,3397.00,N/A,3397.00,N/A,1632.02,N/A,1950.06,N/A,2039.85,N/A,708.21,N/A,N/A,708.21,6994.38,,Hospital 66930,"Extract Lens,Intracap,Disloc Lens",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22413.25,N/A,13447.95,N/A,3137.85,N/A,3577.00,N/A,12903.96,N/A,7620.50,N/A,8746.66,N/A,3137.85,N/A,3608.17,N/A,3608.17,N/A,5444.97,N/A,8746.66,N/A,8746.66,N/A,8746.66,N/A,12903.96,N/A,3608.17,N/A,3137.85,N/A,3660.50,N/A,3660.50,N/A,3137.85,N/A,3608.17,N/A,3577.00,N/A,1280.20,N/A,N/A,1280.20,13447.95,,Hospital 66989,Xcapsl Ctrc Rmvl Insj Io Lens Prsth Cplx Insj 1+,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40254.93,N/A,24152.96,N/A,5635.69,N/A,923.04,N/A,23003.58,N/A,13686.68,N/A,4263.03,N/A,5635.69,N/A,3838.37,N/A,3838.37,N/A,4258.31,N/A,4263.03,N/A,4263.03,N/A,4263.03,N/A,23003.59,N/A,3838.37,N/A,5635.69,N/A,5963.00,N/A,5963.00,N/A,5635.69,N/A,3838.37,N/A,923.04,N/A,877.73,N/A,N/A,877.73,24152.96,,Hospital 66990,Ophthalmic Endoscope Use,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33082.77,N/A,19849.66,N/A,4621.09,N/A,980.12,N/A,19043.51,N/A,11248.14,N/A,8757.25,N/A,4621.09,N/A,3608.17,N/A,3608.17,N/A,5451.56,N/A,8757.25,N/A,8757.25,N/A,8757.25,N/A,19043.55,N/A,3608.17,N/A,4621.09,N/A,6226.50,N/A,6226.50,N/A,4621.09,N/A,3608.17,N/A,980.12,N/A,1078.14,N/A,N/A,980.12,19849.66,,Hospital CPT 67040,Vtrectomy Mchnl Pars Plna Endolaser Panrta Pc,N/A,N/A,2366.00,2366.00,1419.60,1419.60,N/A,331.24,N/A,964.20,N/A,2366.00,N/A,804.44,N/A,2366.00,N/A,331.24,N/A,964.20,N/A,964.20,N/A,1795.28,N/A,2366.00,N/A,2366.00,N/A,2366.00,N/A,2366.00,N/A,964.20,N/A,331.24,N/A,2366.00,N/A,2366.00,N/A,331.24,N/A,964.20,N/A,964.20,N/A,1060.62,1419.60,1419.60,331.24,2366.00,,Hospital 67105,Rpr Retinal Dtchmnt Drg Subretinal Fluid Pc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48982.47,N/A,29389.48,N/A,6847.34,N/A,3842.24,N/A,28201.41,N/A,16654.03,N/A,8751.83,N/A,6847.34,N/A,3612.10,N/A,3612.10,N/A,5448.18,N/A,8751.83,N/A,8751.83,N/A,8751.83,N/A,28201.41,N/A,3612.10,N/A,6847.34,N/A,6678.50,N/A,6678.50,N/A,6847.34,N/A,3612.10,N/A,3842.24,N/A,1524.59,N/A,N/A,1524.59,29389.48,,Hospital 67141,Proph Retinal Dtchmnt W/O Drg Crtx Diathermy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38934.63,N/A,23360.78,N/A,5450.86,N/A,1309.38,N/A,22398.64,N/A,13237.77,N/A,8763.67,N/A,5450.86,N/A,3608.17,N/A,3608.17,N/A,5455.56,N/A,8763.67,N/A,8763.67,N/A,8763.67,N/A,22398.65,N/A,3608.17,N/A,5450.86,N/A,6226.50,N/A,6226.50,N/A,5450.86,N/A,3608.17,N/A,1309.38,N/A,1440.31,N/A,N/A,1309.38,23360.78,,Hospital 67208,"Destruc Retinal Lesn,Cryotherapy",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8505.80,N/A,5103.48,N/A,1190.81,N/A,375.08,N/A,4892.41,N/A,2891.97,N/A,967.12,N/A,1190.81,N/A,358.57,N/A,358.57,N/A,602.05,N/A,967.12,N/A,967.12,N/A,967.12,N/A,4892.41,N/A,358.57,N/A,1190.81,N/A,790.50,N/A,790.50,N/A,1190.81,N/A,358.57,N/A,375.08,N/A,589.62,N/A,N/A,358.57,5103.48,,Hospital 67228,Treatment Extensive Retinopathy Photocoagulation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27013.80,N/A,16208.28,N/A,3760.01,N/A,1257.76,N/A,15534.20,N/A,8910.11,N/A,8849.66,N/A,3760.01,N/A,3608.17,N/A,3608.17,N/A,5509.09,N/A,8849.66,N/A,8849.66,N/A,8849.66,N/A,15534.22,N/A,3608.17,N/A,3760.01,N/A,6678.50,N/A,6678.50,N/A,3760.01,N/A,3608.17,N/A,1257.76,N/A,1383.55,N/A,N/A,1257.76,16208.28,,Hospital CPT 67311,Strabismus Recession/Rescj 1 Hrzntl Musc,N/A,N/A,1166.00,1166.00,699.60,699.60,N/A,163.24,N/A,446.66,N/A,1166.00,N/A,396.44,N/A,1166.00,N/A,163.24,N/A,446.66,N/A,446.66,N/A,787.34,N/A,1166.00,N/A,1166.00,N/A,1166.00,N/A,1166.00,N/A,446.66,N/A,163.24,N/A,1166.00,N/A,1166.00,N/A,163.24,N/A,446.66,N/A,446.66,N/A,491.33,699.60,699.60,163.24,1166.00,,Hospital CPT 67314,Strabismus Recession/Rescj 1 Ver Musc,N/A,N/A,1312.00,1312.00,787.20,787.20,N/A,183.68,N/A,507.41,N/A,1312.00,N/A,446.08,N/A,1264.80,N/A,183.68,N/A,507.41,N/A,507.41,N/A,787.34,N/A,1264.80,N/A,1264.80,N/A,1264.80,N/A,1312.00,N/A,507.41,N/A,183.68,N/A,1312.00,N/A,1312.00,N/A,183.68,N/A,507.41,N/A,507.41,N/A,558.15,787.20,787.20,183.68,1312.00,,Hospital 67343,Release Exten Scar Tissue Eye,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7387.50,N/A,4432.50,N/A,1034.25,N/A,1899.46,N/A,4247.01,N/A,2511.75,N/A,4746.49,N/A,1034.25,N/A,1909.23,N/A,1909.23,N/A,2954.78,N/A,4746.49,N/A,4746.49,N/A,4746.49,N/A,4247.01,N/A,1909.23,N/A,1034.25,N/A,3397.00,N/A,3397.00,N/A,1034.25,N/A,1909.23,N/A,1899.46,N/A,683.58,N/A,N/A,683.58,4746.49,,Hospital 67412,Orbitotomy W/O Bone Flap W/Removal Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,99129.02,36607.20,59477.41,21964.32,9651.93,5125.03,11713.03,1997.13,36392.43,21075.82,33703.87,12446.44,21959.47,4650.94,9949.32,5125.03,94978.00,1909.23,94978.00,1909.23,13669.26,2895.31,21959.47,4650.94,21959.47,4650.94,21959.47,4650.94,36392.43,21075.84,11683.38,1909.23,9949.32,5125.03,26126.29,4800.25,26126.29,4800.25,238.28,5125.03,11683.38,1909.23,11713.03,1997.13,10645.77,2244.10,238.28,94978.00,1909.23,21964.32,,Hospital CPT 67700,HC Drainage of Eyelid Abscess,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,988.00,988.00,592.80,592.80,N/A,138.32,N/A,107.23,N/A,568.89,N/A,335.92,N/A,775.08,N/A,138.32,N/A,107.23,N/A,107.23,N/A,482.49,N/A,775.08,N/A,775.08,N/A,775.08,N/A,568.89,N/A,107.23,N/A,138.32,N/A,988.00,N/A,988.00,N/A,138.32,N/A,107.23,N/A,107.23,N/A,117.95,592.80,592.80,107.23,988.00,,Hospital 67808,Exc Chalazion Anes Req Hospization Single/Mult,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11626.20,N/A,6975.72,N/A,1627.66,N/A,1983.56,N/A,6693.34,N/A,3952.91,N/A,4629.99,N/A,1627.66,N/A,1909.23,N/A,1909.23,N/A,2882.26,N/A,4629.99,N/A,4629.99,N/A,4629.99,N/A,6693.35,N/A,1909.23,N/A,1627.66,N/A,3397.00,N/A,3397.00,N/A,1627.66,N/A,1909.23,N/A,1983.56,N/A,374.32,N/A,N/A,374.32,6975.72,,Hospital 67810,Incisional Biopsy Eyelid Skin & Lid Margin,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11595.35,N/A,6957.21,N/A,1613.49,N/A,103.40,N/A,6674.60,N/A,3942.42,N/A,587.51,N/A,1613.49,N/A,239.04,N/A,239.04,N/A,365.73,N/A,587.51,N/A,587.51,N/A,587.51,N/A,6674.59,N/A,239.04,N/A,1613.49,N/A,527.00,N/A,527.00,N/A,1613.49,N/A,239.04,N/A,103.40,N/A,113.74,N/A,N/A,103.40,6957.21,,Hospital 67875,Temporary Closure Eyelids Suture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36607.20,N/A,21964.32,N/A,5125.03,N/A,1997.13,N/A,21075.82,N/A,12446.44,N/A,4650.94,N/A,5125.03,N/A,1909.23,N/A,1909.23,N/A,2895.31,N/A,4650.94,N/A,4650.94,N/A,4650.94,N/A,21075.84,N/A,1909.23,N/A,5125.03,N/A,4800.25,N/A,4800.25,N/A,5125.03,N/A,1909.23,N/A,1997.13,N/A,2244.10,N/A,N/A,1909.23,21964.32,,Hospital 67901,"Fix Lid Ptosis,Frontalis Musc,Sut",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12213.00,N/A,7327.80,N/A,1709.82,N/A,1997.13,N/A,7031.94,N/A,4152.42,N/A,4623.75,N/A,1709.82,N/A,1909.23,N/A,1909.23,N/A,2878.38,N/A,4623.75,N/A,4623.75,N/A,4623.75,N/A,7031.93,N/A,1909.23,N/A,1709.82,N/A,3397.00,N/A,3397.00,N/A,1709.82,N/A,1909.23,N/A,1997.13,N/A,602.86,N/A,N/A,602.86,7327.80,,Hospital 67903,Rpr Blepharoptosis Levator Rescj/Advmnt Internal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,84203.00,N/A,50521.80,N/A,11788.42,N/A,6184.27,N/A,48475.45,N/A,28629.01,N/A,6246.73,N/A,11788.42,N/A,6173.26,N/A,6173.26,N/A,3888.71,N/A,6246.73,N/A,6246.73,N/A,6246.73,N/A,48475.46,N/A,6173.26,N/A,11788.42,N/A,7109.75,N/A,7109.75,N/A,11788.42,N/A,6173.26,N/A,6184.27,N/A,3206.86,N/A,N/A,3206.86,50521.80,,Hospital 67917,Repair Ectropion Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9659.00,N/A,5795.40,N/A,1352.26,N/A,1997.13,N/A,5561.52,N/A,3284.06,N/A,4621.37,N/A,1352.26,N/A,1909.23,N/A,1909.23,N/A,2876.89,N/A,4621.37,N/A,4621.37,N/A,4621.37,N/A,5561.52,N/A,1909.23,N/A,1352.26,N/A,3397.00,N/A,3397.00,N/A,1352.26,N/A,1909.23,N/A,1997.13,N/A,465.43,N/A,N/A,465.43,5795.40,,Hospital CPT 67961,HC Excision and Repair Eyelid,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5506.00,5506.00,3303.60,3303.60,N/A,770.84,N/A,420.44,N/A,3170.35,N/A,1872.04,N/A,1626.87,N/A,770.84,N/A,420.44,N/A,420.44,N/A,1012.73,N/A,1626.87,N/A,1626.87,N/A,1626.87,N/A,3170.35,N/A,420.44,N/A,770.84,N/A,5506.00,N/A,5506.00,N/A,770.84,N/A,420.44,N/A,420.44,N/A,462.48,3303.60,3303.60,420.44,5506.00,,Hospital 67971,"Reconstruc Eyelid,<2/3,One Stage",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,4813.00,N/A,2887.80,N/A,673.82,N/A,1997.13,N/A,2770.78,N/A,1636.42,N/A,4624.11,N/A,673.82,N/A,1909.23,N/A,1909.23,N/A,2878.60,N/A,4624.11,N/A,4624.11,N/A,4624.11,N/A,2770.78,N/A,1909.23,N/A,673.82,N/A,3397.00,N/A,3397.00,N/A,673.82,N/A,1909.23,N/A,1997.13,N/A,737.30,N/A,N/A,673.82,4624.11,,Hospital 67973,"Reconstruc Eyelid,Tot Lower,1 Stage",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12167.40,N/A,7300.44,N/A,1703.43,N/A,1997.13,N/A,7005.38,N/A,4136.91,N/A,4630.64,N/A,1703.43,N/A,1909.23,N/A,1909.23,N/A,2882.66,N/A,4630.64,N/A,4630.64,N/A,4630.64,N/A,7005.39,N/A,1909.23,N/A,1703.43,N/A,3397.00,N/A,3397.00,N/A,1703.43,N/A,1909.23,N/A,1997.13,N/A,948.02,N/A,N/A,948.02,7300.44,,Hospital 68100,Biopsy Conjunctiva,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8541.50,N/A,5124.90,N/A,1195.82,N/A,2106.10,N/A,4916.16,N/A,2903.86,N/A,4620.07,N/A,1195.82,N/A,1909.23,N/A,1909.23,N/A,2876.09,N/A,4620.07,N/A,4620.07,N/A,4620.07,N/A,4916.16,N/A,1909.23,N/A,1195.82,N/A,1431.00,N/A,1431.00,N/A,1195.82,N/A,1909.23,N/A,174.34,N/A,191.78,N/A,N/A,174.34,5124.90,,Hospital 68200,Subconjunctival Injection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27808.08,N/A,16684.85,N/A,3893.15,N/A,3774.30,N/A,15849.66,N/A,9454.74,N/A,9863.98,N/A,3893.15,N/A,3608.17,N/A,3608.17,N/A,6140.50,N/A,9863.98,N/A,9863.98,N/A,9863.98,N/A,15849.66,N/A,3608.17,N/A,3893.15,N/A,8375.75,N/A,8375.75,N/A,3893.15,N/A,3608.17,N/A,3774.30,N/A,919.08,N/A,N/A,919.08,16684.85,,Hospital 69005,HC Drain External Ear Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 69100,Biopsy of External Ear,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29881.20,N/A,17928.72,N/A,4183.37,N/A,711.19,N/A,17203.92,N/A,10159.61,N/A,1690.28,N/A,4183.37,N/A,679.89,N/A,679.89,N/A,1052.22,N/A,1690.28,N/A,1690.28,N/A,1690.28,N/A,17203.94,N/A,679.89,N/A,4183.37,N/A,1694.50,N/A,1694.50,N/A,4183.37,N/A,679.89,N/A,711.19,N/A,755.67,N/A,N/A,679.89,17928.72,,Hospital 69433,HC Pbb Tympanostomy Local/Topical Anesthesia,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,639.00,N/A,383.40,N/A,89.46,N/A,437.17,N/A,367.94,N/A,217.26,N/A,N/A,N/A,89.46,N/A,412.53,N/A,412.53,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,367.94,N/A,412.53,N/A,89.46,N/A,342.50,N/A,342.50,N/A,89.46,N/A,412.53,N/A,437.17,N/A,136.16,N/A,N/A,89.46,437.17,,Hospital 69601,Mastoidect Revisn W Complete Remval,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30399.10,N/A,18239.46,N/A,4255.87,N/A,4950.73,N/A,17500.28,N/A,10335.69,N/A,11699.43,N/A,4255.87,N/A,4821.94,N/A,4821.94,N/A,7283.12,N/A,11699.43,N/A,11699.43,N/A,11699.43,N/A,17500.28,N/A,4821.94,N/A,4255.87,N/A,6898.50,N/A,6898.50,N/A,4255.87,N/A,4821.94,N/A,4950.73,N/A,1758.64,N/A,N/A,1758.64,18239.46,,Hospital 69643,Tmpp Mastoidect Ntc/Rcnsted Wall W/O Ocr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40579.33,N/A,24347.60,N/A,5681.09,N/A,4780.29,N/A,23339.19,N/A,13796.97,N/A,11726.34,N/A,5681.09,N/A,4821.94,N/A,4821.94,N/A,7299.87,N/A,11726.34,N/A,11726.34,N/A,11726.34,N/A,23339.20,N/A,4821.94,N/A,5681.09,N/A,6898.50,N/A,6898.50,N/A,5681.09,N/A,4821.94,N/A,4780.29,N/A,1943.58,N/A,N/A,1943.58,24347.60,,Hospital 69646,"Tympanoplas/Mastoidec,Rad,Rebld Ossi",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62011.52,N/A,37206.91,N/A,8612.29,N/A,4987.25,N/A,35677.00,N/A,21083.91,N/A,11783.87,N/A,8612.29,N/A,4821.94,N/A,4821.94,N/A,7335.68,N/A,11783.87,N/A,11783.87,N/A,11783.87,N/A,35676.98,N/A,4821.94,N/A,8612.29,N/A,8244.00,N/A,8244.00,N/A,8612.29,N/A,4821.94,N/A,4987.25,N/A,2840.98,N/A,N/A,2840.98,37206.91,,Hospital 69705,Surg Nasopharyngoscopy Dilat Eustachian Tube Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15957.88,N/A,9574.73,N/A,2234.10,N/A,4821.94,N/A,9181.42,N/A,5425.68,N/A,11698.26,N/A,2234.10,N/A,4821.94,N/A,4821.94,N/A,7282.39,N/A,11698.26,N/A,11698.26,N/A,11698.26,N/A,9181.42,N/A,4821.94,N/A,2234.10,N/A,6898.50,N/A,6898.50,N/A,2234.10,N/A,4821.94,N/A,4821.94,N/A,5304.13,N/A,N/A,2234.10,11698.26,,Hospital 69706,Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16869.63,N/A,10121.78,N/A,2361.53,N/A,4821.94,N/A,9703.93,N/A,5735.68,N/A,11679.29,N/A,2361.53,N/A,4821.94,N/A,4821.94,N/A,7270.57,N/A,11679.29,N/A,11679.29,N/A,11679.29,N/A,9703.94,N/A,4821.94,N/A,2361.53,N/A,7366.25,N/A,7366.25,N/A,2361.53,N/A,4821.94,N/A,4821.94,N/A,5304.13,N/A,N/A,2361.53,11679.29,,Hospital 69711,"Remove/Repair Hear Aid,Temp Bone",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32168.20,N/A,19300.92,N/A,4499.34,N/A,2733.05,N/A,18513.03,N/A,10937.19,N/A,6265.70,N/A,4499.34,N/A,2569.18,N/A,2569.18,N/A,3900.51,N/A,6265.70,N/A,6265.70,N/A,6265.70,N/A,18513.02,N/A,2569.18,N/A,4499.34,N/A,6898.50,N/A,6898.50,N/A,4499.34,N/A,2569.18,N/A,2733.05,N/A,1722.84,N/A,N/A,1722.84,19300.92,,Hospital 69714,Impltj Oi Implt Skull Perq Attachment Esp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44079.97,N/A,26447.98,N/A,6155.59,N/A,12997.98,N/A,25040.08,N/A,14987.21,N/A,28525.41,N/A,6155.59,N/A,11782.94,N/A,11782.94,N/A,17757.62,N/A,28525.41,N/A,28525.41,N/A,28525.41,N/A,25040.09,N/A,11782.94,N/A,6155.59,N/A,11660.00,N/A,11660.00,N/A,6155.59,N/A,11782.94,N/A,21062.98,N/A,22819.62,N/A,N/A,6155.59,28525.41,,Hospital 69806,Endolymph Sac OP W Shunt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65501.58,N/A,39300.95,N/A,9170.23,N/A,5125.97,N/A,37700.22,N/A,22270.54,N/A,12035.03,N/A,9170.23,N/A,4903.95,N/A,4903.95,N/A,7614.99,N/A,12035.03,N/A,12035.03,N/A,12035.03,N/A,37515.43,N/A,4919.45,N/A,9170.23,N/A,5963.00,N/A,5963.00,N/A,9170.23,N/A,4903.95,N/A,5125.97,N/A,1150.78,N/A,N/A,1150.78,39300.95,,Hospital 69930,Implant Cochlear Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,199957.52,N/A,119974.51,N/A,27974.95,N/A,29844.64,N/A,112872.92,N/A,67985.56,N/A,72858.45,N/A,27974.95,N/A,30104.67,N/A,30104.67,N/A,45355.79,N/A,72858.45,N/A,72858.45,N/A,72858.45,N/A,112872.91,N/A,30104.67,N/A,27974.95,N/A,29766.00,N/A,29766.00,N/A,27974.95,N/A,30104.67,N/A,29844.64,N/A,45699.97,N/A,N/A,27974.95,119974.51,,Hospital 69949,Inner Ear Surgery Proc Unlisted,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37796.08,N/A,22677.65,N/A,5283.45,N/A,2687.47,N/A,21758.20,N/A,12850.66,N/A,6261.95,N/A,5283.45,N/A,2569.18,N/A,2569.18,N/A,3898.18,N/A,6261.95,N/A,6261.95,N/A,6261.95,N/A,21758.22,N/A,2569.18,N/A,5283.45,N/A,5563.25,N/A,5563.25,N/A,5283.45,N/A,2569.18,N/A,2687.47,N/A,361.29,N/A,N/A,361.29,22677.65,,Hospital 70030,HC Eye 1-3 Vws for Foreign Body,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,52049.47,2589.00,31229.68,1553.40,10972.18,362.46,6752.92,213.16,54779.34,1536.67,17696.82,880.26,12476.84,510.09,10972.18,362.46,6752.92,210.88,6752.92,210.88,7766.54,317.54,12476.84,510.09,12476.84,510.09,12476.84,510.09,12358.62,1536.67,6752.92,210.88,5652.96,362.46,14844.32,1457.18,14844.32,1457.18,5652.96,362.46,6752.92,210.88,6752.92,213.16,6048.67,152.12,5652.96,54779.34,152.12,1553.40,,Hospital CPT 70110,HC Mandible Mandible Min 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1131.00,1131.00,678.60,678.60,N/A,158.34,N/A,96.52,N/A,651.23,N/A,384.54,N/A,233.46,N/A,158.34,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,651.23,N/A,96.52,N/A,158.34,N/A,606.22,N/A,606.22,N/A,158.34,N/A,96.52,N/A,96.52,N/A,106.17,678.60,678.60,96.52,678.60,,Hospital CPT 70190,HC Optic Foramina,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,396.00,314.00,237.60,188.40,N/A,43.96,N/A,24.65,N/A,180.80,N/A,106.76,N/A,102.99,N/A,43.96,N/A,24.65,N/A,24.65,N/A,64.11,N/A,102.99,N/A,102.99,N/A,102.99,N/A,180.80,N/A,24.65,N/A,43.96,N/A,168.30,N/A,168.30,N/A,43.96,N/A,24.65,N/A,24.65,N/A,27.12,237.60,237.60,24.65,188.40,,Hospital 70355,HC Mandible Panorex,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,33034.10,644.00,19820.46,386.40,4773.95,90.16,5912.98,80.09,10758.49,370.82,11231.59,218.96,10861.40,189.77,4921.05,90.16,3372.00,78.46,3372.00,78.46,6760.97,118.14,10861.40,189.77,10861.40,189.77,10861.40,189.77,10758.49,370.82,N/A,78.46,4921.05,90.16,12922.36,345.18,12922.36,345.18,4392.68,90.16,5912.98,78.46,N/A,80.09,5265.52,7.92,3372.00,19820.46,7.92,386.40,,Hospital CPT 70450,HC CT Brain W/O Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2583.00,1834.00,1549.80,1100.40,N/A,256.76,N/A,96.52,N/A,914.00,N/A,623.56,N/A,233.46,N/A,256.76,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,96.52,N/A,96.52,N/A,106.17,1549.80,1549.80,96.52,1100.40,,Hospital CPT 70460,HC CT Brain W/ Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2949.00,2108.00,1769.40,1264.80,N/A,295.12,N/A,161.45,N/A,914.00,N/A,716.72,N/A,393.92,N/A,295.12,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,295.12,N/A,689.00,N/A,689.00,N/A,295.12,N/A,162.85,N/A,90.50,N/A,99.55,1769.40,1769.40,90.50,1264.80,,Hospital CPT 70480,HC CT Orbit/Ear/Fossa W/O Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2583.00,1834.00,1549.80,1100.40,N/A,256.76,N/A,96.52,N/A,914.00,N/A,623.56,N/A,233.46,N/A,256.76,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,96.52,N/A,96.52,N/A,106.17,1549.80,1549.80,96.52,1100.40,,Hospital CPT 70481,HC CT Orbit/Ear/Fossa W/ Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2949.00,2108.00,1769.40,1264.80,N/A,295.12,N/A,162.85,N/A,914.00,N/A,716.72,N/A,393.92,N/A,295.12,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,295.12,N/A,689.00,N/A,689.00,N/A,295.12,N/A,162.85,N/A,162.85,N/A,179.14,1769.40,1769.40,162.85,1264.80,,Hospital CPT 70482,HC CT Orbit/Ear/Fossa W/WO Contrast,N/A,0351 - CT SCAN - HEAD SCAN,3318.00,2428.00,1990.80,1456.80,N/A,339.92,N/A,162.85,N/A,914.00,N/A,825.52,N/A,393.92,N/A,339.92,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,339.92,N/A,689.00,N/A,689.00,N/A,339.92,N/A,162.85,N/A,162.85,N/A,179.14,1990.80,1990.80,162.85,1456.80,,Hospital CPT 70490,HC CT Soft Tissue Neck W/O Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2583.00,1834.00,1549.80,1100.40,N/A,256.76,N/A,96.52,N/A,914.00,N/A,623.56,N/A,233.46,N/A,256.76,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,96.52,N/A,96.52,N/A,106.17,1549.80,1549.80,96.52,1100.40,,Hospital CPT 70496,HC Cta Head W & W/O Cont,N/A,0351 - CT SCAN - HEAD SCAN,3318.00,1834.00,1990.80,1100.40,N/A,256.76,N/A,162.85,N/A,914.00,N/A,623.56,N/A,393.92,N/A,256.76,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,162.85,N/A,162.85,N/A,179.14,1990.80,1990.80,162.85,1100.40,,Hospital CPT 70498,HC Cta Neck/Carotid W & W/O Cont,N/A,0351 - CT SCAN - HEAD SCAN,3318.00,1834.00,1990.80,1100.40,N/A,256.76,N/A,162.85,N/A,914.00,N/A,623.56,N/A,393.92,N/A,256.76,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,162.85,N/A,162.85,N/A,179.14,1990.80,1990.80,162.85,1100.40,,Hospital CPT 70542,HC MRI Face Neck Eye W Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2965.00,2313.00,1779.00,1387.80,N/A,323.82,N/A,186.42,N/A,1110.00,N/A,786.42,N/A,767.28,N/A,323.82,N/A,186.42,N/A,186.42,N/A,477.63,N/A,767.28,N/A,767.28,N/A,767.28,N/A,1110.00,N/A,186.42,N/A,323.82,N/A,1060.00,N/A,1060.00,N/A,323.82,N/A,186.42,N/A,186.42,N/A,205.06,1779.00,1779.00,186.42,1387.80,,Hospital CPT 70551,HC MRI Brain WO Ctrst,N/A,0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN/BRAINSTEM,2372.00,2013.00,1423.20,1207.80,N/A,281.82,N/A,210.88,N/A,1110.00,N/A,684.42,N/A,510.09,N/A,281.82,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,281.82,N/A,1060.00,N/A,1060.00,N/A,281.82,N/A,210.88,N/A,210.88,N/A,231.97,1423.20,1423.20,210.88,1207.80,,Hospital Custom 7100000000,HC Pacu Recovery - First 15 Min,N/A,0710 - RECOVERY ROOM - GENERAL CLASSIFICATION,536.00,536.00,321.60,321.60,N/A,75.04,N/A,536.00,N/A,308.63,N/A,182.24,N/A,75.04,N/A,75.04,N/A,536.00,N/A,536.00,N/A,46.63,N/A,75.04,N/A,75.04,N/A,75.04,N/A,308.63,N/A,536.00,N/A,75.04,N/A,287.30,N/A,287.30,N/A,75.04,N/A,536.00,N/A,536.00,N/A,536.00,321.60,321.60,46.63,536.00,,Hospital Custom 7100000001,HC Pacu Recovery - Addtl 15 Min,N/A,0710 - RECOVERY ROOM - GENERAL CLASSIFICATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital CPT 71047,HC X-Ray Exam Chest 3 Views,N/A,0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY,803.00,803.00,481.80,481.80,N/A,112.42,N/A,82.88,N/A,462.37,N/A,273.02,N/A,189.77,N/A,112.42,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,462.37,N/A,78.46,N/A,112.42,N/A,430.41,N/A,430.41,N/A,112.42,N/A,78.46,N/A,26.45,N/A,29.10,481.80,481.80,26.45,481.80,,Hospital CPT 71101,"HC X-Ray, Ribs, Pa Chest, 3",N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,770.00,770.00,462.00,462.00,N/A,107.80,N/A,96.52,N/A,443.37,N/A,261.80,N/A,233.46,N/A,107.80,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,443.37,N/A,96.52,N/A,107.80,N/A,412.72,N/A,412.72,N/A,107.80,N/A,96.52,N/A,96.52,N/A,106.17,462.00,462.00,96.52,462.00,,Hospital CPT 71260,HC CT Chest W/ Contrast,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1043.00,1664.40,625.80,N/A,146.02,N/A,162.85,N/A,914.00,N/A,354.62,N/A,393.92,N/A,146.02,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,146.02,N/A,689.00,N/A,689.00,N/A,146.02,N/A,162.85,N/A,162.85,N/A,179.14,1664.40,1664.40,146.02,914.00,,Hospital CPT 71271,HC CT Chest Screening Low Dose Wout Cont,N/A,0352 - CT SCAN - BODY SCAN,189.00,189.00,113.40,113.40,N/A,26.46,N/A,96.52,N/A,189.00,N/A,64.26,N/A,189.00,N/A,26.46,N/A,96.52,N/A,96.52,N/A,145.34,N/A,189.00,N/A,189.00,N/A,189.00,N/A,189.00,N/A,96.52,N/A,26.46,N/A,189.00,N/A,189.00,N/A,26.46,N/A,96.52,N/A,96.52,N/A,106.17,113.40,113.40,26.46,189.00,,Hospital CPT 71550,HC MRI-Chest WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,262.18,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,213.16,N/A,288.40,1963.80,1963.80,210.88,1461.00,,Hospital Custom 7200000001,HC Vaginal Delivery,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,5812.00,5812.00,3487.20,3487.20,N/A,813.68,N/A,5812.00,N/A,3346.55,N/A,1976.08,N/A,813.68,N/A,813.68,N/A,5812.00,N/A,5812.00,N/A,505.64,N/A,813.68,N/A,813.68,N/A,813.68,N/A,3346.55,N/A,5812.00,N/A,813.68,N/A,3115.23,N/A,3115.23,N/A,813.68,N/A,5812.00,N/A,5812.00,N/A,5812.00,3487.20,3487.20,505.64,5812.00,,Hospital CPT 72020,HC X-Ray Spine 1 View,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,805.00,805.00,483.00,483.00,N/A,112.70,N/A,78.46,N/A,463.52,N/A,273.70,N/A,189.77,N/A,112.70,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,463.52,N/A,78.46,N/A,112.70,N/A,431.48,N/A,431.48,N/A,112.70,N/A,78.46,N/A,78.46,N/A,86.30,483.00,483.00,78.46,483.00,,Hospital CPT 72070,HC T-Spine 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,768.00,768.00,460.80,460.80,N/A,107.52,N/A,96.52,N/A,442.21,N/A,261.12,N/A,233.46,N/A,107.52,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,442.21,N/A,96.52,N/A,107.52,N/A,411.65,N/A,411.65,N/A,107.52,N/A,96.52,N/A,96.52,N/A,106.17,460.80,460.80,96.52,460.80,,Hospital CPT 72072,HC T-Spine Routine W/ Swimmer 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1136.00,897.00,681.60,538.20,N/A,125.58,N/A,96.52,N/A,516.49,N/A,304.98,N/A,233.46,N/A,125.58,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,516.49,N/A,96.52,N/A,125.58,N/A,480.79,N/A,480.79,N/A,125.58,N/A,96.52,N/A,96.52,N/A,106.17,681.60,681.60,96.52,538.20,,Hospital CPT 72074,"HC X-Ray, Thoracic Spine/4 V",N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1136.00,1136.00,681.60,681.60,N/A,159.04,N/A,101.95,N/A,654.11,N/A,386.24,N/A,233.46,N/A,159.04,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,654.11,N/A,96.52,N/A,159.04,N/A,608.90,N/A,608.90,N/A,159.04,N/A,96.52,N/A,29.46,N/A,32.41,681.60,681.60,29.46,681.60,,Hospital CPT 72110,HC L-Spine Min 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1551.00,1551.00,930.60,930.60,N/A,217.14,N/A,96.52,N/A,893.07,N/A,527.34,N/A,233.46,N/A,217.14,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,893.07,N/A,96.52,N/A,217.14,N/A,831.34,N/A,831.34,N/A,217.14,N/A,96.52,N/A,96.52,N/A,106.17,930.60,930.60,96.52,930.60,,Hospital CPT 72114,HC L-Spine Comp Inc Bend Min 6 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1872.00,1872.00,1123.20,1123.20,N/A,262.08,N/A,96.52,N/A,1077.90,N/A,636.48,N/A,233.46,N/A,262.08,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1077.90,N/A,96.52,N/A,262.08,N/A,1003.39,N/A,1003.39,N/A,262.08,N/A,96.52,N/A,96.52,N/A,106.17,1123.20,1123.20,96.52,1123.20,,Hospital CPT 72125,HC CT C-Spine W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,2583.00,1834.00,1549.80,1100.40,N/A,256.76,N/A,96.52,N/A,914.00,N/A,623.56,N/A,233.46,N/A,256.76,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,96.52,N/A,96.52,N/A,106.17,1549.80,1549.80,96.52,1100.40,,Hospital CPT 72148,HC MRI-Spine Lumbar WO Contrast,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),3273.00,1898.00,1963.80,1138.80,N/A,265.72,N/A,210.88,N/A,1110.00,N/A,645.32,N/A,510.09,N/A,265.72,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,265.72,N/A,1060.00,N/A,1060.00,N/A,265.72,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1138.80,,Hospital CPT 72157,HC MRI-Spine Thoracic WO&W Cont,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,332.71,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1930.80,,Hospital CPT 72158,HC MRI-Spine Lumbar WO & W Cont,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,332.71,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1930.80,,Hospital CPT 72194,HC CT Pelvis W/WO Contrast,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,162.85,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1369.80,,Hospital CPT 72196,HC MRI-Pelvis W Contrast,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,348.82,N/A,1110.00,N/A,951.32,N/A,804.78,N/A,391.72,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,332.71,N/A,182.21,N/A,200.43,2454.00,2454.00,182.21,1678.80,,Hospital 72200,HC Sacroiliac Joints Less Than 3,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,1742.00,N/A,1045.20,N/A,243.88,N/A,98.52,N/A,1003.05,N/A,592.28,N/A,233.46,N/A,243.88,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1003.05,N/A,96.52,N/A,243.88,N/A,933.71,N/A,933.71,N/A,243.88,N/A,96.52,N/A,98.52,N/A,84.64,N/A,N/A,84.64,1045.20,,Hospital CPT 72240,HC Cervical Myelogram S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,2232.00,2232.00,1339.20,1339.20,N/A,312.48,N/A,699.73,N/A,1285.19,N/A,758.88,N/A,1618.07,N/A,312.48,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1285.19,N/A,668.93,N/A,312.48,N/A,1196.35,N/A,1196.35,N/A,312.48,N/A,668.93,N/A,699.73,N/A,735.82,1339.20,1339.20,312.48,1618.07,,Hospital CPT 72255,HC Thoracic Myelogram S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1852.00,1852.00,1111.20,1111.20,N/A,259.28,N/A,699.73,N/A,1066.38,N/A,629.68,N/A,1618.07,N/A,259.28,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1066.38,N/A,668.93,N/A,259.28,N/A,992.67,N/A,992.67,N/A,259.28,N/A,668.93,N/A,699.73,N/A,72.77,1111.20,1111.20,72.77,1618.07,,Hospital CPT 73000,HC X-Ray Clavicle,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,670.00,670.00,402.00,402.00,N/A,93.80,N/A,78.46,N/A,385.79,N/A,227.80,N/A,189.77,N/A,93.80,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,385.79,N/A,78.46,N/A,93.80,N/A,359.12,N/A,359.12,N/A,93.80,N/A,78.46,N/A,78.46,N/A,86.30,402.00,402.00,78.46,402.00,,Hospital CPT 73040,HC Arthrogram Shoulder S&I,N/A,0322 - RADIOLOGY - DIAGNOSTIC - ARTHROGRAPHY,2241.00,2241.00,1344.60,1344.60,N/A,313.74,N/A,360.52,N/A,1290.37,N/A,761.94,N/A,804.78,N/A,313.74,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1290.37,N/A,332.71,N/A,313.74,N/A,1201.18,N/A,1201.18,N/A,313.74,N/A,332.71,N/A,95.62,N/A,105.18,1344.60,1344.60,95.62,1344.60,,Hospital CPT 73085,HC Extrem Up Elbow Arthrogram,N/A,0322 - RADIOLOGY - DIAGNOSTIC - ARTHROGRAPHY,1014.00,1014.00,608.40,608.40,N/A,141.96,N/A,360.52,N/A,583.86,N/A,344.76,N/A,804.78,N/A,141.96,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,583.86,N/A,332.71,N/A,141.96,N/A,543.50,N/A,543.50,N/A,141.96,N/A,332.71,N/A,360.52,N/A,85.66,608.40,608.40,85.66,804.78,,Hospital CPT 73221,HC MRI-Upper Ext Jnt WO Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,1626.00,1963.80,975.60,N/A,227.64,N/A,210.88,N/A,1110.00,N/A,552.84,N/A,510.09,N/A,227.64,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,227.64,N/A,1060.00,N/A,1060.00,N/A,227.64,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1110.00,,Hospital CPT 73222,HC MRI-Upper Ext Jnt W Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,737.91,N/A,1110.00,N/A,951.32,N/A,1618.07,N/A,391.72,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1110.00,N/A,668.93,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,668.93,N/A,230.33,N/A,253.36,2454.00,2454.00,230.33,1678.80,,Hospital CPT 73521,HC X-Ray Exam Bil Hips W/Pelvis 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1079.00,1079.00,647.40,647.40,N/A,151.06,N/A,96.52,N/A,621.29,N/A,366.86,N/A,233.46,N/A,151.06,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,621.29,N/A,96.52,N/A,151.06,N/A,578.34,N/A,578.34,N/A,151.06,N/A,96.52,N/A,96.52,N/A,106.17,647.40,647.40,96.52,647.40,,Hospital CPT 73525,HC Arthrogram Hip S&I,N/A,0322 - RADIOLOGY - DIAGNOSTIC - ARTHROGRAPHY,1983.00,1983.00,1189.80,1189.80,N/A,277.62,N/A,353.93,N/A,1141.81,N/A,674.22,N/A,804.78,N/A,277.62,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1141.81,N/A,332.71,N/A,277.62,N/A,1062.89,N/A,1062.89,N/A,277.62,N/A,332.71,N/A,348.03,N/A,106.17,1189.80,1189.80,106.17,1189.80,,Hospital CPT 73610,HC X-Ray Ankle Rout 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,953.00,953.00,571.80,571.80,N/A,133.42,N/A,78.46,N/A,548.74,N/A,324.02,N/A,189.77,N/A,133.42,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,548.74,N/A,78.46,N/A,133.42,N/A,510.81,N/A,510.81,N/A,133.42,N/A,78.46,N/A,78.46,N/A,86.30,571.80,571.80,78.46,571.80,,Hospital CPT 73630,HC X-Ray Foot Min 3 Views Complete,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,857.00,857.00,514.20,514.20,N/A,119.98,N/A,78.46,N/A,493.46,N/A,291.38,N/A,189.77,N/A,119.98,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,493.46,N/A,78.46,N/A,119.98,N/A,459.35,N/A,459.35,N/A,119.98,N/A,78.46,N/A,78.46,N/A,86.30,514.20,514.20,78.46,514.20,,Hospital CPT 73700,HC CT Lower Ext W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 73706,HC CT Angio Lower Ext W & W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,224.89,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,224.89,N/A,247.38,1872.00,1872.00,162.85,1034.40,,Hospital CPT 73718,HC MRI Lower Ext W/O Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1461.00,,Hospital CPT 73722,HC MRI Lower Ext Jnt W/ Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,230.93,N/A,1110.00,N/A,951.32,N/A,1618.07,N/A,391.72,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1110.00,N/A,668.93,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,668.93,N/A,230.93,N/A,254.02,2454.00,2454.00,230.93,1678.80,,Hospital 73725,MR Angio Lower Extrem (Mra),N/A,N/A,N/A,4858.00,N/A,2914.80,N/A,680.12,N/A,241.43,N/A,2220.00,N/A,1651.72,N/A,954.45,N/A,680.12,N/A,241.43,N/A,241.43,N/A,594.15,N/A,954.45,N/A,954.45,N/A,954.45,N/A,2220.00,N/A,241.43,N/A,680.12,N/A,1060.00,N/A,1060.00,N/A,680.12,N/A,210.88,N/A,241.43,N/A,531.14,N/A,N/A,210.88,2914.80,,Hospital CPT 74021,HC X-Ray Exam Abdomen 3+ Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1411.00,1411.00,846.60,846.60,N/A,197.54,N/A,27.35,N/A,812.45,N/A,479.74,N/A,117.96,N/A,197.54,N/A,27.35,N/A,27.35,N/A,73.43,N/A,117.96,N/A,117.96,N/A,117.96,N/A,812.45,N/A,27.35,N/A,197.54,N/A,756.30,N/A,756.30,N/A,197.54,N/A,27.35,N/A,27.35,N/A,30.09,846.60,846.60,27.35,846.60,,Hospital CPT 74150,HC CT Abdomen W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 74177,HC CT Hemangioma 3 Ph Liver Prot,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,5581.00,1073.00,3348.60,643.80,N/A,150.22,N/A,332.71,N/A,914.00,N/A,364.82,N/A,804.78,N/A,150.22,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,150.22,N/A,689.00,N/A,689.00,N/A,150.22,N/A,332.71,N/A,332.71,N/A,365.98,3348.60,3348.60,150.22,914.00,,Hospital CPT 74177,HC CT Abd/Pel W Cont,N/A,0352 - CT SCAN - BODY SCAN,5581.00,1073.00,3348.60,643.80,N/A,150.22,N/A,332.71,N/A,914.00,N/A,364.82,N/A,804.78,N/A,150.22,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,150.22,N/A,689.00,N/A,689.00,N/A,150.22,N/A,332.71,N/A,332.71,N/A,365.98,3348.60,3348.60,150.22,914.00,,Hospital CPT 74182,HC MRI-Abdomen W Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,367.02,N/A,1110.00,N/A,951.32,N/A,804.78,N/A,391.72,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,332.71,N/A,214.39,N/A,235.83,2454.00,2454.00,214.39,1678.80,,Hospital CPT 74183,HC MRI-Abdomen W & WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4753.00,3071.00,2851.80,1842.60,N/A,429.94,N/A,332.71,N/A,1110.00,N/A,1044.14,N/A,804.78,N/A,429.94,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,429.94,N/A,1060.00,N/A,1060.00,N/A,429.94,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1842.60,,Hospital CPT 74190,HC Xray Exam of Peritoneum,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1150.00,1150.00,690.00,690.00,N/A,161.00,N/A,463.80,N/A,662.17,N/A,391.00,N/A,1099.02,N/A,161.00,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,662.17,N/A,454.35,N/A,161.00,N/A,616.40,N/A,616.40,N/A,161.00,N/A,454.35,N/A,463.80,N/A,1150.00,690.00,690.00,161.00,1150.00,,Hospital CPT 74240,HC Rad Exam Upr GI Tract Single Contrast Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,299.00,291.00,179.40,174.60,N/A,40.74,N/A,162.85,N/A,167.56,N/A,98.94,N/A,291.00,N/A,40.74,N/A,162.85,N/A,162.85,N/A,245.22,N/A,291.00,N/A,291.00,N/A,291.00,N/A,167.56,N/A,162.85,N/A,40.74,N/A,155.98,N/A,155.98,N/A,40.74,N/A,162.85,N/A,162.85,N/A,179.14,179.40,179.40,40.74,291.00,,Hospital 74241,HC Ugi Series W/ Kub,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,87008.90,N/A,52205.34,N/A,8909.88,N/A,9629.10,N/A,19681.22,N/A,29583.02,N/A,19869.48,N/A,9184.41,N/A,820520.00,N/A,820520.00,N/A,12368.29,N/A,19869.48,N/A,19869.48,N/A,19869.48,N/A,19681.22,N/A,9569.80,N/A,9184.41,N/A,23639.72,N/A,23639.72,N/A,4864.79,N/A,9569.80,N/A,9629.10,N/A,9827.32,N/A,4864.79,820520.00,N/A,N/A,,Hospital 74245,"HC Fluoro X-Ray, GI With Sm",N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,48854.70,N/A,29312.82,N/A,5798.73,N/A,7125.25,N/A,N/A,N/A,16610.59,N/A,13192.92,N/A,5977.40,N/A,3934.00,N/A,3934.00,N/A,8212.29,N/A,13192.92,N/A,13192.92,N/A,13192.92,N/A,13067.91,N/A,7125.25,N/A,5977.40,N/A,15696.28,N/A,15696.28,N/A,N/A,N/A,7125.25,N/A,7125.25,N/A,6395.82,N/A,3934.00,29312.82,N/A,N/A,,Hospital 74261,HC CT Cologrph Dx W/O Cont,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,N/A,2191.00,N/A,1314.60,N/A,306.74,N/A,296.49,N/A,914.00,N/A,744.94,N/A,233.46,N/A,306.74,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,306.74,N/A,689.00,N/A,689.00,N/A,306.74,N/A,96.52,N/A,296.49,N/A,326.14,N/A,N/A,96.52,1314.60,,Hospital CPT 74280,HC Air Contrast Barium Enema,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1542.00,1218.00,925.20,730.80,N/A,170.52,N/A,176.47,N/A,701.32,N/A,414.12,N/A,393.92,N/A,170.52,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,701.32,N/A,162.85,N/A,170.52,N/A,652.85,N/A,652.85,N/A,170.52,N/A,162.85,N/A,170.35,N/A,166.71,925.20,925.20,162.85,730.80,,Hospital CPT 74329,HC Endo Cath Panc S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1465.00,1465.00,879.00,879.00,N/A,205.10,N/A,1465.00,N/A,843.55,N/A,498.10,N/A,1465.00,N/A,205.10,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,843.55,N/A,1465.00,N/A,205.10,N/A,785.24,N/A,785.24,N/A,205.10,N/A,1465.00,N/A,1465.00,N/A,1465.00,879.00,879.00,205.10,1465.00,,Hospital CPT 74360,HC Dilation Stricture/Obst S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,856.00,856.00,513.60,513.60,N/A,119.84,N/A,856.00,N/A,492.88,N/A,291.04,N/A,856.00,N/A,119.84,N/A,856.00,N/A,856.00,N/A,856.00,N/A,856.00,N/A,856.00,N/A,856.00,N/A,492.88,N/A,856.00,N/A,119.84,N/A,458.82,N/A,458.82,N/A,119.84,N/A,856.00,N/A,856.00,N/A,856.00,513.60,513.60,119.84,856.00,,Hospital 74363,HC Bil Duct Dila W/ W/O Stent S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,56104.98,N/A,33662.99,N/A,7854.69,N/A,5192.14,N/A,31955.30,N/A,19075.69,N/A,11433.77,N/A,7854.69,N/A,4706.78,N/A,4706.78,N/A,7117.74,N/A,11433.77,N/A,11433.77,N/A,11433.77,N/A,31955.29,N/A,4706.78,N/A,7854.69,N/A,10178.00,N/A,10178.00,N/A,7854.69,N/A,4706.78,N/A,454.08,N/A,499.49,N/A,N/A,454.08,33662.99,,Hospital CPT 74415,HC Ivp W or W/O Tomo,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,2084.00,1645.00,1250.40,987.00,N/A,230.30,N/A,121.48,N/A,947.19,N/A,559.30,N/A,393.92,N/A,230.30,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,947.19,N/A,162.85,N/A,230.30,N/A,881.72,N/A,881.72,N/A,230.30,N/A,162.85,N/A,121.48,N/A,133.63,1250.40,1250.40,121.48,987.00,,Hospital CPT 74425,HC Nephrostogram/Urography Antegrade,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,609.00,482.00,365.40,289.20,N/A,67.48,N/A,348.03,N/A,277.54,N/A,163.88,N/A,482.00,N/A,67.48,N/A,332.71,N/A,332.71,N/A,482.00,N/A,482.00,N/A,482.00,N/A,482.00,N/A,277.54,N/A,332.71,N/A,67.48,N/A,258.35,N/A,258.35,N/A,67.48,N/A,332.71,N/A,348.03,N/A,114.44,365.40,365.40,67.48,482.00,,Hospital CPT 74455,HC Xray Cystogram Voiding,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1393.00,1100.00,835.80,660.00,N/A,154.00,N/A,82.08,N/A,633.38,N/A,374.00,N/A,510.09,N/A,154.00,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,633.38,N/A,210.88,N/A,154.00,N/A,589.60,N/A,589.60,N/A,154.00,N/A,210.88,N/A,210.88,N/A,90.29,835.80,835.80,82.08,660.00,,Hospital 75565,HC Cardiac MRI for Velocity Flow Mapping,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,97279.28,4256.60,58367.57,2553.96,N/A,595.92,N/A,348.03,27254.55,2742.62,33074.95,1447.24,24076.89,924.44,10500.32,595.92,12315.69,332.71,12315.69,332.71,14987.67,575.48,24076.89,924.44,24076.89,924.44,24076.89,924.44,27254.55,2742.62,12315.69,332.71,10500.32,595.92,27573.18,1060.00,27573.18,1060.00,N/A,595.92,12315.69,332.71,12315.69,348.03,11235.34,300.34,10500.32,58367.57,300.34,2742.62,,Hospital CPT 75743,HC Pulmonary Arteriogram Bil,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,11157.00,11157.00,6694.20,6694.20,N/A,1561.98,N/A,64.93,N/A,6424.20,N/A,3793.38,N/A,6507.21,N/A,1561.98,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,6424.20,N/A,2690.13,N/A,1561.98,N/A,5980.15,N/A,5980.15,N/A,1561.98,N/A,2690.13,N/A,64.93,N/A,71.42,6694.20,6694.20,64.93,6694.20,,Hospital CPT 75746,HC Main Pul Art/Rt Heart,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,3612.00,3612.00,2167.20,2167.20,N/A,505.68,N/A,72.75,N/A,2079.79,N/A,1228.08,N/A,373.23,N/A,505.68,N/A,72.75,N/A,72.75,N/A,232.34,N/A,373.23,N/A,373.23,N/A,373.23,N/A,2079.79,N/A,72.75,N/A,505.68,N/A,1936.03,N/A,1936.03,N/A,505.68,N/A,72.75,N/A,72.75,N/A,80.03,2167.20,2167.20,72.75,2167.20,,Hospital 75842,HC Venogram Adrenal Bilat/Sel,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,21887.32,N/A,13132.39,N/A,2889.24,N/A,4855.12,N/A,12595.21,N/A,7441.69,N/A,11263.17,N/A,2889.24,N/A,4641.41,N/A,4641.41,N/A,7011.54,N/A,11263.17,N/A,11263.17,N/A,11263.17,N/A,12595.21,N/A,4641.41,N/A,2889.24,N/A,922.25,N/A,922.25,N/A,2889.24,N/A,4641.41,N/A,4855.12,N/A,1940.42,N/A,N/A,922.25,13132.39,,Hospital CPT 75860,HC Venography Sinus/Jugular Catheter,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,3731.00,3731.00,2238.60,2238.60,N/A,522.34,N/A,2861.72,N/A,2148.31,N/A,1268.54,N/A,3731.00,N/A,522.34,N/A,2690.13,N/A,2690.13,N/A,3731.00,N/A,3731.00,N/A,3731.00,N/A,3731.00,N/A,2148.31,N/A,2690.13,N/A,522.34,N/A,1999.82,N/A,1999.82,N/A,522.34,N/A,2690.13,N/A,2861.72,N/A,72.09,2238.60,2238.60,72.09,3731.00,,Hospital 75889,HC Hepatic Vein W/Hemo Eval,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,111486.15,33493.90,66891.69,20096.34,N/A,4670.11,9507.84,639.17,17604.50,19284.83,54788.32,11387.93,54788.32,6510.27,N/A,4670.11,9507.84,2690.13,9507.84,2690.13,54788.32,4052.76,54788.32,6510.27,54788.32,6510.27,54788.32,6510.27,17604.50,19284.83,9507.84,2690.13,N/A,4670.11,17604.50,9401.77,17604.50,9401.77,N/A,4670.11,10557.80,2690.13,9507.84,639.17,N/A,703.10,9507.84,66891.69,639.17,20096.34,,Hospital 75891,HC Veno Hepatic W/O Hemo Eval S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,314516.03,N/A,188709.62,N/A,7380.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7380.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7380.27,N/A,N/A,N/A,N/A,N/A,7380.27,N/A,N/A,N/A,N/A,N/A,7380.27,N/A,7380.27,188709.62,N/A,N/A,,Hospital 76100,"HC Xr Exam of Single Plane Body Section, Ex Tomo",N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,68646.72,N/A,41188.03,N/A,9567.30,N/A,7888.50,N/A,39480.59,N/A,23339.89,N/A,18788.91,N/A,9567.30,N/A,7727.79,N/A,7727.79,N/A,11696.43,N/A,18788.91,N/A,18788.91,N/A,18788.91,N/A,37167.01,N/A,7727.79,N/A,9567.30,N/A,8019.25,N/A,8019.25,N/A,9567.30,N/A,7727.79,N/A,7888.50,N/A,1465.24,N/A,N/A,1465.24,41188.03,,Hospital CPT 76376,HC 3d Rendering C/T/MRI/US,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,1339.00,1339.00,803.40,803.40,N/A,187.46,N/A,1339.00,N/A,914.00,N/A,455.26,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,914.00,N/A,1339.00,N/A,187.46,N/A,689.00,N/A,689.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,13.21,803.40,803.40,13.21,1339.00,,Hospital CPT 76377,HC 3d Rendering Requiring Sep Wor,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,1489.00,1489.00,893.40,893.40,N/A,208.46,N/A,1489.00,N/A,914.00,N/A,506.26,N/A,1489.00,N/A,208.46,N/A,1489.00,N/A,1489.00,N/A,1489.00,N/A,1489.00,N/A,1489.00,N/A,1489.00,N/A,914.00,N/A,1489.00,N/A,208.46,N/A,689.00,N/A,689.00,N/A,208.46,N/A,1489.00,N/A,30.66,N/A,33.73,893.40,893.40,30.66,1489.00,,Hospital CPT 76380,HC CT for Limited or Localized St,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,1402.00,1402.00,841.20,841.20,N/A,196.28,N/A,82.07,N/A,914.00,N/A,476.68,N/A,189.77,N/A,196.28,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,914.00,N/A,78.46,N/A,196.28,N/A,689.00,N/A,689.00,N/A,196.28,N/A,78.46,N/A,77.78,N/A,90.96,841.20,841.20,77.78,914.00,,Hospital CPT 76390,HC MRI-MR Spectroscopy,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2000.00,1568.00,1200.00,940.80,N/A,219.52,N/A,83.46,N/A,1110.00,N/A,533.12,N/A,189.77,N/A,219.52,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,1110.00,N/A,78.46,N/A,219.52,N/A,1060.00,N/A,1060.00,N/A,219.52,N/A,78.46,N/A,83.46,N/A,1568.00,1200.00,1200.00,78.46,1568.00,,Hospital CPT 76604,HC Ultrasound Chest,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,576.00,576.00,345.60,345.60,N/A,80.64,N/A,96.52,N/A,331.66,N/A,195.84,N/A,233.46,N/A,80.64,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,331.66,N/A,96.52,N/A,80.64,N/A,308.74,N/A,308.74,N/A,80.64,N/A,96.52,N/A,96.52,N/A,106.17,345.60,345.60,80.64,345.60,,Hospital CPT 76642,HC US Breast Ltd,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1215.00,790.00,729.00,474.00,N/A,110.60,N/A,78.46,N/A,454.88,N/A,268.60,N/A,189.77,N/A,110.60,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,454.88,N/A,78.46,N/A,110.60,N/A,423.44,N/A,423.44,N/A,110.60,N/A,78.46,N/A,78.46,N/A,86.30,729.00,729.00,78.46,474.00,,Hospital CPT 76700,HC US Abdomen Complete,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,991.00,991.00,594.60,594.60,N/A,138.74,N/A,96.52,N/A,570.62,N/A,336.94,N/A,233.46,N/A,138.74,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,570.62,N/A,96.52,N/A,138.74,N/A,531.18,N/A,531.18,N/A,138.74,N/A,96.52,N/A,96.52,N/A,106.17,594.60,594.60,96.52,594.60,,Hospital CPT 76706,HC Aaa Screening Ultrasound,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,717.00,717.00,430.20,430.20,N/A,100.38,N/A,96.52,N/A,412.85,N/A,243.78,N/A,233.46,N/A,100.38,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,412.85,N/A,96.52,N/A,100.38,N/A,384.31,N/A,384.31,N/A,100.38,N/A,96.52,N/A,96.52,N/A,106.17,430.20,430.20,96.52,430.20,,Hospital CPT 76770,HC US Retroperitoneal Complete,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,2499.00,2499.00,1499.40,1499.40,N/A,349.86,N/A,96.52,N/A,1438.92,N/A,849.66,N/A,233.46,N/A,349.86,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1438.92,N/A,96.52,N/A,349.86,N/A,1339.46,N/A,1339.46,N/A,349.86,N/A,96.52,N/A,96.52,N/A,106.17,1499.40,1499.40,96.52,1499.40,,Hospital CPT 76775,HC US Retroperitoneal Limited,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1427.00,1427.00,856.20,856.20,N/A,199.78,N/A,96.52,N/A,821.67,N/A,485.18,N/A,233.46,N/A,199.78,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,821.67,N/A,96.52,N/A,199.78,N/A,764.87,N/A,764.87,N/A,199.78,N/A,96.52,N/A,96.52,N/A,106.17,856.20,856.20,96.52,856.20,,Hospital CPT 76776,HC Transp Kidney W/WO Doppler Flo,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1031.00,1031.00,618.60,618.60,N/A,144.34,N/A,97.56,N/A,593.65,N/A,350.54,N/A,233.46,N/A,144.34,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,593.65,N/A,96.52,N/A,144.34,N/A,552.62,N/A,552.62,N/A,144.34,N/A,96.52,N/A,97.56,N/A,113.10,618.60,618.60,96.52,618.60,,Hospital 76821,HC Doppler Veloc Fetal Mid Cereb,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,29174.80,3372.00,17504.88,2023.20,4653.92,472.32,5771.00,95.68,11458.86,1941.60,9919.43,1146.48,7322.00,233.46,4797.32,472.32,5771.00,96.52,5771.00,96.52,4558.00,145.34,7322.00,233.46,7322.00,233.46,7322.00,233.46,11458.86,1941.61,5771.00,205.66,4797.32,472.32,12597.46,512.94,12597.46,512.94,5096.25,472.32,5771.00,205.66,5771.00,203.88,5133.13,216.31,4558.00,17504.88,95.68,2023.20,,Hospital 76827,HC Echo Exam of Fetal Heart Complete,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,27051.20,2802.00,16230.72,1681.20,3722.50,392.28,4669.17,586.00,8388.95,1613.39,9197.41,952.68,4696.00,1332.48,3837.19,392.28,4669.17,550.87,4669.17,550.87,2923.00,829.50,4696.00,1332.48,4696.00,1332.48,4696.00,1332.48,8388.95,1613.39,4669.17,550.87,3837.19,392.28,10076.23,111.48,10076.23,111.48,4451.09,392.28,4669.17,550.87,4669.17,586.00,4105.80,420.01,2923.00,16230.72,111.48,1681.20,,Hospital CPT 76870,HC US Scrotum & Contents,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,738.00,738.00,442.80,442.80,N/A,103.32,N/A,96.52,N/A,424.94,N/A,250.92,N/A,233.46,N/A,103.32,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,424.94,N/A,96.52,N/A,103.32,N/A,395.57,N/A,395.57,N/A,103.32,N/A,96.52,N/A,96.52,N/A,106.17,442.80,442.80,96.52,442.80,,Hospital 76872,HC Transrectal Ultrasound,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,41645.50,4885.00,24987.30,2931.00,6119.34,683.90,7504.51,100.27,13790.44,2812.78,14159.47,1660.90,13922.35,233.46,6307.89,683.90,7504.51,96.52,7504.51,96.52,8666.34,145.34,13922.35,233.46,13922.35,233.46,13922.35,233.46,13790.44,2812.78,34207.39,1675.03,6307.89,683.90,16564.12,1111.23,16564.12,1111.23,N/A,683.90,34207.39,1675.03,7504.51,1740.25,6749.44,704.51,6119.34,34207.39,96.52,2931.00,,Hospital 76930,HC US Guide Percardio S&I,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,82996.10,N/A,49797.66,N/A,5869.15,N/A,7208.54,N/A,14352.58,N/A,28218.67,N/A,N/A,N/A,6049.99,N/A,3934.00,N/A,N/A,N/A,N/A,N/A,13872.42,N/A,13872.42,N/A,13872.42,N/A,14352.58,N/A,7208.54,N/A,6049.99,N/A,15886.89,N/A,15886.89,N/A,N/A,N/A,N/A,N/A,7208.54,N/A,6473.49,N/A,3934.00,49797.66,N/A,N/A,,Hospital 76936,HC Pseudo-Aneurysm Compression,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,69255.37,2656.10,41553.22,1593.66,N/A,371.85,7808.87,259.66,N/A,1529.38,N/A,903.07,N/A,611.76,N/A,371.85,7808.87,252.91,7808.87,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,1529.38,7808.87,252.91,N/A,371.85,N/A,1214.58,N/A,1214.58,N/A,371.85,7808.87,252.91,7808.87,259.66,N/A,167.32,7808.87,41553.22,167.32,1593.66,,Hospital CPT 76942,HC US Guidance for Needle Place,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1286.00,1286.00,771.60,771.60,N/A,180.04,N/A,1286.00,N/A,740.48,N/A,437.24,N/A,1286.00,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,740.48,N/A,1286.00,N/A,180.04,N/A,689.30,N/A,689.30,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,771.60,771.60,180.04,1286.00,,Hospital CPT 76942,HC US Guidance for Needle Place - Anes Block,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1286.00,1286.00,771.60,771.60,N/A,180.04,N/A,1286.00,N/A,740.48,N/A,437.24,N/A,1286.00,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,740.48,N/A,1286.00,N/A,180.04,N/A,689.30,N/A,689.30,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,771.60,771.60,180.04,1286.00,,Hospital CPT 76946,HC US Guidance for Amniocentsis,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,455.00,455.00,273.00,273.00,N/A,63.70,N/A,455.00,N/A,261.99,N/A,154.70,N/A,455.00,N/A,63.70,N/A,455.00,N/A,455.00,N/A,455.00,N/A,455.00,N/A,455.00,N/A,455.00,N/A,261.99,N/A,455.00,N/A,63.70,N/A,243.88,N/A,243.88,N/A,63.70,N/A,455.00,N/A,12.62,N/A,13.88,273.00,273.00,12.62,455.00,,Hospital 76965,HC Interoperative U/S Guid Rd Mat,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,34423.00,N/A,20653.80,N/A,4819.22,N/A,7220.92,N/A,19756.51,N/A,11703.82,N/A,16520.60,N/A,4819.22,N/A,7107.51,N/A,7107.51,N/A,10284.39,N/A,16520.60,N/A,16520.60,N/A,16520.60,N/A,19756.51,N/A,7107.51,N/A,4819.22,N/A,7897.00,N/A,7897.00,N/A,4819.22,N/A,7107.51,N/A,7220.92,N/A,1421.11,N/A,N/A,1421.11,20653.80,,Hospital 76998,HC Ult Guidance Intraoperative,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,145107.85,19548.80,87064.71,11729.28,N/A,2736.83,11327.85,1709.87,N/A,11253.57,N/A,6646.59,N/A,4075.27,N/A,2736.83,10970.91,1675.03,10970.91,1675.03,N/A,2536.93,N/A,4075.27,N/A,4075.27,N/A,4075.27,N/A,11253.56,11327.85,1675.03,N/A,2736.83,N/A,1871.00,24496.02,1871.00,N/A,2736.83,11327.85,1675.03,11327.85,1709.87,N/A,533.85,10970.91,87064.71,533.85,11729.28,,Hospital CPT 77001,HC Fluoroscopy for Central Line,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,638.00,505.00,382.80,303.00,N/A,70.70,N/A,505.00,N/A,290.78,N/A,171.70,N/A,505.00,N/A,70.70,N/A,505.00,N/A,505.00,N/A,505.00,N/A,505.00,N/A,505.00,N/A,505.00,N/A,290.78,N/A,505.00,N/A,70.70,N/A,505.00,N/A,505.00,N/A,70.70,N/A,505.00,N/A,505.00,N/A,505.00,382.80,382.80,70.70,505.00,,Hospital CPT 77001,HC Fluoro for Central Line Place,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,638.00,505.00,382.80,303.00,N/A,70.70,N/A,505.00,N/A,290.78,N/A,171.70,N/A,505.00,N/A,70.70,N/A,505.00,N/A,505.00,N/A,505.00,N/A,505.00,N/A,505.00,N/A,505.00,N/A,290.78,N/A,505.00,N/A,70.70,N/A,270.68,N/A,270.68,N/A,70.70,N/A,505.00,N/A,505.00,N/A,505.00,382.80,382.80,70.70,505.00,,Hospital CPT 77002,HC Fluoro Guidance for Needl Plac,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1695.00,1695.00,1017.00,1017.00,N/A,237.30,N/A,1695.00,N/A,975.98,N/A,576.30,N/A,1695.00,N/A,237.30,N/A,1695.00,N/A,1695.00,N/A,1695.00,N/A,1695.00,N/A,1695.00,N/A,1695.00,N/A,975.98,N/A,1695.00,N/A,237.30,N/A,908.52,N/A,908.52,N/A,237.30,N/A,1695.00,N/A,1695.00,N/A,1695.00,1017.00,1017.00,237.30,1695.00,,Hospital CPT 77003,HC Fluoro Guidance Spine,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1353.00,1069.00,811.80,641.40,N/A,149.66,N/A,1069.00,N/A,615.53,N/A,363.46,N/A,1069.00,N/A,149.66,N/A,1069.00,N/A,1069.00,N/A,1069.00,N/A,1069.00,N/A,1069.00,N/A,1069.00,N/A,615.53,N/A,1069.00,N/A,149.66,N/A,572.98,N/A,572.98,N/A,149.66,N/A,1069.00,N/A,1069.00,N/A,76.40,811.80,811.80,76.40,1069.00,,Hospital CPT 77054,HC Galactogram Multi S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,772.00,772.00,463.20,463.20,N/A,108.08,N/A,218.11,N/A,444.52,N/A,262.48,N/A,510.09,N/A,108.08,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,444.52,N/A,210.88,N/A,108.08,N/A,413.79,N/A,413.79,N/A,108.08,N/A,210.88,N/A,218.11,N/A,46.96,463.20,463.20,46.96,510.09,,Hospital 77061,Digital Breast Tomosynthesis Unilateral,N/A,N/A,N/A,546.00,N/A,327.60,N/A,76.44,N/A,78.78,N/A,203.00,N/A,185.64,N/A,232.53,N/A,76.44,N/A,78.78,N/A,78.78,N/A,144.75,N/A,232.53,N/A,232.53,N/A,232.53,N/A,203.00,N/A,78.78,N/A,76.44,N/A,318.00,N/A,318.00,N/A,76.44,N/A,78.78,N/A,78.78,N/A,86.66,N/A,N/A,76.44,327.60,,Hospital 77062,HC Breast Tomosynthesis Dx Digital Bi,N/A,0990 - PATIENT CONVENIENCE ITEMS - GENERAL CLASSIFICATION,N/A,1244.00,N/A,746.40,N/A,174.16,N/A,100.43,N/A,434.47,N/A,422.96,N/A,296.43,N/A,174.16,N/A,100.43,N/A,100.43,N/A,184.53,N/A,296.43,N/A,296.43,N/A,296.43,N/A,203.00,N/A,100.43,N/A,174.16,N/A,318.00,N/A,318.00,N/A,174.16,N/A,100.43,N/A,100.43,N/A,110.47,N/A,N/A,100.43,746.40,,Hospital CPT 77076,HC Babygram/Osseous Survey,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,736.00,736.00,441.60,441.60,N/A,103.04,N/A,95.68,N/A,423.79,N/A,250.24,N/A,233.46,N/A,103.04,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,423.79,N/A,96.52,N/A,103.04,N/A,394.50,N/A,394.50,N/A,103.04,N/A,96.52,N/A,95.68,N/A,73.10,441.60,441.60,73.10,441.60,,Hospital CPT 77300,HC Basic Radiation Dosimetry Calc,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,345.00,345.00,207.00,207.00,N/A,48.30,N/A,28.86,N/A,198.65,N/A,117.30,N/A,291.34,N/A,48.30,N/A,120.45,N/A,120.45,N/A,181.37,N/A,291.34,N/A,291.34,N/A,291.34,N/A,198.65,N/A,120.45,N/A,48.30,N/A,184.92,N/A,184.92,N/A,48.30,N/A,120.45,N/A,28.86,N/A,31.75,207.00,207.00,28.86,291.34,,Hospital 77316,HC Brachytherapy Isodose Plan Simple,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,32096.00,N/A,19257.60,N/A,4493.44,N/A,2340.53,N/A,18427.52,N/A,10912.64,N/A,15352.00,N/A,4493.44,N/A,6444.33,N/A,6444.33,N/A,9556.97,N/A,15352.00,N/A,15352.00,N/A,15352.00,N/A,18427.52,N/A,6444.33,N/A,4493.44,N/A,15100.17,N/A,15100.17,N/A,4493.44,N/A,6444.33,N/A,2340.53,N/A,2574.60,N/A,N/A,2340.53,19257.60,,Hospital 77321,HC Special Plan Calculation,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,33574.00,N/A,20144.40,N/A,4700.36,N/A,6484.56,N/A,19331.97,N/A,11415.16,N/A,14219.52,N/A,4700.36,N/A,5878.48,N/A,5878.48,N/A,8851.88,N/A,14219.52,N/A,14219.52,N/A,14219.52,N/A,19331.97,N/A,5878.48,N/A,4700.36,N/A,17995.56,N/A,17995.56,N/A,4700.36,N/A,5878.48,N/A,442.39,N/A,486.64,N/A,N/A,442.39,20144.40,,Hospital CPT 77334,HC Treatment Devices Complex,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,982.00,982.00,589.20,589.20,N/A,137.48,N/A,56.52,N/A,565.44,N/A,333.88,N/A,783.58,N/A,137.48,N/A,323.94,N/A,323.94,N/A,487.80,N/A,783.58,N/A,783.58,N/A,783.58,N/A,565.44,N/A,323.94,N/A,137.48,N/A,526.35,N/A,526.35,N/A,137.48,N/A,323.94,N/A,56.52,N/A,62.17,589.20,589.20,56.52,783.58,,Hospital 77371,HC Srs Multisource Cranial Cobalt,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,110125.10,N/A,66075.06,N/A,15417.51,N/A,9005.11,N/A,62959.04,N/A,37442.53,N/A,20931.00,N/A,15417.51,N/A,8608.73,N/A,8608.73,N/A,13029.96,N/A,20931.00,N/A,20931.00,N/A,20931.00,N/A,62953.42,N/A,8608.73,N/A,15417.51,N/A,59027.05,N/A,59027.05,N/A,15417.51,N/A,8608.73,N/A,9005.11,N/A,957.23,N/A,N/A,957.23,66075.06,,Hospital 77412,"HC Rad Tx Delivery, >=1 Mev; Cplx",N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,94704.08,21320.00,56822.45,12792.00,8766.47,2984.80,10454.34,2197.56,22714.83,12276.05,31764.17,7248.80,31764.17,5177.48,8766.47,2984.80,12727.02,2140.42,12727.02,2140.42,31764.17,3223.06,31764.17,5177.48,31764.17,5177.48,31764.17,5177.48,22714.83,12276.05,11584.30,2140.42,8766.47,2984.80,22714.83,11427.47,22714.83,11427.47,8766.47,2984.80,9570.52,2140.42,10454.34,2197.56,8766.47,172.74,8766.47,56822.45,172.74,12792.00,,Hospital CPT 77424,HC Io Rad Tx Delivery by X-Ray,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,20680.00,20680.00,12408.00,12408.00,N/A,2895.20,N/A,6944.89,N/A,11907.54,N/A,7031.20,N/A,16799.12,N/A,2895.20,N/A,6944.89,N/A,6944.89,N/A,10457.78,N/A,16799.12,N/A,16799.12,N/A,16799.12,N/A,11907.54,N/A,6944.89,N/A,2895.20,N/A,11084.48,N/A,11084.48,N/A,2895.20,N/A,6944.89,N/A,6944.89,N/A,7639.38,12408.00,12408.00,2895.20,16799.12,,Hospital 78071,HC Parathyrd Planar W/WO Subtrj,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,44730.00,3402.00,26838.00,2041.20,4773.95,476.28,5912.98,373.38,10758.49,1911.85,15208.20,1156.68,10861.40,849.03,N/A,476.28,19889.82,350.99,2810.00,350.99,6760.97,528.54,10861.40,849.03,10861.40,849.03,10861.40,849.03,16724.69,1911.85,5912.98,350.99,4921.05,476.28,12922.36,1316.42,12922.36,1316.42,N/A,476.28,5912.98,350.99,19889.82,373.38,5265.52,273.16,2810.00,26838.00,273.16,2041.20,,Hospital CPT 78195,"HC NM Lymphatics,Lymph Gland Imaging",N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,833.00,833.00,499.80,499.80,N/A,116.62,N/A,251.94,N/A,479.64,N/A,283.22,N/A,833.00,N/A,116.62,N/A,455.58,N/A,455.58,N/A,686.03,N/A,833.00,N/A,833.00,N/A,833.00,N/A,479.64,N/A,455.58,N/A,116.62,N/A,446.49,N/A,446.49,N/A,116.62,N/A,455.58,N/A,251.94,N/A,277.13,499.80,499.80,116.62,833.00,,Hospital 78201,HC NM Liver Imaging Static Only,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,N/A,43322.88,N/A,25993.73,N/A,6050.91,N/A,4800.54,N/A,24800.99,N/A,14729.79,N/A,11452.99,N/A,6050.91,N/A,4641.41,N/A,4641.41,N/A,7129.71,N/A,11452.99,N/A,11452.99,N/A,11452.99,N/A,24793.96,N/A,4641.41,N/A,6050.91,N/A,922.25,N/A,922.25,N/A,6050.91,N/A,4641.41,N/A,4800.54,N/A,780.50,N/A,N/A,780.50,25993.73,,Hospital CPT 78227,HC NM Hepatobiliary Imaging W Pharm,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3936.00,3936.00,2361.60,2361.60,N/A,551.04,N/A,455.58,N/A,2266.35,N/A,1338.24,N/A,1102.01,N/A,551.04,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,2266.35,N/A,455.58,N/A,551.04,N/A,2109.70,N/A,2109.70,N/A,551.04,N/A,455.58,N/A,455.58,N/A,501.14,2361.60,2361.60,455.58,2361.60,,Hospital CPT 78291,HC NM Peritoneal Venous Shunt Paten,N/A,0340 - NUCLEAR MEDICINE - GENERAL CLASSIFICATION,1296.00,1296.00,777.60,777.60,N/A,181.44,N/A,186.09,N/A,746.24,N/A,440.64,N/A,849.03,N/A,181.44,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,746.24,N/A,350.99,N/A,181.44,N/A,694.66,N/A,694.66,N/A,181.44,N/A,350.99,N/A,186.09,N/A,204.70,777.60,777.60,181.44,849.03,,Hospital CPT 78291,HC NM Denver/Laveen Shunt Eval,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1296.00,1296.00,777.60,777.60,N/A,181.44,N/A,186.09,N/A,746.24,N/A,440.64,N/A,849.03,N/A,181.44,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,746.24,N/A,350.99,N/A,181.44,N/A,694.66,N/A,694.66,N/A,181.44,N/A,350.99,N/A,186.09,N/A,204.70,777.60,777.60,181.44,849.03,,Hospital CPT 78606,HC NM Brain With Flow,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2205.00,2205.00,1323.00,1323.00,N/A,308.70,N/A,252.24,N/A,1269.64,N/A,749.70,N/A,817.65,N/A,308.70,N/A,252.24,N/A,252.24,N/A,508.99,N/A,817.65,N/A,817.65,N/A,817.65,N/A,1269.64,N/A,252.24,N/A,308.70,N/A,1181.88,N/A,1181.88,N/A,308.70,N/A,252.24,N/A,252.24,N/A,277.46,1323.00,1323.00,252.24,1323.00,,Hospital CPT 78630,HC NM Cisternography,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1588.00,1588.00,952.80,952.80,N/A,222.32,N/A,467.75,N/A,914.37,N/A,539.92,N/A,1102.01,N/A,222.32,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,914.37,N/A,455.58,N/A,222.32,N/A,851.17,N/A,851.17,N/A,222.32,N/A,455.58,N/A,259.15,N/A,285.07,952.80,952.80,222.32,1102.01,,Hospital CPT 78707,HC NM Kidney Image W/O Pharmacologic,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1548.00,1548.00,928.80,928.80,N/A,216.72,N/A,476.56,N/A,891.34,N/A,526.32,N/A,1102.01,N/A,216.72,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,891.34,N/A,455.58,N/A,216.72,N/A,829.73,N/A,829.73,N/A,216.72,N/A,455.58,N/A,158.73,N/A,174.60,928.80,928.80,158.73,1102.01,,Hospital CPT 78708,HC NM Kidney Imag Vasc Flow Funct Ph,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3008.00,3008.00,1804.80,1804.80,N/A,421.12,N/A,455.58,N/A,1732.01,N/A,1022.72,N/A,1102.01,N/A,421.12,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,1732.01,N/A,455.58,N/A,421.12,N/A,1612.29,N/A,1612.29,N/A,421.12,N/A,455.58,N/A,455.58,N/A,501.14,1804.80,1804.80,421.12,1804.80,,Hospital CPT 78800,HC Rp Loclzj Tum Plnr 1 Area Single Day Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2842.00,2842.00,1705.20,1705.20,N/A,397.88,N/A,188.80,N/A,1636.42,N/A,966.28,N/A,849.03,N/A,397.88,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1636.42,N/A,350.99,N/A,397.88,N/A,1523.31,N/A,1523.31,N/A,397.88,N/A,350.99,N/A,188.80,N/A,207.68,1705.20,1705.20,188.80,1705.20,,Hospital CPT 78801,HC NM Tumor Localization Mult,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2957.00,2957.00,1774.20,1774.20,N/A,413.98,N/A,347.96,N/A,1702.64,N/A,1005.38,N/A,849.03,N/A,413.98,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1702.64,N/A,350.99,N/A,413.98,N/A,1584.95,N/A,1584.95,N/A,413.98,N/A,350.99,N/A,347.96,N/A,224.88,1774.20,1774.20,224.88,1774.20,,Hospital CPT 78802,HC Rp Loclzj Tum Plnr Whole Body Single Day Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3771.00,3771.00,2262.60,2262.60,N/A,527.94,N/A,1223.50,N/A,2171.34,N/A,1282.14,N/A,2899.26,N/A,527.94,N/A,1198.58,N/A,1198.58,N/A,1804.84,N/A,2899.26,N/A,2899.26,N/A,2899.26,N/A,2171.34,N/A,1198.58,N/A,527.94,N/A,2021.26,N/A,2021.26,N/A,527.94,N/A,1198.58,N/A,1223.50,N/A,254.32,2262.60,2262.60,254.32,2899.26,,Hospital CPT 78803,HC Rp Loclzj Tum Spect 1 Area Single Day Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3318.00,3318.00,1990.80,1990.80,N/A,464.52,N/A,1253.77,N/A,1910.50,N/A,1128.12,N/A,2899.26,N/A,464.52,N/A,1198.58,N/A,1198.58,N/A,1804.84,N/A,2899.26,N/A,2899.26,N/A,2899.26,N/A,1910.50,N/A,1198.58,N/A,464.52,N/A,1778.45,N/A,1778.45,N/A,464.52,N/A,1198.58,N/A,1275.03,N/A,310.54,1990.80,1990.80,310.54,2899.26,,Hospital CPT 78816,HC Pet/CT Whole Body,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,8798.00,2435.00,5278.80,1461.00,N/A,340.90,N/A,1344.94,N/A,2435.00,N/A,827.90,N/A,2435.00,N/A,340.90,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,2435.00,N/A,2435.00,N/A,2435.00,N/A,2435.00,N/A,1344.94,N/A,340.90,N/A,1305.16,N/A,1305.16,N/A,340.90,N/A,1344.94,N/A,1344.94,N/A,1479.44,5278.80,5278.80,340.90,2435.00,,Hospital CPT 80047,"HC Bmp, (Calcium Ionized)",N/A,0301 - LABORATORY - CHEMISTRY,122.00,102.00,73.20,61.20,N/A,13.73,N/A,13.73,N/A,58.73,N/A,34.68,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,8.55,N/A,5.69,N/A,5.69,N/A,13.73,N/A,58.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,73.20,73.20,5.69,61.20,,Hospital CPT 80061,HC So Lipid Panel,N/A,0301 - LABORATORY - CHEMISTRY,264.00,264.00,158.40,158.40,N/A,13.39,N/A,13.39,N/A,152.01,N/A,89.76,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,8.34,N/A,13.39,N/A,13.39,N/A,9.68,N/A,152.01,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,14.73,158.40,158.40,8.34,158.40,,Hospital CPT 80061,HC Lipid Panel,N/A,0301 - LABORATORY - CHEMISTRY,292.00,63.00,175.20,37.80,N/A,13.39,N/A,13.39,N/A,36.28,N/A,21.42,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,8.34,N/A,13.39,N/A,13.39,N/A,9.68,N/A,36.28,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,14.73,175.20,175.20,8.34,37.80,,Hospital CPT 80069,HC Renal Function Panel,N/A,0301 - LABORATORY - CHEMISTRY,100.00,85.00,60.00,51.00,N/A,8.68,N/A,8.68,N/A,48.94,N/A,28.90,N/A,8.68,N/A,8.68,N/A,8.68,N/A,8.68,N/A,5.40,N/A,8.68,N/A,8.68,N/A,8.68,N/A,48.94,N/A,8.68,N/A,8.68,N/A,8.68,N/A,8.68,N/A,8.68,N/A,8.68,N/A,8.68,N/A,9.55,60.00,60.00,5.40,51.00,,Hospital CPT 80076,HC Liver Profile-Hepatic Panel,N/A,0301 - LABORATORY - CHEMISTRY,205.00,174.00,123.00,104.40,N/A,8.17,N/A,8.17,N/A,100.19,N/A,59.16,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,5.09,N/A,8.17,N/A,8.17,N/A,8.17,N/A,100.19,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.99,123.00,123.00,5.09,104.40,,Hospital CPT 80151,HC So Drug Assay Amiodarone,N/A,0301 - LABORATORY - CHEMISTRY,70.00,70.00,42.00,42.00,N/A,18.64,N/A,18.64,N/A,40.31,N/A,23.80,N/A,7.46,N/A,18.64,N/A,18.64,N/A,18.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,7.46,N/A,40.31,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,42.00,42.00,7.46,42.00,,Hospital CPT 80165,HC Free Valproic Acid,N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,13.54,N/A,13.54,N/A,38.58,N/A,22.78,N/A,11.51,N/A,13.54,N/A,13.54,N/A,13.54,N/A,11.51,N/A,11.51,N/A,11.51,N/A,11.51,N/A,38.58,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,14.89,40.20,40.20,11.51,40.20,,Hospital CPT 80165,HC So Free Valproic Acid,N/A,0301 - LABORATORY - CHEMISTRY,53.00,53.00,31.80,31.80,N/A,13.54,N/A,13.54,N/A,30.52,N/A,18.02,N/A,11.51,N/A,13.54,N/A,13.54,N/A,13.54,N/A,11.51,N/A,11.51,N/A,11.51,N/A,11.51,N/A,30.52,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,14.89,31.80,31.80,11.51,31.80,,Hospital CPT 80171,HC So1 Gabapentin Neurontin,N/A,0301 - LABORATORY - CHEMISTRY,31.00,31.00,18.60,18.60,N/A,21.67,N/A,21.67,N/A,17.85,N/A,10.54,N/A,18.09,N/A,21.67,N/A,21.67,N/A,21.67,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,17.85,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,23.84,18.60,18.60,10.54,23.84,,Hospital CPT 80171,HC So Gabapentin Neurontin,N/A,0301 - LABORATORY - CHEMISTRY,46.00,46.00,27.60,27.60,N/A,21.67,N/A,21.67,N/A,26.49,N/A,15.64,N/A,18.09,N/A,21.67,N/A,21.67,N/A,21.67,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,26.49,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,21.67,N/A,23.84,27.60,27.60,15.64,27.60,,Hospital CPT 80173,HC So Haloperidol,N/A,0301 - LABORATORY - CHEMISTRY,47.00,47.00,28.20,28.20,N/A,15.78,N/A,15.78,N/A,47.00,N/A,15.98,N/A,12.37,N/A,15.78,N/A,15.78,N/A,15.78,N/A,12.37,N/A,12.37,N/A,12.37,N/A,12.37,N/A,27.06,N/A,15.78,N/A,15.78,N/A,15.78,N/A,15.78,N/A,15.78,N/A,15.78,N/A,15.78,N/A,17.36,28.20,28.20,12.37,47.00,,Hospital CPT 80179,HC Drug Assay Saliclate,N/A,0301 - LABORATORY - CHEMISTRY,154.00,154.00,92.40,92.40,N/A,18.64,N/A,18.64,N/A,88.67,N/A,52.36,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,11.60,N/A,18.64,N/A,18.64,N/A,18.64,N/A,88.67,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,92.40,92.40,11.60,92.40,,Hospital CPT 80185,HC So Phenyton / Dilantin,N/A,0301 - LABORATORY - CHEMISTRY,141.00,141.00,84.60,84.60,N/A,13.25,N/A,13.25,N/A,81.19,N/A,47.94,N/A,11.26,N/A,13.25,N/A,13.25,N/A,13.25,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,81.19,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,84.60,84.60,11.26,84.60,,Hospital CPT 80185,HC Phenyton / Dilantin,N/A,0301 - LABORATORY - CHEMISTRY,156.00,118.00,93.60,70.80,N/A,13.25,N/A,13.25,N/A,67.94,N/A,40.12,N/A,11.26,N/A,13.25,N/A,13.25,N/A,13.25,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,67.94,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,93.60,93.60,11.26,70.80,,Hospital CPT 80186,HC So Phenytoin Free,N/A,0301 - LABORATORY - CHEMISTRY,119.00,119.00,71.40,71.40,N/A,13.76,N/A,13.76,N/A,68.52,N/A,40.46,N/A,11.70,N/A,13.76,N/A,13.76,N/A,13.76,N/A,11.70,N/A,11.70,N/A,11.70,N/A,11.70,N/A,68.52,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,15.14,71.40,71.40,11.70,71.40,,Hospital CPT 80186,HC Phenytoin Free,N/A,0301 - LABORATORY - CHEMISTRY,131.00,98.00,78.60,58.80,N/A,13.76,N/A,13.76,N/A,56.43,N/A,33.32,N/A,11.70,N/A,13.76,N/A,13.76,N/A,13.76,N/A,11.70,N/A,11.70,N/A,11.70,N/A,11.70,N/A,56.43,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,13.76,N/A,15.14,78.60,78.60,11.70,58.80,,Hospital 80187,HC So Drug Assay Posaconazole,N/A,0301 - LABORATORY - CHEMISTRY,390072.02,2527.00,234043.21,1516.20,54446.50,365.41,N/A,348.45,N/A,1455.05,N/A,859.18,N/A,814.92,54446.50,365.41,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1455.05,N/A,336.90,54446.50,365.41,N/A,527.00,N/A,527.00,54446.50,365.41,N/A,336.90,N/A,348.45,54446.50,96.18,54446.50,234043.21,96.18,1516.20,,Hospital CPT 80194,HC Quinidine,N/A,0301 - LABORATORY - CHEMISTRY,128.00,96.00,76.80,57.60,N/A,14.60,N/A,14.60,N/A,55.28,N/A,32.64,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,9.09,N/A,14.60,N/A,14.60,N/A,14.60,N/A,55.28,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,16.06,76.80,76.80,9.09,57.60,,Hospital CPT 80201,HC So Topiramate,N/A,0301 - LABORATORY - CHEMISTRY,141.00,141.00,84.60,84.60,N/A,11.92,N/A,11.92,N/A,81.19,N/A,47.94,N/A,10.13,N/A,11.92,N/A,11.92,N/A,11.92,N/A,10.13,N/A,10.13,N/A,10.13,N/A,10.13,N/A,81.19,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,13.11,84.60,84.60,10.13,84.60,,Hospital CPT 80201,HC Topiramate,N/A,0301 - LABORATORY - CHEMISTRY,156.00,118.00,93.60,70.80,N/A,11.92,N/A,11.92,N/A,67.94,N/A,40.12,N/A,10.13,N/A,11.92,N/A,11.92,N/A,11.92,N/A,10.13,N/A,10.13,N/A,10.13,N/A,10.13,N/A,67.94,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,11.92,N/A,13.11,93.60,93.60,10.13,70.80,,Hospital CPT 80210,HC So Drug Assay Rufinamide,N/A,0301 - LABORATORY - CHEMISTRY,212.00,212.00,127.20,127.20,N/A,27.11,N/A,27.11,N/A,122.07,N/A,72.08,N/A,10.84,N/A,27.11,N/A,27.11,N/A,27.11,N/A,10.84,N/A,10.84,N/A,10.84,N/A,10.84,N/A,122.07,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,29.82,127.20,127.20,10.84,127.20,,Hospital CPT 80285,HC So Drug Assay Voriconazole,N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,27.11,N/A,27.11,N/A,50.67,N/A,29.92,N/A,10.84,N/A,27.11,N/A,27.11,N/A,27.11,N/A,10.84,N/A,10.84,N/A,10.84,N/A,10.84,N/A,50.67,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,29.82,52.80,52.80,10.84,52.80,,Hospital CPT 80299,"HC Quantation of Therapuetic Drug, Nes",N/A,0301 - LABORATORY - CHEMISTRY,148.00,109.00,88.80,65.40,N/A,18.64,N/A,18.64,N/A,62.76,N/A,37.06,N/A,11.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,11.64,N/A,11.64,N/A,11.64,N/A,18.64,N/A,62.76,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,88.80,88.80,11.64,65.40,,Hospital CPT 80299,"HC So Quantation of Therapuetic Drug, Nes",N/A,0301 - LABORATORY - CHEMISTRY,173.00,173.00,103.80,103.80,N/A,18.64,N/A,18.64,N/A,99.61,N/A,58.82,N/A,11.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,11.64,N/A,11.64,N/A,11.64,N/A,18.64,N/A,99.61,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,103.80,103.80,11.64,103.80,,Hospital CPT 80305,HC So Drug Test Prsmv Dir Optical Obs,N/A,0301 - LABORATORY - CHEMISTRY,382.00,382.00,229.20,229.20,N/A,12.60,N/A,12.60,N/A,219.96,N/A,129.88,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,7.84,N/A,12.60,N/A,6.43,N/A,12.60,N/A,219.96,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,13.86,229.20,229.20,6.43,229.20,,Hospital CPT 80305,HC Drug Test Prsmv Dir Optical Obs,N/A,0301 - LABORATORY - CHEMISTRY,422.00,422.00,253.20,253.20,N/A,12.60,N/A,12.60,N/A,242.99,N/A,143.48,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,7.84,N/A,12.60,N/A,6.43,N/A,12.60,N/A,242.99,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,12.60,N/A,13.86,253.20,253.20,6.43,253.20,,Hospital CPT 80307,HC Drug Test Prsmv Chem Anlyzr,N/A,0301 - LABORATORY - CHEMISTRY,1791.00,1350.00,1074.60,810.00,N/A,62.14,N/A,62.14,N/A,777.33,N/A,459.00,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,38.68,N/A,62.14,N/A,62.14,N/A,62.14,N/A,777.33,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,68.35,1074.60,1074.60,38.68,810.00,,Hospital CPT 80307,HC Drug Test Prsmv Chem Anlyzr,N/A,0301 - LABORATORY - CHEMISTRY,658.00,406.00,394.80,243.60,N/A,62.14,N/A,62.14,N/A,233.77,N/A,138.04,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,38.68,N/A,62.14,N/A,62.14,N/A,62.14,N/A,233.77,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,68.35,394.80,394.80,38.68,243.60,,Hospital CPT 80307,HC So Drg Scrn Class List A,N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,62.14,N/A,62.14,N/A,63.34,N/A,37.40,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,38.68,N/A,62.14,N/A,62.14,N/A,62.14,N/A,63.34,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,62.14,N/A,68.35,66.00,66.00,37.40,68.35,,Hospital 80320,HC Volatile Alcohols,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,69263.35,N/A,41558.01,N/A,8859.61,N/A,13872.63,N/A,24184.91,N/A,23543.94,N/A,23543.94,N/A,8859.61,N/A,13872.63,N/A,13872.63,N/A,23543.94,N/A,23543.94,N/A,23543.94,N/A,23543.94,N/A,24184.91,N/A,13872.63,N/A,8859.61,N/A,24184.91,N/A,24184.91,N/A,8859.61,N/A,13872.63,N/A,13872.63,N/A,8859.61,N/A,8859.61,41558.01,N/A,N/A,,Hospital 80354,HC So Drug Screening Fentanyl,N/A,0309 - LABORATORY - OTHER LABORATORY,57816.67,N/A,34690.00,N/A,14517.38,N/A,9873.49,N/A,18303.50,N/A,N/A,N/A,18478.58,N/A,8372.21,N/A,9873.49,N/A,9873.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,24184.91,N/A,9873.49,N/A,14517.38,N/A,24184.91,N/A,21984.90,N/A,14517.38,N/A,9873.49,N/A,7837.81,N/A,14517.38,N/A,7837.81,34690.00,N/A,N/A,,Hospital 80377,HC So Drug/Substance Nos 7/More,N/A,0309 - LABORATORY - OTHER LABORATORY,62865.38,N/A,37719.23,N/A,19983.46,N/A,12616.71,N/A,23529.46,N/A,N/A,N/A,N/A,N/A,19983.46,N/A,2810.00,N/A,2810.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12616.71,N/A,19983.46,N/A,28261.97,N/A,N/A,N/A,19983.46,N/A,12616.71,N/A,12616.71,N/A,11516.01,N/A,2810.00,37719.23,N/A,N/A,,Hospital 81000,HC Urinalysis Nonauto W/Scope,N/A,0307 - LABORATORY - UROLOGY,10883.40,82.00,6530.04,49.20,4673.13,13.49,5793.71,19.06,10531.27,47.22,3700.35,27.88,10632.01,13.19,4817.11,13.49,562.00,19.06,562.00,19.06,6618.18,13.19,10632.01,13.19,10632.01,13.19,10632.01,13.19,10531.27,47.22,5793.71,19.06,4817.11,13.49,10883.40,13.49,10883.40,13.49,N/A,13.49,5793.71,19.06,5793.71,19.06,5154.31,14.84,562.00,10883.40,13.19,49.20,,Hospital CPT 81001,HC Urinalysis W/ Microscopy,N/A,0307 - LABORATORY - UROLOGY,103.00,88.00,61.80,52.80,N/A,3.17,N/A,3.17,N/A,50.67,N/A,29.92,N/A,3.17,N/A,3.17,N/A,3.17,N/A,3.17,N/A,2.69,N/A,3.17,N/A,3.17,N/A,3.17,N/A,50.67,N/A,3.17,N/A,3.17,N/A,3.17,N/A,3.17,N/A,3.17,N/A,3.17,N/A,3.17,N/A,3.49,61.80,61.80,2.69,52.80,,Hospital CPT 81015,HC Microscopic Exam of Urine,N/A,0307 - LABORATORY - UROLOGY,39.00,30.00,23.40,18.00,N/A,3.05,N/A,3.05,N/A,17.27,N/A,10.20,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,2.59,N/A,2.59,N/A,2.59,N/A,3.05,N/A,17.27,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.36,23.40,23.40,2.59,18.00,,Hospital CPT 81105,HC So Hpa-1 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,76.08,N/A,122.22,N/A,122.22,N/A,122.22,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,76.08,183.60,,Hospital CPT 81106,HC So Hpa-2 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,60.36,N/A,122.22,N/A,122.22,N/A,122.22,N/A,60.36,N/A,60.36,N/A,60.36,N/A,60.36,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,60.36,183.60,,Hospital CPT 81163,HC So Brca1&2 Full Seq Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,3720.00,3720.00,2232.00,2232.00,N/A,468.00,N/A,468.00,N/A,2141.98,N/A,1264.80,N/A,468.00,N/A,468.00,N/A,468.00,N/A,468.00,N/A,291.33,N/A,468.00,N/A,468.00,N/A,468.00,N/A,2141.98,N/A,468.00,N/A,468.00,N/A,468.00,N/A,468.00,N/A,468.00,N/A,468.00,N/A,468.00,N/A,514.80,2232.00,2232.00,291.33,2232.00,,Hospital CPT 81175,HC So Asxl1 Gene Analysis Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1150.00,1150.00,690.00,690.00,N/A,676.50,N/A,676.50,N/A,662.17,N/A,391.00,N/A,282.81,N/A,676.50,N/A,676.50,N/A,676.50,N/A,282.81,N/A,282.81,N/A,282.81,N/A,282.81,N/A,662.17,N/A,676.50,N/A,676.50,N/A,676.50,N/A,676.50,N/A,676.50,N/A,676.50,N/A,676.50,N/A,744.15,690.00,690.00,282.81,744.15,,Hospital CPT 81194,HC So Ntrk Translocation Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1555.00,1555.00,933.00,933.00,N/A,518.28,N/A,518.28,N/A,895.37,N/A,528.70,N/A,518.28,N/A,518.28,N/A,518.28,N/A,518.28,N/A,322.63,N/A,518.28,N/A,518.28,N/A,518.28,N/A,895.37,N/A,518.28,N/A,518.28,N/A,518.28,N/A,518.28,N/A,518.28,N/A,518.28,N/A,518.28,N/A,570.11,933.00,933.00,322.63,933.00,,Hospital CPT 81202,HC So Targeted Sequencing,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,483.00,483.00,289.80,289.80,N/A,280.00,N/A,280.00,N/A,278.11,N/A,164.22,N/A,280.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,174.30,N/A,280.00,N/A,280.00,N/A,280.00,N/A,278.11,N/A,280.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,308.00,289.80,289.80,164.22,308.00,,Hospital CPT 81205,HC So Bckdhb Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,237.00,237.00,142.20,142.20,N/A,94.99,N/A,94.99,N/A,136.46,N/A,80.58,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,59.13,N/A,94.99,N/A,94.99,N/A,94.99,N/A,136.46,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,104.49,142.20,142.20,59.13,142.20,,Hospital CPT 81206,HC Bcr/Abl1 Translocation Anal,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,752.00,752.00,451.20,451.20,N/A,163.96,N/A,163.96,N/A,433.00,N/A,255.68,N/A,36.53,N/A,163.96,N/A,163.96,N/A,163.96,N/A,36.53,N/A,36.53,N/A,36.53,N/A,36.53,N/A,433.00,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,180.36,451.20,451.20,36.53,451.20,,Hospital CPT 81206,HC So Bcr/Abl1 Translocation Anal,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,681.00,681.00,408.60,408.60,N/A,163.96,N/A,163.96,N/A,392.12,N/A,231.54,N/A,36.53,N/A,163.96,N/A,163.96,N/A,163.96,N/A,36.53,N/A,36.53,N/A,36.53,N/A,36.53,N/A,392.12,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,163.96,N/A,180.36,408.60,408.60,36.53,408.60,,Hospital CPT 81217,HC So Brca2 Gene Known Fam Variant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,750.00,750.00,450.00,450.00,N/A,375.25,N/A,375.25,N/A,431.85,N/A,255.00,N/A,375.25,N/A,375.25,N/A,375.25,N/A,375.25,N/A,233.59,N/A,375.25,N/A,375.25,N/A,375.25,N/A,431.85,N/A,375.25,N/A,375.25,N/A,375.25,N/A,375.25,N/A,375.25,N/A,375.25,N/A,375.25,N/A,412.78,450.00,450.00,233.59,450.00,,Hospital CPT 81225,HC So Cyp2c19 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,728.00,728.00,436.80,436.80,N/A,291.36,N/A,291.36,N/A,419.18,N/A,247.52,N/A,67.07,N/A,291.36,N/A,291.36,N/A,291.36,N/A,67.07,N/A,67.07,N/A,67.07,N/A,67.07,N/A,419.18,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,320.50,436.80,436.80,67.07,436.80,,Hospital CPT 81229,HC So Cytogen Micro Array Copy No&Snp,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2093.00,2093.00,1255.80,1255.80,N/A,1160.00,N/A,1160.00,N/A,1205.15,N/A,711.62,N/A,9.64,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,9.64,N/A,9.64,N/A,9.64,N/A,9.64,N/A,1205.15,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1276.00,1255.80,1255.80,9.64,1276.00,,Hospital CPT 81229,HC Cytogen Micro Array Copy No&Snp,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2308.00,2308.00,1384.80,1384.80,N/A,1160.00,N/A,1160.00,N/A,1328.95,N/A,784.72,N/A,9.64,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,9.64,N/A,9.64,N/A,9.64,N/A,9.64,N/A,1328.95,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1160.00,N/A,1276.00,1384.80,1384.80,9.64,1384.80,,Hospital CPT 81232,HC So Dpyd Gene Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,700.00,700.00,420.00,420.00,N/A,174.81,N/A,174.81,N/A,403.06,N/A,238.00,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,108.82,N/A,174.81,N/A,174.81,N/A,174.81,N/A,403.06,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,420.00,420.00,108.82,420.00,,Hospital 81234,HC So1 Dmpk Gene Analysis Eval Detect Abnormal Alleles,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,N/A,1450.00,N/A,870.00,N/A,296.17,N/A,296.17,N/A,834.91,N/A,493.00,N/A,124.94,N/A,296.17,N/A,296.17,N/A,296.17,N/A,124.94,N/A,124.94,N/A,124.94,N/A,124.94,N/A,834.91,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,325.79,N/A,N/A,124.94,870.00,,Hospital 81238,HC F9 Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,N/A,5639.00,N/A,3383.40,N/A,3994.90,N/A,3953.48,N/A,3246.94,N/A,1917.26,N/A,4314.84,N/A,3994.90,N/A,3940.03,N/A,3940.03,N/A,2685.92,N/A,4314.84,N/A,4314.84,N/A,4314.84,N/A,3246.94,N/A,3940.03,N/A,3994.90,N/A,3955.82,N/A,3955.82,N/A,3994.90,N/A,3940.03,N/A,3953.48,N/A,4263.33,N/A,N/A,1917.26,4314.84,,Hospital CPT 81243,HC Fmr1 Gene Detection,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,401.00,401.00,240.60,240.60,N/A,57.04,N/A,57.04,N/A,230.90,N/A,136.34,N/A,42.14,N/A,57.04,N/A,57.04,N/A,57.04,N/A,42.14,N/A,42.14,N/A,42.14,N/A,42.14,N/A,230.90,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,62.74,240.60,240.60,42.14,240.60,,Hospital CPT 81243,HC So Fragile X Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,363.00,363.00,217.80,217.80,N/A,57.04,N/A,57.04,N/A,209.02,N/A,123.42,N/A,42.14,N/A,57.04,N/A,57.04,N/A,57.04,N/A,42.14,N/A,42.14,N/A,42.14,N/A,42.14,N/A,209.02,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,57.04,N/A,62.74,217.80,217.80,42.14,217.80,,Hospital CPT 81254,HC So Gjb6 Gene Com Variants,N/A,0301 - LABORATORY - CHEMISTRY,378.00,378.00,226.80,226.80,N/A,35.00,N/A,35.00,N/A,217.65,N/A,128.52,N/A,35.00,N/A,35.00,N/A,35.00,N/A,35.00,N/A,21.79,N/A,35.00,N/A,35.00,N/A,35.00,N/A,217.65,N/A,35.00,N/A,35.00,N/A,35.00,N/A,35.00,N/A,35.00,N/A,35.00,N/A,35.00,N/A,38.50,226.80,226.80,21.79,226.80,,Hospital CPT 81260,HC So Ikbkap Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,345.00,345.00,207.00,207.00,N/A,39.31,N/A,39.31,N/A,198.65,N/A,117.30,N/A,36.53,N/A,39.31,N/A,39.31,N/A,39.31,N/A,36.53,N/A,36.53,N/A,36.53,N/A,36.53,N/A,198.65,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,43.24,207.00,207.00,36.53,207.00,,Hospital CPT 81270,HC So Jak2 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1175.00,1175.00,705.00,705.00,N/A,91.66,N/A,91.66,N/A,676.57,N/A,399.50,N/A,26.30,N/A,91.66,N/A,91.66,N/A,91.66,N/A,26.30,N/A,26.30,N/A,91.66,N/A,26.30,N/A,676.57,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,100.83,705.00,705.00,26.30,705.00,,Hospital CPT 81270,"HC Jak2,Janus Kinase 2 Gene Analy",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1296.00,1101.00,777.60,660.60,N/A,91.66,N/A,91.66,N/A,633.96,N/A,374.34,N/A,26.30,N/A,91.66,N/A,91.66,N/A,91.66,N/A,26.30,N/A,26.30,N/A,91.66,N/A,26.30,N/A,633.96,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,91.66,N/A,100.83,777.60,777.60,26.30,660.60,,Hospital CPT 81272,HC So Aml Kit Mutation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1813.00,1813.00,1087.80,1087.80,N/A,329.51,N/A,329.51,N/A,1813.00,N/A,616.42,N/A,69.13,N/A,329.51,N/A,329.51,N/A,329.51,N/A,69.13,N/A,69.13,N/A,69.13,N/A,69.13,N/A,1043.93,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,362.46,1087.80,1087.80,69.13,1813.00,,Hospital CPT 81272,HC Kit Gene Targeted Seq Analys,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1101.00,1101.00,660.60,660.60,N/A,329.51,N/A,329.51,N/A,1101.00,N/A,374.34,N/A,69.13,N/A,329.51,N/A,329.51,N/A,329.51,N/A,69.13,N/A,69.13,N/A,69.13,N/A,69.13,N/A,633.96,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,362.46,660.60,660.60,69.13,1101.00,,Hospital CPT 81290,HC So Cloln1 Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,500.00,500.00,300.00,300.00,N/A,70.00,N/A,39.31,N/A,287.90,N/A,170.00,N/A,70.00,N/A,70.00,N/A,39.31,N/A,39.31,N/A,43.50,N/A,70.00,N/A,70.00,N/A,70.00,N/A,287.90,N/A,39.31,N/A,70.00,N/A,500.00,N/A,500.00,N/A,70.00,N/A,39.31,N/A,39.31,N/A,500.00,300.00,300.00,39.31,500.00,,Hospital CPT 81304,HC So Mecp2 Gene Analysis Dup/Del VA,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,450.00,450.00,270.00,270.00,N/A,150.00,N/A,150.00,N/A,259.11,N/A,153.00,N/A,46.53,N/A,150.00,N/A,150.00,N/A,150.00,N/A,46.53,N/A,46.53,N/A,46.53,N/A,46.53,N/A,259.11,N/A,150.00,N/A,150.00,N/A,150.00,N/A,150.00,N/A,150.00,N/A,150.00,N/A,150.00,N/A,165.00,270.00,270.00,46.53,270.00,,Hospital CPT 81313,Ref Prostatic Ca Ag 3,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1320.00,1320.00,792.00,792.00,N/A,255.05,N/A,255.05,N/A,760.06,N/A,448.80,N/A,255.05,N/A,255.05,N/A,255.05,N/A,255.05,N/A,158.77,N/A,255.05,N/A,255.05,N/A,255.05,N/A,760.06,N/A,255.05,N/A,255.05,N/A,255.05,N/A,255.05,N/A,255.05,N/A,255.05,N/A,255.05,N/A,280.56,792.00,792.00,158.77,792.00,,Hospital CPT 81315,HC So Pml/Rar Alpha Translocation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,500.00,500.00,300.00,300.00,N/A,207.31,N/A,207.31,N/A,287.90,N/A,170.00,N/A,207.31,N/A,207.31,N/A,207.31,N/A,207.31,N/A,129.05,N/A,207.31,N/A,207.31,N/A,207.31,N/A,287.90,N/A,207.31,N/A,207.31,N/A,207.31,N/A,207.31,N/A,207.31,N/A,207.31,N/A,207.31,N/A,228.04,300.00,300.00,129.05,300.00,,Hospital CPT 81321,HC So Pten Gene Full Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1500.00,1500.00,900.00,900.00,N/A,600.00,N/A,600.00,N/A,863.70,N/A,510.00,N/A,738.70,N/A,600.00,N/A,600.00,N/A,600.00,N/A,738.70,N/A,738.70,N/A,738.70,N/A,738.70,N/A,863.70,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,660.00,900.00,900.00,510.00,900.00,,Hospital CPT 81335,HC So Tpmt Gene Com Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,530.00,530.00,318.00,318.00,N/A,174.81,N/A,174.81,N/A,305.17,N/A,180.20,N/A,69.92,N/A,174.81,N/A,174.81,N/A,174.81,N/A,69.92,N/A,69.92,N/A,69.92,N/A,69.92,N/A,305.17,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,318.00,318.00,69.92,318.00,,Hospital CPT 81335,HC Tpmt Gene Com Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,585.00,585.00,351.00,351.00,N/A,174.81,N/A,174.81,N/A,336.84,N/A,198.90,N/A,69.92,N/A,174.81,N/A,174.81,N/A,174.81,N/A,69.92,N/A,69.92,N/A,69.92,N/A,69.92,N/A,336.84,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,351.00,351.00,69.92,351.00,,Hospital CPT 81340,HC So Trb@ Gene Rearrange Amp,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,522.00,522.00,313.20,313.20,N/A,208.92,N/A,208.92,N/A,300.57,N/A,177.48,N/A,208.92,N/A,208.92,N/A,208.92,N/A,208.92,N/A,130.05,N/A,208.92,N/A,208.92,N/A,208.92,N/A,300.57,N/A,208.92,N/A,208.92,N/A,208.92,N/A,208.92,N/A,208.92,N/A,208.92,N/A,208.92,N/A,229.81,313.20,313.20,130.05,313.20,,Hospital CPT 81342,HC So Trg Gene Rearrangement,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,754.00,754.00,452.40,452.40,N/A,201.50,N/A,201.50,N/A,434.15,N/A,256.36,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,125.43,N/A,201.50,N/A,201.50,N/A,201.50,N/A,434.15,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,221.65,452.40,452.40,125.43,452.40,,Hospital CPT 81342,"HC T-Cell Gene Rearrangement,Pcr",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,832.00,832.00,499.20,499.20,N/A,201.50,N/A,201.50,N/A,479.07,N/A,282.88,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,125.43,N/A,201.50,N/A,201.50,N/A,201.50,N/A,479.07,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,201.50,N/A,221.65,499.20,499.20,125.43,499.20,,Hospital CPT 81346,HC So Tyms Gene Com Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,700.00,700.00,420.00,420.00,N/A,174.81,N/A,174.81,N/A,403.06,N/A,238.00,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,108.82,N/A,174.81,N/A,174.81,N/A,174.81,N/A,403.06,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,420.00,420.00,108.82,420.00,,Hospital CPT 81355,HC So Vkorc1 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,352.00,352.00,211.20,211.20,N/A,88.20,N/A,88.20,N/A,202.68,N/A,119.68,N/A,88.20,N/A,88.20,N/A,88.20,N/A,88.20,N/A,54.90,N/A,88.20,N/A,88.20,N/A,88.20,N/A,202.68,N/A,88.20,N/A,88.20,N/A,88.20,N/A,88.20,N/A,88.20,N/A,88.20,N/A,88.20,N/A,97.02,211.20,211.20,54.90,211.20,,Hospital CPT 81364,HC So Hbb Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,575.00,575.00,345.00,345.00,N/A,324.58,N/A,324.58,N/A,331.09,N/A,195.50,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,202.05,N/A,324.58,N/A,324.58,N/A,324.58,N/A,331.09,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,357.04,345.00,345.00,195.50,357.04,,Hospital CPT 81373,HC So Hla I Typing 1 Locus Lr,N/A,0301 - LABORATORY - CHEMISTRY,319.00,319.00,191.40,191.40,N/A,127.43,N/A,127.43,N/A,183.68,N/A,108.46,N/A,127.43,N/A,127.43,N/A,127.43,N/A,127.43,N/A,79.33,N/A,127.43,N/A,127.43,N/A,127.43,N/A,183.68,N/A,127.43,N/A,127.43,N/A,127.43,N/A,127.43,N/A,127.43,N/A,127.43,N/A,127.43,N/A,140.17,191.40,191.40,79.33,191.40,,Hospital CPT 81374,HC So Hla I Typing 1 Antigen Lr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,188.00,188.00,112.80,112.80,N/A,74.33,N/A,74.33,N/A,108.25,N/A,63.92,N/A,74.33,N/A,74.33,N/A,74.33,N/A,74.33,N/A,46.27,N/A,74.33,N/A,74.33,N/A,74.33,N/A,108.25,N/A,74.33,N/A,74.33,N/A,74.33,N/A,74.33,N/A,74.33,N/A,74.33,N/A,74.33,N/A,81.76,112.80,112.80,46.27,112.80,,Hospital CPT 81376,HC So Hla Class II Typing One Locus,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,360.00,360.00,216.00,216.00,N/A,122.22,N/A,122.22,N/A,207.29,N/A,122.40,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,76.08,N/A,122.22,N/A,122.22,N/A,122.22,N/A,207.29,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,216.00,216.00,76.08,216.00,,Hospital CPT 81376,HC So Hla II Typing 1 Locus Lr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,305.00,305.00,183.00,183.00,N/A,122.22,N/A,122.22,N/A,175.62,N/A,103.70,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,76.08,N/A,122.22,N/A,122.22,N/A,122.22,N/A,175.62,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.00,183.00,76.08,183.00,,Hospital CPT 81377,HC So Hla II Low Resolution One Antigen Equivalent Ea,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,378.00,378.00,226.80,226.80,N/A,94.74,N/A,94.74,N/A,217.65,N/A,128.52,N/A,94.74,N/A,94.74,N/A,94.74,N/A,94.74,N/A,58.98,N/A,94.74,N/A,94.74,N/A,94.74,N/A,217.65,N/A,94.74,N/A,94.74,N/A,94.74,N/A,94.74,N/A,94.74,N/A,94.74,N/A,94.74,N/A,104.21,226.80,226.80,58.98,226.80,,Hospital CPT 81379,HC So Hla I Typing Complete Hr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,838.00,838.00,502.80,502.80,N/A,335.38,N/A,335.38,N/A,482.52,N/A,284.92,N/A,64.30,N/A,335.38,N/A,335.38,N/A,335.38,N/A,64.30,N/A,64.30,N/A,64.30,N/A,64.30,N/A,482.52,N/A,335.38,N/A,335.38,N/A,335.38,N/A,335.38,N/A,335.38,N/A,335.38,N/A,335.38,N/A,368.92,502.80,502.80,64.30,502.80,,Hospital CPT 81381,HC Molecular Pathology,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,446.00,446.00,267.60,267.60,N/A,169.90,N/A,169.90,N/A,256.81,N/A,151.64,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,105.76,N/A,169.90,N/A,169.90,N/A,169.90,N/A,256.81,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,186.89,267.60,267.60,105.76,267.60,,Hospital CPT 81381,HC Hla I Typing 1 Allele Hr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,492.00,492.00,295.20,295.20,N/A,169.90,N/A,169.90,N/A,283.29,N/A,167.28,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,105.76,N/A,169.90,N/A,169.90,N/A,169.90,N/A,283.29,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,169.90,N/A,186.89,295.20,295.20,105.76,295.20,,Hospital CPT 81382,HC Hla 2 Typing,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,990.00,990.00,594.00,594.00,N/A,123.68,N/A,123.68,N/A,570.04,N/A,336.60,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,76.99,N/A,123.68,N/A,123.68,N/A,123.68,N/A,570.04,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,136.05,594.00,594.00,76.99,594.00,,Hospital CPT 81382,HC So Hla Class II Typing Ea,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,898.00,898.00,538.80,538.80,N/A,123.68,N/A,123.68,N/A,517.07,N/A,305.32,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,76.99,N/A,123.68,N/A,123.68,N/A,123.68,N/A,517.07,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,123.68,N/A,136.05,538.80,538.80,76.99,538.80,,Hospital CPT 81383,HC So Hla Dqb1 06:02 Genotype,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,273.00,273.00,163.80,163.80,N/A,109.13,N/A,109.13,N/A,157.19,N/A,92.82,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,67.93,N/A,109.13,N/A,109.13,N/A,109.13,N/A,157.19,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,120.04,163.80,163.80,67.93,163.80,,Hospital CPT 81383,HC So Hla Dqb1 06:02 Genotype,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,375.00,375.00,225.00,225.00,N/A,109.13,N/A,109.13,N/A,215.93,N/A,127.50,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,67.93,N/A,109.13,N/A,109.13,N/A,109.13,N/A,215.93,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,109.13,N/A,120.04,225.00,225.00,67.93,225.00,,Hospital CPT 81403,HC So Mopath Procedure Level 4,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,500.00,500.00,300.00,300.00,N/A,185.20,N/A,185.20,N/A,287.90,N/A,170.00,N/A,60.26,N/A,185.20,N/A,185.20,N/A,185.20,N/A,60.26,N/A,60.26,N/A,60.26,N/A,60.26,N/A,287.90,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,203.72,300.00,300.00,60.26,300.00,,Hospital CPT 81403,HC So1 Mopath Procedure Level 4,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,500.00,500.00,300.00,300.00,N/A,185.20,N/A,185.20,N/A,287.90,N/A,170.00,N/A,60.26,N/A,185.20,N/A,185.20,N/A,185.20,N/A,60.26,N/A,60.26,N/A,60.26,N/A,60.26,N/A,287.90,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,203.72,300.00,300.00,60.26,300.00,,Hospital CPT 81404,HC So Mopath Procedure Level 5,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,967.00,967.00,580.20,580.20,N/A,274.83,N/A,274.83,N/A,556.80,N/A,328.78,N/A,133.97,N/A,274.83,N/A,274.83,N/A,274.83,N/A,133.97,N/A,133.97,N/A,133.97,N/A,133.97,N/A,556.80,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,302.31,580.20,580.20,133.97,580.20,,Hospital CPT 81430,HC So Hearing Loss Sequence Analys,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4063.00,4063.00,2437.80,2437.80,N/A,1625.00,N/A,1625.00,N/A,2339.48,N/A,1381.42,N/A,1883.31,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1883.31,N/A,1883.31,N/A,1883.31,N/A,1883.31,N/A,2339.48,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1787.50,2437.80,2437.80,1381.42,2437.80,,Hospital CPT 81430,HC So1 Hearing Loss Sequence Analys,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4063.00,4063.00,2437.80,2437.80,N/A,1625.00,N/A,1625.00,N/A,2339.48,N/A,1381.42,N/A,1883.31,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1883.31,N/A,1883.31,N/A,1883.31,N/A,1883.31,N/A,2339.48,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1625.00,N/A,1787.50,2437.80,2437.80,1381.42,2437.80,,Hospital CPT 81436,HC So Duplication/Deletion Analysis Panel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1755.00,1755.00,1053.00,1053.00,N/A,584.90,N/A,584.90,N/A,1010.53,N/A,596.70,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,364.10,N/A,584.90,N/A,584.90,N/A,584.90,N/A,1010.53,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,643.39,1053.00,1053.00,364.10,1053.00,,Hospital CPT 81437,HC So Hereditary Neuroendocrine Tumor Disorders,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1316.00,1316.00,789.60,789.60,N/A,438.93,N/A,438.93,N/A,757.75,N/A,447.44,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,273.23,N/A,438.93,N/A,438.93,N/A,438.93,N/A,757.75,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,482.82,789.60,789.60,273.23,789.60,,Hospital CPT 81438,HC So Duplication/Deletion Analysis Panel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1316.00,1316.00,789.60,789.60,N/A,438.93,N/A,438.93,N/A,757.75,N/A,447.44,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,273.23,N/A,438.93,N/A,438.93,N/A,438.93,N/A,757.75,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,482.82,789.60,789.60,273.23,789.60,,Hospital CPT 81440,HC So Mitochondrial Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,3325.00,3325.00,1995.00,1995.00,N/A,3324.00,N/A,3324.00,N/A,1914.54,N/A,1130.50,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,2069.19,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,1914.54,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,3324.00,N/A,3656.40,1995.00,1995.00,1130.50,3656.40,,Hospital CPT 81510,HC So Maternal Screen Triple,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,225.00,225.00,135.00,135.00,N/A,55.54,N/A,55.54,N/A,129.56,N/A,76.50,N/A,55.54,N/A,55.54,N/A,55.54,N/A,55.54,N/A,34.57,N/A,55.54,N/A,55.54,N/A,55.54,N/A,129.56,N/A,55.54,N/A,55.54,N/A,55.54,N/A,55.54,N/A,55.54,N/A,55.54,N/A,55.54,N/A,61.09,135.00,135.00,34.57,135.00,,Hospital CPT 81513,HC So Nfct Ds Bacteral Vaginosis Rna Vagl-Fluid Alg,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,347.00,347.00,208.20,208.20,N/A,142.63,N/A,142.63,N/A,199.80,N/A,117.98,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,88.79,N/A,142.63,N/A,142.63,N/A,142.63,N/A,199.80,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,156.89,208.20,208.20,88.79,208.20,,Hospital CPT 81596,HC So Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,490.00,490.00,294.00,294.00,N/A,72.19,N/A,72.19,N/A,282.14,N/A,166.60,N/A,28.88,N/A,72.19,N/A,72.19,N/A,72.19,N/A,28.88,N/A,28.88,N/A,28.88,N/A,28.88,N/A,282.14,N/A,72.19,N/A,72.19,N/A,72.19,N/A,72.19,N/A,72.19,N/A,72.19,N/A,72.19,N/A,79.41,294.00,294.00,28.88,294.00,,Hospital CPT 82009,"HC Acetone, Serum",N/A,0307 - LABORATORY - UROLOGY,63.00,46.00,37.80,27.60,N/A,4.52,N/A,4.52,N/A,26.49,N/A,15.64,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,2.81,N/A,4.52,N/A,4.52,N/A,4.52,N/A,26.49,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.97,37.80,37.80,2.81,27.60,,Hospital CPT 82009,"HC Acetone, Urine",N/A,0307 - LABORATORY - UROLOGY,93.00,70.00,55.80,42.00,N/A,4.52,N/A,4.52,N/A,40.31,N/A,23.80,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,2.81,N/A,4.52,N/A,4.52,N/A,4.52,N/A,40.31,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.97,55.80,55.80,2.81,42.00,,Hospital CPT 82017,HC So Acylcarnitine,N/A,0307 - LABORATORY - UROLOGY,273.00,273.00,163.80,163.80,N/A,16.87,N/A,16.87,N/A,157.19,N/A,92.82,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,157.19,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,163.80,163.80,1.73,163.80,,Hospital CPT 82024,HC Acth,N/A,0307 - LABORATORY - UROLOGY,237.00,176.00,142.20,105.60,N/A,38.62,N/A,38.62,N/A,101.34,N/A,59.84,N/A,28.03,N/A,38.62,N/A,38.62,N/A,38.62,N/A,28.03,N/A,28.03,N/A,28.03,N/A,28.03,N/A,101.34,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,42.48,142.20,142.20,28.03,105.60,,Hospital CPT 82024,HC So Acth,N/A,0307 - LABORATORY - UROLOGY,215.00,215.00,129.00,129.00,N/A,38.62,N/A,38.62,N/A,123.80,N/A,73.10,N/A,28.03,N/A,38.62,N/A,38.62,N/A,38.62,N/A,28.03,N/A,28.03,N/A,28.03,N/A,28.03,N/A,123.80,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,38.62,N/A,42.48,129.00,129.00,28.03,129.00,,Hospital CPT 82030,HC So Cyclic Amp,N/A,0307 - LABORATORY - UROLOGY,307.00,307.00,184.20,184.20,N/A,25.80,N/A,25.80,N/A,176.77,N/A,104.38,N/A,25.80,N/A,25.80,N/A,25.80,N/A,25.80,N/A,16.06,N/A,25.80,N/A,25.80,N/A,25.80,N/A,176.77,N/A,25.80,N/A,25.80,N/A,25.80,N/A,25.80,N/A,25.80,N/A,25.80,N/A,25.80,N/A,28.38,184.20,184.20,16.06,184.20,,Hospital CPT 82042,"HC Albumin Other Source, Quan Ea",N/A,0307 - LABORATORY - UROLOGY,158.00,117.00,94.80,70.20,N/A,7.78,N/A,7.78,N/A,67.37,N/A,39.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,4.84,N/A,7.78,N/A,7.78,N/A,7.78,N/A,67.37,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,8.56,94.80,94.80,4.84,70.20,,Hospital CPT 82042,"HC So Albumin Other Source, Quan Ea",N/A,0307 - LABORATORY - UROLOGY,142.00,142.00,85.20,85.20,N/A,7.78,N/A,7.78,N/A,81.76,N/A,48.28,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,4.84,N/A,7.78,N/A,7.78,N/A,7.78,N/A,81.76,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,7.78,N/A,8.56,85.20,85.20,4.84,85.20,,Hospital CPT 82043,"HC Urine,Microalbumin,Quantitativ",N/A,0307 - LABORATORY - UROLOGY,92.00,69.00,55.20,41.40,N/A,5.78,N/A,5.78,N/A,39.73,N/A,23.46,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,3.60,N/A,5.78,N/A,5.78,N/A,5.78,N/A,39.73,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,6.36,55.20,55.20,3.60,41.40,,Hospital CPT 82085,HC Aldolase,N/A,0307 - LABORATORY - UROLOGY,120.00,91.00,72.00,54.60,N/A,9.71,N/A,9.71,N/A,52.40,N/A,30.94,N/A,8.25,N/A,9.71,N/A,9.71,N/A,9.71,N/A,8.25,N/A,8.25,N/A,8.25,N/A,8.25,N/A,52.40,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,10.68,72.00,72.00,8.25,54.60,,Hospital CPT 82085,HC So Aldolase,N/A,0307 - LABORATORY - UROLOGY,108.00,108.00,64.80,64.80,N/A,9.71,N/A,9.71,N/A,62.19,N/A,36.72,N/A,8.25,N/A,9.71,N/A,9.71,N/A,9.71,N/A,8.25,N/A,8.25,N/A,8.25,N/A,8.25,N/A,62.19,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,10.68,64.80,64.80,8.25,64.80,,Hospital CPT 82128,HC Amino Acids Qual,N/A,0301 - LABORATORY - CHEMISTRY,200.00,200.00,120.00,120.00,N/A,13.87,N/A,13.87,N/A,115.16,N/A,68.00,N/A,13.87,N/A,13.87,N/A,13.87,N/A,13.87,N/A,8.63,N/A,13.87,N/A,13.87,N/A,13.87,N/A,115.16,N/A,13.87,N/A,13.87,N/A,13.87,N/A,13.87,N/A,13.87,N/A,13.87,N/A,13.87,N/A,15.26,120.00,120.00,8.63,120.00,,Hospital CPT 82150,HC So Amylase,N/A,0301 - LABORATORY - CHEMISTRY,189.00,189.00,113.40,113.40,N/A,6.48,N/A,6.48,N/A,108.83,N/A,64.26,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,4.03,N/A,6.48,N/A,6.48,N/A,6.48,N/A,108.83,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,7.13,113.40,113.40,4.03,113.40,,Hospital CPT 82150,HC Amylase,N/A,0301 - LABORATORY - CHEMISTRY,209.00,158.00,125.40,94.80,N/A,6.48,N/A,6.48,N/A,90.98,N/A,53.72,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,4.03,N/A,6.48,N/A,6.48,N/A,6.48,N/A,90.98,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,6.48,N/A,7.13,125.40,125.40,4.03,94.80,,Hospital CPT 82164,HC So Angiotensin Conv Enzyme,N/A,0301 - LABORATORY - CHEMISTRY,143.00,143.00,85.80,85.80,N/A,14.60,N/A,14.60,N/A,82.34,N/A,48.62,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,9.09,N/A,14.60,N/A,14.60,N/A,14.60,N/A,82.34,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,16.06,85.80,85.80,9.09,85.80,,Hospital CPT 82164,HC Angiotensin Conv Enzyme,N/A,0301 - LABORATORY - CHEMISTRY,159.00,119.00,95.40,71.40,N/A,14.60,N/A,14.60,N/A,68.52,N/A,40.46,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,9.09,N/A,14.60,N/A,14.60,N/A,14.60,N/A,68.52,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,14.60,N/A,16.06,95.40,95.40,9.09,71.40,,Hospital CPT 82272,"HC Occult Blood, Feces",N/A,0301 - LABORATORY - CHEMISTRY,42.00,30.00,25.20,18.00,N/A,4.23,N/A,4.23,N/A,17.27,N/A,10.20,N/A,2.77,N/A,4.23,N/A,4.23,N/A,4.23,N/A,2.63,N/A,2.77,N/A,2.77,N/A,2.77,N/A,17.27,N/A,4.23,N/A,4.23,N/A,4.23,N/A,4.23,N/A,4.23,N/A,4.23,N/A,4.23,N/A,4.65,25.20,25.20,2.63,18.00,,Hospital CPT 82330,HC So Calcium Ionized,N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,13.68,N/A,13.68,N/A,69.67,N/A,41.14,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,8.52,N/A,13.68,N/A,13.68,N/A,13.68,N/A,69.67,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,15.05,72.60,72.60,8.52,72.60,,Hospital CPT 82330,HC Ionized Calcium,N/A,0301 - LABORATORY - CHEMISTRY,134.00,101.00,80.40,60.60,N/A,13.68,N/A,13.68,N/A,58.16,N/A,34.34,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,8.52,N/A,13.68,N/A,13.68,N/A,13.68,N/A,58.16,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,13.68,N/A,15.05,80.40,80.40,8.52,60.60,,Hospital CPT 82397,HC So Chemiluminescent Assay,N/A,0301 - LABORATORY - CHEMISTRY,138.00,138.00,82.80,82.80,N/A,14.12,N/A,14.12,N/A,79.46,N/A,46.92,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,8.79,N/A,14.12,N/A,14.12,N/A,14.12,N/A,79.46,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,15.53,82.80,82.80,8.79,82.80,,Hospital CPT 82397,HC Chemiluminescent Assay,N/A,0301 - LABORATORY - CHEMISTRY,152.00,116.00,91.20,69.60,N/A,14.12,N/A,14.12,N/A,66.79,N/A,39.44,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,8.79,N/A,14.12,N/A,14.12,N/A,14.12,N/A,66.79,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,14.12,N/A,15.53,91.20,91.20,8.79,69.60,,Hospital CPT 82436,"HC Chloride, Urine Spot",N/A,0301 - LABORATORY - CHEMISTRY,50.00,40.00,30.00,24.00,N/A,5.75,N/A,5.75,N/A,23.03,N/A,13.60,N/A,4.27,N/A,5.75,N/A,5.75,N/A,5.75,N/A,4.27,N/A,5.75,N/A,4.27,N/A,4.27,N/A,23.03,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,6.33,30.00,30.00,4.27,24.00,,Hospital CPT 82436,"HC So Chloride, Urine Spot",N/A,0301 - LABORATORY - CHEMISTRY,45.00,45.00,27.00,27.00,N/A,5.75,N/A,5.75,N/A,25.91,N/A,15.30,N/A,4.27,N/A,5.75,N/A,5.75,N/A,5.75,N/A,4.27,N/A,5.75,N/A,4.27,N/A,4.27,N/A,25.91,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,5.75,N/A,6.33,27.00,27.00,4.27,27.00,,Hospital CPT 82441,HC So Polychlorinated Biphenyls,N/A,0301 - LABORATORY - CHEMISTRY,199.00,199.00,119.40,119.40,N/A,6.01,N/A,6.01,N/A,114.58,N/A,67.66,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,3.74,N/A,6.01,N/A,6.01,N/A,6.01,N/A,114.58,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.61,119.40,119.40,3.74,119.40,,Hospital CPT 82441,HC Polychlorinated Biphenyls,N/A,0301 - LABORATORY - CHEMISTRY,199.00,199.00,119.40,119.40,N/A,6.01,N/A,6.01,N/A,114.58,N/A,67.66,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,3.74,N/A,6.01,N/A,6.01,N/A,6.01,N/A,114.58,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.61,119.40,119.40,3.74,119.40,,Hospital CPT 82495,HC So Chromium Serum,N/A,0301 - LABORATORY - CHEMISTRY,132.00,132.00,79.20,79.20,N/A,20.28,N/A,20.28,N/A,76.01,N/A,44.88,N/A,17.24,N/A,20.28,N/A,20.28,N/A,20.28,N/A,17.24,N/A,17.24,N/A,17.24,N/A,17.24,N/A,76.01,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,22.31,79.20,79.20,17.24,79.20,,Hospital CPT 82495,"HC Chromium,Serum",N/A,0301 - LABORATORY - CHEMISTRY,146.00,108.00,87.60,64.80,N/A,20.28,N/A,20.28,N/A,62.19,N/A,36.72,N/A,17.24,N/A,20.28,N/A,20.28,N/A,20.28,N/A,17.24,N/A,17.24,N/A,17.24,N/A,17.24,N/A,62.19,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,20.28,N/A,22.31,87.60,87.60,17.24,64.80,,Hospital CPT 82523,HC So Collagen Cross-Link N-Telopep,N/A,0301 - LABORATORY - CHEMISTRY,77.00,77.00,46.20,46.20,N/A,18.68,N/A,18.68,N/A,44.34,N/A,26.18,N/A,15.89,N/A,18.68,N/A,18.68,N/A,18.68,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,44.34,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,20.55,46.20,46.20,15.89,46.20,,Hospital CPT 82523,HC Collagen Cross-Link N-Telopep,N/A,0301 - LABORATORY - CHEMISTRY,85.00,85.00,51.00,51.00,N/A,18.68,N/A,18.68,N/A,48.94,N/A,28.90,N/A,15.89,N/A,18.68,N/A,18.68,N/A,18.68,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,48.94,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,18.68,N/A,20.55,51.00,51.00,15.89,51.00,,Hospital CPT 82528,HC So Corticosterone,N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,22.52,N/A,22.52,N/A,50.67,N/A,29.92,N/A,19.13,N/A,22.52,N/A,22.52,N/A,22.52,N/A,19.13,N/A,19.13,N/A,19.13,N/A,19.13,N/A,50.67,N/A,22.52,N/A,22.52,N/A,22.52,N/A,22.52,N/A,22.52,N/A,22.52,N/A,22.52,N/A,24.77,52.80,52.80,19.13,52.80,,Hospital CPT 82542,HC So2 Column Chromotography Quant,N/A,0301 - LABORATORY - CHEMISTRY,213.00,213.00,127.80,127.80,N/A,24.09,N/A,24.09,N/A,122.65,N/A,72.42,N/A,8.50,N/A,24.09,N/A,24.09,N/A,24.09,N/A,8.50,N/A,8.50,N/A,8.50,N/A,8.50,N/A,122.65,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,26.50,127.80,127.80,8.50,127.80,,Hospital CPT 82542,HC Column Chromotography Quant,N/A,0301 - LABORATORY - CHEMISTRY,118.00,88.00,70.80,52.80,N/A,24.09,N/A,24.09,N/A,50.67,N/A,29.92,N/A,8.50,N/A,24.09,N/A,24.09,N/A,24.09,N/A,8.50,N/A,8.50,N/A,8.50,N/A,8.50,N/A,50.67,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,26.50,70.80,70.80,8.50,52.80,,Hospital CPT 82542,HC So Column Chromotography Quant,N/A,0301 - LABORATORY - CHEMISTRY,106.00,106.00,63.60,63.60,N/A,24.09,N/A,24.09,N/A,61.03,N/A,36.04,N/A,8.50,N/A,24.09,N/A,24.09,N/A,24.09,N/A,8.50,N/A,8.50,N/A,8.50,N/A,8.50,N/A,61.03,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,26.50,63.60,63.60,8.50,63.60,,Hospital CPT 82542,HC So1 Column Chromotography Quant,N/A,0301 - LABORATORY - CHEMISTRY,147.00,147.00,88.20,88.20,N/A,24.09,N/A,24.09,N/A,84.64,N/A,49.98,N/A,8.50,N/A,24.09,N/A,24.09,N/A,24.09,N/A,8.50,N/A,8.50,N/A,8.50,N/A,8.50,N/A,84.64,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,24.09,N/A,26.50,88.20,88.20,8.50,88.20,,Hospital CPT 82565,"HC Creatinine,Serum",N/A,0301 - LABORATORY - CHEMISTRY,148.00,148.00,88.80,88.80,N/A,5.12,N/A,5.12,N/A,85.22,N/A,50.32,N/A,5.12,N/A,5.12,N/A,5.12,N/A,5.12,N/A,3.19,N/A,5.12,N/A,5.12,N/A,4.36,N/A,85.22,N/A,5.12,N/A,5.12,N/A,5.12,N/A,5.12,N/A,5.12,N/A,5.12,N/A,5.12,N/A,5.63,88.80,88.80,3.19,88.80,,Hospital CPT 82570,HC Creatinine Urine/Other,N/A,0301 - LABORATORY - CHEMISTRY,65.00,49.00,39.00,29.40,N/A,5.18,N/A,5.18,N/A,28.21,N/A,16.66,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,5.18,N/A,5.18,N/A,5.18,N/A,28.21,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,39.00,39.00,3.22,29.40,,Hospital CPT 82570,HC So Creatinine Urine/Other,N/A,0301 - LABORATORY - CHEMISTRY,59.00,59.00,35.40,35.40,N/A,5.18,N/A,5.18,N/A,33.97,N/A,20.06,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,5.18,N/A,5.18,N/A,5.18,N/A,33.97,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,35.40,35.40,3.22,35.40,,Hospital CPT 82626,HC So Dhea Level,N/A,0301 - LABORATORY - CHEMISTRY,290.00,290.00,174.00,174.00,N/A,25.27,N/A,25.27,N/A,166.98,N/A,98.60,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,15.73,N/A,25.27,N/A,21.47,N/A,25.27,N/A,166.98,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,27.80,174.00,174.00,15.73,174.00,,Hospital CPT 82626,HC Dhea Level,N/A,0301 - LABORATORY - CHEMISTRY,320.00,238.00,192.00,142.80,N/A,25.27,N/A,25.27,N/A,137.04,N/A,80.92,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,15.73,N/A,25.27,N/A,21.47,N/A,25.27,N/A,137.04,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,25.27,N/A,27.80,192.00,192.00,15.73,142.80,,Hospital CPT 82627,HC So Dhea Sulfate,N/A,0301 - LABORATORY - CHEMISTRY,196.00,196.00,117.60,117.60,N/A,22.23,N/A,22.23,N/A,112.86,N/A,66.64,N/A,18.89,N/A,22.23,N/A,22.23,N/A,22.23,N/A,18.89,N/A,18.89,N/A,18.89,N/A,18.89,N/A,112.86,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,24.45,117.60,117.60,18.89,117.60,,Hospital CPT 82627,HC Dhea Sulfate,N/A,0301 - LABORATORY - CHEMISTRY,216.00,163.00,129.60,97.80,N/A,22.23,N/A,22.23,N/A,93.86,N/A,55.42,N/A,18.89,N/A,22.23,N/A,22.23,N/A,22.23,N/A,18.89,N/A,18.89,N/A,18.89,N/A,18.89,N/A,93.86,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,22.23,N/A,24.45,129.60,129.60,18.89,97.80,,Hospital 82653,HC So Elastase Pancreatic Fecal Qt,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,45778.62,1672.00,27467.17,1003.20,3756.14,341.04,5235.86,348.47,10417.60,962.73,14403.51,568.48,14403.51,349.41,3756.14,341.04,7364.17,348.47,7364.17,348.47,14403.51,349.41,14403.51,349.41,14403.51,349.41,14403.51,349.41,10417.60,962.73,5235.86,348.47,3756.14,341.04,11372.94,348.47,10417.60,348.47,3756.14,341.04,5235.86,348.47,7364.17,348.47,3756.14,358.05,3756.14,27467.17,341.04,1003.20,,Hospital CPT 82657,"HC So1 Enzyme Activity,Cells/Tissue",N/A,0301 - LABORATORY - CHEMISTRY,306.00,306.00,183.60,183.60,N/A,22.17,N/A,22.17,N/A,176.19,N/A,104.04,N/A,15.34,N/A,22.17,N/A,22.17,N/A,22.17,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,176.19,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,24.39,183.60,183.60,15.34,183.60,,Hospital CPT 82657,"HC Enzyme Activity,Cells/Tissue",N/A,0301 - LABORATORY - CHEMISTRY,338.00,252.00,202.80,151.20,N/A,22.17,N/A,22.17,N/A,145.10,N/A,85.68,N/A,15.34,N/A,22.17,N/A,22.17,N/A,22.17,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,145.10,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,24.39,202.80,202.80,15.34,151.20,,Hospital CPT 82657,"HC So Enzyme Activity,Cells/Tissue",N/A,0301 - LABORATORY - CHEMISTRY,306.00,306.00,183.60,183.60,N/A,22.17,N/A,22.17,N/A,176.19,N/A,104.04,N/A,15.34,N/A,22.17,N/A,22.17,N/A,22.17,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,176.19,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,22.17,N/A,24.39,183.60,183.60,15.34,183.60,,Hospital CPT 82672,HC So Estrogens Total,N/A,0301 - LABORATORY - CHEMISTRY,87.00,87.00,52.20,52.20,N/A,21.70,N/A,21.70,N/A,50.09,N/A,29.58,N/A,18.43,N/A,21.70,N/A,21.70,N/A,21.70,N/A,13.51,N/A,21.70,N/A,21.70,N/A,21.70,N/A,50.09,N/A,21.70,N/A,21.70,N/A,21.70,N/A,21.70,N/A,21.70,N/A,21.70,N/A,21.70,N/A,23.87,52.20,52.20,13.51,52.20,,Hospital CPT 82677,HC Estriol,N/A,0301 - LABORATORY - CHEMISTRY,205.00,152.00,123.00,91.20,N/A,24.18,N/A,24.18,N/A,87.52,N/A,51.68,N/A,20.55,N/A,24.18,N/A,24.18,N/A,24.18,N/A,20.55,N/A,20.55,N/A,20.55,N/A,20.55,N/A,87.52,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,26.60,123.00,123.00,20.55,91.20,,Hospital CPT 82677,HC So Estriol,N/A,0301 - LABORATORY - CHEMISTRY,185.00,185.00,111.00,111.00,N/A,24.18,N/A,24.18,N/A,106.52,N/A,62.90,N/A,20.55,N/A,24.18,N/A,24.18,N/A,24.18,N/A,20.55,N/A,20.55,N/A,20.55,N/A,20.55,N/A,106.52,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,24.18,N/A,26.60,111.00,111.00,20.55,111.00,,Hospital CPT 82681,HC Assay Dir Meas Free Estradiol,N/A,0301 - LABORATORY - CHEMISTRY,137.00,137.00,82.20,82.20,N/A,27.94,N/A,27.94,N/A,78.88,N/A,46.58,N/A,11.18,N/A,27.94,N/A,27.94,N/A,27.94,N/A,11.18,N/A,11.18,N/A,11.18,N/A,11.18,N/A,78.88,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,30.73,82.20,82.20,11.18,82.20,,Hospital CPT 82681,HC So Assay of Direct Measurement Free Estradiol,N/A,0301 - LABORATORY - CHEMISTRY,123.00,123.00,73.80,73.80,N/A,27.94,N/A,27.94,N/A,70.82,N/A,41.82,N/A,11.18,N/A,27.94,N/A,27.94,N/A,27.94,N/A,11.18,N/A,11.18,N/A,11.18,N/A,11.18,N/A,70.82,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,30.73,73.80,73.80,11.18,73.80,,Hospital CPT 82705,"HC So Fecal Fat, Qualitative",N/A,0301 - LABORATORY - CHEMISTRY,22.00,22.00,13.20,13.20,N/A,5.10,N/A,5.10,N/A,22.00,N/A,7.48,N/A,N/A,N/A,5.10,N/A,5.10,N/A,5.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12.67,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.61,13.20,13.20,5.10,22.00,,Hospital CPT 82705,"HC Fecal Fat, Qualitative",N/A,0301 - LABORATORY - CHEMISTRY,25.00,18.00,15.00,10.80,N/A,5.10,N/A,5.10,N/A,18.00,N/A,6.12,N/A,N/A,N/A,5.10,N/A,5.10,N/A,5.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10.36,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.10,N/A,5.61,15.00,15.00,5.10,18.00,,Hospital CPT 82710,"HC So Fat, Total Feces",N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,16.80,N/A,16.80,N/A,63.34,N/A,37.40,N/A,14.28,N/A,16.80,N/A,16.80,N/A,16.80,N/A,14.28,N/A,14.28,N/A,14.28,N/A,14.28,N/A,63.34,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,18.48,66.00,66.00,14.28,66.00,,Hospital CPT 82710,"HC Fat, Total Feces",N/A,0301 - LABORATORY - CHEMISTRY,122.00,92.00,73.20,55.20,N/A,16.80,N/A,16.80,N/A,52.97,N/A,31.28,N/A,14.28,N/A,16.80,N/A,16.80,N/A,16.80,N/A,14.28,N/A,14.28,N/A,14.28,N/A,14.28,N/A,52.97,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,18.48,73.20,73.20,14.28,55.20,,Hospital CPT 82725,HC So Free Fatty Acids,N/A,0301 - LABORATORY - CHEMISTRY,82.00,82.00,49.20,49.20,N/A,18.77,N/A,18.77,N/A,82.00,N/A,27.88,N/A,11.32,N/A,18.77,N/A,18.77,N/A,18.77,N/A,11.32,N/A,11.32,N/A,11.32,N/A,11.32,N/A,47.22,N/A,18.77,N/A,18.77,N/A,18.77,N/A,18.77,N/A,18.77,N/A,18.77,N/A,18.77,N/A,20.65,49.20,49.20,11.32,82.00,,Hospital CPT 82757,HC So Assay of Semen Fructose,N/A,0301 - LABORATORY - CHEMISTRY,70.00,70.00,42.00,42.00,N/A,17.34,N/A,17.34,N/A,40.31,N/A,23.80,N/A,14.74,N/A,17.34,N/A,17.34,N/A,17.34,N/A,14.74,N/A,14.74,N/A,14.74,N/A,14.74,N/A,40.31,N/A,17.34,N/A,17.34,N/A,17.34,N/A,17.34,N/A,17.34,N/A,17.34,N/A,17.34,N/A,19.07,42.00,42.00,14.74,42.00,,Hospital CPT 82759,HC So Galactokinase,N/A,0301 - LABORATORY - CHEMISTRY,327.00,327.00,196.20,196.20,N/A,21.48,N/A,21.48,N/A,188.29,N/A,111.18,N/A,21.48,N/A,21.48,N/A,21.48,N/A,21.48,N/A,13.37,N/A,21.48,N/A,21.48,N/A,21.48,N/A,188.29,N/A,21.48,N/A,21.48,N/A,21.48,N/A,21.48,N/A,21.48,N/A,21.48,N/A,21.48,N/A,23.63,196.20,196.20,13.37,196.20,,Hospital CPT 82775,"HC Galactose-1-Phosphate, Quant",N/A,0301 - LABORATORY - CHEMISTRY,165.00,122.00,99.00,73.20,N/A,21.07,N/A,21.07,N/A,70.25,N/A,41.48,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,13.12,N/A,21.07,N/A,21.07,N/A,21.07,N/A,70.25,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,23.18,99.00,99.00,13.12,73.20,,Hospital CPT 82775,HC So Galactose-1-Phosphate Quant,N/A,0301 - LABORATORY - CHEMISTRY,149.00,149.00,89.40,89.40,N/A,21.07,N/A,21.07,N/A,85.79,N/A,50.66,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,13.12,N/A,21.07,N/A,21.07,N/A,21.07,N/A,85.79,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,21.07,N/A,23.18,89.40,89.40,13.12,89.40,,Hospital CPT 82803,"HC Blood Gases:Ph, P02 7 Pc02",N/A,0301 - LABORATORY - CHEMISTRY,122.00,92.00,73.20,55.20,N/A,26.07,N/A,26.07,N/A,52.97,N/A,31.28,N/A,13.34,N/A,26.07,N/A,26.07,N/A,26.07,N/A,13.34,N/A,26.07,N/A,13.34,N/A,26.07,N/A,52.97,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,28.68,73.20,73.20,13.34,55.20,,Hospital CPT 82938,HC So Gastrin Test,N/A,0301 - LABORATORY - CHEMISTRY,25.00,25.00,15.00,15.00,N/A,17.69,N/A,17.69,N/A,14.40,N/A,8.50,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,11.01,N/A,17.69,N/A,17.69,N/A,17.69,N/A,14.40,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,19.46,15.00,15.00,8.50,19.46,,Hospital CPT 82945,"HC Glucose, Body Fluid",N/A,0301 - LABORATORY - CHEMISTRY,143.00,105.00,85.80,63.00,N/A,3.93,N/A,3.93,N/A,60.46,N/A,35.70,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,2.45,N/A,3.93,N/A,3.93,N/A,3.93,N/A,60.46,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,4.32,85.80,85.80,2.45,63.00,,Hospital CPT 82950,"HC Glucose, Post Prandial",N/A,0301 - LABORATORY - CHEMISTRY,151.00,116.00,90.60,69.60,N/A,4.75,N/A,4.75,N/A,66.79,N/A,39.44,N/A,4.04,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.04,N/A,4.04,N/A,4.04,N/A,4.04,N/A,66.79,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,90.60,90.60,4.04,69.60,,Hospital CPT 82962,HC Blood Glucose Check,N/A,0301 - LABORATORY - CHEMISTRY,32.00,25.00,19.20,15.00,N/A,3.28,N/A,3.28,N/A,14.40,N/A,8.50,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,2.04,N/A,3.28,N/A,3.28,N/A,3.28,N/A,14.40,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.61,19.20,19.20,2.04,15.00,,Hospital CPT 83018,"HC Heavy Metals,Quant Ea",N/A,0301 - LABORATORY - CHEMISTRY,144.00,106.00,86.40,63.60,N/A,21.96,N/A,21.96,N/A,61.03,N/A,36.04,N/A,18.67,N/A,21.96,N/A,21.96,N/A,21.96,N/A,18.67,N/A,18.67,N/A,18.67,N/A,18.67,N/A,61.03,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,24.16,86.40,86.40,18.67,63.60,,Hospital CPT 83018,"HC So1 Heavy Metals,Quant Ea",N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,21.96,N/A,21.96,N/A,74.85,N/A,44.20,N/A,18.67,N/A,21.96,N/A,21.96,N/A,21.96,N/A,18.67,N/A,18.67,N/A,18.67,N/A,18.67,N/A,74.85,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,24.16,78.00,78.00,18.67,78.00,,Hospital CPT 83018,"HC So Heavy Metals,Quant Ea",N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,21.96,N/A,21.96,N/A,74.85,N/A,44.20,N/A,18.67,N/A,21.96,N/A,21.96,N/A,21.96,N/A,18.67,N/A,18.67,N/A,18.67,N/A,18.67,N/A,74.85,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,21.96,N/A,24.16,78.00,78.00,18.67,78.00,,Hospital CPT 83033,HC So Hemoglobin Fetal Qual,N/A,0301 - LABORATORY - CHEMISTRY,148.00,148.00,88.80,88.80,N/A,8.00,N/A,8.00,N/A,85.22,N/A,50.32,N/A,8.00,N/A,8.00,N/A,8.00,N/A,8.00,N/A,4.98,N/A,8.00,N/A,8.00,N/A,8.00,N/A,85.22,N/A,8.00,N/A,8.00,N/A,8.00,N/A,8.00,N/A,8.00,N/A,8.00,N/A,8.00,N/A,8.80,88.80,88.80,4.98,88.80,,Hospital 83065,"HC Hemoglobin, Urine",N/A,0301 - LABORATORY - CHEMISTRY,N/A,155729.60,N/A,93437.76,N/A,21746.54,N/A,27285.34,N/A,87575.49,N/A,52948.06,N/A,71319.84,N/A,21746.54,N/A,27281.46,N/A,27281.46,N/A,44397.29,N/A,71319.84,N/A,71319.84,N/A,71319.84,N/A,87120.61,N/A,27281.46,N/A,21746.54,N/A,453.94,N/A,453.94,N/A,21746.54,N/A,27281.46,N/A,27285.34,N/A,129.79,N/A,N/A,129.79,93437.76,,Hospital CPT 83070,HC Hemosiderin Urine,N/A,0301 - LABORATORY - CHEMISTRY,49.00,49.00,29.40,29.40,N/A,4.75,N/A,4.75,N/A,28.21,N/A,16.66,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,2.96,N/A,4.75,N/A,4.75,N/A,4.75,N/A,28.21,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,29.40,29.40,2.96,29.40,,Hospital CPT 83070,HC So Hemosiderin Urine,N/A,0301 - LABORATORY - CHEMISTRY,44.00,44.00,26.40,26.40,N/A,4.75,N/A,4.75,N/A,25.34,N/A,14.96,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,2.96,N/A,4.75,N/A,4.75,N/A,4.75,N/A,25.34,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,26.40,26.40,2.96,26.40,,Hospital CPT 83088,HC So Histamine,N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,29.53,N/A,29.53,N/A,63.34,N/A,37.40,N/A,25.10,N/A,29.53,N/A,29.53,N/A,29.53,N/A,25.10,N/A,25.10,N/A,29.53,N/A,25.10,N/A,63.34,N/A,29.53,N/A,29.53,N/A,29.53,N/A,29.53,N/A,29.53,N/A,29.53,N/A,29.53,N/A,32.48,66.00,66.00,25.10,66.00,,Hospital CPT 83150,HC So Homovanillic Acid,N/A,0301 - LABORATORY - CHEMISTRY,77.00,77.00,46.20,46.20,N/A,22.41,N/A,22.41,N/A,44.34,N/A,26.18,N/A,22.41,N/A,22.41,N/A,22.41,N/A,22.41,N/A,13.95,N/A,22.41,N/A,22.41,N/A,22.41,N/A,44.34,N/A,22.41,N/A,22.41,N/A,22.41,N/A,22.41,N/A,22.41,N/A,22.41,N/A,22.41,N/A,24.65,46.20,46.20,13.95,46.20,,Hospital CPT 83505,HC Urine Hydroxyproline,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,24.30,N/A,24.30,N/A,43.19,N/A,25.50,N/A,24.30,N/A,24.30,N/A,24.30,N/A,24.30,N/A,15.13,N/A,24.30,N/A,24.30,N/A,24.30,N/A,43.19,N/A,24.30,N/A,24.30,N/A,24.30,N/A,24.30,N/A,24.30,N/A,24.30,N/A,24.30,N/A,26.73,45.00,45.00,15.13,45.00,,Hospital 83518,HC So Immunoassay Dipstick,N/A,0301 - LABORATORY - CHEMISTRY,N/A,3183.00,N/A,1909.80,N/A,262.96,N/A,80.12,N/A,1832.79,N/A,860.20,N/A,593.92,N/A,262.96,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1832.79,N/A,245.53,N/A,262.96,N/A,527.00,N/A,527.00,N/A,262.96,N/A,245.53,N/A,80.12,N/A,88.13,N/A,N/A,80.12,1909.80,,Hospital CPT 83519,HC So2 Immunoassay Quant,N/A,0301 - LABORATORY - CHEMISTRY,851.00,851.00,510.60,510.60,N/A,18.40,N/A,18.40,N/A,490.01,N/A,289.34,N/A,11.48,N/A,18.40,N/A,18.40,N/A,18.40,N/A,11.48,N/A,11.48,N/A,11.48,N/A,18.40,N/A,490.01,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,20.24,510.60,510.60,11.48,510.60,,Hospital CPT 83519,HC So1 Immunoassay Quant,N/A,0301 - LABORATORY - CHEMISTRY,247.00,247.00,148.20,148.20,N/A,18.40,N/A,18.40,N/A,142.22,N/A,83.98,N/A,11.48,N/A,18.40,N/A,18.40,N/A,18.40,N/A,11.48,N/A,11.48,N/A,11.48,N/A,18.40,N/A,142.22,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,20.24,148.20,148.20,11.48,148.20,,Hospital CPT 83519,HC So Immunoassay Quant,N/A,0301 - LABORATORY - CHEMISTRY,2385.00,2385.00,1431.00,1431.00,N/A,18.40,N/A,18.40,N/A,1373.28,N/A,810.90,N/A,11.48,N/A,18.40,N/A,18.40,N/A,18.40,N/A,11.48,N/A,11.48,N/A,11.48,N/A,18.40,N/A,1373.28,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,20.24,1431.00,1431.00,11.48,1431.00,,Hospital CPT 83519,HC Immunoassay Quant,N/A,0301 - LABORATORY - CHEMISTRY,273.00,204.00,163.80,122.40,N/A,18.40,N/A,18.40,N/A,117.46,N/A,69.36,N/A,11.48,N/A,18.40,N/A,18.40,N/A,18.40,N/A,11.48,N/A,11.48,N/A,11.48,N/A,18.40,N/A,117.46,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,20.24,163.80,163.80,11.48,122.40,,Hospital CPT 83519,"HC Immunoassay Quant, Rp",N/A,0301 - LABORATORY - CHEMISTRY,939.00,699.00,563.40,419.40,N/A,18.40,N/A,18.40,N/A,402.48,N/A,237.66,N/A,11.48,N/A,18.40,N/A,18.40,N/A,18.40,N/A,11.48,N/A,11.48,N/A,11.48,N/A,18.40,N/A,402.48,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,18.40,N/A,20.24,563.40,563.40,11.48,419.40,,Hospital CPT 83520,HC Tryptase,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,17.27,N/A,17.27,N/A,139.00,N/A,47.26,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,80.04,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,111.60,111.60,11.00,139.00,,Hospital CPT 83520,HC Immunoassay Ria,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,17.27,N/A,17.27,N/A,139.00,N/A,47.26,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,80.04,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,111.60,111.60,11.00,139.00,,Hospital CPT 83520,"HC So2 Immunoassay,Analyte,Nos",N/A,0301 - LABORATORY - CHEMISTRY,333.00,333.00,199.80,199.80,N/A,17.27,N/A,17.27,N/A,333.00,N/A,113.22,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,191.74,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,199.80,199.80,11.00,333.00,,Hospital CPT 83520,"HC Immunoassay,Analyte,Nos",N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,17.27,N/A,17.27,N/A,139.00,N/A,47.26,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,80.04,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,111.60,111.60,11.00,139.00,,Hospital CPT 83520,HC Antiglomerular Membrane Anti,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,17.27,N/A,17.27,N/A,139.00,N/A,47.26,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,80.04,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,111.60,111.60,11.00,139.00,,Hospital CPT 83520,HC Nmo/Aqp4 Igg Elisa,N/A,0301 - LABORATORY - CHEMISTRY,2296.00,1714.00,1377.60,1028.40,N/A,17.27,N/A,17.27,N/A,1714.00,N/A,582.76,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,986.92,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,1377.60,1377.60,11.00,1714.00,,Hospital CPT 83520,HC Interferon - Beta Antibodies,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,17.27,N/A,17.27,N/A,139.00,N/A,47.26,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,80.04,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,111.60,111.60,11.00,139.00,,Hospital CPT 83520,"HC So1 Immunoassay,Analyte,Nos",N/A,0301 - LABORATORY - CHEMISTRY,2082.00,2082.00,1249.20,1249.20,N/A,17.27,N/A,17.27,N/A,2082.00,N/A,707.88,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,1198.82,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,1249.20,1249.20,11.00,2082.00,,Hospital CPT 83520,HC So Immunoassay Ria,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,17.27,N/A,17.27,N/A,168.00,N/A,57.12,N/A,11.00,N/A,17.27,N/A,17.27,N/A,17.27,N/A,11.00,N/A,17.27,N/A,11.00,N/A,11.00,N/A,96.73,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,100.80,100.80,11.00,168.00,,Hospital CPT 83521,HC So Immunoglobulin Light Chains Free Each,N/A,0301 - LABORATORY - CHEMISTRY,47.00,47.00,28.20,28.20,N/A,6.58,N/A,17.27,N/A,27.06,N/A,15.98,N/A,17.27,N/A,6.58,N/A,17.27,N/A,17.27,N/A,6.91,N/A,6.91,N/A,6.91,N/A,6.91,N/A,27.06,N/A,17.27,N/A,6.58,N/A,17.27,N/A,17.27,N/A,6.58,N/A,17.27,N/A,17.27,N/A,47.00,28.20,28.20,6.58,47.00,,Hospital CPT 83630,"HC So Lactoferrin, Fecal Qual",N/A,0301 - LABORATORY - CHEMISTRY,116.00,116.00,69.60,69.60,N/A,19.70,N/A,19.70,N/A,116.00,N/A,39.44,N/A,16.68,N/A,19.70,N/A,19.70,N/A,19.70,N/A,16.68,N/A,16.68,N/A,16.68,N/A,16.68,N/A,66.79,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,21.67,69.60,69.60,16.68,116.00,,Hospital CPT 83630,"HC Lactoferrin, Fecal Qual",N/A,0301 - LABORATORY - CHEMISTRY,128.00,95.00,76.80,57.00,N/A,19.70,N/A,19.70,N/A,95.00,N/A,32.30,N/A,16.68,N/A,19.70,N/A,19.70,N/A,19.70,N/A,16.68,N/A,16.68,N/A,16.68,N/A,16.68,N/A,54.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,19.70,N/A,21.67,76.80,76.80,16.68,95.00,,Hospital CPT 83655,HC Lead,N/A,0301 - LABORATORY - CHEMISTRY,134.00,101.00,80.40,60.60,N/A,12.11,N/A,12.11,N/A,58.16,N/A,34.34,N/A,10.29,N/A,12.11,N/A,12.11,N/A,12.11,N/A,7.54,N/A,10.29,N/A,10.29,N/A,10.29,N/A,58.16,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,13.32,80.40,80.40,7.54,60.60,,Hospital CPT 83655,HC So Lead,N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,12.11,N/A,12.11,N/A,69.67,N/A,41.14,N/A,10.29,N/A,12.11,N/A,12.11,N/A,12.11,N/A,7.54,N/A,10.29,N/A,10.29,N/A,10.29,N/A,69.67,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,13.32,72.60,72.60,7.54,72.60,,Hospital CPT 83661,HC Lecithin Sphingomyelin Ratio,N/A,0301 - LABORATORY - CHEMISTRY,220.00,220.00,132.00,132.00,N/A,21.99,N/A,21.99,N/A,126.68,N/A,74.80,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,13.69,N/A,21.99,N/A,21.99,N/A,21.99,N/A,126.68,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,24.19,132.00,132.00,13.69,132.00,,Hospital CPT 83663,HC Fetal Lung Maturity,N/A,0301 - LABORATORY - CHEMISTRY,319.00,319.00,191.40,191.40,N/A,18.91,N/A,18.91,N/A,183.68,N/A,108.46,N/A,18.91,N/A,18.91,N/A,18.91,N/A,18.91,N/A,11.77,N/A,18.91,N/A,18.91,N/A,18.91,N/A,183.68,N/A,18.91,N/A,18.91,N/A,18.91,N/A,18.91,N/A,18.91,N/A,18.91,N/A,18.91,N/A,20.80,191.40,191.40,11.77,191.40,,Hospital CPT 83690,HC Lipase,N/A,0301 - LABORATORY - CHEMISTRY,214.00,160.00,128.40,96.00,N/A,6.89,N/A,6.89,N/A,92.13,N/A,54.40,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,4.29,N/A,6.89,N/A,6.89,N/A,6.89,N/A,92.13,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,7.58,128.40,128.40,4.29,96.00,,Hospital CPT 83690,HC So Lipase,N/A,0301 - LABORATORY - CHEMISTRY,194.00,194.00,116.40,116.40,N/A,6.89,N/A,6.89,N/A,111.71,N/A,65.96,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,4.29,N/A,6.89,N/A,6.89,N/A,6.89,N/A,111.71,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,7.58,116.40,116.40,4.29,116.40,,Hospital CPT 83698,HC So Lipoprotein-Assoc Phospholipas,N/A,0301 - LABORATORY - CHEMISTRY,222.00,222.00,133.20,133.20,N/A,46.31,N/A,46.31,N/A,127.83,N/A,75.48,N/A,28.85,N/A,46.31,N/A,46.31,N/A,46.31,N/A,28.85,N/A,28.85,N/A,28.85,N/A,28.85,N/A,127.83,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,50.94,133.20,133.20,28.85,133.20,,Hospital CPT 83698,HC Lipoprotein-Assoc Phospholipas,N/A,0301 - LABORATORY - CHEMISTRY,246.00,183.00,147.60,109.80,N/A,46.31,N/A,46.31,N/A,105.37,N/A,62.22,N/A,28.85,N/A,46.31,N/A,46.31,N/A,46.31,N/A,28.85,N/A,28.85,N/A,28.85,N/A,28.85,N/A,105.37,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,46.31,N/A,50.94,147.60,147.60,28.85,109.80,,Hospital CPT 83700,HC So Lipoprotein Electrophoresis,N/A,0301 - LABORATORY - CHEMISTRY,95.00,95.00,57.00,57.00,N/A,11.26,N/A,11.26,N/A,54.70,N/A,32.30,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,7.01,N/A,11.26,N/A,11.26,N/A,11.26,N/A,54.70,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,12.39,57.00,57.00,7.01,57.00,,Hospital CPT 83835,HC Assay of Metanephrines,N/A,0301 - LABORATORY - CHEMISTRY,179.00,132.00,107.40,79.20,N/A,16.94,N/A,16.94,N/A,132.00,N/A,44.88,N/A,14.40,N/A,16.94,N/A,16.94,N/A,16.94,N/A,14.40,N/A,14.40,N/A,14.40,N/A,14.40,N/A,76.01,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,18.63,107.40,107.40,14.40,132.00,,Hospital CPT 83835,HC So Assay of Metanephrines,N/A,0301 - LABORATORY - CHEMISTRY,161.00,161.00,96.60,96.60,N/A,16.94,N/A,16.94,N/A,161.00,N/A,54.74,N/A,14.40,N/A,16.94,N/A,16.94,N/A,16.94,N/A,14.40,N/A,14.40,N/A,14.40,N/A,14.40,N/A,92.70,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,18.63,96.60,96.60,14.40,161.00,,Hospital CPT 83919,HC Organic Acids Qual Each,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,16.45,N/A,16.45,N/A,93.28,N/A,55.08,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,10.24,N/A,16.45,N/A,16.45,N/A,16.45,N/A,93.28,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,18.10,97.20,97.20,10.24,97.20,,Hospital CPT 83937,HC So Osteocalcin,N/A,0301 - LABORATORY - CHEMISTRY,119.00,119.00,71.40,71.40,N/A,29.85,N/A,29.85,N/A,68.52,N/A,40.46,N/A,24.20,N/A,29.85,N/A,29.85,N/A,29.85,N/A,24.20,N/A,24.20,N/A,24.20,N/A,24.20,N/A,68.52,N/A,29.85,N/A,29.85,N/A,29.85,N/A,29.85,N/A,29.85,N/A,29.85,N/A,29.85,N/A,32.84,71.40,71.40,24.20,71.40,,Hospital CPT 83970,HC Parathyroid Hormone,N/A,0301 - LABORATORY - CHEMISTRY,457.00,340.00,274.20,204.00,N/A,41.28,N/A,41.28,N/A,195.77,N/A,115.60,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,25.70,N/A,41.28,N/A,41.28,N/A,41.28,N/A,195.77,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,45.41,274.20,274.20,25.70,204.00,,Hospital CPT 83970,HC So Parathyroid Hormone,N/A,0301 - LABORATORY - CHEMISTRY,414.00,414.00,248.40,248.40,N/A,41.28,N/A,41.28,N/A,238.38,N/A,140.76,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,25.70,N/A,41.28,N/A,41.28,N/A,41.28,N/A,238.38,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,41.28,N/A,45.41,248.40,248.40,25.70,248.40,,Hospital CPT 84066,HC So Prostatic Acid Phosphatase,N/A,0301 - LABORATORY - CHEMISTRY,55.00,55.00,33.00,33.00,N/A,9.66,N/A,9.66,N/A,31.67,N/A,18.70,N/A,8.21,N/A,9.66,N/A,9.66,N/A,9.66,N/A,8.21,N/A,8.21,N/A,8.21,N/A,8.21,N/A,31.67,N/A,9.66,N/A,9.66,N/A,9.66,N/A,9.66,N/A,9.66,N/A,9.66,N/A,9.66,N/A,10.63,33.00,33.00,8.21,33.00,,Hospital CPT 84080,HC So Phosphatase Isoenzymes,N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,14.78,N/A,14.78,N/A,50.67,N/A,29.92,N/A,12.57,N/A,14.78,N/A,14.78,N/A,14.78,N/A,12.57,N/A,12.57,N/A,12.57,N/A,12.57,N/A,50.67,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,16.26,52.80,52.80,12.57,52.80,,Hospital CPT 84080,HC Phosphatase Isoenzymes,N/A,0301 - LABORATORY - CHEMISTRY,98.00,72.00,58.80,43.20,N/A,14.78,N/A,14.78,N/A,41.46,N/A,24.48,N/A,12.57,N/A,14.78,N/A,14.78,N/A,14.78,N/A,12.57,N/A,12.57,N/A,12.57,N/A,12.57,N/A,41.46,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,16.26,58.80,58.80,12.57,43.20,,Hospital CPT 84081,HC Phosphatydylglycerol,N/A,0301 - LABORATORY - CHEMISTRY,291.00,291.00,174.60,174.60,N/A,16.52,N/A,16.52,N/A,167.56,N/A,98.94,N/A,16.52,N/A,16.52,N/A,16.52,N/A,16.52,N/A,10.28,N/A,16.52,N/A,16.52,N/A,16.52,N/A,167.56,N/A,16.52,N/A,16.52,N/A,16.52,N/A,16.52,N/A,16.52,N/A,16.52,N/A,16.52,N/A,18.17,174.60,174.60,10.28,174.60,,Hospital CPT 84100,"HC Phosphorus, Serum",N/A,0301 - LABORATORY - CHEMISTRY,101.00,76.00,60.60,45.60,N/A,4.74,N/A,4.74,N/A,43.76,N/A,25.84,N/A,4.03,N/A,4.74,N/A,4.74,N/A,4.74,N/A,2.95,N/A,4.74,N/A,4.03,N/A,4.03,N/A,43.76,N/A,4.74,N/A,4.74,N/A,4.74,N/A,4.74,N/A,4.74,N/A,4.74,N/A,4.74,N/A,5.21,60.60,60.60,2.95,45.60,,Hospital CPT 84120,"HC Porphyrins,Quantitive",N/A,0301 - LABORATORY - CHEMISTRY,278.00,208.00,166.80,124.80,N/A,14.71,N/A,14.71,N/A,119.77,N/A,70.72,N/A,12.50,N/A,14.71,N/A,14.71,N/A,14.71,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,119.77,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,16.18,166.80,166.80,12.50,124.80,,Hospital CPT 84120,"HC So Porphyrins,Quantitive",N/A,0301 - LABORATORY - CHEMISTRY,252.00,252.00,151.20,151.20,N/A,14.71,N/A,14.71,N/A,145.10,N/A,85.68,N/A,12.50,N/A,14.71,N/A,14.71,N/A,14.71,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,145.10,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,14.71,N/A,16.18,151.20,151.20,12.50,151.20,,Hospital CPT 84134,HC Prealbumin,N/A,0301 - LABORATORY - CHEMISTRY,201.00,147.00,120.60,88.20,N/A,14.59,N/A,14.59,N/A,84.64,N/A,49.98,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,9.08,N/A,14.59,N/A,14.59,N/A,14.59,N/A,84.64,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,16.05,120.60,120.60,9.08,88.20,,Hospital CPT 84134,HC So Prealbumin,N/A,0301 - LABORATORY - CHEMISTRY,181.00,181.00,108.60,108.60,N/A,14.59,N/A,14.59,N/A,104.22,N/A,61.54,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,9.08,N/A,14.59,N/A,14.59,N/A,14.59,N/A,104.22,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,16.05,108.60,108.60,9.08,108.60,,Hospital CPT 84144,HC Progesterone,N/A,0301 - LABORATORY - CHEMISTRY,328.00,247.00,196.80,148.20,N/A,20.86,N/A,20.86,N/A,142.22,N/A,83.98,N/A,17.73,N/A,20.86,N/A,20.86,N/A,20.86,N/A,17.73,N/A,17.73,N/A,17.73,N/A,17.73,N/A,142.22,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,22.95,196.80,196.80,17.73,148.20,,Hospital CPT 84144,HC So Progesterone,N/A,0301 - LABORATORY - CHEMISTRY,297.00,297.00,178.20,178.20,N/A,20.86,N/A,20.86,N/A,171.01,N/A,100.98,N/A,17.73,N/A,20.86,N/A,20.86,N/A,20.86,N/A,17.73,N/A,17.73,N/A,17.73,N/A,17.73,N/A,171.01,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,20.86,N/A,22.95,178.20,178.20,17.73,178.20,,Hospital CPT 84146,HC Prolactin,N/A,0301 - LABORATORY - CHEMISTRY,397.00,296.00,238.20,177.60,N/A,19.38,N/A,19.38,N/A,170.44,N/A,100.64,N/A,16.47,N/A,19.38,N/A,19.38,N/A,19.38,N/A,16.47,N/A,16.47,N/A,16.47,N/A,16.47,N/A,170.44,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,21.32,238.20,238.20,16.47,177.60,,Hospital CPT 84146,HC So Prolactin,N/A,0301 - LABORATORY - CHEMISTRY,360.00,360.00,216.00,216.00,N/A,19.38,N/A,19.38,N/A,207.29,N/A,122.40,N/A,16.47,N/A,19.38,N/A,19.38,N/A,19.38,N/A,16.47,N/A,16.47,N/A,16.47,N/A,16.47,N/A,207.29,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,19.38,N/A,21.32,216.00,216.00,16.47,216.00,,Hospital 84152,"Prostate Specific Antigen, Complexed",N/A,N/A,N/A,173.00,N/A,103.80,N/A,47.20,N/A,52.77,N/A,99.62,N/A,58.82,N/A,42.58,N/A,47.20,N/A,52.77,N/A,52.77,N/A,42.58,N/A,42.58,N/A,42.58,N/A,42.58,N/A,99.62,N/A,52.77,N/A,47.20,N/A,47.20,N/A,47.20,N/A,47.20,N/A,52.77,N/A,52.77,N/A,51.92,N/A,N/A,42.58,103.80,,Hospital CPT 84160,HC So Total Protein by Refract,N/A,0301 - LABORATORY - CHEMISTRY,38.00,38.00,22.80,22.80,N/A,5.61,N/A,5.61,N/A,21.88,N/A,12.92,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,3.49,N/A,5.61,N/A,5.61,N/A,5.61,N/A,21.88,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,6.17,22.80,22.80,3.49,22.80,,Hospital CPT 84160,"HC Protein,Total,by Refractometry",N/A,0301 - LABORATORY - CHEMISTRY,42.00,30.00,25.20,18.00,N/A,5.61,N/A,5.61,N/A,17.27,N/A,10.20,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,3.49,N/A,5.61,N/A,5.61,N/A,5.61,N/A,17.27,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,5.61,N/A,6.17,25.20,25.20,3.49,18.00,,Hospital CPT 84207,HC So Pryridoxal Phosphate Vit B-6,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,28.10,N/A,28.10,N/A,96.73,N/A,57.12,N/A,23.88,N/A,28.10,N/A,28.10,N/A,28.10,N/A,17.49,N/A,23.88,N/A,23.88,N/A,23.88,N/A,96.73,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,30.91,100.80,100.80,17.49,100.80,,Hospital CPT 84207,HC Pryridoxal Phosphate Vit B-6,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,28.10,N/A,28.10,N/A,80.04,N/A,47.26,N/A,23.88,N/A,28.10,N/A,28.10,N/A,28.10,N/A,17.49,N/A,23.88,N/A,23.88,N/A,23.88,N/A,80.04,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,28.10,N/A,30.91,111.60,111.60,17.49,83.40,,Hospital 84235,HC Receptor Assay Endocrine,N/A,0301 - LABORATORY - CHEMISTRY,219376.33,N/A,131625.80,N/A,20431.40,N/A,49959.28,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20431.40,N/A,49959.28,N/A,49959.28,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49959.28,N/A,20431.40,N/A,N/A,N/A,N/A,N/A,20431.40,N/A,49959.28,N/A,49959.28,N/A,20431.40,N/A,20431.40,131625.80,N/A,N/A,,Hospital CPT 84252,HC Assay of Vit B-2,N/A,0301 - LABORATORY - CHEMISTRY,459.00,343.00,275.40,205.80,N/A,20.24,N/A,20.24,N/A,197.50,N/A,116.62,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,12.60,N/A,20.24,N/A,17.20,N/A,17.20,N/A,197.50,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,22.26,275.40,275.40,12.60,205.80,,Hospital CPT 84252,HC So Assay of Vit B-2,N/A,0301 - LABORATORY - CHEMISTRY,416.00,416.00,249.60,249.60,N/A,20.24,N/A,20.24,N/A,239.53,N/A,141.44,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,12.60,N/A,20.24,N/A,17.20,N/A,17.20,N/A,239.53,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,20.24,N/A,22.26,249.60,249.60,12.60,249.60,,Hospital CPT 84270,HC Sex Hormone Binding Globulin,N/A,0301 - LABORATORY - CHEMISTRY,144.00,106.00,86.40,63.60,N/A,21.73,N/A,21.73,N/A,61.03,N/A,36.04,N/A,18.47,N/A,21.73,N/A,21.73,N/A,21.73,N/A,18.47,N/A,18.47,N/A,18.47,N/A,18.47,N/A,61.03,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,23.90,86.40,86.40,18.47,63.60,,Hospital CPT 84270,HC So Sex Hormone Binding Globulin,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,21.73,N/A,21.73,N/A,74.85,N/A,44.20,N/A,18.47,N/A,21.73,N/A,21.73,N/A,21.73,N/A,18.47,N/A,18.47,N/A,18.47,N/A,18.47,N/A,74.85,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,21.73,N/A,23.90,78.00,78.00,18.47,78.00,,Hospital CPT 84285,HC So Assay of Silica,N/A,0301 - LABORATORY - CHEMISTRY,210.00,210.00,126.00,126.00,N/A,25.21,N/A,25.21,N/A,120.92,N/A,71.40,N/A,25.21,N/A,25.21,N/A,25.21,N/A,25.21,N/A,15.69,N/A,25.21,N/A,25.21,N/A,25.21,N/A,120.92,N/A,25.21,N/A,25.21,N/A,25.21,N/A,25.21,N/A,25.21,N/A,25.21,N/A,25.21,N/A,27.73,126.00,126.00,15.69,126.00,,Hospital CPT 84305,HC Somatomedin,N/A,0301 - LABORATORY - CHEMISTRY,201.00,157.00,120.60,94.20,N/A,21.26,N/A,21.26,N/A,90.40,N/A,53.38,N/A,18.07,N/A,21.26,N/A,21.26,N/A,21.26,N/A,18.07,N/A,18.07,N/A,18.07,N/A,18.07,N/A,90.40,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,23.39,120.60,120.60,18.07,94.20,,Hospital CPT 84305,HC So Somato Medin - C,N/A,0301 - LABORATORY - CHEMISTRY,191.00,191.00,114.60,114.60,N/A,21.26,N/A,21.26,N/A,109.98,N/A,64.94,N/A,18.07,N/A,21.26,N/A,21.26,N/A,21.26,N/A,18.07,N/A,18.07,N/A,18.07,N/A,18.07,N/A,109.98,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,21.26,N/A,23.39,114.60,114.60,18.07,114.60,,Hospital CPT 84307,HC So Somatostatin,N/A,0301 - LABORATORY - CHEMISTRY,330.00,330.00,198.00,198.00,N/A,18.28,N/A,18.28,N/A,330.00,N/A,112.20,N/A,15.54,N/A,18.28,N/A,18.28,N/A,18.28,N/A,15.54,N/A,15.54,N/A,15.54,N/A,15.54,N/A,190.01,N/A,18.28,N/A,18.28,N/A,18.28,N/A,18.28,N/A,18.28,N/A,18.28,N/A,18.28,N/A,20.11,198.00,198.00,15.54,330.00,,Hospital CPT 84377,HC So Sugars Qual,N/A,0301 - LABORATORY - CHEMISTRY,382.00,382.00,229.20,229.20,N/A,5.50,N/A,5.50,N/A,219.96,N/A,129.88,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,3.42,N/A,5.50,N/A,5.50,N/A,5.50,N/A,219.96,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.05,229.20,229.20,3.42,229.20,,Hospital CPT 84377,HC Sugars Qual,N/A,0301 - LABORATORY - CHEMISTRY,30.00,30.00,18.00,18.00,N/A,5.50,N/A,5.50,N/A,17.27,N/A,10.20,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,3.42,N/A,5.50,N/A,5.50,N/A,5.50,N/A,17.27,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.05,18.00,18.00,3.42,18.00,,Hospital CPT 84402,HC So Testosterone Free,N/A,0301 - LABORATORY - CHEMISTRY,197.00,197.00,118.20,118.20,N/A,25.47,N/A,25.47,N/A,113.43,N/A,66.98,N/A,21.64,N/A,25.47,N/A,25.47,N/A,25.47,N/A,21.64,N/A,21.64,N/A,21.64,N/A,25.47,N/A,113.43,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,28.02,118.20,118.20,21.64,118.20,,Hospital CPT 84402,HC Testosterone Free,N/A,0301 - LABORATORY - CHEMISTRY,217.00,164.00,130.20,98.40,N/A,25.47,N/A,25.47,N/A,94.43,N/A,55.76,N/A,21.64,N/A,25.47,N/A,25.47,N/A,25.47,N/A,21.64,N/A,21.64,N/A,21.64,N/A,25.47,N/A,94.43,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,25.47,N/A,28.02,130.20,130.20,21.64,98.40,,Hospital CPT 84432,HC So Thyroglobulin,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,16.06,N/A,16.06,N/A,39.15,N/A,23.12,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,13.66,N/A,13.66,N/A,13.66,N/A,13.66,N/A,39.15,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,17.67,40.80,40.80,13.66,40.80,,Hospital CPT 84432,HC Thyroglobulin,N/A,0301 - LABORATORY - CHEMISTRY,76.00,56.00,45.60,33.60,N/A,16.06,N/A,16.06,N/A,32.24,N/A,19.04,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,13.66,N/A,13.66,N/A,13.66,N/A,13.66,N/A,32.24,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,16.06,N/A,17.67,45.60,45.60,13.66,33.60,,Hospital CPT 84436,HC So Thyroxine Total,N/A,0301 - LABORATORY - CHEMISTRY,197.00,197.00,118.20,118.20,N/A,6.87,N/A,6.87,N/A,113.43,N/A,66.98,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,4.28,N/A,6.87,N/A,6.87,N/A,6.87,N/A,113.43,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,7.56,118.20,118.20,4.28,118.20,,Hospital CPT 84436,HC T-4,N/A,0301 - LABORATORY - CHEMISTRY,217.00,164.00,130.20,98.40,N/A,6.87,N/A,6.87,N/A,94.43,N/A,55.76,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,4.28,N/A,6.87,N/A,6.87,N/A,6.87,N/A,94.43,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,6.87,N/A,7.56,130.20,130.20,4.28,98.40,,Hospital CPT 84466,HC Transferrin,N/A,0301 - LABORATORY - CHEMISTRY,144.00,106.00,86.40,63.60,N/A,12.76,N/A,12.76,N/A,61.03,N/A,36.04,N/A,10.85,N/A,12.76,N/A,12.76,N/A,12.76,N/A,7.94,N/A,12.76,N/A,10.85,N/A,10.85,N/A,61.03,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,14.04,86.40,86.40,7.94,63.60,,Hospital CPT 84466,HC So Transferrin,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,12.76,N/A,12.76,N/A,74.85,N/A,44.20,N/A,10.85,N/A,12.76,N/A,12.76,N/A,12.76,N/A,7.94,N/A,12.76,N/A,10.85,N/A,10.85,N/A,74.85,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,12.76,N/A,14.04,78.00,78.00,7.94,78.00,,Hospital CPT 84484,HC Troponin,N/A,0301 - LABORATORY - CHEMISTRY,135.00,102.00,81.00,61.20,N/A,12.47,N/A,12.47,N/A,58.73,N/A,34.68,N/A,12.47,N/A,12.47,N/A,12.47,N/A,12.47,N/A,7.76,N/A,12.47,N/A,12.47,N/A,12.47,N/A,58.73,N/A,12.47,N/A,12.47,N/A,12.47,N/A,12.47,N/A,12.47,N/A,12.47,N/A,12.47,N/A,13.72,81.00,81.00,7.76,61.20,,Hospital 84488,HC So Feces for Trypsin,N/A,0301 - LABORATORY - CHEMISTRY,N/A,227.00,N/A,136.20,N/A,26.93,N/A,26.93,N/A,80.79,N/A,77.18,N/A,22.88,N/A,26.93,N/A,26.93,N/A,26.93,N/A,22.88,N/A,22.88,N/A,22.88,N/A,22.88,N/A,130.70,N/A,26.93,N/A,26.93,N/A,26.93,N/A,26.93,N/A,26.93,N/A,26.93,N/A,26.93,N/A,29.62,N/A,N/A,22.88,136.20,,Hospital CPT 84550,HC Uric Acid,N/A,0301 - LABORATORY - CHEMISTRY,162.00,121.00,97.20,72.60,N/A,4.52,N/A,4.52,N/A,69.67,N/A,41.14,N/A,3.84,N/A,4.52,N/A,4.52,N/A,4.52,N/A,2.81,N/A,4.52,N/A,4.52,N/A,3.84,N/A,69.67,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.52,N/A,4.97,97.20,97.20,2.81,72.60,,Hospital CPT 84597,HC Vitamin K,N/A,0301 - LABORATORY - CHEMISTRY,895.00,667.00,537.00,400.20,N/A,13.72,N/A,13.72,N/A,384.06,N/A,226.78,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,8.54,N/A,13.72,N/A,13.72,N/A,11.65,N/A,384.06,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,15.09,537.00,537.00,8.54,400.20,,Hospital CPT 84597,HC So Vitamin K,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,13.72,N/A,13.72,N/A,74.85,N/A,44.20,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,8.54,N/A,13.72,N/A,13.72,N/A,11.65,N/A,74.85,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,13.72,N/A,15.09,78.00,78.00,8.54,78.00,,Hospital CPT 84702,HC Hcg Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,383.00,284.00,229.80,170.40,N/A,15.05,N/A,15.05,N/A,163.53,N/A,96.56,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,9.37,N/A,15.05,N/A,15.05,N/A,12.80,N/A,163.53,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,229.80,229.80,9.37,170.40,,Hospital CPT 84702,HC So Hcg Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,347.00,347.00,208.20,208.20,N/A,15.05,N/A,15.05,N/A,199.80,N/A,117.98,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,9.37,N/A,15.05,N/A,15.05,N/A,12.80,N/A,199.80,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,208.20,208.20,9.37,208.20,,Hospital CPT 84703,"HC Gonadotropin, Chorionic (Hcg) Qualitative",N/A,0301 - LABORATORY - CHEMISTRY,166.00,123.00,99.60,73.80,N/A,7.52,N/A,7.52,N/A,70.82,N/A,41.82,N/A,7.52,N/A,7.52,N/A,7.52,N/A,7.52,N/A,4.68,N/A,7.52,N/A,7.52,N/A,7.52,N/A,70.82,N/A,7.52,N/A,7.52,N/A,7.52,N/A,7.52,N/A,7.52,N/A,7.52,N/A,7.52,N/A,8.27,99.60,99.60,4.68,73.80,,Hospital CPT 84704,HC So Hcg Free Betachain Test,N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,15.29,N/A,15.29,N/A,50.67,N/A,29.92,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,9.52,N/A,15.29,N/A,12.80,N/A,15.29,N/A,50.67,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,16.82,52.80,52.80,9.52,52.80,,Hospital CPT 84999,HC Unlisted Chemistry Procedure,N/A,0301 - LABORATORY - CHEMISTRY,82.00,61.00,49.20,36.60,N/A,8.54,N/A,61.00,N/A,35.12,N/A,20.74,N/A,N/A,N/A,8.54,N/A,61.00,N/A,61.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,35.12,N/A,61.00,N/A,8.54,N/A,61.00,N/A,61.00,N/A,8.54,N/A,61.00,N/A,61.00,N/A,61.00,49.20,49.20,8.54,61.00,,Hospital CPT 84999,HC So Unlisted Chemistry Procedure,N/A,0301 - LABORATORY - CHEMISTRY,74.00,74.00,44.40,44.40,N/A,10.36,N/A,74.00,N/A,42.61,N/A,25.16,N/A,N/A,N/A,10.36,N/A,74.00,N/A,74.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,42.61,N/A,74.00,N/A,10.36,N/A,74.00,N/A,74.00,N/A,10.36,N/A,74.00,N/A,74.00,N/A,74.00,44.40,44.40,10.36,74.00,,Hospital 85004,HC Automated Differential Wbc Count,N/A,0305 - LABORATORY - HEMATOLOGY,35079.98,348.00,21047.99,208.80,4201.55,24.40,5235.86,29.97,12310.97,200.38,11927.19,118.32,9559.10,26.69,4331.00,24.40,2810.00,29.97,2810.00,29.97,5950.32,26.69,9559.10,26.69,9559.10,26.69,9559.10,26.69,12310.97,200.38,5235.86,29.97,4331.00,24.40,11372.94,24.40,11372.94,24.40,4331.00,24.40,N/A,29.97,5235.86,29.97,4634.17,26.85,2810.00,21047.99,24.40,208.80,,Hospital CPT 85007,"HC Blood Smear,Microscopic W/Diff",N/A,0305 - LABORATORY - HEMATOLOGY,50.00,43.00,30.00,25.80,N/A,3.80,N/A,3.80,N/A,24.76,N/A,14.62,N/A,1.99,N/A,3.80,N/A,3.80,N/A,3.80,N/A,1.99,N/A,1.99,N/A,1.99,N/A,1.99,N/A,24.76,N/A,3.80,N/A,3.80,N/A,3.80,N/A,3.80,N/A,3.80,N/A,3.80,N/A,3.80,N/A,4.18,30.00,30.00,1.99,25.80,,Hospital CPT 85032,HC So Manual Cell Count Each,N/A,0305 - LABORATORY - HEMATOLOGY,15.00,15.00,9.00,9.00,N/A,4.31,N/A,4.31,N/A,8.64,N/A,5.10,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,2.68,N/A,4.31,N/A,4.31,N/A,4.31,N/A,8.64,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.74,9.00,9.00,2.68,9.00,,Hospital 85044,HC Retic Count,N/A,0305 - LABORATORY - HEMATOLOGY,53229.60,N/A,31937.76,N/A,5567.08,N/A,13658.59,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5567.08,N/A,13658.59,N/A,13658.59,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13658.59,N/A,5567.08,N/A,N/A,N/A,N/A,N/A,5567.08,N/A,13658.59,N/A,13658.59,N/A,5567.08,N/A,5567.08,31937.76,N/A,N/A,,Hospital CPT 85045,HC Reticulocyte,N/A,0305 - LABORATORY - HEMATOLOGY,69.00,57.00,41.40,34.20,N/A,3.99,N/A,3.99,N/A,32.82,N/A,19.38,N/A,3.40,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.40,N/A,3.99,N/A,3.99,N/A,3.99,N/A,32.82,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,4.39,41.40,41.40,3.40,34.20,,Hospital CPT 85045,HC So Reticulocyte,N/A,0305 - LABORATORY - HEMATOLOGY,62.00,62.00,37.20,37.20,N/A,3.99,N/A,3.99,N/A,35.70,N/A,21.08,N/A,3.40,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.40,N/A,3.99,N/A,3.99,N/A,3.99,N/A,35.70,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,3.99,N/A,4.39,37.20,37.20,3.40,37.20,,Hospital CPT 85049,"HC Platelet,Automated",N/A,0305 - LABORATORY - HEMATOLOGY,78.00,66.00,46.80,39.60,N/A,4.48,N/A,4.48,N/A,38.00,N/A,22.44,N/A,4.48,N/A,4.48,N/A,4.48,N/A,4.48,N/A,2.79,N/A,3.80,N/A,4.48,N/A,4.48,N/A,38.00,N/A,4.48,N/A,4.48,N/A,4.48,N/A,4.48,N/A,4.48,N/A,4.48,N/A,4.48,N/A,4.93,46.80,46.80,2.79,39.60,,Hospital CPT 85055,HC Reticulated Platelet Assay,N/A,0305 - LABORATORY - HEMATOLOGY,139.00,118.00,83.40,70.80,N/A,35.74,N/A,35.74,N/A,67.94,N/A,40.12,N/A,22.75,N/A,35.74,N/A,35.74,N/A,35.74,N/A,22.25,N/A,22.75,N/A,22.75,N/A,22.75,N/A,67.94,N/A,35.74,N/A,35.74,N/A,35.74,N/A,35.74,N/A,35.74,N/A,35.74,N/A,35.74,N/A,39.31,83.40,83.40,22.25,70.80,,Hospital CPT 85097,HC Bone Marrow Interpretation,N/A,0305 - LABORATORY - HEMATOLOGY,1941.00,1941.00,1164.60,1164.60,N/A,66.01,N/A,46.29,N/A,1117.63,N/A,659.94,N/A,193.17,N/A,66.01,N/A,46.29,N/A,46.29,N/A,120.25,N/A,193.17,N/A,193.17,N/A,193.17,N/A,1117.63,N/A,46.29,N/A,66.01,N/A,669.29,N/A,669.29,N/A,66.01,N/A,46.29,N/A,46.29,N/A,72.61,1164.60,1164.60,46.29,1164.60,,Hospital 85130,HC So Chromogenic Substrate Assay,N/A,0305 - LABORATORY - HEMATOLOGY,N/A,889.00,N/A,533.40,N/A,179.65,N/A,148.82,N/A,511.89,N/A,302.26,N/A,343.50,N/A,179.65,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,511.89,N/A,142.00,N/A,179.65,N/A,447.89,N/A,447.89,N/A,179.65,N/A,142.00,N/A,148.82,N/A,157.58,N/A,N/A,142.00,533.40,,Hospital CPT 85210,HC Clotting;Factor II Prothrombin,N/A,0305 - LABORATORY - HEMATOLOGY,56.00,56.00,33.60,33.60,N/A,12.98,N/A,12.98,N/A,32.24,N/A,19.04,N/A,11.03,N/A,12.98,N/A,12.98,N/A,12.98,N/A,11.03,N/A,11.03,N/A,11.03,N/A,11.03,N/A,32.24,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,14.28,33.60,33.60,11.03,33.60,,Hospital CPT 85210,HC So Clotting;Factor II Prothrombin,N/A,0305 - LABORATORY - HEMATOLOGY,50.00,50.00,30.00,30.00,N/A,12.98,N/A,12.98,N/A,28.79,N/A,17.00,N/A,11.03,N/A,12.98,N/A,12.98,N/A,12.98,N/A,11.03,N/A,11.03,N/A,11.03,N/A,11.03,N/A,28.79,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,12.98,N/A,14.28,30.00,30.00,11.03,30.00,,Hospital CPT 85220,HC So Factor 5,N/A,0305 - LABORATORY - HEMATOLOGY,141.00,141.00,84.60,84.60,N/A,17.65,N/A,17.65,N/A,81.19,N/A,47.94,N/A,15.00,N/A,17.65,N/A,17.65,N/A,17.65,N/A,15.00,N/A,15.00,N/A,17.65,N/A,15.00,N/A,81.19,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,19.42,84.60,84.60,15.00,84.60,,Hospital CPT 85220,HC Factor 5,N/A,0305 - LABORATORY - HEMATOLOGY,156.00,135.00,93.60,81.00,N/A,17.65,N/A,17.65,N/A,77.73,N/A,45.90,N/A,15.00,N/A,17.65,N/A,17.65,N/A,17.65,N/A,15.00,N/A,15.00,N/A,17.65,N/A,15.00,N/A,77.73,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,19.42,93.60,93.60,15.00,81.00,,Hospital CPT 85250,HC Factor IX,N/A,0305 - LABORATORY - HEMATOLOGY,119.00,100.00,71.40,60.00,N/A,19.04,N/A,19.04,N/A,57.58,N/A,34.00,N/A,16.18,N/A,19.04,N/A,19.04,N/A,19.04,N/A,16.18,N/A,16.18,N/A,16.18,N/A,19.04,N/A,57.58,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,20.94,71.40,71.40,16.18,60.00,,Hospital CPT 85250,HC So Factor IX,N/A,0305 - LABORATORY - HEMATOLOGY,107.00,107.00,64.20,64.20,N/A,19.04,N/A,19.04,N/A,61.61,N/A,36.38,N/A,16.18,N/A,19.04,N/A,19.04,N/A,19.04,N/A,16.18,N/A,16.18,N/A,16.18,N/A,19.04,N/A,61.61,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,19.04,N/A,20.94,64.20,64.20,16.18,64.20,,Hospital CPT 85292,HC So Clot Factor Fletcher Fac,N/A,0305 - LABORATORY - HEMATOLOGY,182.00,182.00,109.20,109.20,N/A,18.93,N/A,18.93,N/A,104.80,N/A,61.88,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,11.78,N/A,18.93,N/A,18.93,N/A,18.93,N/A,104.80,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,20.82,109.20,109.20,11.78,109.20,,Hospital CPT 85306,"HC Protein S, Free",N/A,0305 - LABORATORY - HEMATOLOGY,237.00,203.00,142.20,121.80,N/A,15.32,N/A,15.32,N/A,116.89,N/A,69.02,N/A,13.02,N/A,15.32,N/A,15.32,N/A,15.32,N/A,9.54,N/A,15.32,N/A,13.02,N/A,13.02,N/A,116.89,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,16.85,142.20,142.20,9.54,121.80,,Hospital CPT 85306,"HC So Protein S, Free",N/A,0305 - LABORATORY - HEMATOLOGY,215.00,215.00,129.00,129.00,N/A,15.32,N/A,15.32,N/A,123.80,N/A,73.10,N/A,13.02,N/A,15.32,N/A,15.32,N/A,15.32,N/A,9.54,N/A,15.32,N/A,13.02,N/A,13.02,N/A,123.80,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,16.85,129.00,129.00,9.54,129.00,,Hospital CPT 85307,HC Activated Protein C (Apc),N/A,0305 - LABORATORY - HEMATOLOGY,121.00,103.00,72.60,61.80,N/A,15.32,N/A,15.32,N/A,59.31,N/A,35.02,N/A,13.02,N/A,15.32,N/A,15.32,N/A,15.32,N/A,13.02,N/A,13.02,N/A,13.02,N/A,13.02,N/A,59.31,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,16.85,72.60,72.60,13.02,61.80,,Hospital CPT 85307,HC So Activated Protein C (Apc),N/A,0305 - LABORATORY - HEMATOLOGY,109.00,109.00,65.40,65.40,N/A,15.32,N/A,15.32,N/A,62.76,N/A,37.06,N/A,13.02,N/A,15.32,N/A,15.32,N/A,15.32,N/A,13.02,N/A,13.02,N/A,13.02,N/A,13.02,N/A,62.76,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,15.32,N/A,16.85,65.40,65.40,13.02,65.40,,Hospital CPT 85347,HC Coagulation Time Activated,N/A,0305 - LABORATORY - HEMATOLOGY,122.00,103.00,73.20,61.80,N/A,4.28,N/A,4.28,N/A,59.31,N/A,35.02,N/A,4.28,N/A,4.28,N/A,4.28,N/A,4.28,N/A,2.66,N/A,4.28,N/A,4.28,N/A,4.28,N/A,59.31,N/A,4.28,N/A,4.28,N/A,4.28,N/A,4.28,N/A,4.28,N/A,4.28,N/A,4.28,N/A,4.71,73.20,73.20,2.66,61.80,,Hospital CPT 85441,HC So Heinz Body Stain,N/A,0305 - LABORATORY - HEMATOLOGY,77.00,77.00,46.20,46.20,N/A,4.20,N/A,4.20,N/A,44.34,N/A,26.18,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,44.34,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.62,46.20,46.20,2.61,46.20,,Hospital CPT 85441,HC Heinz Body Stain,N/A,0305 - LABORATORY - HEMATOLOGY,77.00,77.00,46.20,46.20,N/A,4.20,N/A,4.20,N/A,44.34,N/A,26.18,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,44.34,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.20,N/A,4.62,46.20,46.20,2.61,46.20,,Hospital CPT 85597,HC Platelet Neutralization,N/A,0305 - LABORATORY - HEMATOLOGY,95.00,79.00,57.00,47.40,N/A,17.98,N/A,17.98,N/A,45.49,N/A,26.86,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,11.19,N/A,17.98,N/A,15.28,N/A,15.28,N/A,45.49,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,19.78,57.00,57.00,11.19,47.40,,Hospital CPT 85597,HC So Platelet Neutralization,N/A,0305 - LABORATORY - HEMATOLOGY,85.00,85.00,51.00,51.00,N/A,17.98,N/A,17.98,N/A,48.94,N/A,28.90,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,11.19,N/A,17.98,N/A,15.28,N/A,15.28,N/A,48.94,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,19.78,51.00,51.00,11.19,51.00,,Hospital CPT 85598,HC Hexagonal Phospholipid,N/A,0305 - LABORATORY - HEMATOLOGY,92.00,78.00,55.20,46.80,N/A,17.98,N/A,17.98,N/A,44.91,N/A,26.52,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,11.19,N/A,17.98,N/A,17.98,N/A,17.98,N/A,44.91,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,19.78,55.20,55.20,11.19,46.80,,Hospital CPT 85598,HC So Hexagonal Phospholipid,N/A,0305 - LABORATORY - HEMATOLOGY,83.00,83.00,49.80,49.80,N/A,17.98,N/A,17.98,N/A,47.79,N/A,28.22,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,11.19,N/A,17.98,N/A,17.98,N/A,17.98,N/A,47.79,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,19.78,49.80,49.80,11.19,49.80,,Hospital CPT 85611,HC So Substitution Plasma Fraction,N/A,0305 - LABORATORY - HEMATOLOGY,14.00,14.00,8.40,8.40,N/A,3.94,N/A,3.94,N/A,8.06,N/A,4.76,N/A,3.35,N/A,3.94,N/A,3.94,N/A,3.94,N/A,2.45,N/A,3.94,N/A,3.94,N/A,3.94,N/A,8.06,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,4.33,8.40,8.40,2.45,8.40,,Hospital CPT 85611,HC Pt Mixing Study,N/A,0305 - LABORATORY - HEMATOLOGY,16.00,15.00,9.60,9.00,N/A,3.94,N/A,3.94,N/A,8.64,N/A,5.10,N/A,3.35,N/A,3.94,N/A,3.94,N/A,3.94,N/A,2.45,N/A,3.94,N/A,3.94,N/A,3.94,N/A,8.64,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,3.94,N/A,4.33,9.60,9.60,2.45,9.00,,Hospital CPT 85635,HC So Reptilase Test,N/A,0305 - LABORATORY - HEMATOLOGY,61.00,61.00,36.60,36.60,N/A,9.85,N/A,9.85,N/A,35.12,N/A,20.74,N/A,8.37,N/A,9.85,N/A,9.85,N/A,9.85,N/A,8.37,N/A,8.37,N/A,8.37,N/A,8.37,N/A,35.12,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,10.84,36.60,36.60,8.37,36.60,,Hospital CPT 85635,HC Reptilase Test,N/A,0305 - LABORATORY - HEMATOLOGY,68.00,56.00,40.80,33.60,N/A,9.85,N/A,9.85,N/A,32.24,N/A,19.04,N/A,8.37,N/A,9.85,N/A,9.85,N/A,9.85,N/A,8.37,N/A,8.37,N/A,8.37,N/A,8.37,N/A,32.24,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,9.85,N/A,10.84,40.80,40.80,8.37,33.60,,Hospital CPT 85651,HC Sedimentation Rate,N/A,0305 - LABORATORY - HEMATOLOGY,91.00,91.00,54.60,54.60,N/A,4.27,N/A,4.27,N/A,52.40,N/A,30.94,N/A,3.01,N/A,4.27,N/A,4.27,N/A,4.27,N/A,3.01,N/A,3.01,N/A,3.01,N/A,3.01,N/A,52.40,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,54.60,54.60,3.01,54.60,,Hospital CPT 85652,HC Sed Rate,N/A,0305 - LABORATORY - HEMATOLOGY,101.00,88.00,60.60,52.80,N/A,2.70,N/A,2.70,N/A,50.67,N/A,29.92,N/A,2.70,N/A,2.70,N/A,2.70,N/A,2.70,N/A,1.68,N/A,2.30,N/A,2.70,N/A,2.70,N/A,50.67,N/A,2.70,N/A,2.70,N/A,2.70,N/A,2.70,N/A,2.70,N/A,2.70,N/A,2.70,N/A,2.97,60.60,60.60,1.68,52.80,,Hospital CPT 85670,HC So Thrombin Clotting Level,N/A,0305 - LABORATORY - HEMATOLOGY,42.00,42.00,25.20,25.20,N/A,5.77,N/A,5.77,N/A,24.18,N/A,14.28,N/A,4.91,N/A,5.77,N/A,5.77,N/A,5.77,N/A,4.91,N/A,4.91,N/A,5.77,N/A,4.91,N/A,24.18,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,6.35,25.20,25.20,4.91,25.20,,Hospital CPT 85670,HC Thrombin Time,N/A,0305 - LABORATORY - HEMATOLOGY,47.00,41.00,28.20,24.60,N/A,5.77,N/A,5.77,N/A,23.61,N/A,13.94,N/A,4.91,N/A,5.77,N/A,5.77,N/A,5.77,N/A,4.91,N/A,4.91,N/A,5.77,N/A,4.91,N/A,23.61,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,6.35,28.20,28.20,4.91,24.60,,Hospital CPT 85730,HC Ptt,N/A,0305 - LABORATORY - HEMATOLOGY,101.00,88.00,60.60,52.80,N/A,6.01,N/A,6.01,N/A,50.67,N/A,29.92,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,3.74,N/A,5.10,N/A,6.01,N/A,5.10,N/A,50.67,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.61,60.60,60.60,3.74,52.80,,Hospital CPT 85730,HC So Ptt,N/A,0305 - LABORATORY - HEMATOLOGY,91.00,91.00,54.60,54.60,N/A,6.01,N/A,6.01,N/A,52.40,N/A,30.94,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,3.74,N/A,5.10,N/A,6.01,N/A,5.10,N/A,52.40,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.01,N/A,6.61,54.60,54.60,3.74,54.60,,Hospital CPT 86001,HC Allergen Specific Igg,N/A,0305 - LABORATORY - HEMATOLOGY,30.00,25.00,18.00,15.00,N/A,7.82,N/A,7.82,N/A,14.40,N/A,8.50,N/A,4.43,N/A,7.82,N/A,7.82,N/A,7.82,N/A,4.43,N/A,4.43,N/A,4.43,N/A,4.43,N/A,14.40,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,8.60,18.00,18.00,4.43,15.00,,Hospital CPT 86001,HC So Allergen Specific Igg,N/A,0305 - LABORATORY - HEMATOLOGY,27.00,27.00,16.20,16.20,N/A,7.82,N/A,7.82,N/A,15.55,N/A,9.18,N/A,4.43,N/A,7.82,N/A,7.82,N/A,7.82,N/A,4.43,N/A,4.43,N/A,4.43,N/A,4.43,N/A,15.55,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,7.82,N/A,8.60,16.20,16.20,4.43,16.20,,Hospital CPT 86005,HC So Allergen Specific Ige Qual Mul,N/A,0305 - LABORATORY - HEMATOLOGY,12.00,12.00,7.20,7.20,N/A,7.97,N/A,7.97,N/A,6.91,N/A,4.08,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,4.96,N/A,7.97,N/A,6.77,N/A,7.97,N/A,6.91,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,8.77,7.20,7.20,4.08,8.77,,Hospital CPT 86005,HC Allergen Specific Ige Qual Mul,N/A,0305 - LABORATORY - HEMATOLOGY,35.00,35.00,21.00,21.00,N/A,7.97,N/A,7.97,N/A,20.15,N/A,11.90,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,4.96,N/A,7.97,N/A,6.77,N/A,7.97,N/A,20.15,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,7.97,N/A,8.77,21.00,21.00,4.96,21.00,,Hospital 86051,HC So Aquaporin-4 Antibody Elisa,N/A,0302 - LABORATORY - IMMUNOLOGY,83731.83,768.00,50239.10,460.80,6749.90,79.34,12144.13,64.94,15211.44,442.22,28468.82,261.12,15356.95,45.90,6957.87,79.34,12144.13,64.94,12144.13,64.94,8325.66,45.90,8325.66,45.90,15356.95,45.90,8325.66,45.90,15211.44,442.22,12144.13,64.94,6957.87,79.34,18270.93,59.37,18270.93,59.37,6957.87,79.34,12144.13,64.94,12144.13,64.94,N/A,52.63,6749.90,50239.10,45.90,460.80,,Hospital CPT 86060,HC Aso Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,132.00,101.00,79.20,60.60,N/A,7.30,N/A,7.30,N/A,58.16,N/A,34.34,N/A,4.36,N/A,7.30,N/A,7.30,N/A,7.30,N/A,4.36,N/A,4.36,N/A,4.36,N/A,4.36,N/A,58.16,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,8.03,79.20,79.20,4.36,60.60,,Hospital CPT 86060,HC So Aso Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,120.00,120.00,72.00,72.00,N/A,7.30,N/A,7.30,N/A,69.10,N/A,40.80,N/A,4.36,N/A,7.30,N/A,7.30,N/A,7.30,N/A,4.36,N/A,4.36,N/A,4.36,N/A,4.36,N/A,69.10,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,7.30,N/A,8.03,72.00,72.00,4.36,72.00,,Hospital CPT 86140,HC Crp,N/A,0302 - LABORATORY - IMMUNOLOGY,41.00,30.00,24.60,18.00,N/A,5.18,N/A,5.18,N/A,17.27,N/A,10.20,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,3.25,N/A,5.18,N/A,5.18,N/A,17.27,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,24.60,24.60,3.22,18.00,,Hospital CPT 86140,HC So Crp,N/A,0302 - LABORATORY - IMMUNOLOGY,37.00,37.00,22.20,22.20,N/A,5.18,N/A,5.18,N/A,21.30,N/A,12.58,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,3.25,N/A,5.18,N/A,5.18,N/A,21.30,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,22.20,22.20,3.22,22.20,,Hospital CPT 86146,HC Beta 2 Glycoprotein 1 Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,236.00,182.00,141.60,109.20,N/A,25.45,N/A,25.45,N/A,104.80,N/A,61.88,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,15.84,N/A,21.62,N/A,21.62,N/A,21.62,N/A,104.80,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,28.00,141.60,141.60,15.84,109.20,,Hospital CPT 86146,HC So Beta 2 Glycoprotein 1 Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,214.00,214.00,128.40,128.40,N/A,25.45,N/A,25.45,N/A,123.22,N/A,72.76,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,15.84,N/A,21.62,N/A,21.62,N/A,21.62,N/A,123.22,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,28.00,128.40,128.40,15.84,128.40,,Hospital CPT 86148,HC So Phospholipid Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,198.00,198.00,118.80,118.80,N/A,16.07,N/A,16.07,N/A,114.01,N/A,67.32,N/A,13.66,N/A,16.07,N/A,16.07,N/A,16.07,N/A,13.66,N/A,13.66,N/A,13.66,N/A,16.07,N/A,114.01,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,17.68,118.80,118.80,13.66,118.80,,Hospital CPT 86148,HC Phospholipid Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,218.00,168.00,130.80,100.80,N/A,16.07,N/A,16.07,N/A,96.73,N/A,57.12,N/A,13.66,N/A,16.07,N/A,16.07,N/A,16.07,N/A,13.66,N/A,13.66,N/A,13.66,N/A,16.07,N/A,96.73,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,17.68,130.80,130.80,13.66,100.80,,Hospital CPT 86156,HC So Cold Agglutinin Screen,N/A,0302 - LABORATORY - IMMUNOLOGY,61.00,61.00,36.60,36.60,N/A,8.07,N/A,8.07,N/A,35.12,N/A,20.74,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,5.02,N/A,8.07,N/A,8.07,N/A,8.07,N/A,35.12,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.88,36.60,36.60,5.02,36.60,,Hospital CPT 86162,HC Complement Total Ch-50,N/A,0302 - LABORATORY - IMMUNOLOGY,197.00,151.00,118.20,90.60,N/A,20.32,N/A,20.32,N/A,86.95,N/A,51.34,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,86.95,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,22.35,118.20,118.20,17.27,90.60,,Hospital CPT 86162,HC So Complement Total Ch-50,N/A,0302 - LABORATORY - IMMUNOLOGY,179.00,179.00,107.40,107.40,N/A,20.32,N/A,20.32,N/A,103.07,N/A,60.86,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,103.07,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,20.32,N/A,22.35,107.40,107.40,17.27,107.40,,Hospital CPT 86215,HC Anti Dnase B,N/A,0302 - LABORATORY - IMMUNOLOGY,117.00,98.00,70.20,58.80,N/A,13.25,N/A,13.25,N/A,56.43,N/A,33.32,N/A,11.26,N/A,13.25,N/A,13.25,N/A,13.25,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,56.43,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,70.20,70.20,11.26,58.80,,Hospital CPT 86215,HC So Anti Dnase B,N/A,0302 - LABORATORY - IMMUNOLOGY,105.00,105.00,63.00,63.00,N/A,13.25,N/A,13.25,N/A,60.46,N/A,35.70,N/A,11.26,N/A,13.25,N/A,13.25,N/A,13.25,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,60.46,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,63.00,63.00,11.26,63.00,,Hospital CPT 86226,HC Dna Antibody Single Strand,N/A,0302 - LABORATORY - IMMUNOLOGY,124.00,124.00,74.40,74.40,N/A,12.11,N/A,12.11,N/A,71.40,N/A,42.16,N/A,10.29,N/A,12.11,N/A,12.11,N/A,12.11,N/A,10.29,N/A,10.29,N/A,10.29,N/A,10.29,N/A,71.40,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,13.32,74.40,74.40,10.29,74.40,,Hospital CPT 86235,HC Nuclear Antigen Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,191.00,145.00,114.60,87.00,N/A,17.93,N/A,17.93,N/A,83.49,N/A,49.30,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,15.24,N/A,15.24,N/A,15.24,N/A,15.24,N/A,83.49,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,19.72,114.60,114.60,15.24,87.00,,Hospital CPT 86235,HC So Nuclear Antigen Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,173.00,173.00,103.80,103.80,N/A,17.93,N/A,17.93,N/A,99.61,N/A,58.82,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,15.24,N/A,15.24,N/A,15.24,N/A,15.24,N/A,99.61,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,19.72,103.80,103.80,15.24,103.80,,Hospital CPT 86301,HC So Carbohydrate Antigen 19-9,N/A,0302 - LABORATORY - IMMUNOLOGY,216.00,216.00,129.60,129.60,N/A,20.81,N/A,20.81,N/A,124.37,N/A,73.44,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,12.95,N/A,20.81,N/A,20.81,N/A,20.81,N/A,124.37,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,129.60,129.60,12.95,129.60,,Hospital CPT 86301,HC Carbohydrate Antigen 19-9,N/A,0302 - LABORATORY - IMMUNOLOGY,238.00,183.00,142.80,109.80,N/A,20.81,N/A,20.81,N/A,105.37,N/A,62.22,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,12.95,N/A,20.81,N/A,20.81,N/A,20.81,N/A,105.37,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,142.80,142.80,12.95,109.80,,Hospital CPT 86308,"HC Mono Spot Test,Agglutination",N/A,0302 - LABORATORY - IMMUNOLOGY,224.00,170.00,134.40,102.00,N/A,5.18,N/A,5.18,N/A,97.89,N/A,57.80,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,4.40,N/A,4.40,N/A,4.40,N/A,97.89,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,134.40,134.40,3.22,102.00,,Hospital CPT 86308,HC So Mono Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,202.00,202.00,121.20,121.20,N/A,5.18,N/A,5.18,N/A,116.31,N/A,68.68,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,4.40,N/A,4.40,N/A,4.40,N/A,116.31,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,121.20,121.20,3.22,121.20,,Hospital CPT 86334,HC So Immunofixation Serum,N/A,0302 - LABORATORY - IMMUNOLOGY,186.00,186.00,111.60,111.60,N/A,22.34,N/A,22.34,N/A,107.10,N/A,63.24,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,13.91,N/A,22.34,N/A,22.34,N/A,22.34,N/A,107.10,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,24.57,111.60,111.60,13.91,111.60,,Hospital CPT 86334,HC Immunofixation Serum,N/A,0302 - LABORATORY - IMMUNOLOGY,206.00,158.00,123.60,94.80,N/A,22.34,N/A,22.34,N/A,90.98,N/A,53.72,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,13.91,N/A,22.34,N/A,22.34,N/A,22.34,N/A,90.98,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,22.34,N/A,24.57,123.60,123.60,13.91,94.80,,Hospital CPT 86335,"HC So Immunofix Electphoresis,Othfld",N/A,0302 - LABORATORY - IMMUNOLOGY,268.00,268.00,160.80,160.80,N/A,29.35,N/A,29.35,N/A,268.00,N/A,91.12,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,24.94,N/A,24.94,N/A,24.94,N/A,24.94,N/A,154.31,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,32.29,160.80,160.80,24.94,268.00,,Hospital CPT 86335,"HC Immunofix Electphoresis,Othfld",N/A,0302 - LABORATORY - IMMUNOLOGY,296.00,227.00,177.60,136.20,N/A,29.35,N/A,29.35,N/A,227.00,N/A,77.18,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,24.94,N/A,24.94,N/A,24.94,N/A,24.94,N/A,130.71,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,29.35,N/A,32.29,177.60,177.60,24.94,227.00,,Hospital CPT 86336,HC Inhibin-A,N/A,0302 - LABORATORY - IMMUNOLOGY,91.00,91.00,54.60,54.60,N/A,15.59,N/A,15.59,N/A,52.40,N/A,30.94,N/A,12.74,N/A,15.59,N/A,15.59,N/A,15.59,N/A,12.74,N/A,12.74,N/A,12.74,N/A,12.74,N/A,52.40,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,17.15,54.60,54.60,12.74,54.60,,Hospital CPT 86336,HC So Inhibin-A,N/A,0302 - LABORATORY - IMMUNOLOGY,77.00,77.00,46.20,46.20,N/A,15.59,N/A,15.59,N/A,44.34,N/A,26.18,N/A,12.74,N/A,15.59,N/A,15.59,N/A,15.59,N/A,12.74,N/A,12.74,N/A,12.74,N/A,12.74,N/A,44.34,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,15.59,N/A,17.15,46.20,46.20,12.74,46.20,,Hospital CPT 86353,HC So Lymphocyte Ag,N/A,0302 - LABORATORY - IMMUNOLOGY,168.00,168.00,100.80,100.80,N/A,49.03,N/A,49.03,N/A,96.73,N/A,57.12,N/A,41.66,N/A,49.03,N/A,49.03,N/A,49.03,N/A,41.66,N/A,41.66,N/A,41.66,N/A,41.66,N/A,96.73,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,53.93,100.80,100.80,41.66,100.80,,Hospital CPT 86353,HC Lymphocyte Ag,N/A,0302 - LABORATORY - IMMUNOLOGY,186.00,186.00,111.60,111.60,N/A,49.03,N/A,49.03,N/A,107.10,N/A,63.24,N/A,41.66,N/A,49.03,N/A,49.03,N/A,49.03,N/A,41.66,N/A,41.66,N/A,41.66,N/A,41.66,N/A,107.10,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,49.03,N/A,53.93,111.60,111.60,41.66,111.60,,Hospital CPT 86355,"HC B-Cells, Total Count",N/A,0302 - LABORATORY - IMMUNOLOGY,301.00,229.00,180.60,137.40,N/A,37.73,N/A,37.73,N/A,131.86,N/A,77.86,N/A,32.06,N/A,37.73,N/A,37.73,N/A,37.73,N/A,32.06,N/A,32.06,N/A,32.06,N/A,32.06,N/A,131.86,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,41.50,180.60,180.60,32.06,137.40,,Hospital CPT 86355,HC So B Cell Total,N/A,0302 - LABORATORY - IMMUNOLOGY,273.00,273.00,163.80,163.80,N/A,37.73,N/A,37.73,N/A,157.19,N/A,92.82,N/A,32.06,N/A,37.73,N/A,37.73,N/A,37.73,N/A,32.06,N/A,32.06,N/A,32.06,N/A,32.06,N/A,157.19,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,41.50,163.80,163.80,32.06,163.80,,Hospital CPT 86357,"HC Nk Cell, Total Count",N/A,0302 - LABORATORY - IMMUNOLOGY,301.00,229.00,180.60,137.40,N/A,37.73,N/A,37.73,N/A,131.86,N/A,77.86,N/A,32.06,N/A,37.73,N/A,37.73,N/A,37.73,N/A,32.06,N/A,32.06,N/A,32.06,N/A,32.06,N/A,131.86,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,41.50,180.60,180.60,32.06,137.40,,Hospital CPT 86357,HC So Nk Cell Total,N/A,0302 - LABORATORY - IMMUNOLOGY,273.00,273.00,163.80,163.80,N/A,37.73,N/A,37.73,N/A,157.19,N/A,92.82,N/A,32.06,N/A,37.73,N/A,37.73,N/A,37.73,N/A,32.06,N/A,32.06,N/A,32.06,N/A,32.06,N/A,157.19,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,41.50,163.80,163.80,32.06,163.80,,Hospital CPT 86360,"HC Absolute Cd4 & Cd8,Incl Ratio",N/A,0302 - LABORATORY - IMMUNOLOGY,630.00,481.00,378.00,288.60,N/A,46.98,N/A,46.98,N/A,276.96,N/A,163.54,N/A,39.93,N/A,46.98,N/A,46.98,N/A,46.98,N/A,39.93,N/A,39.93,N/A,39.93,N/A,39.93,N/A,276.96,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,51.68,378.00,378.00,39.93,288.60,,Hospital CPT 86360,HC So T Cell Absolute,N/A,0302 - LABORATORY - IMMUNOLOGY,571.00,571.00,342.60,342.60,N/A,46.98,N/A,46.98,N/A,328.78,N/A,194.14,N/A,39.93,N/A,46.98,N/A,46.98,N/A,46.98,N/A,39.93,N/A,39.93,N/A,39.93,N/A,39.93,N/A,328.78,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,46.98,N/A,51.68,342.60,342.60,39.93,342.60,,Hospital CPT 86362,HC So Mog-Igg1 Antibody Cell-Based Imfluor Assay Each,N/A,0302 - LABORATORY - IMMUNOLOGY,267.00,267.00,160.20,160.20,N/A,37.38,N/A,12.05,N/A,153.74,N/A,90.78,N/A,4.82,N/A,37.38,N/A,12.05,N/A,12.05,N/A,4.82,N/A,4.82,N/A,4.82,N/A,4.82,N/A,153.74,N/A,12.05,N/A,37.38,N/A,12.05,N/A,12.05,N/A,37.38,N/A,12.05,N/A,12.05,N/A,267.00,160.20,160.20,4.82,267.00,,Hospital 86363,HC So Mog-Igg1 Antibody Flow Cytometry Each,N/A,0302 - LABORATORY - IMMUNOLOGY,128762.67,N/A,77257.60,N/A,19081.01,N/A,11448.65,N/A,N/A,N/A,11794.57,N/A,11794.57,N/A,19081.01,N/A,11448.65,N/A,11448.65,N/A,11794.57,N/A,11794.57,N/A,11794.57,N/A,11794.57,N/A,N/A,N/A,11448.65,N/A,19081.01,N/A,N/A,N/A,N/A,N/A,19081.01,N/A,11448.65,N/A,26669.72,N/A,19081.01,N/A,11448.65,77257.60,N/A,N/A,,Hospital CPT 86406,HC Cryptococcal Antigen,N/A,0302 - LABORATORY - IMMUNOLOGY,194.00,148.00,116.40,88.80,N/A,10.64,N/A,10.64,N/A,85.22,N/A,50.32,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,6.62,N/A,10.64,N/A,10.64,N/A,10.64,N/A,85.22,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,11.70,116.40,116.40,6.62,88.80,,Hospital CPT 86406,HC So Cryptococcal Antigen,N/A,0302 - LABORATORY - IMMUNOLOGY,176.00,176.00,105.60,105.60,N/A,10.64,N/A,10.64,N/A,101.34,N/A,59.84,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,6.62,N/A,10.64,N/A,10.64,N/A,10.64,N/A,101.34,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,10.64,N/A,11.70,105.60,105.60,6.62,105.60,,Hospital CPT 86596,HC So Voltage-Gated Calcium Channel Antibody Each,N/A,0302 - LABORATORY - IMMUNOLOGY,254.00,254.00,152.40,152.40,N/A,35.56,N/A,12.05,N/A,146.25,N/A,86.36,N/A,7.36,N/A,35.56,N/A,12.05,N/A,12.05,N/A,7.36,N/A,7.36,N/A,7.36,N/A,7.36,N/A,146.25,N/A,12.05,N/A,35.56,N/A,18.40,N/A,18.40,N/A,35.56,N/A,12.05,N/A,12.05,N/A,254.00,152.40,152.40,7.36,254.00,,Hospital CPT 86603,HC Adenovirus Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,119.00,91.00,71.40,54.60,N/A,12.87,N/A,12.87,N/A,52.40,N/A,30.94,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,8.01,N/A,12.87,N/A,12.87,N/A,12.87,N/A,52.40,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,71.40,71.40,8.01,54.60,,Hospital CPT 86603,HC So Adenovirus Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,107.00,107.00,64.20,64.20,N/A,12.87,N/A,12.87,N/A,61.61,N/A,36.38,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,8.01,N/A,12.87,N/A,12.87,N/A,12.87,N/A,61.61,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,64.20,64.20,8.01,64.20,,Hospital CPT 86612,HC So Blastomyces,N/A,0302 - LABORATORY - IMMUNOLOGY,89.00,89.00,53.40,53.40,N/A,12.90,N/A,12.90,N/A,51.25,N/A,30.26,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,8.03,N/A,10.97,N/A,10.97,N/A,10.97,N/A,51.25,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,14.19,53.40,53.40,8.03,53.40,,Hospital CPT 86612,HC Blastomyces,N/A,0302 - LABORATORY - IMMUNOLOGY,99.00,76.00,59.40,45.60,N/A,12.90,N/A,12.90,N/A,43.76,N/A,25.84,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,8.03,N/A,10.97,N/A,10.97,N/A,10.97,N/A,43.76,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,14.19,59.40,59.40,8.03,45.60,,Hospital CPT 86617,HC So Lyme Disease Ab by Westrn Blot,N/A,0302 - LABORATORY - IMMUNOLOGY,373.00,373.00,223.80,223.80,N/A,15.49,N/A,15.49,N/A,214.77,N/A,126.82,N/A,13.16,N/A,15.49,N/A,15.49,N/A,15.49,N/A,13.16,N/A,13.16,N/A,13.16,N/A,13.16,N/A,214.77,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,17.04,223.80,223.80,13.16,223.80,,Hospital CPT 86617,HC Lyme Disease Ab by Westrn Blot,N/A,0302 - LABORATORY - IMMUNOLOGY,412.00,314.00,247.20,188.40,N/A,15.49,N/A,15.49,N/A,180.80,N/A,106.76,N/A,13.16,N/A,15.49,N/A,15.49,N/A,15.49,N/A,13.16,N/A,13.16,N/A,13.16,N/A,13.16,N/A,180.80,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,17.04,247.20,247.20,13.16,188.40,,Hospital CPT 86625,HC So Campylobacter Jejuni Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,106.00,106.00,63.60,63.60,N/A,13.12,N/A,13.12,N/A,61.03,N/A,36.04,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,8.17,N/A,13.12,N/A,13.12,N/A,13.12,N/A,61.03,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,14.43,63.60,63.60,8.17,63.60,,Hospital CPT 86628,HC Candida Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,54.00,54.00,32.40,32.40,N/A,12.01,N/A,12.01,N/A,31.09,N/A,18.36,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,7.48,N/A,12.01,N/A,10.21,N/A,12.01,N/A,31.09,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,13.21,32.40,32.40,7.48,32.40,,Hospital CPT 86628,HC So Candida Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,48.00,48.00,28.80,28.80,N/A,12.01,N/A,12.01,N/A,27.64,N/A,16.32,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,7.48,N/A,12.01,N/A,10.21,N/A,12.01,N/A,27.64,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,13.21,28.80,28.80,7.48,28.80,,Hospital CPT 86638,HC So Q Fever Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,126.00,126.00,75.60,75.60,N/A,12.12,N/A,12.12,N/A,72.55,N/A,42.84,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,7.54,N/A,12.12,N/A,12.12,N/A,12.12,N/A,72.55,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,13.33,75.60,75.60,7.54,75.60,,Hospital CPT 86638,HC Q Fever Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,55.00,55.00,33.00,33.00,N/A,12.12,N/A,12.12,N/A,31.67,N/A,18.70,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,7.54,N/A,12.12,N/A,12.12,N/A,12.12,N/A,31.67,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,12.12,N/A,13.33,33.00,33.00,7.54,33.00,,Hospital CPT 86645,"HC So Cytomegalovirus,Igm Antibody",N/A,0302 - LABORATORY - IMMUNOLOGY,290.00,290.00,174.00,174.00,N/A,16.85,N/A,16.85,N/A,166.98,N/A,98.60,N/A,14.32,N/A,16.85,N/A,16.85,N/A,16.85,N/A,14.32,N/A,14.32,N/A,16.85,N/A,14.32,N/A,166.98,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,18.54,174.00,174.00,14.32,174.00,,Hospital CPT 86645,"HC Cytomegalovirus,Igm Antibody",N/A,0302 - LABORATORY - IMMUNOLOGY,320.00,245.00,192.00,147.00,N/A,16.85,N/A,16.85,N/A,141.07,N/A,83.30,N/A,14.32,N/A,16.85,N/A,16.85,N/A,16.85,N/A,14.32,N/A,14.32,N/A,16.85,N/A,14.32,N/A,141.07,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,18.54,192.00,192.00,14.32,147.00,,Hospital CPT 86652,"HC Encephalitis, Eastern Equine",N/A,0302 - LABORATORY - IMMUNOLOGY,203.00,152.00,121.80,91.20,N/A,13.19,N/A,13.19,N/A,87.52,N/A,51.68,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,87.52,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,121.80,121.80,8.21,91.20,,Hospital CPT 86652,"HC So Encephalitis, Eastern Equine",N/A,0302 - LABORATORY - IMMUNOLOGY,183.00,183.00,109.80,109.80,N/A,13.19,N/A,13.19,N/A,105.37,N/A,62.22,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,105.37,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,109.80,109.80,8.21,109.80,,Hospital CPT 86663,"HC Epstein-Barr Virus, Ea",N/A,0302 - LABORATORY - IMMUNOLOGY,122.00,95.00,73.20,57.00,N/A,13.12,N/A,13.12,N/A,54.70,N/A,32.30,N/A,11.15,N/A,13.12,N/A,13.12,N/A,13.12,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,54.70,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,14.43,73.20,73.20,11.15,57.00,,Hospital CPT 86663,"HC So Epstein-Barr Virus, Ea",N/A,0302 - LABORATORY - IMMUNOLOGY,110.00,110.00,66.00,66.00,N/A,13.12,N/A,13.12,N/A,63.34,N/A,37.40,N/A,11.15,N/A,13.12,N/A,13.12,N/A,13.12,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,63.34,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,13.12,N/A,14.43,66.00,66.00,11.15,66.00,,Hospital CPT 86664,"HC So Epstein-Barr Virus,Ebna",N/A,0302 - LABORATORY - IMMUNOLOGY,183.00,183.00,109.80,109.80,N/A,15.29,N/A,15.29,N/A,105.37,N/A,62.22,N/A,13.00,N/A,15.29,N/A,15.29,N/A,15.29,N/A,13.00,N/A,13.00,N/A,13.00,N/A,13.00,N/A,105.37,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,16.82,109.80,109.80,13.00,109.80,,Hospital CPT 86664,"HC Epstein-Barr Virus,Ebna",N/A,0302 - LABORATORY - IMMUNOLOGY,203.00,152.00,121.80,91.20,N/A,15.29,N/A,15.29,N/A,87.52,N/A,51.68,N/A,13.00,N/A,15.29,N/A,15.29,N/A,15.29,N/A,13.00,N/A,13.00,N/A,13.00,N/A,13.00,N/A,87.52,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,16.82,121.80,121.80,13.00,91.20,,Hospital CPT 86671,"HC So Fungus, Nes",N/A,0302 - LABORATORY - IMMUNOLOGY,302.00,302.00,181.20,181.20,N/A,12.25,N/A,12.25,N/A,173.89,N/A,102.68,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,10.42,N/A,10.42,N/A,12.25,N/A,10.42,N/A,173.89,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,13.48,181.20,181.20,10.42,181.20,,Hospital CPT 86671,"HC Fungus, Nes",N/A,0302 - LABORATORY - IMMUNOLOGY,334.00,254.00,200.40,152.40,N/A,12.25,N/A,12.25,N/A,146.25,N/A,86.36,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,10.42,N/A,10.42,N/A,12.25,N/A,10.42,N/A,146.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,13.48,200.40,200.40,10.42,152.40,,Hospital 86684,Hemophilus Influenza,N/A,N/A,150589.63,N/A,90353.78,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,90353.78,90353.78,N/A,N/A,,Hospital 86688,HC So Htlv-II Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,64781.70,3042.00,38869.02,1825.20,5869.15,317.20,7208.54,322.77,13295.99,1751.59,N/A,1034.28,13872.42,269.59,6049.99,317.20,4496.00,322.77,4496.00,322.77,8635.47,269.59,N/A,269.59,13872.42,269.59,13872.42,269.59,13295.99,1751.59,7208.54,322.77,6049.99,317.20,15886.89,317.20,15886.89,317.20,N/A,317.20,7208.54,322.77,7208.54,322.77,6473.49,348.93,4496.00,38869.02,269.59,1825.20,,Hospital CPT 86694,"HC So Herpes Simplex, Non-Spec",N/A,0302 - LABORATORY - IMMUNOLOGY,222.00,222.00,133.20,133.20,N/A,14.39,N/A,14.39,N/A,127.83,N/A,75.48,N/A,12.23,N/A,14.39,N/A,14.39,N/A,14.39,N/A,12.23,N/A,14.39,N/A,12.23,N/A,12.23,N/A,127.83,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,133.20,133.20,12.23,133.20,,Hospital CPT 86694,"HC Herpes Simplex, Non-Spec",N/A,0302 - LABORATORY - IMMUNOLOGY,246.00,187.00,147.60,112.20,N/A,14.39,N/A,14.39,N/A,107.67,N/A,63.58,N/A,12.23,N/A,14.39,N/A,14.39,N/A,14.39,N/A,12.23,N/A,14.39,N/A,12.23,N/A,12.23,N/A,107.67,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,147.60,147.60,12.23,112.20,,Hospital CPT 86696,"HC So Herpes Simplex, Type 2",N/A,0302 - LABORATORY - IMMUNOLOGY,172.00,172.00,103.20,103.20,N/A,19.35,N/A,19.35,N/A,99.04,N/A,58.48,N/A,16.45,N/A,19.35,N/A,19.35,N/A,19.35,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,99.04,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,103.20,103.20,16.45,103.20,,Hospital CPT 86696,"HC Herpes Simplex, Type 2",N/A,0302 - LABORATORY - IMMUNOLOGY,190.00,144.00,114.00,86.40,N/A,19.35,N/A,19.35,N/A,82.92,N/A,48.96,N/A,16.45,N/A,19.35,N/A,19.35,N/A,19.35,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,82.92,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,114.00,114.00,16.45,86.40,,Hospital CPT 86698,HC So Histoplasm,N/A,0302 - LABORATORY - IMMUNOLOGY,89.00,89.00,53.40,53.40,N/A,13.79,N/A,13.79,N/A,51.25,N/A,30.26,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,8.58,N/A,10.63,N/A,10.63,N/A,10.63,N/A,51.25,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,15.17,53.40,53.40,8.58,53.40,,Hospital CPT 86698,HC Histoplasm,N/A,0302 - LABORATORY - IMMUNOLOGY,99.00,76.00,59.40,45.60,N/A,13.79,N/A,13.79,N/A,43.76,N/A,25.84,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,8.58,N/A,10.63,N/A,10.63,N/A,10.63,N/A,43.76,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,13.79,N/A,15.17,59.40,59.40,8.58,45.60,,Hospital CPT 86701,HC So Hiv-1antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,186.00,186.00,111.60,111.60,N/A,8.89,N/A,8.89,N/A,107.10,N/A,63.24,N/A,7.55,N/A,8.89,N/A,8.89,N/A,8.89,N/A,7.55,N/A,7.55,N/A,7.55,N/A,7.55,N/A,107.10,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,9.78,111.60,111.60,7.55,111.60,,Hospital CPT 86701,HC Hiv-1antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,206.00,175.00,123.60,105.00,N/A,8.89,N/A,8.89,N/A,100.77,N/A,59.50,N/A,7.55,N/A,8.89,N/A,8.89,N/A,8.89,N/A,7.55,N/A,7.55,N/A,7.55,N/A,7.55,N/A,100.77,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,9.78,123.60,123.60,7.55,105.00,,Hospital CPT 86702,HC So Hiv-2 Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,46.00,46.00,27.60,27.60,N/A,13.52,N/A,13.52,N/A,26.49,N/A,15.64,N/A,11.48,N/A,13.52,N/A,13.52,N/A,13.52,N/A,11.48,N/A,11.48,N/A,11.48,N/A,11.48,N/A,26.49,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,14.87,27.60,27.60,11.48,27.60,,Hospital CPT 86702,HC Hiv-2 Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,51.00,51.00,30.60,30.60,N/A,13.52,N/A,13.52,N/A,29.37,N/A,17.34,N/A,11.48,N/A,13.52,N/A,13.52,N/A,13.52,N/A,11.48,N/A,11.48,N/A,11.48,N/A,11.48,N/A,29.37,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,14.87,30.60,30.60,11.48,30.60,,Hospital CPT 86704,HC So Hepatitis B Core Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,120.00,120.00,72.00,72.00,N/A,12.05,N/A,12.05,N/A,69.10,N/A,40.80,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,10.24,N/A,10.24,N/A,10.24,N/A,10.24,N/A,69.10,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,13.26,72.00,72.00,10.24,72.00,,Hospital CPT 86704,HC Hepatitis B Core Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,132.00,101.00,79.20,60.60,N/A,12.05,N/A,12.05,N/A,58.16,N/A,34.34,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,10.24,N/A,10.24,N/A,10.24,N/A,10.24,N/A,58.16,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,13.26,79.20,79.20,10.24,60.60,,Hospital 86727,HC So Lymphocytic Choriomening Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,35590.60,N/A,21354.36,N/A,4524.83,N/A,5618.27,N/A,11478.93,N/A,12100.80,N/A,10294.60,N/A,4664.24,N/A,3372.00,N/A,3372.00,N/A,N/A,N/A,10294.60,N/A,10294.60,N/A,10294.60,N/A,11478.93,N/A,5618.27,N/A,4664.24,N/A,12248.01,N/A,12248.01,N/A,N/A,N/A,5618.27,N/A,5618.27,N/A,4990.74,N/A,3372.00,21354.36,N/A,N/A,,Hospital CPT 86735,HC So Antibody; Mumps,N/A,0302 - LABORATORY - IMMUNOLOGY,143.00,143.00,85.80,85.80,N/A,13.05,N/A,13.05,N/A,82.34,N/A,48.62,N/A,11.09,N/A,13.05,N/A,13.05,N/A,13.05,N/A,11.09,N/A,11.09,N/A,11.09,N/A,11.09,N/A,82.34,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,14.36,85.80,85.80,11.09,85.80,,Hospital CPT 86735,HC Antibody; Mumps,N/A,0302 - LABORATORY - IMMUNOLOGY,159.00,121.00,95.40,72.60,N/A,13.05,N/A,13.05,N/A,69.67,N/A,41.14,N/A,11.09,N/A,13.05,N/A,13.05,N/A,13.05,N/A,11.09,N/A,11.09,N/A,11.09,N/A,11.09,N/A,69.67,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,13.05,N/A,14.36,95.40,95.40,11.09,72.60,,Hospital CPT 86750,HC So Ab Plasmodium Malaria,N/A,0302 - LABORATORY - IMMUNOLOGY,143.00,143.00,85.80,85.80,N/A,13.19,N/A,13.19,N/A,82.34,N/A,48.62,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,82.34,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,85.80,85.80,8.21,85.80,,Hospital CPT 86769,HC Antb Severe Aqt Respir Synd Sars-Cov-D Covid-19,N/A,0302 - LABORATORY - IMMUNOLOGY,122.00,122.00,73.20,73.20,N/A,42.00,N/A,42.13,N/A,70.25,N/A,41.48,N/A,42.13,N/A,42.00,N/A,42.13,N/A,42.13,N/A,42.13,N/A,42.13,N/A,42.13,N/A,42.13,N/A,70.25,N/A,42.13,N/A,42.00,N/A,42.13,N/A,42.13,N/A,42.00,N/A,42.13,N/A,42.13,N/A,46.20,73.20,73.20,41.48,73.20,,Hospital CPT 86769,HC So Antb Severe Aqt Respir Synd Sars-Cov-D Covid-19,N/A,0302 - LABORATORY - IMMUNOLOGY,105.00,105.00,63.00,63.00,N/A,42.00,N/A,42.13,N/A,60.46,N/A,35.70,N/A,42.13,N/A,42.00,N/A,42.13,N/A,42.13,N/A,42.13,N/A,42.13,N/A,42.13,N/A,42.13,N/A,60.46,N/A,42.13,N/A,42.00,N/A,42.13,N/A,42.13,N/A,42.00,N/A,42.13,N/A,42.13,N/A,46.20,63.00,63.00,35.70,63.00,,Hospital CPT 86777,HC So Ab Toxoplasma,N/A,0302 - LABORATORY - IMMUNOLOGY,48.00,48.00,28.80,28.80,N/A,14.39,N/A,14.39,N/A,27.64,N/A,16.32,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,8.96,N/A,14.39,N/A,12.23,N/A,12.23,N/A,27.64,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,28.80,28.80,8.96,28.80,,Hospital CPT 86777,HC Ab Toxoplasma,N/A,0302 - LABORATORY - IMMUNOLOGY,54.00,54.00,32.40,32.40,N/A,14.39,N/A,14.39,N/A,31.09,N/A,18.36,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,8.96,N/A,14.39,N/A,12.23,N/A,12.23,N/A,31.09,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,32.40,32.40,8.96,32.40,,Hospital CPT 86789,HC So West Nile Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,131.00,131.00,78.60,78.60,N/A,14.39,N/A,14.39,N/A,75.43,N/A,44.54,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,8.96,N/A,14.39,N/A,14.39,N/A,14.39,N/A,75.43,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,78.60,78.60,8.96,78.60,,Hospital CPT 86789,HC West Nile Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,145.00,109.00,87.00,65.40,N/A,14.39,N/A,14.39,N/A,62.76,N/A,37.06,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,8.96,N/A,14.39,N/A,14.39,N/A,14.39,N/A,62.76,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,87.00,87.00,8.96,65.40,,Hospital CPT 86804,HC Hepatitis C Antibody Riba,N/A,0302 - LABORATORY - IMMUNOLOGY,280.00,280.00,168.00,168.00,N/A,15.49,N/A,15.49,N/A,161.22,N/A,95.20,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,9.64,N/A,15.49,N/A,15.49,N/A,15.49,N/A,161.22,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,15.49,N/A,17.04,168.00,168.00,9.64,168.00,,Hospital CPT 86812,HC Hla B-27,N/A,0302 - LABORATORY - IMMUNOLOGY,257.00,197.00,154.20,118.20,N/A,25.81,N/A,25.81,N/A,113.43,N/A,66.98,N/A,18.40,N/A,25.81,N/A,25.81,N/A,25.81,N/A,16.07,N/A,18.40,N/A,18.40,N/A,18.40,N/A,113.43,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,28.39,154.20,154.20,16.07,118.20,,Hospital CPT 86812,HC So Hla B-27,N/A,0302 - LABORATORY - IMMUNOLOGY,233.00,233.00,139.80,139.80,N/A,25.81,N/A,25.81,N/A,134.16,N/A,79.22,N/A,18.40,N/A,25.81,N/A,25.81,N/A,25.81,N/A,16.07,N/A,18.40,N/A,18.40,N/A,18.40,N/A,134.16,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,28.39,139.80,139.80,16.07,139.80,,Hospital CPT 86828,HC So Hla Class I&II Antibody Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,825.00,825.00,495.00,495.00,N/A,64.19,N/A,64.19,N/A,475.04,N/A,280.50,N/A,54.40,N/A,64.19,N/A,64.19,N/A,64.19,N/A,54.40,N/A,54.40,N/A,54.40,N/A,54.40,N/A,475.04,N/A,64.19,N/A,64.19,N/A,64.19,N/A,64.19,N/A,64.19,N/A,64.19,N/A,64.19,N/A,70.61,495.00,495.00,54.40,495.00,,Hospital CPT 86832,HC So Hla Class I High Defin Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,809.00,809.00,485.40,485.40,N/A,323.75,N/A,323.75,N/A,465.82,N/A,275.06,N/A,323.75,N/A,323.75,N/A,323.75,N/A,323.75,N/A,164.67,N/A,323.75,N/A,323.75,N/A,323.75,N/A,465.82,N/A,323.75,N/A,323.75,N/A,323.75,N/A,323.75,N/A,323.75,N/A,323.75,N/A,323.75,N/A,356.13,485.40,485.40,164.67,485.40,,Hospital CPT 86850,HC Antibody Screen,N/A,0302 - LABORATORY - IMMUNOLOGY,123.00,92.00,73.80,55.20,N/A,9.77,N/A,45.28,N/A,52.97,N/A,31.28,N/A,92.00,N/A,9.77,N/A,45.28,N/A,45.28,N/A,68.18,N/A,92.00,N/A,92.00,N/A,92.00,N/A,52.97,N/A,45.28,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,45.28,N/A,45.28,N/A,49.81,73.80,73.80,9.77,92.00,,Hospital CPT 86850,HC So Antibody Screen,N/A,0302 - LABORATORY - IMMUNOLOGY,111.00,111.00,66.60,66.60,N/A,9.77,N/A,45.28,N/A,63.91,N/A,37.74,N/A,109.52,N/A,9.77,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,63.91,N/A,45.28,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,45.28,N/A,45.28,N/A,49.81,66.60,66.60,9.77,109.52,,Hospital CPT 86870,HC So Additional Panel Charge,N/A,0302 - LABORATORY - IMMUNOLOGY,280.00,280.00,168.00,168.00,N/A,39.20,N/A,292.68,N/A,161.22,N/A,95.20,N/A,280.00,N/A,39.20,N/A,292.68,N/A,292.68,N/A,280.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,161.22,N/A,292.68,N/A,39.20,N/A,280.00,N/A,280.00,N/A,39.20,N/A,292.68,N/A,292.68,N/A,321.95,168.00,168.00,39.20,321.95,,Hospital CPT 86870,HC Additional Panel Charge,N/A,0302 - LABORATORY - IMMUNOLOGY,810.00,810.00,486.00,486.00,N/A,113.40,N/A,292.68,N/A,466.40,N/A,275.40,N/A,707.98,N/A,113.40,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,466.40,N/A,292.68,N/A,113.40,N/A,297.45,N/A,297.45,N/A,113.40,N/A,292.68,N/A,292.68,N/A,321.95,486.00,486.00,113.40,707.98,,Hospital CPT 86886,HC Antibody Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,440.00,440.00,264.00,264.00,N/A,5.18,N/A,151.06,N/A,253.35,N/A,149.60,N/A,343.50,N/A,5.18,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,253.35,N/A,142.00,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,142.00,N/A,151.06,N/A,5.70,264.00,264.00,5.18,343.50,,Hospital CPT 86886,HC So Antibody Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,399.00,399.00,239.40,239.40,N/A,5.18,N/A,151.06,N/A,229.74,N/A,135.66,N/A,343.50,N/A,5.18,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,229.74,N/A,142.00,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,142.00,N/A,151.06,N/A,5.70,239.40,239.40,5.18,343.50,,Hospital CPT 86900,"HC Blood Typing, Abo",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,125.00,126.00,75.00,75.60,N/A,2.99,N/A,104.85,N/A,72.55,N/A,42.84,N/A,126.00,N/A,2.99,N/A,104.85,N/A,104.85,N/A,126.00,N/A,126.00,N/A,126.00,N/A,126.00,N/A,72.55,N/A,104.85,N/A,2.99,N/A,2.99,N/A,2.99,N/A,2.99,N/A,104.85,N/A,104.85,N/A,115.34,75.00,75.00,2.99,126.00,,Hospital CPT 86900,"HC So Blood Typing, Abo",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,113.00,113.00,67.80,67.80,N/A,2.99,N/A,104.85,N/A,65.07,N/A,38.42,N/A,113.00,N/A,2.99,N/A,104.85,N/A,104.85,N/A,113.00,N/A,113.00,N/A,113.00,N/A,113.00,N/A,65.07,N/A,104.85,N/A,2.99,N/A,2.99,N/A,2.99,N/A,2.99,N/A,104.85,N/A,104.85,N/A,115.34,67.80,67.80,2.99,115.34,,Hospital CPT 86905,HC Antigen Typing,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,810.00,810.00,486.00,486.00,N/A,3.83,N/A,292.68,N/A,466.40,N/A,275.40,N/A,707.98,N/A,3.83,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,466.40,N/A,292.68,N/A,3.83,N/A,3.83,N/A,3.83,N/A,3.83,N/A,292.68,N/A,292.68,N/A,321.95,486.00,486.00,3.83,707.98,,Hospital CPT 86905,HC So Antigen Typing,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,125.00,125.00,75.00,75.00,N/A,3.83,N/A,292.68,N/A,71.98,N/A,42.50,N/A,125.00,N/A,3.83,N/A,292.68,N/A,292.68,N/A,125.00,N/A,125.00,N/A,125.00,N/A,125.00,N/A,71.98,N/A,292.68,N/A,3.83,N/A,3.83,N/A,3.83,N/A,3.83,N/A,292.68,N/A,292.68,N/A,321.95,75.00,75.00,3.83,321.95,,Hospital CPT 86921,HC Compatibility Test Incubate Ea Unit,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,259.00,259.00,155.40,155.40,N/A,21.50,N/A,143.54,N/A,149.13,N/A,88.06,N/A,259.00,N/A,21.50,N/A,142.00,N/A,142.00,N/A,213.84,N/A,259.00,N/A,259.00,N/A,259.00,N/A,149.13,N/A,142.00,N/A,21.50,N/A,152.32,N/A,152.32,N/A,21.50,N/A,142.00,N/A,143.54,N/A,23.65,155.40,155.40,21.50,259.00,,Hospital CPT 86927,HC Fresh Frozen Plasma Thawing,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,294.00,294.00,176.40,176.40,N/A,31.13,N/A,146.87,N/A,169.29,N/A,99.96,N/A,294.00,N/A,31.13,N/A,142.00,N/A,142.00,N/A,213.84,N/A,294.00,N/A,294.00,N/A,294.00,N/A,169.29,N/A,142.00,N/A,31.13,N/A,152.32,N/A,152.32,N/A,31.13,N/A,142.00,N/A,146.87,N/A,34.24,176.40,176.40,31.13,294.00,,Hospital CPT 86940,"HC Hemolysins/Agglutinins Auto, Ea",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,270.00,270.00,162.00,162.00,N/A,8.77,N/A,8.77,N/A,155.47,N/A,91.80,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,5.46,N/A,8.77,N/A,8.77,N/A,8.77,N/A,155.47,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,9.65,162.00,162.00,5.46,162.00,,Hospital CPT 86940,HC So Hemolysins/Agglutinins Auto,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,89.00,89.00,53.40,53.40,N/A,8.77,N/A,8.77,N/A,51.25,N/A,30.26,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,5.46,N/A,8.77,N/A,8.77,N/A,8.77,N/A,51.25,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,8.77,N/A,9.65,53.40,53.40,5.46,53.40,,Hospital CPT 86965,HC Pooling Blood Platelets,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,237.00,208.00,142.20,124.80,N/A,29.12,N/A,208.00,N/A,119.77,N/A,70.72,N/A,29.12,N/A,29.12,N/A,208.00,N/A,208.00,N/A,18.10,N/A,29.12,N/A,29.12,N/A,29.12,N/A,119.77,N/A,208.00,N/A,29.12,N/A,152.32,N/A,152.32,N/A,29.12,N/A,208.00,N/A,208.00,N/A,208.00,142.20,142.20,18.10,208.00,,Hospital 86999,HC So Unlisted Transfusion Procedure,N/A,0309 - LABORATORY - OTHER LABORATORY,43097.60,3919.00,25858.56,2351.40,4790.49,459.21,5932.54,407.12,10795.76,2458.87,14653.18,1332.46,10899.03,941.44,4938.09,459.21,5932.54,389.20,5932.54,389.20,6784.39,586.07,10899.03,941.44,N/A,941.44,10899.03,941.44,10795.76,2458.87,5932.54,389.20,4938.09,459.21,12967.12,1918.93,12967.12,1918.93,N/A,459.21,5932.54,389.20,5932.54,407.12,5283.76,297.45,4790.49,25858.56,297.45,2458.87,,Hospital CPT 87040,HC Culture Blood,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,179.00,142.00,107.40,85.20,N/A,10.32,N/A,10.32,N/A,81.76,N/A,48.28,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,6.42,N/A,10.32,N/A,10.32,N/A,10.32,N/A,81.76,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,11.35,107.40,107.40,6.42,85.20,,Hospital CPT 87045,HC Stool Culture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,269.00,214.00,161.40,128.40,N/A,9.44,N/A,9.44,N/A,123.22,N/A,72.76,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,7.91,N/A,7.91,N/A,7.91,N/A,7.91,N/A,123.22,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,10.38,161.40,161.40,7.91,128.40,,Hospital CPT 87045,HC So Stool Culture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,243.00,243.00,145.80,145.80,N/A,9.44,N/A,9.44,N/A,139.92,N/A,82.62,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,7.91,N/A,7.91,N/A,7.91,N/A,7.91,N/A,139.92,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,10.38,145.80,145.80,7.91,145.80,,Hospital CPT 87046,HC Stool Culture Add Pathogens,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,36.00,28.00,21.60,16.80,N/A,9.44,N/A,9.44,N/A,16.12,N/A,9.52,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,5.88,N/A,9.44,N/A,7.91,N/A,9.44,N/A,16.12,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,10.38,21.60,21.60,5.88,16.80,,Hospital CPT 87046,HC So Stool Cult Addl Pathogens - D,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,32.00,32.00,19.20,19.20,N/A,9.44,N/A,9.44,N/A,18.43,N/A,10.88,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,5.88,N/A,9.44,N/A,7.91,N/A,9.44,N/A,18.43,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,10.38,19.20,19.20,5.88,19.20,,Hospital CPT 87086,HC Urine Cult./Colony Count,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,193.00,154.00,115.80,92.40,N/A,8.07,N/A,8.07,N/A,88.67,N/A,52.36,N/A,6.86,N/A,8.07,N/A,8.07,N/A,8.07,N/A,6.86,N/A,8.07,N/A,8.07,N/A,8.07,N/A,88.67,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.07,N/A,8.88,115.80,115.80,6.86,92.40,,Hospital CPT 87103,"HC Culture, Fungus Blood",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,99.00,79.00,59.40,47.40,N/A,20.46,N/A,20.46,N/A,45.49,N/A,26.86,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,12.74,N/A,20.46,N/A,7.66,N/A,7.66,N/A,45.49,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,22.51,59.40,59.40,7.66,47.40,,Hospital CPT 87103,"HC So Culture, Fungus Blood",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,89.00,89.00,53.40,53.40,N/A,20.46,N/A,20.46,N/A,51.25,N/A,30.26,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,12.74,N/A,20.46,N/A,7.66,N/A,7.66,N/A,51.25,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,20.46,N/A,22.51,53.40,53.40,7.66,53.40,,Hospital CPT 87107,HC So Fungus ID Mold,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,62.00,62.00,37.20,37.20,N/A,10.32,N/A,10.32,N/A,35.70,N/A,21.08,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,6.42,N/A,10.32,N/A,10.32,N/A,10.32,N/A,35.70,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,11.35,37.20,37.20,6.42,37.20,,Hospital CPT 87107,HC Fungus ID Mold,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,69.00,54.00,41.40,32.40,N/A,10.32,N/A,10.32,N/A,31.09,N/A,18.36,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,6.42,N/A,10.32,N/A,10.32,N/A,10.32,N/A,31.09,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,11.35,41.40,41.40,6.42,32.40,,Hospital CPT 87110,"HC So Culture, Chlamydia, Any Source",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,103.00,103.00,61.80,61.80,N/A,19.60,N/A,19.60,N/A,59.31,N/A,35.02,N/A,16.65,N/A,19.60,N/A,19.60,N/A,19.60,N/A,16.65,N/A,16.65,N/A,16.65,N/A,16.65,N/A,59.31,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,21.56,61.80,61.80,16.65,61.80,,Hospital CPT 87110,"HC Culture, Chlamydia, Any Source",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,114.00,98.00,68.40,58.80,N/A,19.60,N/A,19.60,N/A,56.43,N/A,33.32,N/A,16.65,N/A,19.60,N/A,19.60,N/A,19.60,N/A,16.65,N/A,16.65,N/A,16.65,N/A,16.65,N/A,56.43,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,19.60,N/A,21.56,68.40,68.40,16.65,58.80,,Hospital CPT 87116,"HC Culture, Afb",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,272.00,216.00,163.20,129.60,N/A,10.80,N/A,10.80,N/A,124.37,N/A,73.44,N/A,9.18,N/A,10.80,N/A,10.80,N/A,10.80,N/A,9.18,N/A,10.80,N/A,9.18,N/A,10.80,N/A,124.37,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,11.88,163.20,163.20,9.18,129.60,,Hospital CPT 87116,"HC So Culture, Afb",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,246.00,246.00,147.60,147.60,N/A,10.80,N/A,10.80,N/A,141.65,N/A,83.64,N/A,9.18,N/A,10.80,N/A,10.80,N/A,10.80,N/A,9.18,N/A,10.80,N/A,9.18,N/A,10.80,N/A,141.65,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,10.80,N/A,11.88,147.60,147.60,9.18,147.60,,Hospital CPT 87168,HC Macroscopic Exam Arthropod,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,343.00,343.00,205.80,205.80,N/A,4.27,N/A,4.27,N/A,197.50,N/A,116.62,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,4.27,N/A,4.27,N/A,197.50,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,205.80,205.80,2.66,205.80,,Hospital CPT 87168,HC So Macroscopic Exam Arthropod,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,343.00,343.00,205.80,205.80,N/A,4.27,N/A,4.27,N/A,197.50,N/A,116.62,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,4.27,N/A,4.27,N/A,197.50,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,205.80,205.80,2.66,205.80,,Hospital CPT 87186,HC So Microbe Suscept,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,140.00,140.00,84.00,84.00,N/A,8.65,N/A,8.65,N/A,80.61,N/A,47.60,N/A,7.35,N/A,8.65,N/A,8.65,N/A,8.65,N/A,5.38,N/A,8.65,N/A,8.65,N/A,8.65,N/A,80.61,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,9.52,84.00,84.00,5.38,84.00,,Hospital CPT 87186,"Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral)",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,154.00,122.00,92.40,73.20,N/A,8.65,N/A,8.65,N/A,70.25,N/A,41.48,N/A,7.35,N/A,8.65,N/A,8.65,N/A,8.65,N/A,5.38,N/A,8.65,N/A,8.65,N/A,8.65,N/A,70.25,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,9.52,92.40,92.40,5.38,73.20,,Hospital CPT 87190,HC Microbe Suscept Mycobacteri,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,124.00,124.00,74.40,74.40,N/A,7.31,N/A,7.31,N/A,71.40,N/A,42.16,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,4.55,N/A,7.31,N/A,7.31,N/A,7.31,N/A,71.40,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,8.04,74.40,74.40,4.55,74.40,,Hospital CPT 87206,HC So Smear Afb,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,92.00,92.00,55.20,55.20,N/A,5.39,N/A,5.39,N/A,52.97,N/A,31.28,N/A,4.57,N/A,5.39,N/A,5.39,N/A,5.39,N/A,4.57,N/A,5.39,N/A,4.57,N/A,5.39,N/A,52.97,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.93,55.20,55.20,4.57,55.20,,Hospital CPT 87206,"HC Smear,Afb",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,102.00,82.00,61.20,49.20,N/A,5.39,N/A,5.39,N/A,47.22,N/A,27.88,N/A,4.57,N/A,5.39,N/A,5.39,N/A,5.39,N/A,4.57,N/A,5.39,N/A,4.57,N/A,5.39,N/A,47.22,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.93,61.20,61.20,4.57,49.20,,Hospital CPT 87210,HC Smear Wet Mount Saline/Ink,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,68.00,68.00,40.80,40.80,N/A,5.82,N/A,5.82,N/A,68.00,N/A,23.12,N/A,3.05,N/A,5.82,N/A,5.82,N/A,5.82,N/A,3.62,N/A,3.05,N/A,3.05,N/A,3.05,N/A,39.15,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,6.40,40.80,40.80,3.05,68.00,,Hospital CPT 87210,HC POC Assay Ph Body Fluid Nos,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,76.00,60.00,45.60,36.00,N/A,5.82,N/A,5.82,N/A,60.00,N/A,20.40,N/A,3.05,N/A,5.82,N/A,5.82,N/A,5.82,N/A,3.62,N/A,3.05,N/A,3.05,N/A,3.05,N/A,34.55,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,6.40,45.60,45.60,3.05,60.00,,Hospital CPT 87230,HC Toxin or Antitoxin Assay,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,109.00,109.00,65.40,65.40,N/A,19.74,N/A,19.74,N/A,62.76,N/A,37.06,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,12.29,N/A,19.74,N/A,19.74,N/A,19.74,N/A,62.76,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,21.71,65.40,65.40,12.29,65.40,,Hospital CPT 87230,HC So Toxin or Antitoxin Assay,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,109.00,109.00,65.40,65.40,N/A,19.74,N/A,19.74,N/A,62.76,N/A,37.06,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,12.29,N/A,19.74,N/A,19.74,N/A,19.74,N/A,62.76,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,19.74,N/A,21.71,65.40,65.40,12.29,65.40,,Hospital CPT 87254,HC So Cmv Culture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,116.00,116.00,69.60,69.60,N/A,19.56,N/A,19.56,N/A,66.79,N/A,39.44,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,12.18,N/A,19.56,N/A,19.56,N/A,19.56,N/A,66.79,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,21.52,69.60,69.60,12.18,69.60,,Hospital CPT 87254,"HC Virus Inoc,Shell Vial,Each Vir",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,128.00,101.00,76.80,60.60,N/A,19.56,N/A,19.56,N/A,58.16,N/A,34.34,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,12.18,N/A,19.56,N/A,19.56,N/A,19.56,N/A,58.16,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,19.56,N/A,21.52,76.80,76.80,12.18,60.60,,Hospital CPT 87265,HC Pertussis Direct Fluorescence,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,194.00,194.00,116.40,116.40,N/A,11.98,N/A,11.98,N/A,111.71,N/A,65.96,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,111.71,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,116.40,116.40,7.46,116.40,,Hospital CPT 87275,HC Influenza B Virus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,68.00,53.00,40.80,31.80,N/A,12.25,N/A,12.25,N/A,30.52,N/A,18.02,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,7.63,N/A,12.25,N/A,12.25,N/A,12.25,N/A,30.52,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,13.48,40.80,40.80,7.63,31.80,,Hospital CPT 87275,HC So Influenza B Virus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,61.00,61.00,36.60,36.60,N/A,12.25,N/A,12.25,N/A,35.12,N/A,20.74,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,7.63,N/A,12.25,N/A,12.25,N/A,12.25,N/A,35.12,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,13.48,36.60,36.60,7.63,36.60,,Hospital CPT 87278,HC Legionella Antigen 16104,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,207.00,176.00,124.20,105.60,N/A,15.60,N/A,15.60,N/A,101.34,N/A,59.84,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,9.71,N/A,15.60,N/A,15.60,N/A,15.60,N/A,101.34,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,17.16,124.20,124.20,9.71,105.60,,Hospital CPT 87278,HC So Legionella Antigen 16104,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,187.00,187.00,112.20,112.20,N/A,15.60,N/A,15.60,N/A,107.67,N/A,63.58,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,9.71,N/A,15.60,N/A,15.60,N/A,15.60,N/A,107.67,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,15.60,N/A,17.16,112.20,112.20,9.71,112.20,,Hospital 87281,HC Pneumocystis Carinii Ag,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,115966.27,18484.90,69579.76,11090.94,7817.08,2554.93,13026.36,3043.02,63920.61,10642.89,39639.82,6284.87,39639.82,7296.20,20158.20,2554.93,13026.36,3010.42,23398.97,3010.42,39639.82,4542.02,39639.82,7296.20,25666.72,7296.20,39639.82,7296.20,63858.87,10642.89,13026.36,3010.42,7817.08,2554.93,26672.15,3274.25,26672.15,3274.25,9985.63,2554.93,23398.97,3010.42,13026.36,3043.02,7817.08,1095.08,7817.08,69579.76,1095.08,11090.94,,Hospital CPT 87300,HC Polyvalent Ag Ift Ea Antiserum,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,182.00,182.00,109.20,109.20,N/A,11.98,N/A,11.98,N/A,104.80,N/A,61.88,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,104.80,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,109.20,109.20,7.46,109.20,,Hospital CPT 87305,HC Aspergillus Galactomannan,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,291.00,231.00,174.60,138.60,N/A,11.98,N/A,11.98,N/A,133.01,N/A,78.54,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,9.73,N/A,9.73,N/A,11.98,N/A,133.01,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,174.60,174.60,7.46,138.60,,Hospital CPT 87305,HC So Aspergillus Galactomannan,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,263.00,263.00,157.80,157.80,N/A,11.98,N/A,11.98,N/A,151.44,N/A,89.42,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,9.73,N/A,9.73,N/A,11.98,N/A,151.44,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,157.80,157.80,7.46,157.80,,Hospital CPT 87425,HC So Rotavirus Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,240.00,240.00,144.00,144.00,N/A,11.98,N/A,11.98,N/A,138.19,N/A,81.60,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,138.19,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,144.00,144.00,9.73,144.00,,Hospital CPT 87425,HC Rotavirus Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,265.00,211.00,159.00,126.60,N/A,11.98,N/A,11.98,N/A,121.49,N/A,71.74,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,121.49,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,159.00,159.00,9.73,126.60,,Hospital 87450,HC Direct Strep B Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,17999.60,N/A,10799.76,N/A,5275.05,N/A,11497.84,N/A,17999.60,N/A,6119.87,N/A,17999.60,N/A,5437.58,N/A,1124.00,N/A,1124.00,N/A,13447.14,N/A,17999.60,N/A,17999.60,N/A,17999.60,N/A,17999.60,N/A,11497.84,N/A,5437.58,N/A,17999.60,N/A,17999.60,N/A,N/A,N/A,11497.84,N/A,11497.84,N/A,5818.22,N/A,1124.00,17999.60,N/A,N/A,,Hospital 87468,HC So Iadna Anaplasma Phagocytophilum Amplifed Prb Tq,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,23198.62,N/A,13919.17,N/A,5483.99,N/A,6752.92,N/A,12358.62,N/A,7887.53,N/A,12476.84,N/A,5652.96,N/A,2248.00,N/A,2248.00,N/A,7766.54,N/A,12476.84,N/A,12476.84,N/A,12476.84,N/A,12358.62,N/A,6752.92,N/A,5652.96,N/A,14844.32,N/A,14844.32,N/A,5652.96,N/A,6752.92,N/A,6752.92,N/A,6048.67,N/A,2248.00,14844.32,N/A,N/A,,Hospital CPT 87497,HC So Cmv Dna Quantitation by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,608.00,608.00,364.80,364.80,N/A,42.84,N/A,42.84,N/A,350.09,N/A,206.72,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,350.09,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,364.80,364.80,36.40,364.80,,Hospital CPT 87497,HC Cmv Dna Quantitation by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,671.00,534.00,402.60,320.40,N/A,42.84,N/A,42.84,N/A,307.48,N/A,181.56,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,307.48,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,402.60,402.60,36.40,320.40,,Hospital CPT 87506,HC So Iadna-Dna/Rna Probe Tq 6-11,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,806.00,806.00,483.60,483.60,N/A,262.99,N/A,262.99,N/A,806.00,N/A,274.04,N/A,293.37,N/A,262.99,N/A,262.99,N/A,262.99,N/A,293.37,N/A,293.37,N/A,293.37,N/A,293.37,N/A,464.09,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,289.29,483.60,483.60,262.99,806.00,,Hospital CPT 87506,HC Iadna-Dna/Rna Probe Tq 6-11,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,889.00,889.00,533.40,533.40,N/A,262.99,N/A,262.99,N/A,889.00,N/A,302.26,N/A,293.37,N/A,262.99,N/A,262.99,N/A,262.99,N/A,293.37,N/A,293.37,N/A,293.37,N/A,293.37,N/A,511.89,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,289.29,533.40,533.40,262.99,889.00,,Hospital CPT 87529,HC So Hsv Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,242.00,242.00,145.20,145.20,N/A,35.09,N/A,35.09,N/A,139.34,N/A,82.28,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,139.34,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,145.20,145.20,21.84,145.20,,Hospital CPT 87529,HC Hsv Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,268.00,212.00,160.80,127.20,N/A,35.09,N/A,35.09,N/A,122.07,N/A,72.08,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,122.07,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,160.80,160.80,21.84,127.20,,Hospital CPT 87532,HC Herpes Virus-6 Direct Probe,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,35.09,N/A,35.09,N/A,93.28,N/A,55.08,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,93.28,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,97.20,97.20,21.84,97.20,,Hospital CPT 87541,HC So Legionella Pneum Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,160.00,160.00,96.00,96.00,N/A,35.09,N/A,35.09,N/A,92.13,N/A,54.40,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,92.13,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,96.00,96.00,21.84,96.00,,Hospital 87634,HC Iadna Dna/Rna Rsv Amplified Probe Technique,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,33945.35,800.00,20367.21,480.00,4938.79,254.99,6107.98,217.31,14851.81,460.64,11541.41,272.00,11236.43,217.31,5090.96,254.99,2248.00,217.31,2248.00,217.31,6994.42,135.28,11236.43,217.31,11236.43,217.31,11236.43,217.31,14851.81,460.64,6107.98,160.45,5090.96,254.99,13368.55,217.31,13368.55,217.31,5090.96,254.99,6107.98,160.45,6107.98,161.63,5447.33,239.06,2248.00,20367.21,135.28,480.00,,Hospital CPT 87635,HC So Iadna Sars-Cov-2-19 Amp Probe Tq,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,160.00,160.00,96.00,96.00,N/A,51.33,N/A,51.31,N/A,92.13,N/A,54.40,N/A,51.31,N/A,51.33,N/A,51.31,N/A,51.31,N/A,31.94,N/A,51.31,N/A,51.31,N/A,51.31,N/A,92.13,N/A,51.31,N/A,51.33,N/A,51.31,N/A,51.31,N/A,51.33,N/A,51.31,N/A,51.31,N/A,56.46,96.00,96.00,31.94,96.00,,Hospital CPT 87635,HC Iadna Sars-Cov-2-19 Amp Probe Tq,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,176.00,176.00,105.60,105.60,N/A,51.33,N/A,51.31,N/A,101.34,N/A,59.84,N/A,51.31,N/A,51.33,N/A,51.31,N/A,51.31,N/A,31.94,N/A,51.31,N/A,51.31,N/A,51.31,N/A,101.34,N/A,51.31,N/A,51.33,N/A,51.31,N/A,51.31,N/A,51.33,N/A,51.31,N/A,51.31,N/A,56.46,105.60,105.60,31.94,105.60,,Hospital CPT 87797,HC So Inf Agent Det by Nuc Acid Prob,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,275.00,275.00,165.00,165.00,N/A,30.03,N/A,30.03,N/A,158.35,N/A,93.50,N/A,30.03,N/A,30.03,N/A,30.03,N/A,30.03,N/A,18.69,N/A,30.03,N/A,30.03,N/A,30.03,N/A,158.35,N/A,30.03,N/A,30.03,N/A,30.03,N/A,30.03,N/A,30.03,N/A,30.03,N/A,30.03,N/A,33.03,165.00,165.00,18.69,165.00,,Hospital CPT 87800,HC Inf Agnt Mult Nuc Acd Dir Ea,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,221.00,221.00,132.60,132.60,N/A,43.67,N/A,43.67,N/A,127.25,N/A,75.14,N/A,43.67,N/A,43.67,N/A,43.67,N/A,43.67,N/A,27.18,N/A,43.67,N/A,43.67,N/A,43.67,N/A,127.25,N/A,43.67,N/A,43.67,N/A,43.67,N/A,43.67,N/A,43.67,N/A,43.67,N/A,43.67,N/A,48.04,132.60,132.60,27.18,132.60,,Hospital CPT 87804,HC Influenza Ab Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,106.00,83.00,63.60,49.80,N/A,16.55,N/A,16.55,N/A,47.79,N/A,28.22,N/A,9.73,N/A,16.55,N/A,16.55,N/A,16.55,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,47.79,N/A,16.55,N/A,16.55,N/A,16.55,N/A,16.55,N/A,16.55,N/A,16.55,N/A,16.55,N/A,18.21,63.60,63.60,9.73,49.80,,Hospital CPT 87807,HC Rsv Antigen Assay,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,171.00,171.00,102.60,102.60,N/A,13.10,N/A,13.10,N/A,98.46,N/A,58.14,N/A,9.73,N/A,13.10,N/A,13.10,N/A,13.10,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,98.46,N/A,13.10,N/A,13.10,N/A,13.10,N/A,13.10,N/A,13.10,N/A,13.10,N/A,13.10,N/A,14.41,102.60,102.60,9.73,102.60,,Hospital CPT 87880,HC Beta Strep Screen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,61.00,49.00,36.60,29.40,N/A,16.53,N/A,16.53,N/A,28.21,N/A,16.66,N/A,9.73,N/A,16.53,N/A,16.53,N/A,16.53,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,28.21,N/A,16.53,N/A,16.53,N/A,16.53,N/A,16.53,N/A,16.53,N/A,16.53,N/A,16.53,N/A,18.18,36.60,36.60,9.73,29.40,,Hospital CPT 87902,HC Hepatitis C Virus Genotyping,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,853.00,677.00,511.80,406.20,N/A,257.45,N/A,257.45,N/A,389.82,N/A,230.18,N/A,218.78,N/A,257.45,N/A,257.45,N/A,257.45,N/A,218.78,N/A,218.78,N/A,218.78,N/A,218.78,N/A,389.82,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,511.80,511.80,218.78,406.20,,Hospital CPT 87902,HC So Hepatitis C Virus Genotyping,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,773.00,773.00,463.80,463.80,N/A,257.45,N/A,257.45,N/A,445.09,N/A,262.82,N/A,218.78,N/A,257.45,N/A,257.45,N/A,257.45,N/A,218.78,N/A,218.78,N/A,218.78,N/A,218.78,N/A,445.09,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,463.80,463.80,218.78,463.80,,Hospital CPT 87902,HC So1 Hepatitis C Virus Genotyping,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,773.00,773.00,463.80,463.80,N/A,257.45,N/A,257.45,N/A,445.09,N/A,262.82,N/A,218.78,N/A,257.45,N/A,257.45,N/A,257.45,N/A,218.78,N/A,218.78,N/A,218.78,N/A,218.78,N/A,445.09,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,463.80,463.80,218.78,463.80,,Hospital CPT 87912,HC So Genotype Dna Hepatitis B Virus,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,876.00,876.00,525.60,525.60,N/A,257.45,N/A,257.45,N/A,504.40,N/A,297.84,N/A,353.88,N/A,257.45,N/A,257.45,N/A,257.45,N/A,353.88,N/A,353.88,N/A,353.88,N/A,353.88,N/A,504.40,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,525.60,525.60,257.45,525.60,,Hospital CPT 87912,HC Genotype Dna Hepatitis B Virus,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,966.00,966.00,579.60,579.60,N/A,257.45,N/A,257.45,N/A,556.22,N/A,328.44,N/A,353.88,N/A,257.45,N/A,257.45,N/A,257.45,N/A,353.88,N/A,353.88,N/A,353.88,N/A,353.88,N/A,556.22,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,579.60,579.60,257.45,579.60,,Hospital CPT 87912,HC So Ezh2 Gene Analysis Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,876.00,876.00,525.60,525.60,N/A,257.45,N/A,257.45,N/A,504.40,N/A,297.84,N/A,353.88,N/A,257.45,N/A,257.45,N/A,257.45,N/A,353.88,N/A,353.88,N/A,353.88,N/A,353.88,N/A,504.40,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,525.60,525.60,257.45,525.60,,Hospital CPT 88120,HC in Situ Hybrid Uri Tract Spec,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,927.00,927.00,556.20,556.20,N/A,129.78,N/A,146.87,N/A,533.77,N/A,315.18,N/A,343.50,N/A,129.78,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,533.77,N/A,142.00,N/A,129.78,N/A,152.32,N/A,152.32,N/A,129.78,N/A,142.00,N/A,147.53,N/A,547.09,556.20,556.20,129.78,556.20,,Hospital CPT 88184,HC Flow Cytometry First Marker,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,810.00,810.00,486.00,486.00,N/A,113.40,N/A,292.68,N/A,466.40,N/A,275.40,N/A,707.98,N/A,113.40,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,466.40,N/A,292.68,N/A,113.40,N/A,297.45,N/A,297.45,N/A,113.40,N/A,292.68,N/A,292.68,N/A,321.95,486.00,486.00,113.40,707.98,,Hospital CPT 88184,HC So Flow Cytometry,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,246.00,246.00,147.60,147.60,N/A,34.44,N/A,292.68,N/A,141.65,N/A,83.64,N/A,246.00,N/A,34.44,N/A,292.68,N/A,292.68,N/A,246.00,N/A,246.00,N/A,246.00,N/A,246.00,N/A,141.65,N/A,292.68,N/A,34.44,N/A,246.00,N/A,246.00,N/A,34.44,N/A,292.68,N/A,292.68,N/A,321.95,147.60,147.60,34.44,321.95,,Hospital CPT 88184,"HC Flow Cytometry, First Marker (Path)",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,810.00,810.00,486.00,486.00,N/A,113.40,N/A,292.68,N/A,466.40,N/A,275.40,N/A,707.98,N/A,113.40,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,466.40,N/A,292.68,N/A,113.40,N/A,297.45,N/A,297.45,N/A,113.40,N/A,292.68,N/A,292.68,N/A,321.95,486.00,486.00,113.40,707.98,,Hospital CPT 88237,HC Tissue Cult of Neoplastic Dis,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,630.00,469.00,378.00,281.40,N/A,143.75,N/A,143.75,N/A,270.05,N/A,159.46,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,107.34,N/A,107.34,N/A,107.34,N/A,143.75,N/A,270.05,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,158.13,378.00,378.00,107.34,281.40,,Hospital CPT 88237,HC So Tissue Cult of Neoplastic Dis,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,571.00,571.00,342.60,342.60,N/A,143.75,N/A,143.75,N/A,328.78,N/A,194.14,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,107.34,N/A,107.34,N/A,107.34,N/A,143.75,N/A,328.78,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,143.75,N/A,158.13,342.60,342.60,107.34,342.60,,Hospital CPT 88261,HC So Chromosome Analysis Tissue,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,661.00,661.00,396.60,396.60,N/A,264.34,N/A,264.34,N/A,380.60,N/A,224.74,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,164.55,N/A,264.34,N/A,264.34,N/A,264.34,N/A,380.60,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,290.77,396.60,396.60,164.55,396.60,,Hospital CPT 88261,HC Chromosome Analysis Tissue,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,661.00,661.00,396.60,396.60,N/A,264.34,N/A,264.34,N/A,380.60,N/A,224.74,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,164.55,N/A,264.34,N/A,264.34,N/A,264.34,N/A,380.60,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,264.34,N/A,290.77,396.60,396.60,164.55,396.60,,Hospital CPT 88275,"HC So1 Molecular Cyto, 100-300 Cells",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,710.00,710.00,426.00,426.00,N/A,51.19,N/A,51.19,N/A,408.82,N/A,241.40,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,34.13,N/A,34.13,N/A,34.13,N/A,34.13,N/A,408.82,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,56.31,426.00,426.00,34.13,426.00,,Hospital CPT 88275,"HC So Molecular Cyto, 100-300 Cells",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,330.00,330.00,198.00,198.00,N/A,51.19,N/A,51.19,N/A,190.01,N/A,112.20,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,34.13,N/A,34.13,N/A,34.13,N/A,34.13,N/A,190.01,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,56.31,198.00,198.00,34.13,198.00,,Hospital CPT 88275,"HC Mol Cyto,Insitu,100-300 Cells",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,783.00,585.00,469.80,351.00,N/A,51.19,N/A,51.19,N/A,336.84,N/A,198.90,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,34.13,N/A,34.13,N/A,34.13,N/A,34.13,N/A,336.84,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,56.31,469.80,469.80,34.13,351.00,,Hospital CPT 88275,"HC Molecular Cyto, 100-300 Cells",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,364.00,271.00,218.40,162.60,N/A,51.19,N/A,51.19,N/A,156.04,N/A,92.14,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,34.13,N/A,34.13,N/A,34.13,N/A,34.13,N/A,156.04,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,51.19,N/A,56.31,218.40,218.40,34.13,162.60,,Hospital CPT 88280,HC Chromosome Karyotype Study,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,84.00,84.00,50.40,50.40,N/A,33.47,N/A,33.47,N/A,48.37,N/A,28.56,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,20.84,N/A,33.47,N/A,21.33,N/A,21.33,N/A,48.37,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,36.82,50.40,50.40,20.84,50.40,,Hospital CPT 88280,HC So Chromosome Karyotype Study,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,84.00,84.00,50.40,50.40,N/A,33.47,N/A,33.47,N/A,48.37,N/A,28.56,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,20.84,N/A,33.47,N/A,21.33,N/A,21.33,N/A,48.37,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,33.47,N/A,36.82,50.40,50.40,20.84,50.40,,Hospital CPT 88283,HC Chromosome Banding Study,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,372.00,372.00,223.20,223.20,N/A,68.60,N/A,68.60,N/A,214.20,N/A,126.48,N/A,68.60,N/A,68.60,N/A,68.60,N/A,68.60,N/A,42.70,N/A,68.60,N/A,68.60,N/A,68.60,N/A,214.20,N/A,68.60,N/A,68.60,N/A,68.60,N/A,68.60,N/A,68.60,N/A,68.60,N/A,68.60,N/A,75.46,223.20,223.20,42.70,223.20,,Hospital CPT 88285,HC Chromosome Count Additional,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,241.00,241.00,144.60,144.60,N/A,26.91,N/A,26.91,N/A,138.77,N/A,81.94,N/A,16.15,N/A,26.91,N/A,26.91,N/A,26.91,N/A,16.15,N/A,16.15,N/A,16.15,N/A,16.15,N/A,138.77,N/A,26.91,N/A,26.91,N/A,26.91,N/A,26.91,N/A,26.91,N/A,26.91,N/A,26.91,N/A,29.60,144.60,144.60,16.15,144.60,,Hospital CPT 88289,HC Chro Addl High Res Study,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,96.00,96.00,57.60,57.60,N/A,34.43,N/A,34.43,N/A,55.28,N/A,32.64,N/A,34.43,N/A,34.43,N/A,34.43,N/A,34.43,N/A,21.43,N/A,34.43,N/A,34.43,N/A,34.43,N/A,55.28,N/A,34.43,N/A,34.43,N/A,34.43,N/A,34.43,N/A,34.43,N/A,34.43,N/A,34.43,N/A,37.87,57.60,57.60,21.43,57.60,,Hospital CPT 88304,HC So Tissue Level III,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,334.00,334.00,200.40,200.40,N/A,46.76,N/A,45.28,N/A,192.32,N/A,113.56,N/A,109.52,N/A,46.76,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,192.32,N/A,45.28,N/A,46.76,N/A,50.75,N/A,50.75,N/A,46.76,N/A,45.28,N/A,45.28,N/A,49.81,200.40,200.40,45.28,200.40,,Hospital CPT 88304,HC Tissue Level III,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,369.00,314.00,221.40,188.40,N/A,43.96,N/A,45.28,N/A,180.80,N/A,106.76,N/A,109.52,N/A,43.96,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,180.80,N/A,45.28,N/A,43.96,N/A,50.75,N/A,50.75,N/A,43.96,N/A,45.28,N/A,45.28,N/A,49.81,221.40,221.40,43.96,188.40,,Hospital CPT 88305,HC So1 Tissue Level IV,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,580.00,580.00,348.00,348.00,N/A,81.20,N/A,45.28,N/A,333.96,N/A,197.20,N/A,109.52,N/A,81.20,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,333.96,N/A,45.28,N/A,81.20,N/A,50.75,N/A,50.75,N/A,81.20,N/A,45.28,N/A,45.28,N/A,49.81,348.00,348.00,45.28,348.00,,Hospital CPT 88305,HC So Tissue Level IV,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,580.00,580.00,348.00,348.00,N/A,81.20,N/A,45.28,N/A,333.96,N/A,197.20,N/A,109.52,N/A,81.20,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,333.96,N/A,45.28,N/A,81.20,N/A,50.75,N/A,50.75,N/A,81.20,N/A,45.28,N/A,45.28,N/A,49.81,348.00,348.00,45.28,348.00,,Hospital CPT 88305,HC Tissue Level IV,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,639.00,135.00,383.40,81.00,N/A,18.90,N/A,45.28,N/A,77.73,N/A,45.90,N/A,109.52,N/A,18.90,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,77.73,N/A,45.28,N/A,18.90,N/A,50.75,N/A,50.75,N/A,18.90,N/A,45.28,N/A,45.28,N/A,49.81,383.40,383.40,18.90,109.52,,Hospital CPT 88309,HC So Tissue Level VI,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,721.00,721.00,432.60,432.60,N/A,100.94,N/A,701.22,N/A,415.15,N/A,245.14,N/A,721.00,N/A,100.94,N/A,701.22,N/A,701.22,N/A,721.00,N/A,721.00,N/A,721.00,N/A,721.00,N/A,415.15,N/A,701.22,N/A,100.94,N/A,669.29,N/A,669.29,N/A,100.94,N/A,701.22,N/A,701.22,N/A,771.34,432.60,432.60,100.94,771.34,,Hospital CPT 88309,HC Tissue Level VI,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,796.00,1941.00,477.60,1164.60,N/A,271.74,N/A,701.22,N/A,1117.63,N/A,659.94,N/A,1696.20,N/A,271.74,N/A,701.22,N/A,701.22,N/A,1055.92,N/A,1696.20,N/A,1696.20,N/A,1696.20,N/A,1117.63,N/A,701.22,N/A,271.74,N/A,669.29,N/A,669.29,N/A,271.74,N/A,701.22,N/A,701.22,N/A,771.34,477.60,477.60,271.74,1696.20,,Hospital CPT 88311,HC Decalcification,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,149.00,128.00,89.40,76.80,N/A,17.92,N/A,128.00,N/A,73.70,N/A,43.52,N/A,128.00,N/A,17.92,N/A,128.00,N/A,128.00,N/A,128.00,N/A,128.00,N/A,128.00,N/A,128.00,N/A,73.70,N/A,128.00,N/A,17.92,N/A,8.65,N/A,8.65,N/A,17.92,N/A,128.00,N/A,128.00,N/A,128.00,89.40,89.40,8.65,128.00,,Hospital CPT 88311,HC So Decalcification,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,135.00,135.00,81.00,81.00,N/A,18.90,N/A,135.00,N/A,77.73,N/A,45.90,N/A,135.00,N/A,18.90,N/A,135.00,N/A,135.00,N/A,135.00,N/A,135.00,N/A,135.00,N/A,135.00,N/A,77.73,N/A,135.00,N/A,18.90,N/A,8.65,N/A,8.65,N/A,18.90,N/A,135.00,N/A,135.00,N/A,135.00,81.00,81.00,8.65,135.00,,Hospital CPT 88313,HC So Special Stain Grp 2,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,245.00,245.00,147.00,147.00,N/A,34.30,N/A,30.67,N/A,141.07,N/A,83.30,N/A,74.18,N/A,34.30,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,141.07,N/A,30.67,N/A,34.30,N/A,34.57,N/A,34.57,N/A,34.30,N/A,30.67,N/A,30.67,N/A,33.73,147.00,147.00,30.67,147.00,,Hospital CPT 88313,HC Special Stain Grp 2,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,271.00,229.00,162.60,137.40,N/A,32.06,N/A,30.67,N/A,131.86,N/A,77.86,N/A,74.18,N/A,32.06,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,131.86,N/A,30.67,N/A,32.06,N/A,34.57,N/A,34.57,N/A,32.06,N/A,30.67,N/A,30.67,N/A,33.73,162.60,162.60,30.67,137.40,,Hospital CPT 88332,HC Path Consult Surg Add'l Frozen,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,229.00,195.00,137.40,117.00,N/A,27.30,N/A,195.00,N/A,112.28,N/A,66.30,N/A,195.00,N/A,27.30,N/A,195.00,N/A,195.00,N/A,195.00,N/A,195.00,N/A,195.00,N/A,195.00,N/A,112.28,N/A,195.00,N/A,27.30,N/A,24.57,N/A,24.57,N/A,27.30,N/A,195.00,N/A,195.00,N/A,195.00,137.40,137.40,24.57,195.00,,Hospital CPT 88358,"HC Analysis, Tumor",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,269.00,237.00,161.40,142.20,N/A,33.18,N/A,79.98,N/A,136.46,N/A,80.58,N/A,237.00,N/A,33.18,N/A,79.98,N/A,79.98,N/A,236.91,N/A,237.00,N/A,237.00,N/A,237.00,N/A,136.46,N/A,79.98,N/A,33.18,N/A,152.32,N/A,152.32,N/A,33.18,N/A,79.98,N/A,79.98,N/A,87.98,161.40,161.40,33.18,237.00,,Hospital CPT 88360,"HC So1morph Analysis,Tumor,Ea Ab",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,647.00,647.00,388.20,388.20,N/A,90.58,N/A,142.00,N/A,372.54,N/A,219.98,N/A,343.50,N/A,90.58,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,372.54,N/A,142.00,N/A,90.58,N/A,152.32,N/A,152.32,N/A,90.58,N/A,142.00,N/A,142.00,N/A,156.20,388.20,388.20,90.58,388.20,,Hospital CPT 88360,"HC Morph Analysis,Tumor,Ea Ab",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,714.00,714.00,428.40,428.40,N/A,99.96,N/A,142.00,N/A,411.12,N/A,242.76,N/A,343.50,N/A,99.96,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,411.12,N/A,142.00,N/A,99.96,N/A,152.32,N/A,152.32,N/A,99.96,N/A,142.00,N/A,142.00,N/A,156.20,428.40,428.40,99.96,428.40,,Hospital CPT 88360,M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,N/A,N/A,218.00,218.00,130.80,130.80,N/A,218.00,N/A,218.00,N/A,218.00,N/A,74.12,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,N/A,218.00,130.80,130.80,74.12,218.00,,Hospital CPT 88360,"HC So Morph Analysis,Tumor,Ea Ab",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,647.00,647.00,388.20,388.20,N/A,90.58,N/A,142.00,N/A,372.54,N/A,219.98,N/A,343.50,N/A,90.58,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,372.54,N/A,142.00,N/A,90.58,N/A,152.32,N/A,152.32,N/A,90.58,N/A,142.00,N/A,142.00,N/A,156.20,388.20,388.20,90.58,388.20,,Hospital CPT 88361,"HC Morphometric Analy, Comp Asst/Discrt Serv",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,553.00,470.00,331.80,282.00,N/A,65.80,N/A,292.68,N/A,270.63,N/A,159.80,N/A,470.00,N/A,65.80,N/A,292.68,N/A,292.68,N/A,440.73,N/A,470.00,N/A,470.00,N/A,470.00,N/A,270.63,N/A,292.68,N/A,65.80,N/A,297.45,N/A,297.45,N/A,65.80,N/A,292.68,N/A,292.68,N/A,321.95,331.80,331.80,65.80,470.00,,Hospital CPT 88361,"HC So Morphometric Analy, Comp Asst/Discrt Serv",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,501.00,501.00,300.60,300.60,N/A,70.14,N/A,292.68,N/A,288.48,N/A,170.34,N/A,501.00,N/A,70.14,N/A,292.68,N/A,292.68,N/A,440.73,N/A,501.00,N/A,501.00,N/A,501.00,N/A,288.48,N/A,292.68,N/A,70.14,N/A,297.45,N/A,297.45,N/A,70.14,N/A,292.68,N/A,292.68,N/A,321.95,300.60,300.60,70.14,501.00,,Hospital CPT 88365,HC So Tissue in Situ Hybridization,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,522.00,522.00,313.20,313.20,N/A,73.08,N/A,144.96,N/A,300.57,N/A,177.48,N/A,343.50,N/A,73.08,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,300.57,N/A,142.00,N/A,73.08,N/A,152.32,N/A,152.32,N/A,73.08,N/A,142.00,N/A,148.54,N/A,132.95,313.20,313.20,73.08,343.50,,Hospital CPT 88365,HC Tissue in Situ Hybridization,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,576.00,490.00,345.60,294.00,N/A,68.60,N/A,144.96,N/A,282.14,N/A,166.60,N/A,343.50,N/A,68.60,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,282.14,N/A,142.00,N/A,68.60,N/A,152.32,N/A,152.32,N/A,68.60,N/A,142.00,N/A,148.54,N/A,132.95,345.60,345.60,68.60,343.50,,Hospital CPT 88367,"HC Morph Analy,Insitu, Dist Serv",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,816.00,816.00,489.60,489.60,N/A,114.24,N/A,70.66,N/A,469.85,N/A,277.44,N/A,707.98,N/A,114.24,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,469.85,N/A,292.68,N/A,114.24,N/A,297.45,N/A,297.45,N/A,114.24,N/A,292.68,N/A,70.66,N/A,77.73,489.60,489.60,70.66,707.98,,Hospital CPT 88374,HC M/Phmtrc Alys Ishquant/Semiq,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,826.00,826.00,495.60,495.60,N/A,115.64,N/A,142.00,N/A,475.61,N/A,280.84,N/A,343.50,N/A,115.64,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,475.61,N/A,142.00,N/A,115.64,N/A,152.32,N/A,152.32,N/A,115.64,N/A,142.00,N/A,142.00,N/A,156.20,495.60,495.60,115.64,495.60,,Hospital CPT 88374,HC So M/Phmtrc Alys Ishquant/Semiq,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,749.00,749.00,449.40,449.40,N/A,104.86,N/A,142.00,N/A,431.27,N/A,254.66,N/A,343.50,N/A,104.86,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,431.27,N/A,142.00,N/A,104.86,N/A,152.32,N/A,152.32,N/A,104.86,N/A,142.00,N/A,142.00,N/A,156.20,449.40,449.40,104.86,449.40,,Hospital CPT 88377,HC Ish Ea Multiplex Probe Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,733.00,733.00,439.80,439.80,N/A,102.62,N/A,146.87,N/A,422.06,N/A,249.22,N/A,343.50,N/A,102.62,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,422.06,N/A,142.00,N/A,102.62,N/A,152.32,N/A,152.32,N/A,102.62,N/A,142.00,N/A,302.50,N/A,332.75,439.80,439.80,102.62,439.80,,Hospital CPT 88377,HC So Chromogenic Ish,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,733.00,733.00,439.80,439.80,N/A,102.62,N/A,146.87,N/A,422.06,N/A,249.22,N/A,343.50,N/A,102.62,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,422.06,N/A,142.00,N/A,102.62,N/A,152.32,N/A,152.32,N/A,102.62,N/A,142.00,N/A,302.50,N/A,332.75,439.80,439.80,102.62,439.80,,Hospital 88740,HC Noninvasive Carboxyhgb,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 89190,HC Nasal Smear for Eosinophils,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,79.00,79.00,47.40,47.40,N/A,5.79,N/A,5.79,N/A,45.49,N/A,26.86,N/A,5.79,N/A,5.79,N/A,5.79,N/A,5.79,N/A,3.60,N/A,5.79,N/A,4.04,N/A,5.79,N/A,45.49,N/A,5.79,N/A,5.79,N/A,5.79,N/A,5.79,N/A,5.79,N/A,5.79,N/A,5.79,N/A,6.37,47.40,47.40,3.60,47.40,,Hospital CPT 89321,HC Semen Analysis Post Vasectomy,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,249.00,249.00,149.40,149.40,N/A,12.05,N/A,12.05,N/A,249.00,N/A,84.66,N/A,10.24,N/A,12.05,N/A,12.05,N/A,12.05,N/A,10.24,N/A,10.24,N/A,10.24,N/A,10.24,N/A,143.37,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,13.26,149.40,149.40,10.24,249.00,,Hospital HCPCS 90371,HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5ML IM SOSY,13533-0636-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2388.20,2388.20,1432.92,1432.92,N/A,334.35,N/A,2388.20,N/A,1342.65,N/A,811.99,N/A,1079.02,N/A,334.35,N/A,2388.20,N/A,2388.20,N/A,671.70,N/A,1079.02,N/A,1079.02,N/A,1079.02,N/A,1342.65,N/A,2388.20,N/A,334.35,N/A,1280.08,N/A,1280.08,N/A,334.35,N/A,2388.20,N/A,2388.20,N/A,2388.20,1432.92,1432.92,334.35,2388.20,,Hospital 90378,Respiratory Syncytial Virus Ig Im 50 Mg Ea,N/A,N/A,1945644.77,N/A,1167386.86,N/A,N/A,N/A,N/A,N/A,437452.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,437452.67,N/A,N/A,N/A,N/A,N/A,437452.67,N/A,437452.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,437452.67,1167386.86,N/A,N/A,,Hospital CPT 90471,HC Immunization Administration,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,60.93,N/A,70.25,N/A,41.48,N/A,122.00,N/A,17.08,N/A,60.93,N/A,60.93,N/A,91.74,N/A,122.00,N/A,122.00,N/A,122.00,N/A,70.25,N/A,60.93,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,60.93,N/A,60.93,N/A,67.02,73.20,73.20,17.08,122.00,,Hospital 90473,HC Immune Admin Oral/Nasal,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,N/A,875.02,N/A,525.01,N/A,122.50,N/A,40.12,N/A,501.00,N/A,297.50,N/A,355.37,N/A,122.50,N/A,38.26,N/A,38.26,N/A,347.89,N/A,355.37,N/A,355.37,N/A,355.37,N/A,501.00,N/A,38.26,N/A,122.50,N/A,469.02,N/A,469.02,N/A,122.50,N/A,38.26,N/A,54.56,N/A,60.02,N/A,N/A,38.26,525.01,,Hospital 90620,HC Menb 4c Vacc 2 Dose Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),234983.95,752.50,140990.37,451.50,9071.64,105.36,25216.97,120.40,134482.68,433.00,104200.87,255.86,104200.87,21.25,9071.64,105.36,34413.17,109.14,34413.17,109.14,104200.87,324.56,104200.87,21.25,104200.87,21.25,104200.87,21.25,134482.68,433.00,34413.17,109.14,9071.64,105.36,134482.68,403.34,134482.68,403.34,9071.64,105.36,34413.17,109.14,34413.17,15.49,9071.64,17.04,9071.64,140990.37,15.49,451.50,,Hospital 90633,HC Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,546.00,N/A,327.60,N/A,76.44,N/A,110.32,N/A,312.64,N/A,94.18,N/A,276.37,N/A,76.44,N/A,109.14,N/A,109.14,N/A,191.51,N/A,276.37,N/A,276.37,N/A,276.37,N/A,312.64,N/A,109.14,N/A,76.44,N/A,292.66,N/A,292.66,N/A,76.44,N/A,109.14,N/A,110.32,N/A,30.01,N/A,N/A,30.01,327.60,,Hospital 90636,HC Hepa/Hepb Vaccine Adult Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,899.00,N/A,539.40,N/A,120.57,N/A,64.57,N/A,514.21,N/A,305.66,N/A,400.37,N/A,120.57,N/A,60.93,N/A,60.93,N/A,280.04,N/A,400.37,N/A,400.37,N/A,400.37,N/A,514.21,N/A,177.64,N/A,120.57,N/A,68.34,N/A,68.34,N/A,120.57,N/A,177.64,N/A,188.25,N/A,68.00,N/A,N/A,60.93,539.40,,Hospital 90648,HC Hib Prp-T Vaccine 4 Dose Schedule Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),234983.95,705.00,140990.37,423.00,17354.43,98.70,25216.97,198.68,34784.37,400.17,104200.87,239.70,104200.87,542.45,17354.43,98.70,25358.66,198.26,25358.66,198.26,104200.87,705.00,104200.87,542.45,104200.87,542.45,104200.87,542.45,34784.37,400.17,25358.66,198.26,17354.43,98.70,34784.37,377.89,34784.37,377.89,17354.43,98.70,25358.66,198.26,25358.66,198.68,17354.43,42.98,17354.43,140990.37,42.98,705.00,,Hospital 90653,Iiv Adjuvanted Vaccine for Intramuscular Use,N/A,N/A,N/A,979.90,N/A,587.94,N/A,132.20,N/A,38.68,N/A,556.67,N/A,333.17,N/A,147.40,N/A,132.20,N/A,38.26,N/A,38.26,N/A,91.76,N/A,147.40,N/A,147.40,N/A,147.40,N/A,556.67,N/A,147.40,N/A,132.20,N/A,46.16,N/A,46.16,N/A,132.20,N/A,147.40,N/A,149.00,N/A,10.68,N/A,N/A,10.68,587.94,,Hospital 90674,HC Cciv4 Vac No Prsv 0.5 Ml Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,670.10,N/A,402.06,N/A,93.81,N/A,154.19,N/A,383.13,N/A,227.83,N/A,77.54,N/A,93.81,N/A,147.40,N/A,147.40,N/A,48.27,N/A,77.54,N/A,77.54,N/A,77.54,N/A,383.13,N/A,147.40,N/A,93.81,N/A,359.18,N/A,359.18,N/A,93.81,N/A,147.40,N/A,154.19,N/A,152.58,N/A,N/A,48.27,402.06,,Hospital HCPCS 90675,"RABIES VACCINE, PCEC IM SUSR",58160-0964-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),852.90,852.90,511.74,511.74,N/A,119.41,N/A,329.99,N/A,479.50,N/A,289.99,N/A,755.74,N/A,119.41,N/A,329.99,N/A,329.99,N/A,470.45,N/A,755.74,N/A,755.74,N/A,755.74,N/A,479.50,N/A,329.99,N/A,119.41,N/A,457.15,N/A,457.15,N/A,119.41,N/A,329.99,N/A,329.99,N/A,362.99,511.74,511.74,119.41,755.74,,Hospital 90697,HC Dtap-Ipv-Hib-Hepb Vaccine Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,903.00,N/A,541.80,N/A,126.42,N/A,187.68,N/A,514.08,N/A,307.02,N/A,432.00,N/A,126.42,N/A,185.66,N/A,185.66,N/A,852.31,N/A,432.00,N/A,432.00,N/A,432.00,N/A,514.08,N/A,185.66,N/A,126.42,N/A,484.01,N/A,484.01,N/A,126.42,N/A,185.66,N/A,187.68,N/A,17.04,N/A,N/A,17.04,852.31,,Hospital CPT 90834,HC Php Psych Tx 45 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,644.00,571.00,386.40,342.60,N/A,79.94,N/A,139.43,N/A,328.78,N/A,194.14,N/A,318.26,N/A,79.94,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,456.80,N/A,131.57,N/A,79.94,N/A,571.00,N/A,571.00,N/A,79.94,N/A,131.57,N/A,139.43,N/A,97.69,386.40,386.40,79.94,571.00,,Hospital CPT 90834,HC OP Tx 45 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,644.00,644.00,386.40,386.40,N/A,90.16,N/A,139.43,N/A,370.82,N/A,218.96,N/A,318.26,N/A,90.16,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,515.20,N/A,131.57,N/A,90.16,N/A,644.00,N/A,644.00,N/A,90.16,N/A,131.57,N/A,139.43,N/A,97.69,386.40,386.40,90.16,644.00,,Hospital CPT 90834,HC Iop Tx 45 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,644.00,571.00,386.40,342.60,N/A,79.94,N/A,139.43,N/A,328.78,N/A,194.14,N/A,318.26,N/A,79.94,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,456.80,N/A,131.57,N/A,79.94,N/A,571.00,N/A,571.00,N/A,79.94,N/A,131.57,N/A,139.43,N/A,97.69,386.40,386.40,79.94,571.00,,Hospital CPT 90839,HC Iop Crisis Tx First 60 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,714.00,714.00,428.40,428.40,N/A,99.96,N/A,139.43,N/A,411.12,N/A,242.76,N/A,318.26,N/A,99.96,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,571.20,N/A,131.57,N/A,99.96,N/A,714.00,N/A,714.00,N/A,99.96,N/A,131.57,N/A,139.43,N/A,137.48,428.40,428.40,99.96,714.00,,Hospital CPT 90839,HC Php Crisis Tx First 60 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,714.00,714.00,428.40,428.40,N/A,99.96,N/A,139.43,N/A,411.12,N/A,242.76,N/A,318.26,N/A,99.96,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,571.20,N/A,131.57,N/A,99.96,N/A,714.00,N/A,714.00,N/A,99.96,N/A,131.57,N/A,139.43,N/A,137.48,428.40,428.40,99.96,714.00,,Hospital CPT 90935,HC Hemodialysis,N/A,0821 - HEMODIALYSIS - OUTPATIENT OR HOME - HEMODIALYSIS COMPOSITE OR OTHER RATE,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,605.70,N/A,1017.44,N/A,600.78,N/A,1377.30,N/A,247.38,N/A,569.38,N/A,569.38,N/A,857.39,N/A,1377.30,N/A,1377.30,N/A,1377.30,N/A,1017.44,N/A,569.38,N/A,247.38,N/A,947.11,N/A,947.11,N/A,247.38,N/A,569.38,N/A,70.03,N/A,77.03,1060.20,1060.20,70.03,1377.30,,Hospital CPT 90937,HC Hemodialysis,N/A,0821 - HEMODIALYSIS - OUTPATIENT OR HOME - HEMODIALYSIS COMPOSITE OR OTHER RATE,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,100.21,N/A,1017.44,N/A,600.78,N/A,293.46,N/A,247.38,N/A,100.21,N/A,100.21,N/A,182.68,N/A,293.46,N/A,293.46,N/A,293.46,N/A,1017.44,N/A,100.21,N/A,247.38,N/A,947.11,N/A,947.11,N/A,247.38,N/A,100.21,N/A,100.21,N/A,110.23,1060.20,1060.20,100.21,1060.20,,Hospital 91038,"Gerd Tst W/ Mucos Impede Electrod,>1hr",N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,3582.00,N/A,2149.20,N/A,501.48,N/A,456.66,N/A,2062.52,N/A,1217.88,N/A,1055.99,N/A,501.48,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,2062.52,N/A,436.56,N/A,501.48,N/A,527.00,N/A,790.50,N/A,501.48,N/A,436.56,N/A,456.66,N/A,366.50,N/A,N/A,366.50,2149.20,,Hospital 91040,Esophgl Balo Distension Dx Std W/Provocation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10428.00,N/A,6256.80,N/A,1459.92,N/A,1236.45,N/A,6003.96,N/A,3545.52,N/A,2874.76,N/A,1459.92,N/A,1182.03,N/A,1182.03,N/A,1789.58,N/A,2874.76,N/A,2874.76,N/A,2874.76,N/A,5972.29,N/A,1182.03,N/A,1459.92,N/A,2134.50,N/A,2134.50,N/A,1459.92,N/A,1182.03,N/A,1236.45,N/A,673.06,N/A,N/A,673.06,6256.80,,Hospital 91110,HC GI Imag Intraluminal Esophagus-Ileum W/I&R,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,60979.47,6518.00,36587.68,3910.80,4790.49,912.52,5932.54,765.38,10795.76,3753.06,20733.02,2216.12,10899.03,1803.23,4938.09,912.52,5932.54,745.47,5932.54,745.47,6784.39,1122.54,10899.03,1803.23,10899.03,1803.23,10899.03,1803.23,10795.76,3753.06,5932.54,745.47,4938.09,912.52,12967.12,1871.00,12967.12,1871.00,N/A,912.52,5932.54,745.47,5932.54,765.38,5283.76,661.58,4790.49,36587.68,661.58,3910.80,,Hospital 91111,Gastrointestinal Tract Imaging Esophagus W/I&R,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13441.52,N/A,8064.91,N/A,1866.20,N/A,1233.51,N/A,7737.64,N/A,4570.11,N/A,2718.83,N/A,1866.20,N/A,1118.20,N/A,1118.20,N/A,1692.52,N/A,2718.83,N/A,2718.83,N/A,2718.83,N/A,7737.64,N/A,1118.20,N/A,1866.20,N/A,2806.50,N/A,2806.50,N/A,1866.20,N/A,1118.20,N/A,1272.96,N/A,1400.25,N/A,N/A,1118.20,8064.91,,Hospital 91301,HC Sarscov2 Vac 100mcg/0.5ml Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),71385.70,N/A,42831.42,N/A,18663.70,N/A,22343.84,N/A,52331.56,N/A,24271.14,N/A,44113.85,N/A,19238.76,N/A,4496.00,N/A,4496.00,N/A,27460.51,N/A,44113.85,N/A,44113.85,N/A,N/A,N/A,52331.56,N/A,22343.84,N/A,19238.76,N/A,50519.78,N/A,50519.78,N/A,N/A,N/A,22343.84,N/A,22343.84,N/A,20585.48,N/A,4496.00,52331.56,N/A,N/A,,Hospital 91312,HC Sarscov2 Vaccine Bivalent 30 Mcg/0.3 Ml Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,521.02,N/A,312.61,N/A,72.94,N/A,161.76,N/A,300.00,N/A,177.14,N/A,90.69,N/A,72.94,N/A,146.63,N/A,146.63,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,300.00,N/A,146.63,N/A,72.94,N/A,279.27,N/A,279.27,N/A,72.94,N/A,146.63,N/A,161.76,N/A,195.76,N/A,N/A,56.46,312.61,,Hospital 92004,HC Ophth Medical Xm&Eval Compre New Pt 1/> Vst,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,483.00,N/A,289.80,N/A,67.62,N/A,231.32,N/A,278.12,N/A,164.22,N/A,N/A,N/A,67.62,N/A,218.28,N/A,218.28,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,278.12,N/A,218.28,N/A,67.62,N/A,258.89,N/A,258.89,N/A,67.62,N/A,218.28,N/A,231.32,N/A,100.63,N/A,N/A,67.62,289.80,,Hospital 92071,HC Fit Contact Lens Tx Ocular Surface Disease,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,165.00,N/A,99.00,N/A,23.10,N/A,115.66,N/A,95.01,N/A,56.10,N/A,N/A,N/A,23.10,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,95.01,N/A,109.14,N/A,23.10,N/A,88.44,N/A,88.44,N/A,23.10,N/A,109.14,N/A,115.66,N/A,34.10,N/A,N/A,23.10,115.66,,Hospital 92082,HC Visual Field Exam Intermediate,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1743.00,N/A,1045.80,N/A,244.02,N/A,457.96,N/A,1003.62,N/A,592.62,N/A,1045.33,N/A,244.02,N/A,432.15,N/A,432.15,N/A,650.74,N/A,1045.33,N/A,1045.33,N/A,1045.33,N/A,1003.62,N/A,432.15,N/A,244.02,N/A,1743.00,N/A,1743.00,N/A,244.02,N/A,432.15,N/A,457.96,N/A,280.55,N/A,N/A,244.02,1743.00,,Hospital CPT 92507,HC Speech/Language Therapy,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,457.00,457.00,274.20,274.20,N/A,63.98,N/A,76.79,N/A,263.14,N/A,155.38,N/A,223.65,N/A,63.98,N/A,76.79,N/A,76.79,N/A,223.65,N/A,223.65,N/A,223.65,N/A,223.65,N/A,263.14,N/A,74.55,N/A,63.98,N/A,244.95,N/A,244.95,N/A,63.98,N/A,76.79,N/A,76.79,N/A,84.47,274.20,274.20,63.98,274.20,,Hospital CPT 92508,HC Speech Language Group - Rehab,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,246.00,246.00,147.60,147.60,N/A,34.44,N/A,22.93,N/A,141.65,N/A,83.64,N/A,68.94,N/A,34.44,N/A,22.93,N/A,22.93,N/A,68.94,N/A,68.94,N/A,68.94,N/A,68.94,N/A,141.65,N/A,22.98,N/A,34.44,N/A,131.86,N/A,131.86,N/A,34.44,N/A,22.93,N/A,22.93,N/A,25.22,147.60,147.60,22.93,147.60,,Hospital 92516,Facial Nerve Function Test,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65501.58,N/A,39300.95,N/A,9170.23,N/A,5125.97,N/A,37700.22,N/A,22270.54,N/A,12035.03,N/A,9170.23,N/A,4903.95,N/A,4903.95,N/A,7614.99,N/A,12035.03,N/A,12035.03,N/A,12035.03,N/A,37515.43,N/A,4919.45,N/A,9170.23,N/A,5963.00,N/A,5963.00,N/A,9170.23,N/A,4903.95,N/A,5125.97,N/A,1150.78,N/A,N/A,1150.78,39300.95,,Hospital CPT 92522,HC Speech Evaluation - Rehab,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,684.00,684.00,410.40,410.40,N/A,95.76,N/A,89.31,N/A,393.85,N/A,232.56,N/A,325.14,N/A,95.76,N/A,89.31,N/A,89.31,N/A,325.14,N/A,325.14,N/A,325.14,N/A,325.14,N/A,393.85,N/A,108.38,N/A,95.76,N/A,366.62,N/A,366.62,N/A,95.76,N/A,89.31,N/A,89.31,N/A,98.24,410.40,410.40,89.31,410.40,,Hospital CPT 92522,HC Eval of Speech Production,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,684.00,684.00,410.40,410.40,N/A,95.76,N/A,89.31,N/A,393.85,N/A,232.56,N/A,325.14,N/A,95.76,N/A,89.31,N/A,89.31,N/A,325.14,N/A,325.14,N/A,325.14,N/A,325.14,N/A,393.85,N/A,108.38,N/A,95.76,N/A,366.62,N/A,366.62,N/A,95.76,N/A,89.31,N/A,89.31,N/A,98.24,410.40,410.40,89.31,410.40,,Hospital CPT 92524,HC Behavral Qualit Analys Voice,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,311.00,311.00,186.60,186.60,N/A,43.54,N/A,87.42,N/A,179.07,N/A,105.74,N/A,311.00,N/A,43.54,N/A,87.42,N/A,87.42,N/A,311.00,N/A,311.00,N/A,311.00,N/A,311.00,N/A,179.07,N/A,107.14,N/A,43.54,N/A,166.70,N/A,166.70,N/A,43.54,N/A,87.42,N/A,87.42,N/A,96.16,186.60,186.60,43.54,311.00,,Hospital 92537,HC Cal Vstblr Test W/Rec 4 Irriga,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,3277.00,N/A,1966.20,N/A,458.78,N/A,261.32,N/A,1886.89,N/A,1114.18,N/A,635.34,N/A,458.78,N/A,262.66,N/A,262.66,N/A,395.50,N/A,635.34,N/A,635.34,N/A,635.34,N/A,1886.89,N/A,262.66,N/A,458.78,N/A,1756.47,N/A,1756.47,N/A,458.78,N/A,262.66,N/A,261.32,N/A,42.65,N/A,N/A,42.65,1966.20,,Hospital 92540,HC Eng Complete Test,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,73799.60,3349.00,44279.76,2009.40,6255.38,468.86,7665.43,134.06,14097.00,1928.35,25091.86,1138.66,14785.31,317.67,6448.12,468.86,4496.00,131.33,4496.00,131.33,9203.74,197.75,14785.31,317.67,14785.31,317.67,N/A,317.67,14097.00,1928.35,7665.43,131.33,6448.12,468.86,16932.34,1795.06,16932.34,1795.06,N/A,468.86,7665.43,131.33,7665.43,134.06,6899.48,78.32,4496.00,44279.76,78.32,2009.40,,Hospital 92541,HC Eng Spontaneous Nystagmus Test,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,3542.00,N/A,2125.20,N/A,495.88,N/A,526.28,N/A,2039.49,N/A,1204.28,N/A,1247.10,N/A,495.88,N/A,515.57,N/A,515.57,N/A,776.33,N/A,1247.10,N/A,1247.10,N/A,1247.10,N/A,2039.49,N/A,515.57,N/A,495.88,N/A,1898.51,N/A,1898.51,N/A,495.88,N/A,515.57,N/A,526.28,N/A,67.35,N/A,N/A,67.35,2125.20,,Hospital 92544,HC Eng Optokinetic Nystagmus Test,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,1859.00,N/A,1115.40,N/A,260.26,N/A,392.22,N/A,1070.41,N/A,632.06,N/A,929.43,N/A,260.26,N/A,384.24,N/A,384.24,N/A,578.58,N/A,929.43,N/A,929.43,N/A,929.43,N/A,1070.41,N/A,384.24,N/A,260.26,N/A,996.42,N/A,996.42,N/A,260.26,N/A,384.24,N/A,392.22,N/A,52.82,N/A,N/A,52.82,1115.40,,Hospital 92546,HC Sinusoidal Rotational Test,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,4741.00,N/A,2844.60,N/A,663.74,N/A,404.52,N/A,2729.87,N/A,1611.94,N/A,953.01,N/A,663.74,N/A,393.99,N/A,393.99,N/A,593.25,N/A,953.01,N/A,953.01,N/A,953.01,N/A,2729.87,N/A,393.99,N/A,663.74,N/A,2541.17,N/A,2541.17,N/A,663.74,N/A,393.99,N/A,404.52,N/A,175.25,N/A,N/A,175.25,2844.60,,Hospital 92547,HC Eng Vertical Electrodes,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,2941.00,N/A,1764.60,N/A,411.74,N/A,269.68,N/A,1693.43,N/A,999.94,N/A,635.34,N/A,411.74,N/A,262.66,N/A,262.66,N/A,395.50,N/A,635.34,N/A,635.34,N/A,635.34,N/A,1693.43,N/A,262.66,N/A,411.74,N/A,1576.37,N/A,1576.37,N/A,411.74,N/A,262.66,N/A,269.68,N/A,52.90,N/A,N/A,52.90,1764.60,,Hospital 92548,HC Computerized Post,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,4741.00,N/A,2844.60,N/A,663.74,N/A,404.52,N/A,2729.87,N/A,1611.94,N/A,953.01,N/A,663.74,N/A,393.99,N/A,393.99,N/A,593.25,N/A,953.01,N/A,953.01,N/A,953.01,N/A,2729.87,N/A,393.99,N/A,663.74,N/A,2541.17,N/A,2541.17,N/A,663.74,N/A,393.99,N/A,404.52,N/A,175.25,N/A,N/A,175.25,2844.60,,Hospital 92551,"HC Hearing Screen, Pure Tone, Air",N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,6787.80,N/A,4072.68,N/A,1079.73,N/A,1542.91,N/A,2433.25,N/A,2307.85,N/A,1589.00,N/A,1113.00,N/A,1542.91,N/A,1542.91,N/A,989.00,N/A,1589.00,N/A,1589.00,N/A,1589.00,N/A,2433.25,N/A,1542.91,N/A,1113.00,N/A,1352.00,N/A,1352.00,N/A,1684.16,N/A,1542.91,N/A,1542.91,N/A,1190.91,N/A,989.00,4072.68,N/A,N/A,,Hospital 92556,HC Audiomtry Sp Thresh W Sp Recog,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,981.00,N/A,588.60,N/A,137.34,N/A,103.95,N/A,564.86,N/A,333.54,N/A,253.64,N/A,137.34,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,564.86,N/A,104.85,N/A,137.34,N/A,525.82,N/A,525.82,N/A,137.34,N/A,104.85,N/A,103.95,N/A,82.99,N/A,N/A,82.99,588.60,,Hospital 92583,HC Select Picture Audiometry,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,785.00,N/A,471.00,N/A,109.90,N/A,116.10,N/A,452.00,N/A,266.90,N/A,757.19,N/A,109.90,N/A,109.14,N/A,109.14,N/A,757.19,N/A,757.19,N/A,757.19,N/A,757.19,N/A,452.00,N/A,109.14,N/A,109.90,N/A,420.76,N/A,420.76,N/A,109.90,N/A,109.14,N/A,116.10,N/A,100.65,N/A,N/A,100.65,757.19,,Hospital 92584,HC Electrocochleography,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,881.00,N/A,528.60,N/A,123.34,N/A,134.06,N/A,507.28,N/A,299.54,N/A,317.67,N/A,123.34,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,507.28,N/A,131.33,N/A,123.34,N/A,472.21,N/A,472.21,N/A,123.34,N/A,131.33,N/A,134.06,N/A,162.96,N/A,N/A,123.34,528.60,,Hospital 92592,"HC Hearing Aid Check, One Ear",N/A,0471 - AUDIOLOGY - DIAGNOSTIC,68640.10,22.00,41184.06,13.20,11591.60,3.08,13977.90,134.06,34340.00,12.67,23337.63,7.48,26372.49,3.08,11948.75,3.08,2248.00,134.06,2248.00,134.06,16416.26,1.91,26372.49,3.08,26372.49,3.08,26372.49,3.08,34340.00,12.67,13977.90,134.06,11948.75,3.08,31376.68,11.79,31376.68,11.79,N/A,3.08,13977.90,134.06,13977.90,134.06,12785.17,N/A,2248.00,41184.06,1.91,134.06,,Hospital CPT 92597,HC Voice Prosthesis Eval,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,667.00,667.00,400.20,400.20,N/A,93.38,N/A,71.23,N/A,384.06,N/A,226.78,N/A,210.30,N/A,93.38,N/A,71.23,N/A,71.23,N/A,210.30,N/A,210.30,N/A,210.30,N/A,210.30,N/A,384.06,N/A,70.10,N/A,93.38,N/A,357.51,N/A,357.51,N/A,93.38,N/A,71.23,N/A,71.23,N/A,78.35,400.20,400.20,70.10,400.20,,Hospital 92606,HC Sp Ther Svs Use of Non Spc Gen De,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,N/A,1171.00,N/A,702.60,N/A,163.94,N/A,146.83,N/A,674.26,N/A,398.14,N/A,450.05,N/A,163.94,N/A,146.83,N/A,146.83,N/A,441.41,N/A,450.05,N/A,450.05,N/A,450.05,N/A,674.26,N/A,142.41,N/A,163.94,N/A,627.66,N/A,627.66,N/A,163.94,N/A,146.83,N/A,146.83,N/A,161.51,N/A,N/A,142.41,702.60,,Hospital 92608,HC Sp Eval Speech-Gen Dvc Addl 30m,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,N/A,2183.00,N/A,1309.80,N/A,305.62,N/A,324.01,N/A,1256.97,N/A,742.22,N/A,944.31,N/A,305.62,N/A,324.01,N/A,324.01,N/A,892.32,N/A,944.31,N/A,944.31,N/A,944.31,N/A,1256.97,N/A,315.58,N/A,305.62,N/A,1170.09,N/A,1170.09,N/A,305.62,N/A,324.01,N/A,324.01,N/A,356.41,N/A,N/A,305.62,1309.80,,Hospital CPT 92612,HC Endo Swallow Tst (Fees),N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,580.00,580.00,348.00,348.00,N/A,81.20,N/A,64.58,N/A,333.96,N/A,197.20,N/A,538.23,N/A,81.20,N/A,64.58,N/A,64.58,N/A,335.05,N/A,538.23,N/A,538.23,N/A,538.23,N/A,333.96,N/A,64.58,N/A,81.20,N/A,310.88,N/A,310.88,N/A,81.20,N/A,64.58,N/A,64.58,N/A,71.04,348.00,348.00,64.58,538.23,,Hospital 92621,HC Eval Central Auditory Funcj W/Reprt Ea 15 Min,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,153432.63,N/A,92059.58,N/A,32492.64,N/A,N/A,N/A,84572.07,N/A,52167.09,N/A,73925.25,N/A,33493.80,N/A,1686.00,N/A,1686.00,N/A,46016.75,N/A,73925.25,N/A,73925.25,N/A,73925.25,N/A,84572.07,N/A,38702.76,N/A,33493.80,N/A,87952.60,N/A,87952.60,N/A,4741.26,N/A,38702.76,N/A,38702.76,N/A,35838.36,N/A,1686.00,92059.58,N/A,N/A,,Hospital CPT 92651,HC Aep Hearing Status Deter Broadband Stimuli I&R,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,339.00,339.00,203.40,203.40,N/A,47.46,N/A,130.19,N/A,195.20,N/A,115.26,N/A,317.67,N/A,47.46,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,195.20,N/A,131.33,N/A,47.46,N/A,181.70,N/A,181.70,N/A,47.46,N/A,131.33,N/A,130.19,N/A,91.25,203.40,203.40,47.46,317.67,,Hospital CPT 92652,HC Aep Threshold Estimation Mlt Frequencies I&R,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,651.00,651.00,390.60,390.60,N/A,91.14,N/A,250.72,N/A,374.85,N/A,221.34,N/A,611.76,N/A,91.14,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,374.85,N/A,252.91,N/A,91.14,N/A,348.94,N/A,348.94,N/A,91.14,N/A,252.91,N/A,250.72,N/A,120.47,390.60,390.60,91.14,611.76,,Hospital CPT 92924,HC Prq Card Angio/Athrect 1 Art,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,29365.00,29365.00,17619.00,17619.00,N/A,4111.10,N/A,10027.43,N/A,16908.37,N/A,9984.10,N/A,23187.86,N/A,4111.10,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,23187.86,N/A,23187.86,N/A,23187.86,N/A,16908.37,N/A,9586.05,N/A,4111.10,N/A,11660.00,N/A,11660.00,N/A,4111.10,N/A,9586.05,N/A,10027.43,N/A,666.56,17619.00,17619.00,666.56,23187.86,,Hospital CPT 92928,HC Prq Card Stent W/Angio 1 Vsl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,10832.00,10832.00,6499.20,6499.20,N/A,1516.48,N/A,9586.05,N/A,6237.07,N/A,3682.88,N/A,10832.00,N/A,1516.48,N/A,9586.05,N/A,9586.05,N/A,10832.00,N/A,10832.00,N/A,10832.00,N/A,10832.00,N/A,6237.07,N/A,9586.05,N/A,1516.48,N/A,7897.00,N/A,7897.00,N/A,1516.48,N/A,9586.05,N/A,9586.05,N/A,10544.65,6499.20,6499.20,1516.48,10832.00,,Hospital CPT 92929,HC Prq Card Stent W/Angio Addl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,7519.00,7519.00,4511.40,4511.40,N/A,1052.66,N/A,7519.00,N/A,4329.44,N/A,2556.46,N/A,7519.00,N/A,1052.66,N/A,7519.00,N/A,7519.00,N/A,7519.00,N/A,7519.00,N/A,7519.00,N/A,7519.00,N/A,4329.44,N/A,7519.00,N/A,1052.66,N/A,7897.00,N/A,7897.00,N/A,1052.66,N/A,7519.00,N/A,7519.00,N/A,7519.00,4511.40,4511.40,1052.66,7897.00,,Hospital CPT 92937,HC Prq Revasc Byp Graft 1 Vsl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,17245.00,17245.00,10347.00,10347.00,N/A,2414.30,N/A,565.05,N/A,9929.67,N/A,5863.30,N/A,17245.00,N/A,2414.30,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,9929.67,N/A,9586.05,N/A,2414.30,N/A,7897.00,N/A,7897.00,N/A,2414.30,N/A,9586.05,N/A,10387.29,N/A,621.56,10347.00,10347.00,565.05,17245.00,,Hospital CPT 92938,HC Prq Revasc Byp Graft Addl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,26585.00,26585.00,15951.00,15951.00,N/A,3721.90,N/A,26585.00,N/A,15307.64,N/A,9038.90,N/A,26585.00,N/A,3721.90,N/A,26585.00,N/A,26585.00,N/A,26585.00,N/A,26585.00,N/A,26585.00,N/A,26585.00,N/A,15307.64,N/A,26585.00,N/A,3721.90,N/A,7897.00,N/A,7897.00,N/A,3721.90,N/A,26585.00,N/A,26585.00,N/A,26585.00,15951.00,15951.00,3721.90,26585.00,,Hospital CPT 92975,HC Intracoronary Thrombolysis,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,148.00,148.00,88.80,88.80,N/A,20.72,N/A,361.31,N/A,85.22,N/A,50.32,N/A,148.00,N/A,20.72,N/A,361.31,N/A,361.31,N/A,148.00,N/A,148.00,N/A,148.00,N/A,148.00,N/A,85.22,N/A,361.31,N/A,20.72,N/A,148.00,N/A,148.00,N/A,20.72,N/A,361.31,N/A,361.31,N/A,397.44,88.80,88.80,20.72,397.44,,Hospital CPT 92986,HC Perc Balloon Valvuloplasty; Aortic Valve,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,12890.00,12890.00,7734.00,7734.00,N/A,1804.60,N/A,4709.71,N/A,7422.06,N/A,4382.60,N/A,11392.42,N/A,1804.60,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,11392.42,N/A,11392.42,N/A,11392.42,N/A,7422.06,N/A,4709.71,N/A,1804.60,N/A,7897.00,N/A,7897.00,N/A,1804.60,N/A,4709.71,N/A,4709.71,N/A,5180.69,7734.00,7734.00,1804.60,11392.42,,Hospital CPT 93017,HC Cardiac Stress Test,N/A,0482 - CARDIOLOGY - STRESS TEST,2387.00,2387.00,1432.20,1432.20,N/A,334.18,N/A,252.91,N/A,1374.43,N/A,811.58,N/A,611.76,N/A,334.18,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,1374.43,N/A,252.91,N/A,334.18,N/A,1279.43,N/A,1279.43,N/A,334.18,N/A,252.91,N/A,252.91,N/A,278.20,1432.20,1432.20,252.91,1432.20,,Hospital 93224,Wmhc Holter Monitor - Complete,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,2476.00,N/A,1485.60,N/A,346.64,N/A,109.68,N/A,1425.68,N/A,841.84,N/A,253.64,N/A,346.64,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,1425.68,N/A,104.85,N/A,346.64,N/A,1327.14,N/A,1327.14,N/A,346.64,N/A,104.85,N/A,109.68,N/A,84.49,N/A,N/A,84.49,1485.60,,Hospital CPT 93225,HC Holter Monitor,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,1592.00,1592.00,955.20,955.20,N/A,222.88,N/A,104.85,N/A,916.67,N/A,541.28,N/A,253.64,N/A,222.88,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,916.67,N/A,104.85,N/A,222.88,N/A,853.31,N/A,853.31,N/A,222.88,N/A,104.85,N/A,104.85,N/A,115.34,955.20,955.20,104.85,955.20,,Hospital 93243,HC External Ecg Rec>48hr<7d Scanning Alys W/Report,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,50631.80,804.00,30379.08,482.40,6749.90,112.56,8250.42,113.39,15211.44,462.94,17214.81,273.36,15356.95,634.15,6957.87,112.56,8250.42,109.14,8250.42,109.14,9559.34,634.15,15356.95,634.15,15356.95,634.15,15356.95,634.15,15211.44,462.94,8250.42,109.14,6957.87,112.56,18270.93,430.95,18270.93,430.95,4913.12,112.56,8250.42,109.14,8250.42,113.39,7444.92,13.88,4913.12,30379.08,13.88,634.15,,Hospital 93247,HC External Ecg Rec>7d<15d Scanning Alys W/Report,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,30405.20,646.00,18243.12,387.60,4548.83,90.44,5646.67,12.62,10251.16,371.96,10337.77,219.64,10751.69,253.64,4688.99,90.44,1124.00,104.85,1124.00,104.85,6692.84,157.89,10751.69,253.64,10751.69,253.64,10751.69,253.64,10251.16,371.96,5646.67,104.85,4688.99,90.44,12312.99,346.26,12312.99,346.26,3740.76,90.44,5646.67,104.85,5646.67,12.62,5017.22,13.88,1124.00,18243.12,12.62,387.60,,Hospital 93261,HC Interrogation Eval F2f Implant Subq Lead Defib,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,3481.00,N/A,2088.60,N/A,502.24,N/A,485.43,N/A,2004.36,N/A,1183.52,N/A,1112.41,N/A,502.24,N/A,467.74,N/A,467.74,N/A,692.50,N/A,1112.41,N/A,1112.41,N/A,1112.41,N/A,2004.38,N/A,576.88,N/A,502.24,N/A,1634.86,N/A,1634.86,N/A,502.24,N/A,576.88,N/A,598.82,N/A,242.45,N/A,N/A,242.45,2088.60,,Hospital 93270,HC Event Monitor - Hookup,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,48258.82,785.00,28955.29,471.00,5254.60,109.90,6481.56,32.26,11841.67,452.00,16408.00,143.14,11954.95,76.46,5416.50,109.90,2248.00,51.91,2248.00,51.91,7441.68,47.60,11954.95,76.46,11954.95,76.46,11954.95,76.46,11841.67,452.00,6481.56,51.91,5416.50,109.90,14223.40,420.76,14223.40,420.76,5057.53,109.90,6481.56,51.91,6481.56,52.99,5795.66,14.19,2248.00,28955.29,14.19,471.00,,Hospital 93279,HC Prog Eval Sng Lead Pacemaker,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,77805.33,355.00,46683.20,213.00,12504.35,49.70,10053.58,113.39,38469.35,204.42,26453.81,120.70,31755.77,N/A,12889.63,49.70,10023.93,109.14,10023.93,109.14,19767.71,N/A,31755.77,N/A,31755.77,N/A,31755.77,N/A,38469.35,204.42,10023.93,109.14,12889.63,49.70,36367.14,190.28,36367.14,190.28,3659.01,49.70,10023.93,109.14,10053.58,113.39,13791.91,43.31,3659.01,46683.20,43.31,213.00,,Hospital 93282,HC Prog Eval Single Lead Icd,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,70986.60,680.00,42591.96,408.00,10440.92,95.20,12616.71,120.40,23529.46,391.54,N/A,231.20,23754.54,N/A,10762.62,95.20,12616.71,109.14,12616.71,109.14,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,23529.46,391.54,12616.71,109.14,10762.62,95.20,28261.97,364.48,28261.97,364.48,4771.37,95.20,12616.71,109.14,12616.71,36.67,11516.01,40.34,4771.37,42591.96,36.67,408.00,,Hospital CPT 93284,HC Prog Eval Multi Lead Icd,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,318.00,318.00,190.80,190.80,N/A,44.52,N/A,34.87,N/A,183.10,N/A,108.12,N/A,76.46,N/A,44.52,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,183.10,N/A,31.61,N/A,44.52,N/A,170.45,N/A,170.45,N/A,44.52,N/A,31.61,N/A,42.69,N/A,46.96,190.80,190.80,31.61,190.80,,Hospital 93296,HC Interr Remte Pacemak-Icd Tech,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,44548.20,192.00,26728.92,115.20,7153.52,26.88,11440.56,32.45,44548.20,110.55,15146.39,65.28,22501.29,76.46,8244.63,26.88,11440.56,31.61,11440.56,31.61,5734.03,47.60,22501.29,76.46,22501.29,76.46,22501.29,76.46,16247.00,110.55,11437.28,31.61,24269.34,26.88,22572.00,102.91,22572.00,102.91,24269.34,26.88,11440.56,31.61,11440.56,32.45,8821.76,22.81,5734.03,44548.20,22.81,115.20,,Hospital 93298,Rem Interrog Scrms <30 D Phys/Qhp,N/A,N/A,N/A,195.00,N/A,117.00,N/A,27.30,N/A,25.46,N/A,112.28,N/A,66.30,N/A,75.03,N/A,27.30,N/A,25.46,N/A,25.46,N/A,46.71,N/A,75.03,N/A,75.03,N/A,75.03,N/A,112.28,N/A,25.46,N/A,27.30,N/A,104.52,N/A,104.52,N/A,27.30,N/A,25.46,N/A,25.46,N/A,28.01,N/A,N/A,25.46,117.00,,Hospital 93303,HC Echo Cong Anom Complete,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,19661.00,3559.00,11796.60,2135.40,1079.73,498.26,1542.91,575.21,2433.25,2049.28,6684.74,1210.06,1589.00,1363.03,1113.00,498.26,1542.91,563.49,1542.91,563.49,989.00,848.51,1589.00,1363.03,1589.00,1363.03,1589.00,1363.03,2433.25,2049.28,1542.91,563.49,1113.00,498.26,2704.00,1907.63,2704.00,1907.63,2521.56,498.26,1542.91,563.49,1542.91,575.21,1190.91,214.99,989.00,11796.60,214.99,2135.40,,Hospital 93304,HC Echo Cong. Anom - Lmt,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,32653.60,1577.00,19592.16,946.20,7975.79,220.78,9700.59,1046.12,17974.09,908.04,11102.22,536.18,16493.33,1577.00,8221.54,220.78,9700.59,987.16,9700.59,987.16,10266.29,1486.46,16493.33,1577.00,16493.33,1577.00,16493.33,1577.00,17974.09,908.04,9700.59,987.16,8221.54,220.78,8320.00,845.27,8320.00,845.27,2782.52,220.78,9700.59,987.16,9700.59,1046.12,8797.05,337.99,2782.52,19592.16,220.78,1577.00,,Hospital CPT 93306,HC 2d Echo Without Contrast - With Dop/Color Flow,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,3344.00,3344.00,2006.40,2006.40,N/A,468.16,N/A,454.35,N/A,1925.48,N/A,1136.96,N/A,1099.02,N/A,468.16,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,1925.48,N/A,454.35,N/A,468.16,N/A,1792.38,N/A,1792.38,N/A,468.16,N/A,454.35,N/A,454.35,N/A,499.78,2006.40,2006.40,454.35,2006.40,,Hospital 93313,HC Transesophageal Echo,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,108345.42,17344.82,65007.25,10406.89,9470.12,2428.27,15391.99,501.20,16967.09,9985.62,36837.44,5897.24,N/A,1109.90,9470.12,2428.27,15391.99,454.35,15391.99,454.35,N/A,690.93,N/A,1109.90,N/A,1109.90,N/A,1109.90,59719.99,9985.62,31193.81,454.35,9470.12,2428.27,16967.09,9296.82,70770.44,9296.82,9470.12,2428.27,15391.99,454.35,31193.81,11.07,9470.12,12.18,9470.12,70770.44,11.07,10406.89,,Hospital CPT 93315,HC Tee Cong Anom,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,1331.00,1331.00,798.60,798.60,N/A,186.34,N/A,475.27,N/A,766.39,N/A,452.54,N/A,1099.02,N/A,186.34,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,766.39,N/A,454.35,N/A,186.34,N/A,713.42,N/A,713.42,N/A,186.34,N/A,454.35,N/A,475.27,N/A,1331.00,798.60,798.60,186.34,1331.00,,Hospital 93319,HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,254244.03,17786.00,152546.42,10671.60,29778.92,2490.04,21466.05,501.20,140139.31,10240.17,86442.97,6047.24,88527.77,1103.99,26057.87,2490.04,562.00,454.35,562.00,454.35,55120.11,687.26,88527.77,1103.99,88527.77,1103.99,88527.77,1103.99,140139.31,10240.17,21466.05,454.35,26057.87,2490.04,183291.62,9533.30,183291.62,9533.30,26057.87,2490.04,21466.05,454.35,21466.05,144.41,27881.92,158.86,562.00,183291.62,144.41,10671.60,,Hospital CPT 93350,HC Stress Echo WO Contrast,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,2598.00,2598.00,1558.80,1558.80,N/A,363.72,N/A,454.35,N/A,1495.93,N/A,883.32,N/A,1099.02,N/A,363.72,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,1495.93,N/A,454.35,N/A,363.72,N/A,1392.53,N/A,1392.53,N/A,363.72,N/A,454.35,N/A,454.35,N/A,499.78,1558.80,1558.80,363.72,1558.80,,Hospital CPT 93351,HC 2d Echo Stress Tst Rest&Cardio,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,1511.00,1511.00,906.60,906.60,N/A,211.54,N/A,501.20,N/A,870.03,N/A,513.74,N/A,1099.02,N/A,211.54,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,870.03,N/A,454.35,N/A,211.54,N/A,809.90,N/A,809.90,N/A,211.54,N/A,454.35,N/A,136.47,N/A,150.12,906.60,906.60,136.47,1099.02,,Hospital CPT 93355,HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,1998.00,1998.00,1198.80,1198.80,N/A,279.72,N/A,219.73,N/A,1150.45,N/A,679.32,N/A,1998.00,N/A,279.72,N/A,1998.00,N/A,1998.00,N/A,1998.00,N/A,1998.00,N/A,1998.00,N/A,1998.00,N/A,1150.45,N/A,1998.00,N/A,279.72,N/A,1070.93,N/A,1070.93,N/A,279.72,N/A,1998.00,N/A,219.73,N/A,241.70,1198.80,1198.80,219.73,1998.00,,Hospital CPT 93454,HC Coronary Artery Cath WO Graft,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9758.00,9758.00,5854.80,5854.80,N/A,1366.12,N/A,2842.02,N/A,5618.66,N/A,3317.72,N/A,6462.39,N/A,1366.12,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,5618.66,N/A,2671.61,N/A,1366.12,N/A,5963.00,N/A,5963.00,N/A,1366.12,N/A,2671.61,N/A,2700.54,N/A,2938.77,5854.80,5854.80,1366.12,6462.39,,Hospital CPT 93457,HC Rh With Coron With Graft Nolv,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,14139.00,14139.00,8483.40,8483.40,N/A,1979.46,N/A,2727.17,N/A,8141.24,N/A,4807.26,N/A,6462.39,N/A,1979.46,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,8141.24,N/A,2671.61,N/A,1979.46,N/A,5963.00,N/A,5963.00,N/A,1979.46,N/A,2671.61,N/A,833.85,N/A,917.24,8483.40,8483.40,833.85,8483.40,,Hospital CPT 93462,HC L Hrt Cath Trnsptl Puncture,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,7176.00,7176.00,4305.60,4305.60,N/A,1004.64,N/A,7176.00,N/A,4131.94,N/A,2439.84,N/A,7176.00,N/A,1004.64,N/A,7176.00,N/A,7176.00,N/A,7176.00,N/A,7176.00,N/A,7176.00,N/A,7176.00,N/A,4131.94,N/A,7176.00,N/A,1004.64,N/A,527.00,N/A,527.00,N/A,1004.64,N/A,7176.00,N/A,201.19,N/A,221.31,4305.60,4305.60,201.19,7176.00,,Hospital CPT 93463,HC Drug Admin & Hemodynmic Meas,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,154.00,154.00,92.40,92.40,N/A,21.56,N/A,154.00,N/A,88.67,N/A,52.36,N/A,154.00,N/A,21.56,N/A,154.00,N/A,154.00,N/A,154.00,N/A,154.00,N/A,154.00,N/A,154.00,N/A,88.67,N/A,154.00,N/A,21.56,N/A,527.00,N/A,527.00,N/A,21.56,N/A,154.00,N/A,154.00,N/A,104.97,92.40,92.40,21.56,527.00,,Hospital 93532,HC R&L Heart Cath Congenital,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,N/A,130563.55,N/A,78338.13,N/A,17840.10,N/A,10205.35,N/A,75112.88,N/A,44391.60,N/A,23339.32,N/A,17840.10,N/A,9593.91,N/A,9593.91,N/A,14529.18,N/A,23339.32,N/A,23339.32,N/A,23339.32,N/A,75112.88,N/A,9593.91,N/A,17840.10,N/A,20405.00,N/A,17621.75,N/A,17840.10,N/A,9593.91,N/A,10205.35,N/A,2317.23,N/A,N/A,2317.23,78338.13,,Hospital 93561,HC Thermil Cardiac Output,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,239726.47,N/A,143835.88,N/A,22062.33,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,22062.33,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,22062.33,N/A,N/A,N/A,N/A,N/A,22062.33,N/A,N/A,N/A,N/A,N/A,22062.33,N/A,22062.33,143835.88,N/A,N/A,,Hospital CPT 93567,HC Aortic Root Injection,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1808.00,1808.00,1084.80,1084.80,N/A,253.12,N/A,1808.00,N/A,1041.05,N/A,614.72,N/A,1808.00,N/A,253.12,N/A,1808.00,N/A,1808.00,N/A,1808.00,N/A,1808.00,N/A,1808.00,N/A,1808.00,N/A,1041.05,N/A,1808.00,N/A,253.12,N/A,527.00,N/A,527.00,N/A,253.12,N/A,1808.00,N/A,1808.00,N/A,1808.00,1084.80,1084.80,253.12,1808.00,,Hospital CPT 93571,HC Ffr 1st Vessel,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,4601.00,4601.00,2760.60,2760.60,N/A,644.14,N/A,4601.00,N/A,2649.26,N/A,1564.34,N/A,4601.00,N/A,644.14,N/A,4601.00,N/A,4601.00,N/A,4601.00,N/A,4601.00,N/A,4601.00,N/A,4601.00,N/A,2649.26,N/A,4601.00,N/A,644.14,N/A,2466.14,N/A,2466.14,N/A,644.14,N/A,4601.00,N/A,4601.00,N/A,4601.00,2760.60,2760.60,644.14,4601.00,,Hospital 93573,HC Njx Drg C-Cathj Slctv P-Art Angiography Bi,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,102867.97,N/A,61720.78,N/A,11314.73,N/A,13650.39,N/A,25636.04,N/A,34975.11,N/A,26743.69,N/A,N/A,N/A,N/A,N/A,13650.39,N/A,16647.73,N/A,26743.69,N/A,26743.69,N/A,26743.69,N/A,25636.04,N/A,13650.39,N/A,11663.36,N/A,N/A,N/A,30627.24,N/A,N/A,N/A,13650.39,N/A,13650.39,N/A,12479.79,N/A,11314.73,61720.78,N/A,N/A,,Hospital CPT 93582,HC Perq Transcath Closure Pda,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,42150.00,42150.00,25290.00,25290.00,N/A,5901.00,N/A,16226.30,N/A,24269.97,N/A,14331.00,N/A,37522.38,N/A,5901.00,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,24269.97,N/A,15512.06,N/A,5901.00,N/A,16637.00,N/A,16637.00,N/A,5901.00,N/A,15512.06,N/A,16226.30,N/A,700.17,25290.00,25290.00,700.17,37522.38,,Hospital CPT 93583,HC Percutaneous Transcatheter Septal Reduction Ther,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,46788.00,46788.00,28072.80,28072.80,N/A,6550.32,N/A,710.92,N/A,26940.53,N/A,15907.92,N/A,37522.73,N/A,6550.32,N/A,710.92,N/A,710.92,N/A,23358.63,N/A,37522.73,N/A,37522.73,N/A,37522.73,N/A,26940.53,N/A,710.92,N/A,6550.32,N/A,46788.00,N/A,46788.00,N/A,6550.32,N/A,710.92,N/A,710.92,N/A,782.01,28072.80,28072.80,710.92,46788.00,,Hospital CPT 93594,HC R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13028.00,13028.00,7816.80,7816.80,N/A,1823.92,N/A,13028.00,N/A,7501.52,N/A,4429.52,N/A,1823.92,N/A,1823.92,N/A,13028.00,N/A,13028.00,N/A,1133.44,N/A,1823.92,N/A,1823.92,N/A,1823.92,N/A,7501.52,N/A,13028.00,N/A,1823.92,N/A,13028.00,N/A,13028.00,N/A,1823.92,N/A,13028.00,N/A,13028.00,N/A,13028.00,7816.80,7816.80,1133.44,13028.00,,Hospital CPT 93619,HC Ep Study WO Attempt/Induc Arrh,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,6359.89,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,6079.94,N/A,1842.26,N/A,7897.00,N/A,7897.00,N/A,1842.26,N/A,6079.94,N/A,6359.89,N/A,13159.00,7895.40,7895.40,1842.26,13159.00,,Hospital CPT 93642,HC Ep Eval Single/Dual Icd Flw Up,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4637.00,4637.00,2782.20,2782.20,N/A,649.18,N/A,1019.67,N/A,2669.98,N/A,1576.58,N/A,2440.09,N/A,649.18,N/A,1008.75,N/A,1008.75,N/A,1519.00,N/A,2440.09,N/A,2440.09,N/A,2440.09,N/A,2669.98,N/A,1008.75,N/A,649.18,N/A,1871.00,N/A,1871.00,N/A,649.18,N/A,1008.75,N/A,1019.67,N/A,80.36,2782.20,2782.20,80.36,2782.20,,Hospital 93644,HC Ephys Eval Subq Implantable Defibrillator,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,24536.08,N/A,14721.65,N/A,3385.95,N/A,1368.82,N/A,14045.33,N/A,8342.27,N/A,3384.99,N/A,3385.95,N/A,1354.15,N/A,1354.15,N/A,2107.22,N/A,3384.99,N/A,3384.99,N/A,3384.99,N/A,14045.33,N/A,1354.15,N/A,3385.95,N/A,2134.50,N/A,2134.50,N/A,3385.95,N/A,1354.15,N/A,1368.82,N/A,224.27,N/A,N/A,224.27,14721.65,,Hospital CPT 93655,HC Ablate Arrhythmia Add On,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11279.00,11279.00,6767.40,6767.40,N/A,1579.06,N/A,298.24,N/A,6494.45,N/A,3834.86,N/A,11279.00,N/A,1579.06,N/A,11279.00,N/A,11279.00,N/A,11279.00,N/A,11279.00,N/A,11279.00,N/A,11279.00,N/A,6494.45,N/A,11279.00,N/A,1579.06,N/A,527.00,N/A,527.00,N/A,1579.06,N/A,11279.00,N/A,11279.00,N/A,328.06,6767.40,6767.40,298.24,11279.00,,Hospital CPT 93657,HC Ep Tx L/R Atrial Fib Addl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,14712.00,14712.00,8827.20,8827.20,N/A,2059.68,N/A,297.94,N/A,8471.17,N/A,5002.08,N/A,14712.00,N/A,2059.68,N/A,14712.00,N/A,14712.00,N/A,14712.00,N/A,14712.00,N/A,14712.00,N/A,14712.00,N/A,8471.17,N/A,14712.00,N/A,2059.68,N/A,527.00,N/A,527.00,N/A,2059.68,N/A,14712.00,N/A,297.94,N/A,327.73,8827.20,8827.20,297.94,14712.00,,Hospital CPT 93660,HC Tilt Table Test,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,3524.00,3524.00,2114.40,2114.40,N/A,493.36,N/A,436.56,N/A,2029.12,N/A,1198.16,N/A,1055.99,N/A,493.36,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,2029.12,N/A,436.56,N/A,493.36,N/A,1888.86,N/A,1888.86,N/A,493.36,N/A,436.56,N/A,436.56,N/A,480.21,2114.40,2114.40,436.56,2114.40,,Hospital 93788,HC Abpm Scan and Report,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,17182.20,1288.00,10309.32,772.80,3606.74,180.32,4561.88,109.68,8128.07,741.63,4211.31,437.92,5349.54,253.64,3717.87,180.32,4532.23,104.85,4532.23,104.85,3331.13,157.89,5349.54,253.64,5349.54,253.64,5349.54,253.64,8128.07,741.63,4532.23,104.85,3717.87,180.32,9762.88,690.37,9762.88,690.37,N/A,180.32,4532.23,104.85,4561.88,109.68,3978.12,27.09,3331.13,10309.32,27.09,772.80,,Hospital CPT 93880,HC Extracranial Bilat Study,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,2416.00,2416.00,1449.60,1449.60,N/A,338.24,N/A,210.88,N/A,1391.13,N/A,821.44,N/A,510.09,N/A,338.24,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1391.13,N/A,210.88,N/A,338.24,N/A,1294.98,N/A,1294.98,N/A,338.24,N/A,210.88,N/A,210.88,N/A,231.97,1449.60,1449.60,210.88,1449.60,,Hospital 93892,HC Tcd Emboli Detect W/O Inj,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,N/A,1781.00,N/A,1068.60,N/A,249.34,N/A,446.94,N/A,1025.50,N/A,605.54,N/A,1020.18,N/A,249.34,N/A,421.76,N/A,421.76,N/A,635.08,N/A,1020.18,N/A,1020.18,N/A,1020.18,N/A,1025.50,N/A,421.76,N/A,249.34,N/A,954.62,N/A,954.62,N/A,249.34,N/A,421.76,N/A,446.94,N/A,630.34,N/A,N/A,249.34,1068.60,,Hospital 93893,HC Trcran Dplr Emboli W Inj,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,670431.63,24369.77,402258.98,14621.86,N/A,3028.94,N/A,1342.45,N/A,14015.87,227946.76,8285.73,233444.30,4124.35,N/A,3028.94,N/A,1555.52,N/A,1555.52,145349.58,2877.86,233444.30,4124.35,233444.30,4124.35,233444.30,4124.35,N/A,14015.85,N/A,1573.28,N/A,3028.94,N/A,6332.61,N/A,6332.61,N/A,3028.94,N/A,1555.52,N/A,1342.45,N/A,1470.57,145349.58,402258.98,1342.45,14621.86,,Hospital CPT 93922,HC Tcp02/Abi 1-2 Levels,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,1555.00,1555.00,933.00,933.00,N/A,217.70,N/A,104.85,N/A,895.37,N/A,528.70,N/A,253.64,N/A,217.70,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,895.37,N/A,104.85,N/A,217.70,N/A,833.48,N/A,833.48,N/A,217.70,N/A,104.85,N/A,104.85,N/A,115.34,933.00,933.00,104.85,933.00,,Hospital CPT 93924,HC Bil Niv Arterial With Stress Tc,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,1745.00,1745.00,1047.00,1047.00,N/A,244.30,N/A,259.66,N/A,1004.77,N/A,593.30,N/A,611.76,N/A,244.30,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,1004.77,N/A,252.91,N/A,244.30,N/A,935.32,N/A,935.32,N/A,244.30,N/A,252.91,N/A,120.83,N/A,132.91,1047.00,1047.00,120.83,1047.00,,Hospital CPT 93970,HC Niv Venous Duplex Bilat Study,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,3018.00,3018.00,1810.80,1810.80,N/A,422.52,N/A,210.88,N/A,1737.76,N/A,1026.12,N/A,510.09,N/A,422.52,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1737.76,N/A,210.88,N/A,422.52,N/A,1617.65,N/A,1617.65,N/A,422.52,N/A,210.88,N/A,210.88,N/A,231.97,1810.80,1810.80,210.88,1810.80,,Hospital CPT 93971,HC Niv Venous Duplex Uni/Ltd Study,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,2557.00,2557.00,1534.20,1534.20,N/A,357.98,N/A,96.52,N/A,1472.32,N/A,869.38,N/A,233.46,N/A,357.98,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1472.32,N/A,96.52,N/A,357.98,N/A,1370.55,N/A,1370.55,N/A,357.98,N/A,96.52,N/A,96.52,N/A,106.17,1534.20,1534.20,96.52,1534.20,,Hospital CPT 93986,HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Uni Std,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,680.00,680.00,408.00,408.00,N/A,95.20,N/A,100.96,N/A,391.54,N/A,231.20,N/A,233.46,N/A,95.20,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,391.54,N/A,96.52,N/A,95.20,N/A,364.48,N/A,364.48,N/A,95.20,N/A,96.52,N/A,100.96,N/A,125.02,408.00,408.00,95.20,408.00,,Hospital CPT 93990,HC Duplex Av Dialysis Shunt,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,331.00,331.00,198.60,198.60,N/A,46.34,N/A,100.96,N/A,190.59,N/A,112.54,N/A,233.46,N/A,46.34,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,190.59,N/A,96.52,N/A,46.34,N/A,177.42,N/A,177.42,N/A,46.34,N/A,96.52,N/A,98.52,N/A,123.68,198.60,198.60,46.34,233.46,,Hospital CPT 94002,HC Ventilator Initial Day,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,3275.00,3275.00,1965.00,1965.00,N/A,458.50,N/A,513.20,N/A,1885.75,N/A,1113.50,N/A,1216.09,N/A,458.50,N/A,502.74,N/A,502.74,N/A,757.04,N/A,1216.09,N/A,1216.09,N/A,1216.09,N/A,1885.75,N/A,502.74,N/A,458.50,N/A,1755.40,N/A,1755.40,N/A,458.50,N/A,502.74,N/A,522.31,N/A,98.97,1965.00,1965.00,98.97,1965.00,,Hospital CPT 94070,HC Methacoline Challenge Test,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,1617.00,1617.00,970.20,970.20,N/A,226.38,N/A,258.16,N/A,931.07,N/A,549.78,N/A,611.76,N/A,226.38,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,931.07,N/A,252.91,N/A,226.38,N/A,866.71,N/A,866.71,N/A,226.38,N/A,252.91,N/A,250.72,N/A,33.07,970.20,970.20,33.07,970.20,,Hospital CPT 94200,HC Max Breathing Capacity,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,320.00,320.00,192.00,192.00,N/A,44.80,N/A,54.30,N/A,184.26,N/A,108.80,N/A,125.56,N/A,44.80,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,184.26,N/A,51.91,N/A,44.80,N/A,171.52,N/A,171.52,N/A,44.80,N/A,51.91,N/A,54.30,N/A,11.89,192.00,192.00,11.89,192.00,,Hospital CPT 94610,HC Surfactant Admin Thru Tube,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,479.00,479.00,287.40,287.40,N/A,67.06,N/A,53.85,N/A,275.81,N/A,162.86,N/A,162.27,N/A,67.06,N/A,53.85,N/A,53.85,N/A,101.01,N/A,162.27,N/A,162.27,N/A,162.27,N/A,275.81,N/A,53.85,N/A,67.06,N/A,256.74,N/A,256.74,N/A,67.06,N/A,53.85,N/A,53.85,N/A,59.24,287.40,287.40,53.85,287.40,,Hospital CPT 94618,HC 6-Minute Walk Test/Pulm Stress Test,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,460.00,460.00,276.00,276.00,N/A,64.40,N/A,108.93,N/A,264.87,N/A,156.40,N/A,253.64,N/A,64.40,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,264.87,N/A,104.85,N/A,64.40,N/A,246.56,N/A,246.56,N/A,64.40,N/A,104.85,N/A,104.85,N/A,115.34,276.00,276.00,64.40,276.00,,Hospital 94621,HC Pulmonary Exercise Testing,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,40902.97,689.00,24541.78,413.40,7451.40,96.46,9080.25,278.98,16792.33,396.73,13907.01,234.26,16952.96,611.76,7680.99,96.46,2810.00,252.91,2810.00,252.91,10552.82,380.83,16952.96,611.76,16952.96,611.76,16952.96,611.76,16792.33,396.73,9080.25,252.91,7680.99,96.46,20169.79,369.30,20169.79,369.30,7680.99,96.46,9080.25,252.91,9080.25,76.93,8218.66,84.62,2810.00,24541.78,76.93,611.76,,Hospital CPT 94642,HC Pentamidine Treatment,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,516.00,516.00,309.60,309.60,N/A,72.24,N/A,172.05,N/A,297.11,N/A,175.44,N/A,418.30,N/A,72.24,N/A,172.93,N/A,172.93,N/A,260.40,N/A,418.30,N/A,418.30,N/A,418.30,N/A,297.11,N/A,172.93,N/A,72.24,N/A,276.58,N/A,276.58,N/A,72.24,N/A,172.93,N/A,172.05,N/A,516.00,309.60,309.60,72.24,516.00,,Hospital CPT 94645,HC Continuous Inhale Tx Addl Hour,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,264.00,264.00,158.40,158.40,N/A,36.96,N/A,14.12,N/A,152.01,N/A,89.76,N/A,41.70,N/A,36.96,N/A,14.12,N/A,14.12,N/A,25.96,N/A,41.70,N/A,41.70,N/A,41.70,N/A,152.01,N/A,14.12,N/A,36.96,N/A,141.50,N/A,141.50,N/A,36.96,N/A,14.12,N/A,14.12,N/A,15.53,158.40,158.40,14.12,158.40,,Hospital CPT 94664,HC Demo/Eval Aer Neb Mdi Ippb,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,235.00,235.00,141.00,141.00,N/A,32.90,N/A,15.02,N/A,135.31,N/A,79.90,N/A,235.00,N/A,32.90,N/A,172.93,N/A,172.93,N/A,235.00,N/A,235.00,N/A,235.00,N/A,235.00,N/A,135.31,N/A,172.93,N/A,32.90,N/A,125.96,N/A,125.96,N/A,32.90,N/A,172.93,N/A,183.96,N/A,16.52,141.00,141.00,15.02,235.00,,Hospital CPT 94726,HC Lung Volumes Airway Resist,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,324.00,324.00,194.40,194.40,N/A,45.36,N/A,252.91,N/A,186.56,N/A,110.16,N/A,324.00,N/A,45.36,N/A,252.91,N/A,252.91,N/A,324.00,N/A,324.00,N/A,324.00,N/A,324.00,N/A,186.56,N/A,252.91,N/A,45.36,N/A,173.66,N/A,173.66,N/A,45.36,N/A,252.91,N/A,252.91,N/A,278.20,194.40,194.40,45.36,324.00,,Hospital 94776,HC Peds - Home Apnea Rec Downld,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,14814.50,251.00,8888.70,150.60,3792.38,35.14,4751.83,139.71,8546.44,144.53,5036.93,85.34,8628.19,251.00,3909.23,35.14,4751.83,131.33,4751.83,131.33,5370.85,197.75,8628.19,251.00,8628.19,251.00,8628.19,251.00,8546.44,144.53,4751.83,131.33,3909.23,35.14,10265.40,134.54,10265.40,134.54,9913.66,35.14,4751.83,131.33,4751.83,139.71,4182.88,N/A,3792.38,10265.40,35.14,251.00,,Hospital 95115,HC Allergy Injection Single,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,N/A,106.00,N/A,63.60,N/A,14.84,N/A,39.75,N/A,61.03,N/A,36.04,N/A,92.56,N/A,14.84,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,61.03,N/A,38.26,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,38.26,N/A,39.75,N/A,9.25,N/A,N/A,9.25,92.56,,Hospital CPT 95705,HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,4005.00,4005.00,2403.00,2403.00,N/A,560.70,N/A,131.33,N/A,2306.08,N/A,1361.70,N/A,317.67,N/A,560.70,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,2306.08,N/A,131.33,N/A,560.70,N/A,2146.68,N/A,2146.68,N/A,560.70,N/A,131.33,N/A,131.33,N/A,144.46,2403.00,2403.00,131.33,2403.00,,Hospital CPT 95708,HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,4005.00,4005.00,2403.00,2403.00,N/A,560.70,N/A,481.57,N/A,2306.08,N/A,1361.70,N/A,1055.99,N/A,560.70,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,2306.08,N/A,436.56,N/A,560.70,N/A,2146.68,N/A,2146.68,N/A,560.70,N/A,436.56,N/A,4005.00,N/A,4005.00,2403.00,2403.00,436.56,4005.00,,Hospital 95709,HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,189417.33,N/A,113650.40,N/A,N/A,N/A,19904.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,19904.73,N/A,19904.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,19318.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,19904.73,N/A,19904.73,N/A,N/A,N/A,19318.54,113650.40,N/A,N/A,,Hospital CPT 95813,HC Eeg Extended More Than 1 Hour,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,1117.00,1117.00,670.20,670.20,N/A,156.38,N/A,252.91,N/A,643.17,N/A,379.78,N/A,611.76,N/A,156.38,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,643.17,N/A,252.91,N/A,156.38,N/A,598.71,N/A,598.71,N/A,156.38,N/A,252.91,N/A,252.91,N/A,278.20,670.20,670.20,156.38,670.20,,Hospital 95861,HC Emg 2 Ext & Paraspinal,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,N/A,484.00,N/A,290.40,N/A,67.76,N/A,75.47,N/A,278.69,N/A,164.56,N/A,253.64,N/A,67.76,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,278.69,N/A,104.85,N/A,67.76,N/A,259.42,N/A,259.42,N/A,67.76,N/A,104.85,N/A,75.47,N/A,83.02,N/A,N/A,67.76,290.40,,Hospital CPT 95874,HC Needle Emg Guidance for Chemo Denervation,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,269.00,269.00,161.40,161.40,N/A,37.66,N/A,269.00,N/A,154.89,N/A,91.46,N/A,269.00,N/A,37.66,N/A,269.00,N/A,269.00,N/A,269.00,N/A,269.00,N/A,269.00,N/A,269.00,N/A,154.89,N/A,269.00,N/A,37.66,N/A,144.18,N/A,144.18,N/A,37.66,N/A,269.00,N/A,269.00,N/A,269.00,161.40,161.40,37.66,269.00,,Hospital CPT 95885,HC Emg W Nerve Conduct Limited,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,373.00,373.00,223.80,223.80,N/A,52.22,N/A,373.00,N/A,214.77,N/A,126.82,N/A,373.00,N/A,52.22,N/A,373.00,N/A,373.00,N/A,373.00,N/A,373.00,N/A,373.00,N/A,373.00,N/A,214.77,N/A,373.00,N/A,52.22,N/A,199.93,N/A,199.93,N/A,52.22,N/A,373.00,N/A,373.00,N/A,45.65,223.80,223.80,45.65,373.00,,Hospital 95887,HC Emg Nonextrem W Nerve Conduct,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,N/A,7076.00,N/A,4245.60,N/A,990.64,N/A,441.28,N/A,4074.36,N/A,2405.84,N/A,1055.99,N/A,990.64,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,4074.36,N/A,436.56,N/A,990.64,N/A,3792.73,N/A,3792.73,N/A,990.64,N/A,436.56,N/A,441.28,N/A,132.64,N/A,N/A,132.64,4245.60,,Hospital CPT 95908,HC Nerve Conduction 3-4 Studies,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,1230.00,1230.00,738.00,738.00,N/A,172.20,N/A,252.91,N/A,708.23,N/A,418.20,N/A,611.76,N/A,172.20,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,708.23,N/A,252.91,N/A,172.20,N/A,659.28,N/A,659.28,N/A,172.20,N/A,252.91,N/A,252.91,N/A,278.20,738.00,738.00,172.20,738.00,,Hospital CPT 95909,HC Nerve Conduction 5-6 Studies,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,1230.00,1230.00,738.00,738.00,N/A,172.20,N/A,252.91,N/A,708.23,N/A,418.20,N/A,611.76,N/A,172.20,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,708.23,N/A,252.91,N/A,172.20,N/A,659.28,N/A,659.28,N/A,172.20,N/A,252.91,N/A,252.91,N/A,278.20,738.00,738.00,172.20,738.00,,Hospital CPT 95910,HC Nerve Conduction 7-8 Studies,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,1230.00,1230.00,738.00,738.00,N/A,172.20,N/A,252.91,N/A,708.23,N/A,418.20,N/A,611.76,N/A,172.20,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,708.23,N/A,252.91,N/A,172.20,N/A,659.28,N/A,659.28,N/A,172.20,N/A,252.91,N/A,252.91,N/A,278.20,738.00,738.00,172.20,738.00,,Hospital 95912,HC Nerve Conduction Studies 11-12,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,183107.40,3633.00,109864.44,2179.80,14014.77,508.62,4970.81,566.67,14535.12,2110.63,74720.62,1235.22,74720.62,1365.74,5538.86,508.62,43068.53,540.60,43068.53,540.60,74720.62,850.19,74720.62,1365.74,74720.62,1365.74,74720.62,1365.74,100928.80,2110.63,43068.53,540.60,5538.86,508.62,10766.46,2093.77,10766.46,2093.77,5538.86,508.62,43068.53,540.60,43068.53,566.67,5538.86,402.53,4970.81,109864.44,402.53,2179.80,,Hospital CPT 95913,HC Nerve Conduction 13 or More,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,1230.00,1230.00,738.00,738.00,N/A,172.20,N/A,436.56,N/A,708.23,N/A,418.20,N/A,1055.99,N/A,172.20,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,708.23,N/A,436.56,N/A,172.20,N/A,659.28,N/A,659.28,N/A,172.20,N/A,436.56,N/A,436.56,N/A,480.21,738.00,738.00,172.20,1055.99,,Hospital CPT 95930,HC Visual Evoked Response,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,413.00,413.00,247.80,247.80,N/A,57.82,N/A,42.09,N/A,237.81,N/A,140.42,N/A,180.24,N/A,57.82,N/A,42.09,N/A,42.09,N/A,112.20,N/A,180.24,N/A,180.24,N/A,180.24,N/A,237.81,N/A,42.09,N/A,57.82,N/A,221.37,N/A,221.37,N/A,57.82,N/A,42.09,N/A,42.09,N/A,46.30,247.80,247.80,42.09,247.80,,Hospital 95950,HC Amb Eeg 24 Hr,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,N/A,6155.00,N/A,3693.00,N/A,861.70,N/A,N/A,N/A,3544.05,N/A,2092.70,N/A,861.70,N/A,861.70,N/A,N/A,N/A,N/A,N/A,535.49,N/A,861.70,N/A,861.70,N/A,861.70,N/A,3544.05,N/A,N/A,N/A,861.70,N/A,3299.08,N/A,3299.08,N/A,861.70,N/A,N/A,N/A,N/A,N/A,644.10,N/A,N/A,535.49,3693.00,,Hospital 95970,HC Scs Analysis W/O Program,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,559.00,N/A,335.40,N/A,78.26,N/A,108.20,N/A,321.87,N/A,190.06,N/A,N/A,N/A,78.26,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,321.87,N/A,109.14,N/A,78.26,N/A,299.62,N/A,299.62,N/A,78.26,N/A,109.14,N/A,108.20,N/A,19.88,N/A,N/A,19.88,335.40,,Hospital 95971,HC Scs Analysis W/Program,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,N/A,546.00,N/A,327.60,N/A,76.44,N/A,198.25,N/A,314.39,N/A,185.64,N/A,218.02,N/A,76.44,N/A,199.27,N/A,199.27,N/A,135.72,N/A,218.02,N/A,218.02,N/A,218.02,N/A,314.39,N/A,109.14,N/A,76.44,N/A,292.65,N/A,292.65,N/A,76.44,N/A,199.27,N/A,198.25,N/A,42.46,N/A,N/A,42.46,327.60,,Hospital CPT 95977,HC Elec Alys Implt Cplx Cn Npgt Prgrmg,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,250.00,250.00,150.00,150.00,N/A,35.00,N/A,90.13,N/A,143.95,N/A,85.00,N/A,218.02,N/A,35.00,N/A,90.13,N/A,90.13,N/A,135.72,N/A,218.02,N/A,218.02,N/A,218.02,N/A,143.95,N/A,90.13,N/A,35.00,N/A,134.00,N/A,134.00,N/A,35.00,N/A,90.13,N/A,90.13,N/A,99.15,150.00,150.00,35.00,218.02,,Hospital 95991,Rfl&Main Implt Pmp/Rsvr Dlvr Spi/Brn Phy/Qhp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5274.00,N/A,3164.40,N/A,738.36,N/A,253.95,N/A,3036.77,N/A,1793.16,N/A,593.92,N/A,738.36,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,3036.77,N/A,245.53,N/A,738.36,N/A,527.00,N/A,527.00,N/A,738.36,N/A,245.53,N/A,253.95,N/A,42.74,N/A,N/A,42.74,3164.40,,Hospital 96110,HC Develop Screen W/Scoring & Std Instrm,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,551.03,N/A,330.62,N/A,77.14,N/A,154.55,N/A,317.29,N/A,187.34,N/A,151.15,N/A,77.14,N/A,147.40,N/A,147.40,N/A,94.09,N/A,151.15,N/A,151.15,N/A,151.15,N/A,317.29,N/A,147.40,N/A,77.14,N/A,295.37,N/A,295.37,N/A,77.14,N/A,147.40,N/A,27.28,N/A,30.01,N/A,N/A,27.28,330.62,,Hospital CPT 96125,HC Std Cognitiv Perf Test per Hr,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,374.00,374.00,224.40,224.40,N/A,52.36,N/A,105.36,N/A,215.35,N/A,127.16,N/A,298.92,N/A,52.36,N/A,105.36,N/A,105.36,N/A,298.92,N/A,298.92,N/A,298.92,N/A,298.92,N/A,215.35,N/A,99.64,N/A,52.36,N/A,200.46,N/A,200.46,N/A,52.36,N/A,105.36,N/A,105.36,N/A,115.90,224.40,224.40,52.36,298.92,,Hospital 96127,HC Behav Assmt W/Score & Docd/Stand Instrument,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,1526.00,N/A,915.60,N/A,195.79,N/A,67.21,N/A,875.62,N/A,518.84,N/A,372.37,N/A,195.79,N/A,60.93,N/A,60.93,N/A,320.20,N/A,372.37,N/A,372.37,N/A,372.37,N/A,875.62,N/A,109.14,N/A,195.79,N/A,115.81,N/A,115.81,N/A,195.79,N/A,109.14,N/A,28.30,N/A,31.13,N/A,N/A,28.30,915.60,,Hospital 96130,HC Psychological Tst Eval Svc Phys/Qhp First Hour,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,1355.00,N/A,813.00,N/A,189.70,N/A,397.63,N/A,780.22,N/A,460.70,N/A,904.16,N/A,189.70,N/A,373.78,N/A,373.78,N/A,562.86,N/A,904.16,N/A,904.16,N/A,904.16,N/A,780.22,N/A,373.78,N/A,189.70,N/A,527.96,N/A,527.96,N/A,189.70,N/A,373.78,N/A,397.63,N/A,481.36,N/A,N/A,189.70,904.16,,Hospital CPT 96375,HC IV Push Diff Drug,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,445.00,445.00,267.00,267.00,N/A,62.30,N/A,38.26,N/A,256.23,N/A,151.30,N/A,92.56,N/A,62.30,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,256.23,N/A,38.26,N/A,62.30,N/A,238.52,N/A,238.52,N/A,62.30,N/A,38.26,N/A,38.26,N/A,42.09,267.00,267.00,38.26,267.00,,Hospital CPT 96402,HC Chemo Subq/Im Inj Hormonal,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,513.00,513.00,307.80,307.80,N/A,71.82,N/A,60.93,N/A,295.39,N/A,174.42,N/A,147.37,N/A,71.82,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,295.39,N/A,60.93,N/A,71.82,N/A,274.97,N/A,274.97,N/A,71.82,N/A,60.93,N/A,60.93,N/A,67.02,307.80,307.80,60.93,307.80,,Hospital CPT 96402,HC Chemo Im Inject Hormonal,N/A,0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED,513.00,513.00,307.80,307.80,N/A,71.82,N/A,60.93,N/A,295.39,N/A,174.42,N/A,147.37,N/A,71.82,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,295.39,N/A,60.93,N/A,71.82,N/A,274.97,N/A,274.97,N/A,71.82,N/A,60.93,N/A,60.93,N/A,67.02,307.80,307.80,60.93,307.80,,Hospital CPT 96409,HC Chemo IV Push Initial Drug,N/A,0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED,920.00,920.00,552.00,552.00,N/A,128.80,N/A,186.54,N/A,529.74,N/A,312.80,N/A,451.22,N/A,128.80,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,529.74,N/A,186.54,N/A,128.80,N/A,493.12,N/A,493.12,N/A,128.80,N/A,186.54,N/A,186.54,N/A,205.20,552.00,552.00,128.80,552.00,,Hospital CPT 96522,HC Implantable Pump - Refill/Main,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,637.00,637.00,382.20,382.20,N/A,89.18,N/A,195.13,N/A,366.78,N/A,216.58,N/A,451.22,N/A,89.18,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,366.78,N/A,186.54,N/A,89.18,N/A,341.43,N/A,341.43,N/A,89.18,N/A,186.54,N/A,188.56,N/A,120.65,382.20,382.20,89.18,451.22,,Hospital CPT 96522,HC Implantable Pump - Refill/Main,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,637.00,637.00,382.20,382.20,N/A,89.18,N/A,195.13,N/A,366.78,N/A,216.58,N/A,451.22,N/A,89.18,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,366.78,N/A,186.54,N/A,89.18,N/A,341.43,N/A,341.43,N/A,89.18,N/A,186.54,N/A,188.56,N/A,120.65,382.20,382.20,89.18,451.22,,Hospital CPT 96549,HC Chemo Infusion Concurrent,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,557.00,557.00,334.20,334.20,N/A,77.98,N/A,37.93,N/A,320.72,N/A,189.38,N/A,92.56,N/A,77.98,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,320.72,N/A,38.26,N/A,77.98,N/A,298.55,N/A,298.55,N/A,77.98,N/A,38.26,N/A,38.68,N/A,557.00,334.20,334.20,37.93,557.00,,Hospital CPT 97022,HC Ot Whirlpool/Fluidotherapy,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,752.00,638.00,451.20,382.80,N/A,89.32,N/A,16.84,N/A,367.36,N/A,216.92,N/A,48.96,N/A,89.32,N/A,16.84,N/A,16.84,N/A,48.96,N/A,48.96,N/A,48.96,N/A,48.96,N/A,367.36,N/A,16.32,N/A,89.32,N/A,341.97,N/A,341.97,N/A,89.32,N/A,16.84,N/A,16.84,N/A,18.52,451.20,451.20,16.32,382.80,,Hospital CPT 97022,HC Pt Whirlpool/Fluidotherapy,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,752.00,638.00,451.20,382.80,N/A,89.32,N/A,16.84,N/A,367.36,N/A,216.92,N/A,48.96,N/A,89.32,N/A,16.84,N/A,16.84,N/A,48.96,N/A,48.96,N/A,48.96,N/A,48.96,N/A,367.36,N/A,16.32,N/A,89.32,N/A,341.97,N/A,341.97,N/A,89.32,N/A,16.84,N/A,16.84,N/A,18.52,451.20,451.20,16.32,382.80,,Hospital CPT 97110,"HC Pt Therapeutic Exercise,Ea 15 Min",N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,119.00,101.00,71.40,60.60,N/A,14.14,N/A,29.45,N/A,58.16,N/A,34.34,N/A,85.77,N/A,14.14,N/A,29.45,N/A,29.45,N/A,85.77,N/A,85.77,N/A,85.77,N/A,85.77,N/A,58.16,N/A,28.59,N/A,14.14,N/A,54.14,N/A,54.14,N/A,14.14,N/A,29.45,N/A,29.45,N/A,32.40,71.40,71.40,14.14,85.77,,Hospital CPT 97110,HC Ot Ther Ex per 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,119.00,101.00,71.40,60.60,N/A,14.14,N/A,29.45,N/A,58.16,N/A,34.34,N/A,85.77,N/A,14.14,N/A,29.45,N/A,29.45,N/A,85.77,N/A,85.77,N/A,85.77,N/A,85.77,N/A,58.16,N/A,28.59,N/A,14.14,N/A,54.14,N/A,54.14,N/A,14.14,N/A,29.45,N/A,29.45,N/A,32.40,71.40,71.40,14.14,85.77,,Hospital CPT 97110,HC Oral Motor Exercises 15 Min,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,119.00,101.00,71.40,60.60,N/A,14.14,N/A,29.45,N/A,58.16,N/A,34.34,N/A,85.77,N/A,14.14,N/A,29.45,N/A,29.45,N/A,85.77,N/A,85.77,N/A,85.77,N/A,85.77,N/A,58.16,N/A,28.59,N/A,14.14,N/A,54.14,N/A,54.14,N/A,14.14,N/A,29.45,N/A,29.45,N/A,32.40,71.40,71.40,14.14,85.77,,Hospital CPT 97112,HC Pt Neuro Facilitation Ea 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,107.00,92.00,64.20,55.20,N/A,12.88,N/A,33.78,N/A,52.97,N/A,31.28,N/A,92.00,N/A,12.88,N/A,33.78,N/A,33.78,N/A,92.00,N/A,92.00,N/A,92.00,N/A,92.00,N/A,52.97,N/A,32.76,N/A,12.88,N/A,49.31,N/A,49.31,N/A,12.88,N/A,33.78,N/A,33.78,N/A,37.16,64.20,64.20,12.88,92.00,,Hospital CPT 97112,"HC Neuromuscular Re-Education, Ot",N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,107.00,92.00,64.20,55.20,N/A,12.88,N/A,33.78,N/A,52.97,N/A,31.28,N/A,92.00,N/A,12.88,N/A,33.78,N/A,33.78,N/A,92.00,N/A,92.00,N/A,92.00,N/A,92.00,N/A,52.97,N/A,32.76,N/A,12.88,N/A,49.31,N/A,49.31,N/A,12.88,N/A,33.78,N/A,33.78,N/A,37.16,64.20,64.20,12.88,92.00,,Hospital CPT 97163,HC Pt Eval High Complex,N/A,0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION,512.00,512.00,307.20,307.20,N/A,71.68,N/A,82.01,N/A,294.81,N/A,174.08,N/A,292.53,N/A,71.68,N/A,82.01,N/A,82.01,N/A,292.53,N/A,292.53,N/A,292.53,N/A,292.53,N/A,294.81,N/A,97.51,N/A,71.68,N/A,274.43,N/A,274.43,N/A,71.68,N/A,82.01,N/A,82.01,N/A,90.21,307.20,307.20,71.68,307.20,,Hospital CPT 97164,HC Pt Re-Eval Est Plan Care,N/A,0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION,90.00,90.00,54.00,54.00,N/A,12.60,N/A,56.03,N/A,51.82,N/A,30.60,N/A,90.00,N/A,12.60,N/A,56.03,N/A,56.03,N/A,90.00,N/A,90.00,N/A,90.00,N/A,90.00,N/A,51.82,N/A,67.35,N/A,12.60,N/A,48.24,N/A,48.24,N/A,12.60,N/A,56.03,N/A,56.03,N/A,61.63,54.00,54.00,12.60,90.00,,Hospital CPT 97167,HC Ot Eval High Complex,N/A,0434 - OCCUPATIONAL THERAPY - EVALUATION OR REEVALUATION,585.00,585.00,351.00,351.00,N/A,81.90,N/A,86.43,N/A,336.84,N/A,198.90,N/A,292.53,N/A,81.90,N/A,86.43,N/A,86.43,N/A,292.53,N/A,292.53,N/A,292.53,N/A,292.53,N/A,336.84,N/A,97.51,N/A,81.90,N/A,313.56,N/A,313.56,N/A,81.90,N/A,86.43,N/A,86.43,N/A,95.07,351.00,351.00,81.90,351.00,,Hospital CPT 97530,HC Pt Therapeutic Activities 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,162.00,138.00,97.20,82.80,N/A,19.32,N/A,37.29,N/A,79.46,N/A,46.92,N/A,107.01,N/A,19.32,N/A,37.29,N/A,37.29,N/A,107.01,N/A,107.01,N/A,107.01,N/A,107.01,N/A,79.46,N/A,35.67,N/A,19.32,N/A,73.97,N/A,73.97,N/A,19.32,N/A,37.29,N/A,37.29,N/A,41.02,97.20,97.20,19.32,107.01,,Hospital CPT 97530,HC Ot Therapeutic Activities 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,162.00,138.00,97.20,82.80,N/A,19.32,N/A,37.29,N/A,79.46,N/A,46.92,N/A,107.01,N/A,19.32,N/A,37.29,N/A,37.29,N/A,107.01,N/A,107.01,N/A,107.01,N/A,107.01,N/A,79.46,N/A,35.67,N/A,19.32,N/A,73.97,N/A,73.97,N/A,19.32,N/A,37.29,N/A,37.29,N/A,41.02,97.20,97.20,19.32,107.01,,Hospital 97537,HC Ot Work Conditioning 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,N/A,1419.00,N/A,851.40,N/A,198.66,N/A,259.64,N/A,817.06,N/A,482.46,N/A,790.86,N/A,198.66,N/A,259.64,N/A,259.64,N/A,790.86,N/A,790.86,N/A,790.86,N/A,790.86,N/A,817.06,N/A,263.62,N/A,198.66,N/A,760.59,N/A,760.59,N/A,198.66,N/A,259.64,N/A,259.64,N/A,285.60,N/A,N/A,198.66,851.40,,Hospital 97546,"Work Hardening/Condn,Ea Addnl Hr",N/A,N/A,N/A,1276.00,N/A,765.60,N/A,178.64,N/A,N/A,N/A,734.72,N/A,433.84,N/A,178.64,N/A,178.64,N/A,N/A,N/A,N/A,N/A,111.00,N/A,178.64,N/A,178.64,N/A,178.64,N/A,734.72,N/A,N/A,N/A,178.64,N/A,683.93,N/A,683.93,N/A,178.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,111.00,765.60,,Hospital CPT 97607,HC Neg Pressure Wnd <= 50 Sq Cm Disposable,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,642.00,642.00,385.20,385.20,N/A,89.88,N/A,352.41,N/A,369.66,N/A,218.28,N/A,642.00,N/A,89.88,N/A,336.90,N/A,336.90,N/A,507.30,N/A,642.00,N/A,642.00,N/A,642.00,N/A,369.66,N/A,336.90,N/A,89.88,N/A,344.11,N/A,344.11,N/A,89.88,N/A,336.90,N/A,21.59,N/A,23.75,385.20,385.20,21.59,642.00,,Hospital CPT 97607,HC Neg Press Wnd Tx <=50 Sq Cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,642.00,642.00,385.20,385.20,N/A,89.88,N/A,352.41,N/A,369.66,N/A,218.28,N/A,642.00,N/A,89.88,N/A,336.90,N/A,336.90,N/A,507.30,N/A,642.00,N/A,642.00,N/A,642.00,N/A,369.66,N/A,336.90,N/A,89.88,N/A,642.00,N/A,642.00,N/A,89.88,N/A,336.90,N/A,21.59,N/A,23.75,385.20,385.20,21.59,642.00,,Hospital CPT 97608,HC Neg Press Wnd Tx >50 Sq Cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,584.00,584.00,350.40,350.40,N/A,81.76,N/A,24.21,N/A,336.27,N/A,198.56,N/A,584.00,N/A,81.76,N/A,336.90,N/A,336.90,N/A,507.30,N/A,584.00,N/A,584.00,N/A,584.00,N/A,336.27,N/A,336.90,N/A,81.76,N/A,584.00,N/A,584.00,N/A,81.76,N/A,336.90,N/A,24.21,N/A,26.63,350.40,350.40,24.21,584.00,,Hospital CPT 97608,HC Neg Pressure Wnd > 50 Sq Cm Disposable,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,642.00,642.00,385.20,385.20,N/A,89.88,N/A,24.21,N/A,369.66,N/A,218.28,N/A,642.00,N/A,89.88,N/A,336.90,N/A,336.90,N/A,507.30,N/A,642.00,N/A,642.00,N/A,642.00,N/A,369.66,N/A,336.90,N/A,89.88,N/A,344.11,N/A,344.11,N/A,89.88,N/A,336.90,N/A,24.21,N/A,26.63,385.20,385.20,24.21,642.00,,Hospital 97755,HC at Assessment,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,N/A,952.00,N/A,571.20,N/A,133.28,N/A,127.37,N/A,548.16,N/A,323.68,N/A,378.96,N/A,133.28,N/A,127.37,N/A,127.37,N/A,378.96,N/A,378.96,N/A,378.96,N/A,378.96,N/A,548.16,N/A,126.32,N/A,133.28,N/A,510.27,N/A,510.27,N/A,133.28,N/A,127.37,N/A,127.37,N/A,140.11,N/A,N/A,126.32,571.20,,Hospital 97761,HC Pt Prosthetic Training 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,54081.63,1418.00,32448.98,850.80,10482.65,198.52,13130.88,256.95,31199.68,816.48,18387.77,482.12,25638.20,804.60,10805.64,198.52,1686.00,256.95,1686.00,256.95,15959.18,804.60,25638.20,804.60,25638.20,804.60,25638.20,804.60,31199.68,816.48,13130.88,268.20,10805.64,198.52,30503.06,760.05,30503.06,760.05,6749.36,198.52,13130.88,256.95,13130.88,256.95,11562.04,282.65,1686.00,32448.98,198.52,850.80,,Hospital 97763,HC Ot Orthotic Fit/Train Subsq per 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,65768.80,2074.00,39461.28,1244.40,N/A,290.36,N/A,224.26,N/A,1194.22,N/A,705.16,N/A,654.36,N/A,290.36,N/A,224.26,N/A,224.26,N/A,654.36,N/A,654.36,N/A,654.36,N/A,654.36,N/A,1194.22,N/A,218.12,N/A,290.36,N/A,1111.66,N/A,1111.66,N/A,290.36,N/A,224.26,N/A,224.26,N/A,246.69,39461.28,39461.28,218.12,1244.40,,Hospital 97804,HC Med Nutr Ther Group Init/Fu 30 Min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,1442.00,N/A,865.20,N/A,201.88,N/A,283.66,N/A,830.31,N/A,490.28,N/A,824.76,N/A,201.88,N/A,283.66,N/A,283.66,N/A,531.31,N/A,824.76,N/A,824.76,N/A,824.76,N/A,830.31,N/A,283.66,N/A,201.88,N/A,772.92,N/A,772.92,N/A,201.88,N/A,283.66,N/A,283.66,N/A,180.47,N/A,N/A,180.47,865.20,,Hospital 97813,HC Acupunct W/Stimul 15 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,162.00,N/A,97.20,N/A,22.68,N/A,24.86,N/A,93.28,N/A,55.08,N/A,N/A,N/A,22.68,N/A,22.54,N/A,22.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,93.28,N/A,22.54,N/A,22.68,N/A,86.84,N/A,86.84,N/A,22.68,N/A,22.54,N/A,60.66,N/A,66.73,N/A,N/A,22.54,97.20,,Hospital CPT 98960,HC Self-Mgmt Educ & Train 1 Pt,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,422.00,422.00,253.20,253.20,N/A,59.08,N/A,422.00,N/A,242.99,N/A,143.48,N/A,59.08,N/A,59.08,N/A,422.00,N/A,422.00,N/A,36.71,N/A,59.08,N/A,59.08,N/A,59.08,N/A,242.99,N/A,422.00,N/A,59.08,N/A,226.19,N/A,226.19,N/A,59.08,N/A,422.00,N/A,422.00,N/A,422.00,253.20,253.20,36.71,422.00,,Hospital Custom 9900000038,HC Cardiac Rehab Phase 3 - Monthly,N/A,0990 - PATIENT CONVENIENCE ITEMS - GENERAL CLASSIFICATION,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,17.27,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital CPT 99205,"HC New Pt, E/M Level 5",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,748.00,1353.00,448.80,811.80,N/A,189.42,N/A,110.32,N/A,779.06,N/A,460.02,N/A,1353.00,N/A,189.42,N/A,109.14,N/A,109.14,N/A,1353.00,N/A,1353.00,N/A,1353.00,N/A,1353.00,N/A,779.06,N/A,109.14,N/A,189.42,N/A,725.21,N/A,725.21,N/A,189.42,N/A,109.14,N/A,113.39,N/A,194.25,448.80,448.80,109.14,1353.00,,Hospital CPT 99212,"HC Est Pt, Outpt Visit Level 2",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,605.00,605.00,363.00,363.00,N/A,84.70,N/A,109.14,N/A,348.36,N/A,205.70,N/A,264.01,N/A,84.70,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,348.36,N/A,109.14,N/A,84.70,N/A,324.28,N/A,324.28,N/A,84.70,N/A,109.14,N/A,109.14,N/A,120.06,363.00,363.00,84.70,363.00,,Hospital CPT 99212,"HC Est Pt, E/M Level 2",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,605.00,605.00,363.00,363.00,N/A,84.70,N/A,109.14,N/A,348.36,N/A,205.70,N/A,605.00,N/A,84.70,N/A,109.14,N/A,109.14,N/A,605.00,N/A,605.00,N/A,605.00,N/A,605.00,N/A,348.36,N/A,109.14,N/A,84.70,N/A,324.28,N/A,324.28,N/A,84.70,N/A,109.14,N/A,109.14,N/A,120.06,363.00,363.00,84.70,605.00,,Hospital CPT 99213,"HC Est Pt, Outpt Visit Level 3",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,634.00,634.00,380.40,380.40,N/A,88.76,N/A,109.14,N/A,365.06,N/A,215.56,N/A,264.01,N/A,88.76,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,365.06,N/A,109.14,N/A,88.76,N/A,339.82,N/A,339.82,N/A,88.76,N/A,109.14,N/A,109.14,N/A,120.06,380.40,380.40,88.76,380.40,,Hospital CPT 99213,"HC Est Pt, E/M Level 3",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,634.00,634.00,380.40,380.40,N/A,88.76,N/A,109.14,N/A,365.06,N/A,215.56,N/A,634.00,N/A,88.76,N/A,109.14,N/A,109.14,N/A,634.00,N/A,634.00,N/A,634.00,N/A,634.00,N/A,365.06,N/A,109.14,N/A,88.76,N/A,339.82,N/A,339.82,N/A,88.76,N/A,109.14,N/A,109.14,N/A,120.06,380.40,380.40,88.76,634.00,,Hospital CPT 99232,Sbsq Hospital Care/Day 25 Minutes,N/A,N/A,104.00,104.00,62.40,62.40,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,N/A,104.00,62.40,62.40,62.40,104.00,,Hospital CPT 99233,Sbsq Hospital Care/Day 35 Minutes,N/A,N/A,149.00,149.00,89.40,89.40,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,N/A,149.00,89.40,89.40,89.40,149.00,,Hospital 99235,Observation/Inpatient Hospital Care 50 Minutes,N/A,N/A,44261.60,N/A,26556.96,N/A,3726.23,N/A,4718.76,N/A,8799.43,N/A,15048.94,N/A,8885.54,N/A,3841.04,N/A,4689.11,N/A,4689.11,N/A,5531.51,N/A,8885.54,N/A,8885.54,N/A,8885.54,N/A,8799.43,N/A,4689.11,N/A,3841.04,N/A,10265.40,N/A,9339.76,N/A,N/A,N/A,4689.11,N/A,4718.76,N/A,4109.92,N/A,3726.23,26556.96,N/A,N/A,,Hospital CPT 99282,HC ER Level 2,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,911.00,911.00,546.60,546.60,N/A,127.54,N/A,127.51,N/A,524.55,N/A,309.74,N/A,305.14,N/A,127.54,N/A,126.15,N/A,126.15,N/A,189.96,N/A,305.14,N/A,305.14,N/A,305.14,N/A,524.55,N/A,126.15,N/A,127.54,N/A,673.00,N/A,673.00,N/A,127.54,N/A,126.15,N/A,127.51,N/A,45.50,546.60,546.60,45.50,673.00,,Hospital CPT 99285,HC ER Level 5,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2263.00,2263.00,1357.80,1357.80,N/A,316.82,N/A,505.26,N/A,1303.04,N/A,769.42,N/A,1197.28,N/A,316.82,N/A,494.97,N/A,494.97,N/A,745.33,N/A,1197.28,N/A,1197.28,N/A,1197.28,N/A,1303.04,N/A,494.97,N/A,316.82,N/A,1940.00,N/A,1940.00,N/A,316.82,N/A,494.97,N/A,505.26,N/A,190.30,1357.80,1357.80,190.30,1940.00,,Hospital CPT 99291,"HC E/M Crit Care,ER, 1st 30-74min",N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3127.00,3127.00,1876.20,1876.20,N/A,437.78,N/A,210.17,N/A,1800.53,N/A,1063.18,N/A,779.52,N/A,437.78,N/A,210.17,N/A,210.17,N/A,485.25,N/A,779.52,N/A,779.52,N/A,779.52,N/A,1800.53,N/A,210.17,N/A,437.78,N/A,2544.00,N/A,2544.00,N/A,437.78,N/A,210.17,N/A,210.17,N/A,231.19,1876.20,1876.20,210.17,2544.00,,Hospital 99383,"HC Prev Visit New, Age5-11",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,651.02,N/A,390.61,N/A,91.14,N/A,63.88,N/A,372.33,N/A,221.34,N/A,332.37,N/A,91.14,N/A,60.93,N/A,60.93,N/A,335.17,N/A,332.37,N/A,332.37,N/A,332.37,N/A,372.33,N/A,60.93,N/A,91.14,N/A,348.95,N/A,348.95,N/A,91.14,N/A,60.93,N/A,27.28,N/A,30.01,N/A,N/A,27.28,390.61,,Hospital 99402,Prevent Med Counsel&/Risk Factor Redj Spx 30 Min,N/A,N/A,N/A,292.00,N/A,175.20,N/A,40.88,N/A,N/A,N/A,168.13,N/A,99.28,N/A,40.88,N/A,40.88,N/A,N/A,N/A,N/A,N/A,25.40,N/A,40.88,N/A,40.88,N/A,40.88,N/A,168.13,N/A,N/A,N/A,40.88,N/A,156.51,N/A,156.51,N/A,40.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,25.40,175.20,,Hospital 99411,HC Prevent Counsel Group 30 Min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,78.00,N/A,46.80,N/A,10.92,N/A,N/A,N/A,44.91,N/A,26.52,N/A,10.92,N/A,10.92,N/A,N/A,N/A,N/A,N/A,6.79,N/A,10.92,N/A,10.92,N/A,10.92,N/A,44.91,N/A,N/A,N/A,10.92,N/A,41.81,N/A,41.81,N/A,10.92,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6.79,46.80,,Hospital 99412,"HC Prevent Counsel,Group,60 Min",N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,3716.00,N/A,2229.60,N/A,481.15,N/A,385.05,N/A,2139.67,N/A,1263.40,N/A,385.05,N/A,481.15,N/A,385.05,N/A,385.05,N/A,239.71,N/A,385.05,N/A,385.05,N/A,385.05,N/A,2139.66,N/A,218.28,N/A,481.15,N/A,373.91,N/A,373.91,N/A,481.15,N/A,218.28,N/A,216.40,N/A,411.30,N/A,N/A,216.40,2229.60,,Hospital 99497,HC Advncd Care Plan 30 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,572.00,N/A,343.20,N/A,80.08,N/A,120.40,N/A,329.36,N/A,194.48,N/A,N/A,N/A,80.08,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,329.36,N/A,109.14,N/A,80.08,N/A,306.59,N/A,306.59,N/A,80.08,N/A,109.14,N/A,74.32,N/A,81.75,N/A,N/A,74.32,343.20,,Hospital 99605,HC Med Tx Mgmt Indiv New 15 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1501.00,N/A,900.60,N/A,193.88,N/A,456.68,N/A,864.26,N/A,510.34,N/A,1056.04,N/A,193.88,N/A,436.56,N/A,436.56,N/A,657.40,N/A,1056.04,N/A,1056.04,N/A,1056.04,N/A,864.25,N/A,654.84,N/A,193.88,N/A,25.74,N/A,25.74,N/A,193.88,N/A,654.84,N/A,685.02,N/A,28.32,N/A,N/A,25.74,1056.04,,Hospital CPT A0428,"HC Ambulance, Bls Non-Emergent",N/A,0540 - AMBULANCE - GENERAL CLASSIFICATION,670.00,670.00,402.00,402.00,N/A,93.80,N/A,234.00,N/A,385.79,N/A,227.80,N/A,670.00,N/A,93.80,N/A,234.00,N/A,234.00,N/A,670.00,N/A,670.00,N/A,670.00,N/A,670.00,N/A,385.79,N/A,234.00,N/A,93.80,N/A,359.12,N/A,359.12,N/A,93.80,N/A,234.00,N/A,234.00,N/A,670.00,402.00,402.00,93.80,670.00,,Hospital CPT A0434,"HC Ambulance,Specialty Care Trans",N/A,0540 - AMBULANCE - GENERAL CLASSIFICATION,2455.00,2455.00,1473.00,1473.00,N/A,343.70,N/A,767.96,N/A,1413.59,N/A,834.70,N/A,2455.00,N/A,343.70,N/A,760.50,N/A,760.50,N/A,2455.00,N/A,2455.00,N/A,2455.00,N/A,2455.00,N/A,1413.59,N/A,767.96,N/A,343.70,N/A,1315.88,N/A,1315.88,N/A,343.70,N/A,767.96,N/A,767.96,N/A,2455.00,1473.00,1473.00,343.70,2455.00,,Hospital A4221,"Tray,Dressing Change,Chloraprep,Lf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4324.57,N/A,2594.74,N/A,1282.86,N/A,69.93,N/A,N/A,N/A,1470.36,N/A,890.00,N/A,605.44,N/A,N/A,N/A,N/A,N/A,1134.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,2490.09,N/A,N/A,N/A,1282.86,N/A,857.60,N/A,857.60,N/A,1282.86,N/A,N/A,N/A,69.93,N/A,76.92,N/A,N/A,69.93,2594.74,,Hospital A4270,Disposable Endoscope Sheath,N/A,N/A,N/A,49178.68,N/A,29507.21,N/A,6879.36,N/A,4334.56,N/A,28289.56,N/A,16720.76,N/A,10295.11,N/A,6879.36,N/A,4246.26,N/A,4246.26,N/A,6408.90,N/A,10295.11,N/A,10295.11,N/A,10295.11,N/A,28217.58,N/A,4246.26,N/A,6879.36,N/A,5963.00,N/A,5963.00,N/A,6879.36,N/A,4246.26,N/A,4334.56,N/A,446.13,N/A,N/A,446.13,29507.21,,Hospital A4314,"Tray,Foley,Cath,Sil-Elast,16fr,10ml,Bg",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2577.57,N/A,1546.54,N/A,1345.64,N/A,1055.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1345.64,N/A,1055.00,N/A,1055.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1055.00,N/A,1345.64,N/A,N/A,N/A,N/A,N/A,1345.64,N/A,1055.00,N/A,1055.00,N/A,1345.64,N/A,N/A,1055.00,1546.54,,Hospital A4340,"Catheter,Foley,Coude,Latex,16fr,10ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2587.32,N/A,1552.39,N/A,N/A,N/A,1010.00,N/A,760.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1010.00,N/A,1010.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,760.00,N/A,1010.00,N/A,N/A,N/A,760.00,N/A,760.00,N/A,N/A,N/A,1010.00,N/A,1010.00,N/A,N/A,N/A,N/A,760.00,1552.39,,Hospital A4352,"Catheter, Urethral, Coude, Vinyl, 14",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2409.48,N/A,1445.69,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1445.69,1445.69,,Hospital A4362,"Strips,Brava,Barrier,Elastic,Nds",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2091.32,N/A,1254.79,N/A,N/A,N/A,1993.11,N/A,431.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1993.11,N/A,1993.11,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,431.00,N/A,1993.11,N/A,N/A,N/A,431.00,N/A,431.00,N/A,N/A,N/A,1993.11,N/A,1993.11,N/A,N/A,N/A,N/A,431.00,1993.11,,Hospital A4367,"Belt,Ostomy,Adjustable,Up to 42",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2523.97,N/A,1514.38,N/A,656.88,N/A,N/A,N/A,638.60,N/A,N/A,N/A,N/A,N/A,656.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,638.60,N/A,N/A,N/A,656.88,N/A,638.60,N/A,638.60,N/A,656.88,N/A,N/A,N/A,N/A,N/A,656.88,N/A,N/A,638.60,1514.38,,Hospital A4368,"Filter,Pouch,Ostomy Supply,50bx",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,11307.52,N/A,6784.51,N/A,N/A,N/A,2970.00,N/A,N/A,N/A,3844.56,N/A,1842.00,N/A,1583.06,N/A,2970.00,N/A,2970.00,N/A,3040.80,N/A,1842.00,N/A,1842.00,N/A,1842.00,N/A,6510.86,N/A,2970.00,N/A,N/A,N/A,4502.40,N/A,4502.40,N/A,N/A,N/A,2970.00,N/A,2970.00,N/A,6.84,N/A,N/A,6.84,6784.51,,Hospital A4393,"Pouch,1pc,Urostomy,Convlt,Precut,Opaque",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4432.68,N/A,2659.61,N/A,N/A,N/A,855.00,N/A,N/A,N/A,1507.11,N/A,999.00,N/A,620.57,N/A,855.00,N/A,855.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2552.33,N/A,855.00,N/A,N/A,N/A,446.30,N/A,446.30,N/A,N/A,N/A,66.48,N/A,855.00,N/A,73.14,N/A,N/A,66.48,2659.61,,Hospital A4407,"Barrier,W/Flange, Durhsv,Mldbl-Ft 2 1/4",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2004.98,N/A,1202.99,N/A,N/A,N/A,1215.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1215.00,N/A,1215.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1215.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1215.00,N/A,1215.00,N/A,N/A,N/A,N/A,1202.99,1215.00,,Hospital A4408,"Barrier,2pc,Click,Convdeep,Yellw,Cut",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3431.05,N/A,2058.63,N/A,656.88,N/A,82.52,N/A,N/A,N/A,1166.55,N/A,777.00,N/A,480.35,N/A,N/A,N/A,N/A,N/A,777.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,1975.59,N/A,N/A,N/A,656.88,N/A,338.23,N/A,338.23,N/A,656.88,N/A,N/A,N/A,82.52,N/A,90.78,N/A,N/A,82.52,2058.63,,Hospital A4412,Pouch Ni High Output 2pc Drnbl 2.25",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3431.05,N/A,2058.63,N/A,656.88,N/A,82.52,N/A,N/A,N/A,1166.55,N/A,777.00,N/A,480.35,N/A,N/A,N/A,N/A,N/A,777.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,1975.59,N/A,N/A,N/A,656.88,N/A,338.23,N/A,338.23,N/A,656.88,N/A,N/A,N/A,82.52,N/A,90.78,N/A,N/A,82.52,2058.63,,Hospital A4414,"Barrier,Mio,Flex,70mm,Ctf,3/8-2 11/16",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2445.73,N/A,1467.44,N/A,N/A,N/A,1350.00,N/A,1080.00,N/A,453.13,N/A,453.13,N/A,205.53,N/A,1890.00,N/A,1890.00,N/A,453.13,N/A,453.13,N/A,453.13,N/A,453.13,N/A,1080.00,N/A,1890.00,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,N/A,N/A,1890.00,N/A,1890.00,N/A,N/A,N/A,N/A,205.53,1890.00,,Hospital A4415,"Barrier,Mio,Tabs,70mm,Ctf,3/8-2 9/16",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2091.32,N/A,1254.79,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1254.79,1254.79,,Hospital A4419,"Pouch,9clsd,Quitewer,W/Fltr,2.25flange",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1641.90,N/A,985.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,985.14,985.14,,Hospital A4424,"Pouch,1pc,Drain,Trans,Cut-Fit,3/8-2 1/8",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3646.80,N/A,2188.08,N/A,656.88,N/A,11.69,N/A,1080.00,N/A,1239.91,N/A,833.00,N/A,510.55,N/A,1650.00,N/A,1650.00,N/A,811.80,N/A,833.00,N/A,833.00,N/A,833.00,N/A,2099.83,N/A,1650.00,N/A,656.88,N/A,25.08,N/A,25.08,N/A,656.88,N/A,1650.00,N/A,11.69,N/A,12.86,N/A,N/A,11.69,2188.08,,Hospital A4427,"Pouch,2p,Wde,Easiclse,Maxi,Trns,40mm,Nds",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1773.92,N/A,1064.35,N/A,656.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,656.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,656.88,N/A,N/A,N/A,N/A,N/A,656.88,N/A,N/A,N/A,N/A,N/A,656.88,N/A,N/A,656.88,1064.35,,Hospital A4428,"Pouch,Urostomy,PR,Ft,Tnsp,2 1/2"" Ctf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2523.97,N/A,1514.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1514.38,1514.38,,Hospital A4450,"Strip,Closure,Wound,Medi-Strip,1/2x4",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2805.52,N/A,1683.31,N/A,820.44,N/A,1215.00,N/A,800.00,N/A,953.87,N/A,392.77,N/A,392.77,N/A,783.00,N/A,783.00,N/A,702.48,N/A,392.77,N/A,392.77,N/A,392.77,N/A,1615.42,N/A,2040.83,N/A,820.44,N/A,1500.80,N/A,1500.80,N/A,820.44,N/A,864.00,N/A,1826.07,N/A,820.44,N/A,N/A,392.77,2040.83,,Hospital A4455,"Spray,Adhesive Remover,1.7 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3487.17,N/A,2092.30,N/A,656.88,N/A,325.76,N/A,1100.00,N/A,1185.63,N/A,722.31,N/A,488.20,N/A,N/A,N/A,N/A,N/A,700.99,N/A,722.31,N/A,722.31,N/A,722.31,N/A,2007.90,N/A,N/A,N/A,656.88,N/A,153.90,N/A,153.90,N/A,656.88,N/A,N/A,N/A,325.76,N/A,358.34,N/A,N/A,153.90,2092.30,,Hospital A4641,Radiopharm dx agent noc,N/A,N/A,84650.02,1597.30,50790.01,958.38,8409.23,223.61,21437.13,333.12,46621.73,919.55,28755.51,543.08,14753.74,900.65,8409.23,223.61,8043.54,334.52,10798.73,334.52,9183.86,653.97,14753.74,900.65,14753.74,900.65,14753.74,900.65,32759.19,919.55,13006.17,332.68,8409.23,223.61,32759.19,814.18,32759.19,814.18,5959.85,223.61,10607.81,334.52,11228.29,333.12,8409.23,292.68,5959.85,50790.01,223.61,958.38,,Hospital A5061,"Pouch,Mio,1pc,Easi,Trns,Ctf,3/8-2 1/8",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2897.27,N/A,1738.36,N/A,N/A,N/A,570.00,N/A,800.00,N/A,985.07,N/A,666.00,N/A,405.62,N/A,570.00,N/A,570.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1668.24,N/A,570.00,N/A,N/A,N/A,52.13,N/A,52.13,N/A,N/A,N/A,570.00,N/A,570.00,N/A,9.50,N/A,N/A,9.50,1738.36,,Hospital A5063,"Pouch,Ni Drnbl,Lk'nrol,2 1/4""Flange,Beig",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2686.62,N/A,1611.97,N/A,1611.87,N/A,1215.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1611.87,N/A,1215.00,N/A,1215.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1215.00,N/A,1611.87,N/A,N/A,N/A,N/A,N/A,1611.87,N/A,1215.00,N/A,1215.00,N/A,1611.87,N/A,N/A,1215.00,1611.97,,Hospital A5114,"Straps, Leg Bag, Elastic, Hook&Loop",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1007.18,N/A,604.31,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,604.31,604.31,,Hospital A5122,"Strips,Brava,Barrier,Sheets,Protect,",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1641.90,N/A,985.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,985.14,985.14,,Hospital A6022,"Dressing,Collagen,Puracol,Strl,4x4.25",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2825.00,N/A,1695.00,N/A,1239.90,N/A,1677.00,N/A,1080.00,N/A,214.00,N/A,214.00,N/A,132.25,N/A,1677.00,N/A,1677.00,N/A,214.00,N/A,214.00,N/A,214.00,N/A,214.00,N/A,1080.00,N/A,2004.25,N/A,1239.90,N/A,1080.00,N/A,1080.00,N/A,1239.90,N/A,1677.00,N/A,1677.00,N/A,1239.90,N/A,N/A,132.25,2004.25,,Hospital A6154,"Pouch,Eakin,Fistula,6.9 X4.3,W/Tap Closr",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1732.30,N/A,1039.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1039.38,1039.38,,Hospital A6199,"Silver Alginate, Maxorb II Ag, 1x12",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2520.88,N/A,1512.53,N/A,182.32,N/A,2303.35,N/A,1310.47,N/A,449.92,N/A,449.92,N/A,108.30,N/A,2303.35,N/A,2303.35,N/A,449.92,N/A,449.92,N/A,449.92,N/A,449.92,N/A,1310.47,N/A,2303.35,N/A,182.32,N/A,1310.47,N/A,1310.47,N/A,182.32,N/A,2303.35,N/A,2303.35,N/A,182.32,N/A,N/A,108.30,2303.35,,Hospital A6209,"Dressing,Hydrofera,Blue,Ready,2.5x2.5",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4253.83,N/A,2552.30,N/A,867.93,N/A,2224.30,N/A,N/A,N/A,1446.30,N/A,1000.39,N/A,595.54,N/A,2224.30,N/A,2224.30,N/A,999.86,N/A,1000.39,N/A,1000.39,N/A,1000.39,N/A,2449.35,N/A,2354.69,N/A,867.93,N/A,136.05,N/A,136.05,N/A,867.93,N/A,1620.00,N/A,2224.30,N/A,81.07,N/A,N/A,81.07,2552.30,,Hospital A6215,Dressing Tube 9mm Dia Hydro Blue,N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,977.68,N/A,586.61,N/A,N/A,N/A,977.68,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,977.68,N/A,977.68,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,977.68,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,977.68,N/A,977.68,N/A,N/A,N/A,N/A,586.61,977.68,,Hospital A6217,"Pad,Abdominal,5""X9"",Ns,Lf,1ea",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2673.82,N/A,1604.29,N/A,N/A,N/A,2727.29,N/A,1490.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2727.29,N/A,2727.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1490.00,N/A,2727.29,N/A,N/A,N/A,1490.00,N/A,1490.00,N/A,N/A,N/A,2727.29,N/A,2727.29,N/A,N/A,N/A,N/A,1490.00,2727.29,,Hospital A6229,"Dressing,Ribbon,Mesalt,0.75 X 39",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2409.88,N/A,1445.93,N/A,N/A,N/A,1235.00,N/A,1660.36,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1235.00,N/A,1235.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1660.36,N/A,1235.00,N/A,N/A,N/A,1660.36,N/A,1660.36,N/A,N/A,N/A,1235.00,N/A,1235.00,N/A,N/A,N/A,N/A,1235.00,1660.36,,Hospital A6237,"Hydrocolloid,Exuderm Satin Sacral,4x3.6",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2220.80,N/A,1332.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.49,1332.48,,Hospital A6251,"Pad,Non-Adherent,3x4,Sterile,Lf,1/Pk",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3363.88,N/A,2018.33,N/A,867.93,N/A,17.99,N/A,N/A,N/A,1143.72,N/A,910.94,N/A,470.94,N/A,2200.00,N/A,2200.00,N/A,902.25,N/A,910.94,N/A,910.94,N/A,910.94,N/A,1936.94,N/A,2200.00,N/A,867.93,N/A,87.85,N/A,87.85,N/A,867.93,N/A,2200.00,N/A,17.99,N/A,19.80,N/A,N/A,17.99,2200.00,,Hospital A6252,"Pad,Abdominal,5x9,St,Lf,1ea",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2811.92,N/A,1687.15,N/A,1176.63,N/A,1755.00,N/A,994.00,N/A,1177.00,N/A,1177.00,N/A,1176.63,N/A,1369.00,N/A,1369.00,N/A,1177.00,N/A,1177.00,N/A,1177.00,N/A,1177.00,N/A,1054.00,N/A,2004.25,N/A,1176.63,N/A,994.00,N/A,994.00,N/A,1176.63,N/A,1045.00,N/A,2199.46,N/A,1176.63,N/A,N/A,994.00,2199.46,,Hospital A6253,"Pad,Abdominal,8x10,St,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3890.90,N/A,2334.54,N/A,1070.00,N/A,1755.00,N/A,994.00,N/A,562.40,N/A,562.40,N/A,135.93,N/A,856.00,N/A,856.00,N/A,562.40,N/A,562.40,N/A,562.40,N/A,562.40,N/A,994.00,N/A,2303.35,N/A,1070.00,N/A,994.00,N/A,994.00,N/A,1070.00,N/A,1045.00,N/A,1766.95,N/A,1070.00,N/A,N/A,135.93,2334.54,,Hospital A6255,"Optifoam Gentle Sa, Postop, 4x12",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2462.03,N/A,1477.22,N/A,N/A,N/A,317.44,N/A,N/A,N/A,837.08,N/A,619.68,N/A,344.68,N/A,N/A,N/A,N/A,N/A,595.20,N/A,619.68,N/A,619.68,N/A,619.68,N/A,1417.64,N/A,N/A,N/A,N/A,N/A,247.65,N/A,247.65,N/A,N/A,N/A,N/A,N/A,317.44,N/A,349.18,N/A,N/A,247.65,1477.22,,Hospital A6266,"Gauze,Packing Strip,Iodoform,1/4x5yd,St",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2601.20,N/A,1560.72,N/A,1177.00,N/A,122.11,N/A,638.60,N/A,884.39,N/A,500.00,N/A,364.15,N/A,1773.91,N/A,1773.91,N/A,561.00,N/A,500.00,N/A,500.00,N/A,500.00,N/A,1497.77,N/A,1801.26,N/A,1177.00,N/A,214.40,N/A,214.40,N/A,1177.00,N/A,1773.91,N/A,122.11,N/A,134.31,N/A,N/A,122.11,1801.26,,Hospital A6402,"Gauze,Sponge,4""X4"",12ply,Sterile,Lf,2's",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2673.82,N/A,1604.29,N/A,563.04,N/A,1404.00,N/A,648.00,N/A,925.52,N/A,925.52,N/A,563.04,N/A,935.00,N/A,935.00,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,648.00,N/A,2095.64,N/A,563.04,N/A,648.00,N/A,648.00,N/A,563.04,N/A,880.00,N/A,1509.17,N/A,563.04,N/A,N/A,563.04,2095.64,,Hospital A6403,"Mbo-Dressing,Telfa,8 X 3,Sterile",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2204.45,N/A,1322.67,N/A,N/A,N/A,2204.45,N/A,1159.00,N/A,N/A,N/A,N/A,N/A,36.42,N/A,2204.45,N/A,2204.45,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1159.00,N/A,2204.45,N/A,N/A,N/A,1159.00,N/A,1159.00,N/A,N/A,N/A,2204.45,N/A,2204.45,N/A,N/A,N/A,N/A,36.42,2204.45,,Hospital A6407,"Gauze,Packing Strip,Plain,1/2x5yd,Strl",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2716.07,N/A,1629.64,N/A,995.61,N/A,1773.91,N/A,1310.47,N/A,N/A,N/A,N/A,N/A,995.61,N/A,1773.91,N/A,1773.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1310.47,N/A,1773.91,N/A,995.61,N/A,1310.47,N/A,1310.47,N/A,995.61,N/A,1773.91,N/A,1773.91,N/A,995.61,N/A,N/A,995.61,1773.91,,Hospital A6443,"Bandage,Gauze,Roll,4.5""X4.1yd,Ns,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3067.52,N/A,1840.51,N/A,1070.00,N/A,2032.97,N/A,574.70,N/A,1042.95,N/A,779.77,N/A,429.45,N/A,2032.97,N/A,2032.97,N/A,778.72,N/A,779.77,N/A,779.77,N/A,779.77,N/A,1766.26,N/A,2313.94,N/A,1070.00,N/A,143.38,N/A,143.38,N/A,1070.00,N/A,2032.97,N/A,2032.97,N/A,42.90,N/A,N/A,42.90,2313.94,,Hospital A6455,"Bandage,Coflex,Lf2,6x5yd,Tan,Ns,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2656.73,N/A,1594.04,N/A,722.28,N/A,2303.35,N/A,N/A,N/A,112.48,N/A,112.48,N/A,722.28,N/A,2303.35,N/A,2303.35,N/A,112.48,N/A,112.48,N/A,112.48,N/A,112.48,N/A,N/A,N/A,2303.35,N/A,722.28,N/A,N/A,N/A,N/A,N/A,722.28,N/A,2303.35,N/A,2303.35,N/A,722.28,N/A,N/A,112.48,2303.35,,Hospital A6545,"Inelast Garment, Comprecares,Medium Reg",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2054.55,N/A,1232.73,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,1232.73,2095.64,,Hospital A9505,TL201 thallium,N/A,N/A,149896.98,N/A,89938.19,N/A,18915.40,N/A,56899.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18915.40,N/A,56899.06,N/A,56899.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56899.06,N/A,18915.40,N/A,N/A,N/A,N/A,N/A,18915.40,N/A,56899.06,N/A,56899.06,N/A,18915.40,N/A,18915.40,89938.19,N/A,N/A,,Hospital A9509,Iodine I-123 Sod Iodide Mil,N/A,N/A,N/A,2750.00,N/A,1650.00,N/A,385.00,N/A,350.99,N/A,1567.35,N/A,935.00,N/A,849.06,N/A,385.00,N/A,350.99,N/A,350.99,N/A,528.56,N/A,849.06,N/A,849.06,N/A,849.06,N/A,1567.35,N/A,350.99,N/A,385.00,N/A,1300.34,N/A,1300.34,N/A,385.00,N/A,350.99,N/A,350.99,N/A,386.09,N/A,N/A,350.99,1650.00,,Hospital A9542,"In111 ibritumomab, dx",N/A,N/A,N/A,9117.00,N/A,5470.20,N/A,1276.38,N/A,358.29,N/A,4861.26,N/A,3099.78,N/A,1541.55,N/A,1276.38,N/A,350.99,N/A,350.99,N/A,959.64,N/A,1541.55,N/A,1541.55,N/A,1541.55,N/A,4861.26,N/A,350.99,N/A,1276.38,N/A,698.94,N/A,698.94,N/A,1276.38,N/A,350.99,N/A,358.29,N/A,137.21,N/A,N/A,137.21,5470.20,,Hospital HCPCS A9548,INDIUM-111 PENTETATE,N/A,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,3582.00,3582.00,2149.20,2149.20,N/A,501.48,N/A,3582.00,N/A,1884.49,N/A,1217.88,N/A,1070.16,N/A,501.48,N/A,3582.00,N/A,3582.00,N/A,666.19,N/A,1070.16,N/A,1070.16,N/A,1070.16,N/A,1884.49,N/A,3582.00,N/A,501.48,N/A,1919.95,N/A,1919.95,N/A,501.48,N/A,3582.00,N/A,3582.00,N/A,3582.00,2149.20,2149.20,501.48,3582.00,,Hospital A9556,Ga67 gallium,N/A,N/A,105522.68,21997.50,63313.61,13198.50,N/A,3079.65,11662.03,1359.51,N/A,5528.57,N/A,7479.15,N/A,4652.11,N/A,3079.65,11662.03,1344.94,11662.03,1344.94,N/A,2896.01,N/A,4652.11,N/A,4652.11,N/A,4652.11,N/A,5528.57,11662.03,1344.94,N/A,3079.65,N/A,9032.14,N/A,9032.14,N/A,3079.65,11662.03,1344.94,11662.03,1359.51,N/A,N/A,11662.03,63313.61,1344.94,13198.50,,Hospital A9570,Indium In-111 auto WBC,N/A,N/A,46907.65,7531.00,28144.59,4518.60,10053.63,1054.34,12158.56,1988.07,23248.80,4205.64,15948.61,2560.54,22873.39,7227.32,10363.40,1054.34,3372.00,1900.56,3372.00,1900.56,14238.15,7531.00,22873.39,7227.32,22873.39,7227.32,22873.39,7227.32,23248.80,4205.64,12158.56,1900.56,10363.40,1054.34,27213.62,2613.53,27213.62,2613.53,N/A,1054.34,12158.56,1900.56,12158.56,1988.07,11088.83,924.30,3372.00,28144.59,924.30,7531.00,,Hospital A9575,Inj gadoterate meglumi 0.1ml,N/A,N/A,31579.32,7624.00,18947.59,4574.40,4201.55,1067.36,5235.86,204.14,9468.53,1337.69,10736.97,2592.16,9559.10,855.29,4331.00,1067.36,1686.00,332.71,1686.00,332.71,5950.32,532.43,9559.10,855.29,9559.10,855.29,9559.10,855.29,9468.53,1337.69,5235.86,332.71,4331.00,1067.36,11372.94,1060.00,11372.94,1060.00,4331.00,1067.36,5235.86,332.71,5235.86,204.14,4634.17,224.55,1686.00,18947.59,204.14,4574.40,,Hospital HCPCS A9579,GADOTERIDOL 279.3 MG/ML IV SOLN,00270-1111-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),203.60,203.60,122.16,122.16,N/A,28.50,N/A,203.60,N/A,114.46,N/A,69.22,N/A,40.40,N/A,28.50,N/A,203.60,N/A,203.60,N/A,25.15,N/A,40.40,N/A,40.40,N/A,40.40,N/A,114.46,N/A,203.60,N/A,28.50,N/A,109.13,N/A,109.13,N/A,28.50,N/A,203.60,N/A,203.60,N/A,203.60,122.16,122.16,25.15,203.60,,Hospital A9592,Copper cu 64 dotatate diag,N/A,N/A,N/A,17526.00,N/A,10515.60,N/A,2453.64,N/A,4970.96,N/A,10866.79,N/A,5958.84,N/A,12577.30,N/A,2453.64,N/A,4970.96,N/A,4970.96,N/A,7829.52,N/A,12577.30,N/A,12577.30,N/A,12577.30,N/A,10866.79,N/A,4970.96,N/A,2453.64,N/A,2452.74,N/A,2452.74,N/A,2453.64,N/A,4970.96,N/A,4970.96,N/A,5468.06,N/A,N/A,2452.74,12577.30,,Hospital HCPCS A9594,GALLIUM GA 68 GOZETOTIDE 25 MCG IV KIT,74725-0100-25,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,16450.00,16450.00,9870.00,9870.00,N/A,2303.00,N/A,49820.00,N/A,8654.35,N/A,5593.00,N/A,16450.00,N/A,2303.00,N/A,49820.00,N/A,49820.00,N/A,16450.00,N/A,16450.00,N/A,16450.00,N/A,16450.00,N/A,8654.35,N/A,49820.00,N/A,2303.00,N/A,8817.20,N/A,8817.20,N/A,2303.00,N/A,49820.00,N/A,49820.00,N/A,54802.00,9870.00,9870.00,2303.00,54802.00,,Hospital A9597,"Pet, dx, for tumor id, noc",N/A,N/A,N/A,8316.50,N/A,4989.90,N/A,1164.31,N/A,1372.91,N/A,3629.88,N/A,2827.61,N/A,3253.30,N/A,1164.31,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,3253.30,N/A,3253.30,N/A,3253.30,N/A,3629.88,N/A,1344.94,N/A,1164.31,N/A,3633.54,N/A,3633.54,N/A,1164.31,N/A,1344.94,N/A,1372.91,N/A,N/A,N/A,N/A,1164.31,4989.90,,Hospital A9606,Radium ra223 dichloride ther,N/A,N/A,195709.18,69443.00,117425.51,41665.80,17771.61,9722.02,13596.12,18808.36,107874.91,36648.33,66541.13,23610.62,68145.94,45532.76,14454.42,9722.02,8430.00,18805.92,8430.00,18805.92,42429.75,28344.60,68145.94,45532.76,68145.94,45532.76,68145.94,45532.76,107874.91,36648.33,13596.12,18805.92,14454.42,9722.02,30503.06,1233.34,30503.06,1233.34,12131.21,9722.02,13596.12,18805.92,13596.12,18808.36,15466.23,51.91,8430.00,117425.51,51.91,45532.76,,Hospital C1062,HC Intravertebral Fx Aug Implt,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,223180.13,82025.78,133908.08,49215.47,24546.57,11482.37,24031.30,22622.27,123016.89,46415.14,75881.24,27888.77,77711.32,21733.20,21074.97,11482.37,2248.00,17035.17,2248.00,17035.17,48385.45,13521.44,77711.32,21733.20,77711.32,21733.20,77711.32,21733.20,123016.89,46415.15,24031.30,17035.17,21074.97,11482.37,134150.63,8160.50,134150.63,8160.50,16933.13,11482.37,24031.30,17035.17,24031.30,22622.27,22550.22,547.90,2248.00,134150.63,547.90,49215.47,,Hospital C1717,HC Hdr Brachy Seed IR 192,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,41364.42,49616.00,24818.65,29769.60,N/A,6946.24,N/A,2257.05,N/A,28488.68,N/A,16869.44,N/A,13789.38,N/A,6946.24,N/A,5863.44,N/A,5863.44,N/A,8584.20,N/A,13789.38,N/A,13789.38,N/A,13789.38,N/A,28488.68,N/A,5863.44,N/A,6946.24,N/A,23434.44,N/A,23434.44,N/A,6946.24,N/A,5863.44,N/A,2257.05,N/A,2482.79,24818.65,24818.65,2257.05,29769.60,,Hospital C1726,HC Misc Cath Bal Dilation Non-Vasc,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,58862.33,18817.13,35317.40,11290.28,10126.71,2634.41,12245.02,4821.94,22821.36,10825.11,17127.73,6397.84,23039.67,11685.78,10438.73,2634.41,12245.02,4821.94,12245.02,4821.94,14341.66,7274.62,23039.67,11685.78,23039.67,11685.78,23039.67,11685.78,22821.36,10825.12,12245.02,4821.94,10438.73,2634.41,27411.45,7366.25,27411.45,7366.25,6342.28,2634.41,12245.02,4821.94,12245.02,4821.94,11169.44,5304.13,6342.28,35317.40,2634.41,11685.78,,Hospital C1728,HC Misc Cath Brachtherapy Seed Admin,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,N/A,65165.75,N/A,39099.45,N/A,9116.33,N/A,6944.89,N/A,37402.30,N/A,22156.36,N/A,16895.57,N/A,9116.33,N/A,6944.89,N/A,6944.89,N/A,10517.83,N/A,16895.57,N/A,16895.57,N/A,16895.57,N/A,37402.31,N/A,6944.89,N/A,9116.33,N/A,8585.00,N/A,8585.00,N/A,9116.33,N/A,6944.89,N/A,6944.89,N/A,7639.38,N/A,N/A,6944.89,39099.45,,Hospital C1729,HC Catheter Drainage,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,137154.40,9071.08,82292.64,5442.65,25839.30,1237.39,10002.64,913.92,58892.10,5223.13,51424.55,3084.17,51424.55,2210.69,10383.19,1237.39,30832.21,913.92,30832.21,913.92,51424.55,1376.19,51424.55,2210.69,51424.55,2210.69,51424.55,2210.69,58892.10,5223.13,26002.72,913.92,22427.08,1237.39,103174.60,2134.50,103174.60,2134.50,22427.08,1237.39,27567.74,913.92,10002.64,913.92,22427.08,1005.31,10002.64,103174.60,913.92,5442.65,,Hospital C1732,HC Cath Ep Diag/Abl 3d/Vect,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,176809.08,76468.58,106085.45,45881.15,N/A,10705.62,27794.76,21204.54,N/A,43707.46,105105.86,25999.33,105105.86,51364.91,N/A,10705.62,27794.76,21204.54,27794.76,21204.54,105105.86,31975.65,105105.86,51364.91,105105.86,51364.91,105105.86,51364.91,N/A,43707.48,27794.76,21204.54,N/A,10705.62,N/A,16637.00,N/A,16637.00,N/A,10705.62,27794.76,21204.54,27794.76,21204.54,N/A,23325.00,27794.76,106085.45,10705.62,51364.91,,Hospital C1753,HC Misc Cath Intravascular Ultrasound,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,163443.18,58062.63,98065.91,34837.58,14264.78,8075.79,21363.81,4709.71,167079.20,33399.04,28770.76,19741.30,28770.76,11435.85,14264.78,8075.79,21363.81,4709.71,21363.81,4709.71,28770.76,7119.01,28770.76,11435.85,28770.76,11435.85,28770.76,11435.85,167079.20,33399.04,21363.81,4709.71,14264.78,8075.79,167079.20,7897.00,167079.20,7897.00,14264.78,8075.79,21363.81,4709.71,21363.81,4709.71,14264.78,5180.69,14264.78,167079.20,4709.71,34837.58,,Hospital C1759,HC Cath Intra Echocardiography,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,185874.22,152070.35,111524.53,91242.21,16184.08,21228.77,22058.03,22180.90,71563.73,87109.25,55703.87,51703.91,55703.87,51491.76,16184.08,21228.77,26775.20,21204.54,23009.01,21204.54,55703.87,32054.59,55703.87,51491.76,55485.50,51491.76,55703.87,51491.76,71563.73,87109.25,22058.03,21204.54,16184.08,21228.77,71563.73,17032.25,68722.63,17032.25,16184.08,21228.77,22494.57,21204.54,22573.15,22180.90,16184.08,2381.04,16184.08,111524.53,2381.04,91242.21,,Hospital C1767,HC Misc Nerve Stimulator,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,227877.53,187855.52,136726.52,112713.31,25031.66,26290.92,21832.68,19429.23,125606.09,105858.93,77478.36,63852.52,79346.96,47034.13,21512.90,26290.92,21832.68,19429.23,21832.68,19429.23,49403.85,29279.65,79346.96,47034.13,79346.96,47034.13,79346.96,47034.13,125606.09,105858.94,21832.68,19429.23,21512.90,26290.92,142831.40,37100.00,142831.40,37100.00,17754.23,26290.92,21832.68,19429.23,21832.68,19429.23,23018.80,21372.15,17754.23,142831.40,19429.23,112713.31,,Hospital C1768,HC Vascular Graft,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,97444.95,38549.22,58466.97,23129.53,15979.32,5375.32,19095.96,4641.41,42673.16,22033.27,53919.87,13106.73,53919.87,11362.21,16471.67,5375.32,10586.59,4641.41,10586.59,4641.41,53919.87,7073.19,53919.87,11362.21,53919.87,11362.21,53919.87,11362.21,42673.16,22033.26,19066.31,4641.41,26950.55,5375.32,45114.89,8612.50,45112.25,8612.50,26950.55,5375.32,10586.59,4641.41,10586.59,4641.41,17624.69,5105.55,10586.59,58466.97,4641.41,23129.53,,Hospital C1769,HC Misc Guidewire,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,88408.07,24631.95,53044.84,14779.17,13777.72,3440.86,16563.99,5973.28,35404.16,14151.20,30058.73,8374.86,31346.23,14507.21,14202.24,3440.86,16563.99,5973.28,16563.99,5973.28,19512.30,9031.02,31346.23,14507.21,31346.23,14507.21,31346.23,14507.21,35404.16,14151.21,16563.99,5973.28,14202.24,3440.86,37294.19,8970.25,37294.19,8970.25,10710.31,3440.86,16563.99,5973.28,16563.99,5973.28,15196.40,6570.60,10710.31,53044.84,3440.86,14779.17,,Hospital C1780,HC Misc Iol Lens,N/A,0276 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - INTRAOCULAR LENS,N/A,16413.28,N/A,9847.97,N/A,2297.87,N/A,2039.85,N/A,9441.92,N/A,5580.52,N/A,4731.20,N/A,2297.87,N/A,1950.06,N/A,1950.06,N/A,2945.26,N/A,4731.20,N/A,4731.20,N/A,4731.20,N/A,9441.91,N/A,1950.06,N/A,2297.87,N/A,3397.00,N/A,3397.00,N/A,2297.87,N/A,1950.06,N/A,2039.85,N/A,556.44,N/A,N/A,556.44,9847.97,,Hospital C1814,HC Retinal Tamp Silicone Oil,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,105995.12,45617.47,63597.07,27370.48,10063.76,6364.59,12170.55,1251.02,58424.51,26138.48,36038.35,15509.94,N/A,8801.90,10373.84,6364.59,2810.00,3608.17,2810.00,3608.17,14252.51,5479.36,22896.45,8801.90,22896.45,8801.90,22896.45,8801.90,58424.51,26138.52,12170.55,3608.17,10373.84,6364.59,27241.06,5963.00,27241.06,5963.00,N/A,6364.59,12170.55,3608.17,12170.55,1251.02,11100.01,1376.13,2810.00,63597.07,1251.02,27370.48,,Hospital C1815,HC Misc Prosth Urin Sphincter Impl,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,122635.97,118159.85,73581.58,70895.91,6010.52,16542.38,18213.89,18213.89,67596.94,66989.75,41696.22,40174.35,13674.76,42227.57,6195.71,16542.38,64068.00,17412.16,64068.00,17412.16,8512.22,26287.48,13674.76,42227.57,13674.76,42227.57,13674.76,42227.57,67596.94,66989.76,7375.78,17412.16,6195.71,16542.38,16269.55,16637.00,16269.55,16637.00,N/A,16542.38,7375.78,17412.16,7405.43,18213.89,6629.41,794.76,6010.52,73581.58,794.76,70895.91,,Hospital C1817,HC Septal Defect Implant System Intracardiac,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,122889.97,143370.27,73733.98,86022.16,17921.66,20067.00,21495.70,17111.64,67736.95,81140.09,41782.59,48745.90,42359.94,37551.28,18473.86,20067.00,21466.05,15512.06,21466.05,15512.06,26368.72,23376.40,42359.94,37551.28,42359.94,37551.28,42359.94,37551.28,67736.95,81140.10,21466.05,15512.06,18473.86,20067.00,48511.18,16900.50,48511.18,16900.50,17063.27,20067.00,21466.05,15512.06,21495.70,1109.92,17063.27,1220.94,17063.27,73733.98,1109.92,86022.16,,Hospital C1824,HC Research Optimizer Smart Pas Study Device,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,190700.68,N/A,114420.41,N/A,26783.53,N/A,31949.18,N/A,105114.22,N/A,64838.24,N/A,66401.98,N/A,27608.78,N/A,31949.18,N/A,31949.18,N/A,41343.91,N/A,66401.98,N/A,66401.98,N/A,N/A,N/A,105114.22,N/A,31949.18,N/A,27608.78,N/A,72498.91,N/A,72498.91,N/A,11255.72,N/A,31949.18,N/A,31949.18,N/A,29541.39,N/A,11255.72,114420.41,N/A,N/A,,Hospital C1875,"Stent, coated/cov w/o del sy",N/A,N/A,86616.62,N/A,51969.97,N/A,10186.46,N/A,12315.69,N/A,25378.33,N/A,29449.65,N/A,24076.89,N/A,10500.32,N/A,12315.69,N/A,12315.69,N/A,14987.67,N/A,24076.89,N/A,24076.89,N/A,24076.89,N/A,25378.33,N/A,12315.69,N/A,10500.32,N/A,27573.18,N/A,27573.18,N/A,N/A,N/A,12315.69,N/A,12315.69,N/A,11235.34,N/A,10186.46,51969.97,N/A,N/A,,Hospital C1876,HC Misc Stent Nonctd/Cvd W Del Sys,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,136834.25,55458.10,82100.55,33274.86,14264.78,7745.19,17140.14,9586.05,75423.04,31825.22,46523.65,18855.75,33716.47,23245.35,14704.30,7745.19,17140.14,9586.05,17140.14,9586.05,20988.23,14470.69,33716.47,23245.35,33716.47,23245.35,33716.47,23245.35,75423.04,31825.22,17140.14,9586.05,14704.30,7745.19,38612.56,15608.50,38612.56,15608.50,1839.87,7745.19,17140.14,9586.05,17140.14,9586.05,15733.60,10544.65,1839.87,82100.55,7745.19,33274.86,,Hospital C1883,HC Misc Neuro Extension/Adaptor,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,93900.83,48027.18,56340.50,28816.31,34146.37,6722.53,40659.05,6578.49,78617.08,27180.98,31926.29,16329.25,80708.95,14466.44,35198.48,6722.53,40659.05,5963.54,40659.05,5963.54,50240.66,9005.62,80708.95,14466.44,80708.95,14466.44,80708.95,14466.44,78617.08,27181.00,40659.05,5963.54,35198.48,6722.53,92429.00,7897.00,92429.00,7897.00,N/A,6722.53,40659.05,5963.54,40659.05,298.12,37662.38,327.94,31926.29,92429.00,298.12,28816.31,,Hospital C1889,"HC Implant/Insert Device, Noc",N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,136028.62,36291.63,81617.17,21774.98,21756.72,5080.82,26002.72,4706.78,74978.97,7923.00,45707.94,12339.15,45707.94,12364.02,20709.19,5080.82,24031.30,4706.78,26002.72,4706.78,45707.94,7696.84,45707.94,12364.02,45707.94,12364.02,45707.94,12364.02,74978.97,7923.00,26002.72,4706.78,22427.08,5080.82,58892.10,7897.00,58892.10,7897.00,20709.19,5080.82,26002.72,4706.78,21566.87,4706.78,23996.97,5177.46,20709.19,81617.17,4706.78,21774.98,,Hospital C1893,HC Misc Introducr Not Peelaway,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,146026.02,39625.07,87615.61,23775.04,14264.78,5529.83,17140.14,1343.59,80489.54,22808.12,49648.84,13472.50,33716.47,3350.01,14704.30,5529.83,17140.14,1343.59,17140.14,1343.59,20988.23,2085.43,33716.47,3350.01,33716.47,3350.01,33716.47,3350.01,80489.54,22785.09,17140.14,1343.59,14704.30,5529.83,38612.56,1871.00,38612.56,1871.00,3446.59,5529.83,17140.14,1343.59,17140.14,1343.59,15733.60,1477.95,3446.59,87615.61,1343.59,23775.04,,Hospital C2617,HC Misc Stent Noncor Temp WO Del Sys,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,53256.12,23840.27,31953.67,14304.16,9049.65,3310.19,10970.91,4246.26,21009.41,13711.71,18107.08,8105.70,20589.21,10377.03,9328.49,3312.29,10970.91,4246.26,10970.91,4246.26,12816.30,6459.90,20589.21,10377.03,20589.21,10377.03,20589.21,10377.03,21009.41,13711.71,10970.91,4246.26,9328.49,3312.29,24496.02,5963.00,24496.02,5963.00,8303.39,3312.29,10970.91,4246.26,10970.91,4246.26,9981.48,4670.88,8303.39,31953.67,3310.19,14304.16,,Hospital C2621,HC Misc Pacemaker Bi-V,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,176194.98,148159.87,105716.99,88895.92,14459.32,20664.63,15057.65,611.60,97118.68,83787.98,59906.30,50374.36,29555.50,14825.38,12889.63,20664.63,1124.00,11057.10,1124.00,11057.10,18398.06,9229.09,29555.50,14825.38,29555.50,14825.38,29555.50,14825.38,97118.68,83788.02,15057.65,11057.10,12889.63,20664.63,33847.36,7897.00,33847.36,7897.00,12889.63,20664.63,15057.65,11057.10,15057.65,611.60,13791.91,672.77,1124.00,105716.99,611.60,88895.92,,Hospital C2627,HC Misc Cath Suprapubic,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,115861.88,21905.00,69517.13,13143.00,10520.90,3066.70,22818.46,3027.62,N/A,12611.92,62720.14,7447.70,62720.14,7016.90,10520.90,3066.70,23413.12,2894.35,23413.12,2894.35,62720.14,4368.15,62720.14,7016.90,62720.14,7016.90,62720.14,7016.90,63863.07,12611.93,23413.12,2894.35,26950.55,3066.70,70770.44,5095.50,70770.44,5095.50,10520.90,3066.70,22818.46,2894.35,23413.12,3027.62,10520.90,547.01,10520.90,70770.44,547.01,13143.00,,Hospital C2629,HC Non Cardiac Intro/Sheath Laser,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,117933.18,134307.17,70759.91,80584.30,10193.39,18735.87,13164.75,30299.94,65004.77,76525.59,N/A,45664.44,N/A,70151.36,10507.47,18735.87,13164.75,28966.21,13164.75,28966.21,N/A,43670.71,N/A,70151.36,N/A,70151.36,N/A,70151.36,65004.77,76525.61,12323.90,28966.21,N/A,18735.87,N/A,33187.50,27591.95,33187.50,N/A,18735.87,13164.75,28966.21,13164.75,30299.94,11242.99,2198.58,10193.39,70759.91,2198.58,80584.30,,Hospital C2638,HC Rad Seeds I125 Stranded,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,34423.00,N/A,20653.80,N/A,4819.22,N/A,7220.92,N/A,19756.51,N/A,11703.82,N/A,16520.60,N/A,4819.22,N/A,7107.51,N/A,7107.51,N/A,10284.39,N/A,16520.60,N/A,16520.60,N/A,16520.60,N/A,19756.51,N/A,7107.51,N/A,4819.22,N/A,7897.00,N/A,7897.00,N/A,4819.22,N/A,7107.51,N/A,7220.92,N/A,1421.11,N/A,N/A,1421.11,20653.80,,Hospital CPT C5276,"HC App Lc,H,H,F,Add 25 Sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,818.00,818.00,490.80,490.80,N/A,114.52,N/A,818.00,N/A,471.00,N/A,278.12,N/A,114.52,N/A,114.52,N/A,818.00,N/A,818.00,N/A,71.17,N/A,114.52,N/A,114.52,N/A,114.52,N/A,471.00,N/A,818.00,N/A,114.52,N/A,818.00,N/A,818.00,N/A,114.52,N/A,818.00,N/A,818.00,N/A,818.00,490.80,490.80,71.17,818.00,,Hospital C8919,HC Mra Pelvis Without Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,N/A,2937.00,N/A,1762.20,N/A,411.18,N/A,488.77,N/A,2220.00,N/A,998.58,N/A,1151.54,N/A,411.18,N/A,476.06,N/A,476.06,N/A,716.85,N/A,1151.54,N/A,1151.54,N/A,1151.54,N/A,2220.00,N/A,476.06,N/A,411.18,N/A,1060.00,N/A,1060.00,N/A,411.18,N/A,476.06,N/A,488.77,N/A,128.98,N/A,N/A,128.98,2220.00,,Hospital C8922,"TTE w or w/o fol w/cont, f/u",N/A,N/A,N/A,5255.00,N/A,3153.00,N/A,735.70,N/A,699.73,N/A,3025.83,N/A,1786.70,N/A,1618.07,N/A,735.70,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,3025.83,N/A,668.93,N/A,735.70,N/A,2816.68,N/A,2816.68,N/A,735.70,N/A,668.93,N/A,699.73,N/A,53.92,N/A,N/A,53.92,3153.00,,Hospital CPT C8937,HC Cad MRI Image,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,2435.00,N/A,1110.00,N/A,827.90,N/A,340.90,N/A,340.90,N/A,2435.00,N/A,2435.00,N/A,211.85,N/A,340.90,N/A,340.90,N/A,340.90,N/A,1110.00,N/A,2435.00,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,2435.00,N/A,2435.00,N/A,2435.00,1461.00,1461.00,211.85,2435.00,,Hospital C9076,Lisocabtagene car pos t,N/A,N/A,2917184.50,N/A,1750310.70,N/A,550479.12,N/A,521158.38,N/A,1607952.10,N/A,991842.73,N/A,1015763.64,N/A,527597.51,N/A,521158.38,N/A,521158.38,N/A,632445.60,N/A,1015763.64,N/A,1015763.64,N/A,1015763.64,N/A,1607952.10,N/A,521158.38,N/A,527597.51,N/A,1382745.45,N/A,1382745.45,N/A,487845.09,N/A,521158.38,N/A,521158.38,N/A,564529.33,N/A,487845.09,1750310.70,N/A,N/A,,Hospital C9084,"Loncastuximab-lpyl, 0.1 mg",N/A,N/A,N/A,167326.80,N/A,100396.08,N/A,23387.10,N/A,1403.48,N/A,94107.57,N/A,56891.11,N/A,22426.85,N/A,23387.10,N/A,1405.41,N/A,1405.41,N/A,13942.92,N/A,22426.85,N/A,22426.85,N/A,22426.85,N/A,93989.99,N/A,1405.41,N/A,23387.10,N/A,1066.21,N/A,1066.21,N/A,23387.10,N/A,1405.41,N/A,1403.48,N/A,200.75,N/A,N/A,200.75,100396.08,,Hospital C9146,"Injection, mirvetuximab soravtansine-gynx, 1 mg",N/A,N/A,N/A,154527.40,N/A,92716.44,N/A,21638.59,N/A,18.33,N/A,86878.23,N/A,52539.32,N/A,21625.90,N/A,21638.59,N/A,18.33,N/A,18.33,N/A,13438.98,N/A,21625.90,N/A,21625.90,N/A,21625.90,N/A,86867.32,N/A,18.33,N/A,21638.59,N/A,18.33,N/A,18.33,N/A,21638.59,N/A,18.33,N/A,18.33,N/A,20.17,N/A,N/A,18.33,92716.44,,Hospital C9353,HC Microporius Collagen Impl Slit Tube (Neurowrap) per Cm Length,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,155293.43,115551.03,93176.06,69330.62,9602.03,16177.14,8877.68,8388.23,85597.74,65999.70,52799.77,39287.38,16563.36,6556.86,7504.47,16177.14,2810.00,8366.80,2810.00,8366.80,10310.31,4081.76,16563.36,6556.86,N/A,6556.86,16563.36,6556.86,85597.74,65999.70,8877.68,8366.80,7504.47,16177.14,19706.27,7109.75,19706.27,7109.75,5066.53,16177.14,8877.68,8366.80,8877.68,8388.23,8029.78,1520.78,2810.00,93176.06,1520.78,69330.62,,Hospital HCPCS C9488,CONIVAPTAN HCL IN DEXTROSE 5% IV BOLUS,66220-0160-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3008.20,3008.20,1804.92,1804.92,N/A,421.15,N/A,3008.20,N/A,1691.21,N/A,1022.79,N/A,1154.36,N/A,421.15,N/A,3008.20,N/A,3008.20,N/A,718.60,N/A,1154.36,N/A,1154.36,N/A,1154.36,N/A,1691.21,N/A,3008.20,N/A,421.15,N/A,1612.40,N/A,1612.40,N/A,421.15,N/A,3008.20,N/A,3008.20,N/A,3008.20,1804.92,1804.92,421.15,3008.20,,Hospital HCPCS C9488,CONIVAPTAN HCL IN DEXTROSE 20-5 MG/100ML-% IV SOLN,66220-0160-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6016.30,6016.30,3609.78,3609.78,N/A,842.28,N/A,6016.30,N/A,3382.36,N/A,2045.54,N/A,2308.73,N/A,842.28,N/A,6016.30,N/A,6016.30,N/A,1437.20,N/A,2308.73,N/A,2308.73,N/A,2308.73,N/A,3382.36,N/A,6016.30,N/A,842.28,N/A,3224.74,N/A,3224.74,N/A,842.28,N/A,6016.30,N/A,6016.30,N/A,6016.30,3609.78,3609.78,842.28,6016.30,,Hospital CPT C9602,HC Perc D-E Cor Stent Ather S,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,37979.00,37979.00,22787.40,22787.40,N/A,5317.06,N/A,16226.30,N/A,21868.31,N/A,12912.86,N/A,37522.38,N/A,5317.06,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,21868.31,N/A,15512.06,N/A,5317.06,N/A,11660.00,N/A,11660.00,N/A,5317.06,N/A,15512.06,N/A,16226.30,N/A,37979.00,22787.40,22787.40,5317.06,37979.00,,Hospital CPT C9603,HC Perc D-E Cor Stent Ather Br,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,18990.00,18990.00,11394.00,11394.00,N/A,2658.60,N/A,18990.00,N/A,10934.44,N/A,6456.60,N/A,2658.60,N/A,2658.60,N/A,18990.00,N/A,18990.00,N/A,1652.13,N/A,2658.60,N/A,2658.60,N/A,2658.60,N/A,10934.44,N/A,18990.00,N/A,2658.60,N/A,18990.00,N/A,18990.00,N/A,2658.60,N/A,18990.00,N/A,18990.00,N/A,18990.00,11394.00,11394.00,1652.13,18990.00,,Hospital C9605,HC Perc D-E Cor Revasc T Cabg B,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,88014.02,229234.08,52808.41,137540.45,15979.32,32015.59,19168.37,127.50,44878.03,130323.12,29924.77,77939.60,37769.00,30484.20,16471.67,32015.59,562.00,24227.14,562.00,24227.14,23510.89,18969.48,37769.00,30484.20,37769.00,30484.20,37769.00,30484.20,44878.03,130323.12,19168.37,24227.14,16471.67,32015.59,43253.58,17621.75,43253.58,17621.75,16471.67,32015.59,19168.37,24227.14,19168.37,127.50,17624.69,134.13,562.00,52808.41,127.50,137540.45,,Hospital C9756,Fluorescence lymph map w/icg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52479.00,40624.38,31487.40,24374.63,6244.71,5655.91,7652.80,9052.40,14072.95,23375.77,17842.86,13812.28,14207.57,19950.00,6437.12,5655.91,562.00,8206.20,562.00,8206.20,N/A,12419.25,14207.57,19950.00,14207.57,19950.00,14207.57,19950.00,14072.95,22403.31,7652.80,8206.20,6437.12,5655.91,16903.46,11977.25,16903.46,11977.25,6437.12,5655.91,7652.80,8206.20,7652.80,2973.14,6887.72,3258.21,562.00,31487.40,2973.14,24374.63,,Hospital C9765,HC Revasc Intra Lithotrip-Stent,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,171077.72,108524.63,102646.63,65114.78,N/A,15065.44,18520.77,16116.02,N/A,61905.03,N/A,36898.37,N/A,37559.93,N/A,15065.44,32529.13,15512.06,32529.13,15512.06,N/A,23381.79,N/A,37559.93,N/A,37559.93,N/A,37559.93,N/A,61905.03,18520.77,15512.06,N/A,15065.44,N/A,11660.00,N/A,11660.00,N/A,15065.44,18520.77,15512.06,18520.77,16116.02,N/A,113.25,18520.77,102646.63,113.25,65114.78,,Hospital C9767,HC Revasc Lithotrip-Stent-Ather,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,309313.10,102673.68,185587.86,61604.21,N/A,14358.59,N/A,15926.38,N/A,58499.95,N/A,34909.06,N/A,37602.02,N/A,14358.59,N/A,15512.06,N/A,15512.06,N/A,23407.98,N/A,37602.02,N/A,37602.02,N/A,37602.02,N/A,58499.95,N/A,15512.06,N/A,14358.59,N/A,11923.50,N/A,11923.50,N/A,14358.59,N/A,15512.06,N/A,15926.38,N/A,401.17,185587.86,185587.86,401.17,61604.21,,Hospital C9776,Fluo bile duct imaging w/icg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,40058.50,33759.52,24035.10,20255.71,6961.68,4717.48,8530.60,4706.78,15688.71,11012.00,13619.89,11478.23,15838.79,11420.70,7176.18,4717.48,4706.78,4706.78,4706.78,4706.78,9859.28,7109.60,15838.79,11420.70,15838.79,11420.70,15838.79,11420.70,15688.71,11012.00,8500.95,4706.78,7176.18,4717.48,18844.20,7897.00,18844.20,7897.00,7176.18,4717.48,8500.95,4706.78,8530.60,4706.78,7678.51,5177.46,4706.78,24035.10,4706.78,20255.71,,Hospital C9781,Arthro/shoul surg; w/spacer,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67581.07,N/A,40548.64,N/A,9461.32,N/A,12325.48,N/A,38476.72,N/A,22977.54,N/A,28606.49,N/A,9461.32,N/A,11782.94,N/A,11782.94,N/A,17808.08,N/A,28606.49,N/A,28606.49,N/A,28606.49,N/A,38476.73,N/A,11782.94,N/A,9461.32,N/A,8612.50,N/A,8612.50,N/A,9461.32,N/A,11782.94,N/A,12325.48,N/A,67.42,N/A,N/A,67.42,40548.64,,Hospital HCPCS D9243,PR Intravenous Moderate (Conscious) Sedation/Analgesia - Ea 15 Min Inc,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital G0102,Prostate Ca Screening; Dre,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,16210.00,N/A,9726.00,N/A,2257.10,N/A,7.86,N/A,9299.63,N/A,5511.40,N/A,345.21,N/A,2257.10,N/A,7.86,N/A,7.86,N/A,214.55,N/A,345.21,N/A,345.21,N/A,345.21,N/A,9299.63,N/A,7.86,N/A,2257.10,N/A,8221.60,N/A,8221.60,N/A,2257.10,N/A,7.86,N/A,7.86,N/A,18.12,N/A,N/A,7.86,9726.00,,Hospital CPT G0103,HC Psa Screening,N/A,0301 - LABORATORY - CHEMISTRY,296.00,208.00,177.60,124.80,N/A,18.39,N/A,19.31,N/A,119.77,N/A,70.72,N/A,15.64,N/A,18.39,N/A,19.31,N/A,19.31,N/A,15.64,N/A,15.64,N/A,15.64,N/A,15.64,N/A,119.77,N/A,19.31,N/A,18.39,N/A,19.31,N/A,19.31,N/A,18.39,N/A,19.31,N/A,19.31,N/A,20.23,177.60,177.60,15.64,124.80,,Hospital G0104,Ca Screen;Flexi Sigmoidscope,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,5146.60,N/A,3087.96,N/A,720.52,N/A,750.46,N/A,2962.44,N/A,1749.84,N/A,1823.33,N/A,720.52,N/A,750.46,N/A,750.46,N/A,1135.06,N/A,1823.33,N/A,1823.33,N/A,1823.33,N/A,2962.44,N/A,750.46,N/A,720.52,N/A,1431.00,N/A,1431.00,N/A,720.52,N/A,750.46,N/A,750.46,N/A,825.51,N/A,N/A,720.52,3087.96,,Hospital G0108,HC Diabetes Indiv/30min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,59420.60,332.00,35652.36,199.20,4673.13,46.48,5793.71,105.46,10531.27,191.17,20203.00,112.88,10632.01,310.74,4817.11,46.48,5793.71,105.46,5793.71,105.46,6618.18,193.44,10632.01,310.74,10632.01,310.74,10632.01,310.74,10531.27,191.17,5793.71,105.46,4817.11,46.48,12649.44,177.95,12649.44,177.95,5971.89,46.48,5793.71,105.46,5793.71,105.46,5154.31,116.01,4673.13,35652.36,46.48,310.74,,Hospital G0121,Colon Ca Scrn Not Hi Rsk Ind,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,27680.20,5405.80,16608.12,3243.48,4790.49,756.59,5581.22,750.46,10582.97,3111.34,9411.27,1837.97,10684.20,1827.06,4938.09,756.59,327084.00,750.46,327084.00,750.46,6650.67,1137.38,10684.20,1827.06,10684.20,1827.06,10684.20,1827.06,10582.97,3111.34,5551.57,750.46,4938.09,756.59,12711.53,1431.00,12711.53,1431.00,2225.68,756.59,5551.57,750.46,5581.22,750.46,5283.76,825.51,2225.68,327084.00,750.46,3243.48,,Hospital CPT G0145,"HC Screen C/V Cyto,Thinlayer,Rescr",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,50.00,50.00,30.00,30.00,N/A,26.61,N/A,26.49,N/A,50.00,N/A,17.00,N/A,21.82,N/A,26.61,N/A,26.49,N/A,26.49,N/A,21.82,N/A,21.82,N/A,21.82,N/A,21.82,N/A,28.79,N/A,26.49,N/A,26.61,N/A,26.61,N/A,26.61,N/A,26.61,N/A,26.49,N/A,26.49,N/A,29.27,30.00,30.00,17.00,50.00,,Hospital G0160,Ot Maintenance Visit,N/A,0431 - OCCUPATIONAL THERAPY - VISIT,N/A,2971.73,N/A,1783.04,N/A,N/A,N/A,2724.80,N/A,1420.87,N/A,N/A,N/A,N/A,N/A,43.81,N/A,2724.80,N/A,2724.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1420.87,N/A,2724.80,N/A,N/A,N/A,1420.87,N/A,1420.87,N/A,N/A,N/A,2724.80,N/A,2724.80,N/A,N/A,N/A,N/A,43.81,2724.80,,Hospital G0177,HC Iop Psycho ED Group,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,7621.00,N/A,4572.60,N/A,1095.87,N/A,696.16,N/A,4388.16,N/A,2591.14,N/A,1607.39,N/A,1095.87,N/A,667.77,N/A,667.77,N/A,1000.64,N/A,1607.39,N/A,1607.39,N/A,1607.39,N/A,5992.32,N/A,667.77,N/A,1095.87,N/A,215.33,N/A,215.33,N/A,1095.87,N/A,667.77,N/A,696.16,N/A,288.12,N/A,N/A,215.33,5992.32,,Hospital CPT G0257,HC Emergent/Unsched Dialysis,N/A,0829 - HEMODIALYSIS - OUTPATIENT OR HOME - OTHER OP HEMODIALYSIS,3539.00,3539.00,2123.40,2123.40,N/A,495.46,N/A,569.38,N/A,2037.76,N/A,1203.26,N/A,1377.30,N/A,495.46,N/A,569.38,N/A,569.38,N/A,857.39,N/A,1377.30,N/A,1377.30,N/A,1377.30,N/A,2037.76,N/A,569.38,N/A,495.46,N/A,1896.90,N/A,1896.90,N/A,495.46,N/A,569.38,N/A,569.38,N/A,626.32,2123.40,2123.40,495.46,2123.40,,Hospital CPT G0257,HC Unscheduled/Emerg OP Dialysis,N/A,0829 - HEMODIALYSIS - OUTPATIENT OR HOME - OTHER OP HEMODIALYSIS,3539.00,3539.00,2123.40,2123.40,N/A,495.46,N/A,569.38,N/A,2037.76,N/A,1203.26,N/A,1377.30,N/A,495.46,N/A,569.38,N/A,569.38,N/A,857.39,N/A,1377.30,N/A,1377.30,N/A,1377.30,N/A,2037.76,N/A,569.38,N/A,495.46,N/A,1896.90,N/A,1896.90,N/A,495.46,N/A,569.38,N/A,569.38,N/A,626.32,2123.40,2123.40,495.46,2123.40,,Hospital G0268,Removal of Impacted Wax MD,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12340.00,N/A,7404.00,N/A,1727.60,N/A,250.72,N/A,7105.36,N/A,4195.60,N/A,611.76,N/A,1727.60,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,7105.36,N/A,252.91,N/A,1727.60,N/A,527.00,N/A,527.00,N/A,1727.60,N/A,252.91,N/A,250.72,N/A,155.79,N/A,N/A,155.79,7404.00,,Hospital G0270,HC Mnt 2nd Addl Ref Ind 15 Min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,180.00,N/A,108.00,N/A,25.20,N/A,52.74,N/A,103.64,N/A,61.20,N/A,180.00,N/A,25.20,N/A,52.74,N/A,52.74,N/A,112.20,N/A,180.00,N/A,180.00,N/A,180.00,N/A,103.64,N/A,52.74,N/A,25.20,N/A,96.48,N/A,96.48,N/A,25.20,N/A,52.74,N/A,52.74,N/A,58.01,N/A,N/A,25.20,180.00,,Hospital CPT G0283,HC Pt Elec Stim Unattended,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,289.00,289.00,173.40,173.40,N/A,40.46,N/A,13.10,N/A,166.41,N/A,98.26,N/A,40.46,N/A,40.46,N/A,13.10,N/A,13.10,N/A,25.14,N/A,40.46,N/A,40.46,N/A,40.46,N/A,166.41,N/A,11.71,N/A,40.46,N/A,154.90,N/A,154.90,N/A,40.46,N/A,13.10,N/A,13.10,N/A,289.00,173.40,173.40,11.71,289.00,,Hospital G0289,"Arthro, Loose Body + Chondro",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17258.00,N/A,10354.80,N/A,2416.12,N/A,2759.84,N/A,7823.00,N/A,5867.72,N/A,6565.22,N/A,2416.12,N/A,2688.04,N/A,2688.04,N/A,4086.99,N/A,6565.22,N/A,6565.22,N/A,6565.22,N/A,7823.00,N/A,2688.04,N/A,2416.12,N/A,5409.25,N/A,5409.25,N/A,2416.12,N/A,2688.04,N/A,2759.84,N/A,761.28,N/A,N/A,761.28,10354.80,,Hospital G0381,HC B-Level 2 Em,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital G0384,HC B-Level 5 Em,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital G0390,Trauma Respons w/hosp criti,N/A,N/A,317354.63,N/A,190412.78,N/A,16961.26,N/A,52516.12,N/A,174925.88,N/A,107900.58,N/A,30633.65,N/A,16961.26,N/A,52516.12,N/A,52516.12,N/A,30633.65,N/A,30633.65,N/A,30633.65,N/A,30633.65,N/A,449042.43,N/A,52516.12,N/A,16961.26,N/A,157889.86,N/A,157889.86,N/A,33394.83,N/A,52516.12,N/A,52516.12,N/A,38684.08,N/A,16961.26,449042.43,N/A,N/A,,Hospital CPT G0398,HC Home Sleep Study Type II,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,855.00,855.00,513.00,513.00,N/A,119.70,N/A,142.31,N/A,492.31,N/A,290.70,N/A,317.67,N/A,119.70,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,492.31,N/A,131.33,N/A,119.70,N/A,458.28,N/A,458.28,N/A,119.70,N/A,131.33,N/A,142.31,N/A,117.08,513.00,513.00,117.08,513.00,,Hospital G0403,EKG for initial prevent exam,N/A,0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT G0404,HC Welcome to Medicare Ekg,N/A,0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION,492.00,492.00,295.20,295.20,N/A,68.88,N/A,22.54,N/A,283.29,N/A,167.28,N/A,54.51,N/A,68.88,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,283.29,N/A,22.54,N/A,68.88,N/A,263.71,N/A,263.71,N/A,68.88,N/A,22.54,N/A,22.54,N/A,24.79,295.20,295.20,22.54,295.20,,Hospital CPT G0410,HC Php Group,N/A,0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - GROUP THERAPY,509.00,509.00,305.40,305.40,N/A,71.26,N/A,509.00,N/A,293.08,N/A,173.06,N/A,71.26,N/A,71.26,N/A,509.00,N/A,509.00,N/A,44.28,N/A,71.26,N/A,71.26,N/A,71.26,N/A,407.20,N/A,509.00,N/A,71.26,N/A,509.00,N/A,509.00,N/A,71.26,N/A,509.00,N/A,509.00,N/A,509.00,305.40,305.40,44.28,509.00,,Hospital G0411,Inter active grp psych parti,N/A,N/A,N/A,9240.00,N/A,5544.00,N/A,1293.60,N/A,N/A,N/A,5320.40,N/A,3141.60,N/A,1293.60,N/A,1293.60,N/A,N/A,N/A,N/A,N/A,803.90,N/A,1293.60,N/A,1293.60,N/A,1293.60,N/A,1587.10,N/A,N/A,N/A,1293.60,N/A,N/A,N/A,N/A,N/A,1293.60,N/A,5475.00,N/A,N/A,N/A,N/A,N/A,N/A,803.90,5544.00,,Hospital G0413,Pelvic ring fracture uni/bil,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,93061.87,N/A,55837.12,N/A,13028.67,N/A,6354.28,N/A,52965.86,N/A,31641.05,N/A,14500.36,N/A,13028.67,N/A,5973.28,N/A,5973.28,N/A,9026.75,N/A,14500.36,N/A,14500.36,N/A,14500.36,N/A,52965.85,N/A,5973.28,N/A,13028.67,N/A,4562.00,N/A,4562.00,N/A,13028.67,N/A,5973.28,N/A,6354.28,N/A,1117.61,N/A,N/A,1117.61,55837.12,,Hospital CPT G0416,HC Surg Path Prostate Bx 10-20,N/A,0314 - LABORATORY PATHOLOGICAL - BIOPSY,3482.00,3482.00,2089.20,2089.20,N/A,487.48,N/A,157.22,N/A,2004.94,N/A,1183.88,N/A,707.98,N/A,487.48,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,2004.94,N/A,292.68,N/A,487.48,N/A,297.45,N/A,297.45,N/A,487.48,N/A,292.68,N/A,157.22,N/A,172.94,2089.20,2089.20,157.22,2089.20,,Hospital G0422,HC Icr Cardiac Rehab W/Exerc,N/A,0943 - OTHER THERAPEUTIC SERVICES - CARDIAC REHABILITATION,24594.80,5040.00,14756.88,3024.00,5254.60,705.60,6481.56,1174.90,11841.67,2902.00,8362.23,1713.60,11954.95,2622.70,5416.50,705.60,1124.00,1084.30,1124.00,1084.30,7441.68,1632.70,11954.95,2622.70,11954.95,2622.70,11954.95,2622.70,11841.67,2902.00,6481.56,1084.30,5416.50,705.60,14223.40,2701.40,14223.40,2701.40,N/A,705.60,6481.56,1084.30,6481.56,1174.90,5795.66,1216.60,1124.00,14756.88,705.60,3024.00,,Hospital G0424,HC Pulmonary Rehab,N/A,0948 - OTHER THERAPEUTIC SERVICES - PULMONARY REHABILITATION,N/A,1380.00,N/A,828.00,N/A,193.20,N/A,N/A,N/A,794.58,N/A,469.20,N/A,193.20,N/A,193.20,N/A,N/A,N/A,N/A,N/A,120.06,N/A,193.20,N/A,193.20,N/A,193.20,N/A,794.58,N/A,N/A,N/A,193.20,N/A,739.68,N/A,739.68,N/A,193.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,120.06,828.00,,Hospital CPT G0480,"HC So Cannabinoids, Natural",N/A,0301 - LABORATORY - CHEMISTRY,146.00,146.00,87.60,87.60,N/A,20.44,N/A,114.43,N/A,84.07,N/A,49.64,N/A,20.44,N/A,20.44,N/A,114.43,N/A,114.43,N/A,12.70,N/A,20.44,N/A,20.44,N/A,20.44,N/A,84.07,N/A,114.43,N/A,20.44,N/A,146.00,N/A,146.00,N/A,20.44,N/A,114.43,N/A,114.43,N/A,146.00,87.60,87.60,12.70,146.00,,Hospital CPT G0480,HC Acetaminophen,N/A,0301 - LABORATORY - CHEMISTRY,270.00,229.00,162.00,137.40,N/A,32.06,N/A,114.43,N/A,131.86,N/A,77.86,N/A,32.06,N/A,32.06,N/A,114.43,N/A,114.43,N/A,19.92,N/A,32.06,N/A,32.06,N/A,32.06,N/A,131.86,N/A,114.43,N/A,32.06,N/A,229.00,N/A,229.00,N/A,32.06,N/A,114.43,N/A,114.43,N/A,229.00,162.00,162.00,19.92,229.00,,Hospital CPT G0480,HC So1 Antidepressants Nes,N/A,0301 - LABORATORY - CHEMISTRY,51.00,51.00,30.60,30.60,N/A,7.14,N/A,114.43,N/A,29.37,N/A,17.34,N/A,7.14,N/A,7.14,N/A,114.43,N/A,114.43,N/A,4.44,N/A,7.14,N/A,7.14,N/A,7.14,N/A,29.37,N/A,114.43,N/A,7.14,N/A,51.00,N/A,51.00,N/A,7.14,N/A,114.43,N/A,114.43,N/A,51.00,30.60,30.60,4.44,114.43,,Hospital CPT G0480,HC Drug Screening Oxycodone,N/A,0301 - LABORATORY - CHEMISTRY,286.00,286.00,171.60,171.60,N/A,40.04,N/A,114.43,N/A,164.68,N/A,97.24,N/A,40.04,N/A,40.04,N/A,114.43,N/A,114.43,N/A,24.88,N/A,40.04,N/A,40.04,N/A,40.04,N/A,164.68,N/A,114.43,N/A,40.04,N/A,286.00,N/A,286.00,N/A,40.04,N/A,114.43,N/A,114.43,N/A,286.00,171.60,171.60,24.88,286.00,,Hospital CPT G0480,HC So Tramadol Level,N/A,0301 - LABORATORY - CHEMISTRY,134.00,134.00,80.40,80.40,N/A,18.76,N/A,114.43,N/A,77.16,N/A,45.56,N/A,18.76,N/A,18.76,N/A,114.43,N/A,114.43,N/A,11.66,N/A,18.76,N/A,18.76,N/A,18.76,N/A,77.16,N/A,114.43,N/A,18.76,N/A,134.00,N/A,134.00,N/A,18.76,N/A,114.43,N/A,114.43,N/A,134.00,80.40,80.40,11.66,134.00,,Hospital CPT G0480,HC So Amphetamines 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,96.00,96.00,57.60,57.60,N/A,13.44,N/A,114.43,N/A,55.28,N/A,32.64,N/A,13.44,N/A,13.44,N/A,114.43,N/A,114.43,N/A,8.35,N/A,13.44,N/A,13.44,N/A,13.44,N/A,55.28,N/A,114.43,N/A,13.44,N/A,96.00,N/A,96.00,N/A,13.44,N/A,114.43,N/A,114.43,N/A,96.00,57.60,57.60,8.35,114.43,,Hospital CPT G0480,HC So Opiates G0480,N/A,0301 - LABORATORY - CHEMISTRY,218.00,218.00,130.80,130.80,N/A,30.52,N/A,114.43,N/A,125.52,N/A,74.12,N/A,30.52,N/A,30.52,N/A,114.43,N/A,114.43,N/A,18.97,N/A,30.52,N/A,30.52,N/A,30.52,N/A,125.52,N/A,114.43,N/A,30.52,N/A,218.00,N/A,218.00,N/A,30.52,N/A,114.43,N/A,114.43,N/A,218.00,130.80,130.80,18.97,218.00,,Hospital CPT G0480,HC So1 Tramadol Level,N/A,0301 - LABORATORY - CHEMISTRY,49.00,49.00,29.40,29.40,N/A,6.86,N/A,114.43,N/A,28.21,N/A,16.66,N/A,6.86,N/A,6.86,N/A,114.43,N/A,114.43,N/A,4.26,N/A,6.86,N/A,6.86,N/A,6.86,N/A,28.21,N/A,114.43,N/A,6.86,N/A,49.00,N/A,49.00,N/A,6.86,N/A,114.43,N/A,114.43,N/A,49.00,29.40,29.40,4.26,114.43,,Hospital CPT G0480,HC So Antidressants 6 or More,N/A,0301 - LABORATORY - CHEMISTRY,150.00,150.00,90.00,90.00,N/A,21.00,N/A,114.43,N/A,86.37,N/A,51.00,N/A,21.00,N/A,21.00,N/A,114.43,N/A,114.43,N/A,13.05,N/A,21.00,N/A,21.00,N/A,21.00,N/A,86.37,N/A,114.43,N/A,21.00,N/A,150.00,N/A,150.00,N/A,21.00,N/A,114.43,N/A,114.43,N/A,150.00,90.00,90.00,13.05,150.00,,Hospital CPT G0480,HC So Meprobamate,N/A,0301 - LABORATORY - CHEMISTRY,445.00,445.00,267.00,267.00,N/A,62.30,N/A,114.43,N/A,256.23,N/A,151.30,N/A,62.30,N/A,62.30,N/A,114.43,N/A,114.43,N/A,38.72,N/A,62.30,N/A,62.30,N/A,62.30,N/A,256.23,N/A,114.43,N/A,62.30,N/A,445.00,N/A,445.00,N/A,62.30,N/A,114.43,N/A,114.43,N/A,445.00,267.00,267.00,38.72,445.00,,Hospital CPT G0480,HC So Drug or Substance Nos 7 or Mor,N/A,0301 - LABORATORY - CHEMISTRY,336.00,336.00,201.60,201.60,N/A,47.04,N/A,114.43,N/A,193.47,N/A,114.24,N/A,47.04,N/A,47.04,N/A,114.43,N/A,114.43,N/A,29.23,N/A,47.04,N/A,47.04,N/A,47.04,N/A,193.47,N/A,114.43,N/A,47.04,N/A,336.00,N/A,336.00,N/A,47.04,N/A,114.43,N/A,114.43,N/A,336.00,201.60,201.60,29.23,336.00,,Hospital CPT G0480,HC Imipramine,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,22.68,N/A,114.43,N/A,93.28,N/A,55.08,N/A,22.68,N/A,22.68,N/A,114.43,N/A,114.43,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,93.28,N/A,114.43,N/A,22.68,N/A,162.00,N/A,162.00,N/A,22.68,N/A,114.43,N/A,114.43,N/A,162.00,97.20,97.20,14.09,162.00,,Hospital CPT G0480,HC So1 Methadone Toxocology,N/A,0301 - LABORATORY - CHEMISTRY,52.00,52.00,31.20,31.20,N/A,7.28,N/A,114.43,N/A,29.94,N/A,17.68,N/A,7.28,N/A,7.28,N/A,114.43,N/A,114.43,N/A,4.52,N/A,7.28,N/A,7.28,N/A,7.28,N/A,29.94,N/A,114.43,N/A,7.28,N/A,52.00,N/A,52.00,N/A,7.28,N/A,114.43,N/A,114.43,N/A,52.00,31.20,31.20,4.52,114.43,,Hospital CPT G0480,HC So Benzodiazepines,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,16.80,N/A,114.43,N/A,69.10,N/A,40.80,N/A,16.80,N/A,16.80,N/A,114.43,N/A,114.43,N/A,10.44,N/A,16.80,N/A,16.80,N/A,16.80,N/A,69.10,N/A,114.43,N/A,16.80,N/A,120.00,N/A,120.00,N/A,16.80,N/A,114.43,N/A,114.43,N/A,120.00,72.00,72.00,10.44,120.00,,Hospital CPT G0480,HC So Antipsychotics Not Otherwise Specified 7 or More,N/A,0301 - LABORATORY - CHEMISTRY,60.00,60.00,36.00,36.00,N/A,8.40,N/A,114.43,N/A,34.55,N/A,20.40,N/A,8.40,N/A,8.40,N/A,114.43,N/A,114.43,N/A,5.22,N/A,8.40,N/A,8.40,N/A,8.40,N/A,34.55,N/A,114.43,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,114.43,N/A,114.43,N/A,60.00,36.00,36.00,5.22,114.43,,Hospital CPT G0480,HC So Buprenorphine,N/A,0301 - LABORATORY - CHEMISTRY,127.00,127.00,76.20,76.20,N/A,17.78,N/A,114.43,N/A,73.13,N/A,43.18,N/A,17.78,N/A,17.78,N/A,114.43,N/A,114.43,N/A,11.05,N/A,17.78,N/A,17.78,N/A,17.78,N/A,73.13,N/A,114.43,N/A,17.78,N/A,127.00,N/A,127.00,N/A,17.78,N/A,114.43,N/A,114.43,N/A,127.00,76.20,76.20,11.05,127.00,,Hospital CPT G0480,HC So Alcohol Biomarkers,N/A,0301 - LABORATORY - CHEMISTRY,95.00,95.00,57.00,57.00,N/A,13.30,N/A,114.43,N/A,54.70,N/A,32.30,N/A,13.30,N/A,13.30,N/A,114.43,N/A,114.43,N/A,8.27,N/A,13.30,N/A,13.30,N/A,13.30,N/A,54.70,N/A,114.43,N/A,13.30,N/A,95.00,N/A,95.00,N/A,13.30,N/A,114.43,N/A,114.43,N/A,95.00,57.00,57.00,8.27,114.43,,Hospital CPT G0480,"HC So Antidepressants, Serotonergic Class; 1 or 2",N/A,0301 - LABORATORY - CHEMISTRY,340.00,340.00,204.00,204.00,N/A,47.60,N/A,114.43,N/A,195.77,N/A,115.60,N/A,47.60,N/A,47.60,N/A,114.43,N/A,114.43,N/A,29.58,N/A,47.60,N/A,47.60,N/A,47.60,N/A,195.77,N/A,114.43,N/A,47.60,N/A,340.00,N/A,340.00,N/A,47.60,N/A,114.43,N/A,114.43,N/A,340.00,204.00,204.00,29.58,340.00,,Hospital CPT G0480,HC So Alkaloids Nos,N/A,0301 - LABORATORY - CHEMISTRY,245.00,245.00,147.00,147.00,N/A,34.30,N/A,114.43,N/A,141.07,N/A,83.30,N/A,34.30,N/A,34.30,N/A,114.43,N/A,114.43,N/A,21.32,N/A,34.30,N/A,34.30,N/A,34.30,N/A,141.07,N/A,114.43,N/A,34.30,N/A,245.00,N/A,245.00,N/A,34.30,N/A,114.43,N/A,114.43,N/A,245.00,147.00,147.00,21.32,245.00,,Hospital CPT G0480,HC So Drug Screening Opioids and Opiate Analogs 3 or 4,N/A,0301 - LABORATORY - CHEMISTRY,106.00,106.00,63.60,63.60,N/A,14.84,N/A,114.43,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,114.43,N/A,114.43,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,114.43,N/A,14.84,N/A,106.00,N/A,106.00,N/A,14.84,N/A,114.43,N/A,114.43,N/A,106.00,63.60,63.60,9.22,114.43,,Hospital CPT G0480,HC So Alcohol,N/A,0301 - LABORATORY - CHEMISTRY,195.00,195.00,117.00,117.00,N/A,27.30,N/A,114.43,N/A,112.28,N/A,66.30,N/A,27.30,N/A,27.30,N/A,114.43,N/A,114.43,N/A,16.97,N/A,27.30,N/A,27.30,N/A,27.30,N/A,112.28,N/A,114.43,N/A,27.30,N/A,195.00,N/A,195.00,N/A,27.30,N/A,114.43,N/A,114.43,N/A,195.00,117.00,117.00,16.97,195.00,,Hospital CPT G0480,HC So Methadone Toxocology,N/A,0301 - LABORATORY - CHEMISTRY,146.00,146.00,87.60,87.60,N/A,20.44,N/A,114.43,N/A,84.07,N/A,49.64,N/A,20.44,N/A,20.44,N/A,114.43,N/A,114.43,N/A,12.70,N/A,20.44,N/A,20.44,N/A,20.44,N/A,84.07,N/A,114.43,N/A,20.44,N/A,146.00,N/A,146.00,N/A,20.44,N/A,114.43,N/A,114.43,N/A,146.00,87.60,87.60,12.70,146.00,,Hospital CPT G0480,HC So Antiepileptic Nos 1-3,N/A,0301 - LABORATORY - CHEMISTRY,421.00,421.00,252.60,252.60,N/A,58.94,N/A,114.43,N/A,242.41,N/A,143.14,N/A,58.94,N/A,58.94,N/A,114.43,N/A,114.43,N/A,36.63,N/A,58.94,N/A,58.94,N/A,58.94,N/A,242.41,N/A,114.43,N/A,58.94,N/A,421.00,N/A,421.00,N/A,58.94,N/A,114.43,N/A,114.43,N/A,421.00,252.60,252.60,36.63,421.00,,Hospital CPT G0480,HC So1 Barbiturates Nes,N/A,0301 - LABORATORY - CHEMISTRY,132.00,132.00,79.20,79.20,N/A,18.48,N/A,114.43,N/A,76.01,N/A,44.88,N/A,18.48,N/A,18.48,N/A,114.43,N/A,114.43,N/A,11.48,N/A,18.48,N/A,18.48,N/A,18.48,N/A,76.01,N/A,114.43,N/A,18.48,N/A,132.00,N/A,132.00,N/A,18.48,N/A,114.43,N/A,114.43,N/A,132.00,79.20,79.20,11.48,132.00,,Hospital CPT G0480,HC So1 Ketamine and Norketamine,N/A,0301 - LABORATORY - CHEMISTRY,49.00,49.00,29.40,29.40,N/A,6.86,N/A,114.43,N/A,28.21,N/A,16.66,N/A,6.86,N/A,6.86,N/A,114.43,N/A,114.43,N/A,4.26,N/A,6.86,N/A,6.86,N/A,6.86,N/A,28.21,N/A,114.43,N/A,6.86,N/A,49.00,N/A,49.00,N/A,6.86,N/A,114.43,N/A,114.43,N/A,49.00,29.40,29.40,4.26,114.43,,Hospital CPT G0480,HC So1 Skel Musc Relaxant 3 or More,N/A,0301 - LABORATORY - CHEMISTRY,47.00,47.00,28.20,28.20,N/A,6.58,N/A,114.43,N/A,27.06,N/A,15.98,N/A,6.58,N/A,6.58,N/A,114.43,N/A,114.43,N/A,4.09,N/A,6.58,N/A,6.58,N/A,6.58,N/A,27.06,N/A,114.43,N/A,6.58,N/A,47.00,N/A,47.00,N/A,6.58,N/A,114.43,N/A,114.43,N/A,47.00,28.20,28.20,4.09,114.43,,Hospital CPT G0480,HC So Cocaine or Cocaine Metabolite,N/A,0301 - LABORATORY - CHEMISTRY,149.00,149.00,89.40,89.40,N/A,20.86,N/A,114.43,N/A,85.79,N/A,50.66,N/A,20.86,N/A,20.86,N/A,114.43,N/A,114.43,N/A,12.96,N/A,20.86,N/A,20.86,N/A,20.86,N/A,85.79,N/A,114.43,N/A,20.86,N/A,149.00,N/A,149.00,N/A,20.86,N/A,114.43,N/A,114.43,N/A,149.00,89.40,89.40,12.96,149.00,,Hospital CPT G0480,HC Opiates 1 or More,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,22.68,N/A,114.43,N/A,93.28,N/A,55.08,N/A,22.68,N/A,22.68,N/A,114.43,N/A,114.43,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,93.28,N/A,114.43,N/A,22.68,N/A,162.00,N/A,162.00,N/A,22.68,N/A,114.43,N/A,114.43,N/A,162.00,97.20,97.20,14.09,162.00,,Hospital CPT G0480,HC Opioids and Opiate Analogs; 3 or 4,N/A,0301 - LABORATORY - CHEMISTRY,399.00,399.00,239.40,239.40,N/A,55.86,N/A,114.43,N/A,229.74,N/A,135.66,N/A,55.86,N/A,55.86,N/A,114.43,N/A,114.43,N/A,34.71,N/A,55.86,N/A,55.86,N/A,55.86,N/A,229.74,N/A,114.43,N/A,55.86,N/A,399.00,N/A,399.00,N/A,55.86,N/A,114.43,N/A,114.43,N/A,399.00,239.40,239.40,34.71,399.00,,Hospital CPT G0480,HC So Drug Screening Skel Muscle Relaxants 3 or More,N/A,0301 - LABORATORY - CHEMISTRY,60.00,60.00,36.00,36.00,N/A,8.40,N/A,114.43,N/A,34.55,N/A,20.40,N/A,8.40,N/A,8.40,N/A,114.43,N/A,114.43,N/A,5.22,N/A,8.40,N/A,8.40,N/A,8.40,N/A,34.55,N/A,114.43,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,114.43,N/A,114.43,N/A,60.00,36.00,36.00,5.22,114.43,,Hospital CPT G0480,HC Cocaine or Cocaine Metabolite,N/A,0301 - LABORATORY - CHEMISTRY,149.00,149.00,89.40,89.40,N/A,20.86,N/A,114.43,N/A,85.79,N/A,50.66,N/A,20.86,N/A,20.86,N/A,114.43,N/A,114.43,N/A,12.96,N/A,20.86,N/A,20.86,N/A,20.86,N/A,85.79,N/A,114.43,N/A,20.86,N/A,149.00,N/A,149.00,N/A,20.86,N/A,114.43,N/A,114.43,N/A,149.00,89.40,89.40,12.96,149.00,,Hospital CPT G0480,HC So1 Tapentadol,N/A,0301 - LABORATORY - CHEMISTRY,51.00,51.00,30.60,30.60,N/A,7.14,N/A,114.43,N/A,29.37,N/A,17.34,N/A,7.14,N/A,7.14,N/A,114.43,N/A,114.43,N/A,4.44,N/A,7.14,N/A,7.14,N/A,7.14,N/A,29.37,N/A,114.43,N/A,7.14,N/A,51.00,N/A,51.00,N/A,7.14,N/A,114.43,N/A,114.43,N/A,51.00,30.60,30.60,4.44,114.43,,Hospital CPT G0480,"HC Cannabinoids, Natural",N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,22.68,N/A,114.43,N/A,93.28,N/A,55.08,N/A,22.68,N/A,22.68,N/A,114.43,N/A,114.43,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,93.28,N/A,114.43,N/A,22.68,N/A,162.00,N/A,162.00,N/A,22.68,N/A,114.43,N/A,114.43,N/A,162.00,97.20,97.20,14.09,162.00,,Hospital CPT G0480,HC So1 Drug/Substance Nos 7/More,N/A,0301 - LABORATORY - CHEMISTRY,31.00,31.00,18.60,18.60,N/A,4.34,N/A,114.43,N/A,17.85,N/A,10.54,N/A,4.34,N/A,4.34,N/A,114.43,N/A,114.43,N/A,2.70,N/A,4.34,N/A,4.34,N/A,4.34,N/A,17.85,N/A,114.43,N/A,4.34,N/A,31.00,N/A,31.00,N/A,4.34,N/A,114.43,N/A,114.43,N/A,31.00,18.60,18.60,2.70,114.43,,Hospital CPT G0480,HC So Benzodiazepines 13+ G0480,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,16.80,N/A,114.43,N/A,69.10,N/A,40.80,N/A,16.80,N/A,16.80,N/A,114.43,N/A,114.43,N/A,10.44,N/A,16.80,N/A,16.80,N/A,16.80,N/A,69.10,N/A,114.43,N/A,16.80,N/A,120.00,N/A,120.00,N/A,16.80,N/A,114.43,N/A,114.43,N/A,120.00,72.00,72.00,10.44,120.00,,Hospital CPT G0480,HC Methylenedioxyamphetamines,N/A,0301 - LABORATORY - CHEMISTRY,323.00,323.00,193.80,193.80,N/A,45.22,N/A,114.43,N/A,185.98,N/A,109.82,N/A,45.22,N/A,45.22,N/A,114.43,N/A,114.43,N/A,28.10,N/A,45.22,N/A,45.22,N/A,45.22,N/A,185.98,N/A,114.43,N/A,45.22,N/A,323.00,N/A,323.00,N/A,45.22,N/A,114.43,N/A,114.43,N/A,323.00,193.80,193.80,28.10,323.00,,Hospital CPT G0480,HC So1 Alkaloids Nos,N/A,0301 - LABORATORY - CHEMISTRY,245.00,245.00,147.00,147.00,N/A,34.30,N/A,114.43,N/A,141.07,N/A,83.30,N/A,34.30,N/A,34.30,N/A,114.43,N/A,114.43,N/A,21.32,N/A,34.30,N/A,34.30,N/A,34.30,N/A,141.07,N/A,114.43,N/A,34.30,N/A,245.00,N/A,245.00,N/A,34.30,N/A,114.43,N/A,114.43,N/A,245.00,147.00,147.00,21.32,245.00,,Hospital CPT G0480,HC So1 Antipsychotics Nos 1-3,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,18.20,N/A,114.43,N/A,74.85,N/A,44.20,N/A,18.20,N/A,18.20,N/A,114.43,N/A,114.43,N/A,11.31,N/A,18.20,N/A,18.20,N/A,18.20,N/A,74.85,N/A,114.43,N/A,18.20,N/A,130.00,N/A,130.00,N/A,18.20,N/A,114.43,N/A,114.43,N/A,130.00,78.00,78.00,11.31,130.00,,Hospital CPT G0480,HC So1 Analgesics Non-Opioid 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,46.00,46.00,27.60,27.60,N/A,6.44,N/A,114.43,N/A,26.49,N/A,15.64,N/A,6.44,N/A,6.44,N/A,114.43,N/A,114.43,N/A,4.00,N/A,6.44,N/A,6.44,N/A,6.44,N/A,26.49,N/A,114.43,N/A,6.44,N/A,46.00,N/A,46.00,N/A,6.44,N/A,114.43,N/A,114.43,N/A,46.00,27.60,27.60,4.00,114.43,,Hospital CPT G0480,HC Amphetamines 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,323.00,323.00,193.80,193.80,N/A,45.22,N/A,114.43,N/A,185.98,N/A,109.82,N/A,45.22,N/A,45.22,N/A,114.43,N/A,114.43,N/A,28.10,N/A,45.22,N/A,45.22,N/A,45.22,N/A,185.98,N/A,114.43,N/A,45.22,N/A,323.00,N/A,323.00,N/A,45.22,N/A,114.43,N/A,114.43,N/A,323.00,193.80,193.80,28.10,323.00,,Hospital CPT G0480,HC Methadone Toxicology,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,22.68,N/A,114.43,N/A,93.28,N/A,55.08,N/A,22.68,N/A,22.68,N/A,114.43,N/A,114.43,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,93.28,N/A,114.43,N/A,22.68,N/A,162.00,N/A,162.00,N/A,22.68,N/A,114.43,N/A,114.43,N/A,162.00,97.20,97.20,14.09,162.00,,Hospital CPT G0480,HC So1 Antipsychotics Nos 7/More,N/A,0301 - LABORATORY - CHEMISTRY,33.00,33.00,19.80,19.80,N/A,4.62,N/A,114.43,N/A,19.00,N/A,11.22,N/A,4.62,N/A,4.62,N/A,114.43,N/A,114.43,N/A,2.87,N/A,4.62,N/A,4.62,N/A,4.62,N/A,19.00,N/A,114.43,N/A,4.62,N/A,33.00,N/A,33.00,N/A,4.62,N/A,114.43,N/A,114.43,N/A,33.00,19.80,19.80,2.87,114.43,,Hospital CPT G0480,HC Antidepressant Tricyclic 1/2,N/A,0301 - LABORATORY - CHEMISTRY,240.00,206.00,144.00,123.60,N/A,28.84,N/A,114.43,N/A,118.61,N/A,70.04,N/A,28.84,N/A,28.84,N/A,114.43,N/A,114.43,N/A,17.92,N/A,28.84,N/A,28.84,N/A,28.84,N/A,118.61,N/A,114.43,N/A,28.84,N/A,206.00,N/A,206.00,N/A,28.84,N/A,114.43,N/A,114.43,N/A,206.00,144.00,144.00,17.92,206.00,,Hospital CPT G0480,HC So1 Opiates 1 or More,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,9.52,N/A,114.43,N/A,39.15,N/A,23.12,N/A,9.52,N/A,9.52,N/A,114.43,N/A,114.43,N/A,5.92,N/A,9.52,N/A,9.52,N/A,9.52,N/A,39.15,N/A,114.43,N/A,9.52,N/A,68.00,N/A,68.00,N/A,9.52,N/A,114.43,N/A,114.43,N/A,68.00,40.80,40.80,5.92,114.43,,Hospital CPT G0480,HC So Drug or Substance Nos 1-3,N/A,0301 - LABORATORY - CHEMISTRY,412.00,412.00,247.20,247.20,N/A,57.68,N/A,114.43,N/A,237.23,N/A,140.08,N/A,57.68,N/A,57.68,N/A,114.43,N/A,114.43,N/A,35.84,N/A,57.68,N/A,57.68,N/A,57.68,N/A,237.23,N/A,114.43,N/A,57.68,N/A,412.00,N/A,412.00,N/A,57.68,N/A,114.43,N/A,114.43,N/A,412.00,247.20,247.20,35.84,412.00,,Hospital CPT G0480,HC So Analgesics Non-Opioid 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,105.00,105.00,63.00,63.00,N/A,14.70,N/A,114.43,N/A,60.46,N/A,35.70,N/A,14.70,N/A,14.70,N/A,114.43,N/A,114.43,N/A,9.14,N/A,14.70,N/A,14.70,N/A,14.70,N/A,60.46,N/A,114.43,N/A,14.70,N/A,105.00,N/A,105.00,N/A,14.70,N/A,114.43,N/A,114.43,N/A,105.00,63.00,63.00,9.14,114.43,,Hospital CPT G0480,HC So Cannabinoid Synthetic 7/More,N/A,0301 - LABORATORY - CHEMISTRY,107.00,107.00,64.20,64.20,N/A,14.98,N/A,114.43,N/A,61.61,N/A,36.38,N/A,14.98,N/A,14.98,N/A,114.43,N/A,114.43,N/A,9.31,N/A,14.98,N/A,14.98,N/A,14.98,N/A,61.61,N/A,114.43,N/A,14.98,N/A,107.00,N/A,107.00,N/A,14.98,N/A,114.43,N/A,114.43,N/A,107.00,64.20,64.20,9.31,114.43,,Hospital CPT G0480,HC So Ketamine and Norketamine,N/A,0301 - LABORATORY - CHEMISTRY,180.00,180.00,108.00,108.00,N/A,25.20,N/A,114.43,N/A,103.64,N/A,61.20,N/A,25.20,N/A,25.20,N/A,114.43,N/A,114.43,N/A,15.66,N/A,25.20,N/A,25.20,N/A,25.20,N/A,103.64,N/A,114.43,N/A,25.20,N/A,180.00,N/A,180.00,N/A,25.20,N/A,114.43,N/A,114.43,N/A,180.00,108.00,108.00,15.66,180.00,,Hospital CPT G0480,HC So1 Antidepressants Serotonergic Class 6 or More,N/A,0301 - LABORATORY - CHEMISTRY,38.00,38.00,22.80,22.80,N/A,5.32,N/A,114.43,N/A,21.88,N/A,12.92,N/A,5.32,N/A,5.32,N/A,114.43,N/A,114.43,N/A,3.31,N/A,5.32,N/A,5.32,N/A,5.32,N/A,21.88,N/A,114.43,N/A,5.32,N/A,38.00,N/A,38.00,N/A,5.32,N/A,114.43,N/A,114.43,N/A,38.00,22.80,22.80,3.31,114.43,,Hospital CPT G0480,HC So Tapentadol,N/A,0301 - LABORATORY - CHEMISTRY,231.00,231.00,138.60,138.60,N/A,32.34,N/A,114.43,N/A,133.01,N/A,78.54,N/A,32.34,N/A,32.34,N/A,114.43,N/A,114.43,N/A,20.10,N/A,32.34,N/A,32.34,N/A,32.34,N/A,133.01,N/A,114.43,N/A,32.34,N/A,231.00,N/A,231.00,N/A,32.34,N/A,114.43,N/A,114.43,N/A,231.00,138.60,138.60,20.10,231.00,,Hospital CPT G0480,HC Alcohol,N/A,0301 - LABORATORY - CHEMISTRY,215.00,183.00,129.00,109.80,N/A,25.62,N/A,114.43,N/A,105.37,N/A,62.22,N/A,25.62,N/A,25.62,N/A,114.43,N/A,114.43,N/A,15.92,N/A,25.62,N/A,25.62,N/A,25.62,N/A,105.37,N/A,114.43,N/A,25.62,N/A,183.00,N/A,183.00,N/A,25.62,N/A,114.43,N/A,114.43,N/A,183.00,129.00,129.00,15.92,183.00,,Hospital CPT G0480,HC So1 Antidressants 6 or More,N/A,0301 - LABORATORY - CHEMISTRY,41.00,41.00,24.60,24.60,N/A,5.74,N/A,114.43,N/A,23.61,N/A,13.94,N/A,5.74,N/A,5.74,N/A,114.43,N/A,114.43,N/A,3.57,N/A,5.74,N/A,5.74,N/A,5.74,N/A,23.61,N/A,114.43,N/A,5.74,N/A,41.00,N/A,41.00,N/A,5.74,N/A,114.43,N/A,114.43,N/A,41.00,24.60,24.60,3.57,114.43,,Hospital CPT G0480,HC So Amphetamines; 3 or 4,N/A,0301 - LABORATORY - CHEMISTRY,50.00,50.00,30.00,30.00,N/A,7.00,N/A,114.43,N/A,28.79,N/A,17.00,N/A,7.00,N/A,7.00,N/A,114.43,N/A,114.43,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,28.79,N/A,114.43,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,114.43,N/A,114.43,N/A,50.00,30.00,30.00,4.35,114.43,,Hospital CPT G0480,HC So Gabapentin Nonblood G0480,N/A,0301 - LABORATORY - CHEMISTRY,220.00,220.00,132.00,132.00,N/A,30.80,N/A,114.43,N/A,126.68,N/A,74.80,N/A,30.80,N/A,30.80,N/A,114.43,N/A,114.43,N/A,19.14,N/A,30.80,N/A,30.80,N/A,30.80,N/A,126.68,N/A,114.43,N/A,30.80,N/A,220.00,N/A,220.00,N/A,30.80,N/A,114.43,N/A,114.43,N/A,220.00,132.00,132.00,19.14,220.00,,Hospital CPT G0480,HC Dihydrotestosterone,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,22.68,N/A,114.43,N/A,93.28,N/A,55.08,N/A,22.68,N/A,22.68,N/A,114.43,N/A,114.43,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,93.28,N/A,114.43,N/A,22.68,N/A,162.00,N/A,162.00,N/A,22.68,N/A,114.43,N/A,114.43,N/A,162.00,97.20,97.20,14.09,162.00,,Hospital CPT G0480,HC So Barbiturates Nes,N/A,0301 - LABORATORY - CHEMISTRY,83.00,83.00,49.80,49.80,N/A,11.62,N/A,114.43,N/A,47.79,N/A,28.22,N/A,11.62,N/A,11.62,N/A,114.43,N/A,114.43,N/A,7.22,N/A,11.62,N/A,11.62,N/A,11.62,N/A,47.79,N/A,114.43,N/A,11.62,N/A,83.00,N/A,83.00,N/A,11.62,N/A,114.43,N/A,114.43,N/A,83.00,49.80,49.80,7.22,114.43,,Hospital CPT G0480,HC Salicylates,N/A,0301 - LABORATORY - CHEMISTRY,149.00,149.00,89.40,89.40,N/A,20.86,N/A,114.43,N/A,85.79,N/A,50.66,N/A,20.86,N/A,20.86,N/A,114.43,N/A,114.43,N/A,12.96,N/A,20.86,N/A,20.86,N/A,20.86,N/A,85.79,N/A,114.43,N/A,20.86,N/A,149.00,N/A,149.00,N/A,20.86,N/A,114.43,N/A,114.43,N/A,149.00,89.40,89.40,12.96,149.00,,Hospital CPT G0480,HC Assay of Benzodiazepines,N/A,0301 - LABORATORY - CHEMISTRY,131.00,131.00,78.60,78.60,N/A,18.34,N/A,114.43,N/A,75.43,N/A,44.54,N/A,18.34,N/A,18.34,N/A,114.43,N/A,114.43,N/A,11.40,N/A,18.34,N/A,18.34,N/A,18.34,N/A,75.43,N/A,114.43,N/A,18.34,N/A,131.00,N/A,131.00,N/A,18.34,N/A,114.43,N/A,114.43,N/A,131.00,78.60,78.60,11.40,131.00,,Hospital CPT G0480,HC So Propoxyphene,N/A,0301 - LABORATORY - CHEMISTRY,257.00,257.00,154.20,154.20,N/A,35.98,N/A,114.43,N/A,147.98,N/A,87.38,N/A,35.98,N/A,35.98,N/A,114.43,N/A,114.43,N/A,22.36,N/A,35.98,N/A,35.98,N/A,35.98,N/A,147.98,N/A,114.43,N/A,35.98,N/A,257.00,N/A,257.00,N/A,35.98,N/A,114.43,N/A,114.43,N/A,257.00,154.20,154.20,22.36,257.00,,Hospital CPT G0480,HC So Drug Screening Oxycodone,N/A,0301 - LABORATORY - CHEMISTRY,96.00,96.00,57.60,57.60,N/A,13.44,N/A,114.43,N/A,55.28,N/A,32.64,N/A,13.44,N/A,13.44,N/A,114.43,N/A,114.43,N/A,8.35,N/A,13.44,N/A,13.44,N/A,13.44,N/A,55.28,N/A,114.43,N/A,13.44,N/A,96.00,N/A,96.00,N/A,13.44,N/A,114.43,N/A,114.43,N/A,96.00,57.60,57.60,8.35,114.43,,Hospital CPT G0480,HC So1 Fentanyl,N/A,0301 - LABORATORY - CHEMISTRY,61.00,61.00,36.60,36.60,N/A,8.54,N/A,114.43,N/A,35.12,N/A,20.74,N/A,8.54,N/A,8.54,N/A,114.43,N/A,114.43,N/A,5.31,N/A,8.54,N/A,8.54,N/A,8.54,N/A,35.12,N/A,114.43,N/A,8.54,N/A,61.00,N/A,61.00,N/A,8.54,N/A,114.43,N/A,114.43,N/A,61.00,36.60,36.60,5.31,114.43,,Hospital CPT G0480,HC So Opioids & Opiate Analogs 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,244.00,244.00,146.40,146.40,N/A,34.16,N/A,114.43,N/A,140.50,N/A,82.96,N/A,34.16,N/A,34.16,N/A,114.43,N/A,114.43,N/A,21.23,N/A,34.16,N/A,34.16,N/A,34.16,N/A,140.50,N/A,114.43,N/A,34.16,N/A,244.00,N/A,244.00,N/A,34.16,N/A,114.43,N/A,114.43,N/A,244.00,146.40,146.40,21.23,244.00,,Hospital CPT G0480,HC So Heroin Metabolite,N/A,0301 - LABORATORY - CHEMISTRY,197.00,197.00,118.20,118.20,N/A,27.58,N/A,114.43,N/A,113.43,N/A,66.98,N/A,27.58,N/A,27.58,N/A,114.43,N/A,114.43,N/A,17.14,N/A,27.58,N/A,27.58,N/A,27.58,N/A,113.43,N/A,114.43,N/A,27.58,N/A,197.00,N/A,197.00,N/A,27.58,N/A,114.43,N/A,114.43,N/A,197.00,118.20,118.20,17.14,197.00,,Hospital CPT G0480,HC Amitriptyline,N/A,0301 - LABORATORY - CHEMISTRY,132.00,132.00,79.20,79.20,N/A,18.48,N/A,114.43,N/A,76.01,N/A,44.88,N/A,18.48,N/A,18.48,N/A,114.43,N/A,114.43,N/A,11.48,N/A,18.48,N/A,18.48,N/A,18.48,N/A,76.01,N/A,114.43,N/A,18.48,N/A,132.00,N/A,132.00,N/A,18.48,N/A,114.43,N/A,114.43,N/A,132.00,79.20,79.20,11.48,132.00,,Hospital CPT G0480,HC So1 Methylenedioxyamphetamines,N/A,0301 - LABORATORY - CHEMISTRY,40.00,40.00,24.00,24.00,N/A,5.60,N/A,114.43,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,114.43,N/A,114.43,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,114.43,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,114.43,N/A,114.43,N/A,40.00,24.00,24.00,3.48,114.43,,Hospital CPT G0480,HC Antiepileptic Nos 1-3,N/A,0301 - LABORATORY - CHEMISTRY,465.00,465.00,279.00,279.00,N/A,65.10,N/A,114.43,N/A,267.75,N/A,158.10,N/A,65.10,N/A,65.10,N/A,114.43,N/A,114.43,N/A,40.46,N/A,65.10,N/A,65.10,N/A,65.10,N/A,267.75,N/A,114.43,N/A,65.10,N/A,465.00,N/A,465.00,N/A,65.10,N/A,114.43,N/A,114.43,N/A,465.00,279.00,279.00,40.46,465.00,,Hospital CPT G0480,HC Benzodiazepines 1-12,N/A,0301 - LABORATORY - CHEMISTRY,131.00,131.00,78.60,78.60,N/A,18.34,N/A,114.43,N/A,75.43,N/A,44.54,N/A,18.34,N/A,18.34,N/A,114.43,N/A,114.43,N/A,11.40,N/A,18.34,N/A,18.34,N/A,18.34,N/A,75.43,N/A,114.43,N/A,18.34,N/A,131.00,N/A,131.00,N/A,18.34,N/A,114.43,N/A,114.43,N/A,131.00,78.60,78.60,11.40,131.00,,Hospital CPT G0480,HC So Antidepressant Tricyclic 1/2,N/A,0301 - LABORATORY - CHEMISTRY,45.00,45.00,27.00,27.00,N/A,6.30,N/A,114.43,N/A,25.91,N/A,15.30,N/A,6.30,N/A,6.30,N/A,114.43,N/A,114.43,N/A,3.92,N/A,6.30,N/A,6.30,N/A,6.30,N/A,25.91,N/A,114.43,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,114.43,N/A,114.43,N/A,45.00,27.00,27.00,3.92,114.43,,Hospital CPT G0480,HC So1 Opioids and Opiate Analogs; 3 or 4,N/A,0301 - LABORATORY - CHEMISTRY,85.00,85.00,51.00,51.00,N/A,11.90,N/A,114.43,N/A,48.94,N/A,28.90,N/A,11.90,N/A,11.90,N/A,114.43,N/A,114.43,N/A,7.40,N/A,11.90,N/A,11.90,N/A,11.90,N/A,48.94,N/A,114.43,N/A,11.90,N/A,85.00,N/A,85.00,N/A,11.90,N/A,114.43,N/A,114.43,N/A,85.00,51.00,51.00,7.40,114.43,,Hospital CPT G0480,HC So1 Drug Screening Methylphenidate,N/A,0301 - LABORATORY - CHEMISTRY,43.00,43.00,25.80,25.80,N/A,6.02,N/A,114.43,N/A,24.76,N/A,14.62,N/A,6.02,N/A,6.02,N/A,114.43,N/A,114.43,N/A,3.74,N/A,6.02,N/A,6.02,N/A,6.02,N/A,24.76,N/A,114.43,N/A,6.02,N/A,43.00,N/A,43.00,N/A,6.02,N/A,114.43,N/A,114.43,N/A,43.00,25.80,25.80,3.74,114.43,,Hospital CPT G0480,HC Drug or Substance Nos 1-3,N/A,0301 - LABORATORY - CHEMISTRY,433.00,433.00,259.80,259.80,N/A,60.62,N/A,114.43,N/A,249.32,N/A,147.22,N/A,60.62,N/A,60.62,N/A,114.43,N/A,114.43,N/A,37.67,N/A,60.62,N/A,60.62,N/A,60.62,N/A,249.32,N/A,114.43,N/A,60.62,N/A,433.00,N/A,433.00,N/A,60.62,N/A,114.43,N/A,114.43,N/A,433.00,259.80,259.80,37.67,433.00,,Hospital CPT G0480,HC So Antiepileptics Not Otherwise Specified 7 or More,N/A,0301 - LABORATORY - CHEMISTRY,50.00,50.00,30.00,30.00,N/A,7.00,N/A,114.43,N/A,28.79,N/A,17.00,N/A,7.00,N/A,7.00,N/A,114.43,N/A,114.43,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,28.79,N/A,114.43,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,114.43,N/A,114.43,N/A,50.00,30.00,30.00,4.35,114.43,,Hospital CPT G0480,HC So1 Sedative Hypnotics,N/A,0301 - LABORATORY - CHEMISTRY,42.00,42.00,25.20,25.20,N/A,5.88,N/A,114.43,N/A,24.18,N/A,14.28,N/A,5.88,N/A,5.88,N/A,114.43,N/A,114.43,N/A,3.65,N/A,5.88,N/A,5.88,N/A,5.88,N/A,24.18,N/A,114.43,N/A,5.88,N/A,42.00,N/A,42.00,N/A,5.88,N/A,114.43,N/A,114.43,N/A,42.00,25.20,25.20,3.65,114.43,,Hospital CPT G0480,HC So1 Buprenorphine,N/A,0301 - LABORATORY - CHEMISTRY,65.00,65.00,39.00,39.00,N/A,9.10,N/A,114.43,N/A,37.43,N/A,22.10,N/A,9.10,N/A,9.10,N/A,114.43,N/A,114.43,N/A,5.66,N/A,9.10,N/A,9.10,N/A,9.10,N/A,37.43,N/A,114.43,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,114.43,N/A,114.43,N/A,65.00,39.00,39.00,5.66,114.43,,Hospital CPT G0480,HC Opioids and Opiate Analog 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,270.00,270.00,162.00,162.00,N/A,37.80,N/A,114.43,N/A,155.47,N/A,91.80,N/A,37.80,N/A,37.80,N/A,114.43,N/A,114.43,N/A,23.49,N/A,37.80,N/A,37.80,N/A,37.80,N/A,155.47,N/A,114.43,N/A,37.80,N/A,270.00,N/A,270.00,N/A,37.80,N/A,114.43,N/A,114.43,N/A,270.00,162.00,162.00,23.49,270.00,,Hospital CPT G0480,HC So1 Benzodiazepines1-12,N/A,0301 - LABORATORY - CHEMISTRY,64.00,64.00,38.40,38.40,N/A,8.96,N/A,114.43,N/A,36.85,N/A,21.76,N/A,8.96,N/A,8.96,N/A,114.43,N/A,114.43,N/A,5.57,N/A,8.96,N/A,8.96,N/A,8.96,N/A,36.85,N/A,114.43,N/A,8.96,N/A,64.00,N/A,64.00,N/A,8.96,N/A,114.43,N/A,114.43,N/A,64.00,38.40,38.40,5.57,114.43,,Hospital CPT G0480,HC So Amphetamines 5 or More G0480,N/A,0301 - LABORATORY - CHEMISTRY,34.00,34.00,20.40,20.40,N/A,4.76,N/A,114.43,N/A,19.58,N/A,11.56,N/A,4.76,N/A,4.76,N/A,114.43,N/A,114.43,N/A,2.96,N/A,4.76,N/A,4.76,N/A,4.76,N/A,19.58,N/A,114.43,N/A,4.76,N/A,34.00,N/A,34.00,N/A,4.76,N/A,114.43,N/A,114.43,N/A,34.00,20.40,20.40,2.96,114.43,,Hospital CPT G0480,HC So1 Cocaine or Cocaine Metabolite,N/A,0301 - LABORATORY - CHEMISTRY,49.00,49.00,29.40,29.40,N/A,6.86,N/A,114.43,N/A,28.21,N/A,16.66,N/A,6.86,N/A,6.86,N/A,114.43,N/A,114.43,N/A,4.26,N/A,6.86,N/A,6.86,N/A,6.86,N/A,28.21,N/A,114.43,N/A,6.86,N/A,49.00,N/A,49.00,N/A,6.86,N/A,114.43,N/A,114.43,N/A,49.00,29.40,29.40,4.26,114.43,,Hospital CPT G0480,HC So1 Antiepileptics Nos 7/More,N/A,0301 - LABORATORY - CHEMISTRY,27.00,27.00,16.20,16.20,N/A,3.78,N/A,114.43,N/A,15.55,N/A,9.18,N/A,3.78,N/A,3.78,N/A,114.43,N/A,114.43,N/A,2.35,N/A,3.78,N/A,3.78,N/A,3.78,N/A,15.55,N/A,114.43,N/A,3.78,N/A,27.00,N/A,27.00,N/A,3.78,N/A,114.43,N/A,114.43,N/A,27.00,16.20,16.20,2.35,114.43,,Hospital CPT G0480,HC So Antidepressants; Nes,N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,15.40,N/A,114.43,N/A,63.34,N/A,37.40,N/A,15.40,N/A,15.40,N/A,114.43,N/A,114.43,N/A,9.57,N/A,15.40,N/A,15.40,N/A,15.40,N/A,63.34,N/A,114.43,N/A,15.40,N/A,110.00,N/A,110.00,N/A,15.40,N/A,114.43,N/A,114.43,N/A,110.00,66.00,66.00,9.57,114.43,,Hospital CPT G0480,HC So Sedative Hypnotics,N/A,0301 - LABORATORY - CHEMISTRY,235.00,235.00,141.00,141.00,N/A,32.90,N/A,114.43,N/A,135.31,N/A,79.90,N/A,32.90,N/A,32.90,N/A,114.43,N/A,114.43,N/A,20.45,N/A,32.90,N/A,32.90,N/A,32.90,N/A,135.31,N/A,114.43,N/A,32.90,N/A,235.00,N/A,235.00,N/A,32.90,N/A,114.43,N/A,114.43,N/A,235.00,141.00,141.00,20.45,235.00,,Hospital CPT G0480,HC So1 Amphetamines 5 or More G0480,N/A,0301 - LABORATORY - CHEMISTRY,37.00,37.00,22.20,22.20,N/A,5.18,N/A,114.43,N/A,21.30,N/A,12.58,N/A,5.18,N/A,5.18,N/A,114.43,N/A,114.43,N/A,3.22,N/A,5.18,N/A,5.18,N/A,5.18,N/A,21.30,N/A,114.43,N/A,5.18,N/A,37.00,N/A,37.00,N/A,5.18,N/A,114.43,N/A,114.43,N/A,37.00,22.20,22.20,3.22,114.43,,Hospital CPT G0480,HC So Fentanyl,N/A,0301 - LABORATORY - CHEMISTRY,160.00,160.00,96.00,96.00,N/A,22.40,N/A,114.43,N/A,92.13,N/A,54.40,N/A,22.40,N/A,22.40,N/A,114.43,N/A,114.43,N/A,13.92,N/A,22.40,N/A,22.40,N/A,22.40,N/A,92.13,N/A,114.43,N/A,22.40,N/A,160.00,N/A,160.00,N/A,22.40,N/A,114.43,N/A,114.43,N/A,160.00,96.00,96.00,13.92,160.00,,Hospital CPT G0480,HC So Opiates 1 or More,N/A,0301 - LABORATORY - CHEMISTRY,96.00,96.00,57.60,57.60,N/A,13.44,N/A,114.43,N/A,55.28,N/A,32.64,N/A,13.44,N/A,13.44,N/A,114.43,N/A,114.43,N/A,8.35,N/A,13.44,N/A,13.44,N/A,13.44,N/A,55.28,N/A,114.43,N/A,13.44,N/A,96.00,N/A,96.00,N/A,13.44,N/A,114.43,N/A,114.43,N/A,96.00,57.60,57.60,8.35,114.43,,Hospital CPT G0480,HC So Methylenedioxyamphetamines,N/A,0301 - LABORATORY - CHEMISTRY,50.00,50.00,30.00,30.00,N/A,7.00,N/A,114.43,N/A,28.79,N/A,17.00,N/A,7.00,N/A,7.00,N/A,114.43,N/A,114.43,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,28.79,N/A,114.43,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,114.43,N/A,114.43,N/A,50.00,30.00,30.00,4.35,114.43,,Hospital CPT G0480,HC Nortriptyline (Aventyl),N/A,0301 - LABORATORY - CHEMISTRY,186.00,162.00,111.60,97.20,N/A,22.68,N/A,114.43,N/A,93.28,N/A,55.08,N/A,22.68,N/A,22.68,N/A,114.43,N/A,114.43,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,93.28,N/A,114.43,N/A,22.68,N/A,162.00,N/A,162.00,N/A,22.68,N/A,114.43,N/A,114.43,N/A,162.00,111.60,111.60,14.09,162.00,,Hospital CPT G0480,HC So Antipsychotics Nos 1-3,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,18.20,N/A,114.43,N/A,74.85,N/A,44.20,N/A,18.20,N/A,18.20,N/A,114.43,N/A,114.43,N/A,11.31,N/A,18.20,N/A,18.20,N/A,18.20,N/A,74.85,N/A,114.43,N/A,18.20,N/A,130.00,N/A,130.00,N/A,18.20,N/A,114.43,N/A,114.43,N/A,130.00,78.00,78.00,11.31,130.00,,Hospital CPT G0480,HC So Ritalin,N/A,0301 - LABORATORY - CHEMISTRY,148.00,148.00,88.80,88.80,N/A,20.72,N/A,114.43,N/A,85.22,N/A,50.32,N/A,20.72,N/A,20.72,N/A,114.43,N/A,114.43,N/A,12.88,N/A,20.72,N/A,20.72,N/A,20.72,N/A,85.22,N/A,114.43,N/A,20.72,N/A,148.00,N/A,148.00,N/A,20.72,N/A,114.43,N/A,114.43,N/A,148.00,88.80,88.80,12.88,148.00,,Hospital CPT G0480,HC So Drug Screening Pregabalin,N/A,0301 - LABORATORY - CHEMISTRY,220.00,220.00,132.00,132.00,N/A,30.80,N/A,114.43,N/A,126.68,N/A,74.80,N/A,30.80,N/A,30.80,N/A,114.43,N/A,114.43,N/A,19.14,N/A,30.80,N/A,30.80,N/A,30.80,N/A,126.68,N/A,114.43,N/A,30.80,N/A,220.00,N/A,220.00,N/A,30.80,N/A,114.43,N/A,114.43,N/A,220.00,132.00,132.00,19.14,220.00,,Hospital CPT G0480,HC So1 Drug Screen Benzodiazepines 1-12,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,10.50,N/A,114.43,N/A,43.19,N/A,25.50,N/A,10.50,N/A,10.50,N/A,114.43,N/A,114.43,N/A,6.53,N/A,10.50,N/A,10.50,N/A,10.50,N/A,43.19,N/A,114.43,N/A,10.50,N/A,75.00,N/A,75.00,N/A,10.50,N/A,114.43,N/A,114.43,N/A,75.00,45.00,45.00,6.53,114.43,,Hospital CPT G0480,HC Alkaloids Nos,N/A,0301 - LABORATORY - CHEMISTRY,257.00,218.00,154.20,130.80,N/A,30.52,N/A,114.43,N/A,125.52,N/A,74.12,N/A,30.52,N/A,30.52,N/A,114.43,N/A,114.43,N/A,18.97,N/A,30.52,N/A,30.52,N/A,30.52,N/A,125.52,N/A,114.43,N/A,30.52,N/A,218.00,N/A,218.00,N/A,30.52,N/A,114.43,N/A,114.43,N/A,218.00,154.20,154.20,18.97,218.00,,Hospital G0495,Rn Training and Education,N/A,0551 - HOME HEALTH (HH) - SKILLED NURSING - VISIT CHARGE,N/A,4000.00,N/A,2400.00,N/A,1066.41,N/A,1544.00,N/A,1088.00,N/A,1360.00,N/A,670.00,N/A,560.00,N/A,1544.00,N/A,1544.00,N/A,1041.00,N/A,670.00,N/A,670.00,N/A,670.00,N/A,2303.20,N/A,2089.58,N/A,1066.41,N/A,1715.20,N/A,1715.20,N/A,1066.41,N/A,1316.00,N/A,1544.00,N/A,1066.41,N/A,N/A,560.00,2400.00,,Hospital G2082,HC Visit Esketamine 56m or Less,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,N/A,4173.30,N/A,2503.98,N/A,584.26,N/A,958.92,N/A,2369.51,N/A,1418.92,N/A,2821.44,N/A,584.26,N/A,948.64,N/A,948.64,N/A,2152.93,N/A,2821.44,N/A,2821.44,N/A,2821.44,N/A,2369.51,N/A,948.64,N/A,584.26,N/A,2236.89,N/A,2236.89,N/A,584.26,N/A,948.64,N/A,958.92,N/A,154.22,N/A,N/A,154.22,2821.44,,Hospital G2083,HC Visit Esketamine >56m,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,N/A,4961.20,N/A,2976.72,N/A,694.57,N/A,1324.05,N/A,2823.19,N/A,1686.81,N/A,3911.70,N/A,694.57,N/A,1309.86,N/A,1309.86,N/A,3104.14,N/A,3911.70,N/A,3911.70,N/A,3911.70,N/A,2823.19,N/A,1309.86,N/A,694.57,N/A,2659.20,N/A,2659.20,N/A,694.57,N/A,1309.86,N/A,1324.05,N/A,154.22,N/A,N/A,154.22,3911.70,,Hospital G2169,Ot Cota Maintenance Visit,N/A,0431 - OCCUPATIONAL THERAPY - VISIT,N/A,3135.12,N/A,1881.07,N/A,N/A,N/A,2957.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2957.67,N/A,2957.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2957.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2957.67,N/A,2957.67,N/A,N/A,N/A,N/A,1881.07,2957.67,,Hospital G2170,Avf by tissue w thermal e,N/A,N/A,N/A,80722.83,N/A,48433.70,N/A,11301.20,N/A,790.11,N/A,46461.43,N/A,27445.77,N/A,7791.37,N/A,11301.20,N/A,769.55,N/A,769.55,N/A,4843.85,N/A,7791.37,N/A,7791.37,N/A,7791.37,N/A,46461.44,N/A,769.55,N/A,11301.20,N/A,1431.00,N/A,1431.00,N/A,11301.20,N/A,769.55,N/A,790.11,N/A,94.54,N/A,N/A,94.54,48433.70,,Hospital G6040,Assay of ethanol,N/A,N/A,N/A,30516.60,N/A,18309.96,N/A,4357.76,N/A,1842.21,N/A,17562.62,N/A,10375.65,N/A,5263.84,N/A,4357.76,N/A,1791.33,N/A,1791.33,N/A,3779.26,N/A,5263.84,N/A,5263.84,N/A,5263.84,N/A,16789.95,N/A,1802.56,N/A,4357.76,N/A,4241.58,N/A,4241.58,N/A,4357.76,N/A,1791.33,N/A,1842.21,N/A,1759.39,N/A,N/A,1759.39,18309.96,,Hospital H0001,HC Iop Alco and/or Drug Assess,N/A,0906 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INTENSIVE OUTPATIENT SERVICES - CHEMICAL DEPENDENCY,N/A,552.00,N/A,331.20,N/A,77.28,N/A,N/A,N/A,317.84,N/A,187.68,N/A,77.28,N/A,77.28,N/A,N/A,N/A,N/A,N/A,48.02,N/A,77.28,N/A,77.28,N/A,77.28,N/A,552.00,N/A,N/A,N/A,77.28,N/A,N/A,N/A,N/A,N/A,77.28,N/A,552.00,N/A,N/A,N/A,N/A,N/A,N/A,48.02,552.00,,Hospital H0036,HC Comm Psych Supportive Trmt 15 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,N/A,114.00,N/A,68.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38.76,N/A,15.96,N/A,15.96,N/A,N/A,N/A,N/A,N/A,9.92,N/A,15.96,N/A,15.96,N/A,15.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9.92,68.40,,Hospital H2012,HC Iop Mh Day Trtmt per Hr Group,N/A,0905 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INTENSIVE OUTPATIENT SERVICES - PSYCHIATRIC,N/A,518.00,N/A,310.80,N/A,72.52,N/A,N/A,N/A,298.26,N/A,176.12,N/A,72.52,N/A,72.52,N/A,N/A,N/A,N/A,N/A,45.06,N/A,72.52,N/A,72.52,N/A,72.52,N/A,518.00,N/A,N/A,N/A,72.52,N/A,N/A,N/A,N/A,N/A,72.52,N/A,518.00,N/A,N/A,N/A,421.94,N/A,N/A,45.06,518.00,,Hospital HCPCS J0132,ACETYLCYSTEINE 200 MG/ML IV SOLN,63323-0963-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),127.00,127.00,76.20,76.20,N/A,17.78,N/A,127.00,N/A,71.40,N/A,43.18,N/A,8.55,N/A,17.78,N/A,127.00,N/A,127.00,N/A,5.32,N/A,8.55,N/A,8.55,N/A,8.55,N/A,71.40,N/A,127.00,N/A,17.78,N/A,68.07,N/A,68.07,N/A,17.78,N/A,127.00,N/A,127.00,N/A,127.00,76.20,76.20,5.32,127.00,,Hospital HCPCS J0171,EPINEPHRINE 1 MG/ML IJ SOLN (MIXTURES ONLY),76329-9060-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.94,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.21,15.00,,Hospital HCPCS J0171,EPINEPHRINE PF 1 MG/ML IJ SOLN,54288-0103-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.94,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.21,15.00,,Hospital HCPCS J0171,EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML IJ SOLN,76329-9060-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.94,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.21,15.00,,Hospital HCPCS J0171,EPINEPHRINE 1 MG/10ML IV SOSY,76329-3318-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),66.50,66.50,39.90,39.90,N/A,9.31,N/A,66.50,N/A,37.39,N/A,22.61,N/A,19.43,N/A,9.31,N/A,66.50,N/A,66.50,N/A,12.09,N/A,19.43,N/A,19.43,N/A,19.43,N/A,37.39,N/A,66.50,N/A,9.31,N/A,35.64,N/A,35.64,N/A,9.31,N/A,66.50,N/A,66.50,N/A,66.50,39.90,39.90,9.31,66.50,,Hospital HCPCS J0171,EPINEPHRINE 1 MG/10 ML IJ SOLN (MIXTURES ONLY),00409-4933-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.94,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.21,15.00,,Hospital HCPCS J0171,EPINEPHRINE 1 MG/10ML IJ SOSY,69374-0925-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),32.40,32.40,19.44,19.44,N/A,4.54,N/A,32.40,N/A,18.22,N/A,11.02,N/A,19.43,N/A,4.54,N/A,32.40,N/A,32.40,N/A,12.09,N/A,19.43,N/A,19.43,N/A,19.43,N/A,18.22,N/A,32.40,N/A,4.54,N/A,17.37,N/A,17.37,N/A,4.54,N/A,32.40,N/A,32.40,N/A,32.40,19.44,19.44,4.54,32.40,,Hospital HCPCS J0171,EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN,42023-0159-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.94,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.21,15.00,,Hospital HCPCS J0171,EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,49502-0102-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1012.50,1012.50,607.50,607.50,N/A,141.75,N/A,1012.50,N/A,569.23,N/A,344.25,N/A,1.94,N/A,141.75,N/A,1012.50,N/A,1012.50,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,569.23,N/A,1012.50,N/A,141.75,N/A,542.70,N/A,542.70,N/A,141.75,N/A,1012.50,N/A,1012.50,N/A,1012.50,607.50,607.50,1.21,1012.50,,Hospital J0180,Agalsidase beta injection,N/A,N/A,N/A,61961.92,N/A,37177.15,N/A,8674.67,N/A,25005.94,N/A,34846.05,N/A,21067.06,N/A,61693.20,N/A,8674.67,N/A,24993.27,N/A,24993.27,N/A,38519.07,N/A,61693.20,N/A,61693.20,N/A,61693.20,N/A,34846.05,N/A,24993.27,N/A,8674.67,N/A,33211.58,N/A,33211.58,N/A,8674.67,N/A,24993.27,N/A,80.49,N/A,88.54,N/A,N/A,80.49,61693.20,,Hospital J0221,Lumizyme injection,N/A,N/A,N/A,153929.90,N/A,92357.94,N/A,21550.19,N/A,38707.63,N/A,86556.36,N/A,52336.17,N/A,95840.87,N/A,21550.19,N/A,38699.59,N/A,38699.59,N/A,59661.87,N/A,95840.87,N/A,95840.87,N/A,95840.87,N/A,86556.36,N/A,38699.59,N/A,21550.19,N/A,82506.43,N/A,82506.43,N/A,21550.19,N/A,38699.59,N/A,38707.63,N/A,131.33,N/A,N/A,131.33,95840.87,,Hospital HCPCS J0290,AMPICILLIN SODIUM 1 G IJ SOLR (MIXTURES ONLY),00781-3404-85,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),46.60,46.60,27.96,27.96,N/A,6.52,N/A,46.60,N/A,26.20,N/A,15.84,N/A,3.89,N/A,6.52,N/A,46.60,N/A,46.60,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,26.20,N/A,46.60,N/A,6.52,N/A,24.98,N/A,24.98,N/A,6.52,N/A,46.60,N/A,46.60,N/A,46.60,27.96,27.96,2.42,46.60,,Hospital HCPCS J0290,AMPICILLIN SODIUM 500 MG IJ SOLR,00781-3407-78,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),23.80,23.80,14.28,14.28,N/A,3.33,N/A,23.80,N/A,13.38,N/A,8.09,N/A,1.94,N/A,3.33,N/A,23.80,N/A,23.80,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,13.38,N/A,23.80,N/A,3.33,N/A,12.76,N/A,12.76,N/A,3.33,N/A,23.80,N/A,23.80,N/A,23.80,14.28,14.28,1.21,23.80,,Hospital HCPCS J0290,AMPICILLIN SODIUM 2 G IJ SOLR,00781-9273-80,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),90.50,90.50,54.30,54.30,N/A,12.67,N/A,90.50,N/A,50.88,N/A,30.77,N/A,7.77,N/A,12.67,N/A,90.50,N/A,90.50,N/A,4.84,N/A,7.77,N/A,7.77,N/A,7.77,N/A,50.88,N/A,90.50,N/A,12.67,N/A,48.51,N/A,48.51,N/A,12.67,N/A,90.50,N/A,90.50,N/A,90.50,54.30,54.30,4.84,90.50,,Hospital HCPCS J0290,AMPICILLIN SODIUM 2000 MG IJ SOLR (MIXTURES ONLY),00781-3408-80,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),90.50,90.50,54.30,54.30,N/A,12.67,N/A,90.50,N/A,50.88,N/A,30.77,N/A,7.77,N/A,12.67,N/A,90.50,N/A,90.50,N/A,4.84,N/A,7.77,N/A,7.77,N/A,7.77,N/A,50.88,N/A,90.50,N/A,12.67,N/A,48.51,N/A,48.51,N/A,12.67,N/A,90.50,N/A,90.50,N/A,90.50,54.30,54.30,4.84,90.50,,Hospital HCPCS J0290,AMPICILLIN SODIUM 1 G IJ SOLR,00781-9261-95,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),46.70,46.70,28.02,28.02,N/A,6.54,N/A,46.70,N/A,26.25,N/A,15.88,N/A,3.89,N/A,6.54,N/A,46.70,N/A,46.70,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,26.25,N/A,46.70,N/A,6.54,N/A,25.03,N/A,25.03,N/A,6.54,N/A,46.70,N/A,46.70,N/A,46.70,28.02,28.02,2.42,46.70,,Hospital HCPCS J0290,AMPICILLIN SODIUM 250 MG IJ SOLR,00781-3402-78,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),18.10,18.10,10.86,10.86,N/A,2.53,N/A,18.10,N/A,10.18,N/A,6.15,N/A,1.94,N/A,2.53,N/A,18.10,N/A,18.10,N/A,1.21,N/A,1.94,N/A,1.94,N/A,1.94,N/A,10.18,N/A,18.10,N/A,2.53,N/A,9.70,N/A,9.70,N/A,2.53,N/A,18.10,N/A,18.10,N/A,18.10,10.86,10.86,1.21,18.10,,Hospital HCPCS J0291,PLAZOMICIN SULFATE 500 MG/10ML IV SOLN,80735-0820-37,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2234.30,2234.30,1340.58,1340.58,N/A,312.80,N/A,335.60,N/A,1256.12,N/A,759.66,N/A,810.67,N/A,312.80,N/A,335.60,N/A,335.60,N/A,504.65,N/A,810.67,N/A,810.67,N/A,810.67,N/A,1256.12,N/A,335.60,N/A,312.80,N/A,1197.58,N/A,1197.58,N/A,312.80,N/A,335.60,N/A,335.60,N/A,369.16,1340.58,1340.58,312.80,1340.58,,Hospital HCPCS J0295,AMPICILLIN-SULBACTAM 1500 (1000-500) MG IJ (MIXTURES ONLY),00049-0013-83,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),52.10,52.10,31.26,31.26,N/A,7.29,N/A,52.10,N/A,29.29,N/A,17.71,N/A,5.80,N/A,7.29,N/A,52.10,N/A,52.10,N/A,3.61,N/A,5.80,N/A,5.80,N/A,5.80,N/A,29.29,N/A,52.10,N/A,7.29,N/A,27.93,N/A,27.93,N/A,7.29,N/A,52.10,N/A,52.10,N/A,52.10,31.26,31.26,3.61,52.10,,Hospital HCPCS J0295,AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,00049-0013-81,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),52.10,52.10,31.26,31.26,N/A,7.29,N/A,52.10,N/A,29.29,N/A,17.71,N/A,5.80,N/A,7.29,N/A,52.10,N/A,52.10,N/A,3.61,N/A,5.80,N/A,5.80,N/A,5.80,N/A,29.29,N/A,52.10,N/A,7.29,N/A,27.93,N/A,27.93,N/A,7.29,N/A,52.10,N/A,52.10,N/A,52.10,31.26,31.26,3.61,52.10,,Hospital HCPCS J0295,AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,55150-0117-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),36.20,36.20,21.72,21.72,N/A,5.07,N/A,36.20,N/A,20.35,N/A,12.31,N/A,11.60,N/A,5.07,N/A,36.20,N/A,36.20,N/A,7.22,N/A,11.60,N/A,11.60,N/A,11.60,N/A,20.35,N/A,36.20,N/A,5.07,N/A,19.40,N/A,19.40,N/A,5.07,N/A,36.20,N/A,36.20,N/A,36.20,21.72,21.72,5.07,36.20,,Hospital HCPCS J0360,HYDRALAZINE HCL 20 MG/ML IJ SOLN,63323-0614-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),24.20,24.20,14.52,14.52,N/A,3.39,N/A,24.20,N/A,13.61,N/A,8.23,N/A,11.45,N/A,3.39,N/A,24.20,N/A,24.20,N/A,7.13,N/A,11.45,N/A,11.45,N/A,11.45,N/A,13.61,N/A,24.20,N/A,3.39,N/A,12.97,N/A,12.97,N/A,3.39,N/A,24.20,N/A,24.20,N/A,24.20,14.52,14.52,3.39,24.20,,Hospital HCPCS J0456,AZITHROMYCIN 500 MG IV SOLR,63323-0398-14,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),23.70,23.70,14.22,14.22,N/A,3.32,N/A,23.70,N/A,13.32,N/A,8.06,N/A,6.55,N/A,3.32,N/A,23.70,N/A,23.70,N/A,4.08,N/A,6.55,N/A,6.55,N/A,6.55,N/A,13.32,N/A,23.70,N/A,3.32,N/A,12.70,N/A,12.70,N/A,3.32,N/A,23.70,N/A,23.70,N/A,23.70,14.22,14.22,3.32,23.70,,Hospital HCPCS J0456,AZITHROMYCIN 500 MG IN NS 250 ML (PREMIX) IVPB,99999-9917-51,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22.00,22.00,13.20,13.20,N/A,3.08,N/A,22.00,N/A,12.37,N/A,7.48,N/A,6.55,N/A,3.08,N/A,22.00,N/A,22.00,N/A,4.08,N/A,6.55,N/A,6.55,N/A,6.55,N/A,12.37,N/A,22.00,N/A,3.08,N/A,11.79,N/A,11.79,N/A,3.08,N/A,22.00,N/A,22.00,N/A,22.00,13.20,13.20,3.08,22.00,,Hospital HCPCS J0457,AZTREONAM 2 G IJ SOLR,00003-2570-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),97.90,97.90,58.74,58.74,N/A,13.71,N/A,97.90,N/A,55.04,N/A,33.29,N/A,13.71,N/A,13.71,N/A,97.90,N/A,97.90,N/A,8.52,N/A,13.71,N/A,13.71,N/A,13.71,N/A,55.04,N/A,97.90,N/A,13.71,N/A,52.47,N/A,52.47,N/A,13.71,N/A,97.90,N/A,97.90,N/A,97.90,58.74,58.74,8.52,97.90,,Hospital HCPCS J0457,AZTREONAM 1 G IJ SOLR,63323-0401-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),92.20,92.20,55.32,55.32,N/A,12.91,N/A,92.20,N/A,51.83,N/A,31.35,N/A,12.91,N/A,12.91,N/A,92.20,N/A,92.20,N/A,8.02,N/A,12.91,N/A,12.91,N/A,12.91,N/A,51.83,N/A,92.20,N/A,12.91,N/A,49.42,N/A,49.42,N/A,12.91,N/A,92.20,N/A,92.20,N/A,92.20,55.32,55.32,8.02,92.20,,Hospital HCPCS J0490,BELIMUMAB 120 MG IV SOLR,49401-0101-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2613.60,2613.60,1568.16,1568.16,N/A,365.90,N/A,611.12,N/A,1469.37,N/A,888.62,N/A,1536.60,N/A,365.90,N/A,611.12,N/A,611.12,N/A,956.55,N/A,1536.60,N/A,1536.60,N/A,1536.60,N/A,1469.37,N/A,611.12,N/A,365.90,N/A,1400.89,N/A,1400.89,N/A,365.90,N/A,611.12,N/A,611.12,N/A,2613.60,1568.16,1568.16,365.90,2613.60,,Hospital HCPCS J0490,BELIMUMAB 400 MG IV SOLR,49401-0102-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),8711.70,8711.70,5227.02,5227.02,N/A,1219.64,N/A,2037.08,N/A,4897.72,N/A,2961.98,N/A,5121.98,N/A,1219.64,N/A,2037.08,N/A,2037.08,N/A,3188.48,N/A,5121.98,N/A,5121.98,N/A,5121.98,N/A,4897.72,N/A,2037.08,N/A,1219.64,N/A,4669.47,N/A,4669.47,N/A,1219.64,N/A,2037.08,N/A,2037.08,N/A,8711.70,5227.02,5227.02,1219.64,8711.70,,Hospital J0565,"Inj, bezlotoxumab, 10 mg",N/A,N/A,141339.73,28024.00,84803.84,16814.40,N/A,3923.36,N/A,4170.89,N/A,15769.29,N/A,9528.16,N/A,10777.55,N/A,3923.36,N/A,4171.84,N/A,4171.84,N/A,6709.13,N/A,10777.55,N/A,10777.55,N/A,10777.55,N/A,15769.29,N/A,4171.84,N/A,3923.36,N/A,15020.86,N/A,15020.86,N/A,3923.36,N/A,4171.84,N/A,4170.89,N/A,67.14,84803.84,84803.84,67.14,16814.40,,Hospital HCPCS J0572,BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,65162-0416-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J0572,BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM,12496-1202-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11.30,11.30,6.78,6.78,N/A,1.58,N/A,11.30,N/A,6.35,N/A,3.84,N/A,1.58,N/A,1.58,N/A,11.30,N/A,11.30,N/A,N/A,N/A,1.58,N/A,1.58,N/A,1.58,N/A,6.35,N/A,11.30,N/A,1.58,N/A,6.06,N/A,6.06,N/A,1.58,N/A,11.30,N/A,11.30,N/A,11.30,6.78,6.78,1.58,11.30,,Hospital J0592,Buprenorphine Hydrochloride,N/A,N/A,45097.90,N/A,27058.74,N/A,7975.79,N/A,N/A,N/A,17974.09,N/A,15333.29,N/A,22778.95,N/A,8221.54,N/A,9700.59,N/A,9700.59,N/A,14178.78,N/A,22778.95,N/A,22778.95,N/A,22778.95,N/A,17974.09,N/A,9700.59,N/A,8221.54,N/A,37440.00,N/A,37440.00,N/A,9546.76,N/A,9700.59,N/A,9700.59,N/A,8797.05,N/A,7975.79,37440.00,N/A,N/A,,Hospital HCPCS J0595,BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,00409-1626-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,7.69,N/A,2.10,N/A,15.00,N/A,15.00,N/A,4.79,N/A,7.69,N/A,7.69,N/A,7.69,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0595,BUTORPHANOL TARTRATE 1 MG/ML IJ SOLN,00409-1623-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17.20,17.20,10.32,10.32,N/A,2.41,N/A,17.20,N/A,9.67,N/A,5.85,N/A,7.69,N/A,2.41,N/A,17.20,N/A,17.20,N/A,4.79,N/A,7.69,N/A,7.69,N/A,7.69,N/A,9.67,N/A,17.20,N/A,2.41,N/A,9.22,N/A,9.22,N/A,2.41,N/A,17.20,N/A,17.20,N/A,17.20,10.32,10.32,2.41,17.20,,Hospital HCPCS J0595,BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,00409-1626-42,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,7.69,N/A,2.10,N/A,15.00,N/A,15.00,N/A,4.79,N/A,7.69,N/A,7.69,N/A,7.69,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J0610,Calcium glucon (fresenius),N/A,N/A,77842.90,8052.10,46705.74,4831.26,5030.55,1114.22,6216.52,1811.83,11336.75,4587.99,26466.58,2737.72,23754.54,4505.74,5185.55,1114.22,6216.52,1811.83,6216.52,1811.83,23754.54,2804.90,23754.54,4505.74,23754.54,4505.74,11445.19,4505.74,11336.75,4587.99,6216.52,1811.83,5185.55,1114.22,13616.92,14.93,13616.92,14.93,8372.21,1114.22,6216.52,1811.83,17382.30,1811.83,5548.54,1993.02,5030.55,46705.74,14.93,4831.26,,Hospital HCPCS J0612,CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN,44567-0620-24,0250 - PHARMACY - GENERAL CLASSIFICATION,133.40,133.40,80.04,80.04,N/A,18.68,N/A,133.40,N/A,76.81,N/A,45.36,N/A,133.40,N/A,18.68,N/A,133.40,N/A,133.40,N/A,133.40,N/A,133.40,N/A,133.40,N/A,133.40,N/A,76.81,N/A,133.40,N/A,18.68,N/A,71.50,N/A,71.50,N/A,18.68,N/A,133.40,N/A,133.40,N/A,133.40,80.04,80.04,18.68,133.40,,Hospital HCPCS J0630,CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,67457-0675-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3523.70,3523.70,2114.22,2114.22,N/A,493.32,N/A,1366.44,N/A,1981.02,N/A,1198.06,N/A,3523.70,N/A,493.32,N/A,1366.44,N/A,1366.44,N/A,3523.70,N/A,3523.70,N/A,3523.70,N/A,3523.70,N/A,1981.02,N/A,1366.44,N/A,493.32,N/A,1888.70,N/A,1888.70,N/A,493.32,N/A,1366.44,N/A,1366.44,N/A,1503.08,2114.22,2114.22,493.32,3523.70,,Hospital J0636,Inj Calcitriol per 0.1 Mcg,N/A,N/A,70885.23,N/A,42531.14,N/A,8841.60,N/A,10724.80,N/A,20156.68,N/A,N/A,N/A,N/A,N/A,8841.60,N/A,71532.62,N/A,10724.80,N/A,12521.66,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20156.68,N/A,71532.62,N/A,9114.03,N/A,23932.86,N/A,23932.86,N/A,8841.60,N/A,10724.80,N/A,10724.80,N/A,9752.01,N/A,8841.60,71532.62,N/A,N/A,,Hospital J0637,Caspofungin Acetate,N/A,N/A,3280555.52,1528.20,1968333.31,916.92,N/A,213.95,N/A,185.59,N/A,873.36,1694202.79,519.59,1694202.79,593.15,N/A,213.95,N/A,186.54,N/A,186.54,1694202.79,369.24,1694202.79,593.15,1694202.79,593.15,1694202.79,593.15,N/A,873.36,N/A,186.54,N/A,213.95,N/A,819.11,N/A,819.11,N/A,213.95,N/A,186.54,N/A,185.59,N/A,67.14,1694202.79,1968333.31,67.14,916.92,,Hospital HCPCS J0640,LEUCOVORIN CALCIUM 500 MG IJ SOLR,25021-0828-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),450.00,450.00,270.00,270.00,N/A,63.00,N/A,450.00,N/A,252.99,N/A,153.00,N/A,113.18,N/A,63.00,N/A,450.00,N/A,450.00,N/A,70.46,N/A,113.18,N/A,113.18,N/A,113.18,N/A,252.99,N/A,450.00,N/A,63.00,N/A,241.20,N/A,241.20,N/A,63.00,N/A,450.00,N/A,450.00,N/A,450.00,270.00,270.00,63.00,450.00,,Hospital HCPCS J0640,LEUCOVORIN CALCIUM 350 MG IJ SOLR,67457-0530-35,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,79.23,N/A,21.00,N/A,150.00,N/A,150.00,N/A,49.32,N/A,79.23,N/A,79.23,N/A,79.23,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,21.00,150.00,,Hospital HCPCS J0640,LEUCOVORIN CALCIUM 50 MG IJ SOLR,00143-9555-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,11.32,N/A,21.00,N/A,150.00,N/A,150.00,N/A,7.05,N/A,11.32,N/A,11.32,N/A,11.32,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,7.05,150.00,,Hospital HCPCS J0640,LEUCOVORIN CALCIUM 100 MG IJ SOLR,67457-0528-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,22.64,N/A,21.00,N/A,150.00,N/A,150.00,N/A,14.09,N/A,22.64,N/A,22.64,N/A,22.64,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,14.09,150.00,,Hospital HCPCS J0640,LEUCOVORIN CALCIUM 200 MG IJ SOLR,63323-0710-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,45.27,N/A,21.00,N/A,150.00,N/A,150.00,N/A,28.18,N/A,45.27,N/A,45.27,N/A,45.27,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,21.00,150.00,,Hospital J0641,Inj levoleucovorin nos 0.5mg,N/A,N/A,N/A,5369.60,N/A,3221.76,N/A,751.73,N/A,653.91,N/A,3074.38,N/A,1825.65,N/A,1545.37,N/A,751.73,N/A,604.52,N/A,604.52,N/A,962.03,N/A,1545.37,N/A,1545.37,N/A,1545.37,N/A,3074.38,N/A,604.52,N/A,751.73,N/A,2878.10,N/A,2878.10,N/A,751.73,N/A,604.52,N/A,653.91,N/A,288.55,N/A,N/A,288.55,3221.76,,Hospital HCPCS J0690,CEFAZOLIN SODIUM 10 G IJ SOLR,25021-0102-69,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),40.50,40.50,24.30,24.30,N/A,5.67,N/A,40.50,N/A,22.77,N/A,13.77,N/A,39.37,N/A,5.67,N/A,40.50,N/A,40.50,N/A,24.51,N/A,39.37,N/A,39.37,N/A,39.37,N/A,22.77,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,5.67,N/A,40.50,N/A,40.50,N/A,40.50,24.30,24.30,5.67,40.50,,Hospital HCPCS J0690,VANCOMYCIN 1500 MG NS 500 ML (PREMIX) IVPB,09999-0276-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),499.50,499.50,299.70,299.70,N/A,69.93,N/A,499.50,N/A,280.82,N/A,169.83,N/A,5.91,N/A,69.93,N/A,499.50,N/A,499.50,N/A,3.68,N/A,5.91,N/A,5.91,N/A,5.91,N/A,280.82,N/A,499.50,N/A,69.93,N/A,267.73,N/A,267.73,N/A,69.93,N/A,499.50,N/A,499.50,N/A,499.50,299.70,299.70,3.68,499.50,,Hospital HCPCS J0690,CEFAZOLIN 2000 MG IN NS 50 ML IVPB,09999-9912-58,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),23.30,23.30,13.98,13.98,N/A,3.26,N/A,23.30,N/A,13.10,N/A,7.92,N/A,7.87,N/A,3.26,N/A,23.30,N/A,23.30,N/A,4.90,N/A,7.87,N/A,7.87,N/A,7.87,N/A,13.10,N/A,23.30,N/A,3.26,N/A,12.49,N/A,12.49,N/A,3.26,N/A,23.30,N/A,23.30,N/A,23.30,13.98,13.98,3.26,23.30,,Hospital HCPCS J0690,CEFAZOLIN SODIUM 500 MG IJ SOLR,00781-3450-70,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.97,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.23,N/A,1.97,N/A,1.97,N/A,1.97,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.23,15.00,,Hospital HCPCS J0690,CEFAZOLIN SODIUM 1 G IJ SOLR,25021-0101-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.97,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.23,N/A,1.97,N/A,1.97,N/A,1.97,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.23,15.00,,Hospital HCPCS J0690,CEFAZOLIN 2000 MG IN D5W 100 ML IVPB,09999-9900-46,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),43.90,43.90,26.34,26.34,N/A,6.15,N/A,43.90,N/A,24.68,N/A,14.93,N/A,7.87,N/A,6.15,N/A,43.90,N/A,43.90,N/A,4.90,N/A,7.87,N/A,7.87,N/A,7.87,N/A,24.68,N/A,43.90,N/A,6.15,N/A,23.53,N/A,23.53,N/A,6.15,N/A,43.90,N/A,43.90,N/A,43.90,26.34,26.34,4.90,43.90,,Hospital HCPCS J0690,CEFAZOLIN 3000 MG IN NS 100 ML IVPB,09999-9912-52,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),46.60,46.60,27.96,27.96,N/A,6.52,N/A,46.60,N/A,26.20,N/A,15.84,N/A,11.81,N/A,6.52,N/A,46.60,N/A,46.60,N/A,7.35,N/A,11.81,N/A,11.81,N/A,11.81,N/A,26.20,N/A,46.60,N/A,6.52,N/A,24.98,N/A,24.98,N/A,6.52,N/A,46.60,N/A,46.60,N/A,46.60,27.96,27.96,6.52,46.60,,Hospital HCPCS J0690,VANCOMYCIN 1500 MG IN NS 250 ML (PREMIX) IVPB,09999-9915-83,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),76.00,76.00,45.60,45.60,N/A,10.64,N/A,76.00,N/A,42.73,N/A,25.84,N/A,5.91,N/A,10.64,N/A,76.00,N/A,76.00,N/A,3.68,N/A,5.91,N/A,5.91,N/A,5.91,N/A,42.73,N/A,76.00,N/A,10.64,N/A,40.74,N/A,40.74,N/A,10.64,N/A,76.00,N/A,76.00,N/A,76.00,45.60,45.60,3.68,76.00,,Hospital HCPCS J0690,CEFAZOLIN SODIUM 2 G IJ SOLR,60505-6231-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.97,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.23,N/A,1.97,N/A,1.97,N/A,1.97,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.23,15.00,,Hospital HCPCS J0690,CEFAZOLIN IN SODIUM CHLORIDE 2-0.9 GM/100ML-% IV SOLN,99990-0043-19,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),43.90,43.90,26.34,26.34,N/A,6.15,N/A,43.90,N/A,24.68,N/A,14.93,N/A,7.87,N/A,6.15,N/A,43.90,N/A,43.90,N/A,4.90,N/A,7.87,N/A,7.87,N/A,7.87,N/A,24.68,N/A,43.90,N/A,6.15,N/A,23.53,N/A,23.53,N/A,6.15,N/A,43.90,N/A,43.90,N/A,43.90,26.34,26.34,4.90,43.90,,Hospital HCPCS J0690,CEFAZOLIN SODIUM 2 G SOLR (MIXTURES ONLY),60505-6231-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.97,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.23,N/A,1.97,N/A,1.97,N/A,1.97,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.23,15.00,,Hospital HCPCS J0697,CEFUROXIME SODIUM 1.5 G IV SOLR,00143-9977-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),39.50,39.50,23.70,23.70,N/A,5.53,N/A,39.50,N/A,22.21,N/A,13.43,N/A,10.57,N/A,5.53,N/A,39.50,N/A,39.50,N/A,6.58,N/A,10.57,N/A,10.57,N/A,10.57,N/A,22.21,N/A,39.50,N/A,5.53,N/A,21.17,N/A,21.17,N/A,5.53,N/A,39.50,N/A,39.50,N/A,39.50,23.70,23.70,5.53,39.50,,Hospital HCPCS J0697,CEFUROXIME 1.5 G IV SOLN (MIXTURES ONLY),00143-9977-90,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),39.50,39.50,23.70,23.70,N/A,5.53,N/A,39.50,N/A,22.21,N/A,13.43,N/A,10.57,N/A,5.53,N/A,39.50,N/A,39.50,N/A,6.58,N/A,10.57,N/A,10.57,N/A,10.57,N/A,22.21,N/A,39.50,N/A,5.53,N/A,21.17,N/A,21.17,N/A,5.53,N/A,39.50,N/A,39.50,N/A,39.50,23.70,23.70,5.53,39.50,,Hospital HCPCS J0697,CEFUROXIME SODIUM 750 MG IJ SOLR,00143-9979-90,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19.80,19.80,11.88,11.88,N/A,2.77,N/A,19.80,N/A,11.13,N/A,6.73,N/A,5.28,N/A,2.77,N/A,19.80,N/A,19.80,N/A,3.29,N/A,5.28,N/A,5.28,N/A,5.28,N/A,11.13,N/A,19.80,N/A,2.77,N/A,10.61,N/A,10.61,N/A,2.77,N/A,19.80,N/A,19.80,N/A,19.80,11.88,11.88,2.77,19.80,,Hospital J0699,"Inj, cefiderocol, 10 mg",N/A,N/A,157955.97,N/A,94773.58,N/A,8629.11,N/A,29374.64,N/A,N/A,N/A,65501.36,N/A,65501.36,N/A,8629.11,N/A,13439.50,N/A,13439.50,N/A,65501.36,N/A,65501.36,N/A,65501.36,N/A,65501.36,N/A,N/A,N/A,29374.64,N/A,8629.11,N/A,N/A,N/A,N/A,N/A,8629.11,N/A,29610.48,N/A,29374.64,N/A,8629.11,N/A,8629.11,94773.58,N/A,N/A,,Hospital HCPCS J0736,CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN,25021-0115-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0737,CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,00338-3814-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),88.10,88.10,52.86,52.86,N/A,12.33,N/A,88.10,N/A,49.53,N/A,29.95,N/A,88.10,N/A,12.33,N/A,88.10,N/A,88.10,N/A,88.10,N/A,88.10,N/A,88.10,N/A,88.10,N/A,49.53,N/A,88.10,N/A,12.33,N/A,47.22,N/A,47.22,N/A,12.33,N/A,88.10,N/A,88.10,N/A,88.10,52.86,52.86,12.33,88.10,,Hospital J0741,"Inj, cabote rilpivir 2mg 3mg",N/A,N/A,N/A,55433.20,N/A,33259.92,N/A,7809.91,N/A,4433.21,N/A,31194.19,N/A,18847.29,N/A,11051.27,N/A,7809.91,N/A,4429.33,N/A,4429.33,N/A,6879.52,N/A,11051.27,N/A,11051.27,N/A,11051.27,N/A,31194.19,N/A,4429.33,N/A,7809.91,N/A,591.92,N/A,591.92,N/A,7809.91,N/A,4429.33,N/A,4433.21,N/A,326.81,N/A,N/A,326.81,33259.92,,Hospital HCPCS J0834,COSYNTROPIN 0.25 MG IJ SOLR,00548-5900-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),719.50,719.50,431.70,431.70,N/A,100.73,N/A,719.50,N/A,404.50,N/A,244.63,N/A,69.80,N/A,100.73,N/A,719.50,N/A,719.50,N/A,43.45,N/A,69.80,N/A,69.80,N/A,69.80,N/A,404.50,N/A,719.50,N/A,100.73,N/A,385.65,N/A,385.65,N/A,100.73,N/A,719.50,N/A,719.50,N/A,719.50,431.70,431.70,43.45,719.50,,Hospital HCPCS J0875,DALBAVANCIN HCL 500 MG IV SOLR,57970-0100-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5659.90,5659.90,3395.94,3395.94,N/A,792.39,N/A,1102.73,N/A,3182.00,N/A,1924.37,N/A,2896.27,N/A,792.39,N/A,1102.73,N/A,1102.73,N/A,1802.95,N/A,2896.27,N/A,2896.27,N/A,2896.27,N/A,3182.00,N/A,1102.73,N/A,792.39,N/A,3033.71,N/A,3033.71,N/A,792.39,N/A,1102.73,N/A,5659.90,N/A,5659.90,3395.94,3395.94,792.39,5659.90,,Hospital J0877,"Inj, daptomycin (hospira)",N/A,N/A,105348.00,1577.30,63208.80,946.38,4761.58,220.82,13639.39,184.93,N/A,896.32,16441.40,536.28,16441.40,451.22,4761.58,220.82,13639.39,186.54,13639.39,186.54,16441.40,280.89,16441.40,451.22,16441.40,451.22,16441.40,451.22,N/A,896.32,13639.39,186.54,4761.58,220.82,N/A,845.44,N/A,845.44,4761.58,220.82,12616.71,186.54,13639.39,184.93,4761.58,39.24,4761.58,63208.80,39.24,946.38,,Hospital HCPCS J0883,ARGATROBAN 250 MG/2.5ML IV SOLN,00143-9674-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3375.00,3375.00,2025.00,2025.00,N/A,472.50,N/A,313.00,N/A,1897.43,N/A,1147.50,N/A,2525.25,N/A,472.50,N/A,313.00,N/A,313.00,N/A,1571.99,N/A,2525.25,N/A,2525.25,N/A,2525.25,N/A,1897.43,N/A,313.00,N/A,472.50,N/A,1809.00,N/A,1809.00,N/A,472.50,N/A,313.00,N/A,313.00,N/A,3375.00,2025.00,2025.00,313.00,3375.00,,Hospital HCPCS J0885,EPOETIN ALFA 20000 UNIT/ML IJ SOLN,55513-0478-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1492.20,1492.20,895.32,895.32,N/A,208.91,N/A,137.52,N/A,838.91,N/A,507.35,N/A,425.80,N/A,208.91,N/A,137.52,N/A,137.52,N/A,265.06,N/A,425.80,N/A,425.80,N/A,425.80,N/A,838.91,N/A,137.52,N/A,208.91,N/A,799.82,N/A,799.82,N/A,208.91,N/A,137.52,N/A,137.52,N/A,1492.20,895.32,895.32,137.52,1492.20,,Hospital HCPCS J0895,DEFEROXAMINE MESYLATE 500 MG IJ SOLR,00078-0467-91,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),229.80,229.80,137.88,137.88,N/A,32.17,N/A,229.80,N/A,129.19,N/A,78.13,N/A,26.99,N/A,32.17,N/A,229.80,N/A,229.80,N/A,16.80,N/A,26.99,N/A,26.99,N/A,26.99,N/A,129.19,N/A,229.80,N/A,32.17,N/A,123.17,N/A,123.17,N/A,32.17,N/A,229.80,N/A,229.80,N/A,229.80,137.88,137.88,16.80,229.80,,Hospital HCPCS J0896,LUSPATERCEPT-AAMT 25 MG SC SOLR,59572-0711-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),18261.70,18261.70,10957.02,10957.02,N/A,2556.64,N/A,3918.10,N/A,10266.73,N/A,6208.98,N/A,9826.46,N/A,2556.64,N/A,3918.10,N/A,3918.10,N/A,6117.07,N/A,9826.46,N/A,9826.46,N/A,9826.46,N/A,10266.73,N/A,3918.10,N/A,2556.64,N/A,9788.27,N/A,9788.27,N/A,2556.64,N/A,3918.10,N/A,3918.10,N/A,4309.91,10957.02,10957.02,2556.64,10957.02,,Hospital HCPCS J0896,LUSPATERCEPT-AAMT 75 MG SC SOLR,59572-0775-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),54785.10,54785.10,32871.06,32871.06,N/A,7669.91,N/A,11754.30,N/A,30800.18,N/A,18626.93,N/A,29479.38,N/A,7669.91,N/A,11754.30,N/A,11754.30,N/A,18351.20,N/A,29479.38,N/A,29479.38,N/A,29479.38,N/A,30800.18,N/A,11754.30,N/A,7669.91,N/A,29364.81,N/A,29364.81,N/A,7669.91,N/A,11754.30,N/A,11754.30,N/A,12929.73,32871.06,32871.06,7669.91,32871.06,,Hospital HCPCS J0897,DENOSUMAB 120 MG/1.7ML SC SOLN,55513-0730-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12227.20,12227.20,7336.32,7336.32,N/A,1711.81,N/A,2903.04,N/A,6874.13,N/A,4157.25,N/A,6918.41,N/A,1711.81,N/A,2903.04,N/A,2903.04,N/A,4306.78,N/A,6918.41,N/A,6918.41,N/A,6918.41,N/A,6874.13,N/A,2903.04,N/A,1711.81,N/A,6553.78,N/A,6553.78,N/A,1711.81,N/A,2903.04,N/A,2903.04,N/A,3193.34,7336.32,7336.32,1711.81,7336.32,,Hospital HCPCS J0897,DENOSUMAB 60 MG/ML SC SOSY,55513-0710-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6647.30,6647.30,3988.38,3988.38,N/A,930.62,N/A,1451.52,N/A,3737.11,N/A,2260.08,N/A,3459.20,N/A,930.62,N/A,1451.52,N/A,1451.52,N/A,2153.39,N/A,3459.20,N/A,3459.20,N/A,3459.20,N/A,3737.11,N/A,1451.52,N/A,930.62,N/A,3562.95,N/A,3562.95,N/A,930.62,N/A,1451.52,N/A,1451.52,N/A,1596.67,3988.38,3988.38,930.62,3988.38,,Hospital HCPCS J1000,ESTRADIOL CYPIONATE 5 MG/ML IM OIL,00009-0271-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),63.10,63.10,37.86,37.86,N/A,8.83,N/A,63.10,N/A,35.47,N/A,21.45,N/A,63.10,N/A,8.83,N/A,63.10,N/A,63.10,N/A,42.06,N/A,63.10,N/A,63.10,N/A,63.10,N/A,35.47,N/A,63.10,N/A,8.83,N/A,33.82,N/A,33.82,N/A,8.83,N/A,63.10,N/A,63.10,N/A,63.10,37.86,37.86,8.83,63.10,,Hospital HCPCS J1030,METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,00009-3073-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19.20,19.20,11.52,11.52,N/A,2.69,N/A,19.20,N/A,10.79,N/A,6.53,N/A,17.95,N/A,2.69,N/A,19.20,N/A,19.20,N/A,11.17,N/A,17.95,N/A,17.95,N/A,17.95,N/A,10.79,N/A,19.20,N/A,2.69,N/A,10.29,N/A,10.29,N/A,2.69,N/A,19.20,N/A,19.20,N/A,19.20,11.52,11.52,2.69,19.20,,Hospital HCPCS J1050,MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,00548-5400-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),303.80,303.80,182.28,182.28,N/A,42.53,N/A,303.80,N/A,170.80,N/A,103.29,N/A,221.45,N/A,42.53,N/A,303.80,N/A,303.80,N/A,137.85,N/A,221.45,N/A,221.45,N/A,221.45,N/A,170.80,N/A,303.80,N/A,42.53,N/A,162.84,N/A,162.84,N/A,42.53,N/A,303.80,N/A,303.80,N/A,303.80,182.28,182.28,42.53,303.80,,Hospital HCPCS J1071,TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,00009-0417-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),35.50,35.50,21.30,21.30,N/A,4.97,N/A,35.50,N/A,19.96,N/A,12.07,N/A,3.89,N/A,4.97,N/A,35.50,N/A,35.50,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,19.96,N/A,35.50,N/A,4.97,N/A,19.03,N/A,19.03,N/A,4.97,N/A,35.50,N/A,35.50,N/A,35.50,21.30,21.30,2.42,35.50,,Hospital HCPCS J1071,TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,00009-0417-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),35.50,35.50,21.30,21.30,N/A,4.97,N/A,35.50,N/A,19.96,N/A,12.07,N/A,3.89,N/A,4.97,N/A,35.50,N/A,35.50,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,19.96,N/A,35.50,N/A,4.97,N/A,19.03,N/A,19.03,N/A,4.97,N/A,35.50,N/A,35.50,N/A,35.50,21.30,21.30,2.42,35.50,,Hospital HCPCS J1162,DIGOXIN IMMUNE FAB 40 MG IV SOLR,50633-0120-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19899.00,19899.00,11939.40,11939.40,N/A,2785.86,N/A,19899.00,N/A,11187.22,N/A,6765.66,N/A,11119.80,N/A,2785.86,N/A,19899.00,N/A,19899.00,N/A,6922.18,N/A,11119.80,N/A,11119.80,N/A,11119.80,N/A,11187.22,N/A,19899.00,N/A,2785.86,N/A,10665.86,N/A,10665.86,N/A,2785.86,N/A,19899.00,N/A,19899.00,N/A,19899.00,11939.40,11939.40,2785.86,19899.00,,Hospital HCPCS J1165,PHENYTOIN SODIUM 50 MG/ML IJ SOLN,00641-0493-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.28,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.42,N/A,2.28,N/A,2.28,N/A,2.28,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.42,15.00,,Hospital HCPCS J1165,PHENYTOIN SODIUM 50 MG/ML IJ SOLN,00641-2555-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.28,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.42,N/A,2.28,N/A,2.28,N/A,2.28,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.42,15.00,,Hospital J1190,Dexrazoxane Hcl Injection,N/A,N/A,401195.82,13544.97,240717.49,8126.98,N/A,1668.98,N/A,441.96,N/A,7729.46,10704.00,4605.29,10704.00,2681.99,N/A,1668.98,N/A,928.68,N/A,928.68,10704.00,1669.59,10704.00,2681.99,10704.00,2681.99,10704.00,2681.99,N/A,7729.48,N/A,928.68,N/A,1668.98,N/A,2299.77,N/A,2299.77,N/A,1668.98,N/A,928.68,N/A,441.96,N/A,486.16,10704.00,240717.49,441.96,8126.98,,Hospital HCPCS J1205,CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,63323-0658-94,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),328.70,328.70,197.22,197.22,N/A,46.02,N/A,328.70,N/A,184.80,N/A,111.76,N/A,79.12,N/A,46.02,N/A,328.70,N/A,328.70,N/A,49.26,N/A,79.12,N/A,79.12,N/A,79.12,N/A,184.80,N/A,328.70,N/A,46.02,N/A,176.18,N/A,176.18,N/A,46.02,N/A,328.70,N/A,328.70,N/A,328.70,197.22,197.22,46.02,328.70,,Hospital HCPCS J1230,METHADONE HCL 10 MG/ML IJ SOLN,67457-0217-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),32.90,32.90,19.74,19.74,N/A,4.61,N/A,32.90,N/A,18.50,N/A,11.19,N/A,32.90,N/A,4.61,N/A,32.90,N/A,32.90,N/A,27.07,N/A,32.90,N/A,32.90,N/A,32.90,N/A,18.50,N/A,32.90,N/A,4.61,N/A,17.63,N/A,17.63,N/A,4.61,N/A,32.90,N/A,32.90,N/A,32.90,19.74,19.74,4.61,32.90,,Hospital HCPCS J1300,ECULIZUMAB 300 MG/30ML IV SOLN,25682-0001-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29353.50,29353.50,17612.10,17612.10,N/A,4109.49,N/A,6773.73,N/A,16502.54,N/A,9980.19,N/A,17717.15,N/A,4109.49,N/A,6773.73,N/A,6773.73,N/A,11029.10,N/A,17717.15,N/A,17717.15,N/A,17717.15,N/A,16502.54,N/A,6773.73,N/A,4109.49,N/A,15733.48,N/A,15733.48,N/A,4109.49,N/A,6773.73,N/A,6773.73,N/A,7451.10,17612.10,17612.10,4109.49,17717.15,,Hospital HCPCS J1306,INCLISIRAN SODIUM 284 MG/1.5ML SC SOSY,00078-1000-60,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21937.60,21937.60,13162.56,13162.56,N/A,3071.26,N/A,3424.76,N/A,12333.32,N/A,7458.78,N/A,8414.81,N/A,3071.26,N/A,3424.76,N/A,3424.76,N/A,5238.30,N/A,8414.81,N/A,8414.81,N/A,8414.81,N/A,12333.32,N/A,3424.76,N/A,3071.26,N/A,11758.55,N/A,11758.55,N/A,3071.26,N/A,3424.76,N/A,3424.76,N/A,21937.60,13162.56,13162.56,3071.26,21937.60,,Hospital HCPCS J1335,ERTAPENEM SODIUM 1 G IJ SOLR,60505-6196-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),790.30,790.30,474.18,474.18,N/A,110.64,N/A,790.30,N/A,444.31,N/A,268.70,N/A,89.30,N/A,110.64,N/A,790.30,N/A,790.30,N/A,55.59,N/A,89.30,N/A,89.30,N/A,89.30,N/A,444.31,N/A,790.30,N/A,110.64,N/A,423.60,N/A,423.60,N/A,110.64,N/A,790.30,N/A,790.30,N/A,790.30,474.18,474.18,55.59,790.30,,Hospital HCPCS J1364,ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,00409-6482-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),557.70,557.70,334.62,334.62,N/A,78.08,N/A,87.33,N/A,313.54,N/A,189.62,N/A,190.75,N/A,78.08,N/A,87.33,N/A,87.33,N/A,118.75,N/A,190.75,N/A,190.75,N/A,190.75,N/A,313.54,N/A,87.33,N/A,78.08,N/A,298.93,N/A,298.93,N/A,78.08,N/A,87.33,N/A,87.33,N/A,96.06,334.62,334.62,78.08,334.62,,Hospital HCPCS J1447,TBO-FILGRASTIM 480 MCG/0.8ML SC SOSY,63459-0912-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1799.60,1799.60,1079.76,1079.76,N/A,251.94,N/A,204.48,N/A,1011.74,N/A,611.86,N/A,522.14,N/A,251.94,N/A,204.48,N/A,204.48,N/A,325.04,N/A,522.14,N/A,522.14,N/A,522.14,N/A,1011.74,N/A,204.48,N/A,251.94,N/A,964.59,N/A,964.59,N/A,251.94,N/A,204.48,N/A,204.48,N/A,224.93,1079.76,1079.76,204.48,1079.76,,Hospital HCPCS J1450,FLUCONAZOLE IN SODIUM CHLORIDE 100-0.9 MG/50ML-% IV SOLN,69784-0261-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),33.80,33.80,20.28,20.28,N/A,4.73,N/A,33.80,N/A,19.00,N/A,11.49,N/A,7.46,N/A,4.73,N/A,33.80,N/A,33.80,N/A,4.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,19.00,N/A,33.80,N/A,4.73,N/A,18.12,N/A,18.12,N/A,4.73,N/A,33.80,N/A,33.80,N/A,33.80,20.28,20.28,4.64,33.80,,Hospital HCPCS J1450,FLUCONAZOLE (DIFLUCAN) IVPB,00409-4688-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),25.40,25.40,15.24,15.24,N/A,3.56,N/A,25.40,N/A,14.28,N/A,8.64,N/A,7.46,N/A,3.56,N/A,25.40,N/A,25.40,N/A,4.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,14.28,N/A,25.40,N/A,3.56,N/A,13.61,N/A,13.61,N/A,3.56,N/A,25.40,N/A,25.40,N/A,25.40,15.24,15.24,3.56,25.40,,Hospital HCPCS J1450,FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,00409-4688-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),50.70,50.70,30.42,30.42,N/A,7.10,N/A,50.70,N/A,28.50,N/A,17.24,N/A,7.46,N/A,7.10,N/A,50.70,N/A,50.70,N/A,4.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,28.50,N/A,50.70,N/A,7.10,N/A,27.18,N/A,27.18,N/A,7.10,N/A,50.70,N/A,50.70,N/A,50.70,30.42,30.42,4.64,50.70,,Hospital HCPCS J1450,FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,00409-4688-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),47.30,47.30,28.38,28.38,N/A,6.62,N/A,47.30,N/A,26.59,N/A,16.08,N/A,14.92,N/A,6.62,N/A,47.30,N/A,47.30,N/A,9.29,N/A,14.92,N/A,14.92,N/A,14.92,N/A,26.59,N/A,47.30,N/A,6.62,N/A,25.35,N/A,25.35,N/A,6.62,N/A,47.30,N/A,47.30,N/A,47.30,28.38,28.38,6.62,47.30,,Hospital HCPCS J1450,FLUCONAZOLE (DIFLUCAN) IVPB,00409-4688-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),25.40,25.40,15.24,15.24,N/A,3.56,N/A,25.40,N/A,14.28,N/A,8.64,N/A,7.46,N/A,3.56,N/A,25.40,N/A,25.40,N/A,4.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,14.28,N/A,25.40,N/A,3.56,N/A,13.61,N/A,13.61,N/A,3.56,N/A,25.40,N/A,25.40,N/A,25.40,15.24,15.24,3.56,25.40,,Hospital HCPCS J1566,IMMUNE GLOBULIN (HUMAN) 10%,13533-0800-71,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6003.00,6003.00,3601.80,3601.80,N/A,840.42,N/A,1012.80,N/A,3374.89,N/A,2041.02,N/A,2247.60,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1399.15,N/A,2247.60,N/A,2247.60,N/A,2247.60,N/A,3374.89,N/A,1012.80,N/A,840.42,N/A,3217.61,N/A,3217.61,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1114.08,3601.80,3601.80,840.42,3601.80,,Hospital J1568,Octagam Injection,N/A,N/A,N/A,22600.00,N/A,13560.00,N/A,3164.00,N/A,2032.87,N/A,12719.97,N/A,7684.00,N/A,4951.86,N/A,3164.00,N/A,2012.19,N/A,2012.19,N/A,3082.58,N/A,4951.86,N/A,4951.86,N/A,4951.86,N/A,12719.98,N/A,2012.19,N/A,3164.00,N/A,12113.60,N/A,12113.61,N/A,3164.00,N/A,2012.19,N/A,2032.87,N/A,97.50,N/A,N/A,97.50,13560.00,,Hospital HCPCS J1569,IMMUNE GLOBULIN (GAMMAGARD) 10%,00944-2700-07,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6985.80,6985.80,4191.48,4191.48,N/A,978.01,N/A,920.62,N/A,3927.42,N/A,2375.17,N/A,2331.00,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1451.07,N/A,2331.00,N/A,2331.00,N/A,2331.00,N/A,3927.42,N/A,920.62,N/A,978.01,N/A,3744.39,N/A,3744.39,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1012.68,4191.48,4191.48,920.62,4191.48,,Hospital HCPCS J1569,IMMUNE GLOBULIN (GAMMAGARD) 10%,00944-2700-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6985.80,6985.80,4191.48,4191.48,N/A,978.01,N/A,920.62,N/A,3927.42,N/A,2375.17,N/A,2331.00,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1451.07,N/A,2331.00,N/A,2331.00,N/A,2331.00,N/A,3927.42,N/A,920.62,N/A,978.01,N/A,3744.39,N/A,3744.39,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1012.68,4191.48,4191.48,920.62,4191.48,,Hospital HCPCS J1569,IMMUNE GLOBULIN (HUMAN) 30 GM/300ML IJ SOLN,00944-2700-07,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20957.40,20957.40,12574.44,12574.44,N/A,2934.04,N/A,2761.86,N/A,11782.25,N/A,7125.52,N/A,6993.00,N/A,2934.04,N/A,2761.86,N/A,2761.86,N/A,4353.21,N/A,6993.00,N/A,6993.00,N/A,6993.00,N/A,11782.25,N/A,2761.86,N/A,2934.04,N/A,11233.17,N/A,11233.17,N/A,2934.04,N/A,2761.86,N/A,2761.86,N/A,3038.05,12574.44,12574.44,2761.86,12574.44,,Hospital HCPCS J1569,IMMUNE GLOBULIN (GAMMAGARD) 10%,00944-2700-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6985.80,6985.80,4191.48,4191.48,N/A,978.01,N/A,920.62,N/A,3927.42,N/A,2375.17,N/A,2331.00,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1451.07,N/A,2331.00,N/A,2331.00,N/A,2331.00,N/A,3927.42,N/A,920.62,N/A,978.01,N/A,3744.39,N/A,3744.39,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1012.68,4191.48,4191.48,920.62,4191.48,,Hospital HCPCS J1569,IMMUNE GLOBULIN (HUMAN) 2.5 GM/25ML IJ SOLN,00944-2700-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2619.70,2619.70,1571.82,1571.82,N/A,366.76,N/A,230.16,N/A,1472.80,N/A,890.70,N/A,582.75,N/A,366.76,N/A,230.16,N/A,230.16,N/A,362.77,N/A,582.75,N/A,582.75,N/A,582.75,N/A,1472.80,N/A,230.16,N/A,366.76,N/A,1404.16,N/A,1404.16,N/A,366.76,N/A,230.16,N/A,230.16,N/A,253.17,1571.82,1571.82,230.16,1571.82,,Hospital HCPCS J1569,IMMUNE GLOBULIN (GAMMAGARD) 10%,00944-2700-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6985.80,6985.80,4191.48,4191.48,N/A,978.01,N/A,920.62,N/A,3927.42,N/A,2375.17,N/A,2331.00,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1451.07,N/A,2331.00,N/A,2331.00,N/A,2331.00,N/A,3927.42,N/A,920.62,N/A,978.01,N/A,3744.39,N/A,3744.39,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1012.68,4191.48,4191.48,920.62,4191.48,,Hospital HCPCS J1569,IMMUNE GLOBULIN (GAMMAGARD) 10%,13533-0800-40,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6985.80,6985.80,4191.48,4191.48,N/A,978.01,N/A,920.62,N/A,3927.42,N/A,2375.17,N/A,2331.00,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1451.07,N/A,2331.00,N/A,2331.00,N/A,2331.00,N/A,3927.42,N/A,920.62,N/A,978.01,N/A,3744.39,N/A,3744.39,N/A,978.01,N/A,920.62,N/A,920.62,N/A,1012.68,4191.48,4191.48,920.62,4191.48,,Hospital HCPCS J1569,IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN,13533-0800-71,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6003.00,6003.00,3601.80,3601.80,N/A,840.42,N/A,1012.80,N/A,3374.89,N/A,2041.02,N/A,2247.60,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1399.15,N/A,2247.60,N/A,2247.60,N/A,2247.60,N/A,3374.89,N/A,1012.80,N/A,840.42,N/A,3217.61,N/A,3217.61,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1114.08,3601.80,3601.80,840.42,3601.80,,Hospital J1572,Flebogamma Injection,N/A,N/A,152370.40,49233.30,91422.24,29539.98,12291.45,6864.39,13671.93,8131.48,36745.25,27698.16,23180.70,16739.31,23180.70,15331.48,12291.45,6864.39,13671.93,8119.36,13671.93,8119.36,23180.70,9544.00,23180.70,15331.48,23180.70,15331.48,23180.70,15331.48,36745.25,27278.14,13671.93,8119.36,12291.45,6864.39,36745.25,390.51,36745.25,390.51,12291.45,6864.39,13671.93,8119.36,13671.93,8131.48,12291.45,178.25,12291.45,91422.24,178.25,29539.98,,Hospital HCPCS J1602,GOLIMUMAB 50 MG/4ML IV SOLN,57894-0350-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),8996.40,8996.40,5397.84,5397.84,N/A,1259.50,N/A,664.35,N/A,5057.78,N/A,3058.78,N/A,1902.36,N/A,1259.50,N/A,664.35,N/A,664.35,N/A,1184.23,N/A,1902.36,N/A,1902.36,N/A,1902.36,N/A,5057.78,N/A,664.35,N/A,1259.50,N/A,4822.07,N/A,4822.07,N/A,1259.50,N/A,664.35,N/A,664.35,N/A,730.79,5397.84,5397.84,664.35,5397.84,,Hospital J1630,HC Haloperidol Injection,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21543.80,28771.97,12926.28,17263.18,9864.30,4028.08,5821.77,489.59,14595.00,16554.95,7324.90,9766.91,9528.00,5678.61,9864.30,4028.08,5821.77,2320.33,5821.77,2320.33,5934.00,3535.04,9528.00,5678.61,9528.00,5678.61,9528.00,5678.61,10218.12,16554.97,5821.77,2320.33,10061.64,4028.08,21543.80,3397.00,21543.80,3397.00,3912.30,4028.08,9294.00,2320.33,5821.77,489.59,10061.58,538.55,3912.30,21543.80,489.59,17263.18,,Hospital HCPCS J1644,HEPARIN (PORCINE) IN NACL 2000-0.9 UNIT/L-% IV SOLN,00338-0433-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),47.30,47.30,28.38,28.38,N/A,6.62,N/A,47.30,N/A,26.59,N/A,16.08,N/A,1.24,N/A,6.62,N/A,47.30,N/A,47.30,N/A,N/A,N/A,1.24,N/A,1.24,N/A,1.24,N/A,26.59,N/A,47.30,N/A,6.62,N/A,25.35,N/A,25.35,N/A,6.62,N/A,47.30,N/A,47.30,N/A,47.30,28.38,28.38,1.24,47.30,,Hospital HCPCS J1644,HEPARIN (PORCINE) IN NACL 1000-0.9 UT/500ML-% IV SOLN,00409-7620-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),37.20,37.20,22.32,22.32,N/A,5.21,N/A,37.20,N/A,20.91,N/A,12.65,N/A,N/A,N/A,5.21,N/A,37.20,N/A,37.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20.91,N/A,37.20,N/A,5.21,N/A,19.94,N/A,19.94,N/A,5.21,N/A,37.20,N/A,37.20,N/A,37.20,22.32,22.32,5.21,37.20,,Hospital HCPCS J1644,HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN,63323-0542-09,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),25.80,25.80,15.48,15.48,N/A,3.61,N/A,25.80,N/A,14.50,N/A,8.77,N/A,3.11,N/A,3.61,N/A,25.80,N/A,25.80,N/A,1.93,N/A,3.11,N/A,3.11,N/A,3.11,N/A,14.50,N/A,25.80,N/A,3.61,N/A,13.83,N/A,13.83,N/A,3.61,N/A,25.80,N/A,25.80,N/A,25.80,15.48,15.48,1.93,25.80,,Hospital HCPCS J1644,HEPARIN SODIUM (PORCINE) PF 5000 UNIT/0.5ML IJ SOLN,63323-0543-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),38.30,38.30,22.98,22.98,N/A,5.36,N/A,38.30,N/A,21.53,N/A,13.02,N/A,3.11,N/A,5.36,N/A,38.30,N/A,38.30,N/A,1.93,N/A,3.11,N/A,3.11,N/A,3.11,N/A,21.53,N/A,38.30,N/A,5.36,N/A,20.53,N/A,20.53,N/A,5.36,N/A,38.30,N/A,38.30,N/A,38.30,22.98,22.98,1.93,38.30,,Hospital HCPCS J1644,HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,00264-9587-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),94.50,94.50,56.70,56.70,N/A,13.23,N/A,94.50,N/A,53.13,N/A,32.13,N/A,15.54,N/A,13.23,N/A,94.50,N/A,94.50,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,53.13,N/A,94.50,N/A,13.23,N/A,50.65,N/A,50.65,N/A,13.23,N/A,94.50,N/A,94.50,N/A,94.50,56.70,56.70,9.67,94.50,,Hospital HCPCS J1644,HEPARIN (PORCINE) IN D5W 100-5 UNIT/ML-% IV SOLN RATE BASED DOSING,61553-0419-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),94.50,94.50,56.70,56.70,N/A,13.23,N/A,94.50,N/A,53.13,N/A,32.13,N/A,15.54,N/A,13.23,N/A,94.50,N/A,94.50,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,53.13,N/A,94.50,N/A,13.23,N/A,50.65,N/A,50.65,N/A,13.23,N/A,94.50,N/A,94.50,N/A,94.50,56.70,56.70,9.67,94.50,,Hospital HCPCS J1644,"HEPARIN 25,000 UNITS IN 250 ML 0.9% SODIUM CHLORIDE (PREMIX)",09999-9915-84,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),65.90,65.90,39.54,39.54,N/A,9.23,N/A,65.90,N/A,37.05,N/A,22.41,N/A,15.54,N/A,9.23,N/A,65.90,N/A,65.90,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,37.05,N/A,65.90,N/A,9.23,N/A,35.32,N/A,35.32,N/A,9.23,N/A,65.90,N/A,65.90,N/A,65.90,39.54,39.54,9.23,65.90,,Hospital HCPCS J1652,FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,55111-0681-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),373.30,373.30,223.98,223.98,N/A,52.26,N/A,373.30,N/A,209.87,N/A,126.92,N/A,60.09,N/A,52.26,N/A,373.30,N/A,373.30,N/A,37.41,N/A,60.09,N/A,60.09,N/A,60.09,N/A,209.87,N/A,373.30,N/A,52.26,N/A,200.09,N/A,200.09,N/A,52.26,N/A,373.30,N/A,373.30,N/A,373.30,223.98,223.98,37.41,373.30,,Hospital HCPCS J1652,FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,67457-0582-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),167.80,167.80,100.68,100.68,N/A,23.49,N/A,167.80,N/A,94.34,N/A,57.05,N/A,15.02,N/A,23.49,N/A,167.80,N/A,167.80,N/A,9.35,N/A,15.02,N/A,15.02,N/A,15.02,N/A,94.34,N/A,167.80,N/A,23.49,N/A,89.94,N/A,89.94,N/A,23.49,N/A,167.80,N/A,167.80,N/A,167.80,100.68,100.68,9.35,167.80,,Hospital HCPCS J1742,IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,67457-0366-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2013.60,2013.60,1208.16,1208.16,N/A,281.90,N/A,271.86,N/A,1132.05,N/A,684.62,N/A,772.60,N/A,281.90,N/A,271.86,N/A,271.86,N/A,480.95,N/A,772.60,N/A,772.60,N/A,772.60,N/A,1132.05,N/A,271.86,N/A,281.90,N/A,1079.29,N/A,1079.29,N/A,281.90,N/A,271.86,N/A,271.86,N/A,2013.60,1208.16,1208.16,271.86,2013.60,,Hospital HCPCS J1817,INSULIN LISPRO 100 UNIT/ML IJ SOLN,00002-7510-17,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),226.70,226.70,136.02,136.02,N/A,31.74,N/A,226.70,N/A,127.45,N/A,77.08,N/A,129.14,N/A,31.74,N/A,226.70,N/A,226.70,N/A,80.39,N/A,129.14,N/A,129.14,N/A,129.14,N/A,127.45,N/A,226.70,N/A,31.74,N/A,121.51,N/A,121.51,N/A,31.74,N/A,226.70,N/A,226.70,N/A,226.70,136.02,136.02,31.74,226.70,,Hospital HCPCS J1817,INSULIN LISPRO 100 UNIT/ML IJ SOLN,00002-7510-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),755.50,755.50,453.30,453.30,N/A,105.77,N/A,755.50,N/A,424.74,N/A,256.87,N/A,430.46,N/A,105.77,N/A,755.50,N/A,755.50,N/A,267.96,N/A,430.46,N/A,430.46,N/A,430.46,N/A,424.74,N/A,755.50,N/A,105.77,N/A,404.95,N/A,404.95,N/A,105.77,N/A,755.50,N/A,755.50,N/A,755.50,453.30,453.30,105.77,755.50,,Hospital HCPCS J1920,LABETALOL HCL 20 MG/4ML IV SOSY,69374-0946-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1950,LEUPROLIDE ACETATE 3.75 MG IM KIT,00074-3641-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7779.40,7779.40,4667.64,4667.64,N/A,1089.12,N/A,1543.52,N/A,4373.58,N/A,2645.00,N/A,3873.01,N/A,1089.12,N/A,1543.52,N/A,1543.52,N/A,2410.99,N/A,3873.01,N/A,3873.01,N/A,3873.01,N/A,4373.58,N/A,1543.52,N/A,1089.12,N/A,4169.76,N/A,4169.76,N/A,1089.12,N/A,1543.52,N/A,1543.52,N/A,7779.40,4667.64,4667.64,1089.12,7779.40,,Hospital HCPCS J1953,LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,67457-0266-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),192.40,192.40,115.44,115.44,N/A,26.94,N/A,192.40,N/A,108.17,N/A,65.42,N/A,34.97,N/A,26.94,N/A,192.40,N/A,192.40,N/A,21.77,N/A,34.97,N/A,34.97,N/A,34.97,N/A,108.17,N/A,192.40,N/A,26.94,N/A,103.13,N/A,103.13,N/A,26.94,N/A,192.40,N/A,192.40,N/A,192.40,115.44,115.44,21.77,192.40,,Hospital HCPCS J1953,LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,67457-0265-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),72.60,72.60,43.56,43.56,N/A,10.16,N/A,72.60,N/A,40.82,N/A,24.68,N/A,11.66,N/A,10.16,N/A,72.60,N/A,72.60,N/A,7.26,N/A,11.66,N/A,11.66,N/A,11.66,N/A,40.82,N/A,72.60,N/A,10.16,N/A,38.91,N/A,38.91,N/A,10.16,N/A,72.60,N/A,72.60,N/A,72.60,43.56,43.56,7.26,72.60,,Hospital HCPCS J1953,LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN,67457-0255-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),94.50,94.50,56.70,56.70,N/A,13.23,N/A,94.50,N/A,53.13,N/A,32.13,N/A,11.66,N/A,13.23,N/A,94.50,N/A,94.50,N/A,7.26,N/A,11.66,N/A,11.66,N/A,11.66,N/A,53.13,N/A,94.50,N/A,13.23,N/A,50.65,N/A,50.65,N/A,13.23,N/A,94.50,N/A,94.50,N/A,94.50,56.70,56.70,7.26,94.50,,Hospital HCPCS J1955,LEVOCARNITINE 200 MG/ML IV SOLN,54482-0147-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),229.90,229.90,137.94,137.94,N/A,32.19,N/A,229.90,N/A,129.25,N/A,78.17,N/A,65.73,N/A,32.19,N/A,229.90,N/A,229.90,N/A,40.92,N/A,65.73,N/A,65.73,N/A,65.73,N/A,129.25,N/A,229.90,N/A,32.19,N/A,123.23,N/A,123.23,N/A,32.19,N/A,229.90,N/A,229.90,N/A,229.90,137.94,137.94,32.19,229.90,,Hospital HCPCS J2150,MANNITOL 25 % IV SOLN,63323-0024-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.40,16.40,9.84,9.84,N/A,2.30,N/A,16.40,N/A,9.22,N/A,5.58,N/A,6.73,N/A,2.30,N/A,16.40,N/A,16.40,N/A,4.19,N/A,6.73,N/A,6.73,N/A,6.73,N/A,9.22,N/A,16.40,N/A,2.30,N/A,8.79,N/A,8.79,N/A,2.30,N/A,16.40,N/A,16.40,N/A,16.40,9.84,9.84,2.30,16.40,,Hospital HCPCS J2175,MEPERIDINE HCL 100 MG/ML IJ SOLN,00409-1180-69,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21.60,21.60,12.96,12.96,N/A,3.02,N/A,21.60,N/A,12.14,N/A,7.34,N/A,15.82,N/A,3.02,N/A,21.60,N/A,21.60,N/A,9.85,N/A,15.82,N/A,15.82,N/A,15.82,N/A,12.14,N/A,21.60,N/A,3.02,N/A,11.58,N/A,11.58,N/A,3.02,N/A,21.60,N/A,21.60,N/A,21.60,12.96,12.96,3.02,21.60,,Hospital HCPCS J2175,MEPERIDINE HCL 75 MG/ML IJ SOLN,00409-1179-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29.00,29.00,17.40,17.40,N/A,4.06,N/A,29.00,N/A,16.30,N/A,9.86,N/A,15.82,N/A,4.06,N/A,29.00,N/A,29.00,N/A,9.85,N/A,15.82,N/A,15.82,N/A,15.82,N/A,16.30,N/A,29.00,N/A,4.06,N/A,15.54,N/A,15.54,N/A,4.06,N/A,29.00,N/A,29.00,N/A,29.00,17.40,17.40,4.06,29.00,,Hospital HCPCS J2175,MEPERIDINE HCL 50 MG/ML IJ SOLN,00409-1178-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21.10,21.10,12.66,12.66,N/A,2.95,N/A,21.10,N/A,11.86,N/A,7.17,N/A,15.82,N/A,2.95,N/A,21.10,N/A,21.10,N/A,9.85,N/A,15.82,N/A,15.82,N/A,15.82,N/A,11.86,N/A,21.10,N/A,2.95,N/A,11.31,N/A,11.31,N/A,2.95,N/A,21.10,N/A,21.10,N/A,21.10,12.66,12.66,2.95,21.10,,Hospital HCPCS J2175,MEPERIDINE HCL 25 MG/ML IJ SOLN,00409-1176-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20.40,20.40,12.24,12.24,N/A,2.86,N/A,20.40,N/A,11.47,N/A,6.94,N/A,15.82,N/A,2.86,N/A,20.40,N/A,20.40,N/A,9.85,N/A,15.82,N/A,15.82,N/A,15.82,N/A,11.47,N/A,20.40,N/A,2.86,N/A,10.93,N/A,10.93,N/A,2.86,N/A,20.40,N/A,20.40,N/A,20.40,12.24,12.24,2.86,20.40,,Hospital J2182,"HC Injection, Mepolizumab, 1mg",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,23982.80,N/A,14389.68,N/A,3357.59,N/A,3036.29,N/A,13485.38,N/A,8154.15,N/A,7686.86,N/A,3357.59,N/A,3035.63,N/A,3035.63,N/A,4785.15,N/A,7686.86,N/A,7686.86,N/A,7686.86,N/A,13485.38,N/A,3035.63,N/A,3357.59,N/A,12854.78,N/A,12854.78,N/A,3357.59,N/A,3035.63,N/A,3036.29,N/A,14.73,N/A,N/A,14.73,14389.68,,Hospital HCPCS J2184,MEROPENEM-SODIUM CHLORIDE 1 GM/50ML IV SOLR,00264-3185-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),167.60,167.60,100.56,100.56,N/A,23.46,N/A,167.60,N/A,94.22,N/A,56.98,N/A,167.60,N/A,23.46,N/A,167.60,N/A,167.60,N/A,167.60,N/A,167.60,N/A,167.60,N/A,167.60,N/A,94.22,N/A,167.60,N/A,23.46,N/A,89.83,N/A,89.83,N/A,23.46,N/A,167.60,N/A,167.60,N/A,167.60,100.56,100.56,23.46,167.60,,Hospital HCPCS J2184,MEROPENEM-SODIUM CHLORIDE 500 MG/50ML IV SOLR,00264-3183-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),119.80,119.80,71.88,71.88,N/A,16.77,N/A,119.80,N/A,67.35,N/A,40.73,N/A,119.80,N/A,16.77,N/A,119.80,N/A,119.80,N/A,119.80,N/A,119.80,N/A,119.80,N/A,119.80,N/A,67.35,N/A,119.80,N/A,16.77,N/A,64.21,N/A,64.21,N/A,16.77,N/A,119.80,N/A,119.80,N/A,119.80,71.88,71.88,16.77,119.80,,Hospital HCPCS J2186,MEROPENEM-VABORBACTAM 2 (1-1) G IV SOLR,70842-0120-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1388.30,1388.30,832.98,832.98,N/A,194.36,N/A,1388.30,N/A,780.50,N/A,472.02,N/A,533.54,N/A,194.36,N/A,1388.30,N/A,1388.30,N/A,332.13,N/A,533.54,N/A,533.54,N/A,533.54,N/A,780.50,N/A,1388.30,N/A,194.36,N/A,744.13,N/A,744.13,N/A,194.36,N/A,1388.30,N/A,1388.30,N/A,1388.30,832.98,832.98,194.36,1388.30,,Hospital J2280,"Inj, Moxifloxacin 100 Mg",N/A,N/A,203667.63,N/A,122200.58,N/A,14939.99,N/A,14168.56,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14939.99,N/A,14168.56,N/A,14168.56,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14168.56,N/A,14939.99,N/A,N/A,N/A,N/A,N/A,14939.99,N/A,14168.56,N/A,14168.56,N/A,14939.99,N/A,14168.56,122200.58,N/A,N/A,,Hospital HCPCS J2300,NALBUPHINE HCL 10 MG/ML IJ SOLN,00409-1463-71,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,7.20,N/A,2.10,N/A,15.00,N/A,15.00,N/A,4.48,N/A,7.20,N/A,7.20,N/A,7.20,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2310,NALOXONE HCL 2 MG/2ML IJ SOSY,76329-3369-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),44.60,44.60,26.76,26.76,N/A,6.24,N/A,44.60,N/A,25.07,N/A,15.16,N/A,24.84,N/A,6.24,N/A,44.60,N/A,44.60,N/A,15.46,N/A,24.84,N/A,24.84,N/A,24.84,N/A,25.07,N/A,44.60,N/A,6.24,N/A,23.91,N/A,23.91,N/A,6.24,N/A,44.60,N/A,44.60,N/A,44.60,26.76,26.76,6.24,44.60,,Hospital HCPCS J2310,NALOXONE HCL 4 MG/10ML IJ SOLN,00409-1219-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20.10,20.10,12.06,12.06,N/A,2.81,N/A,20.10,N/A,11.30,N/A,6.83,N/A,20.10,N/A,2.81,N/A,20.10,N/A,20.10,N/A,15.46,N/A,20.10,N/A,20.10,N/A,20.10,N/A,11.30,N/A,20.10,N/A,2.81,N/A,10.77,N/A,10.77,N/A,2.81,N/A,20.10,N/A,20.10,N/A,20.10,12.06,12.06,2.81,20.10,,Hospital HCPCS J2310,NALOXONE HCL 0.4 MG/ML IJ SOLN,00409-1215-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),26.80,26.80,16.08,16.08,N/A,3.75,N/A,26.80,N/A,15.07,N/A,9.11,N/A,24.84,N/A,3.75,N/A,26.80,N/A,26.80,N/A,15.46,N/A,24.84,N/A,24.84,N/A,24.84,N/A,15.07,N/A,26.80,N/A,3.75,N/A,14.36,N/A,14.36,N/A,3.75,N/A,26.80,N/A,26.80,N/A,26.80,16.08,16.08,3.75,26.80,,Hospital J2327,Inj risankizumab-rzaa 1 mg,N/A,N/A,N/A,47487.50,N/A,28492.50,N/A,6662.15,N/A,9511.33,N/A,26722.03,N/A,16145.75,N/A,9903.81,N/A,6662.15,N/A,9511.33,N/A,9511.33,N/A,9728.43,N/A,9903.81,N/A,9903.81,N/A,9903.81,N/A,26722.03,N/A,9511.33,N/A,6662.15,N/A,728.13,N/A,728.13,N/A,6662.15,N/A,9511.33,N/A,9511.33,N/A,10462.47,N/A,N/A,728.13,28492.50,,Hospital J2329,"Injection, Ublituximab-Xiiy, 1 Mg",N/A,N/A,N/A,45089.70,N/A,27053.82,N/A,6312.56,N/A,10702.96,N/A,25380.02,N/A,15330.50,N/A,1372.01,N/A,6312.56,N/A,10688.00,N/A,10688.00,N/A,854.10,N/A,1372.01,N/A,1372.01,N/A,1372.01,N/A,25380.02,N/A,10688.00,N/A,6312.56,N/A,24168.09,N/A,24168.09,N/A,6312.56,N/A,10688.00,N/A,10702.96,N/A,255.35,N/A,N/A,255.35,27053.82,,Hospital HCPCS J2350,OCRELIZUMAB 300 MG/10ML IV SOLN,50242-0150-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),80085.60,80085.60,48051.36,48051.36,N/A,11211.98,N/A,18425.10,N/A,45024.12,N/A,27229.10,N/A,47000.73,N/A,11211.98,N/A,18425.10,N/A,18425.10,N/A,29258.41,N/A,47000.73,N/A,47000.73,N/A,47000.73,N/A,45024.12,N/A,18425.10,N/A,11211.98,N/A,42925.88,N/A,42925.88,N/A,11211.98,N/A,18425.10,N/A,18425.10,N/A,20267.61,48051.36,48051.36,11211.98,48051.36,,Hospital HCPCS J2353,OCTREOTIDE ACETATE 20 MG IM KIT,00078-0818-81,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21323.70,21323.70,12794.22,12794.22,N/A,2985.32,N/A,4162.34,N/A,11988.18,N/A,7250.06,N/A,10749.02,N/A,2985.32,N/A,4162.34,N/A,4162.34,N/A,6691.37,N/A,10749.02,N/A,10749.02,N/A,10749.02,N/A,11988.18,N/A,4162.34,N/A,2985.32,N/A,11429.50,N/A,11429.50,N/A,2985.32,N/A,4162.34,N/A,4162.34,N/A,4578.57,12794.22,12794.22,2985.32,12794.22,,Hospital HCPCS J2353,OCTREOTIDE ACETATE 30 MG IM KIT,00078-0825-81,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),31930.70,31930.70,19158.42,19158.42,N/A,4470.30,N/A,6243.51,N/A,17951.44,N/A,10856.44,N/A,16123.53,N/A,4470.30,N/A,6243.51,N/A,6243.51,N/A,10037.05,N/A,16123.53,N/A,16123.53,N/A,16123.53,N/A,17951.44,N/A,6243.51,N/A,4470.30,N/A,17114.86,N/A,17114.86,N/A,4470.30,N/A,6243.51,N/A,6243.51,N/A,6867.86,19158.42,19158.42,4470.30,19158.42,,Hospital HCPCS J2353,OCTREOTIDE ACETATE 10 MG IM KIT,00078-0811-81,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16275.50,16275.50,9765.30,9765.30,N/A,2278.57,N/A,2081.17,N/A,9150.09,N/A,5533.67,N/A,5374.51,N/A,2278.57,N/A,2081.17,N/A,2081.17,N/A,3345.68,N/A,5374.51,N/A,5374.51,N/A,5374.51,N/A,9150.09,N/A,2081.17,N/A,2278.57,N/A,8723.67,N/A,8723.67,N/A,2278.57,N/A,2081.17,N/A,2081.17,N/A,2289.29,9765.30,9765.30,2081.17,9765.30,,Hospital HCPCS J2354,OCTREOTIDE ACETATE 500 MCG/ML SC SOSY,67457-0246-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),45.30,45.30,27.18,27.18,N/A,6.34,N/A,45.30,N/A,25.47,N/A,15.40,N/A,8.50,N/A,6.34,N/A,45.30,N/A,45.30,N/A,5.29,N/A,8.50,N/A,8.50,N/A,8.50,N/A,25.47,N/A,45.30,N/A,6.34,N/A,24.28,N/A,24.28,N/A,6.34,N/A,45.30,N/A,45.30,N/A,45.30,27.18,27.18,5.29,45.30,,Hospital HCPCS J2354,OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,63323-0377-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,8.50,N/A,21.00,N/A,150.00,N/A,150.00,N/A,5.29,N/A,8.50,N/A,8.50,N/A,8.50,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,5.29,150.00,,Hospital HCPCS J2354,OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,00641-6175-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,4.25,N/A,21.00,N/A,150.00,N/A,150.00,N/A,2.64,N/A,4.25,N/A,4.25,N/A,4.25,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,2.64,150.00,,Hospital HCPCS J2357,OMALIZUMAB 150 MG/ML SC SOSY,50242-0215-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5495.20,5495.20,3297.12,3297.12,N/A,769.33,N/A,1181.49,N/A,3089.40,N/A,1868.37,N/A,2961.92,N/A,769.33,N/A,1181.49,N/A,1181.49,N/A,1843.83,N/A,2961.92,N/A,2961.92,N/A,2961.92,N/A,3089.40,N/A,1181.49,N/A,769.33,N/A,2945.43,N/A,2945.43,N/A,769.33,N/A,1181.49,N/A,1181.49,N/A,1299.64,3297.12,3297.12,769.33,3297.12,,Hospital J2358,Olanzapine long-acting inj,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital J2360,Orphenadrine Injection,N/A,N/A,44115.80,17992.70,26469.48,10795.62,4754.21,2543.22,16400.54,605.68,30737.85,10356.55,14999.37,6117.55,16682.31,3200.91,14059.82,2543.22,16400.54,1295.43,16400.54,1295.43,19894.46,1992.64,31957.44,3200.91,31957.44,3200.91,16682.31,3200.91,30737.85,10356.55,16400.54,1295.43,14059.82,2543.22,36920.19,2586.50,36920.19,2586.50,4754.21,2543.22,16400.54,1295.43,12882.39,605.68,15044.00,666.28,4754.21,36920.19,605.68,10795.62,,Hospital HCPCS J2540,PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV SOLN,00338-1025-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),72.60,72.60,43.56,43.56,N/A,10.16,N/A,72.60,N/A,40.82,N/A,24.68,N/A,8.94,N/A,10.16,N/A,72.60,N/A,72.60,N/A,5.56,N/A,8.94,N/A,8.94,N/A,8.94,N/A,40.82,N/A,72.60,N/A,10.16,N/A,38.91,N/A,38.91,N/A,10.16,N/A,72.60,N/A,72.60,N/A,72.60,43.56,43.56,5.56,72.60,,Hospital HCPCS J2540,PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR,00049-0530-28,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),343.50,343.50,206.10,206.10,N/A,48.09,N/A,343.50,N/A,193.12,N/A,116.79,N/A,60.76,N/A,48.09,N/A,343.50,N/A,343.50,N/A,37.82,N/A,60.76,N/A,60.76,N/A,60.76,N/A,193.12,N/A,343.50,N/A,48.09,N/A,184.12,N/A,184.12,N/A,48.09,N/A,343.50,N/A,343.50,N/A,343.50,206.10,206.10,37.82,343.50,,Hospital HCPCS J2540,PENICILLIN G POTASSIUM IN D5W 2500000 UNIT/100 ML IV SOLN,09999-9902-40,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),202.50,202.50,121.50,121.50,N/A,28.35,N/A,202.50,N/A,113.85,N/A,68.85,N/A,8.94,N/A,28.35,N/A,202.50,N/A,202.50,N/A,5.56,N/A,8.94,N/A,8.94,N/A,8.94,N/A,113.85,N/A,202.50,N/A,28.35,N/A,108.54,N/A,108.54,N/A,28.35,N/A,202.50,N/A,202.50,N/A,202.50,121.50,121.50,5.56,202.50,,Hospital HCPCS J2540,PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,00049-0520-84,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),85.90,85.90,51.54,51.54,N/A,12.03,N/A,85.90,N/A,48.29,N/A,29.21,N/A,16.08,N/A,12.03,N/A,85.90,N/A,85.90,N/A,10.01,N/A,16.08,N/A,16.08,N/A,16.08,N/A,48.29,N/A,85.90,N/A,12.03,N/A,46.04,N/A,46.04,N/A,12.03,N/A,85.90,N/A,85.90,N/A,85.90,51.54,51.54,10.01,85.90,,Hospital HCPCS J2540,PENICILLIN G POTASSIUM IN NS 2500000 UNIT/100 ML IVPB,09999-9912-43,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),202.50,202.50,121.50,121.50,N/A,28.35,N/A,202.50,N/A,113.85,N/A,68.85,N/A,8.94,N/A,28.35,N/A,202.50,N/A,202.50,N/A,5.56,N/A,8.94,N/A,8.94,N/A,8.94,N/A,113.85,N/A,202.50,N/A,28.35,N/A,108.54,N/A,108.54,N/A,28.35,N/A,202.50,N/A,202.50,N/A,202.50,121.50,121.50,5.56,202.50,,Hospital HCPCS J2710,NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN,43598-0529-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.38,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.48,N/A,2.38,N/A,2.38,N/A,2.38,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.48,15.00,,Hospital HCPCS J2710,NEOSTIGMINE METHYLSULFATE 3 MG/3ML IV SOSY,69374-0932-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21.10,21.10,12.66,12.66,N/A,2.95,N/A,21.10,N/A,11.86,N/A,7.17,N/A,2.38,N/A,2.95,N/A,21.10,N/A,21.10,N/A,1.48,N/A,2.38,N/A,2.38,N/A,2.38,N/A,11.86,N/A,21.10,N/A,2.95,N/A,11.31,N/A,11.31,N/A,2.95,N/A,21.10,N/A,21.10,N/A,21.10,12.66,12.66,1.48,21.10,,Hospital HCPCS J2710,NEOSTIGMINE METHYLSULFATE 5 MG/5ML IV SOSY,69374-0902-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.38,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.48,N/A,2.38,N/A,2.38,N/A,2.38,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.48,15.00,,Hospital HCPCS J2720,PROTAMINE SULFATE 10 MG/ML IV SOLN,63323-0229-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,4.69,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.92,N/A,4.69,N/A,4.69,N/A,4.69,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J2791,Rhophylac Injection,N/A,N/A,17478.00,1140.70,10486.80,684.42,3368.28,159.70,4250.13,62.56,7590.69,647.33,5942.52,387.84,4696.00,334.24,3472.06,159.70,4250.13,60.93,4250.13,60.93,2923.00,208.07,4696.00,334.24,4696.00,334.24,4696.00,334.24,7590.69,647.33,4250.13,60.93,3472.06,159.70,9117.42,611.42,9117.42,611.42,3339.36,159.70,4250.13,60.93,4250.13,62.56,3715.11,14.73,2923.00,10486.80,14.73,684.42,,Hospital HCPCS J2794,RISPERIDONE MICROSPHERES ER 12.5 MG IM SRER,50458-0309-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1257.90,1257.90,754.74,754.74,N/A,176.11,N/A,300.58,N/A,707.19,N/A,427.69,N/A,742.68,N/A,176.11,N/A,300.58,N/A,300.58,N/A,462.33,N/A,742.68,N/A,742.68,N/A,742.68,N/A,707.19,N/A,300.58,N/A,176.11,N/A,674.23,N/A,674.23,N/A,176.11,N/A,300.58,N/A,300.58,N/A,1257.90,754.74,754.74,176.11,1257.90,,Hospital HCPCS J2794,RISPERIDONE MICROSPHERES ER 25 MG IM SRER,50458-0306-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2515.60,2515.60,1509.36,1509.36,N/A,352.18,N/A,601.15,N/A,1414.27,N/A,855.30,N/A,1485.37,N/A,352.18,N/A,601.15,N/A,601.15,N/A,924.65,N/A,1485.37,N/A,1485.37,N/A,1485.37,N/A,1414.27,N/A,601.15,N/A,352.18,N/A,1348.36,N/A,1348.36,N/A,352.18,N/A,601.15,N/A,601.15,N/A,2515.60,1509.36,1509.36,352.18,2515.60,,Hospital HCPCS J2794,RISPERIDONE MICROSPHERES ER 50 MG IM SRER,50458-0308-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5031.60,5031.60,3018.96,3018.96,N/A,704.42,N/A,1202.30,N/A,2828.77,N/A,1710.74,N/A,2970.73,N/A,704.42,N/A,1202.30,N/A,1202.30,N/A,1849.31,N/A,2970.73,N/A,2970.73,N/A,2970.73,N/A,2828.77,N/A,1202.30,N/A,704.42,N/A,2696.94,N/A,2696.94,N/A,704.42,N/A,1202.30,N/A,1202.30,N/A,5031.60,3018.96,3018.96,704.42,5031.60,,Hospital J2798,"Inj., perseris, 0.5 mg",N/A,N/A,31117.30,N/A,18670.38,N/A,11508.35,N/A,8441.00,N/A,16680.00,N/A,10579.88,N/A,11116.00,N/A,11508.35,N/A,8441.00,N/A,8441.00,N/A,6923.00,N/A,11116.00,N/A,11116.00,N/A,11116.00,N/A,10276.63,N/A,6271.01,N/A,11738.58,N/A,31117.30,N/A,31117.30,N/A,4160.97,N/A,10843.00,N/A,8441.00,N/A,11738.51,N/A,4160.97,31117.30,N/A,N/A,,Hospital J2805,Sincalide injection,N/A,N/A,55494.83,5143.68,33296.90,3086.21,8860.80,720.12,10747.52,334.91,19968.54,2935.05,18868.24,1748.85,20159.56,1557.26,9133.82,720.12,2248.00,455.58,2248.00,455.58,12548.86,969.42,20159.56,1557.26,20159.56,1557.26,20159.56,1557.26,19968.54,2935.05,10747.52,455.58,9133.82,720.12,23984.84,2318.74,23984.84,2318.74,5935.43,720.12,10747.52,455.58,10747.52,334.91,9773.19,368.40,2248.00,33296.90,334.91,3086.21,,Hospital J3000,Streptomycin Injection,N/A,N/A,94843.28,N/A,56905.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56905.97,56905.97,N/A,N/A,,Hospital HCPCS J3010,FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN,00409-9093-35,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),00409-9093-35,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),00641-6030-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL CITRATE 1000 MCG/100ML IV SOLN,09999-9907-27,0250 - PHARMACY - GENERAL CLASSIFICATION,173.50,173.50,104.10,104.10,N/A,24.29,N/A,173.50,N/A,99.90,N/A,58.99,N/A,173.50,N/A,24.29,N/A,173.50,N/A,173.50,N/A,173.50,N/A,173.50,N/A,173.50,N/A,173.50,N/A,99.90,N/A,173.50,N/A,24.29,N/A,93.00,N/A,93.00,N/A,24.29,N/A,173.50,N/A,173.50,N/A,173.50,104.10,104.10,24.29,173.50,,Hospital HCPCS J3010,FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN,09999-9902-36,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL CITRATE 100 MCG/2ML IV SOSY,71266-9170-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),00641-6027-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN,00641-6027-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL CITRATE (PF) 2500 MCG/50ML IJ SOLN,63323-0806-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL CITRATE (PF) 1000 MCG/20ML IJ SOLN,63323-0806-14,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital HCPCS J3010,FENTANYL CITRATE PF 50 MCG/ML IJ SOSY,63323-0808-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.18,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.35,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.35,15.00,,Hospital J3101,Tenecteplase injection,N/A,N/A,91865.62,N/A,55119.37,N/A,10227.53,N/A,12364.28,N/A,23048.58,N/A,31234.30,N/A,23963.08,N/A,10542.66,N/A,12364.28,N/A,12364.28,N/A,14917.73,N/A,23963.08,N/A,23963.08,N/A,23963.08,N/A,23048.58,N/A,12364.28,N/A,10542.66,N/A,27684.37,N/A,27684.37,N/A,5779.28,N/A,12364.28,N/A,12364.28,N/A,11280.65,N/A,5779.28,55119.37,N/A,N/A,,Hospital HCPCS J3230,CHLORPROMAZINE HCL 50 MG/2ML IJ SOLN,00641-1398-31,0250 - PHARMACY - GENERAL CLASSIFICATION,44.70,44.70,26.82,26.82,N/A,6.26,N/A,44.70,N/A,25.74,N/A,15.20,N/A,44.70,N/A,6.26,N/A,44.70,N/A,44.70,N/A,44.70,N/A,44.70,N/A,44.70,N/A,44.70,N/A,25.74,N/A,44.70,N/A,6.26,N/A,23.96,N/A,23.96,N/A,6.26,N/A,44.70,N/A,44.70,N/A,44.70,26.82,26.82,6.26,44.70,,Hospital HCPCS J3230,CHLORPROMAZINE HCL 25 MG/ML IJ SOLN,00641-1397-31,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),78.10,78.10,46.86,46.86,N/A,10.93,N/A,78.10,N/A,43.91,N/A,26.55,N/A,78.10,N/A,10.93,N/A,78.10,N/A,78.10,N/A,50.43,N/A,78.10,N/A,78.10,N/A,78.10,N/A,43.91,N/A,78.10,N/A,10.93,N/A,41.86,N/A,41.86,N/A,10.93,N/A,78.10,N/A,78.10,N/A,78.10,46.86,46.86,10.93,78.10,,Hospital HCPCS J3241,TEPROTUMUMAB-TRBW 500 MG IV SOLR,75987-0130-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),68324.00,68324.00,40994.40,40994.40,N/A,9565.36,N/A,16399.90,N/A,38411.75,N/A,23230.16,N/A,41617.42,N/A,9565.36,N/A,16399.90,N/A,16399.90,N/A,25907.24,N/A,41617.42,N/A,41617.42,N/A,41617.42,N/A,38411.75,N/A,16399.90,N/A,9565.36,N/A,36621.66,N/A,36621.66,N/A,9565.36,N/A,16399.90,N/A,16399.90,N/A,18039.89,40994.40,40994.40,9565.36,41617.42,,Hospital J3243,Tigecycline injection,N/A,N/A,112687.30,N/A,67612.38,N/A,6883.36,N/A,13869.73,N/A,84748.76,N/A,23465.84,N/A,23465.84,N/A,6883.36,N/A,13869.73,N/A,13869.73,N/A,23465.84,N/A,23465.84,N/A,23465.84,N/A,23465.84,N/A,84748.76,N/A,13869.73,N/A,6883.36,N/A,84748.76,N/A,84748.76,N/A,6883.36,N/A,13869.73,N/A,13869.73,N/A,6883.36,N/A,6883.36,84748.76,N/A,N/A,,Hospital HCPCS J3245,Tirofiban Hydrochloride,N/A,N/A,346.00,346.00,207.60,207.60,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,N/A,346.00,207.60,207.60,207.60,346.00,,Hospital J3250,Trimethobenzamide Hcl Inj,N/A,N/A,56417.90,53041.03,33850.74,31824.62,5821.98,7386.90,10747.40,12247.49,87421.98,30260.98,14047.10,18033.95,22171.70,29242.75,5821.98,7386.90,5932.54,11932.77,5932.54,11932.77,22171.70,18400.18,22171.70,29242.75,21354.84,29242.75,21782.35,29242.75,10795.76,30261.00,10208.76,11956.02,4938.09,7386.90,22336.78,12507.25,31599.72,12507.25,6527.29,7386.90,10002.75,11932.77,10033.54,12247.49,5821.98,1873.18,4938.09,87421.98,1873.18,31824.62,,Hospital J3300,Triamcinolone A inj PRS-free,N/A,N/A,N/A,39322.10,N/A,23593.26,N/A,5505.08,N/A,3838.31,N/A,22608.06,N/A,13369.50,N/A,9280.82,N/A,5505.08,N/A,3608.17,N/A,3608.17,N/A,5777.49,N/A,9280.82,N/A,9280.82,N/A,9280.82,N/A,22608.05,N/A,3608.17,N/A,5505.08,N/A,5963.00,N/A,5963.00,N/A,5505.08,N/A,3608.17,N/A,3838.31,N/A,1172.05,N/A,N/A,1172.05,23593.26,,Hospital HCPCS J3315,TRIPTORELIN PAMOATE 22.5 MG IM SUSR,74676-5906-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),24397.20,24397.20,14638.32,14638.32,N/A,3415.61,N/A,2294.35,N/A,13716.11,N/A,8295.05,N/A,5649.88,N/A,3415.61,N/A,2294.35,N/A,2294.35,N/A,3517.10,N/A,5649.88,N/A,5649.88,N/A,5649.88,N/A,13716.11,N/A,2294.35,N/A,3415.61,N/A,13076.90,N/A,13076.90,N/A,3415.61,N/A,2294.35,N/A,2294.35,N/A,2523.79,14638.32,14638.32,2294.35,14638.32,,Hospital HCPCS J3315,TRIPTORELIN PAMOATE 11.25 MG IM SUSR,74676-5904-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12198.60,12198.60,7319.16,7319.16,N/A,1707.80,N/A,1147.18,N/A,6858.05,N/A,4147.52,N/A,2824.94,N/A,1707.80,N/A,1147.18,N/A,1147.18,N/A,1758.55,N/A,2824.94,N/A,2824.94,N/A,2824.94,N/A,6858.05,N/A,1147.18,N/A,1707.80,N/A,6538.45,N/A,6538.45,N/A,1707.80,N/A,1147.18,N/A,1147.18,N/A,1261.89,7319.16,7319.16,1147.18,7319.16,,Hospital HCPCS J3315,TRIPTORELIN PAMOATE 3.75 MG IM SUSR,74676-5902-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4066.20,4066.20,2439.72,2439.72,N/A,569.27,N/A,382.39,N/A,2286.02,N/A,1382.51,N/A,941.65,N/A,569.27,N/A,382.39,N/A,382.39,N/A,586.18,N/A,941.65,N/A,941.65,N/A,941.65,N/A,2286.02,N/A,382.39,N/A,569.27,N/A,2179.48,N/A,2179.48,N/A,569.27,N/A,382.39,N/A,382.39,N/A,420.63,2439.72,2439.72,382.39,2439.72,,Hospital HCPCS J3357,USTEKINUMAB 90 MG/ML SC SOSY,57894-0061-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),57368.60,57368.60,34421.16,34421.16,N/A,8031.60,N/A,6644.12,N/A,32252.63,N/A,19505.32,N/A,20360.12,N/A,8031.60,N/A,6644.12,N/A,6644.12,N/A,12674.37,N/A,20360.12,N/A,20360.12,N/A,20360.12,N/A,32252.63,N/A,6644.12,N/A,8031.60,N/A,30749.57,N/A,30749.57,N/A,8031.60,N/A,6644.12,N/A,6644.12,N/A,57368.60,34421.16,34421.16,6644.12,57368.60,,Hospital J3372,"Inj, vancomycin hcl (xellia)",N/A,N/A,N/A,49863.43,N/A,29918.06,N/A,6971.31,N/A,4855.12,N/A,28634.73,N/A,16953.57,N/A,11251.77,N/A,6971.31,N/A,4641.41,N/A,4641.41,N/A,7004.44,N/A,11251.77,N/A,11251.77,N/A,11251.77,N/A,28634.72,N/A,4641.41,N/A,6971.31,N/A,7897.00,N/A,7897.00,N/A,6971.31,N/A,4641.41,N/A,4855.12,N/A,725.29,N/A,N/A,725.29,29918.06,,Hospital HCPCS J3380,VEDOLIZUMAB 300 MG IV SOLR,64764-0300-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),34709.60,34709.60,20825.76,20825.76,N/A,4859.34,N/A,6803.10,N/A,19513.74,N/A,11801.26,N/A,17684.52,N/A,4859.34,N/A,6803.10,N/A,6803.10,N/A,11008.78,N/A,17684.52,N/A,17684.52,N/A,17684.52,N/A,19513.74,N/A,6803.10,N/A,4859.34,N/A,18604.35,N/A,18604.35,N/A,4859.34,N/A,6803.10,N/A,6803.10,N/A,7483.41,20825.76,20825.76,4859.34,20825.76,,Hospital HCPCS J3430,PHYTONADIONE 1 MG/0.5ML IJ SOLN,76329-1240-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),83.50,83.50,50.10,50.10,N/A,11.69,N/A,83.50,N/A,46.94,N/A,28.39,N/A,8.34,N/A,11.69,N/A,83.50,N/A,83.50,N/A,5.19,N/A,8.34,N/A,8.34,N/A,8.34,N/A,46.94,N/A,83.50,N/A,11.69,N/A,44.76,N/A,44.76,N/A,11.69,N/A,83.50,N/A,83.50,N/A,83.50,50.10,50.10,5.19,83.50,,Hospital HCPCS J3430,PHYTONADIONE 10 MG/ML IJ SOLN,00409-9158-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),66.20,66.20,39.72,39.72,N/A,9.27,N/A,66.20,N/A,37.22,N/A,22.51,N/A,16.68,N/A,9.27,N/A,66.20,N/A,66.20,N/A,10.38,N/A,16.68,N/A,16.68,N/A,16.68,N/A,37.22,N/A,66.20,N/A,9.27,N/A,35.48,N/A,35.48,N/A,9.27,N/A,66.20,N/A,66.20,N/A,66.20,39.72,39.72,9.27,66.20,,Hospital HCPCS J3430,VITAMIN K1 1 MG/0.5ML IJ SOLN,00409-9157-01,0250 - PHARMACY - GENERAL CLASSIFICATION,32.10,32.10,19.26,19.26,N/A,4.49,N/A,32.10,N/A,18.48,N/A,10.91,N/A,32.10,N/A,4.49,N/A,32.10,N/A,32.10,N/A,32.10,N/A,32.10,N/A,32.10,N/A,32.10,N/A,18.48,N/A,32.10,N/A,4.49,N/A,17.21,N/A,17.21,N/A,4.49,N/A,32.10,N/A,32.10,N/A,32.10,19.26,19.26,4.49,32.10,,Hospital HCPCS J3480,POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,00338-0705-48,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),27.70,27.70,16.62,16.62,N/A,3.88,N/A,27.70,N/A,15.57,N/A,9.42,N/A,4.40,N/A,3.88,N/A,27.70,N/A,27.70,N/A,2.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,15.57,N/A,27.70,N/A,3.88,N/A,14.85,N/A,14.85,N/A,3.88,N/A,27.70,N/A,27.70,N/A,27.70,16.62,16.62,2.74,27.70,,Hospital HCPCS J3480,POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,63323-0965-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.81,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.48,N/A,8.81,N/A,8.81,N/A,8.81,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J3480,POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,09999-9912-08,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),168.80,168.80,101.28,101.28,N/A,23.63,N/A,168.80,N/A,94.90,N/A,57.39,N/A,4.40,N/A,23.63,N/A,168.80,N/A,168.80,N/A,2.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,94.90,N/A,168.80,N/A,23.63,N/A,90.48,N/A,90.48,N/A,23.63,N/A,168.80,N/A,168.80,N/A,168.80,101.28,101.28,2.74,168.80,,Hospital HCPCS J3480,POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,00338-0704-34,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),47.30,47.30,28.38,28.38,N/A,6.62,N/A,47.30,N/A,26.59,N/A,16.08,N/A,4.40,N/A,6.62,N/A,47.30,N/A,47.30,N/A,2.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,26.59,N/A,47.30,N/A,6.62,N/A,25.35,N/A,25.35,N/A,6.62,N/A,47.30,N/A,47.30,N/A,47.30,28.38,28.38,2.74,47.30,,Hospital HCPCS J3480,POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,00338-0683-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),67.50,67.50,40.50,40.50,N/A,9.45,N/A,67.50,N/A,37.95,N/A,22.95,N/A,4.40,N/A,9.45,N/A,67.50,N/A,67.50,N/A,2.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,37.95,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,9.45,N/A,67.50,N/A,67.50,N/A,67.50,40.50,40.50,2.74,67.50,,Hospital HCPCS J3480,POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,00338-0709-48,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),33.10,33.10,19.86,19.86,N/A,4.63,N/A,33.10,N/A,18.61,N/A,11.25,N/A,2.20,N/A,4.63,N/A,33.10,N/A,33.10,N/A,1.37,N/A,2.20,N/A,2.20,N/A,2.20,N/A,18.61,N/A,33.10,N/A,4.63,N/A,17.74,N/A,17.74,N/A,4.63,N/A,33.10,N/A,33.10,N/A,33.10,19.86,19.86,1.37,33.10,,Hospital HCPCS J3480,POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,63323-0965-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.90,16.90,10.14,10.14,N/A,2.37,N/A,16.90,N/A,9.50,N/A,5.75,N/A,2.20,N/A,2.37,N/A,16.90,N/A,16.90,N/A,1.37,N/A,2.20,N/A,2.20,N/A,2.20,N/A,9.50,N/A,16.90,N/A,2.37,N/A,9.06,N/A,9.06,N/A,2.37,N/A,16.90,N/A,16.90,N/A,16.90,10.14,10.14,1.37,16.90,,Hospital HCPCS J3480,POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,00409-6651-19,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22.30,22.30,13.38,13.38,N/A,3.12,N/A,22.30,N/A,12.54,N/A,7.58,N/A,4.40,N/A,3.12,N/A,22.30,N/A,22.30,N/A,2.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,12.54,N/A,22.30,N/A,3.12,N/A,11.95,N/A,11.95,N/A,3.12,N/A,22.30,N/A,22.30,N/A,22.30,13.38,13.38,2.74,22.30,,Hospital HCPCS J3490,SODIUM CHLORIDE 0.45 % IV SOLN,00338-0043-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 0.45 % IV SOLN,00338-0043-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J3490,DEXTROSE-NACL 5-0.2 % IV SOLN,00338-0077-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J3490,DEXTROSE-NACL 5-0.2 % IV SOLN,00338-0077-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),00409-7101-69,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J3490,DEXTROSE-NACL 5-0.45 % IV SOLN,00338-0085-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 0.45 % IV SOLN,00338-0043-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),00409-7101-69,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J3490,DEXTROSE-NACL 5-0.45 % IV SOLN,00338-0085-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 3 % IN NEBU,00378-6997-89,0258 - PHARMACY - IV SOLUTIONS,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.88,N/A,1.70,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,2.88,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,3.00,3.00,1.70,5.00,,Hospital HCPCS J3490,DEXTROSE-NACL 5-0.45 % IV SOLN,00338-0085-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 0.45 % IV SOLN,00338-0043-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J3490,SODIUM CHLORIDE 3 % IN NEBU,00378-6997-89,0250 - PHARMACY - GENERAL CLASSIFICATION,5.00,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.00,N/A,N/A,5.00,5.00,,Hospital HCPCS J3490,DEXTROSE-NACL 5-0.45 % IV SOLN,00338-0085-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital J7040,Normal Saline Solution Infus,N/A,N/A,55717.70,32301.80,33430.62,19381.08,8569.53,4522.25,10402.96,1405.41,19312.14,18203.68,18944.02,10982.61,20255.10,5800.00,8833.58,4522.25,10402.96,1405.41,10402.96,1405.41,12608.63,3610.57,20255.10,5800.00,20255.10,5800.00,20255.10,5800.00,19312.14,17679.92,10402.96,1405.41,8833.58,4522.25,23196.42,17313.76,23196.42,17313.76,5165.08,4522.25,10402.96,1405.41,10402.96,1405.41,9451.93,1545.96,5165.08,33430.62,1405.41,19381.08,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-31,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-48,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-31,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7050,SODIUM CHLORIDE 0.9 % IV BOLUS,00338-0049-48,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7121,DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,00338-0125-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7121,DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,00338-0125-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital J7186,Antihemophilic viii/vwf comp,N/A,N/A,1453207.70,N/A,871924.62,N/A,N/A,N/A,N/A,N/A,N/A,N/A,790945.24,N/A,790945.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,790945.24,N/A,790945.24,N/A,790945.24,N/A,790945.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,790945.24,871924.62,N/A,N/A,,Hospital J7298,"HC Mirena, 52 Mg",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),50260.30,5537.00,30156.18,3322.20,4653.92,770.77,5771.00,8.61,10487.99,3152.10,17088.50,1882.58,7322.00,2663.61,4797.32,770.77,5771.00,8.61,5771.00,8.61,4558.00,1697.05,7322.00,2663.61,7322.00,2663.61,7322.00,2663.61,10487.99,3152.10,5771.00,8.61,4797.32,770.77,12597.46,8.61,12597.46,8.61,5735.37,770.77,5771.00,8.61,N/A,8.61,5133.13,9.47,4558.00,30156.18,8.61,3322.20,,Hospital J7315,Opthalmic mitomycin,N/A,N/A,N/A,26077.88,N/A,15646.73,N/A,3650.91,N/A,3774.30,N/A,14853.13,N/A,8866.48,N/A,9869.35,N/A,3650.91,N/A,3608.17,N/A,3608.17,N/A,6143.84,N/A,9869.35,N/A,9869.35,N/A,9869.35,N/A,14853.13,N/A,3608.17,N/A,3650.91,N/A,5963.00,N/A,5963.00,N/A,3650.91,N/A,3608.17,N/A,3774.30,N/A,N/A,N/A,N/A,3608.17,15646.73,,Hospital J7402,Mometasone sinus sinuva,N/A,N/A,N/A,72336.38,N/A,43401.83,N/A,10120.90,N/A,5538.92,N/A,41438.92,N/A,24594.36,N/A,21200.56,N/A,10120.90,N/A,5587.18,N/A,5587.18,N/A,13197.69,N/A,21200.56,N/A,21200.56,N/A,21200.56,N/A,41438.92,N/A,5587.18,N/A,10120.90,N/A,7692.25,N/A,7692.25,N/A,10120.89,N/A,5587.18,N/A,5538.92,N/A,2050.01,N/A,N/A,2050.01,43401.83,,Hospital HCPCS J7500,AZATHIOPRINE 50 MG PO TABS,68382-0003-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7502,CYCLOSPORINE 100 MG PO CAPS,60505-0134-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),27.70,27.70,16.62,16.62,N/A,3.88,N/A,27.70,N/A,15.57,N/A,9.42,N/A,5.52,N/A,3.88,N/A,27.70,N/A,27.70,N/A,3.43,N/A,5.52,N/A,5.52,N/A,5.52,N/A,15.57,N/A,27.70,N/A,3.88,N/A,14.85,N/A,14.85,N/A,3.88,N/A,27.70,N/A,27.70,N/A,27.70,16.62,16.62,3.43,27.70,,Hospital HCPCS J7509,METHYLPREDNISOLONE 4 MG PO TBPK,68001-0005-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7509,METHYLPREDNISOLONE 4 MG PO TABS,00603-4593-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7512,PREDNISONE 1 MG PO TABS,00054-8739-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7512,PREDNISONE 5 MG PO TABS,00054-8724-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7512,PREDNISONE 50 MG PO TABS,00054-0019-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,1.30,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,1.30,N/A,1.30,N/A,1.30,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.30,5.00,,Hospital HCPCS J7512,PREDNISONE 20 MG PO TABS,00054-0018-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7512,PREDNISONE 10 MG PO TABS,00904-6923-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7512,PREDNISONE 2.5 MG PO TABS,00054-8740-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7517,MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR,00004-0261-29,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3106.80,3106.80,1864.08,1864.08,N/A,434.95,N/A,3106.80,N/A,1746.64,N/A,1056.31,N/A,76.25,N/A,434.95,N/A,3106.80,N/A,3106.80,N/A,47.47,N/A,76.25,N/A,76.25,N/A,76.25,N/A,1746.64,N/A,3106.80,N/A,434.95,N/A,1665.24,N/A,1665.24,N/A,434.95,N/A,3106.80,N/A,3106.80,N/A,3106.80,1864.08,1864.08,47.47,3106.80,,Hospital HCPCS J7517,MYCOPHENOLATE MOFETIL 250 MG PO CAPS,16729-0094-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7520,SIROLIMUS 1 MG/ML PO SOLN,00008-1030-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),141.70,141.70,85.02,85.02,N/A,19.84,N/A,141.70,N/A,79.66,N/A,48.18,N/A,11.50,N/A,19.84,N/A,141.70,N/A,141.70,N/A,7.16,N/A,11.50,N/A,11.50,N/A,11.50,N/A,79.66,N/A,141.70,N/A,19.84,N/A,75.95,N/A,75.95,N/A,19.84,N/A,141.70,N/A,141.70,N/A,141.70,85.02,85.02,7.16,141.70,,Hospital HCPCS J7520,SIROLIMUS 1 MG PO TABS,00008-1041-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),74.40,74.40,44.64,44.64,N/A,10.42,N/A,74.40,N/A,41.83,N/A,25.30,N/A,5.75,N/A,10.42,N/A,74.40,N/A,74.40,N/A,3.58,N/A,5.75,N/A,5.75,N/A,5.75,N/A,41.83,N/A,74.40,N/A,10.42,N/A,39.88,N/A,39.88,N/A,10.42,N/A,74.40,N/A,74.40,N/A,74.40,44.64,44.64,3.58,74.40,,Hospital HCPCS J7608,ACETYLCYSTEINE 20 % IN SOLN,63323-0694-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28.80,28.80,17.28,17.28,N/A,4.03,N/A,28.80,N/A,16.19,N/A,9.79,N/A,15.62,N/A,4.03,N/A,28.80,N/A,28.80,N/A,9.72,N/A,15.62,N/A,15.62,N/A,15.62,N/A,16.19,N/A,28.80,N/A,4.03,N/A,15.44,N/A,15.44,N/A,4.03,N/A,28.80,N/A,28.80,N/A,28.80,17.28,17.28,4.03,28.80,,Hospital HCPCS J7608,ACETYLCYSTEINE 20 % IN SOLN,00409-3308-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),26.90,26.90,16.14,16.14,N/A,3.77,N/A,26.90,N/A,15.12,N/A,9.15,N/A,26.90,N/A,3.77,N/A,26.90,N/A,26.90,N/A,26.90,N/A,26.90,N/A,26.90,N/A,26.90,N/A,15.12,N/A,26.90,N/A,3.77,N/A,14.42,N/A,14.42,N/A,3.77,N/A,26.90,N/A,26.90,N/A,26.90,16.14,16.14,3.77,26.90,,Hospital HCPCS J7608,ACETYLCYSTEINE 20 % IN SOLN,63323-0692-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),27.40,27.40,16.44,16.44,N/A,3.84,N/A,27.40,N/A,15.40,N/A,9.32,N/A,27.40,N/A,3.84,N/A,27.40,N/A,27.40,N/A,19.44,N/A,27.40,N/A,27.40,N/A,27.40,N/A,15.40,N/A,27.40,N/A,3.84,N/A,14.69,N/A,14.69,N/A,3.84,N/A,27.40,N/A,27.40,N/A,27.40,16.44,16.44,3.84,27.40,,Hospital HCPCS J7613,ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,00487-9501-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital J7676,Pentamidine comp unit dose,N/A,N/A,N/A,872.00,N/A,523.20,N/A,122.08,N/A,N/A,N/A,490.31,N/A,296.48,N/A,121.33,N/A,122.08,N/A,N/A,N/A,N/A,N/A,75.40,N/A,121.33,N/A,121.33,N/A,121.33,N/A,490.31,N/A,N/A,N/A,122.08,N/A,467.39,N/A,467.39,N/A,122.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,75.40,523.20,,Hospital HCPCS J7682,TOBRAMYCIN 300 MG/5ML IN NEBU,09999-9902-97,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),66.30,66.30,39.78,39.78,N/A,9.28,N/A,66.30,N/A,37.27,N/A,22.54,N/A,66.30,N/A,9.28,N/A,66.30,N/A,66.30,N/A,44.77,N/A,66.30,N/A,66.30,N/A,66.30,N/A,37.27,N/A,66.30,N/A,9.28,N/A,35.54,N/A,35.54,N/A,9.28,N/A,66.30,N/A,66.30,N/A,66.30,39.78,39.78,9.28,66.30,,Hospital HCPCS J8530,CYCLOPHOSPHAMIDE 25 MG PO CAPS,00054-0382-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.90,16.90,10.14,10.14,N/A,2.37,N/A,16.90,N/A,9.50,N/A,5.75,N/A,1.97,N/A,2.37,N/A,16.90,N/A,16.90,N/A,1.23,N/A,1.97,N/A,1.97,N/A,1.97,N/A,9.50,N/A,16.90,N/A,2.37,N/A,9.06,N/A,9.06,N/A,2.37,N/A,16.90,N/A,16.90,N/A,16.90,10.14,10.14,1.23,16.90,,Hospital HCPCS J8540,DEXAMETHASONE 1 MG PO TABS,00054-8174-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,1.04,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,1.04,N/A,1.04,N/A,1.04,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.04,5.00,,Hospital HCPCS J8540,DEXAMETHASONE 0.5 MG PO TABS,00054-4179-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J8540,DEXAMETHASONE 2 MG PO TABS,00054-8176-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,2.07,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.29,N/A,2.07,N/A,2.07,N/A,2.07,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.29,5.00,,Hospital HCPCS J8540,DEXAMETHASONE 0.5 MG/5ML PO ELIX,09999-9901-76,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J8540,DEXAMETHASONE 4 MG PO TABS,00054-8175-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,4.14,N/A,N/A,N/A,5.00,N/A,5.00,N/A,2.58,N/A,4.14,N/A,4.14,N/A,4.14,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J8540,DEXAMETHASONE 1 MG/ML PO CONC,09999-9903-61,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,1.04,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,1.04,N/A,1.04,N/A,1.04,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.04,5.00,,Hospital HCPCS J9000,DOXORUBICIN HCL 2 MG/ML IV SOLN,00069-4026-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),177.70,177.70,106.62,106.62,N/A,24.88,N/A,177.70,N/A,99.90,N/A,60.42,N/A,32.50,N/A,24.88,N/A,177.70,N/A,177.70,N/A,20.23,N/A,32.50,N/A,32.50,N/A,32.50,N/A,99.90,N/A,177.70,N/A,24.88,N/A,95.25,N/A,95.25,N/A,24.88,N/A,177.70,N/A,177.70,N/A,177.70,106.62,106.62,20.23,177.70,,Hospital HCPCS J9000,DOXORUBICIN HCL 2 MG/ML IV SOLN,00069-3030-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,6.50,N/A,21.00,N/A,150.00,N/A,150.00,N/A,4.05,N/A,6.50,N/A,6.50,N/A,6.50,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,4.05,150.00,,Hospital HCPCS J9000,DOXORUBICIN HCL 2 MG/ML IV SOLN,00069-3031-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,13.00,N/A,21.00,N/A,150.00,N/A,150.00,N/A,8.09,N/A,13.00,N/A,13.00,N/A,13.00,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,8.09,150.00,,Hospital J9017,Arsenic Trioxide,N/A,N/A,295647.22,6440.70,177388.33,3864.42,N/A,907.21,34857.00,597.95,N/A,3657.37,234075.03,2189.84,234075.03,1464.91,N/A,907.21,34857.00,597.95,34857.00,597.95,234075.03,911.93,234075.03,1464.91,234075.03,1464.91,234075.03,1464.91,N/A,3657.37,34857.00,597.95,N/A,907.21,N/A,1352.75,N/A,1352.75,N/A,907.21,34230.47,597.95,34857.00,597.95,N/A,657.75,34230.47,234075.03,597.95,3864.42,,Hospital J9021,"Inj, aspara, rylaze, 0.1 mg",N/A,N/A,N/A,98534.95,N/A,59120.97,N/A,13469.72,N/A,401.50,N/A,55493.44,N/A,33501.89,N/A,49103.25,N/A,13469.72,N/A,20151.59,N/A,20151.59,N/A,30567.25,N/A,49103.25,N/A,49103.25,N/A,49103.25,N/A,55490.95,N/A,20151.59,N/A,13469.72,N/A,1481.67,N/A,1481.67,N/A,13469.72,N/A,20151.59,N/A,401.50,N/A,441.66,N/A,N/A,401.50,59120.97,,Hospital HCPCS J9022,ATEZOLIZUMAB 1200 MG/20ML IV SOLN,50242-0917-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),49243.20,49243.20,29545.92,29545.92,N/A,6894.05,N/A,9921.36,N/A,27684.53,N/A,16742.69,N/A,25569.52,N/A,6894.05,N/A,9921.36,N/A,9921.36,N/A,15917.27,N/A,25569.52,N/A,25569.52,N/A,25569.52,N/A,27684.53,N/A,9921.36,N/A,6894.05,N/A,26394.36,N/A,26394.36,N/A,6894.05,N/A,9921.36,N/A,9921.36,N/A,10913.50,29545.92,29545.92,6894.05,29545.92,,Hospital HCPCS J9022,ATEZOLIZUMAB 840 MG/14ML IV SOLN,50242-0918-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),34470.30,34470.30,20682.18,20682.18,N/A,4825.84,N/A,6944.95,N/A,19379.20,N/A,11719.90,N/A,17898.66,N/A,4825.84,N/A,6944.95,N/A,6944.95,N/A,11142.09,N/A,17898.66,N/A,17898.66,N/A,17898.66,N/A,19379.20,N/A,6944.95,N/A,4825.84,N/A,18476.08,N/A,18476.08,N/A,4825.84,N/A,6944.95,N/A,6944.95,N/A,7639.45,20682.18,20682.18,4825.84,20682.18,,Hospital J9030,HC Bcg Live Intravesical 1mg,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,2978.70,N/A,1787.22,N/A,417.02,N/A,570.82,N/A,1698.58,N/A,1012.76,N/A,1373.30,N/A,417.02,N/A,564.71,N/A,564.71,N/A,854.90,N/A,1373.30,N/A,1373.30,N/A,1373.30,N/A,1698.58,N/A,564.71,N/A,417.02,N/A,1596.58,N/A,1596.58,N/A,417.02,N/A,564.71,N/A,570.82,N/A,46.19,N/A,N/A,46.19,1787.22,,Hospital HCPCS J9036,BENDAMUSTINE HCL 100 MG/4ML IV SOLN,63459-0348-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12369.00,12369.00,7421.40,7421.40,N/A,1731.66,N/A,1650.80,N/A,6953.85,N/A,4205.46,N/A,4620.56,N/A,1731.66,N/A,1650.80,N/A,1650.80,N/A,2876.34,N/A,4620.56,N/A,4620.56,N/A,4620.56,N/A,6953.85,N/A,1650.80,N/A,1731.66,N/A,6629.78,N/A,6629.78,N/A,1731.66,N/A,1650.80,N/A,1650.80,N/A,1815.88,7421.40,7421.40,1650.80,7421.40,,Hospital J9039,"Injection, blinatumomab",N/A,N/A,74789.00,72886.12,44873.40,43731.67,7333.50,10204.06,8940.80,10432.23,39738.64,40998.73,25428.26,24781.28,16684.73,24262.92,7559.46,10204.06,8940.80,10428.18,8940.80,10428.18,10385.86,15103.91,16684.73,24262.92,16684.73,24262.92,16684.73,24262.92,39738.64,40998.73,8940.80,10428.18,7559.46,10204.06,19850.67,39066.96,19850.67,39066.96,N/A,10204.06,8940.80,10428.18,8940.80,10432.23,8088.62,N/A,7333.50,44873.40,10204.06,43731.67,,Hospital HCPCS J9043,CABAZITAXEL 60 MG/1.5ML IV SOLN,00024-5824-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),42722.30,42722.30,25633.38,25633.38,N/A,5981.12,N/A,12361.92,N/A,24018.48,N/A,14525.58,N/A,30553.19,N/A,5981.12,N/A,12361.92,N/A,12361.92,N/A,19019.66,N/A,30553.19,N/A,30553.19,N/A,30553.19,N/A,24018.48,N/A,12361.92,N/A,5981.12,N/A,22899.15,N/A,22899.15,N/A,5981.12,N/A,12361.92,N/A,42722.30,N/A,42722.30,25633.38,25633.38,5981.12,42722.30,,Hospital HCPCS J9057,COPANLISIB HCL 60 MG IV SOLR,50419-0385-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),24753.00,24753.00,14851.80,14851.80,N/A,3465.42,N/A,24753.00,N/A,13916.14,N/A,8416.02,N/A,12570.31,N/A,3465.42,N/A,5140.56,N/A,5140.56,N/A,7825.14,N/A,12570.31,N/A,12570.31,N/A,12570.31,N/A,13916.14,N/A,5140.56,N/A,3465.42,N/A,13267.61,N/A,13267.61,N/A,3465.42,N/A,5140.56,N/A,24753.00,N/A,24753.00,14851.80,14851.80,3465.42,24753.00,,Hospital HCPCS J9100,CYTARABINE (PF) 20 MG/ML IJ SOLN,61703-0305-58,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,2.38,N/A,21.00,N/A,150.00,N/A,150.00,N/A,1.48,N/A,2.38,N/A,2.38,N/A,2.38,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,1.48,150.00,,Hospital HCPCS J9100,CYTARABINE 20 MG/ML IJ SOLN,61703-0304-36,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,11.91,N/A,21.00,N/A,150.00,N/A,150.00,N/A,7.42,N/A,11.91,N/A,11.91,N/A,11.91,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,7.42,150.00,,Hospital HCPCS J9100,CYTARABINE (PF) 100 MG/ML IJ SOLN,63323-0120-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,47.66,N/A,21.00,N/A,150.00,N/A,150.00,N/A,29.67,N/A,47.66,N/A,47.66,N/A,47.66,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,21.00,150.00,,Hospital J9118,Inj. calaspargase pegol-mknl,N/A,N/A,401195.82,5900.42,240717.49,3540.25,N/A,826.06,N/A,293.32,N/A,3385.79,N/A,2006.14,N/A,1571.85,N/A,826.06,N/A,575.28,N/A,575.28,N/A,978.51,N/A,1571.85,N/A,1571.85,N/A,1571.85,N/A,3385.81,N/A,575.28,N/A,826.06,N/A,3162.62,N/A,3162.62,N/A,826.06,N/A,575.28,N/A,293.32,N/A,322.65,240717.49,240717.49,293.32,3540.25,,Hospital HCPCS J9144,DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN,57894-0503-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),41830.90,41830.90,25098.54,25098.54,N/A,5856.33,N/A,8841.60,N/A,23517.33,N/A,14222.51,N/A,21715.60,N/A,5856.33,N/A,8841.60,N/A,8841.60,N/A,13518.17,N/A,21715.60,N/A,21715.60,N/A,21715.60,N/A,23517.33,N/A,8841.60,N/A,5856.33,N/A,22421.36,N/A,22421.36,N/A,5856.33,N/A,8841.60,N/A,8841.60,N/A,9725.76,25098.54,25098.54,5856.33,25098.54,,Hospital HCPCS J9155,DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,55566-8403-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7620.90,7620.90,4572.54,4572.54,N/A,1066.93,N/A,1006.56,N/A,4284.47,N/A,2591.11,N/A,2505.05,N/A,1066.93,N/A,1006.56,N/A,1006.56,N/A,1559.42,N/A,2505.05,N/A,2505.05,N/A,2505.05,N/A,4284.47,N/A,1006.56,N/A,1066.93,N/A,4084.80,N/A,4084.80,N/A,1066.93,N/A,1006.56,N/A,1006.56,N/A,7620.90,4572.54,4572.54,1006.56,7620.90,,Hospital HCPCS J9155,DEGARELIX ACETATE 80 MG SC SOLR,55566-8303-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2442.30,2442.30,1465.38,1465.38,N/A,341.92,N/A,335.52,N/A,1373.06,N/A,830.38,N/A,835.02,N/A,341.92,N/A,335.52,N/A,335.52,N/A,519.81,N/A,835.02,N/A,835.02,N/A,835.02,N/A,1373.06,N/A,335.52,N/A,341.92,N/A,1309.07,N/A,1309.07,N/A,341.92,N/A,335.52,N/A,335.52,N/A,2442.30,1465.38,1465.38,335.52,2442.30,,Hospital HCPCS J9173,DURVALUMAB 500 MG/10ML IV SOLN,00310-4611-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19162.10,19162.10,11497.26,11497.26,N/A,2682.69,N/A,3988.15,N/A,10772.93,N/A,6515.11,N/A,10126.90,N/A,2682.69,N/A,3988.15,N/A,3988.15,N/A,6304.09,N/A,10126.90,N/A,10126.90,N/A,10126.90,N/A,10772.93,N/A,3988.15,N/A,2682.69,N/A,10270.89,N/A,10270.89,N/A,2682.69,N/A,3988.15,N/A,3988.15,N/A,4386.97,11497.26,11497.26,2682.69,11497.26,,Hospital HCPCS J9173,DURVALUMAB 120 MG/2.4ML IV SOLN,00310-4500-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4599.00,4599.00,2759.40,2759.40,N/A,643.86,N/A,957.16,N/A,2585.56,N/A,1563.66,N/A,2430.46,N/A,643.86,N/A,957.16,N/A,957.16,N/A,1512.98,N/A,2430.46,N/A,2430.46,N/A,2430.46,N/A,2585.56,N/A,957.16,N/A,643.86,N/A,2465.06,N/A,2465.06,N/A,643.86,N/A,957.16,N/A,957.16,N/A,1052.87,2759.40,2759.40,643.86,2759.40,,Hospital HCPCS J9173,DURVALUMAB 50 MG/ML (MIXTURES ONLY),00310-4500-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4599.00,4599.00,2759.40,2759.40,N/A,643.86,N/A,957.16,N/A,2585.56,N/A,1563.66,N/A,2430.46,N/A,643.86,N/A,957.16,N/A,957.16,N/A,1512.98,N/A,2430.46,N/A,2430.46,N/A,2430.46,N/A,2585.56,N/A,957.16,N/A,643.86,N/A,2465.06,N/A,2465.06,N/A,643.86,N/A,957.16,N/A,957.16,N/A,1052.87,2759.40,2759.40,643.86,2759.40,,Hospital HCPCS J9173,DURVALUMAB 50 MG/ML (MIXTURES ONLY),00310-4611-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19162.10,19162.10,11497.26,11497.26,N/A,2682.69,N/A,3988.15,N/A,10772.93,N/A,6515.11,N/A,10126.90,N/A,2682.69,N/A,3988.15,N/A,3988.15,N/A,6304.09,N/A,10126.90,N/A,10126.90,N/A,10126.90,N/A,10772.93,N/A,3988.15,N/A,2682.69,N/A,10270.89,N/A,10270.89,N/A,2682.69,N/A,3988.15,N/A,3988.15,N/A,4386.97,11497.26,11497.26,2682.69,11497.26,,Hospital HCPCS J9185,FLUDARABINE PHOSPHATE 50 MG/2ML IV SOLN,63323-0192-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1359.40,1359.40,815.64,815.64,N/A,190.32,N/A,604.75,N/A,764.25,N/A,462.20,N/A,124.48,N/A,190.32,N/A,604.75,N/A,604.75,N/A,77.49,N/A,124.48,N/A,124.48,N/A,124.48,N/A,764.25,N/A,604.75,N/A,190.32,N/A,728.64,N/A,728.64,N/A,190.32,N/A,604.75,N/A,604.75,N/A,1359.40,815.64,815.64,77.49,1359.40,,Hospital HCPCS J9202,GOSERELIN ACETATE 3.6 MG SC IMPL,70720-0950-36,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3918.10,3918.10,2350.86,2350.86,N/A,548.53,N/A,613.57,N/A,2202.76,N/A,1332.15,N/A,1492.10,N/A,548.53,N/A,613.57,N/A,613.57,N/A,928.85,N/A,1492.10,N/A,1492.10,N/A,1492.10,N/A,2202.76,N/A,613.57,N/A,548.53,N/A,2100.10,N/A,2100.10,N/A,548.53,N/A,613.57,N/A,613.57,N/A,674.92,2350.86,2350.86,548.53,2350.86,,Hospital HCPCS J9205,IRINOTECAN HCL LIPOSOME 43 MG/10ML IV INJ,15054-0043-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12915.00,12915.00,7749.00,7749.00,N/A,1808.10,N/A,2664.45,N/A,7260.81,N/A,4391.10,N/A,6697.79,N/A,1808.10,N/A,2664.45,N/A,2664.45,N/A,4169.44,N/A,6697.79,N/A,6697.79,N/A,6697.79,N/A,7260.81,N/A,2664.45,N/A,1808.10,N/A,6922.44,N/A,6922.44,N/A,1808.10,N/A,2664.45,N/A,2664.45,N/A,2930.90,7749.00,7749.00,1808.10,7749.00,,Hospital HCPCS J9206,IRINOTECAN HCL 40 MG/2ML IV SOLN,00009-7529-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,12.28,N/A,21.00,N/A,150.00,N/A,150.00,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,7.64,150.00,,Hospital HCPCS J9206,IRINOTECAN HCL 300 MG/15ML IV SOLN,00009-7529-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),568.50,568.50,341.10,341.10,N/A,79.59,N/A,568.50,N/A,319.61,N/A,193.29,N/A,92.07,N/A,79.59,N/A,568.50,N/A,568.50,N/A,57.32,N/A,92.07,N/A,92.07,N/A,92.07,N/A,319.61,N/A,568.50,N/A,79.59,N/A,304.72,N/A,304.72,N/A,79.59,N/A,568.50,N/A,568.50,N/A,568.50,341.10,341.10,57.32,568.50,,Hospital HCPCS J9206,IRINOTECAN HCL 100 MG/5ML IV SOLN,00009-7529-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),206.40,206.40,123.84,123.84,N/A,28.90,N/A,206.40,N/A,116.04,N/A,70.18,N/A,30.69,N/A,28.90,N/A,206.40,N/A,206.40,N/A,19.11,N/A,30.69,N/A,30.69,N/A,30.69,N/A,116.04,N/A,206.40,N/A,28.90,N/A,110.63,N/A,110.63,N/A,28.90,N/A,206.40,N/A,206.40,N/A,206.40,123.84,123.84,19.11,206.40,,Hospital HCPCS J9218,LEUPROLIDE ACETATE 1 MG/0.2ML IJ KIT,47335-0936-40,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4763.30,4763.30,2857.98,2857.98,N/A,666.86,N/A,4763.30,N/A,2677.93,N/A,1619.52,N/A,34.50,N/A,666.86,N/A,4763.30,N/A,4763.30,N/A,21.48,N/A,34.50,N/A,34.50,N/A,34.50,N/A,2677.93,N/A,4763.30,N/A,666.86,N/A,2553.13,N/A,2553.13,N/A,666.86,N/A,4763.30,N/A,4763.30,N/A,4763.30,2857.98,2857.98,21.48,4763.30,,Hospital HCPCS J9223,LURBINECTEDIN 4 MG IV SOLR,68727-0712-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),36050.00,36050.00,21630.00,21630.00,N/A,5047.00,N/A,7887.08,N/A,20267.31,N/A,12257.00,N/A,19060.33,N/A,5047.00,N/A,7887.08,N/A,7887.08,N/A,11865.24,N/A,19060.33,N/A,19060.33,N/A,19060.33,N/A,20267.31,N/A,7887.08,N/A,5047.00,N/A,19322.80,N/A,19322.80,N/A,5047.00,N/A,7887.08,N/A,7887.08,N/A,8675.79,21630.00,21630.00,5047.00,21630.00,,Hospital HCPCS J9250,METHOTREXATE SODIUM (PF) 250 MG/10ML IJ SOLN,00703-3675-01,0250 - PHARMACY - GENERAL CLASSIFICATION,61.00,61.00,36.60,36.60,N/A,8.54,N/A,61.00,N/A,35.12,N/A,20.74,N/A,61.00,N/A,8.54,N/A,61.00,N/A,61.00,N/A,61.00,N/A,61.00,N/A,61.00,N/A,61.00,N/A,35.12,N/A,61.00,N/A,8.54,N/A,32.70,N/A,32.70,N/A,8.54,N/A,61.00,N/A,61.00,N/A,61.00,36.60,36.60,8.54,61.00,,Hospital HCPCS J9250,METHOTREXATE SODIUM 50 MG/2ML IJ SOLN,61703-0350-38,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,1.55,N/A,21.00,N/A,150.00,N/A,150.00,N/A,N/A,N/A,1.55,N/A,1.55,N/A,1.55,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,1.55,150.00,,Hospital HCPCS J9250,METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN,61703-0408-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),183.60,183.60,110.16,110.16,N/A,25.70,N/A,183.60,N/A,103.22,N/A,62.42,N/A,103.60,N/A,25.70,N/A,183.60,N/A,183.60,N/A,64.49,N/A,103.60,N/A,103.60,N/A,103.60,N/A,103.22,N/A,183.60,N/A,25.70,N/A,98.41,N/A,98.41,N/A,25.70,N/A,183.60,N/A,183.60,N/A,183.60,110.16,110.16,25.70,183.60,,Hospital HCPCS J9259,PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,68817-0134-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7900.30,7900.30,4740.18,4740.18,N/A,1106.04,N/A,1205.60,N/A,4441.55,N/A,2686.10,N/A,3804.71,N/A,1106.04,N/A,1205.60,N/A,1205.60,N/A,2368.47,N/A,3804.71,N/A,3804.71,N/A,3804.71,N/A,4441.55,N/A,1205.60,N/A,1106.04,N/A,4234.56,N/A,4234.56,N/A,1106.04,N/A,1205.60,N/A,1205.60,N/A,1326.16,4740.18,4740.18,1106.04,4740.18,,Hospital J9266,Pegaspargase/Singl Dose Vial,N/A,N/A,201839.02,107645.32,121103.41,64587.19,12953.59,14890.44,N/A,360.87,152993.98,61975.84,10704.00,36599.15,10704.00,1373.83,12953.59,14890.44,N/A,537.02,N/A,537.02,10704.00,855.23,10704.00,1373.83,10704.00,1373.83,10704.00,1373.83,152993.98,61975.87,N/A,537.02,12953.59,14890.44,152993.98,2099.15,152993.98,2099.15,12953.59,14890.44,N/A,537.02,N/A,360.87,12953.59,396.96,10704.00,152993.98,360.87,64587.19,,Hospital HCPCS J9267,PACLITAXEL 30 MG/5ML IV CONC,00703-3213-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,9.32,N/A,21.00,N/A,150.00,N/A,150.00,N/A,5.80,N/A,9.32,N/A,9.32,N/A,9.32,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,5.80,150.00,,Hospital HCPCS J9267,PACLITAXEL 100 MG/16.7ML IV CONC,61703-0342-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,31.39,N/A,21.00,N/A,150.00,N/A,150.00,N/A,19.54,N/A,31.39,N/A,31.39,N/A,31.39,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,19.54,150.00,,Hospital HCPCS J9267,PACLITAXEL 300 MG/50ML IV CONC,00703-3218-81,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),500.00,500.00,300.00,300.00,N/A,70.00,N/A,500.00,N/A,281.10,N/A,170.00,N/A,93.24,N/A,70.00,N/A,500.00,N/A,500.00,N/A,58.04,N/A,93.24,N/A,93.24,N/A,93.24,N/A,281.10,N/A,500.00,N/A,70.00,N/A,268.00,N/A,268.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,500.00,300.00,300.00,58.04,500.00,,Hospital HCPCS J9271,PEMBROLIZUMAB 100 MG/4ML IV SOLN,00006-3026-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),26185.20,26185.20,15711.12,15711.12,N/A,3665.93,N/A,5481.10,N/A,14721.32,N/A,8902.97,N/A,13763.26,N/A,3665.93,N/A,5481.10,N/A,5481.10,N/A,8567.76,N/A,13763.26,N/A,13763.26,N/A,13763.26,N/A,14721.32,N/A,5481.10,N/A,3665.93,N/A,14035.27,N/A,14035.27,N/A,3665.93,N/A,5481.10,N/A,5481.10,N/A,6029.21,15711.12,15711.12,3665.93,15711.12,,Hospital J9272,"Inj, dostarlimab-gxly, 10 mg",N/A,N/A,N/A,156581.80,N/A,93949.08,N/A,21916.86,N/A,12152.66,N/A,88144.97,N/A,53237.81,N/A,30558.36,N/A,21916.86,N/A,12104.32,N/A,12104.32,N/A,19022.86,N/A,30558.36,N/A,30558.36,N/A,30558.36,N/A,86589.11,N/A,12213.46,N/A,21916.86,N/A,3934.56,N/A,3934.56,N/A,21916.86,N/A,12213.46,N/A,12268.76,N/A,488.46,N/A,N/A,488.46,93949.08,,Hospital HCPCS J9280,MITOMYCIN 20 MG IV SOLR (1 MG/ML),16729-0108-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3159.90,3159.90,1895.94,1895.94,N/A,442.39,N/A,316.10,N/A,1776.50,N/A,1074.37,N/A,488.58,N/A,442.39,N/A,316.10,N/A,316.10,N/A,304.14,N/A,488.58,N/A,488.58,N/A,488.58,N/A,1776.50,N/A,316.10,N/A,442.39,N/A,1693.71,N/A,1693.71,N/A,442.39,N/A,316.10,N/A,316.10,N/A,3159.90,1895.94,1895.94,304.14,3159.90,,Hospital HCPCS J9280,MITOMYCIN 40 MG IV SOLR,00143-9280-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6320.00,6320.00,3792.00,3792.00,N/A,884.80,N/A,632.19,N/A,3553.10,N/A,2148.80,N/A,977.16,N/A,884.80,N/A,632.19,N/A,632.19,N/A,608.29,N/A,977.16,N/A,977.16,N/A,977.16,N/A,3553.10,N/A,632.19,N/A,884.80,N/A,3387.52,N/A,3387.52,N/A,884.80,N/A,632.19,N/A,632.19,N/A,6320.00,3792.00,3792.00,608.29,6320.00,,Hospital HCPCS J9280,MITOMYCIN 5 MG IV SOLR,16729-0115-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1216.40,1216.40,729.84,729.84,N/A,170.30,N/A,79.02,N/A,683.86,N/A,413.58,N/A,122.14,N/A,170.30,N/A,79.02,N/A,79.02,N/A,76.04,N/A,122.14,N/A,122.14,N/A,122.14,N/A,683.86,N/A,79.02,N/A,170.30,N/A,651.99,N/A,651.99,N/A,170.30,N/A,79.02,N/A,79.02,N/A,1216.40,729.84,729.84,76.04,1216.40,,Hospital J9281,Mitomycin instillation,N/A,N/A,N/A,117454.00,N/A,70472.40,N/A,16437.83,N/A,23898.46,N/A,66176.45,N/A,39934.36,N/A,59599.89,N/A,16437.83,N/A,23887.88,N/A,23887.88,N/A,37101.51,N/A,59599.89,N/A,59599.89,N/A,59599.89,N/A,66176.45,N/A,23887.88,N/A,16437.83,N/A,527.00,N/A,527.00,N/A,16437.83,N/A,23891.81,N/A,23898.46,N/A,108.01,N/A,N/A,108.01,70472.40,,Hospital J9293,Mitoxantrone Hydrochl / 5 Mg,N/A,N/A,307847.97,N/A,184708.78,N/A,N/A,N/A,N/A,N/A,108187.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,108187.35,N/A,N/A,N/A,N/A,N/A,108187.35,N/A,108187.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,108187.35,184708.78,N/A,N/A,,Hospital HCPCS J9308,RAMUCIRUMAB 500 MG/50ML IV SOLN,00002-7678-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),32996.30,32996.30,19797.78,19797.78,N/A,4619.48,N/A,6887.00,N/A,18550.52,N/A,11218.74,N/A,17008.53,N/A,4619.48,N/A,6887.00,N/A,6887.00,N/A,10587.97,N/A,17008.53,N/A,17008.53,N/A,17008.53,N/A,18550.52,N/A,6887.00,N/A,4619.48,N/A,17686.02,N/A,17686.02,N/A,4619.48,N/A,6887.00,N/A,6887.00,N/A,32996.30,19797.78,19797.78,4619.48,32996.30,,Hospital HCPCS J9308,RAMUCIRUMAB 100 MG/10ML IV SOLN,00002-7669-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6599.30,6599.30,3959.58,3959.58,N/A,923.90,N/A,1377.40,N/A,3710.13,N/A,2243.76,N/A,3401.71,N/A,923.90,N/A,1377.40,N/A,1377.40,N/A,2117.59,N/A,3401.71,N/A,3401.71,N/A,3401.71,N/A,3710.13,N/A,1377.40,N/A,923.90,N/A,3537.22,N/A,3537.22,N/A,923.90,N/A,1377.40,N/A,1377.40,N/A,6599.30,3959.58,3959.58,923.90,6599.30,,Hospital HCPCS J9311,RITUXIMAB-HYALURONIDASE HUMAN 1400-23400 MG -UT/11.7ML SC SOLN,50242-0108-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),32883.00,32883.00,19729.80,19729.80,N/A,4603.62,N/A,5244.12,N/A,18486.82,N/A,11180.22,N/A,13742.54,N/A,4603.62,N/A,5244.12,N/A,5244.12,N/A,8554.86,N/A,13742.54,N/A,13742.54,N/A,13742.54,N/A,18486.82,N/A,5244.12,N/A,4603.62,N/A,17625.29,N/A,17625.29,N/A,4603.62,N/A,5244.12,N/A,5244.12,N/A,32883.00,19729.80,19729.80,4603.62,32883.00,,Hospital HCPCS J9316,PERTUZ-TRASTUZ-HYALURON-ZZXF 60-60-2000 MG-MG-U/ML SC SOLN,50242-0260-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),42355.00,42355.00,25413.00,25413.00,N/A,5929.70,N/A,8185.20,N/A,23811.98,N/A,14400.70,N/A,21871.00,N/A,5929.70,N/A,8185.20,N/A,8185.20,N/A,13614.91,N/A,21871.00,N/A,21871.00,N/A,21871.00,N/A,23811.98,N/A,8185.20,N/A,5929.70,N/A,22702.28,N/A,22702.28,N/A,5929.70,N/A,8185.20,N/A,8185.20,N/A,9003.72,25413.00,25413.00,5929.70,25413.00,,Hospital HCPCS J9316,PERTUZ-TRASTUZ-HYALURON-ZZXF 80-40-2000 MG-MG-U/ML SC SOLN,50242-0245-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),63535.00,63535.00,38121.00,38121.00,N/A,8894.90,N/A,12277.80,N/A,35719.38,N/A,21601.90,N/A,32806.49,N/A,8894.90,N/A,12277.80,N/A,12277.80,N/A,20422.36,N/A,32806.49,N/A,32806.49,N/A,32806.49,N/A,35719.38,N/A,12277.80,N/A,8894.90,N/A,34054.76,N/A,34054.76,N/A,8894.90,N/A,12277.80,N/A,12277.80,N/A,13505.58,38121.00,38121.00,8894.90,38121.00,,Hospital HCPCS J9360,VINBLASTINE SULFATE 1 MG/ML IV SOLN,63323-0278-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),235.80,235.80,141.48,141.48,N/A,33.01,N/A,235.80,N/A,132.57,N/A,80.17,N/A,103.86,N/A,33.01,N/A,235.80,N/A,235.80,N/A,64.65,N/A,103.86,N/A,103.86,N/A,103.86,N/A,132.57,N/A,235.80,N/A,33.01,N/A,126.39,N/A,126.39,N/A,33.01,N/A,235.80,N/A,235.80,N/A,235.80,141.48,141.48,33.01,235.80,,Hospital J9390,Vinorelbine Tartrate/10 Mg,N/A,N/A,83846.02,3657.00,50307.61,2194.20,6498.10,518.27,7952.56,486.91,14644.00,2100.68,28507.67,1243.38,14784.08,1325.41,6698.32,518.27,1124.00,486.91,1124.00,486.91,9202.75,825.09,14784.08,1325.41,14784.08,1325.41,14784.08,1325.41,14644.00,2100.68,7952.56,486.91,6698.32,518.27,17589.36,1691.72,17589.36,1691.72,6698.32,518.27,7952.56,486.91,7952.56,486.91,7167.20,535.61,1124.00,50307.61,486.91,2194.20,,Hospital J9394,"Inj, fulvestrant (fresenius)",N/A,N/A,76634.10,6517.70,45980.46,3910.62,12084.52,914.57,14561.00,93.99,27233.44,3684.26,26055.59,2216.02,28313.98,229.74,12456.86,914.57,14561.00,93.99,14561.00,93.99,17626.30,172.57,28313.98,229.74,28313.98,229.74,28313.98,229.74,27233.44,3684.26,14561.00,142.20,12456.86,914.57,32710.93,441.72,32710.93,441.72,N/A,914.57,14561.00,142.20,14561.00,142.20,13328.84,156.43,12084.52,45980.46,93.99,3910.62,,Hospital L0120,HC Cerv Flex N/Adj Foam Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,98170.90,63532.20,58902.54,38119.32,10665.51,8859.32,12971.34,11782.94,42968.92,36336.43,33378.11,21407.51,24265.50,28659.08,16887.40,8859.32,12882.39,11782.94,12882.39,11782.94,30768.51,17840.83,24265.50,28659.08,24265.50,28659.08,24265.50,28659.08,42968.92,36336.43,12882.39,11782.94,10994.13,8859.32,N/A,13336.25,N/A,13336.25,16887.40,8859.32,12971.34,11782.94,12971.34,11782.94,16887.40,12961.23,10665.51,58902.54,8859.32,38119.32,,Hospital L0174,HC Cerv Sr 2pc Thor Ext Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,99846.32,41014.55,59907.79,24608.73,12650.07,5726.94,37652.58,6206.72,43608.20,23600.24,33947.74,13944.95,73462.87,15170.32,12650.07,5726.94,20182.56,6142.03,5620.00,6142.03,76852.17,9664.65,76852.17,15170.32,73462.87,15170.32,76852.17,15170.32,86322.07,23600.30,37356.08,6168.30,32320.31,5726.94,84871.10,8160.50,43608.20,8160.50,12650.07,5726.94,20182.56,6142.03,37356.08,6206.72,34582.73,1867.75,5620.00,86322.07,1867.75,24608.73,,Hospital L0450,HC Tlso Flex Trunk/Thor Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,25049.92,50908.48,15029.95,30545.09,4653.92,7080.79,5771.00,3345.78,10505.65,29274.44,8508.95,17308.90,7322.00,7759.23,4797.32,7080.79,5771.00,3198.50,5771.00,3198.50,4558.00,4830.26,7322.00,7759.23,7322.00,7759.23,7322.00,7759.23,10505.65,29274.45,5771.00,3198.50,4797.32,7080.79,12597.46,7983.50,12597.46,7983.50,5110.03,7080.79,5771.00,3198.50,5771.00,3345.78,5133.13,630.76,4558.00,15029.95,630.76,30545.09,,Hospital L0457,HC Tlso Flex Trnk Sj-Ss Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,15568.82,N/A,9341.29,N/A,5123.90,N/A,6326.96,N/A,11547.13,N/A,5293.40,N/A,11657.59,N/A,5281.78,N/A,562.00,N/A,562.00,N/A,7256.58,N/A,11657.59,N/A,11657.59,N/A,11657.59,N/A,11547.13,N/A,6326.96,N/A,5281.78,N/A,13869.62,N/A,13869.62,N/A,5281.78,N/A,6326.96,N/A,6326.96,N/A,5651.50,N/A,562.00,13869.62,N/A,N/A,,Hospital L0464,HC Tlso 4mod Sacro-Scap Pre,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,55900.10,17207.30,33540.06,10324.38,5809.40,2356.85,7137.86,2376.53,15460.51,9848.94,19006.03,5850.48,13217.19,5870.59,5988.40,2356.85,7137.86,2352.67,7137.86,2352.67,8227.40,3850.56,13217.19,5870.59,13217.19,5870.59,13217.19,5870.59,15460.51,9848.99,7137.86,2375.61,5988.40,2356.85,15725.16,5858.64,15725.16,5858.64,9368.93,2356.85,7137.86,2352.67,7137.86,2376.53,6407.59,621.82,5809.40,33540.06,621.82,10324.38,,Hospital L0710,HC Ctlso a-P-L Control W/ Inter,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,121025.80,N/A,72615.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,40890.13,N/A,18232.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11349.12,N/A,18232.20,N/A,18232.20,N/A,18232.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11349.12,72615.48,N/A,N/A,,Hospital L0859,HC MRI Compatible System,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,50904.40,N/A,30542.64,N/A,5123.90,N/A,6326.96,N/A,17997.81,N/A,17307.50,N/A,11657.59,N/A,5281.78,N/A,1124.00,N/A,1124.00,N/A,7256.58,N/A,11657.59,N/A,11657.59,N/A,11657.59,N/A,17997.81,N/A,6326.96,N/A,5281.78,N/A,13869.62,N/A,13869.62,N/A,N/A,N/A,6326.96,N/A,6326.96,N/A,5651.50,N/A,1124.00,30542.64,N/A,N/A,,Hospital L1820,HC Ko Elas W/ Condyle Pads & Jo,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,76516.40,N/A,45909.84,N/A,N/A,N/A,19871.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23403.11,N/A,23403.11,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23403.11,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23403.11,N/A,23403.11,N/A,N/A,N/A,19871.00,45909.84,N/A,N/A,,Hospital L1851,HC Ko Single Upright Prefab Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,94526.37,N/A,56715.82,N/A,13223.35,N/A,6915.93,N/A,7823.00,N/A,32138.96,N/A,7000.18,N/A,13223.35,N/A,6904.41,N/A,6904.41,N/A,4357.75,N/A,7000.18,N/A,7000.18,N/A,7000.18,N/A,7823.00,N/A,6904.41,N/A,13223.35,N/A,6618.25,N/A,6618.25,N/A,13223.35,N/A,6904.41,N/A,6915.93,N/A,1238.26,N/A,N/A,1238.26,56715.82,,Hospital L2036,HC Kafo Plas Doub Free Knee Mol,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,247608.10,N/A,148564.86,N/A,11242.60,N/A,64580.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,11242.60,N/A,11242.60,148564.86,N/A,N/A,,Hospital L2128,HC Kafo Fem Fx Cast Molded to P,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,21879.40,N/A,13127.64,N/A,N/A,N/A,7137.86,N/A,16096.35,N/A,7439.00,N/A,13217.19,N/A,5988.40,N/A,N/A,N/A,N/A,N/A,8227.40,N/A,13217.19,N/A,13217.19,N/A,13217.19,N/A,16096.35,N/A,N/A,N/A,5988.40,N/A,15725.16,N/A,15725.16,N/A,N/A,N/A,N/A,N/A,7137.86,N/A,N/A,N/A,5988.40,16096.35,N/A,N/A,,Hospital L2136,HC Kafo Femoral Fx Cast Rigid,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,617443.45,N/A,370466.07,N/A,N/A,N/A,130475.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130475.30,N/A,130475.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130475.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130475.30,N/A,130475.30,N/A,N/A,N/A,130475.30,370466.07,N/A,N/A,,Hospital L2330,HC Lacer Molded to Patient Mode,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,65493.30,N/A,39295.98,N/A,7153.52,N/A,16944.43,N/A,77300.42,N/A,22267.72,N/A,33080.67,N/A,7156.93,N/A,16944.43,N/A,16944.43,N/A,6692.00,N/A,33080.67,N/A,N/A,N/A,33080.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,22572.00,N/A,22572.00,N/A,N/A,N/A,16944.43,N/A,16944.43,N/A,6272.53,N/A,6272.53,77300.42,N/A,N/A,,Hospital L2405,HC Knee Joint Drop Lock Ea Jnt,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,164726.30,N/A,98835.78,N/A,11242.60,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,43027.77,N/A,33639.01,N/A,11242.60,N/A,11242.60,98835.78,N/A,N/A,,Hospital L2755,HC Carbon Graphite Lamination Custom Fab Orthosis,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,85660.20,N/A,51396.12,N/A,N/A,N/A,31710.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,22376.16,N/A,22376.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31710.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31710.09,N/A,31710.09,N/A,N/A,N/A,22376.16,51396.12,N/A,N/A,,Hospital L2830,HC Soft Interface Above Knee Se,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,247608.10,N/A,148564.86,N/A,11242.60,N/A,64580.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,11242.60,N/A,11242.60,148564.86,N/A,N/A,,Hospital L3010,HC Ot Foot Ins Molded Long,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,442.00,N/A,265.20,N/A,61.88,N/A,184.82,N/A,248.49,N/A,150.28,N/A,61.88,N/A,61.88,N/A,184.82,N/A,184.82,N/A,38.45,N/A,61.88,N/A,61.88,N/A,61.88,N/A,248.49,N/A,184.82,N/A,61.88,N/A,236.91,N/A,236.91,N/A,61.88,N/A,184.82,N/A,184.82,N/A,N/A,N/A,N/A,38.45,265.20,,Hospital L3332,HC Shoe Lifts Tapered to One-Ha,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,65493.30,N/A,39295.98,N/A,N/A,N/A,16944.43,N/A,N/A,N/A,22267.72,N/A,33080.67,N/A,N/A,N/A,16944.43,N/A,16944.43,N/A,6692.00,N/A,33080.67,N/A,33080.67,N/A,33080.67,N/A,N/A,N/A,16940.61,N/A,N/A,N/A,22572.00,N/A,22572.00,N/A,N/A,N/A,16944.43,N/A,16944.43,N/A,6272.53,N/A,6272.53,39295.98,N/A,N/A,,Hospital L3702,HC Custom Elbow Static,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,58844.78,1815.88,35306.87,1089.53,15312.08,254.22,18681.49,389.08,41117.21,1038.83,20007.22,617.40,35998.34,69.42,15783.87,254.22,18681.49,387.90,18681.49,387.90,22408.13,43.14,35998.34,69.42,35998.34,69.42,35998.34,69.42,41117.21,1038.83,18681.49,387.90,15783.87,254.22,42829.04,563.34,42829.04,563.34,N/A,254.22,18681.49,387.90,18681.49,389.08,16888.74,49.58,15312.08,42829.04,43.14,1089.53,,Hospital L3809,HC Whfo W/O Joints Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,65151.95,859.08,39091.17,515.45,10557.21,120.27,12783.93,351.72,32850.41,494.11,22151.66,292.09,24019.12,5.61,10882.50,120.27,120830.00,350.54,120830.00,350.54,14951.35,3.49,24019.12,5.61,24019.12,5.61,24019.12,5.61,32850.41,494.11,12754.28,350.54,10882.50,120.27,28576.76,303.91,28576.76,303.91,N/A,120.27,12754.28,350.54,12783.93,351.72,11644.28,76.92,10557.21,120830.00,3.49,515.45,,Hospital L3905,HC Who W/1 or More Customfit,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,247608.10,N/A,148564.86,N/A,N/A,N/A,64580.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,50210.30,N/A,50210.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,50210.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,50210.30,N/A,50210.30,N/A,N/A,N/A,50210.30,148564.86,N/A,N/A,,Hospital L3919,HC Custom Hand Static,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,86987.00,2465.00,52192.20,1479.00,N/A,345.10,34923.17,558.63,N/A,1415.79,N/A,838.10,N/A,894.66,N/A,345.10,22732.29,558.63,22732.29,558.63,N/A,880.83,N/A,894.66,N/A,894.66,N/A,894.66,N/A,1415.79,34923.17,547.51,N/A,345.10,N/A,1181.38,N/A,1181.38,N/A,345.10,34923.17,558.63,34923.17,558.63,N/A,326.86,22732.29,52192.20,326.86,1479.00,,Hospital L3921,HC Hfo W/1 or More Customfit,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,3190.00,N/A,1914.00,N/A,446.60,N/A,633.03,N/A,1834.56,N/A,1084.60,N/A,957.17,N/A,446.60,N/A,633.03,N/A,633.03,N/A,948.37,N/A,957.17,N/A,957.17,N/A,957.17,N/A,1834.56,N/A,621.37,N/A,446.60,N/A,1620.89,N/A,1620.89,N/A,446.60,N/A,633.03,N/A,633.03,N/A,355.25,N/A,N/A,355.25,1914.00,,Hospital L3931,HC Brace Wrist/Thumb,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,36439.82,N/A,21863.89,N/A,5101.57,N/A,6248.31,N/A,11735.00,N/A,12389.53,N/A,14497.44,N/A,5101.57,N/A,5973.28,N/A,5973.28,N/A,9025.52,N/A,14497.44,N/A,14497.44,N/A,14497.44,N/A,11735.00,N/A,5973.28,N/A,5101.57,N/A,12203.25,N/A,12203.25,N/A,5101.57,N/A,5973.28,N/A,6248.31,N/A,2107.57,N/A,N/A,2107.57,21863.89,,Hospital L4361,HC Pneuma/Vac Walk Boot Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,3248.57,N/A,1949.14,N/A,454.80,N/A,641.93,N/A,1866.09,N/A,1104.51,N/A,45.58,N/A,454.80,N/A,640.75,N/A,640.75,N/A,28.33,N/A,45.58,N/A,45.58,N/A,45.58,N/A,1866.09,N/A,640.75,N/A,454.80,N/A,1422.54,N/A,1422.54,N/A,454.80,N/A,640.75,N/A,641.93,N/A,135.55,N/A,N/A,28.33,1949.14,,Hospital L8420,HC Prosthetic Sock Multi Ply Bk,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,112032.90,N/A,67219.74,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62883.30,N/A,62883.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62883.30,N/A,62883.30,N/A,62883.30,N/A,62883.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62883.30,67219.74,N/A,N/A,,Hospital L8509,HC Trach-Esoph Voice Pros MD In,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,36028.88,2384.43,21617.33,1430.66,4904.12,333.82,6066.96,187.31,12609.56,1349.97,12249.81,810.71,11157.54,446.96,5055.22,333.82,1686.00,187.31,1686.00,187.31,6945.31,357.37,11157.54,446.96,11157.54,446.96,N/A,446.96,12609.56,1349.97,6066.96,186.18,5055.22,333.82,13274.69,371.98,13274.69,371.98,N/A,333.82,6066.96,187.31,6066.96,187.31,5409.09,78.35,1686.00,21617.33,78.35,1430.66,,Hospital L8604,HC Dextranomer/Hyaluronic Acid 1ml,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,41317.58,N/A,24790.55,N/A,5784.46,N/A,4517.10,N/A,23370.61,N/A,14047.98,N/A,10271.33,N/A,5784.46,N/A,4246.26,N/A,4246.26,N/A,6394.10,N/A,10271.33,N/A,10271.33,N/A,10271.33,N/A,23370.61,N/A,4246.26,N/A,5784.46,N/A,5963.00,N/A,5963.00,N/A,5784.46,N/A,4246.26,N/A,4517.10,N/A,277.50,N/A,N/A,277.50,24790.55,,Hospital L8607,HC Inj Vocal Cord Bulking Agent,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,163013.72,20917.48,97808.23,12550.49,N/A,2928.45,8924.96,282.97,N/A,11941.41,N/A,7111.94,N/A,7318.38,N/A,2928.45,8924.96,3010.42,8924.96,3010.42,N/A,4555.83,N/A,7318.38,N/A,7318.38,N/A,7318.38,N/A,11941.42,8924.96,3010.42,N/A,2928.45,N/A,3397.00,N/A,3397.00,N/A,2928.45,8924.96,3010.42,8924.96,282.97,N/A,261.11,8924.96,97808.23,261.11,12550.49,,Hospital L8670,HC� Vascular Graft Synthetic,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,244672.02,65306.62,146803.21,39183.97,22951.93,9124.88,29113.42,4945.32,129647.38,37444.98,70204.02,22204.26,70204.02,11312.73,22951.93,9124.88,51559.94,4649.27,51559.94,4649.27,70204.02,7042.40,70204.02,11312.73,70204.02,11312.73,70204.02,11312.73,129647.38,37444.98,29113.42,4649.27,44697.44,9124.88,115974.54,7897.00,129647.38,7897.00,22951.93,9124.88,29113.42,4649.27,29113.42,4945.32,22951.93,740.44,22951.93,146803.21,740.44,39183.97,,Hospital L8680,Implt neurostim elctr each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21788.60,N/A,13073.16,N/A,3079.34,N/A,6238.13,N/A,12457.41,N/A,7408.11,N/A,14437.85,N/A,3079.34,N/A,5963.54,N/A,5963.54,N/A,8987.83,N/A,14437.85,N/A,14437.85,N/A,14437.85,N/A,12457.40,N/A,5963.54,N/A,3079.34,N/A,11845.50,N/A,11845.50,N/A,3079.34,N/A,5963.54,N/A,6238.13,N/A,973.62,N/A,N/A,973.62,14437.85,,Hospital L8699,HC Misc Prosthetic Implant Nos,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,68485.03,15957.88,41091.02,9574.73,17702.40,2234.10,21206.68,4821.94,39964.60,9181.42,23284.91,5425.68,40275.42,11698.26,18247.85,2234.10,3934.00,4821.94,3934.00,4821.94,47877.86,7282.39,40275.42,11698.26,40275.42,11698.26,40275.42,11698.26,N/A,9181.42,21206.68,4821.94,18247.85,2234.10,N/A,6898.50,N/A,6898.50,N/A,2234.10,N/A,4821.94,21206.68,4821.94,19525.20,5304.13,3934.00,47877.86,2234.10,11698.26,,Hospital M0250,Adm tocilizu covid-19 2nd,N/A,N/A,169057.80,N/A,101434.68,N/A,N/A,N/A,23067.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23067.02,N/A,23067.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23067.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20282.16,N/A,23067.02,N/A,N/A,N/A,20282.16,101434.68,N/A,N/A,,Hospital MED10110,"Remover,Staple,Skin,Sterile",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2222.10,N/A,1333.26,N/A,N/A,N/A,1080.00,N/A,800.00,N/A,925.52,N/A,925.52,N/A,N/A,N/A,1826.07,N/A,1826.07,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,800.00,N/A,1931.46,N/A,N/A,N/A,800.00,N/A,800.00,N/A,N/A,N/A,1826.07,N/A,1826.07,N/A,N/A,N/A,N/A,800.00,1931.46,,Hospital MED10156,"Scissors,Bandage,Lister,5.5",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2919.72,N/A,1751.83,N/A,563.04,N/A,1755.00,N/A,700.00,N/A,1574.72,N/A,1574.72,N/A,563.04,N/A,2014.63,N/A,2014.63,N/A,1574.72,N/A,1574.72,N/A,1574.72,N/A,1574.72,N/A,700.00,N/A,2304.31,N/A,563.04,N/A,700.00,N/A,700.00,N/A,563.04,N/A,1140.00,N/A,2434.51,N/A,563.04,N/A,N/A,563.04,2434.51,,Hospital MED10161,"Blade, Tongue, 5 1/2, Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1298.28,N/A,778.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,778.97,778.97,,Hospital MED10163,"Applicator,Cotton-Tip,Plastic,6,Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3082.02,N/A,1849.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1849.21,1849.21,,Hospital MED10164,"Container,Sharps,1 Qt.,Red,Phleb.",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1202.92,N/A,721.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,408.99,N/A,222.41,N/A,168.41,N/A,N/A,N/A,N/A,N/A,222.25,N/A,222.41,N/A,222.41,N/A,222.41,N/A,692.64,N/A,N/A,N/A,N/A,N/A,1.56,N/A,1.56,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.56,721.75,,Hospital MED10197,"Paste,Calazime, Remedy Ist Phyto 4oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2988.97,N/A,1793.38,N/A,1201.62,N/A,1575.00,N/A,701.40,N/A,N/A,N/A,N/A,N/A,48.54,N/A,1575.00,N/A,1575.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,701.40,N/A,1575.00,N/A,1201.62,N/A,701.40,N/A,701.40,N/A,1201.62,N/A,1575.00,N/A,1575.00,N/A,1201.62,N/A,N/A,48.54,1793.38,,Hospital MED10212,"Absorbent Sheet, 6x14, 10ea/Bg, 25bg",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3252.02,N/A,1951.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,110.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,110.40,1951.21,,Hospital MED10309,"Accuwrap Xl, 2 Layer, Compression Sys",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2202.75,N/A,1321.65,N/A,N/A,N/A,2202.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2202.90,N/A,2202.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2202.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2202.90,N/A,2202.90,N/A,N/A,N/A,N/A,1321.65,2202.90,,Hospital MED10311,"Accuwrap Lite, 2 Layer, Compression Sys",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3008.28,N/A,1804.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1804.97,1804.97,,Hospital MED10443,"Tape,Zinc,Pinc,2x5yd",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,8797.80,N/A,5278.68,N/A,N/A,N/A,2090.00,N/A,N/A,N/A,2991.26,N/A,1890.00,N/A,1231.69,N/A,2090.00,N/A,2090.00,N/A,2256.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,5065.76,N/A,2090.00,N/A,N/A,N/A,1286.40,N/A,1286.40,N/A,N/A,N/A,2090.00,N/A,2090.00,N/A,306.23,N/A,N/A,306.23,5278.68,,Hospital MED10508,"Syringe, Luer Lock, Sterile, 10ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1250.58,N/A,750.35,N/A,481.52,N/A,153.77,N/A,400.00,N/A,674.88,N/A,674.88,N/A,5.40,N/A,153.77,N/A,153.77,N/A,674.88,N/A,674.88,N/A,674.88,N/A,674.88,N/A,400.00,N/A,153.77,N/A,481.52,N/A,400.00,N/A,400.00,N/A,481.52,N/A,153.77,N/A,153.77,N/A,481.52,N/A,N/A,5.40,750.35,,Hospital MED10509,"Syringe, Luer Lock, Sterile, 20ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1509.17,N/A,905.50,N/A,N/A,N/A,1140.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1140.00,N/A,1140.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1140.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1140.00,N/A,1140.00,N/A,N/A,N/A,N/A,905.50,1140.00,,Hospital MED10581,"Field,Sterile,Tissue-Poly-Tiss,18x26",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3386.23,N/A,2031.74,N/A,573.64,N/A,28.73,N/A,N/A,N/A,1151.33,N/A,613.39,N/A,474.08,N/A,1475.00,N/A,1475.00,N/A,713.66,N/A,613.39,N/A,613.39,N/A,613.39,N/A,1949.79,N/A,1475.00,N/A,573.64,N/A,428.80,N/A,428.80,N/A,573.64,N/A,1475.00,N/A,28.73,N/A,31.61,N/A,N/A,28.73,2031.74,,Hospital MED10595,"Saline,.9%,15 Ml,Vial",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2574.73,N/A,1544.84,N/A,N/A,N/A,648.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,648.00,N/A,648.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,648.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,648.00,N/A,648.00,N/A,N/A,N/A,N/A,648.00,1544.84,,Hospital MED10613,"Cleanser,Wound,Microklenz,8 Oz,Spray",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3185.03,N/A,1911.02,N/A,724.08,N/A,1313.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,724.08,N/A,1313.00,N/A,1313.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1313.00,N/A,724.08,N/A,N/A,N/A,N/A,N/A,724.08,N/A,1313.00,N/A,1313.00,N/A,724.08,N/A,N/A,724.08,1911.02,,Hospital MED10821,"Bandage,Gauze,4.5""X4.1yd,Sterile,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3282.73,N/A,1969.64,N/A,986.68,N/A,1404.00,N/A,785.00,N/A,1116.12,N/A,557.00,N/A,459.57,N/A,1260.00,N/A,1260.00,N/A,801.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,1890.22,N/A,2709.87,N/A,986.68,N/A,857.60,N/A,857.60,N/A,986.68,N/A,864.00,N/A,1404.00,N/A,100.90,N/A,N/A,100.90,2709.87,,Hospital MED10907,"Tape,Cloth,Surgical,Medipore-H,4x2yd",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5106.08,N/A,3063.65,N/A,271.53,N/A,213.32,N/A,N/A,N/A,1736.06,N/A,1112.78,N/A,714.86,N/A,1430.00,N/A,1430.00,N/A,1111.72,N/A,1112.78,N/A,1112.78,N/A,1112.78,N/A,2940.07,N/A,1430.00,N/A,271.53,N/A,378.46,N/A,378.46,N/A,271.53,N/A,1430.00,N/A,213.32,N/A,234.66,N/A,N/A,213.32,3063.65,,Hospital MED11175,"Cleanser,Wound/Skin,Carraklenz,6 Oz,Bt",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2159.93,N/A,1295.96,N/A,N/A,N/A,420.00,N/A,N/A,N/A,734.38,N/A,335.16,N/A,302.39,N/A,420.00,N/A,420.00,N/A,456.72,N/A,335.16,N/A,335.16,N/A,335.16,N/A,1243.69,N/A,420.00,N/A,N/A,N/A,428.80,N/A,428.80,N/A,N/A,N/A,420.00,N/A,420.00,N/A,154.58,N/A,N/A,154.58,1295.96,,Hospital MED11221,"Sol,Dakin.125%,1/4 Strength,No Retrn",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3854.28,N/A,2312.57,N/A,N/A,N/A,1045.00,N/A,N/A,N/A,1310.47,N/A,999.00,N/A,539.60,N/A,1045.00,N/A,1045.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2219.29,N/A,1045.00,N/A,N/A,N/A,136.30,N/A,136.30,N/A,N/A,N/A,1045.00,N/A,1045.00,N/A,145.11,N/A,N/A,136.30,2312.57,,Hospital MED11365,"Scissors,Bandage,Lister,7.25",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2344.93,N/A,1406.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,108.34,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,108.34,1406.96,,Hospital MED11368,"Gauze, Border, 3x6, 1.5x4pad,Sterile",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4846.80,N/A,2908.08,N/A,1805.70,N/A,1178.00,N/A,N/A,N/A,1647.91,N/A,1111.00,N/A,678.55,N/A,1178.00,N/A,1178.00,N/A,1150.80,N/A,1111.00,N/A,1111.00,N/A,1111.00,N/A,2790.79,N/A,1178.00,N/A,1805.70,N/A,214.40,N/A,214.40,N/A,1805.70,N/A,1178.00,N/A,1178.00,N/A,1805.70,N/A,N/A,214.40,2908.08,,Hospital MED11372,"Dbf-See Mmm2862hh,Tape,Cloth,Surgical,Me",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,7373.82,N/A,4424.29,N/A,2090.45,N/A,169.94,N/A,N/A,N/A,2507.12,N/A,1446.00,N/A,1032.34,N/A,N/A,N/A,N/A,N/A,1812.00,N/A,1446.00,N/A,1446.00,N/A,1446.00,N/A,4245.83,N/A,N/A,N/A,2090.45,N/A,1286.40,N/A,1286.40,N/A,2090.45,N/A,N/A,N/A,169.94,N/A,186.93,N/A,N/A,169.94,4424.29,,Hospital MED11412,"Jet,Curos,Loose,5400/Cs,270/Bx,1ea",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4531.02,N/A,2718.61,N/A,N/A,N/A,87.24,N/A,994.00,N/A,1540.54,N/A,1000.00,N/A,634.33,N/A,N/A,N/A,N/A,N/A,1122.00,N/A,1000.00,N/A,1000.00,N/A,1000.00,N/A,2608.96,N/A,N/A,N/A,N/A,N/A,428.80,N/A,428.80,N/A,N/A,N/A,N/A,N/A,87.24,N/A,95.96,N/A,N/A,87.24,2718.61,,Hospital MED11426,"Dressing,Hydrofiber,Advantage,2x2",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3471.23,N/A,2082.74,N/A,986.68,N/A,78.00,N/A,N/A,N/A,1180.23,N/A,925.97,N/A,485.97,N/A,N/A,N/A,N/A,N/A,911.59,N/A,925.97,N/A,925.97,N/A,925.97,N/A,1998.74,N/A,N/A,N/A,986.68,N/A,145.38,N/A,145.38,N/A,986.68,N/A,N/A,N/A,78.00,N/A,85.80,N/A,N/A,78.00,2082.74,,Hospital MED11508,"Scissor,Bandage,Plastic Probe, Red, 7.5""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1746.63,N/A,1047.98,N/A,N/A,N/A,330.00,N/A,N/A,N/A,593.86,N/A,280.09,N/A,244.53,N/A,330.00,N/A,330.00,N/A,340.30,N/A,280.09,N/A,280.09,N/A,280.09,N/A,1005.71,N/A,330.00,N/A,N/A,N/A,214.40,N/A,214.40,N/A,N/A,N/A,330.00,N/A,330.00,N/A,32.04,N/A,N/A,32.04,1047.98,,Hospital MED11517,"Bottle,Preevacuated,W/Cap,1000ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2175.38,N/A,1305.23,N/A,N/A,N/A,2175.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2175.38,N/A,2175.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2175.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2175.38,N/A,2175.38,N/A,N/A,N/A,N/A,1305.23,2175.38,,Hospital MED11639,Modudose 5ml .9% 5ml,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1219.77,N/A,731.86,N/A,N/A,N/A,216.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,216.00,N/A,216.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,216.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,216.00,N/A,216.00,N/A,N/A,N/A,N/A,216.00,731.86,,Hospital MED11659,"Ointment,Phytoplex,Clear Aid,2.5 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2871.58,N/A,1722.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1722.95,1722.95,,Hospital MED11691,"Bandage,Adhesive,Plastic,3/4""X3"",St,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1915.12,N/A,1149.07,N/A,N/A,N/A,1944.31,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1944.31,N/A,1944.31,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1944.31,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1944.31,N/A,1944.31,N/A,N/A,N/A,N/A,1149.07,1944.31,,Hospital MED11736,"Dressing,Hydrofiber,Advantage,8""X12""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3643.33,N/A,2186.00,N/A,N/A,N/A,950.00,N/A,N/A,N/A,1238.73,N/A,779.39,N/A,510.06,N/A,950.00,N/A,950.00,N/A,900.86,N/A,779.39,N/A,779.39,N/A,779.39,N/A,2097.84,N/A,950.00,N/A,N/A,N/A,428.80,N/A,428.80,N/A,N/A,N/A,950.00,N/A,950.00,N/A,5.75,N/A,N/A,5.75,2186.00,,Hospital MED11779,"Scissors, Lister Bandage, 5.5",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5489.58,N/A,3293.75,N/A,N/A,N/A,26.50,N/A,N/A,N/A,1866.47,N/A,1333.39,N/A,768.55,N/A,3792.66,N/A,3792.66,N/A,1332.86,N/A,1333.39,N/A,1333.39,N/A,1333.39,N/A,3160.90,N/A,3792.66,N/A,N/A,N/A,369.61,N/A,369.61,N/A,N/A,N/A,3792.66,N/A,26.50,N/A,29.15,N/A,N/A,26.50,3792.66,,Hospital MED11788,"Posiflush,Pre-Filled,Saline,Syringe,10ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2601.20,N/A,1560.72,N/A,928.93,N/A,122.11,N/A,510.88,N/A,884.39,N/A,500.00,N/A,364.15,N/A,315.00,N/A,315.00,N/A,561.00,N/A,500.00,N/A,500.00,N/A,500.00,N/A,1497.77,N/A,315.00,N/A,928.93,N/A,214.40,N/A,214.40,N/A,928.93,N/A,315.00,N/A,122.11,N/A,134.31,N/A,N/A,122.11,1560.72,,Hospital MED11836,"Cleanser,Wound,Safewash,Saline,Sterile",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,8635.57,N/A,5181.34,N/A,N/A,N/A,2199.99,N/A,N/A,N/A,2936.10,N/A,1615.00,N/A,1208.97,N/A,2199.99,N/A,2199.99,N/A,2286.00,N/A,1615.00,N/A,1615.00,N/A,1615.00,N/A,4972.35,N/A,2199.99,N/A,N/A,N/A,2358.40,N/A,2358.40,N/A,N/A,N/A,2199.99,N/A,2199.99,N/A,40.41,N/A,N/A,40.41,5181.34,,Hospital MED11855,"Gauze,Packing Strip,Plain,1/4""X5yd,Strl",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1237.27,N/A,742.36,N/A,263.43,N/A,6.03,N/A,N/A,N/A,420.66,N/A,222.00,N/A,173.22,N/A,N/A,N/A,N/A,N/A,222.00,N/A,222.00,N/A,222.00,N/A,222.00,N/A,712.42,N/A,N/A,N/A,263.43,N/A,19.97,N/A,19.97,N/A,263.43,N/A,N/A,N/A,6.03,N/A,6.63,N/A,N/A,6.03,742.36,,Hospital MED11866,"Mbo-Cleanser,Vashe,Wound Therapy4oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2499.13,N/A,1499.48,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,674.88,N/A,674.88,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,674.88,N/A,674.88,N/A,674.88,N/A,674.88,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,674.88,2004.25,,Hospital MED11943,"Statlock Universal Plus,Medium",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2432.97,N/A,1459.78,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1459.78,1459.78,,Hospital MED12081,Exudry Dressing Wound Full 6"X 9"S,N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,9673.98,N/A,5804.39,N/A,N/A,N/A,2430.00,N/A,N/A,N/A,3289.16,N/A,1945.77,N/A,1354.36,N/A,2430.00,N/A,2430.00,N/A,1923.52,N/A,1945.77,N/A,1945.77,N/A,1945.77,N/A,5570.27,N/A,2430.00,N/A,N/A,N/A,1326.06,N/A,1326.06,N/A,N/A,N/A,2430.00,N/A,2430.00,N/A,399.89,N/A,N/A,399.89,5804.39,,Hospital MED12108,"Dressing,Aquacel,Ag,Advantage,.75""X18""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2673.82,N/A,1604.29,N/A,N/A,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,N/A,N/A,N/A,1080.00,1604.29,,Hospital MED12330,"Dressing,Aquacel,Ag,Advantage,.75""X18""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4735.93,N/A,2841.56,N/A,N/A,N/A,1080.00,N/A,N/A,N/A,1610.21,N/A,1111.39,N/A,663.03,N/A,1080.00,N/A,1080.00,N/A,1110.86,N/A,1111.39,N/A,1111.39,N/A,1111.39,N/A,2726.95,N/A,1080.00,N/A,N/A,N/A,180.07,N/A,180.07,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,93.14,N/A,N/A,93.14,2841.56,,Hospital MED12338,"Glove,Exam,Vinyl,Pf,Lf,M",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1965.73,N/A,1179.44,N/A,481.52,N/A,55.27,N/A,N/A,N/A,668.35,N/A,444.00,N/A,275.20,N/A,N/A,N/A,N/A,N/A,444.00,N/A,444.00,N/A,444.00,N/A,444.00,N/A,1131.87,N/A,N/A,N/A,481.52,N/A,196.03,N/A,196.03,N/A,481.52,N/A,N/A,N/A,55.27,N/A,60.81,N/A,N/A,55.27,1179.44,,Hospital MED12362,Urea Care 10% Cream 6 Oz Tube,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3261.88,N/A,1957.13,N/A,722.28,N/A,3327.13,N/A,N/A,N/A,N/A,N/A,N/A,N/A,722.28,N/A,3327.13,N/A,3327.13,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3327.13,N/A,722.28,N/A,N/A,N/A,N/A,N/A,722.28,N/A,3327.13,N/A,3327.13,N/A,722.28,N/A,N/A,722.28,3327.13,,Hospital MED12469,"Ointment,Antifungal,Aloe Vesta,5 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1250.58,N/A,750.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,750.35,750.35,,Hospital MED12599,"Dressing,Sni,5999034s,Trach,3 X 4in",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,10336.58,N/A,6201.95,N/A,N/A,N/A,61.66,N/A,N/A,N/A,3514.45,N/A,2169.00,N/A,1447.12,N/A,N/A,N/A,N/A,N/A,2718.00,N/A,2169.00,N/A,2169.00,N/A,2169.00,N/A,5951.80,N/A,N/A,N/A,N/A,N/A,1929.60,N/A,1929.60,N/A,N/A,N/A,N/A,N/A,61.66,N/A,67.83,N/A,N/A,61.66,6201.95,,Hospital MED12619,"Catheter,Foley,Silastic,16fr,5cc",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1303.82,N/A,782.29,N/A,N/A,N/A,375.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,375.00,N/A,375.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,375.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,375.00,N/A,375.00,N/A,N/A,N/A,N/A,375.00,782.29,,Hospital MED12639,"G-10meter,Tubigrip,Lrg-Thigh,Natural",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4702.53,N/A,2821.52,N/A,1324.18,N/A,1045.00,N/A,N/A,N/A,1598.86,N/A,823.36,N/A,658.36,N/A,1045.00,N/A,1045.00,N/A,1324.92,N/A,823.36,N/A,823.36,N/A,823.36,N/A,2707.72,N/A,1045.00,N/A,1324.18,N/A,1715.20,N/A,1715.20,N/A,1324.18,N/A,1045.00,N/A,1045.00,N/A,1324.18,N/A,N/A,658.36,2821.52,,Hospital MED12642,"Ointment,Moist Barr,Calmoseptine,2.5oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4237.30,N/A,2542.38,N/A,N/A,N/A,23.76,N/A,1265.90,N/A,1440.69,N/A,672.90,N/A,593.23,N/A,N/A,N/A,N/A,N/A,1136.80,N/A,672.90,N/A,672.90,N/A,672.90,N/A,2439.83,N/A,N/A,N/A,N/A,N/A,1500.80,N/A,1500.80,N/A,N/A,N/A,N/A,N/A,23.76,N/A,26.14,N/A,N/A,23.76,2542.38,,Hospital MED12662,"Bandage,Elas,Hookloop,2-End,Lf,4x5yd",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,6273.83,N/A,3764.30,N/A,N/A,N/A,1805.00,N/A,N/A,N/A,2133.10,N/A,1225.00,N/A,878.34,N/A,1805.00,N/A,1805.00,N/A,1713.00,N/A,1225.00,N/A,1225.00,N/A,1225.00,N/A,3612.47,N/A,1805.00,N/A,N/A,N/A,1715.20,N/A,1715.20,N/A,N/A,N/A,1805.00,N/A,1805.00,N/A,124.02,N/A,N/A,124.02,3764.30,,Hospital MED12686,"Saline,.9%,15 Ml,Addipak,Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2522.28,N/A,1513.37,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1513.37,1513.37,,Hospital MED12707,Securement Cathgrip Sm 1 Strap Sterile,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4265.57,N/A,2559.34,N/A,N/A,N/A,93.52,N/A,N/A,N/A,1450.29,N/A,999.00,N/A,597.17,N/A,1215.00,N/A,1215.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2456.11,N/A,1215.00,N/A,N/A,N/A,142.34,N/A,142.34,N/A,N/A,N/A,1215.00,N/A,1215.00,N/A,102.87,N/A,N/A,93.52,2559.34,,Hospital MED12791,"Swab,Oral,Dentips,Untreat,Indv Wrp,Blue",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6112.53,N/A,3667.52,N/A,N/A,N/A,1861.88,N/A,N/A,N/A,2078.26,N/A,1059.00,N/A,855.75,N/A,1861.88,N/A,1861.88,N/A,1397.60,N/A,1059.00,N/A,1059.00,N/A,1059.00,N/A,3519.59,N/A,1861.88,N/A,N/A,N/A,1286.40,N/A,1286.40,N/A,N/A,N/A,1861.88,N/A,1861.88,N/A,N/A,N/A,N/A,855.75,3667.52,,Hospital MED12872,"Dressing,Mepilex,Border,Flex Lite,3""X3""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2592.00,N/A,1555.20,N/A,N/A,N/A,47.52,N/A,N/A,N/A,881.28,N/A,472.88,N/A,362.88,N/A,N/A,N/A,N/A,N/A,706.70,N/A,472.88,N/A,472.88,N/A,472.88,N/A,1492.47,N/A,N/A,N/A,N/A,N/A,857.60,N/A,857.60,N/A,N/A,N/A,N/A,N/A,47.52,N/A,52.27,N/A,N/A,47.52,1555.20,,Hospital MED12902,"Cleanser,S/Bw,Baby/Adult, Medspa,16oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2574.73,N/A,1544.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1544.84,1544.84,,Hospital MED12909,"Cath,Foley,Lubricath,Strl,18fr,5ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,296.58,N/A,177.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,177.95,177.95,,Hospital MED12947,"Crusher,Pill,Blue,Individually Boxed",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2159.93,N/A,1295.96,N/A,N/A,N/A,420.00,N/A,N/A,N/A,734.38,N/A,335.16,N/A,302.39,N/A,420.00,N/A,420.00,N/A,456.72,N/A,335.16,N/A,335.16,N/A,335.16,N/A,1243.69,N/A,420.00,N/A,N/A,N/A,428.80,N/A,428.80,N/A,N/A,N/A,420.00,N/A,420.00,N/A,154.58,N/A,N/A,154.58,1295.96,,Hospital MED12959,"A&D Ointment, 13oz Jar",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2673.82,N/A,1604.29,N/A,N/A,N/A,N/A,N/A,1300.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1300.00,N/A,N/A,N/A,N/A,N/A,1300.00,N/A,1300.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1300.00,1604.29,,Hospital MED13014,"Mbo-Drssing,Hydroferablue,Ready Brd,4""X4",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1158.88,N/A,695.33,N/A,N/A,N/A,1161.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1161.84,N/A,1161.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,150.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1161.84,N/A,1161.84,N/A,N/A,N/A,N/A,150.16,1161.84,,Hospital MED13029,"Template,Endoform,Antimicrobial,Fen,2x2""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2433.17,N/A,1459.90,N/A,N/A,N/A,2443.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2443.02,N/A,2443.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,793.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2443.02,N/A,2443.02,N/A,N/A,N/A,N/A,793.24,2443.02,,Hospital MED13066,"Mbo-Gauze,Sponge,8 Ply,Sterile,2""X2""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,7212.97,N/A,4327.78,N/A,N/A,N/A,1870.00,N/A,N/A,N/A,2452.41,N/A,1282.00,N/A,1009.82,N/A,1870.00,N/A,1870.00,N/A,1953.00,N/A,1282.00,N/A,1282.00,N/A,1282.00,N/A,4153.22,N/A,1870.00,N/A,N/A,N/A,2358.40,N/A,2358.40,N/A,N/A,N/A,1870.00,N/A,1870.00,N/A,N/A,N/A,N/A,1009.82,4327.78,,Hospital MED13071,Bag Leg Urinary Drainage Lg,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2964.35,N/A,1778.61,N/A,N/A,N/A,2836.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2836.16,N/A,2836.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,103.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2836.16,N/A,2836.16,N/A,N/A,N/A,N/A,103.60,2836.16,,Hospital MED13104,"Tray,Medication,Pill,7 Day,4x per Day",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1695.08,N/A,1017.05,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1017.05,1017.05,,Hospital MED13116,"Moisturizer,Nourishing Skin CRM,8oz Btl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1509.17,N/A,905.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,905.50,905.50,,Hospital MED13126,"Strip,Packing,Iodoform,1/4inx5yd,Str",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3293.63,N/A,1976.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,90.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,90.26,1976.18,,Hospital MED13133,"Cushions,Ear,Pre Slit",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6244.53,N/A,3746.72,N/A,N/A,N/A,1926.17,N/A,N/A,N/A,2123.15,N/A,1115.39,N/A,874.23,N/A,1926.17,N/A,1926.17,N/A,1602.86,N/A,1115.39,N/A,1115.39,N/A,1115.39,N/A,3595.60,N/A,1926.17,N/A,N/A,N/A,1715.20,N/A,1715.20,N/A,N/A,N/A,1926.17,N/A,1926.17,N/A,39.32,N/A,N/A,39.32,3746.72,,Hospital MED13174,"Splint,Finger,Plastalume,1.25""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4840.92,N/A,2904.55,N/A,N/A,N/A,1045.00,N/A,N/A,N/A,1645.91,N/A,946.00,N/A,677.73,N/A,1045.00,N/A,1045.00,N/A,1251.00,N/A,946.00,N/A,946.00,N/A,946.00,N/A,2787.41,N/A,1045.00,N/A,N/A,N/A,1072.00,N/A,1072.00,N/A,N/A,N/A,1045.00,N/A,1045.00,N/A,N/A,N/A,N/A,677.73,2904.55,,Hospital MED13227,"Valve, Ultrasite",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2344.93,N/A,1406.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,108.34,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,108.34,1406.96,,Hospital MED13277,"Applicator,Chloraprep,3ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1877.07,N/A,1126.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1126.24,1126.24,,Hospital MED13282,"Underpad,Ultrasorbs,30x36",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,13534.68,N/A,8120.81,N/A,4090.07,N/A,7.64,N/A,N/A,N/A,4601.81,N/A,2451.00,N/A,1894.87,N/A,N/A,N/A,N/A,N/A,3549.00,N/A,2451.00,N/A,2451.00,N/A,2451.00,N/A,7793.27,N/A,N/A,N/A,4090.07,N/A,3859.20,N/A,3859.20,N/A,4090.07,N/A,N/A,N/A,7.64,N/A,8.41,N/A,N/A,7.64,8120.81,,Hospital MED13306,"Posiflush,Prefill,Saline,Syrnge,10ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5271.50,N/A,3162.90,N/A,N/A,N/A,1251.55,N/A,1404.92,N/A,1792.31,N/A,1221.00,N/A,738.02,N/A,N/A,N/A,N/A,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,3035.33,N/A,N/A,N/A,N/A,N/A,467.10,N/A,467.10,N/A,N/A,N/A,N/A,N/A,1251.55,N/A,1376.71,N/A,N/A,467.10,3162.90,,Hospital MED13310,"Syringe, Luer Lock, Sterile, 10ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1755.50,N/A,1053.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1053.30,1053.30,,Hospital MED13476,"Ointment,Barrier,Critic-Aid,Clear,Af",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1250.58,N/A,750.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,750.35,750.35,,Hospital Custom MISC618,Half Foam Exercise Roller 6x18,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISC904,Glucosamine 30day,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISC905,Glucosamine 90day,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISC917,Airband Tennis Elbow,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC925,Bionic Gloves Work,N/A,N/A,40.00,40.00,24.00,24.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,24.00,24.00,3.48,40.00,,Hospital Custom MISC936,Full Foam Exercise Roller 6x36,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISC955,Theraball 55,N/A,N/A,35.00,35.00,21.00,21.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,11.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,3.05,N/A,4.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,35.00,21.00,21.00,3.05,35.00,,Hospital Custom MISC966,Neuroma Pad,N/A,N/A,1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital Custom MISC968,Turf Toe Steel Shanks Each,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISC969,Heel Elevator,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCBB2,Bi-Implant remv& replac of Bi- Implant,N/A,N/A,3200.00,3200.00,1920.00,1920.00,N/A,448.00,N/A,3200.00,N/A,3200.00,N/A,1088.00,N/A,448.00,N/A,448.00,N/A,3200.00,N/A,3200.00,N/A,278.40,N/A,448.00,N/A,448.00,N/A,448.00,N/A,3200.00,N/A,3200.00,N/A,448.00,N/A,3200.00,N/A,3200.00,N/A,448.00,N/A,3200.00,N/A,3200.00,N/A,3200.00,1920.00,1920.00,278.40,3200.00,,Hospital Custom MISCCELEBRATEPSC&C,MISCCELEBRATEPROTEINSHAKE - Cookies & Cream (Protein 20 Bag/Powder 15 Serv Bag),N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCClbrtPrtzls,MISCCELEBRATESLTTFPRTZL- Salty Toffee Pretzel,N/A,N/A,12.95,12.95,7.77,7.77,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,7.77,7.77,7.77,12.95,,Hospital Custom MISCClbrtZstyLmn,MISCCELEBRATEZSTYLMN- Zesty Lemon Crisp Bar,N/A,N/A,12.95,12.95,7.77,7.77,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,7.77,7.77,7.77,12.95,,Hospital Custom MISCD112,Patella Stabilizer,N/A,N/A,65.00,65.00,39.00,39.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,22.10,N/A,9.10,N/A,9.10,N/A,65.00,N/A,65.00,N/A,5.66,N/A,9.10,N/A,9.10,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,65.00,39.00,39.00,5.66,65.00,,Hospital Custom MISCD120,Knee Extension Board (Full Extensions Knee Device),N/A,N/A,250.00,250.00,150.00,150.00,N/A,35.00,N/A,250.00,N/A,250.00,N/A,85.00,N/A,35.00,N/A,35.00,N/A,250.00,N/A,250.00,N/A,21.75,N/A,35.00,N/A,35.00,N/A,35.00,N/A,250.00,N/A,250.00,N/A,35.00,N/A,250.00,N/A,250.00,N/A,35.00,N/A,250.00,N/A,250.00,N/A,250.00,150.00,150.00,21.75,250.00,,Hospital Custom MISCD279,M-F Heel Cups,N/A,N/A,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital Custom MISCD296,Xerosox Lower Leg,N/A,N/A,45.00,45.00,27.00,27.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,15.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,3.92,N/A,6.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,45.00,27.00,27.00,3.92,45.00,,Hospital Custom MISCD34,Pulley's,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCD376,Horseshoe Patella,N/A,N/A,65.00,65.00,39.00,39.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,22.10,N/A,9.10,N/A,9.10,N/A,65.00,N/A,65.00,N/A,5.66,N/A,9.10,N/A,9.10,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,65.00,39.00,39.00,5.66,65.00,,Hospital Custom MISCD85,Padded Elbow Sleeve-Breg,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISCD86,Tennis Elbow Strap-Breg,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISCDRUGTEST,Drugtest - Random Drug Screen for Schools,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCEQNGLVS,Equestrian Gloves,N/A,N/A,50.00,50.00,30.00,30.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,17.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,50.00,30.00,30.00,4.35,50.00,,Hospital Custom MISCFITGLVFL,Fitness Gloves Full Finger,N/A,N/A,50.00,50.00,30.00,30.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,17.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,50.00,30.00,30.00,4.35,50.00,,Hospital Custom MISCFMARMELV,Foam Arm Elevator,N/A,N/A,35.00,35.00,21.00,21.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,11.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,3.05,N/A,4.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,35.00,21.00,21.00,3.05,35.00,,Hospital Custom MISCFTNSGLVS,Fitness Gloves,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISCGLMETPAD,Gel Metatarsal Pad,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISCGOLFGLVS,Golf Gloves,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCGRDNGLVS,Gardening Gloves,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISCH&FEXSYS,Hand and Finger Exercise System,N/A,N/A,35.00,35.00,21.00,21.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,11.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,3.05,N/A,4.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,35.00,21.00,21.00,3.05,35.00,,Hospital Custom MISCJUVENCASE,MISCJUVEN - Case/30,N/A,N/A,46.07,46.07,27.64,27.64,N/A,6.45,N/A,46.07,N/A,46.07,N/A,15.66,N/A,6.45,N/A,6.45,N/A,46.07,N/A,46.07,N/A,4.01,N/A,6.45,N/A,6.45,N/A,6.45,N/A,46.07,N/A,46.07,N/A,6.45,N/A,46.07,N/A,46.07,N/A,6.45,N/A,46.07,N/A,46.07,N/A,46.07,27.64,27.64,4.01,46.07,,Hospital Custom MISCKAYSPRETJHMBOX,MISCKAYSNATURALPRETZELS - Jalapeno Honey Mustard (6bags/box),N/A,N/A,8.95,8.95,5.37,5.37,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,5.37,5.37,5.37,8.95,,Hospital Custom MISCLL11,Liposuction Hip - Unilateral Limited,N/A,N/A,300.00,300.00,180.00,180.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,102.00,N/A,42.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,26.10,N/A,42.00,N/A,42.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,300.00,180.00,180.00,26.10,300.00,,Hospital Custom MISCLMBRROLL,Lumbar Roll W/Strat Reg,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCLOD,Misc IP Service Nonbillable,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCMULTICOMPCAP,MISCMULTICOMPCAP-30ct Capsule,N/A,N/A,14.95,14.95,8.97,8.97,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,8.97,8.97,8.97,14.95,,Hospital Custom MISCPROD,Misc Cosmetic Procedure,N/A,N/A,700.00,700.00,420.00,420.00,N/A,98.00,N/A,700.00,N/A,700.00,N/A,238.00,N/A,98.00,N/A,98.00,N/A,700.00,N/A,700.00,N/A,60.90,N/A,98.00,N/A,98.00,N/A,98.00,N/A,700.00,N/A,700.00,N/A,98.00,N/A,700.00,N/A,700.00,N/A,98.00,N/A,700.00,N/A,700.00,N/A,700.00,420.00,420.00,60.90,700.00,,Hospital Custom MISCPT1,Miscpt1,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCPWRBBLUE,Power Web X Heavy Blue,N/A,N/A,60.00,60.00,36.00,36.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,20.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,5.22,N/A,8.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,60.00,36.00,36.00,5.22,60.00,,Hospital Custom MISCTENSGLVS,Tennis Gloves,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISCVES6,Ves Evaluation Initial Traumatic Brain Injury,N/A,N/A,315.00,315.00,189.00,189.00,N/A,44.10,N/A,315.00,N/A,315.00,N/A,107.10,N/A,44.10,N/A,44.10,N/A,315.00,N/A,315.00,N/A,27.41,N/A,44.10,N/A,44.10,N/A,44.10,N/A,315.00,N/A,315.00,N/A,44.10,N/A,315.00,N/A,315.00,N/A,44.10,N/A,315.00,N/A,315.00,N/A,315.00,189.00,189.00,27.41,315.00,,Hospital Custom MISCY107,Replacement of Breast Implants,N/A,N/A,6200.00,6200.00,3720.00,3720.00,N/A,868.00,N/A,6200.00,N/A,6200.00,N/A,2108.00,N/A,868.00,N/A,868.00,N/A,6200.00,N/A,6200.00,N/A,539.40,N/A,868.00,N/A,868.00,N/A,868.00,N/A,6200.00,N/A,6200.00,N/A,868.00,N/A,6200.00,N/A,6200.00,N/A,868.00,N/A,6200.00,N/A,6200.00,N/A,6200.00,3720.00,3720.00,539.40,6200.00,,Hospital P9034,HC Platelets Pheresis Ea Unit,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",185053.82,5445.70,111032.29,3267.42,14123.16,660.52,47600.54,138.72,19389.20,3135.35,57093.48,1851.54,57093.48,2495.59,14123.16,660.52,14092.38,1077.93,14092.38,1077.93,57093.48,1553.55,57093.48,2495.59,57093.48,2495.59,57093.48,2495.59,19389.20,2838.25,34487.03,1077.93,14123.16,660.52,19389.20,740.41,19389.20,740.41,14123.16,660.52,15061.61,1077.93,34487.03,138.72,14123.16,180.59,14092.38,111032.29,138.72,3267.42,,Hospital CPT P9035,HC Leukopoor Plt Pher,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1531.00,1343.00,918.60,805.80,N/A,188.02,N/A,485.66,N/A,773.30,N/A,456.62,N/A,1060.87,N/A,188.02,N/A,485.66,N/A,485.66,N/A,660.41,N/A,1060.87,N/A,1060.87,N/A,1060.87,N/A,773.30,N/A,485.66,N/A,188.02,N/A,719.85,N/A,719.85,N/A,188.02,N/A,485.66,N/A,485.66,N/A,534.23,918.60,918.60,188.02,1060.87,,Hospital CPT P9040,HC Leukored Rbcs Irradiated,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1032.00,903.00,619.20,541.80,N/A,126.42,N/A,259.12,N/A,519.95,N/A,307.02,N/A,566.01,N/A,126.42,N/A,259.12,N/A,259.12,N/A,352.35,N/A,566.01,N/A,566.01,N/A,566.01,N/A,519.95,N/A,259.12,N/A,126.42,N/A,484.01,N/A,484.01,N/A,126.42,N/A,259.12,N/A,259.12,N/A,285.03,619.20,619.20,126.42,566.01,,Hospital P9044,HC Cryoprecipitate Reduced Plasma,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",295252.60,N/A,177151.56,N/A,N/A,N/A,13309.04,N/A,210048.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13309.04,N/A,13309.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,210048.02,N/A,13309.04,N/A,N/A,N/A,210048.02,N/A,210048.02,N/A,N/A,N/A,13309.04,N/A,13309.04,N/A,N/A,N/A,13309.04,210048.02,N/A,N/A,,Hospital HCPCS P9046,ALBUMIN HUMAN 25 % IV SOLN,68516-5216-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),312.60,312.60,187.56,187.56,N/A,43.76,N/A,53.08,N/A,175.74,N/A,106.28,N/A,135.85,N/A,43.76,N/A,53.08,N/A,53.08,N/A,84.57,N/A,135.85,N/A,135.85,N/A,135.85,N/A,175.74,N/A,53.08,N/A,43.76,N/A,167.55,N/A,167.55,N/A,43.76,N/A,53.08,N/A,53.08,N/A,58.38,187.56,187.56,43.76,187.56,,Hospital CPT P9051,"HC Whole/Red Bld,Leuko Red,Cmv",N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",765.00,673.00,459.00,403.80,N/A,94.22,N/A,673.00,N/A,387.51,N/A,228.82,N/A,94.22,N/A,94.22,N/A,673.00,N/A,673.00,N/A,58.55,N/A,94.22,N/A,94.22,N/A,94.22,N/A,387.51,N/A,673.00,N/A,94.22,N/A,360.73,N/A,360.73,N/A,94.22,N/A,673.00,N/A,673.00,N/A,673.00,459.00,459.00,58.55,673.00,,Hospital CPT P9058,"HC Red Cell,Leuko Red,Cmv-, Irr",N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1218.00,1069.00,730.80,641.40,N/A,149.66,N/A,1069.00,N/A,615.53,N/A,363.46,N/A,149.66,N/A,149.66,N/A,1069.00,N/A,1069.00,N/A,93.00,N/A,149.66,N/A,149.66,N/A,149.66,N/A,615.53,N/A,1069.00,N/A,149.66,N/A,572.98,N/A,572.98,N/A,149.66,N/A,1069.00,N/A,1069.00,N/A,1069.00,730.80,730.80,93.00,1069.00,,Hospital CPT P9059,HC So Fresh Plasma 24hrs,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1275.00,1275.00,765.00,765.00,N/A,178.50,N/A,76.20,N/A,734.15,N/A,433.50,N/A,166.44,N/A,178.50,N/A,76.20,N/A,76.20,N/A,103.61,N/A,166.44,N/A,166.44,N/A,166.44,N/A,734.15,N/A,76.20,N/A,178.50,N/A,683.40,N/A,683.40,N/A,178.50,N/A,76.20,N/A,76.20,N/A,1275.00,765.00,765.00,76.20,1275.00,,Hospital HCPCS P9059,HC Fresh Plasma 24hrs,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",431.00,377.00,258.60,226.20,N/A,52.78,N/A,76.20,N/A,217.08,N/A,128.18,N/A,166.44,N/A,52.78,N/A,76.20,N/A,76.20,N/A,103.61,N/A,166.44,N/A,166.44,N/A,166.44,N/A,217.08,N/A,76.20,N/A,52.78,N/A,202.07,N/A,202.07,N/A,52.78,N/A,76.20,N/A,76.20,N/A,377.00,258.60,258.60,52.78,377.00,,Hospital Q0163,HC Diphenhydramine Hci 50mg,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,8863.00,N/A,5317.80,N/A,1240.82,N/A,1118.73,N/A,5006.30,N/A,3013.42,N/A,4331.72,N/A,1240.82,N/A,1098.38,N/A,1098.38,N/A,2715.29,N/A,4331.72,N/A,4331.72,N/A,4331.72,N/A,5006.30,N/A,1098.38,N/A,1240.82,N/A,4750.57,N/A,4750.57,N/A,1240.82,N/A,1098.38,N/A,149.62,N/A,164.58,N/A,N/A,149.62,5317.80,,Hospital Q0166,Granisetron Hcl 1 Mg Oral,N/A,N/A,41744.17,N/A,25046.50,N/A,7333.50,N/A,8940.80,N/A,17047.72,N/A,13059.28,N/A,16684.73,N/A,7559.46,N/A,8940.80,N/A,8940.80,N/A,10385.86,N/A,16684.73,N/A,16684.73,N/A,16684.73,N/A,17047.72,N/A,8940.80,N/A,7559.46,N/A,19850.67,N/A,19850.67,N/A,N/A,N/A,8940.80,N/A,8940.80,N/A,8088.62,N/A,7333.50,25046.50,N/A,N/A,,Hospital Q0220,"Injection, Tixagevimab and Cilgavimab, for the Pre-Exposure Prophylaxis Only, for Certain Adults and Pediatric Individuals (12 Years of Age and Older Weighing at Least 40kg), Wiht No Known Sars-Cov-2 Exposure, Who Either Have Moderate to Severely Immun.",N/A,N/A,N/A,790.20,N/A,474.12,N/A,110.63,N/A,271.82,N/A,454.99,N/A,268.67,N/A,301.03,N/A,110.63,N/A,271.82,N/A,271.82,N/A,301.02,N/A,301.03,N/A,301.03,N/A,301.03,N/A,454.99,N/A,271.82,N/A,110.63,N/A,423.55,N/A,423.55,N/A,110.63,N/A,271.82,N/A,271.82,N/A,299.00,N/A,N/A,110.63,474.12,,Hospital Q0221,"Tixagev and cilgav, 600mg",N/A,N/A,N/A,475.07,N/A,285.04,N/A,66.51,N/A,135.91,N/A,273.54,N/A,161.52,N/A,150.56,N/A,66.51,N/A,135.91,N/A,135.91,N/A,150.54,N/A,150.56,N/A,150.56,N/A,150.56,N/A,273.54,N/A,135.91,N/A,66.51,N/A,254.63,N/A,254.63,N/A,66.51,N/A,135.91,N/A,135.91,N/A,N/A,N/A,N/A,66.51,285.04,,Hospital Q0243,Casirivimab and imdevimab,N/A,N/A,175096.62,1871.70,105057.97,1123.02,N/A,262.03,28072.84,411.23,N/A,1077.73,N/A,636.37,N/A,450.53,N/A,262.03,20418.86,406.82,20418.86,406.82,N/A,450.52,N/A,450.53,N/A,450.53,N/A,450.53,N/A,1077.73,20418.86,406.82,N/A,262.03,N/A,1003.22,N/A,1003.22,N/A,262.03,20418.86,406.82,20418.86,411.23,N/A,432.21,20418.86,105057.97,262.03,1123.02,,Hospital Q0245,Bamlanivimab and etesevima,N/A,N/A,42990.30,1292.20,25794.18,775.32,8791.75,180.90,2398.17,539.72,22229.88,744.05,14616.70,439.34,22442.53,714.54,9062.64,180.90,12480.09,515.96,12480.09,515.96,13969.95,614.87,22442.53,714.54,22442.53,714.54,22442.53,714.54,22229.88,744.05,12480.09,515.96,9062.64,180.90,26701.00,692.61,26701.00,692.61,12186.17,180.90,12480.09,515.96,12598.69,539.72,9697.03,435.69,2398.17,26701.00,180.90,775.32,,Hospital HCPCS Q2043,SIPULEUCEL-T 50000000 CELLS IV SUSP,30237-8900-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),313012.50,313012.50,187807.50,187807.50,N/A,43821.75,N/A,53062.44,N/A,175975.63,N/A,106424.25,N/A,142747.20,N/A,43821.75,N/A,53062.44,N/A,53062.44,N/A,88861.51,N/A,142747.20,N/A,142747.20,N/A,142747.20,N/A,175975.63,N/A,53062.44,N/A,43821.75,N/A,167774.70,N/A,167774.70,N/A,43821.75,N/A,53062.44,N/A,53062.44,N/A,313012.50,187807.50,187807.50,43821.75,313012.50,,Hospital Q4117,HC Hyalomatrix per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,6287.43,N/A,3772.46,N/A,880.24,N/A,823.17,N/A,3611.88,N/A,2137.73,N/A,1903.53,N/A,880.24,N/A,786.93,N/A,786.93,N/A,1184.98,N/A,1903.53,N/A,1903.53,N/A,1903.53,N/A,3611.88,N/A,786.93,N/A,880.24,N/A,790.50,N/A,790.50,N/A,880.24,N/A,786.93,N/A,823.17,N/A,162.00,N/A,N/A,162.00,3772.46,,Hospital Q4121,HC Theraskin per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),89334.25,9368.25,53600.55,5620.95,15706.51,1311.56,13814.17,1875.32,N/A,5333.65,30098.95,3185.21,30098.95,4336.60,15706.51,1311.56,13814.17,1792.78,13814.17,1792.78,30098.95,2699.61,30098.95,4336.60,30098.95,4336.60,30098.95,4336.60,N/A,5333.65,13814.17,1792.78,15706.51,1311.56,N/A,2266.25,N/A,2266.25,15706.51,1311.56,13814.17,1792.78,13814.17,1875.32,15706.51,181.00,13814.17,53600.55,181.00,5620.95,,Hospital Q4122,HC Dermacell per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,95995.88,N/A,57597.53,N/A,13430.29,N/A,6248.31,N/A,11735.00,N/A,32638.61,N/A,15001.79,N/A,13430.29,N/A,5973.28,N/A,5973.28,N/A,9338.88,N/A,15001.79,N/A,15001.79,N/A,15001.79,N/A,11735.00,N/A,5973.28,N/A,13430.29,N/A,12203.25,N/A,12203.25,N/A,13430.29,N/A,5973.28,N/A,6248.31,N/A,2345.18,N/A,N/A,2345.18,57597.53,,Hospital Q4124,"HC Oasis Ultra Tri-Layer Wound Matrix, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,4838.07,N/A,2902.84,N/A,677.33,N/A,634.07,N/A,2776.35,N/A,1644.94,N/A,1466.25,N/A,677.33,N/A,606.16,N/A,606.16,N/A,912.77,N/A,1466.25,N/A,1466.25,N/A,1466.25,N/A,2776.35,N/A,606.16,N/A,677.33,N/A,527.00,N/A,527.00,N/A,677.33,N/A,606.16,N/A,634.07,N/A,38.80,N/A,N/A,38.80,2902.84,,Hospital Q4126,HC Memoderm/Derma/Tranz/Integup per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,62975.23,N/A,37785.14,N/A,8816.52,N/A,6248.31,N/A,35884.99,N/A,21411.57,N/A,14569.06,N/A,8816.52,N/A,5973.28,N/A,5973.28,N/A,9069.42,N/A,14569.06,N/A,14569.06,N/A,14569.06,N/A,35884.99,N/A,5973.28,N/A,8816.52,N/A,5963.00,N/A,5963.00,N/A,8816.52,N/A,5973.28,N/A,6248.31,N/A,728.02,N/A,N/A,728.02,37785.14,,Hospital Q4130,HC Strattice Tm per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,163583.82,N/A,98150.29,N/A,22901.75,N/A,12141.33,N/A,93311.17,N/A,55618.51,N/A,14546.83,N/A,22901.75,N/A,12115.73,N/A,12115.73,N/A,9055.67,N/A,14546.83,N/A,14546.83,N/A,14546.83,N/A,93311.16,N/A,12115.73,N/A,22901.75,N/A,9793.75,N/A,9793.75,N/A,22901.74,N/A,12115.73,N/A,12141.33,N/A,2372.73,N/A,N/A,2372.73,98150.29,,Hospital Q4133,HC Grafix Prime Grafixpl Prime Stravix Stravixpl per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),99204.67,48500.30,59522.80,29100.18,14113.60,6768.31,15924.62,521.94,42526.49,27432.10,33729.58,16490.11,42406.68,1285.65,19213.47,6768.31,15069.53,524.62,22314.82,524.62,28250.11,800.34,28250.11,1285.65,42406.68,1285.65,28250.11,1285.65,42526.49,27432.10,15924.62,524.62,19213.47,6768.31,50453.36,527.00,50453.36,527.00,14113.60,6768.31,22314.82,524.62,15924.62,521.94,14113.60,241.84,14113.60,59522.80,241.84,29100.18,,Hospital Q4139,"HC Aminomatrix or Biodmatrix, Injectable, 1cc",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,74636.67,N/A,44782.00,N/A,10449.14,N/A,6248.31,N/A,42472.55,N/A,25376.45,N/A,14487.87,N/A,10449.14,N/A,5973.28,N/A,5973.28,N/A,9018.98,N/A,14487.87,N/A,14487.87,N/A,14487.87,N/A,42472.55,N/A,5973.28,N/A,10449.14,N/A,5944.75,N/A,5944.75,N/A,10449.14,N/A,5973.28,N/A,6248.31,N/A,1253.44,N/A,N/A,1253.44,44782.00,,Hospital Q4151,HC Amnioband or Gardian per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),113670.12,107462.57,68202.07,64477.54,9613.52,15038.94,11637.93,8487.54,62654.97,61565.25,38647.84,36537.26,21872.09,19902.19,9909.73,15038.94,562.00,8206.20,562.00,8206.20,13614.87,12389.51,21872.09,19902.19,21872.09,19902.19,21872.09,19902.19,62654.97,61565.24,11637.93,8206.20,9909.73,15038.94,26022.32,7897.00,26022.32,7897.00,N/A,15038.94,11637.93,8206.20,11637.93,8487.54,10603.41,1172.25,562.00,68202.07,1172.25,64477.54,,Hospital Q4159,HC Affinity per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,13089.25,N/A,7853.55,N/A,1832.50,N/A,1545.06,N/A,7420.10,N/A,4450.35,N/A,3769.94,N/A,1832.50,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,7420.10,N/A,1558.52,N/A,1832.50,N/A,1871.00,N/A,1871.00,N/A,1832.50,N/A,1558.52,N/A,1545.06,N/A,88.51,N/A,N/A,88.51,7853.55,,Hospital Q4166,HC Cytal per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),218141.85,31012.42,130885.11,18607.45,19468.41,4274.79,N/A,2688.73,N/A,17735.58,N/A,10544.23,N/A,6413.75,19468.41,4274.79,N/A,2663.98,N/A,2663.98,N/A,3992.68,N/A,6413.75,N/A,6413.75,N/A,6413.75,N/A,17735.59,N/A,2663.98,19468.41,4274.79,N/A,2134.50,N/A,2134.50,19468.41,4274.79,N/A,2663.98,N/A,2688.73,19468.41,423.19,19468.41,130885.11,423.19,18607.45,,Hospital Q4186,HC Epifix 1 Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),100950.67,6395.58,60570.40,3837.35,N/A,895.38,N/A,1875.32,25354.40,3665.43,N/A,2174.50,N/A,4336.60,N/A,895.38,N/A,1792.78,N/A,1792.78,N/A,2699.61,N/A,4336.60,N/A,4336.60,N/A,4336.60,32117.96,3665.43,N/A,1792.78,N/A,895.38,32117.96,2266.25,32117.96,2266.25,N/A,895.38,N/A,1792.78,N/A,1875.32,N/A,181.00,25354.40,60570.40,181.00,4336.60,,Hospital Q4187,HC Epicord 1 Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,10359.65,N/A,6215.79,N/A,1450.35,N/A,1904.67,N/A,5888.19,N/A,3522.28,N/A,4404.45,N/A,1450.35,N/A,1820.83,N/A,1820.83,N/A,2741.85,N/A,4404.45,N/A,4404.45,N/A,4404.45,N/A,5888.19,N/A,1820.83,N/A,1450.35,N/A,2134.50,N/A,2134.50,N/A,1450.35,N/A,1820.83,N/A,1904.67,N/A,250.51,N/A,N/A,250.51,6215.79,,Hospital Q4191,Restorigin 1 sq cm,N/A,N/A,N/A,19558.90,N/A,11735.34,N/A,2738.24,N/A,1630.28,N/A,11146.75,N/A,6650.02,N/A,3799.72,N/A,2738.24,N/A,1558.52,N/A,1558.52,N/A,2365.40,N/A,3799.72,N/A,3799.72,N/A,3799.72,N/A,11146.75,N/A,1558.52,N/A,2738.24,N/A,1871.00,N/A,1871.00,N/A,2738.24,N/A,1558.52,N/A,1630.28,N/A,119.93,N/A,N/A,119.93,11735.34,,Hospital Q4199,"Cygnus matrix, per sq cm",N/A,N/A,N/A,4974.98,N/A,2984.99,N/A,696.50,N/A,1600.15,N/A,2855.50,N/A,1691.50,N/A,3769.94,N/A,696.50,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,2855.50,N/A,1558.52,N/A,696.50,N/A,1871.00,N/A,1871.00,N/A,696.50,N/A,1558.52,N/A,1600.15,N/A,99.44,N/A,N/A,99.44,3769.94,,Hospital Q5001,Hospice or home hlth in home,N/A,N/A,N/A,8540.00,N/A,5124.00,N/A,2461.47,N/A,3838.17,N/A,4707.36,N/A,2903.60,N/A,1195.60,N/A,1195.60,N/A,3838.17,N/A,3838.17,N/A,743.12,N/A,1195.60,N/A,1195.60,N/A,1195.60,N/A,4917.36,N/A,3838.17,N/A,2461.47,N/A,1839.15,N/A,1839.15,N/A,2461.47,N/A,3838.17,N/A,3838.17,N/A,2461.47,N/A,N/A,743.12,5124.00,,Hospital Q5003,Hospice in LT/non-skilled NF,N/A,N/A,N/A,9150.00,N/A,5490.00,N/A,2238.76,N/A,311.76,N/A,5043.60,N/A,3111.00,N/A,1281.00,N/A,1281.00,N/A,311.76,N/A,311.76,N/A,796.20,N/A,1281.00,N/A,1281.00,N/A,1281.00,N/A,5268.60,N/A,311.76,N/A,2238.76,N/A,N/A,N/A,N/A,N/A,2238.76,N/A,311.76,N/A,311.76,N/A,2238.76,N/A,N/A,311.76,5490.00,,Hospital Q5005,"Hospice, inpatient hospital",N/A,N/A,N/A,3650.00,N/A,2190.00,N/A,4261.92,N/A,1065.48,N/A,1763.84,N/A,1088.00,N/A,448.00,N/A,448.00,N/A,1065.48,N/A,1065.48,N/A,278.40,N/A,448.00,N/A,448.00,N/A,448.00,N/A,1842.56,N/A,1065.48,N/A,4261.92,N/A,2824.00,N/A,2824.00,N/A,4261.92,N/A,1065.48,N/A,1065.48,N/A,4261.92,N/A,N/A,278.40,4261.92,,Hospital Q5006,Hospice in hospice facility,N/A,N/A,N/A,8100.00,N/A,4860.00,N/A,486.12,N/A,4317.94,N/A,4409.60,N/A,2720.00,N/A,1120.00,N/A,1120.00,N/A,4317.94,N/A,4317.94,N/A,696.00,N/A,1120.00,N/A,1120.00,N/A,1120.00,N/A,4606.40,N/A,4317.94,N/A,486.12,N/A,3504.00,N/A,3504.00,N/A,486.12,N/A,4317.94,N/A,4317.94,N/A,486.12,N/A,N/A,486.12,4860.00,,Hospital HCPCS Q5104,INFLIXIMAB-ABDA 100 MG IV SOLR,00006-4305-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3390.30,3390.30,2034.18,2034.18,N/A,474.64,N/A,355.47,N/A,1906.03,N/A,1152.70,N/A,1327.38,N/A,474.64,N/A,355.47,N/A,355.47,N/A,826.30,N/A,1327.38,N/A,1327.38,N/A,1327.38,N/A,1906.03,N/A,355.47,N/A,474.64,N/A,1817.20,N/A,1817.20,N/A,474.64,N/A,355.47,N/A,355.47,N/A,391.02,2034.18,2034.18,355.47,2034.18,,Hospital Q5105,Inj retacrit esrd on dialysi,N/A,N/A,182332.68,5459.00,109399.61,3275.40,14791.87,764.26,14439.62,77.61,N/A,3090.50,61993.11,1856.06,220532.14,572.42,N/A,764.26,3934.00,106.15,3934.00,106.15,220532.14,356.09,220532.14,572.42,220532.14,572.42,220532.14,572.42,N/A,3090.50,14439.62,106.15,11559.71,764.26,N/A,2926.03,N/A,2926.03,N/A,764.26,10402.96,106.15,14439.62,77.61,N/A,N/A,3934.00,220532.14,77.61,3275.40,,Hospital HCPCS Q5106,EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,00069-1305-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),992.70,992.70,595.62,595.62,N/A,138.98,N/A,14.99,N/A,558.10,N/A,337.52,N/A,43.51,N/A,138.98,N/A,14.99,N/A,14.99,N/A,27.09,N/A,43.51,N/A,43.51,N/A,43.51,N/A,558.10,N/A,14.99,N/A,138.98,N/A,532.09,N/A,532.09,N/A,138.98,N/A,14.99,N/A,14.99,N/A,16.49,595.62,595.62,14.99,595.62,,Hospital HCPCS Q5106,EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,00069-1307-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),198.60,198.60,119.16,119.16,N/A,27.80,N/A,29.98,N/A,111.65,N/A,67.52,N/A,87.02,N/A,27.80,N/A,29.98,N/A,29.98,N/A,54.17,N/A,87.02,N/A,87.02,N/A,87.02,N/A,111.65,N/A,29.98,N/A,27.80,N/A,106.45,N/A,106.45,N/A,27.80,N/A,29.98,N/A,29.98,N/A,32.98,119.16,119.16,27.80,119.16,,Hospital HCPCS Q5106,EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,00069-1309-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1985.40,1985.40,1191.24,1191.24,N/A,277.96,N/A,299.80,N/A,1116.19,N/A,675.04,N/A,870.24,N/A,277.96,N/A,299.80,N/A,299.80,N/A,541.73,N/A,870.24,N/A,870.24,N/A,870.24,N/A,1116.19,N/A,299.80,N/A,277.96,N/A,1064.17,N/A,1064.17,N/A,277.96,N/A,299.80,N/A,299.80,N/A,329.78,1191.24,1191.24,277.96,1191.24,,Hospital HCPCS Q5106,EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,00069-1306-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,22.49,N/A,84.33,N/A,51.00,N/A,65.27,N/A,21.00,N/A,22.49,N/A,22.49,N/A,40.63,N/A,65.27,N/A,65.27,N/A,65.27,N/A,84.33,N/A,22.49,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,22.49,N/A,22.49,N/A,24.73,90.00,90.00,21.00,90.00,,Hospital HCPCS Q5106,EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,00069-1308-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),496.40,496.40,297.84,297.84,N/A,69.50,N/A,74.95,N/A,279.08,N/A,168.78,N/A,217.56,N/A,69.50,N/A,74.95,N/A,74.95,N/A,135.43,N/A,217.56,N/A,217.56,N/A,217.56,N/A,279.08,N/A,74.95,N/A,69.50,N/A,266.07,N/A,266.07,N/A,69.50,N/A,74.95,N/A,74.95,N/A,82.45,297.84,297.84,69.50,297.84,,Hospital HCPCS Q5111,PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY,70114-0101-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17662.60,17662.60,10597.56,10597.56,N/A,2472.76,N/A,1497.39,N/A,9929.91,N/A,6005.28,N/A,5341.72,N/A,2472.76,N/A,1497.39,N/A,1497.39,N/A,3325.27,N/A,5341.72,N/A,5341.72,N/A,5341.72,N/A,9929.91,N/A,1497.39,N/A,2472.76,N/A,9467.15,N/A,9467.15,N/A,2472.76,N/A,1497.39,N/A,1497.39,N/A,1647.13,10597.56,10597.56,1497.39,10597.56,,Hospital CPT Q9003,HC Chaplain Counsel Group,N/A,0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION,10.00,10.00,6.00,6.00,N/A,1.40,N/A,10.00,N/A,5.76,N/A,3.40,N/A,1.40,N/A,1.40,N/A,10.00,N/A,10.00,N/A,N/A,N/A,1.40,N/A,1.40,N/A,1.40,N/A,5.76,N/A,10.00,N/A,1.40,N/A,5.36,N/A,5.36,N/A,1.40,N/A,10.00,N/A,10.00,N/A,10.00,6.00,6.00,1.40,10.00,,Hospital HCPCS Q9957,PERFLUTREN LIPID MICROSPHERE IV SUSP,11994-0011-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),447.20,447.20,268.32,268.32,N/A,62.61,N/A,447.20,N/A,251.42,N/A,152.05,N/A,236.52,N/A,62.61,N/A,447.20,N/A,447.20,N/A,147.24,N/A,236.52,N/A,236.52,N/A,236.52,N/A,251.42,N/A,447.20,N/A,62.61,N/A,239.70,N/A,239.70,N/A,62.61,N/A,447.20,N/A,447.20,N/A,447.20,268.32,268.32,62.61,447.20,,Hospital Q9960,"HOCM 200-249mg/ml iodine,1ml",N/A,N/A,36585.40,16379.83,21951.24,9827.90,7528.22,2293.18,9171.14,4601.18,17229.49,9421.16,12439.04,5316.86,17127.73,10305.72,7760.17,2293.18,1686.00,4246.26,1686.00,4246.26,10661.62,6415.50,17127.73,10305.72,17127.73,10305.72,17127.73,10305.72,17229.49,9421.17,9171.14,4246.26,7760.17,2293.18,20377.73,5963.00,20377.73,5963.00,3571.89,2293.18,9171.14,4246.26,9171.14,4601.18,8303.39,505.12,1686.00,21951.24,505.12,10305.72,,Hospital Q9961,"HOCM 250-299mg/ml iodine,1ml",N/A,N/A,66773.00,26207.90,40063.80,15724.74,11982.62,3668.93,14440.47,4923.50,27003.82,11012.00,22702.82,8910.69,27262.13,11413.37,12351.83,3668.93,3934.00,4706.78,3934.00,4706.78,21143.48,7105.03,27262.13,11413.37,27262.13,11413.37,27262.13,11413.37,27003.82,11012.00,14440.47,4706.78,12351.83,3668.93,32435.13,7897.00,32435.13,7897.00,7532.47,3668.93,14440.47,4706.78,14440.47,4923.50,13216.46,821.52,3934.00,40063.80,821.52,15724.74,,Hospital HCPCS Q9968,METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,00517-0374-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1758.00,1758.00,1054.80,1054.80,N/A,246.12,N/A,386.15,N/A,988.35,N/A,597.72,N/A,370.05,N/A,246.12,N/A,386.15,N/A,386.15,N/A,370.05,N/A,370.05,N/A,370.05,N/A,370.05,N/A,988.35,N/A,386.15,N/A,246.12,N/A,942.29,N/A,942.29,N/A,246.12,N/A,386.15,N/A,386.15,N/A,424.77,1054.80,1054.80,246.12,1054.80,,Hospital S0077,"Injection, Clindamycin Phosp",N/A,N/A,N/A,93337.18,N/A,56002.31,N/A,13067.19,N/A,718.57,N/A,53709.67,N/A,31711.28,N/A,10513.90,N/A,13067.19,N/A,718.57,N/A,718.57,N/A,6533.68,N/A,10513.90,N/A,10513.90,N/A,10513.90,N/A,53709.65,N/A,718.57,N/A,13067.19,N/A,N/A,N/A,N/A,N/A,13067.19,N/A,718.57,N/A,718.57,N/A,790.43,N/A,N/A,718.57,56002.31,,Hospital S2117,"Arthroereisis, subtalar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26385.57,N/A,15831.34,N/A,3693.97,N/A,N/A,N/A,15064.90,N/A,8971.08,N/A,1443.45,N/A,3693.97,N/A,N/A,N/A,N/A,N/A,897.13,N/A,1443.45,N/A,1443.45,N/A,1443.45,N/A,15064.91,N/A,N/A,N/A,3693.97,N/A,N/A,N/A,N/A,N/A,3693.97,N/A,N/A,N/A,N/A,N/A,398.61,N/A,N/A,398.61,15831.34,,Hospital S9446,HC Diabetes OP Group/30min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,212.00,N/A,127.20,N/A,29.68,N/A,N/A,N/A,122.07,N/A,72.08,N/A,29.68,N/A,29.68,N/A,N/A,N/A,N/A,N/A,18.44,N/A,29.68,N/A,29.68,N/A,29.68,N/A,122.07,N/A,N/A,N/A,29.68,N/A,113.63,N/A,113.63,N/A,29.68,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18.44,127.20,,Hospital S9470,HH/Hspc Rd Nutrition Initial Evalution,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,4800.00,N/A,2880.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1496.00,N/A,1055.00,N/A,672.00,N/A,N/A,N/A,N/A,N/A,1116.00,N/A,1055.00,N/A,1055.00,N/A,1055.00,N/A,2533.52,N/A,N/A,N/A,N/A,N/A,214.40,N/A,214.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,214.40,2880.00,,Hospital CPT U0002,HC So Covid-19 Any Technique Non-Cdc,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,152.00,152.00,91.20,91.20,N/A,51.31,N/A,51.31,N/A,152.00,N/A,51.68,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,31.94,N/A,51.31,N/A,51.31,N/A,51.31,N/A,87.52,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,56.44,91.20,91.20,31.94,152.00,,Hospital CPT U0002,HC Covid-19 Any Technique Non-Cdc,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,176.00,176.00,105.60,105.60,N/A,51.31,N/A,51.31,N/A,176.00,N/A,59.84,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,31.94,N/A,51.31,N/A,51.31,N/A,51.31,N/A,101.34,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,51.31,N/A,56.44,105.60,105.60,31.94,176.00,,Hospital V2632,HC Misc Posterior Chamber Iol,N/A,0276 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - INTRAOCULAR LENS,156820.67,14968.32,94092.40,8980.99,N/A,2095.57,15085.26,2039.85,N/A,8610.24,N/A,5089.23,N/A,4720.09,N/A,2095.57,6182.00,1950.06,6182.00,1950.06,N/A,2938.34,N/A,4720.09,N/A,4720.09,N/A,4720.09,N/A,8610.23,15085.26,1950.06,N/A,2095.57,N/A,3397.00,N/A,3397.00,N/A,2095.57,15085.26,1950.06,15085.26,2039.85,N/A,556.44,6182.00,94092.40,556.44,8980.99,,Hospital MS-DRG V40 (FY 2023) 001,Heart Transplant Or Implant Of Heart Assist System With McC,N/A,N/A,808843.07,N/A,485305.84,N/A,7441.45,N/A,195950.79,N/A,N/A,N/A,470697.38,N/A,470697.38,N/A,7441.45,N/A,195950.79,N/A,195950.79,N/A,470697.38,N/A,470697.38,N/A,470697.38,N/A,470697.38,N/A,N/A,N/A,195950.79,N/A,7441.45,N/A,N/A,N/A,N/A,N/A,7441.45,N/A,195950.79,N/A,195950.79,N/A,7441.45,N/A,7441.45,485305.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 004,"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures",N/A,N/A,383049.03,N/A,229829.42,N/A,67619.38,N/A,88677.90,N/A,220099.12,N/A,311355.00,N/A,311355.00,N/A,67619.38,N/A,88677.90,N/A,88778.28,N/A,311355.00,N/A,311355.00,N/A,322269.97,N/A,311355.00,N/A,220099.12,N/A,87237.64,N/A,67619.38,N/A,220099.12,N/A,220099.12,N/A,67619.38,N/A,88677.90,N/A,88677.90,N/A,67619.38,N/A,67619.38,322269.97,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 012,"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",N/A,N/A,107057.30,N/A,64234.38,N/A,20855.70,N/A,24936.86,N/A,59009.98,N/A,36399.48,N/A,47449.60,N/A,21498.30,N/A,24936.86,N/A,24936.86,N/A,52868.17,N/A,47449.60,N/A,47449.60,N/A,47449.60,N/A,59009.98,N/A,24936.86,N/A,21498.30,N/A,56453.18,N/A,56453.18,N/A,N/A,N/A,24936.86,N/A,24936.86,N/A,23003.18,N/A,20855.70,64234.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 013,"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/McC",N/A,N/A,50448.23,N/A,30268.94,N/A,15087.91,N/A,18113.86,N/A,34001.82,N/A,17152.40,N/A,34327.08,N/A,15552.79,N/A,18113.86,N/A,18113.86,N/A,21367.81,N/A,34327.08,N/A,34327.08,N/A,34327.08,N/A,34001.82,N/A,18113.86,N/A,15552.79,N/A,40840.65,N/A,40840.65,N/A,15552.79,N/A,18113.86,N/A,18113.86,N/A,16641.49,N/A,15087.91,40840.65,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 027,Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,N/A,N/A,102114.57,N/A,61268.74,N/A,13312.01,N/A,16013.07,N/A,37596.53,N/A,34718.94,N/A,31190.00,N/A,13722.18,N/A,16013.07,N/A,16013.07,N/A,19416.71,N/A,31190.00,N/A,31190.00,N/A,31190.00,N/A,37596.53,N/A,16013.07,N/A,13722.18,N/A,36033.58,N/A,36033.58,N/A,14496.84,N/A,16013.07,N/A,16013.07,N/A,14682.73,N/A,13312.01,61268.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 037,Extracranial Procedures With McC,N/A,N/A,149313.38,N/A,89588.03,N/A,17993.67,N/A,23098.90,N/A,82301.54,N/A,42159.13,N/A,42159.13,N/A,19836.82,N/A,23098.90,N/A,23098.90,N/A,42159.13,N/A,42159.13,N/A,42159.13,N/A,42159.13,N/A,82301.54,N/A,23098.90,N/A,19836.82,N/A,N/A,N/A,N/A,N/A,4021.22,N/A,22662.14,N/A,23098.90,N/A,19836.82,N/A,4021.22,89588.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 038,Extracranial Procedures With Cc,N/A,N/A,74654.13,N/A,44792.48,N/A,8724.77,N/A,10586.59,N/A,20342.27,N/A,N/A,N/A,20442.11,N/A,8993.60,N/A,10586.59,N/A,10586.59,N/A,12725.83,N/A,20442.11,N/A,N/A,N/A,N/A,N/A,20342.27,N/A,10586.59,N/A,8993.60,N/A,23616.62,N/A,23616.62,N/A,N/A,N/A,10586.59,N/A,10586.59,N/A,9623.15,N/A,8724.77,44792.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 042,"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/McC",N/A,N/A,85166.80,N/A,51100.08,N/A,9867.45,N/A,11938.32,N/A,22237.09,N/A,28966.95,N/A,23119.40,N/A,10171.48,N/A,11938.32,N/A,11938.32,N/A,14392.52,N/A,23119.40,N/A,23119.40,N/A,23119.40,N/A,22237.09,N/A,11938.32,N/A,10171.48,N/A,26709.67,N/A,26709.67,N/A,4923.93,N/A,11938.32,N/A,11938.32,N/A,10883.48,N/A,4923.93,51100.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 054,Nervous System Neoplasms With McC,N/A,N/A,32215.80,N/A,19329.48,N/A,7399.12,N/A,9018.41,N/A,16674.51,N/A,17336.11,N/A,17336.11,N/A,7627.10,N/A,9018.41,N/A,9018.41,N/A,10792.25,N/A,17336.11,N/A,17336.11,N/A,17336.11,N/A,16674.51,N/A,9018.41,N/A,7627.10,N/A,20028.28,N/A,20028.28,N/A,7627.10,N/A,9018.41,N/A,9018.41,N/A,8161.00,N/A,7399.12,20028.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 060,Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,N/A,N/A,33546.60,N/A,20127.96,N/A,4834.77,N/A,6044.22,N/A,10895.54,N/A,11405.84,N/A,11327.84,N/A,4983.73,N/A,2370.97,N/A,2370.97,N/A,7051.92,N/A,11327.84,N/A,11327.84,N/A,11327.84,N/A,10895.54,N/A,5984.92,N/A,4983.73,N/A,13086.97,N/A,13086.97,N/A,5009.84,N/A,5984.92,N/A,6044.22,N/A,5332.60,N/A,2370.97,20127.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 066,Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,N/A,N/A,32661.80,N/A,19597.08,N/A,3726.23,N/A,4673.57,N/A,8397.37,N/A,N/A,N/A,8730.55,N/A,3841.04,N/A,4673.57,N/A,4673.57,N/A,5435.03,N/A,8730.55,N/A,8730.55,N/A,8730.55,N/A,8397.37,N/A,4673.57,N/A,3841.04,N/A,10086.34,N/A,10086.34,N/A,4109.92,N/A,4673.57,N/A,4673.57,N/A,4109.92,N/A,3726.23,19597.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 067,Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,N/A,N/A,45355.30,N/A,27213.18,N/A,7543.69,N/A,9189.44,N/A,17000.31,N/A,N/A,N/A,17674.84,N/A,7776.12,N/A,2810.00,N/A,2810.00,N/A,11003.11,N/A,17674.84,N/A,17674.84,N/A,17674.84,N/A,17000.31,N/A,9189.44,N/A,7776.12,N/A,20419.60,N/A,20419.60,N/A,4778.50,N/A,9189.44,N/A,9189.44,N/A,8320.45,N/A,2810.00,27213.18,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 079,Hypertensive Encephalopathy Without Cc/McC,N/A,N/A,38544.60,N/A,23126.76,N/A,3915.08,N/A,4896.98,N/A,8822.95,N/A,13105.16,N/A,9173.02,N/A,4035.71,N/A,4896.98,N/A,4896.98,N/A,5710.48,N/A,9173.02,N/A,9173.02,N/A,9173.02,N/A,8822.95,N/A,4896.98,N/A,4035.71,N/A,10597.52,N/A,10597.52,N/A,1169.19,N/A,4896.98,N/A,4896.98,N/A,4318.21,N/A,1169.19,23126.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 081,Nontraumatic Stupor And Coma Without McC,N/A,N/A,35973.00,N/A,21583.80,N/A,4793.16,N/A,2425.03,N/A,10801.77,N/A,12230.82,N/A,11230.35,N/A,4940.84,N/A,1324.85,N/A,1324.85,N/A,6991.23,N/A,11230.35,N/A,11230.35,N/A,11230.35,N/A,10801.77,N/A,1324.85,N/A,4940.84,N/A,12974.34,N/A,12974.34,N/A,340.86,N/A,5935.70,N/A,1324.85,N/A,1676.93,N/A,340.86,21583.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 083,Traumatic Stupor And Coma >1 Hour With Cc,N/A,N/A,42115.30,N/A,25269.18,N/A,7192.14,N/A,8773.57,N/A,16208.06,N/A,14319.20,N/A,16851.15,N/A,7413.74,N/A,2248.00,N/A,2248.00,N/A,10490.34,N/A,16851.15,N/A,16851.15,N/A,16851.15,N/A,16208.06,N/A,8773.57,N/A,7413.74,N/A,19468.01,N/A,19468.01,N/A,5481.88,N/A,8773.57,N/A,8773.57,N/A,7932.70,N/A,2248.00,25269.18,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 085,Traumatic Stupor And Coma <1 Hour With McC,N/A,N/A,48943.00,N/A,29365.80,N/A,12460.07,N/A,15005.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12843.99,N/A,15005.26,N/A,15005.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28079.79,N/A,15005.26,N/A,12843.99,N/A,33727.51,N/A,33727.51,N/A,N/A,N/A,15005.26,N/A,15005.26,N/A,13743.07,N/A,12460.07,33727.51,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 086,Traumatic Stupor And Coma <1 Hour With Cc,N/A,N/A,38014.90,N/A,22808.94,N/A,6933.41,N/A,8467.50,N/A,15624.99,N/A,12925.07,N/A,16244.95,N/A,7147.04,N/A,2248.00,N/A,2248.00,N/A,10112.97,N/A,16244.95,N/A,16244.95,N/A,16244.95,N/A,15624.99,N/A,8467.50,N/A,7147.04,N/A,18767.67,N/A,18767.67,N/A,5599.42,N/A,8467.50,N/A,8467.50,N/A,7647.33,N/A,2248.00,22808.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 087,Traumatic Stupor And Coma <1 Hour Without Cc/McC,N/A,N/A,25431.30,N/A,15258.78,N/A,4653.92,N/A,5771.00,N/A,10487.99,N/A,8646.64,N/A,10904.13,N/A,4797.32,N/A,5771.00,N/A,5771.00,N/A,6788.14,N/A,10904.13,N/A,10904.13,N/A,10904.13,N/A,10487.99,N/A,5771.00,N/A,4797.32,N/A,12597.46,N/A,12597.46,N/A,4797.32,N/A,5771.00,N/A,5771.00,N/A,5133.13,N/A,4653.92,15258.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 088,Concussion With McC,N/A,N/A,35861.40,N/A,21516.84,N/A,8408.96,N/A,10213.00,N/A,18950.28,N/A,12192.88,N/A,19702.17,N/A,8668.06,N/A,1686.00,N/A,1686.00,N/A,12265.19,N/A,19702.17,N/A,19702.17,N/A,19702.17,N/A,18950.28,N/A,10213.00,N/A,8668.06,N/A,22761.77,N/A,22761.77,N/A,7964.41,N/A,10213.00,N/A,10213.00,N/A,9274.82,N/A,1686.00,22761.77,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 089,Concussion With Cc,N/A,N/A,39144.40,N/A,23486.64,N/A,6229.24,N/A,7634.51,N/A,14038.09,N/A,15248.99,N/A,14595.08,N/A,6421.17,N/A,7634.51,N/A,7634.51,N/A,9085.87,N/A,14595.08,N/A,14595.08,N/A,14595.08,N/A,14038.09,N/A,7634.51,N/A,6421.17,N/A,16861.59,N/A,16861.59,N/A,4564.51,N/A,7634.51,N/A,7634.51,N/A,6870.65,N/A,4564.51,23486.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 090,Concussion Without Cc/McC,N/A,N/A,31910.80,N/A,19146.48,N/A,4390.93,N/A,5459.89,N/A,9895.31,N/A,10849.67,N/A,10287.93,N/A,4526.22,N/A,562.00,N/A,562.00,N/A,6404.54,N/A,10287.93,N/A,10287.93,N/A,10287.93,N/A,9895.31,N/A,5459.89,N/A,4526.22,N/A,11885.56,N/A,11885.56,N/A,4228.08,N/A,5459.89,N/A,5459.89,N/A,4843.05,N/A,562.00,19146.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 091,Other Disorders Of Nervous System With McC,N/A,N/A,25891.90,N/A,15535.14,N/A,9215.02,N/A,10736.61,N/A,20766.80,N/A,8803.25,N/A,21590.77,N/A,9498.95,N/A,10647.66,N/A,10647.66,N/A,13440.90,N/A,21590.77,N/A,21590.77,N/A,21590.77,N/A,20766.80,N/A,10647.66,N/A,9498.95,N/A,24943.66,N/A,24943.66,N/A,N/A,N/A,10647.66,N/A,10736.61,N/A,10163.88,N/A,8803.25,24943.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 116,Intraocular Procedures With Cc/McC,N/A,N/A,105995.12,N/A,63597.07,N/A,10063.76,N/A,12170.55,N/A,58424.51,N/A,36038.35,N/A,22896.45,N/A,10373.84,N/A,2810.00,N/A,2810.00,N/A,14252.51,N/A,22896.45,N/A,22896.45,N/A,22896.45,N/A,58424.51,N/A,12170.55,N/A,10373.84,N/A,27241.06,N/A,27241.06,N/A,N/A,N/A,12170.55,N/A,12170.55,N/A,11100.01,N/A,2810.00,63597.07,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 125,Other Disorders Of The Eye Without McC,N/A,N/A,24803.50,N/A,14882.10,N/A,4598.98,N/A,5705.99,N/A,10364.17,N/A,8433.19,N/A,10463.31,N/A,4740.68,N/A,1686.00,N/A,1686.00,N/A,6513.17,N/A,10463.31,N/A,10463.31,N/A,10463.31,N/A,10364.17,N/A,5705.99,N/A,4740.68,N/A,12448.72,N/A,12448.72,N/A,762.84,N/A,5705.99,N/A,5705.99,N/A,5072.53,N/A,762.84,14882.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 137,Mouth Procedures With Cc/McC,N/A,N/A,43041.60,N/A,25824.96,N/A,7999.80,N/A,9728.99,N/A,18028.19,N/A,14634.15,N/A,18200.65,N/A,8246.28,N/A,2810.00,N/A,2810.00,N/A,11329.48,N/A,18200.65,N/A,18200.65,N/A,18200.65,N/A,18028.19,N/A,9728.99,N/A,8246.28,N/A,21654.22,N/A,21654.22,N/A,15843.29,N/A,9728.99,N/A,9728.99,N/A,8823.52,N/A,2810.00,25824.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 138,Mouth Procedures Without Cc/McC,N/A,N/A,33558.07,N/A,20134.84,N/A,4717.40,N/A,5846.09,N/A,10631.05,N/A,11409.74,N/A,10732.75,N/A,4862.76,N/A,5846.09,N/A,5846.09,N/A,6680.89,N/A,10732.75,N/A,10732.75,N/A,10732.75,N/A,10631.05,N/A,5846.09,N/A,4862.76,N/A,12769.29,N/A,12769.29,N/A,49.50,N/A,5846.09,N/A,5846.09,N/A,5203.15,N/A,49.50,20134.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 141,Major Head And Neck Procedures With Cc,N/A,N/A,80525.92,N/A,48315.55,N/A,11910.07,N/A,14354.65,N/A,26975.75,N/A,27378.82,N/A,27097.07,N/A,12277.04,N/A,562.00,N/A,562.00,N/A,16867.29,N/A,27097.07,N/A,27097.07,N/A,27097.07,N/A,26975.75,N/A,14354.65,N/A,12277.04,N/A,32238.74,N/A,32238.74,N/A,14460.11,N/A,14354.65,N/A,14354.65,N/A,13136.44,N/A,562.00,48315.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 144,"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",N/A,N/A,66173.42,N/A,39704.05,N/A,9651.93,N/A,11683.38,N/A,21751.40,N/A,22498.96,N/A,21959.47,N/A,9949.32,N/A,11683.38,N/A,11683.38,N/A,13669.26,N/A,21959.47,N/A,21959.47,N/A,21959.47,N/A,21751.40,N/A,11683.38,N/A,9949.32,N/A,26126.29,N/A,26126.29,N/A,4976.92,N/A,11683.38,N/A,11683.38,N/A,4976.92,N/A,4976.92,39704.05,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 148,"Ear, Nose, Mouth And Throat Malignancy Without Cc/McC",N/A,N/A,23089.45,N/A,13853.67,N/A,4361.59,N/A,5425.16,N/A,9829.19,N/A,7850.41,N/A,9923.21,N/A,4495.97,N/A,1686.00,N/A,1686.00,N/A,6176.97,N/A,9923.21,N/A,9923.21,N/A,9923.21,N/A,9829.19,N/A,5425.16,N/A,4495.97,N/A,11806.14,N/A,11806.14,N/A,4495.97,N/A,5425.16,N/A,5425.16,N/A,4810.69,N/A,1686.00,13853.67,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 154,"Other Ear, Nose, Mouth And Throat Diagnoses With McC",N/A,N/A,39856.88,N/A,23914.13,N/A,8017.40,N/A,9749.82,N/A,18067.86,N/A,13551.34,N/A,18240.70,N/A,8264.43,N/A,1686.00,N/A,1686.00,N/A,11354.41,N/A,18240.70,N/A,18240.70,N/A,18240.70,N/A,18067.86,N/A,9749.82,N/A,8264.43,N/A,21701.88,N/A,21701.88,N/A,8264.43,N/A,9749.82,N/A,9749.82,N/A,8842.94,N/A,1686.00,23914.13,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 168,Other Respiratory System O.R. Procedures Without Cc/McC,N/A,N/A,59692.22,N/A,35815.33,N/A,7562.36,N/A,9211.52,N/A,19261.35,N/A,20295.35,N/A,17205.41,N/A,7795.37,N/A,9211.52,N/A,9211.52,N/A,10709.97,N/A,17205.41,N/A,17205.41,N/A,17205.41,N/A,19261.35,N/A,9211.52,N/A,7795.37,N/A,20470.14,N/A,20470.14,N/A,7795.37,N/A,9211.52,N/A,9211.52,N/A,8341.04,N/A,7562.36,35815.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 175,Pulmonary Embolism With McC Or Acute Cor Pulmonale,N/A,N/A,40357.20,N/A,24214.32,N/A,7451.40,N/A,9080.25,N/A,16792.33,N/A,13721.45,N/A,16952.96,N/A,7680.99,N/A,9080.25,N/A,9080.25,N/A,10552.82,N/A,16952.96,N/A,16952.96,N/A,16952.96,N/A,16792.33,N/A,9080.25,N/A,7680.99,N/A,20169.79,N/A,20169.79,N/A,7451.40,N/A,9080.25,N/A,9080.25,N/A,8218.66,N/A,7451.40,24214.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 177,Respiratory Infections And Inflammations With McC,N/A,N/A,43534.70,N/A,26120.82,N/A,9495.09,N/A,11497.84,N/A,21397.96,N/A,14801.80,N/A,21602.65,N/A,9787.65,N/A,11497.84,N/A,11497.84,N/A,13447.14,N/A,21602.65,N/A,21602.65,N/A,21602.65,N/A,21397.96,N/A,11497.84,N/A,9787.65,N/A,25701.76,N/A,25701.76,N/A,N/A,N/A,11497.84,N/A,11497.84,N/A,10472.79,N/A,9495.09,26120.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 179,Respiratory Infections And Inflammations Without Cc/McC,N/A,N/A,22871.90,N/A,13723.14,N/A,4189.81,N/A,5221.98,N/A,9442.08,N/A,7776.45,N/A,9532.40,N/A,4318.91,N/A,1367.83,N/A,1367.83,N/A,5933.70,N/A,9532.40,N/A,9532.40,N/A,9532.40,N/A,9442.08,N/A,5221.98,N/A,4318.91,N/A,11341.18,N/A,11341.18,N/A,N/A,N/A,5221.98,N/A,5221.98,N/A,4621.23,N/A,1367.83,13723.14,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 188,Pleural Effusion Without Cc/McC,N/A,N/A,25674.30,N/A,15404.58,N/A,3862.27,N/A,4834.51,N/A,15753.24,N/A,8729.26,N/A,8787.19,N/A,3981.27,N/A,4834.51,N/A,4834.51,N/A,5469.82,N/A,8787.19,N/A,8787.19,N/A,8787.19,N/A,15753.24,N/A,4834.51,N/A,3981.27,N/A,10454.56,N/A,10454.56,N/A,4887.26,N/A,4834.51,N/A,4834.51,N/A,4259.96,N/A,3862.27,15753.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 189,Pulmonary Edema And Respiratory Failure,N/A,N/A,34795.40,N/A,20877.24,N/A,6438.89,N/A,7882.51,N/A,14510.55,N/A,11830.43,N/A,14649.36,N/A,6637.28,N/A,7882.51,N/A,7882.51,N/A,9118.89,N/A,14649.36,N/A,14649.36,N/A,14649.36,N/A,14510.55,N/A,7882.51,N/A,6637.28,N/A,17429.08,N/A,17429.08,N/A,6637.28,N/A,7882.51,N/A,7882.51,N/A,7101.89,N/A,6438.89,20877.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 190,Chronic Obstructive Pulmonary Disease With McC,N/A,N/A,29979.10,N/A,17987.46,N/A,5790.73,N/A,7115.77,N/A,13049.88,N/A,10192.89,N/A,13174.71,N/A,5969.15,N/A,7115.77,N/A,7115.77,N/A,8200.95,N/A,13174.71,N/A,13174.71,N/A,13174.71,N/A,13049.88,N/A,7115.77,N/A,5969.15,N/A,15674.62,N/A,15674.62,N/A,6386.99,N/A,7115.77,N/A,7115.77,N/A,6386.99,N/A,5790.73,17987.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 197,Interstitial Lung Disease With Cc,N/A,N/A,28272.60,N/A,16963.56,N/A,5247.13,N/A,6472.74,N/A,11824.84,N/A,9612.68,N/A,11937.95,N/A,5408.81,N/A,6472.74,N/A,6472.74,N/A,7431.10,N/A,11937.95,N/A,11937.95,N/A,11937.95,N/A,11824.84,N/A,6472.74,N/A,5408.81,N/A,14203.18,N/A,14203.18,N/A,7149.00,N/A,6472.74,N/A,6472.74,N/A,5787.42,N/A,5247.13,16963.56,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 216,Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,N/A,N/A,286325.23,N/A,171795.14,N/A,49281.27,N/A,61742.70,N/A,167079.20,N/A,97414.74,N/A,99764.15,N/A,49281.27,N/A,61742.70,N/A,61742.70,N/A,62116.22,N/A,99764.15,N/A,99764.15,N/A,99764.15,N/A,167079.20,N/A,61742.70,N/A,49281.27,N/A,167079.20,N/A,167079.20,N/A,49281.27,N/A,61742.70,N/A,61742.70,N/A,49281.27,N/A,49281.27,171795.14,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 219,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,N/A,N/A,286056.70,N/A,171634.02,N/A,32217.10,N/A,54017.91,N/A,129118.05,N/A,125696.03,N/A,125696.03,N/A,32217.10,N/A,52675.88,N/A,52675.88,N/A,125696.03,N/A,125696.03,N/A,125696.03,N/A,162639.15,N/A,129118.05,N/A,51774.43,N/A,32217.10,N/A,129118.05,N/A,129118.05,N/A,32217.10,N/A,53517.46,N/A,52675.88,N/A,32217.10,N/A,32217.10,171634.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 226,Cardiac Defibrillator Implant Without Cardiac Catheterization With McC,N/A,N/A,244147.32,N/A,146488.39,N/A,50317.03,N/A,44537.55,N/A,134574.00,N/A,86559.37,N/A,86559.37,N/A,35198.48,N/A,40659.05,N/A,40659.05,N/A,86559.37,N/A,86559.37,N/A,86559.37,N/A,86559.37,N/A,162859.50,N/A,40659.05,N/A,50317.03,N/A,164304.88,N/A,162859.50,N/A,50317.03,N/A,44537.55,N/A,44537.55,N/A,50317.03,N/A,35198.48,164304.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 227,Cardiac Defibrillator Implant Without Cardiac Catheterization Without McC,N/A,N/A,177582.45,N/A,106549.47,N/A,26783.53,N/A,31949.18,N/A,97883.45,N/A,60378.03,N/A,63306.01,N/A,27608.78,N/A,31949.18,N/A,31949.18,N/A,39407.47,N/A,63306.01,N/A,63306.01,N/A,63306.01,N/A,97883.45,N/A,31949.18,N/A,27608.78,N/A,72498.91,N/A,72498.91,N/A,8962.65,N/A,31949.18,N/A,31949.18,N/A,29541.39,N/A,8962.65,106549.47,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 245,Aicd Generator Procedures,N/A,N/A,189676.82,N/A,113806.09,N/A,26011.61,N/A,31095.34,N/A,104549.86,N/A,64490.12,N/A,66045.47,N/A,26813.07,N/A,1124.00,N/A,1124.00,N/A,41121.93,N/A,66045.47,N/A,66045.47,N/A,66045.47,N/A,104549.86,N/A,31036.04,N/A,26813.07,N/A,70409.44,N/A,70409.44,N/A,11076.75,N/A,31036.04,N/A,31036.04,N/A,28689.99,N/A,1124.00,113806.09,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 246,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With McC Or 4+ Arteries Or Stents,N/A,N/A,97444.95,N/A,58466.97,N/A,15979.32,N/A,19168.37,N/A,42673.16,N/A,33131.28,N/A,37769.00,N/A,16471.67,N/A,19168.37,N/A,19168.37,N/A,37769.00,N/A,37769.00,N/A,37769.00,N/A,37769.00,N/A,42673.16,N/A,19168.37,N/A,16471.67,N/A,43253.58,N/A,45114.89,N/A,16471.67,N/A,19168.37,N/A,19168.37,N/A,16471.67,N/A,15979.32,58466.97,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 250,Percutaneous Cardiovascular Procedures Without Coronary Artery Stent With McC,N/A,N/A,86949.42,N/A,52169.65,N/A,12908.18,N/A,15535.36,N/A,29089.63,N/A,29562.80,N/A,30510.00,N/A,13305.90,N/A,15535.36,N/A,15535.36,N/A,18992.23,N/A,30510.00,N/A,30510.00,N/A,30510.00,N/A,29089.63,N/A,15535.36,N/A,13305.90,N/A,34940.47,N/A,34940.47,N/A,13545.31,N/A,15535.36,N/A,16751.44,N/A,14237.32,N/A,12908.18,52169.65,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 252,Other Vascular Procedures With McC,N/A,N/A,139431.43,N/A,83658.86,N/A,19671.71,N/A,21363.81,N/A,76854.60,N/A,47406.68,N/A,N/A,N/A,19671.71,N/A,21363.81,N/A,21363.81,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,21363.81,N/A,19671.71,N/A,N/A,N/A,48277.25,N/A,2293.85,N/A,21363.81,N/A,21363.81,N/A,19671.71,N/A,2293.85,83658.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 260,Cardiac Pacemaker Revision Except Device Replacement With McC,N/A,N/A,97426.72,N/A,58456.03,N/A,18663.70,N/A,22343.84,N/A,68497.62,N/A,33125.08,N/A,44113.85,N/A,19238.76,N/A,1124.00,N/A,1124.00,N/A,27460.51,N/A,44113.85,N/A,44113.85,N/A,44113.85,N/A,68497.62,N/A,22343.84,N/A,19238.76,N/A,50519.78,N/A,50519.78,N/A,19238.76,N/A,22343.84,N/A,22343.84,N/A,20585.48,N/A,1124.00,68497.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 261,Cardiac Pacemaker Revision Except Device Replacement With Cc,N/A,N/A,60541.58,N/A,36324.95,N/A,10193.39,N/A,12323.90,N/A,33973.55,N/A,20584.14,N/A,24093.28,N/A,10507.47,N/A,12323.90,N/A,12323.90,N/A,14997.87,N/A,24093.28,N/A,24093.28,N/A,24093.28,N/A,33973.55,N/A,12323.90,N/A,10507.47,N/A,27591.95,N/A,27591.95,N/A,3610.22,N/A,12323.90,N/A,12323.90,N/A,11242.99,N/A,3610.22,36324.95,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 262,Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,N/A,N/A,59820.25,N/A,35892.15,N/A,8945.09,N/A,10876.87,N/A,41156.66,N/A,19670.70,N/A,17830.58,N/A,9220.71,N/A,10847.22,N/A,10847.22,N/A,11099.88,N/A,17830.58,N/A,17830.58,N/A,17830.58,N/A,41156.66,N/A,10847.22,N/A,9220.71,N/A,24212.99,N/A,24212.99,N/A,9220.71,N/A,10847.22,N/A,10876.87,N/A,9866.15,N/A,8945.09,41156.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 265,Aicd Lead Procedures,N/A,N/A,125074.37,N/A,75044.62,N/A,18042.22,N/A,21608.67,N/A,68940.99,N/A,42525.28,N/A,42644.90,N/A,18598.13,N/A,21608.67,N/A,21608.67,N/A,26546.10,N/A,42644.90,N/A,42644.90,N/A,42644.90,N/A,68940.99,N/A,21608.67,N/A,18598.13,N/A,48837.52,N/A,48837.52,N/A,14501.55,N/A,21608.67,N/A,21608.67,N/A,19900.00,N/A,14501.55,75044.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 268,Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,N/A,N/A,307114.73,N/A,184268.84,N/A,19364.13,N/A,46083.81,N/A,156968.66,N/A,N/A,N/A,N/A,N/A,19364.13,N/A,43939.92,N/A,46083.81,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,156968.66,N/A,46083.81,N/A,19364.13,N/A,205752.34,N/A,205752.34,N/A,19364.13,N/A,46083.81,N/A,46083.81,N/A,19364.13,N/A,19364.13,205752.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 273,Percutaneous And Other Intracardiac Procedures With McC,N/A,N/A,158197.58,N/A,94918.55,N/A,21407.83,N/A,25590.01,N/A,87198.51,N/A,53787.18,N/A,50599.92,N/A,22067.44,N/A,3934.00,N/A,3934.00,N/A,31498.04,N/A,50599.92,N/A,50599.92,N/A,50599.92,N/A,87198.51,N/A,25590.01,N/A,22067.44,N/A,57947.72,N/A,57947.72,N/A,5574.18,N/A,25590.01,N/A,25590.01,N/A,23612.17,N/A,3934.00,94918.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 280,"Acute Myocardial Infarction, Discharged Alive With McC",N/A,N/A,56357.50,N/A,33814.50,N/A,8569.53,N/A,10462.26,N/A,19312.14,N/A,20255.10,N/A,20255.10,N/A,8833.58,N/A,10402.96,N/A,10402.96,N/A,12608.63,N/A,20255.10,N/A,20255.10,N/A,20255.10,N/A,19312.14,N/A,10402.96,N/A,8833.58,N/A,23196.42,N/A,23196.42,N/A,9451.93,N/A,10402.96,N/A,10462.26,N/A,9451.93,N/A,8569.53,33814.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 288,Acute And Subacute Endocarditis With McC,N/A,N/A,44166.80,N/A,26500.08,N/A,7531.44,N/A,14646.27,N/A,32417.32,N/A,60002.52,N/A,60002.52,N/A,7531.44,N/A,12651.62,N/A,12651.62,N/A,60002.52,N/A,60002.52,N/A,60002.52,N/A,60002.52,N/A,32417.32,N/A,12651.62,N/A,7531.44,N/A,N/A,N/A,38937.46,N/A,7531.44,N/A,12651.62,N/A,12651.62,N/A,15642.52,N/A,7531.44,60002.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 289,Acute And Subacute Endocarditis With Cc,N/A,N/A,45565.40,N/A,27339.24,N/A,8573.27,N/A,9833.36,N/A,19320.56,N/A,15492.24,N/A,20263.92,N/A,8837.43,N/A,9833.36,N/A,9833.36,N/A,12614.13,N/A,20263.92,N/A,20263.92,N/A,20263.92,N/A,19320.56,N/A,9833.36,N/A,8837.43,N/A,23206.52,N/A,23206.52,N/A,1602.59,N/A,9833.36,N/A,9833.36,N/A,9456.05,N/A,1602.59,27339.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 301,Peripheral Vascular Disorders Without Cc/McC,N/A,N/A,16951.60,N/A,10170.96,N/A,3820.66,N/A,4785.27,N/A,8610.16,N/A,5609.52,N/A,9030.57,N/A,3938.38,N/A,4785.27,N/A,4785.27,N/A,5621.45,N/A,9030.57,N/A,9030.57,N/A,9030.57,N/A,8610.16,N/A,4785.27,N/A,3938.38,N/A,10341.93,N/A,10341.93,N/A,3938.38,N/A,4785.27,N/A,4785.27,N/A,4214.06,N/A,3820.66,10341.93,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 306,Cardiac Congenital And Valvular Disorders With McC,N/A,N/A,39529.70,N/A,23717.82,N/A,7872.83,N/A,9638.10,N/A,17742.07,N/A,13440.10,N/A,18608.36,N/A,8115.41,N/A,2366.06,N/A,2366.06,N/A,11583.55,N/A,18608.36,N/A,18608.36,N/A,18608.36,N/A,17742.07,N/A,9578.80,N/A,8115.41,N/A,21310.55,N/A,21310.55,N/A,6473.73,N/A,9578.80,N/A,9638.10,N/A,8683.49,N/A,2366.06,23717.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 309,Cardiac Arrhythmia And Conduction Disorders With Cc,N/A,N/A,28987.20,N/A,17392.32,N/A,3934.82,N/A,4920.32,N/A,8867.43,N/A,9855.65,N/A,9300.40,N/A,4056.05,N/A,4920.32,N/A,4920.32,N/A,5789.42,N/A,9300.40,N/A,9300.40,N/A,9300.40,N/A,8867.43,N/A,4920.32,N/A,4056.05,N/A,10650.94,N/A,10650.94,N/A,3934.82,N/A,4920.32,N/A,4920.32,N/A,4339.98,N/A,3934.82,17392.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 312,Syncope And Collapse,N/A,N/A,30778.90,N/A,18467.34,N/A,4548.83,N/A,5646.67,N/A,10670.73,N/A,10464.83,N/A,10751.69,N/A,4688.99,N/A,5646.67,N/A,5646.67,N/A,6692.84,N/A,10751.69,N/A,10751.69,N/A,10751.69,N/A,10670.73,N/A,5646.67,N/A,4688.99,N/A,12312.99,N/A,12312.99,N/A,4688.99,N/A,5646.67,N/A,5646.67,N/A,5017.22,N/A,4548.83,18467.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 314,Other Circulatory System Diagnoses With McC,N/A,N/A,44909.20,N/A,26945.52,N/A,11109.88,N/A,13408.05,N/A,25037.02,N/A,15269.13,N/A,19068.40,N/A,11452.20,N/A,13408.05,N/A,13408.05,N/A,19068.40,N/A,26259.50,N/A,26259.50,N/A,26259.50,N/A,25037.02,N/A,13408.05,N/A,11452.20,N/A,30072.74,N/A,30072.74,N/A,12253.85,N/A,13408.05,N/A,13408.05,N/A,12253.85,N/A,11109.88,30072.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 320,Other Endovascular Cardiac Valve Procedures Without McC,N/A,N/A,77325.87,N/A,46395.52,N/A,13183.98,N/A,15861.61,N/A,35894.93,N/A,26290.79,N/A,31161.88,N/A,13590.20,N/A,15861.61,N/A,15861.61,N/A,19398.02,N/A,31161.88,N/A,31161.88,N/A,31161.88,N/A,35894.93,N/A,15861.61,N/A,13590.20,N/A,35687.02,N/A,35687.02,N/A,16184.08,N/A,15861.61,N/A,15861.61,N/A,14541.52,N/A,13183.98,46395.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 327,"Stomach, Esophageal And Duodenal Procedures With Cc",N/A,N/A,84250.83,N/A,50550.50,N/A,13663.56,N/A,16428.94,N/A,30791.95,N/A,28645.28,N/A,31086.50,N/A,14084.56,N/A,3934.00,N/A,3934.00,N/A,19350.62,N/A,31086.50,N/A,31086.50,N/A,31086.50,N/A,30791.95,N/A,16428.94,N/A,14084.56,N/A,36985.17,N/A,36985.17,N/A,14084.56,N/A,16428.94,N/A,16428.94,N/A,15070.48,N/A,3934.00,50550.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 329,Major Small And Large Bowel Procedures With McC,N/A,N/A,117041.17,N/A,70224.70,N/A,4178.16,N/A,29708.20,N/A,56695.40,N/A,56112.99,N/A,56112.99,N/A,4178.16,N/A,29708.20,N/A,29708.20,N/A,56112.99,N/A,56112.99,N/A,56112.99,N/A,56112.99,N/A,56695.40,N/A,29708.20,N/A,4178.16,N/A,56695.40,N/A,56695.40,N/A,4178.16,N/A,29708.20,N/A,29708.20,N/A,4178.16,N/A,4178.16,70224.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 330,Major Small And Large Bowel Procedures With Cc,N/A,N/A,80265.40,N/A,48159.24,N/A,13502.22,N/A,15760.65,N/A,29518.82,N/A,27290.23,N/A,29801.19,N/A,13502.22,N/A,15760.65,N/A,15760.65,N/A,29801.19,N/A,29801.19,N/A,29801.19,N/A,29801.19,N/A,29518.82,N/A,15760.65,N/A,13502.22,N/A,35455.98,N/A,35455.98,N/A,13502.22,N/A,15760.65,N/A,15997.85,N/A,14447.37,N/A,13502.22,48159.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 331,Major Small And Large Bowel Procedures Without Cc/McC,N/A,N/A,56166.15,N/A,33699.69,N/A,9115.80,N/A,11049.17,N/A,20543.19,N/A,19096.49,N/A,20739.71,N/A,9396.67,N/A,11049.17,N/A,11049.17,N/A,12909.98,N/A,20739.71,N/A,20739.71,N/A,20739.71,N/A,20543.19,N/A,11049.17,N/A,9396.67,N/A,24675.07,N/A,24675.07,N/A,9396.67,N/A,11049.17,N/A,11049.17,N/A,10054.44,N/A,9115.80,33699.69,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 332,Rectal Resection With McC,N/A,N/A,76889.75,N/A,46133.85,N/A,21660.16,N/A,25888.50,N/A,48812.93,N/A,26142.52,N/A,49279.86,N/A,22327.55,N/A,25888.50,N/A,25888.50,N/A,N/A,N/A,N/A,N/A,49279.86,N/A,49279.86,N/A,48812.93,N/A,25888.50,N/A,22327.55,N/A,58630.73,N/A,58630.73,N/A,N/A,N/A,25888.50,N/A,26001.63,N/A,23890.48,N/A,21660.16,58630.73,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 333,Rectal Resection With Cc,N/A,N/A,106504.72,N/A,63902.83,N/A,11912.74,N/A,14357.80,N/A,58705.40,N/A,36211.60,N/A,27103.13,N/A,12279.79,N/A,2810.00,N/A,2810.00,N/A,16871.07,N/A,27103.13,N/A,27103.13,N/A,27103.13,N/A,58705.40,N/A,14357.80,N/A,12279.79,N/A,32245.96,N/A,32245.96,N/A,12279.79,N/A,14357.80,N/A,14357.80,N/A,13139.38,N/A,2810.00,63902.83,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 335,Peritoneal Adhesiolysis With McC,N/A,N/A,124611.72,N/A,74767.03,N/A,27176.37,N/A,24907.13,N/A,48105.23,N/A,42367.98,N/A,44710.28,N/A,27176.37,N/A,24907.13,N/A,24907.13,N/A,27831.11,N/A,44710.28,N/A,44710.28,N/A,44710.28,N/A,48105.23,N/A,24907.13,N/A,27176.37,N/A,48105.23,N/A,48105.23,N/A,27176.37,N/A,24907.13,N/A,24907.13,N/A,27176.37,N/A,24907.13,74767.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 336,Peritoneal Adhesiolysis With Cc,N/A,N/A,75044.70,N/A,45026.82,N/A,11346.74,N/A,13688.24,N/A,25570.79,N/A,25515.20,N/A,25815.40,N/A,11696.35,N/A,3372.00,N/A,3372.00,N/A,16069.49,N/A,25815.40,N/A,25815.40,N/A,25815.40,N/A,25570.79,N/A,13688.24,N/A,11696.35,N/A,30713.88,N/A,30713.88,N/A,11696.35,N/A,13688.24,N/A,13866.14,N/A,12515.10,N/A,3372.00,45026.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 338,Appendectomy With Complicated Principal Diagnosis With McC,N/A,N/A,79565.02,N/A,47739.01,N/A,14171.42,N/A,17029.71,N/A,31936.44,N/A,27052.10,N/A,32241.94,N/A,14608.07,N/A,2248.00,N/A,2248.00,N/A,20069.86,N/A,32241.94,N/A,32241.94,N/A,32241.94,N/A,31936.44,N/A,17029.71,N/A,14608.07,N/A,38359.86,N/A,38359.86,N/A,17876.08,N/A,17029.71,N/A,17029.71,N/A,15630.63,N/A,2248.00,47739.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 342,Appendectomy Without Complicated Principal Diagnosis With Cc,N/A,N/A,46044.58,N/A,27626.75,N/A,7752.27,N/A,9436.18,N/A,17888.70,N/A,15655.16,N/A,17637.49,N/A,7991.13,N/A,562.00,N/A,562.00,N/A,10978.93,N/A,17637.49,N/A,17637.49,N/A,17637.49,N/A,17888.70,N/A,9436.18,N/A,7991.13,N/A,20984.21,N/A,7897.00,N/A,5965.32,N/A,9436.18,N/A,9436.18,N/A,8550.51,N/A,562.00,27626.75,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 344,Minor Small And Large Bowel Procedures With McC,N/A,N/A,79931.47,N/A,47958.88,N/A,151.09,N/A,17382.30,N/A,42791.29,N/A,31950.65,N/A,31950.65,N/A,151.09,N/A,17382.30,N/A,17382.30,N/A,31950.65,N/A,31950.65,N/A,31950.65,N/A,31950.65,N/A,42791.29,N/A,16878.25,N/A,151.09,N/A,38013.30,N/A,42791.29,N/A,151.09,N/A,17382.30,N/A,17382.30,N/A,151.09,N/A,151.09,47958.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 351,Inguinal And Femoral Hernia Procedures With Cc,N/A,N/A,59625.62,N/A,35775.37,N/A,7842.96,N/A,9721.36,N/A,18416.57,N/A,20272.70,N/A,17843.82,N/A,8084.61,N/A,3372.00,N/A,3372.00,N/A,11107.36,N/A,17843.82,N/A,17843.82,N/A,17843.82,N/A,18416.57,N/A,9543.46,N/A,8084.61,N/A,21229.69,N/A,21229.69,N/A,6214.30,N/A,9543.46,N/A,9543.46,N/A,8650.54,N/A,3372.00,35775.37,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 375,Digestive Malignancy With Cc,N/A,N/A,40938.40,N/A,24563.04,N/A,6426.08,N/A,7867.36,N/A,14481.70,N/A,13919.06,N/A,14620.23,N/A,6624.08,N/A,2810.00,N/A,2810.00,N/A,9100.75,N/A,14620.23,N/A,14620.23,N/A,14620.23,N/A,14481.70,N/A,7867.36,N/A,6624.08,N/A,17394.42,N/A,17394.42,N/A,6587.28,N/A,7867.36,N/A,7867.36,N/A,7087.77,N/A,2810.00,24563.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 382,Complicated Peptic Ulcer Without Cc/McC,N/A,N/A,32246.78,N/A,19348.07,N/A,4106.59,N/A,5123.53,N/A,9254.54,N/A,10963.90,N/A,9343.06,N/A,4233.12,N/A,2810.00,N/A,2810.00,N/A,5815.84,N/A,9343.06,N/A,9343.06,N/A,9343.06,N/A,9254.54,N/A,5123.53,N/A,4233.12,N/A,11115.91,N/A,11115.91,N/A,3881.99,N/A,5123.53,N/A,5123.53,N/A,4529.44,N/A,2810.00,19348.07,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 388,Gastrointestinal Obstruction With McC,N/A,N/A,33023.80,N/A,19814.28,N/A,7828.02,N/A,9525.79,N/A,17641.08,N/A,11228.09,N/A,17809.83,N/A,8069.22,N/A,9525.79,N/A,9525.79,N/A,11086.21,N/A,17809.83,N/A,17809.83,N/A,17809.83,N/A,17641.08,N/A,9525.79,N/A,8069.22,N/A,21189.26,N/A,N/A,N/A,3221.03,N/A,9525.79,N/A,9525.79,N/A,8634.06,N/A,3221.03,21189.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 391,"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC",N/A,N/A,41963.32,N/A,25177.99,N/A,6849.65,N/A,8368.43,N/A,15436.25,N/A,14267.53,N/A,14611.63,N/A,7060.70,N/A,8368.43,N/A,8368.43,N/A,9097.65,N/A,14611.63,N/A,14611.63,N/A,14611.63,N/A,15436.25,N/A,8368.43,N/A,7060.70,N/A,18540.96,N/A,18540.96,N/A,7060.70,N/A,8368.43,N/A,8368.43,N/A,7554.95,N/A,6849.65,25177.99,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 405,"Pancreas, Liver And Shunt Procedures With McC",N/A,N/A,226967.22,N/A,136180.33,N/A,20581.56,N/A,35238.26,N/A,101732.66,N/A,77149.81,N/A,79010.49,N/A,20581.56,N/A,3372.00,N/A,35867.54,N/A,49194.35,N/A,79010.49,N/A,79010.49,N/A,79010.49,N/A,101732.66,N/A,35867.54,N/A,20581.56,N/A,101732.66,N/A,101732.66,N/A,17595.11,N/A,35867.54,N/A,35867.54,N/A,32608.09,N/A,3372.00,136180.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 406,"Pancreas, Liver And Shunt Procedures With Cc",N/A,N/A,122222.53,N/A,73333.52,N/A,15628.84,N/A,18753.76,N/A,67369.06,N/A,41555.66,N/A,35557.77,N/A,16110.39,N/A,2810.00,N/A,2810.00,N/A,22133.88,N/A,35557.77,N/A,35557.77,N/A,35557.77,N/A,67369.06,N/A,18753.76,N/A,16110.39,N/A,42304.87,N/A,42304.87,N/A,16110.39,N/A,18753.76,N/A,18753.76,N/A,17238.12,N/A,2810.00,73333.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 408,Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,N/A,N/A,129559.05,N/A,77735.43,N/A,N/A,N/A,23659.53,N/A,49721.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23773.52,N/A,23773.52,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49721.73,N/A,23773.52,N/A,N/A,N/A,49721.73,N/A,49721.73,N/A,N/A,N/A,23773.52,N/A,23773.52,N/A,N/A,N/A,23659.53,77735.43,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 409,Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,N/A,N/A,84809.20,N/A,50885.52,N/A,11370.21,N/A,13716.02,N/A,25623.69,N/A,28833.76,N/A,25868.80,N/A,11720.55,N/A,13716.02,N/A,14031.52,N/A,16102.73,N/A,25868.80,N/A,25868.80,N/A,25868.80,N/A,25623.69,N/A,14031.52,N/A,11720.55,N/A,30777.42,N/A,30777.42,N/A,N/A,N/A,13716.02,N/A,13716.02,N/A,12540.98,N/A,11370.21,50885.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 417,Laparoscopic Cholecystectomy Without C.D.E. With McC,N/A,N/A,59606.87,N/A,35764.12,N/A,12684.13,N/A,15270.31,N/A,28584.71,N/A,20266.34,N/A,28858.14,N/A,13074.95,N/A,15270.31,N/A,N/A,N/A,17963.52,N/A,28858.14,N/A,30742.89,N/A,28858.14,N/A,28584.71,N/A,15270.31,N/A,13074.95,N/A,34333.99,N/A,N/A,N/A,5177.46,N/A,15270.31,N/A,N/A,N/A,13990.19,N/A,5177.46,35764.12,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 439,Disorders Of Pancreas Except Malignancy With Cc,N/A,N/A,29956.30,N/A,17973.78,N/A,4640.05,N/A,5754.58,N/A,10456.74,N/A,10185.14,N/A,10556.76,N/A,4783.02,N/A,5754.58,N/A,5754.58,N/A,6571.34,N/A,10556.76,N/A,10556.76,N/A,10556.76,N/A,10456.74,N/A,5754.58,N/A,4783.02,N/A,12559.91,N/A,12559.91,N/A,4783.02,N/A,5754.58,N/A,5754.58,N/A,5117.83,N/A,4640.05,17973.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 442,"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",N/A,N/A,25146.60,N/A,15087.96,N/A,5046.55,N/A,6235.45,N/A,11372.81,N/A,8549.84,N/A,11481.60,N/A,5202.04,N/A,6235.45,N/A,6235.45,N/A,7147.03,N/A,11481.60,N/A,11481.60,N/A,11481.60,N/A,11372.81,N/A,6235.45,N/A,5202.04,N/A,13660.24,N/A,13660.24,N/A,5202.04,N/A,6235.45,N/A,6235.45,N/A,5566.19,N/A,5046.55,15087.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 443,"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/McC",N/A,N/A,20817.20,N/A,12490.32,N/A,3477.64,N/A,4379.50,N/A,7837.14,N/A,7077.85,N/A,7912.11,N/A,3584.79,N/A,1124.00,N/A,1124.00,N/A,4925.10,N/A,7912.11,N/A,7912.11,N/A,7912.11,N/A,7837.14,N/A,4379.50,N/A,3584.79,N/A,9413.44,N/A,9413.44,N/A,3627.39,N/A,4379.50,N/A,4379.50,N/A,3835.73,N/A,1124.00,12490.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 446,Disorders Of The Biliary Tract Without Cc/McC,N/A,N/A,32172.28,N/A,19303.37,N/A,4330.11,N/A,5387.94,N/A,9758.26,N/A,10938.58,N/A,9851.60,N/A,4463.53,N/A,5387.94,N/A,5387.94,N/A,6132.39,N/A,9851.60,N/A,9851.60,N/A,9851.60,N/A,9758.26,N/A,5387.94,N/A,4463.53,N/A,11720.95,N/A,11720.95,N/A,N/A,N/A,5387.94,N/A,5387.94,N/A,4775.98,N/A,4330.11,19303.37,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 453,Combined Anterior And Posterior Spinal Fusion With McC,N/A,N/A,248873.47,N/A,149324.08,N/A,32315.14,N/A,60775.51,N/A,137179.05,N/A,126273.74,N/A,126273.74,N/A,32315.14,N/A,63376.76,N/A,63376.76,N/A,126273.74,N/A,126273.74,N/A,126273.74,N/A,126273.74,N/A,137179.05,N/A,58037.75,N/A,32315.14,N/A,159252.03,N/A,136723.39,N/A,32315.14,N/A,60775.51,N/A,60775.51,N/A,32315.14,N/A,32315.14,159252.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 454,Combined Anterior And Posterior Spinal Fusion With Cc,N/A,N/A,196279.47,N/A,117767.68,N/A,18935.62,N/A,38702.76,N/A,108189.24,N/A,66735.02,N/A,68344.51,N/A,33493.80,N/A,40578.42,N/A,40578.42,N/A,42553.39,N/A,68344.51,N/A,68344.51,N/A,68344.51,N/A,108189.24,N/A,38702.76,N/A,33493.80,N/A,87952.60,N/A,87952.60,N/A,12230.89,N/A,38702.76,N/A,38702.76,N/A,35838.36,N/A,12230.89,117767.68,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 456,"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With McC",N/A,N/A,349226.12,N/A,209535.67,N/A,11695.17,N/A,51245.34,N/A,192493.44,N/A,118736.88,N/A,N/A,N/A,11695.17,N/A,54783.96,N/A,54783.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,192493.44,N/A,54783.96,N/A,11695.17,N/A,210929.78,N/A,210929.78,N/A,38965.97,N/A,51245.34,N/A,51245.34,N/A,51636.46,N/A,11695.17,210929.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 472,Cervical Spinal Fusion With Cc,N/A,N/A,123674.13,N/A,74204.48,N/A,16382.62,N/A,19645.44,N/A,68169.18,N/A,42049.21,N/A,37272.73,N/A,16887.40,N/A,4496.00,N/A,4496.00,N/A,23201.41,N/A,37272.73,N/A,37272.73,N/A,37272.73,N/A,68169.18,N/A,19645.44,N/A,16887.40,N/A,44345.24,N/A,44345.24,N/A,17170.59,N/A,19645.44,N/A,20232.50,N/A,18069.51,N/A,4496.00,74204.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 474,Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,N/A,N/A,103586.00,N/A,62151.60,N/A,22444.87,N/A,25375.16,N/A,35563.70,N/A,81974.87,N/A,81974.87,N/A,22444.87,N/A,25375.16,N/A,25375.16,N/A,81974.87,N/A,81974.87,N/A,81974.87,N/A,81974.87,N/A,35563.70,N/A,25375.16,N/A,22444.87,N/A,35563.70,N/A,35563.70,N/A,22444.87,N/A,25375.16,N/A,25375.16,N/A,22444.87,N/A,22444.87,81974.87,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 475,Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,N/A,N/A,68124.90,N/A,40874.94,N/A,11849.26,N/A,14282.70,N/A,26703.27,N/A,23162.47,N/A,26958.70,N/A,7510.74,N/A,2810.00,N/A,14705.08,N/A,29379.81,N/A,26958.70,N/A,26958.70,N/A,26958.70,N/A,26703.27,N/A,14282.70,N/A,12214.36,N/A,32074.13,N/A,32074.13,N/A,7510.74,N/A,14282.70,N/A,14282.70,N/A,13069.36,N/A,2810.00,40874.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 476,Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,N/A,N/A,41870.80,N/A,25122.48,N/A,6548.25,N/A,8011.88,N/A,14757.01,N/A,14236.07,N/A,14898.17,N/A,6750.01,N/A,1686.00,N/A,1686.00,N/A,9273.76,N/A,14898.17,N/A,14898.17,N/A,14898.17,N/A,14757.01,N/A,8011.88,N/A,6750.01,N/A,17725.10,N/A,17725.10,N/A,8593.89,N/A,8011.88,N/A,8011.88,N/A,7222.51,N/A,1686.00,25122.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 477,Biopsies Of Musculoskeletal System And Connective Tissue With McC,N/A,N/A,104729.10,N/A,62837.46,N/A,8655.26,N/A,21976.50,N/A,123500.05,N/A,44563.07,N/A,44563.07,N/A,8655.26,N/A,22309.00,N/A,22309.00,N/A,44563.07,N/A,44563.07,N/A,44563.07,N/A,44563.07,N/A,123500.05,N/A,22349.48,N/A,8655.26,N/A,123500.05,N/A,49136.43,N/A,8655.26,N/A,22858.60,N/A,22349.48,N/A,8655.26,N/A,8655.26,123500.05,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 478,Biopsies Of Musculoskeletal System And Connective Tissue With Cc,N/A,N/A,78862.20,N/A,47317.32,N/A,7536.41,N/A,14425.32,N/A,26974.96,N/A,26813.15,N/A,27233.00,N/A,7536.41,N/A,15543.05,N/A,15526.88,N/A,16951.91,N/A,31764.17,N/A,31764.17,N/A,27233.00,N/A,26974.96,N/A,14425.32,N/A,7536.41,N/A,32400.47,N/A,32400.47,N/A,7536.41,N/A,14425.32,N/A,15543.05,N/A,13202.34,N/A,7536.41,47317.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 481,Hip And Femur Procedures Except Major Joint With Cc,N/A,N/A,68992.35,N/A,41395.41,N/A,10482.65,N/A,13130.88,N/A,36997.01,N/A,23457.40,N/A,25638.20,N/A,10805.64,N/A,13130.88,N/A,13130.88,N/A,15959.18,N/A,25638.20,N/A,25638.20,N/A,25638.20,N/A,36997.01,N/A,13130.88,N/A,10805.64,N/A,30503.06,N/A,30503.06,N/A,3221.03,N/A,13130.88,N/A,13130.88,N/A,11562.04,N/A,3221.03,41395.41,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 482,Hip And Femur Procedures Except Major Joint Without Cc/McC,N/A,N/A,50245.17,N/A,30147.10,N/A,8781.32,N/A,10653.49,N/A,26778.68,N/A,17083.36,N/A,19978.72,N/A,9051.89,N/A,10653.49,N/A,10653.49,N/A,12436.29,N/A,19978.72,N/A,19978.72,N/A,19978.72,N/A,26778.68,N/A,10653.49,N/A,9051.89,N/A,23769.68,N/A,23769.68,N/A,9051.89,N/A,10653.49,N/A,10653.49,N/A,9685.52,N/A,8781.32,30147.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 485,Knee Procedures With Principal Diagnosis Of Infection With McC,N/A,N/A,128618.00,N/A,77170.80,N/A,17342.85,N/A,21339.08,N/A,70894.24,N/A,43730.12,N/A,39457.39,N/A,29369.35,N/A,20781.34,N/A,21339.08,N/A,43000.98,N/A,39457.39,N/A,39457.39,N/A,43000.98,N/A,70894.24,N/A,21339.08,N/A,17877.21,N/A,46944.44,N/A,46944.44,N/A,403.67,N/A,21339.08,N/A,20781.34,N/A,29369.35,N/A,403.67,77170.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 492,"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC",N/A,N/A,130110.98,N/A,78066.59,N/A,18595.95,N/A,22843.77,N/A,71717.18,N/A,44237.74,N/A,42308.37,N/A,23173.39,N/A,4496.00,N/A,4496.00,N/A,26335.97,N/A,42308.37,N/A,42308.37,N/A,42308.37,N/A,71717.18,N/A,22263.69,N/A,19168.93,N/A,50336.40,N/A,50336.40,N/A,664.64,N/A,22263.69,N/A,22263.69,N/A,20510.75,N/A,664.64,78066.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 497,Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,N/A,N/A,35226.28,N/A,21135.77,N/A,8117.69,N/A,9868.45,N/A,18293.88,N/A,11976.94,N/A,18468.87,N/A,8367.81,N/A,562.00,N/A,562.00,N/A,11496.44,N/A,18468.87,N/A,18468.87,N/A,18468.87,N/A,18293.88,N/A,9868.45,N/A,8367.81,N/A,21973.35,N/A,21973.35,N/A,8367.81,N/A,9868.45,N/A,9868.45,N/A,8953.56,N/A,562.00,21973.35,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 499,Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,N/A,N/A,65788.77,N/A,39473.26,N/A,7034.76,N/A,8587.40,N/A,16337.34,N/A,22368.18,N/A,16005.06,N/A,7251.52,N/A,1124.00,N/A,1124.00,N/A,9962.78,N/A,16005.06,N/A,16005.06,N/A,16005.06,N/A,16337.34,N/A,8587.40,N/A,7251.52,N/A,19042.03,N/A,19042.03,N/A,7251.52,N/A,8587.40,N/A,8587.40,N/A,7759.12,N/A,1124.00,39473.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 505,Foot Procedures Without Cc/McC,N/A,N/A,58925.13,N/A,35355.08,N/A,9425.21,N/A,11415.18,N/A,21240.47,N/A,20034.55,N/A,21443.65,N/A,9715.61,N/A,1686.00,N/A,1686.00,N/A,13348.17,N/A,21443.65,N/A,21443.65,N/A,21443.65,N/A,21240.47,N/A,11415.18,N/A,9715.61,N/A,25512.59,N/A,25512.59,N/A,7861.76,N/A,11415.18,N/A,12380.43,N/A,10395.71,N/A,1686.00,35355.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 508,Major Shoulder Or Elbow Joint Procedures Without Cc/McC,N/A,N/A,58834.90,N/A,35300.94,N/A,7725.60,N/A,9434.27,N/A,19978.11,N/A,20003.87,N/A,17576.80,N/A,7963.64,N/A,562.00,N/A,562.00,N/A,10941.15,N/A,17576.80,N/A,17576.80,N/A,17576.80,N/A,19978.11,N/A,9404.62,N/A,7963.64,N/A,20912.01,N/A,20912.01,N/A,N/A,N/A,9404.62,N/A,9404.62,N/A,8521.09,N/A,562.00,35300.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 518,Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,N/A,N/A,140418.03,N/A,84250.82,N/A,19885.86,N/A,23789.59,N/A,77398.42,N/A,47742.14,N/A,45243.09,N/A,20498.58,N/A,23789.59,N/A,23789.59,N/A,28162.77,N/A,45243.09,N/A,45243.09,N/A,45243.09,N/A,77398.42,N/A,23789.59,N/A,20498.58,N/A,53827.99,N/A,53827.99,N/A,2466.31,N/A,23789.59,N/A,23789.59,N/A,21933.48,N/A,2466.31,84250.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 520,Back And Neck Procedures Except Spinal Fusion Without Cc/McC,N/A,N/A,56316.98,N/A,33790.19,N/A,7894.17,N/A,9604.05,N/A,17790.16,N/A,19147.78,N/A,17960.33,N/A,8137.40,N/A,4496.00,N/A,4496.00,N/A,11179.89,N/A,17960.33,N/A,17960.33,N/A,17960.33,N/A,17790.16,N/A,9604.05,N/A,8137.40,N/A,21368.31,N/A,21368.31,N/A,10330.32,N/A,9560.00,N/A,9604.05,N/A,8707.02,N/A,4496.00,33790.19,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 534,Fractures Of Femur Without McC,N/A,N/A,21535.02,N/A,12921.01,N/A,4245.82,N/A,5288.24,N/A,9568.31,N/A,7321.91,N/A,9659.84,N/A,4376.65,N/A,1686.00,N/A,1686.00,N/A,6013.02,N/A,9659.84,N/A,9659.84,N/A,9659.84,N/A,9568.31,N/A,5288.24,N/A,4376.65,N/A,11492.80,N/A,11492.80,N/A,4376.65,N/A,5288.24,N/A,5288.24,N/A,4683.01,N/A,1686.00,12921.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 540,Osteomyelitis With Cc,N/A,N/A,33593.00,N/A,20155.80,N/A,7183.60,N/A,8763.47,N/A,16188.83,N/A,11421.62,N/A,16343.68,N/A,7404.94,N/A,8763.47,N/A,8763.47,N/A,10173.56,N/A,16343.68,N/A,16343.68,N/A,16343.68,N/A,16188.83,N/A,8763.47,N/A,7404.94,N/A,19444.90,N/A,19444.90,N/A,6577.11,N/A,8763.47,N/A,8763.47,N/A,7923.29,N/A,6577.11,20155.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 545,Connective Tissue Disorders With McC,N/A,N/A,44500.18,N/A,26700.11,N/A,13382.43,N/A,16096.37,N/A,30158.39,N/A,15130.06,N/A,38725.26,N/A,13794.77,N/A,5058.00,N/A,5058.00,N/A,38725.26,N/A,30446.88,N/A,38725.26,N/A,38725.26,N/A,30158.39,N/A,16096.37,N/A,13794.77,N/A,36224.18,N/A,36224.18,N/A,13794.77,N/A,16096.37,N/A,16964.07,N/A,10961.87,N/A,5058.00,38725.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 552,Medical Back Problems Without McC,N/A,N/A,33977.90,N/A,20386.74,N/A,5123.90,N/A,6326.96,N/A,11547.13,N/A,11552.49,N/A,11657.59,N/A,5281.78,N/A,6326.96,N/A,6326.96,N/A,7256.58,N/A,11657.59,N/A,11657.59,N/A,11657.59,N/A,11547.13,N/A,6326.96,N/A,5281.78,N/A,13869.62,N/A,13869.62,N/A,5651.50,N/A,6326.96,N/A,6326.96,N/A,5651.50,N/A,5123.90,20386.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 556,Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,N/A,N/A,34541.00,N/A,20724.60,N/A,4754.21,N/A,2102.21,N/A,34541.00,N/A,N/A,N/A,N/A,N/A,4443.18,N/A,2102.21,N/A,8816.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2102.21,N/A,4754.21,N/A,N/A,N/A,N/A,N/A,4754.21,N/A,2102.21,N/A,2102.21,N/A,4754.21,N/A,2102.21,34541.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 557,"Tendonitis, Myositis And Bursitis With McC",N/A,N/A,31669.63,N/A,19001.78,N/A,7638.64,N/A,9301.77,N/A,17214.30,N/A,10767.67,N/A,17378.97,N/A,7874.00,N/A,10058.05,N/A,9301.77,N/A,10818.00,N/A,17378.97,N/A,17378.97,N/A,17378.97,N/A,17214.30,N/A,10058.05,N/A,7874.00,N/A,20676.64,N/A,20676.64,N/A,9322.80,N/A,9301.77,N/A,10058.05,N/A,9322.80,N/A,7638.64,20676.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 561,"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/McC",N/A,N/A,35825.50,N/A,21495.30,N/A,7153.52,N/A,9179.24,N/A,35825.50,N/A,12180.67,N/A,18095.45,N/A,4345.30,N/A,9179.24,N/A,9179.24,N/A,4305.71,N/A,18095.45,N/A,18095.45,N/A,18095.45,N/A,16247.00,N/A,8229.68,N/A,4345.30,N/A,22572.00,N/A,22572.00,N/A,4649.47,N/A,9179.24,N/A,9179.24,N/A,4649.47,N/A,4305.71,35825.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 566,Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,N/A,N/A,21928.70,N/A,13157.22,N/A,3962.02,N/A,4952.52,N/A,8928.74,N/A,7455.76,N/A,9014.15,N/A,4084.10,N/A,2810.00,N/A,2356.59,N/A,5611.10,N/A,9014.15,N/A,9014.15,N/A,9014.15,N/A,11947.07,N/A,4952.52,N/A,4084.10,N/A,10724.59,N/A,10724.59,N/A,4856.68,N/A,4952.52,N/A,4952.52,N/A,4369.99,N/A,2356.59,13157.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 572,Skin Debridement Without Cc/McC,N/A,N/A,38926.90,N/A,23356.14,N/A,6420.75,N/A,7890.70,N/A,14469.68,N/A,13235.15,N/A,14608.09,N/A,6618.58,N/A,66316.00,N/A,66316.00,N/A,9093.20,N/A,14608.09,N/A,14608.09,N/A,14608.09,N/A,14469.68,N/A,7861.05,N/A,6618.58,N/A,17379.98,N/A,17379.98,N/A,4708.92,N/A,7861.05,N/A,7890.70,N/A,7081.88,N/A,4708.92,66316.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 583,Mastectomy For Malignancy Without Cc/McC,N/A,N/A,78186.52,N/A,46911.91,N/A,8059.54,N/A,9799.67,N/A,22840.34,N/A,26583.42,N/A,18336.58,N/A,8307.87,N/A,1124.00,N/A,1124.00,N/A,11414.09,N/A,18336.58,N/A,18336.58,N/A,18336.58,N/A,22840.34,N/A,9799.67,N/A,8307.87,N/A,21815.95,N/A,21815.95,N/A,N/A,N/A,9799.67,N/A,9799.67,N/A,8889.42,N/A,1124.00,46911.91,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 584,"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC",N/A,N/A,61311.15,N/A,36786.69,N/A,11393.68,N/A,13743.77,N/A,25676.59,N/A,20845.79,N/A,25922.20,N/A,11744.74,N/A,562.00,N/A,562.00,N/A,16135.97,N/A,25922.20,N/A,25922.20,N/A,25922.20,N/A,25676.59,N/A,13743.77,N/A,11744.74,N/A,30840.95,N/A,30840.95,N/A,5200.75,N/A,13743.77,N/A,13743.77,N/A,12566.87,N/A,562.00,36786.69,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 593,Skin Ulcers With Cc,N/A,N/A,24726.60,N/A,14835.96,N/A,4496.30,N/A,5643.78,N/A,13848.14,N/A,8407.04,N/A,13980.61,N/A,4634.84,N/A,135442.00,N/A,135442.00,N/A,8702.60,N/A,13980.61,N/A,13980.61,N/A,13980.61,N/A,13848.14,N/A,5584.48,N/A,4634.84,N/A,16633.44,N/A,16633.44,N/A,5951.31,N/A,5584.48,N/A,5643.78,N/A,4959.28,N/A,4496.30,135442.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 598,Malignant Breast Disorders With Cc,N/A,N/A,34257.55,N/A,20554.53,N/A,5697.91,N/A,7003.31,N/A,13379.28,N/A,11647.56,N/A,13507.27,N/A,5873.47,N/A,6944.01,N/A,6944.01,N/A,8407.96,N/A,13507.27,N/A,13507.27,N/A,13507.27,N/A,13379.28,N/A,6944.01,N/A,5873.47,N/A,16070.28,N/A,16070.28,N/A,8485.36,N/A,6944.01,N/A,3198.50,N/A,6284.61,N/A,3198.50,20554.53,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 602,Cellulitis With McC,N/A,N/A,40371.20,N/A,24222.72,N/A,7925.14,N/A,9360.45,N/A,20810.93,N/A,N/A,N/A,N/A,N/A,7925.14,N/A,9360.45,N/A,9360.45,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,17326.11,N/A,9360.45,N/A,7925.14,N/A,20810.93,N/A,20810.93,N/A,7925.14,N/A,9360.45,N/A,9360.45,N/A,7925.14,N/A,7925.14,24222.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 605,"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC",N/A,N/A,25593.00,N/A,15355.80,N/A,4856.64,N/A,6010.79,N/A,10944.83,N/A,8701.62,N/A,11049.52,N/A,5006.28,N/A,562.00,N/A,562.00,N/A,6878.07,N/A,11049.52,N/A,11049.52,N/A,11049.52,N/A,10944.83,N/A,6010.79,N/A,5006.28,N/A,13146.18,N/A,13146.18,N/A,2365.17,N/A,6010.79,N/A,6010.79,N/A,5356.72,N/A,562.00,15355.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 614,Adrenal And Pituitary Procedures With Cc/McC,N/A,N/A,143044.47,N/A,85826.68,N/A,12535.82,N/A,15094.88,N/A,78846.11,N/A,48635.12,N/A,28520.74,N/A,12922.08,N/A,15094.88,N/A,15094.88,N/A,17753.49,N/A,28520.74,N/A,28520.74,N/A,28520.74,N/A,78846.11,N/A,15094.88,N/A,12922.08,N/A,33932.56,N/A,33932.56,N/A,12922.08,N/A,15094.88,N/A,15094.88,N/A,13826.62,N/A,12535.82,85826.68,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 618,"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/McC",N/A,N/A,31914.92,N/A,19148.95,N/A,6256.98,N/A,7667.33,N/A,14100.60,N/A,10851.07,N/A,14235.49,N/A,6449.76,N/A,562.00,N/A,562.00,N/A,8861.26,N/A,14235.49,N/A,14235.49,N/A,14235.49,N/A,N/A,N/A,7667.33,N/A,6449.76,N/A,16936.68,N/A,16936.68,N/A,6449.76,N/A,7667.33,N/A,7667.33,N/A,6901.25,N/A,562.00,19148.95,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 621,O.R. Procedures For Obesity Without Cc/McC,N/A,N/A,69569.13,N/A,41741.48,N/A,8295.33,N/A,10078.59,N/A,18694.21,N/A,23653.51,N/A,18873.04,N/A,8550.93,N/A,562.00,N/A,562.00,N/A,11748.03,N/A,18873.04,N/A,18873.04,N/A,18873.04,N/A,18694.21,N/A,10078.59,N/A,8550.93,N/A,22454.20,N/A,22454.20,N/A,8994.55,N/A,10078.59,N/A,10078.59,N/A,9149.49,N/A,562.00,41741.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 626,"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",N/A,N/A,78012.33,N/A,46807.40,N/A,8637.82,N/A,10513.40,N/A,19466.02,N/A,25514.73,N/A,11472.82,N/A,8903.96,N/A,122516.00,N/A,122516.00,N/A,7142.06,N/A,11472.82,N/A,11472.82,N/A,11472.82,N/A,19466.02,N/A,10483.75,N/A,8903.96,N/A,23381.25,N/A,23381.25,N/A,N/A,N/A,10483.75,N/A,10513.40,N/A,9527.24,N/A,7142.06,122516.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 637,Diabetes With McC,N/A,N/A,36418.40,N/A,21851.04,N/A,7445.53,N/A,7278.61,N/A,16779.11,N/A,12382.26,N/A,16939.61,N/A,7674.94,N/A,7219.31,N/A,7219.31,N/A,10544.51,N/A,16939.61,N/A,16939.61,N/A,16939.61,N/A,16779.11,N/A,7219.31,N/A,7674.94,N/A,20153.91,N/A,20153.91,N/A,7674.94,N/A,7219.31,N/A,7278.61,N/A,8212.19,N/A,7219.31,21851.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 653,Major Bladder Procedures With McC,N/A,N/A,182009.57,N/A,109205.74,N/A,29061.65,N/A,32827.06,N/A,100323.67,N/A,61883.25,N/A,67441.67,N/A,29957.09,N/A,5058.00,N/A,5058.00,N/A,41980.87,N/A,67441.67,N/A,67441.67,N/A,67441.67,N/A,100323.67,N/A,27767.92,N/A,29957.09,N/A,80238.75,N/A,80238.75,N/A,9736.51,N/A,27767.92,N/A,27767.92,N/A,32054.09,N/A,5058.00,109205.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 656,Kidney And Ureter Procedures For Neoplasm With McC,N/A,N/A,117509.08,N/A,70505.45,N/A,17632.52,N/A,19008.67,N/A,64771.00,N/A,39953.09,N/A,40116.43,N/A,18175.81,N/A,2248.00,N/A,2248.00,N/A,24971.54,N/A,40116.43,N/A,40116.43,N/A,40116.43,N/A,64771.00,N/A,18890.07,N/A,18175.81,N/A,47728.53,N/A,47728.53,N/A,20856.98,N/A,18890.07,N/A,18890.07,N/A,19448.12,N/A,2248.00,70505.45,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 657,Kidney And Ureter Procedures For Neoplasm With Cc,N/A,N/A,100469.68,N/A,60281.81,N/A,10018.42,N/A,12205.86,N/A,22710.95,N/A,34159.69,N/A,22793.29,N/A,10327.10,N/A,1686.00,N/A,1686.00,N/A,14188.29,N/A,22793.29,N/A,22793.29,N/A,22793.29,N/A,22710.95,N/A,12116.91,N/A,10327.10,N/A,27118.32,N/A,27118.32,N/A,10461.74,N/A,12116.91,N/A,12116.91,N/A,11050.00,N/A,1686.00,60281.81,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 658,Kidney And Ureter Procedures For Neoplasm Without Cc/McC,N/A,N/A,87537.77,N/A,52522.66,N/A,8423.37,N/A,10230.05,N/A,18982.74,N/A,29762.84,N/A,19164.32,N/A,8682.90,N/A,1124.00,N/A,1124.00,N/A,11929.35,N/A,19164.32,N/A,19164.32,N/A,19164.32,N/A,18982.74,N/A,10230.05,N/A,8682.90,N/A,22800.76,N/A,22800.76,N/A,9843.54,N/A,10230.05,N/A,10230.05,N/A,9290.71,N/A,1124.00,52522.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 665,Prostatectomy With McC,N/A,N/A,82498.98,N/A,49499.39,N/A,14147.36,N/A,20164.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14147.36,N/A,7868.00,N/A,7868.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20164.80,N/A,14147.36,N/A,N/A,N/A,N/A,N/A,14147.36,N/A,20164.80,N/A,20164.80,N/A,14147.36,N/A,7868.00,49499.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 666,Prostatectomy With Cc,N/A,N/A,48200.97,N/A,28920.58,N/A,9185.68,N/A,11161.48,N/A,20700.68,N/A,16388.33,N/A,20898.70,N/A,9468.71,N/A,92730.00,N/A,92730.00,N/A,13008.95,N/A,20898.70,N/A,20898.70,N/A,20898.70,N/A,20700.68,N/A,11131.83,N/A,9468.71,N/A,24864.24,N/A,24864.24,N/A,9468.71,N/A,11131.83,N/A,11161.48,N/A,10131.52,N/A,9185.68,92730.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 668,Transurethral Procedures With McC,N/A,N/A,88839.93,N/A,53303.96,N/A,15059.10,N/A,18079.78,N/A,63414.89,N/A,30205.57,N/A,34261.54,N/A,15523.10,N/A,2248.00,N/A,2248.00,N/A,21327.01,N/A,34261.54,N/A,34261.54,N/A,34261.54,N/A,63414.89,N/A,18079.78,N/A,15523.10,N/A,40762.68,N/A,40762.68,N/A,N/A,N/A,18079.78,N/A,18079.78,N/A,16609.71,N/A,2248.00,63414.89,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 671,Urethral Procedures With Cc/McC,N/A,N/A,44851.62,N/A,26910.97,N/A,9770.36,N/A,11823.48,N/A,22077.03,N/A,15249.54,N/A,22228.92,N/A,10071.40,N/A,2248.00,N/A,2248.00,N/A,13836.98,N/A,22228.92,N/A,22228.92,N/A,22228.92,N/A,22077.03,N/A,11823.48,N/A,10071.40,N/A,26446.86,N/A,26446.86,N/A,N/A,N/A,11823.48,N/A,11823.48,N/A,10776.40,N/A,2248.00,26910.97,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 673,Other Kidney And Urinary Tract Procedures With McC,N/A,N/A,76167.07,N/A,45700.24,N/A,18639.16,N/A,22314.82,N/A,N/A,N/A,25896.81,N/A,42406.68,N/A,19213.47,N/A,22314.82,N/A,22314.82,N/A,26397.17,N/A,42406.68,N/A,42406.68,N/A,42406.68,N/A,N/A,N/A,22314.82,N/A,19213.47,N/A,50453.36,N/A,50453.36,N/A,20558.41,N/A,22314.82,N/A,22314.82,N/A,20558.41,N/A,18639.16,50453.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 684,Renal Failure Without Cc/McC,N/A,N/A,25365.70,N/A,15219.42,N/A,3226.38,N/A,4111.93,N/A,7270.91,N/A,8624.34,N/A,7340.46,N/A,3325.79,N/A,4082.28,N/A,4082.28,N/A,4569.26,N/A,7340.46,N/A,7340.46,N/A,7340.46,N/A,7270.91,N/A,4082.28,N/A,3325.79,N/A,8733.31,N/A,8733.31,N/A,3325.79,N/A,2202.53,N/A,4111.93,N/A,3558.59,N/A,2202.53,15219.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 688,Kidney And Urinary Tract Neoplasms Without Cc/McC,N/A,N/A,10909.03,N/A,6545.42,N/A,4621.92,N/A,5733.14,N/A,10415.86,N/A,3709.07,N/A,3798.52,N/A,4764.32,N/A,1686.00,N/A,1686.00,N/A,2365.08,N/A,3798.52,N/A,3798.52,N/A,3798.52,N/A,10415.86,N/A,5733.14,N/A,4764.32,N/A,10909.03,N/A,10909.03,N/A,4255.82,N/A,5733.14,N/A,5733.14,N/A,5097.83,N/A,1686.00,10909.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 696,Kidney And Urinary Tract Signs And Symptoms Without McC,N/A,N/A,21743.20,N/A,13045.92,N/A,3696.89,N/A,4638.87,N/A,8331.25,N/A,7392.69,N/A,8410.94,N/A,3810.80,N/A,4638.87,N/A,4638.87,N/A,5235.62,N/A,8410.94,N/A,8410.94,N/A,8410.94,N/A,8331.25,N/A,4638.87,N/A,3810.80,N/A,10006.92,N/A,10006.92,N/A,3851.32,N/A,4638.87,N/A,4638.87,N/A,4077.56,N/A,3696.89,13045.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 698,Other Kidney And Urinary Tract Diagnoses With McC,N/A,N/A,39774.30,N/A,23864.58,N/A,8548.73,N/A,10378.35,N/A,19265.26,N/A,13523.26,N/A,3748.75,N/A,8812.13,N/A,10378.35,N/A,10378.35,N/A,12106.89,N/A,19449.54,N/A,19449.54,N/A,19449.54,N/A,19265.26,N/A,10378.35,N/A,8812.13,N/A,23140.10,N/A,23140.10,N/A,N/A,N/A,10378.35,N/A,10526.60,N/A,9428.98,N/A,3748.75,23864.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 699,Other Kidney And Urinary Tract Diagnoses With Cc,N/A,N/A,24745.50,N/A,14847.30,N/A,5399.17,N/A,6652.58,N/A,12167.47,N/A,8389.13,N/A,12283.86,N/A,5565.53,N/A,6652.58,N/A,6652.58,N/A,7646.42,N/A,12283.86,N/A,12283.86,N/A,12283.86,N/A,12167.47,N/A,6652.58,N/A,5565.53,N/A,14614.72,N/A,14614.72,N/A,4908.34,N/A,6652.58,N/A,6741.53,N/A,5955.11,N/A,4908.34,14847.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 709,Penis Procedures With Cc/McC,N/A,N/A,85904.70,N/A,51542.82,N/A,12867.10,N/A,7876.20,N/A,28997.06,N/A,29207.60,N/A,29274.44,N/A,13263.56,N/A,15486.76,N/A,15486.76,N/A,18222.66,N/A,29274.44,N/A,29274.44,N/A,29274.44,N/A,28997.06,N/A,15486.76,N/A,13263.56,N/A,34829.28,N/A,34829.28,N/A,6411.03,N/A,15486.76,N/A,15486.76,N/A,14192.01,N/A,6411.03,51542.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 711,Testes Procedures With Cc/McC,N/A,N/A,62147.00,N/A,37288.20,N/A,10900.76,N/A,N/A,N/A,24565.75,N/A,21129.98,N/A,24800.75,N/A,11236.64,N/A,2248.00,N/A,2248.00,N/A,15437.89,N/A,24800.75,N/A,24800.75,N/A,24800.75,N/A,24565.75,N/A,13160.69,N/A,11236.64,N/A,29506.70,N/A,29506.70,N/A,6145.38,N/A,13160.69,N/A,13160.69,N/A,12023.20,N/A,2248.00,37288.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 725,Benign Prostatic Hypertrophy With McC,N/A,N/A,33746.20,N/A,20247.72,N/A,6664.54,N/A,8149.45,N/A,15019.08,N/A,11473.71,N/A,15162.75,N/A,6869.89,N/A,8149.45,N/A,8149.45,N/A,9438.46,N/A,15162.75,N/A,15162.75,N/A,15162.75,N/A,15019.08,N/A,8149.45,N/A,6869.89,N/A,18039.89,N/A,18039.89,N/A,N/A,N/A,8149.45,N/A,8149.45,N/A,7350.78,N/A,6664.54,20247.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 726,Benign Prostatic Hypertrophy Without McC,N/A,N/A,21741.22,N/A,13044.73,N/A,4116.19,N/A,5682.67,N/A,9276.18,N/A,7392.01,N/A,N/A,N/A,4243.02,N/A,88234.00,N/A,88234.00,N/A,N/A,N/A,N/A,N/A,9364.91,N/A,N/A,N/A,9276.18,N/A,5134.89,N/A,4243.02,N/A,11141.90,N/A,N/A,N/A,4243.02,N/A,5134.89,N/A,5342.44,N/A,4540.03,N/A,4116.19,88234.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 728,Inflammation Of The Male Reproductive System Without McC,N/A,N/A,20993.70,N/A,12596.22,N/A,4383.46,N/A,5451.04,N/A,10468.34,N/A,7137.86,N/A,9972.97,N/A,4518.52,N/A,1686.00,N/A,1686.00,N/A,6207.94,N/A,9972.97,N/A,9972.97,N/A,9972.97,N/A,10468.34,N/A,5451.04,N/A,4518.52,N/A,11865.35,N/A,11865.35,N/A,3569.76,N/A,5451.04,N/A,5451.04,N/A,4834.82,N/A,1686.00,12596.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 729,Other Male Reproductive System Diagnoses With Cc/McC,N/A,N/A,25621.90,N/A,15373.14,N/A,5749.65,N/A,2390.38,N/A,12112.17,N/A,8711.45,N/A,12228.03,N/A,5926.81,N/A,335514.00,N/A,335514.00,N/A,7611.66,N/A,12228.03,N/A,12228.03,N/A,12228.03,N/A,12112.17,N/A,6317.64,N/A,5926.81,N/A,14548.30,N/A,14548.30,N/A,4142.52,N/A,6317.64,N/A,6376.94,N/A,6341.69,N/A,2390.38,335514.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 734,"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/McC",N/A,N/A,188529.08,N/A,113117.45,N/A,16539.63,N/A,N/A,N/A,29103.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4496.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,29103.98,N/A,N/A,N/A,N/A,N/A,29103.98,N/A,29103.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4496.00,113117.45,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 735,"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/McC",N/A,N/A,155094.42,N/A,93056.65,N/A,9467.04,N/A,8293.97,N/A,85488.04,N/A,52732.11,N/A,15440.69,N/A,6995.81,N/A,1686.00,N/A,1686.00,N/A,9611.47,N/A,15440.69,N/A,15440.69,N/A,15440.69,N/A,85488.04,N/A,8293.97,N/A,6995.81,N/A,18370.57,N/A,18370.57,N/A,5031.74,N/A,8293.97,N/A,8293.97,N/A,7485.52,N/A,1686.00,93056.65,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 736,Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With McC,N/A,N/A,40134.18,N/A,24080.51,N/A,22753.22,N/A,27181.53,N/A,39329.18,N/A,13645.62,N/A,40134.19,N/A,23454.29,N/A,2248.00,N/A,2248.00,N/A,32223.59,N/A,40134.19,N/A,40134.19,N/A,40134.19,N/A,39329.18,N/A,27181.53,N/A,23454.29,N/A,40134.19,N/A,40134.19,N/A,N/A,N/A,27181.53,N/A,27181.53,N/A,25096.09,N/A,2248.00,40134.19,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 739,Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,N/A,N/A,68515.87,N/A,41109.52,N/A,20817.29,N/A,24891.42,N/A,47020.85,N/A,23295.40,N/A,47362.22,N/A,21458.71,N/A,24891.42,N/A,24891.42,N/A,29481.88,N/A,47362.22,N/A,47362.22,N/A,47362.22,N/A,47020.85,N/A,24891.42,N/A,21458.71,N/A,56349.21,N/A,56349.21,N/A,21458.71,N/A,24891.42,N/A,24891.42,N/A,22960.82,N/A,20817.29,56349.21,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 745,"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/McC",N/A,N/A,19371.97,N/A,11623.18,N/A,6139.08,N/A,7527.85,N/A,13834.92,N/A,6586.47,N/A,13967.26,N/A,6328.24,N/A,562.00,N/A,562.00,N/A,8694.29,N/A,13967.26,N/A,13967.26,N/A,13967.26,N/A,13834.92,N/A,7527.85,N/A,6328.24,N/A,16617.55,N/A,16617.55,N/A,4863.77,N/A,7527.85,N/A,7527.85,N/A,6771.21,N/A,562.00,16617.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 756,"Malignancy, Female Reproductive System Without Cc/McC",N/A,N/A,13218.50,N/A,7931.10,N/A,5317.55,N/A,6585.67,N/A,11983.53,N/A,4494.29,N/A,12098.16,N/A,5481.39,N/A,99474.00,N/A,99474.00,N/A,7530.82,N/A,12098.16,N/A,12098.16,N/A,12098.16,N/A,11983.53,N/A,6556.02,N/A,5481.39,N/A,13218.50,N/A,13218.50,N/A,4329.98,N/A,6556.02,N/A,6585.67,N/A,5865.09,N/A,4329.98,99474.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 758,"Infections, Female Reproductive System With Cc",N/A,N/A,29557.20,N/A,17734.32,N/A,5097.23,N/A,6295.40,N/A,11487.02,N/A,10049.45,N/A,11596.90,N/A,5254.28,N/A,6295.40,N/A,6295.40,N/A,7218.80,N/A,11596.90,N/A,11596.90,N/A,11596.90,N/A,11487.02,N/A,6295.40,N/A,5254.28,N/A,13797.42,N/A,13797.42,N/A,3347.40,N/A,6295.40,N/A,6295.40,N/A,5622.08,N/A,3347.40,17734.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 759,"Infections, Female Reproductive System Without Cc/McC",N/A,N/A,23646.70,N/A,14188.02,N/A,3309.60,N/A,4180.73,N/A,7458.45,N/A,8039.88,N/A,7529.79,N/A,3411.57,N/A,4180.73,N/A,4180.73,N/A,4687.12,N/A,7529.79,N/A,7529.79,N/A,7529.79,N/A,7458.45,N/A,4180.73,N/A,3411.57,N/A,8958.58,N/A,8958.58,N/A,3346.10,N/A,4180.73,N/A,4180.73,N/A,3650.38,N/A,3309.60,14188.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 768,Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,N/A,N/A,17272.80,N/A,10363.68,N/A,6117.74,N/A,7502.61,N/A,13786.83,N/A,5872.75,N/A,13918.71,N/A,6306.24,N/A,7502.61,N/A,7502.61,N/A,8664.07,N/A,13918.71,N/A,13918.71,N/A,13918.71,N/A,13786.83,N/A,7502.61,N/A,6306.24,N/A,16559.79,N/A,16559.79,N/A,6306.24,N/A,7502.61,N/A,7502.61,N/A,6747.68,N/A,5872.75,16559.79,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 770,"Abortion With D&C, Aspiration Curettage Or Hysterotomy",N/A,N/A,26527.10,N/A,15916.26,N/A,4618.71,N/A,5729.34,N/A,10408.65,N/A,9019.21,N/A,10508.21,N/A,4761.03,N/A,1124.00,N/A,1124.00,N/A,6541.12,N/A,10508.21,N/A,10508.21,N/A,10508.21,N/A,10408.65,N/A,5729.34,N/A,4761.03,N/A,12502.15,N/A,12502.15,N/A,3867.80,N/A,5729.34,N/A,5729.34,N/A,5094.30,N/A,1124.00,15916.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 787,Cesarean Section Without Sterilization With Cc,N/A,N/A,29049.48,N/A,17429.69,N/A,5682.97,N/A,6988.30,N/A,13295.58,N/A,9876.83,N/A,7322.00,N/A,5858.07,N/A,6988.30,N/A,6988.30,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,13295.58,N/A,6988.30,N/A,5858.07,N/A,15382.93,N/A,15382.93,N/A,5858.07,N/A,6988.30,N/A,6988.30,N/A,6268.14,N/A,4558.00,17429.69,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 789,"Neonates, Died Or Transferred To Another Acute Care Facility",N/A,N/A,10205.70,N/A,6123.42,N/A,9739.95,N/A,11787.50,N/A,10205.70,N/A,3469.94,N/A,5154.90,N/A,10040.06,N/A,11787.50,N/A,11787.50,N/A,3208.67,N/A,5154.90,N/A,5154.90,N/A,5154.90,N/A,10205.70,N/A,11787.50,N/A,10040.06,N/A,2080.00,N/A,2080.00,N/A,6927.40,N/A,11787.50,N/A,11787.50,N/A,10205.70,N/A,2080.00,11787.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 794,Neonate With Other Significant Problems,N/A,N/A,8563.40,N/A,5138.04,N/A,7975.79,N/A,9700.59,N/A,8563.40,N/A,2911.56,N/A,4325.37,N/A,8221.54,N/A,9700.59,N/A,9700.59,N/A,2692.33,N/A,4325.37,N/A,4325.37,N/A,4325.37,N/A,8563.40,N/A,9700.59,N/A,8221.54,N/A,6240.00,N/A,6240.00,N/A,8757.45,N/A,9700.59,N/A,9700.59,N/A,8563.40,N/A,2692.33,9700.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 797,Vaginal Delivery With Sterilization And/Or D&C With Cc,N/A,N/A,25206.08,N/A,15123.65,N/A,4949.99,N/A,6121.23,N/A,11155.21,N/A,8570.07,N/A,4696.00,N/A,5102.51,N/A,6121.23,N/A,6121.23,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,11155.21,N/A,6121.23,N/A,5102.51,N/A,13398.88,N/A,13398.88,N/A,4907.50,N/A,6121.23,N/A,6121.23,N/A,5459.69,N/A,2923.00,15123.65,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 803,Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,N/A,N/A,67749.13,N/A,40649.48,N/A,10953.58,N/A,13223.16,N/A,26548.91,N/A,23034.70,N/A,24920.90,N/A,11291.08,N/A,13223.16,N/A,13223.16,N/A,15512.68,N/A,24920.90,N/A,24920.90,N/A,24920.90,N/A,26548.91,N/A,13223.16,N/A,11291.08,N/A,29649.65,N/A,29649.65,N/A,N/A,N/A,13223.16,N/A,13223.16,N/A,12081.45,N/A,10953.58,40649.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 805,Vaginal Delivery Without Sterilization Or D&C With McC,N/A,N/A,12328.20,N/A,7396.92,N/A,5364.49,N/A,6611.56,N/A,12089.32,N/A,4191.59,N/A,4696.00,N/A,5529.78,N/A,6611.56,N/A,6611.56,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,12089.32,N/A,6611.56,N/A,5529.78,N/A,12328.20,N/A,12328.20,N/A,5916.87,N/A,6611.56,N/A,6611.56,N/A,5916.87,N/A,2923.00,12328.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 809,Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,N/A,N/A,38814.40,N/A,23288.64,N/A,6485.30,N/A,7937.41,N/A,14615.15,N/A,13196.90,N/A,14754.95,N/A,6685.12,N/A,7937.41,N/A,7937.41,N/A,9184.61,N/A,14754.95,N/A,14754.95,N/A,14754.95,N/A,14615.15,N/A,7937.41,N/A,6685.12,N/A,17554.71,N/A,17554.71,N/A,6685.12,N/A,7937.41,N/A,7937.41,N/A,7153.08,N/A,6485.30,23288.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 813,Coagulation Disorders,N/A,N/A,105939.70,N/A,63563.82,N/A,N/A,N/A,10142.34,N/A,94540.50,N/A,36019.49,N/A,18995.62,N/A,8606.47,N/A,10142.34,N/A,10142.34,N/A,18995.62,N/A,18995.62,N/A,18995.62,N/A,18995.62,N/A,94540.50,N/A,10142.34,N/A,N/A,N/A,94540.50,N/A,22600.04,N/A,N/A,N/A,10142.34,N/A,10142.34,N/A,9208.92,N/A,8606.47,94540.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 815,Reticuloendothelial And Immunity Disorders With Cc,N/A,N/A,31665.25,N/A,18999.15,N/A,5500.53,N/A,6802.13,N/A,12395.88,N/A,10766.18,N/A,12514.46,N/A,5670.01,N/A,122516.00,N/A,122516.00,N/A,7789.96,N/A,12514.46,N/A,12514.46,N/A,12514.46,N/A,12395.88,N/A,6772.48,N/A,5670.01,N/A,14889.08,N/A,14889.08,N/A,4765.33,N/A,6772.48,N/A,6802.13,N/A,6066.91,N/A,4765.33,122516.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 816,Reticuloendothelial And Immunity Disorders Without Cc/McC,N/A,N/A,20671.40,N/A,12402.84,N/A,3888.94,N/A,4866.05,N/A,8764.04,N/A,7028.28,N/A,8847.87,N/A,4008.76,N/A,1686.00,N/A,1686.00,N/A,5507.60,N/A,8847.87,N/A,8847.87,N/A,8847.87,N/A,8764.04,N/A,4866.05,N/A,4008.76,N/A,10526.76,N/A,10526.76,N/A,3522.04,N/A,4866.05,N/A,4866.05,N/A,4289.38,N/A,1686.00,12402.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 823,Lymphoma And Non-Acute Leukemia With Other Procedures With McC,N/A,N/A,129676.45,N/A,77805.87,N/A,23079.70,N/A,28946.91,N/A,71477.66,N/A,44089.99,N/A,52509.52,N/A,23790.83,N/A,4496.00,N/A,28946.91,N/A,32685.95,N/A,52509.52,N/A,52509.52,N/A,52509.52,N/A,71477.66,N/A,28946.91,N/A,N/A,N/A,69594.47,N/A,69594.47,N/A,N/A,N/A,28946.91,N/A,28946.91,N/A,25456.19,N/A,4496.00,77805.87,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 824,Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,N/A,N/A,61556.30,N/A,36933.78,N/A,12217.88,N/A,14718.77,N/A,27533.99,N/A,20929.14,N/A,27797.37,N/A,12594.34,N/A,2810.00,N/A,2810.00,N/A,17303.22,N/A,27797.37,N/A,27797.37,N/A,27797.37,N/A,27533.99,N/A,14718.77,N/A,12594.34,N/A,33071.93,N/A,33071.93,N/A,11380.90,N/A,14718.77,N/A,14718.77,N/A,13475.94,N/A,2810.00,36933.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 825,Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,N/A,N/A,54351.03,N/A,32610.62,N/A,7023.56,N/A,8574.16,N/A,15828.17,N/A,18479.36,N/A,15979.57,N/A,7239.97,N/A,2248.00,N/A,2248.00,N/A,9946.91,N/A,15979.57,N/A,15979.57,N/A,15979.57,N/A,15828.17,N/A,8574.16,N/A,7239.97,N/A,19011.70,N/A,19011.70,N/A,N/A,N/A,8574.16,N/A,8574.16,N/A,7746.77,N/A,2248.00,32610.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 834,Acute Leukemia Without Major O.R. Procedures With McC,N/A,N/A,126826.30,N/A,76095.78,N/A,34342.31,N/A,36881.00,N/A,104566.77,N/A,75998.79,N/A,75998.79,N/A,34342.31,N/A,39717.89,N/A,39717.89,N/A,75998.79,N/A,75998.79,N/A,75998.79,N/A,75998.79,N/A,104566.77,N/A,36881.00,N/A,34342.31,N/A,104566.77,N/A,104566.77,N/A,34342.31,N/A,35163.16,N/A,36881.00,N/A,34342.31,N/A,34342.31,104566.77,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 836,Acute Leukemia Without Major O.R. Procedures Without Cc/McC,N/A,N/A,25803.93,N/A,15482.36,N/A,8368.95,N/A,7598.59,N/A,20348.79,N/A,8773.34,N/A,8984.93,N/A,8626.81,N/A,562.00,N/A,562.00,N/A,5594.29,N/A,8984.93,N/A,8984.93,N/A,8984.93,N/A,20348.79,N/A,7598.59,N/A,8626.81,N/A,22653.47,N/A,22653.47,N/A,10656.65,N/A,7598.59,N/A,7598.59,N/A,9230.69,N/A,562.00,22653.47,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 838,Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,N/A,N/A,57043.98,N/A,34226.39,N/A,9941.55,N/A,15088.64,N/A,35776.87,N/A,19394.95,N/A,26993.90,N/A,9941.55,N/A,3372.00,N/A,15088.64,N/A,16803.08,N/A,26993.90,N/A,26993.90,N/A,26993.90,N/A,35776.87,N/A,15088.64,N/A,9941.55,N/A,32116.00,N/A,32116.00,N/A,12230.30,N/A,15088.64,N/A,15088.64,N/A,13086.42,N/A,3372.00,35776.87,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 855,Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,N/A,N/A,36785.50,N/A,22071.30,N/A,8149.70,N/A,9906.32,N/A,18366.01,N/A,N/A,N/A,N/A,N/A,8238.94,N/A,10266.81,N/A,10266.81,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10266.81,N/A,8400.81,N/A,N/A,N/A,N/A,N/A,8238.94,N/A,10266.81,N/A,10266.81,N/A,8238.94,N/A,8149.70,22071.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 862,Postoperative And Post-Traumatic Infections With McC,N/A,N/A,29656.50,N/A,17793.90,N/A,9757.55,N/A,11808.33,N/A,21989.44,N/A,N/A,N/A,22199.79,N/A,10058.20,N/A,11808.33,N/A,11808.33,N/A,13818.85,N/A,N/A,N/A,N/A,N/A,22199.79,N/A,21989.44,N/A,11808.33,N/A,10058.20,N/A,26412.20,N/A,26412.20,N/A,8046.56,N/A,11808.33,N/A,11808.33,N/A,8046.56,N/A,8046.56,26412.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 866,Viral Illness Without McC,N/A,N/A,25167.00,N/A,15100.20,N/A,4799.56,N/A,5943.28,N/A,10816.19,N/A,8556.78,N/A,10919.66,N/A,4947.44,N/A,5943.28,N/A,5943.28,N/A,6797.23,N/A,10919.66,N/A,10919.66,N/A,10919.66,N/A,10816.19,N/A,5943.28,N/A,4947.44,N/A,12991.67,N/A,12991.67,N/A,4009.99,N/A,5943.28,N/A,5943.28,N/A,5293.76,N/A,4009.99,15100.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 868,Other Infectious And Parasitic Diseases Diagnoses With Cc,N/A,N/A,30138.20,N/A,18082.92,N/A,5631.76,N/A,6927.73,N/A,12691.63,N/A,10246.99,N/A,12813.03,N/A,5805.28,N/A,6927.73,N/A,6927.73,N/A,7975.81,N/A,12813.03,N/A,12813.03,N/A,12813.03,N/A,12691.63,N/A,6927.73,N/A,5805.28,N/A,15244.31,N/A,15244.31,N/A,7161.90,N/A,6927.73,N/A,6927.73,N/A,6211.65,N/A,5631.76,18082.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 894,"Alcohol, Drug Abuse Or Dependence, Left Ama",N/A,N/A,12235.20,N/A,7341.12,N/A,3050.34,N/A,2194.93,N/A,4170.00,N/A,4159.97,N/A,3176.00,N/A,3144.32,N/A,2194.93,N/A,2194.93,N/A,1978.00,N/A,3176.00,N/A,3176.00,N/A,3176.00,N/A,6874.18,N/A,2194.93,N/A,3144.32,N/A,8256.79,N/A,8256.79,N/A,3144.32,N/A,3874.03,N/A,2194.93,N/A,3353.86,N/A,1978.00,8256.79,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 901,Wound Debridements For Injuries With McC,N/A,N/A,103157.67,N/A,61894.60,N/A,23464.86,N/A,28023.37,N/A,52879.97,N/A,35073.61,N/A,53385.81,N/A,24187.86,N/A,3372.00,N/A,3372.00,N/A,33231.42,N/A,53385.81,N/A,53385.81,N/A,53385.81,N/A,52879.97,N/A,28717.24,N/A,24187.86,N/A,63515.78,N/A,63515.78,N/A,12150.01,N/A,28717.24,N/A,28023.37,N/A,25881.01,N/A,3372.00,63515.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 903,Wound Debridements For Injuries Without Cc/McC,N/A,N/A,34755.90,N/A,20853.54,N/A,6484.76,N/A,7936.79,N/A,14613.94,N/A,11817.01,N/A,14753.74,N/A,6684.57,N/A,2248.00,N/A,2248.00,N/A,9183.86,N/A,14753.74,N/A,14753.74,N/A,14753.74,N/A,14613.94,N/A,7936.79,N/A,6684.57,N/A,17553.26,N/A,17553.26,N/A,4631.92,N/A,7936.79,N/A,7936.79,N/A,7152.49,N/A,2248.00,20853.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 908,Other O.R. Procedures For Injuries With Cc,N/A,N/A,91656.77,N/A,54994.06,N/A,10970.65,N/A,13243.35,N/A,N/A,N/A,31163.30,N/A,24959.74,N/A,11308.67,N/A,13243.35,N/A,13243.35,N/A,24959.74,N/A,24959.74,N/A,24959.74,N/A,24959.74,N/A,24723.24,N/A,13243.35,N/A,11308.67,N/A,29695.86,N/A,29695.86,N/A,N/A,N/A,13243.35,N/A,13243.35,N/A,12100.28,N/A,10970.65,54994.06,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 917,Poisoning And Toxic Effects Of Drugs With McC,N/A,N/A,33926.80,N/A,20356.08,N/A,8121.96,N/A,9873.49,N/A,18303.50,N/A,11535.11,N/A,18478.58,N/A,8372.21,N/A,9873.49,N/A,9873.49,N/A,11502.49,N/A,18478.58,N/A,18478.58,N/A,18478.58,N/A,18303.50,N/A,9873.49,N/A,8372.21,N/A,21984.90,N/A,21984.90,N/A,8372.21,N/A,9873.49,N/A,9873.49,N/A,8958.27,N/A,8121.96,21984.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 918,Poisoning And Toxic Effects Of Drugs Without McC,N/A,N/A,19951.30,N/A,11970.78,N/A,4362.12,N/A,5425.81,N/A,9830.39,N/A,6783.44,N/A,9924.42,N/A,4496.52,N/A,5425.81,N/A,5425.81,N/A,6177.72,N/A,9924.42,N/A,9924.42,N/A,9924.42,N/A,9830.39,N/A,5425.81,N/A,4496.52,N/A,11807.59,N/A,11807.59,N/A,4496.52,N/A,5425.81,N/A,5425.81,N/A,4811.28,N/A,4362.12,11970.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 921,Complications Of Treatment Without Cc/McC,N/A,N/A,22406.40,N/A,13443.84,N/A,3883.07,N/A,4859.11,N/A,8750.81,N/A,7618.18,N/A,8834.52,N/A,4002.71,N/A,1686.00,N/A,1686.00,N/A,5499.28,N/A,8834.52,N/A,8834.52,N/A,8834.52,N/A,8750.81,N/A,4859.11,N/A,4002.71,N/A,10510.88,N/A,10510.88,N/A,2500.71,N/A,4859.11,N/A,4859.11,N/A,4282.90,N/A,1686.00,13443.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 951,Other Factors Influencing Health Status,N/A,N/A,10245.20,N/A,6147.12,N/A,1079.73,N/A,1542.91,N/A,2433.25,N/A,3483.37,N/A,1589.00,N/A,1113.00,N/A,1542.91,N/A,1542.91,N/A,989.00,N/A,1589.00,N/A,1589.00,N/A,1589.00,N/A,2433.25,N/A,1542.91,N/A,1113.00,N/A,1352.00,N/A,1352.00,N/A,3036.47,N/A,1542.91,N/A,1542.91,N/A,1190.91,N/A,989.00,6147.12,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 955,Craniotomy For Multiple Significant Trauma,N/A,N/A,360231.47,N/A,216138.88,N/A,25966.60,N/A,43759.05,N/A,78417.38,N/A,122701.46,N/A,125660.74,N/A,25966.60,N/A,43759.05,N/A,43759.05,N/A,78240.23,N/A,125660.74,N/A,125660.74,N/A,125660.74,N/A,78417.38,N/A,43759.05,N/A,25966.60,N/A,78417.38,N/A,78417.38,N/A,25966.60,N/A,43759.05,N/A,43759.05,N/A,25966.60,N/A,25966.60,216138.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 969,Hiv With Extensive O.R. Procedures With McC,N/A,N/A,147213.65,N/A,88328.19,N/A,35169.69,N/A,N/A,N/A,135395.82,N/A,99603.77,N/A,99603.77,N/A,35169.69,N/A,N/A,N/A,N/A,N/A,99603.77,N/A,99603.77,N/A,99603.77,N/A,99603.77,N/A,135395.82,N/A,N/A,N/A,35169.69,N/A,135395.82,N/A,135395.82,N/A,35169.69,N/A,N/A,N/A,N/A,N/A,35169.69,N/A,35169.69,135395.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 976,Hiv With Major Related Condition Without Cc/McC,N/A,N/A,20147.60,N/A,12088.56,N/A,4922.79,N/A,6089.05,N/A,11093.90,N/A,6850.18,N/A,11200.02,N/A,5074.47,N/A,1124.00,N/A,1124.00,N/A,6971.75,N/A,11200.02,N/A,11200.02,N/A,11200.02,N/A,11093.90,N/A,6089.05,N/A,5074.47,N/A,13325.23,N/A,13325.23,N/A,5367.18,N/A,6089.05,N/A,6089.05,N/A,5429.68,N/A,1124.00,13325.23,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 981,Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,N/A,N/A,128872.10,N/A,77323.26,N/A,N/A,N/A,29170.64,N/A,N/A,N/A,34604.92,N/A,34604.92,N/A,N/A,N/A,29170.64,N/A,29170.64,N/A,34604.92,N/A,34604.92,N/A,34604.92,N/A,34604.92,N/A,N/A,N/A,29170.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,29170.64,N/A,29170.64,N/A,N/A,N/A,29170.64,77323.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 988,Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,N/A,N/A,60203.55,N/A,36122.13,N/A,7882.79,N/A,10970.91,N/A,20394.12,N/A,20469.21,N/A,20589.21,N/A,9328.49,N/A,5058.00,N/A,5058.00,N/A,12816.30,N/A,20589.21,N/A,20589.21,N/A,20589.21,N/A,20394.12,N/A,10970.91,N/A,7882.79,N/A,24496.02,N/A,24496.02,N/A,7882.79,N/A,10970.91,N/A,10970.91,N/A,9981.48,N/A,5058.00,36122.13,N/A,N/A,,Hospital V5011,HC Hearing Aid Check,N/A,0479 - AUDIOLOGY - OTHER AUDIOLOGY,N/A,338.00,N/A,202.80,N/A,47.32,N/A,N/A,N/A,194.63,N/A,114.92,N/A,47.32,N/A,47.32,N/A,N/A,N/A,N/A,N/A,29.41,N/A,47.32,N/A,47.32,N/A,47.32,N/A,194.63,N/A,N/A,N/A,47.32,N/A,181.17,N/A,181.17,N/A,47.32,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,29.41,202.80,,Hospital V5014,HC Hearing Aid Repair,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,20.00,N/A,12.00,N/A,2.80,N/A,42.31,N/A,11.52,N/A,6.80,N/A,2.80,N/A,2.80,N/A,42.31,N/A,42.31,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,11.52,N/A,42.31,N/A,2.80,N/A,10.72,N/A,10.72,N/A,2.80,N/A,42.31,N/A,42.31,N/A,20.00,N/A,N/A,1.74,42.31,,Hospital V5200,HC Hearing Aid Disp Fee Contralat Monau,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,1850.00,N/A,1110.00,N/A,203.70,N/A,N/A,N/A,N/A,N/A,629.00,N/A,259.00,N/A,259.00,N/A,N/A,N/A,N/A,N/A,160.95,N/A,259.00,N/A,259.00,N/A,259.00,N/A,N/A,N/A,N/A,N/A,203.70,N/A,N/A,N/A,N/A,N/A,203.70,N/A,N/A,N/A,N/A,N/A,203.70,N/A,N/A,160.95,1110.00,,Hospital V5211,HC Hearing Aid Cros Binaural Ite/Ite (Non-Pmm),N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1850.00,N/A,1110.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,629.00,N/A,259.00,N/A,259.00,N/A,N/A,N/A,N/A,N/A,160.95,N/A,259.00,N/A,259.00,N/A,259.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,160.95,1110.00,,Hospital V5221,HC Hearing Aid Cros Binaural Bte/Bte (Non-Pmm),N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1794.00,N/A,1076.40,N/A,1229.10,N/A,N/A,N/A,1032.99,N/A,609.96,N/A,251.16,N/A,251.16,N/A,N/A,N/A,N/A,N/A,156.08,N/A,251.16,N/A,251.16,N/A,251.16,N/A,1032.99,N/A,N/A,N/A,1229.10,N/A,961.58,N/A,961.58,N/A,1229.10,N/A,N/A,N/A,N/A,N/A,1229.10,N/A,N/A,156.08,1229.10,,Hospital V5246,"HC Hearing Aid, Prog, Mon, Ite",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1944.00,N/A,1166.40,N/A,272.16,N/A,427.68,N/A,1119.36,N/A,660.96,N/A,272.16,N/A,272.16,N/A,427.68,N/A,427.68,N/A,169.13,N/A,272.16,N/A,272.16,N/A,272.16,N/A,1119.36,N/A,427.68,N/A,272.16,N/A,1041.98,N/A,1041.98,N/A,272.16,N/A,427.68,N/A,427.68,N/A,N/A,N/A,N/A,169.13,1166.40,,Hospital V5253,"HC Hearing Aid, Prog, Bin, Bte",N/A,0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY,N/A,3437.00,N/A,2062.20,N/A,N/A,N/A,3437.00,N/A,1979.02,N/A,1168.58,N/A,481.18,N/A,481.18,N/A,3437.00,N/A,3437.00,N/A,299.02,N/A,481.18,N/A,481.18,N/A,481.18,N/A,1979.02,N/A,3437.00,N/A,N/A,N/A,1842.23,N/A,1842.23,N/A,N/A,N/A,3437.00,N/A,3437.00,N/A,N/A,N/A,N/A,299.02,3437.00,,Hospital V5255,HC Itc Economy,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,165.00,N/A,99.00,N/A,23.10,N/A,N/A,N/A,95.01,N/A,56.10,N/A,23.10,N/A,23.10,N/A,N/A,N/A,N/A,N/A,14.36,N/A,23.10,N/A,23.10,N/A,23.10,N/A,95.01,N/A,N/A,N/A,23.10,N/A,88.44,N/A,88.44,N/A,23.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14.36,99.00,,Hospital V5258,HC Cic Economy Binaural,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2000.00,N/A,1200.00,N/A,N/A,N/A,N/A,N/A,2000.00,N/A,680.00,N/A,280.00,N/A,280.00,N/A,N/A,N/A,N/A,N/A,174.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,2000.00,N/A,N/A,N/A,N/A,N/A,2000.00,N/A,2000.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,174.00,2000.00,,Hospital V5261,"HC Hearing Aid, Digit, Bin, Bte",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4300.00,N/A,2580.00,N/A,1047.60,N/A,1455.00,N/A,900.00,N/A,1462.00,N/A,602.00,N/A,602.00,N/A,1455.00,N/A,1455.00,N/A,374.10,N/A,602.00,N/A,602.00,N/A,602.00,N/A,900.00,N/A,1455.00,N/A,1047.60,N/A,900.00,N/A,900.00,N/A,1047.60,N/A,1455.00,N/A,1455.00,N/A,1047.60,N/A,N/A,374.10,2580.00,,Hospital V5267,HC Wax Filters,N/A,0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY,N/A,25.00,N/A,15.00,N/A,15.00,N/A,30.94,N/A,N/A,N/A,8.50,N/A,3.50,N/A,3.50,N/A,30.94,N/A,30.94,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,N/A,N/A,30.94,N/A,15.00,N/A,N/A,N/A,N/A,N/A,15.00,N/A,30.94,N/A,30.94,N/A,15.00,N/A,N/A,2.18,30.94,,Hospital W0710,HC Ot Work Cond Prog per 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,34736.40,N/A,20841.84,N/A,5202.56,N/A,8861.77,N/A,34736.40,N/A,11810.38,N/A,17545.37,N/A,10052.15,N/A,8861.77,N/A,8861.77,N/A,4170.20,N/A,17545.37,N/A,17545.37,N/A,17545.37,N/A,11816.00,N/A,8856.11,N/A,10052.15,N/A,16416.00,N/A,16416.00,N/A,N/A,N/A,8861.77,N/A,8861.77,N/A,10755.80,N/A,4170.20,34736.40,N/A,N/A,,Hospital 0003A,HC Imm Admn Sarscov2 30mcg/0.3ml Dil Recons 3rd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,54499.40,N/A,32699.64,N/A,N/A,N/A,9646.96,N/A,17871.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,17871.91,N/A,9646.96,N/A,8174.80,N/A,N/A,N/A,21466.50,N/A,N/A,N/A,N/A,N/A,9646.96,N/A,N/A,N/A,8174.80,32699.64,N/A,N/A,,Hospital 00104,PR Anesth for Electroshock,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,15401.30,19944.10,9240.78,11966.46,6911.00,2792.17,8470.65,451.52,15401.30,11483.81,5236.44,6780.99,1588.00,1055.99,7123.94,2792.17,8441.00,436.56,8441.00,436.56,989.00,657.37,1588.00,1055.99,1588.00,1055.99,1588.00,1055.99,15401.30,3222.64,1389.87,436.56,7123.94,2792.17,15401.30,2180.50,15401.30,2180.50,537.12,2792.17,8441.00,436.56,8470.65,451.52,784.10,114.87,537.12,15401.30,114.87,11966.46,,Hospital CPT 0011A,HC Imm Admin Sarscov2 100mcg/0.5 Ml 1st Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,122.00,N/A,70.25,N/A,41.48,N/A,17.08,N/A,17.08,N/A,122.00,N/A,122.00,N/A,10.61,N/A,17.08,N/A,17.08,N/A,17.08,N/A,70.25,N/A,122.00,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,122.00,N/A,122.00,N/A,122.00,73.20,73.20,10.61,122.00,,Hospital 00126,"Anesth,Tympanotomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10844.92,N/A,6506.95,N/A,1468.35,N/A,2569.18,N/A,6241.69,N/A,3687.27,N/A,6219.82,N/A,1468.35,N/A,2569.18,N/A,2569.18,N/A,3871.96,N/A,6219.82,N/A,6219.82,N/A,6219.82,N/A,6241.70,N/A,2569.18,N/A,1380.53,N/A,4800.25,N/A,4800.25,N/A,1468.35,N/A,2569.18,N/A,2569.18,N/A,2826.09,N/A,N/A,1380.53,6506.95,,Hospital CPT 0013A,HC Imm Admn Sarscov2 100 Mcg/0.5 Ml 3rd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,122.00,N/A,70.25,N/A,41.48,N/A,17.08,N/A,17.08,N/A,122.00,N/A,122.00,N/A,10.61,N/A,17.08,N/A,17.08,N/A,17.08,N/A,70.25,N/A,122.00,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,122.00,N/A,122.00,N/A,122.00,73.20,73.20,10.61,122.00,,Hospital 00140,"Anesth,Procedures on Eye",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,16402.80,N/A,9841.68,N/A,2296.40,N/A,2039.85,N/A,9421.20,N/A,5576.96,N/A,5005.57,N/A,2296.40,N/A,1950.06,N/A,1950.06,N/A,3115.84,N/A,5005.57,N/A,5005.57,N/A,5005.57,N/A,9421.21,N/A,1950.06,N/A,2296.40,N/A,3397.00,N/A,3397.00,N/A,2296.40,N/A,1950.06,N/A,2039.85,N/A,866.86,N/A,N/A,866.86,9841.68,,Hospital 00142,Anesthesia for Lens Surgery,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,14029.72,N/A,8417.83,N/A,1964.17,N/A,2039.85,N/A,8069.93,N/A,4770.10,N/A,4717.91,N/A,1964.17,N/A,1950.06,N/A,1950.06,N/A,2936.99,N/A,4717.91,N/A,4717.91,N/A,4717.91,N/A,8069.92,N/A,1950.06,N/A,1964.17,N/A,3397.00,N/A,3397.00,N/A,1964.17,N/A,1950.06,N/A,2039.85,N/A,556.44,N/A,N/A,556.44,8417.83,,Hospital 00162,"Anesth,Nose,Radical Sinus Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,72531.67,N/A,43519.00,N/A,10154.43,N/A,4922.21,N/A,41757.27,N/A,24660.78,N/A,11708.72,N/A,10154.43,N/A,4821.94,N/A,4821.94,N/A,7291.23,N/A,11708.72,N/A,11708.72,N/A,11708.72,N/A,41757.29,N/A,4821.94,N/A,10154.43,N/A,5563.25,N/A,5563.25,N/A,10154.43,N/A,4821.94,N/A,4922.21,N/A,1360.04,N/A,N/A,1360.04,43519.00,,Hospital 00164,"Anesth,Biopsy of Nose",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,19107.00,N/A,11464.20,N/A,2674.98,N/A,1279.62,N/A,10997.79,N/A,6496.38,N/A,3058.91,N/A,2674.98,N/A,1253.55,N/A,1253.55,N/A,1904.21,N/A,3058.91,N/A,3058.91,N/A,3058.91,N/A,10997.79,N/A,1253.55,N/A,2674.98,N/A,1871.00,N/A,1871.00,N/A,2674.98,N/A,1253.55,N/A,1279.62,N/A,103.06,N/A,N/A,103.06,11464.20,,Hospital 00190,"Anesth,Facial Bone Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,31985.18,N/A,19191.11,N/A,4477.93,N/A,5129.50,N/A,18384.05,N/A,10874.97,N/A,11716.66,N/A,4477.93,N/A,4821.94,N/A,4821.94,N/A,7293.84,N/A,11716.66,N/A,11716.66,N/A,11716.66,N/A,18384.05,N/A,4821.94,N/A,4477.93,N/A,5963.00,N/A,5963.00,N/A,4477.93,N/A,4821.94,N/A,5129.50,N/A,1138.70,N/A,N/A,1138.70,19191.11,,Hospital 00222,"Anesth,Intracran Nerve Coagulatn",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10592.80,N/A,6355.68,N/A,1508.43,N/A,1640.81,N/A,6096.21,N/A,3601.55,N/A,3945.97,N/A,1508.43,N/A,1623.23,N/A,1623.23,N/A,2456.44,N/A,3945.97,N/A,3945.97,N/A,3945.97,N/A,6096.21,N/A,1623.23,N/A,1508.43,N/A,3397.00,N/A,3397.00,N/A,1508.43,N/A,1623.23,N/A,1640.81,N/A,1243.38,N/A,N/A,1243.38,6355.68,,Hospital 0031A,HC Adm Sarscov2 Vac Ad26 .5ml,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,180330.20,N/A,108198.12,N/A,N/A,N/A,40438.69,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,52452.26,N/A,52452.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,40438.69,N/A,N/A,N/A,36936.00,N/A,N/A,N/A,N/A,N/A,40438.69,N/A,40438.69,N/A,N/A,N/A,36936.00,108198.12,N/A,N/A,,Hospital 00350,"Anesth,Neck Vessel Surgery Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,59534.23,N/A,35720.54,N/A,8724.77,N/A,10616.24,N/A,20180.69,N/A,20241.64,N/A,20442.11,N/A,8993.60,N/A,10586.59,N/A,10586.59,N/A,12725.83,N/A,20442.11,N/A,20442.11,N/A,20442.11,N/A,20180.69,N/A,10586.59,N/A,8993.60,N/A,23616.62,N/A,23616.62,N/A,N/A,N/A,10586.59,N/A,10616.24,N/A,9623.15,N/A,8724.77,35720.54,N/A,N/A,,Hospital CPT 0035U,HC So Neuro CSF Prion Prtn Qual,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,650.00,650.00,390.00,390.00,N/A,540.99,N/A,540.99,N/A,374.27,N/A,221.00,N/A,540.99,N/A,540.99,N/A,540.99,N/A,540.99,N/A,336.77,N/A,540.99,N/A,540.99,N/A,540.99,N/A,374.27,N/A,540.99,N/A,540.99,N/A,540.99,N/A,540.99,N/A,540.99,N/A,540.99,N/A,540.99,N/A,595.09,390.00,390.00,221.00,595.09,,Hospital CPT 0037U,HC So Trgt Gen Seq Alys Sld Orgn Neo Dna 324 Genes,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,9188.00,9188.00,5512.80,5512.80,N/A,3500.00,N/A,3500.00,N/A,5290.45,N/A,3123.92,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,2178.75,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,5290.45,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,3500.00,N/A,3850.00,5512.80,5512.80,2178.75,5512.80,,Hospital 00470,"Anesth,Partial Rib Resectn",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,23499.60,28483.87,14099.76,17090.32,8054.74,3987.74,9793.99,2440.19,18152.02,16371.17,7989.86,9684.52,18325.66,6571.80,8302.92,3987.74,9793.99,2332.78,9793.99,2332.78,11407.29,4091.06,18325.66,6571.80,18325.66,6571.80,18325.66,6571.80,18152.02,16371.18,9793.99,2332.78,8302.92,3987.74,21802.96,3397.00,21802.96,3397.00,N/A,3987.74,9793.99,2332.78,9793.99,2440.19,8884.13,480.83,7989.86,21802.96,480.83,17090.32,,Hospital CPT 0051A,HC Imm Admn Sarscov2 30mcg/0.3ml Tris-Sucrose 1st,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,110.00,N/A,63.34,N/A,37.40,N/A,15.40,N/A,15.40,N/A,110.00,N/A,110.00,N/A,9.57,N/A,15.40,N/A,15.40,N/A,15.40,N/A,63.34,N/A,110.00,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,110.00,N/A,110.00,N/A,110.00,66.00,66.00,9.57,110.00,,Hospital 00520,"Anesth,Chest Proc Closed,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,45106.72,16868.60,27064.03,10121.16,9036.31,2361.38,10955.14,1443.56,20364.07,9710.95,15336.28,5735.32,20558.86,3527.75,9314.74,2361.38,10955.14,1443.56,10955.14,1443.56,12797.41,2196.09,20558.86,3527.75,20558.86,3527.75,20558.86,3527.75,20364.07,9710.95,10955.14,1443.56,9314.74,2361.38,24459.92,1871.00,24459.92,1871.00,2593.58,2361.38,3010.42,1443.56,10955.14,1443.56,9966.77,1587.92,2593.58,27064.03,1443.56,10121.16,,Hospital 00529,"Anesth, Chest Partition View",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18877.50,N/A,11326.50,N/A,2525.31,N/A,4832.50,N/A,10868.19,N/A,6418.35,N/A,11398.73,N/A,2525.31,N/A,4706.78,N/A,4706.78,N/A,7095.93,N/A,11398.73,N/A,11398.73,N/A,11398.73,N/A,10868.20,N/A,4706.78,N/A,2525.31,N/A,5963.00,N/A,5963.00,N/A,2525.31,N/A,4706.78,N/A,4832.50,N/A,1419.32,N/A,N/A,1419.32,11398.73,,Hospital CPT 0052A,HC Imm Admn Sarscov2 30mcg/0.3ml Tris-Sucrose 2nd,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,110.00,N/A,63.34,N/A,37.40,N/A,15.40,N/A,15.40,N/A,110.00,N/A,110.00,N/A,9.57,N/A,15.40,N/A,15.40,N/A,15.40,N/A,63.34,N/A,110.00,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,110.00,N/A,110.00,N/A,110.00,66.00,66.00,9.57,110.00,,Hospital 00537,"Anesth,Card Electrophys Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,94158.27,127345.60,56494.96,76407.36,17921.66,17706.11,21466.05,22180.90,46484.56,72795.93,32013.81,43297.50,42359.94,51399.37,18473.86,17706.11,21466.05,21204.54,21466.05,21204.54,26368.72,31997.10,42359.94,51399.37,42359.94,51399.37,42359.94,51399.37,46484.56,72795.97,21466.05,21204.54,18473.86,17706.11,48511.18,17032.25,48511.18,17032.25,2983.54,17706.11,21466.05,21204.54,21466.05,22180.90,19767.03,1591.71,2983.54,56494.96,1591.71,76407.36,,Hospital 00540,"Anesth,Chest Surgery,Thoracotomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,25976.17,N/A,15585.70,N/A,3636.67,N/A,1185.73,N/A,14949.73,N/A,8831.90,N/A,12589.24,N/A,3636.67,N/A,1177.08,N/A,1177.08,N/A,7836.76,N/A,12589.24,N/A,12589.24,N/A,12589.24,N/A,14694.66,N/A,1177.08,N/A,3636.67,N/A,1906.50,N/A,1906.50,N/A,3636.67,N/A,1177.08,N/A,1185.73,N/A,1040.04,N/A,N/A,1040.04,15585.70,,Hospital 00550,"Anesth,Sternal Debridement",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,36753.10,N/A,22051.86,N/A,11250.71,N/A,13574.65,N/A,25354.40,N/A,12496.05,N/A,25596.93,N/A,11597.37,N/A,13574.65,N/A,13574.65,N/A,15933.50,N/A,25596.93,N/A,25596.93,N/A,25596.93,N/A,25354.40,N/A,13574.65,N/A,11597.37,N/A,30453.96,N/A,30453.96,N/A,N/A,N/A,13574.65,N/A,13574.65,N/A,12409.18,N/A,11250.71,30453.96,N/A,N/A,,Hospital 00600,"Anesth,Cerv Spine,Cord Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,97615.17,50332.73,58569.10,30199.64,13523.80,7016.73,16263.60,11782.94,45141.41,28806.10,33189.16,17113.13,30768.51,28695.15,13940.49,7016.73,562.00,11782.94,562.00,11782.94,19152.68,17863.29,30768.51,28695.15,30768.51,28695.15,30768.51,28695.15,45141.41,24840.02,16263.60,11782.94,13940.49,7016.73,36606.84,11977.25,36606.84,11977.25,N/A,7016.73,16263.60,11782.94,16263.60,11782.94,14916.32,12961.23,562.00,58569.10,7016.73,30199.64,,Hospital 00604,"Anesth,Cerv Spine, Sitting Position",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,138822.72,N/A,83293.63,N/A,19447.82,N/A,5787.94,N/A,79426.56,N/A,47199.74,N/A,50459.53,N/A,19447.82,N/A,5781.57,N/A,5781.57,N/A,31410.02,N/A,50459.53,N/A,50459.53,N/A,50459.53,N/A,78088.96,N/A,5781.57,N/A,19447.82,N/A,12055.25,N/A,12055.25,N/A,19447.82,N/A,5781.57,N/A,5787.94,N/A,2767.63,N/A,N/A,2767.63,83293.63,,Hospital 00632,"Anesth,Lumbar Sympathectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,25098.12,N/A,15058.87,N/A,3490.01,N/A,847.02,N/A,14443.63,N/A,8487.79,N/A,14301.17,N/A,3490.01,N/A,847.55,N/A,847.55,N/A,8902.20,N/A,14301.17,N/A,14301.17,N/A,14301.17,N/A,14443.62,N/A,847.55,N/A,3490.01,N/A,1643.00,N/A,1643.00,N/A,3490.01,N/A,847.55,N/A,847.02,N/A,876.50,N/A,N/A,847.02,15058.87,,Hospital 00635,"Anesth,Lumbar Puncture",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,6293.50,N/A,3776.10,N/A,883.17,N/A,578.89,N/A,3622.26,N/A,2139.79,N/A,1438.76,N/A,883.17,N/A,581.86,N/A,581.86,N/A,895.65,N/A,1438.76,N/A,1438.76,N/A,1438.76,N/A,3622.26,N/A,581.86,N/A,883.17,N/A,1431.00,N/A,1431.00,N/A,883.17,N/A,581.86,N/A,578.89,N/A,112.16,N/A,N/A,112.16,3776.10,,Hospital 00670,"Anesth,Extensive Spine,Cord Proced",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,93856.33,63532.20,56313.80,38119.32,10665.51,8859.32,12187.61,11782.94,23563.12,36336.43,31911.16,21407.51,20572.95,28659.08,10994.13,8859.32,12201.06,11782.94,214122.00,11782.94,20572.95,17840.83,20572.95,28659.08,20572.95,28659.08,20572.95,28659.08,23563.12,36336.43,12201.06,11782.94,10994.13,8859.32,28302.40,13336.25,28302.40,13336.25,6037.91,8859.32,6123.11,11782.94,12187.61,11782.94,6037.91,12961.23,6037.91,214122.00,8859.32,38119.32,,Hospital 00702,"Anesth,for Liver Biopsy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,7441.50,N/A,4464.90,N/A,1041.67,N/A,1382.32,N/A,4283.45,N/A,2530.11,N/A,3289.53,N/A,1041.67,N/A,1354.15,N/A,1354.15,N/A,2047.79,N/A,3289.53,N/A,3289.53,N/A,3289.53,N/A,4211.47,N/A,1354.15,N/A,1041.67,N/A,1871.00,N/A,1871.00,N/A,1041.67,N/A,1354.15,N/A,1382.32,N/A,467.29,N/A,N/A,467.29,4464.90,,Hospital 00770,"Anesth,Major Abd Blood Vessel Repair",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,54222.42,16368.80,32533.45,9821.28,8843.20,2291.64,10756.34,3058.80,19928.87,9414.13,18435.62,5565.40,20119.50,7366.88,9115.67,2291.64,146682.00,3026.02,146682.00,3026.02,12523.92,4586.02,20119.50,7366.88,20119.50,7366.88,20119.50,7366.88,19928.87,9404.46,10726.69,3026.02,9115.67,2291.64,23937.19,4562.00,23937.19,4562.00,4707.19,2291.64,10726.69,3026.02,10756.34,3058.80,9753.77,432.38,4707.19,146682.00,432.38,9821.28,,Hospital 00800,"Anesth,Abd Wall,Lower Ant,Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,36159.00,16098.50,21695.40,9659.10,5456.64,2229.95,4401.68,2440.19,19362.63,9267.79,12294.06,5473.49,19547.85,5668.35,5624.76,2229.95,210188.00,2332.78,210188.00,2332.78,12168.08,3528.65,19547.85,5668.35,19547.85,5668.35,19547.85,5668.35,19362.63,9267.79,4372.03,2332.78,5624.76,2229.95,23257.06,3397.00,23257.06,3397.00,2274.39,2229.95,4372.03,2332.78,4401.68,2440.19,6018.50,688.12,2274.39,210188.00,688.12,9659.10,,Hospital 00811,Anesthesia Lower Intst Endoscopic Px Nos,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,36199.50,5649.70,21719.70,3389.82,5030.55,790.95,6275.82,750.46,11336.75,3251.38,12307.83,1920.89,11445.19,1834.57,5185.55,790.95,6216.52,750.46,6216.52,750.46,7124.37,1142.06,11445.19,1834.57,11445.19,1834.57,11445.19,1834.57,11336.75,3251.38,6216.52,750.46,5185.55,790.95,13616.92,1431.00,13616.92,1431.00,2443.43,790.95,6216.52,750.46,6275.82,750.46,2443.43,825.51,2443.43,21719.70,750.46,3389.82,,Hospital 00820,"Anesth,Abd Wall,Lower Post,Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,15441.90,N/A,9265.14,N/A,2161.86,N/A,1416.50,N/A,8889.57,N/A,5250.24,N/A,3299.52,N/A,2161.86,N/A,1354.15,N/A,1354.15,N/A,2054.02,N/A,3299.52,N/A,3299.52,N/A,3299.52,N/A,8889.57,N/A,1354.15,N/A,2161.86,N/A,3397.00,N/A,3397.00,N/A,2161.86,N/A,1354.15,N/A,1416.50,N/A,524.95,N/A,N/A,524.95,9265.14,,Hospital 00840,"Anesth,Surg Lower Abdomen",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,32328.87,37462.73,19397.32,22477.64,5829.14,5206.66,7190.86,8206.20,13136.44,21568.16,10991.81,12721.54,13262.10,19890.56,6008.75,5206.66,7161.21,8206.20,7161.21,8206.20,8255.35,12382.27,13262.10,19890.56,13262.10,19890.56,13262.10,19890.56,13136.44,21568.16,7161.21,8206.20,6008.75,5206.66,15778.59,7897.00,15778.59,7897.00,5177.46,5206.66,7161.21,8206.20,7190.86,8206.20,5177.46,9026.81,5177.46,19397.32,5206.66,22477.64,,Hospital 00860,"Anesth,Surg Low Abd,Extraperintoneal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,102829.57,33995.62,61697.74,20397.37,6244.71,4754.98,7652.80,1781.87,16147.28,19573.45,34962.05,11558.51,14207.57,4073.19,6437.12,4754.98,7652.80,1675.03,7652.80,1675.03,8843.88,2535.64,14207.57,4073.19,14207.57,4073.19,14207.57,4073.19,16147.28,19573.45,7652.80,1675.03,6437.12,4754.98,16903.46,3397.00,16903.46,3397.00,N/A,4754.98,7652.80,1675.03,7652.80,1781.87,6887.72,313.82,6244.71,61697.74,313.82,20397.37,,Hospital 00862,"Anesth,Kidney,Prox Ureter Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,100256.87,94446.03,60154.12,56667.62,5750.19,13212.62,7067.82,8083.61,13122.37,54371.41,34087.33,32111.64,13082.47,18772.74,5927.36,13212.62,562.00,7727.79,562.00,7727.79,8143.53,11686.38,13082.47,18772.74,13082.47,18772.74,13082.47,18772.74,13122.37,54119.22,7067.82,7727.79,5927.36,13212.62,15564.88,8510.75,15564.88,8510.75,4404.67,13212.62,7067.82,7727.79,7067.82,8083.61,6342.28,1828.30,562.00,60154.12,1828.30,56667.62,,Hospital 00865,"Anesth,Removal of Prostate",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,92133.02,110687.33,55279.81,66412.40,6769.63,15493.24,8273.78,8733.55,15255.92,63727.05,31325.22,37624.00,15401.85,19896.42,6978.22,15493.24,562.00,8210.13,562.00,8210.13,9587.30,12385.90,15401.85,19896.42,15401.85,19896.42,15401.85,19896.42,15255.92,63727.05,8273.78,8210.13,6978.22,15493.24,18324.36,15608.50,18324.36,15608.50,N/A,15493.24,8273.78,8210.13,8273.78,8733.55,7466.69,2727.18,562.00,55279.81,2727.18,66412.40,,Hospital 00910,"Anesth,Transurethral Surg,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,36497.77,18947.03,21898.66,11368.22,6207.08,2652.58,7607.82,2894.35,25000.98,10887.34,12409.24,6442.00,24948.82,7218.24,6398.33,2652.58,7607.82,2894.35,7607.82,2894.35,15530.06,4493.27,24948.82,7218.24,24948.82,7218.24,24948.82,7218.24,25000.98,10887.34,7607.82,2894.35,6398.33,2652.58,29682.86,3397.00,29682.86,3397.00,2113.48,2652.58,7607.82,2894.35,7607.82,2894.35,6846.22,3183.79,2113.48,29682.86,2652.58,11368.22,,Hospital 00914,"Anesth,Xurethral Removal of Prostate",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,42189.58,22687.72,25313.75,13612.63,7905.37,3130.19,9617.28,4246.26,17815.40,13060.64,14344.46,7713.83,17985.82,10306.05,8148.95,3130.19,562.00,4246.26,562.00,4246.26,11195.75,6415.71,17985.82,10306.05,17985.82,10306.05,17985.82,10306.05,17815.40,13060.67,9617.28,4246.26,8148.95,3130.19,21398.64,5963.00,21398.64,5963.00,N/A,3130.19,9617.28,4246.26,9617.28,4246.26,8719.38,4670.88,562.00,25313.75,3130.19,13612.63,,Hospital 00916,"Anesth,Post Xurethral Bleeding Contr",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,29567.83,32143.67,17740.70,19286.20,4116.19,4500.12,5164.54,4391.84,9276.18,18503.97,10053.06,10928.85,9364.91,10306.43,4243.02,4500.12,118020.00,4246.26,118020.00,4246.26,5829.44,6415.94,9364.91,10306.43,9364.91,10306.43,9364.91,10306.43,9276.18,18503.97,5134.89,4246.26,4243.02,4500.12,11141.90,5963.00,11141.90,5963.00,N/A,4500.12,2894.35,4246.26,5164.54,4391.84,4540.03,727.85,2894.35,118020.00,727.85,19286.20,,Hospital 00930,"Anesth,Testis Suspension",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,25676.00,N/A,15405.60,N/A,3594.62,N/A,3345.78,N/A,14780.84,N/A,8729.82,N/A,7805.29,N/A,3594.62,N/A,3198.50,N/A,3198.50,N/A,4858.93,N/A,7805.29,N/A,7805.29,N/A,7805.29,N/A,14780.84,N/A,3198.50,N/A,3594.62,N/A,6260.50,N/A,6260.50,N/A,3594.62,N/A,3198.50,N/A,3345.78,N/A,1108.29,N/A,N/A,1108.29,15405.60,,Hospital 00942,"Anesth,Colpot,Vaginect,Colporr,Ureth Pro",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,26881.20,32612.80,16128.72,19567.68,13476.32,4565.80,16207.43,4378.42,26881.20,18776.13,9139.61,11088.36,26881.20,10175.85,13891.55,4565.80,16207.43,4185.69,16207.43,4185.69,19085.44,6334.67,26881.20,10175.85,26881.20,10175.85,26881.20,10175.85,26881.20,18776.15,16207.43,4185.69,13891.55,4565.80,26881.20,4562.00,26881.20,4562.00,N/A,4565.80,16207.43,4185.69,16207.43,4378.42,14863.96,829.87,9139.61,26881.20,829.87,19567.68,,Hospital 00948,"Anesth,Repair of Cervix",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,49065.70,11898.90,29439.42,7139.34,8482.58,1593.87,8498.71,2531.24,16347.52,6851.38,16682.36,3860.33,16503.89,6176.19,8743.94,1593.87,8439.41,2553.29,8439.41,2553.29,10273.29,3844.80,16503.89,6176.19,16503.89,6176.19,16503.89,6176.19,16347.52,6851.38,8439.41,2553.29,8743.94,1593.87,19635.51,3397.00,19635.51,3397.00,2613.96,1593.87,8439.41,2553.29,8498.71,2531.24,9356.02,245.57,2613.96,29439.42,245.57,7139.34,,Hospital 0098T,"Revision Total Disc Arthroplasty, Cervical, Ea Add",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,90594.82,N/A,54356.89,N/A,12652.35,N/A,6962.37,N/A,51524.52,N/A,30597.13,N/A,49631.25,N/A,12652.35,N/A,6960.17,N/A,6960.17,N/A,31146.28,N/A,49631.25,N/A,49631.25,N/A,49631.25,N/A,51524.55,N/A,6980.81,N/A,12652.35,N/A,11660.00,N/A,11660.00,N/A,12652.35,N/A,6960.17,N/A,6962.37,N/A,2724.82,N/A,N/A,2724.82,54356.89,,Hospital CPT 0112A,HC Imm Admn Sarscov2 25 Mcg/0.25 Ml 2nd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital 0124A,HC Imm Admn Sarscov2 Bivalent 30 Mcg/0.3 Ml Bst,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,N/A,521.02,N/A,312.61,N/A,72.94,N/A,161.76,N/A,300.00,N/A,177.14,N/A,90.69,N/A,72.94,N/A,146.63,N/A,146.63,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,300.00,N/A,146.63,N/A,72.94,N/A,279.27,N/A,279.27,N/A,72.94,N/A,146.63,N/A,161.76,N/A,195.76,N/A,N/A,56.46,312.61,,Hospital 01250,"Anesth,Upper Leg Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,14037.80,N/A,8422.68,N/A,1965.29,N/A,2332.78,N/A,8071.82,N/A,4772.85,N/A,5763.15,N/A,1965.29,N/A,2332.78,N/A,2332.78,N/A,3587.57,N/A,5763.15,N/A,5763.15,N/A,5763.15,N/A,8071.83,N/A,2332.78,N/A,1965.29,N/A,1871.00,N/A,1871.00,N/A,1965.29,N/A,2332.78,N/A,2332.78,N/A,2566.06,N/A,N/A,1871.00,8422.68,,Hospital 01274,"Anesth,Femoral Embolectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,56453.70,N/A,33872.22,N/A,7764.20,N/A,4855.12,N/A,32489.50,N/A,19194.27,N/A,11347.55,N/A,7764.20,N/A,4641.41,N/A,4641.41,N/A,7064.04,N/A,11347.55,N/A,11347.55,N/A,11347.55,N/A,32489.51,N/A,4641.41,N/A,7764.20,N/A,7897.00,N/A,7897.00,N/A,7764.20,N/A,4641.41,N/A,4855.12,N/A,1555.96,N/A,N/A,1555.96,33872.22,,Hospital 0134A,HC Imm Admn Sarscov2 Bivalent 50 Mcg/0.5 Ml Bst,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,18938.72,105.02,11363.23,63.01,4244.22,14.70,5286.34,39.73,9564.70,60.47,6439.14,35.70,9656.20,90.69,4375.00,14.70,5286.34,37.49,5286.34,37.49,6010.76,56.46,9656.20,90.69,9656.20,90.69,9656.20,90.69,9564.70,60.47,5286.34,37.49,4375.00,14.70,11488.46,56.29,11488.46,56.29,N/A,14.70,5286.34,37.49,5286.34,39.73,4681.25,N/A,4244.22,11488.46,14.70,90.69,,Hospital 01400,"Anesth,Knee Joint; Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,46081.50,15140.80,27648.90,9084.48,7809.88,2110.01,7947.02,2688.04,23751.87,7823.00,15667.71,5146.85,23979.07,6570.72,8050.52,2110.01,209626.00,2688.04,209626.00,2688.04,14926.41,4090.39,23979.07,6570.72,23979.07,6570.72,23979.07,6570.72,23751.87,7823.00,7917.37,2688.04,8050.52,2110.01,28529.11,4562.00,28529.11,4562.00,2392.44,2110.01,7917.37,2688.04,7947.02,2688.04,8614.06,2956.85,2392.44,209626.00,2110.01,9084.48,,Hospital 01430,"Anesth,Knee Veins Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18879.15,N/A,11327.49,N/A,2554.99,N/A,2719.26,N/A,10869.61,N/A,6418.92,N/A,6513.69,N/A,2554.99,N/A,2690.13,N/A,2690.13,N/A,4054.89,N/A,6513.69,N/A,6513.69,N/A,6513.69,N/A,10869.61,N/A,2690.13,N/A,2554.99,N/A,6843.00,N/A,6843.00,N/A,2554.99,N/A,2690.13,N/A,2719.26,N/A,668.50,N/A,N/A,668.50,11327.49,,Hospital 01462,"Anesth,Lower Leg,Closed Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,36488.80,17182.80,21893.28,10309.68,4594.18,2405.59,5729.97,1403.71,10353.35,9892.30,12406.19,5842.15,10452.38,3153.84,4735.73,2405.59,1445.57,1295.43,1445.57,1295.43,6506.37,1963.31,10452.38,3153.84,10452.38,3153.84,10452.38,3153.84,10353.35,9892.31,5700.32,1295.43,4735.73,2405.59,12435.73,1431.00,12435.73,1431.00,254.83,2405.59,5700.32,1295.43,5729.97,1403.71,5067.23,487.71,254.83,21893.28,487.71,10309.68,,Hospital 01472,"Anesth,Achilles Tendon Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,43530.40,45235.15,26118.24,27141.09,13380.30,6332.92,16093.85,5921.68,30962.92,25732.12,N/A,15379.61,30442.02,14495.45,13792.57,6332.92,2810.00,5973.28,2810.00,5973.28,18949.45,9023.71,N/A,14495.45,30442.02,14495.45,30442.02,14495.45,30962.92,25732.13,16093.85,5973.28,13792.57,6332.92,36218.41,7661.50,36218.41,7661.50,N/A,6332.92,16093.85,5973.28,16093.85,5921.68,14758.05,1196.87,2810.00,36218.41,1196.87,27141.09,,Hospital 01480,"Anesth,Lower Leg Bone Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,75830.27,21551.38,45498.16,12930.83,10076.03,3017.20,12185.08,5973.28,29053.87,12372.26,25782.29,7327.48,22924.37,14465.68,10386.49,3017.20,6123.11,5973.28,6123.11,5973.28,14269.88,9005.16,22924.37,14465.68,22924.37,14465.68,22924.37,14465.68,29053.87,12372.26,12185.08,5973.28,10386.49,3017.20,27274.27,8612.50,27274.27,8612.50,3378.87,3017.20,12185.08,5973.28,12185.08,5973.28,11113.55,6570.60,3378.87,45498.16,3017.20,14465.68,,Hospital 01482,"Anesth,Radical Leg Resection",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,24763.05,N/A,14857.83,N/A,3428.36,N/A,2664.83,N/A,14255.10,N/A,8419.43,N/A,6530.34,N/A,3428.36,N/A,2688.04,N/A,2688.04,N/A,4065.26,N/A,6530.34,N/A,6530.34,N/A,6530.34,N/A,14229.19,N/A,2688.04,N/A,3428.36,N/A,7692.25,N/A,7692.25,N/A,3428.36,N/A,2688.04,N/A,2664.83,N/A,2664.67,N/A,N/A,2664.67,14857.83,,Hospital 01522,"Anesth,Lower Leg Vein Thrombectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,45821.57,N/A,27492.94,N/A,6405.69,N/A,2865.65,N/A,26374.80,N/A,15579.35,N/A,6541.44,N/A,6405.69,N/A,2694.06,N/A,2694.06,N/A,4072.17,N/A,6541.44,N/A,6541.44,N/A,6541.44,N/A,26374.78,N/A,2694.06,N/A,6405.69,N/A,4562.00,N/A,4562.00,N/A,6405.69,N/A,2694.06,N/A,2865.65,N/A,822.20,N/A,N/A,822.20,27492.94,,Hospital 01610,"Anesth,Surgery of Shoulder",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,66555.10,48105.73,39933.06,28863.44,9261.97,6734.81,11251.72,5366.90,20872.60,27453.31,22628.73,16355.96,21072.26,14353.64,9547.35,6734.81,11222.07,5366.90,11222.07,5366.90,13116.99,8935.34,21072.26,14353.64,21072.26,14353.64,21072.26,14353.64,20872.60,27453.31,11222.07,5366.90,9547.35,6734.81,25070.73,11718.50,25070.73,11718.50,N/A,6734.81,5386.55,5366.90,11251.72,5366.90,10215.66,5903.59,5386.55,39933.06,5366.90,28863.44,,Hospital 01630,"Anesth,Shoulder Joint,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,55622.63,28287.67,33373.58,16972.60,12673.99,3951.42,15287.97,5973.28,39493.98,11735.00,18911.69,9617.80,28835.08,14562.63,13064.50,3951.42,119706.00,5973.28,119706.00,5973.28,17949.17,9088.45,28835.08,14562.63,28835.08,14562.63,28835.08,14562.63,39493.98,11735.00,15258.32,5973.28,13064.50,3951.42,34306.55,8744.25,34306.55,8744.25,N/A,3951.42,11864.95,5973.28,15287.97,5973.28,13979.01,6570.60,11864.95,119706.00,3951.42,16972.60,,Hospital 01638,"Anesth,Shoulder Replacement",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,80377.20,68345.42,48226.32,41007.25,12576.90,9568.36,15173.12,11782.94,45692.05,38846.39,27328.24,23237.45,28614.19,28602.18,12964.42,9568.36,138814.00,11782.94,138814.00,11782.94,17811.67,17805.40,28614.19,28602.18,28614.19,28602.18,28614.19,28602.18,45692.05,38846.40,15143.47,11782.94,12964.42,9568.36,34043.74,11660.00,34043.74,11660.00,N/A,9568.36,15143.47,11782.94,15173.12,11782.94,13871.93,12961.23,12576.90,138814.00,9568.36,41007.25,,Hospital 01656,"Anesth,Axill-Fem Bypass Grft Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,35540.40,N/A,21324.24,N/A,4966.21,N/A,483.98,N/A,20457.49,N/A,12083.73,N/A,4050.29,N/A,4966.21,N/A,480.37,N/A,480.37,N/A,2520.76,N/A,4050.29,N/A,4050.29,N/A,4050.29,N/A,20457.49,N/A,480.37,N/A,4966.21,N/A,1643.00,N/A,1643.00,N/A,4966.21,N/A,480.37,N/A,483.98,N/A,490.79,N/A,N/A,480.37,21324.24,,Hospital CPT 0165U,HC So Peanut Allg Spec Ige&Quan 64 Epi Elisa Bld,N/A,0305 - LABORATORY - HEMATOLOGY,12.00,12.00,7.20,7.20,N/A,7.80,N/A,463.76,N/A,6.91,N/A,4.08,N/A,12.00,N/A,7.80,N/A,463.76,N/A,463.76,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,6.91,N/A,463.76,N/A,1.68,N/A,12.00,N/A,12.00,N/A,5.40,N/A,463.76,N/A,463.76,N/A,12.00,7.20,7.20,1.68,463.76,,Hospital 01710,"Anesth,Elbow Area Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,39598.70,20843.80,23759.22,12506.28,N/A,2917.90,16123.50,1623.23,30153.58,11997.50,13463.56,7086.88,30442.02,3986.10,13792.57,2905.29,110152.00,1623.23,110152.00,1623.23,18949.45,2481.43,N/A,3986.10,30442.02,3986.10,30442.02,3986.10,30153.58,11997.52,16093.85,1623.23,13792.57,2917.90,36218.41,3397.00,36218.41,3397.00,N/A,2917.90,16093.85,1623.23,16123.50,1623.23,14758.05,1785.56,13463.56,110152.00,1623.23,12506.28,,Hospital 01730,"Anesth,Arm/Elbow Bones,Closed Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18679.30,N/A,11207.58,N/A,2606.23,N/A,1355.08,N/A,10725.94,N/A,6350.96,N/A,3441.87,N/A,2606.23,N/A,1295.43,N/A,1295.43,N/A,2142.31,N/A,3441.87,N/A,3441.87,N/A,3441.87,N/A,10725.94,N/A,1295.43,N/A,2606.23,N/A,1871.00,N/A,1871.00,N/A,2606.23,N/A,1295.43,N/A,1355.08,N/A,457.88,N/A,N/A,457.88,11207.58,,Hospital 01760,"Anesth,Elbow Replacement",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,91795.35,99436.22,55077.21,59661.73,12576.90,13920.85,15143.47,20185.67,55035.67,56433.00,31210.41,33808.31,28614.19,47904.56,12964.42,13920.85,19924.58,19774.44,19924.58,19774.44,17811.67,29823.83,28614.19,47904.56,28614.19,47904.56,28614.19,47904.56,55035.67,56433.00,15143.47,19774.44,12964.42,13920.85,34043.74,11660.00,34043.74,11660.00,N/A,13920.85,15143.47,19774.44,15143.47,20185.67,13871.93,1559.79,12576.90,55077.21,1559.79,59661.73,,Hospital 01820,"Anesth,Forearm Bones,Closed Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,29708.70,11506.97,17825.22,6904.18,5509.06,1610.97,6782.57,1295.43,12415.12,6624.03,10100.96,3912.36,12533.88,3145.09,5678.81,1610.97,6782.57,1295.43,6782.57,1295.43,7802.05,1957.87,12533.88,3145.09,12533.88,3145.09,12533.88,3145.09,12415.12,6624.03,6782.57,1295.43,5678.81,1610.97,14912.19,527.00,14912.19,527.00,N/A,1610.97,6782.57,1295.43,6782.57,1295.43,6076.32,1424.97,5509.06,17825.22,527.00,6904.18,,Hospital 01840,"Anesth,Lower Arm Artery Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,57394.37,20260.60,34436.62,12156.36,10970.65,2826.91,4855.12,2813.99,24723.24,11663.31,19514.09,6888.60,24959.74,6583.24,11308.67,2826.91,13243.35,2690.13,13243.35,2690.13,15536.86,4099.36,24959.74,6583.24,24959.74,6583.24,24959.74,6583.24,24723.24,11631.64,13243.35,2690.13,11308.67,2826.91,29695.86,4562.00,29695.86,4562.00,N/A,2826.91,13243.35,2690.13,13273.00,2813.99,12100.28,415.01,4855.12,34436.62,415.01,12156.36,,Hospital 01850,"Anesth,Lower Arm Vein Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,16736.70,N/A,10042.02,N/A,2343.14,N/A,1382.32,N/A,9633.29,N/A,5690.48,N/A,3297.87,N/A,2343.14,N/A,1354.15,N/A,1354.15,N/A,2052.98,N/A,3297.87,N/A,3297.87,N/A,3297.87,N/A,9633.29,N/A,1354.15,N/A,2343.14,N/A,1871.00,N/A,1871.00,N/A,2343.14,N/A,1354.15,N/A,1382.32,N/A,373.85,N/A,N/A,373.85,10042.02,,Hospital 0191T,Ant Segment Insertion Drainage W/O Reservoir Int,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18400.40,N/A,11040.24,N/A,2576.05,N/A,1940.08,N/A,10472.59,N/A,6256.14,N/A,4717.91,N/A,2576.05,N/A,1950.06,N/A,1950.06,N/A,2936.99,N/A,4717.91,N/A,4717.91,N/A,4717.91,N/A,10472.59,N/A,1950.06,N/A,2576.05,N/A,3397.00,N/A,3397.00,N/A,2576.05,N/A,1950.06,N/A,1940.08,N/A,556.44,N/A,N/A,556.44,11040.24,,Hospital 01925,"Anesth,Inter Rad,Carotid/Coronary",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,82455.03,N/A,49473.02,N/A,12183.21,N/A,14677.74,N/A,35743.40,N/A,28034.71,N/A,28545.22,N/A,12558.59,N/A,14677.74,N/A,14677.74,N/A,17770.25,N/A,28545.22,N/A,28545.22,N/A,28545.22,N/A,35743.40,N/A,14677.74,N/A,12558.59,N/A,32978.07,N/A,32978.07,N/A,N/A,N/A,14677.74,N/A,14677.74,N/A,13437.69,N/A,12183.21,49473.02,N/A,N/A,,Hospital 01931,"Anesth,Inter Rad,Intrahepat/Portal Circ",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,57398.13,N/A,34438.88,N/A,8005.92,N/A,2107.30,N/A,32670.71,N/A,19515.36,N/A,26223.55,N/A,8005.92,N/A,2028.18,N/A,2028.18,N/A,16324.67,N/A,26223.55,N/A,26223.55,N/A,26223.55,N/A,32670.71,N/A,2028.18,N/A,8005.92,N/A,12595.50,N/A,12595.50,N/A,8005.92,N/A,2028.18,N/A,2107.30,N/A,1067.07,N/A,N/A,1067.07,34438.88,,Hospital 01935,"Anesth,Perc Image Guide Spinal Proc, Diag",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10497.10,N/A,6298.26,N/A,1470.44,N/A,1178.33,N/A,6037.01,N/A,3569.01,N/A,2873.83,N/A,1470.44,N/A,1154.33,N/A,1154.33,N/A,1788.95,N/A,2873.83,N/A,2873.83,N/A,2873.83,N/A,6037.02,N/A,1154.33,N/A,1470.44,N/A,2278.25,N/A,2278.25,N/A,1470.44,N/A,1154.33,N/A,1178.33,N/A,303.16,N/A,N/A,303.16,6298.26,,Hospital 01936,"Anesth,Perc Image Guide Spinal Proc, Ther",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,26561.28,N/A,15936.77,N/A,3719.94,N/A,6168.00,N/A,15209.80,N/A,9030.84,N/A,14432.31,N/A,3719.94,N/A,5963.54,N/A,5963.54,N/A,8984.38,N/A,14432.31,N/A,14432.31,N/A,14432.31,N/A,15209.80,N/A,5963.54,N/A,3719.94,N/A,11845.50,N/A,11845.50,N/A,3719.94,N/A,5963.54,N/A,6168.00,N/A,884.37,N/A,N/A,884.37,15936.77,,Hospital 01940,Anes Perq Img Dstrj Px Nulyt Agt Spi/Sp Lmbr/Sac,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,13273.70,N/A,7964.22,N/A,1858.32,N/A,1656.99,N/A,7642.56,N/A,4513.06,N/A,3929.89,N/A,1858.32,N/A,1623.23,N/A,1623.23,N/A,2446.43,N/A,3929.89,N/A,3929.89,N/A,3929.89,N/A,7642.56,N/A,1623.23,N/A,1858.32,N/A,5227.25,N/A,5227.25,N/A,1858.32,N/A,1623.23,N/A,1656.99,N/A,327.61,N/A,N/A,327.61,7964.22,,Hospital 01960,"Anesth,Vaginal Delivery Only",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,17373.00,N/A,10423.80,N/A,2450.60,N/A,3423.07,N/A,9985.80,N/A,5906.83,N/A,9930.61,N/A,2450.60,N/A,3432.94,N/A,3432.94,N/A,6181.86,N/A,9930.61,N/A,9930.61,N/A,9930.61,N/A,7726.95,N/A,3432.94,N/A,2450.60,N/A,6939.01,N/A,6939.01,N/A,2450.60,N/A,3432.94,N/A,3423.07,N/A,3336.33,N/A,N/A,2450.60,10423.80,,Hospital 01990,"Phys Support,Brain-Dead Organ Donor",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10965.10,N/A,6579.06,N/A,1529.45,N/A,1656.99,N/A,6313.10,N/A,3728.14,N/A,3930.20,N/A,1529.45,N/A,1623.23,N/A,1623.23,N/A,2446.63,N/A,3930.20,N/A,3930.20,N/A,3930.20,N/A,6313.10,N/A,1623.23,N/A,1529.45,N/A,3660.50,N/A,3660.50,N/A,1529.45,N/A,1623.23,N/A,1656.99,N/A,282.64,N/A,N/A,282.64,6579.06,,Hospital 01991,Anes Dx/Ther Nrv Blk/Njx Oth/Thn Prone POS,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,8330.90,11476.37,4998.54,6885.82,2688.65,1606.69,3475.83,950.09,6059.09,6603.52,2832.51,3901.96,6117.05,2211.71,2771.49,1606.69,3446.18,950.09,3446.18,950.09,3807.72,1376.84,6117.05,2211.71,6117.05,2211.71,6117.05,2211.71,6059.09,6603.52,3446.18,950.09,2771.49,1606.69,7277.76,1694.50,7277.76,1694.50,635.82,1606.69,3446.18,950.09,3475.83,950.09,2965.50,981.55,635.82,7277.76,950.09,6885.82,,Hospital 01992,Anes Dx/Ther Nerve Block/Injection Prone POS,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10213.20,N/A,6127.92,N/A,1429.85,N/A,593.97,N/A,5875.55,N/A,3472.49,N/A,1438.55,N/A,1429.85,N/A,581.86,N/A,581.86,N/A,895.53,N/A,1438.55,N/A,1438.55,N/A,1438.55,N/A,5875.55,N/A,581.86,N/A,1429.85,N/A,1431.00,N/A,1431.00,N/A,1429.85,N/A,581.86,N/A,593.97,N/A,714.23,N/A,N/A,581.86,6127.92,,Hospital 01996,"Daily Mgmt,Epidur/Subarach Cont Drug Adm",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,4866.50,N/A,2919.90,N/A,712.89,N/A,1195.67,N/A,2801.63,N/A,1654.62,N/A,2846.59,N/A,712.89,N/A,1205.64,N/A,1205.64,N/A,1772.05,N/A,2846.59,N/A,2846.59,N/A,2846.59,N/A,2801.64,N/A,1205.64,N/A,712.89,N/A,2278.25,N/A,2278.25,N/A,712.88,N/A,1205.64,N/A,1195.67,N/A,266.94,N/A,N/A,266.94,2919.90,,Hospital 0223U,Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 0238T,HC Iliac Atherectomy,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,43056.00,43056.00,25833.60,25833.60,N/A,6027.84,N/A,16043.88,N/A,24791.64,N/A,14639.04,N/A,37522.38,N/A,6027.84,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,24791.64,N/A,15512.06,N/A,6027.84,N/A,11660.00,N/A,11660.00,N/A,6027.84,N/A,15512.06,N/A,16043.88,N/A,43056.00,25833.60,25833.60,6027.84,43056.00,,Hospital 0253T,Insert Ant Sgm Drainage Dev W/O Reservr Int Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26235.20,N/A,15741.12,N/A,3672.93,N/A,3774.30,N/A,15000.36,N/A,8919.97,N/A,8730.91,N/A,3672.93,N/A,3608.17,N/A,3608.17,N/A,5435.16,N/A,8730.91,N/A,8730.91,N/A,8730.91,N/A,15000.34,N/A,3608.17,N/A,3672.93,N/A,7661.50,N/A,7661.50,N/A,3672.93,N/A,3608.17,N/A,3774.30,N/A,556.44,N/A,N/A,556.44,15741.12,,Hospital 0296T,HC Ext Ecg Recording 2-21 Day Hookup,N/A,0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION,N/A,13181.10,N/A,7908.66,N/A,1910.01,N/A,1270.06,N/A,7587.74,N/A,4481.56,N/A,3900.73,N/A,1910.01,N/A,1230.05,N/A,1230.05,N/A,2680.90,N/A,3900.73,N/A,3900.73,N/A,3900.73,N/A,7435.80,N/A,1251.55,N/A,1910.01,N/A,4469.92,N/A,4469.92,N/A,1910.01,N/A,1230.05,N/A,1270.06,N/A,871.19,N/A,N/A,871.19,7908.66,,Hospital CPT 0345T,HC Transcath Mtral Vlve Repair Perc Apprch,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15495.00,15495.00,9297.00,9297.00,N/A,2169.30,N/A,15495.00,N/A,8922.02,N/A,5268.30,N/A,2169.30,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,1348.07,N/A,2169.30,N/A,2169.30,N/A,2169.30,N/A,8922.02,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,15495.00,9297.00,9297.00,1348.07,15495.00,,Hospital 0376T,Ant Segment Insert Drain W/O Reservoir Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22892.00,N/A,13735.20,N/A,3204.88,N/A,2025.99,N/A,13043.98,N/A,7783.28,N/A,4729.80,N/A,3204.88,N/A,1950.06,N/A,1950.06,N/A,2944.39,N/A,4729.80,N/A,4729.80,N/A,4729.80,N/A,13043.98,N/A,1950.06,N/A,3204.88,N/A,3397.00,N/A,3397.00,N/A,3204.88,N/A,1950.06,N/A,2025.99,N/A,580.41,N/A,N/A,580.41,13735.20,,Hospital 0505T,Ev Fempop Artl Revsc Tcat Plmt IV St Grf & Clsr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,140958.82,N/A,84575.29,N/A,19715.75,N/A,11073.52,N/A,80866.18,N/A,47925.99,N/A,23239.60,N/A,19715.75,N/A,10997.09,N/A,10997.09,N/A,14467.10,N/A,23239.60,N/A,23239.60,N/A,23239.60,N/A,80805.72,N/A,10997.09,N/A,19715.75,N/A,11660.00,N/A,11660.00,N/A,19715.75,N/A,10997.09,N/A,11073.52,N/A,32.50,N/A,N/A,32.50,84575.29,,Hospital 0540T,HC Car-T Therapy Autologous Cell Admin,N/A,0874 - CELL/GENE THERAPY - INFUSION OF MODIFIED CELLS,2891559.10,2549521.00,1734935.46,1529712.60,545805.04,356893.53,516730.31,449754.20,1593827.38,1468014.05,983130.09,866837.14,1006840.88,1233.46,523118.19,356893.53,516730.31,449740.37,516730.31,449740.37,N/A,767.30,N/A,1233.46,1006840.88,1233.46,1006840.88,1233.46,1593827.38,1468008.44,516730.31,449740.37,523118.19,356893.53,1393724.34,71.75,1393724.34,71.75,N/A,356893.53,516730.31,449740.37,N/A,449754.20,559736.46,108.03,516730.31,1734935.46,71.75,1529712.60,,Hospital CPT 0570T,HC Ttvr Perq Approach Each Addl Prothesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,15495.00,15495.00,9297.00,9297.00,N/A,2169.30,N/A,15495.00,N/A,8922.02,N/A,5268.30,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,14434.61,N/A,15495.00,N/A,15495.00,N/A,15495.00,N/A,8922.02,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,15495.00,9297.00,9297.00,2169.30,15495.00,,Hospital 0600T,Ire Ablation 1+Tumors per Organ W/Img Gdn Perq,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76071.57,N/A,45642.94,N/A,10644.84,N/A,8729.62,N/A,43795.64,N/A,25864.33,N/A,19910.93,N/A,10644.84,N/A,8206.20,N/A,8206.20,N/A,12394.93,N/A,19910.93,N/A,19910.93,N/A,19910.93,N/A,43795.63,N/A,8206.20,N/A,10644.84,N/A,7897.00,N/A,7897.00,N/A,10644.84,N/A,8206.20,N/A,8729.62,N/A,5.24,N/A,N/A,5.24,45642.94,,Hospital 0621T,Trabeculostomy Ab Interno by Laser,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27148.80,N/A,16289.28,N/A,3800.83,N/A,2039.85,N/A,15620.46,N/A,9230.59,N/A,4788.95,N/A,3800.83,N/A,1950.06,N/A,1950.06,N/A,2981.21,N/A,4788.95,N/A,4788.95,N/A,4788.95,N/A,15620.44,N/A,1950.06,N/A,3800.83,N/A,4218.50,N/A,4218.50,N/A,3800.83,N/A,1950.06,N/A,2039.85,N/A,556.44,N/A,N/A,556.44,16289.28,,Hospital 0627T,Perq Njx Algc Cell &/Prdct Uni/Bi Fluor Lmbr 1st,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64489.10,N/A,38693.46,N/A,9028.47,N/A,12186.91,N/A,36605.09,N/A,21926.29,N/A,28506.77,N/A,9028.47,N/A,11782.94,N/A,11782.94,N/A,17746.02,N/A,28506.77,N/A,28506.77,N/A,28506.77,N/A,36605.09,N/A,11782.94,N/A,9028.47,N/A,7897.00,N/A,7897.00,N/A,9028.47,N/A,11782.94,N/A,12186.91,N/A,23.97,N/A,N/A,23.97,38693.46,,Hospital 0658,Hspc Room and Board,N/A,0658 - HOSPICE SERVICE - HOSPICE ROOM & BOARD - NURSING FACILITY,N/A,9455.00,N/A,5673.00,N/A,N/A,N/A,5402.70,N/A,5211.72,N/A,3214.70,N/A,1323.70,N/A,1323.70,N/A,5402.70,N/A,5402.70,N/A,822.74,N/A,1323.70,N/A,1323.70,N/A,1323.70,N/A,5444.22,N/A,5402.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5402.70,N/A,5402.70,N/A,N/A,N/A,N/A,822.74,5673.00,,Hospital CPT 0662T,HC Scalp Cool 1st Meas&Calbrj,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4857.00,4857.00,2914.20,2914.20,N/A,679.98,N/A,4857.00,N/A,2796.66,N/A,1651.38,N/A,679.98,N/A,679.98,N/A,4857.00,N/A,4857.00,N/A,422.56,N/A,679.98,N/A,679.98,N/A,679.98,N/A,2796.66,N/A,4857.00,N/A,679.98,N/A,2603.35,N/A,2603.35,N/A,679.98,N/A,4857.00,N/A,4857.00,N/A,4857.00,2914.20,2914.20,422.56,4857.00,,Hospital 0671T,Insj Ant Sgm Drg Dev Trab Mw W/O Res&Ctrc Rmvl1+,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18663.60,N/A,11198.16,N/A,2612.90,N/A,1940.08,N/A,10626.62,N/A,6345.62,N/A,4840.98,N/A,2612.90,N/A,1950.06,N/A,1950.06,N/A,3013.61,N/A,4840.98,N/A,4840.98,N/A,4840.98,N/A,10626.63,N/A,1950.06,N/A,2612.90,N/A,3397.00,N/A,3397.00,N/A,2612.90,N/A,1950.06,N/A,1940.08,N/A,N/A,N/A,N/A,1940.08,11198.16,,Hospital 0707T,Njx Bone Sub Matrl Into Subchondral Bone Defect,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37585.27,N/A,22551.16,N/A,5261.94,N/A,6248.31,N/A,7823.00,N/A,12778.98,N/A,14483.77,N/A,5261.94,N/A,5973.28,N/A,5973.28,N/A,9016.42,N/A,14483.77,N/A,14483.77,N/A,14483.77,N/A,7823.00,N/A,5973.28,N/A,5261.94,N/A,11318.50,N/A,11318.50,N/A,5261.94,N/A,5973.28,N/A,6248.31,N/A,1440.65,N/A,N/A,1440.65,22551.16,,Hospital CPT 10035,HC Perq Dev Soft Tiss 1st Imag,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1745.00,1745.00,1047.00,1047.00,N/A,244.30,N/A,592.39,N/A,1004.77,N/A,593.30,N/A,1417.60,N/A,244.30,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1004.77,N/A,586.05,N/A,244.30,N/A,1431.00,N/A,1431.00,N/A,244.30,N/A,586.05,N/A,592.39,N/A,90.24,1047.00,1047.00,90.24,1431.00,,Hospital CPT 10080,HC I&D Pilonidal Cyst Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,869.00,869.00,521.40,521.40,N/A,121.66,N/A,98.16,N/A,500.37,N/A,295.46,N/A,688.41,N/A,121.66,N/A,98.16,N/A,98.16,N/A,428.54,N/A,688.41,N/A,688.41,N/A,688.41,N/A,500.37,N/A,98.16,N/A,121.66,N/A,869.00,N/A,869.00,N/A,121.66,N/A,98.16,N/A,98.16,N/A,107.98,521.40,521.40,98.16,869.00,,Hospital 11005,Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12589.60,N/A,7553.76,N/A,1743.43,N/A,801.05,N/A,7244.63,N/A,4280.46,N/A,993.86,N/A,1743.43,N/A,801.50,N/A,801.50,N/A,618.70,N/A,993.86,N/A,993.86,N/A,993.86,N/A,7192.82,N/A,801.50,N/A,1743.43,N/A,1643.00,N/A,1643.00,N/A,1743.43,N/A,801.50,N/A,801.05,N/A,883.26,N/A,N/A,618.70,7553.76,,Hospital CPT 11043,HC Debride/Musc/Fasc First 20 Sq Cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3185.00,3185.00,1911.00,1911.00,N/A,445.90,N/A,524.62,N/A,1833.92,N/A,1082.90,N/A,1269.02,N/A,445.90,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,1833.92,N/A,524.62,N/A,445.90,N/A,527.00,N/A,527.00,N/A,445.90,N/A,524.62,N/A,524.62,N/A,577.08,1911.00,1911.00,445.90,1911.00,,Hospital CPT 11043,HC Deb Mus/Fas 20sq Cm/<,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3185.00,3185.00,1911.00,1911.00,N/A,445.90,N/A,524.62,N/A,1833.92,N/A,1082.90,N/A,1269.02,N/A,445.90,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,1833.92,N/A,524.62,N/A,445.90,N/A,3185.00,N/A,3185.00,N/A,445.90,N/A,524.62,N/A,524.62,N/A,577.08,1911.00,1911.00,445.90,3185.00,,Hospital CPT 11102,HC Tangential Biopsy Skin Single Lesion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,172.81,N/A,723.78,N/A,427.38,N/A,394.46,N/A,175.98,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,723.78,N/A,163.07,N/A,175.98,N/A,527.00,N/A,527.00,N/A,175.98,N/A,163.07,N/A,35.97,N/A,39.57,754.20,754.20,35.97,754.20,,Hospital CPT 11102,HC Tangential Biopsy Skin Single Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,172.81,N/A,723.78,N/A,427.38,N/A,394.46,N/A,175.98,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,723.78,N/A,163.07,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,175.98,N/A,163.07,N/A,35.97,N/A,39.57,754.20,754.20,35.97,1257.00,,Hospital CPT 11105,HC Punch Biopsy Skin Ea Sep/Additional Lesion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,24.52,N/A,723.78,N/A,427.38,N/A,1257.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,723.78,N/A,1257.00,N/A,175.98,N/A,527.00,N/A,527.00,N/A,175.98,N/A,1257.00,N/A,24.52,N/A,26.97,754.20,754.20,24.52,1257.00,,Hospital CPT 11105,HC Punch Biopsy Skin Ea Sep/Additional Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,763.00,763.00,457.80,457.80,N/A,106.82,N/A,24.52,N/A,439.34,N/A,259.42,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,439.34,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,106.82,N/A,763.00,N/A,24.52,N/A,26.97,457.80,457.80,24.52,763.00,,Hospital CPT 11200,HC Excision Up to 15 Skin Tags,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,531.00,531.00,318.60,318.60,N/A,74.34,N/A,172.81,N/A,305.75,N/A,180.54,N/A,394.46,N/A,74.34,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,305.75,N/A,163.07,N/A,74.34,N/A,531.00,N/A,531.00,N/A,74.34,N/A,163.07,N/A,169.42,N/A,77.39,318.60,318.60,74.34,531.00,,Hospital 11201,Removal Sk Tgs Mlt Fibrq Tags Any Area Ea 10,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24798.12,N/A,14878.87,N/A,3464.58,N/A,3247.41,N/A,14277.68,N/A,8431.36,N/A,7527.99,N/A,3464.58,N/A,3104.47,N/A,3104.47,N/A,4686.32,N/A,7527.99,N/A,7527.99,N/A,7527.99,N/A,14277.68,N/A,3104.47,N/A,3464.58,N/A,3792.25,N/A,3792.25,N/A,3464.58,N/A,3104.47,N/A,3247.41,N/A,1458.61,N/A,N/A,1458.61,14878.87,,Hospital 11302,"Shav Skin Les 11-20mm Trunk,Arm,Leg",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17224.70,N/A,10334.82,N/A,2411.46,N/A,535.53,N/A,9917.98,N/A,5856.40,N/A,1269.02,N/A,2411.46,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,9917.98,N/A,524.62,N/A,2411.46,N/A,790.50,N/A,790.50,N/A,2411.46,N/A,524.62,N/A,535.53,N/A,411.13,N/A,N/A,411.13,10334.82,,Hospital 11311,HC Shave Lesion Face Dia 0.6 to 1,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,18855.80,N/A,11313.48,N/A,2639.81,N/A,1674.16,N/A,10854.26,N/A,6410.97,N/A,3985.24,N/A,2639.81,N/A,1640.06,N/A,1640.06,N/A,2480.89,N/A,3985.24,N/A,3985.24,N/A,3985.24,N/A,10854.26,N/A,1640.06,N/A,2639.81,N/A,2134.50,N/A,2134.50,N/A,2639.81,N/A,1640.06,N/A,1674.16,N/A,969.94,N/A,N/A,969.94,11313.48,,Hospital CPT 11422,Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,N/A,N/A,296.00,296.00,177.60,177.60,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,177.60,177.60,177.60,296.00,,Hospital CPT 11423,Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 2.1-3.0cm,N/A,N/A,338.00,338.00,202.80,202.80,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,N/A,338.00,202.80,202.80,202.80,338.00,,Hospital 11424,Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16591.60,N/A,9954.96,N/A,2322.82,N/A,1440.53,N/A,9550.34,N/A,5641.14,N/A,3298.96,N/A,2322.82,N/A,1354.15,N/A,1354.15,N/A,2053.66,N/A,3298.96,N/A,3298.96,N/A,3298.96,N/A,9550.34,N/A,1354.15,N/A,2322.82,N/A,1871.00,N/A,1871.00,N/A,2322.82,N/A,1354.15,N/A,1440.53,N/A,213.58,N/A,N/A,213.58,9954.96,,Hospital CPT 11442,Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 1.1-2.0cm,N/A,N/A,317.00,317.00,190.20,190.20,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,N/A,317.00,190.20,190.20,190.20,317.00,,Hospital 11443,HC Excis Benign Les Face 2.1-3.0c,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,13456.10,N/A,8073.66,N/A,1883.86,N/A,1368.82,N/A,7745.83,N/A,4575.08,N/A,3300.20,N/A,1883.86,N/A,1354.15,N/A,1354.15,N/A,2054.43,N/A,3300.20,N/A,3300.20,N/A,3300.20,N/A,7745.83,N/A,1354.15,N/A,1883.86,N/A,4112.50,N/A,4112.50,N/A,1883.86,N/A,1354.15,N/A,1368.82,N/A,742.51,N/A,N/A,742.51,8073.66,,Hospital 11451,Excision Hidradenitis Axillary Complex Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15523.30,N/A,9313.98,N/A,2171.43,N/A,2320.84,N/A,8934.11,N/A,5277.92,N/A,5683.96,N/A,2171.43,N/A,2332.78,N/A,2332.78,N/A,3538.38,N/A,5683.96,N/A,5683.96,N/A,5683.96,N/A,8934.11,N/A,2332.78,N/A,2171.43,N/A,3397.00,N/A,3397.00,N/A,2171.43,N/A,2332.78,N/A,2320.84,N/A,416.38,N/A,N/A,416.38,9313.98,,Hospital CPT 11606,HC Exc Malig Skin Lesion >4.0cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6938.00,6938.00,4162.80,4162.80,N/A,971.32,N/A,1406.88,N/A,3994.90,N/A,2358.92,N/A,3275.59,N/A,971.32,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3994.90,N/A,1354.15,N/A,971.32,N/A,1871.00,N/A,1871.00,N/A,971.32,N/A,1354.15,N/A,1406.88,N/A,332.00,4162.80,4162.80,332.00,4162.80,,Hospital CPT 11622,Excision Malignant Lesion S/N/H/F/G 1.1-2.0 Cm,N/A,N/A,424.00,424.00,254.40,254.40,N/A,59.36,N/A,158.79,N/A,424.00,N/A,144.16,N/A,424.00,N/A,59.36,N/A,158.79,N/A,158.79,N/A,424.00,N/A,424.00,N/A,424.00,N/A,424.00,N/A,424.00,N/A,158.79,N/A,59.36,N/A,424.00,N/A,424.00,N/A,59.36,N/A,158.79,N/A,158.79,N/A,174.67,254.40,254.40,59.36,424.00,,Hospital 11623,Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18429.30,N/A,11057.58,N/A,2580.10,N/A,1416.50,N/A,10609.60,N/A,6265.95,N/A,3303.82,N/A,2580.10,N/A,1354.15,N/A,1354.15,N/A,2056.68,N/A,3303.82,N/A,3303.82,N/A,3303.82,N/A,10609.61,N/A,1354.15,N/A,2580.10,N/A,2504.25,N/A,2504.25,N/A,2580.10,N/A,1354.15,N/A,1416.50,N/A,574.96,N/A,N/A,574.96,11057.58,,Hospital 11624,Excision Malignant Lesion S/N/H/F/G 3.1-4.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18920.90,N/A,11352.54,N/A,2648.92,N/A,1382.32,N/A,10892.47,N/A,6433.10,N/A,3290.25,N/A,2648.92,N/A,1354.15,N/A,1354.15,N/A,2048.25,N/A,3290.25,N/A,3290.25,N/A,3290.25,N/A,10892.48,N/A,1354.15,N/A,2648.92,N/A,2134.50,N/A,2134.50,N/A,2648.92,N/A,1354.15,N/A,1382.32,N/A,635.35,N/A,N/A,635.35,11352.54,,Hospital 11644,Excision Malignant Lesion F/E/E/N/L 3.1-4.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20405.10,N/A,12243.06,N/A,2856.72,N/A,1435.04,N/A,11748.31,N/A,6937.73,N/A,3299.08,N/A,2856.72,N/A,1354.15,N/A,1354.15,N/A,2053.74,N/A,3299.08,N/A,3299.08,N/A,3299.08,N/A,11748.33,N/A,1354.15,N/A,2856.72,N/A,2806.50,N/A,2806.50,N/A,2856.72,N/A,1354.15,N/A,1435.04,N/A,1198.34,N/A,N/A,1198.34,12243.06,,Hospital 11646,Excision Malignant Lesion F/E/E/N/L >4.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19047.40,N/A,11428.44,N/A,2666.63,N/A,2381.29,N/A,10964.76,N/A,6476.12,N/A,5653.17,N/A,2666.63,N/A,2332.78,N/A,2332.78,N/A,3519.21,N/A,5653.17,N/A,5653.17,N/A,5653.17,N/A,10964.77,N/A,2332.78,N/A,2666.63,N/A,3397.00,N/A,3397.00,N/A,2666.63,N/A,2332.78,N/A,2381.29,N/A,506.68,N/A,N/A,506.68,11428.44,,Hospital 11720,HC Debride Nails 1-5,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,14732.50,80.00,8839.50,48.00,9532.84,11.20,8723.60,55.01,14732.50,46.06,5009.05,27.20,14732.50,135.60,9826.57,11.20,1686.00,51.91,1686.00,51.91,14732.50,135.60,14732.50,135.60,14732.50,135.60,14732.50,135.60,14732.50,46.06,8723.60,51.91,9826.57,11.20,14732.50,42.88,14732.50,42.88,9826.57,11.20,8723.60,51.91,8723.60,55.01,10514.43,15.75,1686.00,14732.50,11.20,135.60,,Hospital CPT 11730,HC Avulsion of Nail Plate,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,656.00,656.00,393.60,393.60,N/A,91.84,N/A,172.81,N/A,377.72,N/A,223.04,N/A,394.46,N/A,91.84,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,377.72,N/A,163.07,N/A,91.84,N/A,527.00,N/A,527.00,N/A,91.84,N/A,163.07,N/A,51.84,N/A,57.02,393.60,393.60,51.84,527.00,,Hospital CPT 11730,HC ED Avulsion Nail Plate Single,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,656.00,656.00,393.60,393.60,N/A,91.84,N/A,172.81,N/A,377.72,N/A,223.04,N/A,394.46,N/A,91.84,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,377.72,N/A,163.07,N/A,91.84,N/A,656.00,N/A,656.00,N/A,91.84,N/A,163.07,N/A,51.84,N/A,57.02,393.60,393.60,51.84,656.00,,Hospital CPT 11740,HC Evacuation--Subungual Hematoma,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,225.00,225.00,135.00,135.00,N/A,31.50,N/A,29.29,N/A,129.56,N/A,76.50,N/A,156.54,N/A,31.50,N/A,29.29,N/A,29.29,N/A,97.45,N/A,156.54,N/A,156.54,N/A,156.54,N/A,129.56,N/A,29.29,N/A,31.50,N/A,225.00,N/A,225.00,N/A,31.50,N/A,29.29,N/A,29.29,N/A,32.22,135.00,135.00,29.29,225.00,,Hospital CPT 11760,HC Repair Nail Bed,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1079.00,1079.00,647.40,647.40,N/A,151.06,N/A,105.44,N/A,621.29,N/A,366.86,N/A,518.88,N/A,151.06,N/A,105.44,N/A,105.44,N/A,323.00,N/A,518.88,N/A,518.88,N/A,518.88,N/A,621.29,N/A,105.44,N/A,151.06,N/A,1079.00,N/A,1079.00,N/A,151.06,N/A,105.44,N/A,105.44,N/A,115.98,647.40,647.40,105.44,1079.00,,Hospital 11771,Excision Pilonidal Cyst/Sinus Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19871.20,N/A,11922.72,N/A,2781.97,N/A,2440.19,N/A,11440.55,N/A,6678.35,N/A,5666.79,N/A,2781.97,N/A,2332.78,N/A,2332.78,N/A,3527.69,N/A,5666.79,N/A,5666.79,N/A,5666.79,N/A,11440.55,N/A,2332.78,N/A,2781.97,N/A,3397.00,N/A,3397.00,N/A,2781.97,N/A,2332.78,N/A,2440.19,N/A,500.84,N/A,N/A,500.84,11922.72,,Hospital 11981,HC Insert Drug Implant Device,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,2085.00,N/A,1251.00,N/A,291.90,N/A,116.10,N/A,1179.13,N/A,708.90,N/A,1575.00,N/A,291.90,N/A,109.14,N/A,109.14,N/A,1661.70,N/A,1575.00,N/A,1575.00,N/A,1575.00,N/A,1179.13,N/A,109.14,N/A,291.90,N/A,1117.56,N/A,1117.56,N/A,291.90,N/A,109.14,N/A,116.10,N/A,67.19,N/A,N/A,67.19,1661.70,,Hospital CPT 12007,HC Repr Smp Not Face >30cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1813.00,1813.00,1087.80,1087.80,N/A,253.82,N/A,141.65,N/A,1043.93,N/A,616.42,N/A,654.09,N/A,253.82,N/A,141.65,N/A,141.65,N/A,407.17,N/A,654.09,N/A,654.09,N/A,654.09,N/A,1043.93,N/A,141.65,N/A,253.82,N/A,1813.00,N/A,1813.00,N/A,253.82,N/A,141.65,N/A,141.65,N/A,155.82,1087.80,1087.80,141.65,1813.00,,Hospital CPT 12015,HC Rep Lac Smp Face 7.6-12.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1461.00,1461.00,876.60,876.60,N/A,204.54,N/A,92.31,N/A,841.24,N/A,496.74,N/A,485.19,N/A,204.54,N/A,92.31,N/A,92.31,N/A,302.03,N/A,485.19,N/A,485.19,N/A,485.19,N/A,841.24,N/A,92.31,N/A,204.54,N/A,1461.00,N/A,1461.00,N/A,204.54,N/A,92.31,N/A,92.31,N/A,101.54,876.60,876.60,92.31,1461.00,,Hospital CPT 12032,HC Lyr Clos Sc Tk Ext 2.6-7 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1554.00,1554.00,932.40,932.40,N/A,217.56,N/A,357.02,N/A,894.79,N/A,528.36,N/A,814.92,N/A,217.56,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,894.79,N/A,336.90,N/A,217.56,N/A,1554.00,N/A,1554.00,N/A,217.56,N/A,336.90,N/A,357.02,N/A,194.73,932.40,932.40,194.73,1554.00,,Hospital CPT 12032,Repair Intermediate S/a/T/E 2.6-7.5 Cm,N/A,N/A,504.00,504.00,302.40,302.40,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,302.40,302.40,302.40,504.00,,Hospital CPT 12036,HC Repair Wounds 20.1cm to 30cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1915.00,1915.00,1149.00,1149.00,N/A,268.10,N/A,269.29,N/A,1102.66,N/A,651.10,N/A,1207.23,N/A,268.10,N/A,269.29,N/A,269.29,N/A,751.50,N/A,1207.23,N/A,1207.23,N/A,1207.23,N/A,1102.66,N/A,269.29,N/A,268.10,N/A,1915.00,N/A,1915.00,N/A,268.10,N/A,269.29,N/A,269.29,N/A,296.22,1149.00,1149.00,268.10,1915.00,,Hospital CPT 12041,HC Lyr Clos Nk Hnd Ft <2.6cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1353.00,1353.00,811.80,811.80,N/A,189.42,N/A,357.02,N/A,779.06,N/A,460.02,N/A,814.92,N/A,189.42,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,779.06,N/A,336.90,N/A,189.42,N/A,1353.00,N/A,1353.00,N/A,189.42,N/A,336.90,N/A,357.02,N/A,149.34,811.80,811.80,149.34,1353.00,,Hospital CPT 12041,Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,N/A,N/A,436.00,436.00,261.60,261.60,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,261.60,261.60,261.60,436.00,,Hospital CPT 12044,HC Lyr Clos Nk Hnd Ft 7.6-12.5,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1629.00,1629.00,977.40,977.40,N/A,228.06,N/A,201.49,N/A,937.98,N/A,553.86,N/A,1059.03,N/A,228.06,N/A,201.49,N/A,201.49,N/A,659.25,N/A,1059.03,N/A,1059.03,N/A,1059.03,N/A,937.98,N/A,201.49,N/A,228.06,N/A,1629.00,N/A,1629.00,N/A,228.06,N/A,201.49,N/A,201.49,N/A,221.64,977.40,977.40,201.49,1629.00,,Hospital CPT 12051,HC Layer Closure Face <2.5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1457.00,1457.00,874.20,874.20,N/A,203.98,N/A,158.70,N/A,838.94,N/A,495.38,N/A,787.92,N/A,203.98,N/A,158.70,N/A,158.70,N/A,490.48,N/A,787.92,N/A,787.92,N/A,787.92,N/A,838.94,N/A,158.70,N/A,203.98,N/A,1457.00,N/A,1457.00,N/A,203.98,N/A,158.70,N/A,158.70,N/A,174.57,874.20,874.20,158.70,1457.00,,Hospital CPT 12053,HC Layer Clos Face 5.1-7.5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1705.00,1705.00,1023.00,1023.00,N/A,238.70,N/A,202.05,N/A,981.74,N/A,579.70,N/A,1013.52,N/A,238.70,N/A,202.05,N/A,202.05,N/A,630.92,N/A,1013.52,N/A,1013.52,N/A,1013.52,N/A,981.74,N/A,202.05,N/A,238.70,N/A,1705.00,N/A,1705.00,N/A,238.70,N/A,202.05,N/A,202.05,N/A,222.26,1023.00,1023.00,202.05,1705.00,,Hospital CPT 12054,HC ED Layer Clos Face 7.6-12.5,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1908.00,1908.00,1144.80,1144.80,N/A,267.12,N/A,207.82,N/A,1098.63,N/A,648.72,N/A,1073.64,N/A,267.12,N/A,207.82,N/A,207.82,N/A,668.34,N/A,1073.64,N/A,1073.64,N/A,1073.64,N/A,1098.63,N/A,207.82,N/A,267.12,N/A,1908.00,N/A,1908.00,N/A,267.12,N/A,207.82,N/A,207.82,N/A,228.60,1144.80,1144.80,207.82,1908.00,,Hospital CPT 13100,HC Repair Complex Trunk 1.1-2.5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1445.00,1445.00,867.00,867.00,N/A,202.30,N/A,189.02,N/A,832.03,N/A,491.30,N/A,949.20,N/A,202.30,N/A,189.02,N/A,189.02,N/A,590.88,N/A,949.20,N/A,949.20,N/A,949.20,N/A,832.03,N/A,189.02,N/A,202.30,N/A,1445.00,N/A,1445.00,N/A,202.30,N/A,189.02,N/A,189.02,N/A,207.92,867.00,867.00,189.02,1445.00,,Hospital CPT 13121,HC Rep Cpx Sc Arm Lg 2.6-7.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2093.00,2093.00,1255.80,1255.80,N/A,293.02,N/A,243.07,N/A,1205.15,N/A,711.62,N/A,1185.75,N/A,293.02,N/A,243.07,N/A,243.07,N/A,738.13,N/A,1185.75,N/A,1185.75,N/A,1185.75,N/A,1205.15,N/A,243.07,N/A,293.02,N/A,2093.00,N/A,2093.00,N/A,293.02,N/A,243.07,N/A,243.07,N/A,267.38,1255.80,1255.80,243.07,2093.00,,Hospital CPT 13132,HC Rep Cpx Face H Ft 2.6-7.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2842.00,2842.00,1705.20,1705.20,N/A,397.88,N/A,286.46,N/A,1636.42,N/A,966.28,N/A,1318.26,N/A,397.88,N/A,286.46,N/A,286.46,N/A,820.62,N/A,1318.26,N/A,1318.26,N/A,1318.26,N/A,1636.42,N/A,286.46,N/A,397.88,N/A,2842.00,N/A,2842.00,N/A,397.88,N/A,286.46,N/A,286.46,N/A,315.11,1705.20,1705.20,286.46,2842.00,,Hospital CPT 13132,Repair Complex F/C/C/M/N/Ax/G/H/F 2.6-7.5 Cm,N/A,N/A,784.00,784.00,470.40,470.40,N/A,109.76,N/A,286.46,N/A,784.00,N/A,266.56,N/A,784.00,N/A,109.76,N/A,286.46,N/A,286.46,N/A,784.00,N/A,784.00,N/A,784.00,N/A,784.00,N/A,784.00,N/A,286.46,N/A,109.76,N/A,784.00,N/A,784.00,N/A,109.76,N/A,286.46,N/A,286.46,N/A,315.11,470.40,470.40,109.76,784.00,,Hospital 13152,HC Repair of Wound or Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,45314.40,20250.10,27188.64,12150.06,8375.35,2835.01,7029.26,887.42,18765.00,11658.54,15406.90,6885.03,4896.00,2070.19,8633.41,2835.01,5058.00,848.36,5058.00,848.36,4896.00,1288.73,4896.00,2070.19,4896.00,2070.19,4896.00,2070.19,18874.54,11658.55,7029.26,848.36,8633.41,2835.01,22670.80,1694.50,22670.80,1694.50,N/A,2835.01,10173.26,848.36,7029.26,887.42,10061.58,566.00,4896.00,27188.64,566.00,12150.06,,Hospital 13153,HC Repair Wound/Lesion +,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,8438.20,N/A,5062.92,N/A,1181.35,N/A,2358.04,N/A,4857.49,N/A,2869.01,N/A,5665.45,N/A,1181.35,N/A,2332.78,N/A,2332.78,N/A,3526.85,N/A,5665.45,N/A,5665.45,N/A,5665.45,N/A,4804.23,N/A,2332.78,N/A,1181.35,N/A,4244.25,N/A,4244.25,N/A,1181.35,N/A,2332.78,N/A,2358.04,N/A,1120.05,N/A,N/A,1120.05,5665.45,,Hospital CPT 14040,Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<,N/A,N/A,1258.00,1258.00,754.80,754.80,N/A,176.12,N/A,584.47,N/A,1258.00,N/A,427.72,N/A,1258.00,N/A,176.12,N/A,584.47,N/A,584.47,N/A,1258.00,N/A,1258.00,N/A,1258.00,N/A,1258.00,N/A,1258.00,N/A,584.47,N/A,176.12,N/A,1258.00,N/A,1258.00,N/A,176.12,N/A,584.47,N/A,584.47,N/A,642.92,754.80,754.80,176.12,1258.00,,Hospital CPT 14040,HC Adj Tsu Trnsfr 10cm or Less,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,9724.00,9724.00,5834.40,5834.40,N/A,1361.36,N/A,584.47,N/A,5599.08,N/A,3306.16,N/A,2127.12,N/A,1361.36,N/A,584.47,N/A,584.47,N/A,1324.13,N/A,2127.12,N/A,2127.12,N/A,2127.12,N/A,5599.08,N/A,584.47,N/A,1361.36,N/A,9724.00,N/A,9724.00,N/A,1361.36,N/A,584.47,N/A,584.47,N/A,642.92,5834.40,5834.40,584.47,9724.00,,Hospital CPT 14060,Adjt Tis Trnsfr/Rearrgmt E/N/E/L Dfct 10 Sq Cm/<,N/A,N/A,1278.00,1278.00,766.80,766.80,N/A,178.92,N/A,623.37,N/A,1278.00,N/A,434.52,N/A,1278.00,N/A,178.92,N/A,623.37,N/A,623.37,N/A,1278.00,N/A,1278.00,N/A,1278.00,N/A,1278.00,N/A,1278.00,N/A,623.37,N/A,178.92,N/A,1278.00,N/A,1278.00,N/A,178.92,N/A,623.37,N/A,623.37,N/A,685.71,766.80,766.80,178.92,1278.00,,Hospital CPT 14061,Adjt Tis Reargmt Eye/Nose/Ear/Lip 10.1-30.0 Sqcm,N/A,N/A,1667.00,1667.00,1000.20,1000.20,N/A,233.38,N/A,767.03,N/A,1667.00,N/A,566.78,N/A,1667.00,N/A,233.38,N/A,767.03,N/A,767.03,N/A,1667.00,N/A,1667.00,N/A,1667.00,N/A,1667.00,N/A,1667.00,N/A,767.03,N/A,233.38,N/A,1667.00,N/A,1667.00,N/A,233.38,N/A,767.03,N/A,767.03,N/A,843.73,1000.20,1000.20,233.38,1667.00,,Hospital CPT 14302,Adjt Tis Trnsfr/Reargmt Defec Ea Addl 30 Sqcm,N/A,N/A,356.00,356.00,213.60,213.60,N/A,49.84,N/A,206.63,N/A,356.00,N/A,121.04,N/A,356.00,N/A,49.84,N/A,206.63,N/A,206.63,N/A,356.00,N/A,356.00,N/A,356.00,N/A,356.00,N/A,356.00,N/A,206.63,N/A,49.84,N/A,356.00,N/A,356.00,N/A,49.84,N/A,206.63,N/A,206.63,N/A,227.29,213.60,213.60,49.84,356.00,,Hospital 14350,Filleted Finger/Toe Flap W/Prepj Recipient Site,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30530.40,N/A,18318.24,N/A,4276.81,N/A,2871.29,N/A,17572.32,N/A,10380.34,N/A,6582.84,N/A,4276.81,N/A,2699.83,N/A,2699.83,N/A,4097.94,N/A,6582.84,N/A,6582.84,N/A,6582.84,N/A,17572.32,N/A,2699.83,N/A,4276.81,N/A,4332.50,N/A,4332.50,N/A,4276.81,N/A,2699.83,N/A,2871.29,N/A,988.37,N/A,N/A,988.37,18318.24,,Hospital CPT 15004,Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,N/A,N/A,661.00,661.00,396.60,396.60,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,N/A,661.00,396.60,396.60,396.60,661.00,,Hospital CPT 15004,HC Surg Prep Non-Trunk 100sqcm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2970.00,2970.00,1782.00,1782.00,N/A,415.80,N/A,542.61,N/A,1710.13,N/A,1009.80,N/A,1269.02,N/A,415.80,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,1710.13,N/A,524.62,N/A,415.80,N/A,527.00,N/A,527.00,N/A,415.80,N/A,524.62,N/A,542.61,N/A,275.53,1782.00,1782.00,275.53,1782.00,,Hospital CPT 15115,HC Epidrm Autograft Other 1st 100,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4380.00,4380.00,2628.00,2628.00,N/A,613.20,N/A,659.93,N/A,2522.00,N/A,1489.20,N/A,2274.24,N/A,613.20,N/A,659.93,N/A,659.93,N/A,1415.71,N/A,2274.24,N/A,2274.24,N/A,2274.24,N/A,2522.00,N/A,659.93,N/A,613.20,N/A,4380.00,N/A,4380.00,N/A,613.20,N/A,659.93,N/A,659.93,N/A,725.92,2628.00,2628.00,613.20,4380.00,,Hospital 15120,Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/100 Ea Adl 100,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1989.00,1989.00,1193.40,1193.40,N/A,278.46,N/A,54.46,N/A,1145.27,N/A,676.26,N/A,266.67,N/A,278.46,N/A,54.46,N/A,54.46,N/A,166.00,N/A,266.67,N/A,266.67,N/A,266.67,N/A,1145.27,N/A,54.46,N/A,278.46,N/A,1989.00,N/A,1989.00,N/A,278.46,N/A,54.46,N/A,54.46,N/A,59.91,1193.40,1193.40,54.46,1989.00,,Hospital 15600,Delay Flap/Sectioning Flap Trunk,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18902.78,N/A,11341.67,N/A,2646.39,N/A,3240.55,N/A,10876.79,N/A,6077.44,N/A,7122.59,N/A,2646.39,N/A,2937.63,N/A,2937.63,N/A,4433.94,N/A,7122.59,N/A,7122.59,N/A,7122.59,N/A,10876.81,N/A,2937.63,N/A,2646.39,N/A,4562.00,N/A,4562.00,N/A,2646.39,N/A,2937.63,N/A,225.69,N/A,248.26,N/A,N/A,225.69,11341.67,,Hospital 15733,Musc Myoq/Fscq Flap Head&Neck W/Named Vasc Pedcl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36826.77,N/A,22096.06,N/A,5155.75,N/A,1829.28,N/A,21195.15,N/A,12521.10,N/A,13658.20,N/A,5155.75,N/A,3784.93,N/A,3784.93,N/A,8502.50,N/A,13658.20,N/A,13658.20,N/A,13658.20,N/A,21195.18,N/A,3784.93,N/A,5155.75,N/A,5383.50,N/A,5383.50,N/A,5155.75,N/A,3784.93,N/A,1829.28,N/A,2012.21,N/A,N/A,1829.28,22096.06,,Hospital 15734,Musc Myocutaneous/Fasciocutaneous Flap Trunk,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,51830.68,36316.00,31098.41,21789.60,13663.56,5084.23,8135.31,8164.21,30791.95,20903.09,17622.43,12347.43,31086.50,19970.91,14084.56,5084.23,68564.00,8206.20,68564.00,8206.20,19350.62,12432.28,31086.50,19970.91,31086.50,19970.91,31086.50,19970.91,30791.95,20903.08,16428.94,8206.20,14084.56,5084.23,36985.17,10178.00,36985.17,10178.00,N/A,5084.23,16428.94,8206.20,16458.59,8164.21,15070.48,3217.12,8135.31,68564.00,3217.12,21789.60,,Hospital 15757,Free Skin Flap W/Microvascular Anastomosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23890.80,N/A,14334.48,N/A,3336.04,N/A,1416.50,N/A,13753.63,N/A,7903.22,N/A,10817.70,N/A,3336.04,N/A,1354.15,N/A,1354.15,N/A,6734.22,N/A,10817.70,N/A,10817.70,N/A,10817.70,N/A,13753.63,N/A,1354.15,N/A,3336.04,N/A,4332.50,N/A,4332.50,N/A,3336.04,N/A,1354.15,N/A,1416.50,N/A,2769.01,N/A,N/A,1354.15,14334.48,,Hospital 15770,Graft Derma-Fat-Fascia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34728.38,N/A,20837.03,N/A,4853.12,N/A,2440.19,N/A,19777.68,N/A,11807.66,N/A,5674.48,N/A,4853.12,N/A,2332.78,N/A,2332.78,N/A,3532.47,N/A,5674.48,N/A,5674.48,N/A,5674.48,N/A,19777.69,N/A,2332.78,N/A,4853.12,N/A,6260.50,N/A,6260.50,N/A,4853.12,N/A,2332.78,N/A,2440.19,N/A,1177.94,N/A,N/A,1177.94,20837.03,,Hospital 15771,Grafting of Autologous Fat by Lipo 50 Cc or Less,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52591.07,N/A,31554.64,N/A,7347.15,N/A,8337.10,N/A,30084.87,N/A,17880.97,N/A,19399.98,N/A,7347.15,N/A,7951.94,N/A,7951.94,N/A,12076.86,N/A,19399.98,N/A,19399.98,N/A,19399.98,N/A,30084.90,N/A,7951.94,N/A,7347.15,N/A,12986.00,N/A,12986.00,N/A,7347.15,N/A,7951.94,N/A,3253.82,N/A,3579.22,N/A,N/A,3253.82,31554.64,,Hospital 15772,Grafting of Autologous Fat by Lipo Ea Addl 50 Cc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,53177.60,N/A,31906.56,N/A,7436.02,N/A,6248.31,N/A,30469.49,N/A,18080.36,N/A,14595.36,N/A,7436.02,N/A,5973.28,N/A,5973.28,N/A,9085.86,N/A,14595.36,N/A,14595.36,N/A,14595.36,N/A,30469.51,N/A,5973.28,N/A,7436.02,N/A,10085.00,N/A,10085.00,N/A,7436.02,N/A,5973.28,N/A,6248.31,N/A,1594.33,N/A,N/A,1594.33,31906.56,,Hospital 15820,Blepharoplasty Lower Eyelid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38204.40,N/A,22922.64,N/A,5348.63,N/A,2451.01,N/A,21967.83,N/A,12989.51,N/A,5817.31,N/A,5348.63,N/A,2337.78,N/A,2337.78,N/A,3621.38,N/A,5817.31,N/A,5817.31,N/A,5817.31,N/A,21967.83,N/A,2337.78,N/A,5348.63,N/A,2806.50,N/A,2806.50,N/A,5348.63,N/A,2337.78,N/A,480.34,N/A,528.37,N/A,N/A,480.34,22922.64,,Hospital 15821,Blepharoplasty Lower Eyelid Herniated Fat Pad,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27419.90,N/A,16451.94,N/A,3838.78,N/A,3876.37,N/A,15784.93,N/A,9322.76,N/A,9481.36,N/A,3838.78,N/A,3896.30,N/A,3896.30,N/A,5902.81,N/A,9481.36,N/A,9481.36,N/A,9481.36,N/A,15784.93,N/A,3896.30,N/A,3838.78,N/A,3274.25,N/A,3274.25,N/A,3838.78,N/A,3896.30,N/A,3876.37,N/A,1181.79,N/A,N/A,1181.79,16451.94,,Hospital CPT 15823,Blepharoplasty Upper Eyelid W/Excessive Skin,N/A,N/A,1032.00,1032.00,619.20,619.20,N/A,144.48,N/A,514.77,N/A,1032.00,N/A,350.88,N/A,1032.00,N/A,144.48,N/A,514.77,N/A,514.77,N/A,1032.00,N/A,1032.00,N/A,1032.00,N/A,1032.00,N/A,1032.00,N/A,514.77,N/A,144.48,N/A,1032.00,N/A,1032.00,N/A,144.48,N/A,514.77,N/A,514.77,N/A,566.25,619.20,619.20,144.48,1032.00,,Hospital 15824,Rhytidectomy Forehead,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28503.70,N/A,17102.22,N/A,3990.96,N/A,1661.86,N/A,16364.90,N/A,9691.26,N/A,4223.58,N/A,3990.96,N/A,1562.45,N/A,1562.45,N/A,2628.79,N/A,4223.58,N/A,4223.58,N/A,4223.58,N/A,16364.90,N/A,1562.45,N/A,3990.96,N/A,1871.00,N/A,1871.00,N/A,3990.96,N/A,1562.45,N/A,1661.86,N/A,4.32,N/A,N/A,4.32,17102.22,,Hospital 15833,Excision Excessive Skin & Subq Tissue Leg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,86316.62,N/A,51789.97,N/A,12084.34,N/A,5920.33,N/A,49683.76,N/A,29347.65,N/A,13050.14,N/A,12084.34,N/A,5366.90,N/A,5366.90,N/A,8123.97,N/A,13050.14,N/A,13050.14,N/A,13050.14,N/A,49683.79,N/A,5366.90,N/A,12084.34,N/A,7983.50,N/A,7983.50,N/A,12084.34,N/A,5366.90,N/A,2859.47,N/A,3145.42,N/A,N/A,2859.47,51789.97,,Hospital 15836,Excision Excessive Skin & Subq Tissue Arm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57189.12,N/A,34313.47,N/A,7925.75,N/A,778.03,N/A,32902.75,N/A,19444.30,N/A,5801.80,N/A,7925.75,N/A,2332.78,N/A,2332.78,N/A,3611.72,N/A,5801.80,N/A,5801.80,N/A,5801.80,N/A,32902.76,N/A,2332.78,N/A,7925.75,N/A,2806.50,N/A,2806.50,N/A,7925.75,N/A,2332.78,N/A,2238.63,N/A,855.84,N/A,N/A,778.03,34313.47,,Hospital CPT 15847,Excision Excessive Skin & Subq Tissue Abdomen,N/A,N/A,2892.00,2892.00,1735.20,1735.20,N/A,404.88,N/A,2892.00,N/A,2892.00,N/A,983.28,N/A,404.88,N/A,404.88,N/A,2892.00,N/A,2892.00,N/A,251.60,N/A,404.88,N/A,404.88,N/A,404.88,N/A,2892.00,N/A,2892.00,N/A,404.88,N/A,2892.00,N/A,2892.00,N/A,404.88,N/A,2892.00,N/A,2892.00,N/A,2892.00,1735.20,1735.20,251.60,2892.00,,Hospital 15851,Removal Sutures/Staples Requiring Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10644.70,N/A,6386.82,N/A,1485.85,N/A,1657.93,N/A,6127.92,N/A,3619.20,N/A,3777.66,N/A,1485.85,N/A,1558.52,N/A,1558.52,N/A,2351.66,N/A,3777.66,N/A,3777.66,N/A,3777.66,N/A,6127.92,N/A,1558.52,N/A,1485.85,N/A,1871.00,N/A,1871.00,N/A,1485.85,N/A,1558.52,N/A,1657.93,N/A,57.28,N/A,N/A,57.28,6386.82,,Hospital CPT 15853,HC Removal Sutures/Staples Not Requiring Anest,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,188.00,188.00,112.80,112.80,N/A,26.32,N/A,188.00,N/A,108.25,N/A,63.92,N/A,30.18,N/A,26.32,N/A,188.00,N/A,188.00,N/A,18.79,N/A,30.18,N/A,30.18,N/A,30.18,N/A,108.25,N/A,188.00,N/A,26.32,N/A,188.00,N/A,188.00,N/A,26.32,N/A,188.00,N/A,188.00,N/A,188.00,112.80,112.80,18.79,188.00,,Hospital 15877,Suction Assisted Lipectomy Trunk,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49434.37,N/A,29660.62,N/A,6920.80,N/A,3125.00,N/A,28448.03,N/A,16807.68,N/A,7215.68,N/A,6920.80,N/A,2937.63,N/A,2937.63,N/A,4491.89,N/A,7215.68,N/A,7215.68,N/A,7215.68,N/A,28448.04,N/A,2937.63,N/A,6920.80,N/A,4562.00,N/A,4562.00,N/A,6920.80,N/A,2937.63,N/A,3125.00,N/A,N/A,N/A,N/A,2937.63,29660.62,,Hospital CPT 16025,HC Dress or Debride Burn Medium,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,823.00,823.00,493.80,493.80,N/A,115.22,N/A,161.66,N/A,473.88,N/A,279.82,N/A,394.46,N/A,115.22,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,473.88,N/A,163.07,N/A,115.22,N/A,823.00,N/A,823.00,N/A,115.22,N/A,163.07,N/A,166.46,N/A,116.41,493.80,493.80,115.22,823.00,,Hospital CPT 16025,HC Burn Dress/Debrid 5-10%,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,823.00,823.00,493.80,493.80,N/A,115.22,N/A,161.66,N/A,473.88,N/A,279.82,N/A,394.46,N/A,115.22,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,473.88,N/A,163.07,N/A,115.22,N/A,527.00,N/A,527.00,N/A,115.22,N/A,163.07,N/A,166.46,N/A,116.41,493.80,493.80,115.22,527.00,,Hospital CPT 16030,HC Dress or Debride Burn Large,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1153.00,1153.00,691.80,691.80,N/A,161.42,N/A,348.45,N/A,663.90,N/A,392.02,N/A,814.92,N/A,161.42,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,663.90,N/A,336.90,N/A,161.42,N/A,1153.00,N/A,1153.00,N/A,161.42,N/A,336.90,N/A,348.45,N/A,137.76,691.80,691.80,137.76,1153.00,,Hospital CPT 16030,HC Burn Dress/Debrid >10%,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1153.00,1153.00,691.80,691.80,N/A,161.42,N/A,348.45,N/A,663.90,N/A,392.02,N/A,814.92,N/A,161.42,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,663.90,N/A,336.90,N/A,161.42,N/A,527.00,N/A,527.00,N/A,161.42,N/A,336.90,N/A,348.45,N/A,137.76,691.80,691.80,137.76,814.92,,Hospital CPT 16035,HC Incision of Burn Scab Ini,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,954.00,954.00,572.40,572.40,N/A,133.56,N/A,186.05,N/A,549.31,N/A,324.36,N/A,559.32,N/A,133.56,N/A,186.05,N/A,186.05,N/A,348.18,N/A,559.32,N/A,559.32,N/A,559.32,N/A,549.31,N/A,186.05,N/A,133.56,N/A,954.00,N/A,954.00,N/A,133.56,N/A,186.05,N/A,186.05,N/A,204.66,572.40,572.40,133.56,954.00,,Hospital CPT 17000,"HC Wound Cautery, Electr Hi-Temp",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,384.00,384.00,230.40,230.40,N/A,53.76,N/A,172.81,N/A,221.11,N/A,130.56,N/A,384.00,N/A,53.76,N/A,163.07,N/A,163.07,N/A,245.56,N/A,384.00,N/A,384.00,N/A,384.00,N/A,221.11,N/A,163.07,N/A,53.76,N/A,527.00,N/A,527.00,N/A,53.76,N/A,163.07,N/A,172.81,N/A,56.19,230.40,230.40,53.76,527.00,,Hospital 17003,HC Destruction Benign Lesion 2-14,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1231.00,N/A,738.60,N/A,172.34,N/A,47.98,N/A,708.81,N/A,418.54,N/A,109.52,N/A,172.34,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,708.81,N/A,272.21,N/A,172.34,N/A,50.75,N/A,50.75,N/A,172.34,N/A,272.21,N/A,288.47,N/A,131.02,N/A,N/A,45.28,738.60,,Hospital CPT 17110,HC Destruct B9 Lesion 1-14,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,436.00,436.00,261.60,261.60,N/A,61.04,N/A,172.81,N/A,251.05,N/A,148.24,N/A,394.46,N/A,61.04,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,251.05,N/A,163.07,N/A,61.04,N/A,436.00,N/A,436.00,N/A,61.04,N/A,163.07,N/A,172.81,N/A,67.87,261.60,261.60,61.04,436.00,,Hospital 17264,HC Destruction of Skin Lesions,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1096.00,N/A,657.60,N/A,153.44,N/A,472.68,N/A,631.08,N/A,372.64,N/A,N/A,N/A,153.44,N/A,446.04,N/A,446.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,631.08,N/A,446.04,N/A,153.44,N/A,587.46,N/A,587.46,N/A,153.44,N/A,446.04,N/A,472.68,N/A,134.98,N/A,N/A,134.98,657.60,,Hospital 17273,Destruction Malignant Lesion S/N/H/F/G 2.1-3.0cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24507.10,N/A,14704.26,N/A,3431.00,N/A,1382.32,N/A,14102.42,N/A,8332.41,N/A,3289.68,N/A,3431.00,N/A,1354.15,N/A,1354.15,N/A,2047.89,N/A,3289.68,N/A,3289.68,N/A,3289.68,N/A,14102.42,N/A,1354.15,N/A,3431.00,N/A,2718.25,N/A,2718.25,N/A,3431.00,N/A,1354.15,N/A,1382.32,N/A,1331.98,N/A,N/A,1331.98,14704.26,,Hospital CPT 19082,HC Bx Breast Add Lesion Strtctc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9519.00,9519.00,5711.40,5711.40,N/A,1332.66,N/A,9519.00,N/A,5481.04,N/A,3236.46,N/A,9519.00,N/A,1332.66,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,5481.04,N/A,9519.00,N/A,1332.66,N/A,527.00,N/A,527.00,N/A,1332.66,N/A,9519.00,N/A,9519.00,N/A,9519.00,5711.40,5711.40,527.00,9519.00,,Hospital CPT 19082,HC Bx Breast Add Lesion Strtctc,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,9519.00,9519.00,5711.40,5711.40,N/A,1332.66,N/A,9519.00,N/A,5481.04,N/A,3236.46,N/A,9519.00,N/A,1332.66,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,5481.04,N/A,9519.00,N/A,1332.66,N/A,5102.18,N/A,5102.18,N/A,1332.66,N/A,9519.00,N/A,9519.00,N/A,9519.00,5711.40,5711.40,1332.66,9519.00,,Hospital CPT 19083,HC Bx Breast 1st Lesion US Img,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9519.00,9519.00,5711.40,5711.40,N/A,1332.66,N/A,1354.15,N/A,5481.04,N/A,3236.46,N/A,3275.59,N/A,1332.66,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,5481.04,N/A,1354.15,N/A,1332.66,N/A,1871.00,N/A,1871.00,N/A,1332.66,N/A,1354.15,N/A,1354.15,N/A,1489.57,5711.40,5711.40,1332.66,5711.40,,Hospital 19086,HC Bx Breast Add Les MR Image,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,N/A,23291.20,N/A,13974.72,N/A,3260.77,N/A,2518.97,N/A,6144.71,N/A,7919.01,N/A,5937.63,N/A,3260.77,N/A,2411.56,N/A,2411.56,N/A,3696.29,N/A,5937.63,N/A,5937.63,N/A,5937.63,N/A,6144.71,N/A,2411.56,N/A,3260.77,N/A,2792.14,N/A,2792.14,N/A,3260.77,N/A,2411.56,N/A,2518.97,N/A,1390.61,N/A,N/A,1390.61,13974.72,,Hospital CPT 19100,HC Bx Breast Percut W/O Image,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4505.00,4505.00,2703.00,2703.00,N/A,630.70,N/A,67.26,N/A,2593.98,N/A,1531.70,N/A,419.22,N/A,630.70,N/A,67.26,N/A,67.26,N/A,260.96,N/A,419.22,N/A,419.22,N/A,419.22,N/A,2593.98,N/A,67.26,N/A,630.70,N/A,4505.00,N/A,4505.00,N/A,630.70,N/A,67.26,N/A,67.26,N/A,73.99,2703.00,2703.00,67.26,4505.00,,Hospital 19110,Nipple Exploration,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10073.60,N/A,6044.16,N/A,1460.82,N/A,3077.66,N/A,5798.71,N/A,3425.02,N/A,7528.14,N/A,1460.82,N/A,3104.47,N/A,3104.47,N/A,4686.42,N/A,7528.14,N/A,7528.14,N/A,7528.14,N/A,5746.89,N/A,3104.47,N/A,1460.82,N/A,3397.00,N/A,3397.00,N/A,1460.82,N/A,3104.47,N/A,3077.66,N/A,469.14,N/A,N/A,469.14,7528.14,,Hospital 19112,Excision Lactiferous Duct Fistula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14960.00,N/A,8976.00,N/A,2080.82,N/A,3108.40,N/A,8611.35,N/A,5086.40,N/A,7546.58,N/A,2080.82,N/A,3108.40,N/A,3108.40,N/A,4697.90,N/A,7546.58,N/A,7546.58,N/A,7546.58,N/A,8611.35,N/A,3108.40,N/A,2078.59,N/A,3397.00,N/A,3397.00,N/A,2080.82,N/A,3108.40,N/A,3108.40,N/A,3419.24,N/A,N/A,2078.59,8976.00,,Hospital CPT 19120,HC Excise Breast Cyst,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8286.00,8286.00,4971.60,4971.60,N/A,1160.04,N/A,398.56,N/A,4771.08,N/A,2817.24,N/A,1461.39,N/A,1160.04,N/A,398.56,N/A,398.56,N/A,909.72,N/A,1461.39,N/A,1461.39,N/A,1461.39,N/A,4771.08,N/A,398.56,N/A,1160.04,N/A,8286.00,N/A,8286.00,N/A,1160.04,N/A,398.56,N/A,398.56,N/A,438.42,4971.60,4971.60,398.56,8286.00,,Hospital CPT 19120,Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion,N/A,N/A,855.00,855.00,513.00,513.00,N/A,119.70,N/A,398.56,N/A,855.00,N/A,290.70,N/A,855.00,N/A,119.70,N/A,398.56,N/A,398.56,N/A,855.00,N/A,855.00,N/A,855.00,N/A,855.00,N/A,855.00,N/A,398.56,N/A,119.70,N/A,855.00,N/A,855.00,N/A,119.70,N/A,398.56,N/A,398.56,N/A,438.42,513.00,513.00,119.70,855.00,,Hospital 19126,Exc Brst Les Preop Plmt Rad Marker Opn Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14769.68,N/A,8861.81,N/A,2067.76,N/A,3424.60,N/A,8499.30,N/A,5021.69,N/A,7527.94,N/A,2067.76,N/A,3104.47,N/A,3104.47,N/A,4686.29,N/A,7527.94,N/A,7527.94,N/A,7527.94,N/A,8499.32,N/A,3104.47,N/A,2067.76,N/A,3660.50,N/A,3660.50,N/A,2067.76,N/A,3104.47,N/A,1053.45,N/A,1158.80,N/A,N/A,1053.45,8861.81,,Hospital 19283,HC Perq Dev Breast 1st Strtctc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,14699.02,N/A,8819.41,N/A,2057.86,N/A,1547.88,N/A,8080.37,N/A,4997.66,N/A,3740.65,N/A,2057.86,N/A,1511.71,N/A,1511.71,N/A,2328.62,N/A,3740.65,N/A,3740.65,N/A,3740.65,N/A,8080.37,N/A,1511.71,N/A,2057.86,N/A,1431.00,N/A,1431.00,N/A,2057.86,N/A,1511.71,N/A,1547.88,N/A,659.66,N/A,N/A,659.66,8819.41,,Hospital 19284,HC Perq Dev Breast Add Strtctc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,21547.63,N/A,12928.58,N/A,3016.67,N/A,1479.36,N/A,12461.76,N/A,7326.20,N/A,3508.12,N/A,3016.67,N/A,1432.93,N/A,1432.93,N/A,2183.87,N/A,3508.12,N/A,3508.12,N/A,3508.12,N/A,12461.76,N/A,1432.93,N/A,3016.67,N/A,1694.50,N/A,1694.50,N/A,3016.67,N/A,1432.93,N/A,1479.36,N/A,967.10,N/A,N/A,967.10,12928.58,,Hospital 19287,HC Perq Dev Breast 1st MR Guide,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,19419.17,N/A,11651.50,N/A,2718.68,N/A,2460.07,N/A,8019.31,N/A,6602.52,N/A,5875.34,N/A,2718.68,N/A,2411.56,N/A,2411.56,N/A,3657.51,N/A,5875.34,N/A,5875.34,N/A,5875.34,N/A,8019.31,N/A,2411.56,N/A,2718.68,N/A,1431.00,N/A,1431.00,N/A,2718.68,N/A,2411.56,N/A,2460.07,N/A,643.69,N/A,N/A,643.69,11651.50,,Hospital 19300,Mastectomy Gynecomastia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43050.68,N/A,25830.41,N/A,6027.12,N/A,5614.02,N/A,24784.85,N/A,14637.24,N/A,13084.63,N/A,6027.12,N/A,5366.90,N/A,5366.90,N/A,8152.68,N/A,13084.63,N/A,13084.63,N/A,13084.63,N/A,24784.86,N/A,5366.90,N/A,6027.12,N/A,5095.50,N/A,5095.50,N/A,6027.12,N/A,5366.90,N/A,5614.02,N/A,517.70,N/A,N/A,517.70,25830.41,,Hospital CPT 19301,Mastectomy Partial,N/A,N/A,1311.00,1311.00,786.60,786.60,N/A,183.54,N/A,635.93,N/A,1311.00,N/A,445.74,N/A,1311.00,N/A,183.54,N/A,635.93,N/A,635.93,N/A,1174.28,N/A,1311.00,N/A,1311.00,N/A,1311.00,N/A,1311.00,N/A,635.93,N/A,183.54,N/A,1311.00,N/A,1311.00,N/A,183.54,N/A,635.93,N/A,635.93,N/A,699.52,786.60,786.60,183.54,1311.00,,Hospital 19303,Mastectomy Simple Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,66555.10,40486.77,39933.06,24292.06,9261.97,5653.51,11251.72,5366.90,20872.60,23246.80,22628.73,13765.50,21072.26,14244.17,9547.35,5653.51,11222.07,5366.90,11222.07,5366.90,13116.99,8867.25,21072.26,14244.17,21072.26,14244.17,21072.26,14244.17,20872.60,23246.80,11222.07,5366.90,9547.35,5653.51,25070.73,7692.25,25070.73,7692.25,N/A,5653.51,5386.55,5366.90,11251.72,5366.90,10215.66,5903.59,5386.55,39933.06,5366.90,24292.06,,Hospital 19307,Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,73845.98,52036.00,44307.59,31221.60,7529.82,7279.77,9173.03,5614.02,16969.05,29958.04,25107.64,17692.22,17131.38,13097.84,7761.82,7279.77,9173.03,5366.90,9173.03,5366.90,10663.88,8158.59,17131.38,13097.84,17131.38,13097.84,17131.38,13097.84,16969.05,29958.08,9173.03,5366.90,7761.82,7279.77,20382.06,9093.25,20382.06,9093.25,N/A,7279.77,5453.33,5366.90,9173.03,5614.02,8305.15,4060.52,5453.33,44307.59,4060.52,31221.60,,Hospital 19316,Mastopexy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,65639.73,49518.77,39383.84,29711.26,11393.68,6932.62,11341.25,7911.25,22080.81,28318.11,22317.52,16836.37,22292.03,19325.94,11744.74,6932.62,255710.00,7951.94,255710.00,7951.94,13876.27,12030.72,22292.03,19325.94,22292.03,19325.94,22292.03,19325.94,22080.81,28318.09,11311.60,7951.94,11744.74,6932.62,26521.95,12986.00,26521.95,12986.00,N/A,6932.62,5366.90,7951.94,11341.25,7911.25,12566.87,3039.51,5366.90,255710.00,3039.51,29711.26,,Hospital 19357,Tissue Expander Placement Breast Reconstruction,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65249.77,N/A,39149.86,N/A,9134.96,N/A,15066.11,N/A,37299.55,N/A,22184.91,N/A,37950.67,N/A,9134.96,N/A,15066.11,N/A,15066.11,N/A,23625.00,N/A,37950.67,N/A,37950.67,N/A,37950.67,N/A,37299.56,N/A,15066.11,N/A,9134.96,N/A,12986.00,N/A,12986.00,N/A,9134.96,N/A,15066.11,N/A,15066.11,N/A,16572.72,N/A,N/A,9134.96,39149.86,,Hospital 19364,Breast Reconstruction W/Free Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55854.00,N/A,33512.40,N/A,7819.56,N/A,5614.02,N/A,32129.73,N/A,18990.36,N/A,26919.11,N/A,7819.56,N/A,5366.90,N/A,5366.90,N/A,16757.65,N/A,26919.11,N/A,26919.11,N/A,26919.11,N/A,32129.75,N/A,5366.90,N/A,7819.56,N/A,10085.00,N/A,10085.00,N/A,7819.56,N/A,5366.90,N/A,5614.02,N/A,3943.11,N/A,N/A,3943.11,33512.40,,Hospital CPT 19380,Revision of Reconstructed Breast,N/A,N/A,1538.00,1538.00,922.80,922.80,N/A,215.32,N/A,765.50,N/A,1538.00,N/A,522.92,N/A,1538.00,N/A,215.32,N/A,765.50,N/A,765.50,N/A,1425.82,N/A,1538.00,N/A,1538.00,N/A,1538.00,N/A,1538.00,N/A,765.50,N/A,215.32,N/A,1538.00,N/A,1538.00,N/A,215.32,N/A,765.50,N/A,765.50,N/A,842.05,922.80,922.80,215.32,1538.00,,Hospital 19499,Unlisted Procedure Breast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43988.25,N/A,26392.95,N/A,6152.61,N/A,24.31,N/A,25000.52,N/A,14956.01,N/A,7607.55,N/A,6152.61,N/A,3104.47,N/A,3104.47,N/A,4735.85,N/A,7607.55,N/A,7607.55,N/A,7607.55,N/A,25000.54,N/A,3104.47,N/A,6152.61,N/A,3397.00,N/A,3397.00,N/A,6152.61,N/A,3104.47,N/A,24.31,N/A,26.74,N/A,N/A,24.31,26392.95,,Hospital 20101,Exploration Penetrating Wound Spx Chest,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12540.10,N/A,7524.06,N/A,1755.61,N/A,1630.28,N/A,7219.80,N/A,4263.63,N/A,3784.37,N/A,1755.61,N/A,1558.52,N/A,1558.52,N/A,2355.84,N/A,3784.37,N/A,3784.37,N/A,3784.37,N/A,7219.80,N/A,1558.52,N/A,1755.61,N/A,1871.00,N/A,1871.00,N/A,1755.61,N/A,1558.52,N/A,1630.28,N/A,222.85,N/A,N/A,222.85,7524.06,,Hospital 20102,Expl Penetrating Wound Spx Abdomen/Flank/Back,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16779.10,N/A,10067.46,N/A,2318.33,N/A,1575.40,N/A,9659.37,N/A,5704.90,N/A,3790.84,N/A,2318.33,N/A,1558.52,N/A,1558.52,N/A,2359.86,N/A,3790.84,N/A,3790.84,N/A,3790.84,N/A,9659.41,N/A,1558.52,N/A,2318.33,N/A,1871.00,N/A,1871.00,N/A,2318.33,N/A,1558.52,N/A,1575.40,N/A,320.67,N/A,N/A,320.67,10067.46,,Hospital CPT 20103,HC Explore Wound Extremity,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3071.00,3071.00,1842.60,1842.60,N/A,429.94,N/A,329.51,N/A,1768.28,N/A,1044.14,N/A,1572.96,N/A,429.94,N/A,329.51,N/A,329.51,N/A,979.17,N/A,1572.96,N/A,1572.96,N/A,1572.96,N/A,1768.28,N/A,329.51,N/A,429.94,N/A,3071.00,N/A,3071.00,N/A,429.94,N/A,329.51,N/A,329.51,N/A,362.46,1842.60,1842.60,329.51,3071.00,,Hospital 20240,Biopsy Bone Open Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25151.05,N/A,15090.63,N/A,3476.01,N/A,2320.84,N/A,14358.63,N/A,8551.36,N/A,5682.02,N/A,3476.01,N/A,2332.78,N/A,2332.78,N/A,3537.17,N/A,5682.02,N/A,5682.02,N/A,5682.02,N/A,14358.63,N/A,2332.78,N/A,3476.01,N/A,5095.50,N/A,5095.50,N/A,3476.01,N/A,2332.78,N/A,2320.84,N/A,672.40,N/A,N/A,672.40,15090.63,,Hospital CPT 20561,HC Needle Insertion W/O Injection 3 or More Muscles,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,23.58,N/A,63.34,N/A,37.40,N/A,54.51,N/A,15.40,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,63.34,N/A,22.54,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,22.54,N/A,23.89,N/A,23.86,66.00,66.00,15.40,66.00,,Hospital CPT 20600,HC Injection Small Joint/Bursa,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1372.00,1372.00,823.20,823.20,N/A,192.08,N/A,245.53,N/A,790.00,N/A,466.48,N/A,593.92,N/A,192.08,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,790.00,N/A,245.53,N/A,192.08,N/A,527.00,N/A,527.00,N/A,192.08,N/A,245.53,N/A,245.53,N/A,270.08,823.20,823.20,192.08,823.20,,Hospital CPT 20600,HC Joint Bursa Inj Small Joint,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1372.00,1372.00,823.20,823.20,N/A,192.08,N/A,245.53,N/A,790.00,N/A,466.48,N/A,593.92,N/A,192.08,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,790.00,N/A,245.53,N/A,192.08,N/A,735.39,N/A,735.39,N/A,192.08,N/A,245.53,N/A,245.53,N/A,270.08,823.20,823.20,192.08,823.20,,Hospital 20604,HC Drain/Inj Joint/Bursa W/US,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,20853.90,19276.93,12512.34,11566.16,4350.38,2698.77,5441.98,455.63,20853.90,11096.59,7090.33,6554.16,7261.33,3962.37,4484.43,2698.77,562.00,1623.23,562.00,1623.23,4521.13,2466.66,7261.33,3962.37,7261.33,3962.37,7261.33,3962.37,20853.90,11096.60,5412.33,1623.23,4484.43,2698.77,20853.90,5227.25,20853.90,5227.25,N/A,2698.77,5412.33,1623.23,5412.33,455.63,4798.34,501.19,562.00,20853.90,455.63,11566.16,,Hospital CPT 20605,HC Arthrocts Asp and/or Inj Med,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1441.00,1441.00,864.60,864.60,N/A,201.74,N/A,245.53,N/A,829.73,N/A,489.94,N/A,593.92,N/A,201.74,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,829.73,N/A,245.53,N/A,201.74,N/A,527.00,N/A,527.00,N/A,201.74,N/A,245.53,N/A,245.53,N/A,270.08,864.60,864.60,201.74,864.60,,Hospital CPT 20605,HC Asp Inj Intermediate Joint,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1441.00,1441.00,864.60,864.60,N/A,201.74,N/A,245.53,N/A,829.73,N/A,489.94,N/A,593.92,N/A,201.74,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,829.73,N/A,245.53,N/A,201.74,N/A,1441.00,N/A,1441.00,N/A,201.74,N/A,245.53,N/A,245.53,N/A,270.08,864.60,864.60,201.74,1441.00,,Hospital CPT 20605,HC Joint Bursa Inj Med Arm,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1441.00,1441.00,864.60,864.60,N/A,201.74,N/A,245.53,N/A,829.73,N/A,489.94,N/A,593.92,N/A,201.74,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,829.73,N/A,245.53,N/A,201.74,N/A,772.38,N/A,772.38,N/A,201.74,N/A,245.53,N/A,245.53,N/A,270.08,864.60,864.60,201.74,864.60,,Hospital CPT 20610,HC Asp Injection Major Joint,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1590.00,1590.00,954.00,954.00,N/A,222.60,N/A,245.53,N/A,915.52,N/A,540.60,N/A,593.92,N/A,222.60,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,915.52,N/A,245.53,N/A,222.60,N/A,1590.00,N/A,1590.00,N/A,222.60,N/A,245.53,N/A,245.53,N/A,270.08,954.00,954.00,222.60,1590.00,,Hospital CPT 20610,HC Arthrocent/Aspiration Maj Jnt,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1590.00,1590.00,954.00,954.00,N/A,222.60,N/A,245.53,N/A,915.52,N/A,540.60,N/A,593.92,N/A,222.60,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,915.52,N/A,245.53,N/A,222.60,N/A,527.00,N/A,527.00,N/A,222.60,N/A,245.53,N/A,245.53,N/A,270.08,954.00,954.00,222.60,954.00,,Hospital CPT 20610,"HC Arthro, Asp, and/or Inj Major Jnt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1590.00,1590.00,954.00,954.00,N/A,222.60,N/A,245.53,N/A,915.52,N/A,540.60,N/A,593.92,N/A,222.60,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,915.52,N/A,245.53,N/A,222.60,N/A,527.00,N/A,527.00,N/A,222.60,N/A,245.53,N/A,245.53,N/A,270.08,954.00,954.00,222.60,954.00,,Hospital CPT 20610,HC Inj/Asp Maj Jnt or Bursa,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1590.00,1590.00,954.00,954.00,N/A,222.60,N/A,245.53,N/A,915.52,N/A,540.60,N/A,593.92,N/A,222.60,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,915.52,N/A,245.53,N/A,222.60,N/A,852.24,N/A,852.24,N/A,222.60,N/A,245.53,N/A,245.53,N/A,270.08,954.00,954.00,222.60,954.00,,Hospital CPT 20650,HC Insert and Remove Bone Pin,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,8804.00,8804.00,5282.40,5282.40,N/A,1232.56,N/A,152.99,N/A,5069.34,N/A,2993.36,N/A,632.82,N/A,1232.56,N/A,152.99,N/A,152.99,N/A,393.93,N/A,632.82,N/A,632.82,N/A,632.82,N/A,5069.34,N/A,152.99,N/A,1232.56,N/A,8804.00,N/A,8804.00,N/A,1232.56,N/A,152.99,N/A,152.99,N/A,168.29,5282.40,5282.40,152.99,8804.00,,Hospital CPT 20661,HC Application of Head Brace,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3364.00,3364.00,2018.40,2018.40,N/A,470.96,N/A,477.88,N/A,1936.99,N/A,1143.76,N/A,3133.28,N/A,470.96,N/A,477.88,N/A,477.88,N/A,1950.53,N/A,3133.28,N/A,3133.28,N/A,3133.28,N/A,1936.99,N/A,477.88,N/A,470.96,N/A,3364.00,N/A,3364.00,N/A,470.96,N/A,477.88,N/A,477.88,N/A,525.67,2018.40,2018.40,470.96,3364.00,,Hospital 20694,HC Removal External Fixation,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,48713.65,35335.48,29228.19,21201.29,12645.72,4946.97,15224.87,6472.55,30729.33,20149.41,16562.64,12014.06,28770.76,14467.79,13035.35,4946.97,1124.00,5973.28,1124.00,5973.28,17909.13,9006.48,28770.76,14467.79,28770.76,14467.79,28770.76,14467.79,30729.33,20149.43,15224.87,5973.28,13035.35,4946.97,34230.02,8832.50,34230.02,8832.50,N/A,4946.97,15224.87,5973.28,15224.87,6472.55,13947.83,1414.47,1124.00,34230.02,1414.47,21201.29,,Hospital 20702,Manual Prep&Insj Intramedullary Drug Dlvr Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38749.80,N/A,23249.88,N/A,5225.00,N/A,579.27,N/A,22132.99,N/A,13174.93,N/A,5677.88,N/A,5225.00,N/A,2332.78,N/A,2332.78,N/A,3534.58,N/A,5677.88,N/A,5677.88,N/A,5677.88,N/A,22133.00,N/A,2332.78,N/A,5225.00,N/A,3660.50,N/A,3660.50,N/A,5225.00,N/A,2332.78,N/A,579.27,N/A,637.20,N/A,N/A,579.27,23249.88,,Hospital 20704,Manual Prep&Insj I-Artic Drug Delivery Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,95300.22,45682.57,57180.13,27409.54,12576.90,6147.10,15143.47,2780.20,49784.09,26242.93,32402.07,15532.05,28614.19,6564.48,12964.42,6147.10,15143.47,2688.04,15143.47,2688.04,17811.67,4086.51,28614.19,6564.48,28614.19,6564.48,28614.19,6564.48,49784.09,26242.93,15143.47,2688.04,12964.42,6147.10,34043.74,5227.25,34043.74,5227.25,N/A,6147.10,15143.47,2688.04,15143.47,2780.20,13871.93,1218.43,12576.90,57180.13,1218.43,27409.54,,Hospital 20705,Removal Intra-Articular Drug Delivery Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24033.60,N/A,14420.16,N/A,3333.31,N/A,2440.19,N/A,13837.01,N/A,8171.41,N/A,5676.87,N/A,3333.31,N/A,2332.78,N/A,2332.78,N/A,3533.95,N/A,5676.87,N/A,5676.87,N/A,5676.87,N/A,13837.01,N/A,2332.78,N/A,3333.31,N/A,4244.25,N/A,4244.25,N/A,3333.31,N/A,2332.78,N/A,2440.19,N/A,804.28,N/A,N/A,804.28,14420.16,,Hospital 20910,Cartilage Graft Costochondral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52750.27,N/A,31650.16,N/A,7385.04,N/A,5043.96,N/A,30330.29,N/A,17935.10,N/A,11708.21,N/A,7385.04,N/A,4821.94,N/A,4821.94,N/A,7288.57,N/A,11708.21,N/A,11708.21,N/A,11708.21,N/A,30330.31,N/A,4821.94,N/A,7385.04,N/A,6226.50,N/A,6226.50,N/A,7385.04,N/A,4821.94,N/A,5043.96,N/A,2020.46,N/A,N/A,2020.46,31650.16,,Hospital 20922,Fascia Lata Graft Incision & Area Exposure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29507.38,N/A,17704.43,N/A,4131.03,N/A,2759.84,N/A,16884.87,N/A,10032.50,N/A,6563.80,N/A,4131.03,N/A,2688.04,N/A,2688.04,N/A,4086.09,N/A,6563.80,N/A,6563.80,N/A,6563.80,N/A,16884.87,N/A,2688.04,N/A,4131.03,N/A,8019.25,N/A,8019.25,N/A,4131.03,N/A,2688.04,N/A,2759.84,N/A,1446.14,N/A,N/A,1446.14,17704.43,,Hospital 20938,Autograft Spine Surgery Bicort/Tricort Sep Inc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,79638.22,N/A,47782.93,N/A,11149.36,N/A,2161.50,N/A,45403.32,N/A,27077.01,N/A,28687.28,N/A,11149.36,N/A,11782.94,N/A,11782.94,N/A,17858.39,N/A,28687.28,N/A,28687.28,N/A,28687.28,N/A,45403.35,N/A,11782.94,N/A,11149.36,N/A,10309.75,N/A,10309.75,N/A,11149.36,N/A,11782.94,N/A,2161.50,N/A,2377.66,N/A,N/A,2161.50,47782.93,,Hospital 20975,Electrical Stimulation Bone Healing Invasive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24655.83,N/A,14793.50,N/A,3451.82,N/A,6132.82,N/A,14163.30,N/A,8382.98,N/A,14495.40,N/A,3451.82,N/A,5973.28,N/A,5973.28,N/A,9023.67,N/A,14495.40,N/A,14495.40,N/A,14495.40,N/A,14163.30,N/A,5973.28,N/A,3451.82,N/A,8744.25,N/A,8744.25,N/A,3451.82,N/A,5973.28,N/A,6132.82,N/A,1053.61,N/A,N/A,1053.61,14793.50,,Hospital Custom 2100000000,HC Ccu R&B,N/A,0210 - CORONARY CARE - GENERAL CLASSIFICATION,3426.00,3426.00,2055.60,2055.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2055.60,2055.60,2055.60,2055.60,,Hospital 21013,Exc Tumor Soft Tiss Face&Scalp Subfascial <2cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16812.50,N/A,10087.50,N/A,2353.75,N/A,1416.50,N/A,9679.98,N/A,5716.25,N/A,3289.05,N/A,2353.75,N/A,1354.15,N/A,1354.15,N/A,2047.50,N/A,3289.05,N/A,3289.05,N/A,3289.05,N/A,9679.98,N/A,1354.15,N/A,2353.75,N/A,2146.50,N/A,2146.50,N/A,2353.75,N/A,1354.15,N/A,1416.50,N/A,943.45,N/A,N/A,943.45,10087.50,,Hospital 21025,Excision Bone Mandible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38314.30,N/A,22988.58,N/A,5364.01,N/A,4874.16,N/A,22058.69,N/A,13026.87,N/A,11697.23,N/A,5364.01,N/A,4821.94,N/A,4821.94,N/A,7281.75,N/A,11697.23,N/A,11697.23,N/A,11697.23,N/A,22058.69,N/A,4821.94,N/A,5364.01,N/A,5963.00,N/A,5963.00,N/A,5364.01,N/A,4821.94,N/A,4874.16,N/A,696.78,N/A,N/A,696.78,22988.58,,Hospital 21026,Excision Facial Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72531.67,N/A,43519.00,N/A,10154.43,N/A,4922.21,N/A,41757.27,N/A,24660.78,N/A,11708.72,N/A,10154.43,N/A,4821.94,N/A,4821.94,N/A,7291.23,N/A,11708.72,N/A,11708.72,N/A,11708.72,N/A,41757.29,N/A,4821.94,N/A,10154.43,N/A,5563.25,N/A,5563.25,N/A,10154.43,N/A,4821.94,N/A,4922.21,N/A,1360.04,N/A,N/A,1360.04,43519.00,,Hospital 21143,Rcnstj Midface Lefort I 3/> Piece W/O Bone Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80058.97,N/A,48035.38,N/A,11208.26,N/A,5319.17,N/A,45902.31,N/A,27187.18,N/A,11845.46,N/A,11208.26,N/A,4821.94,N/A,4821.94,N/A,7374.02,N/A,11845.46,N/A,11845.46,N/A,11845.46,N/A,45902.37,N/A,4821.94,N/A,11208.26,N/A,5963.00,N/A,5963.00,N/A,11208.26,N/A,4821.94,N/A,1362.46,N/A,1498.70,N/A,N/A,1362.46,48035.38,,Hospital 21145,Rcnstj Midface Lefort I 1 Piece W/Bone Grafts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,158154.58,N/A,94892.75,N/A,22086.41,N/A,9689.55,N/A,90468.70,N/A,53772.56,N/A,13587.29,N/A,22086.41,N/A,9688.13,N/A,9688.13,N/A,8457.37,N/A,13587.29,N/A,13587.29,N/A,13587.29,N/A,90468.72,N/A,9688.13,N/A,22086.41,N/A,6226.50,N/A,6226.50,N/A,22086.41,N/A,9688.13,N/A,9689.55,N/A,1790.43,N/A,N/A,1790.43,94892.75,,Hospital 21146,Rcnstj Midface Lefort I 2 Pieces W/Bone Grafts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,96973.13,N/A,58183.88,N/A,13558.79,N/A,1655.24,N/A,55568.76,N/A,32970.83,N/A,13389.98,N/A,13558.79,N/A,1650.41,N/A,1650.41,N/A,8335.28,N/A,13389.98,N/A,13389.98,N/A,13389.98,N/A,55568.80,N/A,1650.41,N/A,13558.79,N/A,5963.00,N/A,5963.00,N/A,13558.79,N/A,1650.41,N/A,1655.24,N/A,1720.74,N/A,N/A,1650.41,58183.88,,Hospital 21195,Rcnstj Mndblr Rami&/Body Sgtl Splt W/O Int Rgd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,89019.47,N/A,53411.68,N/A,12447.12,N/A,5319.17,N/A,51057.44,N/A,30266.60,N/A,11888.92,N/A,12447.12,N/A,4821.94,N/A,4821.94,N/A,7401.10,N/A,11888.92,N/A,11888.92,N/A,11888.92,N/A,49779.81,N/A,4821.94,N/A,12447.12,N/A,9076.25,N/A,9076.25,N/A,12447.12,N/A,4821.94,N/A,2720.40,N/A,2992.43,N/A,N/A,2720.40,53411.68,,Hospital 21206,Osteotomy Maxilla Segmental,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64447.72,N/A,38668.63,N/A,9022.68,N/A,4987.25,N/A,37069.08,N/A,21912.22,N/A,11732.35,N/A,9022.68,N/A,4821.94,N/A,4821.94,N/A,7303.62,N/A,11732.35,N/A,11732.35,N/A,11732.35,N/A,35697.50,N/A,4821.94,N/A,9022.68,N/A,8944.50,N/A,8944.50,N/A,9022.68,N/A,4821.94,N/A,4987.25,N/A,1093.17,N/A,N/A,1093.17,38668.63,,Hospital 21270,Malar Augmentation Prosthetic Material,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,199327.00,N/A,119596.20,N/A,27880.32,N/A,14483.72,N/A,113214.65,N/A,67771.14,N/A,23534.83,N/A,27880.32,N/A,14455.97,N/A,14455.97,N/A,14650.89,N/A,23534.83,N/A,23534.83,N/A,23534.83,N/A,113186.09,N/A,14455.97,N/A,27880.32,N/A,9076.25,N/A,9076.25,N/A,27880.32,N/A,14455.97,N/A,14483.72,N/A,2864.20,N/A,N/A,2864.20,119596.20,,Hospital 21299,Unlisted Craniofacial & Maxillofacial Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20985.93,N/A,12591.56,N/A,2965.59,N/A,62.14,N/A,12078.77,N/A,7130.11,N/A,489.07,N/A,2965.59,N/A,187.68,N/A,187.68,N/A,304.46,N/A,489.07,N/A,489.07,N/A,489.07,N/A,12078.78,N/A,187.68,N/A,2965.59,N/A,527.00,N/A,527.00,N/A,2965.59,N/A,187.68,N/A,62.14,N/A,68.35,N/A,N/A,62.14,12591.56,,Hospital CPT 21320,Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization,N/A,N/A,444.00,444.00,266.40,266.40,N/A,62.16,N/A,91.36,N/A,444.00,N/A,150.96,N/A,444.00,N/A,62.16,N/A,91.36,N/A,91.36,N/A,375.16,N/A,444.00,N/A,444.00,N/A,444.00,N/A,444.00,N/A,91.36,N/A,62.16,N/A,444.00,N/A,444.00,N/A,62.16,N/A,91.36,N/A,91.36,N/A,100.50,266.40,266.40,62.16,444.00,,Hospital 21325,Open Treatment Nasal Fracture Uncomplicated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 21336,Open Tx Nasal Septal Fracture W/WO Stabilization,N/A,N/A,1264.00,1264.00,758.40,758.40,N/A,176.96,N/A,607.24,N/A,1264.00,N/A,429.76,N/A,1264.00,N/A,176.96,N/A,607.24,N/A,607.24,N/A,1112.77,N/A,1264.00,N/A,1264.00,N/A,1264.00,N/A,1264.00,N/A,607.24,N/A,176.96,N/A,1264.00,N/A,1264.00,N/A,176.96,N/A,607.24,N/A,607.24,N/A,667.96,758.40,758.40,176.96,1264.00,,Hospital 21360,Open Tx Depressed Malar Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34775.67,N/A,20865.40,N/A,4868.57,N/A,5129.50,N/A,19930.58,N/A,11823.73,N/A,11732.79,N/A,4868.57,N/A,4821.94,N/A,4821.94,N/A,7303.89,N/A,11732.79,N/A,11732.79,N/A,11732.79,N/A,19930.58,N/A,4821.94,N/A,4868.57,N/A,3397.00,N/A,3397.00,N/A,4868.57,N/A,4821.94,N/A,5129.50,N/A,545.99,N/A,N/A,545.99,20865.40,,Hospital 21365,Open Tx Comp Fx Malar W/Internal Fx&Mult Surg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11568.50,N/A,6941.10,N/A,1619.60,N/A,5129.50,N/A,6656.90,N/A,3933.30,N/A,11568.50,N/A,1619.60,N/A,4821.94,N/A,4821.94,N/A,7282.60,N/A,11568.50,N/A,11568.50,N/A,11568.50,N/A,6656.91,N/A,4821.94,N/A,1619.60,N/A,5963.00,N/A,5963.00,N/A,1619.60,N/A,4821.94,N/A,5129.50,N/A,1138.70,N/A,N/A,1138.70,11568.50,,Hospital 21386,Open Tx Orbital Floor Blowout Fx Periorbital,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44558.40,N/A,26735.04,N/A,6238.17,N/A,4874.16,N/A,25482.17,N/A,15149.85,N/A,11755.07,N/A,6238.17,N/A,4821.94,N/A,4821.94,N/A,7317.76,N/A,11755.07,N/A,11755.07,N/A,11755.07,N/A,24761.28,N/A,4821.94,N/A,6238.17,N/A,5963.00,N/A,5963.00,N/A,6238.17,N/A,4821.94,N/A,4874.16,N/A,868.96,N/A,N/A,868.96,26735.04,,Hospital Custom 2140000000,HC Ccu Intermediate R&B,N/A,0214 - CORONARY CARE - INTERMEDIATE CCU,3047.00,3047.00,1828.20,1828.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1828.20,1828.20,1828.20,1828.20,,Hospital 21450,Closed Tx Mandibular Fracture W/O Manipulation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30558.42,N/A,18335.05,N/A,4278.18,N/A,416.99,N/A,17452.77,N/A,10389.86,N/A,1017.03,N/A,4278.18,N/A,412.53,N/A,412.53,N/A,633.12,N/A,1017.03,N/A,1017.03,N/A,1017.03,N/A,17452.77,N/A,412.53,N/A,4278.18,N/A,527.00,N/A,527.00,N/A,4278.18,N/A,412.53,N/A,416.99,N/A,497.63,N/A,N/A,412.53,18335.05,,Hospital 21451,HC Treatment Lower Jaw Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 21558,Rad Resect Tumor Soft Tiss Neck/Ant Thorax 5cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30434.30,N/A,18260.58,N/A,4152.40,N/A,2380.25,N/A,17497.69,N/A,10347.65,N/A,7882.52,N/A,4152.40,N/A,3104.47,N/A,3104.47,N/A,5145.13,N/A,7882.52,N/A,7882.52,N/A,7882.52,N/A,17497.71,N/A,3104.47,N/A,4152.40,N/A,5227.25,N/A,5227.25,N/A,4152.40,N/A,3104.47,N/A,2380.25,N/A,2618.29,N/A,N/A,2380.25,18260.58,,Hospital 21615,Excision 1st &/Cervical Rib,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67911.37,N/A,40746.82,N/A,9490.17,N/A,668.21,N/A,39101.97,N/A,23089.88,N/A,14881.66,N/A,9490.17,N/A,664.85,N/A,664.85,N/A,9263.89,N/A,14881.66,N/A,14881.66,N/A,14881.66,N/A,39101.97,N/A,664.85,N/A,9490.17,N/A,7897.00,N/A,7897.00,N/A,9490.17,N/A,664.85,N/A,668.21,N/A,717.64,N/A,N/A,664.85,40746.82,,Hospital 21700,Division Scalenus Anticus W/O Rescj Cervical Rib,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,40626.30,N/A,24375.78,N/A,9867.45,N/A,11611.58,N/A,22660.27,N/A,13812.94,N/A,23559.37,N/A,10171.48,N/A,11581.93,N/A,11581.93,N/A,14666.41,N/A,23559.37,N/A,23559.37,N/A,23559.37,N/A,22660.27,N/A,11581.93,N/A,10171.48,N/A,27217.96,N/A,27217.96,N/A,10375.42,N/A,11581.93,N/A,11611.58,N/A,10883.48,N/A,9867.45,27217.96,N/A,N/A,,Hospital CPT 21931,Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,N/A,N/A,943.00,943.00,565.80,565.80,N/A,132.02,N/A,450.47,N/A,943.00,N/A,320.62,N/A,943.00,N/A,132.02,N/A,450.47,N/A,450.47,N/A,834.53,N/A,943.00,N/A,943.00,N/A,943.00,N/A,943.00,N/A,450.47,N/A,132.02,N/A,943.00,N/A,943.00,N/A,132.02,N/A,450.47,N/A,450.47,N/A,495.52,565.80,565.80,132.02,943.00,,Hospital CPT 21933,Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,N/A,N/A,1483.00,1483.00,889.80,889.80,N/A,207.62,N/A,709.18,N/A,1483.00,N/A,504.22,N/A,1483.00,N/A,207.62,N/A,709.18,N/A,709.18,N/A,1312.70,N/A,1483.00,N/A,1483.00,N/A,1483.00,N/A,1483.00,N/A,709.18,N/A,207.62,N/A,1483.00,N/A,1483.00,N/A,207.62,N/A,709.18,N/A,709.18,N/A,780.10,889.80,889.80,207.62,1483.00,,Hospital 21935,Rad Resection Tumor Soft Tissue Back/Flank <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,69357.50,N/A,41614.50,N/A,9377.20,N/A,11358.38,N/A,27496.38,N/A,23581.55,N/A,21334.42,N/A,9666.12,N/A,562.00,N/A,562.00,N/A,13280.18,N/A,21334.42,N/A,21334.42,N/A,21334.42,N/A,27496.38,N/A,11358.38,N/A,9666.12,N/A,25382.63,N/A,25382.63,N/A,N/A,N/A,11358.38,N/A,11358.38,N/A,10342.75,N/A,562.00,41614.50,N/A,N/A,,Hospital 21936,Rad Resection Tumor Soft Tissue Back/Flank 5cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31361.22,N/A,18816.73,N/A,4286.98,N/A,3921.06,N/A,18034.05,N/A,10647.24,N/A,7858.03,N/A,4286.98,N/A,3104.47,N/A,3104.47,N/A,5129.87,N/A,7858.03,N/A,7858.03,N/A,7858.03,N/A,18034.07,N/A,3104.47,N/A,4286.98,N/A,7692.25,N/A,7692.25,N/A,4286.98,N/A,3104.47,N/A,3921.06,N/A,4313.18,N/A,N/A,3104.47,18816.73,,Hospital 22101,Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Thrc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22375.38,N/A,13425.23,N/A,3132.55,N/A,813.67,N/A,12871.12,N/A,7607.62,N/A,14528.69,N/A,3132.55,N/A,5973.28,N/A,5973.28,N/A,9044.39,N/A,14528.69,N/A,14528.69,N/A,14528.69,N/A,12871.14,N/A,5973.28,N/A,3132.55,N/A,7897.00,N/A,7897.00,N/A,3132.55,N/A,5973.28,N/A,813.67,N/A,895.04,N/A,N/A,813.67,14528.69,,Hospital 22103,Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42424.07,N/A,25454.44,N/A,5916.49,N/A,6248.31,N/A,24416.04,N/A,14424.20,N/A,14572.88,N/A,5916.49,N/A,5973.28,N/A,5973.28,N/A,9071.88,N/A,14572.88,N/A,14572.88,N/A,14572.88,N/A,23726.85,N/A,5973.28,N/A,5916.49,N/A,8292.25,N/A,8292.25,N/A,5916.49,N/A,5973.28,N/A,6248.31,N/A,1480.22,N/A,N/A,1480.22,25454.44,,Hospital 22214,Osteotomy Spine Pst/Pstlat Appr 1 Vrt Sgm Lmbr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,369404.73,N/A,221642.84,N/A,N/A,N/A,N/A,N/A,178995.23,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,178995.23,N/A,N/A,N/A,N/A,N/A,178995.23,N/A,178995.23,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,178995.23,221642.84,N/A,N/A,,Hospital 22510,HC Perq Cervicothoracic Inject,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,107268.95,20276.40,64361.37,12165.84,23271.14,2832.57,24973.51,6097.50,59126.65,11656.25,N/A,6893.98,N/A,14469.79,N/A,2832.57,24973.51,5973.28,24973.51,5973.28,N/A,9007.72,N/A,14469.79,N/A,14469.79,N/A,14469.79,N/A,11656.25,24973.51,5973.28,N/A,2832.57,N/A,4825.50,66140.98,4825.50,N/A,2832.57,24352.17,5973.28,24973.51,6097.50,N/A,1210.57,23271.14,66140.98,1210.57,14469.79,,Hospital 22511,HC Perq Lumbosacral Injection,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,76807.77,28983.22,46084.66,17389.93,10849.55,4057.66,13189.05,2848.60,26007.22,16682.37,26114.65,9854.30,24684.23,6533.42,11183.84,4057.66,142186.00,2688.04,142186.00,2688.04,15365.36,4067.17,24684.23,6533.42,24684.23,6533.42,24684.23,6533.42,26007.22,16682.38,13100.10,2688.04,11183.84,4057.66,29368.07,4562.00,29368.07,4562.00,11183.84,4057.66,13100.10,2688.04,13189.05,2848.60,11966.71,429.33,10849.55,142186.00,429.33,17389.93,,Hospital 22548,Arthrd Ant Transorl/Xtroral C1-C2 W/WO Exc Odntd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,70723.77,N/A,42434.26,N/A,9872.00,N/A,2420.25,N/A,40415.53,N/A,24046.09,N/A,48471.92,N/A,9872.00,N/A,2417.45,N/A,2417.45,N/A,30285.11,N/A,48471.92,N/A,48471.92,N/A,48471.92,N/A,40415.54,N/A,2432.95,N/A,9872.00,N/A,12055.25,N/A,12055.25,N/A,9872.00,N/A,2417.45,N/A,2420.25,N/A,2736.00,N/A,N/A,2417.45,48471.92,,Hospital 22554,Arthrd Ant Interbody Min Dsc Crv Below C2,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63266.68,N/A,37960.01,N/A,8846.39,N/A,12325.48,N/A,36326.09,N/A,21510.69,N/A,43096.90,N/A,8846.39,N/A,11782.94,N/A,11782.94,N/A,26828.66,N/A,43096.90,N/A,43096.90,N/A,43096.90,N/A,36326.12,N/A,11782.94,N/A,8846.39,N/A,13819.75,N/A,13819.75,N/A,8846.39,N/A,11782.94,N/A,12325.48,N/A,4088.16,N/A,N/A,4088.16,43096.90,,Hospital 22558,Arthrd Ant Interbody Min Dsc Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,113675.87,177930.57,68205.52,106758.34,20090.18,24910.27,17898.51,21577.10,62658.14,101110.23,38649.80,59277.76,45707.94,96358.44,20709.19,24910.27,17868.86,19924.27,17868.86,19924.27,28452.13,60181.00,45707.94,96358.44,45707.94,96358.44,45707.94,96358.44,62658.14,101110.29,17868.86,19947.52,20709.19,24910.27,54381.04,19464.25,54381.04,19464.25,N/A,24910.27,17868.86,19924.27,17898.51,21577.10,22158.84,6244.48,17868.86,68205.52,6244.48,106758.34,,Hospital 22614,Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,147330.72,138236.23,88398.43,82941.74,32492.64,19309.07,38702.76,2808.36,81208.69,78468.94,50092.44,47000.33,73925.25,49331.00,33493.80,19309.07,562.00,19924.58,562.00,19924.58,46016.75,30905.49,73925.25,49331.00,73925.25,49331.00,73925.25,49331.00,81208.69,78468.95,38702.76,19947.52,33493.80,19309.07,87952.60,11977.25,87952.60,11977.25,3674.65,19309.07,38702.76,19924.58,38702.76,2808.36,35838.36,3083.07,562.00,88398.43,2808.36,82941.74,,Hospital 22630,Arthrodesis Posterior Interbody 1 Ntrspc Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,154035.30,150009.50,92421.18,90005.70,14881.62,21003.91,17868.86,20602.22,84904.26,85746.32,52372.00,51003.26,45707.94,48473.28,15340.14,21003.91,562.00,19924.27,562.00,19924.27,28452.13,30371.56,45707.94,48473.28,45707.94,48473.28,45707.94,48473.28,84904.26,85746.31,17868.86,19947.52,15340.14,21003.91,54381.04,12055.25,54381.04,12055.25,15340.14,21003.91,17868.86,19924.27,17868.86,20602.22,16413.95,3076.26,562.00,92421.18,3076.26,90005.70,,Hospital 22830,Exploration Spinal Fusion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,172954.43,190027.58,103772.66,114016.55,25542.16,26524.03,30540.01,3929.84,95332.48,107540.89,58804.50,64609.37,58111.96,77026.89,26329.16,26524.03,162980.00,19924.58,162980.00,19924.58,36173.34,48146.73,58111.96,77026.89,58111.96,77026.89,58111.96,77026.89,95332.48,107540.92,30480.71,19947.52,26329.16,26524.03,69138.72,21726.00,69138.72,21726.00,26329.16,26524.03,19924.58,19924.58,30540.01,3929.84,28172.20,4322.84,19924.58,162980.00,3929.84,114016.55,,Hospital 22846,Anterior Instrumentation 4-7 Vertebral Segments,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,89042.33,114496.13,53425.40,68697.68,16382.62,15985.34,19645.44,12027.98,65707.60,65080.52,30274.39,38928.68,37272.73,29065.54,16887.40,15985.34,562.00,11782.94,562.00,11782.94,23201.41,18093.86,37272.73,29065.54,37272.73,29065.54,37272.73,29065.54,65707.60,65080.56,19645.44,11782.94,16887.40,15985.34,44345.24,13336.25,44345.24,13336.25,16887.40,15985.34,19645.44,11782.94,19645.44,12027.98,18069.51,3877.75,562.00,65707.60,3877.75,68697.68,,Hospital 22847,Anterior Instrumentation 8/> Vertebral Segments,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83348.33,N/A,50009.00,N/A,11668.74,N/A,12186.91,N/A,47680.79,N/A,28338.43,N/A,29010.13,N/A,11668.74,N/A,11782.94,N/A,11782.94,N/A,18059.36,N/A,29010.13,N/A,29010.13,N/A,29010.13,N/A,47680.78,N/A,11782.94,N/A,11668.74,N/A,13336.25,N/A,13336.25,N/A,11668.74,N/A,11782.94,N/A,12186.91,N/A,3159.70,N/A,N/A,3159.70,50009.00,,Hospital 22853,Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,104390.07,67133.20,62634.04,40279.92,13523.80,9372.31,16293.25,11782.94,66080.54,38457.80,35233.88,22825.26,29078.38,28590.87,13940.49,9372.31,80928.00,11782.94,80928.00,11782.94,18297.86,17798.36,29078.38,28590.87,29078.38,28590.87,29078.38,28590.87,66080.54,38457.79,16263.60,11782.94,13940.49,9372.31,36606.84,12019.00,36606.84,12019.00,13940.49,9372.31,16263.60,11782.94,16293.25,11782.94,14916.32,12961.23,13523.80,80928.00,9372.31,40279.92,,Hospital 22857,Total Disc Arthrp Ant Single Interspace Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,94734.10,N/A,56840.46,N/A,19885.86,N/A,23819.24,N/A,68298.57,N/A,32209.59,N/A,45243.09,N/A,20498.58,N/A,100598.00,N/A,100598.00,N/A,28162.77,N/A,45243.09,N/A,45243.09,N/A,45243.09,N/A,68298.57,N/A,23789.59,N/A,20498.58,N/A,53827.99,N/A,53827.99,N/A,533.18,N/A,23789.59,N/A,23819.24,N/A,21933.48,N/A,533.18,100598.00,N/A,N/A,,Hospital 22858,Total Disc Arthrp Ant 2nd Level Cervical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,153822.68,119528.98,92293.61,71717.39,19885.86,16732.79,21854.89,21963.37,84787.06,67822.91,52299.71,40533.95,43534.21,48433.47,20498.58,16732.79,21825.24,19924.27,21825.24,19924.27,27099.03,30346.77,43534.21,48433.47,43534.21,48433.47,43534.21,48433.47,84787.06,67822.95,21825.24,19947.52,20498.58,16732.79,51794.84,8160.50,51794.84,8160.50,4809.44,16732.79,21825.24,19924.27,21854.89,2265.21,21933.48,2491.73,4809.44,92293.61,2265.21,71717.39,,Hospital 22867,Insj Stablj Dev W/Dcmprn Lumbar Single Level,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80469.70,N/A,48281.82,N/A,11265.75,N/A,20452.39,N/A,45745.60,N/A,27359.67,N/A,47859.49,N/A,11265.75,N/A,19774.44,N/A,19774.44,N/A,29793.46,N/A,47859.49,N/A,47859.49,N/A,47859.49,N/A,45745.59,N/A,19774.44,N/A,11265.75,N/A,8160.50,N/A,8160.50,N/A,11265.75,N/A,19774.44,N/A,20452.39,N/A,1378.24,N/A,N/A,1378.24,48281.82,,Hospital 22868,Insj Stablj Dev W/Dcmprn Lumbar Second Level,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80469.70,N/A,48281.82,N/A,11265.75,N/A,20452.39,N/A,45745.60,N/A,27359.67,N/A,47859.49,N/A,11265.75,N/A,19774.44,N/A,19774.44,N/A,29793.46,N/A,47859.49,N/A,47859.49,N/A,47859.49,N/A,45745.59,N/A,19774.44,N/A,11265.75,N/A,8160.50,N/A,8160.50,N/A,11265.75,N/A,19774.44,N/A,20452.39,N/A,1378.24,N/A,N/A,1378.24,48281.82,,Hospital 22900,Exc Tumor Soft Tissue Abdl Wall Subfascial <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,69673.10,12771.40,41803.86,7662.84,7400.19,1787.99,9049.34,2312.63,16676.92,7351.19,23688.85,4342.27,16836.45,5671.33,7628.20,1787.99,95540.00,2332.78,95540.00,2332.78,10480.30,3530.51,16836.45,5671.33,16836.45,5671.33,16836.45,5671.33,16676.92,7325.30,9019.69,2332.78,7628.20,1787.99,20031.17,3397.00,20031.17,3397.00,N/A,1787.99,9019.69,2332.78,9049.34,2312.63,8162.17,629.25,7400.19,95540.00,629.25,7662.84,,Hospital CPT 23073,Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>,N/A,N/A,1391.00,1391.00,834.60,834.60,N/A,194.74,N/A,666.65,N/A,1391.00,N/A,472.94,N/A,1391.00,N/A,194.74,N/A,666.65,N/A,666.65,N/A,1237.87,N/A,1391.00,N/A,1391.00,N/A,1391.00,N/A,1391.00,N/A,666.65,N/A,194.74,N/A,1391.00,N/A,1391.00,N/A,194.74,N/A,666.65,N/A,666.65,N/A,733.32,834.60,834.60,194.74,1391.00,,Hospital 23101,Arthrt Acromclav/Strnclav Jt W/Bx&/Exc Crtlg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55640.08,N/A,33384.05,N/A,7732.08,N/A,12325.48,N/A,31918.18,N/A,18917.63,N/A,29011.04,N/A,7732.08,N/A,11782.94,N/A,11782.94,N/A,18059.92,N/A,29011.04,N/A,29011.04,N/A,29011.04,N/A,31918.18,N/A,11782.94,N/A,7732.08,N/A,14298.75,N/A,14298.75,N/A,7732.08,N/A,11782.94,N/A,12325.48,N/A,2126.79,N/A,N/A,2126.79,33384.05,,Hospital 23184,Partial Excision Bone Proximal Humerus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35916.97,N/A,21550.18,N/A,4863.38,N/A,918.48,N/A,20516.12,N/A,12211.77,N/A,14468.11,N/A,4863.38,N/A,5973.28,N/A,5973.28,N/A,9006.68,N/A,14468.11,N/A,14468.11,N/A,14468.11,N/A,20516.13,N/A,5973.28,N/A,4863.38,N/A,5409.25,N/A,5409.25,N/A,4863.38,N/A,5973.28,N/A,918.48,N/A,1010.34,N/A,N/A,918.48,21550.18,,Hospital 23200,Radical Resection Tumor Clavicle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,91678.98,N/A,55007.39,N/A,12810.68,N/A,4804.66,N/A,52777.03,N/A,31170.85,N/A,25904.19,N/A,12810.68,N/A,4706.78,N/A,4706.78,N/A,16125.87,N/A,25904.19,N/A,25904.19,N/A,25904.19,N/A,52707.38,N/A,4706.78,N/A,12810.68,N/A,11845.50,N/A,11845.50,N/A,12810.68,N/A,4706.78,N/A,4804.66,N/A,2965.12,N/A,N/A,2965.12,55007.39,,Hospital 23406,Tenotomy Shoulder Multiple Thru Same Incision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,92949.15,N/A,55769.49,N/A,13012.89,N/A,6178.06,N/A,11735.00,N/A,31602.69,N/A,15421.05,N/A,13012.89,N/A,5973.28,N/A,5973.28,N/A,9599.89,N/A,15421.05,N/A,15421.05,N/A,15421.05,N/A,11735.00,N/A,5973.28,N/A,13012.89,N/A,12986.00,N/A,12986.00,N/A,13012.89,N/A,5973.28,N/A,6178.06,N/A,2797.06,N/A,N/A,2797.06,55769.49,,Hospital 23420,Reconstruction Rotator Cuff Avulsion Chronic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62056.52,N/A,37233.91,N/A,8662.54,N/A,2378.76,N/A,11735.00,N/A,21099.22,N/A,14552.50,N/A,8662.54,N/A,5973.28,N/A,5973.28,N/A,9059.20,N/A,14552.50,N/A,14552.50,N/A,14552.50,N/A,11735.00,N/A,5973.28,N/A,8662.54,N/A,12369.25,N/A,12369.25,N/A,8662.54,N/A,5973.28,N/A,2378.76,N/A,2616.64,N/A,N/A,2378.76,37233.91,,Hospital 23460,Capsulorrhaphy Anterior With Bone Block,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,110375.70,N/A,66225.42,N/A,15452.59,N/A,8443.37,N/A,63184.13,N/A,37527.73,N/A,15427.70,N/A,15452.59,N/A,8417.77,N/A,8417.77,N/A,9604.03,N/A,15427.70,N/A,15427.70,N/A,15427.70,N/A,63184.13,N/A,8417.77,N/A,15452.59,N/A,7897.00,N/A,7897.00,N/A,15452.59,N/A,8417.77,N/A,8443.37,N/A,1145.12,N/A,N/A,1145.12,66225.42,,Hospital 23470,Arthroplasty Glenohumrl Jt Hemiarthroplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80366.60,N/A,48219.96,N/A,11192.77,N/A,12475.31,N/A,11735.00,N/A,27317.60,N/A,29597.27,N/A,11192.77,N/A,11932.77,N/A,11932.77,N/A,18624.67,N/A,29597.27,N/A,29597.27,N/A,29597.27,N/A,11735.00,N/A,11956.02,N/A,11192.77,N/A,15966.25,N/A,15966.25,N/A,11192.77,N/A,11932.77,N/A,12475.31,N/A,2549.72,N/A,N/A,2549.72,48219.96,,Hospital 23474,Revis Shoulder Arthrplsty Humeral&Glenoid Compnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,91937.00,N/A,55162.20,N/A,12613.77,N/A,2450.99,N/A,52257.09,N/A,31258.57,N/A,30415.69,N/A,12613.77,N/A,2450.99,N/A,2450.99,N/A,18934.35,N/A,30415.69,N/A,30415.69,N/A,30415.69,N/A,52257.11,N/A,2450.99,N/A,12613.77,N/A,8612.50,N/A,8612.50,N/A,12613.77,N/A,2450.99,N/A,2450.99,N/A,2676.86,N/A,N/A,2450.99,55162.20,,Hospital CPT 23500,HC Treat Clavicle Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,518.00,518.00,310.80,310.80,N/A,72.52,N/A,188.96,N/A,298.26,N/A,176.12,N/A,452.19,N/A,72.52,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,298.26,N/A,186.94,N/A,72.52,N/A,518.00,N/A,518.00,N/A,72.52,N/A,186.94,N/A,188.96,N/A,236.29,310.80,310.80,72.52,518.00,,Hospital CPT 23515,Open Tx Clavicular Fracture Internal Fixation,N/A,N/A,1432.00,1432.00,859.20,859.20,N/A,200.48,N/A,685.57,N/A,1432.00,N/A,486.88,N/A,1432.00,N/A,200.48,N/A,685.57,N/A,685.57,N/A,1279.14,N/A,1432.00,N/A,1432.00,N/A,1432.00,N/A,1432.00,N/A,685.57,N/A,200.48,N/A,1432.00,N/A,1432.00,N/A,200.48,N/A,685.57,N/A,685.57,N/A,754.13,859.20,859.20,200.48,1432.00,,Hospital 23545,HC Treat Clavicle Disloc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 23570,HC Treat Shoulder Blade Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,488.00,N/A,292.80,N/A,68.32,N/A,313.76,N/A,280.99,N/A,165.92,N/A,N/A,N/A,68.32,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,280.99,N/A,296.08,N/A,68.32,N/A,261.56,N/A,261.56,N/A,68.32,N/A,296.08,N/A,313.76,N/A,251.87,N/A,N/A,68.32,313.76,,Hospital 23585,Open Tx Scapular Fx W/Int Fixation When Pfrmd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58858.32,N/A,35314.99,N/A,8214.81,N/A,2690.38,N/A,33603.81,N/A,20011.82,N/A,14496.67,N/A,8214.81,N/A,5973.28,N/A,5973.28,N/A,9024.46,N/A,14496.67,N/A,14496.67,N/A,14496.67,N/A,33603.81,N/A,5973.28,N/A,8214.81,N/A,13336.25,N/A,13336.25,N/A,8214.81,N/A,5973.28,N/A,2690.38,N/A,2959.42,N/A,N/A,2690.38,35314.99,,Hospital 23616,Optx Prox Humrl Fx W/Int Fixj Rpr Tubrst Rplcmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51292.02,N/A,30775.21,N/A,7148.64,N/A,20684.94,N/A,29340.84,N/A,17439.29,N/A,47875.50,N/A,7148.64,N/A,19774.44,N/A,19774.44,N/A,29803.42,N/A,47875.50,N/A,47875.50,N/A,47875.50,N/A,29340.85,N/A,19774.44,N/A,7148.64,N/A,8612.50,N/A,8612.50,N/A,7148.64,N/A,19774.44,N/A,20684.94,N/A,1442.00,N/A,N/A,1442.00,47875.50,,Hospital 23630,Optx Greater Humeral Tuberosity Fx W/Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74555.82,N/A,44733.49,N/A,10437.81,N/A,6248.31,N/A,11735.00,N/A,25348.96,N/A,14630.70,N/A,10437.81,N/A,5973.28,N/A,5973.28,N/A,9107.88,N/A,14630.70,N/A,14630.70,N/A,14630.70,N/A,11735.00,N/A,5973.28,N/A,10437.81,N/A,13819.75,N/A,13819.75,N/A,10437.81,N/A,5973.28,N/A,6248.31,N/A,2967.96,N/A,N/A,2967.96,44733.49,,Hospital CPT 23675,HC Clsd Tx Shdr Disl W Neck Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4030.00,4030.00,2418.00,2418.00,N/A,564.20,N/A,477.70,N/A,2320.47,N/A,1370.20,N/A,1574.25,N/A,564.20,N/A,477.70,N/A,477.70,N/A,979.97,N/A,1574.25,N/A,1574.25,N/A,1574.25,N/A,2320.47,N/A,477.70,N/A,564.20,N/A,4030.00,N/A,4030.00,N/A,564.20,N/A,477.70,N/A,477.70,N/A,525.47,2418.00,2418.00,477.70,4030.00,,Hospital 23802,Arthrodesis Glenohumeral Jt W/Autogenous Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57709.23,N/A,34625.54,N/A,8079.29,N/A,12241.71,N/A,11735.00,N/A,19621.14,N/A,28563.50,N/A,8079.29,N/A,11782.94,N/A,11782.94,N/A,17781.34,N/A,28563.50,N/A,28563.50,N/A,28563.50,N/A,11735.00,N/A,11782.94,N/A,8079.29,N/A,10535.75,N/A,10535.75,N/A,8079.29,N/A,11782.94,N/A,12241.71,N/A,2004.10,N/A,N/A,2004.10,34625.54,,Hospital 23929,Unlisted Procedure Shoulder,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58989.40,N/A,35393.64,N/A,8258.51,N/A,2780.20,N/A,11735.00,N/A,20056.40,N/A,7638.29,N/A,8258.51,N/A,2688.04,N/A,2688.04,N/A,4754.98,N/A,7638.29,N/A,7638.29,N/A,7638.29,N/A,11735.00,N/A,2688.04,N/A,8258.51,N/A,8160.50,N/A,8160.50,N/A,8258.51,N/A,2688.04,N/A,2780.20,N/A,708.50,N/A,N/A,708.50,35393.64,,Hospital 24000,Arthrt Elbow W/Exploration Drainage/Removal FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11786.90,N/A,7072.14,N/A,1639.82,N/A,2674.29,N/A,6785.43,N/A,4007.54,N/A,6520.91,N/A,1639.82,N/A,2688.04,N/A,2688.04,N/A,4059.39,N/A,6520.91,N/A,6520.91,N/A,6520.91,N/A,6785.43,N/A,2688.04,N/A,1639.82,N/A,4562.00,N/A,4562.00,N/A,1639.82,N/A,2688.04,N/A,2674.29,N/A,524.01,N/A,N/A,524.01,7072.14,,Hospital CPT 24073,Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>,N/A,N/A,1387.00,1387.00,832.20,832.20,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,N/A,1387.00,832.20,832.20,832.20,1387.00,,Hospital CPT 24120,Exc/Curtg Bone Cyst/Benign Tumor H/N Rds/Olecrn,N/A,N/A,1047.00,1047.00,628.20,628.20,N/A,146.58,N/A,507.44,N/A,1047.00,N/A,355.98,N/A,1047.00,N/A,146.58,N/A,507.44,N/A,507.44,N/A,946.26,N/A,1047.00,N/A,1047.00,N/A,1047.00,N/A,1047.00,N/A,507.44,N/A,146.58,N/A,1047.00,N/A,1047.00,N/A,146.58,N/A,507.44,N/A,507.44,N/A,558.18,628.20,628.20,146.58,1047.00,,Hospital 24140,Partial Excision Bone Humerus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37604.47,N/A,22562.68,N/A,5258.95,N/A,2724.30,N/A,21474.16,N/A,12785.52,N/A,6548.79,N/A,5258.95,N/A,2688.04,N/A,2688.04,N/A,4076.74,N/A,6548.79,N/A,6548.79,N/A,6548.79,N/A,21474.18,N/A,2688.04,N/A,5258.95,N/A,7200.75,N/A,7200.75,N/A,5258.95,N/A,2688.04,N/A,1366.98,N/A,1503.69,N/A,N/A,1366.98,22562.68,,Hospital 24150,Radical Resection Tumor Shaft/Distal Humerus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,68423.30,N/A,41053.98,N/A,9377.20,N/A,9988.52,N/A,20172.92,N/A,11795.00,N/A,11795.00,N/A,9666.12,N/A,681144.00,N/A,681144.00,N/A,11795.00,N/A,11795.00,N/A,11795.00,N/A,11795.00,N/A,20172.92,N/A,9780.97,N/A,9666.12,N/A,24230.32,N/A,24230.32,N/A,N/A,N/A,9780.97,N/A,9988.52,N/A,10342.75,N/A,9377.20,681144.00,N/A,N/A,,Hospital 24300,Manipulation Elbow Under Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14405.40,N/A,8643.24,N/A,2016.75,N/A,1309.46,N/A,8293.27,N/A,4897.84,N/A,3155.63,N/A,2016.75,N/A,1295.43,N/A,1295.43,N/A,1964.43,N/A,3155.63,N/A,3155.63,N/A,3155.63,N/A,8293.27,N/A,1295.43,N/A,2016.75,N/A,2938.25,N/A,2938.25,N/A,2016.75,N/A,1295.43,N/A,1309.46,N/A,2340.14,N/A,N/A,1295.43,8643.24,,Hospital CPT 24342,Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf,N/A,N/A,1544.00,1544.00,926.40,926.40,N/A,216.16,N/A,739.92,N/A,1544.00,N/A,524.96,N/A,1544.00,N/A,216.16,N/A,739.92,N/A,739.92,N/A,1375.81,N/A,1544.00,N/A,1544.00,N/A,1544.00,N/A,1544.00,N/A,739.92,N/A,216.16,N/A,1544.00,N/A,1544.00,N/A,216.16,N/A,739.92,N/A,739.92,N/A,813.91,926.40,926.40,216.16,1544.00,,Hospital 24361,Arthroplasty Elbow W/Distal Humrl Prostc Rplcmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,89201.47,N/A,53520.88,N/A,12465.75,N/A,20834.77,N/A,51129.05,N/A,30328.51,N/A,48836.22,N/A,12465.75,N/A,19924.27,N/A,19924.27,N/A,30597.49,N/A,48836.22,N/A,48836.22,N/A,48836.22,N/A,50929.28,N/A,19947.52,N/A,12465.75,N/A,13716.25,N/A,13716.25,N/A,12465.75,N/A,19924.27,N/A,20834.77,N/A,2255.38,N/A,N/A,2255.38,53520.88,,Hospital 24366,Arthroplasty Radial Head W/Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,71626.02,49900.48,42975.61,29940.29,7332.44,6986.07,12475.31,12325.48,25642.41,28462.44,24352.85,16966.16,16682.31,28612.33,7558.36,6986.07,162418.00,11782.94,162418.00,11782.94,10384.35,17811.74,16682.31,28612.33,16682.31,28612.33,16682.31,28612.33,25642.41,28462.44,8217.00,11782.94,7558.36,6986.07,19847.78,15966.25,19847.78,15966.25,N/A,6986.07,8217.00,11782.94,8246.65,12325.48,8087.45,1470.48,7332.44,162418.00,1470.48,29940.29,,Hospital 24370,Revis Elbow Arthrplsty Humeral/Ulna Compnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,132877.98,N/A,79726.79,N/A,18541.38,N/A,11831.30,N/A,75275.95,N/A,45178.52,N/A,29110.47,N/A,18541.38,N/A,11933.08,N/A,11933.08,N/A,18317.82,N/A,29110.47,N/A,29110.47,N/A,29110.47,N/A,75275.97,N/A,11956.02,N/A,18541.38,N/A,13716.25,N/A,13716.25,N/A,18541.38,N/A,11933.08,N/A,11831.30,N/A,2615.92,N/A,N/A,2615.92,79726.79,,Hospital 24516,Tx Humral Shaft Fx W/Insj Imed Implt W/W Cerclge,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,55622.63,80381.95,33373.58,48229.17,12673.99,11212.52,15287.97,1017.91,39493.98,45595.59,18911.69,27329.86,28835.08,28525.31,13064.50,11212.52,119706.00,11782.94,119706.00,11782.94,17949.17,17757.56,28835.08,28525.31,28835.08,28525.31,28835.08,28525.31,39493.98,45595.60,15258.32,11782.94,13064.50,11212.52,34306.55,8612.50,34306.55,8612.50,N/A,11212.52,11864.95,11782.94,15287.97,1017.91,13979.01,1010.57,11864.95,119706.00,1010.57,48229.17,,Hospital CPT 24620,HC Cl Tx Montegg Fx Disl Elbow,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4030.00,4030.00,2418.00,2418.00,N/A,564.20,N/A,537.92,N/A,2320.47,N/A,1370.20,N/A,1676.97,N/A,564.20,N/A,537.92,N/A,537.92,N/A,1043.91,N/A,1676.97,N/A,1676.97,N/A,1676.97,N/A,2320.47,N/A,537.92,N/A,564.20,N/A,4030.00,N/A,4030.00,N/A,564.20,N/A,537.92,N/A,537.92,N/A,591.71,2418.00,2418.00,537.92,4030.00,,Hospital CPT 24640,HC ED Clsd Tx Rad Hd Sublux Child,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1594.00,1594.00,956.40,956.40,N/A,223.16,N/A,77.11,N/A,917.83,N/A,541.96,N/A,293.91,N/A,223.16,N/A,77.11,N/A,77.11,N/A,182.96,N/A,293.91,N/A,293.91,N/A,293.91,N/A,917.83,N/A,77.11,N/A,223.16,N/A,1594.00,N/A,1594.00,N/A,223.16,N/A,77.11,N/A,77.11,N/A,84.82,956.40,956.40,77.11,1594.00,,Hospital 24666,Open Tx Radial Head/Neck Fracture Prosthetic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67882.80,N/A,40729.68,N/A,9503.59,N/A,721.82,N/A,38557.87,N/A,23080.15,N/A,28558.46,N/A,9503.59,N/A,11782.94,N/A,11782.94,N/A,17778.19,N/A,28558.46,N/A,28558.46,N/A,28558.46,N/A,38557.89,N/A,11782.94,N/A,9503.59,N/A,7897.00,N/A,7897.00,N/A,9503.59,N/A,11782.94,N/A,721.82,N/A,794.01,N/A,N/A,721.82,40729.68,,Hospital 25001,Incision Flexor Tendon Sheath Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24286.20,N/A,14571.72,N/A,3400.91,N/A,2743.94,N/A,13975.74,N/A,8257.31,N/A,6519.88,N/A,3400.91,N/A,2688.04,N/A,2688.04,N/A,4058.75,N/A,6519.88,N/A,6519.88,N/A,6519.88,N/A,13975.74,N/A,2688.04,N/A,3400.91,N/A,3397.00,N/A,3397.00,N/A,3400.91,N/A,2688.04,N/A,2743.94,N/A,365.41,N/A,N/A,365.41,14571.72,,Hospital 25020,Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,73746.73,N/A,44248.04,N/A,10352.37,N/A,2859.50,N/A,42298.53,N/A,25073.87,N/A,6587.72,N/A,10352.37,N/A,2688.04,N/A,2688.04,N/A,4100.96,N/A,6587.72,N/A,6587.72,N/A,6587.72,N/A,41929.45,N/A,2688.04,N/A,10352.37,N/A,7692.25,N/A,7692.25,N/A,10352.37,N/A,2688.04,N/A,2859.50,N/A,2678.50,N/A,N/A,2678.50,44248.04,,Hospital 25031,Incision & Drainage Forearm&/Wrist Bursa,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37873.50,N/A,22724.10,N/A,5160.92,N/A,1322.37,N/A,21777.82,N/A,12877.00,N/A,3259.58,N/A,5160.92,N/A,1295.43,N/A,1295.43,N/A,2029.14,N/A,3259.58,N/A,3259.58,N/A,3259.58,N/A,21777.81,N/A,1295.43,N/A,5160.92,N/A,4112.50,N/A,4112.50,N/A,5160.92,N/A,1295.43,N/A,1322.37,N/A,817.68,N/A,N/A,817.68,22724.10,,Hospital 25035,Incision Deep Bone Cortex Forearm&/Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29972.50,N/A,17983.50,N/A,4092.17,N/A,6248.31,N/A,17198.60,N/A,10190.65,N/A,14489.97,N/A,4092.17,N/A,5973.28,N/A,5973.28,N/A,9020.29,N/A,14489.97,N/A,14489.97,N/A,14489.97,N/A,17198.60,N/A,5973.28,N/A,4092.17,N/A,3397.00,N/A,3397.00,N/A,4092.17,N/A,5973.28,N/A,6248.31,N/A,778.80,N/A,N/A,778.80,17983.50,,Hospital 25105,Arthrotomy Wrist Joint With Synovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27716.40,N/A,16629.84,N/A,3880.32,N/A,2811.81,N/A,15955.50,N/A,9423.58,N/A,6559.66,N/A,3880.32,N/A,2688.04,N/A,2688.04,N/A,4083.51,N/A,6559.66,N/A,6559.66,N/A,6559.66,N/A,15955.52,N/A,2688.04,N/A,3880.32,N/A,5965.25,N/A,5965.25,N/A,3880.32,N/A,2688.04,N/A,2811.81,N/A,1440.29,N/A,N/A,1440.29,16629.84,,Hospital CPT 25111,Excision Ganglion Wrist Dorsal/Volar Primary,N/A,N/A,629.00,629.00,377.40,377.40,N/A,88.06,N/A,306.15,N/A,629.00,N/A,213.86,N/A,629.00,N/A,88.06,N/A,306.15,N/A,306.15,N/A,574.65,N/A,629.00,N/A,629.00,N/A,629.00,N/A,629.00,N/A,306.15,N/A,88.06,N/A,629.00,N/A,629.00,N/A,88.06,N/A,306.15,N/A,306.15,N/A,336.77,377.40,377.40,88.06,629.00,,Hospital 25125,Exc/Curtg Cyst/Tumor Radius/Ulna W/Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30380.20,N/A,18228.12,N/A,4253.23,N/A,1355.08,N/A,17489.04,N/A,10329.27,N/A,3208.76,N/A,4253.23,N/A,1295.43,N/A,1295.43,N/A,1997.52,N/A,3208.76,N/A,3208.76,N/A,3208.76,N/A,17489.04,N/A,1295.43,N/A,4253.23,N/A,4112.50,N/A,4112.50,N/A,4253.23,N/A,1295.43,N/A,1355.08,N/A,743.89,N/A,N/A,743.89,18228.12,,Hospital 25135,Exc/Curtg Cyst/Tumor Carpal Bones W/Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33748.43,N/A,20249.06,N/A,4724.66,N/A,6334.00,N/A,19318.19,N/A,11474.47,N/A,14503.00,N/A,4724.66,N/A,5973.28,N/A,5973.28,N/A,9032.27,N/A,14503.00,N/A,14503.00,N/A,14503.00,N/A,19318.21,N/A,5973.28,N/A,4724.66,N/A,9093.25,N/A,9093.25,N/A,4724.66,N/A,5977.21,N/A,6334.00,N/A,1898.00,N/A,N/A,1898.00,20249.06,,Hospital 25240,Excision Distal Ulna Partial/Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18041.60,N/A,10824.96,N/A,2527.56,N/A,2759.84,N/A,10385.08,N/A,6134.14,N/A,6545.73,N/A,2527.56,N/A,2688.04,N/A,2688.04,N/A,4074.84,N/A,6545.73,N/A,6545.73,N/A,6545.73,N/A,10385.08,N/A,2688.04,N/A,2527.56,N/A,6618.25,N/A,6618.25,N/A,2527.56,N/A,2688.04,N/A,2759.84,N/A,1012.91,N/A,N/A,1012.91,10824.96,,Hospital 25259,Manipulation Wrist Under Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39128.92,N/A,23477.35,N/A,5479.88,N/A,1381.99,N/A,22526.59,N/A,13303.83,N/A,3168.83,N/A,5479.88,N/A,1299.36,N/A,1299.36,N/A,1972.64,N/A,3168.83,N/A,3168.83,N/A,3168.83,N/A,22526.59,N/A,1299.36,N/A,5479.88,N/A,2718.25,N/A,2718.25,N/A,5479.88,N/A,1299.36,N/A,1381.99,N/A,2359.16,N/A,N/A,1299.36,23477.35,,Hospital CPT 25260,HC Repair Forearm Tendon/Muscle,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7967.00,7967.00,4780.20,4780.20,N/A,1115.38,N/A,602.93,N/A,4587.40,N/A,2708.78,N/A,1810.89,N/A,1115.38,N/A,602.93,N/A,602.93,N/A,1127.28,N/A,1810.89,N/A,1810.89,N/A,1810.89,N/A,4587.40,N/A,602.93,N/A,1115.38,N/A,7967.00,N/A,7967.00,N/A,1115.38,N/A,602.93,N/A,602.93,N/A,663.22,4780.20,4780.20,602.93,7967.00,,Hospital 25275,Rpr Tendon Sheath Extensor F/Arm&/Wrist W/Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33492.48,N/A,20095.49,N/A,4688.95,N/A,1203.98,N/A,19155.44,N/A,11387.44,N/A,6562.04,N/A,4688.95,N/A,2688.04,N/A,2688.04,N/A,4085.00,N/A,6562.04,N/A,6562.04,N/A,6562.04,N/A,19155.45,N/A,2688.04,N/A,4688.95,N/A,6974.75,N/A,6974.75,N/A,4688.95,N/A,2688.04,N/A,1203.98,N/A,1324.38,N/A,N/A,1203.98,20095.49,,Hospital 25290,Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,66550.53,N/A,39930.32,N/A,9317.07,N/A,6354.28,N/A,38190.37,N/A,22627.18,N/A,14570.07,N/A,9317.07,N/A,5973.28,N/A,5973.28,N/A,9070.14,N/A,14570.07,N/A,14570.07,N/A,14570.07,N/A,38190.37,N/A,5973.28,N/A,9317.07,N/A,10535.75,N/A,10535.75,N/A,9317.07,N/A,5973.28,N/A,6354.28,N/A,2192.28,N/A,N/A,2192.28,39930.32,,Hospital 25300,Tenodesis Wrist Flexors Fingers,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29319.88,N/A,17591.93,N/A,4104.78,N/A,5531.37,N/A,16706.32,N/A,9968.77,N/A,13557.79,N/A,4104.78,N/A,5579.57,N/A,5579.57,N/A,8439.98,N/A,13557.79,N/A,13557.79,N/A,13557.79,N/A,16706.32,N/A,5579.57,N/A,4104.78,N/A,8244.00,N/A,8244.00,N/A,4104.78,N/A,5579.57,N/A,5531.37,N/A,1779.09,N/A,N/A,1779.09,17591.93,,Hospital CPT 25310,Tdn Trnsplj/Tr Flxr/Xtnsr F/Arm&/Wrst 1 Ea Tdn,N/A,N/A,1226.00,1226.00,735.60,735.60,N/A,171.64,N/A,589.92,N/A,1226.00,N/A,416.84,N/A,1226.00,N/A,171.64,N/A,589.92,N/A,589.92,N/A,1103.86,N/A,1226.00,N/A,1226.00,N/A,1226.00,N/A,1226.00,N/A,589.92,N/A,171.64,N/A,1226.00,N/A,1226.00,N/A,171.64,N/A,589.92,N/A,589.92,N/A,648.91,735.60,735.60,171.64,1226.00,,Hospital 25332,Arthrp Wrst W/WO Interpos W/WO Xtrnl/Int Fixj,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,43816.00,N/A,26289.60,N/A,6138.56,N/A,2863.43,N/A,25223.37,N/A,14897.44,N/A,6546.18,N/A,6138.56,N/A,2691.97,N/A,2691.97,N/A,4075.12,N/A,6546.18,N/A,6546.18,N/A,6546.18,N/A,25223.37,N/A,2691.97,N/A,6138.56,N/A,4112.50,N/A,4112.50,N/A,6138.56,N/A,2691.97,N/A,2863.43,N/A,6787.00,N/A,N/A,2691.97,26289.60,,Hospital 25337,Rcnstj Stablj Dstl U/Dstl Jt 2 Soft Tiss Stablj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20587.10,N/A,12352.26,N/A,2882.19,N/A,5921.68,N/A,11776.73,N/A,6999.62,N/A,14470.29,N/A,2882.19,N/A,5973.28,N/A,5973.28,N/A,9008.03,N/A,14470.29,N/A,14470.29,N/A,14470.29,N/A,11776.73,N/A,5973.28,N/A,2882.19,N/A,7661.50,N/A,7661.50,N/A,2882.19,N/A,5973.28,N/A,5921.68,N/A,1379.13,N/A,N/A,1379.13,14470.29,,Hospital 25355,Osteotomy Radius Middle/Proximal Third,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47168.62,N/A,28301.17,N/A,6594.75,N/A,2811.81,N/A,27126.45,N/A,16037.33,N/A,6616.69,N/A,6594.75,N/A,2688.04,N/A,2688.04,N/A,4119.01,N/A,6616.69,N/A,6616.69,N/A,6616.69,N/A,27126.45,N/A,2688.04,N/A,6594.75,N/A,6678.50,N/A,6678.50,N/A,6594.75,N/A,2688.04,N/A,2811.81,N/A,906.07,N/A,N/A,906.07,28301.17,,Hospital 25390,Osteoplasty Radius/Ulna Shortening,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24364.65,N/A,14618.79,N/A,3402.19,N/A,6248.31,N/A,13988.37,N/A,8283.99,N/A,14472.35,N/A,3402.19,N/A,5973.28,N/A,5973.28,N/A,9009.31,N/A,14472.35,N/A,14472.35,N/A,14472.35,N/A,13988.37,N/A,5973.28,N/A,3402.19,N/A,5963.00,N/A,5963.00,N/A,3402.19,N/A,5973.28,N/A,6248.31,N/A,835.81,N/A,N/A,835.81,14618.79,,Hospital 25400,Rpr Nonunion/Malunion Radius/Ulna W/O Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46387.58,N/A,27832.55,N/A,6494.26,N/A,6248.31,N/A,26578.44,N/A,15771.77,N/A,14504.47,N/A,6494.26,N/A,5973.28,N/A,5973.28,N/A,9029.30,N/A,14504.47,N/A,14504.47,N/A,14504.47,N/A,26578.45,N/A,5973.28,N/A,6494.26,N/A,5963.00,N/A,5963.00,N/A,6494.26,N/A,5973.28,N/A,6248.31,N/A,867.52,N/A,N/A,867.52,27832.55,,Hospital 25446,Arthrp W/Prostc Rplcmt Dstl Rds&Prtl/Carpus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,99858.93,N/A,59915.36,N/A,13980.25,N/A,19753.77,N/A,56709.47,N/A,33952.04,N/A,48523.98,N/A,13980.25,N/A,19924.58,N/A,19924.58,N/A,30403.13,N/A,48523.98,N/A,48523.98,N/A,48523.98,N/A,53825.84,N/A,19947.52,N/A,13980.25,N/A,11660.00,N/A,11660.00,N/A,13980.25,N/A,19924.58,N/A,19753.77,N/A,1532.69,N/A,N/A,1532.69,59915.36,,Hospital CPT 25447,Arthrp Interpos Intercarpal/Metacarpal Joints,N/A,N/A,1644.00,1644.00,986.40,986.40,N/A,230.16,N/A,789.70,N/A,1644.00,N/A,558.96,N/A,1644.00,N/A,230.16,N/A,789.70,N/A,789.70,N/A,1475.29,N/A,1644.00,N/A,1644.00,N/A,1644.00,N/A,1644.00,N/A,789.70,N/A,230.16,N/A,1644.00,N/A,1644.00,N/A,230.16,N/A,789.70,N/A,789.70,N/A,868.67,986.40,986.40,230.16,1644.00,,Hospital CPT 25515,Open Treatment Radial Shaft Fracture,N/A,N/A,1326.00,1326.00,795.60,795.60,N/A,185.64,N/A,637.35,N/A,1326.00,N/A,450.84,N/A,1326.00,N/A,185.64,N/A,637.35,N/A,637.35,N/A,1189.17,N/A,1326.00,N/A,1326.00,N/A,1326.00,N/A,1326.00,N/A,637.35,N/A,185.64,N/A,1326.00,N/A,1326.00,N/A,185.64,N/A,637.35,N/A,637.35,N/A,701.09,795.60,795.60,185.64,1326.00,,Hospital 25545,Open Treatment of Ulnar Shaft Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38216.95,N/A,22930.17,N/A,5350.37,N/A,5973.28,N/A,21882.44,N/A,12993.75,N/A,14481.24,N/A,5350.37,N/A,5973.28,N/A,5973.28,N/A,9014.85,N/A,14481.24,N/A,14481.24,N/A,14481.24,N/A,21882.45,N/A,5973.28,N/A,5350.37,N/A,8612.50,N/A,8612.50,N/A,5350.37,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,5350.37,22930.17,,Hospital 25652,Open Treatment Ulnar Styloid Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50572.52,N/A,30343.51,N/A,7080.17,N/A,5921.68,N/A,28877.61,N/A,17194.67,N/A,14540.39,N/A,7080.17,N/A,5973.28,N/A,5973.28,N/A,9051.68,N/A,14540.39,N/A,14540.39,N/A,14540.39,N/A,28877.61,N/A,5973.28,N/A,7080.17,N/A,13819.75,N/A,13819.75,N/A,7080.17,N/A,5973.28,N/A,5921.68,N/A,2506.27,N/A,N/A,2506.27,30343.51,,Hospital 25676,Open Tx Distal Radioulnar Dislc Acute/Chronic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52378.32,N/A,31426.99,N/A,7317.63,N/A,1634.58,N/A,29870.37,N/A,17808.63,N/A,14495.58,N/A,7317.63,N/A,5973.28,N/A,5973.28,N/A,9023.79,N/A,14495.58,N/A,14495.58,N/A,14495.58,N/A,29870.37,N/A,5973.28,N/A,7317.63,N/A,7692.25,N/A,7692.25,N/A,7317.63,N/A,5973.28,N/A,1634.58,N/A,1798.04,N/A,N/A,1634.58,31426.99,,Hospital CPT 25690,HC Closed Red Dislocated Lunate,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3384.00,3384.00,2030.40,2030.40,N/A,473.76,N/A,467.49,N/A,1948.51,N/A,1150.56,N/A,1403.88,N/A,473.76,N/A,467.49,N/A,467.49,N/A,873.92,N/A,1403.88,N/A,1403.88,N/A,1403.88,N/A,1948.51,N/A,467.49,N/A,473.76,N/A,3384.00,N/A,3384.00,N/A,473.76,N/A,467.49,N/A,467.49,N/A,514.24,2030.40,2030.40,467.49,3384.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS,00338-0017-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 250 MG/ML IV SOLN,00409-1775-10,0258 - PHARMACY - IV SOLUTIONS,40.70,40.70,24.42,24.42,N/A,N/A,N/A,40.70,N/A,23.44,N/A,13.84,N/A,5.70,N/A,5.70,N/A,40.70,N/A,40.70,N/A,3.54,N/A,5.70,N/A,5.70,N/A,5.70,N/A,23.44,N/A,40.70,N/A,5.70,N/A,21.82,N/A,21.82,N/A,N/A,N/A,40.70,N/A,40.70,N/A,N/A,24.42,24.42,3.54,40.70,,Hospital HCPCS 2580000003,STERILE WATER FOR IRRIGATION IR SOLN,00338-0004-02,0258 - PHARMACY - IV SOLUTIONS,57.40,57.40,34.44,34.44,N/A,N/A,N/A,57.40,N/A,33.05,N/A,19.52,N/A,8.04,N/A,8.04,N/A,57.40,N/A,57.40,N/A,4.99,N/A,8.04,N/A,8.04,N/A,8.04,N/A,33.05,N/A,57.40,N/A,8.04,N/A,30.77,N/A,30.77,N/A,N/A,N/A,57.40,N/A,57.40,N/A,N/A,34.44,34.44,4.99,57.40,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-41,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML,00338-0049-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,00338-0089-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-10,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,15.00,N/A,N/A,2.10,15.00,,Hospital HCPCS 2580000003,DELFLEX-LC/1.5% DEXTROSE 344 MOSM/L IP SOLN,49230-0206-20,0250 - PHARMACY - GENERAL CLASSIFICATION,40.50,40.50,N/A,N/A,N/A,5.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.67,N/A,N/A,N/A,N/A,N/A,40.50,N/A,N/A,5.67,40.50,,Hospital HCPCS 2580000003,DELFLEX-LC/2.5% DEXTROSE 394 MOSM/L IP SOLN,49230-0209-50,0250 - PHARMACY - GENERAL CLASSIFICATION,67.50,67.50,N/A,N/A,N/A,9.45,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9.45,N/A,N/A,N/A,N/A,N/A,67.50,N/A,N/A,9.45,67.50,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-20,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,15.00,N/A,N/A,2.10,15.00,,Hospital HCPCS 2580000003,DELFLEX-LC/1.5% DEXTROSE 344 MOSM/L IP SOLN,49230-0206-50,0258 - PHARMACY - IV SOLUTIONS,40.50,40.50,24.30,24.30,N/A,N/A,N/A,40.50,N/A,23.32,N/A,13.77,N/A,5.67,N/A,5.67,N/A,40.50,N/A,40.50,N/A,3.52,N/A,5.67,N/A,5.67,N/A,5.67,N/A,23.32,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,N/A,N/A,40.50,N/A,40.50,N/A,N/A,24.30,24.30,3.52,40.50,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),00338-0553-11,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE BACTERIOSTATIC 0.9% IJ (MIXTURES ONLY),00409-1966-05,0258 - PHARMACY - IV SOLUTIONS,15.00,15.00,9.00,9.00,N/A,N/A,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,N/A,N/A,15.00,N/A,15.00,N/A,N/A,9.00,9.00,1.31,15.00,,Hospital HCPCS 2580000003,DELFLEX-LC/2.5% DEXTROSE 394 MOSM/L IP SOLN,49230-0209-92,0258 - PHARMACY - IV SOLUTIONS,67.50,67.50,40.50,40.50,N/A,N/A,N/A,67.50,N/A,38.87,N/A,22.95,N/A,9.45,N/A,9.45,N/A,67.50,N/A,67.50,N/A,5.87,N/A,9.45,N/A,9.45,N/A,9.45,N/A,38.87,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,N/A,N/A,67.50,N/A,67.50,N/A,N/A,40.50,40.50,5.87,67.50,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS (PEDS),00264-7510-20,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,HETASTARCH-NACL 6-0.9 % IV SOLN,00409-7248-03,0258 - PHARMACY - IV SOLUTIONS,52.50,52.50,31.50,31.50,N/A,N/A,N/A,52.50,N/A,30.23,N/A,17.85,N/A,7.35,N/A,7.35,N/A,52.50,N/A,52.50,N/A,4.57,N/A,7.35,N/A,7.35,N/A,7.35,N/A,30.23,N/A,52.50,N/A,7.35,N/A,28.14,N/A,28.14,N/A,N/A,N/A,52.50,N/A,52.50,N/A,N/A,31.50,31.50,4.57,52.50,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,00264-1510-32,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,00338-0125-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,00338-0017-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,00338-0089-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-50,0258 - PHARMACY - IV SOLUTIONS,16.20,16.20,9.72,9.72,N/A,N/A,N/A,16.20,N/A,9.33,N/A,5.51,N/A,2.27,N/A,2.27,N/A,16.20,N/A,16.20,N/A,1.41,N/A,2.27,N/A,2.27,N/A,2.27,N/A,9.33,N/A,16.20,N/A,2.27,N/A,8.68,N/A,8.68,N/A,N/A,N/A,16.20,N/A,16.20,N/A,N/A,9.72,9.72,1.41,16.20,,Hospital HCPCS 2580000003,PLASMA-LYTE A IV SOLN,00338-0221-04,0258 - PHARMACY - IV SOLUTIONS,101.30,101.30,60.78,60.78,N/A,N/A,N/A,101.30,N/A,58.33,N/A,34.44,N/A,14.18,N/A,14.18,N/A,101.30,N/A,101.30,N/A,8.81,N/A,14.18,N/A,14.18,N/A,14.18,N/A,58.33,N/A,101.30,N/A,14.18,N/A,54.30,N/A,54.30,N/A,N/A,N/A,101.30,N/A,101.30,N/A,N/A,60.78,60.78,8.81,101.30,,Hospital HCPCS 2580000003,LACTATED RINGERS IV BOLUS PEDS,00338-0117-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 3% IV BOLUS,00338-0054-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,LACTATED RINGERS IV BOLUS PEDS,00338-0117-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE BACTERIOSTATIC 0.9% IJ (MIXTURES ONLY),00409-1966-07,0258 - PHARMACY - IV SOLUTIONS,15.00,15.00,9.00,9.00,N/A,N/A,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,N/A,N/A,15.00,N/A,15.00,N/A,N/A,9.00,9.00,1.31,15.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.45 % IV BOLUS,00338-0043-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV SOLN,00338-0023-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% IV SOLN 250 ML,00338-0049-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5% IV SOLN NEONATE,00264-7510-20,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,00338-0017-31,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-48,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,00338-0017-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DELFLEX-LC/1.5% DEXTROSE 344 MOSM/L IP SOLN,49230-0206-50,0250 - PHARMACY - GENERAL CLASSIFICATION,40.50,40.50,N/A,N/A,N/A,5.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.67,N/A,N/A,N/A,N/A,N/A,40.50,N/A,N/A,5.67,40.50,,Hospital HCPCS 2580000003,PLASMA-LYTE A IV SOLN,00338-0221-04,0250 - PHARMACY - GENERAL CLASSIFICATION,101.30,101.30,N/A,N/A,N/A,14.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14.18,N/A,N/A,N/A,N/A,N/A,101.30,N/A,N/A,14.18,101.30,,Hospital HCPCS 2580000003,DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,00338-0089-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DELFLEX-LC/2.5% DEXTROSE 394 MOSM/L IP SOLN,49230-0209-92,0250 - PHARMACY - GENERAL CLASSIFICATION,67.50,67.50,N/A,N/A,N/A,9.45,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9.45,N/A,N/A,N/A,N/A,N/A,67.50,N/A,N/A,9.45,67.50,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),00338-0553-18,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN 500 ML,00338-0049-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV BOLUS,00338-0023-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS (PEDS),00338-0017-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV BOLUS,00338-0023-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,EPINEPHRINE INJ 1 MG/ML FOR NEBULIZATION,99990-9917-56,0258 - PHARMACY - IV SOLUTIONS,303.00,303.00,181.80,181.80,N/A,N/A,N/A,303.00,N/A,174.47,N/A,103.02,N/A,42.42,N/A,42.42,N/A,303.00,N/A,303.00,N/A,26.36,N/A,42.42,N/A,42.42,N/A,42.42,N/A,174.47,N/A,303.00,N/A,42.42,N/A,162.41,N/A,162.41,N/A,N/A,N/A,303.00,N/A,303.00,N/A,N/A,181.80,181.80,26.36,303.00,,Hospital HCPCS 2580000003,STERILE WATER FOR IRRIGATION IR SOLN,00338-0004-04,0258 - PHARMACY - IV SOLUTIONS,57.40,57.40,34.44,34.44,N/A,N/A,N/A,57.40,N/A,33.05,N/A,19.52,N/A,8.04,N/A,8.04,N/A,57.40,N/A,57.40,N/A,4.99,N/A,8.04,N/A,8.04,N/A,8.04,N/A,33.05,N/A,57.40,N/A,8.04,N/A,30.77,N/A,30.77,N/A,N/A,N/A,57.40,N/A,57.40,N/A,N/A,34.44,34.44,4.99,57.40,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV BOLUS,00338-0023-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN (MINI-BAG),00338-0551-11,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.45 % IV BOLUS,00338-0043-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN (MINI-BAG),00338-0551-11,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),00338-0553-18,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR IRRIGATION IR SOLN,00338-0004-04,0250 - PHARMACY - GENERAL CLASSIFICATION,57.40,57.40,N/A,N/A,N/A,8.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.04,N/A,N/A,N/A,N/A,N/A,57.40,N/A,N/A,8.04,57.40,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-31,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% IV SOLN 250 ML,00338-0049-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-38,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-10,0258 - PHARMACY - IV SOLUTIONS,15.00,15.00,9.00,9.00,N/A,N/A,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,N/A,N/A,15.00,N/A,15.00,N/A,N/A,9.00,9.00,1.31,15.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV BOLUS,00338-0023-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),00338-0553-11,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS,00338-0017-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,00338-0049-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN (MINI-BAG),00338-0551-18,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV SOLN,00338-0023-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DELFLEX-LC/2.5% DEXTROSE 394 MOSM/L IP SOLN,49230-0209-50,0258 - PHARMACY - IV SOLUTIONS,67.50,67.50,40.50,40.50,N/A,N/A,N/A,67.50,N/A,38.87,N/A,22.95,N/A,9.45,N/A,9.45,N/A,67.50,N/A,67.50,N/A,5.87,N/A,9.45,N/A,9.45,N/A,9.45,N/A,38.87,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,N/A,N/A,67.50,N/A,67.50,N/A,N/A,40.50,40.50,5.87,67.50,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),00338-0049-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-38,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN 500 ML,00338-0017-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-50,0250 - PHARMACY - GENERAL CLASSIFICATION,16.20,16.20,N/A,N/A,N/A,2.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.27,N/A,N/A,N/A,N/A,N/A,16.20,N/A,N/A,2.27,16.20,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 3% IV BOLUS,00338-0054-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-31,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,EPINEPHRINE INJ 1 MG/ML FOR NEBULIZATION,99990-9917-56,0250 - PHARMACY - GENERAL CLASSIFICATION,303.00,303.00,N/A,N/A,N/A,42.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,42.42,N/A,N/A,N/A,N/A,N/A,303.00,N/A,N/A,42.42,303.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,00264-1510-32,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-20,0258 - PHARMACY - IV SOLUTIONS,15.00,15.00,9.00,9.00,N/A,N/A,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,N/A,N/A,15.00,N/A,15.00,N/A,N/A,9.00,9.00,1.31,15.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV BOLUS,00338-0023-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,63323-0624-74,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DEXTROSE 250 MG/ML IV SOLN,00409-1775-10,0250 - PHARMACY - GENERAL CLASSIFICATION,40.70,40.70,N/A,N/A,N/A,5.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.70,N/A,N/A,N/A,N/A,N/A,40.70,N/A,N/A,5.70,40.70,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-41,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN 500 ML,00338-0049-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN 500 ML,00338-0017-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR IRRIGATION IR SOLN,00338-0004-02,0250 - PHARMACY - GENERAL CLASSIFICATION,57.40,57.40,N/A,N/A,N/A,8.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.04,N/A,N/A,N/A,N/A,N/A,57.40,N/A,N/A,8.04,57.40,,Hospital HCPCS 2580000003,DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,00338-0089-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN (MINI-BAG),00338-0551-18,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-25,0258 - PHARMACY - IV SOLUTIONS,29.10,29.10,17.46,17.46,N/A,N/A,N/A,29.10,N/A,16.76,N/A,9.89,N/A,4.07,N/A,4.07,N/A,29.10,N/A,29.10,N/A,2.53,N/A,4.07,N/A,4.07,N/A,4.07,N/A,16.76,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,N/A,N/A,29.10,N/A,29.10,N/A,N/A,17.46,17.46,2.53,29.10,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.45 % IV BOLUS,00338-0043-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML,00338-0049-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS,00338-0017-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DELFLEX-LC/1.5% DEXTROSE 344 MOSM/L IP SOLN,49230-0206-20,0258 - PHARMACY - IV SOLUTIONS,40.50,40.50,24.30,24.30,N/A,N/A,N/A,40.50,N/A,23.32,N/A,13.77,N/A,5.67,N/A,5.67,N/A,40.50,N/A,40.50,N/A,3.52,N/A,5.67,N/A,5.67,N/A,5.67,N/A,23.32,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,N/A,N/A,40.50,N/A,40.50,N/A,N/A,24.30,24.30,3.52,40.50,,Hospital HCPCS 2580000003,DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,00338-0125-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,00338-0049-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS,00338-0017-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,63323-0624-74,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,00338-0049-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-48,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5% IV SOLN NEONATE,00264-7510-20,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS (PEDS),00338-0017-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV BOLUS,00338-0023-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS PEDS,00338-0049-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV SOLN,00338-0023-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,3.48,40.00,,Hospital HCPCS 2580000003,DEXTRAN 40 IN SALINE 10-0.9 % IV SOLN,00409-7419-03,0258 - PHARMACY - IV SOLUTIONS,202.50,202.50,121.50,121.50,N/A,N/A,N/A,202.50,N/A,116.60,N/A,68.85,N/A,28.35,N/A,28.35,N/A,202.50,N/A,202.50,N/A,17.62,N/A,28.35,N/A,28.35,N/A,28.35,N/A,116.60,N/A,202.50,N/A,28.35,N/A,108.54,N/A,108.54,N/A,N/A,N/A,202.50,N/A,202.50,N/A,N/A,121.50,121.50,17.62,202.50,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV BOLUS (PEDS),00264-7510-20,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),00338-0049-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,00338-0049-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.45 % IV BOLUS,00338-0043-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,HETASTARCH-NACL 6-0.9 % IV SOLN,00409-7248-03,0250 - PHARMACY - GENERAL CLASSIFICATION,52.50,52.50,N/A,N/A,N/A,7.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7.35,N/A,N/A,N/A,N/A,N/A,52.50,N/A,N/A,7.35,52.50,,Hospital HCPCS 2580000003,DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,00338-0017-31,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTRAN 40 IN SALINE 10-0.9 % IV SOLN,00409-7419-03,0250 - PHARMACY - GENERAL CLASSIFICATION,202.50,202.50,N/A,N/A,N/A,28.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28.35,N/A,N/A,N/A,N/A,N/A,202.50,N/A,N/A,28.35,202.50,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,DEXTROSE 10 % IV SOLN,00338-0023-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE BACTERIOSTATIC 0.9% IJ (MIXTURES ONLY),00409-1966-05,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,15.00,N/A,N/A,2.10,15.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,00338-0049-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS 2580000003,SODIUM CHLORIDE BACTERIOSTATIC 0.9% IJ (MIXTURES ONLY),00409-1966-07,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,15.00,N/A,N/A,2.10,15.00,,Hospital HCPCS 2580000003,STERILE WATER FOR INJECTION (MIXTURES ONLY),00409-4887-25,0250 - PHARMACY - GENERAL CLASSIFICATION,29.10,29.10,N/A,N/A,N/A,4.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.07,N/A,N/A,N/A,N/A,N/A,29.10,N/A,N/A,4.07,29.10,,Hospital 25900,Amputation Forearm Through Radius & Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24234.93,N/A,14540.96,N/A,3392.89,N/A,691.61,N/A,13946.99,N/A,8239.62,N/A,24234.18,N/A,3392.89,N/A,704.54,N/A,704.54,N/A,17795.14,N/A,24234.18,N/A,24234.18,N/A,24234.18,N/A,13947.02,N/A,704.54,N/A,3392.89,N/A,7897.00,N/A,7897.00,N/A,3392.89,N/A,704.54,N/A,691.61,N/A,760.77,N/A,N/A,691.61,24234.18,,Hospital 25909,Amp Forearm Thru Radius&Ulna Re-Amputation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71468.57,N/A,42881.14,N/A,10005.60,N/A,1127.12,N/A,40591.94,N/A,24226.91,N/A,14533.48,N/A,10005.60,N/A,5973.28,N/A,5973.28,N/A,9047.38,N/A,14533.48,N/A,14533.48,N/A,14533.48,N/A,40591.95,N/A,5973.28,N/A,10005.60,N/A,5453.25,N/A,5453.25,N/A,10005.60,N/A,5973.28,N/A,1127.12,N/A,1239.83,N/A,N/A,1127.12,42881.14,,Hospital CPT 26010,HC I&D Finger Abscess Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,804.00,804.00,482.40,482.40,N/A,112.56,N/A,132.52,N/A,462.94,N/A,273.36,N/A,804.00,N/A,112.56,N/A,132.52,N/A,132.52,N/A,588.95,N/A,804.00,N/A,804.00,N/A,804.00,N/A,462.94,N/A,132.52,N/A,112.56,N/A,804.00,N/A,804.00,N/A,112.56,N/A,132.52,N/A,132.52,N/A,145.77,482.40,482.40,112.56,804.00,,Hospital CPT 26011,HC Drain Finger Abscess,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4505.00,4505.00,2703.00,2703.00,N/A,630.70,N/A,175.27,N/A,2593.98,N/A,1531.70,N/A,1323.66,N/A,630.70,N/A,175.27,N/A,175.27,N/A,823.98,N/A,1323.66,N/A,1323.66,N/A,1323.66,N/A,2593.98,N/A,175.27,N/A,630.70,N/A,4505.00,N/A,4505.00,N/A,630.70,N/A,175.27,N/A,175.27,N/A,192.80,2703.00,2703.00,175.27,4505.00,,Hospital CPT 26034,Incision Bone Cortex Hand/Finger,N/A,N/A,1064.00,1064.00,638.40,638.40,N/A,148.96,N/A,523.22,N/A,1064.00,N/A,361.76,N/A,1064.00,N/A,148.96,N/A,523.22,N/A,523.22,N/A,975.68,N/A,1064.00,N/A,1064.00,N/A,1064.00,N/A,1064.00,N/A,523.22,N/A,148.96,N/A,1064.00,N/A,1064.00,N/A,148.96,N/A,523.22,N/A,523.22,N/A,575.54,638.40,638.40,148.96,1064.00,,Hospital 26075,Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,27067.10,N/A,16240.26,N/A,7520.75,N/A,9162.30,N/A,16948.62,N/A,8266.79,N/A,6551.68,N/A,7752.48,N/A,562.00,N/A,562.00,N/A,4078.54,N/A,6551.68,N/A,6551.68,N/A,6551.68,N/A,16948.62,N/A,9162.30,N/A,7752.48,N/A,20357.51,N/A,20357.51,N/A,N/A,N/A,9162.30,N/A,9162.30,N/A,8295.15,N/A,562.00,20357.51,N/A,N/A,,Hospital 26110,Arthrotomy Biopsy Interphalangeal Joint Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8967.20,N/A,5380.32,N/A,1255.41,N/A,1288.80,N/A,5162.41,N/A,3048.85,N/A,3143.95,N/A,1255.41,N/A,1295.43,N/A,1295.43,N/A,1957.16,N/A,3143.95,N/A,3143.95,N/A,3143.95,N/A,5162.41,N/A,1295.43,N/A,1255.41,N/A,1871.00,N/A,1871.00,N/A,1255.41,N/A,1295.43,N/A,1288.80,N/A,368.42,N/A,N/A,368.42,5380.32,,Hospital CPT 26115,Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm,N/A,N/A,913.00,913.00,547.80,547.80,N/A,127.82,N/A,313.11,N/A,913.00,N/A,310.42,N/A,913.00,N/A,127.82,N/A,313.11,N/A,313.11,N/A,913.00,N/A,913.00,N/A,913.00,N/A,913.00,N/A,913.00,N/A,313.11,N/A,127.82,N/A,913.00,N/A,913.00,N/A,127.82,N/A,313.11,N/A,313.11,N/A,344.42,547.80,547.80,127.82,913.00,,Hospital 26117,Rad Resect Tumor Soft Tissue Hand/Finger <3cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8983.20,N/A,5389.92,N/A,1257.64,N/A,2395.09,N/A,5171.37,N/A,3054.28,N/A,5643.69,N/A,1257.64,N/A,2332.78,N/A,2332.78,N/A,3513.31,N/A,5643.69,N/A,5643.69,N/A,5643.69,N/A,5171.37,N/A,2332.78,N/A,1257.64,N/A,1871.00,N/A,1871.00,N/A,1257.64,N/A,2332.78,N/A,2395.09,N/A,870.43,N/A,N/A,870.43,5643.69,,Hospital CPT 26160,Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr,N/A,N/A,1027.00,1027.00,616.20,616.20,N/A,143.78,N/A,298.21,N/A,1027.00,N/A,349.18,N/A,1027.00,N/A,143.78,N/A,298.21,N/A,298.21,N/A,1027.00,N/A,1027.00,N/A,1027.00,N/A,1027.00,N/A,1027.00,N/A,298.21,N/A,143.78,N/A,1027.00,N/A,1027.00,N/A,143.78,N/A,298.21,N/A,298.21,N/A,328.03,616.20,616.20,143.78,1027.00,,Hospital 26180,Excision Tendon Finger Flexor/Extensor Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25667.10,N/A,15400.26,N/A,3583.45,N/A,2664.83,N/A,14776.90,N/A,8676.49,N/A,6539.48,N/A,3583.45,N/A,2688.04,N/A,2688.04,N/A,4070.95,N/A,6539.48,N/A,6539.48,N/A,6539.48,N/A,14776.91,N/A,2688.04,N/A,3583.45,N/A,6728.25,N/A,6728.25,N/A,3583.45,N/A,2688.04,N/A,2664.83,N/A,3629.71,N/A,N/A,2664.83,15400.26,,Hospital 26210,Excision/Curettage Cyst/Tumor Phalanx Finger,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12525.20,N/A,7515.12,N/A,1755.15,N/A,1345.87,N/A,7210.13,N/A,4258.57,N/A,3170.52,N/A,1755.15,N/A,1295.43,N/A,1295.43,N/A,1973.69,N/A,3170.52,N/A,3170.52,N/A,3170.52,N/A,7210.14,N/A,1295.43,N/A,1755.15,N/A,3274.25,N/A,3274.25,N/A,1755.15,N/A,1295.43,N/A,1345.87,N/A,1109.22,N/A,N/A,1109.22,7515.12,,Hospital 26230,Partial Excision Bone Metacarpal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23256.50,N/A,13953.90,N/A,3247.06,N/A,2811.81,N/A,13388.93,N/A,7907.22,N/A,6536.79,N/A,3247.06,N/A,2688.04,N/A,2688.04,N/A,4069.26,N/A,6536.79,N/A,6536.79,N/A,6536.79,N/A,13388.94,N/A,2688.04,N/A,3247.06,N/A,2806.50,N/A,2806.50,N/A,3247.06,N/A,2688.04,N/A,2811.81,N/A,889.30,N/A,N/A,889.30,13953.90,,Hospital CPT 26236,HC Partial Removal Finger Bone,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3938.00,3938.00,2362.80,2362.80,N/A,551.32,N/A,419.90,N/A,2267.50,N/A,1338.92,N/A,1257.66,N/A,551.32,N/A,419.90,N/A,419.90,N/A,782.89,N/A,1257.66,N/A,1257.66,N/A,1257.66,N/A,2267.50,N/A,419.90,N/A,551.32,N/A,3938.00,N/A,3938.00,N/A,551.32,N/A,419.90,N/A,419.90,N/A,461.89,2362.80,2362.80,419.90,3938.00,,Hospital 26260,Rad Resection Tumor Prox/Middle Phalanx Finger,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23573.80,N/A,14144.28,N/A,3289.83,N/A,1202.31,N/A,13427.97,N/A,8015.09,N/A,6522.46,N/A,3289.83,N/A,2688.04,N/A,2688.04,N/A,4060.36,N/A,6522.46,N/A,6522.46,N/A,6522.46,N/A,13427.98,N/A,2688.04,N/A,3289.83,N/A,4332.50,N/A,4332.50,N/A,3289.83,N/A,2688.04,N/A,1202.31,N/A,1322.55,N/A,N/A,1202.31,14144.28,,Hospital 26320,Removal Implant From Finger/Hand,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11001.20,N/A,6600.72,N/A,1540.15,N/A,1435.04,N/A,6333.17,N/A,3740.40,N/A,3293.79,N/A,1540.15,N/A,1354.15,N/A,1354.15,N/A,2050.45,N/A,3293.79,N/A,3293.79,N/A,3293.79,N/A,6333.16,N/A,1354.15,N/A,1540.15,N/A,1871.00,N/A,1871.00,N/A,1540.15,N/A,1354.15,N/A,1435.04,N/A,365.24,N/A,N/A,365.24,6600.72,,Hospital 26341,Maniplatn Palar Fascial Crd Post Inj Single Cord,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24273.70,N/A,14564.22,N/A,3398.33,N/A,198.86,N/A,13972.27,N/A,8253.07,N/A,475.81,N/A,3398.33,N/A,186.94,N/A,186.94,N/A,296.21,N/A,475.81,N/A,475.81,N/A,475.81,N/A,13972.27,N/A,186.94,N/A,3398.33,N/A,527.00,N/A,527.00,N/A,3398.33,N/A,186.94,N/A,198.86,N/A,110.75,N/A,N/A,110.75,14564.22,,Hospital 26356,Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25758.10,N/A,15454.86,N/A,3606.15,N/A,2859.50,N/A,14824.16,N/A,8757.77,N/A,6544.95,N/A,3606.15,N/A,2688.04,N/A,2688.04,N/A,4074.36,N/A,6544.95,N/A,6544.95,N/A,6544.95,N/A,14824.16,N/A,2688.04,N/A,3606.15,N/A,4562.00,N/A,4562.00,N/A,3606.15,N/A,2688.04,N/A,2859.50,N/A,834.44,N/A,N/A,834.44,15454.86,,Hospital 26358,Rpr/Advmnt Flxr Tdn Zone 2 W/Fr Graft Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34529.60,N/A,20717.76,N/A,4831.28,N/A,5942.72,N/A,19879.03,N/A,11740.07,N/A,14487.91,N/A,4831.28,N/A,5973.28,N/A,5973.28,N/A,9018.99,N/A,14487.91,N/A,14487.91,N/A,14487.91,N/A,19879.02,N/A,5973.28,N/A,4831.28,N/A,6843.00,N/A,6843.00,N/A,4831.28,N/A,5973.28,N/A,5942.72,N/A,1832.60,N/A,N/A,1832.60,20717.76,,Hospital 26390,Exc Flxr Tdn W/Impltj Synth Rod Dlyd Tdn Grf H/F,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33961.72,N/A,20377.03,N/A,4754.77,N/A,6334.00,N/A,19469.65,N/A,11546.97,N/A,14478.93,N/A,4754.77,N/A,5977.21,N/A,5977.21,N/A,9013.41,N/A,14478.93,N/A,14478.93,N/A,14478.93,N/A,19469.66,N/A,5977.21,N/A,4754.77,N/A,5277.50,N/A,5277.50,N/A,4754.77,N/A,5977.21,N/A,6334.00,N/A,1019.68,N/A,N/A,1019.68,20377.03,,Hospital 26426,Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18377.30,N/A,11026.38,N/A,2572.83,N/A,2811.81,N/A,10579.89,N/A,6248.29,N/A,6526.11,N/A,2572.83,N/A,2688.04,N/A,2688.04,N/A,4062.62,N/A,6526.11,N/A,6526.11,N/A,6526.11,N/A,10579.89,N/A,2688.04,N/A,2572.83,N/A,4562.00,N/A,4562.00,N/A,2572.83,N/A,2688.04,N/A,2811.81,N/A,526.49,N/A,N/A,526.49,11026.38,,Hospital 26440,Tenolysis Flexor Tendon Palm/Finger Each Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11027.50,N/A,6616.50,N/A,1543.86,N/A,1284.24,N/A,6343.33,N/A,3749.36,N/A,3209.46,N/A,1543.86,N/A,1295.43,N/A,1295.43,N/A,1997.96,N/A,3209.46,N/A,3209.46,N/A,3209.46,N/A,6295.43,N/A,1295.43,N/A,1543.86,N/A,2806.50,N/A,2806.50,N/A,1543.86,N/A,1295.43,N/A,1284.24,N/A,981.90,N/A,N/A,981.90,6616.50,,Hospital 26442,Tenolysis Flexor Tendon Palm&Finger Each Tendo,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10126.00,N/A,6075.60,N/A,1417.64,N/A,938.99,N/A,5830.55,N/A,3442.84,N/A,6502.16,N/A,1417.64,N/A,2688.04,N/A,2688.04,N/A,4047.72,N/A,6502.16,N/A,6502.16,N/A,6502.16,N/A,5830.56,N/A,2688.04,N/A,1417.64,N/A,4562.00,N/A,4562.00,N/A,1417.64,N/A,2688.04,N/A,938.99,N/A,1032.89,N/A,N/A,938.99,6502.16,,Hospital 26471,Tenodesis Proximal Interphalangeal Joint Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19640.42,N/A,11784.25,N/A,2749.66,N/A,2674.29,N/A,11257.99,N/A,6677.74,N/A,6530.24,N/A,2749.66,N/A,2688.04,N/A,2688.04,N/A,4065.19,N/A,6530.24,N/A,6530.24,N/A,6530.24,N/A,11257.99,N/A,2688.04,N/A,2749.66,N/A,2806.50,N/A,2806.50,N/A,2749.66,N/A,2688.04,N/A,2674.29,N/A,1338.77,N/A,N/A,1338.77,11784.25,,Hospital 26478,Lengthening Tendon Flexor Hand/Finger Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22932.55,N/A,13759.53,N/A,3210.56,N/A,2664.83,N/A,13172.29,N/A,7797.07,N/A,6524.22,N/A,3210.56,N/A,2688.04,N/A,2688.04,N/A,4061.46,N/A,6524.22,N/A,6524.22,N/A,6524.22,N/A,13172.29,N/A,2688.04,N/A,3210.56,N/A,7310.75,N/A,7310.75,N/A,3210.56,N/A,2688.04,N/A,2664.83,N/A,1964.12,N/A,N/A,1964.12,13759.53,,Hospital 26480,Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25032.87,N/A,15019.72,N/A,3504.61,N/A,2965.23,N/A,14403.38,N/A,8511.17,N/A,6563.07,N/A,3504.61,N/A,2688.04,N/A,2688.04,N/A,4085.64,N/A,6563.07,N/A,6563.07,N/A,6563.07,N/A,14403.39,N/A,2688.04,N/A,3504.61,N/A,10085.00,N/A,10085.00,N/A,3504.61,N/A,2688.04,N/A,2342.53,N/A,2576.78,N/A,N/A,2342.53,15019.72,,Hospital 26485,Transfer/Transplant Tendon Palmar W/O Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54448.63,N/A,32669.18,N/A,7622.82,N/A,2818.24,N/A,30820.40,N/A,18512.53,N/A,6582.19,N/A,7622.82,N/A,2688.04,N/A,2688.04,N/A,4097.54,N/A,6582.19,N/A,6582.19,N/A,6582.19,N/A,30820.41,N/A,2688.04,N/A,7622.82,N/A,8244.00,N/A,8244.00,N/A,7622.82,N/A,2688.04,N/A,1476.31,N/A,1623.94,N/A,N/A,1476.31,32669.18,,Hospital 26489,Transfer/Transplant Tendon Palmar W/Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19204.80,N/A,11522.88,N/A,2688.67,N/A,2759.84,N/A,11054.41,N/A,6529.63,N/A,6555.24,N/A,2688.67,N/A,2688.04,N/A,2688.04,N/A,4080.75,N/A,6555.24,N/A,6555.24,N/A,6555.24,N/A,11054.42,N/A,2688.04,N/A,2688.67,N/A,8601.75,N/A,8601.75,N/A,2688.67,N/A,2688.04,N/A,2759.84,N/A,1977.06,N/A,N/A,1977.06,11522.88,,Hospital 26490,Opponensplasty Supfcis Tdn Tr Typ Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20810.12,N/A,12486.07,N/A,2913.43,N/A,2912.72,N/A,11975.64,N/A,7075.44,N/A,6565.87,N/A,2913.43,N/A,2688.04,N/A,2688.04,N/A,4087.38,N/A,6565.87,N/A,6565.87,N/A,6565.87,N/A,11975.65,N/A,2688.04,N/A,2913.43,N/A,8375.75,N/A,8375.75,N/A,2913.43,N/A,2688.04,N/A,2912.72,N/A,1825.13,N/A,N/A,1825.13,12486.07,,Hospital 26497,Tr Tdn Restore Intrnsc Funcj Ring&Sm Fngr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67965.80,N/A,40779.48,N/A,9496.75,N/A,6071.82,N/A,38664.66,N/A,23108.37,N/A,15031.64,N/A,9496.75,N/A,6123.42,N/A,6123.42,N/A,9553.48,N/A,15031.64,N/A,15031.64,N/A,15031.64,N/A,38304.19,N/A,6146.36,N/A,9496.75,N/A,8711.75,N/A,8711.75,N/A,9496.75,N/A,6123.42,N/A,6071.82,N/A,2770.61,N/A,N/A,2770.61,40779.48,,Hospital 26498,Tr Tdn Restore Intrnsc Funcj All 4 Fngrs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37500.80,N/A,22500.48,N/A,5250.13,N/A,2811.81,N/A,21589.50,N/A,12750.27,N/A,6557.32,N/A,5250.13,N/A,2688.04,N/A,2688.04,N/A,4082.06,N/A,6557.32,N/A,6557.32,N/A,6557.32,N/A,21589.51,N/A,2688.04,N/A,5250.13,N/A,5965.25,N/A,5965.25,N/A,5250.13,N/A,2688.04,N/A,2811.81,N/A,4188.40,N/A,N/A,2688.04,22500.48,,Hospital 26502,Rcnstj Tdn Pulley Ea Tdn W/Tdn/Fscal Grf Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22028.70,N/A,13217.22,N/A,3084.02,N/A,2759.84,N/A,12683.66,N/A,7489.77,N/A,6510.03,N/A,3084.02,N/A,2688.04,N/A,2688.04,N/A,4052.62,N/A,6510.03,N/A,6510.03,N/A,6510.03,N/A,12683.66,N/A,2688.04,N/A,3084.02,N/A,7109.75,N/A,7109.75,N/A,3084.02,N/A,2688.04,N/A,2759.84,N/A,3786.07,N/A,N/A,2688.04,13217.22,,Hospital 26520,Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,27407.20,24452.90,16444.32,14671.74,5880.89,3423.43,7222.43,2664.83,13253.05,13957.28,9318.45,8313.99,13379.83,6522.93,6062.09,3423.43,562.00,2688.04,562.00,2688.04,8328.63,4060.65,13379.83,6522.93,13379.83,6522.93,13379.83,6522.93,13253.05,13957.28,7222.43,2688.04,6062.09,3423.43,15918.66,4800.25,15918.66,4800.25,2636.76,3423.43,7222.43,2688.04,7222.43,2664.83,6486.43,5834.90,562.00,16444.32,2664.83,14671.74,,Hospital 26531,Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39042.30,N/A,23425.38,N/A,5465.93,N/A,1228.68,N/A,22205.30,N/A,13274.39,N/A,14494.86,N/A,5465.93,N/A,5973.28,N/A,5973.28,N/A,9023.33,N/A,14494.86,N/A,14494.86,N/A,14494.86,N/A,22205.32,N/A,5973.28,N/A,5465.93,N/A,6898.50,N/A,6898.50,N/A,5465.93,N/A,5973.28,N/A,1228.68,N/A,1351.55,N/A,N/A,1228.68,23425.38,,Hospital 26561,Repair Syndactyly Each Space W/Skin Flaps&Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27527.40,N/A,16516.44,N/A,3850.69,N/A,2859.50,N/A,15842.17,N/A,9359.32,N/A,6524.09,N/A,3850.69,N/A,2688.04,N/A,2688.04,N/A,4061.38,N/A,6524.09,N/A,6524.09,N/A,6524.09,N/A,15842.18,N/A,2688.04,N/A,3850.69,N/A,6843.00,N/A,6843.00,N/A,3850.69,N/A,2688.04,N/A,2859.50,N/A,1763.51,N/A,N/A,1763.51,16516.44,,Hospital 26587,Rcnstj Polydactylous Digit Soft Tissue & Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17958.80,N/A,10775.28,N/A,2514.67,N/A,2863.43,N/A,10332.48,N/A,6106.00,N/A,6551.02,N/A,2514.67,N/A,2691.97,N/A,2691.97,N/A,4078.15,N/A,6551.02,N/A,6551.02,N/A,6551.02,N/A,10332.48,N/A,2691.97,N/A,2514.67,N/A,1871.00,N/A,1871.00,N/A,2514.67,N/A,2691.97,N/A,2863.43,N/A,1139.95,N/A,N/A,1139.95,10775.28,,Hospital 26600,HC Treat Metacarpal Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,477.00,N/A,286.20,N/A,66.78,N/A,313.76,N/A,274.66,N/A,162.18,N/A,N/A,N/A,66.78,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,274.66,N/A,296.08,N/A,66.78,N/A,255.67,N/A,255.67,N/A,66.78,N/A,296.08,N/A,313.76,N/A,349.12,N/A,N/A,66.78,349.12,,Hospital 26675,Cltx Carpo/Mtcrpl Dislc Thumb Manj Ea Jt W/Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18993.77,N/A,11396.26,N/A,2659.14,N/A,1355.08,N/A,10933.66,N/A,6457.89,N/A,3161.89,N/A,2659.14,N/A,1295.43,N/A,1295.43,N/A,1968.33,N/A,3161.89,N/A,3161.89,N/A,3161.89,N/A,10933.66,N/A,1295.43,N/A,2659.14,N/A,790.50,N/A,790.50,N/A,2659.14,N/A,1295.43,N/A,1355.08,N/A,914.97,N/A,N/A,790.50,11396.26,,Hospital CPT 26725,HC ED Clsd Tx Finger Fx W Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,651.00,651.00,390.60,390.60,N/A,91.14,N/A,290.27,N/A,374.85,N/A,221.34,N/A,651.00,N/A,91.14,N/A,290.27,N/A,290.27,N/A,610.15,N/A,651.00,N/A,651.00,N/A,651.00,N/A,374.85,N/A,290.27,N/A,91.14,N/A,651.00,N/A,651.00,N/A,91.14,N/A,290.27,N/A,290.27,N/A,319.30,390.60,390.60,91.14,651.00,,Hospital 26735,Open Tx Phalangeal Shaft Fracture Prox/Middle Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29239.60,N/A,17543.76,N/A,4093.54,N/A,2811.81,N/A,16812.51,N/A,9941.46,N/A,6526.71,N/A,4093.54,N/A,2688.04,N/A,2688.04,N/A,4063.00,N/A,6526.71,N/A,6526.71,N/A,6526.71,N/A,16812.51,N/A,2688.04,N/A,4093.54,N/A,3397.00,N/A,3397.00,N/A,4093.54,N/A,2688.04,N/A,2811.81,N/A,651.36,N/A,N/A,651.36,17543.76,,Hospital CPT 26750,HC Treat Finger Fx Each,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,198.10,N/A,327.05,N/A,193.12,N/A,452.19,N/A,79.52,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,327.05,N/A,186.94,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,186.94,N/A,198.10,N/A,196.00,340.80,340.80,79.52,568.00,,Hospital CPT 26755,HC Clsd Tx Dist Phlnx Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2418.00,2418.00,1450.80,1450.80,N/A,338.52,N/A,262.41,N/A,1392.28,N/A,822.12,N/A,918.36,N/A,338.52,N/A,262.41,N/A,262.41,N/A,571.68,N/A,918.36,N/A,918.36,N/A,918.36,N/A,1392.28,N/A,262.41,N/A,338.52,N/A,2418.00,N/A,2418.00,N/A,338.52,N/A,262.41,N/A,262.41,N/A,288.65,1450.80,1450.80,262.41,2418.00,,Hospital 26776,Prq Skel Fixj Iphal Jt Dislc W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17868.03,N/A,10720.82,N/A,2501.53,N/A,2811.81,N/A,10286.42,N/A,6075.13,N/A,6515.06,N/A,2501.53,N/A,2688.04,N/A,2688.04,N/A,4055.75,N/A,6515.06,N/A,6515.06,N/A,6515.06,N/A,10286.42,N/A,2688.04,N/A,2501.53,N/A,3397.00,N/A,3397.00,N/A,2501.53,N/A,2688.04,N/A,2811.81,N/A,492.42,N/A,N/A,492.42,10720.82,,Hospital 26843,Arthrd Carp/Mtcrpl Jt Dgt Other Than Thumb Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39342.40,N/A,23605.44,N/A,5507.94,N/A,6589.23,N/A,22435.94,N/A,13376.42,N/A,14476.55,N/A,5507.94,N/A,5973.28,N/A,5973.28,N/A,9011.93,N/A,14476.55,N/A,14476.55,N/A,14476.55,N/A,22435.94,N/A,5973.28,N/A,5507.94,N/A,4562.00,N/A,4562.00,N/A,5507.94,N/A,5973.28,N/A,747.76,N/A,822.54,N/A,N/A,747.76,23605.44,,Hospital 26850,Arthrodesis Metacarpophalangeal Jt W/WO Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37970.82,N/A,22782.49,N/A,5315.91,N/A,974.42,N/A,21646.61,N/A,12910.07,N/A,14512.82,N/A,5315.91,N/A,5973.28,N/A,5973.28,N/A,9034.51,N/A,14512.82,N/A,14512.82,N/A,14512.82,N/A,21646.61,N/A,5973.28,N/A,5315.91,N/A,5497.50,N/A,5497.50,N/A,5315.91,N/A,5973.28,N/A,974.42,N/A,1071.87,N/A,N/A,974.42,22782.49,,Hospital 26860,Arthrodesis Interphalangeal Jt W/WO Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27894.43,N/A,16736.66,N/A,3899.54,N/A,1172.36,N/A,15997.97,N/A,9484.11,N/A,6527.36,N/A,3899.54,N/A,2688.04,N/A,2688.04,N/A,4063.40,N/A,6527.36,N/A,6527.36,N/A,6527.36,N/A,15997.97,N/A,2688.04,N/A,3899.54,N/A,5497.50,N/A,5497.50,N/A,3899.54,N/A,2688.04,N/A,1172.36,N/A,1289.60,N/A,N/A,1172.36,16736.66,,Hospital 26989,Unlisted Procedure Hands/Fingers,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51273.00,N/A,30763.80,N/A,7121.96,N/A,195.55,N/A,29521.96,N/A,17432.82,N/A,490.24,N/A,7121.96,N/A,186.94,N/A,186.94,N/A,305.18,N/A,490.24,N/A,490.24,N/A,490.24,N/A,29521.97,N/A,186.94,N/A,7121.96,N/A,527.00,N/A,527.00,N/A,7121.96,N/A,186.94,N/A,195.55,N/A,630.01,N/A,N/A,186.94,30763.80,,Hospital 27001,Tenotomy Adductor Hip Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87455.37,N/A,52473.22,N/A,12235.74,N/A,6248.31,N/A,50093.64,N/A,29734.85,N/A,14657.95,N/A,12235.74,N/A,5973.28,N/A,5973.28,N/A,9224.02,N/A,14657.95,N/A,14657.95,N/A,14657.95,N/A,50030.33,N/A,5973.28,N/A,12235.74,N/A,13819.75,N/A,13819.75,N/A,12235.74,N/A,5973.28,N/A,6248.31,N/A,3834.64,N/A,N/A,3834.64,52473.22,,Hospital 27006,Tenotomy Abductors&/Extensor Hip Open Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45655.70,N/A,27393.42,N/A,6391.81,N/A,2811.81,N/A,26187.29,N/A,15522.95,N/A,6536.03,N/A,6391.81,N/A,2688.04,N/A,2688.04,N/A,4068.80,N/A,6536.03,N/A,6536.03,N/A,6536.03,N/A,26187.29,N/A,2688.04,N/A,6391.81,N/A,6260.50,N/A,6260.50,N/A,6391.81,N/A,2688.04,N/A,2811.81,N/A,1107.83,N/A,N/A,1107.83,27393.42,,Hospital 27030,Arthrotomy Hip W/Drainage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25590.80,N/A,15354.48,N/A,3253.66,N/A,1664.33,N/A,14735.17,N/A,8700.87,N/A,20951.53,N/A,3253.66,N/A,2688.04,N/A,2688.04,N/A,13042.73,N/A,20951.53,N/A,20951.53,N/A,20951.53,N/A,14735.19,N/A,2688.04,N/A,3253.66,N/A,8244.00,N/A,8244.00,N/A,3253.66,N/A,2688.04,N/A,1664.33,N/A,1830.76,N/A,N/A,1664.33,20951.53,,Hospital 27033,Arthrotomy Hip Exploration/Removal Foreign Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,118988.30,N/A,71392.98,N/A,16628.79,N/A,11831.30,N/A,67739.78,N/A,40456.00,N/A,29128.93,N/A,16628.79,N/A,11933.08,N/A,11933.08,N/A,18329.34,N/A,29128.93,N/A,29128.93,N/A,29128.93,N/A,67739.79,N/A,11956.02,N/A,16628.79,N/A,14641.50,N/A,14641.50,N/A,16628.79,N/A,11933.08,N/A,11831.30,N/A,2880.39,N/A,N/A,2880.39,71392.98,,Hospital 27036,Capslctomy/Capsul Hip W/Rls Hip Flxr Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20116.20,N/A,12069.72,N/A,2816.27,N/A,970.29,N/A,11579.36,N/A,6839.51,N/A,14490.62,N/A,2816.27,N/A,970.29,N/A,970.29,N/A,9020.69,N/A,14490.62,N/A,14490.62,N/A,14490.62,N/A,11579.37,N/A,970.29,N/A,2816.27,N/A,5963.00,N/A,5963.00,N/A,2816.27,N/A,970.29,N/A,970.29,N/A,1067.32,N/A,N/A,970.29,14490.62,,Hospital 27040,HC Bx Soft Tissues Pelvic/Hip Superficial,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,7830.40,N/A,4698.24,N/A,1091.23,N/A,1368.82,N/A,4508.75,N/A,2662.34,N/A,3275.59,N/A,1091.23,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,4508.75,N/A,1354.15,N/A,1091.23,N/A,1431.00,N/A,1431.00,N/A,1091.23,N/A,1354.15,N/A,1368.82,N/A,441.30,N/A,N/A,441.30,4698.24,,Hospital 27054,Arthrotomy W/Synovectomy Hip Joint,N/A,N/A,N/A,59824.88,N/A,35894.93,N/A,8324.03,N/A,1480.17,N/A,34186.81,N/A,20340.47,N/A,28772.59,N/A,8324.03,N/A,1478.54,N/A,1478.54,N/A,17911.49,N/A,28772.59,N/A,28772.59,N/A,28772.59,N/A,34114.83,N/A,1478.54,N/A,8324.03,N/A,11660.00,N/A,11660.00,N/A,8324.03,N/A,1478.54,N/A,1480.17,N/A,1629.17,N/A,N/A,1478.54,35894.93,,Hospital 27059,Rad Resection Tumor Soft Tiss Pelvis&Hip 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40485.23,N/A,24291.14,N/A,5667.94,N/A,2481.57,N/A,23298.70,N/A,13764.99,N/A,5774.00,N/A,5667.94,N/A,2332.78,N/A,2332.78,N/A,3594.42,N/A,5774.00,N/A,5774.00,N/A,5774.00,N/A,23298.71,N/A,2332.78,N/A,5667.94,N/A,6260.50,N/A,6260.50,N/A,5667.94,N/A,2332.78,N/A,2481.57,N/A,3574.69,N/A,N/A,2332.78,24291.14,,Hospital 27087,Removal Foreign Body Pelvis/Hip Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17670.90,N/A,10602.54,N/A,2502.86,N/A,2759.84,N/A,10171.72,N/A,6008.10,N/A,6528.38,N/A,2502.86,N/A,2688.04,N/A,2688.04,N/A,4064.03,N/A,6528.38,N/A,6528.38,N/A,6528.38,N/A,10171.73,N/A,2688.04,N/A,2502.86,N/A,3397.00,N/A,3397.00,N/A,2502.86,N/A,2688.04,N/A,2759.84,N/A,702.97,N/A,N/A,702.97,10602.54,,Hospital 27105,Tr Paraspi Musc Hip Fasc/Tdn Xtn Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,70548.33,N/A,42329.00,N/A,9847.30,N/A,2971.35,N/A,40579.35,N/A,23986.44,N/A,7169.89,N/A,9847.30,N/A,2837.87,N/A,2837.87,N/A,4659.39,N/A,7169.89,N/A,7169.89,N/A,7169.89,N/A,40579.39,N/A,2861.12,N/A,9847.30,N/A,6678.50,N/A,6678.50,N/A,9847.30,N/A,2847.58,N/A,2971.35,N/A,1322.23,N/A,N/A,1322.23,42329.00,,Hospital 27176,Tx Slp Fem Epiphysis Single/Multipl Pinning Situ,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31031.52,N/A,18618.91,N/A,4344.42,N/A,879.29,N/A,17804.52,N/A,10550.72,N/A,28541.83,N/A,4344.42,N/A,879.29,N/A,879.29,N/A,17767.83,N/A,28541.83,N/A,28541.83,N/A,28541.83,N/A,17804.54,N/A,879.29,N/A,4344.42,N/A,7897.00,N/A,7897.00,N/A,4344.42,N/A,879.29,N/A,879.29,N/A,967.22,N/A,N/A,879.29,28541.83,,Hospital 27187,Proph Tx N/P/Pltwr W/WO Mma Fem Nck & Prox Femur,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56470.68,N/A,33882.41,N/A,7905.89,N/A,950.99,N/A,32498.27,N/A,19200.03,N/A,14472.32,N/A,7905.89,N/A,950.99,N/A,950.99,N/A,9009.29,N/A,14472.32,N/A,14472.32,N/A,14472.32,N/A,32498.27,N/A,950.99,N/A,7905.89,N/A,7897.00,N/A,7897.00,N/A,7905.89,N/A,950.99,N/A,950.99,N/A,1046.09,N/A,N/A,950.99,33882.41,,Hospital 27230,HC Treat Upper Thigh Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 27240,Cltx Intr/Peri/Sbtrchntc Femoral Fx W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,84096.92,N/A,50458.15,N/A,8781.32,N/A,10272.94,N/A,26969.38,N/A,28592.95,N/A,19987.21,N/A,9051.89,N/A,463650.00,N/A,463650.00,N/A,12441.57,N/A,19987.21,N/A,19987.21,N/A,19987.21,N/A,26969.38,N/A,10183.99,N/A,9051.89,N/A,23779.79,N/A,1871.00,N/A,N/A,N/A,10183.99,N/A,10272.94,N/A,9685.52,N/A,1871.00,463650.00,N/A,N/A,,Hospital 27244,Tx Inter/PR/Subtrchntric Femoral Fx Screw Implt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,83449.77,N/A,50069.86,N/A,10482.65,N/A,12477.98,N/A,39213.80,N/A,28372.92,N/A,25433.08,N/A,10805.64,N/A,441732.00,N/A,441732.00,N/A,15831.50,N/A,25433.08,N/A,25433.08,N/A,25433.08,N/A,39213.80,N/A,12389.03,N/A,10805.64,N/A,30259.02,N/A,30259.02,N/A,N/A,N/A,12389.03,N/A,12477.98,N/A,11562.04,N/A,10482.65,441732.00,N/A,N/A,,Hospital CPT 27250,HC Hip Dislocation Reduction,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,660.00,660.00,396.00,396.00,N/A,92.40,N/A,176.47,N/A,380.03,N/A,224.40,N/A,525.66,N/A,92.40,N/A,176.47,N/A,176.47,N/A,327.22,N/A,525.66,N/A,525.66,N/A,525.66,N/A,380.03,N/A,176.47,N/A,92.40,N/A,660.00,N/A,660.00,N/A,92.40,N/A,176.47,N/A,176.47,N/A,194.12,396.00,396.00,92.40,660.00,,Hospital CPT 27252,HC Treat Hip Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3734.00,3734.00,2240.40,2240.40,N/A,522.76,N/A,722.80,N/A,2150.04,N/A,1269.56,N/A,2153.70,N/A,522.76,N/A,722.80,N/A,722.80,N/A,1340.68,N/A,2153.70,N/A,2153.70,N/A,2153.70,N/A,2150.04,N/A,722.80,N/A,522.76,N/A,3734.00,N/A,3734.00,N/A,522.76,N/A,722.80,N/A,722.80,N/A,795.08,2240.40,2240.40,522.76,3734.00,,Hospital 27253,Optx Hip Dislocation Traumatic W/O Internal Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40950.70,N/A,24570.42,N/A,5681.75,N/A,2029.14,N/A,23570.66,N/A,13923.24,N/A,9778.33,N/A,5681.75,N/A,2019.47,N/A,2019.47,N/A,6367.41,N/A,9778.33,N/A,9778.33,N/A,9778.33,N/A,21504.73,N/A,2038.51,N/A,5681.75,N/A,4562.00,N/A,4562.00,N/A,5681.75,N/A,2019.47,N/A,2029.14,N/A,1785.76,N/A,N/A,1785.76,24570.42,,Hospital CPT 27256,HC Treat Hip Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,230.71,N/A,327.05,N/A,193.12,N/A,568.00,N/A,79.52,N/A,230.71,N/A,230.71,N/A,557.97,N/A,568.00,N/A,568.00,N/A,568.00,N/A,327.05,N/A,230.71,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,230.71,N/A,230.71,N/A,253.78,340.80,340.80,79.52,568.00,,Hospital 27275,Manipulation Hip Joint General Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,17307.20,21598.40,10384.32,12959.04,5844.61,3014.05,7179.50,1347.70,13171.30,12428.46,5884.45,7343.46,13297.30,3195.99,6024.69,3014.05,562.00,1303.29,562.00,1303.29,8277.26,1989.57,13297.30,3195.99,13297.30,3195.99,13297.30,3195.99,13171.30,12428.46,7179.50,1303.29,6024.69,3014.05,15820.46,2586.50,15820.46,2586.50,N/A,3014.05,7179.50,1303.29,7179.50,1347.70,6446.42,276.93,562.00,15820.46,276.93,12959.04,,Hospital 27279,Arthrodesis Si Joint Percutaneous/Min Invasive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62598.48,N/A,37559.09,N/A,8770.17,N/A,20452.39,N/A,35619.56,N/A,21283.49,N/A,47880.36,N/A,8770.17,N/A,19774.44,N/A,19774.44,N/A,29806.45,N/A,47880.36,N/A,47880.36,N/A,47880.36,N/A,35619.56,N/A,19774.44,N/A,8770.17,N/A,11660.00,N/A,11660.00,N/A,8770.17,N/A,19774.44,N/A,20452.39,N/A,916.92,N/A,N/A,916.92,47880.36,,Hospital 27280,Arthrodesis Si Jt Opn W/Obtaining B1 Grf Instrmj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68309.88,N/A,40985.93,N/A,9496.74,N/A,20834.77,N/A,38915.12,N/A,23185.14,N/A,68191.48,N/A,9496.74,N/A,19924.27,N/A,19924.27,N/A,60719.61,N/A,68191.48,N/A,68191.48,N/A,68191.48,N/A,38915.16,N/A,19947.52,N/A,9496.74,N/A,17582.75,N/A,17582.75,N/A,9496.74,N/A,19924.27,N/A,20834.77,N/A,5137.05,N/A,N/A,5137.05,68191.48,,Hospital 27329,Rad Resect Tumor Soft Tissue Thigh/Knee <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6115.00,N/A,3669.00,N/A,856.10,N/A,2440.19,N/A,3521.02,N/A,2079.10,N/A,5642.81,N/A,856.10,N/A,2332.78,N/A,2332.78,N/A,3512.76,N/A,5642.81,N/A,5642.81,N/A,5642.81,N/A,3521.02,N/A,2332.78,N/A,856.10,N/A,1871.00,N/A,1871.00,N/A,856.10,N/A,2332.78,N/A,2440.19,N/A,1128.63,N/A,N/A,856.10,5642.81,,Hospital 27331,Arthrt Kne W/Jt Expl Bx/Rmvl Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32152.00,N/A,19291.20,N/A,4501.28,N/A,2811.81,N/A,7823.00,N/A,10931.68,N/A,6554.96,N/A,4501.28,N/A,2688.04,N/A,2688.04,N/A,4080.59,N/A,6554.96,N/A,6554.96,N/A,6554.96,N/A,7823.00,N/A,2688.04,N/A,4501.28,N/A,6843.00,N/A,6843.00,N/A,4501.28,N/A,2688.04,N/A,2811.81,N/A,923.72,N/A,N/A,923.72,19291.20,,Hospital 27332,Arthrt W/Exc Semilunar Crtlg Knee Medial/Lat,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60339.48,N/A,36203.69,N/A,8447.52,N/A,2961.95,N/A,34493.76,N/A,20515.42,N/A,7125.71,N/A,8447.52,N/A,2838.18,N/A,2838.18,N/A,4664.95,N/A,7125.71,N/A,7125.71,N/A,7125.71,N/A,34493.76,N/A,2861.12,N/A,8447.52,N/A,4562.00,N/A,4562.00,N/A,8447.52,N/A,2838.18,N/A,2961.95,N/A,923.90,N/A,N/A,923.90,36203.69,,Hospital CPT 27337,Excison Tumor Soft Tissue Thigh/Knee Subq 3 Cm/>,N/A,N/A,836.00,836.00,501.60,501.60,N/A,117.04,N/A,401.31,N/A,836.00,N/A,284.24,N/A,836.00,N/A,117.04,N/A,401.31,N/A,401.31,N/A,743.92,N/A,836.00,N/A,836.00,N/A,836.00,N/A,836.00,N/A,401.31,N/A,117.04,N/A,836.00,N/A,836.00,N/A,117.04,N/A,401.31,N/A,401.31,N/A,441.44,501.60,501.60,117.04,836.00,,Hospital 27350,Patellectomy/Hemipatellectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32631.52,N/A,19578.91,N/A,4568.40,N/A,6248.31,N/A,7823.00,N/A,11094.71,N/A,14512.82,N/A,4568.40,N/A,5973.28,N/A,5973.28,N/A,9034.50,N/A,14512.82,N/A,14512.82,N/A,14512.82,N/A,7823.00,N/A,5973.28,N/A,4568.40,N/A,7200.75,N/A,7200.75,N/A,4568.40,N/A,5973.28,N/A,6248.31,N/A,1167.61,N/A,N/A,1167.61,19578.91,,Hospital 27405,Rpr Primary Torn Ligm&/Capsule Knee Collateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54692.38,N/A,32815.43,N/A,7648.08,N/A,6248.31,N/A,7823.00,N/A,18595.41,N/A,14531.29,N/A,7648.08,N/A,5973.28,N/A,5973.28,N/A,9047.81,N/A,14531.29,N/A,14531.29,N/A,14531.29,N/A,7823.00,N/A,5973.28,N/A,7648.08,N/A,8601.75,N/A,8601.75,N/A,7648.08,N/A,5973.28,N/A,6248.31,N/A,1340.52,N/A,N/A,1340.52,32815.43,,Hospital CPT 27422,Rcnstj Dislc Patella W/Xtnsr Relignmt&/Musc Rl,N/A,N/A,1478.00,1478.00,886.80,886.80,N/A,206.92,N/A,708.53,N/A,1478.00,N/A,502.52,N/A,1478.00,N/A,206.92,N/A,708.53,N/A,708.53,N/A,1317.56,N/A,1478.00,N/A,1478.00,N/A,1478.00,N/A,1478.00,N/A,708.53,N/A,206.92,N/A,1478.00,N/A,1478.00,N/A,206.92,N/A,708.53,N/A,708.53,N/A,779.38,886.80,886.80,206.92,1478.00,,Hospital 27438,Arthroplasty Patella W/Prosthesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69126.33,N/A,41475.80,N/A,9671.23,N/A,12407.49,N/A,39730.00,N/A,23502.95,N/A,29288.16,N/A,9671.23,N/A,11864.95,N/A,11864.95,N/A,18342.87,N/A,29288.16,N/A,29288.16,N/A,29288.16,N/A,39730.01,N/A,11880.45,N/A,9671.23,N/A,8612.50,N/A,8612.50,N/A,9671.23,N/A,11864.95,N/A,12407.49,N/A,1089.79,N/A,N/A,1089.79,41475.80,,Hospital 27445,Arthroplasty Knee Hinge Prosthesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,215148.25,N/A,129088.95,N/A,30030.04,N/A,10516.33,N/A,121989.13,N/A,73150.40,N/A,32883.60,N/A,30030.04,N/A,8447.30,N/A,8447.30,N/A,21101.58,N/A,32883.60,N/A,32883.60,N/A,32883.60,N/A,121178.90,N/A,10517.33,N/A,30030.04,N/A,8612.50,N/A,8612.50,N/A,30030.04,N/A,10510.93,N/A,8126.48,N/A,2367.46,N/A,N/A,2367.46,129088.95,,Hospital 27466,Osteoplasty Femur Lengthening,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,158082.77,N/A,94849.66,N/A,22123.56,N/A,11767.79,N/A,90605.11,N/A,53748.14,N/A,29219.04,N/A,22123.56,N/A,11733.41,N/A,11733.41,N/A,18288.59,N/A,29219.04,N/A,29219.04,N/A,29219.04,N/A,90605.15,N/A,11733.41,N/A,22123.56,N/A,11845.50,N/A,11845.50,N/A,22123.56,N/A,11733.41,N/A,11767.79,N/A,2980.04,N/A,N/A,2980.04,94849.66,,Hospital 27477,Arrest Epiphyseal Tibia & Fibula Proximal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,90310.05,N/A,54186.03,N/A,12643.42,N/A,1362.20,N/A,51402.55,N/A,30705.42,N/A,15058.58,N/A,12643.42,N/A,6123.42,N/A,6123.42,N/A,9570.26,N/A,15058.58,N/A,15058.58,N/A,15058.58,N/A,51402.54,N/A,6146.36,N/A,12643.42,N/A,5409.25,N/A,5409.25,N/A,12643.42,N/A,6123.42,N/A,6203.98,N/A,1498.42,N/A,N/A,1362.20,54186.03,,Hospital 27485,Arrst Hemiepiphysl Dstl Femur/Prox Tibia/Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56957.67,N/A,34174.60,N/A,7974.09,N/A,6097.50,N/A,32794.08,N/A,19365.62,N/A,14471.26,N/A,7974.09,N/A,5973.28,N/A,5973.28,N/A,9008.63,N/A,14471.26,N/A,14471.26,N/A,14471.26,N/A,32794.09,N/A,5973.28,N/A,7974.09,N/A,6843.00,N/A,6843.00,N/A,7974.09,N/A,5973.28,N/A,6097.50,N/A,756.69,N/A,N/A,756.69,34174.60,,Hospital 27487,Revj Tot Knee Arthrp Fem&Entire Tibial Compone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,83503.25,88906.35,50101.95,53343.81,14879.86,12393.30,17927.04,2964.78,44377.80,50901.44,26904.08,30228.13,32276.99,32300.94,15338.33,12393.30,N/A,2918.94,174782.00,2918.94,20697.63,20411.35,32276.99,32300.94,32276.99,32300.94,32276.99,32300.94,44377.80,50901.49,17867.74,2937.58,15338.33,12393.30,40277.49,12733.25,40277.49,12733.25,15338.33,12393.30,17867.74,2918.94,17927.04,2964.78,16412.01,2359.05,14879.86,174782.00,2359.05,53343.81,,Hospital 27488,Rmvl Prosth Tot Knee Prosth Mma W/WO Insj Spacer,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,70193.02,N/A,42115.81,N/A,9742.70,N/A,1555.28,N/A,40375.06,N/A,23865.62,N/A,18343.72,N/A,9742.70,N/A,8429.54,N/A,8429.54,N/A,11615.32,N/A,18343.72,N/A,18343.72,N/A,18343.72,N/A,39907.57,N/A,1516.67,N/A,9742.70,N/A,8612.50,N/A,8612.50,N/A,9742.70,N/A,8429.54,N/A,1555.28,N/A,1956.49,N/A,N/A,1516.67,42115.81,,Hospital 27495,Proph Tx N/P/Pltwr W/WO Methylmethacrylate Femur,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57791.28,N/A,34674.77,N/A,8121.39,N/A,1416.50,N/A,33112.97,N/A,19649.02,N/A,17784.84,N/A,8121.39,N/A,1354.15,N/A,1354.15,N/A,11071.40,N/A,17784.84,N/A,17784.84,N/A,17784.84,N/A,33112.98,N/A,1354.15,N/A,8121.39,N/A,9190.25,N/A,9190.25,N/A,8121.39,N/A,1354.15,N/A,1416.50,N/A,2562.89,N/A,N/A,1354.15,34674.77,,Hospital 27507,Optx Fem Shft Fx W/Plate/Screws W/WO Cerclage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42391.53,N/A,25434.92,N/A,5934.80,N/A,925.02,N/A,24160.32,N/A,14413.10,N/A,14503.86,N/A,5934.80,N/A,925.02,N/A,925.02,N/A,9028.93,N/A,14503.86,N/A,14503.86,N/A,14503.86,N/A,24160.31,N/A,925.02,N/A,5934.80,N/A,5963.00,N/A,5963.00,N/A,5934.80,N/A,925.02,N/A,925.02,N/A,1017.52,N/A,N/A,925.02,25434.92,,Hospital 27517,Cltx Dstl Fem Epiphysl Sep W/Manj W/WO Skin/Skel,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 27520,HC Treat Kneecap Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,477.00,N/A,286.20,N/A,66.78,N/A,313.76,N/A,274.66,N/A,162.18,N/A,N/A,N/A,66.78,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,274.66,N/A,296.08,N/A,66.78,N/A,255.67,N/A,255.67,N/A,66.78,N/A,296.08,N/A,313.76,N/A,365.71,N/A,N/A,66.78,365.71,,Hospital 27536,Optx Tibial Fx Prox Bicondylar W/WO Int Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,70082.00,65203.43,42049.20,39122.06,12673.99,9128.48,14286.91,1340.13,33978.96,37258.37,23827.88,22166.78,28228.23,14900.50,N/A,9128.48,372606.00,1338.50,372606.00,1338.50,17571.42,9275.65,28228.23,14900.50,28228.23,14900.50,28228.23,14900.50,33978.96,37258.37,14257.26,1338.50,13064.50,9128.48,N/A,5963.00,33584.55,5963.00,N/A,9128.48,17262.73,1338.50,14286.91,1340.13,13979.01,1270.56,12673.99,372606.00,1270.56,39122.06,,Hospital 27570,HC Manipulatn Knee Jt W/Anesthesia,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,10503.50,N/A,6302.10,N/A,1470.49,N/A,1295.43,N/A,6042.81,N/A,3571.19,N/A,3206.10,N/A,1470.49,N/A,1295.43,N/A,1295.43,N/A,1995.86,N/A,3206.10,N/A,3206.10,N/A,3206.10,N/A,6042.81,N/A,1295.43,N/A,1470.49,N/A,2718.25,N/A,2718.25,N/A,1470.49,N/A,1295.43,N/A,1295.43,N/A,1424.97,N/A,N/A,1295.43,6302.10,,Hospital 27580,Arthrodesis Knee Any Technique,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,128896.60,N/A,77337.96,N/A,18015.87,N/A,7169.27,N/A,73397.26,N/A,43824.84,N/A,30775.34,N/A,18015.87,N/A,7166.78,N/A,7166.78,N/A,19459.92,N/A,30775.34,N/A,30775.34,N/A,30775.34,N/A,73397.25,N/A,7185.61,N/A,18015.87,N/A,8612.50,N/A,8612.50,N/A,18015.87,N/A,7166.78,N/A,7169.27,N/A,1996.52,N/A,N/A,1996.52,77337.96,,Hospital 27596,Amputation Thigh Through Femur Re-Amputation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28855.90,N/A,17313.54,N/A,4035.33,N/A,862.29,N/A,16589.30,N/A,9811.00,N/A,15124.39,N/A,4035.33,N/A,858.69,N/A,858.69,N/A,9415.06,N/A,15124.39,N/A,15124.39,N/A,15124.39,N/A,16589.30,N/A,858.69,N/A,4035.33,N/A,7897.00,N/A,7897.00,N/A,4035.33,N/A,858.69,N/A,862.29,N/A,823.42,N/A,N/A,823.42,17313.54,,Hospital 27605,Tenotomy Prq Achilles Tendon Spx Local Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17757.72,N/A,10654.63,N/A,2486.51,N/A,1349.80,N/A,10143.13,N/A,6037.63,N/A,3143.60,N/A,2486.51,N/A,1299.36,N/A,1299.36,N/A,1956.95,N/A,3143.60,N/A,3143.60,N/A,3143.60,N/A,10143.13,N/A,1299.36,N/A,2486.51,N/A,4332.50,N/A,4332.50,N/A,2486.51,N/A,1299.36,N/A,1349.80,N/A,295.86,N/A,N/A,295.86,10654.63,,Hospital 27607,Incision Leg/Ankle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25910.80,N/A,15546.48,N/A,3554.51,N/A,2811.81,N/A,14916.70,N/A,8809.66,N/A,6595.42,N/A,3554.51,N/A,2688.04,N/A,2688.04,N/A,4109.39,N/A,6595.42,N/A,6595.42,N/A,6595.42,N/A,14916.71,N/A,2688.04,N/A,3554.51,N/A,5095.50,N/A,5095.50,N/A,3554.51,N/A,2688.04,N/A,2811.81,N/A,1158.01,N/A,N/A,1158.01,15546.48,,Hospital 27613,Biopsy Soft Tissue Leg/Ankle Area Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14040.60,N/A,8424.36,N/A,1965.69,N/A,1406.88,N/A,8081.23,N/A,4773.81,N/A,3323.30,N/A,1965.69,N/A,1354.15,N/A,1354.15,N/A,2068.82,N/A,3323.30,N/A,3323.30,N/A,3323.30,N/A,8081.23,N/A,1354.15,N/A,1965.69,N/A,2146.50,N/A,2146.50,N/A,1965.69,N/A,1354.15,N/A,1406.88,N/A,377.28,N/A,N/A,377.28,8424.36,,Hospital 27615,Rad Resection Tumor Soft Tissue Leg/Ankle <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28971.20,N/A,17382.72,N/A,4055.98,N/A,2440.19,N/A,16558.70,N/A,9850.22,N/A,5688.11,N/A,4055.98,N/A,2332.78,N/A,2332.78,N/A,3540.95,N/A,5688.11,N/A,5688.11,N/A,5688.11,N/A,16558.71,N/A,2332.78,N/A,4055.98,N/A,1871.00,N/A,1871.00,N/A,4055.98,N/A,2332.78,N/A,2440.19,N/A,1309.37,N/A,N/A,1309.37,17382.72,,Hospital 27625,Arthrotomy W/Synovectomy Ankle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72702.17,N/A,43621.30,N/A,10162.69,N/A,6262.60,N/A,41575.41,N/A,24718.73,N/A,14501.48,N/A,10162.69,N/A,5973.28,N/A,5973.28,N/A,9027.46,N/A,14501.48,N/A,14501.48,N/A,14501.48,N/A,41575.43,N/A,5973.28,N/A,10162.69,N/A,7200.75,N/A,7200.75,N/A,10162.69,N/A,5973.28,N/A,1224.83,N/A,1347.31,N/A,N/A,1224.83,43621.30,,Hospital 27626,Arthrotomy W/Synovectomy Ankle Tenosynovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40488.52,N/A,24293.11,N/A,5668.39,N/A,646.22,N/A,23233.13,N/A,13766.10,N/A,6608.38,N/A,5668.39,N/A,2688.04,N/A,2688.04,N/A,4113.84,N/A,6608.38,N/A,6608.38,N/A,6608.38,N/A,23233.14,N/A,2688.04,N/A,5668.39,N/A,5277.50,N/A,5277.50,N/A,5668.39,N/A,2688.04,N/A,646.22,N/A,710.84,N/A,N/A,646.22,24293.11,,Hospital 27630,Excision Lesion Tendon Sheath/Capsule Leg&/Ank,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16763.60,N/A,10058.16,N/A,2346.91,N/A,2811.81,N/A,9649.51,N/A,5699.63,N/A,6548.47,N/A,2346.91,N/A,2688.04,N/A,2688.04,N/A,4076.54,N/A,6548.47,N/A,6548.47,N/A,6548.47,N/A,9649.51,N/A,2688.04,N/A,2346.91,N/A,3397.00,N/A,3397.00,N/A,2346.91,N/A,2688.04,N/A,2811.81,N/A,574.52,N/A,N/A,574.52,10058.16,,Hospital 27637,Exc/Curettage Cyst/Tumor Tibia/Fibula W/Agraft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,240877.38,N/A,144526.43,N/A,33727.65,N/A,21185.88,N/A,137460.17,N/A,81898.31,N/A,48469.09,N/A,33727.65,N/A,19924.58,N/A,19924.58,N/A,30368.95,N/A,48469.09,N/A,48469.09,N/A,48469.09,N/A,137093.97,N/A,19947.52,N/A,33727.65,N/A,11318.50,N/A,11318.50,N/A,33727.65,N/A,19924.58,N/A,21185.88,N/A,3255.10,N/A,N/A,3255.10,144526.43,,Hospital 27641,Partial Excision Bone Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24887.23,N/A,14932.34,N/A,3472.85,N/A,1617.23,N/A,14320.68,N/A,8389.26,N/A,6550.39,N/A,3472.85,N/A,2688.04,N/A,2688.04,N/A,4077.74,N/A,6550.39,N/A,6550.39,N/A,6550.39,N/A,14320.69,N/A,2688.04,N/A,3472.85,N/A,7692.25,N/A,7692.25,N/A,3472.85,N/A,2688.04,N/A,1617.23,N/A,1778.96,N/A,N/A,1617.23,14932.34,,Hospital CPT 27652,Rpr Primary Open/Prq Ruptured Achilles W/Graft,N/A,N/A,1368.00,1368.00,820.80,820.80,N/A,191.52,N/A,633.70,N/A,1368.00,N/A,465.12,N/A,1368.00,N/A,191.52,N/A,633.70,N/A,633.70,N/A,1182.50,N/A,1368.00,N/A,1368.00,N/A,1368.00,N/A,1368.00,N/A,633.70,N/A,191.52,N/A,1368.00,N/A,1368.00,N/A,191.52,N/A,633.70,N/A,633.70,N/A,697.07,820.80,820.80,191.52,1368.00,,Hospital 27664,Rpr Extensor Tendon Leg Primary W/O Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49003.80,N/A,29402.28,N/A,6860.54,N/A,6354.28,N/A,28207.38,N/A,16661.30,N/A,14498.41,N/A,6860.54,N/A,5973.28,N/A,5973.28,N/A,9025.53,N/A,14498.41,N/A,14498.41,N/A,14498.41,N/A,28207.38,N/A,5973.28,N/A,6860.54,N/A,5277.50,N/A,5277.50,N/A,6860.54,N/A,5973.28,N/A,6354.28,N/A,437.23,N/A,N/A,437.23,29402.28,,Hospital 27680,Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55052.18,N/A,33031.31,N/A,7707.30,N/A,6178.06,N/A,31511.64,N/A,18717.74,N/A,14476.99,N/A,7707.30,N/A,5973.28,N/A,5973.28,N/A,9012.20,N/A,14476.99,N/A,14476.99,N/A,14476.99,N/A,31511.64,N/A,5973.28,N/A,7707.30,N/A,6260.50,N/A,6260.50,N/A,7707.30,N/A,5973.28,N/A,6178.06,N/A,932.78,N/A,N/A,932.78,33031.31,,Hospital 27685,Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,121316.63,62749.03,72789.98,37649.42,7463.73,8784.87,10640.30,1285.42,66869.73,35677.16,41247.65,21334.41,22924.37,31234.44,7693.70,8784.87,562.00,15808.28,562.00,15808.28,14269.88,19441.16,22924.37,31234.44,22924.37,31234.44,22924.37,31234.44,66869.73,35677.19,10640.30,15808.28,7693.70,8784.87,27274.27,10535.75,27274.27,10535.75,N/A,8784.87,10640.30,15808.28,10640.30,1285.42,8232.26,1413.97,562.00,72789.98,1285.42,37649.42,,Hospital 27686,Lngth/Shrt Tdn Leg/Ankle Mlt Tdn Same Inc Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57766.72,N/A,34660.03,N/A,8087.32,N/A,2811.81,N/A,32958.27,N/A,19640.66,N/A,6589.91,N/A,8087.32,N/A,2688.04,N/A,2688.04,N/A,4102.34,N/A,6589.91,N/A,6589.91,N/A,6589.91,N/A,32958.28,N/A,2688.04,N/A,8087.32,N/A,7983.50,N/A,7983.50,N/A,8087.32,N/A,2688.04,N/A,2811.81,N/A,2904.26,N/A,N/A,2688.04,34660.03,,Hospital 27696,Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62169.23,N/A,37301.54,N/A,8703.70,N/A,6344.61,N/A,35478.41,N/A,21137.54,N/A,14840.37,N/A,8703.70,N/A,6055.29,N/A,6055.29,N/A,9348.84,N/A,14840.37,N/A,14840.37,N/A,14840.37,N/A,35478.44,N/A,6070.79,N/A,8703.70,N/A,7200.75,N/A,7200.75,N/A,8703.70,N/A,6055.29,N/A,1219.56,N/A,1341.52,N/A,N/A,1219.56,37301.54,,Hospital 27700,Arthroplasty Ankle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40897.03,N/A,24538.22,N/A,5725.61,N/A,6248.31,N/A,23477.80,N/A,13905.00,N/A,14560.99,N/A,5725.61,N/A,5973.28,N/A,5973.28,N/A,9064.50,N/A,14560.99,N/A,14560.99,N/A,14560.99,N/A,23477.80,N/A,5973.28,N/A,5725.61,N/A,9793.75,N/A,9793.75,N/A,5725.61,N/A,5973.28,N/A,6248.31,N/A,1915.26,N/A,N/A,1915.26,24538.22,,Hospital 27707,Osteotomy Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,126398.13,N/A,75838.88,N/A,17686.89,N/A,20684.94,N/A,71812.32,N/A,42975.40,N/A,47889.33,N/A,17686.89,N/A,19774.44,N/A,19774.44,N/A,29812.03,N/A,47889.33,N/A,47889.33,N/A,47889.33,N/A,71812.33,N/A,19774.44,N/A,17686.89,N/A,12019.00,N/A,12019.00,N/A,17686.89,N/A,19774.44,N/A,20684.94,N/A,2756.11,N/A,N/A,2756.11,75838.88,,Hospital 27720,Repair Nonunion/Malunion Tibia W/O Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39068.82,N/A,23441.29,N/A,5425.01,N/A,6041.90,N/A,22442.37,N/A,13283.39,N/A,14504.37,N/A,5425.01,N/A,5977.21,N/A,5977.21,N/A,9029.24,N/A,14504.37,N/A,14504.37,N/A,14504.37,N/A,22442.36,N/A,5977.21,N/A,5425.01,N/A,8832.50,N/A,8832.50,N/A,5425.01,N/A,5977.21,N/A,6041.90,N/A,1321.94,N/A,N/A,1321.94,23441.29,,Hospital 27726,Repair Fibula Nonunion/Malunion W/Int Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44356.20,N/A,26613.72,N/A,6181.79,N/A,5921.68,N/A,25293.20,N/A,15081.11,N/A,14503.96,N/A,6181.79,N/A,5973.28,N/A,5973.28,N/A,9028.99,N/A,14503.96,N/A,14503.96,N/A,14503.96,N/A,25293.19,N/A,5973.28,N/A,6181.79,N/A,7897.00,N/A,7897.00,N/A,6181.79,N/A,5973.28,N/A,5921.68,N/A,1041.47,N/A,N/A,1041.47,26613.72,,Hospital 27745,Proph Tx N/P/Pltwr W/WO Methylmethacrylate Tibia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63047.43,N/A,37828.46,N/A,8751.74,N/A,6037.97,N/A,36050.00,N/A,21436.13,N/A,14545.81,N/A,8751.74,N/A,5973.28,N/A,5973.28,N/A,9055.03,N/A,14545.81,N/A,14545.81,N/A,14545.81,N/A,36050.01,N/A,5973.28,N/A,8751.74,N/A,9595.50,N/A,9595.50,N/A,8751.74,N/A,5973.28,N/A,6037.97,N/A,1566.47,N/A,N/A,1566.47,37828.46,,Hospital 27780,HC Cltx Prox Fibula/Shft Fx W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,173882.73,1038.00,104329.64,622.80,14071.49,145.32,N/A,297.15,95844.17,597.67,59120.12,352.92,28835.08,1456.00,N/A,145.32,15258.32,280.41,15258.32,280.41,17949.17,1456.00,N/A,1456.00,N/A,1456.00,28835.08,1456.00,95844.17,597.67,N/A,280.41,13064.50,145.32,34306.55,110.42,34306.55,110.42,8315.94,145.32,15258.32,280.41,15258.32,297.15,13979.01,621.34,8315.94,104329.64,110.42,1456.00,,Hospital CPT 27781,HC Treat Fibula Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3402.00,3402.00,2041.20,2041.20,N/A,476.28,N/A,382.13,N/A,1958.87,N/A,1156.68,N/A,1251.78,N/A,476.28,N/A,382.13,N/A,382.13,N/A,779.23,N/A,1251.78,N/A,1251.78,N/A,1251.78,N/A,1958.87,N/A,382.13,N/A,476.28,N/A,3402.00,N/A,3402.00,N/A,476.28,N/A,382.13,N/A,382.13,N/A,420.34,2041.20,2041.20,382.13,3402.00,,Hospital CPT 27808,HC Treat Ankle Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,749.00,749.00,449.40,449.40,N/A,104.86,N/A,198.10,N/A,431.27,N/A,254.66,N/A,452.19,N/A,104.86,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,431.27,N/A,186.94,N/A,104.86,N/A,749.00,N/A,749.00,N/A,104.86,N/A,186.94,N/A,198.10,N/A,318.87,449.40,449.40,104.86,749.00,,Hospital CPT 27816,HC Treat Ankle Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,552.00,552.00,331.20,331.20,N/A,77.28,N/A,279.19,N/A,317.84,N/A,187.68,N/A,552.00,N/A,77.28,N/A,279.19,N/A,279.19,N/A,552.00,N/A,552.00,N/A,552.00,N/A,552.00,N/A,317.84,N/A,279.19,N/A,77.28,N/A,552.00,N/A,552.00,N/A,77.28,N/A,279.19,N/A,279.19,N/A,307.11,331.20,331.20,77.28,552.00,,Hospital 27822,Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,64145.07,50126.23,38487.04,30075.74,6337.00,7017.67,10785.05,6248.31,30841.40,28756.94,21809.33,17042.92,28228.23,14624.38,6532.25,7017.67,272570.00,5973.28,272570.00,5973.28,17571.42,9103.84,28228.23,14624.38,28228.23,14624.38,28228.23,14624.38,30841.40,28756.95,10755.40,5973.28,6532.25,7017.67,33584.55,12203.25,33584.55,12203.25,3378.87,7017.67,10755.40,5973.28,10785.05,6248.31,6989.51,1796.54,3378.87,272570.00,1796.54,30075.74,,Hospital 27829,Open Tx Distal Tibiofibular Joint Disruption,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,64145.07,58635.87,38487.04,35181.52,6337.00,8209.02,10785.05,1391.61,30841.40,33391.46,N/A,19936.19,28228.23,14502.56,6532.25,8209.02,272570.00,5973.28,272570.00,5973.28,17571.42,9028.12,28228.23,14502.56,28228.23,14502.56,28228.23,14502.56,30841.40,33391.47,10755.40,5973.28,6532.25,8209.02,33584.55,12203.25,33584.55,12203.25,3378.87,8209.02,10755.40,5973.28,10785.05,1391.61,6989.51,1530.77,3378.87,272570.00,1391.61,35181.52,,Hospital CPT 27830,HC Treat Lower Leg Disloc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,342.73,N/A,327.05,N/A,193.12,N/A,568.00,N/A,79.52,N/A,342.73,N/A,342.73,N/A,568.00,N/A,568.00,N/A,568.00,N/A,568.00,N/A,327.05,N/A,342.73,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,342.73,N/A,342.73,N/A,377.00,340.80,340.80,79.52,568.00,,Hospital CPT 27840,HC Closed Tx of Ankle Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,633.00,633.00,379.80,379.80,N/A,88.62,N/A,364.88,N/A,364.48,N/A,215.22,N/A,633.00,N/A,88.62,N/A,364.88,N/A,364.88,N/A,633.00,N/A,633.00,N/A,633.00,N/A,633.00,N/A,364.48,N/A,364.88,N/A,88.62,N/A,633.00,N/A,633.00,N/A,88.62,N/A,364.88,N/A,364.88,N/A,401.37,379.80,379.80,88.62,633.00,,Hospital 27870,Arthrodesis Ankle Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,79908.65,100141.98,47945.19,60085.19,10076.03,14008.52,12214.73,12325.48,40517.50,57178.85,27168.94,34048.27,22924.37,28603.30,10386.49,14008.52,123078.00,11782.94,123078.00,11782.94,14269.88,17806.10,22924.37,28603.30,22924.37,28603.30,22924.37,28603.30,40517.50,57178.86,12185.08,11782.94,10386.49,14008.52,27274.27,8970.25,27274.27,8970.25,N/A,14008.52,11933.08,11782.94,12214.73,12325.48,11113.55,1247.15,10076.03,123078.00,1247.15,60085.19,,Hospital 27886,Amp Leg Thru Tibia&Fibula Re-Amputation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21228.48,N/A,12737.09,N/A,2961.50,N/A,709.30,N/A,12211.78,N/A,7217.69,N/A,14533.07,N/A,2961.50,N/A,709.30,N/A,709.30,N/A,9047.08,N/A,14533.07,N/A,14533.07,N/A,14533.07,N/A,12211.79,N/A,709.30,N/A,2961.50,N/A,7897.00,N/A,7897.00,N/A,2961.50,N/A,709.30,N/A,709.30,N/A,690.58,N/A,N/A,690.58,14533.07,,Hospital 28002,I&D Below Fascia Foot 1 Bursal Space,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26195.07,N/A,15717.04,N/A,3457.16,N/A,838.35,N/A,15067.08,N/A,8906.32,N/A,6559.59,N/A,3457.16,N/A,2688.04,N/A,2688.04,N/A,4083.47,N/A,6559.59,N/A,6559.59,N/A,6559.59,N/A,14856.34,N/A,2688.04,N/A,3457.16,N/A,6618.25,N/A,6618.25,N/A,3457.16,N/A,2688.04,N/A,838.35,N/A,922.21,N/A,N/A,838.35,15717.04,,Hospital 28005,Incision Bone Cortex Foot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29564.00,N/A,17738.40,N/A,4048.63,N/A,2780.20,N/A,17018.92,N/A,10051.77,N/A,6521.59,N/A,4048.63,N/A,2688.04,N/A,2688.04,N/A,4059.80,N/A,6521.59,N/A,6521.59,N/A,6521.59,N/A,17018.92,N/A,2688.04,N/A,4048.63,N/A,4332.50,N/A,4332.50,N/A,4048.63,N/A,2688.04,N/A,2780.20,N/A,943.97,N/A,N/A,943.97,17738.40,,Hospital 28043,Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21930.22,N/A,13158.13,N/A,3070.23,N/A,284.40,N/A,12624.28,N/A,7456.27,N/A,3302.89,N/A,3070.23,N/A,1354.15,N/A,1354.15,N/A,2056.11,N/A,3302.89,N/A,3302.89,N/A,3302.89,N/A,12624.28,N/A,1354.15,N/A,3070.23,N/A,1871.00,N/A,1871.00,N/A,3070.23,N/A,1354.15,N/A,284.40,N/A,312.84,N/A,N/A,284.40,13158.13,,Hospital 28045,Exc Tumor Soft Tissue Foot/Toe Subfasc <1.5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8663.70,N/A,5198.22,N/A,1210.05,N/A,2320.84,N/A,4985.65,N/A,2895.34,N/A,5682.52,N/A,1210.05,N/A,2332.78,N/A,2332.78,N/A,3537.47,N/A,5682.52,N/A,5682.52,N/A,5682.52,N/A,4985.65,N/A,2332.78,N/A,1210.05,N/A,1871.00,N/A,1871.00,N/A,1210.05,N/A,2332.78,N/A,2320.84,N/A,400.68,N/A,N/A,400.68,5682.52,,Hospital 28046,Rad Resection Tumor Soft Tissue Foot/Toe <3cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10540.20,N/A,6324.12,N/A,1476.06,N/A,2427.54,N/A,6068.03,N/A,3583.67,N/A,5665.91,N/A,1476.06,N/A,2336.71,N/A,2336.71,N/A,3527.14,N/A,5665.91,N/A,5665.91,N/A,5665.91,N/A,6068.04,N/A,2336.71,N/A,1476.06,N/A,1871.00,N/A,1871.00,N/A,1476.06,N/A,2336.71,N/A,2427.54,N/A,816.34,N/A,N/A,816.34,6324.12,,Hospital 28055,Neurectomy Intrinsic Musculature of Foot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74636.67,N/A,44782.00,N/A,10449.14,N/A,6248.31,N/A,42472.55,N/A,25376.45,N/A,14487.87,N/A,10449.14,N/A,5973.28,N/A,5973.28,N/A,9018.98,N/A,14487.87,N/A,14487.87,N/A,14487.87,N/A,42472.55,N/A,5973.28,N/A,10449.14,N/A,5944.75,N/A,5944.75,N/A,10449.14,N/A,5973.28,N/A,6248.31,N/A,1253.44,N/A,N/A,1253.44,44782.00,,Hospital CPT 28090,Exc Lesion Tendon Sheath/Capsule W/Synvct Foot,N/A,N/A,790.00,790.00,474.00,474.00,N/A,110.60,N/A,291.50,N/A,790.00,N/A,268.60,N/A,790.00,N/A,110.60,N/A,291.50,N/A,291.50,N/A,790.00,N/A,790.00,N/A,790.00,N/A,790.00,N/A,790.00,N/A,291.50,N/A,110.60,N/A,790.00,N/A,790.00,N/A,110.60,N/A,291.50,N/A,291.50,N/A,320.65,474.00,474.00,110.60,790.00,,Hospital 28092,Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22203.00,N/A,13321.80,N/A,3108.42,N/A,2811.81,N/A,12783.52,N/A,7549.02,N/A,6526.04,N/A,3108.42,N/A,2688.04,N/A,2688.04,N/A,4062.58,N/A,6526.04,N/A,6526.04,N/A,6526.04,N/A,12783.53,N/A,2688.04,N/A,3108.42,N/A,5095.50,N/A,5095.50,N/A,3108.42,N/A,2688.04,N/A,2811.81,N/A,735.65,N/A,N/A,735.65,13321.80,,Hospital 28100,Excision/Curettage Cyst/Tumor Talus/Calcaneus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29464.25,N/A,17678.55,N/A,4124.99,N/A,2780.20,N/A,16947.23,N/A,10017.84,N/A,6557.17,N/A,4124.99,N/A,2688.04,N/A,2688.04,N/A,4081.96,N/A,6557.17,N/A,6557.17,N/A,6557.17,N/A,16947.24,N/A,2688.04,N/A,4124.99,N/A,5095.50,N/A,5095.50,N/A,4124.99,N/A,2688.04,N/A,2780.20,N/A,806.88,N/A,N/A,806.88,17678.55,,Hospital 28113,Ostectomy Complete 5th Metatarsal Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40312.80,N/A,24187.68,N/A,5643.81,N/A,2780.20,N/A,23139.82,N/A,13706.36,N/A,6980.82,N/A,5643.81,N/A,2688.04,N/A,2688.04,N/A,4345.69,N/A,6980.82,N/A,6980.82,N/A,6980.82,N/A,23139.81,N/A,2688.04,N/A,5643.81,N/A,5944.75,N/A,5944.75,N/A,5643.81,N/A,2688.04,N/A,2780.20,N/A,1268.53,N/A,N/A,1268.53,24187.68,,Hospital 28116,Ostectomy Tarsal Coalition,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33565.55,N/A,20139.33,N/A,4690.31,N/A,2811.81,N/A,19150.97,N/A,11412.28,N/A,6529.48,N/A,4690.31,N/A,2688.04,N/A,2688.04,N/A,4064.72,N/A,6529.48,N/A,6529.48,N/A,6529.48,N/A,19150.97,N/A,2688.04,N/A,4690.31,N/A,3397.00,N/A,3397.00,N/A,4690.31,N/A,2688.04,N/A,2811.81,N/A,621.63,N/A,N/A,621.63,20139.33,,Hospital 28118,Ostectomy Calcaneus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47536.65,N/A,28521.99,N/A,6643.76,N/A,2331.45,N/A,27121.98,N/A,16147.16,N/A,14524.49,N/A,6643.76,N/A,5973.28,N/A,5973.28,N/A,9041.78,N/A,14524.49,N/A,14524.49,N/A,14524.49,N/A,27122.00,N/A,5973.28,N/A,6643.76,N/A,10085.00,N/A,10085.00,N/A,6643.76,N/A,5973.28,N/A,2331.45,N/A,2564.61,N/A,N/A,2331.45,28521.99,,Hospital 28130,Talectomy Astragalectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,121316.63,N/A,72789.98,N/A,7463.73,N/A,10640.30,N/A,66869.73,N/A,41247.65,N/A,22924.37,N/A,7693.70,N/A,562.00,N/A,562.00,N/A,14269.88,N/A,22924.37,N/A,22924.37,N/A,22924.37,N/A,66869.73,N/A,10640.30,N/A,7693.70,N/A,27274.27,N/A,27274.27,N/A,N/A,N/A,10640.30,N/A,10640.30,N/A,8232.26,N/A,562.00,72789.98,N/A,N/A,,Hospital 28140,Metatarsectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17660.67,N/A,10596.40,N/A,2471.57,N/A,663.89,N/A,10166.65,N/A,6004.62,N/A,6518.58,N/A,2471.57,N/A,2688.04,N/A,2688.04,N/A,4057.94,N/A,6518.58,N/A,6518.58,N/A,6518.58,N/A,10166.65,N/A,2688.04,N/A,2471.57,N/A,5095.50,N/A,5095.50,N/A,2471.57,N/A,2688.04,N/A,663.89,N/A,730.29,N/A,N/A,663.89,10596.40,,Hospital 28150,Phalangectomy Toe Each Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14396.37,N/A,8637.82,N/A,2013.66,N/A,307.81,N/A,8286.72,N/A,4894.77,N/A,6522.62,N/A,2013.66,N/A,2688.04,N/A,2688.04,N/A,4060.46,N/A,6522.62,N/A,6522.62,N/A,6522.62,N/A,8286.73,N/A,2688.04,N/A,2013.66,N/A,3397.00,N/A,3397.00,N/A,2013.66,N/A,2688.04,N/A,307.81,N/A,338.60,N/A,N/A,307.81,8637.82,,Hospital 28175,Radical Resection Tumor Phalanx or Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20918.30,N/A,12550.98,N/A,2928.56,N/A,1378.06,N/A,12041.47,N/A,7112.22,N/A,3154.91,N/A,2928.56,N/A,1295.43,N/A,1295.43,N/A,1963.98,N/A,3154.91,N/A,3154.91,N/A,3154.91,N/A,12041.48,N/A,1295.43,N/A,2928.56,N/A,3397.00,N/A,3397.00,N/A,2928.56,N/A,1295.43,N/A,1378.06,N/A,561.91,N/A,N/A,561.91,12550.98,,Hospital 28226,Tenolysis Extensor Foot Multiple Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59542.23,N/A,35725.34,N/A,8409.52,N/A,6205.85,N/A,33983.73,N/A,20244.33,N/A,14491.33,N/A,8409.52,N/A,5973.28,N/A,5973.28,N/A,9021.13,N/A,14491.33,N/A,14491.33,N/A,14491.33,N/A,33983.73,N/A,5973.28,N/A,8409.52,N/A,13819.75,N/A,13819.75,N/A,8409.52,N/A,5973.28,N/A,6205.85,N/A,3548.41,N/A,N/A,3548.41,35725.34,,Hospital 28232,HC Incision of Toe Tendon,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,26170.82,N/A,15702.49,N/A,3663.90,N/A,2811.81,N/A,15064.83,N/A,8898.10,N/A,6559.29,N/A,3663.90,N/A,2688.04,N/A,2688.04,N/A,4083.29,N/A,6559.29,N/A,6559.29,N/A,6559.29,N/A,15064.84,N/A,2688.04,N/A,3663.90,N/A,5944.75,N/A,5944.75,N/A,3663.90,N/A,2688.04,N/A,2811.81,N/A,1707.65,N/A,N/A,1707.65,15702.49,,Hospital CPT 28234,HC Tenotomy Open Extensor Foot/Toe Each Tendon,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3922.00,3922.00,2353.20,2353.20,N/A,549.08,N/A,251.32,N/A,2258.29,N/A,1333.48,N/A,1125.69,N/A,549.08,N/A,251.32,N/A,251.32,N/A,700.74,N/A,1125.69,N/A,1125.69,N/A,1125.69,N/A,2258.29,N/A,251.32,N/A,549.08,N/A,3922.00,N/A,3922.00,N/A,549.08,N/A,251.32,N/A,251.32,N/A,276.45,2353.20,2353.20,251.32,3922.00,,Hospital 28270,Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44499.32,N/A,26699.59,N/A,6229.91,N/A,892.37,N/A,25273.95,N/A,15129.77,N/A,14537.23,N/A,6229.91,N/A,5973.28,N/A,5973.28,N/A,9049.71,N/A,14537.23,N/A,14537.23,N/A,14537.23,N/A,25273.96,N/A,5973.28,N/A,6229.91,N/A,9595.50,N/A,9595.50,N/A,6229.91,N/A,5973.28,N/A,892.37,N/A,981.61,N/A,N/A,892.37,26699.59,,Hospital CPT 28285,Correction Hammertoe,N/A,N/A,890.00,890.00,534.00,534.00,N/A,124.60,N/A,363.83,N/A,890.00,N/A,302.60,N/A,890.00,N/A,124.60,N/A,363.83,N/A,363.83,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,363.83,N/A,124.60,N/A,890.00,N/A,890.00,N/A,124.60,N/A,363.83,N/A,363.83,N/A,400.21,534.00,534.00,124.60,890.00,,Hospital 28286,Correction Cock-Up 5th Toe W/Plastic Closure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9317.70,N/A,5590.62,N/A,1304.48,N/A,2664.83,N/A,5363.84,N/A,3168.02,N/A,6515.48,N/A,1304.48,N/A,2688.04,N/A,2688.04,N/A,4056.00,N/A,6515.48,N/A,6515.48,N/A,6515.48,N/A,5363.84,N/A,2688.04,N/A,1304.48,N/A,3397.00,N/A,3397.00,N/A,1304.48,N/A,2688.04,N/A,2664.83,N/A,348.61,N/A,N/A,348.61,6515.48,,Hospital 28289,Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22638.23,N/A,13582.94,N/A,3167.52,N/A,849.39,N/A,13034.14,N/A,7697.00,N/A,6510.91,N/A,3167.52,N/A,2688.04,N/A,2688.04,N/A,4053.17,N/A,6510.91,N/A,6510.91,N/A,6510.91,N/A,13034.15,N/A,2688.04,N/A,3167.52,N/A,3397.00,N/A,3397.00,N/A,3167.52,N/A,2688.04,N/A,849.39,N/A,934.34,N/A,N/A,849.39,13582.94,,Hospital 28291,Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48856.65,N/A,29313.99,N/A,6839.92,N/A,6132.82,N/A,27855.28,N/A,16611.25,N/A,14518.77,N/A,6839.92,N/A,5973.28,N/A,5973.28,N/A,9038.20,N/A,14518.77,N/A,14518.77,N/A,14518.77,N/A,27855.28,N/A,5973.28,N/A,6839.92,N/A,10535.75,N/A,10535.75,N/A,6839.92,N/A,5973.28,N/A,6132.82,N/A,1242.33,N/A,N/A,1242.33,29313.99,,Hospital 28292,Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26965.13,N/A,16179.08,N/A,3775.12,N/A,498.16,N/A,15409.72,N/A,9168.14,N/A,6562.56,N/A,3775.12,N/A,2688.04,N/A,2688.04,N/A,4085.32,N/A,6562.56,N/A,6562.56,N/A,6562.56,N/A,15409.72,N/A,2688.04,N/A,3775.12,N/A,5277.50,N/A,5277.50,N/A,3775.12,N/A,2688.04,N/A,498.16,N/A,547.98,N/A,N/A,498.16,16179.08,,Hospital 28307,Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59051.08,N/A,35430.65,N/A,8267.17,N/A,6248.31,N/A,33786.42,N/A,20077.39,N/A,14489.73,N/A,8267.17,N/A,5973.28,N/A,5973.28,N/A,9020.14,N/A,14489.73,N/A,14489.73,N/A,14489.73,N/A,33786.44,N/A,5973.28,N/A,8267.17,N/A,5944.75,N/A,5944.75,N/A,8267.17,N/A,5973.28,N/A,6248.31,N/A,1365.59,N/A,N/A,1365.59,35430.65,,Hospital 28310,Osteot Shrt Corrj Prox Phalanx 1st Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,75832.13,N/A,45499.28,N/A,10607.65,N/A,12325.48,N/A,43071.02,N/A,25782.92,N/A,28577.50,N/A,10607.65,N/A,11782.94,N/A,11782.94,N/A,17790.04,N/A,28577.50,N/A,28577.50,N/A,28577.50,N/A,43071.03,N/A,11782.94,N/A,10607.65,N/A,6260.50,N/A,6260.50,N/A,10607.65,N/A,11782.94,N/A,12325.48,N/A,1019.99,N/A,N/A,1019.99,45499.28,,Hospital 28313,Rcnstj Angular Dfrm Toe Soft Tiss Px Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49137.67,N/A,29482.60,N/A,6879.28,N/A,1378.26,N/A,28050.67,N/A,16706.80,N/A,28544.58,N/A,6879.28,N/A,11782.94,N/A,11782.94,N/A,17769.55,N/A,28544.58,N/A,28544.58,N/A,28544.58,N/A,28050.67,N/A,11782.94,N/A,6879.28,N/A,10444.75,N/A,10444.75,N/A,6879.28,N/A,11782.94,N/A,1378.26,N/A,1516.09,N/A,N/A,1378.26,29482.60,,Hospital 28315,Sesamoidectomy First Toe Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,57072.05,25021.80,34243.23,15013.08,11201.10,3490.76,13515.98,2788.06,30276.31,14402.84,19404.49,8507.42,25484.06,6527.01,11546.23,3490.76,2810.00,2695.90,2810.00,2695.90,N/A,4063.20,25484.06,6527.01,25484.06,6527.01,25484.06,6527.01,30276.31,14402.84,13515.98,2695.90,11546.23,3490.76,30319.67,5095.50,30319.67,5095.50,N/A,3490.76,13515.98,2695.90,13515.98,2788.06,N/A,426.29,2810.00,34243.23,426.29,15013.08,,Hospital 28456,Prq Skel Fixj Tarsl Fx Xcp Talus&Calcns W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41614.88,N/A,24968.93,N/A,5826.07,N/A,6037.97,N/A,23911.26,N/A,14149.03,N/A,14561.51,N/A,5826.07,N/A,5973.28,N/A,5973.28,N/A,9064.82,N/A,14561.51,N/A,14561.51,N/A,14561.51,N/A,23911.26,N/A,5973.28,N/A,5826.07,N/A,9953.25,N/A,9953.25,N/A,5826.07,N/A,5973.28,N/A,6037.97,N/A,2093.89,N/A,N/A,2093.89,24968.93,,Hospital 28470,HC Closed Tx Metatarsal Fracture W/O Manipulation,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,685.00,N/A,411.00,N/A,95.90,N/A,313.76,N/A,394.42,N/A,232.90,N/A,N/A,N/A,95.90,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,394.42,N/A,296.08,N/A,95.90,N/A,105.59,N/A,105.59,N/A,95.90,N/A,296.08,N/A,313.76,N/A,238.22,N/A,N/A,95.90,411.00,,Hospital 28475,Cltx Metar Fx W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81012.03,N/A,48607.22,N/A,11333.49,N/A,1288.36,N/A,46178.33,N/A,27544.10,N/A,14520.32,N/A,11333.49,N/A,5973.28,N/A,5973.28,N/A,9039.19,N/A,14520.32,N/A,14520.32,N/A,14520.32,N/A,46178.33,N/A,5973.28,N/A,11333.49,N/A,8744.25,N/A,8744.25,N/A,11333.49,N/A,5973.28,N/A,1288.36,N/A,1417.21,N/A,N/A,1288.36,48607.22,,Hospital 28476,Prq Skel Fixj Metar Fx W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18863.53,N/A,11318.12,N/A,2634.03,N/A,2688.04,N/A,10802.50,N/A,6413.61,N/A,6533.32,N/A,2634.03,N/A,2688.04,N/A,2688.04,N/A,4067.11,N/A,6533.32,N/A,6533.32,N/A,6533.32,N/A,10802.50,N/A,2688.04,N/A,2634.03,N/A,4332.50,N/A,4332.50,N/A,2634.03,N/A,2688.04,N/A,2688.04,N/A,2956.85,N/A,N/A,2634.03,11318.12,,Hospital 28510,HC Cltx Fx Phlx/Phlg Oth/Thn Grt Toe W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,3394.00,N/A,2036.40,N/A,475.16,N/A,198.86,N/A,1954.27,N/A,1153.96,N/A,N/A,N/A,475.16,N/A,186.94,N/A,186.94,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1954.27,N/A,186.94,N/A,475.16,N/A,324.28,N/A,324.28,N/A,475.16,N/A,186.94,N/A,198.86,N/A,148.20,N/A,N/A,148.20,2036.40,,Hospital 28530,Closed Treatment Sesamoid Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35424.00,N/A,21254.40,N/A,4988.29,N/A,1105.62,N/A,20297.61,N/A,12044.16,N/A,2686.68,N/A,4988.29,N/A,1111.04,N/A,1111.04,N/A,1672.49,N/A,2686.68,N/A,2686.68,N/A,2686.68,N/A,20297.61,N/A,1111.04,N/A,4988.29,N/A,2278.25,N/A,2278.25,N/A,4988.29,N/A,1111.04,N/A,1105.62,N/A,325.38,N/A,N/A,325.38,21254.40,,Hospital 28585,Open Treatment Talotarsal Joint Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,184766.17,N/A,110859.70,N/A,25867.25,N/A,14381.93,N/A,104864.26,N/A,62820.48,N/A,28530.92,N/A,25867.25,N/A,14314.12,N/A,14314.12,N/A,17761.05,N/A,28530.92,N/A,28530.92,N/A,28530.92,N/A,104864.27,N/A,14314.12,N/A,25867.25,N/A,13819.75,N/A,13819.75,N/A,25867.25,N/A,14314.12,N/A,14381.93,N/A,3420.49,N/A,N/A,3420.49,110859.70,,Hospital 28605,Closed Tx Tarsometatarsal Dislocation W/Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33138.13,N/A,19882.88,N/A,4639.33,N/A,5942.72,N/A,19026.15,N/A,11266.98,N/A,14570.22,N/A,4639.33,N/A,5973.28,N/A,5973.28,N/A,9070.23,N/A,14570.22,N/A,14570.22,N/A,14570.22,N/A,19026.15,N/A,5973.28,N/A,4639.33,N/A,12203.25,N/A,12203.25,N/A,4639.33,N/A,5973.28,N/A,5942.72,N/A,2284.63,N/A,N/A,2284.63,19882.88,,Hospital 28635,Cltx Metatarsophlngl Jt Dislc Req Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6838.60,N/A,4103.16,N/A,957.41,N/A,1284.24,N/A,3932.62,N/A,2325.13,N/A,3196.10,N/A,957.41,N/A,1295.43,N/A,1295.43,N/A,1989.63,N/A,3196.10,N/A,3196.10,N/A,3196.10,N/A,3932.63,N/A,1295.43,N/A,957.41,N/A,1871.00,N/A,1871.00,N/A,957.41,N/A,1295.43,N/A,1284.24,N/A,138.75,N/A,N/A,138.75,4103.16,,Hospital 28636,Prq Skel Fixj Metatarsophlngl Jt Dislc W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11627.90,N/A,6976.74,N/A,1591.82,N/A,2664.83,N/A,6693.65,N/A,3898.07,N/A,6522.05,N/A,1591.82,N/A,2688.04,N/A,2688.04,N/A,4060.10,N/A,6522.05,N/A,6522.05,N/A,6522.05,N/A,6693.65,N/A,2688.04,N/A,1591.82,N/A,3397.00,N/A,3397.00,N/A,1591.82,N/A,2688.04,N/A,2664.83,N/A,322.00,N/A,N/A,322.00,6976.74,,Hospital 28645,Open Tx Metatarsophalangeal Joint Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58876.92,N/A,35326.15,N/A,8242.77,N/A,2811.81,N/A,33540.96,N/A,20018.14,N/A,6518.22,N/A,8242.77,N/A,2688.04,N/A,2688.04,N/A,4057.71,N/A,6518.22,N/A,6518.22,N/A,6518.22,N/A,33540.97,N/A,2688.04,N/A,8242.77,N/A,5563.25,N/A,5563.25,N/A,8242.77,N/A,2688.04,N/A,2811.81,N/A,1200.64,N/A,N/A,1200.64,35326.15,,Hospital 28666,Prq Skel Fixj Interphalangeal Joint Dislc W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21166.30,N/A,12699.78,N/A,2984.20,N/A,2811.81,N/A,12186.14,N/A,7196.55,N/A,6525.11,N/A,2984.20,N/A,2688.04,N/A,2688.04,N/A,4062.00,N/A,6525.11,N/A,6525.11,N/A,6525.11,N/A,12186.15,N/A,2688.04,N/A,2984.20,N/A,3397.00,N/A,3397.00,N/A,2984.20,N/A,2688.04,N/A,2811.81,N/A,274.13,N/A,N/A,274.13,12699.78,,Hospital 28725,Arthrodesis Subtalar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,148398.15,122657.67,89038.89,73594.60,N/A,17172.09,N/A,12325.48,81797.06,69825.76,50455.37,41703.64,N/A,28599.32,10386.49,17172.09,N/A,11782.94,38567.78,11782.94,N/A,17803.62,N/A,28599.32,N/A,28599.32,N/A,28599.32,81797.06,69825.77,N/A,11782.94,10386.49,17172.09,35211.62,12986.00,35211.62,12986.00,3861.24,17172.09,38567.78,11782.94,N/A,12325.48,11113.55,2552.80,3861.24,89038.89,2552.80,73594.60,,Hospital 28740,Arthrodesis Midtarsometatarsal Single Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,127109.15,N/A,76265.49,N/A,17785.41,N/A,1081.12,N/A,72163.64,N/A,42562.95,N/A,14496.67,N/A,17785.41,N/A,9580.75,N/A,9580.75,N/A,9024.45,N/A,14496.67,N/A,14496.67,N/A,14496.67,N/A,72163.64,N/A,9580.75,N/A,17785.41,N/A,10535.75,N/A,10535.75,N/A,17785.41,N/A,9580.75,N/A,1081.12,N/A,1189.24,N/A,N/A,1081.12,76265.49,,Hospital 28805,Amputation Foot Transmetarsal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28818.30,N/A,17290.98,N/A,4024.43,N/A,2811.81,N/A,16588.97,N/A,9798.22,N/A,6567.21,N/A,4024.43,N/A,2688.04,N/A,2688.04,N/A,4088.21,N/A,6567.21,N/A,6567.21,N/A,6567.21,N/A,16588.97,N/A,2688.04,N/A,4024.43,N/A,3397.00,N/A,3397.00,N/A,4024.43,N/A,2688.04,N/A,2811.81,N/A,969.23,N/A,N/A,969.23,17290.98,,Hospital CPT 28825,"HC Amputation Partial,Toe,IP Jnt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,11389.00,11389.00,6833.40,6833.40,N/A,1594.46,N/A,168.25,N/A,6557.79,N/A,3872.26,N/A,816.03,N/A,1594.46,N/A,168.25,N/A,168.25,N/A,507.98,N/A,816.03,N/A,816.03,N/A,816.03,N/A,6557.79,N/A,168.25,N/A,1594.46,N/A,11389.00,N/A,11389.00,N/A,1594.46,N/A,168.25,N/A,168.25,N/A,185.08,6833.40,6833.40,168.25,11389.00,,Hospital CPT 29105,HC Splint Appl Long Arm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1079.00,1079.00,647.40,647.40,N/A,151.06,N/A,133.05,N/A,621.29,N/A,366.86,N/A,318.39,N/A,151.06,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,621.29,N/A,131.63,N/A,151.06,N/A,1079.00,N/A,1079.00,N/A,151.06,N/A,131.63,N/A,139.49,N/A,44.12,647.40,647.40,44.12,1079.00,,Hospital CPT 29260,HC Strapping Elbow/Wrist,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,113.00,113.00,67.80,67.80,N/A,15.82,N/A,18.85,N/A,65.07,N/A,38.42,N/A,83.13,N/A,15.82,N/A,18.85,N/A,18.85,N/A,51.75,N/A,83.13,N/A,83.13,N/A,83.13,N/A,65.07,N/A,18.85,N/A,15.82,N/A,113.00,N/A,113.00,N/A,15.82,N/A,18.85,N/A,18.85,N/A,20.74,67.80,67.80,15.82,113.00,,Hospital CPT 29540,HC Strapping Ankle/Foot,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,455.00,455.00,273.00,273.00,N/A,63.70,N/A,137.69,N/A,261.99,N/A,154.70,N/A,318.39,N/A,63.70,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,261.99,N/A,131.63,N/A,63.70,N/A,455.00,N/A,455.00,N/A,63.70,N/A,131.63,N/A,137.69,N/A,19.09,273.00,273.00,19.09,455.00,,Hospital CPT 29581,"HC Application,Multlayer Wrap Uni",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5035.00,5035.00,3021.00,3021.00,N/A,704.90,N/A,131.63,N/A,2899.15,N/A,1711.90,N/A,318.39,N/A,704.90,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,2899.15,N/A,131.63,N/A,704.90,N/A,527.00,N/A,527.00,N/A,704.90,N/A,131.63,N/A,131.63,N/A,144.79,3021.00,3021.00,131.63,3021.00,,Hospital CPT 29806,Surgical Arthroscopy Shoulder Capsulorrhaphy,N/A,N/A,2122.00,2122.00,1273.20,1273.20,N/A,297.08,N/A,1009.73,N/A,2122.00,N/A,721.48,N/A,2122.00,N/A,297.08,N/A,1009.73,N/A,1009.73,N/A,2122.00,N/A,2122.00,N/A,2122.00,N/A,2122.00,N/A,2122.00,N/A,1009.73,N/A,297.08,N/A,2122.00,N/A,2122.00,N/A,297.08,N/A,1009.73,N/A,1009.73,N/A,1110.70,1273.20,1273.20,297.08,2122.00,,Hospital CPT 29822,Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,N/A,N/A,1126.00,1126.00,675.60,675.60,N/A,157.64,N/A,514.61,N/A,1126.00,N/A,382.84,N/A,1126.00,N/A,157.64,N/A,514.61,N/A,514.61,N/A,1126.00,N/A,1126.00,N/A,1126.00,N/A,1126.00,N/A,1126.00,N/A,514.61,N/A,157.64,N/A,1126.00,N/A,1126.00,N/A,157.64,N/A,514.61,N/A,514.61,N/A,566.07,675.60,675.60,157.64,1126.00,,Hospital CPT 29824,Surgical Arthroscopy Shoulder Dstl Claviculc,N/A,N/A,1324.00,1324.00,794.40,794.40,N/A,185.36,N/A,644.09,N/A,1324.00,N/A,450.16,N/A,1324.00,N/A,185.36,N/A,644.09,N/A,644.09,N/A,1324.00,N/A,1324.00,N/A,1324.00,N/A,1324.00,N/A,1324.00,N/A,644.09,N/A,185.36,N/A,1324.00,N/A,1324.00,N/A,185.36,N/A,644.09,N/A,644.09,N/A,708.50,794.40,794.40,185.36,1324.00,,Hospital 29825,Surgical Arthroscopy Shoulder W/Lss&Rescj Ads,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32489.12,N/A,19493.47,N/A,4545.89,N/A,1502.96,N/A,11735.00,N/A,11046.30,N/A,14575.26,N/A,4545.89,N/A,5973.28,N/A,5973.28,N/A,9073.37,N/A,14575.26,N/A,14575.26,N/A,14575.26,N/A,11735.00,N/A,5973.28,N/A,4545.89,N/A,12203.25,N/A,12203.25,N/A,4545.89,N/A,5973.28,N/A,1502.96,N/A,1653.27,N/A,N/A,1502.96,19493.47,,Hospital 29828,Surgical Arthroscopy Shoulder Biceps Tenodesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27735.32,N/A,16641.19,N/A,3882.94,N/A,5973.28,N/A,11735.00,N/A,9430.00,N/A,14680.00,N/A,3882.94,N/A,5973.28,N/A,5973.28,N/A,9138.56,N/A,14680.00,N/A,14680.00,N/A,14680.00,N/A,11735.00,N/A,5973.28,N/A,3882.94,N/A,12203.25,N/A,12203.25,N/A,3882.94,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,3882.94,16641.19,,Hospital 29836,Arthroscopy Elbow Surgical Synovectomy Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44990.67,N/A,26994.40,N/A,6298.72,N/A,6248.31,N/A,25888.08,N/A,15296.82,N/A,14959.73,N/A,6298.72,N/A,5973.28,N/A,5973.28,N/A,9312.71,N/A,14959.73,N/A,14959.73,N/A,14959.73,N/A,25888.09,N/A,5973.28,N/A,6298.72,N/A,11318.50,N/A,11318.50,N/A,6298.72,N/A,5973.28,N/A,6248.31,N/A,1816.47,N/A,N/A,1816.47,26994.40,,Hospital 29840,Arthroscopy Wrist Diag W/WO Synovial Biopsy Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35024.57,N/A,21014.74,N/A,10965.85,N/A,13060.69,N/A,25513.09,N/A,11908.36,N/A,25757.14,N/A,11303.72,N/A,271446.00,N/A,271446.00,N/A,16033.22,N/A,25757.14,N/A,25757.14,N/A,25757.14,N/A,25513.09,N/A,13031.04,N/A,11303.72,N/A,30644.57,N/A,30644.57,N/A,2987.65,N/A,13031.04,N/A,13060.69,N/A,12094.98,N/A,2987.65,271446.00,N/A,N/A,,Hospital 29844,Arthroscopy Wrist Surgical Synovectomy Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32251.10,N/A,19350.66,N/A,4515.15,N/A,6132.82,N/A,18543.41,N/A,10965.37,N/A,14492.93,N/A,4515.15,N/A,5973.28,N/A,5973.28,N/A,9022.12,N/A,14492.93,N/A,14492.93,N/A,14492.93,N/A,18543.42,N/A,5973.28,N/A,4515.15,N/A,8601.75,N/A,8601.75,N/A,4515.15,N/A,5973.28,N/A,6132.82,N/A,1615.63,N/A,N/A,1615.63,19350.66,,Hospital 29845,Arthroscopy Wrist Surgical Synovectomy Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25299.80,N/A,15179.88,N/A,3541.97,N/A,642.58,N/A,14561.33,N/A,8601.93,N/A,6552.22,N/A,3541.97,N/A,2688.04,N/A,2688.04,N/A,4078.89,N/A,6552.22,N/A,6552.22,N/A,6552.22,N/A,14561.34,N/A,2688.04,N/A,3541.97,N/A,5277.50,N/A,5277.50,N/A,3541.97,N/A,2688.04,N/A,642.58,N/A,706.84,N/A,N/A,642.58,15179.88,,Hospital 29846,Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21264.50,N/A,12758.70,N/A,2977.03,N/A,2664.83,N/A,12241.38,N/A,7229.93,N/A,6540.57,N/A,2977.03,N/A,2688.04,N/A,2688.04,N/A,4071.63,N/A,6540.57,N/A,6540.57,N/A,6540.57,N/A,12241.37,N/A,2688.04,N/A,2977.03,N/A,4562.00,N/A,4562.00,N/A,2977.03,N/A,2688.04,N/A,2664.83,N/A,546.38,N/A,N/A,546.38,12758.70,,Hospital 29867,Arthroscopy Knee Osteochondral Allograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49052.43,N/A,29431.46,N/A,6851.73,N/A,12997.98,N/A,7823.00,N/A,16677.83,N/A,28535.16,N/A,6851.73,N/A,11782.94,N/A,11782.94,N/A,17763.69,N/A,28535.16,N/A,28535.16,N/A,28535.16,N/A,7823.00,N/A,11782.94,N/A,6851.73,N/A,12203.25,N/A,12203.25,N/A,6851.73,N/A,11782.94,N/A,1955.60,N/A,2151.16,N/A,N/A,1955.60,29431.46,,Hospital 29870,Arthroscopy Knee Diagnostic W/WO Synovial Bx Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32152.00,N/A,19291.20,N/A,4501.28,N/A,2811.81,N/A,7823.00,N/A,10931.68,N/A,6554.96,N/A,4501.28,N/A,2688.04,N/A,2688.04,N/A,4080.59,N/A,6554.96,N/A,6554.96,N/A,6554.96,N/A,7823.00,N/A,2688.04,N/A,4501.28,N/A,6843.00,N/A,6843.00,N/A,4501.28,N/A,2688.04,N/A,2811.81,N/A,923.72,N/A,N/A,923.72,19291.20,,Hospital CPT 29880,Arthrs Knee W/Meniscectomy Med&Lat W/Shaving,N/A,N/A,1118.00,1118.00,670.80,670.80,N/A,156.52,N/A,534.47,N/A,1118.00,N/A,380.12,N/A,1118.00,N/A,156.52,N/A,534.47,N/A,534.47,N/A,996.11,N/A,1118.00,N/A,1118.00,N/A,1118.00,N/A,1118.00,N/A,534.47,N/A,156.52,N/A,1118.00,N/A,1118.00,N/A,156.52,N/A,534.47,N/A,534.47,N/A,587.92,670.80,670.80,156.52,1118.00,,Hospital CPT 29888,Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj,N/A,N/A,1971.00,1971.00,1182.60,1182.60,N/A,275.94,N/A,932.57,N/A,1971.00,N/A,670.14,N/A,1971.00,N/A,275.94,N/A,932.57,N/A,932.57,N/A,1729.85,N/A,1971.00,N/A,1971.00,N/A,1971.00,N/A,1971.00,N/A,932.57,N/A,275.94,N/A,1971.00,N/A,1971.00,N/A,275.94,N/A,932.57,N/A,932.57,N/A,1025.83,1182.60,1182.60,275.94,1971.00,,Hospital 29889,Arthrs Aided Pst Cruciate Ligm Rpr/Agmntj/Rcnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,139236.73,N/A,83542.04,N/A,19484.31,N/A,12325.48,N/A,7823.00,N/A,47340.49,N/A,28645.67,N/A,19484.31,N/A,11782.94,N/A,11782.94,N/A,17834.53,N/A,28645.67,N/A,28645.67,N/A,28645.67,N/A,7823.00,N/A,11782.94,N/A,19484.31,N/A,12986.00,N/A,12986.00,N/A,19484.31,N/A,11782.94,N/A,12325.48,N/A,2818.85,N/A,N/A,2818.85,83542.04,,Hospital 29892,Arthrs Aid Rpr Les/Talar Dome Fx/Tibl Plafond Fx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61590.37,N/A,36954.22,N/A,8622.67,N/A,6205.85,N/A,35250.36,N/A,20940.72,N/A,14557.71,N/A,8622.67,N/A,5973.28,N/A,5973.28,N/A,9062.45,N/A,14557.71,N/A,14557.71,N/A,14557.71,N/A,35250.37,N/A,5973.28,N/A,8622.67,N/A,10085.00,N/A,10085.00,N/A,8622.67,N/A,5973.28,N/A,6205.85,N/A,1912.36,N/A,N/A,1912.36,36954.22,,Hospital 29894,Arthroscopy Ankle W/Removal Loose/Foreign Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26247.13,N/A,15748.28,N/A,3668.24,N/A,2688.04,N/A,15101.47,N/A,8924.01,N/A,6543.91,N/A,3668.24,N/A,2688.04,N/A,2688.04,N/A,4073.72,N/A,6543.91,N/A,6543.91,N/A,6543.91,N/A,15101.47,N/A,2688.04,N/A,3668.24,N/A,7200.75,N/A,7200.75,N/A,3668.24,N/A,2688.04,N/A,2688.04,N/A,2956.85,N/A,N/A,2688.04,15748.28,,Hospital 29906,Arthroscopy Subtalar Joint With Debridement,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48141.63,N/A,28884.98,N/A,6739.84,N/A,1808.56,N/A,27503.51,N/A,16367.89,N/A,14528.36,N/A,6739.84,N/A,5973.28,N/A,5973.28,N/A,9044.17,N/A,14528.36,N/A,14528.36,N/A,14528.36,N/A,27503.52,N/A,5973.28,N/A,6739.84,N/A,7692.25,N/A,7692.25,N/A,6739.84,N/A,5973.28,N/A,1808.56,N/A,1989.42,N/A,N/A,1808.56,28884.98,,Hospital CPT 30020,HC Drainage Abscess or Hematoma Nasal Septum,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3191.00,3191.00,1914.60,1914.60,N/A,446.74,N/A,114.65,N/A,1837.38,N/A,1084.94,N/A,747.69,N/A,446.74,N/A,114.65,N/A,114.65,N/A,465.44,N/A,747.69,N/A,747.69,N/A,747.69,N/A,1837.38,N/A,114.65,N/A,446.74,N/A,3191.00,N/A,3191.00,N/A,446.74,N/A,114.65,N/A,114.65,N/A,126.12,1914.60,1914.60,114.65,3191.00,,Hospital 30120,Excision/Surgical Planing Skin Nose Rhinophyma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51670.28,N/A,31002.17,N/A,7233.93,N/A,2733.05,N/A,29500.88,N/A,17567.92,N/A,6252.74,N/A,7233.93,N/A,2569.18,N/A,2569.18,N/A,3892.45,N/A,6252.74,N/A,6252.74,N/A,6252.74,N/A,29500.89,N/A,2569.18,N/A,7233.93,N/A,4800.25,N/A,4800.25,N/A,7233.93,N/A,2569.18,N/A,2733.05,N/A,1582.94,N/A,N/A,1582.94,31002.17,,Hospital CPT 30140,Submucous Rescj Inferior Turbinate Prtl/Compl,N/A,N/A,846.00,846.00,507.60,507.60,N/A,118.44,N/A,170.27,N/A,846.00,N/A,287.64,N/A,832.92,N/A,118.44,N/A,170.27,N/A,170.27,N/A,518.49,N/A,832.92,N/A,832.92,N/A,832.92,N/A,846.00,N/A,170.27,N/A,118.44,N/A,846.00,N/A,846.00,N/A,118.44,N/A,170.27,N/A,170.27,N/A,187.30,507.60,507.60,118.44,846.00,,Hospital 30310,Removal Foreign Body Intranasal General Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5002.00,N/A,3001.20,N/A,700.28,N/A,2546.98,N/A,2880.15,N/A,1700.68,N/A,5002.00,N/A,700.28,N/A,2569.18,N/A,2569.18,N/A,3868.72,N/A,5002.00,N/A,5002.00,N/A,5002.00,N/A,2880.15,N/A,2569.18,N/A,700.28,N/A,1871.00,N/A,1871.00,N/A,700.28,N/A,2569.18,N/A,2546.98,N/A,216.99,N/A,N/A,216.99,5002.00,,Hospital 30430,Rhinoplasty Secondary Minor Revision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40262.58,N/A,24157.55,N/A,5621.15,N/A,5055.49,N/A,23162.20,N/A,13689.28,N/A,11786.11,N/A,5621.15,N/A,4821.94,N/A,4821.94,N/A,7337.07,N/A,11786.11,N/A,11786.11,N/A,11786.11,N/A,23162.22,N/A,4821.94,N/A,5621.15,N/A,7109.75,N/A,7109.75,N/A,5621.15,N/A,4821.94,N/A,1958.85,N/A,2154.74,N/A,N/A,1958.85,24157.55,,Hospital 30450,Rhinoplasty Secondary Major Revision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47627.30,N/A,28576.38,N/A,6652.22,N/A,5055.49,N/A,27407.17,N/A,16193.29,N/A,11749.01,N/A,6652.22,N/A,4821.94,N/A,4821.94,N/A,7313.99,N/A,11749.01,N/A,11749.01,N/A,11749.01,N/A,27407.21,N/A,4821.94,N/A,6652.22,N/A,6898.50,N/A,6898.50,N/A,6652.22,N/A,4821.94,N/A,2214.50,N/A,2435.95,N/A,N/A,2214.50,28576.38,,Hospital CPT 30802,Abltj Sof Tiss Inf Turbs Uni/Bi Supfc Intramural,N/A,N/A,491.00,491.00,294.60,294.60,N/A,68.74,N/A,192.75,N/A,491.00,N/A,166.94,N/A,491.00,N/A,68.74,N/A,192.75,N/A,192.75,N/A,482.39,N/A,491.00,N/A,491.00,N/A,491.00,N/A,491.00,N/A,192.75,N/A,68.74,N/A,491.00,N/A,491.00,N/A,68.74,N/A,192.75,N/A,192.75,N/A,212.03,294.60,294.60,68.74,491.00,,Hospital CPT 30903,HC Anterior Nose Bleed Comp,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,882.00,882.00,529.20,529.20,N/A,123.48,N/A,74.88,N/A,507.86,N/A,299.88,N/A,680.10,N/A,123.48,N/A,74.88,N/A,74.88,N/A,423.36,N/A,680.10,N/A,680.10,N/A,680.10,N/A,507.86,N/A,74.88,N/A,123.48,N/A,882.00,N/A,882.00,N/A,123.48,N/A,74.88,N/A,74.88,N/A,82.37,529.20,529.20,74.88,882.00,,Hospital 31000,Lavage Cannulation Maxillary Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17922.00,N/A,10753.20,N/A,2509.08,N/A,5857.80,N/A,10310.59,N/A,6093.48,N/A,13545.11,N/A,2509.08,N/A,5587.18,N/A,5587.18,N/A,8432.10,N/A,13545.11,N/A,13545.11,N/A,13545.11,N/A,10310.61,N/A,5587.18,N/A,2509.08,N/A,5227.25,N/A,5227.25,N/A,2509.08,N/A,5587.18,N/A,624.29,N/A,686.72,N/A,N/A,624.29,13545.11,,Hospital 31040,Pterygomaxillary Fossa Surgery Any Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27129.70,N/A,16277.82,N/A,3798.17,N/A,5043.96,N/A,15619.87,N/A,9203.47,N/A,11690.01,N/A,3798.17,N/A,4821.94,N/A,4821.94,N/A,7277.24,N/A,11690.01,N/A,11690.01,N/A,11690.01,N/A,15619.86,N/A,4821.94,N/A,3798.17,N/A,5944.75,N/A,5944.75,N/A,3798.16,N/A,4821.94,N/A,5043.96,N/A,2399.93,N/A,N/A,2399.93,16277.82,,Hospital 31225,Maxillectomy W/O Orbital Exenteration,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,99129.02,N/A,59477.41,N/A,9651.93,N/A,11713.03,N/A,36392.43,N/A,33703.87,N/A,21959.47,N/A,9949.32,N/A,94978.00,N/A,94978.00,N/A,13669.26,N/A,21959.47,N/A,21959.47,N/A,21959.47,N/A,36392.43,N/A,11683.38,N/A,9949.32,N/A,26126.29,N/A,26126.29,N/A,238.28,N/A,11683.38,N/A,11713.03,N/A,10645.77,N/A,238.28,94978.00,N/A,N/A,,Hospital CPT 31231,HC Endoscopy Nasal Diagnostic,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,387.00,387.00,232.20,232.20,N/A,54.18,N/A,163.17,N/A,222.83,N/A,131.58,N/A,387.00,N/A,54.18,N/A,161.42,N/A,161.42,N/A,243.07,N/A,387.00,N/A,387.00,N/A,387.00,N/A,222.83,N/A,161.42,N/A,54.18,N/A,387.00,N/A,387.00,N/A,54.18,N/A,161.42,N/A,163.17,N/A,67.12,232.20,232.20,54.18,387.00,,Hospital 31239,Nasal/Sinus Ndsc Surg W/Dacryocstorhinostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39601.60,N/A,23760.96,N/A,5544.21,N/A,5844.44,N/A,22783.31,N/A,13464.52,N/A,13679.28,N/A,5544.21,N/A,5587.18,N/A,5587.18,N/A,8515.51,N/A,13679.28,N/A,13679.28,N/A,13679.28,N/A,22783.32,N/A,5587.18,N/A,5544.21,N/A,5944.75,N/A,5944.75,N/A,5544.21,N/A,5587.18,N/A,5844.44,N/A,1901.63,N/A,N/A,1901.63,23760.96,,Hospital CPT 31256,Nasal/Sinus Endoscopy W/Maxillary Antrostomy,N/A,N/A,396.00,396.00,237.60,237.60,N/A,55.44,N/A,171.97,N/A,396.00,N/A,134.64,N/A,396.00,N/A,55.44,N/A,171.97,N/A,171.97,N/A,321.04,N/A,396.00,N/A,396.00,N/A,396.00,N/A,396.00,N/A,171.97,N/A,55.44,N/A,396.00,N/A,396.00,N/A,55.44,N/A,171.97,N/A,171.97,N/A,189.17,237.60,237.60,55.44,396.00,,Hospital CPT 31267,Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,N/A,N/A,635.00,635.00,381.00,381.00,N/A,88.90,N/A,254.52,N/A,635.00,N/A,215.90,N/A,635.00,N/A,88.90,N/A,254.52,N/A,254.52,N/A,473.39,N/A,635.00,N/A,635.00,N/A,635.00,N/A,635.00,N/A,254.52,N/A,88.90,N/A,635.00,N/A,635.00,N/A,88.90,N/A,254.52,N/A,254.52,N/A,279.97,381.00,381.00,88.90,635.00,,Hospital 31287,Nasal/Sinus Endoscopy W/Sphenoidotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58798.47,N/A,35279.08,N/A,8231.75,N/A,5844.44,N/A,33852.41,N/A,19991.45,N/A,13582.58,N/A,8231.75,N/A,5587.18,N/A,5587.18,N/A,8455.43,N/A,13582.58,N/A,13582.58,N/A,13582.58,N/A,33852.43,N/A,5587.18,N/A,8231.75,N/A,7983.50,N/A,7983.50,N/A,8231.75,N/A,5587.18,N/A,5844.44,N/A,1459.79,N/A,N/A,1459.79,35279.08,,Hospital 31291,Nasal/Sinus Ndsc Rpr Cerebsp Fluid Leak Sphenoid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32105.67,N/A,19263.40,N/A,4495.98,N/A,4128.18,N/A,18378.14,N/A,10915.93,N/A,20655.21,N/A,4495.98,N/A,4096.37,N/A,4096.37,N/A,12858.26,N/A,20655.21,N/A,20655.21,N/A,20655.21,N/A,18378.14,N/A,4096.37,N/A,4495.98,N/A,5383.50,N/A,5383.50,N/A,4495.98,N/A,4096.37,N/A,4128.18,N/A,1783.57,N/A,N/A,1783.57,20655.21,,Hospital 31298,Nasal/Sinus Ndsc Surg W/Dilation Frnt&Sphn Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50478.93,N/A,30287.36,N/A,7067.07,N/A,5538.92,N/A,28837.82,N/A,17162.85,N/A,13536.69,N/A,7067.07,N/A,5587.18,N/A,5587.18,N/A,8426.86,N/A,13536.69,N/A,13536.69,N/A,13536.69,N/A,28837.83,N/A,5587.18,N/A,7067.07,N/A,7983.50,N/A,7983.50,N/A,7067.07,N/A,5587.18,N/A,5538.92,N/A,1612.77,N/A,N/A,1612.77,30287.36,,Hospital 31299,Unlisted Procedure Accessory Sinuses,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,50201.42,45902.67,30120.85,27541.60,9651.93,6426.38,10904.66,53.50,21364.36,26416.35,17068.48,15606.91,21379.33,535.03,9949.32,6426.38,216370.00,187.68,216370.00,187.68,13308.13,333.08,21379.33,535.03,21379.33,535.03,21379.33,535.03,21364.36,26416.38,10845.36,187.68,9949.32,6426.38,4687.01,527.00,3660.50,527.00,N/A,6426.38,10845.36,187.68,10904.66,53.50,10645.77,58.85,3660.50,216370.00,53.50,27541.60,,Hospital 31400,Arytenoidectomy/Arytenoidopexy Xtrnl Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81454.88,N/A,48872.93,N/A,11409.26,N/A,4922.21,N/A,46864.28,N/A,27694.65,N/A,11844.69,N/A,11409.26,N/A,4821.94,N/A,4821.94,N/A,7373.52,N/A,11844.69,N/A,11844.69,N/A,11844.69,N/A,41109.75,N/A,4821.94,N/A,11409.26,N/A,7661.50,N/A,7661.50,N/A,11409.26,N/A,4821.94,N/A,4922.21,N/A,2010.29,N/A,N/A,2010.29,48872.93,,Hospital CPT 31536,Laryngoscopy W/Biopsy Microscope/Telescope,N/A,N/A,425.00,425.00,255.00,255.00,N/A,59.50,N/A,200.60,N/A,425.00,N/A,144.50,N/A,425.00,N/A,59.50,N/A,200.60,N/A,200.60,N/A,373.72,N/A,425.00,N/A,425.00,N/A,425.00,N/A,425.00,N/A,200.60,N/A,59.50,N/A,425.00,N/A,425.00,N/A,59.50,N/A,200.60,N/A,200.60,N/A,220.66,255.00,255.00,59.50,425.00,,Hospital 31541,Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22751.60,N/A,13650.96,N/A,3185.22,N/A,3149.03,N/A,13098.90,N/A,7735.54,N/A,7309.05,N/A,3185.22,N/A,3010.42,N/A,3010.42,N/A,4559.26,N/A,7309.05,N/A,7309.05,N/A,7309.05,N/A,13098.90,N/A,3010.42,N/A,3185.22,N/A,3397.00,N/A,3397.00,N/A,3185.22,N/A,3010.42,N/A,3149.03,N/A,342.37,N/A,N/A,342.37,13650.96,,Hospital 31545,Largsc Micro/Telescope Rmvl Les Vocal Cord Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26535.60,N/A,15921.36,N/A,3715.00,N/A,3149.03,N/A,15277.84,N/A,9022.09,N/A,7309.69,N/A,3715.00,N/A,3010.42,N/A,3010.42,N/A,4550.41,N/A,7309.69,N/A,7309.69,N/A,7309.69,N/A,15277.85,N/A,3010.42,N/A,3715.00,N/A,3397.00,N/A,3397.00,N/A,3715.00,N/A,3010.42,N/A,3149.03,N/A,532.91,N/A,N/A,532.91,15921.36,,Hospital 31552,Laryngoplasty Laryngeal Sten W/O Stent 12 Yrs >,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60956.87,72655.93,36574.12,43593.56,10141.65,10005.85,12262.69,4922.21,22855.02,41823.15,20725.34,24703.02,23073.65,11729.12,10454.13,10005.85,12262.69,4821.94,12262.69,4821.94,14362.81,7301.59,23073.65,11729.12,23073.65,11729.12,23073.65,11729.12,22855.02,41823.15,12262.69,4821.94,N/A,10005.85,27451.88,7661.50,27451.88,7661.50,N/A,10005.85,12262.69,4821.94,12262.69,4922.21,11185.92,2188.44,10141.65,36574.12,2188.44,43593.56,,Hospital 31570,Laryngoscope Injection Vocal Cord Therapeutic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21340.90,N/A,12804.54,N/A,2987.73,N/A,3149.03,N/A,12250.24,N/A,7255.91,N/A,7292.57,N/A,2987.73,N/A,3010.42,N/A,3010.42,N/A,4539.76,N/A,7292.57,N/A,7292.57,N/A,7292.57,N/A,12250.23,N/A,3010.42,N/A,2987.73,N/A,2806.50,N/A,2806.50,N/A,2987.73,N/A,3010.42,N/A,3149.03,N/A,323.50,N/A,N/A,323.50,12804.54,,Hospital 31574,Laryngoscopy Flexible W/Injection Agmntj Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48025.45,N/A,28815.27,N/A,6723.06,N/A,1473.58,N/A,27529.89,N/A,16328.65,N/A,3541.83,N/A,6723.06,N/A,1443.56,N/A,1443.56,N/A,2204.86,N/A,3541.83,N/A,3541.83,N/A,3541.83,N/A,27529.89,N/A,1443.56,N/A,6723.06,N/A,1871.00,N/A,1871.00,N/A,6723.06,N/A,1443.56,N/A,1473.58,N/A,186.40,N/A,N/A,186.40,28815.27,,Hospital 31591,Laryngoplasty Medialization Unliateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27971.30,N/A,16782.78,N/A,3915.98,N/A,5043.96,N/A,16099.71,N/A,9510.24,N/A,11779.85,N/A,3915.98,N/A,4821.94,N/A,4821.94,N/A,7333.17,N/A,11779.85,N/A,11779.85,N/A,11779.85,N/A,16099.73,N/A,4821.94,N/A,3915.98,N/A,5963.00,N/A,5963.00,N/A,3915.98,N/A,4821.94,N/A,5043.96,N/A,1150.53,N/A,N/A,1150.53,16782.78,,Hospital CPT 31605,HC Tracheostomy Emergency Cricothyroid Membrane,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,626.00,626.00,375.60,375.60,N/A,87.64,N/A,322.67,N/A,360.45,N/A,212.84,N/A,626.00,N/A,87.64,N/A,322.67,N/A,322.67,N/A,595.79,N/A,626.00,N/A,626.00,N/A,626.00,N/A,360.45,N/A,322.67,N/A,87.64,N/A,626.00,N/A,626.00,N/A,87.64,N/A,322.67,N/A,322.67,N/A,354.94,375.60,375.60,87.64,626.00,,Hospital 31611,Constj Tracheoesophgl Fstl&Insj Sp Prosth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54105.98,N/A,32463.59,N/A,7574.06,N/A,3005.77,N/A,31089.44,N/A,18396.03,N/A,7154.30,N/A,7574.06,N/A,2944.53,N/A,2944.53,N/A,4453.68,N/A,7154.30,N/A,7154.30,N/A,7154.30,N/A,31089.44,N/A,2944.53,N/A,7574.06,N/A,4332.50,N/A,4332.50,N/A,7574.06,N/A,2944.53,N/A,3005.77,N/A,766.81,N/A,N/A,766.81,32463.59,,Hospital 31612,Tracheal Pnxr Prq W/Transtracheal Aspir&/Njx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,52875.33,N/A,31725.20,N/A,10965.85,N/A,12871.26,N/A,25178.88,N/A,17977.62,N/A,25419.73,N/A,11303.72,N/A,488378.00,N/A,488378.00,N/A,15823.19,N/A,25419.73,N/A,25419.73,N/A,25419.73,N/A,25178.88,N/A,12811.96,N/A,11303.72,N/A,30243.14,N/A,30243.14,N/A,N/A,N/A,12811.96,N/A,12871.26,N/A,12094.98,N/A,10965.85,488378.00,N/A,N/A,,Hospital 31627,Bronchoscopy W/Cptr-Asst Image-Guided Navigation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,83288.48,23588.87,49973.09,14153.32,6047.86,3276.42,7419.94,3010.42,13629.34,13581.38,28318.09,8020.22,13759.72,7291.07,6234.20,3276.42,1124.00,3010.42,1124.00,3010.42,8565.10,4538.82,13759.72,7291.07,13759.72,7291.07,13759.72,7291.07,13629.34,13581.38,7419.94,3010.42,6234.20,3276.42,16370.63,2938.25,16370.63,2938.25,7138.16,3276.42,7419.94,3010.42,7419.94,3010.42,6670.60,3311.46,1124.00,49973.09,2938.25,14153.32,,Hospital 31634,Bronchoscopy Balloon Occlusion,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,18352.80,N/A,11011.68,N/A,2569.39,N/A,5844.44,N/A,10566.66,N/A,6239.95,N/A,13544.50,N/A,2569.39,N/A,5587.18,N/A,5587.18,N/A,8433.23,N/A,13544.50,N/A,13544.50,N/A,13544.50,N/A,10566.66,N/A,5587.18,N/A,2569.39,N/A,4562.00,N/A,4562.00,N/A,2569.39,N/A,5587.18,N/A,5844.44,N/A,202.99,N/A,N/A,202.99,13544.50,,Hospital 31646,HC Rt Bronchoscopy Theraputic Aspiration Subsequent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,363037.82,N/A,217822.69,N/A,40803.11,N/A,31940.37,N/A,86910.83,N/A,277500.00,N/A,277500.00,N/A,40803.11,N/A,39450.03,N/A,39450.03,N/A,277500.00,N/A,277500.00,N/A,277500.00,N/A,277500.00,N/A,86910.83,N/A,31940.37,N/A,40803.11,N/A,86910.83,N/A,86910.83,N/A,40803.11,N/A,31940.37,N/A,31940.37,N/A,40803.11,N/A,31940.37,277500.00,N/A,N/A,,Hospital 31647,Brnchsc Occlusion&Insert Bronch Valve Init Lobe,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,16666.70,N/A,10000.02,N/A,2333.35,N/A,5844.44,N/A,9595.53,N/A,5666.69,N/A,13533.09,N/A,2333.35,N/A,5587.18,N/A,5587.18,N/A,8424.62,N/A,13533.09,N/A,13533.09,N/A,13533.09,N/A,9595.53,N/A,5587.18,N/A,2333.35,N/A,4562.00,N/A,4562.00,N/A,2333.35,N/A,5587.18,N/A,5844.44,N/A,219.55,N/A,N/A,219.55,13533.09,,Hospital 31755,Tracheoplasty Tracheopharyngeal Fstlj Ea Stg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,79564.10,N/A,47738.46,N/A,11071.55,N/A,4932.54,N/A,45750.85,N/A,27051.80,N/A,12080.04,N/A,11071.55,N/A,4821.94,N/A,4821.94,N/A,7520.07,N/A,12080.04,N/A,12080.04,N/A,12080.04,N/A,45750.85,N/A,4821.94,N/A,11071.55,N/A,6898.50,N/A,6898.50,N/A,11071.55,N/A,4832.27,N/A,4932.54,N/A,2865.09,N/A,N/A,2865.09,47738.46,,Hospital 31830,Revision Tracheostomy Scar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22912.60,N/A,13747.56,N/A,3207.77,N/A,2546.98,N/A,13188.33,N/A,7790.28,N/A,6266.00,N/A,3207.77,N/A,2569.18,N/A,2569.18,N/A,3900.71,N/A,6266.00,N/A,6266.00,N/A,6266.00,N/A,13188.33,N/A,2569.18,N/A,3207.77,N/A,3397.00,N/A,3397.00,N/A,3207.77,N/A,2569.18,N/A,2546.98,N/A,481.25,N/A,N/A,481.25,13747.56,,Hospital 31899,Unlisted Procedure Trachea Bronchi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,748.00,N/A,448.80,N/A,104.72,N/A,163.60,N/A,430.70,N/A,254.32,N/A,390.46,N/A,104.72,N/A,161.42,N/A,161.42,N/A,243.07,N/A,390.46,N/A,390.46,N/A,390.46,N/A,430.70,N/A,161.42,N/A,104.72,N/A,527.00,N/A,527.00,N/A,104.72,N/A,161.42,N/A,163.60,N/A,2210.64,N/A,N/A,104.72,2210.64,,Hospital CPT 32160,HC Thoracotomy; With Cardiac Massage,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2433.00,2433.00,1459.80,1459.80,N/A,340.62,N/A,760.45,N/A,1400.92,N/A,827.22,N/A,2433.00,N/A,340.62,N/A,760.45,N/A,760.45,N/A,2433.00,N/A,2433.00,N/A,2433.00,N/A,2433.00,N/A,1400.92,N/A,760.45,N/A,340.62,N/A,2433.00,N/A,2433.00,N/A,340.62,N/A,760.45,N/A,760.45,N/A,836.50,1459.80,1459.80,340.62,2433.00,,Hospital CPT 32400,HC Biopsy-Pleura Needle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4178.00,4178.00,2506.80,2506.80,N/A,584.92,N/A,1416.50,N/A,2405.69,N/A,1420.52,N/A,3275.59,N/A,584.92,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2405.69,N/A,1354.15,N/A,584.92,N/A,1871.00,N/A,1871.00,N/A,584.92,N/A,1354.15,N/A,82.31,N/A,90.54,2506.80,2506.80,82.31,3275.59,,Hospital 32405,"HC Biopsy,Lung or Mediastinum",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,13488.00,N/A,8092.80,N/A,1888.32,N/A,2159.91,N/A,7763.05,N/A,4585.92,N/A,1699.04,N/A,1888.32,N/A,1986.50,N/A,1986.50,N/A,1057.09,N/A,1699.04,N/A,1699.04,N/A,1699.04,N/A,7252.90,N/A,1986.50,N/A,1888.32,N/A,N/A,N/A,N/A,N/A,1888.32,N/A,2098.96,N/A,2159.91,N/A,383.64,N/A,N/A,383.64,8092.80,,Hospital 32550,HC Plcmt Tunnel Pleural Drain Cat,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,77355.68,16730.27,46413.41,10038.16,5389.93,2295.91,6641.86,3345.78,15385.76,9376.52,26300.94,5688.29,16137.00,7740.59,5556.01,2295.91,6641.86,3198.50,6641.86,3198.50,10045.15,4818.66,16137.00,7740.59,16137.00,7740.59,16137.00,7740.59,15385.76,9376.52,6641.86,3198.50,5556.01,2295.91,18480.31,4562.00,18480.31,4562.00,6770.61,2295.91,6641.86,3198.50,6641.86,3345.78,5944.93,360.37,5389.93,46413.41,360.37,10038.16,,Hospital CPT 32556,HC Insert Cath Pleura W/O Image,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4769.00,4769.00,2861.40,2861.40,N/A,667.66,N/A,120.03,N/A,2745.99,N/A,1621.46,N/A,3804.28,N/A,667.66,N/A,1572.73,N/A,1572.73,N/A,2368.24,N/A,3804.28,N/A,3804.28,N/A,3804.28,N/A,2745.99,N/A,1572.73,N/A,667.66,N/A,1871.00,N/A,1871.00,N/A,667.66,N/A,1572.73,N/A,120.03,N/A,132.03,2861.40,2861.40,120.03,3804.28,,Hospital CPT 32556,HC Perq Drainage Pleura Insert Cath W/O Imaging,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4769.00,4769.00,2861.40,2861.40,N/A,667.66,N/A,120.03,N/A,2745.99,N/A,1621.46,N/A,3804.28,N/A,667.66,N/A,1572.73,N/A,1572.73,N/A,2368.24,N/A,3804.28,N/A,3804.28,N/A,3804.28,N/A,2745.99,N/A,1572.73,N/A,667.66,N/A,4769.00,N/A,4769.00,N/A,667.66,N/A,1572.73,N/A,120.03,N/A,132.03,2861.40,2861.40,120.03,4769.00,,Hospital 32608,Thoracoscopy W/Dx Bx of Lung Nodules Unilatrl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28109.52,N/A,16865.71,N/A,3935.34,N/A,2378.88,N/A,16183.20,N/A,9557.23,N/A,5757.46,N/A,3935.34,N/A,2353.39,N/A,2353.39,N/A,3584.13,N/A,5757.46,N/A,5757.46,N/A,5757.46,N/A,16183.18,N/A,2353.39,N/A,3935.34,N/A,6226.50,N/A,6226.50,N/A,3935.34,N/A,2353.39,N/A,2378.88,N/A,425.82,N/A,N/A,425.82,16865.71,,Hospital 32667,Thoracoscopy W/Thera Wedge Resexn Addl Ipsilatrl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40331.95,N/A,24199.17,N/A,5346.25,N/A,4832.50,N/A,23217.60,N/A,13712.88,N/A,11462.22,N/A,5346.25,N/A,4706.78,N/A,4706.78,N/A,7135.46,N/A,11462.22,N/A,11462.22,N/A,11462.22,N/A,22962.53,N/A,4706.78,N/A,5346.25,N/A,7309.25,N/A,7309.25,N/A,5346.25,N/A,4706.78,N/A,4832.50,N/A,2997.21,N/A,N/A,2997.21,24199.17,,Hospital 32674,Thorcoscpy W/Mediastinl & Regionl Lymphdenectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46188.20,N/A,27712.92,N/A,6345.70,N/A,4757.75,N/A,26590.91,N/A,15703.99,N/A,11508.62,N/A,6345.70,N/A,4706.78,N/A,4706.78,N/A,7164.34,N/A,11508.62,N/A,11508.62,N/A,11508.62,N/A,26530.44,N/A,4706.78,N/A,6345.70,N/A,6916.25,N/A,6916.25,N/A,6345.70,N/A,4706.78,N/A,4757.75,N/A,1749.77,N/A,N/A,1749.77,27712.92,,Hospital 33019,HC Perq Pericardial Drg W/Insj Ndwellg Cath W/CT,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,59677.32,N/A,35806.39,N/A,10440.92,N/A,12616.71,N/A,24051.08,N/A,20290.29,N/A,23754.54,N/A,10762.62,N/A,3372.00,N/A,3372.00,N/A,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,24051.08,N/A,12616.71,N/A,10762.62,N/A,28261.97,N/A,28261.97,N/A,N/A,N/A,12616.71,N/A,12616.71,N/A,11516.01,N/A,3372.00,35806.39,N/A,N/A,,Hospital CPT 33207,HC Inital Ventricular Lead Inser,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11559.00,11559.00,6935.40,6935.40,N/A,1618.26,N/A,9521.27,N/A,6655.67,N/A,3930.06,N/A,11559.00,N/A,1618.26,N/A,9327.29,N/A,9327.29,N/A,11559.00,N/A,11559.00,N/A,11559.00,N/A,11559.00,N/A,6655.67,N/A,9327.29,N/A,1618.26,N/A,11660.00,N/A,11660.00,N/A,1618.26,N/A,9327.29,N/A,458.88,N/A,504.77,6935.40,6935.40,458.88,11660.00,,Hospital CPT 33210,HC Temp Pacer Insertion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9190.00,9190.00,5514.00,5514.00,N/A,1286.60,N/A,156.04,N/A,5291.60,N/A,3124.60,N/A,459.87,N/A,1286.60,N/A,156.04,N/A,156.04,N/A,286.27,N/A,459.87,N/A,459.87,N/A,459.87,N/A,5291.60,N/A,156.04,N/A,1286.60,N/A,9190.00,N/A,9190.00,N/A,1286.60,N/A,156.04,N/A,156.04,N/A,171.64,5514.00,5514.00,156.04,9190.00,,Hospital CPT 33210,HC Temp Trnsvns Sgl Pacing Insrtn,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9190.00,9190.00,5514.00,5514.00,N/A,1286.60,N/A,156.04,N/A,5291.60,N/A,3124.60,N/A,459.87,N/A,1286.60,N/A,156.04,N/A,156.04,N/A,286.27,N/A,459.87,N/A,459.87,N/A,459.87,N/A,5291.60,N/A,156.04,N/A,1286.60,N/A,9190.00,N/A,9190.00,N/A,1286.60,N/A,156.04,N/A,156.04,N/A,171.64,5514.00,5514.00,156.04,9190.00,,Hospital CPT 33210,HC Transvenous Pacing,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,9190.00,9190.00,5514.00,5514.00,N/A,1286.60,N/A,156.04,N/A,5291.60,N/A,3124.60,N/A,459.87,N/A,1286.60,N/A,156.04,N/A,156.04,N/A,286.27,N/A,459.87,N/A,459.87,N/A,459.87,N/A,5291.60,N/A,156.04,N/A,1286.60,N/A,9190.00,N/A,9190.00,N/A,1286.60,N/A,156.04,N/A,156.04,N/A,171.64,5514.00,5514.00,156.04,9190.00,,Hospital CPT 33221,HC Ins Ppm Only Exist Mult Leads,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,41076.00,41076.00,24645.60,24645.60,N/A,5750.64,N/A,17637.95,N/A,23651.56,N/A,13965.84,N/A,40786.73,N/A,5750.64,N/A,16861.57,N/A,16861.57,N/A,25390.53,N/A,40786.73,N/A,40786.73,N/A,40786.73,N/A,23651.56,N/A,16861.57,N/A,5750.64,N/A,11660.00,N/A,11660.00,N/A,5750.64,N/A,16861.57,N/A,17637.95,N/A,379.60,24645.60,24645.60,379.60,40786.73,,Hospital CPT 33222,HC Pocket Relocation,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3921.00,3921.00,2352.60,2352.60,N/A,548.94,N/A,1590.93,N/A,2257.71,N/A,1333.14,N/A,3769.94,N/A,548.94,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,2257.71,N/A,1558.52,N/A,548.94,N/A,1871.00,N/A,1871.00,N/A,548.94,N/A,1558.52,N/A,1657.93,N/A,358.52,2352.60,2352.60,358.52,3769.94,,Hospital CPT 33224,HC Upgrade Insert Lv Lead,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15085.00,15085.00,9051.00,9051.00,N/A,2111.90,N/A,494.18,N/A,8685.94,N/A,5128.90,N/A,15085.00,N/A,2111.90,N/A,9327.29,N/A,9327.29,N/A,14045.25,N/A,15085.00,N/A,15085.00,N/A,15085.00,N/A,8685.94,N/A,9327.29,N/A,2111.90,N/A,16637.00,N/A,16637.00,N/A,2111.90,N/A,9327.29,N/A,494.18,N/A,543.60,9051.00,9051.00,494.18,16637.00,,Hospital CPT 33225,HC Left Ventricular Lead Insert,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15085.00,15085.00,9051.00,9051.00,N/A,2111.90,N/A,15085.00,N/A,8685.94,N/A,5128.90,N/A,15085.00,N/A,2111.90,N/A,15085.00,N/A,15085.00,N/A,15085.00,N/A,15085.00,N/A,15085.00,N/A,15085.00,N/A,8685.94,N/A,15085.00,N/A,2111.90,N/A,16637.00,N/A,16637.00,N/A,2111.90,N/A,15085.00,N/A,15085.00,N/A,15085.00,9051.00,9051.00,2111.90,16637.00,,Hospital CPT 33226,HC Reposition Lv Lead,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3875.00,3875.00,2325.00,2325.00,N/A,542.50,N/A,2820.43,N/A,2231.23,N/A,1317.50,N/A,3875.00,N/A,542.50,N/A,2690.13,N/A,2690.13,N/A,3875.00,N/A,3875.00,N/A,3875.00,N/A,3875.00,N/A,2231.23,N/A,2690.13,N/A,542.50,N/A,4562.00,N/A,4562.00,N/A,542.50,N/A,2690.13,N/A,473.69,N/A,521.06,2325.00,2325.00,473.69,4562.00,,Hospital CPT 33227,HC Remv & Replc Pm Gen Sing,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,12299.00,12299.00,7379.40,7379.40,N/A,1721.86,N/A,7568.19,N/A,7081.76,N/A,4181.66,N/A,12299.00,N/A,1721.86,N/A,7371.31,N/A,7371.31,N/A,11099.88,N/A,12299.00,N/A,12299.00,N/A,12299.00,N/A,7081.76,N/A,7371.31,N/A,1721.86,N/A,11660.00,N/A,11660.00,N/A,1721.86,N/A,7371.31,N/A,7451.14,N/A,357.05,7379.40,7379.40,357.05,12299.00,,Hospital CPT 33230,HC Ins Cd Gen Only Dual,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,23855.00,23855.00,14313.00,14313.00,N/A,3339.70,N/A,368.03,N/A,13735.71,N/A,8110.70,N/A,23855.00,N/A,3339.70,N/A,20605.86,N/A,20605.86,N/A,23855.00,N/A,23855.00,N/A,23855.00,N/A,23855.00,N/A,13735.71,N/A,20605.86,N/A,3339.70,N/A,29766.00,N/A,29766.00,N/A,3339.70,N/A,20605.86,N/A,368.03,N/A,404.83,14313.00,14313.00,368.03,29766.00,,Hospital CPT 33234,HC Removal of Single Lead,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4293.00,4293.00,2575.80,2575.80,N/A,601.02,N/A,464.33,N/A,2471.91,N/A,1459.62,N/A,1370.19,N/A,601.02,N/A,464.33,N/A,464.33,N/A,852.94,N/A,1370.19,N/A,1370.19,N/A,1370.19,N/A,2471.91,N/A,464.33,N/A,601.02,N/A,4293.00,N/A,4293.00,N/A,601.02,N/A,464.33,N/A,464.33,N/A,510.76,2575.80,2575.80,464.33,4293.00,,Hospital CPT 33244,HC Remove Icd Lead Single or Dual,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4780.00,4780.00,2868.00,2868.00,N/A,669.20,N/A,3026.02,N/A,2752.32,N/A,1625.20,N/A,4780.00,N/A,669.20,N/A,3026.02,N/A,3026.02,N/A,4556.65,N/A,4780.00,N/A,4780.00,N/A,4780.00,N/A,2752.32,N/A,3026.02,N/A,669.20,N/A,4562.00,N/A,4562.00,N/A,669.20,N/A,3026.02,N/A,3026.02,N/A,3328.63,2868.00,2868.00,669.20,4780.00,,Hospital CPT 33264,HC Remv & Replc Cd Gen Mult,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,80191.00,80191.00,48114.60,48114.60,N/A,11226.74,N/A,28966.21,N/A,46173.98,N/A,27264.94,N/A,70066.82,N/A,11226.74,N/A,28966.21,N/A,28966.21,N/A,43617.96,N/A,70066.82,N/A,70066.82,N/A,70066.82,N/A,46173.98,N/A,28966.21,N/A,11226.74,N/A,29766.00,N/A,29766.00,N/A,11226.74,N/A,28966.21,N/A,28966.21,N/A,31862.83,48114.60,48114.60,11226.74,70066.82,,Hospital CPT 33274,HC Tcat Insj/Rpl Perm Leadless Pacemaker Rv W/Img,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,44276.00,44276.00,26565.60,26565.60,N/A,6198.64,N/A,15512.06,N/A,25494.12,N/A,15053.84,N/A,37522.38,N/A,6198.64,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,25494.12,N/A,15512.06,N/A,6198.64,N/A,37100.00,N/A,37100.00,N/A,6198.64,N/A,15512.06,N/A,15512.06,N/A,17063.27,26565.60,26565.60,6198.64,37522.38,,Hospital CPT 33340,HC Perq Clsr Tcat L Atr Apndge W/Endocardial Implnt,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,31001.00,31001.00,18600.60,18600.60,N/A,4340.14,N/A,754.36,N/A,17850.38,N/A,10540.34,N/A,2217.51,N/A,4340.14,N/A,754.36,N/A,754.36,N/A,1380.40,N/A,2217.51,N/A,2217.51,N/A,2217.51,N/A,17850.38,N/A,754.36,N/A,4340.14,N/A,1643.00,N/A,1643.00,N/A,4340.14,N/A,754.36,N/A,754.36,N/A,829.80,18600.60,18600.60,754.36,18600.60,,Hospital 33363,HC Replace Aortic Valve Open Axil,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,275071.53,N/A,165042.92,N/A,35499.50,N/A,32832.03,N/A,151619.43,N/A,93524.32,N/A,95779.91,N/A,31679.36,N/A,32832.03,N/A,32832.03,N/A,N/A,N/A,95779.91,N/A,95779.91,N/A,N/A,N/A,151619.43,N/A,32832.03,N/A,31679.36,N/A,176113.67,N/A,176113.67,N/A,N/A,N/A,32832.03,N/A,32832.03,N/A,33896.92,N/A,31679.36,176113.67,N/A,N/A,,Hospital 33365,HC Repl Aor Valve Open Trnsaortic,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1117482.08,N/A,670489.25,N/A,N/A,N/A,142148.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,142148.43,N/A,142148.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,142148.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,142148.43,N/A,142148.43,N/A,N/A,N/A,142148.43,670489.25,N/A,N/A,,Hospital CPT 33367,HC Replace Aortic Valve W/Bypass (Tavr/Tavi),N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15495.00,15495.00,9297.00,9297.00,N/A,2169.30,N/A,589.31,N/A,8922.02,N/A,5268.30,N/A,1734.09,N/A,2169.30,N/A,589.31,N/A,589.31,N/A,1079.47,N/A,1734.09,N/A,1734.09,N/A,1734.09,N/A,8922.02,N/A,589.31,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,2169.30,N/A,589.31,N/A,589.31,N/A,648.24,9297.00,9297.00,589.31,15495.00,,Hospital 33858,As-Aort Grf W/Card Byp F/Aortic Dissection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,233098.52,N/A,139859.11,N/A,N/A,N/A,N/A,N/A,56894.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56894.90,N/A,N/A,N/A,N/A,N/A,56894.90,N/A,56894.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56894.90,139859.11,N/A,N/A,,Hospital 33881,HC Endovasc Taa Repr W/O Subcl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1345756.58,N/A,807453.95,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,173728.29,807453.95,N/A,N/A,,Hospital 33948,HC Ecmo/Ecls Daily Mgmt-Venous,N/A,0947 - OTHER THERAPEUTIC SERVICES - COMPLEX MEDICAL EQUIPMENT - ANCILLARY,1504225.68,N/A,902535.41,N/A,137322.81,N/A,336855.67,N/A,N/A,N/A,894020.97,N/A,894020.97,N/A,137322.81,N/A,336855.67,N/A,336855.67,N/A,894020.97,N/A,894020.97,N/A,894020.97,N/A,894020.97,N/A,N/A,N/A,336855.67,N/A,137322.81,N/A,N/A,N/A,N/A,N/A,137322.81,N/A,336855.67,N/A,336855.67,N/A,137322.81,N/A,137322.81,902535.41,N/A,N/A,,Hospital 33958,HC Ecmo/Ecls Repos Perph Cnula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1100855.08,N/A,660513.05,N/A,137322.81,N/A,N/A,N/A,N/A,N/A,1694202.79,N/A,1694202.79,N/A,137322.81,N/A,N/A,N/A,N/A,N/A,1694202.79,N/A,1694202.79,N/A,1694202.79,N/A,1694202.79,N/A,N/A,N/A,N/A,N/A,137322.81,N/A,N/A,N/A,N/A,N/A,137322.81,N/A,N/A,N/A,N/A,N/A,137322.81,N/A,137322.81,1694202.79,N/A,N/A,,Hospital CPT 33967,HC Balloon Pump Insertion,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1789.00,1789.00,1073.40,1073.40,N/A,250.46,N/A,248.60,N/A,1030.11,N/A,608.26,N/A,730.47,N/A,250.46,N/A,248.60,N/A,248.60,N/A,454.72,N/A,730.47,N/A,730.47,N/A,730.47,N/A,1030.11,N/A,248.60,N/A,250.46,N/A,37100.00,N/A,37100.00,N/A,250.46,N/A,248.60,N/A,248.60,N/A,273.46,1073.40,1073.40,248.60,37100.00,,Hospital CPT 33968,HC Remove Aortic Assist Dev,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,4115.00,4115.00,2469.00,2469.00,N/A,576.10,N/A,31.90,N/A,2369.42,N/A,1399.10,N/A,4115.00,N/A,576.10,N/A,31.90,N/A,31.90,N/A,4115.00,N/A,4115.00,N/A,4115.00,N/A,4115.00,N/A,2369.42,N/A,31.90,N/A,576.10,N/A,4115.00,N/A,4115.00,N/A,576.10,N/A,31.90,N/A,31.90,N/A,35.09,2469.00,2469.00,31.90,4115.00,,Hospital CPT 33968,HC Removal Aortic Assist Device,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4115.00,4115.00,2469.00,2469.00,N/A,576.10,N/A,31.90,N/A,2369.42,N/A,1399.10,N/A,4115.00,N/A,576.10,N/A,31.90,N/A,31.90,N/A,4115.00,N/A,4115.00,N/A,4115.00,N/A,4115.00,N/A,2369.42,N/A,31.90,N/A,576.10,N/A,2205.64,N/A,2205.64,N/A,576.10,N/A,31.90,N/A,31.90,N/A,35.09,2469.00,2469.00,31.90,4115.00,,Hospital HCPCS 340b,HYOSCYAMINE SULFATE 0.125 MG/ML PO SOLN,39328-0047-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,PAREGORIC 2 MG/5ML PO TINC,09999-9901-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,AZITHROMYCIN 200 MG/5ML PO SUSR,42806-0150-33,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),31.50,31.50,18.90,18.90,N/A,4.41,N/A,31.50,N/A,17.71,N/A,10.71,N/A,4.41,N/A,4.41,N/A,31.50,N/A,31.50,N/A,2.74,N/A,4.41,N/A,4.41,N/A,4.41,N/A,17.71,N/A,31.50,N/A,4.41,N/A,16.88,N/A,16.88,N/A,4.41,N/A,31.50,N/A,31.50,N/A,31.50,18.90,18.90,2.74,31.50,,Hospital HCPCS 340b,ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR,24338-0130-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1488.60,1488.60,893.16,893.16,N/A,208.40,N/A,1488.60,N/A,836.89,N/A,506.12,N/A,208.40,N/A,208.40,N/A,1488.60,N/A,1488.60,N/A,129.51,N/A,208.40,N/A,208.40,N/A,208.40,N/A,836.89,N/A,1488.60,N/A,208.40,N/A,797.89,N/A,797.89,N/A,208.40,N/A,1488.60,N/A,1488.60,N/A,1488.60,893.16,893.16,129.51,1488.60,,Hospital HCPCS 340b,IBUPROFEN 100 MG/5ML PO SUSP,00904-5309-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 340b,AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5ML PO SUSR,59651-0026-55,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),228.50,228.50,137.10,137.10,N/A,31.99,N/A,228.50,N/A,128.46,N/A,77.69,N/A,31.99,N/A,31.99,N/A,228.50,N/A,228.50,N/A,19.88,N/A,31.99,N/A,31.99,N/A,31.99,N/A,128.46,N/A,228.50,N/A,31.99,N/A,122.48,N/A,122.48,N/A,31.99,N/A,228.50,N/A,228.50,N/A,228.50,137.10,137.10,19.88,228.50,,Hospital HCPCS 340b,CITALOPRAM HYDROBROMIDE 10 MG/5ML PO SOLN,09999-9905-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 340b,METHADONE HCL 10 MG/ML PO CONC,00054-0392-68,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),114.80,114.80,68.88,68.88,N/A,16.07,N/A,114.80,N/A,64.54,N/A,39.03,N/A,16.07,N/A,16.07,N/A,114.80,N/A,114.80,N/A,9.99,N/A,16.07,N/A,16.07,N/A,16.07,N/A,64.54,N/A,114.80,N/A,16.07,N/A,61.53,N/A,61.53,N/A,16.07,N/A,114.80,N/A,114.80,N/A,114.80,68.88,68.88,9.99,114.80,,Hospital HCPCS 340b,LIDOCAINE VISCOUS HCL 2 % MT SOLN,09999-9915-48,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 340b,ZIDOVUDINE 50 MG/5ML PO SYRP,09999-9910-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5ML PO SUSR,59651-0026-75,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),116.50,116.50,69.90,69.90,N/A,16.31,N/A,116.50,N/A,65.50,N/A,39.61,N/A,16.31,N/A,16.31,N/A,116.50,N/A,116.50,N/A,10.14,N/A,16.31,N/A,16.31,N/A,16.31,N/A,65.50,N/A,116.50,N/A,16.31,N/A,62.44,N/A,62.44,N/A,16.31,N/A,116.50,N/A,116.50,N/A,116.50,69.90,69.90,10.14,116.50,,Hospital HCPCS 340b,LIDOCAINE VISCOUS HCL 2 % MT SOLN,00054-3500-49,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),74.30,74.30,44.58,44.58,N/A,10.40,N/A,74.30,N/A,41.77,N/A,25.26,N/A,10.40,N/A,10.40,N/A,74.30,N/A,74.30,N/A,6.46,N/A,10.40,N/A,10.40,N/A,10.40,N/A,41.77,N/A,74.30,N/A,10.40,N/A,39.82,N/A,39.82,N/A,10.40,N/A,74.30,N/A,74.30,N/A,74.30,44.58,44.58,6.46,74.30,,Hospital HCPCS 340b,PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML PO ELIX,09999-9902-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.00,32.00,19.20,19.20,N/A,4.48,N/A,32.00,N/A,17.99,N/A,10.88,N/A,4.48,N/A,4.48,N/A,32.00,N/A,32.00,N/A,2.78,N/A,4.48,N/A,4.48,N/A,4.48,N/A,17.99,N/A,32.00,N/A,4.48,N/A,17.15,N/A,17.15,N/A,4.48,N/A,32.00,N/A,32.00,N/A,32.00,19.20,19.20,2.78,32.00,,Hospital HCPCS 340b,POLY-VI-SOL/IRON 11 MG/ML PO SOLN,09999-9914-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR,00093-4127-74,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.60,26.60,15.96,15.96,N/A,3.72,N/A,26.60,N/A,14.95,N/A,9.04,N/A,3.72,N/A,3.72,N/A,26.60,N/A,26.60,N/A,2.31,N/A,3.72,N/A,3.72,N/A,3.72,N/A,14.95,N/A,26.60,N/A,3.72,N/A,14.26,N/A,14.26,N/A,3.72,N/A,26.60,N/A,26.60,N/A,26.60,15.96,15.96,2.31,26.60,,Hospital HCPCS 340b,AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR,00781-6139-57,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),50.70,50.70,30.42,30.42,N/A,7.10,N/A,50.70,N/A,28.50,N/A,17.24,N/A,7.10,N/A,7.10,N/A,50.70,N/A,50.70,N/A,4.41,N/A,7.10,N/A,7.10,N/A,7.10,N/A,28.50,N/A,50.70,N/A,7.10,N/A,27.18,N/A,27.18,N/A,7.10,N/A,50.70,N/A,50.70,N/A,50.70,30.42,30.42,4.41,50.70,,Hospital HCPCS 340b,LANSOPRAZOLE 3 MG/ML PO SUSP,09999-9913-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,AZITHROMYCIN 200 MG/5ML PO SUSR,42806-0149-32,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),29.30,29.30,17.58,17.58,N/A,4.10,N/A,29.30,N/A,16.47,N/A,9.96,N/A,4.10,N/A,4.10,N/A,29.30,N/A,29.30,N/A,2.55,N/A,4.10,N/A,4.10,N/A,4.10,N/A,16.47,N/A,29.30,N/A,4.10,N/A,15.70,N/A,15.70,N/A,4.10,N/A,29.30,N/A,29.30,N/A,29.30,17.58,17.58,2.55,29.30,,Hospital HCPCS 340b,MIDAZOLAM HCL 2 MG/ML PO SYRP,00054-3566-99,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,DEXTROMETHORPHAN POLISTIREX ER 30 MG/5ML PO SUER,09999-9908-39,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 340b,CEPHALEXIN 125 MG/5ML PO SUSR,00093-4175-73,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),42.80,42.80,25.68,25.68,N/A,5.99,N/A,42.80,N/A,24.06,N/A,14.55,N/A,5.99,N/A,5.99,N/A,42.80,N/A,42.80,N/A,3.72,N/A,5.99,N/A,5.99,N/A,5.99,N/A,24.06,N/A,42.80,N/A,5.99,N/A,22.94,N/A,22.94,N/A,5.99,N/A,42.80,N/A,42.80,N/A,42.80,25.68,25.68,3.72,42.80,,Hospital HCPCS 340b,VANCOMYCIN HCL 50 MG/ML PO SOLR,62559-0830-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1220.40,1220.40,732.24,732.24,N/A,170.86,N/A,1220.40,N/A,686.11,N/A,414.94,N/A,170.86,N/A,170.86,N/A,1220.40,N/A,1220.40,N/A,106.17,N/A,170.86,N/A,170.86,N/A,170.86,N/A,686.11,N/A,1220.40,N/A,170.86,N/A,654.13,N/A,654.13,N/A,170.86,N/A,1220.40,N/A,1220.40,N/A,1220.40,732.24,732.24,106.17,1220.40,,Hospital HCPCS 340b,INSULIN GLULISINE 100 UNIT/ML IJ SOLN,00088-2500-33,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),4.00,4.00,2.40,2.40,N/A,N/A,N/A,4.00,N/A,2.25,N/A,1.36,N/A,N/A,N/A,N/A,N/A,4.00,N/A,4.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.25,N/A,4.00,N/A,N/A,N/A,2.14,N/A,2.14,N/A,N/A,N/A,4.00,N/A,4.00,N/A,4.00,2.40,2.40,1.36,4.00,,Hospital HCPCS 340b,POLY-VI-SOL PO SOLN,09999-9914-41,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD,09999-9901-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.50,3.50,2.10,2.10,N/A,N/A,N/A,3.50,N/A,1.97,N/A,1.19,N/A,N/A,N/A,N/A,N/A,3.50,N/A,3.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.97,N/A,3.50,N/A,N/A,N/A,1.88,N/A,1.88,N/A,N/A,N/A,3.50,N/A,3.50,N/A,3.50,2.10,2.10,1.19,3.50,,Hospital HCPCS 340b,FAMOTIDINE 40 MG/5ML PO SUSR,68180-0150-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.60,5.60,3.36,3.36,N/A,N/A,N/A,5.60,N/A,3.15,N/A,1.90,N/A,N/A,N/A,N/A,N/A,5.60,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.15,N/A,5.60,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,5.60,N/A,5.60,N/A,5.60,3.36,3.36,1.90,5.60,,Hospital HCPCS 340b,POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML PO SOLN,60258-0003-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,LANSOPRAZOLE 3 MG/ML PO SUSP,65628-0080-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),258.80,258.80,155.28,155.28,N/A,36.23,N/A,258.80,N/A,145.50,N/A,87.99,N/A,36.23,N/A,36.23,N/A,258.80,N/A,258.80,N/A,22.52,N/A,36.23,N/A,36.23,N/A,36.23,N/A,145.50,N/A,258.80,N/A,36.23,N/A,138.72,N/A,138.72,N/A,36.23,N/A,258.80,N/A,258.80,N/A,258.80,155.28,155.28,22.52,258.80,,Hospital HCPCS 340b,LORAZEPAM 2 MG/ML PO CONC,09999-9905-54,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,LANSOPRAZOLE 3 MG/ML PO SUSP,65628-0080-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),258.60,258.60,155.16,155.16,N/A,36.20,N/A,258.60,N/A,145.38,N/A,87.92,N/A,36.20,N/A,36.20,N/A,258.60,N/A,258.60,N/A,22.50,N/A,36.20,N/A,36.20,N/A,36.20,N/A,145.38,N/A,258.60,N/A,36.20,N/A,138.61,N/A,138.61,N/A,36.20,N/A,258.60,N/A,258.60,N/A,258.60,155.16,155.16,22.50,258.60,,Hospital HCPCS 340b,AMOXICILLIN-POT CLAVULANATE 200-28.5 MG/5ML PO SUSR,66685-1011-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ACYCLOVIR 200 MG/5ML PO SUSP,09999-9901-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,OXYCODONE HCL 100 MG/5ML PO CONC,68308-0020-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN,66689-0023-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,00406-8003-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN,09999-9910-27,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,AMANTADINE HCL 50 MG/5ML PO SOLN,09999-9910-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,OXCARBAZEPINE 300 MG/5ML PO SUSP,65162-0649-78,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),372.40,372.40,223.44,223.44,N/A,52.14,N/A,372.40,N/A,209.36,N/A,126.62,N/A,52.14,N/A,52.14,N/A,372.40,N/A,372.40,N/A,32.40,N/A,52.14,N/A,52.14,N/A,52.14,N/A,209.36,N/A,372.40,N/A,52.14,N/A,199.61,N/A,199.61,N/A,52.14,N/A,372.40,N/A,372.40,N/A,372.40,223.44,223.44,32.40,372.40,,Hospital HCPCS 340b,AMOXICILLIN-POT CLAVULANATE 200-28.5 MG/5ML PO SUSR,65862-0533-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,POT & SOD CIT-CIT AC 550-500-334 MG/5ML PO SYRP,60258-0002-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR,47781-0384-26,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),225.60,225.60,135.36,135.36,N/A,31.58,N/A,225.60,N/A,126.83,N/A,76.70,N/A,31.58,N/A,31.58,N/A,225.60,N/A,225.60,N/A,19.63,N/A,31.58,N/A,31.58,N/A,31.58,N/A,126.83,N/A,225.60,N/A,31.58,N/A,120.92,N/A,120.92,N/A,31.58,N/A,225.60,N/A,225.60,N/A,225.60,135.36,135.36,19.63,225.60,,Hospital HCPCS 340b,HYDROCOD POLI-CHLORPHE POLI ER 10-8 MG/5ML PO SUER,09999-9900-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.70,5.70,3.42,3.42,N/A,N/A,N/A,5.70,N/A,3.20,N/A,1.94,N/A,N/A,N/A,N/A,N/A,5.70,N/A,5.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.20,N/A,5.70,N/A,N/A,N/A,3.06,N/A,3.06,N/A,N/A,N/A,5.70,N/A,5.70,N/A,5.70,3.42,3.42,1.94,5.70,,Hospital HCPCS 340b,FLUCONAZOLE 40 MG/ML PO SUSR,59762-5030-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),132.40,132.40,79.44,79.44,N/A,18.54,N/A,132.40,N/A,74.44,N/A,45.02,N/A,18.54,N/A,18.54,N/A,132.40,N/A,132.40,N/A,11.52,N/A,18.54,N/A,18.54,N/A,18.54,N/A,74.44,N/A,132.40,N/A,18.54,N/A,70.97,N/A,70.97,N/A,18.54,N/A,132.40,N/A,132.40,N/A,132.40,79.44,79.44,11.52,132.40,,Hospital HCPCS 340b,POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN,09999-9901-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.50,8.50,5.10,5.10,N/A,1.19,N/A,8.50,N/A,4.78,N/A,2.89,N/A,1.19,N/A,1.19,N/A,8.50,N/A,8.50,N/A,N/A,N/A,1.19,N/A,1.19,N/A,1.19,N/A,4.78,N/A,8.50,N/A,1.19,N/A,4.56,N/A,4.56,N/A,1.19,N/A,8.50,N/A,8.50,N/A,8.50,5.10,5.10,1.19,8.50,,Hospital HCPCS 340b,PREDNISOLONE 15 MG/5ML PO SOLN,62135-0250-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),648.00,648.00,388.80,388.80,N/A,90.72,N/A,648.00,N/A,364.31,N/A,220.32,N/A,85.78,N/A,90.72,N/A,648.00,N/A,648.00,N/A,53.40,N/A,85.78,N/A,85.78,N/A,85.78,N/A,364.31,N/A,648.00,N/A,90.72,N/A,347.33,N/A,347.33,N/A,90.72,N/A,648.00,N/A,648.00,N/A,648.00,388.80,388.80,53.40,648.00,,Hospital HCPCS 340b,METHADONE HCL 10 MG/ML PO CONC,09999-9911-38,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.70,12.70,7.62,7.62,N/A,1.78,N/A,12.70,N/A,7.14,N/A,4.32,N/A,1.78,N/A,1.78,N/A,12.70,N/A,12.70,N/A,1.10,N/A,1.78,N/A,1.78,N/A,1.78,N/A,7.14,N/A,12.70,N/A,1.78,N/A,6.81,N/A,6.81,N/A,1.78,N/A,12.70,N/A,12.70,N/A,12.70,7.62,7.62,1.10,12.70,,Hospital HCPCS 340b,CALCITRIOL 1 MCG/ML PO SOLN,00054-3120-41,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.40,5.40,3.24,3.24,N/A,N/A,N/A,5.40,N/A,3.04,N/A,1.84,N/A,N/A,N/A,N/A,N/A,5.40,N/A,5.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.04,N/A,5.40,N/A,N/A,N/A,2.89,N/A,2.89,N/A,N/A,N/A,5.40,N/A,5.40,N/A,5.40,3.24,3.24,1.84,5.40,,Hospital HCPCS 340b,SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP,46287-0006-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 340b,FLUCONAZOLE 10 MG/ML PO SUSR,59762-5029-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.50,10.50,6.30,6.30,N/A,1.47,N/A,10.50,N/A,5.90,N/A,3.57,N/A,1.47,N/A,1.47,N/A,10.50,N/A,10.50,N/A,N/A,N/A,1.47,N/A,1.47,N/A,1.47,N/A,5.90,N/A,10.50,N/A,1.47,N/A,5.63,N/A,5.63,N/A,1.47,N/A,10.50,N/A,10.50,N/A,10.50,6.30,6.30,1.47,10.50,,Hospital HCPCS 340b,CHERRY PO SYRP,00395-2662-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),30.90,30.90,18.54,18.54,N/A,4.33,N/A,30.90,N/A,17.37,N/A,10.51,N/A,4.33,N/A,4.33,N/A,30.90,N/A,30.90,N/A,2.69,N/A,4.33,N/A,4.33,N/A,4.33,N/A,17.37,N/A,30.90,N/A,4.33,N/A,16.56,N/A,16.56,N/A,4.33,N/A,30.90,N/A,30.90,N/A,30.90,18.54,18.54,2.69,30.90,,Hospital HCPCS 340b,CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP,00121-0766-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,IBUPROFEN 100 MG/5ML PO SUSP,45802-0133-26,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 340b,CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR,00574-0129-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),54.90,54.90,32.94,32.94,N/A,7.69,N/A,54.90,N/A,30.86,N/A,18.67,N/A,7.69,N/A,7.69,N/A,54.90,N/A,54.90,N/A,4.78,N/A,7.69,N/A,7.69,N/A,7.69,N/A,30.86,N/A,54.90,N/A,7.69,N/A,29.43,N/A,29.43,N/A,7.69,N/A,54.90,N/A,54.90,N/A,54.90,32.94,32.94,4.78,54.90,,Hospital HCPCS 340b,LEVOFLOXACIN 25 MG/ML PO SOLN,09999-9910-26,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.90,8.90,5.34,5.34,N/A,1.25,N/A,8.90,N/A,5.00,N/A,3.03,N/A,1.25,N/A,1.25,N/A,8.90,N/A,8.90,N/A,N/A,N/A,1.25,N/A,1.25,N/A,1.25,N/A,5.00,N/A,8.90,N/A,1.25,N/A,4.77,N/A,4.77,N/A,1.25,N/A,8.90,N/A,8.90,N/A,8.90,5.34,5.34,1.25,8.90,,Hospital HCPCS 340b,RISPERIDONE 1 MG/ML PO SOLN,65162-0673-84,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,CARBAMAZEPINE 100 MG/5ML PO SUSP,09999-9908-96,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ITRACONAZOLE 10 MG/ML PO SOLN,50458-0295-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),771.20,771.20,462.72,462.72,N/A,107.97,N/A,771.20,N/A,433.57,N/A,262.21,N/A,107.97,N/A,107.97,N/A,771.20,N/A,771.20,N/A,67.09,N/A,107.97,N/A,107.97,N/A,107.97,N/A,433.57,N/A,771.20,N/A,107.97,N/A,413.36,N/A,413.36,N/A,107.97,N/A,771.20,N/A,771.20,N/A,771.20,462.72,462.72,67.09,771.20,,Hospital HCPCS 340b,RISPERIDONE 1 MG/ML PO SOLN,09999-9910-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ACETAMINOPHEN 160 MG/5ML PO SOLN,00121-1314-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),4.10,4.10,2.46,2.46,N/A,N/A,N/A,4.10,N/A,2.31,N/A,1.39,N/A,N/A,N/A,N/A,N/A,4.10,N/A,4.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.31,N/A,4.10,N/A,N/A,N/A,2.20,N/A,2.20,N/A,N/A,N/A,4.10,N/A,4.10,N/A,4.10,2.46,2.46,1.39,4.10,,Hospital HCPCS 340b,PHENOL 1.4 % MT LIQD,00904-6305-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP,09999-9012-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,MIDAZOLAM HCL 2 MG/ML PO SYRP,68094-0764-59,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ATOVAQUONE 750 MG/5ML PO SUSP,09999-9911-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),28.50,28.50,17.10,17.10,N/A,3.99,N/A,28.50,N/A,16.02,N/A,9.69,N/A,3.99,N/A,3.99,N/A,28.50,N/A,28.50,N/A,2.48,N/A,3.99,N/A,3.99,N/A,3.99,N/A,16.02,N/A,28.50,N/A,3.99,N/A,15.28,N/A,15.28,N/A,3.99,N/A,28.50,N/A,28.50,N/A,28.50,17.10,17.10,2.48,28.50,,Hospital HCPCS 340b,FOLIC ACID 5 MG/ML IJ SOLN,63323-0184-10,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 340b,DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD,58657-0528-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.50,3.50,2.10,2.10,N/A,N/A,N/A,3.50,N/A,1.97,N/A,1.19,N/A,N/A,N/A,N/A,N/A,3.50,N/A,3.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.97,N/A,3.50,N/A,N/A,N/A,1.88,N/A,1.88,N/A,N/A,N/A,3.50,N/A,3.50,N/A,3.50,2.10,2.10,1.19,3.50,,Hospital HCPCS 340b,AZITHROMYCIN 200 MG/5ML PO SUSR,42806-0151-34,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.80,33.80,20.28,20.28,N/A,4.73,N/A,33.80,N/A,19.00,N/A,11.49,N/A,4.73,N/A,4.73,N/A,33.80,N/A,33.80,N/A,2.94,N/A,4.73,N/A,4.73,N/A,4.73,N/A,19.00,N/A,33.80,N/A,4.73,N/A,18.12,N/A,18.12,N/A,4.73,N/A,33.80,N/A,33.80,N/A,33.80,20.28,20.28,2.94,33.80,,Hospital HCPCS 340b,METHADONE HCL 10 MG/ML PO CONC,66689-0694-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),149.70,149.70,89.82,89.82,N/A,20.96,N/A,149.70,N/A,84.16,N/A,50.90,N/A,20.96,N/A,20.96,N/A,149.70,N/A,149.70,N/A,13.02,N/A,20.96,N/A,20.96,N/A,20.96,N/A,84.16,N/A,149.70,N/A,20.96,N/A,80.24,N/A,80.24,N/A,20.96,N/A,149.70,N/A,149.70,N/A,149.70,89.82,89.82,13.02,149.70,,Hospital HCPCS 340b,CERTA-VITE PO LIQD,00573-0513-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,IBUPROFEN 100 MG/5ML PO SUSP,09999-9907-23,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 340b,AMOXICILLIN 400 MG/5ML PO SUSR,00093-4161-73,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.80,17.80,10.68,10.68,N/A,2.49,N/A,17.80,N/A,10.01,N/A,6.05,N/A,2.49,N/A,2.49,N/A,17.80,N/A,17.80,N/A,1.55,N/A,2.49,N/A,2.49,N/A,2.49,N/A,10.01,N/A,17.80,N/A,2.49,N/A,9.54,N/A,9.54,N/A,2.49,N/A,17.80,N/A,17.80,N/A,17.80,10.68,10.68,1.55,17.80,,Hospital HCPCS 340b,GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN,00121-1775-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,VANCOMYCIN HCL 50 MG/ML PO SOLR,65628-0206-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),320.00,320.00,192.00,192.00,N/A,44.80,N/A,320.00,N/A,179.90,N/A,108.80,N/A,44.80,N/A,44.80,N/A,320.00,N/A,320.00,N/A,27.84,N/A,44.80,N/A,44.80,N/A,44.80,N/A,179.90,N/A,320.00,N/A,44.80,N/A,171.52,N/A,171.52,N/A,44.80,N/A,320.00,N/A,320.00,N/A,320.00,192.00,192.00,27.84,320.00,,Hospital HCPCS 340b,LACTULOSE ENCEPHALOPATHY 10 GM/15ML PO SOLN,60432-0038-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP,00054-3117-63,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,PREDNISOLONE 15 MG/5ML PO SOLN,09999-9913-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,1.79,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.11,N/A,1.79,N/A,1.79,N/A,1.79,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.11,5.00,,Hospital HCPCS 340b,AMOXICILLIN 250 MG/5ML PO SUSR,00143-9889-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 340b,MINERAL OIL PO OIL,99999-9903-57,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 340b,AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR,66685-1012-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.90,32.90,19.74,19.74,N/A,4.61,N/A,32.90,N/A,18.50,N/A,11.19,N/A,4.61,N/A,4.61,N/A,32.90,N/A,32.90,N/A,2.86,N/A,4.61,N/A,4.61,N/A,4.61,N/A,18.50,N/A,32.90,N/A,4.61,N/A,17.63,N/A,17.63,N/A,4.61,N/A,32.90,N/A,32.90,N/A,32.90,19.74,19.74,2.86,32.90,,Hospital HCPCS 340b,CEPHALEXIN 125 MG/5ML PO SUSR,00093-4175-74,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),72.00,72.00,43.20,43.20,N/A,10.08,N/A,72.00,N/A,40.48,N/A,24.48,N/A,10.08,N/A,10.08,N/A,72.00,N/A,72.00,N/A,6.26,N/A,10.08,N/A,10.08,N/A,10.08,N/A,40.48,N/A,72.00,N/A,10.08,N/A,38.59,N/A,38.59,N/A,10.08,N/A,72.00,N/A,72.00,N/A,72.00,43.20,43.20,6.26,72.00,,Hospital HCPCS 340b,POLY-VI-SOL PO SOLN,00087-0402-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,DEXTROMETHORPHAN POLISTIREX ER 30 MG/5ML PO SUER,00904-6312-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 340b,METHADONE HCL 10 MG/ML PO CONC,09999-9910-19,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR,00093-4127-73,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),18.50,18.50,11.10,11.10,N/A,2.59,N/A,18.50,N/A,10.40,N/A,6.29,N/A,2.59,N/A,2.59,N/A,18.50,N/A,18.50,N/A,1.61,N/A,2.59,N/A,2.59,N/A,2.59,N/A,10.40,N/A,18.50,N/A,2.59,N/A,9.92,N/A,9.92,N/A,2.59,N/A,18.50,N/A,18.50,N/A,18.50,11.10,11.10,1.61,18.50,,Hospital HCPCS 340b,MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,00054-0517-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,POLY-VI-SOL/IRON 11 MG/ML PO SOLN,09999-9904-67,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,AMOXICILLIN 400 MG/5ML PO SUSR,00093-4161-76,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.90,8.90,5.34,5.34,N/A,1.25,N/A,8.90,N/A,5.00,N/A,3.03,N/A,1.25,N/A,1.25,N/A,8.90,N/A,8.90,N/A,N/A,N/A,1.25,N/A,1.25,N/A,1.25,N/A,5.00,N/A,8.90,N/A,1.25,N/A,4.77,N/A,4.77,N/A,1.25,N/A,8.90,N/A,8.90,N/A,8.90,5.34,5.34,1.25,8.90,,Hospital HCPCS 340b,MORPHINE SULFATE 10 MG/5ML PO SOLN,00121-0904-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN,09999-9911-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP,65862-0496-47,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ALUM & MAG HYDROXIDE-SIMETH 400-400-40 MG/5ML PO SUSP,00536-0015-83,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,NYSTATIN 100000 UNIT/ML MT SUSP,70166-0331-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,CARBAMAZEPINE 100 MG/5ML PO SUSP,51672-4047-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,00406-8003-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR,24338-0134-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),846.50,846.50,507.90,507.90,N/A,118.51,N/A,846.50,N/A,475.90,N/A,287.81,N/A,118.51,N/A,118.51,N/A,846.50,N/A,846.50,N/A,73.65,N/A,118.51,N/A,118.51,N/A,118.51,N/A,475.90,N/A,846.50,N/A,118.51,N/A,453.72,N/A,453.72,N/A,118.51,N/A,846.50,N/A,846.50,N/A,846.50,507.90,507.90,73.65,846.50,,Hospital HCPCS 340b,HALOPERIDOL LACTATE 2 MG/ML PO CONC,09999-9910-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP,00536-0091-85,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.90,13.90,8.34,8.34,N/A,1.95,N/A,13.90,N/A,7.81,N/A,4.73,N/A,1.95,N/A,1.95,N/A,13.90,N/A,13.90,N/A,1.21,N/A,1.95,N/A,1.95,N/A,1.95,N/A,7.81,N/A,13.90,N/A,1.95,N/A,7.45,N/A,7.45,N/A,1.95,N/A,13.90,N/A,13.90,N/A,13.90,8.34,8.34,1.21,13.90,,Hospital HCPCS 340b,FIRST-METRONIDAZOLE 50 MG/ML PO SUSR,65628-0202-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.70,5.70,3.42,3.42,N/A,N/A,N/A,5.70,N/A,3.20,N/A,1.94,N/A,N/A,N/A,N/A,N/A,5.70,N/A,5.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.20,N/A,5.70,N/A,N/A,N/A,3.06,N/A,3.06,N/A,N/A,N/A,5.70,N/A,5.70,N/A,5.70,3.42,3.42,1.94,5.70,,Hospital HCPCS 340b,CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,00116-2001-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.40,6.40,3.84,3.84,N/A,N/A,N/A,6.40,N/A,3.60,N/A,2.18,N/A,N/A,N/A,N/A,N/A,6.40,N/A,6.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.60,N/A,6.40,N/A,N/A,N/A,3.43,N/A,3.43,N/A,N/A,N/A,6.40,N/A,6.40,N/A,6.40,3.84,3.84,2.18,6.40,,Hospital HCPCS 340b,RANITIDINE HCL 75 MG/5ML PO SYRP,09999-9907-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,HYDROXYZINE HCL 10 MG/5ML PO SYRP,09999-9902-63,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,METHADONE HCL 5 MG/5ML PO SOLN,68094-0031-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,CEPHALEXIN 250 MG/5ML PO SUSR,00093-4177-73,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),51.80,51.80,31.08,31.08,N/A,7.25,N/A,51.80,N/A,29.12,N/A,17.61,N/A,7.25,N/A,7.25,N/A,51.80,N/A,51.80,N/A,4.51,N/A,7.25,N/A,7.25,N/A,7.25,N/A,29.12,N/A,51.80,N/A,7.25,N/A,27.76,N/A,27.76,N/A,7.25,N/A,51.80,N/A,51.80,N/A,51.80,31.08,31.08,4.51,51.80,,Hospital HCPCS 340b,PAROXETINE HCL 10 MG/5ML PO SUSP,09999-9905-91,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.50,10.50,6.30,6.30,N/A,1.47,N/A,10.50,N/A,5.90,N/A,3.57,N/A,1.47,N/A,1.47,N/A,10.50,N/A,10.50,N/A,N/A,N/A,1.47,N/A,1.47,N/A,1.47,N/A,5.90,N/A,10.50,N/A,1.47,N/A,5.63,N/A,5.63,N/A,1.47,N/A,10.50,N/A,10.50,N/A,10.50,6.30,6.30,1.47,10.50,,Hospital HCPCS 340b,CEPHALEXIN 250 MG/5ML PO SUSR,67877-0545-68,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),58.50,58.50,35.10,35.10,N/A,8.19,N/A,58.50,N/A,32.89,N/A,19.89,N/A,8.19,N/A,8.19,N/A,58.50,N/A,58.50,N/A,5.09,N/A,8.19,N/A,8.19,N/A,8.19,N/A,32.89,N/A,58.50,N/A,8.19,N/A,31.36,N/A,31.36,N/A,8.19,N/A,58.50,N/A,58.50,N/A,58.50,35.10,35.10,5.09,58.50,,Hospital HCPCS 340b,GLYCERIN LIQD,00395-1031-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),47.90,47.90,28.74,28.74,N/A,6.71,N/A,47.90,N/A,26.93,N/A,16.29,N/A,6.71,N/A,6.71,N/A,47.90,N/A,47.90,N/A,4.17,N/A,6.71,N/A,6.71,N/A,6.71,N/A,26.93,N/A,47.90,N/A,6.71,N/A,25.67,N/A,25.67,N/A,6.71,N/A,47.90,N/A,47.90,N/A,47.90,28.74,28.74,4.17,47.90,,Hospital HCPCS 340b,CLARITHROMYCIN 125 MG/5ML PO SUSR,00781-6022-52,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.30,13.30,7.98,7.98,N/A,1.86,N/A,13.30,N/A,7.48,N/A,4.52,N/A,1.86,N/A,1.86,N/A,13.30,N/A,13.30,N/A,1.16,N/A,1.86,N/A,1.86,N/A,1.86,N/A,7.48,N/A,13.30,N/A,1.86,N/A,7.13,N/A,7.13,N/A,1.86,N/A,13.30,N/A,13.30,N/A,13.30,7.98,7.98,1.16,13.30,,Hospital HCPCS 340b,POLY-VI-SOL PO SOLN,09999-9914-38,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,FERRIC SUBSULFATE (BULK) SOLN,38779-1284-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),172.60,172.60,103.56,103.56,N/A,24.16,N/A,172.60,N/A,97.04,N/A,58.68,N/A,24.16,N/A,24.16,N/A,172.60,N/A,172.60,N/A,15.02,N/A,24.16,N/A,24.16,N/A,24.16,N/A,97.04,N/A,172.60,N/A,24.16,N/A,92.51,N/A,92.51,N/A,24.16,N/A,172.60,N/A,172.60,N/A,172.60,103.56,103.56,15.02,172.60,,Hospital HCPCS 340b,GLYCERIN LIQD,00395-1031-96,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.00,16.00,9.60,9.60,N/A,2.24,N/A,16.00,N/A,9.00,N/A,5.44,N/A,2.24,N/A,2.24,N/A,16.00,N/A,16.00,N/A,1.39,N/A,2.24,N/A,2.24,N/A,2.24,N/A,9.00,N/A,16.00,N/A,2.24,N/A,8.58,N/A,8.58,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,9.60,9.60,1.39,16.00,,Hospital HCPCS 340b,DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD,00904-6985-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.50,3.50,2.10,2.10,N/A,N/A,N/A,3.50,N/A,1.97,N/A,1.19,N/A,N/A,N/A,N/A,N/A,3.50,N/A,3.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.97,N/A,3.50,N/A,N/A,N/A,1.88,N/A,1.88,N/A,N/A,N/A,3.50,N/A,3.50,N/A,3.50,2.10,2.10,1.19,3.50,,Hospital HCPCS 340b,PROMETHAZINE-CODEINE 6.25-10 MG/5ML PO SYRP,09999-9999-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,GABAPENTIN 250 MG/5ML PO SOLN,99999-9901-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,EMTRICITABINE 10 MG/ML PO SOLN,61958-0602-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),285.00,285.00,171.00,171.00,N/A,39.90,N/A,285.00,N/A,160.23,N/A,96.90,N/A,39.90,N/A,39.90,N/A,285.00,N/A,285.00,N/A,24.80,N/A,39.90,N/A,39.90,N/A,39.90,N/A,160.23,N/A,285.00,N/A,39.90,N/A,152.76,N/A,152.76,N/A,39.90,N/A,285.00,N/A,285.00,N/A,285.00,171.00,171.00,24.80,285.00,,Hospital HCPCS 340b,AZITHROMYCIN 100 MG/5ML PO SUSR,42806-0147-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.00,27.00,16.20,16.20,N/A,3.78,N/A,27.00,N/A,15.18,N/A,9.18,N/A,3.78,N/A,3.78,N/A,27.00,N/A,27.00,N/A,2.35,N/A,3.78,N/A,3.78,N/A,3.78,N/A,15.18,N/A,27.00,N/A,3.78,N/A,14.47,N/A,14.47,N/A,3.78,N/A,27.00,N/A,27.00,N/A,27.00,16.20,16.20,2.35,27.00,,Hospital HCPCS 340b,FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN,39328-0057-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.80,15.80,9.48,9.48,N/A,2.21,N/A,15.80,N/A,8.88,N/A,5.37,N/A,2.21,N/A,2.21,N/A,15.80,N/A,15.80,N/A,1.37,N/A,2.21,N/A,2.21,N/A,2.21,N/A,8.88,N/A,15.80,N/A,2.21,N/A,8.47,N/A,8.47,N/A,2.21,N/A,15.80,N/A,15.80,N/A,15.80,9.48,9.48,1.37,15.80,,Hospital HCPCS 340b,OXYCODONE HCL 100 MG/5ML PO CONC,09999-9900-24,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,LEVETIRACETAM 100 MG/ML PO SOLN,09999-9900-94,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.50,6.50,3.90,3.90,N/A,N/A,N/A,6.50,N/A,3.65,N/A,2.21,N/A,N/A,N/A,N/A,N/A,6.50,N/A,6.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.65,N/A,6.50,N/A,N/A,N/A,3.48,N/A,3.48,N/A,N/A,N/A,6.50,N/A,6.50,N/A,6.50,3.90,3.90,2.21,6.50,,Hospital HCPCS 340b,PHENYTOIN 125 MG/5ML PO SUSP,N/A,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,POLY-VI-SOL/IRON 11 MG/ML PO SOLN,00087-0405-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,NYSTATIN 100000 UNIT/ML MT SUSP,60432-0537-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,NEVIRAPINE 50 MG/5ML PO SUSP,65862-0057-24,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),340.80,340.80,204.48,204.48,N/A,47.71,N/A,340.80,N/A,191.60,N/A,115.87,N/A,47.71,N/A,47.71,N/A,340.80,N/A,340.80,N/A,29.65,N/A,47.71,N/A,47.71,N/A,47.71,N/A,191.60,N/A,340.80,N/A,47.71,N/A,182.67,N/A,182.67,N/A,47.71,N/A,340.80,N/A,340.80,N/A,340.80,204.48,204.48,29.65,340.80,,Hospital HCPCS 340b,CLARITHROMYCIN 250 MG/5ML PO SUSR,00781-6023-46,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),357.30,357.30,214.38,214.38,N/A,50.02,N/A,357.30,N/A,200.87,N/A,121.48,N/A,50.02,N/A,50.02,N/A,357.30,N/A,357.30,N/A,31.09,N/A,50.02,N/A,50.02,N/A,50.02,N/A,200.87,N/A,357.30,N/A,50.02,N/A,191.51,N/A,191.51,N/A,50.02,N/A,357.30,N/A,357.30,N/A,357.30,214.38,214.38,31.09,357.30,,Hospital HCPCS 340b,SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP,09999-9900-52,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP,01490-0039-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.50,8.50,5.10,5.10,N/A,1.19,N/A,8.50,N/A,4.78,N/A,2.89,N/A,1.19,N/A,1.19,N/A,8.50,N/A,8.50,N/A,N/A,N/A,1.19,N/A,1.19,N/A,1.19,N/A,4.78,N/A,8.50,N/A,1.19,N/A,4.56,N/A,4.56,N/A,1.19,N/A,8.50,N/A,8.50,N/A,8.50,5.10,5.10,1.19,8.50,,Hospital HCPCS 340b,CLARITHROMYCIN 125 MG/5ML PO SUSR,00781-6022-46,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.30,13.30,7.98,7.98,N/A,1.86,N/A,13.30,N/A,7.48,N/A,4.52,N/A,1.86,N/A,1.86,N/A,13.30,N/A,13.30,N/A,1.16,N/A,1.86,N/A,1.86,N/A,1.86,N/A,7.48,N/A,13.30,N/A,1.86,N/A,7.13,N/A,7.13,N/A,1.86,N/A,13.30,N/A,13.30,N/A,13.30,7.98,7.98,1.16,13.30,,Hospital HCPCS 340b,MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,09999-9900-26,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,POLY-VI-SOL/IRON 11 MG/ML PO SOLN,09999-9914-39,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,RITONAVIR 80 MG/ML PO SOLN,99999-9911-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),51.40,51.40,30.84,30.84,N/A,7.20,N/A,51.40,N/A,28.90,N/A,17.48,N/A,7.20,N/A,7.20,N/A,51.40,N/A,51.40,N/A,4.47,N/A,7.20,N/A,7.20,N/A,7.20,N/A,28.90,N/A,51.40,N/A,7.20,N/A,27.55,N/A,27.55,N/A,7.20,N/A,51.40,N/A,51.40,N/A,51.40,30.84,30.84,4.47,51.40,,Hospital HCPCS 340b,POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN,00603-1542-58,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.50,8.50,5.10,5.10,N/A,1.19,N/A,8.50,N/A,4.78,N/A,2.89,N/A,1.19,N/A,1.19,N/A,8.50,N/A,8.50,N/A,N/A,N/A,1.19,N/A,1.19,N/A,1.19,N/A,4.78,N/A,8.50,N/A,1.19,N/A,4.56,N/A,4.56,N/A,1.19,N/A,8.50,N/A,8.50,N/A,8.50,5.10,5.10,1.19,8.50,,Hospital HCPCS 340b,ROCURONIUM BROMIDE 100 MG/10ML IV SOLN,63323-0426-01,0250 - PHARMACY - GENERAL CLASSIFICATION,87.80,87.80,52.68,52.68,N/A,12.29,N/A,87.80,N/A,50.56,N/A,29.85,N/A,12.29,N/A,12.29,N/A,87.80,N/A,87.80,N/A,7.64,N/A,12.29,N/A,12.29,N/A,12.29,N/A,50.56,N/A,87.80,N/A,12.29,N/A,47.06,N/A,47.06,N/A,12.29,N/A,87.80,N/A,87.80,N/A,87.80,52.68,52.68,7.64,87.80,,Hospital HCPCS 340b,LACTULOSE 10 GM/15ML PO SOLN,00121-4577-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 340b,POLY-VI-SOL PO SOLN,09999-9904-68,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital 34203,Emblc/Thrmbc Popliteal-Tibio-Proneal Art Leg Inc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46748.37,N/A,28049.02,N/A,6480.03,N/A,940.65,N/A,26780.17,N/A,15744.55,N/A,11480.11,N/A,6480.03,N/A,4641.41,N/A,4641.41,N/A,7146.59,N/A,11480.11,N/A,11480.11,N/A,11480.11,N/A,26780.19,N/A,4641.41,N/A,6480.03,N/A,7897.00,N/A,7897.00,N/A,6480.03,N/A,4641.41,N/A,940.65,N/A,1034.72,N/A,N/A,940.65,28049.02,,Hospital 34421,Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45821.57,N/A,27492.94,N/A,6405.69,N/A,2865.65,N/A,26374.80,N/A,15579.35,N/A,6541.44,N/A,6405.69,N/A,2694.06,N/A,2694.06,N/A,4072.17,N/A,6541.44,N/A,6541.44,N/A,6541.44,N/A,26374.78,N/A,2694.06,N/A,6405.69,N/A,4562.00,N/A,4562.00,N/A,6405.69,N/A,2694.06,N/A,2865.65,N/A,822.20,N/A,N/A,822.20,27492.94,,Hospital 34708,HC Evasc Rpr Ilio-Iliac Rpt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,157578.22,N/A,94546.93,N/A,27273.78,N/A,32529.13,N/A,86857.11,N/A,53576.59,N/A,N/A,N/A,28114.13,N/A,32529.13,N/A,32529.13,N/A,40128.80,N/A,64464.77,N/A,64464.77,N/A,N/A,N/A,86857.11,N/A,32529.13,N/A,28114.13,N/A,73825.94,N/A,73825.94,N/A,5465.91,N/A,32529.13,N/A,32529.13,N/A,30082.12,N/A,5465.91,94546.93,N/A,N/A,,Hospital 34712,HC Transcatheter Dlvr Enhncd Fixation Devices Rs&I,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,615864.20,N/A,369518.52,N/A,N/A,N/A,N/A,N/A,229830.36,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,229830.36,N/A,N/A,N/A,N/A,N/A,229830.36,N/A,229830.36,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,229830.36,369518.52,N/A,N/A,,Hospital 35011,Dir Rpr Aneurysm Axil-Brachial Arm Incision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,55619.60,N/A,33371.76,N/A,17835.24,N/A,20308.93,N/A,39981.57,N/A,18910.66,N/A,41933.75,N/A,18384.77,N/A,20279.28,N/A,20279.28,N/A,26103.42,N/A,41933.75,N/A,41933.75,N/A,41933.75,N/A,39981.57,N/A,20279.28,N/A,18384.77,N/A,48023.11,N/A,48023.11,N/A,N/A,N/A,4641.41,N/A,20308.93,N/A,19671.71,N/A,4641.41,48023.11,N/A,N/A,,Hospital 35190,Rpr/Traumatic Av Fistula Extremities,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29116.92,N/A,17470.15,N/A,4106.74,N/A,4641.41,N/A,16651.73,N/A,9899.75,N/A,11243.85,N/A,4106.74,N/A,4641.41,N/A,4641.41,N/A,6999.50,N/A,11243.85,N/A,11243.85,N/A,11243.85,N/A,16651.74,N/A,4641.41,N/A,4106.74,N/A,7897.00,N/A,7897.00,N/A,4106.74,N/A,4641.41,N/A,4641.41,N/A,5105.55,N/A,N/A,4106.74,17470.15,,Hospital CPT 35206,HC Rep Blood Vessel Direct Up Ext,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5631.00,5631.00,3378.60,3378.60,N/A,788.34,N/A,751.47,N/A,3242.33,N/A,1914.54,N/A,2228.73,N/A,788.34,N/A,751.47,N/A,751.47,N/A,1387.38,N/A,2228.73,N/A,2228.73,N/A,2228.73,N/A,3242.33,N/A,751.47,N/A,788.34,N/A,5631.00,N/A,5631.00,N/A,788.34,N/A,751.47,N/A,751.47,N/A,826.62,3378.60,3378.60,751.47,5631.00,,Hospital CPT 35221,HC Rpr Blood Vessel Direct Intra-Abd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1211.00,1211.00,726.60,726.60,N/A,169.54,N/A,1417.65,N/A,697.29,N/A,411.74,N/A,1211.00,N/A,169.54,N/A,1417.65,N/A,1417.65,N/A,1211.00,N/A,1211.00,N/A,1211.00,N/A,1211.00,N/A,697.29,N/A,1417.65,N/A,169.54,N/A,1211.00,N/A,1211.00,N/A,169.54,N/A,1417.65,N/A,1417.65,N/A,1559.42,726.60,726.60,169.54,1559.42,,Hospital CPT 35226,"HC Repair Blood Vessel Lesion, Low Extrem",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1364.00,1364.00,818.40,818.40,N/A,190.96,N/A,799.52,N/A,785.39,N/A,463.76,N/A,1364.00,N/A,190.96,N/A,799.52,N/A,799.52,N/A,1364.00,N/A,1364.00,N/A,1364.00,N/A,1364.00,N/A,785.39,N/A,799.52,N/A,190.96,N/A,1364.00,N/A,1364.00,N/A,190.96,N/A,799.52,N/A,799.52,N/A,879.47,818.40,818.40,190.96,1364.00,,Hospital CPT 35226,HC Repair Blood Vessel Low Ext,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1364.00,1364.00,818.40,818.40,N/A,190.96,N/A,799.52,N/A,785.39,N/A,463.76,N/A,1364.00,N/A,190.96,N/A,799.52,N/A,799.52,N/A,1364.00,N/A,1364.00,N/A,1364.00,N/A,1364.00,N/A,785.39,N/A,799.52,N/A,190.96,N/A,1364.00,N/A,1364.00,N/A,190.96,N/A,799.52,N/A,799.52,N/A,879.47,818.40,818.40,190.96,1364.00,,Hospital 35572,Harvest Fempop Vein 1 Sgm Vasc Rcnstj Px,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,61778.70,N/A,37067.22,N/A,9754.35,N/A,11215.97,N/A,21830.75,N/A,21004.76,N/A,22896.68,N/A,10054.90,N/A,1719.64,N/A,1719.64,N/A,14253.00,N/A,22896.68,N/A,22896.68,N/A,22896.68,N/A,21830.75,N/A,11186.32,N/A,10054.90,N/A,26221.60,N/A,26221.60,N/A,N/A,N/A,11186.32,N/A,11215.97,N/A,10758.75,N/A,1719.64,37067.22,N/A,N/A,,Hospital 35875,Thrmbc Artl/Ven Grf Oth/Thn Hemo Grf/Fstl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25720.73,N/A,15432.44,N/A,3589.28,N/A,10574.55,N/A,14787.63,N/A,8583.71,N/A,23295.19,N/A,3589.28,N/A,9586.05,N/A,9586.05,N/A,14501.71,N/A,23295.19,N/A,23295.19,N/A,23295.19,N/A,14787.64,N/A,9586.05,N/A,3589.28,N/A,11845.50,N/A,11845.50,N/A,3589.28,N/A,9586.05,N/A,989.22,N/A,1088.15,N/A,N/A,989.22,23295.19,,Hospital 35876,HC Removal of Clot in Graft,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,78579.57,N/A,47147.74,N/A,9754.35,N/A,11804.54,N/A,25205.25,N/A,26717.05,N/A,23055.56,N/A,10054.90,N/A,11804.54,N/A,11804.54,N/A,N/A,N/A,23055.56,N/A,23055.56,N/A,23055.56,N/A,25205.25,N/A,11804.54,N/A,10054.90,N/A,26403.54,N/A,26403.54,N/A,13000.05,N/A,11804.54,N/A,11804.54,N/A,10758.75,N/A,9754.35,47147.74,N/A,N/A,,Hospital 35903,Excision Infected Graft Extremity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,179423.38,18190.52,107654.03,10914.31,N/A,2464.71,10289.13,2967.53,N/A,10464.14,N/A,6184.77,N/A,6565.44,N/A,2464.71,10289.13,2690.13,10289.13,2690.13,N/A,4087.11,N/A,6565.44,N/A,6565.44,N/A,6565.44,N/A,10464.15,10289.13,2690.13,N/A,2464.71,N/A,4562.00,N/A,4562.00,N/A,2464.71,10289.13,2690.13,10289.13,613.82,N/A,675.22,10289.13,107654.03,613.82,10914.31,,Hospital Custom 3600000001,HC Surgery Level 1 Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1793.00,1793.00,1075.80,1075.80,N/A,251.02,N/A,1793.00,N/A,1032.41,N/A,609.62,N/A,251.02,N/A,251.02,N/A,1793.00,N/A,1793.00,N/A,155.99,N/A,251.02,N/A,251.02,N/A,251.02,N/A,1032.41,N/A,1793.00,N/A,251.02,N/A,1793.00,N/A,1793.00,N/A,251.02,N/A,1793.00,N/A,1793.00,N/A,1793.00,1075.80,1075.80,155.99,1793.00,,Hospital Custom 3600000003,HC Surgery Level 3 Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4430.00,4430.00,2658.00,2658.00,N/A,620.20,N/A,4430.00,N/A,2550.79,N/A,1506.20,N/A,620.20,N/A,620.20,N/A,4430.00,N/A,4430.00,N/A,385.41,N/A,620.20,N/A,620.20,N/A,620.20,N/A,2550.79,N/A,4430.00,N/A,620.20,N/A,4430.00,N/A,4430.00,N/A,620.20,N/A,4430.00,N/A,4430.00,N/A,4430.00,2658.00,2658.00,385.41,4430.00,,Hospital Custom 3600000009,HC Surgery Robot Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,6592.00,6592.00,3955.20,3955.20,N/A,922.88,N/A,6592.00,N/A,3795.67,N/A,2241.28,N/A,922.88,N/A,922.88,N/A,6592.00,N/A,6592.00,N/A,573.50,N/A,922.88,N/A,922.88,N/A,922.88,N/A,3795.67,N/A,6592.00,N/A,922.88,N/A,6592.00,N/A,6592.00,N/A,922.88,N/A,6592.00,N/A,6592.00,N/A,6592.00,3955.20,3955.20,573.50,6592.00,,Hospital Custom 3600000015,HC Surgery Level 5 Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2379.00,2379.00,1427.40,1427.40,N/A,333.06,N/A,2379.00,N/A,1369.83,N/A,808.86,N/A,333.06,N/A,333.06,N/A,2379.00,N/A,2379.00,N/A,206.97,N/A,333.06,N/A,333.06,N/A,333.06,N/A,1369.83,N/A,2379.00,N/A,333.06,N/A,2379.00,N/A,2379.00,N/A,333.06,N/A,2379.00,N/A,2379.00,N/A,2379.00,1427.40,1427.40,206.97,2379.00,,Hospital Custom 3600000100,HC Manipulate Knee Under Anesth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5557.00,5557.00,3334.20,3334.20,N/A,777.98,N/A,5557.00,N/A,3199.72,N/A,1889.38,N/A,777.98,N/A,777.98,N/A,5557.00,N/A,5557.00,N/A,483.46,N/A,777.98,N/A,777.98,N/A,777.98,N/A,3199.72,N/A,5557.00,N/A,777.98,N/A,5557.00,N/A,5557.00,N/A,777.98,N/A,5557.00,N/A,5557.00,N/A,5557.00,3334.20,3334.20,483.46,5557.00,,Hospital CPT 36005,HC Injection Venography,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,365.00,365.00,219.00,219.00,N/A,51.10,N/A,365.00,N/A,210.17,N/A,124.10,N/A,365.00,N/A,51.10,N/A,365.00,N/A,365.00,N/A,365.00,N/A,365.00,N/A,365.00,N/A,365.00,N/A,210.17,N/A,365.00,N/A,51.10,N/A,527.00,N/A,527.00,N/A,51.10,N/A,365.00,N/A,365.00,N/A,365.00,219.00,219.00,51.10,527.00,,Hospital CPT 36014,HC Select Cath Place Pul Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,389.00,389.00,233.40,233.40,N/A,54.46,N/A,145.36,N/A,223.99,N/A,132.26,N/A,389.00,N/A,54.46,N/A,389.00,N/A,389.00,N/A,389.00,N/A,389.00,N/A,389.00,N/A,389.00,N/A,223.99,N/A,389.00,N/A,54.46,N/A,527.00,N/A,527.00,N/A,54.46,N/A,389.00,N/A,145.36,N/A,159.90,233.40,233.40,54.46,527.00,,Hospital CPT 36015,HC Place Cath Seg or Sub Pul Art,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,453.00,453.00,271.80,271.80,N/A,63.42,N/A,164.49,N/A,260.84,N/A,154.02,N/A,453.00,N/A,63.42,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,260.84,N/A,453.00,N/A,63.42,N/A,527.00,N/A,527.00,N/A,63.42,N/A,453.00,N/A,164.49,N/A,180.94,271.80,271.80,63.42,527.00,,Hospital Custom 3604323500,HC Gerd Test W/Electrode (Bravo),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3919.00,3919.00,2351.40,2351.40,N/A,548.66,N/A,3919.00,N/A,2256.56,N/A,1332.46,N/A,548.66,N/A,548.66,N/A,3919.00,N/A,3919.00,N/A,340.95,N/A,548.66,N/A,548.66,N/A,548.66,N/A,2256.56,N/A,3919.00,N/A,548.66,N/A,3919.00,N/A,3919.00,N/A,548.66,N/A,3919.00,N/A,3919.00,N/A,3919.00,2351.40,2351.40,340.95,3919.00,,Hospital Custom 3609008300,HC Sigmoidoscopy W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2291.00,2291.00,1374.60,1374.60,N/A,320.74,N/A,2291.00,N/A,1319.16,N/A,778.94,N/A,320.74,N/A,320.74,N/A,2291.00,N/A,2291.00,N/A,199.32,N/A,320.74,N/A,320.74,N/A,320.74,N/A,1319.16,N/A,2291.00,N/A,320.74,N/A,2291.00,N/A,2291.00,N/A,320.74,N/A,2291.00,N/A,2291.00,N/A,2291.00,1374.60,1374.60,199.32,2291.00,,Hospital Custom 3609008500,HC Sigmoidoscopy Foreign Body Removal,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3256.00,3256.00,1953.60,1953.60,N/A,455.84,N/A,3256.00,N/A,1874.80,N/A,1107.04,N/A,455.84,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,283.27,N/A,455.84,N/A,455.84,N/A,455.84,N/A,1874.80,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,3256.00,1953.60,1953.60,283.27,3256.00,,Hospital Custom 3609008600,HC Sigmoidoscopy Control Hemorrhage,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3256.00,3256.00,1953.60,1953.60,N/A,455.84,N/A,3256.00,N/A,1874.80,N/A,1107.04,N/A,455.84,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,283.27,N/A,455.84,N/A,455.84,N/A,455.84,N/A,1874.80,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,3256.00,1953.60,1953.60,283.27,3256.00,,Hospital Custom 3609009000,HC Sigmoidoscopy Screening,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2117.00,2117.00,1270.20,1270.20,N/A,296.38,N/A,2117.00,N/A,1218.97,N/A,719.78,N/A,296.38,N/A,296.38,N/A,2117.00,N/A,2117.00,N/A,184.18,N/A,296.38,N/A,296.38,N/A,296.38,N/A,1218.97,N/A,2117.00,N/A,296.38,N/A,2117.00,N/A,2117.00,N/A,296.38,N/A,2117.00,N/A,2117.00,N/A,2117.00,1270.20,1270.20,184.18,2117.00,,Hospital Custom 3609009100,HC Sigmoidoscopy Submucosal Injection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2197.00,2197.00,1318.20,1318.20,N/A,307.58,N/A,2197.00,N/A,1265.03,N/A,746.98,N/A,307.58,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,191.14,N/A,307.58,N/A,307.58,N/A,307.58,N/A,1265.03,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,2197.00,1318.20,1318.20,191.14,2197.00,,Hospital Custom 3609009200,HC Sigmoidoscopy Stent Placement,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3256.00,3256.00,1953.60,1953.60,N/A,455.84,N/A,3256.00,N/A,1874.80,N/A,1107.04,N/A,455.84,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,283.27,N/A,455.84,N/A,455.84,N/A,455.84,N/A,1874.80,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,3256.00,1953.60,1953.60,283.27,3256.00,,Hospital Custom 3609009900,HC Colonoscopy W/Control Bleeding Any Method,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010000,HC Colonoscopy Stoma Control Bleeding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010100,HC Colonoscopy Stoma Ablation Lesion,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010200,HC Colonoscopy Ablation Tumor Polyp/Other Les,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010400,HC Colonoscopy Polypectomy Hot Biopsy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010900,HC Bronchoscopy Theraputic Aspiration Initial,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609011000,HC Bronchoscopy Theraputic Aspiration Subsequent,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609011200,HC Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Addl Lobe,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,5635.00,5635.00,3381.00,3381.00,N/A,788.90,N/A,5635.00,N/A,3244.63,N/A,1915.90,N/A,788.90,N/A,788.90,N/A,5635.00,N/A,5635.00,N/A,490.25,N/A,788.90,N/A,788.90,N/A,788.90,N/A,3244.63,N/A,5635.00,N/A,788.90,N/A,5635.00,N/A,5635.00,N/A,788.90,N/A,5635.00,N/A,5635.00,N/A,5635.00,3381.00,3381.00,490.25,5635.00,,Hospital Custom 3609011400,HC Bronchoscopy Cryotherapy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7782.00,7782.00,4669.20,4669.20,N/A,1089.48,N/A,7782.00,N/A,4480.88,N/A,2645.88,N/A,1089.48,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,677.03,N/A,1089.48,N/A,1089.48,N/A,1089.48,N/A,4480.88,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,7782.00,4669.20,4669.20,677.03,7782.00,,Hospital Custom 3609011600,HC Bronchoscopy Foreign Body Removal,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609012000,HC Bronchoscopy Each Addl Major Bronchus Stented,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,5635.00,5635.00,3381.00,3381.00,N/A,788.90,N/A,5635.00,N/A,3244.63,N/A,1915.90,N/A,788.90,N/A,788.90,N/A,5635.00,N/A,5635.00,N/A,490.25,N/A,788.90,N/A,788.90,N/A,788.90,N/A,3244.63,N/A,5635.00,N/A,788.90,N/A,5635.00,N/A,5635.00,N/A,788.90,N/A,5635.00,N/A,5635.00,N/A,5635.00,3381.00,3381.00,490.25,5635.00,,Hospital Custom 3609012100,HC Brnonchoscopy W/Place Brncl Stent 1st Bronchus,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7782.00,7782.00,4669.20,4669.20,N/A,1089.48,N/A,7782.00,N/A,4480.88,N/A,2645.88,N/A,1089.48,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,677.03,N/A,1089.48,N/A,1089.48,N/A,1089.48,N/A,4480.88,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,7782.00,4669.20,4669.20,677.03,7782.00,,Hospital Custom 3609012700,HC Egd Dilation Savory,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609014200,HC Ercp W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609014500,HC Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609014800,HC Ercp Tumor/Polyp/Lesion Ablation W/Dilation&Wire,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609015900,HC Esophagoscopy Dilation Balloon,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609016000,HC Esophagoscopy Dilation Savory,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609016200,HC Esophagoscopy Control Hemorrhage,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609017700,HC Egd Dilation Gastric/Duodenal Stricture,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609018200,HC Egd Injection Sclerosis Esophgl/Gastric Varices,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609018300,HC Gastroduodenoscopy via Stoma,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609019000,HC Egd Capsule Endoscopy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3497.00,3497.00,2098.20,2098.20,N/A,489.58,N/A,3497.00,N/A,2013.57,N/A,1188.98,N/A,489.58,N/A,489.58,N/A,3497.00,N/A,3497.00,N/A,304.24,N/A,489.58,N/A,489.58,N/A,489.58,N/A,2013.57,N/A,3497.00,N/A,489.58,N/A,3497.00,N/A,3497.00,N/A,489.58,N/A,3497.00,N/A,3497.00,N/A,3497.00,2098.20,2098.20,304.24,3497.00,,Hospital Custom 3609019300,HC Esophagoscopy Foreign Body Removal,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4211.00,4211.00,2526.60,2526.60,N/A,589.54,N/A,4211.00,N/A,2424.69,N/A,1431.74,N/A,589.54,N/A,589.54,N/A,4211.00,N/A,4211.00,N/A,366.36,N/A,589.54,N/A,589.54,N/A,589.54,N/A,2424.69,N/A,4211.00,N/A,589.54,N/A,4211.00,N/A,4211.00,N/A,589.54,N/A,4211.00,N/A,4211.00,N/A,4211.00,2526.60,2526.60,366.36,4211.00,,Hospital Custom 3609020500,HC Ileoscopy W/Bx Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609021300,HC Ileoscopy Thru Stoma W Stent Placement,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609022100,HC Sigmoidoscopy W/ Band Ligation(S),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3256.00,3256.00,1953.60,1953.60,N/A,455.84,N/A,3256.00,N/A,1874.80,N/A,1107.04,N/A,455.84,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,283.27,N/A,455.84,N/A,455.84,N/A,455.84,N/A,1874.80,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,3256.00,1953.60,1953.60,283.27,3256.00,,Hospital Custom 3609027000,HC Colonoscopy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609027000,HC Thoracentesis W/Ultrasound,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2185.00,2185.00,1311.00,1311.00,N/A,305.90,N/A,2185.00,N/A,1258.12,N/A,742.90,N/A,305.90,N/A,305.90,N/A,2185.00,N/A,2185.00,N/A,190.10,N/A,305.90,N/A,305.90,N/A,305.90,N/A,1258.12,N/A,2185.00,N/A,305.90,N/A,2185.00,N/A,2185.00,N/A,305.90,N/A,2185.00,N/A,2185.00,N/A,2185.00,1311.00,1311.00,190.10,2185.00,,Hospital Custom 3609027000,HC Bronchial Thermoplasty,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7782.00,7782.00,4669.20,4669.20,N/A,1089.48,N/A,7782.00,N/A,4480.88,N/A,2645.88,N/A,1089.48,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,677.03,N/A,1089.48,N/A,1089.48,N/A,1089.48,N/A,4480.88,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,7782.00,4669.20,4669.20,677.03,7782.00,,Hospital Custom 3609027000,HC Bronchoscopy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609038000,HC Peg Tube Removal,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,918.00,918.00,550.80,550.80,N/A,128.52,N/A,918.00,N/A,528.58,N/A,312.12,N/A,128.52,N/A,128.52,N/A,918.00,N/A,918.00,N/A,79.87,N/A,128.52,N/A,128.52,N/A,128.52,N/A,528.58,N/A,918.00,N/A,128.52,N/A,918.00,N/A,918.00,N/A,128.52,N/A,918.00,N/A,918.00,N/A,918.00,550.80,550.80,79.87,918.00,,Hospital Custom 3609154800,HC Anoscopy Dx W/Collj Spec Br/Wa Spx When Prfrmd,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2197.00,2197.00,1318.20,1318.20,N/A,307.58,N/A,2197.00,N/A,1265.03,N/A,746.98,N/A,307.58,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,191.14,N/A,307.58,N/A,307.58,N/A,307.58,N/A,1265.03,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,2197.00,1318.20,1318.20,191.14,2197.00,,Hospital Custom 3609155700,HC Egd Stent Removal,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609156000,HC Ercp W/Pressure Measurement Sphincter of Oddi,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,8492.00,8492.00,5095.20,5095.20,N/A,1188.88,N/A,8492.00,N/A,4889.69,N/A,2887.28,N/A,1188.88,N/A,1188.88,N/A,8492.00,N/A,8492.00,N/A,738.80,N/A,1188.88,N/A,1188.88,N/A,1188.88,N/A,4889.69,N/A,8492.00,N/A,1188.88,N/A,8492.00,N/A,8492.00,N/A,1188.88,N/A,8492.00,N/A,8492.00,N/A,8492.00,5095.20,5095.20,738.80,8492.00,,Hospital 36100,HC Intro Need/Cath Car/Ver Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,164293.57,35192.62,98576.14,21115.57,11017.47,4863.23,7539.84,1096.45,90558.61,20032.27,55859.80,11965.49,14407.60,6838.58,7907.49,4863.23,7539.84,1092.65,7539.84,1092.65,8969.16,4257.16,14407.60,6838.58,14407.60,6838.58,14407.60,6838.58,90558.61,20032.28,7539.84,1092.65,7907.49,4863.23,16644.99,2038.25,16644.99,2038.25,6639.75,4863.23,7539.84,1092.65,7539.84,1096.45,8461.02,1334.88,6639.75,98576.14,1092.65,21115.57,,Hospital CPT 36216,HC Initial Cath Secord Order,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1555.00,1555.00,933.00,933.00,N/A,217.70,N/A,1555.00,N/A,895.37,N/A,528.70,N/A,1555.00,N/A,217.70,N/A,1555.00,N/A,1555.00,N/A,1555.00,N/A,1555.00,N/A,1555.00,N/A,1555.00,N/A,895.37,N/A,1555.00,N/A,217.70,N/A,527.00,N/A,527.00,N/A,217.70,N/A,1555.00,N/A,1555.00,N/A,285.38,933.00,933.00,217.70,1555.00,,Hospital CPT 36225,HC Place Cath Subclavian Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7943.00,7943.00,4765.80,4765.80,N/A,1112.02,N/A,2813.99,N/A,4573.58,N/A,2700.62,N/A,6507.21,N/A,1112.02,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,4573.58,N/A,2690.13,N/A,1112.02,N/A,4562.00,N/A,4562.00,N/A,1112.02,N/A,2690.13,N/A,306.31,N/A,336.94,4765.80,4765.80,306.31,6507.21,,Hospital CPT 36225,HC Arch & Uni Vert,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,7943.00,7943.00,4765.80,4765.80,N/A,1112.02,N/A,2813.99,N/A,4573.58,N/A,2700.62,N/A,6507.21,N/A,1112.02,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,4573.58,N/A,2690.13,N/A,1112.02,N/A,4562.00,N/A,4562.00,N/A,1112.02,N/A,2690.13,N/A,306.31,N/A,336.94,4765.80,4765.80,306.31,6507.21,,Hospital CPT 36227,HC Selective External Carotid Imaging Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,12339.00,12339.00,7403.40,7403.40,N/A,1727.46,N/A,12339.00,N/A,7104.80,N/A,4195.26,N/A,12339.00,N/A,1727.46,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,7104.80,N/A,12339.00,N/A,1727.46,N/A,527.00,N/A,527.00,N/A,1727.46,N/A,12339.00,N/A,12339.00,N/A,124.97,7403.40,7403.40,124.97,12339.00,,Hospital CPT 36246,HC Sel Cath Abd/Pelvc/Le Init 2nd,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1137.00,1137.00,682.20,682.20,N/A,159.18,N/A,1137.00,N/A,654.68,N/A,386.58,N/A,1137.00,N/A,159.18,N/A,1137.00,N/A,1137.00,N/A,1137.00,N/A,1137.00,N/A,1137.00,N/A,1137.00,N/A,654.68,N/A,1137.00,N/A,159.18,N/A,527.00,N/A,527.00,N/A,159.18,N/A,1137.00,N/A,1137.00,N/A,267.22,682.20,682.20,159.18,1137.00,,Hospital CPT 36430,HC Blood Administration,N/A,"0391 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - ADMINISTRATION (E.G., TRANS",2099.00,2099.00,1259.40,1259.40,N/A,293.86,N/A,368.21,N/A,1208.60,N/A,713.66,N/A,890.69,N/A,293.86,N/A,368.21,N/A,368.21,N/A,554.47,N/A,890.69,N/A,890.69,N/A,890.69,N/A,1208.60,N/A,368.21,N/A,293.86,N/A,1125.06,N/A,1125.06,N/A,293.86,N/A,368.21,N/A,368.21,N/A,405.04,1259.40,1259.40,293.86,1259.40,,Hospital 36483,HC Endoven Ther Chem Adhes Sbsq,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,10784.30,N/A,6470.58,N/A,1509.80,N/A,4822.12,N/A,6209.61,N/A,3666.66,N/A,10784.30,N/A,1509.80,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,10784.30,N/A,10784.30,N/A,10784.30,N/A,6209.61,N/A,4641.41,N/A,1509.80,N/A,8160.50,N/A,8160.50,N/A,1509.80,N/A,4641.41,N/A,4822.12,N/A,285.08,N/A,N/A,285.08,10784.30,,Hospital CPT 36510,HC Cath Umbil Cord Venous,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,202.00,202.00,121.20,121.20,N/A,28.28,N/A,52.04,N/A,116.31,N/A,68.68,N/A,202.00,N/A,28.28,N/A,52.04,N/A,52.04,N/A,149.62,N/A,202.00,N/A,202.00,N/A,202.00,N/A,116.31,N/A,52.04,N/A,28.28,N/A,202.00,N/A,202.00,N/A,28.28,N/A,52.04,N/A,52.04,N/A,57.24,121.20,121.20,28.28,202.00,,Hospital CPT 36510,HC Cath Umbil Cord Venous,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,189.00,189.00,113.40,113.40,N/A,26.46,N/A,52.04,N/A,108.83,N/A,64.26,N/A,189.00,N/A,26.46,N/A,52.04,N/A,52.04,N/A,149.62,N/A,189.00,N/A,189.00,N/A,189.00,N/A,108.83,N/A,52.04,N/A,26.46,N/A,189.00,N/A,189.00,N/A,26.46,N/A,52.04,N/A,52.04,N/A,57.24,113.40,113.40,26.46,189.00,,Hospital 36512,HC Apheresis RBC,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,155816.87,9866.52,93490.12,5919.91,22054.06,1340.26,N/A,162.82,N/A,5677.59,53171.63,3354.62,23754.54,5101.03,22054.06,1340.26,N/A,2163.83,N/A,2163.83,14786.65,3175.49,23754.54,5101.03,23754.54,5101.03,23754.54,5101.03,N/A,5677.60,N/A,2163.83,22054.06,1340.26,N/A,1871.00,N/A,1871.00,22054.06,1340.26,N/A,2163.83,N/A,162.82,22054.06,179.11,14786.65,93490.12,162.82,5919.91,,Hospital 36516,HC Apheresis W/ Affinity Column,N/A,0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION,293037.25,N/A,175822.35,N/A,22054.06,N/A,12624.09,N/A,19991.32,N/A,54300.82,N/A,54300.82,N/A,22054.06,N/A,12624.09,N/A,12624.09,N/A,54300.82,N/A,54300.82,N/A,54300.82,N/A,54300.82,N/A,19991.32,N/A,12624.09,N/A,22054.06,N/A,19991.32,N/A,19991.32,N/A,22054.06,N/A,12624.09,N/A,12624.09,N/A,22054.06,N/A,12624.09,175822.35,N/A,N/A,,Hospital CPT 36561,HC Cv Cath Plac W/Port Tun >5,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7337.00,7337.00,4402.20,4402.20,N/A,1027.18,N/A,2813.99,N/A,4224.64,N/A,2494.58,N/A,6507.21,N/A,1027.18,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,4224.64,N/A,2690.13,N/A,1027.18,N/A,4562.00,N/A,4562.00,N/A,1027.18,N/A,2690.13,N/A,2782.36,N/A,351.87,4402.20,4402.20,351.87,6507.21,,Hospital 36566,HC 2 Cv Cath Plac W/Ports,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,24499.52,N/A,14699.71,N/A,3427.60,N/A,4855.12,N/A,14092.12,N/A,8329.83,N/A,11313.63,N/A,3427.60,N/A,4641.41,N/A,4641.41,N/A,7042.94,N/A,11313.63,N/A,11313.63,N/A,11313.63,N/A,14092.12,N/A,4641.41,N/A,3427.60,N/A,10178.00,N/A,10178.00,N/A,3427.60,N/A,4641.41,N/A,4855.12,N/A,963.90,N/A,N/A,963.90,14699.71,,Hospital CPT 36571,HC�Insert Picc Vad W Sq Port >5 Yrs,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4600.00,4600.00,2760.00,2760.00,N/A,644.00,N/A,300.08,N/A,2648.68,N/A,1564.00,N/A,3445.02,N/A,644.00,N/A,300.08,N/A,300.08,N/A,2144.52,N/A,3445.02,N/A,3445.02,N/A,3445.02,N/A,2648.68,N/A,300.08,N/A,644.00,N/A,4600.00,N/A,4600.00,N/A,644.00,N/A,300.08,N/A,300.08,N/A,330.09,2760.00,2760.00,300.08,4600.00,,Hospital CPT 36573,HC Insertion Picc W/Rs&I 5 Yr/>,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5525.00,5525.00,3315.00,3315.00,N/A,773.50,N/A,81.40,N/A,3181.30,N/A,1878.50,N/A,3250.03,N/A,773.50,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,3181.30,N/A,1343.59,N/A,773.50,N/A,1871.00,N/A,1871.00,N/A,773.50,N/A,1343.59,N/A,1405.45,N/A,1477.95,3315.00,3315.00,81.40,3315.00,,Hospital CPT 36573,HC Insertion Picc W/Rs&I 5 Yr/>,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5525.00,5525.00,3315.00,3315.00,N/A,773.50,N/A,81.40,N/A,3181.30,N/A,1878.50,N/A,3250.03,N/A,773.50,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,3181.30,N/A,1343.59,N/A,773.50,N/A,5525.00,N/A,5525.00,N/A,773.50,N/A,1343.59,N/A,1405.45,N/A,1477.95,3315.00,3315.00,81.40,5525.00,,Hospital 36576,HC Repair Tun or Non Cath W/Port,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,19224.77,N/A,11534.86,N/A,2691.46,N/A,297.92,N/A,10966.67,N/A,6536.42,N/A,3264.07,N/A,2691.46,N/A,1343.59,N/A,1343.59,N/A,2031.94,N/A,3264.07,N/A,3264.07,N/A,3264.07,N/A,10966.67,N/A,1343.59,N/A,2691.46,N/A,1694.50,N/A,1694.50,N/A,2691.46,N/A,1343.59,N/A,297.92,N/A,327.71,N/A,N/A,297.92,11534.86,,Hospital CPT 36580,HC Replac Central Nt Cath WO Port,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3720.00,3720.00,2232.00,2232.00,N/A,520.80,N/A,1371.53,N/A,2141.98,N/A,1264.80,N/A,3250.03,N/A,520.80,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2141.98,N/A,1343.59,N/A,520.80,N/A,1431.00,N/A,1431.00,N/A,520.80,N/A,1343.59,N/A,1371.53,N/A,69.77,2232.00,2232.00,69.77,3250.03,,Hospital CPT 36593,HC Declotting Central Vad,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1327.00,1327.00,796.20,796.20,N/A,185.78,N/A,300.37,N/A,764.09,N/A,451.18,N/A,726.56,N/A,185.78,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,764.09,N/A,300.37,N/A,185.78,N/A,711.27,N/A,711.27,N/A,185.78,N/A,300.37,N/A,300.37,N/A,330.41,796.20,796.20,185.78,796.20,,Hospital CPT 36593,HC Declotting Central Vad,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1327.00,1327.00,796.20,796.20,N/A,185.78,N/A,300.37,N/A,764.09,N/A,451.18,N/A,726.56,N/A,185.78,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,764.09,N/A,300.37,N/A,185.78,N/A,527.00,N/A,527.00,N/A,185.78,N/A,300.37,N/A,300.37,N/A,330.41,796.20,796.20,185.78,796.20,,Hospital CPT 36595,HC Mech Rem Fibrin via Sep Acces,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8072.00,8072.00,4843.20,4843.20,N/A,1130.08,N/A,174.78,N/A,4647.86,N/A,2744.48,N/A,1628.64,N/A,1130.08,N/A,174.78,N/A,174.78,N/A,1013.83,N/A,1628.64,N/A,1628.64,N/A,1628.64,N/A,4647.86,N/A,174.78,N/A,1130.08,N/A,8072.00,N/A,8072.00,N/A,1130.08,N/A,174.78,N/A,174.78,N/A,192.26,4843.20,4843.20,174.78,8072.00,,Hospital CPT 36598,HC Patency Study/Groshong Ca,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,903.00,714.00,541.80,428.40,N/A,99.96,N/A,186.54,N/A,411.12,N/A,242.76,N/A,451.22,N/A,99.96,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,411.12,N/A,186.54,N/A,99.96,N/A,382.70,N/A,382.70,N/A,99.96,N/A,186.54,N/A,186.54,N/A,205.20,541.80,541.80,99.96,451.22,,Hospital CPT 36598,HC Injection Vad,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,903.00,714.00,541.80,428.40,N/A,99.96,N/A,186.54,N/A,411.12,N/A,242.76,N/A,451.22,N/A,99.96,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,411.12,N/A,186.54,N/A,99.96,N/A,382.70,N/A,382.70,N/A,99.96,N/A,186.54,N/A,186.54,N/A,205.20,541.80,541.80,99.96,451.22,,Hospital CPT 36680,HC Intraosseous Needle Placement,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,416.00,416.00,249.60,249.60,N/A,58.24,N/A,57.45,N/A,239.53,N/A,141.44,N/A,171.63,N/A,58.24,N/A,57.45,N/A,57.45,N/A,106.84,N/A,171.63,N/A,171.63,N/A,171.63,N/A,239.53,N/A,57.45,N/A,58.24,N/A,222.98,N/A,222.98,N/A,58.24,N/A,57.45,N/A,57.45,N/A,63.20,249.60,249.60,57.45,249.60,,Hospital CPT 36680,HC Intraosseous Needle Placement (ED),N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,416.00,416.00,249.60,249.60,N/A,58.24,N/A,57.45,N/A,239.53,N/A,141.44,N/A,171.63,N/A,58.24,N/A,57.45,N/A,57.45,N/A,106.84,N/A,171.63,N/A,171.63,N/A,171.63,N/A,239.53,N/A,57.45,N/A,58.24,N/A,416.00,N/A,416.00,N/A,58.24,N/A,57.45,N/A,57.45,N/A,63.20,249.60,249.60,57.45,416.00,,Hospital 36810,Insj Cannula Hemo Oth Purpose Spx Arven Xtrnl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15515.23,N/A,9309.14,N/A,2146.88,N/A,2690.13,N/A,8900.04,N/A,5275.19,N/A,6534.67,N/A,2146.88,N/A,2690.13,N/A,2690.13,N/A,4067.94,N/A,6534.67,N/A,6534.67,N/A,6534.67,N/A,8900.03,N/A,2690.13,N/A,2146.88,N/A,4562.00,N/A,4562.00,N/A,2146.88,N/A,2690.13,N/A,2690.13,N/A,2959.14,N/A,N/A,2146.88,9309.14,,Hospital 36818,Arven Anast Opn Upr Arm Cephalic Vein Trpos,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32867.37,N/A,19720.42,N/A,4533.41,N/A,4855.12,N/A,18922.67,N/A,11174.90,N/A,11263.79,N/A,4533.41,N/A,4641.41,N/A,4641.41,N/A,7012.51,N/A,11263.79,N/A,11263.79,N/A,11263.79,N/A,18922.70,N/A,4641.41,N/A,4533.41,N/A,7897.00,N/A,7897.00,N/A,4533.41,N/A,4641.41,N/A,4855.12,N/A,775.52,N/A,N/A,775.52,19720.42,,Hospital 36821,Arteriovenous Anastomosis Open Direct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52588.10,23464.47,31552.86,14078.68,17655.99,3266.93,21211.07,2690.13,39789.21,13491.99,17879.95,7977.91,41732.01,6568.81,18200.01,3266.93,2690.13,2690.13,2690.13,2690.13,25977.84,4089.19,41732.01,6568.81,41732.01,6568.81,41732.01,6568.81,39789.21,13491.99,21151.77,2690.13,18200.01,3266.93,47792.07,5277.50,47792.07,5277.50,N/A,3266.93,21151.77,2690.13,21211.07,2690.13,19474.01,2959.14,2690.13,47792.07,2690.13,14078.68,,Hospital 36825,Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,68454.78,42250.30,41072.87,25350.18,17655.99,5915.05,21151.77,4855.12,42683.46,24321.71,23274.63,14365.11,41732.01,11394.00,18200.01,5915.05,562.00,4641.41,562.00,4641.41,25977.84,7092.97,41732.01,11394.00,41732.01,11394.00,41732.01,11394.00,42683.46,24321.73,21151.77,4641.41,18200.01,5915.05,47792.07,7897.00,47792.07,7897.00,N/A,5915.05,21151.77,4641.41,21151.77,4855.12,19474.01,837.11,562.00,47792.07,837.11,25350.18,,Hospital 36831,Thrmbc Opn Arven Fstl W/O Revj Dial Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44945.98,N/A,26967.59,N/A,6270.52,N/A,1088.55,N/A,25802.41,N/A,15281.65,N/A,11322.53,N/A,6270.52,N/A,4641.41,N/A,4641.41,N/A,7048.48,N/A,11322.53,N/A,11322.53,N/A,11322.53,N/A,25802.44,N/A,4641.41,N/A,6270.52,N/A,10309.75,N/A,10309.75,N/A,6270.52,N/A,4641.41,N/A,1088.55,N/A,1197.42,N/A,N/A,1088.55,26967.59,,Hospital CPT 36832,HC Av Fistula Revision Open,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,13149.00,13149.00,7889.40,7889.40,N/A,1840.86,N/A,724.58,N/A,7571.19,N/A,4470.66,N/A,2137.35,N/A,1840.86,N/A,724.58,N/A,724.58,N/A,1330.50,N/A,2137.35,N/A,2137.35,N/A,2137.35,N/A,7571.19,N/A,724.58,N/A,1840.86,N/A,13149.00,N/A,13149.00,N/A,1840.86,N/A,724.58,N/A,724.58,N/A,797.04,7889.40,7889.40,724.58,13149.00,,Hospital 36836,HC Perq Av Fistula Creation Uxtr Single Access,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,214384.13,31023.68,128630.48,18614.21,24434.70,4260.93,29170.64,26.25,118168.53,17848.85,72890.61,10548.05,74648.55,31023.69,25187.57,4260.93,4496.00,15512.06,4496.00,15512.06,46478.48,23436.27,74648.55,31023.69,74648.55,31023.69,74648.55,31023.69,118168.53,17848.86,29170.64,15512.06,25187.57,4260.93,107934.14,11660.00,107934.14,11660.00,25187.57,4260.93,29170.64,15512.06,29170.64,26.25,26950.70,28.89,4496.00,128630.48,26.25,31023.69,,Hospital CPT 36902,HC Intro Cath Dialysis Circuit W Pta,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,13751.00,12819.00,8250.60,7691.40,N/A,1794.66,N/A,4709.71,N/A,7381.18,N/A,4358.46,N/A,11392.42,N/A,1794.66,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,11392.42,N/A,11392.42,N/A,11392.42,N/A,7381.18,N/A,4709.71,N/A,1794.66,N/A,7897.00,N/A,7897.00,N/A,1794.66,N/A,4709.71,N/A,4709.71,N/A,5180.69,8250.60,8250.60,1794.66,11392.42,,Hospital CPT 36909,HC Dialysis Circuit Embolj,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,24208.00,24208.00,14524.80,14524.80,N/A,3389.12,N/A,24208.00,N/A,13938.97,N/A,8230.72,N/A,24208.00,N/A,3389.12,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,13938.97,N/A,24208.00,N/A,3389.12,N/A,527.00,N/A,527.00,N/A,3389.12,N/A,24208.00,N/A,24208.00,N/A,213.70,14524.80,14524.80,213.70,24208.00,,Hospital CPT 36909,HC Dialysis Circuit Embolj - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,24208.00,24208.00,14524.80,14524.80,N/A,3389.12,N/A,24208.00,N/A,13938.97,N/A,8230.72,N/A,24208.00,N/A,3389.12,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,24208.00,N/A,13938.97,N/A,24208.00,N/A,3389.12,N/A,527.00,N/A,527.00,N/A,3389.12,N/A,24208.00,N/A,24208.00,N/A,213.70,14524.80,14524.80,213.70,24208.00,,Hospital Custom 3700000001,HC Add 15 Minutes (Anesthesia),N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,209.00,209.00,125.40,125.40,N/A,29.26,N/A,209.00,N/A,120.34,N/A,71.06,N/A,29.26,N/A,29.26,N/A,209.00,N/A,209.00,N/A,18.18,N/A,29.26,N/A,29.26,N/A,29.26,N/A,120.34,N/A,209.00,N/A,29.26,N/A,112.02,N/A,112.02,N/A,29.26,N/A,209.00,N/A,209.00,N/A,209.00,125.40,125.40,18.18,209.00,,Hospital CPT 37185,HC Thromb Mech 2nd Vssl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5247.00,5247.00,3148.20,3148.20,N/A,734.58,N/A,156.46,N/A,3021.22,N/A,1783.98,N/A,5247.00,N/A,734.58,N/A,5247.00,N/A,5247.00,N/A,5247.00,N/A,5247.00,N/A,5247.00,N/A,5247.00,N/A,3021.22,N/A,5247.00,N/A,734.58,N/A,527.00,N/A,527.00,N/A,734.58,N/A,5247.00,N/A,156.46,N/A,172.11,3148.20,3148.20,156.46,5247.00,,Hospital CPT 37186,HC Thromb Mech W/Oth Interv,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6060.00,6060.00,3636.00,3636.00,N/A,848.40,N/A,6060.00,N/A,3489.35,N/A,2060.40,N/A,6060.00,N/A,848.40,N/A,6060.00,N/A,6060.00,N/A,6060.00,N/A,6060.00,N/A,6060.00,N/A,6060.00,N/A,3489.35,N/A,6060.00,N/A,848.40,N/A,527.00,N/A,527.00,N/A,848.40,N/A,6060.00,N/A,6060.00,N/A,258.17,3636.00,3636.00,258.17,6060.00,,Hospital CPT 37188,HC Thromb Mech Vein Sub Day,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,10842.00,10842.00,6505.20,6505.20,N/A,1517.88,N/A,266.78,N/A,6242.82,N/A,3686.28,N/A,4002.75,N/A,1517.88,N/A,266.78,N/A,266.78,N/A,2491.71,N/A,4002.75,N/A,4002.75,N/A,4002.75,N/A,6242.82,N/A,266.78,N/A,1517.88,N/A,10842.00,N/A,10842.00,N/A,1517.88,N/A,266.78,N/A,266.78,N/A,293.46,6505.20,6505.20,266.78,10842.00,,Hospital CPT 37191,"HC Ins Vena Cava Filter Complete, Cath",N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11536.00,11536.00,6921.60,6921.60,N/A,1615.04,N/A,212.70,N/A,6642.43,N/A,3922.24,N/A,11227.17,N/A,1615.04,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,11227.17,N/A,11227.17,N/A,11227.17,N/A,6642.43,N/A,4641.41,N/A,1615.04,N/A,7897.00,N/A,7897.00,N/A,1615.04,N/A,4641.41,N/A,4691.68,N/A,233.97,6921.60,6921.60,212.70,11227.17,,Hospital CPT 37191,HC Insert Ivc Filter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,11536.00,11536.00,6921.60,6921.60,N/A,1615.04,N/A,212.70,N/A,6642.43,N/A,3922.24,N/A,11227.17,N/A,1615.04,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,11227.17,N/A,11227.17,N/A,11227.17,N/A,6642.43,N/A,4641.41,N/A,1615.04,N/A,7897.00,N/A,7897.00,N/A,1615.04,N/A,4641.41,N/A,4691.68,N/A,233.97,6921.60,6921.60,212.70,11227.17,,Hospital 37192,HC Reposition Ivc Filter,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,23405.42,N/A,14043.25,N/A,3262.70,N/A,2782.36,N/A,13428.20,N/A,7957.84,N/A,6546.58,N/A,3262.70,N/A,2690.13,N/A,2690.13,N/A,4075.37,N/A,6546.58,N/A,6546.58,N/A,6546.58,N/A,13428.20,N/A,2690.13,N/A,3262.70,N/A,4562.00,N/A,4562.00,N/A,3262.70,N/A,2690.13,N/A,2782.36,N/A,448.76,N/A,N/A,448.76,14043.25,,Hospital CPT 37212,HC Thrombolysis Venous Infusion W/Imaging Init Tx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5615.00,5615.00,3369.00,3369.00,N/A,786.10,N/A,324.27,N/A,3233.12,N/A,1909.10,N/A,960.00,N/A,786.10,N/A,324.27,N/A,324.27,N/A,597.60,N/A,960.00,N/A,960.00,N/A,960.00,N/A,3233.12,N/A,324.27,N/A,786.10,N/A,5615.00,N/A,5615.00,N/A,786.10,N/A,324.27,N/A,324.27,N/A,356.70,3369.00,3369.00,324.27,5615.00,,Hospital CPT 37212,HC Trancath Thx Venous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5615.00,5615.00,3369.00,3369.00,N/A,786.10,N/A,324.27,N/A,3233.12,N/A,1909.10,N/A,960.00,N/A,786.10,N/A,324.27,N/A,324.27,N/A,597.60,N/A,960.00,N/A,960.00,N/A,960.00,N/A,3233.12,N/A,324.27,N/A,786.10,N/A,5615.00,N/A,5615.00,N/A,786.10,N/A,324.27,N/A,324.27,N/A,356.70,3369.00,3369.00,324.27,5615.00,,Hospital CPT 37220,HC Plasty Uni Iliac Initial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,8090.00,8090.00,4854.00,4854.00,N/A,1132.60,N/A,4871.18,N/A,4658.22,N/A,2750.60,N/A,8090.00,N/A,1132.60,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,8090.00,N/A,8090.00,N/A,8090.00,N/A,4658.22,N/A,4709.71,N/A,1132.60,N/A,7897.00,N/A,7897.00,N/A,1132.60,N/A,4709.71,N/A,4709.71,N/A,5180.69,4854.00,4854.00,1132.60,8090.00,,Hospital CPT 37223,HC Plasty Iliac W Stent Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,14524.00,14524.00,8714.40,8714.40,N/A,2033.36,N/A,14524.00,N/A,8362.92,N/A,4938.16,N/A,14524.00,N/A,2033.36,N/A,14524.00,N/A,14524.00,N/A,14524.00,N/A,14524.00,N/A,14524.00,N/A,14524.00,N/A,8362.92,N/A,14524.00,N/A,2033.36,N/A,7897.00,N/A,7897.00,N/A,2033.36,N/A,14524.00,N/A,14524.00,N/A,225.05,8714.40,8714.40,225.05,14524.00,,Hospital CPT 37233,HC Tib per Terr Addl Ather,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8782.00,8782.00,5269.20,5269.20,N/A,1229.48,N/A,8782.00,N/A,5056.68,N/A,2985.88,N/A,8782.00,N/A,1229.48,N/A,8782.00,N/A,8782.00,N/A,8782.00,N/A,8782.00,N/A,8782.00,N/A,8782.00,N/A,5056.68,N/A,8782.00,N/A,1229.48,N/A,11660.00,N/A,11660.00,N/A,1229.48,N/A,8782.00,N/A,8782.00,N/A,342.89,5269.20,5269.20,342.89,11660.00,,Hospital CPT 37239,HC Stent Place Venous Ea Add,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,16353.00,16353.00,9811.80,9811.80,N/A,2289.42,N/A,16353.00,N/A,9416.06,N/A,5560.02,N/A,16353.00,N/A,2289.42,N/A,16353.00,N/A,16353.00,N/A,16353.00,N/A,16353.00,N/A,16353.00,N/A,16353.00,N/A,9416.06,N/A,16353.00,N/A,2289.42,N/A,7897.00,N/A,7897.00,N/A,2289.42,N/A,16353.00,N/A,16353.00,N/A,159.39,9811.80,9811.80,159.39,16353.00,,Hospital CPT 37244,HC Embolization Bleed Angio,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,58665.00,58665.00,35199.00,35199.00,N/A,8213.10,N/A,10027.43,N/A,33779.31,N/A,19946.10,N/A,23187.86,N/A,8213.10,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,23187.86,N/A,23187.86,N/A,23187.86,N/A,33779.31,N/A,9586.05,N/A,8213.10,N/A,11660.00,N/A,11660.00,N/A,8213.10,N/A,9586.05,N/A,10027.43,N/A,699.26,35199.00,35199.00,699.26,35199.00,,Hospital CPT 37249,HC Trluml Balo Angiop Addl Vein,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9291.00,8360.00,5574.60,5016.00,N/A,1170.40,N/A,139.95,N/A,4813.69,N/A,2842.40,N/A,8360.00,N/A,1170.40,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,4813.69,N/A,8360.00,N/A,1170.40,N/A,527.00,N/A,527.00,N/A,1170.40,N/A,8360.00,N/A,139.95,N/A,153.95,5574.60,5574.60,139.95,8360.00,,Hospital CPT 37249,HC Trluml Balo Angiop Addl Vein - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9291.00,8360.00,5574.60,5016.00,N/A,1170.40,N/A,139.95,N/A,4813.69,N/A,2842.40,N/A,8360.00,N/A,1170.40,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,4813.69,N/A,8360.00,N/A,1170.40,N/A,527.00,N/A,527.00,N/A,1170.40,N/A,8360.00,N/A,139.95,N/A,153.95,5574.60,5574.60,139.95,8360.00,,Hospital 37609,Ligation/Biopsy Temporal Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18432.40,N/A,11059.44,N/A,2563.81,N/A,1354.15,N/A,10611.32,N/A,6267.02,N/A,3309.75,N/A,2563.81,N/A,1354.15,N/A,1354.15,N/A,2060.39,N/A,3309.75,N/A,3309.75,N/A,3309.75,N/A,10611.32,N/A,1354.15,N/A,2563.81,N/A,1871.00,N/A,1871.00,N/A,2563.81,N/A,1354.15,N/A,1354.15,N/A,1489.57,N/A,N/A,1354.15,11059.44,,Hospital 37700,Lig&Div Long Saph Vein Saphfem Junct/Interrupj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45085.33,N/A,27051.20,N/A,6303.54,N/A,4800.54,N/A,25950.28,N/A,15329.01,N/A,11280.21,N/A,6303.54,N/A,4641.41,N/A,4641.41,N/A,7022.15,N/A,11280.21,N/A,11280.21,N/A,11280.21,N/A,25950.29,N/A,4641.41,N/A,6303.54,N/A,6843.00,N/A,6843.00,N/A,6303.54,N/A,4641.41,N/A,4800.54,N/A,601.16,N/A,N/A,601.16,27051.20,,Hospital 38214,HC Allo Manual Plasma Re,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,560838.27,N/A,336502.96,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145771.72,336502.96,N/A,N/A,,Hospital 38241,HC Auto Cryo Pbpc Infusion,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,137635.20,6089.40,82581.12,3653.64,N/A,841.52,40535.58,2180.03,N/A,3504.03,N/A,2070.40,N/A,5094.50,N/A,841.52,38661.75,2084.07,38661.75,2084.07,N/A,3171.42,N/A,5094.50,N/A,5094.50,N/A,5094.50,N/A,2885.39,40535.58,2084.07,N/A,841.52,N/A,573.05,N/A,573.05,N/A,841.52,40535.58,2084.07,40535.58,2180.03,N/A,357.34,38661.75,82581.12,357.34,5094.50,,Hospital 38531,Open Biopsy/Excision Inguinofemoral Nodes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23740.65,N/A,14244.39,N/A,3323.71,N/A,2745.16,N/A,13649.33,N/A,8071.81,N/A,7837.99,N/A,3323.71,N/A,3104.47,N/A,3104.47,N/A,5117.40,N/A,7837.99,N/A,7837.99,N/A,7837.99,N/A,13649.34,N/A,3104.47,N/A,3323.71,N/A,6392.25,N/A,6392.25,N/A,3323.71,N/A,3104.47,N/A,2745.16,N/A,3019.69,N/A,N/A,2745.16,14244.39,,Hospital 38572,Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86892.82,55439.42,52135.69,33263.65,9615.12,7618.98,8584.05,8584.05,21668.45,31919.18,29543.55,18849.40,21875.73,19914.17,9911.38,7618.98,1686.00,8206.20,1686.00,8206.20,13617.13,12396.95,21875.73,19914.17,21875.73,19914.17,21875.73,19914.17,21668.45,31919.22,11639.83,8206.20,9911.38,7618.98,26026.66,11845.50,26026.66,11845.50,N/A,7618.98,11639.83,8206.20,11639.83,8584.05,10605.18,2987.72,1686.00,52135.69,2987.72,33263.65,,Hospital 38573,Laps W/Bi Tot Pel Lmphadec & Omntc Lymph Bx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63972.42,N/A,38383.45,N/A,8845.19,N/A,8734.19,N/A,36824.97,N/A,21750.61,N/A,20681.84,N/A,8845.19,N/A,8356.34,N/A,8356.34,N/A,13070.84,N/A,20681.84,N/A,20681.84,N/A,20681.84,N/A,36825.01,N/A,8379.28,N/A,8845.19,N/A,11845.50,N/A,11845.50,N/A,8845.19,N/A,8356.34,N/A,8734.19,N/A,3765.23,N/A,N/A,3765.23,38383.45,,Hospital 38745,Axillary Lymphadenectomy Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40543.30,N/A,24325.98,N/A,5676.05,N/A,1602.31,N/A,23342.94,N/A,13784.71,N/A,11408.33,N/A,5676.05,N/A,4706.78,N/A,4706.78,N/A,7101.91,N/A,11408.33,N/A,11408.33,N/A,11408.33,N/A,23342.95,N/A,4706.78,N/A,5676.05,N/A,7897.00,N/A,7897.00,N/A,5676.05,N/A,4706.78,N/A,1602.31,N/A,1762.54,N/A,N/A,1602.31,24325.98,,Hospital 38765,Inguinofem Lmphadec Supfc W/Pel Lmphadec,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29311.70,N/A,17587.02,N/A,4132.60,N/A,1460.13,N/A,16874.96,N/A,9965.98,N/A,11802.19,N/A,4132.60,N/A,1453.59,N/A,1453.59,N/A,7347.08,N/A,11802.19,N/A,11802.19,N/A,11802.19,N/A,16874.96,N/A,1453.59,N/A,4132.60,N/A,1643.00,N/A,1643.00,N/A,4132.60,N/A,1453.59,N/A,1460.13,N/A,2452.15,N/A,N/A,1453.59,17587.02,,Hospital 38999,HC Clip Placement Node Biops,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13708.30,N/A,8224.98,N/A,1919.16,N/A,1416.50,N/A,7888.73,N/A,4660.82,N/A,3275.59,N/A,1919.16,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,7888.73,N/A,1354.15,N/A,1919.16,N/A,2134.50,N/A,2134.50,N/A,1919.16,N/A,1354.15,N/A,1416.50,N/A,999.42,N/A,N/A,999.42,8224.98,,Hospital 39402,Mediastinoscopy With Lymph Node Biopsy/Ies,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29565.83,N/A,17739.50,N/A,4098.27,N/A,585.01,N/A,17012.20,N/A,10036.82,N/A,11432.76,N/A,4098.27,N/A,4706.78,N/A,4706.78,N/A,7117.12,N/A,11432.76,N/A,11432.76,N/A,11432.76,N/A,17012.22,N/A,4706.78,N/A,4098.27,N/A,5963.00,N/A,5963.00,N/A,4098.27,N/A,4706.78,N/A,585.01,N/A,643.53,N/A,N/A,585.01,17739.50,,Hospital 40500,Vermilionectomy Lip Shv W/Mucosal Advmnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17785.80,N/A,10671.48,N/A,2490.02,N/A,2733.05,N/A,10236.54,N/A,6047.18,N/A,6228.12,N/A,2490.02,N/A,2569.18,N/A,2569.18,N/A,3877.14,N/A,6228.12,N/A,6228.12,N/A,6228.12,N/A,10236.54,N/A,2569.18,N/A,2490.02,N/A,2806.50,N/A,2806.50,N/A,2490.02,N/A,2569.18,N/A,2733.05,N/A,1132.75,N/A,N/A,1132.75,10671.48,,Hospital CPT 40652,HC Repair Lip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1342.00,1342.00,805.20,805.20,N/A,187.88,N/A,337.75,N/A,772.72,N/A,456.28,N/A,1342.00,N/A,187.88,N/A,337.75,N/A,337.75,N/A,900.64,N/A,1342.00,N/A,1342.00,N/A,1342.00,N/A,772.72,N/A,337.75,N/A,187.88,N/A,1342.00,N/A,1342.00,N/A,187.88,N/A,337.75,N/A,337.75,N/A,371.53,805.20,805.20,187.88,1342.00,,Hospital 40654,HC Repair Lip Full Thkns >One-Half Vert Height/Comple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,18502.10,N/A,11101.26,N/A,2590.29,N/A,1279.62,N/A,10650.59,N/A,6290.71,N/A,3050.29,N/A,2590.29,N/A,1253.55,N/A,1253.55,N/A,1898.86,N/A,3050.29,N/A,3050.29,N/A,3050.29,N/A,10650.59,N/A,1253.55,N/A,2590.29,N/A,1871.00,N/A,1871.00,N/A,2590.29,N/A,1253.55,N/A,1279.62,N/A,441.16,N/A,N/A,441.16,11101.26,,Hospital 40814,Exc Lesion Mucosa & Sbmcsl Vestibule Cplx Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43123.23,N/A,25873.94,N/A,5995.66,N/A,2036.66,N/A,24801.15,N/A,14661.91,N/A,11758.77,N/A,5995.66,N/A,4821.94,N/A,4821.94,N/A,7320.04,N/A,11758.77,N/A,11758.77,N/A,11758.77,N/A,24576.03,N/A,4821.94,N/A,5995.66,N/A,7661.50,N/A,7661.50,N/A,5995.66,N/A,4821.94,N/A,2036.66,N/A,2234.20,N/A,N/A,2036.66,25873.94,,Hospital CPT 40819,HC Frenulectomy-Labial or Buccal,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3360.00,3360.00,2016.00,2016.00,N/A,470.40,N/A,186.68,N/A,1934.69,N/A,1142.40,N/A,748.56,N/A,470.40,N/A,186.68,N/A,186.68,N/A,465.98,N/A,748.56,N/A,748.56,N/A,748.56,N/A,1934.69,N/A,186.68,N/A,470.40,N/A,3360.00,N/A,3360.00,N/A,470.40,N/A,186.68,N/A,186.68,N/A,205.35,2016.00,2016.00,186.68,3360.00,,Hospital 40820,Dstrj Les/Scar Vestibule Mouth Physical Meths,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18616.60,N/A,11169.96,N/A,2606.32,N/A,2687.47,N/A,10718.76,N/A,6329.64,N/A,6223.06,N/A,2606.32,N/A,2569.18,N/A,2569.18,N/A,3873.97,N/A,6223.06,N/A,6223.06,N/A,6223.06,N/A,10718.76,N/A,2569.18,N/A,2606.32,N/A,1871.00,N/A,1871.00,N/A,2606.32,N/A,2569.18,N/A,2687.47,N/A,171.89,N/A,N/A,171.89,11169.96,,Hospital CPT 40830,HC Repair Mouth Laceration,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,755.00,755.00,453.00,453.00,N/A,105.70,N/A,139.91,N/A,434.73,N/A,256.70,N/A,627.81,N/A,105.70,N/A,139.91,N/A,139.91,N/A,390.81,N/A,627.81,N/A,627.81,N/A,627.81,N/A,434.73,N/A,139.91,N/A,105.70,N/A,755.00,N/A,755.00,N/A,105.70,N/A,139.91,N/A,139.91,N/A,153.90,453.00,453.00,105.70,755.00,,Hospital 40840,Vestibuloplasty Anterior,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29875.70,N/A,17925.42,N/A,4182.60,N/A,4922.21,N/A,17194.39,N/A,10157.74,N/A,11700.33,N/A,4182.60,N/A,4821.94,N/A,4821.94,N/A,7283.66,N/A,11700.33,N/A,11700.33,N/A,11700.33,N/A,17194.39,N/A,4821.94,N/A,4182.60,N/A,3397.00,N/A,3397.00,N/A,4182.60,N/A,4821.94,N/A,4922.21,N/A,729.83,N/A,N/A,729.83,17925.42,,Hospital 40899,Unlisted Procedure Vestibule Mouth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40120.60,N/A,24072.36,N/A,5616.90,N/A,5043.96,N/A,23100.60,N/A,13641.00,N/A,11674.25,N/A,5616.90,N/A,4821.94,N/A,4821.94,N/A,7267.44,N/A,11674.25,N/A,11674.25,N/A,11674.25,N/A,23100.61,N/A,4821.94,N/A,5616.90,N/A,6226.50,N/A,6226.50,N/A,5616.90,N/A,4821.94,N/A,5043.96,N/A,482.80,N/A,N/A,482.80,24072.36,,Hospital 41017,Xtroral I&D Absc Cst/Hmtma Floor Mouth Submndb,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13640.72,N/A,8184.43,N/A,1894.36,N/A,330.73,N/A,7847.92,N/A,4637.84,N/A,6248.08,N/A,1894.36,N/A,2569.18,N/A,2569.18,N/A,3889.55,N/A,6248.08,N/A,6248.08,N/A,6248.08,N/A,7847.94,N/A,2569.18,N/A,1894.36,N/A,1871.00,N/A,1871.00,N/A,1894.36,N/A,2569.18,N/A,330.73,N/A,363.80,N/A,N/A,330.73,8184.43,,Hospital 41110,Excision Lesion Tongue W/O Closure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12407.40,N/A,7444.44,N/A,1737.02,N/A,2597.00,N/A,7142.95,N/A,4218.50,N/A,6227.83,N/A,1737.02,N/A,2569.18,N/A,2569.18,N/A,3876.93,N/A,6227.83,N/A,6227.83,N/A,6227.83,N/A,7142.95,N/A,2569.18,N/A,1737.02,N/A,1871.00,N/A,1871.00,N/A,1737.02,N/A,2569.18,N/A,2597.00,N/A,167.55,N/A,N/A,167.55,7444.44,,Hospital CPT 41800,HC Drain Cyst/Absces Dentoaveolar,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,973.00,973.00,583.80,583.80,N/A,136.22,N/A,142.00,N/A,560.25,N/A,330.82,N/A,796.44,N/A,136.22,N/A,142.00,N/A,142.00,N/A,495.78,N/A,796.44,N/A,796.44,N/A,796.44,N/A,560.25,N/A,142.00,N/A,136.22,N/A,973.00,N/A,973.00,N/A,136.22,N/A,142.00,N/A,142.00,N/A,156.20,583.80,583.80,136.22,973.00,,Hospital CPT 41806,HC Removal Foreign Body Jawbone,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3803.00,3803.00,2281.80,2281.80,N/A,532.42,N/A,262.49,N/A,2189.77,N/A,1293.02,N/A,1133.79,N/A,532.42,N/A,262.49,N/A,262.49,N/A,705.78,N/A,1133.79,N/A,1133.79,N/A,1133.79,N/A,2189.77,N/A,262.49,N/A,532.42,N/A,3803.00,N/A,3803.00,N/A,532.42,N/A,262.49,N/A,262.49,N/A,288.74,2281.80,2281.80,262.49,3803.00,,Hospital 41874,Alveoloplasty Each Quadrant Specify,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,61667.70,19140.62,37000.62,11484.37,12119.65,2679.68,N/A,459.84,30153.58,11017.66,N/A,6507.80,N/A,6237.60,12119.65,2679.68,N/A,2569.18,N/A,2569.18,N/A,3883.04,N/A,6237.60,N/A,6237.60,N/A,6237.60,30153.58,11017.66,N/A,2569.18,12119.65,2679.68,N/A,2938.25,36218.41,2938.25,12119.65,2679.68,N/A,2569.18,N/A,459.84,14758.05,505.82,12119.65,37000.62,459.84,11484.37,,Hospital 42145,Palatopharyngoplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,82319.88,28166.67,49391.93,16900.00,9651.93,3943.32,11713.03,826.67,21751.40,16201.57,27988.76,9576.66,21959.47,11768.18,9949.32,3943.32,11683.38,4821.94,11683.38,4821.94,13669.26,7325.91,21959.47,11768.18,21959.47,11768.18,21959.47,11768.18,21751.40,16201.59,11683.38,4821.94,9949.32,3943.32,26126.29,5944.75,26126.29,5944.75,3506.71,3943.32,11683.38,4821.94,11713.03,826.67,10645.77,909.34,3506.71,49391.93,826.67,16900.00,,Hospital 42160,Dstrj Lesion Palate/Uvula Thermal Cryo/Chem,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9303.20,N/A,5581.92,N/A,1299.58,N/A,2556.03,N/A,5352.78,N/A,3163.09,N/A,6255.63,N/A,1299.58,N/A,2569.18,N/A,2569.18,N/A,3894.24,N/A,6255.63,N/A,6255.63,N/A,6255.63,N/A,5352.78,N/A,2569.18,N/A,1299.58,N/A,1871.00,N/A,1871.00,N/A,1299.58,N/A,2569.18,N/A,2556.03,N/A,190.99,N/A,N/A,190.99,6255.63,,Hospital 42299,Unlisted Procedure Palate Uvula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51574.57,N/A,30944.74,N/A,7215.34,N/A,291.17,N/A,29688.62,N/A,17535.35,N/A,716.86,N/A,7215.34,N/A,281.52,N/A,281.52,N/A,446.25,N/A,716.86,N/A,716.86,N/A,716.86,N/A,29688.62,N/A,281.52,N/A,7215.34,N/A,790.50,N/A,790.50,N/A,7215.34,N/A,281.52,N/A,291.17,N/A,9.47,N/A,N/A,9.47,30944.74,,Hospital 42300,Drainage Abscess Parotid Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18188.38,N/A,10913.03,N/A,2519.47,N/A,1342.46,N/A,10471.23,N/A,6184.05,N/A,3305.56,N/A,2519.47,N/A,1354.15,N/A,1354.15,N/A,2057.77,N/A,3305.56,N/A,3305.56,N/A,3305.56,N/A,10471.24,N/A,1354.15,N/A,2519.47,N/A,3274.25,N/A,3274.25,N/A,2519.47,N/A,1354.15,N/A,1342.46,N/A,1474.69,N/A,N/A,1342.46,10913.03,,Hospital 42330,Sialot Submndblr Sublngl/Prtd Uncomp Intraoral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16897.67,N/A,10138.60,N/A,2355.18,N/A,170.92,N/A,9718.10,N/A,5745.21,N/A,6295.73,N/A,2355.18,N/A,2569.18,N/A,2569.18,N/A,3919.21,N/A,6295.73,N/A,6295.73,N/A,6295.73,N/A,9718.12,N/A,2569.18,N/A,2355.18,N/A,1871.00,N/A,1871.00,N/A,2355.18,N/A,2569.18,N/A,170.92,N/A,188.02,N/A,N/A,170.92,10138.60,,Hospital CPT 42405,Biopsy Salivary Gland Incisional,N/A,N/A,508.00,508.00,304.80,304.80,N/A,71.12,N/A,215.69,N/A,508.00,N/A,172.72,N/A,508.00,N/A,71.12,N/A,215.69,N/A,215.69,N/A,508.00,N/A,508.00,N/A,508.00,N/A,508.00,N/A,508.00,N/A,215.69,N/A,71.12,N/A,508.00,N/A,508.00,N/A,71.12,N/A,215.69,N/A,215.69,N/A,237.26,304.80,304.80,71.12,508.00,,Hospital 42410,Exc Prtd Tum/Prtd Glnd Lat Lobe W/O Nrv Dsj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32225.90,N/A,19335.54,N/A,4511.62,N/A,5043.96,N/A,18554.03,N/A,10956.80,N/A,11699.41,N/A,4511.62,N/A,4821.94,N/A,4821.94,N/A,7283.11,N/A,11699.41,N/A,11699.41,N/A,11699.41,N/A,18554.04,N/A,4821.94,N/A,4511.62,N/A,5963.00,N/A,5963.00,N/A,4511.62,N/A,4821.94,N/A,5043.96,N/A,913.92,N/A,N/A,913.92,19335.54,,Hospital 42415,Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44958.40,N/A,26975.04,N/A,6294.17,N/A,1380.39,N/A,25880.83,N/A,15285.84,N/A,11694.42,N/A,6294.17,N/A,4821.94,N/A,4821.94,N/A,7280.01,N/A,11694.42,N/A,11694.42,N/A,11694.42,N/A,25880.84,N/A,4821.94,N/A,6294.17,N/A,5963.00,N/A,5963.00,N/A,6294.17,N/A,4821.94,N/A,1380.39,N/A,1518.43,N/A,N/A,1380.39,26975.04,,Hospital 42420,Exc Prtd Tum/Prtd Glnd Tot Dsj&Prsrv Facial Nr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86968.07,40989.17,52180.84,24593.50,12988.20,5738.49,4801.89,5319.17,30062.21,23587.47,29569.14,13936.32,30349.78,11720.89,13388.39,5738.49,212436.00,4821.94,212436.00,4821.94,18892.03,7296.48,30349.78,11720.89,30349.78,11720.89,30349.78,11720.89,30062.21,23587.51,15291.10,4821.94,13388.39,5738.49,36108.66,5963.00,36108.66,5963.00,13388.39,5738.49,15291.10,4821.94,15320.75,1443.81,14325.58,1452.37,4801.89,212436.00,1443.81,24593.50,,Hospital 42425,Excision Parotid Tumor/Gland Total en Bloc Rmvl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35703.40,N/A,21422.04,N/A,4974.21,N/A,843.92,N/A,20547.00,N/A,12139.16,N/A,11737.21,N/A,4974.21,N/A,4821.94,N/A,4821.94,N/A,7306.65,N/A,11737.21,N/A,11737.21,N/A,11737.21,N/A,20547.03,N/A,4821.94,N/A,4974.21,N/A,5963.00,N/A,5963.00,N/A,4974.21,N/A,4821.94,N/A,843.92,N/A,928.32,N/A,N/A,843.92,21422.04,,Hospital 42450,Exision of Sublingual Gland,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20550.12,N/A,12330.07,N/A,2877.01,N/A,5319.17,N/A,11821.21,N/A,6987.04,N/A,11690.03,N/A,2877.01,N/A,4821.94,N/A,4821.94,N/A,7277.26,N/A,11690.03,N/A,11690.03,N/A,11690.03,N/A,11821.23,N/A,4821.94,N/A,2877.01,N/A,4332.50,N/A,4332.50,N/A,2877.01,N/A,4821.94,N/A,683.43,N/A,751.78,N/A,N/A,683.43,12330.07,,Hospital 42500,Plstc Rpr Salivary Dux Sialodochoplasty Prim,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26366.82,N/A,15820.09,N/A,3694.99,N/A,4987.25,N/A,15178.26,N/A,8964.71,N/A,11703.89,N/A,3694.99,N/A,4821.94,N/A,4821.94,N/A,7285.89,N/A,11703.89,N/A,11703.89,N/A,11703.89,N/A,15178.26,N/A,4821.94,N/A,3694.99,N/A,3397.00,N/A,3397.00,N/A,3694.99,N/A,4821.94,N/A,4987.25,N/A,378.34,N/A,N/A,378.34,15820.09,,Hospital 42505,Plstc Rpr Salivary Dux Sialodochoplasty Sec/Comp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49993.28,N/A,29995.97,N/A,6980.24,N/A,4987.25,N/A,28773.86,N/A,16997.72,N/A,11696.28,N/A,6980.24,N/A,4821.94,N/A,4821.94,N/A,7281.17,N/A,11696.28,N/A,11696.28,N/A,11696.28,N/A,28773.87,N/A,4821.94,N/A,6980.24,N/A,7661.50,N/A,7661.50,N/A,6980.24,N/A,4821.94,N/A,4987.25,N/A,775.98,N/A,N/A,775.98,29995.97,,Hospital CPT 42700,HC I&D Tonsil Abscess,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1158.00,1158.00,694.80,694.80,N/A,162.12,N/A,127.50,N/A,666.78,N/A,393.72,N/A,538.89,N/A,162.12,N/A,127.50,N/A,127.50,N/A,335.46,N/A,538.89,N/A,538.89,N/A,538.89,N/A,666.78,N/A,127.50,N/A,162.12,N/A,1158.00,N/A,1158.00,N/A,162.12,N/A,127.50,N/A,127.50,N/A,140.25,694.80,694.80,127.50,1158.00,,Hospital CPT 42700,HC I&D Abscess Peritonsillar,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1158.00,1158.00,694.80,694.80,N/A,162.12,N/A,127.50,N/A,666.78,N/A,393.72,N/A,538.89,N/A,162.12,N/A,127.50,N/A,127.50,N/A,335.46,N/A,538.89,N/A,538.89,N/A,538.89,N/A,666.78,N/A,127.50,N/A,162.12,N/A,1158.00,N/A,1158.00,N/A,162.12,N/A,127.50,N/A,127.50,N/A,140.25,694.80,694.80,127.50,1158.00,,Hospital CPT 42720,HC Drainage of Throat Abscess,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,6778.00,6778.00,4066.80,4066.80,N/A,948.92,N/A,370.74,N/A,3902.77,N/A,2304.52,N/A,1274.91,N/A,948.92,N/A,370.74,N/A,370.74,N/A,793.63,N/A,1274.91,N/A,1274.91,N/A,1274.91,N/A,3902.77,N/A,370.74,N/A,948.92,N/A,6778.00,N/A,6778.00,N/A,948.92,N/A,370.74,N/A,370.74,N/A,407.81,4066.80,4066.80,370.74,6778.00,,Hospital 42804,Biopsy Nasopharynx Visible Lesion Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16437.77,N/A,9862.66,N/A,2286.49,N/A,2546.98,N/A,9463.05,N/A,5588.85,N/A,6261.49,N/A,2286.49,N/A,2569.18,N/A,2569.18,N/A,3897.90,N/A,6261.49,N/A,6261.49,N/A,6261.49,N/A,9463.06,N/A,2569.18,N/A,2286.49,N/A,2806.50,N/A,2806.50,N/A,2286.49,N/A,2569.18,N/A,2546.98,N/A,420.28,N/A,N/A,420.28,9862.66,,Hospital 42815,Exc Branchial Cleft Cyst Below Subq Tiss&/Phrynx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30735.15,N/A,18441.09,N/A,4302.91,N/A,5043.96,N/A,17695.27,N/A,10449.94,N/A,11691.74,N/A,4302.91,N/A,4821.94,N/A,4821.94,N/A,7278.33,N/A,11691.74,N/A,11691.74,N/A,11691.74,N/A,17695.28,N/A,4821.94,N/A,4302.91,N/A,5963.00,N/A,5963.00,N/A,4302.91,N/A,4821.94,N/A,5043.96,N/A,595.13,N/A,N/A,595.13,18441.09,,Hospital CPT 42821,Tonsillectomy & Adenoidectomy Age 12/>,N/A,N/A,602.00,602.00,361.20,361.20,N/A,84.28,N/A,289.23,N/A,602.00,N/A,204.68,N/A,602.00,N/A,84.28,N/A,289.23,N/A,289.23,N/A,542.10,N/A,602.00,N/A,602.00,N/A,602.00,N/A,602.00,N/A,289.23,N/A,84.28,N/A,602.00,N/A,602.00,N/A,84.28,N/A,289.23,N/A,289.23,N/A,318.15,361.20,361.20,84.28,602.00,,Hospital 43180,Esophagoscp Rig Transoral Hypopharynx Crv Esoph,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35900.22,40239.20,21540.13,24143.52,4201.55,5633.48,5235.86,4874.16,9468.53,23105.51,12206.08,13681.33,9559.10,13288.32,4331.00,5633.48,562.00,4821.94,562.00,4821.94,5950.32,8272.22,9559.10,13288.32,9559.10,13288.32,9559.10,13288.32,9468.53,23105.49,5235.86,4821.94,4331.00,5633.48,11372.94,4332.50,11372.94,4332.50,4331.00,5633.48,5235.86,4821.94,5235.86,4874.16,4634.17,778.63,562.00,21540.13,778.63,24143.52,,Hospital 43195,Esophagoscopy Rigid Transoral Balloon Dilation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35283.83,N/A,21170.30,N/A,4939.73,N/A,3005.77,N/A,20311.95,N/A,11996.50,N/A,7145.85,N/A,4939.73,N/A,2944.53,N/A,2944.53,N/A,4448.43,N/A,7145.85,N/A,7145.85,N/A,7145.85,N/A,20311.95,N/A,2944.53,N/A,4939.73,N/A,2806.50,N/A,2806.50,N/A,4939.73,N/A,2944.53,N/A,3005.77,N/A,357.66,N/A,N/A,357.66,21170.30,,Hospital 43197,Esophagoscopy Flexible Transnasal Diagnostic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23021.40,N/A,13812.84,N/A,3215.81,N/A,3043.02,N/A,13252.10,N/A,7827.27,N/A,7329.56,N/A,3215.81,N/A,3010.42,N/A,3010.42,N/A,4562.78,N/A,7329.56,N/A,7329.56,N/A,7329.56,N/A,13252.10,N/A,3010.42,N/A,3215.81,N/A,4800.25,N/A,4800.25,N/A,3215.81,N/A,3010.42,N/A,3043.02,N/A,841.15,N/A,N/A,841.15,13812.84,,Hospital 43210,Egd Partial/Compl Esophagogastric Fundoplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67699.92,N/A,40619.95,N/A,9477.97,N/A,8487.54,N/A,38629.31,N/A,23017.97,N/A,19919.80,N/A,9477.97,N/A,8206.20,N/A,8206.20,N/A,12400.47,N/A,19919.80,N/A,19919.80,N/A,19919.80,N/A,38629.32,N/A,8206.20,N/A,9477.97,N/A,4562.00,N/A,4562.00,N/A,9477.97,N/A,8206.20,N/A,8487.54,N/A,455.97,N/A,N/A,455.97,40619.95,,Hospital 43240,Egd Transoral Transmural Drainage Pseudocyst,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,13028.97,N/A,7817.38,N/A,1805.64,N/A,4950.49,N/A,7500.73,N/A,4429.85,N/A,11483.56,N/A,1805.64,N/A,4732.58,N/A,4732.58,N/A,7148.74,N/A,11483.56,N/A,11483.56,N/A,11483.56,N/A,7500.73,N/A,4732.58,N/A,1805.64,N/A,3397.00,N/A,3397.00,N/A,1805.64,N/A,4732.58,N/A,4950.49,N/A,563.47,N/A,N/A,563.47,11483.56,,Hospital 43244,Egd Band Ligation Esophgeal/Gastric Varices,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,28973.60,6182.67,17384.16,3709.60,5254.60,865.35,1559.14,1572.73,11943.86,3559.46,9851.03,2102.10,12058.11,3808.94,5416.50,865.35,6233.33,1572.73,6233.33,1572.73,7505.89,2371.14,12058.11,3808.94,12058.11,3808.94,12058.11,3808.94,11943.86,3559.46,6233.33,1572.73,5416.50,865.35,14346.14,1871.00,14346.14,1871.00,2264.07,865.35,6233.33,1572.73,6262.98,1572.73,5795.66,1730.00,1559.14,17384.16,865.35,3808.94,,Hospital 43248,Egd Insert Guide Wire Dilator Passage Esophagus,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,33279.20,10544.40,19967.52,6326.64,6849.65,1476.21,8368.43,1118.20,15436.25,6071.17,11314.93,3585.09,15583.91,2708.26,7060.70,1476.21,3372.00,1118.20,3372.00,1118.20,9700.62,1685.94,15583.91,2708.26,15583.91,2708.26,15583.91,2708.26,15436.25,6071.17,8368.43,1118.20,7060.70,1476.21,18540.96,2806.50,18540.96,2806.50,4464.42,1476.21,8368.43,1118.20,8368.43,1118.20,7554.95,1230.03,3372.00,19967.52,1118.20,6326.64,,Hospital 43254,Egd Transoral Endoscopic Mucosal Resection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,12287.65,N/A,7372.59,N/A,1720.04,N/A,1572.73,N/A,7073.78,N/A,4177.80,N/A,3819.20,N/A,1720.04,N/A,1572.73,N/A,1572.73,N/A,2377.52,N/A,3819.20,N/A,3819.20,N/A,3819.20,N/A,7073.79,N/A,1572.73,N/A,1720.04,N/A,2806.50,N/A,2806.50,N/A,1720.04,N/A,1572.73,N/A,1572.73,N/A,1730.00,N/A,N/A,1572.73,7372.59,,Hospital 43257,Egd Deliver Thermal Energy Sphnctr/Cardia Gerd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20215.25,N/A,12129.15,N/A,2830.14,N/A,689.51,N/A,2552.00,N/A,6873.19,N/A,7141.24,N/A,2830.14,N/A,2944.53,N/A,2944.53,N/A,4445.56,N/A,7141.24,N/A,7141.24,N/A,7141.24,N/A,2552.00,N/A,2944.53,N/A,2830.14,N/A,4800.25,N/A,4800.25,N/A,2830.14,N/A,2944.53,N/A,689.51,N/A,758.47,N/A,N/A,689.51,12129.15,,Hospital 43265,Ercp Destruction/Lithotripsy Calculi Any Method,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,47400.90,N/A,28440.54,N/A,6636.12,N/A,4950.49,N/A,27113.36,N/A,16116.31,N/A,11484.43,N/A,6636.12,N/A,4732.58,N/A,4732.58,N/A,7149.29,N/A,11484.43,N/A,11484.43,N/A,11484.43,N/A,27113.37,N/A,4732.58,N/A,6636.12,N/A,5095.50,N/A,5095.50,N/A,6636.12,N/A,4732.58,N/A,4950.49,N/A,946.26,N/A,N/A,946.26,28440.54,,Hospital 43273,Endoscopic Papilla Cannulation Bile/Pancreatic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,89620.02,46823.68,53772.01,28094.21,19575.39,6555.34,8177.60,4708.37,44114.73,26753.84,30470.81,15920.05,44536.72,11474.86,20178.54,6555.34,8177.60,4732.58,79242.00,4732.58,N/A,7143.32,N/A,11474.86,N/A,11474.86,44536.72,11474.86,44114.73,26753.84,8177.60,4732.58,20178.54,6555.34,52987.58,5227.25,52987.58,5227.25,N/A,6555.34,8177.60,4732.58,8177.60,4708.37,21591.04,1024.68,8177.60,79242.00,1024.68,28094.21,,Hospital 43274,Ercp Stent Placement Biliary/Pancreatic Duct,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,44405.02,22420.48,26643.01,13452.29,5865.95,3138.85,7204.75,4732.58,13219.39,12899.63,15097.71,7622.97,13345.85,11456.73,6046.69,3138.85,1124.00,4732.58,1124.00,4732.58,8307.48,7132.03,13345.85,11456.73,13345.85,11456.73,13345.85,11456.73,13219.39,12899.63,4732.58,4732.58,6046.69,3138.85,15878.22,5095.50,15878.22,5095.50,3346.70,3138.85,7204.75,4732.58,7204.75,4732.58,6469.96,5205.84,1124.00,26643.01,3138.85,13452.29,,Hospital 43280,Laps Surg Esopg/Gstr Fundoplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,49426.13,52841.92,29655.68,31705.15,5940.68,7384.25,7293.44,8135.31,30791.95,30089.54,16804.88,17966.24,31086.50,19930.60,6123.72,7384.25,7293.44,8206.20,7293.44,8206.20,19350.62,12407.20,31086.50,19930.60,31086.50,19930.60,31086.50,19930.60,30791.95,29994.53,7293.44,8206.20,6123.72,7384.25,36985.17,7897.00,36985.17,7897.00,N/A,7384.25,7293.44,8206.20,7293.44,8135.31,6552.38,1201.49,5940.68,36985.17,1201.49,31705.15,,Hospital 43281,Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48470.32,39497.53,29082.19,23698.52,13663.56,5454.35,16458.59,8733.88,30791.95,22724.18,16479.90,13429.16,31086.50,20892.89,14084.56,5454.35,16428.94,8356.03,16428.94,8356.03,19350.62,13204.19,31086.50,20892.89,31086.50,20892.89,31086.50,20892.89,30791.95,22724.20,16428.94,8379.28,14084.56,5454.35,36985.17,10878.50,36985.17,10878.50,3305.26,5454.35,16428.94,8356.03,16458.59,8733.88,15070.48,2108.12,3305.26,36985.17,2108.12,23698.52,,Hospital 43282,Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,92071.53,48498.53,55242.92,29099.12,13663.56,6769.66,16458.59,9052.40,33782.85,27836.58,31304.32,16489.50,31086.50,20096.10,14084.56,6769.66,8206.20,8206.20,8206.20,8206.20,19350.62,12510.21,31086.50,20096.10,31086.50,20096.10,31086.50,20096.10,33782.85,26898.05,16428.94,8206.20,14084.56,6769.66,36985.17,7897.00,36985.17,7897.00,2976.37,6769.66,16428.94,8206.20,16458.59,1763.00,15070.48,1933.18,2976.37,55242.92,1763.00,29099.12,,Hospital 43283,Laps Esophageal Lengthening Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60574.22,N/A,36344.53,N/A,8480.39,N/A,8135.31,N/A,34870.97,N/A,20595.25,N/A,19910.51,N/A,8480.39,N/A,8206.20,N/A,8206.20,N/A,12394.68,N/A,19910.51,N/A,19910.51,N/A,19910.51,N/A,34870.95,N/A,8206.20,N/A,8480.39,N/A,8718.50,N/A,8718.50,N/A,8480.39,N/A,8206.20,N/A,8135.31,N/A,1839.29,N/A,N/A,1839.29,36344.53,,Hospital 43289,Unlisted Laparoscopy Procedure Esophagus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,85120.73,N/A,51072.44,N/A,11892.11,N/A,9052.40,N/A,48400.30,N/A,28941.05,N/A,19944.73,N/A,11892.11,N/A,8206.20,N/A,8206.20,N/A,12415.99,N/A,19944.73,N/A,19944.73,N/A,19944.73,N/A,47682.89,N/A,8206.20,N/A,11892.11,N/A,8244.00,N/A,8244.00,N/A,11892.11,N/A,8206.20,N/A,511.56,N/A,556.60,N/A,N/A,511.56,51072.44,,Hospital 43450,Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,45242.02,10553.60,27145.21,6332.16,4482.15,1477.50,5567.79,1118.20,10100.88,6076.21,15382.29,3588.22,10197.51,2711.06,4620.25,1477.50,2248.00,1118.20,2248.00,1118.20,6347.71,1687.68,10197.51,2711.06,10197.51,2711.06,10197.51,2711.06,10100.88,6076.21,5567.79,1118.20,4620.25,1477.50,12132.49,2806.50,12132.49,2806.50,4620.25,1477.50,5567.79,1118.20,5567.79,1118.20,4943.67,1230.03,2248.00,27145.21,1118.20,6332.16,,Hospital 43610,Exc Local Ulcer/Benign Tumor Stomach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28882.30,N/A,17329.38,N/A,4007.55,N/A,1133.60,N/A,16622.18,N/A,9819.98,N/A,8438.86,N/A,4007.55,N/A,1133.60,N/A,1133.60,N/A,5253.18,N/A,8438.86,N/A,8438.86,N/A,8438.86,N/A,16368.11,N/A,1133.60,N/A,4007.55,N/A,1643.00,N/A,1643.00,N/A,4007.55,N/A,1133.60,N/A,1133.60,N/A,1246.97,N/A,N/A,1133.60,17329.38,,Hospital 43652,Laps Surg Trnsxj Vagus Nrv Slctv/Hily Slctv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35979.13,N/A,21587.48,N/A,5029.88,N/A,8164.21,N/A,20535.41,N/A,12232.90,N/A,19954.93,N/A,5029.88,N/A,8206.20,N/A,8206.20,N/A,12422.36,N/A,19954.93,N/A,19954.93,N/A,19954.93,N/A,19814.51,N/A,8206.20,N/A,5029.88,N/A,11845.50,N/A,11845.50,N/A,5029.88,N/A,8206.20,N/A,8164.21,N/A,2729.09,N/A,N/A,2729.09,21587.48,,Hospital 43659,Unlisted Laparoscopy Procedure Stomach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54222.42,39497.53,32533.45,23698.52,8843.20,5454.35,10756.34,8733.88,19928.87,22724.18,18435.62,13429.16,20119.50,20892.89,9115.67,5454.35,146682.00,8356.03,146682.00,8356.03,12523.92,13204.19,20119.50,20892.89,20119.50,20892.89,20119.50,20892.89,19928.87,22724.20,10726.69,8379.28,9115.67,5454.35,23937.19,10878.50,23937.19,10878.50,4707.19,5454.35,10726.69,8356.03,10756.34,8733.88,9753.77,2108.12,4707.19,146682.00,2108.12,23698.52,,Hospital CPT 43752,HC Feeding Tube Plcmt W Fluoro,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,854.00,854.00,512.40,512.40,N/A,119.56,N/A,350.07,N/A,491.73,N/A,290.36,N/A,824.75,N/A,119.56,N/A,340.96,N/A,340.96,N/A,513.42,N/A,824.75,N/A,824.75,N/A,824.75,N/A,491.73,N/A,340.96,N/A,119.56,N/A,527.00,N/A,527.00,N/A,119.56,N/A,340.96,N/A,350.07,N/A,42.93,512.40,512.40,42.93,824.75,,Hospital 43754,HC Gastric Intub/Asp/Lavage,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 43775,Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,72609.02,70332.12,43565.41,42199.27,8295.33,9794.82,9917.73,1395.43,20673.16,40488.53,24687.05,23879.34,19375.51,12207.69,8550.93,9794.82,415318.00,1370.96,415318.00,1370.96,12060.80,7599.50,19375.51,12207.69,19375.51,12207.69,19375.51,12207.69,20673.16,39799.31,9888.08,1370.96,8550.93,9794.82,23052.02,7897.00,23052.02,7897.00,3493.40,9794.82,9888.08,1370.96,9917.73,1395.43,9149.49,1569.48,3493.40,415318.00,1370.96,42199.27,,Hospital 43840,Gastrorrhaphy Sutr Prf8 Duol/Gstr Ulcer Wnd/Inj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27108.53,N/A,16265.12,N/A,3825.46,N/A,1411.23,N/A,15603.73,N/A,9216.91,N/A,11653.55,N/A,3825.46,N/A,1411.46,N/A,1411.46,N/A,7254.55,N/A,11653.55,N/A,11653.55,N/A,11653.55,N/A,15603.73,N/A,1411.46,N/A,3825.46,N/A,4562.00,N/A,4562.00,N/A,3825.46,N/A,1411.46,N/A,1411.23,N/A,1535.86,N/A,N/A,1411.23,16265.12,,Hospital 43860,Revj Gstr/Jj Anast W/Rcnstj W/O Vgtmy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,144207.35,N/A,86524.41,N/A,20193.89,N/A,2215.53,N/A,83012.04,N/A,49030.47,N/A,9784.63,N/A,20193.89,N/A,2177.64,N/A,2177.64,N/A,6090.64,N/A,9784.63,N/A,9784.63,N/A,9784.63,N/A,80862.00,N/A,2177.64,N/A,20193.89,N/A,1906.50,N/A,1906.50,N/A,20193.89,N/A,2177.64,N/A,2215.53,N/A,2282.73,N/A,N/A,1906.50,86524.41,,Hospital 44125,Enterectomy Rescj Small Intestine W/Enterostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27020.83,N/A,16212.50,N/A,3780.62,N/A,2315.00,N/A,15510.19,N/A,9187.09,N/A,8843.05,N/A,3780.62,N/A,2315.12,N/A,2315.12,N/A,5506.01,N/A,8843.05,N/A,8843.05,N/A,8843.05,N/A,15510.20,N/A,2315.12,N/A,3780.62,N/A,1643.00,N/A,1643.00,N/A,3780.62,N/A,2315.12,N/A,2315.00,N/A,2555.44,N/A,N/A,1643.00,16212.50,,Hospital 44139,Moblj Splenic Flxr Pfrmd Conjunct W/Prtl Colct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74301.27,N/A,44580.76,N/A,10318.23,N/A,4249.40,N/A,42242.76,N/A,25262.44,N/A,22321.38,N/A,10318.23,N/A,4230.86,N/A,4230.86,N/A,13895.45,N/A,22321.38,N/A,22321.38,N/A,22321.38,N/A,41161.41,N/A,4230.86,N/A,10318.23,N/A,2464.50,N/A,2464.50,N/A,10318.23,N/A,4230.86,N/A,4249.40,N/A,3656.68,N/A,N/A,2464.50,44580.76,,Hospital 44150,Colct Tot Abdl W/O Prctect W/Ileost/Ileopxts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,373664.52,N/A,224198.71,N/A,N/A,N/A,18541.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18541.49,N/A,18541.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18541.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18541.49,N/A,18541.49,N/A,N/A,N/A,18541.49,224198.71,N/A,N/A,,Hospital 44180,Laparoscopy Enterolysis Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25627.27,N/A,15376.36,N/A,3580.33,N/A,4923.50,N/A,14755.07,N/A,8713.28,N/A,11396.40,N/A,3580.33,N/A,4706.78,N/A,4706.78,N/A,7094.47,N/A,11396.40,N/A,11396.40,N/A,11396.40,N/A,14755.07,N/A,4706.78,N/A,3580.33,N/A,7897.00,N/A,7897.00,N/A,3580.33,N/A,4706.78,N/A,4923.50,N/A,986.96,N/A,N/A,986.96,15376.36,,Hospital 44227,Laps Clsr Ntrstm Lg/Sm Int W/Rescj & Anastomosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56508.40,N/A,33905.04,N/A,7894.12,N/A,2836.40,N/A,32425.37,N/A,19212.86,N/A,13892.32,N/A,7894.12,N/A,2826.05,N/A,2826.05,N/A,8652.33,N/A,13892.32,N/A,13892.32,N/A,13892.32,N/A,31973.39,N/A,2826.05,N/A,7894.12,N/A,1643.00,N/A,1643.00,N/A,7894.12,N/A,2826.05,N/A,2836.40,N/A,2976.98,N/A,N/A,1643.00,33905.04,,Hospital 44312,Revj Ileostomy Simple Rls Superficial Scar Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13682.37,N/A,8209.42,N/A,1915.55,N/A,2922.60,N/A,7876.47,N/A,4652.02,N/A,7121.52,N/A,1915.55,N/A,2937.63,N/A,2937.63,N/A,4433.28,N/A,7121.52,N/A,7121.52,N/A,7121.52,N/A,7876.47,N/A,2937.63,N/A,1915.55,N/A,4562.00,N/A,4562.00,N/A,1915.55,N/A,2937.63,N/A,2922.60,N/A,661.51,N/A,N/A,661.51,8209.42,,Hospital 44360,Endoscopy Upper Small Intestine,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,32860.20,9628.50,19716.12,5777.10,5254.60,1347.99,6255.46,1614.73,11943.86,5543.45,11172.47,3273.69,12058.11,3813.60,5416.50,1347.99,237164.00,1572.73,237164.00,1572.73,7505.89,2374.04,12058.11,3813.60,12058.11,3813.60,12058.11,3813.60,11943.86,5543.45,6225.81,1572.73,5416.50,1347.99,14346.14,1871.00,14346.14,1871.00,N/A,1347.99,1592.04,1572.73,6255.46,1614.73,5795.66,150.59,1592.04,237164.00,150.59,5777.10,,Hospital 44365,Enteroscopy > 2nd Prtn W/Rmvl Lesion Cautery,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,28457.45,N/A,17074.47,N/A,3984.04,N/A,1645.14,N/A,16383.81,N/A,9675.52,N/A,3852.56,N/A,3984.04,N/A,1572.73,N/A,1572.73,N/A,2398.30,N/A,3852.56,N/A,3852.56,N/A,3852.56,N/A,16383.81,N/A,1572.73,N/A,3984.04,N/A,2806.50,N/A,2806.50,N/A,3984.04,N/A,1572.73,N/A,1645.14,N/A,418.59,N/A,N/A,418.59,17074.47,,Hospital 44372,Enteroscopy > 2nd Prtn W/Plmt Prq Tube,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7452.00,N/A,4471.20,N/A,1043.28,N/A,1589.76,N/A,4289.54,N/A,2533.68,N/A,3820.59,N/A,1043.28,N/A,1572.73,N/A,1572.73,N/A,2378.40,N/A,3820.59,N/A,3820.59,N/A,3820.59,N/A,4289.55,N/A,1572.73,N/A,1043.28,N/A,1871.00,N/A,1871.00,N/A,1043.28,N/A,1572.73,N/A,1589.76,N/A,252.45,N/A,N/A,252.45,4471.20,,Hospital 44389,Colonoscopy Stoma W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,87744.50,10552.90,52646.70,6331.74,5030.55,1477.42,5939.07,1826.18,11311.50,6075.30,29833.13,3587.99,11419.70,4467.06,5185.55,1477.42,252338.00,1842.10,252338.00,1842.10,7108.50,2780.84,11419.70,4467.06,11419.70,4467.06,11419.70,4467.06,11311.50,6075.30,5909.42,1842.10,5185.55,1477.42,13586.60,3164.25,N/A,3164.25,N/A,1477.42,5909.42,1842.10,5939.07,1826.18,5548.54,659.03,5030.55,252338.00,659.03,6331.74,,Hospital 44405,Colonoscopy Stoma W/Balloon Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10887.42,N/A,6532.45,N/A,1525.28,N/A,2310.91,N/A,6268.08,N/A,3701.72,N/A,5647.26,N/A,1525.28,N/A,2331.06,N/A,2331.06,N/A,3515.54,N/A,5647.26,N/A,5647.26,N/A,5647.26,N/A,6268.08,N/A,2331.06,N/A,1525.28,N/A,3274.25,N/A,3274.25,N/A,1525.28,N/A,2331.06,N/A,2310.91,N/A,739.59,N/A,N/A,739.59,6532.45,,Hospital 44625,Clsr Ntrstm Lg/Sm Rescj & Anast Oth/Thn Clrct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48988.43,53546.43,29393.06,32127.86,13098.63,7485.28,15819.95,1040.61,29518.82,30797.42,16656.07,18205.80,29801.19,7959.32,13502.22,7485.28,191080.00,1034.33,191080.00,1034.33,18550.55,4954.83,29801.19,7959.32,29801.19,7959.32,29801.19,7959.32,29518.82,30539.51,15760.65,1034.33,13502.22,7485.28,35455.98,1643.00,35455.98,1643.00,13502.22,7485.28,15760.65,1034.33,15819.95,1060.30,14447.37,1154.09,13098.63,191080.00,1034.33,32127.86,,Hospital 44650,Clsr Enteroenteric/Enterocolic Fstl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71525.10,N/A,42915.06,N/A,10013.52,N/A,1691.46,N/A,41179.15,N/A,24318.53,N/A,8517.44,N/A,10013.52,N/A,1685.37,N/A,1685.37,N/A,5302.27,N/A,8517.44,N/A,8517.44,N/A,8517.44,N/A,41049.59,N/A,1685.37,N/A,10013.52,N/A,1643.00,N/A,1643.00,N/A,10013.52,N/A,1685.37,N/A,1691.46,N/A,2158.63,N/A,N/A,1643.00,42915.06,,Hospital CPT 44799,HC Unlisted Procedure Small Intestine,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2064.00,2064.00,1238.40,1238.40,N/A,288.96,N/A,2064.00,N/A,1188.45,N/A,701.76,N/A,288.96,N/A,288.96,N/A,2064.00,N/A,2064.00,N/A,179.57,N/A,288.96,N/A,288.96,N/A,288.96,N/A,1188.45,N/A,2064.00,N/A,288.96,N/A,2064.00,N/A,2064.00,N/A,288.96,N/A,2064.00,N/A,2064.00,N/A,2064.00,1238.40,1238.40,179.57,2064.00,,Hospital 44800,Exc Meckel's Diverticulum/Omphalomesenteric Duct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,296850.22,N/A,178110.13,N/A,35888.66,N/A,25697.38,N/A,163623.84,N/A,100929.08,N/A,103363.25,N/A,31792.60,N/A,3372.00,N/A,3372.00,N/A,64357.13,N/A,103363.25,N/A,103363.25,N/A,103363.25,N/A,163623.84,N/A,N/A,N/A,31792.60,N/A,140707.00,N/A,140707.00,N/A,29810.66,N/A,25697.38,N/A,25697.38,N/A,34018.09,N/A,3372.00,178110.13,N/A,N/A,,Hospital 44955,Appendec Indicated Purpose Oth Major Px Not Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69762.55,N/A,41857.53,N/A,9659.77,N/A,1383.15,N/A,40134.32,N/A,23719.27,N/A,11006.49,N/A,9659.77,N/A,1271.00,N/A,1271.00,N/A,6851.74,N/A,11006.49,N/A,11006.49,N/A,11006.49,N/A,40003.62,N/A,1271.00,N/A,9659.77,N/A,4957.25,N/A,4957.25,N/A,9659.77,N/A,1271.00,N/A,1383.15,N/A,1515.34,N/A,N/A,1271.00,41857.53,,Hospital 44970,Laparoscopic Appendectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,32328.87,31189.52,19397.32,18713.71,5829.14,4366.54,7190.86,4890.04,13136.44,17956.28,10991.81,10604.44,13262.10,11434.01,6008.75,4366.54,7161.21,4706.78,7161.21,4706.78,8255.35,7117.90,13262.10,11434.01,13262.10,11434.01,13262.10,11434.01,13136.44,17956.29,7161.21,4706.78,6008.75,4366.54,15778.59,7897.00,15778.59,7897.00,5177.46,4366.54,7161.21,4706.78,7190.86,4890.04,5177.46,854.50,5177.46,19397.32,854.50,18713.71,,Hospital 45112,Prctect Cmbn Abdominoprnl Pull-Thru Px,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,91784.58,N/A,55070.75,N/A,11912.74,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12279.79,N/A,N/A,N/A,13129.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,25742.71,N/A,N/A,N/A,12279.79,N/A,N/A,N/A,N/A,N/A,670.82,N/A,N/A,N/A,N/A,N/A,670.82,N/A,670.82,55070.75,N/A,N/A,,Hospital 45172,Exc Rct Tum Incl Muscularis Propria,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28875.60,N/A,17325.36,N/A,3988.72,N/A,2427.17,N/A,2552.00,N/A,9817.70,N/A,6551.67,N/A,3988.72,N/A,2320.33,N/A,2320.33,N/A,4078.53,N/A,6551.67,N/A,6551.67,N/A,6551.67,N/A,2552.00,N/A,2320.33,N/A,3988.72,N/A,5965.25,N/A,5965.25,N/A,3988.72,N/A,2320.33,N/A,2427.17,N/A,1424.38,N/A,N/A,1424.38,17325.36,,Hospital 45315,Proctosgmdsc Rigid Rmvl Mult Tumor Cautery/Snare,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,20012.02,N/A,12007.21,N/A,2801.69,N/A,1645.14,N/A,11522.68,N/A,6804.08,N/A,3807.39,N/A,2801.69,N/A,1572.73,N/A,1572.73,N/A,2370.17,N/A,3807.39,N/A,3807.39,N/A,3807.39,N/A,11522.69,N/A,1572.73,N/A,2801.69,N/A,3274.25,N/A,3274.25,N/A,2801.69,N/A,1572.73,N/A,1645.14,N/A,583.47,N/A,N/A,583.47,12007.21,,Hospital 45321,Proctosgmdsc Rigid Dcmprn Volvulus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20104.00,N/A,12062.40,N/A,2814.56,N/A,98.91,N/A,11570.81,N/A,6835.36,N/A,5623.37,N/A,2814.56,N/A,2320.33,N/A,2320.33,N/A,3500.64,N/A,5623.37,N/A,5623.37,N/A,5623.37,N/A,11570.82,N/A,2320.33,N/A,2814.56,N/A,3397.00,N/A,3397.00,N/A,2814.56,N/A,2320.33,N/A,98.91,N/A,108.80,N/A,N/A,98.91,12062.40,,Hospital 45334,Sigmoidoscopy Flx Control Bleeding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,51482.43,12594.27,30889.46,7556.56,5450.92,1763.20,4070.71,112.18,12284.08,7249.77,17504.03,4282.05,12401.59,2371.69,5618.87,1763.20,6713.79,977.91,6713.79,977.91,7719.70,1476.43,12401.59,2371.69,12401.59,2371.69,12401.59,2371.69,12284.08,7249.77,6713.79,977.91,5618.87,1763.20,14754.79,1871.00,14754.79,1871.00,N/A,1763.20,6713.79,977.91,6743.44,112.18,6012.19,123.40,4070.71,30889.46,112.18,7556.56,,Hospital 45335,Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,65276.10,8648.00,39165.66,5188.80,5630.69,1210.72,6926.46,785.02,12689.22,4978.92,22193.88,2940.32,12810.60,1827.99,5804.18,1210.72,3483.07,750.46,3483.07,750.46,7974.30,1137.96,12810.60,1827.99,12810.60,1827.99,12810.60,1827.99,12689.22,4978.92,6926.46,750.46,5804.18,1210.72,15241.42,1431.00,15241.42,1431.00,N/A,1210.72,6926.46,750.46,6926.46,785.02,6210.48,68.84,3483.07,39165.66,68.84,5188.80,,Hospital 45338,Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10489.80,N/A,6293.88,N/A,1455.86,N/A,1019.30,N/A,6037.51,N/A,3566.54,N/A,2380.80,N/A,1455.86,N/A,985.77,N/A,985.77,N/A,1482.10,N/A,2380.80,N/A,2380.80,N/A,2380.80,N/A,6037.51,N/A,985.77,N/A,1455.86,N/A,1871.00,N/A,1871.00,N/A,1455.86,N/A,985.77,N/A,1019.30,N/A,206.28,N/A,N/A,206.28,6293.88,,Hospital 45346,Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,6936.05,N/A,4161.63,N/A,972.09,N/A,969.46,N/A,3993.14,N/A,2358.26,N/A,2372.01,N/A,972.09,N/A,977.91,N/A,977.91,N/A,1476.62,N/A,2372.01,N/A,2372.01,N/A,2372.01,N/A,3993.14,N/A,977.91,N/A,972.09,N/A,1871.00,N/A,1871.00,N/A,972.09,N/A,977.91,N/A,969.46,N/A,172.24,N/A,N/A,172.24,4161.63,,Hospital 45347,Sigmoidoscopy Flx Placement of Endoscopic Stent,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,44054.75,N/A,26432.85,N/A,6167.67,N/A,5034.45,N/A,25202.47,N/A,14978.62,N/A,11461.96,N/A,6167.67,N/A,4732.58,N/A,4732.58,N/A,7135.29,N/A,11461.96,N/A,11461.96,N/A,11461.96,N/A,25202.47,N/A,4732.58,N/A,6167.67,N/A,2586.50,N/A,2586.50,N/A,6167.67,N/A,4732.58,N/A,5034.45,N/A,511.44,N/A,N/A,511.44,26432.85,,Hospital 45349,Sgmdsc Flx With Endoscopic Mucosal Resection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,20722.82,N/A,12433.69,N/A,2892.33,N/A,2427.17,N/A,11930.05,N/A,7045.76,N/A,5622.95,N/A,2892.33,N/A,2320.33,N/A,2320.33,N/A,3500.39,N/A,5622.95,N/A,5622.95,N/A,5622.95,N/A,11898.39,N/A,2320.33,N/A,2892.33,N/A,2806.50,N/A,2806.50,N/A,2892.33,N/A,2320.33,N/A,2427.17,N/A,828.19,N/A,N/A,828.19,12433.69,,Hospital 45379,Colonoscopy Flx W/Removal of Foreign Body(S),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,6543.00,N/A,3925.80,N/A,916.02,N/A,1022.94,N/A,2552.00,N/A,2224.62,N/A,2370.74,N/A,916.02,N/A,977.91,N/A,977.91,N/A,1475.83,N/A,2370.74,N/A,2370.74,N/A,2370.74,N/A,2552.00,N/A,977.91,N/A,916.02,N/A,1871.00,N/A,1871.00,N/A,916.02,N/A,977.91,N/A,1022.94,N/A,276.05,N/A,N/A,276.05,3925.80,,Hospital 45385,Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,40525.10,6136.30,24315.06,3681.78,8595.67,859.08,10343.57,1466.87,19970.95,2552.00,13778.54,2086.34,20161.98,3562.21,8860.52,859.08,388342.00,1466.87,388342.00,1466.87,12550.37,2217.55,20161.98,3562.21,20161.98,3562.21,20161.98,3562.21,19970.95,2552.00,10254.62,1466.87,8860.52,859.08,23987.73,2806.50,23987.73,2806.50,3629.64,859.08,3439.55,1466.87,10343.57,1466.87,9480.76,1613.55,3439.55,388342.00,859.08,3681.78,,Hospital 45388,Colonoscopy Flx Ablation Tumor Polyp/Other Les,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,5921.90,N/A,3553.14,N/A,828.84,N/A,1466.87,N/A,2552.00,N/A,2013.44,N/A,3557.54,N/A,828.84,N/A,1466.87,N/A,1466.87,N/A,2214.64,N/A,3557.54,N/A,3557.54,N/A,3557.54,N/A,2552.00,N/A,1466.87,N/A,828.84,N/A,2806.50,N/A,2806.50,N/A,828.84,N/A,1466.87,N/A,1466.87,N/A,1613.55,N/A,N/A,828.84,3557.54,,Hospital 45390,Colonoscopy Flx W/Endoscopic Mucosal Resection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,107457.48,15931.48,64474.49,9558.89,15822.48,2230.41,18681.49,2514.28,59230.57,2552.00,36535.55,5416.70,35998.34,5634.34,16310.00,2230.41,18681.49,2320.33,18681.49,2320.33,22408.13,3507.49,35998.34,5634.34,35998.34,5634.34,35998.34,5634.34,59230.57,2552.00,18681.49,2320.33,16310.00,2230.41,42829.04,2806.50,42829.04,2806.50,N/A,2230.41,6879.88,2320.33,18681.49,2514.28,17451.70,512.12,6879.88,64474.49,512.12,9558.89,,Hospital 45392,Colsc Flx W/US Guid Ndl Aspir/Bx W/US Rctm Et Al,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,18250.08,N/A,10950.05,N/A,2555.02,N/A,1022.94,N/A,2552.00,N/A,6205.03,N/A,2395.32,N/A,2555.02,N/A,977.91,N/A,977.91,N/A,1491.13,N/A,2395.32,N/A,2395.32,N/A,2395.32,N/A,2552.00,N/A,977.91,N/A,2555.02,N/A,1871.00,N/A,1871.00,N/A,2555.02,N/A,977.91,N/A,1022.94,N/A,471.29,N/A,N/A,471.29,10950.05,,Hospital 45398,Colonoscopy Flexible With Band Ligation(S),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,11649.95,N/A,6989.97,N/A,1630.99,N/A,1554.48,N/A,2552.00,N/A,3960.98,N/A,3562.21,N/A,1630.99,N/A,1466.87,N/A,1466.87,N/A,2217.55,N/A,3562.21,N/A,3562.21,N/A,3562.21,N/A,2552.00,N/A,1466.87,N/A,1630.99,N/A,2806.50,N/A,2806.50,N/A,1630.99,N/A,1466.87,N/A,1554.48,N/A,555.02,N/A,N/A,555.02,6989.97,,Hospital 45500,Proctoplasty Stenosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19444.22,N/A,11666.53,N/A,2722.19,N/A,2559.60,N/A,11188.88,N/A,6611.03,N/A,5643.13,N/A,2722.19,N/A,2320.33,N/A,2320.33,N/A,3512.96,N/A,5643.13,N/A,5643.13,N/A,5643.13,N/A,11188.88,N/A,2320.33,N/A,2722.19,N/A,3397.00,N/A,3397.00,N/A,2722.19,N/A,2320.33,N/A,574.11,N/A,631.53,N/A,N/A,574.11,11666.53,,Hospital 45905,Dilat Anal Sphnctr Spx Under Anes Oth/Thn Local,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10689.20,N/A,6413.52,N/A,1489.90,N/A,976.84,N/A,6140.69,N/A,3634.32,N/A,2511.92,N/A,1489.90,N/A,981.84,N/A,981.84,N/A,1563.60,N/A,2511.92,N/A,2511.92,N/A,2511.92,N/A,6140.70,N/A,981.84,N/A,1489.90,N/A,1871.00,N/A,1871.00,N/A,1489.90,N/A,981.84,N/A,976.84,N/A,181.44,N/A,N/A,181.44,6413.52,,Hospital 46045,I&D Intramural Im/Absc Transanal Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,17037.40,17387.30,10222.44,10432.38,5319.68,2403.99,6558.55,2300.29,11988.34,10003.96,5792.72,5911.70,12103.02,5690.81,5483.59,2403.99,1124.00,2320.33,1124.00,2320.33,7533.85,3542.63,12103.02,5690.81,12103.02,5690.81,12103.02,5690.81,11988.34,8977.89,6558.55,2320.33,5483.59,2403.99,14399.57,3397.00,14399.57,3397.00,N/A,2403.99,6558.55,2320.33,6558.55,2300.29,5867.44,777.16,1124.00,14399.57,777.16,10432.38,,Hospital CPT 46083,HC Inc Thromb Hemorrhoid Ext,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,957.00,957.00,574.20,574.20,N/A,133.98,N/A,104.52,N/A,551.04,N/A,325.38,N/A,575.10,N/A,133.98,N/A,104.52,N/A,104.52,N/A,358.00,N/A,575.10,N/A,575.10,N/A,575.10,N/A,551.04,N/A,104.52,N/A,133.98,N/A,957.00,N/A,957.00,N/A,133.98,N/A,104.52,N/A,104.52,N/A,114.97,574.20,574.20,104.52,957.00,,Hospital 46221,HC Ligation of Hemorrhoids,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,9537.60,N/A,5722.56,N/A,1335.26,N/A,1341.45,N/A,2552.00,N/A,3242.78,N/A,3287.12,N/A,1335.26,N/A,1353.14,N/A,1353.14,N/A,2046.30,N/A,3287.12,N/A,3287.12,N/A,3287.12,N/A,2552.00,N/A,1353.14,N/A,1335.26,N/A,2586.50,N/A,2586.50,N/A,1335.26,N/A,1353.14,N/A,1341.45,N/A,479.52,N/A,N/A,479.52,5722.56,,Hospital CPT 46255,Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,N/A,N/A,877.00,877.00,526.20,526.20,N/A,122.78,N/A,341.71,N/A,877.00,N/A,298.18,N/A,877.00,N/A,122.78,N/A,341.71,N/A,341.71,N/A,877.00,N/A,877.00,N/A,877.00,N/A,877.00,N/A,877.00,N/A,341.71,N/A,122.78,N/A,877.00,N/A,877.00,N/A,122.78,N/A,341.71,N/A,341.71,N/A,375.88,526.20,526.20,122.78,877.00,,Hospital CPT 46270,Surg Tx Anal Fistula Subq,N/A,N/A,893.00,893.00,535.80,535.80,N/A,125.02,N/A,380.88,N/A,893.00,N/A,303.62,N/A,893.00,N/A,125.02,N/A,380.88,N/A,380.88,N/A,893.00,N/A,893.00,N/A,893.00,N/A,893.00,N/A,893.00,N/A,380.88,N/A,125.02,N/A,893.00,N/A,893.00,N/A,125.02,N/A,380.88,N/A,380.88,N/A,418.97,535.80,535.80,125.02,893.00,,Hospital 46285,Surg Tx Anal Fistula 2nd Stage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30394.23,N/A,18236.54,N/A,4255.19,N/A,401.82,N/A,17471.84,N/A,10334.03,N/A,5842.13,N/A,4255.19,N/A,2320.33,N/A,2320.33,N/A,3636.63,N/A,5842.13,N/A,5842.13,N/A,5842.13,N/A,17471.84,N/A,2320.33,N/A,4255.19,N/A,3397.00,N/A,3397.00,N/A,4255.19,N/A,2320.33,N/A,401.82,N/A,442.00,N/A,N/A,401.82,18236.54,,Hospital 46288,Clsr Anal Fstl W/Rct Advmnt Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32773.60,N/A,19664.16,N/A,4582.50,N/A,2399.88,N/A,18759.97,N/A,11143.02,N/A,6503.87,N/A,4582.50,N/A,2320.33,N/A,2320.33,N/A,4048.33,N/A,6503.87,N/A,6503.87,N/A,6503.87,N/A,18759.96,N/A,2320.33,N/A,4582.50,N/A,4562.00,N/A,4562.00,N/A,4582.50,N/A,2320.33,N/A,2399.88,N/A,596.13,N/A,N/A,596.13,19664.16,,Hospital 46320,Exc Thrombosed Hemorrhoid Xtrnl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25154.00,N/A,15092.40,N/A,3521.57,N/A,1099.69,N/A,14470.83,N/A,8552.34,N/A,5655.07,N/A,3521.57,N/A,2320.33,N/A,2320.33,N/A,3520.38,N/A,5655.07,N/A,5655.07,N/A,5655.07,N/A,14470.85,N/A,2320.33,N/A,3521.57,N/A,5563.25,N/A,5563.25,N/A,3521.57,N/A,2320.33,N/A,1099.69,N/A,1209.66,N/A,N/A,1099.69,15092.40,,Hospital CPT 46600,Anoscopy Dx W/Collj Spec Br/Wa Spx When Prfrmd,N/A,N/A,201.00,201.00,120.60,120.60,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,120.60,120.60,120.60,201.00,,Hospital CPT 46600,HC Anoscopy Diagnostic,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,250.00,250.00,150.00,150.00,N/A,35.00,N/A,108.93,N/A,143.95,N/A,85.00,N/A,250.00,N/A,35.00,N/A,104.85,N/A,104.85,N/A,157.89,N/A,250.00,N/A,250.00,N/A,250.00,N/A,143.95,N/A,104.85,N/A,35.00,N/A,250.00,N/A,250.00,N/A,35.00,N/A,104.85,N/A,108.93,N/A,42.30,150.00,150.00,35.00,250.00,,Hospital CPT 46612,Anosc Rmvl Mult Tumors Cautery/Snare,N/A,N/A,578.00,578.00,346.80,346.80,N/A,80.92,N/A,91.34,N/A,578.00,N/A,196.52,N/A,578.00,N/A,80.92,N/A,91.34,N/A,91.34,N/A,571.08,N/A,578.00,N/A,578.00,N/A,578.00,N/A,578.00,N/A,91.34,N/A,80.92,N/A,578.00,N/A,578.00,N/A,80.92,N/A,91.34,N/A,91.34,N/A,100.47,346.80,346.80,80.92,578.00,,Hospital 46615,Anoscopy Ablation Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24075.00,N/A,14445.00,N/A,3370.51,N/A,2427.17,N/A,13861.32,N/A,8185.51,N/A,5624.77,N/A,3370.51,N/A,2320.33,N/A,2320.33,N/A,3501.52,N/A,5624.77,N/A,5624.77,N/A,5624.77,N/A,13861.32,N/A,2320.33,N/A,3370.51,N/A,5095.50,N/A,5095.50,N/A,3370.51,N/A,2320.33,N/A,2427.17,N/A,844.12,N/A,N/A,844.12,14445.00,,Hospital 46700,Anoplasty Plastic Operation Stricture Adult,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34759.70,N/A,20855.82,N/A,4866.37,N/A,2399.88,N/A,19912.98,N/A,11818.30,N/A,6390.56,N/A,4866.37,N/A,2320.33,N/A,2320.33,N/A,3977.91,N/A,6390.56,N/A,6390.56,N/A,6390.56,N/A,19912.98,N/A,2320.33,N/A,4866.37,N/A,4470.25,N/A,4470.25,N/A,4866.37,N/A,2320.33,N/A,2399.88,N/A,850.35,N/A,N/A,850.35,20855.82,,Hospital 46750,Sphnctrop Anal Incontinence/Prolapse Adult,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42926.25,N/A,25755.75,N/A,5998.09,N/A,4297.49,N/A,24617.50,N/A,14594.92,N/A,10280.29,N/A,5998.09,N/A,4185.69,N/A,4185.69,N/A,6399.68,N/A,10280.29,N/A,10280.29,N/A,10280.29,N/A,24617.54,N/A,4185.69,N/A,5998.09,N/A,9384.50,N/A,9384.50,N/A,5998.09,N/A,4185.69,N/A,4297.49,N/A,2526.19,N/A,N/A,2526.19,25755.75,,Hospital 46900,Dstrj Lesion Anus Simple Chemical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15605.10,N/A,9363.06,N/A,2184.71,N/A,1718.14,N/A,8981.36,N/A,5305.73,N/A,4211.47,N/A,2184.71,N/A,1726.97,N/A,1726.97,N/A,2621.71,N/A,4211.47,N/A,4211.47,N/A,4211.47,N/A,8981.36,N/A,1726.97,N/A,2184.71,N/A,2134.50,N/A,2134.50,N/A,2184.71,N/A,1726.97,N/A,1718.14,N/A,399.80,N/A,N/A,399.80,9363.06,,Hospital 46916,Dstrj Lesion Anus Simple Cryosurgery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16482.10,N/A,9889.26,N/A,2307.49,N/A,2531.24,N/A,9487.87,N/A,5603.91,N/A,6216.35,N/A,2307.49,N/A,2553.29,N/A,2553.29,N/A,3869.81,N/A,6216.35,N/A,6216.35,N/A,6216.35,N/A,9487.88,N/A,2553.29,N/A,2307.49,N/A,3660.50,N/A,3660.50,N/A,2307.49,N/A,2553.29,N/A,2531.24,N/A,1030.39,N/A,N/A,1030.39,9889.26,,Hospital 46924,Dstrj Lesion Anus Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,65196.80,22206.60,39118.08,13323.96,4809.16,3105.77,5630.00,2382.31,16811.47,12783.64,22166.91,7550.25,11104.11,5679.25,4957.34,3105.77,287744.00,2320.33,287744.00,2320.33,6912.64,3535.47,11104.11,5679.25,11104.11,5679.25,11104.11,5679.25,16811.47,12757.73,5600.35,2320.33,4957.34,3105.77,12828.50,3397.00,12828.50,3397.00,N/A,3105.77,5600.35,2320.33,5630.00,2382.31,5304.35,296.19,4809.16,287744.00,296.19,13323.96,,Hospital 46948,Int Hrhc Transanal Hroid Dartlzj 2+ W/US Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25193.28,N/A,15115.97,N/A,3525.52,N/A,2559.60,N/A,14375.29,N/A,8565.73,N/A,6575.51,N/A,3525.52,N/A,2320.33,N/A,2320.33,N/A,4093.38,N/A,6575.51,N/A,6575.51,N/A,6575.51,N/A,14375.31,N/A,2320.33,N/A,3525.52,N/A,3397.00,N/A,3397.00,N/A,3525.52,N/A,2320.33,N/A,428.08,N/A,470.89,N/A,N/A,428.08,15115.97,,Hospital 46999,Unlisted Procedure Anus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22812.87,N/A,13687.72,N/A,3182.44,N/A,623.40,N/A,13129.57,N/A,7756.38,N/A,5650.53,N/A,3182.44,N/A,2320.33,N/A,2320.33,N/A,3517.57,N/A,5650.53,N/A,5650.53,N/A,5650.53,N/A,13129.58,N/A,2320.33,N/A,3182.44,N/A,2586.50,N/A,2586.50,N/A,3182.44,N/A,2326.89,N/A,623.40,N/A,685.75,N/A,N/A,623.40,13687.72,,Hospital 4700000060,HC Lost & Damage,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,250.00,N/A,150.00,N/A,35.00,N/A,N/A,N/A,143.95,N/A,85.00,N/A,35.00,N/A,35.00,N/A,N/A,N/A,N/A,N/A,21.75,N/A,35.00,N/A,35.00,N/A,35.00,N/A,143.95,N/A,N/A,N/A,35.00,N/A,134.00,N/A,134.00,N/A,35.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,21.75,150.00,,Hospital 4700000061,HC Extended Warranty,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,210.00,N/A,126.00,N/A,29.40,N/A,N/A,N/A,120.92,N/A,71.40,N/A,29.40,N/A,29.40,N/A,N/A,N/A,N/A,N/A,18.27,N/A,29.40,N/A,29.40,N/A,29.40,N/A,120.92,N/A,N/A,N/A,29.40,N/A,112.56,N/A,112.56,N/A,29.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18.27,126.00,,Hospital 47120,Hepatectomy Rescj Partial Lobectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76083.03,N/A,45649.82,N/A,10617.58,N/A,2558.07,N/A,43806.22,N/A,25868.21,N/A,9283.28,N/A,10617.58,N/A,2544.59,N/A,2544.59,N/A,5782.90,N/A,9283.28,N/A,9283.28,N/A,9283.28,N/A,43806.22,N/A,2544.59,N/A,10617.58,N/A,1643.00,N/A,1643.00,N/A,10617.58,N/A,2544.59,N/A,2558.07,N/A,3102.18,N/A,N/A,1643.00,45649.82,,Hospital 47360,Mgmt Lvr Hemrrg Cplx Sutr Wnd/Inj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 47370,Laps Surg Abltj 1/> Lvr Tum Rf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59321.42,N/A,35592.85,N/A,8287.33,N/A,8295.07,N/A,34152.34,N/A,20169.27,N/A,20001.66,N/A,8287.33,N/A,8206.20,N/A,8206.20,N/A,12451.39,N/A,20001.66,N/A,20001.66,N/A,20001.66,N/A,32615.52,N/A,8206.20,N/A,8287.33,N/A,11660.00,N/A,11660.00,N/A,8287.33,N/A,8206.20,N/A,8295.07,N/A,1503.67,N/A,N/A,1503.67,35592.85,,Hospital 47382,HC Percut Ablate Liver Rf,N/A,0352 - CT SCAN - BODY SCAN,N/A,36458.33,N/A,21875.00,N/A,5104.17,N/A,5192.14,N/A,20969.69,N/A,12395.83,N/A,11448.11,N/A,5104.17,N/A,4706.78,N/A,4706.78,N/A,7126.67,N/A,11448.11,N/A,11448.11,N/A,11448.11,N/A,20969.69,N/A,4706.78,N/A,5104.17,N/A,7897.00,N/A,7897.00,N/A,5104.17,N/A,4706.78,N/A,793.00,N/A,872.31,N/A,N/A,793.00,21875.00,,Hospital 47399,Unlisted Procedure Liver,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,69673.10,N/A,41803.86,N/A,7400.19,N/A,9049.34,N/A,16676.92,N/A,23688.85,N/A,16836.45,N/A,7628.20,N/A,95540.00,N/A,95540.00,N/A,10480.30,N/A,16836.45,N/A,16836.45,N/A,16836.45,N/A,16676.92,N/A,9019.69,N/A,7628.20,N/A,20031.17,N/A,20031.17,N/A,N/A,N/A,9019.69,N/A,9049.34,N/A,8162.17,N/A,7400.19,95540.00,N/A,N/A,,Hospital CPT 47490,HC Cholecystostomy,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6074.00,6074.00,3644.40,3644.40,N/A,850.36,N/A,314.18,N/A,3497.41,N/A,2065.16,N/A,6074.00,N/A,850.36,N/A,3198.50,N/A,3198.50,N/A,4816.37,N/A,6074.00,N/A,6074.00,N/A,6074.00,N/A,3497.41,N/A,3198.50,N/A,850.36,N/A,4562.00,N/A,4562.00,N/A,850.36,N/A,3198.50,N/A,314.18,N/A,345.60,3644.40,3644.40,314.18,6074.00,,Hospital CPT 47534,HC Plmt Biliary Drainage Cath Internal-External,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6684.00,6684.00,4010.40,4010.40,N/A,935.76,N/A,3233.14,N/A,3848.65,N/A,2272.56,N/A,6684.00,N/A,935.76,N/A,3198.50,N/A,3198.50,N/A,4816.37,N/A,6684.00,N/A,6684.00,N/A,6684.00,N/A,3848.65,N/A,3198.50,N/A,935.76,N/A,4562.00,N/A,4562.00,N/A,935.76,N/A,3198.50,N/A,3233.14,N/A,389.77,4010.40,4010.40,389.77,6684.00,,Hospital CPT 47535,HC Conversion Ext Bil Drng Cath to Intrnl/Extrnl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6684.00,6684.00,4010.40,4010.40,N/A,935.76,N/A,187.61,N/A,3848.65,N/A,2272.56,N/A,6684.00,N/A,935.76,N/A,3198.50,N/A,3198.50,N/A,4816.37,N/A,6684.00,N/A,6684.00,N/A,6684.00,N/A,3848.65,N/A,3198.50,N/A,935.76,N/A,4562.00,N/A,4562.00,N/A,935.76,N/A,3198.50,N/A,187.61,N/A,206.37,4010.40,4010.40,187.61,6684.00,,Hospital CPT 47540,HC Perq Plmt Bile Duct Stent W/ Bili Cath Plmt,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,12640.00,12640.00,7584.00,7584.00,N/A,1769.60,N/A,421.64,N/A,7278.11,N/A,4297.60,N/A,11521.65,N/A,1769.60,N/A,421.64,N/A,421.64,N/A,7172.23,N/A,11521.65,N/A,11521.65,N/A,11521.65,N/A,7278.11,N/A,421.64,N/A,1769.60,N/A,12640.00,N/A,12640.00,N/A,1769.60,N/A,421.64,N/A,421.64,N/A,463.80,7584.00,7584.00,421.64,12640.00,,Hospital 47541,HC Plmt Access Bil Tree Sm Bwl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,130797.77,N/A,78478.66,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,78478.66,78478.66,N/A,N/A,,Hospital 47555,HC Biliary Duct Dilat W/Out Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,68299.92,N/A,40979.95,N/A,9561.97,N/A,446.06,N/A,39313.53,N/A,23221.97,N/A,7791.92,N/A,9561.97,N/A,3198.50,N/A,3198.50,N/A,4850.62,N/A,7791.92,N/A,7791.92,N/A,7791.92,N/A,39313.55,N/A,3198.50,N/A,9561.97,N/A,6843.00,N/A,6843.00,N/A,9561.97,N/A,3198.50,N/A,446.06,N/A,490.67,N/A,N/A,446.06,40979.95,,Hospital 47562,Laparoscopy Surg Cholecystectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,46555.37,30046.32,27933.22,18027.79,8860.80,4197.63,10806.82,4706.78,N/A,7923.00,15828.83,10199.64,20159.56,11523.20,9133.82,4197.63,10747.52,4706.78,10747.52,4706.78,12548.86,7173.42,20159.56,11523.20,20159.56,11523.20,20159.56,11523.20,19968.54,7923.00,10747.52,4706.78,9133.82,4197.63,23984.84,7897.00,23984.84,7897.00,5177.46,4197.63,4706.78,4706.78,10806.82,4706.78,9773.19,5177.46,4706.78,27933.22,4197.63,18027.79,,Hospital 47579,Unlisted Laparoscopy Procedure Biliary Tract,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27043.32,N/A,16225.99,N/A,3780.32,N/A,667.03,N/A,7923.00,N/A,9194.73,N/A,11468.66,N/A,3780.32,N/A,4706.78,N/A,4706.78,N/A,7139.47,N/A,11468.66,N/A,11468.66,N/A,11468.66,N/A,7923.00,N/A,4706.78,N/A,3780.32,N/A,10878.50,N/A,10878.50,N/A,3780.32,N/A,4706.78,N/A,667.03,N/A,733.74,N/A,N/A,667.03,16225.99,,Hospital 47605,Cholecystectomy W/Cholangiography,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,78829.87,N/A,47297.92,N/A,11040.54,N/A,2318.35,N/A,45329.21,N/A,26802.15,N/A,11853.28,N/A,11040.54,N/A,2285.70,N/A,2285.70,N/A,7679.45,N/A,11853.28,N/A,11853.28,N/A,11853.28,N/A,38564.14,N/A,2308.59,N/A,11040.54,N/A,1643.00,N/A,1643.00,N/A,11040.54,N/A,2285.70,N/A,2318.35,N/A,2058.15,N/A,N/A,1643.00,47297.92,,Hospital 49010,Expl Retroperitoneum W/WO Bx Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17368.78,N/A,10421.27,N/A,2431.63,N/A,1897.24,N/A,2552.00,N/A,5905.39,N/A,10119.55,N/A,2431.63,N/A,1871.12,N/A,1871.12,N/A,6299.61,N/A,10119.55,N/A,10119.55,N/A,10119.55,N/A,2552.00,N/A,1871.12,N/A,2431.63,N/A,5497.50,N/A,5497.50,N/A,2431.63,N/A,1871.12,N/A,1897.24,N/A,1283.98,N/A,N/A,1283.98,10421.27,,Hospital 49060,HC Drain Retroperitoneal Abscess,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,189169.87,N/A,113501.92,N/A,4354.15,N/A,55254.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4354.15,N/A,55254.24,N/A,55254.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,55254.24,N/A,4354.15,N/A,N/A,N/A,N/A,N/A,4354.15,N/A,55254.24,N/A,55254.24,N/A,4354.15,N/A,4354.15,113501.92,N/A,N/A,,Hospital 49250,Umbilectomy Omphalectomy Exc Umbilicus Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14584.00,N/A,8750.40,N/A,2033.50,N/A,3198.50,N/A,8394.48,N/A,4958.56,N/A,7761.73,N/A,2041.76,N/A,3198.50,N/A,3198.50,N/A,4831.82,N/A,7761.73,N/A,7761.73,N/A,7761.73,N/A,8394.49,N/A,3198.50,N/A,2041.76,N/A,4562.00,N/A,4562.00,N/A,2041.76,N/A,3198.50,N/A,3198.50,N/A,3518.35,N/A,N/A,2033.50,8750.40,,Hospital 49321,Laparoscopy Surg W/Bx Single/Multiple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34281.12,N/A,20568.67,N/A,4744.43,N/A,8584.05,N/A,19736.87,N/A,11655.57,N/A,19895.30,N/A,4744.43,N/A,8206.20,N/A,8206.20,N/A,12385.21,N/A,19895.30,N/A,19895.30,N/A,19895.30,N/A,19736.87,N/A,8206.20,N/A,4744.43,N/A,10878.50,N/A,10878.50,N/A,4744.43,N/A,8206.20,N/A,8584.05,N/A,1258.53,N/A,N/A,1258.53,20568.67,,Hospital 49325,Laps W/Revision Intraperitoneal Catheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18770.07,N/A,11262.04,N/A,2622.66,N/A,5100.19,N/A,10805.63,N/A,6381.80,N/A,11422.27,N/A,2622.66,N/A,4706.78,N/A,4706.78,N/A,7110.58,N/A,11422.27,N/A,11422.27,N/A,11422.27,N/A,10805.64,N/A,4706.78,N/A,2622.66,N/A,5963.00,N/A,5963.00,N/A,2622.66,N/A,4706.78,N/A,5100.19,N/A,482.80,N/A,N/A,482.80,11422.27,,Hospital 49326,Laparoscopy W/Omentopexy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,37474.78,27778.72,22484.87,16667.23,19651.67,3881.51,4923.50,4923.50,37328.11,15988.49,12741.43,9444.77,37474.78,11434.41,20257.18,3881.51,52828.00,4706.78,52828.00,4706.78,27831.11,7118.14,37474.78,11434.41,37474.78,11434.41,37474.78,11434.41,37328.11,15978.27,23512.56,4706.78,20257.18,3881.51,37474.78,6226.50,37474.78,6226.50,N/A,3881.51,23512.56,4706.78,23542.21,4923.50,21675.18,622.69,4923.50,52828.00,622.69,16667.23,,Hospital 49402,Removal Peritoneal Foreign Body From Cavity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13210.00,N/A,7926.00,N/A,1842.67,N/A,3465.85,N/A,7604.52,N/A,4491.39,N/A,7753.85,N/A,1842.67,N/A,3198.50,N/A,3198.50,N/A,4826.91,N/A,7753.85,N/A,7753.85,N/A,7753.85,N/A,7604.53,N/A,3198.50,N/A,1842.67,N/A,4562.00,N/A,4562.00,N/A,1842.67,N/A,3198.50,N/A,3465.85,N/A,924.50,N/A,N/A,924.50,7926.00,,Hospital CPT 49406,HC CT-Aspiration Drainage,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,6129.00,6129.00,3677.40,3677.40,N/A,858.06,N/A,1416.50,N/A,914.00,N/A,2083.86,N/A,3275.59,N/A,858.06,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,914.00,N/A,1354.15,N/A,858.06,N/A,689.00,N/A,689.00,N/A,858.06,N/A,1354.15,N/A,1406.88,N/A,206.29,3677.40,3677.40,206.29,3677.40,,Hospital CPT 49418,HC Insert Tunneled Perit Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9197.00,9197.00,5518.20,5518.20,N/A,1287.58,N/A,3170.88,N/A,5295.63,N/A,3126.98,N/A,7736.91,N/A,1287.58,N/A,3198.50,N/A,3198.50,N/A,4816.37,N/A,7736.91,N/A,7736.91,N/A,7736.91,N/A,5295.63,N/A,3198.50,N/A,1287.58,N/A,4562.00,N/A,4562.00,N/A,1287.58,N/A,3198.50,N/A,193.30,N/A,212.63,5518.20,5518.20,193.30,7736.91,,Hospital 49421,Insertion Tunnel Intraperitoneal Cath Dial Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,40629.62,45549.83,24377.77,27329.90,24434.70,6376.97,29200.29,3402.52,40482.95,26185.11,13814.07,15486.94,40629.62,7741.26,25187.57,6376.97,124202.00,3198.50,124202.00,3198.50,34604.92,4819.07,40629.62,7741.26,40629.62,7741.26,40629.62,7741.26,40482.95,26185.11,29170.64,3198.50,25187.57,6376.97,40629.62,4562.00,40629.62,4562.00,N/A,6376.97,29170.64,3198.50,3406.22,3402.52,26950.70,265.68,3406.22,124202.00,265.68,27329.90,,Hospital 49425,HC Insert Peritoneal Venous Shunt,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,156823.92,N/A,94094.35,N/A,N/A,N/A,13318.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13879.17,N/A,13879.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13879.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13879.17,N/A,13879.17,N/A,N/A,N/A,13318.93,94094.35,N/A,N/A,,Hospital 49426,Revis Peritoneal-Venous Shunt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55955.98,N/A,33573.59,N/A,7833.83,N/A,4706.78,N/A,32178.12,N/A,19025.03,N/A,11504.53,N/A,7827.33,N/A,4706.78,N/A,4706.78,N/A,7161.79,N/A,11504.53,N/A,11504.53,N/A,11504.53,N/A,32178.10,N/A,4706.78,N/A,7833.83,N/A,10178.00,N/A,10178.00,N/A,7833.83,N/A,4706.78,N/A,4706.78,N/A,5177.46,N/A,N/A,4706.78,33573.59,,Hospital CPT 49427,HC Injection Shunt,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2248.00,2248.00,1348.80,1348.80,N/A,314.72,N/A,37.89,N/A,1294.40,N/A,764.32,N/A,113.52,N/A,314.72,N/A,37.89,N/A,37.89,N/A,70.67,N/A,113.52,N/A,113.52,N/A,113.52,N/A,1294.40,N/A,37.89,N/A,314.72,N/A,2248.00,N/A,2248.00,N/A,314.72,N/A,37.89,N/A,37.89,N/A,41.68,1348.80,1348.80,37.89,2248.00,,Hospital 49429,Rmvl Peritoneal-Venous Shunt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80271.25,N/A,48162.75,N/A,11114.40,N/A,478.28,N/A,46173.33,N/A,27001.26,N/A,6847.34,N/A,11114.40,N/A,2690.13,N/A,2690.13,N/A,4271.53,N/A,6847.34,N/A,6847.34,N/A,6847.34,N/A,46173.36,N/A,2690.13,N/A,11114.40,N/A,4562.00,N/A,4562.00,N/A,11114.40,N/A,2690.13,N/A,478.28,N/A,526.11,N/A,N/A,478.28,48162.75,,Hospital CPT 49451,HC Repl Duo/Jeju Tube Under Fluor,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1776.00,1776.00,1065.60,1065.60,N/A,248.64,N/A,779.79,N/A,1022.62,N/A,603.84,N/A,1776.00,N/A,248.64,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1776.00,N/A,1776.00,N/A,1776.00,N/A,1022.62,N/A,745.47,N/A,248.64,N/A,1776.00,N/A,1776.00,N/A,248.64,N/A,745.47,N/A,779.79,N/A,94.55,1065.60,1065.60,94.55,1776.00,,Hospital 49452,HC Replace G-J Tube,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,51951.18,5337.83,31170.71,3202.70,8791.75,740.67,10665.54,286.73,N/A,3066.45,17663.41,1814.87,21602.65,1825.37,9062.64,740.67,2248.00,745.47,2248.00,745.47,13447.14,1136.32,21602.65,1825.37,21602.65,1825.37,21602.65,1825.37,21397.96,3066.45,10665.54,745.47,9062.64,740.67,25701.76,1871.00,25701.76,1871.00,5209.06,740.67,10665.54,745.47,10665.54,286.73,9697.03,315.41,2248.00,31170.71,286.73,3202.70,,Hospital 49500,Rpr 1st Ingun Hrna Age 6 Mo-5 Yrs Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22794.03,N/A,13676.42,N/A,3191.16,N/A,3528.33,N/A,13121.76,N/A,7749.97,N/A,7744.27,N/A,3191.16,N/A,3198.50,N/A,3198.50,N/A,4820.96,N/A,7744.27,N/A,7744.27,N/A,7744.27,N/A,13121.76,N/A,3198.50,N/A,3191.16,N/A,7692.25,N/A,7692.25,N/A,3191.16,N/A,3198.50,N/A,1060.84,N/A,1166.92,N/A,N/A,1060.84,13676.42,,Hospital 49505,Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,31751.90,25136.42,19051.14,15081.85,5879.29,3519.10,7250.18,3198.50,13430.76,14413.83,10795.65,8546.38,13376.19,8693.14,6060.44,3519.10,7220.53,3198.50,7220.53,3198.50,8326.37,5411.63,13376.19,8693.14,13376.19,8693.14,13376.19,8693.14,16372.29,14413.84,7220.53,3198.50,6060.44,3519.10,15914.32,4825.50,15914.32,4825.50,N/A,3519.10,7220.53,3198.50,7250.18,3198.50,6484.67,3518.35,5879.29,19051.14,3198.50,15081.85,,Hospital 49507,Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,47783.98,29767.58,28670.39,17860.55,5879.29,4167.46,7250.18,3345.78,13387.96,17136.15,16246.55,10120.99,13376.19,7772.31,6060.44,4167.46,142186.00,3198.50,142186.00,3198.50,8326.37,4838.41,13376.19,7772.31,13376.19,7772.31,13376.19,7772.31,13387.96,17015.82,7220.53,3198.50,6060.44,4167.46,15914.32,4562.00,15914.32,4562.00,N/A,4167.46,7220.53,3198.50,7250.18,3345.78,6484.67,647.45,5879.29,142186.00,647.45,17860.55,,Hospital 49520,Rpr Recrt Inguinal Hernia Any Age Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28631.57,N/A,17178.94,N/A,4008.41,N/A,4831.00,N/A,16459.94,N/A,9734.71,N/A,11475.06,N/A,4008.41,N/A,4732.58,N/A,4732.58,N/A,7143.46,N/A,11475.06,N/A,11475.06,N/A,11475.06,N/A,16459.95,N/A,4732.58,N/A,4008.41,N/A,6843.00,N/A,6843.00,N/A,4008.41,N/A,4732.58,N/A,4831.00,N/A,1227.94,N/A,N/A,1227.94,17178.94,,Hospital 49540,Repair Lumbar Hernia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14821.08,N/A,8892.65,N/A,2074.96,N/A,5192.14,N/A,8527.59,N/A,5039.17,N/A,11407.81,N/A,2074.96,N/A,4706.78,N/A,4706.78,N/A,7101.58,N/A,11407.81,N/A,11407.81,N/A,11407.81,N/A,8527.60,N/A,4706.78,N/A,2074.96,N/A,4562.00,N/A,4562.00,N/A,2074.96,N/A,4706.78,N/A,675.57,N/A,743.12,N/A,N/A,675.57,11407.81,,Hospital 49550,Rpr 1st Fem Hrna Any Age Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25307.68,N/A,15184.61,N/A,3543.08,N/A,556.61,N/A,14504.14,N/A,8589.06,N/A,7775.39,N/A,3543.08,N/A,3198.50,N/A,3198.50,N/A,4840.33,N/A,7775.39,N/A,7775.39,N/A,7775.39,N/A,14504.15,N/A,3198.50,N/A,3543.08,N/A,4562.00,N/A,4562.00,N/A,3543.08,N/A,3198.50,N/A,556.61,N/A,612.27,N/A,N/A,556.61,15184.61,,Hospital 49555,Rpr Recrt Fem Hernia Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19403.73,N/A,11642.24,N/A,2716.52,N/A,3345.78,N/A,11163.50,N/A,6597.26,N/A,7770.04,N/A,2716.52,N/A,3198.50,N/A,3198.50,N/A,4836.98,N/A,7770.04,N/A,7770.04,N/A,7770.04,N/A,11163.51,N/A,3198.50,N/A,2716.52,N/A,4562.00,N/A,4562.00,N/A,2716.52,N/A,3198.50,N/A,3345.78,N/A,666.90,N/A,N/A,666.90,11642.24,,Hospital 49592,Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,37474.78,34494.30,22484.87,20696.58,19651.67,4815.43,4923.50,4706.78,37328.11,19742.80,12741.43,11728.06,37474.78,12382.48,20257.18,4815.43,52828.00,4706.78,52828.00,4706.78,27831.11,7708.33,37474.78,12382.48,37474.78,12382.48,37474.78,12382.48,37328.11,19742.80,23512.56,4706.78,20257.18,4815.43,37474.78,7897.00,37474.78,7897.00,N/A,4815.43,23512.56,4706.78,23542.21,4706.78,21675.18,5177.46,4923.50,52828.00,4706.78,20696.58,,Hospital 49617,Rpr Aa Hernia Recr > 10 Cm Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,79163.42,N/A,47498.05,N/A,11082.88,N/A,23.58,N/A,45546.19,N/A,26915.56,N/A,12383.79,N/A,11082.88,N/A,22.54,N/A,22.54,N/A,7709.14,N/A,12383.79,N/A,12383.79,N/A,12383.79,N/A,45546.19,N/A,22.54,N/A,11082.88,N/A,7897.00,N/A,7897.00,N/A,11082.88,N/A,22.54,N/A,23.58,N/A,10.57,N/A,N/A,10.57,47498.05,,Hospital 50040,Nephrostomy Nephrotomy W/Drainage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18344.33,N/A,11006.60,N/A,2568.20,N/A,2954.54,N/A,10532.11,N/A,6237.07,N/A,17294.82,N/A,2568.20,N/A,2894.35,N/A,2894.35,N/A,10766.35,N/A,17294.82,N/A,17294.82,N/A,17294.82,N/A,10532.21,N/A,2894.35,N/A,2568.20,N/A,5095.50,N/A,5095.50,N/A,2568.20,N/A,2894.35,N/A,2954.54,N/A,1137.19,N/A,N/A,1137.19,17294.82,,Hospital 50060,Nephrolithotomy Removal Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51034.65,N/A,30620.79,N/A,7119.97,N/A,4441.77,N/A,29370.10,N/A,17351.77,N/A,20626.94,N/A,7119.97,N/A,4246.26,N/A,4246.26,N/A,12840.93,N/A,20626.94,N/A,20626.94,N/A,20626.94,N/A,29370.11,N/A,4246.26,N/A,7119.97,N/A,5506.25,N/A,5506.25,N/A,7119.97,N/A,4246.26,N/A,4441.77,N/A,1672.97,N/A,N/A,1672.97,30620.79,,Hospital 50075,Nephrolithotomy Rmvl Large Staghorn Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63164.17,N/A,37898.50,N/A,8826.46,N/A,6205.67,N/A,36325.07,N/A,21475.83,N/A,22159.86,N/A,8826.46,N/A,6547.51,N/A,6547.51,N/A,13793.30,N/A,22159.86,N/A,22159.86,N/A,22159.86,N/A,36325.08,N/A,6547.51,N/A,8826.46,N/A,8072.25,N/A,8072.25,N/A,8826.46,N/A,6547.51,N/A,6205.67,N/A,2301.82,N/A,N/A,2301.82,37898.50,,Hospital 50130,Pyelotomy With Removal Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,94899.33,N/A,56939.60,N/A,12952.21,N/A,1212.79,N/A,54628.80,N/A,32265.78,N/A,17311.55,N/A,12952.21,N/A,6957.30,N/A,6957.30,N/A,10776.78,N/A,17311.55,N/A,17311.55,N/A,17311.55,N/A,54528.06,N/A,6957.30,N/A,12952.21,N/A,4218.50,N/A,4218.50,N/A,12952.21,N/A,6957.30,N/A,1212.79,N/A,1327.95,N/A,N/A,1212.79,56939.60,,Hospital 50240,Nephrectomy Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 50382,Rmvl & Rplcmt Intly Dwelling Ureteral Stent Prq,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33889.80,N/A,20333.88,N/A,4629.93,N/A,269.80,N/A,19507.75,N/A,11522.53,N/A,4079.21,N/A,4629.93,N/A,1675.03,N/A,1675.03,N/A,2539.38,N/A,4079.21,N/A,4079.21,N/A,4079.21,N/A,19507.76,N/A,1675.03,N/A,4629.93,N/A,3397.00,N/A,3397.00,N/A,4629.93,N/A,1675.03,N/A,269.80,N/A,290.65,N/A,N/A,269.80,20333.88,,Hospital 50384,HC Rem Int Ureteral Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,198938.53,21482.38,119363.12,12889.43,N/A,3000.70,10309.69,1709.87,N/A,12367.98,N/A,7304.01,N/A,4064.07,N/A,3000.70,10309.69,1675.03,10309.69,1675.03,N/A,2529.96,N/A,4064.07,N/A,4064.07,N/A,4064.07,N/A,12367.98,9171.14,1675.03,N/A,3000.70,N/A,4112.50,N/A,4112.50,N/A,3000.70,10309.69,1675.03,10309.69,1709.87,N/A,351.50,9171.14,119363.12,351.50,12889.43,,Hospital 50400,Pyeloplasty Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87640.45,N/A,52584.27,N/A,12255.40,N/A,6469.46,N/A,50437.29,N/A,29797.74,N/A,27742.36,N/A,12255.40,N/A,6452.80,N/A,6452.80,N/A,17270.16,N/A,27742.36,N/A,27742.36,N/A,27742.36,N/A,49903.53,N/A,6452.80,N/A,12255.40,N/A,6671.25,N/A,6671.25,N/A,12255.40,N/A,6452.81,N/A,6469.46,N/A,2585.74,N/A,N/A,2585.74,52584.27,,Hospital CPT 50433,HC Plmt Nephroureteral Catheter,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4545.00,4545.00,2727.00,2727.00,N/A,636.30,N/A,242.67,N/A,2617.01,N/A,1545.30,N/A,4545.00,N/A,636.30,N/A,2894.35,N/A,2894.35,N/A,4358.38,N/A,4545.00,N/A,4545.00,N/A,4545.00,N/A,2617.01,N/A,2894.35,N/A,636.30,N/A,3397.00,N/A,3397.00,N/A,636.30,N/A,2894.35,N/A,3027.62,N/A,266.94,2727.00,2727.00,242.67,4545.00,,Hospital CPT 50434,HC Convert Nephrostomy Catheter,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4637.00,4637.00,2782.20,2782.20,N/A,649.18,N/A,182.21,N/A,2669.98,N/A,1576.58,N/A,4051.75,N/A,649.18,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,2669.98,N/A,1675.03,N/A,649.18,N/A,1431.00,N/A,1431.00,N/A,649.18,N/A,1675.03,N/A,182.21,N/A,200.43,2782.20,2782.20,182.21,4051.75,,Hospital 50561,Renal Ndsc Nephros/Pyelostomy Rmvl FB/Calculus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23700.27,N/A,14220.16,N/A,3292.10,N/A,4521.03,N/A,13638.36,N/A,8058.10,N/A,10311.52,N/A,3292.10,N/A,4250.19,N/A,4250.19,N/A,6419.13,N/A,10311.52,N/A,10311.52,N/A,10311.52,N/A,13638.37,N/A,4250.19,N/A,3292.10,N/A,4332.50,N/A,4332.50,N/A,3292.10,N/A,4250.19,N/A,4521.03,N/A,614.70,N/A,N/A,614.70,14220.16,,Hospital 50688,HC Change of Ureterostomy Tube,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,31899.02,11896.42,19139.41,7137.85,7528.22,1665.51,9171.14,3027.62,16965.45,6838.23,10845.67,4044.79,17127.73,7035.96,7760.17,1665.51,2810.00,2894.35,2810.00,2894.35,10661.62,4380.02,17127.73,7035.96,17127.73,7035.96,17127.73,7035.96,16965.45,6838.23,9171.14,2894.35,7760.17,1665.51,20377.73,2806.50,20377.73,2806.50,N/A,1665.51,9171.14,2894.35,9171.14,3027.62,8303.39,302.83,2810.00,20377.73,302.83,7137.85,,Hospital 50694,HC IR Plmt Uret Stent Prq New WO,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,78853.82,38763.05,47312.29,23257.83,11913.27,5327.35,14358.44,2954.54,27540.87,22240.20,26810.29,13179.43,27104.35,7024.13,12280.34,5327.35,3372.00,2894.35,3372.00,2894.35,N/A,4372.63,27104.35,7024.13,N/A,7024.13,27104.35,7024.13,27540.87,22240.21,14358.44,2894.35,12280.34,5327.35,32247.41,7109.75,32247.41,7109.75,N/A,5327.35,14358.44,2894.35,14358.44,2954.54,13139.97,674.01,3372.00,47312.29,674.01,23257.83,,Hospital 50770,Transureteroureterostomy Anast Ureter Clat Urtr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,102866.83,N/A,61720.10,N/A,14383.84,N/A,1451.93,N/A,59174.37,N/A,34974.72,N/A,8920.72,N/A,14383.84,N/A,1436.61,N/A,1436.61,N/A,5553.29,N/A,8920.72,N/A,8920.72,N/A,8920.72,N/A,59174.35,N/A,1436.61,N/A,14383.84,N/A,1643.00,N/A,1643.00,N/A,14383.84,N/A,1436.61,N/A,1451.93,N/A,1319.91,N/A,N/A,1319.91,61720.10,,Hospital 51535,Cystotomy Excise/Incise/Repair Ureterocele,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29245.57,N/A,17547.34,N/A,4094.38,N/A,4378.42,N/A,16787.48,N/A,9943.49,N/A,10148.04,N/A,4094.38,N/A,4185.69,N/A,4185.69,N/A,6317.36,N/A,10148.04,N/A,10148.04,N/A,10148.04,N/A,16787.49,N/A,4185.69,N/A,4094.38,N/A,7661.50,N/A,7661.50,N/A,4094.38,N/A,4185.69,N/A,4378.42,N/A,1609.29,N/A,N/A,1609.29,17547.34,,Hospital 51610,HC Inj Proc for Retro Cystography,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,62377.53,14184.38,37426.52,8510.63,8548.73,1985.81,10378.35,98.52,N/A,8159.62,N/A,4822.69,N/A,280.40,8812.13,1985.81,5058.00,96.52,5058.00,96.52,N/A,174.54,N/A,280.40,N/A,280.40,N/A,280.40,N/A,8159.62,11635.00,96.52,8812.13,1985.81,23140.10,527.00,23140.10,527.00,29601.09,1985.81,11635.00,96.52,10378.35,98.52,9428.98,85.76,5058.00,37426.52,85.76,8510.63,,Hospital CPT 51700,HC Bladder Irrigation Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,837.00,837.00,502.20,502.20,N/A,117.18,N/A,198.07,N/A,481.94,N/A,284.58,N/A,469.36,N/A,117.18,N/A,194.04,N/A,194.04,N/A,292.18,N/A,469.36,N/A,469.36,N/A,469.36,N/A,481.94,N/A,194.04,N/A,117.18,N/A,837.00,N/A,837.00,N/A,117.18,N/A,194.04,N/A,201.59,N/A,32.62,502.20,502.20,32.62,837.00,,Hospital CPT 51700,HC Bladder Irrig Simple or Continuous,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,837.00,837.00,502.20,502.20,N/A,117.18,N/A,198.07,N/A,481.94,N/A,284.58,N/A,469.36,N/A,117.18,N/A,194.04,N/A,194.04,N/A,292.18,N/A,469.36,N/A,469.36,N/A,469.36,N/A,481.94,N/A,194.04,N/A,117.18,N/A,448.63,N/A,448.63,N/A,117.18,N/A,194.04,N/A,201.59,N/A,32.62,502.20,502.20,32.62,502.20,,Hospital CPT 51702,HC Indwelling Catheter,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,362.00,362.00,217.20,217.20,N/A,50.68,N/A,111.11,N/A,208.44,N/A,123.08,N/A,253.64,N/A,50.68,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,208.44,N/A,104.85,N/A,50.68,N/A,362.00,N/A,362.00,N/A,50.68,N/A,104.85,N/A,24.72,N/A,27.19,217.20,217.20,24.72,362.00,,Hospital CPT 51702,HC Cath Urethral Simple,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,362.00,362.00,217.20,217.20,N/A,50.68,N/A,111.11,N/A,208.44,N/A,123.08,N/A,253.64,N/A,50.68,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,208.44,N/A,104.85,N/A,50.68,N/A,194.03,N/A,194.03,N/A,50.68,N/A,104.85,N/A,24.72,N/A,27.19,217.20,217.20,24.72,253.64,,Hospital 51710,HC Change Cystostomy Tube Complicated,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,10296.37,N/A,6177.82,N/A,1441.48,N/A,576.45,N/A,5927.08,N/A,3500.76,N/A,1378.48,N/A,1441.48,N/A,564.71,N/A,564.71,N/A,858.12,N/A,1378.48,N/A,1378.48,N/A,1378.48,N/A,5927.08,N/A,564.71,N/A,1441.48,N/A,1431.00,N/A,1431.00,N/A,1441.48,N/A,564.71,N/A,576.45,N/A,142.73,N/A,N/A,142.73,6177.82,,Hospital 51715,Ndsc Njx Implt Matrl Urt&/Bldr Nck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27131.15,N/A,16278.69,N/A,3798.36,N/A,2954.54,N/A,15503.82,N/A,9224.59,N/A,7021.82,N/A,3798.36,N/A,2894.35,N/A,2894.35,N/A,4371.21,N/A,7021.82,N/A,7021.82,N/A,7021.82,N/A,15503.82,N/A,2894.35,N/A,3798.36,N/A,4562.00,N/A,4562.00,N/A,3798.36,N/A,2894.35,N/A,2954.54,N/A,220.57,N/A,N/A,220.57,16278.69,,Hospital CPT 51720,HC Chemo-Bladder Instillation,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,698.00,698.00,418.80,418.80,N/A,97.72,N/A,570.82,N/A,401.91,N/A,237.32,N/A,698.00,N/A,97.72,N/A,564.71,N/A,564.71,N/A,698.00,N/A,698.00,N/A,698.00,N/A,698.00,N/A,401.91,N/A,564.71,N/A,97.72,N/A,374.13,N/A,374.13,N/A,97.72,N/A,564.71,N/A,598.44,N/A,46.19,418.80,418.80,46.19,698.00,,Hospital 51728,Complex Cystometrogram Voiding Pressure Studies,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17975.60,N/A,10785.36,N/A,2516.58,N/A,600.73,N/A,10734.61,N/A,6111.70,N/A,1365.97,N/A,2516.58,N/A,564.71,N/A,564.71,N/A,850.34,N/A,1365.97,N/A,1365.97,N/A,1365.97,N/A,10734.61,N/A,564.71,N/A,2516.58,N/A,1694.50,N/A,1694.50,N/A,2516.58,N/A,564.71,N/A,600.73,N/A,357.54,N/A,N/A,357.54,10785.36,,Hospital 51736,Simple Uroflometry,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14556.00,N/A,8733.60,N/A,2034.99,N/A,1732.46,N/A,8381.35,N/A,4949.04,N/A,4051.75,N/A,2034.99,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,8381.35,N/A,1675.03,N/A,2034.99,N/A,2134.50,N/A,2134.50,N/A,2034.99,N/A,1675.03,N/A,1732.46,N/A,167.51,N/A,N/A,167.51,8733.60,,Hospital CPT 51798,HC Bladder Scan,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,470.00,470.00,282.00,282.00,N/A,65.80,N/A,51.91,N/A,270.63,N/A,159.80,N/A,125.56,N/A,65.80,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,270.63,N/A,51.91,N/A,65.80,N/A,251.92,N/A,251.92,N/A,65.80,N/A,51.91,N/A,51.91,N/A,57.10,282.00,282.00,51.91,282.00,,Hospital CPT 51798,HC Bladder Scan,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,470.00,470.00,282.00,282.00,N/A,65.80,N/A,51.91,N/A,270.63,N/A,159.80,N/A,125.56,N/A,65.80,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,270.63,N/A,51.91,N/A,65.80,N/A,251.92,N/A,251.92,N/A,65.80,N/A,51.91,N/A,51.91,N/A,57.10,282.00,282.00,51.91,282.00,,Hospital CPT 51798,HC Bladder Scan,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,470.00,470.00,282.00,282.00,N/A,65.80,N/A,51.91,N/A,270.63,N/A,159.80,N/A,125.56,N/A,65.80,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,270.63,N/A,51.91,N/A,65.80,N/A,470.00,N/A,470.00,N/A,65.80,N/A,51.91,N/A,51.91,N/A,57.10,282.00,282.00,51.91,470.00,,Hospital 51840,Ant Vesicourethropexy/Urethropexy Smpl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30960.97,N/A,18576.58,N/A,4334.53,N/A,667.95,N/A,17737.83,N/A,10526.73,N/A,10173.39,N/A,4334.53,N/A,667.95,N/A,667.95,N/A,6333.12,N/A,10173.39,N/A,10173.39,N/A,10173.39,N/A,17737.83,N/A,667.95,N/A,4334.53,N/A,3397.00,N/A,3397.00,N/A,4334.53,N/A,667.95,N/A,667.95,N/A,734.75,N/A,N/A,667.95,18576.58,,Hospital 52224,HC Cysto W/Removal of Lesions Small,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,18947.03,N/A,11368.22,N/A,2652.58,N/A,2894.35,N/A,10887.34,N/A,6442.00,N/A,7218.24,N/A,2652.58,N/A,2894.35,N/A,2894.35,N/A,4493.27,N/A,7218.24,N/A,7218.24,N/A,7218.24,N/A,10887.34,N/A,2894.35,N/A,2652.58,N/A,3397.00,N/A,3397.00,N/A,2652.58,N/A,2894.35,N/A,2894.35,N/A,3183.79,N/A,N/A,2652.58,11368.22,,Hospital 52240,Cystourethroscopy W/Dest &/Rmvl Tumor Large,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25602.68,N/A,15361.61,N/A,3576.58,N/A,4246.26,N/A,14723.78,N/A,8704.91,N/A,10312.30,N/A,3548.00,N/A,4246.26,N/A,4246.26,N/A,6419.61,N/A,10312.30,N/A,10312.30,N/A,10312.30,N/A,14723.80,N/A,4246.26,N/A,3576.58,N/A,5095.50,N/A,5095.50,N/A,3576.58,N/A,4246.26,N/A,4246.26,N/A,4670.88,N/A,N/A,3548.00,15361.61,,Hospital 52265,Cystourethroscopy W/Dil Bladder Local Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15711.90,N/A,9427.14,N/A,2199.68,N/A,1752.16,N/A,9044.38,N/A,5342.05,N/A,4111.11,N/A,2199.68,N/A,1675.03,N/A,1675.03,N/A,2559.24,N/A,4111.11,N/A,4111.11,N/A,4111.11,N/A,9044.37,N/A,1675.03,N/A,2199.68,N/A,1431.00,N/A,1431.00,N/A,2199.68,N/A,1675.03,N/A,1752.16,N/A,170.17,N/A,N/A,170.17,9427.14,,Hospital 52270,Cystourethroscopy W/Internal Urethrotomy Female,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28388.23,N/A,17032.94,N/A,3958.18,N/A,807.80,N/A,16330.33,N/A,9651.99,N/A,7099.79,N/A,3958.18,N/A,2894.35,N/A,2894.35,N/A,4419.74,N/A,7099.79,N/A,7099.79,N/A,7099.79,N/A,16330.36,N/A,2894.35,N/A,3958.18,N/A,6728.25,N/A,6728.25,N/A,3958.18,N/A,2894.35,N/A,807.80,N/A,888.59,N/A,N/A,807.80,17032.94,,Hospital 52276,Cystourethroscopy W/Internal Urethrotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16718.20,N/A,10030.92,N/A,2333.68,N/A,1675.03,N/A,9624.02,N/A,5684.19,N/A,4076.00,N/A,2333.68,N/A,1675.03,N/A,1675.03,N/A,2537.38,N/A,4076.00,N/A,4076.00,N/A,4076.00,N/A,9624.01,N/A,1675.03,N/A,2333.68,N/A,3397.00,N/A,3397.00,N/A,2333.68,N/A,1675.03,N/A,1675.03,N/A,1842.53,N/A,N/A,1675.03,10030.92,,Hospital 52277,Cystourethroscopy W/Resecj External Sphincter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18719.00,N/A,11231.40,N/A,2620.66,N/A,2954.54,N/A,10775.75,N/A,6364.46,N/A,7012.13,N/A,2620.66,N/A,2894.35,N/A,2894.35,N/A,4365.18,N/A,7012.13,N/A,7012.13,N/A,7012.13,N/A,10775.75,N/A,2894.35,N/A,2620.66,N/A,3397.00,N/A,3397.00,N/A,2620.66,N/A,2894.35,N/A,2954.54,N/A,339.19,N/A,N/A,339.19,11231.40,,Hospital CPT 52281,HC Cystourethroscopy W Cal/Dil,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4564.00,4564.00,2738.40,2738.40,N/A,638.96,N/A,1740.25,N/A,2627.95,N/A,1551.76,N/A,4051.75,N/A,638.96,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,2627.95,N/A,1675.03,N/A,638.96,N/A,4564.00,N/A,4564.00,N/A,638.96,N/A,1675.03,N/A,1740.25,N/A,159.07,2738.40,2738.40,159.07,4564.00,,Hospital 52325,Cysto Fragmentation Ureteral Stone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,51547.42,N/A,30928.45,N/A,7528.22,N/A,4591.91,N/A,17457.28,N/A,17526.13,N/A,17127.73,N/A,7760.17,N/A,199510.00,N/A,199510.00,N/A,10661.62,N/A,17127.73,N/A,17127.73,N/A,17127.73,N/A,17457.28,N/A,9171.14,N/A,7760.17,N/A,20377.73,N/A,20377.73,N/A,N/A,N/A,9171.14,N/A,9230.44,N/A,8303.39,N/A,4591.91,199510.00,N/A,N/A,,Hospital 52334,Cysto Insj Urtrl Gd Wire Prq Nfros Rtrgr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43097.07,N/A,25858.24,N/A,6030.87,N/A,3027.62,N/A,24793.18,N/A,14653.00,N/A,7043.30,N/A,6030.87,N/A,2894.35,N/A,2894.35,N/A,4384.60,N/A,7043.30,N/A,7043.30,N/A,7043.30,N/A,24787.57,N/A,2894.35,N/A,6030.87,N/A,7109.75,N/A,7109.75,N/A,6030.87,N/A,2894.35,N/A,3027.62,N/A,908.63,N/A,N/A,908.63,25858.24,,Hospital 52345,Cysto W/Urtroscopy W/Tx Urtropel Junct Strix,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26603.05,N/A,15961.83,N/A,3726.22,N/A,3082.90,N/A,15291.34,N/A,9045.04,N/A,7054.34,N/A,3726.22,N/A,2898.28,N/A,2898.28,N/A,4391.46,N/A,7054.34,N/A,7054.34,N/A,7054.34,N/A,15291.34,N/A,2898.28,N/A,3726.22,N/A,3397.00,N/A,3397.00,N/A,3726.22,N/A,2898.28,N/A,3082.90,N/A,434.23,N/A,N/A,434.23,15961.83,,Hospital 52351,"HC Cysto/Uretero/Pyeloscopy, Dx",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,39557.52,18396.85,23734.51,11038.11,5750.19,2568.47,7097.47,2894.35,13221.49,10575.87,13449.56,6254.93,13082.47,7018.46,5927.36,2568.47,2894.35,2894.35,2894.35,2894.35,8143.53,4369.12,13082.47,7018.46,13082.47,7018.46,13082.47,7018.46,13221.49,10575.88,7067.82,2894.35,5927.36,2568.47,15564.88,5944.75,15564.88,5944.75,N/A,2568.47,7067.82,2894.35,7097.47,2894.35,6342.28,3183.79,2894.35,23734.51,2568.47,11038.11,,Hospital 52355,Cysto/Pyeloscopy Rescj Pelvic Tumor,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15952.73,N/A,9571.64,N/A,2233.39,N/A,4359.67,N/A,9178.65,N/A,5423.94,N/A,10308.33,N/A,2233.39,N/A,4246.26,N/A,4246.26,N/A,6417.12,N/A,10308.33,N/A,10308.33,N/A,10308.33,N/A,9178.65,N/A,4246.26,N/A,2233.39,N/A,5095.50,N/A,5095.50,N/A,2233.39,N/A,4246.26,N/A,4359.67,N/A,1265.10,N/A,N/A,1265.10,10308.33,,Hospital CPT 52356,HC Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt,N/A,0790 - EXTRA-CORPOREAL SHOCK WAVE THERAPY (FORMERLY LITHOTRIPSY) - GENERAL CLASSIFICATION,11828.00,11828.00,7096.80,7096.80,N/A,1655.92,N/A,396.96,N/A,6810.56,N/A,4021.52,N/A,1177.77,N/A,1655.92,N/A,396.96,N/A,396.96,N/A,733.16,N/A,1177.77,N/A,1177.77,N/A,1177.77,N/A,6810.56,N/A,396.96,N/A,1655.92,N/A,11828.00,N/A,11828.00,N/A,1655.92,N/A,396.96,N/A,396.96,N/A,436.66,7096.80,7096.80,396.96,11828.00,,Hospital 52441,Cysto Insertion Transprostatic Implant Single,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60858.23,N/A,36514.94,N/A,8520.16,N/A,441.94,N/A,34436.04,N/A,20691.79,N/A,14158.61,N/A,8520.16,N/A,441.94,N/A,441.94,N/A,9404.75,N/A,14158.61,N/A,14158.61,N/A,14158.61,N/A,34436.04,N/A,441.94,N/A,8520.16,N/A,922.25,N/A,922.25,N/A,8520.16,N/A,441.94,N/A,441.94,N/A,486.14,N/A,N/A,441.94,36514.94,,Hospital 52442,Cysto Insertion Transprostatic Implant Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60409.17,N/A,36245.50,N/A,8457.29,N/A,494.93,N/A,34176.15,N/A,20539.10,N/A,14174.83,N/A,8457.29,N/A,493.85,N/A,493.85,N/A,9487.46,N/A,14174.83,N/A,14174.83,N/A,14174.83,N/A,34176.15,N/A,493.85,N/A,8457.29,N/A,922.25,N/A,922.25,N/A,8457.29,N/A,493.85,N/A,494.93,N/A,492.08,N/A,N/A,492.08,36245.50,,Hospital 52649,Laser Enucleation Prostate W/Morcellation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39521.32,N/A,23712.79,N/A,5532.98,N/A,819.82,N/A,22751.73,N/A,13437.26,N/A,10315.41,N/A,5532.98,N/A,4246.26,N/A,4246.26,N/A,6421.54,N/A,10315.41,N/A,10315.41,N/A,10315.41,N/A,22751.77,N/A,4246.26,N/A,5532.98,N/A,5963.00,N/A,5963.00,N/A,5532.98,N/A,4246.26,N/A,819.82,N/A,901.81,N/A,N/A,819.82,23712.79,,Hospital 53060,Drg of Skene's Gland Abscess or Cyst,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21810.48,N/A,13086.29,N/A,3025.49,N/A,1709.87,N/A,12538.32,N/A,7415.56,N/A,4069.93,N/A,3025.49,N/A,1675.03,N/A,1675.03,N/A,2533.61,N/A,4069.93,N/A,4069.93,N/A,4069.93,N/A,12538.32,N/A,1675.03,N/A,3025.49,N/A,3397.00,N/A,3397.00,N/A,3025.49,N/A,1675.03,N/A,1709.87,N/A,208.19,N/A,N/A,208.19,13086.29,,Hospital 53405,Urethroplasty 2nd Stage W/Urinary Diversion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39081.60,N/A,23448.96,N/A,5466.67,N/A,4391.84,N/A,22494.75,N/A,13287.74,N/A,10316.34,N/A,5466.67,N/A,4246.26,N/A,4246.26,N/A,6422.12,N/A,10316.34,N/A,10316.34,N/A,10316.34,N/A,22494.75,N/A,4246.26,N/A,5466.67,N/A,4562.00,N/A,4562.00,N/A,5466.67,N/A,4246.26,N/A,4391.84,N/A,930.42,N/A,N/A,930.42,23448.96,,Hospital 53410,Urethroplasty 1 Stg Recnst Male Anterior Urethra,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47509.90,N/A,28505.94,N/A,6651.39,N/A,4391.84,N/A,27276.01,N/A,16153.36,N/A,10295.88,N/A,6651.39,N/A,4246.26,N/A,4246.26,N/A,6409.39,N/A,10295.88,N/A,10295.88,N/A,10295.88,N/A,27276.01,N/A,4246.26,N/A,6651.39,N/A,4562.00,N/A,4562.00,N/A,6651.39,N/A,4246.26,N/A,4391.84,N/A,1032.82,N/A,N/A,1032.82,28505.94,,Hospital 53445,Insj Inflatable Urethral/Bladder Neck Sphincter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,122635.97,118159.85,73581.58,70895.91,6010.52,16542.38,18213.89,18213.89,67596.94,66989.75,41696.22,40174.35,13674.76,42227.57,6195.71,16542.38,64068.00,17412.16,64068.00,17412.16,8512.22,26287.48,13674.76,42227.57,13674.76,42227.57,13674.76,42227.57,67596.94,66989.76,7375.78,17412.16,6195.71,16542.38,16269.55,16637.00,16269.55,16637.00,N/A,16542.38,7375.78,17412.16,7405.43,18213.89,6629.41,794.76,6010.52,73581.58,794.76,70895.91,,Hospital 53520,Clsr Urethrostomy/Urethroq Fstl Male Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46750.27,N/A,28050.16,N/A,6545.03,N/A,4391.84,N/A,26915.34,N/A,15895.07,N/A,10299.30,N/A,6545.03,N/A,4246.26,N/A,4246.26,N/A,6411.52,N/A,10299.30,N/A,10299.30,N/A,10299.30,N/A,26915.33,N/A,4246.26,N/A,6545.03,N/A,7692.25,N/A,7692.25,N/A,6545.03,N/A,4246.26,N/A,4391.84,N/A,2347.64,N/A,N/A,2347.64,28050.16,,Hospital 53665,Dilat Female Urethra General/Cndj Spinal Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,89917.42,N/A,53950.45,N/A,5750.19,N/A,4923.50,N/A,15640.97,N/A,30571.92,N/A,12910.13,N/A,5927.36,N/A,239974.00,N/A,239974.00,N/A,8036.25,N/A,12910.13,N/A,12910.13,N/A,12910.13,N/A,15640.97,N/A,6648.07,N/A,5927.36,N/A,15359.83,N/A,15359.83,N/A,N/A,N/A,6648.07,N/A,6677.72,N/A,6342.28,N/A,4923.50,239974.00,N/A,N/A,,Hospital 53854,HC Trurl Dstrj Prst8 Tiss Rf Wv Thermotherapy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,68592.63,22057.57,41155.58,13234.54,7905.37,3088.06,9646.93,360.85,17904.34,12697.23,23321.49,7499.57,17985.82,7017.98,8148.95,3088.06,9617.28,2894.35,9617.28,2894.35,11195.75,4368.83,17985.82,7017.98,17985.82,7017.98,17985.82,7017.98,17904.34,12697.23,9617.28,2894.35,8148.95,3088.06,21398.64,3397.00,3397.00,3397.00,N/A,3088.06,9617.28,2894.35,9646.93,360.85,8719.38,396.94,3397.00,41155.58,360.85,13234.54,,Hospital 53899,HC Unlisted Proc Urinary System,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,75838.77,39292.30,45503.26,23575.38,7528.22,5498.07,3082.90,1732.46,17024.19,22401.88,25785.18,13359.38,17127.73,5720.56,7760.17,5498.07,1686.00,1675.03,1686.00,1675.03,10661.62,3561.14,17127.73,5720.56,17127.73,5720.56,17127.73,5720.56,17024.19,22401.88,9171.14,1675.03,7760.17,5498.07,20377.73,3660.50,20377.73,3660.50,29601.09,5498.07,9171.14,1675.03,9171.14,1732.46,8303.39,731.70,1686.00,45503.26,731.70,23575.38,,Hospital 54015,I&D Penis Deep,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,23783.00,N/A,14269.80,N/A,3329.62,N/A,1776.47,N/A,13686.08,N/A,8070.92,N/A,7044.01,N/A,3329.62,N/A,2894.35,N/A,2894.35,N/A,4385.03,N/A,7044.01,N/A,7044.01,N/A,7044.01,N/A,13686.09,N/A,2894.35,N/A,3329.62,N/A,4562.00,N/A,4562.00,N/A,3329.62,N/A,2894.35,N/A,1776.47,N/A,1954.12,N/A,N/A,1776.47,14269.80,,Hospital 54055,Dstrj Lesion Penis Simple Electrodesiccation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36157.50,N/A,21694.50,N/A,5029.28,N/A,4209.58,N/A,20817.18,N/A,12293.54,N/A,10309.61,N/A,5029.28,N/A,4246.26,N/A,4246.26,N/A,6417.93,N/A,10309.61,N/A,10309.61,N/A,10309.61,N/A,20817.18,N/A,4246.26,N/A,5029.28,N/A,6898.50,N/A,6898.50,N/A,5029.28,N/A,4246.26,N/A,4209.58,N/A,1043.06,N/A,N/A,1043.06,21694.50,,Hospital 54060,Dstrj Lesion Penis Simple Surg Excision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14808.25,N/A,8884.95,N/A,2073.16,N/A,124.11,N/A,8524.23,N/A,5034.81,N/A,3788.02,N/A,2073.16,N/A,1558.52,N/A,1558.52,N/A,2358.11,N/A,3788.02,N/A,3788.02,N/A,3788.02,N/A,8524.23,N/A,1558.52,N/A,2073.16,N/A,1871.00,N/A,1871.00,N/A,2073.16,N/A,1558.52,N/A,124.11,N/A,136.52,N/A,N/A,124.11,8884.95,,Hospital 54112,Exc Penile Plaque Graft > 5 Cm Length,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,101256.47,N/A,60753.88,N/A,14168.40,N/A,18213.89,N/A,57678.61,N/A,34427.21,N/A,42191.72,N/A,14168.40,N/A,17412.16,N/A,17412.16,N/A,26265.15,N/A,42191.72,N/A,42191.72,N/A,42191.72,N/A,57678.63,N/A,17412.16,N/A,14168.40,N/A,19618.50,N/A,19618.50,N/A,14168.40,N/A,17412.16,N/A,18213.89,N/A,1911.19,N/A,N/A,1911.19,60753.88,,Hospital 54235,HC Injection of Corpora Cavernosa,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,709.00,N/A,425.40,N/A,99.26,N/A,308.44,N/A,408.24,N/A,241.06,N/A,615.76,N/A,99.26,N/A,291.06,N/A,291.06,N/A,615.76,N/A,615.76,N/A,615.76,N/A,615.76,N/A,408.24,N/A,291.06,N/A,99.26,N/A,380.03,N/A,380.03,N/A,99.26,N/A,291.06,N/A,308.44,N/A,163.91,N/A,N/A,99.26,615.76,,Hospital 54360,Plastic Rpr Penis Correct Angulation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34929.90,N/A,20957.94,N/A,4890.20,N/A,3027.62,N/A,20109.25,N/A,11876.17,N/A,7048.07,N/A,4890.20,N/A,2894.35,N/A,2894.35,N/A,4387.56,N/A,7048.07,N/A,7048.07,N/A,7048.07,N/A,20109.25,N/A,2894.35,N/A,4890.20,N/A,5963.00,N/A,5963.00,N/A,4890.20,N/A,2894.35,N/A,3027.62,N/A,759.62,N/A,N/A,759.62,20957.94,,Hospital 54408,Rpr Component Inflatable Penile Prosthesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43219.20,N/A,25931.52,N/A,6043.18,N/A,4441.77,N/A,24827.24,N/A,14694.54,N/A,10453.88,N/A,6043.18,N/A,4246.26,N/A,4246.26,N/A,6507.73,N/A,10453.88,N/A,10453.88,N/A,10453.88,N/A,24827.24,N/A,4246.26,N/A,6043.18,N/A,5963.00,N/A,5963.00,N/A,6043.18,N/A,4246.26,N/A,4441.77,N/A,841.82,N/A,N/A,841.82,25931.52,,Hospital 54416,Rmvl & Rplcmt Non-Nfltbl/Nfltbl Penile Prosthesi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,119042.92,N/A,71425.75,N/A,16654.55,N/A,18016.98,N/A,67519.67,N/A,40474.60,N/A,42241.23,N/A,16654.55,N/A,17420.02,N/A,17420.02,N/A,26295.96,N/A,42241.23,N/A,42241.23,N/A,42241.23,N/A,66108.37,N/A,17420.02,N/A,16654.55,N/A,16637.00,N/A,16637.00,N/A,16654.55,N/A,17420.02,N/A,18016.98,N/A,880.37,N/A,N/A,880.37,71425.75,,Hospital 54430,Corpora Cavernosa-Corpus Spongiosum Shunt Uni/Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80557.57,N/A,48334.54,N/A,11178.66,N/A,1587.58,N/A,46242.39,N/A,27389.57,N/A,30268.60,N/A,11178.66,N/A,4645.34,N/A,4645.34,N/A,18842.79,N/A,30268.60,N/A,30268.60,N/A,30268.60,N/A,46242.39,N/A,4645.34,N/A,11178.66,N/A,12613.25,N/A,12613.25,N/A,11178.66,N/A,4645.34,N/A,1587.58,N/A,1740.24,N/A,N/A,1587.58,48334.54,,Hospital 54600,Rdctj Torsion Tstis W/WO Fixj Clat Testis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22786.80,N/A,13672.08,N/A,3154.06,N/A,458.46,N/A,13112.53,N/A,7747.51,N/A,7036.58,N/A,3154.06,N/A,2894.35,N/A,2894.35,N/A,4380.40,N/A,7036.58,N/A,7036.58,N/A,7036.58,N/A,13112.55,N/A,2894.35,N/A,3154.06,N/A,3397.00,N/A,3397.00,N/A,3154.06,N/A,2894.35,N/A,458.46,N/A,504.31,N/A,N/A,458.46,13672.08,,Hospital 54620,Fixation Contralateral Testis Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 54670,Suture/Repair Testicular Injury,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 54840,Excision Spermatocele W/WO Epididymectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23157.83,N/A,13894.70,N/A,3242.10,N/A,657.17,N/A,13326.88,N/A,7873.67,N/A,7766.74,N/A,3242.10,N/A,3198.50,N/A,3198.50,N/A,4834.95,N/A,7766.74,N/A,7766.74,N/A,7766.74,N/A,13326.89,N/A,3198.50,N/A,3242.10,N/A,6260.50,N/A,6260.50,N/A,3242.10,N/A,3198.50,N/A,657.17,N/A,722.89,N/A,N/A,657.17,13894.70,,Hospital CPT 55000,HC Punct Aspirat Hydrocele,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1136.00,1136.00,681.60,681.60,N/A,159.04,N/A,80.49,N/A,654.11,N/A,386.24,N/A,337.02,N/A,159.04,N/A,80.49,N/A,80.49,N/A,209.79,N/A,337.02,N/A,337.02,N/A,337.02,N/A,654.11,N/A,80.49,N/A,159.04,N/A,1136.00,N/A,1136.00,N/A,159.04,N/A,80.49,N/A,80.49,N/A,88.54,681.60,681.60,80.49,1136.00,,Hospital 55150,Resection Scrotum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16129.10,N/A,9677.46,N/A,2241.56,N/A,2869.35,N/A,9282.68,N/A,5483.89,N/A,7034.93,N/A,2241.56,N/A,2894.35,N/A,2894.35,N/A,4379.37,N/A,7034.93,N/A,7034.93,N/A,7034.93,N/A,9282.67,N/A,2894.35,N/A,2241.56,N/A,3397.00,N/A,3397.00,N/A,2241.56,N/A,2894.35,N/A,2869.35,N/A,578.63,N/A,N/A,578.63,9677.46,,Hospital 55559,Unlisted Laproscopy Procedure Spermatic Cord,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26923.20,N/A,16153.92,N/A,3769.25,N/A,26.75,N/A,15486.87,N/A,9153.63,N/A,11479.74,N/A,3769.25,N/A,4706.78,N/A,4706.78,N/A,7146.37,N/A,11479.74,N/A,11479.74,N/A,11479.74,N/A,15486.88,N/A,4706.78,N/A,3769.25,N/A,5963.00,N/A,5963.00,N/A,3769.25,N/A,4706.78,N/A,26.75,N/A,29.43,N/A,N/A,26.75,16153.92,,Hospital 55700,HC Biopsy Prostate Needle or Punc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,66636.60,18924.30,39981.96,11354.58,5399.17,2651.21,6652.58,1785.80,12167.47,10892.82,22656.44,6434.27,12283.86,4082.20,5565.53,2651.21,2810.00,1678.96,2810.00,1678.96,7646.42,2541.25,12283.86,4082.20,12283.86,4082.20,12283.86,4082.20,12167.47,10892.82,6652.58,1678.96,5565.53,2651.21,14614.72,1871.00,14614.72,1871.00,N/A,2651.21,6652.58,1678.96,6652.58,1785.80,5955.11,737.33,2810.00,39981.96,737.33,11354.58,,Hospital 55845,Prostect Retropub Rad W/WO Nrv Spar & Bi Plv Lym,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,131991.62,N/A,79194.97,N/A,18458.92,N/A,2049.90,N/A,75979.21,N/A,44877.14,N/A,12029.04,N/A,18458.92,N/A,2005.17,N/A,2005.17,N/A,7488.31,N/A,12029.04,N/A,12029.04,N/A,12029.04,N/A,75979.22,N/A,2005.17,N/A,18458.92,N/A,1643.00,N/A,1643.00,N/A,18458.92,N/A,2005.17,N/A,2049.90,N/A,1999.13,N/A,N/A,1643.00,79194.97,,Hospital 55866,Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,107788.82,97628.57,64673.29,58577.14,10644.17,13621.92,12886.80,8584.05,59413.19,56183.03,36648.20,33193.70,24216.96,20795.77,10972.13,13621.92,124202.00,8206.20,124202.00,8206.20,15074.49,12945.76,24216.96,20795.77,24216.96,20795.77,24216.96,20795.77,59413.19,56183.05,12857.15,8206.20,10972.13,13621.92,15608.50,15608.50,28812.13,15608.50,N/A,13621.92,12857.15,8206.20,12886.80,8584.05,11740.18,2589.54,10644.17,124202.00,2589.54,58577.14,,Hospital 55873,Cryosurgical Ablation Prostate W/US & Monitori,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61561.05,N/A,36936.63,N/A,8618.54,N/A,7992.73,N/A,35438.64,N/A,20930.75,N/A,18713.25,N/A,8618.54,N/A,7727.79,N/A,7727.79,N/A,11649.35,N/A,18713.25,N/A,18713.25,N/A,18713.25,N/A,35438.64,N/A,7727.79,N/A,8618.54,N/A,11660.00,N/A,11660.00,N/A,8618.54,N/A,7727.79,N/A,7992.73,N/A,804.90,N/A,N/A,804.90,36936.63,,Hospital 55876,HC Plcmt Interstit Prostate Rx Tx,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,40300.87,N/A,24180.52,N/A,5669.68,N/A,176.15,N/A,22887.63,N/A,13702.29,N/A,2942.58,N/A,5669.68,N/A,1210.68,N/A,1210.68,N/A,1831.83,N/A,2942.58,N/A,2942.58,N/A,2942.58,N/A,22887.63,N/A,1210.68,N/A,5669.68,N/A,1871.00,N/A,1871.00,N/A,5669.68,N/A,1210.68,N/A,176.15,N/A,193.76,N/A,N/A,176.15,24180.52,,Hospital 55899,Unlisted Procedure Male Genital System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,72610.02,21802.95,43566.01,13081.77,10644.17,3052.42,11856.18,5400.93,24360.88,12551.52,24687.40,7413.00,23329.74,484.45,10972.13,3052.42,327084.00,194.04,327084.00,194.04,14522.22,301.58,23329.74,484.45,23329.74,484.45,23329.74,484.45,40193.36,12551.52,11826.53,194.04,10972.13,3052.42,27756.57,527.00,27756.57,527.00,N/A,3052.42,11826.53,194.04,11856.18,5400.93,11740.18,N/A,10644.17,327084.00,194.04,13081.77,,Hospital CPT 56405,HC I&D Abscess Vulva Perineum,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1062.00,1062.00,637.20,637.20,N/A,148.68,N/A,261.37,N/A,611.50,N/A,361.08,N/A,637.74,N/A,148.68,N/A,263.65,N/A,263.65,N/A,397.01,N/A,637.74,N/A,637.74,N/A,637.74,N/A,611.50,N/A,263.65,N/A,148.68,N/A,1062.00,N/A,1062.00,N/A,148.68,N/A,263.65,N/A,261.37,N/A,132.74,637.20,637.20,132.74,1062.00,,Hospital CPT 56420,HC I&D Abscess Bartholin Gland,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1406.00,1406.00,843.60,843.60,N/A,196.84,N/A,171.12,N/A,809.57,N/A,478.04,N/A,389.10,N/A,196.84,N/A,160.86,N/A,160.86,N/A,242.22,N/A,389.10,N/A,389.10,N/A,389.10,N/A,809.57,N/A,160.86,N/A,196.84,N/A,1406.00,N/A,1406.00,N/A,196.84,N/A,160.86,N/A,171.12,N/A,116.94,843.60,843.60,116.94,1406.00,,Hospital 56442,Hymenotomy Simple Incision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10074.40,N/A,6044.64,N/A,1410.42,N/A,2652.70,N/A,5799.39,N/A,3425.30,N/A,6197.46,N/A,1410.42,N/A,2553.29,N/A,2553.29,N/A,3858.03,N/A,6197.46,N/A,6197.46,N/A,6197.46,N/A,5799.40,N/A,2553.29,N/A,1410.42,N/A,3397.00,N/A,3397.00,N/A,1410.42,N/A,2553.29,N/A,2652.70,N/A,48.86,N/A,N/A,48.86,6197.46,,Hospital 56605,HC Biopsy of Vulva/Perineum,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,9994.90,N/A,5996.94,N/A,1399.29,N/A,660.00,N/A,5753.88,N/A,3398.27,N/A,1555.71,N/A,1399.29,N/A,635.26,N/A,635.26,N/A,968.46,N/A,1555.71,N/A,1555.71,N/A,1555.71,N/A,5753.89,N/A,635.26,N/A,1399.29,N/A,1431.00,N/A,1431.00,N/A,1399.29,N/A,635.26,N/A,660.00,N/A,92.52,N/A,N/A,92.52,5996.94,,Hospital 56625,Vulvectomy Simple Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15315.30,N/A,9189.18,N/A,2144.14,N/A,2816.58,N/A,8811.44,N/A,5207.20,N/A,6201.99,N/A,2144.14,N/A,2553.29,N/A,2553.29,N/A,3860.85,N/A,6201.99,N/A,6201.99,N/A,6201.99,N/A,8811.46,N/A,2553.29,N/A,2144.14,N/A,3397.00,N/A,3397.00,N/A,2144.14,N/A,2553.29,N/A,729.60,N/A,802.56,N/A,N/A,729.60,9189.18,,Hospital CPT 56700,Prtl Hymenectomy/Revj Hymenal Ring,N/A,N/A,371.00,371.00,222.60,222.60,N/A,51.94,N/A,194.76,N/A,371.00,N/A,126.14,N/A,371.00,N/A,51.94,N/A,194.76,N/A,194.76,N/A,361.40,N/A,371.00,N/A,371.00,N/A,371.00,N/A,371.00,N/A,194.76,N/A,51.94,N/A,371.00,N/A,371.00,N/A,51.94,N/A,194.76,N/A,194.76,N/A,214.24,222.60,222.60,51.94,371.00,,Hospital 56800,Plastic Repair Introitus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21070.60,N/A,12642.36,N/A,2949.89,N/A,2670.86,N/A,12131.21,N/A,7163.67,N/A,6205.70,N/A,2949.89,N/A,2553.29,N/A,2553.29,N/A,3863.16,N/A,6205.70,N/A,6205.70,N/A,6205.70,N/A,12131.22,N/A,2553.29,N/A,2949.89,N/A,3397.00,N/A,3397.00,N/A,2949.89,N/A,2553.29,N/A,2670.86,N/A,267.70,N/A,N/A,267.70,12642.36,,Hospital 57022,HC Evacuation of Hematoma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,21693.90,N/A,13016.34,N/A,6117.74,N/A,7502.61,N/A,13786.83,N/A,7362.33,N/A,13918.71,N/A,6306.24,N/A,7502.61,N/A,7502.61,N/A,8664.07,N/A,13918.71,N/A,13918.71,N/A,13918.71,N/A,13786.83,N/A,7502.61,N/A,6306.24,N/A,16559.79,N/A,16559.79,N/A,N/A,N/A,7502.61,N/A,7502.61,N/A,6747.68,N/A,6117.74,16559.79,N/A,N/A,,Hospital 57100,HC Biopsy of Vagina Simple,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,11575.00,N/A,6945.00,N/A,1620.50,N/A,632.01,N/A,6663.24,N/A,3935.50,N/A,1556.47,N/A,1620.50,N/A,635.26,N/A,635.26,N/A,968.93,N/A,1556.47,N/A,1556.47,N/A,1556.47,N/A,6663.24,N/A,635.26,N/A,1620.50,N/A,1431.00,N/A,1431.00,N/A,1620.50,N/A,635.26,N/A,632.01,N/A,304.01,N/A,N/A,304.01,6945.00,,Hospital 57105,Biopsy Vaginal Mucosa Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45185.50,N/A,27111.30,N/A,6172.85,N/A,918.22,N/A,25999.91,N/A,15363.05,N/A,11504.29,N/A,6172.85,N/A,4706.78,N/A,4706.78,N/A,7161.65,N/A,11504.29,N/A,11504.29,N/A,11504.29,N/A,25999.93,N/A,4706.78,N/A,6172.85,N/A,9595.50,N/A,9595.50,N/A,6172.85,N/A,4706.78,N/A,918.22,N/A,1003.94,N/A,N/A,918.22,27111.30,,Hospital 57156,HC Hdr Vaginal Cyl Insertion,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,46102.00,N/A,27661.20,N/A,6454.28,N/A,6027.62,N/A,26483.40,N/A,15674.68,N/A,14096.62,N/A,6454.28,N/A,5925.33,N/A,5925.33,N/A,8775.45,N/A,14096.62,N/A,14096.62,N/A,14096.62,N/A,26483.40,N/A,5925.33,N/A,6454.28,N/A,22262.24,N/A,22262.24,N/A,6454.28,N/A,5925.33,N/A,6027.62,N/A,1842.06,N/A,N/A,1842.06,27661.20,,Hospital CPT 57200,HC Repair of Vagina,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5845.00,5845.00,3507.00,3507.00,N/A,818.30,N/A,318.20,N/A,3365.55,N/A,1987.30,N/A,942.57,N/A,818.30,N/A,318.20,N/A,318.20,N/A,586.75,N/A,942.57,N/A,942.57,N/A,942.57,N/A,3365.55,N/A,318.20,N/A,818.30,N/A,5845.00,N/A,5845.00,N/A,818.30,N/A,318.20,N/A,318.20,N/A,350.02,3507.00,3507.00,318.20,5845.00,,Hospital 57210,Colpoperineorrhaphy Suture Inj Vagina&/Perineu,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,42298.73,38248.90,25379.24,22949.34,9613.52,5338.48,11637.93,2670.86,24794.64,22019.81,14381.57,12998.15,21872.09,6281.63,9909.73,5338.48,11637.93,2553.29,11637.93,2553.29,13614.87,3914.37,21872.09,6281.63,21872.09,6281.63,21872.09,6281.63,24794.64,22019.82,11637.93,2553.29,9909.73,5338.48,26022.32,3397.00,26022.32,3397.00,N/A,5338.48,11637.93,2553.29,11637.93,2670.86,10603.41,443.06,9613.52,26022.32,443.06,22949.34,,Hospital 57265,Cmbnd Anterpost Colporraphy W/Cysto W/Ntrcl Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,56683.12,46947.63,34009.87,28168.58,6244.71,6516.95,7652.80,8164.21,14072.95,27026.43,19272.26,15962.18,14207.57,19980.04,6437.12,6516.95,562.00,8206.20,562.00,8206.20,8843.88,12437.97,14207.57,19980.04,14207.57,19980.04,14207.57,19980.04,14072.95,27026.42,7652.80,8206.20,6437.12,6516.95,16903.46,13336.25,16903.46,13336.25,2522.30,6516.95,7652.80,8206.20,7652.80,8164.21,6887.72,3070.60,562.00,34009.87,3070.60,28168.58,,Hospital 57268,Repair Enterocele Vaginal Approach Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44887.38,N/A,26932.43,N/A,6226.70,N/A,1569.03,N/A,25831.93,N/A,15261.71,N/A,19916.62,N/A,6226.70,N/A,8206.20,N/A,8206.20,N/A,12398.49,N/A,19916.62,N/A,19916.62,N/A,19916.62,N/A,25831.94,N/A,8206.20,N/A,6226.70,N/A,9595.50,N/A,9595.50,N/A,6226.70,N/A,8206.20,N/A,1569.03,N/A,1725.94,N/A,N/A,1569.03,26932.43,,Hospital 57282,Colpopexy Vaginal Extraperitoneal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,89411.67,40203.65,53647.00,24122.19,23540.08,5624.59,18575.51,6776.80,55681.79,23062.31,30399.95,13669.23,53556.94,15185.76,24265.39,5624.59,84300.00,6254.06,84300.00,6254.06,N/A,9453.43,53556.94,15185.76,N/A,15185.76,53556.94,15185.76,55681.79,22602.86,18427.26,6254.06,24265.39,5624.59,63719.39,10085.00,63719.39,10085.00,N/A,5624.59,18427.26,6254.06,18575.51,6776.80,25963.97,2537.41,18427.26,84300.00,2537.41,24122.19,,Hospital 57283,Colpopexy Vaginal Intraperitoneal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44400.60,N/A,26640.36,N/A,6208.08,N/A,6542.02,N/A,25559.74,N/A,15096.21,N/A,15245.00,N/A,6208.08,N/A,6254.06,N/A,6254.06,N/A,9490.31,N/A,15245.00,N/A,15245.00,N/A,15245.00,N/A,25307.55,N/A,6254.06,N/A,6208.08,N/A,9384.50,N/A,9384.50,N/A,6208.08,N/A,6254.06,N/A,6542.02,N/A,2523.44,N/A,N/A,2523.44,26640.36,,Hospital 57287,Rmvl/Revj Sling Stress Incontinence,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26036.80,N/A,15622.08,N/A,3636.30,N/A,2670.86,N/A,14985.69,N/A,8852.52,N/A,6310.11,N/A,3636.30,N/A,2553.29,N/A,2553.29,N/A,3928.16,N/A,6310.11,N/A,6310.11,N/A,6310.11,N/A,14985.72,N/A,2553.29,N/A,3636.30,N/A,4562.00,N/A,4562.00,N/A,3636.30,N/A,2553.29,N/A,2670.86,N/A,795.97,N/A,N/A,795.97,15622.08,,Hospital 57308,Clsr Rectovag Fstl Tprnl Prnl Bdy Rcnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50879.30,N/A,30527.58,N/A,7078.05,N/A,774.28,N/A,29285.34,N/A,17298.96,N/A,10919.57,N/A,7078.05,N/A,768.23,N/A,768.23,N/A,6797.30,N/A,10919.57,N/A,10919.57,N/A,10919.57,N/A,29285.35,N/A,768.23,N/A,7078.05,N/A,3397.00,N/A,3397.00,N/A,7078.05,N/A,768.23,N/A,774.28,N/A,765.69,N/A,N/A,765.69,30527.58,,Hospital 57425,Laparoscopy Colpopexy Suspension Vaginal Apex,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,59102.15,70822.83,35461.29,42493.70,6244.71,9915.21,7652.80,2255.36,15884.90,40484.00,20094.73,24079.76,14207.57,19903.85,6437.12,9915.21,7652.80,8206.20,7652.80,8206.20,8843.88,12390.53,14207.57,19903.85,14207.57,19903.85,14207.57,19903.85,15884.90,40484.03,7652.80,8206.20,6437.12,9915.21,16903.46,12019.00,16903.46,12019.00,N/A,9915.21,7652.80,8206.20,7652.80,2255.36,6887.72,2480.89,6244.71,35461.29,2255.36,42493.70,,Hospital 57452,HC Colposcopy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,2982.00,N/A,1789.20,N/A,417.48,N/A,287.22,N/A,1717.04,N/A,1013.88,N/A,1632.67,N/A,417.48,N/A,270.00,N/A,270.00,N/A,1632.67,N/A,1632.67,N/A,1632.67,N/A,1632.67,N/A,1717.04,N/A,270.00,N/A,417.48,N/A,1598.35,N/A,1598.35,N/A,417.48,N/A,270.00,N/A,287.22,N/A,95.43,N/A,N/A,95.43,1789.20,,Hospital 57454,HC Colposcopy W/Biopsy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,2982.00,N/A,1789.20,N/A,417.48,N/A,396.57,N/A,1717.04,N/A,1013.88,N/A,N/A,N/A,417.48,N/A,372.79,N/A,372.79,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1717.04,N/A,372.79,N/A,417.48,N/A,1598.35,N/A,1598.35,N/A,417.48,N/A,372.79,N/A,396.57,N/A,141.66,N/A,N/A,141.66,1789.20,,Hospital 57455,HC Colposcopy of Cervix With Biop,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1447.00,N/A,868.20,N/A,202.58,N/A,44.89,N/A,833.18,N/A,491.98,N/A,109.52,N/A,202.58,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,833.19,N/A,372.79,N/A,202.58,N/A,152.25,N/A,152.25,N/A,202.58,N/A,372.79,N/A,369.57,N/A,358.05,N/A,N/A,44.89,868.20,,Hospital 57460,Colposcopy Cervix Vag Loop Eltrd Bx Cervix,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,77547.82,13888.40,46528.69,8333.04,13663.56,1943.63,16488.24,2705.80,30791.95,7995.81,26366.25,4722.06,31086.50,6189.77,14084.56,1943.63,8206.20,2553.29,8206.20,2553.29,19350.62,3853.25,31086.50,6189.77,31086.50,6189.77,31086.50,6189.77,30791.95,7995.82,16428.94,2553.29,14084.56,1943.63,36985.17,3397.00,36985.17,3397.00,N/A,1943.63,16428.94,2553.29,16488.24,2705.80,15070.48,443.86,8206.20,46528.69,443.86,8333.04,,Hospital 57505,Endocervical Curettage Not Done as Part of D&C,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35569.03,13636.20,21341.42,8181.72,10068.56,1909.07,12176.23,2705.80,22690.32,7850.66,12093.47,4636.31,22907.37,6187.46,10378.79,1909.07,562.00,2553.29,562.00,2553.29,14259.31,3851.81,22907.37,6187.46,22907.37,6187.46,22907.37,6187.46,22690.32,7850.67,12176.23,2553.29,10378.79,1909.07,27254.06,4112.50,27254.06,4112.50,N/A,1909.07,635.26,2553.29,12176.23,2705.80,11105.31,666.06,562.00,27254.06,666.06,8181.72,,Hospital 57800,Dilation Cervical Canal Instrumental Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9646.70,N/A,5788.02,N/A,1350.54,N/A,2531.24,N/A,5552.82,N/A,3279.88,N/A,6195.10,N/A,1350.54,N/A,2553.29,N/A,2553.29,N/A,3856.57,N/A,6195.10,N/A,6195.10,N/A,6195.10,N/A,5552.82,N/A,2553.29,N/A,1350.54,N/A,3397.00,N/A,3397.00,N/A,1350.54,N/A,2553.29,N/A,2531.24,N/A,49.96,N/A,N/A,49.96,6195.10,,Hospital 58140,Myomectomy 1-4 Myomas W/250 Gm/< Abdominal Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,31642.55,29168.40,18985.53,17501.04,6244.71,4018.70,7682.45,1014.23,14072.95,16791.02,10553.44,9917.25,10866.59,10477.93,6437.12,4018.70,7652.80,1009.40,7652.80,1009.40,6778.45,6522.71,10866.59,10477.93,10866.59,10477.93,10866.59,10477.93,14072.95,16791.04,7652.80,1009.40,6437.12,4018.70,16903.46,4562.00,16903.46,4562.00,6437.12,4018.70,7652.80,1009.40,7682.45,1014.23,6887.72,1074.08,6244.71,18985.53,1009.40,17501.04,,Hospital 58145,Myomectomy 1-4 Myomas 250 Gm/< Vaginal Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25419.30,N/A,15251.58,N/A,3550.69,N/A,2670.86,N/A,14634.33,N/A,8642.57,N/A,6214.66,N/A,3550.69,N/A,2553.29,N/A,2553.29,N/A,3868.73,N/A,6214.66,N/A,6214.66,N/A,6214.66,N/A,14634.33,N/A,2553.29,N/A,3550.69,N/A,3397.00,N/A,3397.00,N/A,3550.69,N/A,2553.29,N/A,2670.86,N/A,645.17,N/A,N/A,645.17,15251.58,,Hospital 58146,Myomectomy 5/> Myomas &/>250 Gm Abdomina,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59003.78,N/A,35402.27,N/A,8169.18,N/A,1237.71,N/A,33870.04,N/A,19948.81,N/A,10688.71,N/A,8169.18,N/A,1308.40,N/A,1308.40,N/A,6653.93,N/A,10688.71,N/A,10688.71,N/A,10688.71,N/A,33644.90,N/A,1308.40,N/A,8169.18,N/A,4562.00,N/A,4562.00,N/A,8169.18,N/A,1308.40,N/A,1237.71,N/A,1355.38,N/A,N/A,1237.71,35402.27,,Hospital 58180,Supracervical Abdl Hyster W/WO Rmvl Tube Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37767.62,N/A,22660.57,N/A,5204.20,N/A,1221.71,N/A,21727.83,N/A,12841.00,N/A,10923.16,N/A,5204.20,N/A,1221.36,N/A,1221.36,N/A,6799.87,N/A,10923.16,N/A,10923.16,N/A,10923.16,N/A,21727.83,N/A,1221.36,N/A,5204.20,N/A,4825.50,N/A,4825.50,N/A,5204.20,N/A,1221.36,N/A,1221.71,N/A,1337.77,N/A,N/A,1221.36,22660.57,,Hospital 58260,Vaginal Hysterectomy Uterus 250 Gm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,56683.12,42185.30,34009.87,25311.18,6244.71,5850.16,7652.80,4378.42,14072.95,24288.78,19272.26,14343.00,14207.57,10151.07,6437.12,5850.16,562.00,4185.69,562.00,4185.69,8843.88,6319.23,14207.57,10151.07,14207.57,10151.07,14207.57,10151.07,14072.95,24288.79,7652.80,4185.69,6437.12,5850.16,16903.46,6843.00,16903.46,6843.00,2522.30,5850.16,7652.80,4185.69,7652.80,4378.42,6887.72,1784.82,562.00,34009.87,1784.82,25311.18,,Hospital 58270,Vaginal Hysterectomy 250 Gm/< W/Rpr Enterocele,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67668.33,N/A,40601.00,N/A,9449.73,N/A,4329.19,N/A,38947.22,N/A,23007.23,N/A,10232.90,N/A,9449.73,N/A,4185.69,N/A,4185.69,N/A,6380.99,N/A,10232.90,N/A,10232.90,N/A,10232.90,N/A,38037.41,N/A,4185.69,N/A,9449.73,N/A,4562.00,N/A,4562.00,N/A,9449.73,N/A,4185.69,N/A,4329.19,N/A,1305.90,N/A,N/A,1305.90,40601.00,,Hospital 58291,Vag Hyst > 250 Gm Rmvl Tube&/Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38438.57,N/A,23063.14,N/A,5371.53,N/A,1398.25,N/A,22128.05,N/A,13069.11,N/A,10162.53,N/A,5371.53,N/A,4185.69,N/A,4185.69,N/A,6326.37,N/A,10162.53,N/A,10162.53,N/A,10162.53,N/A,22128.06,N/A,4185.69,N/A,5371.53,N/A,5963.00,N/A,5963.00,N/A,5371.53,N/A,4185.69,N/A,1398.25,N/A,1538.08,N/A,N/A,1398.25,23063.14,,Hospital CPT 58300,HC Insert Intrauterine Device,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,922.00,922.00,553.20,553.20,N/A,129.08,N/A,922.00,N/A,530.89,N/A,313.48,N/A,129.08,N/A,129.08,N/A,922.00,N/A,922.00,N/A,80.21,N/A,129.08,N/A,129.08,N/A,129.08,N/A,530.89,N/A,922.00,N/A,129.08,N/A,922.00,N/A,922.00,N/A,129.08,N/A,922.00,N/A,922.00,N/A,922.00,553.20,553.20,80.21,922.00,,Hospital CPT 58300,Insertion Intrauterine Device Iud,N/A,N/A,184.00,184.00,110.40,110.40,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,N/A,184.00,110.40,110.40,110.40,184.00,,Hospital 58400,Uterine Suspension W/WO Shortening Ligaments Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34277.90,N/A,20566.74,N/A,4794.63,N/A,584.44,N/A,19730.65,N/A,11654.48,N/A,10853.63,N/A,4794.63,N/A,578.39,N/A,578.39,N/A,6756.25,N/A,10853.63,N/A,10853.63,N/A,10853.63,N/A,19730.67,N/A,578.39,N/A,4794.63,N/A,4562.00,N/A,4562.00,N/A,4794.63,N/A,578.39,N/A,584.44,N/A,535.69,N/A,N/A,535.69,20566.74,,Hospital 58541,Laparoscopy Supracervical Hysterectomy 250 Gm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28364.32,N/A,17018.59,N/A,3918.99,N/A,920.12,N/A,16326.20,N/A,9643.86,N/A,11422.05,N/A,3918.99,N/A,4706.78,N/A,4706.78,N/A,7110.45,N/A,11422.05,N/A,11422.05,N/A,11422.05,N/A,16326.20,N/A,4706.78,N/A,3918.99,N/A,7897.00,N/A,7897.00,N/A,3918.99,N/A,4706.78,N/A,920.12,N/A,1006.01,N/A,N/A,920.12,17018.59,,Hospital 58543,Laps Supracervical Hysterectomy >250,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52983.07,N/A,31789.84,N/A,7402.02,N/A,8603.67,N/A,30461.57,N/A,18014.25,N/A,19903.05,N/A,7402.02,N/A,8206.20,N/A,8206.20,N/A,12390.02,N/A,19903.05,N/A,19903.05,N/A,19903.05,N/A,30461.59,N/A,8206.20,N/A,7402.02,N/A,7897.00,N/A,7897.00,N/A,7402.02,N/A,8206.20,N/A,1072.98,N/A,1180.29,N/A,N/A,1072.98,31789.84,,Hospital 58546,Laps Myomectomy Exc 5/> Myomas >250 Grams,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86682.42,74982.85,52009.45,44989.71,6244.71,10434.92,7652.80,8584.05,14072.95,43158.21,28536.01,23674.59,19913.31,19939.09,6437.12,10434.92,1124.00,8206.20,1124.00,8206.20,12396.42,12412.48,19913.31,19939.09,19913.31,19939.09,19913.31,19939.09,14072.95,42906.05,7652.80,8206.20,6437.12,10434.92,16903.46,8970.25,16903.46,8970.25,N/A,10434.92,7652.80,8206.20,7652.80,8584.05,6887.72,1527.56,1124.00,52009.45,1527.56,44989.71,,Hospital 58548,Laps W/Rad Hyst W/Bilat Lmphadec Rmvl Tube/Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,86661.82,N/A,51997.09,N/A,12065.73,N/A,2547.15,N/A,49896.53,N/A,29465.01,N/A,13017.17,N/A,12065.73,N/A,2514.86,N/A,2514.86,N/A,8102.21,N/A,13017.17,N/A,13017.17,N/A,13017.17,N/A,49896.56,N/A,2514.86,N/A,12065.73,N/A,5963.00,N/A,5963.00,N/A,12065.73,N/A,2514.86,N/A,2547.15,N/A,2534.83,N/A,N/A,2514.86,51997.09,,Hospital 58550,Laps Vaginal Hysterectomy Uterus 250 Gm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,75436.32,N/A,45261.79,N/A,10499.87,N/A,4804.66,N/A,43426.17,N/A,25648.33,N/A,11471.79,N/A,10499.87,N/A,4706.78,N/A,4706.78,N/A,7141.43,N/A,11471.79,N/A,11471.79,N/A,11471.79,N/A,43224.62,N/A,4706.78,N/A,10499.87,N/A,7897.00,N/A,7897.00,N/A,10499.87,N/A,4706.78,N/A,4804.66,N/A,1181.98,N/A,N/A,1181.98,45261.79,,Hospital 58552,Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86892.82,49563.82,52135.69,29738.29,9615.12,6884.00,8584.05,8584.05,21668.45,28532.14,29543.55,16808.17,21875.73,19974.39,9911.38,6884.00,1686.00,8206.20,1686.00,8206.20,13617.13,12441.69,21875.73,19974.39,21875.73,19974.39,21875.73,19974.39,21668.45,28532.15,11639.83,8206.20,9911.38,6884.00,26026.66,7897.00,26026.66,7897.00,N/A,6884.00,11639.83,8206.20,8584.05,8584.05,10605.18,1105.51,1686.00,52135.69,1105.51,29738.29,,Hospital CPT 58562,Hysteroscopy Removal Impacted Foreign Body,N/A,N/A,725.00,725.00,435.00,435.00,N/A,101.50,N/A,213.56,N/A,725.00,N/A,246.50,N/A,725.00,N/A,101.50,N/A,213.56,N/A,213.56,N/A,725.00,N/A,725.00,N/A,725.00,N/A,725.00,N/A,725.00,N/A,213.56,N/A,101.50,N/A,725.00,N/A,725.00,N/A,101.50,N/A,213.56,N/A,213.56,N/A,234.92,435.00,435.00,101.50,725.00,,Hospital CPT 58563,Hysteroscopy Endometrial Ablation,N/A,N/A,3744.00,3744.00,2246.40,2246.40,N/A,524.16,N/A,237.23,N/A,3744.00,N/A,1272.96,N/A,3744.00,N/A,524.16,N/A,237.23,N/A,237.23,N/A,3596.47,N/A,3744.00,N/A,3744.00,N/A,3744.00,N/A,3744.00,N/A,237.23,N/A,524.16,N/A,3744.00,N/A,3744.00,N/A,524.16,N/A,237.23,N/A,237.23,N/A,260.95,2246.40,2246.40,237.23,3744.00,,Hospital 58570,Laparoscopy W Total Hysterectomy Uterus 250 Gm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45864.92,N/A,27518.95,N/A,6421.09,N/A,8525.70,N/A,26404.90,N/A,15594.07,N/A,19957.70,N/A,6421.09,N/A,8206.20,N/A,8206.20,N/A,12424.06,N/A,19957.70,N/A,19957.70,N/A,19957.70,N/A,26404.91,N/A,8206.20,N/A,6421.09,N/A,8160.50,N/A,8160.50,N/A,6421.09,N/A,8206.20,N/A,8525.70,N/A,1129.12,N/A,N/A,1129.12,27518.95,,Hospital 58571,Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,58294.12,40435.73,34976.47,24261.44,9613.52,5622.87,11667.58,8206.20,21664.85,23278.08,19820.00,13748.14,21872.09,19967.78,9909.73,5622.87,11637.93,8206.20,11637.93,8206.20,13614.87,12430.32,21872.09,19967.78,21872.09,19967.78,21872.09,19967.78,21664.85,23278.08,11637.93,8206.20,9909.73,5622.87,26022.32,7897.00,26022.32,7897.00,604.47,5622.87,11637.93,8206.20,11667.58,8206.20,10603.41,9026.81,604.47,34976.47,5622.87,24261.44,,Hospital 58572,Laparoscopy Total Hysterectomy Uterus >250 Gm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38790.72,N/A,23274.43,N/A,5375.43,N/A,8584.05,N/A,22333.20,N/A,13188.85,N/A,19901.31,N/A,5375.43,N/A,8206.20,N/A,8206.20,N/A,12388.96,N/A,19901.31,N/A,19901.31,N/A,19901.31,N/A,22333.20,N/A,8206.20,N/A,5375.43,N/A,7897.00,N/A,7897.00,N/A,5375.43,N/A,8206.20,N/A,8584.05,N/A,1327.31,N/A,N/A,1327.31,23274.43,,Hospital CPT 58671,Laparoscopy W/Plmt Occlusion Device Oviducts,N/A,N/A,719.00,719.00,431.40,431.40,N/A,100.66,N/A,358.30,N/A,719.00,N/A,244.46,N/A,719.00,N/A,100.66,N/A,358.30,N/A,358.30,N/A,664.98,N/A,719.00,N/A,719.00,N/A,719.00,N/A,719.00,N/A,358.30,N/A,100.66,N/A,719.00,N/A,719.00,N/A,100.66,N/A,358.30,N/A,358.30,N/A,394.13,431.40,431.40,100.66,719.00,,Hospital 58679,Unlisted Laparoscopy Procedure Oviduct Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18191.80,N/A,10915.08,N/A,2537.15,N/A,4706.78,N/A,10471.51,N/A,6185.21,N/A,11421.19,N/A,2537.15,N/A,4706.78,N/A,4706.78,N/A,7109.91,N/A,11421.19,N/A,11421.19,N/A,11421.19,N/A,10471.50,N/A,4706.78,N/A,2537.15,N/A,8244.00,N/A,8244.00,N/A,2537.15,N/A,4706.78,N/A,4706.78,N/A,5177.46,N/A,N/A,2537.15,11421.19,,Hospital 58750,Tubotubal Anastatomosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52952.05,N/A,31771.23,N/A,7410.83,N/A,1680.61,N/A,30426.70,N/A,18003.70,N/A,10968.44,N/A,7410.83,N/A,1680.61,N/A,1680.61,N/A,7107.44,N/A,10968.44,N/A,10968.44,N/A,10968.44,N/A,30426.70,N/A,1680.61,N/A,7410.83,N/A,4562.00,N/A,4562.00,N/A,7410.83,N/A,1680.61,N/A,1680.61,N/A,993.02,N/A,N/A,993.02,31771.23,,Hospital 58999,Unlisted Px Female Genital System Nonobstetrical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21974.53,N/A,13184.72,N/A,3076.43,N/A,165.16,N/A,12650.45,N/A,7471.34,N/A,445.96,N/A,3076.43,N/A,160.86,N/A,160.86,N/A,278.13,N/A,445.96,N/A,445.96,N/A,445.96,N/A,12650.45,N/A,160.86,N/A,3076.43,N/A,790.50,N/A,790.50,N/A,3076.43,N/A,160.86,N/A,165.16,N/A,107.35,N/A,N/A,107.35,13184.72,,Hospital 59320,HC Cerclage,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,49065.70,15483.00,29439.42,9289.80,8482.58,2099.16,8498.71,168.14,16347.52,8912.06,16682.36,5248.92,16503.89,6193.12,8743.94,2099.16,8439.41,2553.29,8439.41,2553.29,10273.29,3855.34,16503.89,6193.12,16503.89,6193.12,N/A,6193.12,16347.52,8912.07,8439.41,2553.29,8743.94,2099.16,19635.51,3397.00,19635.51,3397.00,2613.96,2099.16,8439.41,2553.29,8498.71,168.14,9356.02,184.96,2613.96,29439.42,168.14,9289.80,,Hospital 59400,OB Care Antepartum Vag Dlvr & Postpartum,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,N/A,13248.30,N/A,7948.98,N/A,1925.76,N/A,3160.97,N/A,7621.86,N/A,4504.43,N/A,9115.52,N/A,1925.76,N/A,3168.55,N/A,3168.55,N/A,5674.46,N/A,9115.52,N/A,9115.52,N/A,9115.52,N/A,7621.88,N/A,3168.55,N/A,1925.76,N/A,1431.00,N/A,1431.00,N/A,1925.76,N/A,3168.55,N/A,3160.97,N/A,3065.99,N/A,N/A,1431.00,9115.52,,Hospital CPT 59409,HC Obstetrical Care,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7173.00,7173.00,4303.80,4303.80,N/A,1004.22,N/A,773.35,N/A,4130.21,N/A,2438.82,N/A,2310.84,N/A,1004.22,N/A,773.35,N/A,773.35,N/A,1438.50,N/A,2310.84,N/A,2310.84,N/A,2310.84,N/A,4130.21,N/A,773.35,N/A,1004.22,N/A,7173.00,N/A,7173.00,N/A,1004.22,N/A,773.35,N/A,773.35,N/A,850.69,4303.80,4303.80,773.35,7173.00,,Hospital CPT 59412,HC External Version,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,5711.00,5711.00,3426.60,3426.60,N/A,799.54,N/A,2670.86,N/A,3288.39,N/A,1941.74,N/A,5711.00,N/A,799.54,N/A,2553.29,N/A,2553.29,N/A,3844.80,N/A,5711.00,N/A,5711.00,N/A,5711.00,N/A,3288.39,N/A,2553.29,N/A,799.54,N/A,3061.10,N/A,3061.10,N/A,799.54,N/A,2553.29,N/A,2670.86,N/A,107.97,3426.60,3426.60,107.97,5711.00,,Hospital CPT 59514,HC Cesarean Delivery Only,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,11822.00,11822.00,7093.20,7093.20,N/A,1655.08,N/A,873.42,N/A,6807.11,N/A,4019.48,N/A,6176.83,N/A,1655.08,N/A,873.42,N/A,873.42,N/A,3845.20,N/A,6176.83,N/A,6176.83,N/A,6176.83,N/A,6807.11,N/A,873.42,N/A,1655.08,N/A,11822.00,N/A,11822.00,N/A,1655.08,N/A,873.42,N/A,873.42,N/A,960.76,7093.20,7093.20,873.42,11822.00,,Hospital 59610,Routine OB Care Vag Dlvry & Postpartum Care Vb,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,N/A,13122.90,N/A,7873.74,N/A,1793.24,N/A,2617.06,N/A,7546.85,N/A,4461.67,N/A,7667.24,N/A,1793.24,N/A,2609.65,N/A,2609.65,N/A,4772.86,N/A,7667.24,N/A,7667.24,N/A,7667.24,N/A,7546.85,N/A,2718.79,N/A,1793.24,N/A,5328.39,N/A,5328.39,N/A,1793.24,N/A,2718.79,N/A,2731.23,N/A,3182.83,N/A,N/A,1793.24,7873.74,,Hospital CPT 59821,Tx Missed Abortion Second Trimester Surgical,N/A,N/A,715.00,715.00,429.00,429.00,N/A,100.10,N/A,359.26,N/A,715.00,N/A,243.10,N/A,715.00,N/A,100.10,N/A,359.26,N/A,359.26,N/A,715.00,N/A,715.00,N/A,715.00,N/A,715.00,N/A,715.00,N/A,359.26,N/A,100.10,N/A,715.00,N/A,715.00,N/A,100.10,N/A,359.26,N/A,359.26,N/A,395.19,429.00,429.00,100.10,715.00,,Hospital 60212,Prtl Thyroid Lobec Uni W/Contratlat Stot Lobec,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26592.58,N/A,15955.55,N/A,3714.11,N/A,4923.50,N/A,15310.83,N/A,9041.48,N/A,11426.60,N/A,3714.11,N/A,4706.78,N/A,4706.78,N/A,7116.10,N/A,11426.60,N/A,11426.60,N/A,11426.60,N/A,15310.84,N/A,4706.78,N/A,3714.11,N/A,7897.00,N/A,7897.00,N/A,3714.11,N/A,4706.78,N/A,4923.50,N/A,1298.85,N/A,N/A,1298.85,15955.55,,Hospital 60240,Thyroidectomy Total/Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,73481.72,48233.57,44089.03,28940.14,6806.44,6719.31,8346.96,1096.81,15564.84,27761.38,24983.79,15071.12,15485.60,11484.22,7016.16,6719.31,175344.00,4706.78,175344.00,4706.78,9639.42,7149.15,15485.60,11484.22,15485.60,11484.22,15485.60,11484.22,15564.84,27761.40,8317.31,4706.78,7016.16,6719.31,18424.00,7897.00,18424.00,7897.00,61444.19,6719.31,4706.78,4706.78,8346.96,1096.81,7507.29,1194.25,4706.78,175344.00,1096.81,28940.14,,Hospital 60260,Thyroidectomy Rmvl Remaining Tiss Flwg Prtl Rmvl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39608.43,N/A,23765.06,N/A,5521.67,N/A,5043.96,N/A,22802.81,N/A,13466.87,N/A,11716.86,N/A,5521.67,N/A,4821.94,N/A,4821.94,N/A,7293.97,N/A,11716.86,N/A,11716.86,N/A,11716.86,N/A,22802.81,N/A,4821.94,N/A,5521.67,N/A,5963.00,N/A,5963.00,N/A,5521.67,N/A,4821.94,N/A,5043.96,N/A,1410.43,N/A,N/A,1410.43,23765.06,,Hospital 60271,Thyroidectomy Substernal Cervical Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58165.23,N/A,34899.14,N/A,8079.91,N/A,4886.97,N/A,33480.80,N/A,19776.18,N/A,11721.13,N/A,8079.91,N/A,4821.94,N/A,4821.94,N/A,7296.62,N/A,11721.13,N/A,11721.13,N/A,11721.13,N/A,33480.82,N/A,4821.94,N/A,8079.91,N/A,5963.00,N/A,5963.00,N/A,8079.91,N/A,4821.94,N/A,1303.76,N/A,1428.02,N/A,N/A,1303.76,34899.14,,Hospital 60280,Excision Thyroglossal Duct Cyst/Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36313.45,N/A,21788.07,N/A,5075.01,N/A,4923.50,N/A,20907.14,N/A,12346.57,N/A,11421.90,N/A,5075.01,N/A,4706.78,N/A,4706.78,N/A,7110.36,N/A,11421.90,N/A,11421.90,N/A,11421.90,N/A,20907.16,N/A,4706.78,N/A,5075.01,N/A,7897.00,N/A,7897.00,N/A,5075.01,N/A,4706.78,N/A,4923.50,N/A,525.04,N/A,N/A,525.04,21788.07,,Hospital 61055,HC Cisternal or Lat Cervical Punc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,10410.10,N/A,6246.06,N/A,1457.41,N/A,719.84,N/A,5716.50,N/A,3539.43,N/A,4909.04,N/A,1457.41,N/A,701.11,N/A,701.11,N/A,3055.94,N/A,4909.04,N/A,4909.04,N/A,4909.04,N/A,5716.50,N/A,701.11,N/A,1457.41,N/A,527.00,N/A,527.00,N/A,1457.41,N/A,701.11,N/A,719.84,N/A,522.61,N/A,N/A,522.61,6246.06,,Hospital CPT 61107,HC Twist Drill Hole Implt Ventricular Cath/Device,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2432.00,2432.00,1459.20,1459.20,N/A,340.48,N/A,297.19,N/A,1400.35,N/A,826.88,N/A,2432.00,N/A,340.48,N/A,297.19,N/A,297.19,N/A,1950.53,N/A,2432.00,N/A,2432.00,N/A,2432.00,N/A,1400.35,N/A,297.19,N/A,340.48,N/A,2432.00,N/A,2432.00,N/A,340.48,N/A,297.19,N/A,297.19,N/A,326.91,1459.20,1459.20,297.19,2432.00,,Hospital CPT 61107,HC Twist Drill Hole Implt Ventricular Cath/Dev,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,9190.00,9190.00,5514.00,5514.00,N/A,1286.60,N/A,297.19,N/A,5291.60,N/A,3124.60,N/A,3133.28,N/A,1286.60,N/A,297.19,N/A,297.19,N/A,1950.53,N/A,3133.28,N/A,3133.28,N/A,3133.28,N/A,5291.60,N/A,297.19,N/A,1286.60,N/A,9190.00,N/A,9190.00,N/A,1286.60,N/A,297.19,N/A,297.19,N/A,326.91,5514.00,5514.00,297.19,9190.00,,Hospital 61140,Burr Hole/Trephine W/Bx Brain/Intracrnial Lesion,N/A,N/A,N/A,28815.42,N/A,17289.25,N/A,4034.16,N/A,351.18,N/A,15663.84,N/A,9797.25,N/A,841.99,N/A,4034.16,N/A,342.05,N/A,342.05,N/A,524.16,N/A,841.99,N/A,841.99,N/A,841.99,N/A,15663.84,N/A,342.05,N/A,4034.16,N/A,527.00,N/A,527.00,N/A,4034.16,N/A,342.05,N/A,351.18,N/A,748.10,N/A,N/A,342.05,17289.25,,Hospital 61312,Craniectomy Hmtma Supratentorial Extra/Subdural,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36692.37,N/A,22015.42,N/A,5136.93,N/A,2052.96,N/A,20914.49,N/A,12475.39,N/A,29428.51,N/A,5136.93,N/A,2052.96,N/A,2052.96,N/A,18319.27,N/A,29428.51,N/A,29428.51,N/A,29428.51,N/A,20914.49,N/A,2052.96,N/A,5136.93,N/A,2464.50,N/A,2464.50,N/A,5136.93,N/A,2052.96,N/A,2052.96,N/A,2258.26,N/A,N/A,2052.96,29428.51,,Hospital 61531,Subdural Impltj Electrodes Seizure Monitoring,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86259.40,N/A,51755.64,N/A,13312.01,N/A,15422.18,N/A,38097.71,N/A,28351.36,N/A,16527.57,N/A,13722.18,N/A,360242.00,N/A,360242.00,N/A,10287.65,N/A,16527.57,N/A,16527.57,N/A,16527.57,N/A,38097.71,N/A,15392.53,N/A,13722.18,N/A,36306.49,N/A,36306.49,N/A,N/A,N/A,15392.53,N/A,15422.18,N/A,14682.73,N/A,10287.65,360242.00,N/A,N/A,,Hospital 61580,Craniofacial Ant Cranial Fossa W/O Orbital Exntj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82204.22,N/A,49322.53,N/A,11508.57,N/A,5317.01,N/A,47325.55,N/A,27949.42,N/A,41787.97,N/A,11508.57,N/A,4821.94,N/A,4821.94,N/A,26013.79,N/A,41787.97,N/A,41787.97,N/A,41787.97,N/A,47325.56,N/A,4821.94,N/A,11508.57,N/A,8510.75,N/A,8510.75,N/A,11508.57,N/A,5094.99,N/A,5317.01,N/A,9622.12,N/A,N/A,4821.94,49322.53,,Hospital 61616,Excis Base Post Cran Fossa/Intradurl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,66791.73,N/A,40075.04,N/A,9306.51,N/A,6294.29,N/A,38481.40,N/A,22709.18,N/A,30057.98,N/A,9306.51,N/A,6287.92,N/A,6287.92,N/A,18907.67,N/A,30057.98,N/A,30057.98,N/A,30057.98,N/A,38481.44,N/A,6311.17,N/A,9306.51,N/A,2464.50,N/A,2464.50,N/A,9306.51,N/A,6287.92,N/A,6294.29,N/A,7061.16,N/A,N/A,2464.50,40075.04,,Hospital CPT 61651,HC Evasc Prlng Admn Rx Agnt Add,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,771.00,771.00,462.60,462.60,N/A,107.94,N/A,231.76,N/A,443.94,N/A,262.14,N/A,771.00,N/A,107.94,N/A,231.76,N/A,231.76,N/A,771.00,N/A,771.00,N/A,771.00,N/A,771.00,N/A,443.94,N/A,231.76,N/A,107.94,N/A,771.00,N/A,771.00,N/A,107.94,N/A,231.76,N/A,231.76,N/A,254.94,462.60,462.60,107.94,771.00,,Hospital 61781,"Stereotactic Comp Assist Proc,Cranial,Intradural",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,92148.88,N/A,55289.33,N/A,24221.84,N/A,3633.43,N/A,58904.55,N/A,31330.62,N/A,56751.71,N/A,24968.16,N/A,28918.84,N/A,28918.84,N/A,35329.63,N/A,56751.71,N/A,56751.71,N/A,56751.71,N/A,58904.55,N/A,28918.84,N/A,N/A,N/A,65564.82,N/A,65564.82,N/A,N/A,N/A,28918.84,N/A,28918.84,N/A,26715.93,N/A,3633.43,65564.82,N/A,N/A,,Hospital 62000,Fix Simpl Depress Skull Fx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 62142,Remove Skull Plate/Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33818.35,N/A,20291.01,N/A,4494.24,N/A,1935.74,N/A,19456.18,N/A,11498.23,N/A,13728.57,N/A,4494.24,N/A,3784.93,N/A,3784.93,N/A,8546.30,N/A,13728.57,N/A,13728.57,N/A,13728.57,N/A,19456.20,N/A,3784.93,N/A,4494.24,N/A,5383.50,N/A,5383.50,N/A,4494.24,N/A,3784.93,N/A,1935.74,N/A,2129.34,N/A,N/A,1935.74,20291.01,,Hospital 62160,"Neuroendoscop,Place/Replace Ventcath",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27448.28,N/A,16468.97,N/A,3799.35,N/A,999.95,N/A,15791.24,N/A,9332.43,N/A,13565.73,N/A,3799.35,N/A,5579.57,N/A,5579.57,N/A,8444.92,N/A,13565.73,N/A,13565.73,N/A,13565.73,N/A,15791.26,N/A,5579.57,N/A,3799.35,N/A,6226.50,N/A,6226.50,N/A,3799.35,N/A,5579.57,N/A,999.95,N/A,1099.95,N/A,N/A,999.95,16468.97,,Hospital 62165,"Neuroendoscop,Exc,Pit Tum,Transnas/Sphen",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21657.32,N/A,12994.39,N/A,3033.21,N/A,1452.68,N/A,12465.87,N/A,7363.49,N/A,14516.57,N/A,3033.21,N/A,1452.68,N/A,1452.68,N/A,9036.84,N/A,14516.57,N/A,14516.57,N/A,14516.57,N/A,12465.88,N/A,1452.68,N/A,3033.21,N/A,1643.00,N/A,1643.00,N/A,3033.21,N/A,1452.68,N/A,1452.68,N/A,1597.95,N/A,N/A,1452.68,14516.57,,Hospital 62230,"Replacement/Revision,CSF Shunt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,55212.20,68760.13,33127.32,41256.08,10959.98,9568.63,13260.38,5986.31,24699.20,39552.87,18772.15,23378.46,25679.20,14733.95,11297.67,9568.63,146120.00,5729.40,146120.00,5729.40,15986.06,9375.43,25679.20,14733.95,25679.20,14733.95,25679.20,14733.95,24699.20,39552.92,13230.73,5752.65,11297.67,9568.63,29666.98,5963.00,29666.98,5963.00,2985.08,9568.63,13230.73,5729.40,13260.38,5986.31,12088.51,1282.14,2985.08,146120.00,1282.14,41256.08,,Hospital 62256,"Removal,Complete CSF Shunt,W/O Replace",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38527.87,N/A,23116.72,N/A,5261.96,N/A,887.78,N/A,22166.63,N/A,13099.48,N/A,3885.13,N/A,5261.96,N/A,869.11,N/A,869.11,N/A,2418.57,N/A,3885.13,N/A,3885.13,N/A,3885.13,N/A,22166.63,N/A,869.11,N/A,5261.96,N/A,1871.00,N/A,1871.00,N/A,5261.96,N/A,869.11,N/A,887.78,N/A,672.04,N/A,N/A,672.04,23116.72,,Hospital 62258,Remove & Replace CSF Shunt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,95409.98,N/A,57245.99,N/A,13310.10,N/A,1259.00,N/A,54387.27,N/A,32439.40,N/A,14289.25,N/A,13310.10,N/A,1253.86,N/A,1253.86,N/A,8895.06,N/A,14289.25,N/A,14289.25,N/A,14289.25,N/A,54387.29,N/A,1253.86,N/A,13310.10,N/A,1643.00,N/A,1643.00,N/A,13310.10,N/A,1253.86,N/A,1259.00,N/A,1372.30,N/A,N/A,1253.86,57245.99,,Hospital 62281,HC Inj Neurolytic Epi Cerv/Dor,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,2974.53,N/A,1784.72,N/A,416.43,N/A,151.23,N/A,1711.21,N/A,1011.34,N/A,1874.84,N/A,416.43,N/A,769.55,N/A,769.55,N/A,1167.13,N/A,1874.84,N/A,1874.84,N/A,1874.84,N/A,1711.21,N/A,769.55,N/A,416.43,N/A,1431.00,N/A,1431.00,N/A,416.43,N/A,769.55,N/A,151.23,N/A,166.35,N/A,N/A,151.23,1874.84,,Hospital CPT 62284,"HC Inj Proc for Myelogram/CT, Lumbar",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1460.00,1460.00,876.00,876.00,N/A,204.40,N/A,1460.00,N/A,840.67,N/A,496.40,N/A,1460.00,N/A,204.40,N/A,1460.00,N/A,1460.00,N/A,1460.00,N/A,1460.00,N/A,1460.00,N/A,1460.00,N/A,840.67,N/A,1460.00,N/A,204.40,N/A,527.00,N/A,527.00,N/A,204.40,N/A,1460.00,N/A,1460.00,N/A,89.43,876.00,876.00,89.43,1460.00,,Hospital CPT 62302,HC Myelogram Cervical,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1495.00,1495.00,897.00,897.00,N/A,209.30,N/A,115.04,N/A,860.82,N/A,508.30,N/A,1495.00,N/A,209.30,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1495.00,N/A,1495.00,N/A,1495.00,N/A,860.82,N/A,668.93,N/A,209.30,N/A,1431.00,N/A,1431.00,N/A,209.30,N/A,668.93,N/A,115.04,N/A,126.54,897.00,897.00,115.04,1495.00,,Hospital CPT 62303,HC Myelogram Thoracic,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1495.00,1495.00,897.00,897.00,N/A,209.30,N/A,699.73,N/A,860.82,N/A,508.30,N/A,1495.00,N/A,209.30,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1495.00,N/A,1495.00,N/A,1495.00,N/A,860.82,N/A,668.93,N/A,209.30,N/A,1431.00,N/A,1431.00,N/A,209.30,N/A,668.93,N/A,699.73,N/A,126.89,897.00,897.00,126.89,1495.00,,Hospital CPT 62323,HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,581.86,N/A,1402.65,N/A,828.24,N/A,1407.47,N/A,341.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1402.65,N/A,581.86,N/A,341.04,N/A,1305.70,N/A,1305.70,N/A,341.04,N/A,581.86,N/A,581.86,N/A,640.05,1461.60,1461.60,341.04,1461.60,,Hospital CPT 62323,HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,581.86,N/A,1402.65,N/A,828.24,N/A,1407.47,N/A,341.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1402.65,N/A,581.86,N/A,341.04,N/A,1431.00,N/A,1431.00,N/A,341.04,N/A,581.86,N/A,581.86,N/A,640.05,1461.60,1461.60,341.04,1461.60,,Hospital 62326,Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48441.30,N/A,29064.78,N/A,6780.82,N/A,777.89,N/A,27372.57,N/A,16470.04,N/A,1896.91,N/A,6780.82,N/A,769.55,N/A,769.55,N/A,1180.86,N/A,1896.91,N/A,1896.91,N/A,1896.91,N/A,27372.57,N/A,769.55,N/A,6780.82,N/A,1431.00,N/A,1431.00,N/A,6780.82,N/A,769.55,N/A,777.89,N/A,114.11,N/A,N/A,114.11,29064.78,,Hospital CPT 62328,HC Diag Lumbar Spinal Puncture W/Fluor or CT,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3155.00,3155.00,1893.00,1893.00,N/A,441.70,N/A,581.86,N/A,1816.65,N/A,1072.70,N/A,1407.47,N/A,441.70,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1816.65,N/A,581.86,N/A,441.70,N/A,1431.00,N/A,1431.00,N/A,441.70,N/A,581.86,N/A,581.86,N/A,640.05,1893.00,1893.00,441.70,1893.00,,Hospital 62329,HC Tx Spinal Pnxr Drainage CSF W/Fluor/CT,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,92404.00,5858.00,55442.40,3514.80,5422.11,820.12,6679.73,748.34,12219.16,2958.09,31417.36,1991.72,12703.98,1640.93,7878.45,820.12,6679.73,678.38,6679.73,678.38,7908.61,1021.52,12703.98,1640.93,12703.98,1640.93,12703.98,1640.93,12219.16,2958.09,6679.73,678.38,5589.17,820.12,14676.82,1431.00,14676.82,1431.00,7878.45,820.12,6679.73,678.38,6679.73,169.47,5980.42,186.41,5422.11,55442.40,169.47,3514.80,,Hospital CPT 62350,HC Implant Intrathecal/Epid Cath,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,10182.00,10182.00,6109.20,6109.20,N/A,1425.48,N/A,379.67,N/A,5862.80,N/A,3461.88,N/A,1133.88,N/A,1425.48,N/A,379.67,N/A,379.67,N/A,705.84,N/A,1133.88,N/A,1133.88,N/A,1133.88,N/A,5862.80,N/A,379.67,N/A,1425.48,N/A,5457.55,N/A,5457.55,N/A,1425.48,N/A,379.67,N/A,379.67,N/A,417.64,6109.20,6109.20,379.67,6109.20,,Hospital 62360,"Insert Spine Infusn Device,Subcut",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,70053.40,N/A,42032.04,N/A,9799.46,N/A,16000.41,N/A,39760.88,N/A,23818.16,N/A,37036.98,N/A,9799.46,N/A,15296.11,N/A,15296.11,N/A,23056.24,N/A,37036.98,N/A,37036.98,N/A,37036.98,N/A,39760.89,N/A,15296.11,N/A,9799.46,N/A,5963.00,N/A,5963.00,N/A,9799.46,N/A,15296.11,N/A,16000.41,N/A,346.08,N/A,N/A,346.08,42032.04,,Hospital 63017,"Laminectomy,>2 Sgmt,Lumbar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29132.10,N/A,17479.26,N/A,4072.17,N/A,6248.31,N/A,16772.92,N/A,9904.91,N/A,14486.45,N/A,4072.17,N/A,5973.28,N/A,5973.28,N/A,9018.09,N/A,14486.45,N/A,14486.45,N/A,14486.45,N/A,16772.91,N/A,5973.28,N/A,4072.17,N/A,7897.00,N/A,7897.00,N/A,4072.17,N/A,5973.28,N/A,6248.31,N/A,1331.50,N/A,N/A,1331.50,17479.26,,Hospital 63020,Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Cervc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56959.17,N/A,34175.50,N/A,7966.78,N/A,12325.48,N/A,32795.29,N/A,19366.11,N/A,28544.79,N/A,7966.78,N/A,11782.94,N/A,11782.94,N/A,17769.68,N/A,28544.79,N/A,28544.79,N/A,28544.79,N/A,32795.29,N/A,11782.94,N/A,7966.78,N/A,11977.25,N/A,11977.25,N/A,7966.78,N/A,11782.94,N/A,12325.48,N/A,1651.69,N/A,N/A,1651.69,34175.50,,Hospital 63042,Redo Excis Lumbar Disk,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,70576.67,40136.38,42346.00,24081.83,10665.51,5613.42,12882.39,1236.59,24035.58,23100.68,23996.07,13646.37,24265.50,14519.92,10994.13,5613.42,1124.00,5973.28,1124.00,5973.28,15104.71,9038.92,24265.50,14519.92,24265.50,14519.92,24265.50,14519.92,24035.58,23100.72,12882.39,5973.28,10994.13,5613.42,28869.89,7897.00,28869.89,7897.00,N/A,5613.42,6131.28,5973.28,12882.39,6053.84,11763.72,1360.25,1124.00,42346.00,1236.59,24081.83,,Hospital 63044,"Redo Excis Cerv Disk, Addn Lumb Interspc",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28652.02,N/A,17191.21,N/A,4001.57,N/A,5973.28,N/A,16493.47,N/A,9741.68,N/A,14524.66,N/A,4001.57,N/A,5973.28,N/A,5973.28,N/A,9041.87,N/A,14524.66,N/A,14524.66,N/A,14524.66,N/A,16493.48,N/A,5973.28,N/A,4001.57,N/A,10178.00,N/A,10178.00,N/A,4001.57,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,4001.57,17191.21,,Hospital 63048,Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60141.45,32481.87,36084.87,19489.12,10849.55,4518.81,6421.39,5973.28,24450.34,18699.13,20448.10,11043.83,24684.23,14504.14,11183.84,4518.81,6123.11,5973.28,6123.11,5973.28,15365.36,9029.10,24684.23,14504.14,24684.23,14504.14,24684.23,14504.14,24450.34,18699.14,13100.10,5973.28,N/A,4518.81,29368.07,8160.50,29368.07,8160.50,N/A,4518.81,13100.10,5973.28,13100.10,5973.28,N/A,6570.60,6123.11,36084.87,4518.81,19489.12,,Hospital 63051,"C-Laminoplasty W/Graft/Plate, 2 or More",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,74807.02,55608.20,44884.21,33364.92,10665.51,7667.93,12882.39,1726.85,36672.57,31847.45,25434.38,18906.79,24265.50,14826.04,10994.13,7667.93,12882.39,1724.05,12882.39,1724.05,15104.71,9229.49,24265.50,14826.04,24265.50,14826.04,24265.50,14826.04,36672.57,31847.47,12882.39,1724.05,10994.13,7667.93,28869.89,1643.00,28869.89,1643.00,N/A,7667.93,12882.39,1724.05,12882.39,1726.85,11763.72,1826.21,10665.51,44884.21,1643.00,33364.92,,Hospital 63052,Lam Facetec/Foramot Drg Arthrd Lumbar 1 Vrt Sgm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,166812.53,160110.00,100087.52,96066.00,25542.16,22357.24,29105.10,6036.03,91947.07,90757.80,56716.26,54437.45,58030.64,48294.82,26329.16,22357.24,273694.00,19856.45,21208.82,19856.45,36122.72,30174.88,58030.64,48294.82,58030.64,48294.82,58030.64,48294.82,91947.07,90757.81,29045.80,19871.95,26329.16,22357.24,69041.97,19049.75,69041.97,19049.75,7080.07,22357.24,29045.80,19856.45,29105.10,6036.03,28172.20,6627.39,7080.07,273694.00,6036.03,96066.00,,Hospital 63053,Lam Facetec/Foramot Drg Arthrd Lmbr Ea Addl Sgm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,192137.42,180732.32,115282.45,108439.39,25542.16,25277.14,29128.23,3369.79,105906.14,102426.48,65326.72,61449.02,66902.25,49147.11,26329.16,25277.14,251214.00,19856.45,20213.11,19856.45,41655.39,30705.44,N/A,49147.11,66902.25,49147.11,66902.25,49147.11,105906.14,102426.50,29009.63,19871.95,16236.77,25277.14,69041.97,19049.75,N/A,19049.75,11506.86,25277.14,20213.11,19856.45,29128.23,3369.79,28172.20,3700.65,11506.86,251214.00,3369.79,108439.39,,Hospital 63076,"Disk Surg,Anter,Cerv,Ea Addnl Lvl",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,85036.03,54134.88,51021.62,32480.93,16382.62,7485.26,18670.77,6132.82,42498.31,30923.77,28912.25,18405.87,37062.76,14471.27,16887.40,7485.26,11932.77,5973.28,11932.77,5973.28,N/A,9008.64,37062.76,14471.27,N/A,14471.27,37062.76,14471.27,42498.31,30923.78,18641.12,5973.28,16887.40,7485.26,44095.43,8160.50,N/A,8160.50,N/A,7485.26,12083.63,5973.28,18670.77,6132.82,18069.51,1709.81,11932.77,51021.62,1709.81,32480.93,,Hospital 63277,"Bx/Excis Spinal Tumor,Xdural,Lumb",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,55206.97,N/A,33124.18,N/A,8909.88,N/A,10835.22,N/A,21121.55,N/A,18770.36,N/A,20271.22,N/A,9184.41,N/A,123078.00,N/A,123078.00,N/A,12618.36,N/A,20271.22,N/A,20271.22,N/A,20271.22,N/A,21121.55,N/A,10805.57,N/A,9184.41,N/A,24117.69,N/A,24117.69,N/A,N/A,N/A,10805.57,N/A,10835.22,N/A,9827.32,N/A,8909.88,123078.00,N/A,N/A,,Hospital 63281,"Bx/Excis Spin Tum,Indur,Xmed,Thor",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54128.68,N/A,32477.21,N/A,7578.02,N/A,3161.47,N/A,31121.36,N/A,18403.76,N/A,18099.62,N/A,7578.02,N/A,3151.56,N/A,3151.56,N/A,11560.88,N/A,18099.62,N/A,18099.62,N/A,18099.62,N/A,30756.84,N/A,3170.06,N/A,7578.02,N/A,1643.00,N/A,1643.00,N/A,7578.02,N/A,3151.56,N/A,3161.47,N/A,3455.10,N/A,N/A,1643.00,32477.21,,Hospital 63655,"Surg Implnt Neuroelect,Epidural",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,223936.50,148916.38,134361.90,89349.83,22245.33,20837.50,12697.49,26511.88,123433.80,84163.26,76138.41,50631.57,77974.69,64158.40,18692.82,20837.50,562.00,26511.88,562.00,26511.88,48549.43,39939.85,77974.69,64158.40,77974.69,64158.40,77974.69,64158.40,123433.80,84163.25,12697.49,26511.88,18692.82,20837.50,136888.70,42930.00,136888.70,42930.00,17065.34,20837.50,12697.49,26511.88,12697.49,26511.88,20001.32,29163.07,562.00,136888.70,20837.50,89349.83,,Hospital 63707,"Repr,Dural/CSF Leak,Not Req Laminectomy",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46345.92,N/A,27807.55,N/A,6488.43,N/A,1792.35,N/A,26680.19,N/A,15757.61,N/A,20992.61,N/A,6488.43,N/A,1792.35,N/A,1792.35,N/A,13068.31,N/A,20992.61,N/A,20992.61,N/A,20992.61,N/A,26680.19,N/A,1792.35,N/A,6488.43,N/A,8718.50,N/A,8718.50,N/A,6488.43,N/A,1792.35,N/A,1792.35,N/A,1971.59,N/A,N/A,1792.35,27807.55,,Hospital CPT 64400,HC Trigem Nerve Any Branch Inj,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1277.00,1277.00,766.20,766.20,N/A,178.78,N/A,47.92,N/A,735.30,N/A,434.18,N/A,307.83,N/A,178.78,N/A,47.92,N/A,47.92,N/A,191.62,N/A,307.83,N/A,307.83,N/A,307.83,N/A,735.30,N/A,47.92,N/A,178.78,N/A,684.47,N/A,684.47,N/A,178.78,N/A,47.92,N/A,47.92,N/A,52.71,766.20,766.20,47.92,766.20,,Hospital CPT 64400,HC Trigeminal Nerve Block,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1277.00,1277.00,766.20,766.20,N/A,178.78,N/A,47.92,N/A,735.30,N/A,434.18,N/A,307.83,N/A,178.78,N/A,47.92,N/A,47.92,N/A,191.62,N/A,307.83,N/A,307.83,N/A,307.83,N/A,735.30,N/A,47.92,N/A,178.78,N/A,1277.00,N/A,1277.00,N/A,178.78,N/A,47.92,N/A,47.92,N/A,52.71,766.20,766.20,47.92,1277.00,,Hospital CPT 64405,HC Occipital Nerve Injection,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2781.00,2781.00,1668.60,1668.60,N/A,389.34,N/A,245.53,N/A,1601.30,N/A,945.54,N/A,593.92,N/A,389.34,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1601.30,N/A,245.53,N/A,389.34,N/A,1490.62,N/A,1490.62,N/A,389.34,N/A,245.53,N/A,245.53,N/A,270.08,1668.60,1668.60,245.53,1668.60,,Hospital CPT 64405,HC Inj Aa&/Strd Greater Occipital Nerve,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2781.00,2781.00,1668.60,1668.60,N/A,389.34,N/A,245.53,N/A,1601.30,N/A,945.54,N/A,593.92,N/A,389.34,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1601.30,N/A,245.53,N/A,389.34,N/A,2781.00,N/A,2781.00,N/A,389.34,N/A,245.53,N/A,245.53,N/A,270.08,1668.60,1668.60,245.53,2781.00,,Hospital CPT 64418,HC Suprascapular Nerve Inj,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1372.00,1372.00,823.20,823.20,N/A,192.08,N/A,54.43,N/A,790.00,N/A,466.48,N/A,1372.00,N/A,192.08,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1372.00,N/A,1372.00,N/A,1372.00,N/A,790.00,N/A,581.86,N/A,192.08,N/A,735.39,N/A,735.39,N/A,192.08,N/A,581.86,N/A,588.17,N/A,59.87,823.20,823.20,54.43,1372.00,,Hospital CPT 64418,HC N Block Inj Suprascapular Nerv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1372.00,1372.00,823.20,823.20,N/A,192.08,N/A,54.43,N/A,790.00,N/A,466.48,N/A,1372.00,N/A,192.08,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1372.00,N/A,1372.00,N/A,1372.00,N/A,790.00,N/A,581.86,N/A,192.08,N/A,1431.00,N/A,1431.00,N/A,192.08,N/A,581.86,N/A,588.17,N/A,59.87,823.20,823.20,54.43,1431.00,,Hospital CPT 64425,HC Peripheral Block - Ilioinguinal/Iliohypogastric,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1372.00,1372.00,823.20,823.20,N/A,192.08,N/A,581.86,N/A,790.00,N/A,466.48,N/A,1372.00,N/A,192.08,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1372.00,N/A,1372.00,N/A,1372.00,N/A,790.00,N/A,581.86,N/A,192.08,N/A,1431.00,N/A,1431.00,N/A,192.08,N/A,581.86,N/A,581.86,N/A,640.05,823.20,823.20,192.08,1431.00,,Hospital CPT 64425,HC Ilioinguinal Block,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1372.00,1372.00,823.20,823.20,N/A,192.08,N/A,581.86,N/A,790.00,N/A,466.48,N/A,1372.00,N/A,192.08,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1372.00,N/A,1372.00,N/A,1372.00,N/A,790.00,N/A,581.86,N/A,192.08,N/A,735.39,N/A,735.39,N/A,192.08,N/A,581.86,N/A,581.86,N/A,640.05,823.20,823.20,192.08,1372.00,,Hospital CPT 64448,HC Peripheral Block - Femoral Continuous W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2567.00,2567.00,1540.20,1540.20,N/A,359.38,N/A,806.83,N/A,1478.08,N/A,872.78,N/A,1861.48,N/A,359.38,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1478.08,N/A,769.55,N/A,359.38,N/A,1431.00,N/A,1431.00,N/A,359.38,N/A,769.55,N/A,59.46,N/A,65.41,1540.20,1540.20,59.46,1861.48,,Hospital CPT 64449,HC Peripheral Block - Caudal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2363.00,2363.00,1417.80,1417.80,N/A,330.82,N/A,59.73,N/A,1360.62,N/A,803.42,N/A,1861.48,N/A,330.82,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1360.62,N/A,769.55,N/A,330.82,N/A,1431.00,N/A,1431.00,N/A,330.82,N/A,769.55,N/A,59.73,N/A,65.70,1417.80,1417.80,59.73,1861.48,,Hospital CPT 64449,HC Lumb Sacral Plexus Nerve Block,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2363.00,2363.00,1417.80,1417.80,N/A,330.82,N/A,59.73,N/A,1360.62,N/A,803.42,N/A,1861.48,N/A,330.82,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1360.62,N/A,769.55,N/A,330.82,N/A,1266.57,N/A,1266.57,N/A,330.82,N/A,769.55,N/A,59.73,N/A,65.70,1417.80,1417.80,59.73,1861.48,,Hospital 64451,Injection Aa&/Strd Nerves Nrvtg Si Joint W/Img,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10208.70,N/A,6125.22,N/A,1429.22,N/A,593.97,N/A,5873.16,N/A,3470.96,N/A,1437.62,N/A,1429.22,N/A,581.86,N/A,581.86,N/A,894.94,N/A,1437.62,N/A,1437.62,N/A,1437.62,N/A,5873.17,N/A,581.86,N/A,1429.22,N/A,1431.00,N/A,1431.00,N/A,1429.22,N/A,581.86,N/A,593.97,N/A,86.42,N/A,N/A,86.42,6125.22,,Hospital 64454,Injection Aa&/Strd Genicular Nrv Branches W/Img,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,4678.30,N/A,2806.98,N/A,654.96,N/A,578.89,N/A,2693.60,N/A,1590.62,N/A,1407.47,N/A,654.96,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,2693.60,N/A,581.86,N/A,654.96,N/A,1431.00,N/A,1431.00,N/A,654.96,N/A,581.86,N/A,578.89,N/A,87.69,N/A,N/A,87.69,2806.98,,Hospital CPT 64455,HC Peripheral Block - Digital,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1107.00,1107.00,664.20,664.20,N/A,154.98,N/A,261.19,N/A,637.41,N/A,376.38,N/A,593.92,N/A,154.98,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,637.41,N/A,245.53,N/A,154.98,N/A,527.00,N/A,527.00,N/A,154.98,N/A,245.53,N/A,261.19,N/A,36.38,664.20,664.20,36.38,664.20,,Hospital CPT 64462,HC Pvb Thoracic 2 or More Inj Site,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1328.00,1328.00,796.80,796.80,N/A,185.92,N/A,47.86,N/A,764.66,N/A,451.52,N/A,204.99,N/A,185.92,N/A,47.86,N/A,47.86,N/A,127.61,N/A,204.99,N/A,204.99,N/A,204.99,N/A,764.66,N/A,47.86,N/A,185.92,N/A,1328.00,N/A,1328.00,N/A,185.92,N/A,47.86,N/A,47.86,N/A,52.65,796.80,796.80,47.86,1328.00,,Hospital CPT 64486,HC Peripheral Block - Tap Unilateral Injection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1107.00,1107.00,664.20,664.20,N/A,154.98,N/A,1107.00,N/A,637.41,N/A,376.38,N/A,1107.00,N/A,154.98,N/A,1107.00,N/A,1107.00,N/A,1107.00,N/A,1107.00,N/A,1107.00,N/A,1107.00,N/A,637.41,N/A,1107.00,N/A,154.98,N/A,527.00,N/A,527.00,N/A,154.98,N/A,1107.00,N/A,1107.00,N/A,1107.00,664.20,664.20,154.98,1107.00,,Hospital CPT 64489,HC Peripheral Block - Tap Bilateral Infusion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1937.00,1937.00,1162.20,1162.20,N/A,271.18,N/A,75.92,N/A,1115.32,N/A,658.58,N/A,967.50,N/A,271.18,N/A,75.92,N/A,75.92,N/A,602.27,N/A,967.50,N/A,967.50,N/A,967.50,N/A,1115.32,N/A,75.92,N/A,271.18,N/A,1937.00,N/A,1937.00,N/A,271.18,N/A,75.92,N/A,75.92,N/A,83.51,1162.20,1162.20,75.92,1937.00,,Hospital CPT 64492,HC N Block Paravert Thoracic 3+,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3049.00,3049.00,1829.40,1829.40,N/A,426.86,N/A,3049.00,N/A,1755.61,N/A,1036.66,N/A,3049.00,N/A,426.86,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,1755.61,N/A,3049.00,N/A,426.86,N/A,527.00,N/A,527.00,N/A,426.86,N/A,3049.00,N/A,3049.00,N/A,63.83,1829.40,1829.40,63.83,3049.00,,Hospital CPT 64492,"HC Facet Jnt,C/T,3rd & Ea Add",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3049.00,3049.00,1829.40,1829.40,N/A,426.86,N/A,3049.00,N/A,1755.61,N/A,1036.66,N/A,3049.00,N/A,426.86,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,3049.00,N/A,1755.61,N/A,3049.00,N/A,426.86,N/A,1634.26,N/A,1634.26,N/A,426.86,N/A,3049.00,N/A,3049.00,N/A,63.83,1829.40,1829.40,63.83,3049.00,,Hospital CPT 64493,HC N Block Paravert Lumbar 1st,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,769.55,N/A,2054.45,N/A,1213.12,N/A,1861.48,N/A,499.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2054.45,N/A,769.55,N/A,499.52,N/A,1431.00,N/A,1431.00,N/A,499.52,N/A,769.55,N/A,769.55,N/A,846.51,2140.80,2140.80,499.52,2140.80,,Hospital CPT 64493,"HC Facet Jnt, L/S, Single",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,769.55,N/A,2054.45,N/A,1213.12,N/A,1861.48,N/A,499.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2054.45,N/A,769.55,N/A,499.52,N/A,1912.45,N/A,1912.45,N/A,499.52,N/A,769.55,N/A,769.55,N/A,846.51,2140.80,2140.80,499.52,2140.80,,Hospital CPT 64510,HC Stellate Ganglion Inj.Cerv Sym,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3644.00,3644.00,2186.40,2186.40,N/A,510.16,N/A,804.99,N/A,2098.22,N/A,1238.96,N/A,1861.48,N/A,510.16,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2098.22,N/A,769.55,N/A,510.16,N/A,1953.18,N/A,1953.18,N/A,510.16,N/A,769.55,N/A,804.99,N/A,80.33,2186.40,2186.40,80.33,2186.40,,Hospital 64530,HC Inj Anesth Celiac Plexus,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,112484.90,11337.30,67490.94,6802.38,8768.52,1587.22,10638.34,795.94,62001.68,6523.88,38244.86,3854.68,19949.59,1876.72,N/A,1587.22,6182.00,769.55,6182.00,769.55,12418.15,1168.29,19949.59,1876.72,19949.59,1876.72,19949.59,1876.72,62001.68,6523.88,10638.34,769.55,9038.69,1587.22,23735.03,1431.00,23735.03,1431.00,N/A,1587.22,10638.34,769.55,10638.34,795.94,9671.40,112.38,6182.00,67490.94,112.38,6802.38,,Hospital CPT 64555,HC Peripheral Nerve Stim Implant,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,17907.00,17907.00,10744.20,10744.20,N/A,2506.98,N/A,6343.92,N/A,10310.85,N/A,6088.38,N/A,14425.31,N/A,2506.98,N/A,5963.54,N/A,5963.54,N/A,8980.03,N/A,14425.31,N/A,14425.31,N/A,14425.31,N/A,10310.85,N/A,5963.54,N/A,2506.98,N/A,9598.15,N/A,9598.15,N/A,2506.98,N/A,5963.54,N/A,6343.92,N/A,345.60,10744.20,10744.20,345.60,14425.31,,Hospital 64561,HC Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,52122.45,54872.62,31273.47,32923.57,6438.89,7680.21,7912.16,6087.56,23629.47,31266.30,17721.64,18656.69,14649.36,14462.76,6637.28,7680.21,7882.51,5963.54,7882.51,5963.54,9118.89,9003.34,14649.36,14462.76,14649.36,14462.76,14649.36,14462.76,23629.47,31266.30,7882.51,5963.54,6637.28,7680.21,17429.08,7897.00,17429.08,7897.00,2588.30,7680.21,7882.51,5963.54,7912.16,6087.56,7101.89,334.28,2588.30,31273.47,334.28,32923.57,,Hospital 64575,Open Implantation Nea Peripheral Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35749.65,N/A,21449.79,N/A,5004.94,N/A,20323.84,N/A,20338.74,N/A,12154.87,N/A,35749.65,N/A,5004.94,N/A,19429.23,N/A,19429.23,N/A,29289.49,N/A,35749.65,N/A,35749.65,N/A,35749.65,N/A,20338.74,N/A,19429.23,N/A,5004.94,N/A,42930.00,N/A,42930.00,N/A,5004.94,N/A,19429.23,N/A,20323.84,N/A,503.40,N/A,N/A,503.40,42930.00,,Hospital CPT 64582,Open Impltj Hpglsl Nrv Nstim Ra Pg&Respir Sensor,N/A,N/A,1411.00,1411.00,846.60,846.60,N/A,197.54,N/A,830.69,N/A,1411.00,N/A,479.74,N/A,1411.00,N/A,197.54,N/A,830.69,N/A,830.69,N/A,1411.00,N/A,1411.00,N/A,1411.00,N/A,1411.00,N/A,1411.00,N/A,830.69,N/A,197.54,N/A,1411.00,N/A,1411.00,N/A,197.54,N/A,830.69,N/A,830.69,N/A,913.76,846.60,846.60,197.54,1411.00,,Hospital CPT 64611,HC Chemodenerv Parotid&Submandibl Salivary Glnds,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,700.00,700.00,420.00,420.00,N/A,98.00,N/A,245.53,N/A,403.06,N/A,238.00,N/A,593.92,N/A,98.00,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,403.06,N/A,245.53,N/A,98.00,N/A,375.20,N/A,375.20,N/A,98.00,N/A,245.53,N/A,245.53,N/A,270.08,420.00,420.00,98.00,593.92,,Hospital CPT 64634,"HC Rfl,Facet,C/T,Ea Add, W/Img",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4308.00,4308.00,2584.80,2584.80,N/A,603.12,N/A,4308.00,N/A,2480.55,N/A,1464.72,N/A,4308.00,N/A,603.12,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,2480.55,N/A,4308.00,N/A,603.12,N/A,2309.09,N/A,2309.09,N/A,603.12,N/A,4308.00,N/A,4308.00,N/A,71.23,2584.80,2584.80,71.23,4308.00,,Hospital CPT 64635,"HC Rfl,Fac,L/S,Single,W/ Img",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4482.00,4482.00,2689.20,2689.20,N/A,627.48,N/A,1726.77,N/A,2580.74,N/A,1523.88,N/A,3926.47,N/A,627.48,N/A,1623.23,N/A,1623.23,N/A,2444.31,N/A,3926.47,N/A,3926.47,N/A,3926.47,N/A,2580.74,N/A,1623.23,N/A,627.48,N/A,2402.35,N/A,2402.35,N/A,627.48,N/A,1623.23,N/A,1726.77,N/A,201.95,2689.20,2689.20,201.95,3926.47,,Hospital CPT 64636,"HC Rfl,Fac,L/S,Ea Add, W/ Img",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,4308.00,4308.00,2584.80,2584.80,N/A,603.12,N/A,4308.00,N/A,2480.55,N/A,1464.72,N/A,4308.00,N/A,603.12,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,4308.00,N/A,2480.55,N/A,4308.00,N/A,603.12,N/A,2309.09,N/A,2309.09,N/A,603.12,N/A,4308.00,N/A,4308.00,N/A,62.83,2584.80,2584.80,62.83,4308.00,,Hospital CPT 64653,HC Stellate Ganglion W/Neuro Agnt,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1260.00,1260.00,756.00,756.00,N/A,176.40,N/A,50.03,N/A,725.51,N/A,428.40,N/A,289.98,N/A,176.40,N/A,50.03,N/A,50.03,N/A,180.51,N/A,289.98,N/A,289.98,N/A,289.98,N/A,725.51,N/A,50.03,N/A,176.40,N/A,675.36,N/A,675.36,N/A,176.40,N/A,50.03,N/A,50.03,N/A,55.03,756.00,756.00,50.03,756.00,,Hospital 64704,Revise/Repair Hand/Foot Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22309.18,N/A,13385.51,N/A,3113.20,N/A,11722.66,N/A,12802.04,N/A,7585.13,N/A,22309.18,N/A,3113.20,N/A,11782.94,N/A,11782.94,N/A,17792.45,N/A,22309.18,N/A,22309.18,N/A,22309.18,N/A,12802.04,N/A,11782.94,N/A,3113.20,N/A,10063.25,N/A,10063.25,N/A,3113.20,N/A,11782.94,N/A,11722.66,N/A,1987.99,N/A,N/A,1987.99,22309.18,,Hospital 64712,"Neuroplasty Sciatic Nerve,Open",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27216.10,N/A,16329.66,N/A,3844.60,N/A,6132.82,N/A,15666.13,N/A,9253.48,N/A,14541.85,N/A,3844.60,N/A,5973.28,N/A,5973.28,N/A,9052.59,N/A,14541.85,N/A,14541.85,N/A,14541.85,N/A,15666.13,N/A,5973.28,N/A,3844.60,N/A,6260.50,N/A,6260.50,N/A,3844.60,N/A,5973.28,N/A,6132.82,N/A,1335.16,N/A,N/A,1335.16,16329.66,,Hospital 64714,"Neuroplasty Lumbar Plexus,Open",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,159742.38,N/A,95845.43,N/A,N/A,N/A,N/A,N/A,88050.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,55986.41,N/A,N/A,N/A,N/A,N/A,40320.45,N/A,69041.97,N/A,N/A,N/A,29045.80,N/A,29105.10,N/A,N/A,N/A,29045.80,95845.43,N/A,N/A,,Hospital 64726,Release Foot/Toe Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33305.10,N/A,19983.06,N/A,4662.72,N/A,3027.62,N/A,19174.61,N/A,11323.73,N/A,7050.38,N/A,4662.72,N/A,2894.35,N/A,2894.35,N/A,4389.00,N/A,7050.38,N/A,7050.38,N/A,7050.38,N/A,19174.62,N/A,2894.35,N/A,4662.72,N/A,5944.75,N/A,5944.75,N/A,4662.72,N/A,2894.35,N/A,3027.62,N/A,843.78,N/A,N/A,843.78,19983.06,,Hospital 64771,"Transect Other Cran N,Extradural",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27128.20,N/A,16276.92,N/A,3797.96,N/A,1656.99,N/A,15615.79,N/A,9223.59,N/A,3955.04,N/A,3797.96,N/A,1623.23,N/A,1623.23,N/A,2462.09,N/A,3955.04,N/A,3955.04,N/A,3955.04,N/A,15615.79,N/A,1623.23,N/A,3797.96,N/A,4112.50,N/A,4112.50,N/A,3797.96,N/A,1623.23,N/A,1656.99,N/A,673.50,N/A,N/A,673.50,16276.92,,Hospital 64778,"Excise Digital Neuroma,Addnl Digit",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39813.60,N/A,23888.16,N/A,5573.91,N/A,1678.88,N/A,22910.05,N/A,13536.62,N/A,3980.24,N/A,5573.91,N/A,1623.23,N/A,1623.23,N/A,2477.78,N/A,3980.24,N/A,3980.24,N/A,3980.24,N/A,22910.04,N/A,1623.23,N/A,5573.91,N/A,3660.50,N/A,3660.50,N/A,5573.91,N/A,1623.23,N/A,1678.88,N/A,661.58,N/A,N/A,661.58,23888.16,,Hospital 64783,"Excise Hand/Foot Neuroma,Each Addnl",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27737.57,N/A,16642.54,N/A,3883.27,N/A,2859.50,N/A,15923.88,N/A,9427.52,N/A,6534.71,N/A,3883.27,N/A,2688.04,N/A,2688.04,N/A,4067.99,N/A,6534.71,N/A,6534.71,N/A,6534.71,N/A,15923.88,N/A,2688.04,N/A,3883.27,N/A,5944.75,N/A,5944.75,N/A,3883.27,N/A,2688.04,N/A,2859.50,N/A,1520.91,N/A,N/A,1520.91,16642.54,,Hospital 64795,Biopsy of Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12724.00,N/A,7634.40,N/A,1781.36,N/A,1640.81,N/A,7323.74,N/A,4326.16,N/A,3960.17,N/A,1781.36,N/A,1623.23,N/A,1623.23,N/A,2465.27,N/A,3960.17,N/A,3960.17,N/A,3960.17,N/A,7323.76,N/A,1623.23,N/A,1781.36,N/A,3397.00,N/A,3397.00,N/A,1781.36,N/A,1623.23,N/A,1640.81,N/A,272.81,N/A,N/A,272.81,7634.40,,Hospital 64834,"Repair Hand/Foot Nerve,Sensory",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27950.90,N/A,16770.54,N/A,3913.14,N/A,5935.46,N/A,16089.28,N/A,9503.31,N/A,13519.44,N/A,3913.14,N/A,5579.57,N/A,5579.57,N/A,8416.12,N/A,13519.44,N/A,13519.44,N/A,13519.44,N/A,16089.29,N/A,5579.57,N/A,3913.14,N/A,7366.25,N/A,7366.25,N/A,3913.14,N/A,5579.57,N/A,5935.46,N/A,2786.51,N/A,N/A,2786.51,16770.54,,Hospital 64835,"Repair Hand/Foot Nerve,Median Motor",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21654.20,N/A,12992.52,N/A,3031.60,N/A,5935.46,N/A,12460.03,N/A,7362.43,N/A,13538.61,N/A,3031.60,N/A,5579.57,N/A,5579.57,N/A,8428.05,N/A,13538.61,N/A,13538.61,N/A,13538.61,N/A,12460.03,N/A,5579.57,N/A,3031.60,N/A,9384.50,N/A,9384.50,N/A,3031.60,N/A,5579.57,N/A,5935.46,N/A,4170.18,N/A,N/A,3031.60,13538.61,,Hospital 64836,"Repair Hand/Foot Nerve,Ulnar Motor",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22899.80,N/A,13739.88,N/A,3205.97,N/A,5836.48,N/A,13183.76,N/A,7785.95,N/A,13534.26,N/A,3205.97,N/A,5579.57,N/A,5579.57,N/A,8425.34,N/A,13534.26,N/A,13534.26,N/A,13534.26,N/A,13120.43,N/A,5579.57,N/A,3205.97,N/A,9384.50,N/A,9384.50,N/A,3205.97,N/A,5579.57,N/A,5836.48,N/A,2751.76,N/A,N/A,2751.76,13739.88,,Hospital 64837,Repair Each Addnl Hand/Foot Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34345.50,N/A,20607.30,N/A,4808.38,N/A,5935.46,N/A,19769.77,N/A,11677.47,N/A,13527.13,N/A,4808.38,N/A,5579.57,N/A,5579.57,N/A,8420.90,N/A,13527.13,N/A,13527.13,N/A,13527.13,N/A,19769.77,N/A,5579.57,N/A,4808.38,N/A,9384.50,N/A,9384.50,N/A,4808.38,N/A,5579.57,N/A,5935.46,N/A,2809.24,N/A,N/A,2809.24,20607.30,,Hospital 64856,Repair/Transpos Maj Periph Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28398.60,N/A,17039.16,N/A,3975.81,N/A,1912.50,N/A,16337.14,N/A,7188.14,N/A,13589.23,N/A,3975.81,N/A,5579.57,N/A,5579.57,N/A,8459.55,N/A,13589.23,N/A,13589.23,N/A,13589.23,N/A,16337.14,N/A,5579.57,N/A,3975.81,N/A,9093.25,N/A,9093.25,N/A,3975.81,N/A,5579.57,N/A,1912.50,N/A,2103.76,N/A,N/A,1912.50,17039.16,,Hospital 64901,"Ea Addnl Nerve Graft,Single Strand",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,100910.00,N/A,60546.00,N/A,14151.89,N/A,5531.37,N/A,57285.24,N/A,34309.36,N/A,13633.51,N/A,14151.89,N/A,5579.57,N/A,5579.57,N/A,8487.12,N/A,13633.51,N/A,13633.51,N/A,13633.51,N/A,56924.80,N/A,5579.57,N/A,14151.89,N/A,12369.25,N/A,12369.25,N/A,14151.89,N/A,5579.57,N/A,5531.37,N/A,7060.68,N/A,N/A,5531.37,60546.00,,Hospital CPT 65220,HC Rmvl FB Cornea WO Slit Lamp,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,634.00,634.00,380.40,380.40,N/A,88.76,N/A,39.18,N/A,365.06,N/A,215.56,N/A,168.90,N/A,88.76,N/A,39.18,N/A,39.18,N/A,105.14,N/A,168.90,N/A,168.90,N/A,168.90,N/A,365.06,N/A,39.18,N/A,88.76,N/A,634.00,N/A,634.00,N/A,88.76,N/A,39.18,N/A,39.18,N/A,43.10,380.40,380.40,39.18,634.00,,Hospital 65270,Repair Conjunc Laceratn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14849.92,N/A,8909.95,N/A,2078.99,N/A,645.37,N/A,8545.28,N/A,4787.24,N/A,4759.90,N/A,2078.99,N/A,1950.06,N/A,1950.06,N/A,2963.13,N/A,4759.90,N/A,4759.90,N/A,4759.90,N/A,8545.28,N/A,1950.06,N/A,2078.99,N/A,5095.50,N/A,5095.50,N/A,2078.99,N/A,1950.06,N/A,645.37,N/A,709.90,N/A,N/A,645.37,8909.95,,Hospital 65275,"Repair Cornea Lac,Nonperforating",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 65285,"Repair Cornea Lac,Perf,Resec Uveal",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31698.12,N/A,19018.87,N/A,4437.74,N/A,1063.06,N/A,18243.38,N/A,10777.35,N/A,8777.35,N/A,4437.74,N/A,3608.17,N/A,3608.17,N/A,5464.07,N/A,8777.35,N/A,8777.35,N/A,8777.35,N/A,18243.39,N/A,3608.17,N/A,4437.74,N/A,3660.50,N/A,3660.50,N/A,4437.74,N/A,3608.17,N/A,1063.06,N/A,1169.36,N/A,N/A,1063.06,19018.87,,Hospital CPT 65426,Excision/Transposition Pterygium W/Grafg,N/A,N/A,1098.00,1098.00,658.80,658.80,N/A,153.72,N/A,442.38,N/A,1098.00,N/A,373.32,N/A,1098.00,N/A,153.72,N/A,442.38,N/A,442.38,N/A,1098.00,N/A,1098.00,N/A,1098.00,N/A,1098.00,N/A,1098.00,N/A,442.38,N/A,153.72,N/A,1098.00,N/A,1098.00,N/A,153.72,N/A,442.38,N/A,442.38,N/A,486.62,658.80,658.80,153.72,1098.00,,Hospital 65450,"Destr Corneal Lesn,Cryo,Photo,Therm",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,75661.85,N/A,45397.11,N/A,10580.28,N/A,629.55,N/A,43008.56,N/A,25725.03,N/A,4633.80,N/A,10580.28,N/A,1909.23,N/A,1909.23,N/A,2884.63,N/A,4633.80,N/A,4633.80,N/A,4633.80,N/A,43008.56,N/A,1909.23,N/A,10580.28,N/A,3660.50,N/A,3660.50,N/A,10580.28,N/A,1909.23,N/A,629.55,N/A,692.51,N/A,N/A,629.55,45397.11,,Hospital 65756,"Corneal Transplant,Endothelial",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55278.00,N/A,33166.80,N/A,7738.92,N/A,3577.00,N/A,31824.38,N/A,18794.52,N/A,13335.22,N/A,7738.92,N/A,3608.17,N/A,3608.17,N/A,8296.59,N/A,13335.22,N/A,13335.22,N/A,13335.22,N/A,31824.38,N/A,3608.17,N/A,7738.92,N/A,5963.00,N/A,5963.00,N/A,7738.92,N/A,3608.17,N/A,3577.00,N/A,1238.06,N/A,N/A,1238.06,33166.80,,Hospital 65779,Place Amniotic Membrane Ocular Surface Sutured,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33248.20,N/A,19948.92,N/A,4654.75,N/A,397.86,N/A,19048.59,N/A,11304.39,N/A,4629.71,N/A,4654.75,N/A,1909.23,N/A,1909.23,N/A,2882.09,N/A,4629.71,N/A,4629.71,N/A,4629.71,N/A,19048.60,N/A,1909.23,N/A,4654.75,N/A,6260.50,N/A,6260.50,N/A,4654.75,N/A,1909.23,N/A,397.86,N/A,437.65,N/A,N/A,397.86,19948.92,,Hospital 65930,"Removal,Blood Clot,Ant Segment,Eye",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45754.87,N/A,27452.92,N/A,6407.48,N/A,3842.24,N/A,26342.75,N/A,15556.64,N/A,8750.33,N/A,6407.48,N/A,3612.10,N/A,3612.10,N/A,5447.25,N/A,8750.33,N/A,8750.33,N/A,8750.33,N/A,26342.75,N/A,3612.10,N/A,6407.48,N/A,7661.50,N/A,7661.50,N/A,6407.48,N/A,3612.10,N/A,3842.24,N/A,1659.18,N/A,N/A,1659.18,27452.92,,Hospital 66030,"Inject Anter Chmbr Eye,Medicatn",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8645.90,N/A,5187.54,N/A,1211.46,N/A,1940.08,N/A,4968.66,N/A,2939.60,N/A,4970.53,N/A,1211.46,N/A,1950.06,N/A,1950.06,N/A,3094.26,N/A,4970.53,N/A,4970.53,N/A,4970.53,N/A,4968.65,N/A,1950.06,N/A,1211.46,N/A,1871.00,N/A,1871.00,N/A,1211.46,N/A,1950.06,N/A,1940.08,N/A,116.12,N/A,N/A,116.12,5187.54,,Hospital 66170,"Glaucoma Surg,Trabecu Ab Externo",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21786.30,N/A,13071.78,N/A,3050.09,N/A,2039.85,N/A,12505.37,N/A,7407.35,N/A,5855.49,N/A,3050.09,N/A,1950.06,N/A,1950.06,N/A,3645.14,N/A,5855.49,N/A,5855.49,N/A,5855.49,N/A,12505.38,N/A,1950.06,N/A,3050.09,N/A,3397.00,N/A,3397.00,N/A,3050.09,N/A,1950.06,N/A,2039.85,N/A,1115.46,N/A,N/A,1115.46,13071.78,,Hospital 66174,"Transluminal Dilation Aqueous Canal, W/O Retention Device/Stent",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20113.58,N/A,12068.15,N/A,2815.90,N/A,3774.30,N/A,11578.84,N/A,6838.62,N/A,8803.32,N/A,2815.90,N/A,3608.17,N/A,3608.17,N/A,5480.24,N/A,8803.32,N/A,8803.32,N/A,8803.32,N/A,11578.85,N/A,3608.17,N/A,2815.90,N/A,5963.00,N/A,5963.00,N/A,2815.90,N/A,3608.17,N/A,3774.30,N/A,764.47,N/A,N/A,764.47,12068.15,,Hospital CPT 66180,Aqueous Shunt Extraoc Equat Plate Rsvr W/Graft,N/A,N/A,2219.00,2219.00,1331.40,1331.40,N/A,310.66,N/A,1058.42,N/A,2219.00,N/A,754.46,N/A,2219.00,N/A,310.66,N/A,1058.42,N/A,1058.42,N/A,1970.57,N/A,2219.00,N/A,2219.00,N/A,2219.00,N/A,2219.00,N/A,1058.42,N/A,310.66,N/A,2219.00,N/A,2219.00,N/A,310.66,N/A,1058.42,N/A,1058.42,N/A,1164.26,1331.40,1331.40,310.66,2219.00,,Hospital 66185,Revj Aqueous Shunt Extraocular Reservoir W/Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14494.18,N/A,8696.51,N/A,2029.19,N/A,2039.85,N/A,8321.71,N/A,4928.03,N/A,5012.91,N/A,2029.19,N/A,1950.06,N/A,1950.06,N/A,3120.39,N/A,5012.91,N/A,5012.91,N/A,5012.91,N/A,8321.72,N/A,1950.06,N/A,2029.19,N/A,3397.00,N/A,3397.00,N/A,2029.19,N/A,1950.06,N/A,2039.85,N/A,866.86,N/A,N/A,866.86,8696.51,,Hospital 66600,Remv Iris/Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11817.10,N/A,7090.26,N/A,1633.36,N/A,3589.71,N/A,6803.16,N/A,4017.81,N/A,8743.83,N/A,1633.36,N/A,3608.17,N/A,3608.17,N/A,5443.20,N/A,8743.83,N/A,8743.83,N/A,8743.83,N/A,6803.18,N/A,3608.17,N/A,1633.36,N/A,7661.50,N/A,7661.50,N/A,1633.36,N/A,3608.17,N/A,3589.71,N/A,1915.79,N/A,N/A,1633.36,8743.83,,Hospital 66625,"Remv Iris,Periph for Glaucoma",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15773.25,N/A,9463.95,N/A,2208.26,N/A,3589.71,N/A,9073.92,N/A,5362.90,N/A,8734.87,N/A,2208.26,N/A,3608.17,N/A,3608.17,N/A,5437.62,N/A,8734.87,N/A,8734.87,N/A,8734.87,N/A,9073.94,N/A,3608.17,N/A,2208.26,N/A,8129.25,N/A,8129.25,N/A,2208.26,N/A,3608.17,N/A,3589.71,N/A,2277.39,N/A,N/A,2208.26,9463.95,,Hospital 66820,"Discission,2nd Cataract,Incis",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17169.30,N/A,10301.58,N/A,2403.72,N/A,3589.71,N/A,9884.02,N/A,5837.56,N/A,8745.60,N/A,2403.72,N/A,3608.17,N/A,3608.17,N/A,5444.30,N/A,8745.60,N/A,8745.60,N/A,8745.60,N/A,9884.05,N/A,3608.17,N/A,2403.72,N/A,7793.25,N/A,7793.25,N/A,2403.72,N/A,3608.17,N/A,3589.71,N/A,2045.02,N/A,N/A,2045.02,10301.58,,Hospital CPT 66821,Post-Cataract Laser Surgery,N/A,N/A,557.00,557.00,334.20,334.20,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,N/A,557.00,334.20,334.20,334.20,557.00,,Hospital 66830,"Remv 2nd Cataract,Corn-Scler Sectn",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8975.00,N/A,5385.00,N/A,1256.50,N/A,3589.71,N/A,5167.31,N/A,3051.50,N/A,8730.91,N/A,1256.50,N/A,3608.17,N/A,3608.17,N/A,5435.16,N/A,8730.91,N/A,8730.91,N/A,8730.91,N/A,5167.31,N/A,3608.17,N/A,1256.50,N/A,7661.50,N/A,7661.50,N/A,1256.50,N/A,3608.17,N/A,3589.71,N/A,1642.27,N/A,N/A,1256.50,8730.91,,Hospital CPT 66852,Rmvl Lens Material Pars Plana W/WO Vitrectomy,N/A,N/A,1649.00,1649.00,989.40,989.40,N/A,230.86,N/A,780.60,N/A,1649.00,N/A,560.66,N/A,1649.00,N/A,230.86,N/A,780.60,N/A,780.60,N/A,1452.82,N/A,1649.00,N/A,1649.00,N/A,1649.00,N/A,1649.00,N/A,780.60,N/A,230.86,N/A,1649.00,N/A,1649.00,N/A,230.86,N/A,780.60,N/A,780.60,N/A,858.66,989.40,989.40,230.86,1649.00,,Hospital CPT 66982,Xcapsl Ctrc Rmvl Insj Io Lens Prosth Cplx WO Ecp,N/A,N/A,1555.00,1555.00,933.00,933.00,N/A,217.70,N/A,693.72,N/A,1555.00,N/A,528.70,N/A,1555.00,N/A,217.70,N/A,693.72,N/A,693.72,N/A,1291.60,N/A,1555.00,N/A,1555.00,N/A,1555.00,N/A,1555.00,N/A,693.72,N/A,217.70,N/A,1555.00,N/A,1555.00,N/A,217.70,N/A,693.72,N/A,693.72,N/A,763.09,933.00,933.00,217.70,1555.00,,Hospital 66986,Exchange Intraocular Lens,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33075.15,N/A,19845.09,N/A,4630.52,N/A,3774.30,N/A,19032.25,N/A,11245.55,N/A,8829.23,N/A,4630.52,N/A,3608.17,N/A,3608.17,N/A,5496.35,N/A,8829.23,N/A,8829.23,N/A,8829.23,N/A,19032.26,N/A,3608.17,N/A,4630.52,N/A,7661.50,N/A,7661.50,N/A,4630.52,N/A,3608.17,N/A,3774.30,N/A,1841.07,N/A,N/A,1841.07,19845.09,,Hospital 67005,Rmvl Vitreous Ant Appr Partial Removal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21846.37,N/A,13107.82,N/A,3058.49,N/A,3774.30,N/A,12568.86,N/A,7427.75,N/A,8750.34,N/A,3058.49,N/A,3608.17,N/A,3608.17,N/A,5447.25,N/A,8750.34,N/A,8750.34,N/A,8750.34,N/A,12568.88,N/A,3608.17,N/A,3058.49,N/A,5944.75,N/A,5944.75,N/A,3058.49,N/A,3608.17,N/A,3774.30,N/A,1883.52,N/A,N/A,1883.52,13107.82,,Hospital 67025,Replace Eye Fluid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35544.73,N/A,21326.84,N/A,4976.27,N/A,2074.44,N/A,20462.89,N/A,12085.20,N/A,4747.82,N/A,4976.27,N/A,1950.06,N/A,1950.06,N/A,2955.61,N/A,4747.82,N/A,4747.82,N/A,4747.82,N/A,20462.90,N/A,1950.06,N/A,4976.27,N/A,3397.00,N/A,3397.00,N/A,4976.27,N/A,1950.06,N/A,2074.44,N/A,642.50,N/A,N/A,642.50,21326.84,,Hospital 67028,Inject Intravitreal Pharmcologic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9300.30,N/A,5580.18,N/A,1302.05,N/A,3589.71,N/A,5354.74,N/A,3162.10,N/A,8730.91,N/A,1302.05,N/A,3608.17,N/A,3608.17,N/A,5435.16,N/A,8730.91,N/A,8730.91,N/A,8730.91,N/A,5354.76,N/A,3608.17,N/A,1302.05,N/A,6226.50,N/A,6226.50,N/A,1302.05,N/A,3608.17,N/A,3589.71,N/A,1011.41,N/A,N/A,1011.41,8730.91,,Hospital 67039,"Vitrectomy,Focal Laser Rx Retina",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30059.53,N/A,18035.72,N/A,4208.34,N/A,891.99,N/A,17301.17,N/A,10220.24,N/A,8756.05,N/A,4208.34,N/A,3608.17,N/A,3608.17,N/A,5450.82,N/A,8756.05,N/A,8756.05,N/A,8756.05,N/A,17301.18,N/A,3608.17,N/A,4208.34,N/A,5963.00,N/A,5963.00,N/A,4208.34,N/A,3608.17,N/A,891.99,N/A,981.19,N/A,N/A,891.99,18035.72,,Hospital CPT 67041,Vitrectomy Pars Plana Remove Preretinal Membrane,N/A,N/A,2255.00,2255.00,1353.00,1353.00,N/A,315.70,N/A,1065.50,N/A,2255.00,N/A,766.70,N/A,2255.00,N/A,315.70,N/A,1065.50,N/A,1065.50,N/A,1983.45,N/A,2255.00,N/A,2255.00,N/A,2255.00,N/A,2255.00,N/A,1065.50,N/A,315.70,N/A,2255.00,N/A,2255.00,N/A,315.70,N/A,1065.50,N/A,1065.50,N/A,1172.05,1353.00,1353.00,315.70,2255.00,,Hospital 67107,Repair Retinal Detachment Scleral Buckling,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32015.25,N/A,19209.15,N/A,4476.46,N/A,1887.49,N/A,18423.84,N/A,10885.18,N/A,8768.86,N/A,4476.46,N/A,3608.17,N/A,3608.17,N/A,5458.79,N/A,8768.86,N/A,8768.86,N/A,8768.86,N/A,18423.85,N/A,3608.17,N/A,4476.46,N/A,7793.25,N/A,7793.25,N/A,4476.46,N/A,3608.17,N/A,1887.49,N/A,2076.25,N/A,N/A,1887.49,19209.15,,Hospital CPT 67108,Rpr Retinal Dtchmnt W/Vitrectomy Any Meth,N/A,0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION,2673.00,2673.00,1603.80,1603.80,N/A,374.22,N/A,1109.64,N/A,1539.11,N/A,908.82,N/A,2673.00,N/A,374.22,N/A,1109.64,N/A,1109.64,N/A,2063.90,N/A,2673.00,N/A,2673.00,N/A,2673.00,N/A,1539.11,N/A,1109.64,N/A,374.22,N/A,2673.00,N/A,2673.00,N/A,374.22,N/A,1109.64,N/A,1109.64,N/A,1220.60,1603.80,1603.80,374.22,2673.00,,Hospital CPT 67113,Rpr Complex Retina Detach Vitrect &Membrane Peel,N/A,0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION,2905.00,2905.00,1743.00,1743.00,N/A,406.70,N/A,1239.70,N/A,1672.70,N/A,987.70,N/A,2905.00,N/A,406.70,N/A,1239.70,N/A,1239.70,N/A,2307.07,N/A,2905.00,N/A,2905.00,N/A,2905.00,N/A,1672.70,N/A,1239.70,N/A,406.70,N/A,2905.00,N/A,2905.00,N/A,406.70,N/A,1239.70,N/A,1239.70,N/A,1363.67,1743.00,1743.00,406.70,2905.00,,Hospital 67145,Proph Retinal Dtchmnt W/O Drg Photocoagulation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41069.95,N/A,24641.97,N/A,5749.80,N/A,1309.38,N/A,23627.63,N/A,13963.79,N/A,8905.50,N/A,5749.80,N/A,3608.17,N/A,3608.17,N/A,5543.84,N/A,8905.50,N/A,8905.50,N/A,8905.50,N/A,23627.63,N/A,3608.17,N/A,5749.80,N/A,6678.50,N/A,6678.50,N/A,5749.80,N/A,3608.17,N/A,1309.38,N/A,1440.31,N/A,N/A,1309.38,24641.97,,Hospital CPT 67312,Strabismus Recession/Rescj 2 Hrzntl Musc,N/A,N/A,1390.00,1390.00,834.00,834.00,N/A,194.60,N/A,620.61,N/A,1390.00,N/A,472.60,N/A,1390.00,N/A,194.60,N/A,620.61,N/A,620.61,N/A,1154.64,N/A,1390.00,N/A,1390.00,N/A,1390.00,N/A,1390.00,N/A,620.61,N/A,194.60,N/A,1390.00,N/A,1390.00,N/A,194.60,N/A,620.61,N/A,620.61,N/A,682.67,834.00,834.00,194.60,1390.00,,Hospital 67400,Explore Eye Socket,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7285.30,N/A,4371.18,N/A,1019.94,N/A,3301.92,N/A,4194.60,N/A,2477.00,N/A,7285.30,N/A,1019.94,N/A,3156.58,N/A,3156.58,N/A,4755.14,N/A,7285.30,N/A,7285.30,N/A,7285.30,N/A,4194.60,N/A,3156.58,N/A,1019.94,N/A,4562.00,N/A,4562.00,N/A,1019.94,N/A,3156.58,N/A,3301.92,N/A,1068.99,N/A,N/A,1019.94,7285.30,,Hospital 67414,"Explore Eye Socket,Decompress",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,84755.53,N/A,50853.32,N/A,8909.88,N/A,10230.67,N/A,22203.55,N/A,27880.84,N/A,13668.68,N/A,9184.41,N/A,295612.00,N/A,295612.00,N/A,8509.01,N/A,13668.68,N/A,13668.68,N/A,13668.68,N/A,22203.55,N/A,10201.02,N/A,9184.41,N/A,23859.21,N/A,23859.21,N/A,N/A,N/A,10201.02,N/A,10230.67,N/A,9827.32,N/A,8509.01,295612.00,N/A,N/A,,Hospital 67825,Revise Eyelashes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18427.67,N/A,11056.60,N/A,2579.88,N/A,112.18,N/A,10604.14,N/A,6249.85,N/A,921.22,N/A,2579.88,N/A,358.57,N/A,358.57,N/A,573.48,N/A,921.22,N/A,921.22,N/A,921.22,N/A,10604.16,N/A,358.57,N/A,2579.88,N/A,790.50,N/A,790.50,N/A,2579.88,N/A,358.57,N/A,112.18,N/A,123.40,N/A,N/A,112.18,11056.60,,Hospital 67880,Revision of Eyelid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10231.00,N/A,6138.60,N/A,1432.34,N/A,1997.13,N/A,5890.60,N/A,3478.54,N/A,4621.50,N/A,1432.34,N/A,1909.23,N/A,1909.23,N/A,2876.97,N/A,4621.50,N/A,4621.50,N/A,4621.50,N/A,5890.61,N/A,1909.23,N/A,1432.34,N/A,5095.50,N/A,5095.50,N/A,1432.34,N/A,1909.23,N/A,1997.13,N/A,839.75,N/A,N/A,839.75,6138.60,,Hospital 67900,Repair Brow Ptosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12204.70,N/A,7322.82,N/A,1708.66,N/A,1997.13,N/A,7026.78,N/A,4149.60,N/A,4627.54,N/A,1708.66,N/A,1909.23,N/A,1909.23,N/A,2880.73,N/A,4627.54,N/A,4627.54,N/A,4627.54,N/A,7026.78,N/A,1909.23,N/A,1708.66,N/A,5095.50,N/A,5095.50,N/A,1708.66,N/A,1909.23,N/A,1997.13,N/A,517.33,N/A,N/A,517.33,7322.82,,Hospital 67904,Rpr Blepharoptosis Levator Rescj/Advmnt Xtrnl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18166.70,N/A,10900.02,N/A,2537.66,N/A,556.31,N/A,10457.35,N/A,6176.68,N/A,4626.65,N/A,2537.66,N/A,1909.23,N/A,1909.23,N/A,2880.18,N/A,4626.65,N/A,4626.65,N/A,4626.65,N/A,10457.36,N/A,1909.23,N/A,2537.66,N/A,5095.50,N/A,5095.50,N/A,2537.66,N/A,1909.23,N/A,556.31,N/A,611.94,N/A,N/A,556.31,10900.02,,Hospital 67911,Correct Lid Retractn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14416.70,N/A,8650.02,N/A,2018.34,N/A,1997.13,N/A,8277.04,N/A,4901.68,N/A,4625.98,N/A,2018.34,N/A,1909.23,N/A,1909.23,N/A,2879.77,N/A,4625.98,N/A,4625.98,N/A,4625.98,N/A,8277.04,N/A,1909.23,N/A,2018.34,N/A,3397.00,N/A,3397.00,N/A,2018.34,N/A,1909.23,N/A,1997.13,N/A,571.35,N/A,N/A,571.35,8650.02,,Hospital CPT 67924,Repair Entropion Extensive,N/A,0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION,1068.00,1068.00,640.80,640.80,N/A,149.52,N/A,422.56,N/A,614.95,N/A,363.12,N/A,1068.00,N/A,149.52,N/A,422.56,N/A,422.56,N/A,1068.00,N/A,1068.00,N/A,1068.00,N/A,1068.00,N/A,614.95,N/A,422.56,N/A,149.52,N/A,1068.00,N/A,1068.00,N/A,149.52,N/A,422.56,N/A,422.56,N/A,464.82,640.80,640.80,149.52,1068.00,,Hospital 67950,Canthoplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12209.20,N/A,7325.52,N/A,1709.28,N/A,1997.13,N/A,7029.32,N/A,4151.15,N/A,4631.13,N/A,1709.28,N/A,1909.23,N/A,1909.23,N/A,2882.97,N/A,4631.13,N/A,4631.13,N/A,4631.13,N/A,7029.32,N/A,1909.23,N/A,1709.28,N/A,5944.75,N/A,5944.75,N/A,1709.28,N/A,1909.23,N/A,1997.13,N/A,1702.43,N/A,N/A,1702.43,7325.52,,Hospital 68135,Destruction Lesion Conjunctiva,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34145.28,N/A,20487.17,N/A,4768.92,N/A,313.08,N/A,19573.25,N/A,11609.40,N/A,4626.66,N/A,4768.92,N/A,1909.23,N/A,1909.23,N/A,2880.18,N/A,4626.66,N/A,4626.66,N/A,4626.66,N/A,19573.25,N/A,1909.23,N/A,4768.92,N/A,5095.50,N/A,5095.50,N/A,4768.92,N/A,1909.23,N/A,313.08,N/A,344.39,N/A,N/A,313.08,20487.17,,Hospital 68440,Snip Incision Lacrimal Punctum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10407.40,N/A,6244.44,N/A,1457.04,N/A,1997.13,N/A,5991.88,N/A,3538.51,N/A,4629.91,N/A,1457.04,N/A,1909.23,N/A,1909.23,N/A,2882.22,N/A,4629.91,N/A,4629.91,N/A,4629.91,N/A,5991.88,N/A,1909.23,N/A,1457.04,N/A,3660.50,N/A,3660.50,N/A,1457.04,N/A,1909.23,N/A,1997.13,N/A,714.93,N/A,N/A,714.93,6244.44,,Hospital 68760,Clsr Lacrimal Punctum Thermocaut Lig/Laser,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11651.60,N/A,6990.96,N/A,1631.23,N/A,1997.13,N/A,6708.03,N/A,3961.54,N/A,4628.93,N/A,1631.23,N/A,1909.23,N/A,1909.23,N/A,2881.60,N/A,4628.93,N/A,4628.93,N/A,4628.93,N/A,6708.03,N/A,1909.23,N/A,1631.23,N/A,5227.25,N/A,5227.25,N/A,1631.23,N/A,1909.23,N/A,1997.13,N/A,372.78,N/A,N/A,372.78,6990.96,,Hospital 68815,"Probe Nasolac Duct,Insert Tube/Stent",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11651.60,N/A,6990.96,N/A,1631.23,N/A,1997.13,N/A,6708.03,N/A,3961.54,N/A,4628.93,N/A,1631.23,N/A,1909.23,N/A,1909.23,N/A,2881.60,N/A,4628.93,N/A,4628.93,N/A,4628.93,N/A,6708.03,N/A,1909.23,N/A,1631.23,N/A,5227.25,N/A,5227.25,N/A,1631.23,N/A,1909.23,N/A,1997.13,N/A,372.78,N/A,N/A,372.78,6990.96,,Hospital 68840,Probe Lacrimal Canaliculi W/WO Irrigation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16128.67,N/A,9677.20,N/A,2258.01,N/A,3138.09,N/A,9280.61,N/A,5483.75,N/A,7556.47,N/A,2258.01,N/A,3104.47,N/A,3104.47,N/A,4704.05,N/A,7556.47,N/A,7556.47,N/A,7556.47,N/A,9280.60,N/A,3104.47,N/A,2258.01,N/A,3660.50,N/A,3660.50,N/A,2258.01,N/A,3104.47,N/A,3138.09,N/A,713.32,N/A,N/A,713.32,9677.20,,Hospital 69105,Biopsy of Ext Auditory Canal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25049.03,N/A,15029.42,N/A,3486.70,N/A,4780.29,N/A,14396.90,N/A,8317.91,N/A,11725.66,N/A,3486.70,N/A,4821.94,N/A,4821.94,N/A,7299.45,N/A,11725.66,N/A,11725.66,N/A,11725.66,N/A,14396.92,N/A,4821.94,N/A,3486.70,N/A,6898.50,N/A,6898.50,N/A,3486.70,N/A,4821.94,N/A,4780.29,N/A,1216.11,N/A,N/A,1216.11,15029.42,,Hospital 69120,"Removal External Ear,Total",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31740.27,N/A,19044.16,N/A,4443.64,N/A,5319.17,N/A,18269.85,N/A,10791.71,N/A,11690.08,N/A,4443.64,N/A,4821.94,N/A,4821.94,N/A,7277.29,N/A,11690.08,N/A,11690.08,N/A,11690.08,N/A,18269.86,N/A,4821.94,N/A,4443.64,N/A,7109.75,N/A,7109.75,N/A,4443.64,N/A,4821.94,N/A,2323.56,N/A,2555.92,N/A,N/A,2323.56,19044.16,,Hospital 69140,Excision Exostosis External Auditory Canal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15416.40,N/A,9249.84,N/A,2159.47,N/A,4780.29,N/A,8873.90,N/A,5241.57,N/A,11696.97,N/A,2159.47,N/A,4821.94,N/A,4821.94,N/A,7281.58,N/A,11696.97,N/A,11696.97,N/A,11696.97,N/A,8873.90,N/A,4821.94,N/A,2159.47,N/A,5095.50,N/A,5095.50,N/A,2159.47,N/A,4821.94,N/A,4780.29,N/A,1026.75,N/A,N/A,1026.75,11696.97,,Hospital CPT 69145,Remv Ext Canal Soft Tissue Lesn,N/A,N/A,710.00,710.00,426.00,426.00,N/A,99.40,N/A,242.33,N/A,710.00,N/A,241.40,N/A,710.00,N/A,99.40,N/A,242.33,N/A,242.33,N/A,710.00,N/A,710.00,N/A,710.00,N/A,710.00,N/A,710.00,N/A,242.33,N/A,99.40,N/A,710.00,N/A,710.00,N/A,99.40,N/A,242.33,N/A,242.33,N/A,266.56,426.00,426.00,99.40,710.00,,Hospital CPT 69205,Rmvl FB Xtrnl Auditory Canal Anes,N/A,N/A,200.00,200.00,120.00,120.00,N/A,28.00,N/A,89.44,N/A,200.00,N/A,68.00,N/A,200.00,N/A,28.00,N/A,89.44,N/A,89.44,N/A,168.80,N/A,200.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,89.44,N/A,28.00,N/A,200.00,N/A,200.00,N/A,28.00,N/A,89.44,N/A,89.44,N/A,98.38,120.00,120.00,28.00,200.00,,Hospital 69310,Reconstruction External Auditory Canal Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34571.13,N/A,20742.68,N/A,4839.97,N/A,4987.25,N/A,19857.93,N/A,11754.18,N/A,11713.13,N/A,4839.97,N/A,4821.94,N/A,4821.94,N/A,7291.65,N/A,11713.13,N/A,11713.13,N/A,11713.13,N/A,19857.91,N/A,4821.94,N/A,4839.97,N/A,6898.50,N/A,6898.50,N/A,4839.97,N/A,4821.94,N/A,4987.25,N/A,1309.96,N/A,N/A,1309.96,20742.68,,Hospital 69420,"Incision Eardrum,Aspir",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16539.03,N/A,9923.42,N/A,2315.47,N/A,4821.94,N/A,9510.08,N/A,5623.28,N/A,11762.97,N/A,2315.47,N/A,4821.94,N/A,4821.94,N/A,7322.66,N/A,11762.97,N/A,11762.97,N/A,11762.97,N/A,9510.09,N/A,4821.94,N/A,2315.47,N/A,9076.25,N/A,9076.25,N/A,2315.47,N/A,4821.94,N/A,4821.94,N/A,5304.13,N/A,N/A,2315.47,11762.97,,Hospital 69421,Myringotomy Aspir&/Eustachian Tube Nfltj Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14873.18,N/A,8923.91,N/A,2082.24,N/A,4821.94,N/A,8558.48,N/A,5056.88,N/A,11676.57,N/A,2082.24,N/A,4821.94,N/A,4821.94,N/A,7268.88,N/A,11676.57,N/A,11676.57,N/A,11676.57,N/A,8558.49,N/A,4821.94,N/A,2082.24,N/A,6898.50,N/A,6898.50,N/A,2082.24,N/A,4821.94,N/A,4821.94,N/A,5304.13,N/A,N/A,2082.24,11676.57,,Hospital CPT 69436,Tympanostomy General Anesthesia,N/A,N/A,316.00,316.00,189.60,189.60,N/A,44.24,N/A,150.65,N/A,316.00,N/A,107.44,N/A,316.00,N/A,44.24,N/A,150.65,N/A,150.65,N/A,281.28,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,150.65,N/A,44.24,N/A,316.00,N/A,316.00,N/A,44.24,N/A,150.65,N/A,150.65,N/A,165.72,189.60,189.60,44.24,316.00,,Hospital 69450,Eardrum Revision,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,86231.43,N/A,51738.86,N/A,12072.40,N/A,5043.96,N/A,49636.73,N/A,29318.68,N/A,11753.54,N/A,12072.40,N/A,4821.94,N/A,4821.94,N/A,7320.10,N/A,11753.54,N/A,11753.54,N/A,11753.54,N/A,49636.76,N/A,4821.94,N/A,12072.40,N/A,8944.50,N/A,8944.50,N/A,12072.40,N/A,4821.94,N/A,5043.96,N/A,2242.11,N/A,N/A,2242.11,51738.86,,Hospital 69540,Excision Aural Polyp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8833.10,N/A,5299.86,N/A,1236.63,N/A,1311.26,N/A,5081.00,N/A,2814.01,N/A,3113.85,N/A,1236.63,N/A,1253.55,N/A,1253.55,N/A,1938.43,N/A,3113.85,N/A,3113.85,N/A,3113.85,N/A,5080.99,N/A,1253.55,N/A,1236.63,N/A,1871.00,N/A,1871.00,N/A,1236.63,N/A,1253.55,N/A,1311.26,N/A,231.84,N/A,N/A,231.84,5299.86,,Hospital 69550,"Remv Aural Glomus Tumor,Transcanal",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34451.28,N/A,20670.77,N/A,4852.10,N/A,5043.96,N/A,19831.77,N/A,11713.44,N/A,11750.56,N/A,4852.10,N/A,4821.94,N/A,4821.94,N/A,7314.94,N/A,11750.56,N/A,11750.56,N/A,11750.56,N/A,19831.77,N/A,4821.94,N/A,4852.10,N/A,5963.00,N/A,5963.00,N/A,4852.10,N/A,4821.94,N/A,5043.96,N/A,1443.95,N/A,N/A,1443.95,20670.77,,Hospital 69620,Myringoplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15288.30,N/A,9172.98,N/A,2140.36,N/A,2622.61,N/A,8803.00,N/A,5198.02,N/A,6214.61,N/A,2140.36,N/A,2569.18,N/A,2569.18,N/A,3868.72,N/A,6214.61,N/A,6214.61,N/A,6214.61,N/A,8803.01,N/A,2569.18,N/A,2140.36,N/A,7692.25,N/A,7692.25,N/A,2140.36,N/A,2569.18,N/A,2622.61,N/A,578.90,N/A,N/A,578.90,9172.98,,Hospital 69632,Tympnoplsty W/O Mstdc 1st/Revj W/Osicle Recnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42661.80,N/A,25597.08,N/A,5972.64,N/A,5043.96,N/A,24503.68,N/A,14505.02,N/A,11774.80,N/A,5972.64,N/A,4821.94,N/A,4821.94,N/A,7330.02,N/A,11774.80,N/A,11774.80,N/A,11774.80,N/A,24503.69,N/A,4821.94,N/A,5972.64,N/A,5963.00,N/A,5963.00,N/A,5972.64,N/A,4821.94,N/A,5043.96,N/A,1139.67,N/A,N/A,1139.67,25597.08,,Hospital 69635,Tympp Antrt/Mastoid W/O Ossicular Chain Recnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39167.02,N/A,23500.21,N/A,5483.39,N/A,1475.35,N/A,22540.95,N/A,11672.01,N/A,11726.08,N/A,5483.39,N/A,4821.94,N/A,4821.94,N/A,7299.70,N/A,11726.08,N/A,11726.08,N/A,11726.08,N/A,22540.99,N/A,4821.94,N/A,5483.39,N/A,6898.50,N/A,6898.50,N/A,5483.39,N/A,4821.94,N/A,1475.35,N/A,1622.89,N/A,N/A,1475.35,23500.21,,Hospital 69642,"Tympanoplas/Mastoidec,Rebld Ossicles",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63669.38,N/A,38201.63,N/A,8772.84,N/A,4991.18,N/A,36610.71,N/A,21647.60,N/A,11727.01,N/A,8772.84,N/A,4825.87,N/A,4825.87,N/A,7300.29,N/A,11727.01,N/A,11727.01,N/A,11727.01,N/A,36610.73,N/A,4825.87,N/A,8772.84,N/A,6898.50,N/A,6898.50,N/A,8772.84,N/A,4825.87,N/A,4991.18,N/A,1625.93,N/A,N/A,1625.93,38201.63,,Hospital 69644,Tmpp Mastoidect Ntc/Rcnsted Canal Wall Ocr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32982.77,N/A,19789.66,N/A,4617.60,N/A,1437.13,N/A,18970.39,N/A,10391.64,N/A,11809.97,N/A,4617.60,N/A,4821.94,N/A,4821.94,N/A,7351.92,N/A,11809.97,N/A,11809.97,N/A,11809.97,N/A,18970.42,N/A,4821.94,N/A,4617.60,N/A,5963.00,N/A,5963.00,N/A,4617.60,N/A,4821.94,N/A,1437.13,N/A,1580.84,N/A,N/A,1437.13,19789.66,,Hospital 69661,"Stapedectomy,Footplate Drill Out",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35121.23,N/A,21072.74,N/A,4916.98,N/A,5319.17,N/A,20184.38,N/A,11941.22,N/A,11708.34,N/A,4916.98,N/A,4821.94,N/A,4821.94,N/A,7288.66,N/A,11708.34,N/A,11708.34,N/A,11708.34,N/A,20184.40,N/A,4821.94,N/A,4916.98,N/A,8510.75,N/A,8510.75,N/A,4916.98,N/A,4821.94,N/A,1639.69,N/A,1454.01,N/A,N/A,1454.01,21072.74,,Hospital 69662,Revise Stapedectomy/Stapedotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19813.80,N/A,11888.28,N/A,2773.94,N/A,4797.27,N/A,11406.43,N/A,6736.70,N/A,11705.17,N/A,2773.94,N/A,4821.94,N/A,4821.94,N/A,7297.60,N/A,11705.17,N/A,11705.17,N/A,11705.17,N/A,11406.44,N/A,4821.94,N/A,2773.94,N/A,6898.50,N/A,6898.50,N/A,2773.94,N/A,4821.94,N/A,4797.27,N/A,1809.94,N/A,N/A,1809.94,11888.28,,Hospital 69717,Revj/Rplcmt Oi Implt Skull Perq Attachment Esp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39115.10,N/A,23469.06,N/A,5476.12,N/A,5942.72,N/A,22304.56,N/A,13299.14,N/A,14479.10,N/A,5476.12,N/A,5973.28,N/A,5973.28,N/A,9013.51,N/A,14479.10,N/A,14479.10,N/A,14479.10,N/A,22304.57,N/A,5973.28,N/A,5476.12,N/A,5963.00,N/A,5963.00,N/A,5476.12,N/A,5973.28,N/A,5942.72,N/A,44948.98,N/A,N/A,5476.12,44948.98,,Hospital 69727,Removal Oi Implt Skull Mag Tc Attachment Esp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10637.30,N/A,6382.38,N/A,1489.21,N/A,2664.83,N/A,6123.14,N/A,3616.68,N/A,6521.99,N/A,1489.21,N/A,2688.04,N/A,2688.04,N/A,4060.07,N/A,6521.99,N/A,6521.99,N/A,6521.99,N/A,6123.16,N/A,2688.04,N/A,1489.21,N/A,4562.00,N/A,4562.00,N/A,1489.21,N/A,2688.04,N/A,2664.83,N/A,503.66,N/A,N/A,503.66,6521.99,,Hospital 69990,Microsurg Tqs Req Use Operating Microscope,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25221.32,N/A,15132.79,N/A,3530.98,N/A,5973.28,N/A,14519.36,N/A,8575.24,N/A,14497.35,N/A,3530.98,N/A,5973.28,N/A,5973.28,N/A,9024.87,N/A,14497.35,N/A,14497.35,N/A,14497.35,N/A,14519.36,N/A,5973.28,N/A,3530.98,N/A,3660.50,N/A,3660.50,N/A,3530.98,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,3530.98,15132.79,,Hospital CPT 70100,HC Mandible Partial Less Than 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,582.00,459.00,349.20,275.40,N/A,64.26,N/A,82.07,N/A,264.29,N/A,156.06,N/A,189.77,N/A,64.26,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,264.29,N/A,78.46,N/A,64.26,N/A,246.02,N/A,246.02,N/A,64.26,N/A,78.46,N/A,82.07,N/A,29.43,349.20,349.20,29.43,275.40,,Hospital CPT 70150,HC Facial Bones Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1278.00,1278.00,766.80,766.80,N/A,178.92,N/A,100.96,N/A,735.87,N/A,434.52,N/A,233.46,N/A,178.92,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,735.87,N/A,96.52,N/A,178.92,N/A,685.01,N/A,685.01,N/A,178.92,N/A,96.52,N/A,100.96,N/A,34.72,766.80,766.80,34.72,766.80,,Hospital CPT 70160,HC Nasal Bones Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1147.00,1147.00,688.20,688.20,N/A,160.58,N/A,82.07,N/A,660.44,N/A,389.98,N/A,189.77,N/A,160.58,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,660.44,N/A,78.46,N/A,160.58,N/A,614.79,N/A,614.79,N/A,160.58,N/A,78.46,N/A,82.07,N/A,29.43,688.20,688.20,29.43,688.20,,Hospital CPT 70220,HC Sinuses Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,890.00,890.00,534.00,534.00,N/A,124.60,N/A,78.46,N/A,512.46,N/A,302.60,N/A,189.77,N/A,124.60,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,512.46,N/A,78.46,N/A,124.60,N/A,477.04,N/A,477.04,N/A,124.60,N/A,78.46,N/A,78.46,N/A,86.30,534.00,534.00,78.46,534.00,,Hospital CPT 70330,HC Tmj Open/Closed Mouth Bilateral,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,633.00,633.00,379.80,379.80,N/A,88.62,N/A,37.88,N/A,364.48,N/A,215.22,N/A,189.77,N/A,88.62,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,364.48,N/A,78.46,N/A,88.62,N/A,339.29,N/A,339.29,N/A,88.62,N/A,78.46,N/A,82.07,N/A,41.67,379.80,379.80,37.88,379.80,,Hospital 70350,HC X-Ray Head for Orthodontia,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,181.00,N/A,108.60,N/A,25.34,N/A,81.15,N/A,104.22,N/A,61.54,N/A,181.00,N/A,25.34,N/A,78.46,N/A,78.46,N/A,118.14,N/A,181.00,N/A,181.00,N/A,181.00,N/A,104.22,N/A,78.46,N/A,25.34,N/A,97.02,N/A,97.02,N/A,25.34,N/A,78.46,N/A,81.15,N/A,7.59,N/A,N/A,7.59,181.00,,Hospital CPT 70470,HC CT Brain W/WO Contrast,N/A,0351 - CT SCAN - HEAD SCAN,3318.00,2428.00,1990.80,1456.80,N/A,339.92,N/A,162.85,N/A,914.00,N/A,825.52,N/A,393.92,N/A,339.92,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,339.92,N/A,689.00,N/A,689.00,N/A,339.92,N/A,162.85,N/A,162.85,N/A,179.14,1990.80,1990.80,162.85,1456.80,,Hospital CPT 70491,HC CT Soft Tissue Neck W/ Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2949.00,2108.00,1769.40,1264.80,N/A,295.12,N/A,162.85,N/A,914.00,N/A,716.72,N/A,393.92,N/A,295.12,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,295.12,N/A,689.00,N/A,689.00,N/A,295.12,N/A,162.85,N/A,162.85,N/A,179.14,1769.40,1769.40,162.85,1264.80,,Hospital CPT 70492,HC CT Soft Tissue Neck W/WO Contrast,N/A,0351 - CT SCAN - HEAD SCAN,3318.00,2428.00,1990.80,1456.80,N/A,339.92,N/A,162.85,N/A,914.00,N/A,825.52,N/A,393.92,N/A,339.92,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,339.92,N/A,689.00,N/A,689.00,N/A,339.92,N/A,162.85,N/A,162.85,N/A,179.14,1990.80,1990.80,162.85,1456.80,,Hospital CPT 70543,HC MRI Face Neck Eye W & WO Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3447.00,2660.00,2068.20,1596.00,N/A,372.40,N/A,332.71,N/A,1110.00,N/A,904.40,N/A,804.78,N/A,372.40,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,372.40,N/A,1060.00,N/A,1060.00,N/A,372.40,N/A,332.71,N/A,332.71,N/A,365.98,2068.20,2068.20,332.71,1596.00,,Hospital CPT 70549,HC MRI-Angio Neck WO & W Contra,N/A,0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK,3447.00,2660.00,2068.20,1596.00,N/A,372.40,N/A,339.63,N/A,1110.00,N/A,904.40,N/A,804.78,N/A,372.40,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,372.40,N/A,1060.00,N/A,1060.00,N/A,372.40,N/A,332.71,N/A,329.83,N/A,274.18,2068.20,2068.20,274.18,1596.00,,Hospital 70554,HC MRI Brain Functional W/O Phys Admin,N/A,0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN/BRAINSTEM,N/A,2963.00,N/A,1777.80,N/A,414.82,N/A,220.59,N/A,1110.00,N/A,1007.42,N/A,510.09,N/A,414.82,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,414.82,N/A,1060.00,N/A,1060.00,N/A,414.82,N/A,210.88,N/A,220.59,N/A,297.00,N/A,N/A,210.88,1777.80,,Hospital Custom 7100000010,HC Phase II Recovery - First 15 Min,N/A,0710 - RECOVERY ROOM - GENERAL CLASSIFICATION,387.00,387.00,232.20,232.20,N/A,54.18,N/A,387.00,N/A,222.83,N/A,131.58,N/A,54.18,N/A,54.18,N/A,387.00,N/A,387.00,N/A,33.67,N/A,54.18,N/A,54.18,N/A,54.18,N/A,222.83,N/A,387.00,N/A,54.18,N/A,207.43,N/A,207.43,N/A,54.18,N/A,387.00,N/A,387.00,N/A,387.00,232.20,232.20,33.67,387.00,,Hospital Custom 7100000011,HC Phase II Recovery - Addtl 15 Min,N/A,0710 - RECOVERY ROOM - GENERAL CLASSIFICATION,72.00,72.00,43.20,43.20,N/A,10.08,N/A,72.00,N/A,41.46,N/A,24.48,N/A,10.08,N/A,10.08,N/A,72.00,N/A,72.00,N/A,6.26,N/A,10.08,N/A,10.08,N/A,10.08,N/A,41.46,N/A,72.00,N/A,10.08,N/A,38.59,N/A,38.59,N/A,10.08,N/A,72.00,N/A,72.00,N/A,72.00,43.20,43.20,6.26,72.00,,Hospital CPT 71045,HC X-Ray Exam Chest 1 View,N/A,0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY,739.00,739.00,443.40,443.40,N/A,103.46,N/A,78.46,N/A,425.52,N/A,251.26,N/A,189.77,N/A,103.46,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,425.52,N/A,78.46,N/A,103.46,N/A,396.10,N/A,396.10,N/A,103.46,N/A,78.46,N/A,78.46,N/A,86.30,443.40,443.40,78.46,443.40,,Hospital CPT 71048,HC X-Ray Exam Chest 4+ Views,N/A,0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY,856.00,856.00,513.60,513.60,N/A,119.84,N/A,99.83,N/A,492.88,N/A,291.04,N/A,233.46,N/A,119.84,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,492.88,N/A,96.52,N/A,119.84,N/A,458.82,N/A,458.82,N/A,119.84,N/A,96.52,N/A,102.67,N/A,31.08,513.60,513.60,31.08,513.60,,Hospital CPT 71275,HC CT Angio Chest W & W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,162.85,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1034.40,,Hospital CPT 71551,HC MRI-Chest W Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,676.17,N/A,1110.00,N/A,951.32,N/A,1618.07,N/A,391.72,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1110.00,N/A,668.93,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,668.93,N/A,676.17,N/A,313.53,2454.00,2454.00,313.53,1678.80,,Hospital CPT 72050,HC C-Spine Min 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1246.00,1246.00,747.60,747.60,N/A,174.44,N/A,96.52,N/A,717.45,N/A,423.64,N/A,233.46,N/A,174.44,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,717.45,N/A,96.52,N/A,174.44,N/A,667.86,N/A,667.86,N/A,174.44,N/A,96.52,N/A,96.52,N/A,106.17,747.60,747.60,96.52,747.60,,Hospital 72080,HC Spine Thoracolumbar 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,66489.60,719.00,39893.76,431.40,4610.18,100.66,5719.23,82.07,10389.41,414.00,22606.46,244.46,10488.80,189.77,4752.23,100.66,7908.55,78.46,3372.00,78.46,6529.03,118.14,10488.80,189.77,10488.80,189.77,10488.80,189.77,10389.41,414.00,5719.23,78.46,4752.23,100.66,12479.05,385.38,12479.05,385.38,4148.11,100.66,5719.23,78.46,5719.23,82.07,5084.88,48.26,3372.00,39893.76,48.26,431.40,,Hospital CPT 72081,HC X-Ray Exam Entire Spine 1 Vw,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,469.00,469.00,281.40,281.40,N/A,65.66,N/A,78.46,N/A,270.05,N/A,159.46,N/A,189.77,N/A,65.66,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,270.05,N/A,78.46,N/A,65.66,N/A,251.38,N/A,251.38,N/A,65.66,N/A,78.46,N/A,78.46,N/A,86.30,281.40,281.40,65.66,281.40,,Hospital CPT 72082,HC X-Ray Exam Entire Spine 2/3 Vw,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,999.00,999.00,599.40,599.40,N/A,139.86,N/A,96.52,N/A,575.22,N/A,339.66,N/A,233.46,N/A,139.86,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,575.22,N/A,96.52,N/A,139.86,N/A,535.46,N/A,535.46,N/A,139.86,N/A,96.52,N/A,96.52,N/A,106.17,599.40,599.40,96.52,599.40,,Hospital CPT 72127,HC CT C-Spine W/WO Contrast,N/A,0352 - CT SCAN - BODY SCAN,3318.00,2428.00,1990.80,1456.80,N/A,339.92,N/A,161.45,N/A,914.00,N/A,825.52,N/A,393.92,N/A,339.92,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,339.92,N/A,689.00,N/A,689.00,N/A,339.92,N/A,162.85,N/A,162.85,N/A,144.86,1990.80,1990.80,144.86,1456.80,,Hospital CPT 72128,HC CT T-Spine W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 72130,HC CT T-Spine W/WO Contrast,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,173.24,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,173.24,N/A,145.85,1872.00,1872.00,145.85,1369.80,,Hospital CPT 72141,HC MRI-Spine Cervical WO Contrast,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),2976.00,2015.00,1785.60,1209.00,N/A,282.10,N/A,210.88,N/A,1110.00,N/A,685.10,N/A,510.09,N/A,282.10,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,282.10,N/A,1060.00,N/A,1060.00,N/A,282.10,N/A,210.88,N/A,210.88,N/A,231.97,1785.60,1785.60,210.88,1209.00,,Hospital CPT 72142,HC MRI-Spine Cervical W Contrast,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),3718.00,2544.00,2230.80,1526.40,N/A,356.16,N/A,344.11,N/A,1110.00,N/A,864.96,N/A,804.78,N/A,356.16,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,356.16,N/A,1060.00,N/A,1060.00,N/A,356.16,N/A,332.71,N/A,344.11,N/A,203.74,2230.80,2230.80,203.74,1526.40,,Hospital CPT 72170,HC Pelvis Ap Only,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,404.00,404.00,242.40,242.40,N/A,56.56,N/A,96.52,N/A,232.62,N/A,137.36,N/A,233.46,N/A,56.56,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,232.62,N/A,96.52,N/A,56.56,N/A,216.54,N/A,216.54,N/A,56.56,N/A,96.52,N/A,96.52,N/A,106.17,242.40,242.40,56.56,242.40,,Hospital CPT 72193,HC CT Pelvis W/ Contrast,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1982.00,1664.40,1189.20,N/A,277.48,N/A,167.20,N/A,914.00,N/A,673.88,N/A,393.92,N/A,277.48,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,277.48,N/A,689.00,N/A,689.00,N/A,277.48,N/A,162.85,N/A,170.35,N/A,186.56,1664.40,1664.40,162.85,1189.20,,Hospital CPT 72195,HC MRI-Pelvis WO Contrast,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1461.00,,Hospital CPT 72285,HC Diskography Cerv/Thorac S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,3886.00,3586.00,2331.60,2151.60,N/A,502.04,N/A,64.34,N/A,2064.82,N/A,1219.24,N/A,357.54,N/A,502.04,N/A,64.34,N/A,64.34,N/A,222.57,N/A,357.54,N/A,357.54,N/A,357.54,N/A,2064.82,N/A,64.34,N/A,502.04,N/A,1922.10,N/A,1922.10,N/A,502.04,N/A,64.34,N/A,64.34,N/A,70.77,2331.60,2331.60,64.34,2151.60,,Hospital CPT 72295,HC Lumbar Diskography,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4675.00,3691.00,2805.00,2214.60,N/A,516.74,N/A,1678.88,N/A,2125.28,N/A,1254.94,N/A,3691.00,N/A,516.74,N/A,1623.23,N/A,1623.23,N/A,2444.31,N/A,3691.00,N/A,3691.00,N/A,3691.00,N/A,2125.28,N/A,1623.23,N/A,516.74,N/A,1978.38,N/A,1978.38,N/A,516.74,N/A,1623.23,N/A,1678.88,N/A,71.76,2805.00,2805.00,71.76,3691.00,,Hospital CPT 73030,HC Shoulder Complete Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,995.00,995.00,597.00,597.00,N/A,139.30,N/A,78.46,N/A,572.92,N/A,338.30,N/A,189.77,N/A,139.30,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,572.92,N/A,78.46,N/A,139.30,N/A,533.32,N/A,533.32,N/A,139.30,N/A,78.46,N/A,78.46,N/A,86.30,597.00,597.00,78.46,597.00,,Hospital CPT 73080,HC Elbow Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,928.00,848.00,556.80,508.80,N/A,118.72,N/A,78.46,N/A,488.28,N/A,288.32,N/A,189.77,N/A,118.72,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,488.28,N/A,78.46,N/A,118.72,N/A,454.53,N/A,454.53,N/A,118.72,N/A,78.46,N/A,78.46,N/A,86.30,556.80,556.80,78.46,508.80,,Hospital CPT 73090,HC Forearm 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,886.00,886.00,531.60,531.60,N/A,124.04,N/A,78.46,N/A,510.16,N/A,301.24,N/A,189.77,N/A,124.04,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,510.16,N/A,78.46,N/A,124.04,N/A,474.90,N/A,474.90,N/A,124.04,N/A,78.46,N/A,78.46,N/A,86.30,531.60,531.60,78.46,531.60,,Hospital CPT 73092,HC Forearm Infant Ue Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,565.00,565.00,339.00,339.00,N/A,79.10,N/A,96.02,N/A,325.33,N/A,192.10,N/A,233.46,N/A,79.10,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,325.33,N/A,96.52,N/A,79.10,N/A,302.84,N/A,302.84,N/A,79.10,N/A,96.52,N/A,96.02,N/A,23.80,339.00,339.00,23.80,339.00,,Hospital CPT 73110,HC Wrist Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,841.00,841.00,504.60,504.60,N/A,117.74,N/A,78.46,N/A,484.25,N/A,285.94,N/A,189.77,N/A,117.74,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,484.25,N/A,78.46,N/A,117.74,N/A,450.78,N/A,450.78,N/A,117.74,N/A,78.46,N/A,78.46,N/A,86.30,504.60,504.60,78.46,504.60,,Hospital CPT 73115,HC Arthrogram Wrist S&I,N/A,0322 - RADIOLOGY - DIAGNOSTIC - ARTHROGRAPHY,2645.00,2645.00,1587.00,1587.00,N/A,370.30,N/A,348.82,N/A,1522.99,N/A,899.30,N/A,804.78,N/A,370.30,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1522.99,N/A,332.71,N/A,370.30,N/A,1417.72,N/A,1417.72,N/A,370.30,N/A,332.71,N/A,99.83,N/A,109.81,1587.00,1587.00,99.83,1587.00,,Hospital CPT 73130,HC Hand Routine Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,843.00,843.00,505.80,505.80,N/A,118.02,N/A,78.46,N/A,485.40,N/A,286.62,N/A,189.77,N/A,118.02,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,485.40,N/A,78.46,N/A,118.02,N/A,451.85,N/A,451.85,N/A,118.02,N/A,78.46,N/A,78.46,N/A,86.30,505.80,505.80,78.46,505.80,,Hospital CPT 73219,HC MRI-Upper Ext W Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,348.03,N/A,1110.00,N/A,951.32,N/A,804.78,N/A,391.72,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,332.71,N/A,348.03,N/A,271.89,2454.00,2454.00,271.89,1678.80,,Hospital CPT 73501,HC Extrem Low Hip 1 Vw,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,179.00,179.00,107.40,107.40,N/A,25.06,N/A,21.04,N/A,103.07,N/A,60.86,N/A,179.00,N/A,25.06,N/A,78.46,N/A,78.46,N/A,118.14,N/A,179.00,N/A,179.00,N/A,179.00,N/A,103.07,N/A,78.46,N/A,25.06,N/A,95.94,N/A,95.94,N/A,25.06,N/A,78.46,N/A,82.07,N/A,86.30,107.40,107.40,21.04,179.00,,Hospital CPT 73523,HC X-Ray Exam Bil Hips 5/> Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1563.00,1563.00,937.80,937.80,N/A,218.82,N/A,41.79,N/A,899.98,N/A,531.42,N/A,233.46,N/A,218.82,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,899.98,N/A,96.52,N/A,218.82,N/A,837.77,N/A,837.77,N/A,218.82,N/A,96.52,N/A,41.79,N/A,45.97,937.80,937.80,41.79,937.80,,Hospital CPT 73562,HC X-Ray Knee 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,589.00,589.00,353.40,353.40,N/A,82.46,N/A,78.46,N/A,339.15,N/A,200.26,N/A,189.77,N/A,82.46,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,339.15,N/A,78.46,N/A,82.46,N/A,315.70,N/A,315.70,N/A,82.46,N/A,78.46,N/A,78.46,N/A,86.30,353.40,353.40,78.46,353.40,,Hospital CPT 73580,HC Arthrogram Knee Flouro X-Ray,N/A,0322 - RADIOLOGY - DIAGNOSTIC - ARTHROGRAPHY,1310.00,1310.00,786.00,786.00,N/A,183.40,N/A,348.03,N/A,754.30,N/A,445.40,N/A,804.78,N/A,183.40,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,754.30,N/A,332.71,N/A,183.40,N/A,702.16,N/A,702.16,N/A,183.40,N/A,332.71,N/A,348.03,N/A,120.07,786.00,786.00,120.07,804.78,,Hospital CPT 73590,HC X-Ray Tibia/Fibula 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1526.00,1526.00,915.60,915.60,N/A,213.64,N/A,78.46,N/A,878.67,N/A,518.84,N/A,189.77,N/A,213.64,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,878.67,N/A,78.46,N/A,213.64,N/A,817.94,N/A,817.94,N/A,213.64,N/A,78.46,N/A,78.46,N/A,86.30,915.60,915.60,78.46,915.60,,Hospital CPT 73600,HC X-Ray Ankle 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,781.00,781.00,468.60,468.60,N/A,109.34,N/A,78.46,N/A,449.70,N/A,265.54,N/A,189.77,N/A,109.34,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,449.70,N/A,78.46,N/A,109.34,N/A,418.62,N/A,418.62,N/A,109.34,N/A,78.46,N/A,78.46,N/A,86.30,468.60,468.60,78.46,468.60,,Hospital CPT 73620,HC X-Ray Foot 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,748.00,748.00,448.80,448.80,N/A,104.72,N/A,78.46,N/A,430.70,N/A,254.32,N/A,189.77,N/A,104.72,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,430.70,N/A,78.46,N/A,104.72,N/A,400.93,N/A,400.93,N/A,104.72,N/A,78.46,N/A,78.46,N/A,86.30,448.80,448.80,78.46,448.80,,Hospital CPT 73660,HC X-Ray Toes Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,651.00,651.00,390.60,390.60,N/A,91.14,N/A,78.46,N/A,374.85,N/A,221.34,N/A,189.77,N/A,91.14,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,374.85,N/A,78.46,N/A,91.14,N/A,348.94,N/A,348.94,N/A,91.14,N/A,78.46,N/A,78.46,N/A,86.30,390.60,390.60,78.46,390.60,,Hospital CPT 73701,HC CT Lower Ext W/ Cont,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1982.00,1664.40,1189.20,N/A,277.48,N/A,161.45,N/A,914.00,N/A,673.88,N/A,393.92,N/A,277.48,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,277.48,N/A,689.00,N/A,689.00,N/A,277.48,N/A,162.85,N/A,170.35,N/A,117.41,1664.40,1664.40,117.41,1189.20,,Hospital CPT 73702,HC CT Lower Ext W&W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,162.85,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1369.80,,Hospital CPT 73719,HC MRI Lower Ext W/ Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,348.03,N/A,1110.00,N/A,951.32,N/A,804.78,N/A,391.72,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,332.71,N/A,348.03,N/A,198.78,2454.00,2454.00,198.78,1678.80,,Hospital CPT 73720,HC MRI Lower Ext W&W/O Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,332.71,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1930.80,,Hospital CPT 73723,HC MRI Lower Ext Jnt W&W/O Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,332.71,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1930.80,,Hospital CPT 74018,HC X-Ray Exam Abdomen 1 View,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,385.00,385.00,231.00,231.00,N/A,53.90,N/A,78.46,N/A,221.68,N/A,130.90,N/A,189.77,N/A,53.90,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,221.68,N/A,78.46,N/A,53.90,N/A,206.36,N/A,206.36,N/A,53.90,N/A,78.46,N/A,78.46,N/A,86.30,231.00,231.00,53.90,231.00,,Hospital CPT 74170,HC CT Abd W&W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,162.85,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1369.80,,Hospital CPT 74176,HC CT Abd/Pelvis W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,4853.00,1724.00,2911.80,1034.40,N/A,241.36,N/A,210.88,N/A,914.00,N/A,586.16,N/A,510.09,N/A,241.36,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,914.00,N/A,210.88,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,210.88,N/A,210.88,N/A,231.97,2911.80,2911.80,210.88,1034.40,,Hospital CPT 74178,HC CT Abd/Pelvis W W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,6416.00,2283.00,3849.60,1369.80,N/A,319.62,N/A,332.71,N/A,914.00,N/A,776.22,N/A,804.78,N/A,319.62,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,332.71,N/A,332.71,N/A,365.98,3849.60,3849.60,319.62,1369.80,,Hospital CPT 74181,HC MRI-Abdomen WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1461.00,,Hospital CPT 74181,HC MRI-Mrcp Cholangiogram,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1461.00,,Hospital CPT 74220,HC Fluro Esophagram,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,914.00,914.00,548.40,548.40,N/A,127.96,N/A,162.85,N/A,526.28,N/A,310.76,N/A,393.92,N/A,127.96,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,526.28,N/A,162.85,N/A,127.96,N/A,489.90,N/A,489.90,N/A,127.96,N/A,162.85,N/A,162.85,N/A,179.14,548.40,548.40,127.96,548.40,,Hospital CPT 74248,HC Radiologic Small Intestine Follow-Through Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,894.00,708.00,536.40,424.80,N/A,99.12,N/A,708.00,N/A,407.67,N/A,240.72,N/A,708.00,N/A,99.12,N/A,708.00,N/A,708.00,N/A,708.00,N/A,708.00,N/A,708.00,N/A,708.00,N/A,407.67,N/A,708.00,N/A,99.12,N/A,379.49,N/A,379.49,N/A,99.12,N/A,708.00,N/A,708.00,N/A,708.00,536.40,536.40,99.12,708.00,,Hospital CPT 74250,HC Radiologic Exam Small Int Single Contrast Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1688.00,1334.00,1012.80,800.40,N/A,186.76,N/A,176.47,N/A,768.12,N/A,453.56,N/A,393.92,N/A,186.76,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,768.12,N/A,162.85,N/A,186.76,N/A,715.02,N/A,715.02,N/A,186.76,N/A,162.85,N/A,170.35,N/A,86.66,1012.80,1012.80,86.66,800.40,,Hospital 74283,HC Enema Thera Contrast or Air,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,95656.28,N/A,57393.77,N/A,13098.63,N/A,15760.65,N/A,30695.94,N/A,32523.14,N/A,29801.19,N/A,13502.22,N/A,15760.65,N/A,15760.65,N/A,18550.55,N/A,29801.19,N/A,29801.19,N/A,29801.19,N/A,30695.94,N/A,15760.65,N/A,13502.22,N/A,35455.98,N/A,35455.98,N/A,13502.22,N/A,15760.65,N/A,15760.65,N/A,14447.37,N/A,13098.63,57393.77,N/A,N/A,,Hospital CPT 74300,HC Operative Cholangiogram,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1667.00,1319.00,1000.20,791.40,N/A,184.66,N/A,1319.00,N/A,759.48,N/A,448.46,N/A,1319.00,N/A,184.66,N/A,1319.00,N/A,1319.00,N/A,1319.00,N/A,1319.00,N/A,1319.00,N/A,1319.00,N/A,759.48,N/A,1319.00,N/A,184.66,N/A,706.98,N/A,706.98,N/A,184.66,N/A,1319.00,N/A,1319.00,N/A,1319.00,1000.20,1000.20,184.66,1319.00,,Hospital CPT 74430,HC Cystogram Routine Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,709.00,560.00,425.40,336.00,N/A,78.40,N/A,353.93,N/A,322.45,N/A,190.40,N/A,560.00,N/A,78.40,N/A,332.71,N/A,332.71,N/A,500.99,N/A,560.00,N/A,560.00,N/A,560.00,N/A,322.45,N/A,332.71,N/A,78.40,N/A,300.16,N/A,300.16,N/A,78.40,N/A,332.71,N/A,353.93,N/A,25.45,425.40,425.40,25.45,560.00,,Hospital CPT 75561,HC MRI-Myocardium W/WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,1334.00,1044.00,800.40,626.40,N/A,146.16,N/A,336.31,N/A,1044.00,N/A,354.96,N/A,804.78,N/A,146.16,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1044.00,N/A,332.71,N/A,146.16,N/A,1044.00,N/A,1044.00,N/A,146.16,N/A,332.71,N/A,336.31,N/A,263.62,800.40,800.40,146.16,1044.00,,Hospital CPT 75571,HC CT Heart No Contrast Quant Eval Coronry Calcium,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,139.00,139.00,139.00,139.00,N/A,19.46,N/A,78.46,N/A,139.00,N/A,47.26,N/A,139.00,N/A,19.46,N/A,78.46,N/A,78.46,N/A,118.14,N/A,139.00,N/A,139.00,N/A,139.00,N/A,139.00,N/A,78.46,N/A,19.46,N/A,139.00,N/A,139.00,N/A,19.46,N/A,78.46,N/A,78.46,N/A,86.30,139.00,139.00,19.46,139.00,,Hospital CPT 75572,HC CT Heart Scan,N/A,0352 - CT SCAN - BODY SCAN,857.00,857.00,514.20,514.20,N/A,119.98,N/A,164.62,N/A,857.00,N/A,291.38,N/A,393.92,N/A,119.98,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,857.00,N/A,162.85,N/A,119.98,N/A,689.00,N/A,689.00,N/A,119.98,N/A,162.85,N/A,137.98,N/A,151.78,514.20,514.20,119.98,857.00,,Hospital 75600,"HC Aortography, Thoracic WO Serialography, S&I",N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,56273.02,N/A,33763.81,N/A,10032.82,N/A,12133.96,N/A,30775.45,N/A,19132.82,N/A,23506.87,N/A,10341.95,N/A,12133.96,N/A,12133.96,N/A,14633.73,N/A,23506.87,N/A,23506.87,N/A,23506.87,N/A,30775.45,N/A,12133.96,N/A,10341.95,N/A,27157.31,N/A,27157.31,N/A,10341.95,N/A,12133.96,N/A,12133.96,N/A,11065.89,N/A,10032.82,33763.81,N/A,N/A,,Hospital CPT 75726,HC Visceral Arteriogram,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,5372.00,5372.00,3223.20,3223.20,N/A,752.08,N/A,4800.54,N/A,3093.20,N/A,1826.48,N/A,5372.00,N/A,752.08,N/A,4641.41,N/A,4641.41,N/A,5372.00,N/A,5372.00,N/A,5372.00,N/A,5372.00,N/A,3093.20,N/A,4641.41,N/A,752.08,N/A,2879.39,N/A,2879.39,N/A,752.08,N/A,4641.41,N/A,69.74,N/A,76.71,3223.20,3223.20,69.74,5372.00,,Hospital CPT 75733,HC Adrenal Arteriogram Bilateral,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,10151.00,10151.00,6090.60,6090.60,N/A,1421.14,N/A,96.17,N/A,5844.95,N/A,3451.34,N/A,465.96,N/A,1421.14,N/A,96.17,N/A,96.17,N/A,290.06,N/A,465.96,N/A,465.96,N/A,465.96,N/A,5844.95,N/A,96.17,N/A,1421.14,N/A,5440.94,N/A,5440.94,N/A,1421.14,N/A,96.17,N/A,96.17,N/A,105.79,6090.60,6090.60,96.17,6090.60,,Hospital CPT 75774,HC Additional Vessel Selection,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,3760.00,3760.00,2256.00,2256.00,N/A,526.40,N/A,3760.00,N/A,2165.01,N/A,1278.40,N/A,3760.00,N/A,526.40,N/A,3760.00,N/A,3760.00,N/A,3760.00,N/A,3760.00,N/A,3760.00,N/A,3760.00,N/A,2165.01,N/A,3760.00,N/A,526.40,N/A,2015.36,N/A,2015.36,N/A,526.40,N/A,3760.00,N/A,3760.00,N/A,3760.00,2256.00,2256.00,526.40,3760.00,,Hospital CPT 75809,HC Nonvascular Shunt X-Ray,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,790.00,624.00,474.00,374.40,N/A,87.36,N/A,102.67,N/A,359.30,N/A,212.16,N/A,233.46,N/A,87.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,359.30,N/A,96.52,N/A,87.36,N/A,334.46,N/A,334.46,N/A,87.36,N/A,96.52,N/A,102.67,N/A,58.87,474.00,474.00,58.87,374.40,,Hospital CPT 75827,HC Venography Svc,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4044.00,3192.00,2426.40,1915.20,N/A,446.88,N/A,1379.48,N/A,1837.95,N/A,1085.28,N/A,3192.00,N/A,446.88,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3192.00,N/A,3192.00,N/A,3192.00,N/A,1837.95,N/A,1343.59,N/A,446.88,N/A,1710.91,N/A,1710.91,N/A,446.88,N/A,1343.59,N/A,1379.48,N/A,66.47,2426.40,2426.40,66.47,3192.00,,Hospital CPT 75831,HC Renal Venogram Unilateral,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4343.00,3731.00,2605.80,2238.60,N/A,522.34,N/A,2690.13,N/A,2148.31,N/A,1268.54,N/A,3731.00,N/A,522.34,N/A,2690.13,N/A,2690.13,N/A,3731.00,N/A,3731.00,N/A,3731.00,N/A,3731.00,N/A,2148.31,N/A,2690.13,N/A,522.34,N/A,1999.82,N/A,1999.82,N/A,522.34,N/A,2690.13,N/A,2690.13,N/A,2959.14,2605.80,2605.80,522.34,3731.00,,Hospital CPT 75833,HC Veno Renal Bilat Sel S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,7572.00,7572.00,4543.20,4543.20,N/A,1060.08,N/A,70.34,N/A,4359.96,N/A,2574.48,N/A,6507.21,N/A,1060.08,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,4359.96,N/A,2690.13,N/A,1060.08,N/A,4058.59,N/A,4058.59,N/A,1060.08,N/A,2690.13,N/A,70.34,N/A,77.37,4543.20,4543.20,70.34,6507.21,,Hospital 75870,HC Veno Sup Sagital Sinus S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,71815.92,53980.62,43089.55,32388.37,4441.07,7538.81,5519.19,2865.65,10008.32,31077.73,24417.41,18353.41,N/A,6557.81,4577.91,7538.81,1124.00,2694.06,1124.00,2694.06,6477.68,4082.36,10405.42,6557.81,10405.42,6557.81,10405.42,6557.81,10008.32,31077.73,5519.19,2694.06,4577.91,7538.81,12021.30,8292.25,12021.30,8292.25,9407.43,7538.81,5519.19,2694.06,5519.19,2865.65,4898.36,1018.32,1124.00,43089.55,1018.32,32388.37,,Hospital 75872,Venogram Epidural,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,3406.30,N/A,2043.78,N/A,476.88,N/A,608.66,N/A,1959.64,N/A,1158.14,N/A,1440.24,N/A,476.88,N/A,581.86,N/A,581.86,N/A,896.56,N/A,1440.24,N/A,1440.24,N/A,1440.24,N/A,1959.64,N/A,581.86,N/A,476.88,N/A,1431.00,N/A,1431.00,N/A,476.88,N/A,581.86,N/A,608.66,N/A,268.85,N/A,N/A,268.85,2043.78,,Hospital 75885,HC Perc Transhep Port W/Hemo Eval,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,304028.80,37512.97,182417.28,22507.78,63230.84,5245.18,N/A,968.50,110171.98,21561.60,103095.25,12754.41,93488.44,11782.93,63230.84,5245.18,N/A,4641.41,N/A,4641.41,65738.38,7335.09,105581.66,11782.93,105581.66,11782.93,105581.66,11782.93,110171.98,21561.60,N/A,4641.41,63230.84,5245.18,110171.98,8832.50,110171.98,8832.50,63230.84,5245.18,N/A,4641.41,N/A,968.50,63230.84,1065.36,63230.84,182417.28,968.50,22507.78,,Hospital 75887,HC Portogram W/O Hemo S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,220566.95,5141.80,132340.17,3085.08,7380.27,719.86,N/A,2782.36,N/A,2959.67,60576.47,1748.22,60576.47,5141.80,7380.27,719.86,N/A,2690.13,N/A,2690.13,60576.47,4053.44,60576.47,5141.80,60576.47,5141.80,60576.47,5141.80,121576.50,2935.55,N/A,2690.13,7380.27,719.86,N/A,2716.98,117797.18,2716.98,16476.34,719.86,12731.40,2690.13,N/A,2782.36,19932.89,138.17,7380.27,132340.17,138.17,5141.80,,Hospital CPT 75984,HC Ureteral Stent Change S&I,N/A,0321 - RADIOLOGY - DIAGNOSTIC - ANGIOCARDIOGRAPHY,1993.00,1574.00,1195.80,944.40,N/A,220.36,N/A,54.12,N/A,906.31,N/A,535.16,N/A,1574.00,N/A,220.36,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,906.31,N/A,1574.00,N/A,220.36,N/A,843.66,N/A,843.66,N/A,220.36,N/A,1574.00,N/A,54.12,N/A,59.53,1195.80,1195.80,54.12,1574.00,,Hospital CPT 75984,HC Chng Perc Tube/Cath With Cont,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1993.00,1574.00,1195.80,944.40,N/A,220.36,N/A,54.12,N/A,906.31,N/A,535.16,N/A,1574.00,N/A,220.36,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,1574.00,N/A,906.31,N/A,1574.00,N/A,220.36,N/A,843.66,N/A,843.66,N/A,220.36,N/A,1574.00,N/A,54.12,N/A,59.53,1195.80,1195.80,54.12,1574.00,,Hospital CPT 76098,HC X-Ray Specimen,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,819.00,738.00,491.40,442.80,N/A,103.32,N/A,475.27,N/A,424.94,N/A,250.92,N/A,738.00,N/A,103.32,N/A,454.35,N/A,454.35,N/A,684.16,N/A,738.00,N/A,738.00,N/A,738.00,N/A,424.94,N/A,454.35,N/A,103.32,N/A,395.57,N/A,395.57,N/A,103.32,N/A,454.35,N/A,22.84,N/A,25.12,491.40,491.40,22.84,738.00,,Hospital 76498,HC MRI Procedure Unlisted,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,N/A,1122.00,N/A,673.20,N/A,157.08,N/A,86.55,N/A,1110.00,N/A,381.48,N/A,189.77,N/A,157.08,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,1110.00,N/A,78.46,N/A,157.08,N/A,1060.00,N/A,1060.00,N/A,157.08,N/A,78.46,N/A,86.55,N/A,306.20,N/A,N/A,78.46,1110.00,,Hospital CPT 76536,HC Soft Tissue Neck US,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,2141.00,2141.00,1284.60,1284.60,N/A,299.74,N/A,96.52,N/A,1232.79,N/A,727.94,N/A,233.46,N/A,299.74,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1232.79,N/A,96.52,N/A,299.74,N/A,1147.58,N/A,1147.58,N/A,299.74,N/A,96.52,N/A,96.52,N/A,106.17,1284.60,1284.60,96.52,1284.60,,Hospital CPT 76801,HC Fetal Eval 1st Tri Sgl Gest,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1450.00,1450.00,870.00,870.00,N/A,203.00,N/A,96.52,N/A,834.91,N/A,493.00,N/A,233.46,N/A,203.00,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,834.91,N/A,96.52,N/A,203.00,N/A,777.20,N/A,777.20,N/A,203.00,N/A,96.52,N/A,96.52,N/A,106.17,870.00,870.00,96.52,870.00,,Hospital CPT 76805,HC Fetal Eval 2-3 Trim Sgl Gest,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,2186.00,2186.00,1311.60,1311.60,N/A,306.04,N/A,100.27,N/A,1258.70,N/A,743.24,N/A,233.46,N/A,306.04,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1258.70,N/A,96.52,N/A,306.04,N/A,1171.70,N/A,1171.70,N/A,306.04,N/A,96.52,N/A,100.27,N/A,87.65,1311.60,1311.60,87.65,1311.60,,Hospital CPT 76811,HC US Fetal Anatomic Eval,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,301.00,301.00,180.60,180.60,N/A,42.14,N/A,224.33,N/A,173.32,N/A,102.34,N/A,301.00,N/A,42.14,N/A,210.88,N/A,210.88,N/A,301.00,N/A,301.00,N/A,301.00,N/A,301.00,N/A,173.32,N/A,210.88,N/A,42.14,N/A,161.34,N/A,161.34,N/A,42.14,N/A,210.88,N/A,224.33,N/A,82.63,180.60,180.60,42.14,301.00,,Hospital 76814,HC US OB 1st Tr Fetal Tran Ea Add,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,3492.00,N/A,2095.20,N/A,488.88,N/A,102.67,N/A,2010.69,N/A,1187.28,N/A,233.46,N/A,488.88,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,2010.69,N/A,96.52,N/A,488.88,N/A,165.62,N/A,165.62,N/A,488.88,N/A,96.52,N/A,102.67,N/A,181.24,N/A,N/A,96.52,2095.20,,Hospital CPT 76815,HC US Fetal Evaluation-Limited,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,899.00,899.00,539.40,539.40,N/A,125.86,N/A,96.52,N/A,517.64,N/A,305.66,N/A,233.46,N/A,125.86,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,517.64,N/A,96.52,N/A,125.86,N/A,481.86,N/A,481.86,N/A,125.86,N/A,96.52,N/A,96.52,N/A,106.17,539.40,539.40,96.52,539.40,,Hospital CPT 76817,HC US Transvaginal Obsetrical,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,968.00,968.00,580.80,580.80,N/A,135.52,N/A,96.52,N/A,557.37,N/A,329.12,N/A,233.46,N/A,135.52,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,557.37,N/A,96.52,N/A,135.52,N/A,518.85,N/A,518.85,N/A,135.52,N/A,96.52,N/A,96.52,N/A,106.17,580.80,580.80,96.52,580.80,,Hospital 76825,HC Echo Exam of Fetal Heart,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,27051.20,2802.00,16230.72,1681.20,3722.50,392.28,4669.17,586.00,8388.95,1613.39,9197.41,952.68,4696.00,1332.48,3837.19,392.28,4669.17,550.87,4669.17,550.87,2923.00,829.50,4696.00,1332.48,4696.00,1332.48,4696.00,1332.48,8388.95,1613.39,4669.17,550.87,3837.19,392.28,10076.23,111.48,10076.23,111.48,4451.09,392.28,4669.17,550.87,4669.17,586.00,4105.80,420.01,2923.00,16230.72,111.48,1681.20,,Hospital CPT 76856,HC US Pelvis Complete,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,973.00,851.00,583.80,510.60,N/A,119.14,N/A,96.52,N/A,851.00,N/A,289.34,N/A,233.46,N/A,119.14,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,490.01,N/A,96.52,N/A,119.14,N/A,456.14,N/A,456.14,N/A,119.14,N/A,96.52,N/A,96.52,N/A,106.17,583.80,583.80,96.52,851.00,,Hospital CPT 76857,HC US Pelvis Limited,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,609.00,314.00,365.40,188.40,N/A,43.96,N/A,96.52,N/A,314.00,N/A,106.76,N/A,233.46,N/A,43.96,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,180.80,N/A,96.52,N/A,43.96,N/A,168.30,N/A,168.30,N/A,43.96,N/A,96.52,N/A,96.52,N/A,106.17,365.40,365.40,43.96,314.00,,Hospital CPT 76885,HC Infant Hips With Manipulation,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,723.00,723.00,433.80,433.80,N/A,101.22,N/A,78.46,N/A,416.30,N/A,245.82,N/A,189.77,N/A,101.22,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,416.30,N/A,78.46,N/A,101.22,N/A,387.53,N/A,387.53,N/A,101.22,N/A,78.46,N/A,78.46,N/A,86.30,433.80,433.80,78.46,433.80,,Hospital 76886,HC Pediatric Hips Lmtd Nonmanip,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,1058.00,N/A,634.80,N/A,148.12,N/A,80.09,N/A,609.20,N/A,359.72,N/A,189.77,N/A,148.12,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,609.20,N/A,78.46,N/A,148.12,N/A,567.09,N/A,567.09,N/A,148.12,N/A,78.46,N/A,80.09,N/A,71.10,N/A,N/A,71.10,634.80,,Hospital CPT 76937,HC US Guidance or Line Place W/ Permanent Image,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1286.00,1286.00,771.60,771.60,N/A,180.04,N/A,1286.00,N/A,740.48,N/A,437.24,N/A,1286.00,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,740.48,N/A,1286.00,N/A,180.04,N/A,689.30,N/A,689.30,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,771.60,771.60,180.04,1286.00,,Hospital CPT 76937,HC US Guidance Ndl Access,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1286.00,1286.00,771.60,771.60,N/A,180.04,N/A,1286.00,N/A,740.48,N/A,437.24,N/A,1286.00,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,1286.00,N/A,740.48,N/A,1286.00,N/A,180.04,N/A,689.30,N/A,689.30,N/A,180.04,N/A,1286.00,N/A,1286.00,N/A,1286.00,771.60,771.60,180.04,1286.00,,Hospital 76940,HC US Gd Tiss Parench Ablation,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,26593.52,N/A,15956.11,N/A,3723.09,N/A,31.38,N/A,15306.44,N/A,9041.79,N/A,3283.44,N/A,3723.09,N/A,1354.15,N/A,1354.15,N/A,2044.00,N/A,3283.44,N/A,3283.44,N/A,3283.44,N/A,15306.44,N/A,1354.15,N/A,3723.09,N/A,1871.00,N/A,1871.00,N/A,3723.09,N/A,1354.15,N/A,31.38,N/A,34.52,N/A,N/A,31.38,15956.11,,Hospital CPT 76981,HC Ultrasound Elastography Parenchyma,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,343.00,343.00,205.80,205.80,N/A,48.02,N/A,96.52,N/A,197.50,N/A,116.62,N/A,233.46,N/A,48.02,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,197.50,N/A,96.52,N/A,48.02,N/A,183.85,N/A,183.85,N/A,48.02,N/A,96.52,N/A,96.52,N/A,106.17,205.80,205.80,48.02,233.46,,Hospital CPT 76983,HC Ultrasound Elastography Ea Addl Taget Lesion,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,343.00,343.00,205.80,205.80,N/A,48.02,N/A,33.37,N/A,197.50,N/A,116.62,N/A,168.84,N/A,48.02,N/A,33.37,N/A,33.37,N/A,105.10,N/A,168.84,N/A,168.84,N/A,168.84,N/A,197.50,N/A,33.37,N/A,48.02,N/A,183.85,N/A,183.85,N/A,48.02,N/A,33.37,N/A,33.37,N/A,36.71,205.80,205.80,33.37,205.80,,Hospital 77013,HC CT Guide Visc Tissue Ablation,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,210609.72,70273.02,126365.83,42163.81,N/A,9832.54,N/A,440.25,81215.45,40456.51,N/A,23892.82,N/A,19886.64,N/A,9832.54,N/A,8206.20,N/A,8206.20,N/A,12379.81,N/A,19886.64,N/A,19886.64,N/A,19886.64,81215.45,40456.53,N/A,8206.20,N/A,9832.54,81215.45,7897.00,81215.45,7897.00,N/A,9832.54,N/A,8206.20,N/A,440.25,N/A,484.28,81215.45,126365.83,440.25,42163.81,,Hospital 77014,HC CT Treatment Plan,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,101393.00,43929.00,60835.80,26357.40,8372.16,6150.06,11218.79,1210.09,22311.28,25646.99,N/A,14935.86,N/A,19097.01,8372.16,6150.06,12616.71,7894.89,12616.71,7894.89,N/A,11888.21,N/A,19097.01,N/A,19097.01,N/A,19097.01,22311.28,25646.99,11218.79,7894.89,8372.16,6150.06,22311.28,23712.38,22311.28,23712.38,8372.16,6150.06,11218.79,7894.89,11218.79,1210.09,8372.16,1331.12,8372.16,60835.80,1210.09,26357.40,,Hospital CPT 77046,HC MRI Breast W/O Contrast Unilateral,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,220.59,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,220.59,N/A,154.12,1461.00,1461.00,154.12,1461.00,,Hospital CPT 77047,HC MRI Breast W/O Contrast Bilateral,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1461.00,1461.00,210.88,1461.00,,Hospital CPT 77048,HC MRI Breast W&WO Cont Incl Cad Unilateral,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,348.03,N/A,1110.00,N/A,827.90,N/A,962.49,N/A,340.90,N/A,332.71,N/A,332.71,N/A,599.15,N/A,962.49,N/A,962.49,N/A,962.49,N/A,1110.00,N/A,332.71,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,332.71,N/A,348.03,N/A,253.69,1461.00,1461.00,253.69,1461.00,,Hospital CPT 77048,HC MRI Breast W Cont Unilat,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,170.35,N/A,1110.00,N/A,827.90,N/A,962.49,N/A,340.90,N/A,162.85,N/A,162.85,N/A,599.15,N/A,962.49,N/A,962.49,N/A,962.49,N/A,1110.00,N/A,162.85,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,162.85,N/A,170.35,N/A,253.69,1461.00,1461.00,162.85,1461.00,,Hospital 77049,MRI Breast Without&With Contrast W/Cad Bilateral,N/A,N/A,N/A,4286.60,N/A,2571.96,N/A,600.12,N/A,228.82,N/A,1185.11,N/A,1457.44,N/A,1065.41,N/A,600.12,N/A,228.82,N/A,228.82,N/A,663.21,N/A,1065.41,N/A,1065.41,N/A,1065.41,N/A,1185.11,N/A,228.82,N/A,600.12,N/A,1060.00,N/A,1060.00,N/A,600.12,N/A,228.82,N/A,228.82,N/A,251.70,N/A,N/A,228.82,2571.96,,Hospital CPT 77065,HC Mammo Dgx Unilateral Incl Cad if Perf,N/A,0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY,478.00,478.00,286.80,286.80,N/A,66.92,N/A,78.78,N/A,203.00,N/A,162.52,N/A,232.53,N/A,66.92,N/A,78.78,N/A,78.78,N/A,144.75,N/A,232.53,N/A,232.53,N/A,232.53,N/A,203.00,N/A,78.78,N/A,66.92,N/A,318.00,N/A,318.00,N/A,66.92,N/A,78.78,N/A,78.78,N/A,86.66,286.80,286.80,66.92,318.00,,Hospital 77071,HC Man Appl Stress by Phys for Jn,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,1408.63,N/A,845.18,N/A,197.21,N/A,214.05,N/A,809.28,N/A,478.93,N/A,18.57,N/A,197.21,N/A,212.87,N/A,212.87,N/A,11.54,N/A,18.57,N/A,18.57,N/A,18.57,N/A,809.28,N/A,212.87,N/A,197.21,N/A,539.75,N/A,539.75,N/A,197.21,N/A,212.87,N/A,214.05,N/A,173.03,N/A,N/A,11.54,845.18,,Hospital CPT 77072,HC Hands Bone Age Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,385.00,385.00,231.00,231.00,N/A,53.90,N/A,96.52,N/A,221.68,N/A,130.90,N/A,233.46,N/A,53.90,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,221.68,N/A,96.52,N/A,53.90,N/A,206.36,N/A,206.36,N/A,53.90,N/A,96.52,N/A,96.52,N/A,106.17,231.00,231.00,53.90,233.46,,Hospital CPT 77073,HC Leg Bones Lengthening Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,373.00,373.00,223.80,223.80,N/A,52.22,N/A,97.56,N/A,214.77,N/A,126.82,N/A,233.46,N/A,52.22,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,214.77,N/A,96.52,N/A,52.22,N/A,199.93,N/A,199.93,N/A,52.22,N/A,96.52,N/A,97.56,N/A,31.75,223.80,223.80,31.75,233.46,,Hospital CPT 77075,HC Bone Survey Complete,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1350.00,1350.00,810.00,810.00,N/A,189.00,N/A,96.52,N/A,777.33,N/A,459.00,N/A,233.46,N/A,189.00,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,777.33,N/A,96.52,N/A,189.00,N/A,723.60,N/A,723.60,N/A,189.00,N/A,96.52,N/A,96.52,N/A,106.17,810.00,810.00,96.52,810.00,,Hospital 77086,HC Bone Dens DXA Verteb Fx Ass,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,674.00,N/A,404.40,N/A,94.36,N/A,183.35,N/A,306.07,N/A,229.16,N/A,499.52,N/A,94.36,N/A,182.50,N/A,182.50,N/A,310.96,N/A,499.52,N/A,499.52,N/A,499.52,N/A,306.07,N/A,182.50,N/A,94.36,N/A,413.94,N/A,413.94,N/A,94.36,N/A,182.50,N/A,183.35,N/A,138.58,N/A,N/A,94.36,499.52,,Hospital 77290,HC Simualtion Complex,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,99412.90,25406.00,59647.74,15243.60,10440.92,3556.84,12196.24,3058.49,15665.96,14628.75,33800.41,8638.04,31764.17,7318.99,9031.71,3556.84,12616.71,3025.74,12477.57,3025.74,31764.17,4556.20,31764.17,7318.99,23754.54,7318.99,31764.17,7318.99,15665.96,14628.75,12616.71,3025.74,9031.71,3556.84,15665.96,13617.63,15665.96,13617.63,9031.71,3556.84,12616.71,3025.74,12196.24,3058.49,9031.71,591.50,9031.71,59647.74,591.50,15243.60,,Hospital 77293,HC Respirator Motion Mgmt Simul,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,105749.40,38118.00,63449.64,22870.80,9036.31,5336.52,10955.14,3848.45,58289.07,21948.36,N/A,12960.12,N/A,9390.17,6606.16,5336.52,N/A,3881.98,N/A,3881.98,12797.41,5845.54,20558.86,9390.17,20558.86,9390.17,20558.86,9390.17,58289.07,21948.36,10955.14,3881.98,6606.16,5336.52,24459.92,20431.28,74355.64,20431.28,6606.16,5336.52,10955.14,3881.98,N/A,3848.45,6606.16,843.46,6606.16,74355.64,843.46,22870.80,,Hospital 77295,HC 3d Plan,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,105606.97,41787.00,63364.18,25072.20,9883.48,5850.18,12196.24,4491.75,53700.72,24060.98,35906.37,14207.58,40275.42,10748.78,9883.48,5850.18,12727.02,4443.64,8992.00,4443.64,25070.51,6691.32,40275.42,10748.78,40275.42,10748.78,40275.42,10748.78,58210.56,24060.98,21206.68,4443.64,9883.48,5850.18,47917.70,22170.57,53700.72,22170.57,9883.48,5850.18,12196.24,4443.64,21206.68,4491.75,19525.20,1165.11,8992.00,63364.18,1165.11,25072.20,,Hospital 77301,HC Imrt Planning,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,85139.00,40135.00,51083.40,24081.00,16574.67,5618.90,20109.82,5543.74,37352.35,23109.73,28947.26,13645.90,37709.66,13136.67,17085.36,5618.90,12025.33,5430.80,12025.33,5430.80,23473.39,8177.82,37709.66,13136.67,37709.66,13136.67,37709.66,13136.67,37352.35,23109.73,19872.62,5430.80,17085.36,5618.90,29183.79,21379.42,44865.08,21379.42,7103.77,5618.90,12025.33,5430.80,19872.62,5543.74,18281.34,2117.58,7103.77,51083.40,2117.58,24081.00,,Hospital CPT 77332,HC Treatment Devices Simple,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,384.00,384.00,230.40,230.40,N/A,53.76,N/A,12.92,N/A,221.11,N/A,130.56,N/A,291.34,N/A,53.76,N/A,120.45,N/A,120.45,N/A,181.37,N/A,291.34,N/A,291.34,N/A,291.34,N/A,221.11,N/A,120.45,N/A,53.76,N/A,205.82,N/A,205.82,N/A,53.76,N/A,120.45,N/A,121.75,N/A,14.21,230.40,230.40,12.92,291.34,,Hospital 77333,HC Treatment Devices Inter,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,88560.30,19632.00,53136.18,11779.20,9883.48,2748.48,9570.52,2058.34,N/A,11304.10,N/A,6674.88,N/A,4877.48,9883.48,2748.48,9570.52,2016.41,9570.52,2016.41,N/A,3036.34,N/A,4877.48,N/A,4877.48,N/A,4877.48,N/A,11304.10,9570.52,2016.41,9883.48,2748.48,26396.32,10522.75,N/A,9783.07,9883.48,2748.48,9570.52,2016.41,9570.52,2058.34,9883.48,1614.07,9570.52,53136.18,1614.07,11779.20,,Hospital 77386,HC Ntsty Modul Rad Tx Dlvr Cplx,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,70210.80,38700.00,42126.48,23220.00,7393.97,5418.00,10083.64,3135.36,22311.28,22283.46,23871.67,13158.00,18882.74,7502.94,8555.33,5418.00,8161.33,3101.76,8161.33,3101.76,11754.07,4670.70,18882.74,7502.94,18882.74,7502.94,18882.74,7502.94,18703.83,22283.46,10083.64,3101.76,7393.97,5418.00,22465.75,20743.20,22311.28,20743.20,7393.97,5418.00,10083.64,3101.76,10083.64,3135.36,7393.97,6465.92,7393.97,42126.48,3101.76,23220.00,,Hospital 77399,HC Ro Med Rad Physics Unlisted Px,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,84303.08,25860.00,50581.85,15516.00,N/A,3620.40,29555.25,1545.13,N/A,14890.20,N/A,8792.40,N/A,9879.44,N/A,3620.40,29555.25,4084.25,29555.25,4084.25,N/A,6150.14,N/A,9879.44,N/A,9879.44,N/A,9879.44,N/A,14890.20,29555.25,4084.25,N/A,3620.40,N/A,13860.97,N/A,13860.97,N/A,3620.40,29555.25,4084.25,29555.25,1545.13,N/A,1699.65,29555.25,50581.85,1545.13,15516.00,,Hospital 77470,HC Special Treatment Procedure,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,117107.38,18035.00,70264.43,10821.00,8004.46,2524.90,12196.24,1656.06,10540.11,10384.56,30049.32,6131.90,30049.32,7466.90,8004.46,2524.90,12196.24,3086.90,12196.24,3086.90,30049.32,4648.31,30049.32,7466.90,30049.32,7466.90,30049.32,7466.90,10540.11,10384.56,30832.21,3086.90,8004.46,2524.90,10540.11,9499.00,10540.11,9499.00,8004.46,2524.90,12196.24,3086.90,12196.24,1656.06,8004.46,1821.67,8004.46,70264.43,1656.06,10821.00,,Hospital 77767,HC Hdr Rdncl Skn Surf Brachytx,N/A,0342 - NUCLEAR MEDICINE - THERAPEUTIC PROCEDURES,41364.42,2333.00,24818.65,1399.80,N/A,326.62,N/A,170.76,N/A,1327.30,N/A,793.22,N/A,1307.66,N/A,326.62,N/A,573.15,N/A,573.15,N/A,814.04,N/A,1307.66,N/A,1307.66,N/A,1307.66,N/A,1327.30,N/A,573.15,N/A,326.62,N/A,618.54,N/A,618.54,N/A,326.62,N/A,573.15,N/A,170.76,N/A,187.84,24818.65,24818.65,170.76,1399.80,,Hospital 77771,HC Remote Afterld Brachy 2-12 Cha,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,104620.90,N/A,62772.54,N/A,14646.92,N/A,7995.81,N/A,60173.54,N/A,35571.10,N/A,18072.67,N/A,14646.92,N/A,7596.90,N/A,7596.90,N/A,11250.57,N/A,18072.67,N/A,18072.67,N/A,18072.67,N/A,60173.54,N/A,7596.90,N/A,14646.92,N/A,53350.20,N/A,53350.20,N/A,14646.92,N/A,7596.90,N/A,7995.81,N/A,4806.51,N/A,N/A,4806.51,62772.54,,Hospital 77778,HC Complex Interstitial Appl,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,249042.40,N/A,149425.44,N/A,34865.93,N/A,1376.87,N/A,140835.55,N/A,84674.42,N/A,61667.53,N/A,34865.93,N/A,27195.81,N/A,27195.81,N/A,38389.23,N/A,61667.53,N/A,61667.53,N/A,61667.53,N/A,140835.55,N/A,27195.81,N/A,34865.93,N/A,11923.50,N/A,11923.50,N/A,34865.93,N/A,27195.81,N/A,1376.87,N/A,1514.55,N/A,N/A,1376.87,149425.44,,Hospital CPT 78014,HC NM Thyroid Uptake Sgl/Multi,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2426.00,2426.00,1455.60,1455.60,N/A,339.64,N/A,350.99,N/A,1396.89,N/A,824.84,N/A,849.03,N/A,339.64,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1396.89,N/A,350.99,N/A,339.64,N/A,1300.34,N/A,1300.34,N/A,339.64,N/A,350.99,N/A,350.99,N/A,386.09,1455.60,1455.60,339.64,1455.60,,Hospital CPT 78018,HC Thyroid Metastases Imaging; Whole Body,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,4681.00,4681.00,2808.60,2808.60,N/A,655.34,N/A,231.79,N/A,2695.32,N/A,1591.54,N/A,1102.01,N/A,655.34,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,2695.32,N/A,455.58,N/A,655.34,N/A,2509.02,N/A,2509.02,N/A,655.34,N/A,455.58,N/A,231.79,N/A,254.97,2808.60,2808.60,231.79,2808.60,,Hospital CPT 78070,HC NM Parathyroid Scan,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1778.00,1778.00,1066.80,1066.80,N/A,248.92,N/A,350.99,N/A,1023.77,N/A,604.52,N/A,849.03,N/A,248.92,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1023.77,N/A,350.99,N/A,248.92,N/A,953.01,N/A,953.01,N/A,248.92,N/A,350.99,N/A,350.99,N/A,386.09,1066.80,1066.80,248.92,1066.80,,Hospital CPT 78215,HC NM Liver Scan/Spleen Scan,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1762.00,1762.00,1057.20,1057.20,N/A,246.68,N/A,373.38,N/A,1014.56,N/A,599.08,N/A,849.03,N/A,246.68,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1014.56,N/A,350.99,N/A,246.68,N/A,944.43,N/A,944.43,N/A,246.68,N/A,350.99,N/A,373.38,N/A,161.70,1057.20,1057.20,161.70,1057.20,,Hospital CPT 78226,HC NM Hepatobiliary Imaging WO Pharm,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3936.00,3936.00,2361.60,2361.60,N/A,551.04,N/A,350.99,N/A,2266.35,N/A,1338.24,N/A,849.03,N/A,551.04,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,2266.35,N/A,350.99,N/A,551.04,N/A,2109.70,N/A,2109.70,N/A,551.04,N/A,350.99,N/A,350.99,N/A,386.09,2361.60,2361.60,350.99,2361.60,,Hospital 78258,Esophageal Motility Study,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,1572.50,N/A,943.50,N/A,220.15,N/A,373.38,N/A,905.45,N/A,534.65,N/A,849.03,N/A,220.15,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,905.45,N/A,350.99,N/A,220.15,N/A,1294.80,N/A,1294.80,N/A,220.15,N/A,350.99,N/A,373.38,N/A,167.98,N/A,N/A,167.98,1294.80,,Hospital CPT 78290,HC NM Bowel Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1580.00,1580.00,948.00,948.00,N/A,221.20,N/A,367.15,N/A,909.76,N/A,537.20,N/A,849.03,N/A,221.20,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,909.76,N/A,350.99,N/A,221.20,N/A,846.88,N/A,846.88,N/A,221.20,N/A,350.99,N/A,367.15,N/A,277.46,948.00,948.00,221.20,948.00,,Hospital CPT 78452,HC NM Sest. Rest Stress Mult,N/A,0340 - NUCLEAR MEDICINE - GENERAL CLASSIFICATION,9595.00,9595.00,5757.00,5757.00,N/A,1343.30,N/A,1198.58,N/A,5524.80,N/A,3262.30,N/A,2899.26,N/A,1343.30,N/A,1198.58,N/A,1198.58,N/A,1804.84,N/A,2899.26,N/A,2899.26,N/A,2899.26,N/A,5524.80,N/A,1198.58,N/A,1343.30,N/A,5142.92,N/A,5142.92,N/A,1343.30,N/A,1198.58,N/A,1198.58,N/A,1318.44,5757.00,5757.00,1198.58,5757.00,,Hospital 78453,HC NM Planar Stress or Rest Myo Perf,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,74868.33,15059.00,44921.00,9035.40,5869.15,2108.26,6577.44,619.84,13226.60,8534.14,25319.51,5120.06,13872.42,2086.56,6049.99,2108.26,6577.44,599.29,6577.44,599.29,8635.47,1298.92,13872.42,2086.56,13872.42,2086.56,13872.42,2086.56,13226.60,8534.14,6577.44,599.29,6049.99,2108.26,15886.89,4087.00,15886.89,4087.00,N/A,2108.26,6577.44,599.29,6577.44,619.84,6473.49,230.84,5869.15,44921.00,230.84,9035.40,,Hospital CPT 78466,HC NM Pyp Mi,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1040.00,1040.00,624.00,624.00,N/A,145.60,N/A,136.17,N/A,598.83,N/A,353.60,N/A,471.27,N/A,145.60,N/A,136.17,N/A,136.17,N/A,293.37,N/A,471.27,N/A,471.27,N/A,471.27,N/A,598.83,N/A,136.17,N/A,145.60,N/A,557.44,N/A,557.44,N/A,145.60,N/A,136.17,N/A,136.17,N/A,149.79,624.00,624.00,136.17,624.00,,Hospital CPT 78582,HC NM Pulmonary Perfusion & Vent,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3637.00,3637.00,2182.20,2182.20,N/A,509.18,N/A,238.71,N/A,2094.18,N/A,1236.58,N/A,1102.01,N/A,509.18,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,2094.18,N/A,455.58,N/A,509.18,N/A,1949.43,N/A,1949.43,N/A,509.18,N/A,455.58,N/A,238.71,N/A,262.58,2182.20,2182.20,238.71,2182.20,,Hospital CPT 78597,HC NM Quant Lung Perfusion,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2136.00,2136.00,1281.60,1281.60,N/A,299.04,N/A,347.96,N/A,1229.91,N/A,726.24,N/A,849.03,N/A,299.04,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1229.91,N/A,350.99,N/A,299.04,N/A,1144.90,N/A,1144.90,N/A,299.04,N/A,350.99,N/A,347.96,N/A,156.08,1281.60,1281.60,156.08,1281.60,,Hospital 78601,HC NM Brain Scan W/Dynamic Flow Stdy,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,132980.60,N/A,79788.36,N/A,9003.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9003.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9003.29,N/A,N/A,N/A,N/A,N/A,9003.29,N/A,N/A,N/A,N/A,N/A,9003.29,N/A,9003.29,79788.36,N/A,N/A,,Hospital CPT 78645,HC NM Shuntogram,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1149.00,1149.00,689.40,689.40,N/A,160.86,N/A,476.56,N/A,661.59,N/A,390.66,N/A,1102.01,N/A,160.86,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,661.59,N/A,455.58,N/A,160.86,N/A,615.86,N/A,615.86,N/A,160.86,N/A,455.58,N/A,476.56,N/A,276.80,689.40,689.40,160.86,1102.01,,Hospital 78650,HC CSF Leakage Detection & Localization,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,N/A,5786.50,N/A,3471.90,N/A,810.11,N/A,1585.54,N/A,3330.12,N/A,1967.41,N/A,3792.19,N/A,810.11,N/A,1553.25,N/A,1553.25,N/A,3005.11,N/A,3792.19,N/A,3792.19,N/A,3792.19,N/A,3330.12,N/A,1553.25,N/A,810.11,N/A,527.00,N/A,527.00,N/A,810.11,N/A,1553.25,N/A,1585.54,N/A,436.28,N/A,N/A,436.28,3792.19,,Hospital CPT 78709,HC NM Renal Vascular Flow,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,4925.00,4925.00,2955.00,2955.00,N/A,689.50,N/A,476.56,N/A,2835.82,N/A,1674.50,N/A,1102.01,N/A,689.50,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,2835.82,N/A,455.58,N/A,689.50,N/A,2639.80,N/A,2639.80,N/A,689.50,N/A,455.58,N/A,476.56,N/A,282.10,2955.00,2955.00,282.10,2955.00,,Hospital 78740,HC NM Cystogram,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,N/A,6505.40,N/A,3903.24,N/A,911.41,N/A,373.38,N/A,3735.87,N/A,2205.58,N/A,1049.03,N/A,911.41,N/A,350.99,N/A,350.99,N/A,959.62,N/A,1049.03,N/A,1049.03,N/A,1049.03,N/A,3735.87,N/A,350.99,N/A,911.41,N/A,527.00,N/A,527.00,N/A,911.41,N/A,350.99,N/A,373.38,N/A,495.47,N/A,N/A,350.99,3903.24,,Hospital CPT 78813,HC Pet Imaging Whole Body,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,4275.00,4275.00,2565.00,2565.00,N/A,598.50,N/A,1344.94,N/A,2821.00,N/A,1453.50,N/A,3253.30,N/A,598.50,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,3253.30,N/A,3253.30,N/A,3253.30,N/A,2821.00,N/A,1344.94,N/A,598.50,N/A,2291.40,N/A,2291.40,N/A,598.50,N/A,1344.94,N/A,1344.94,N/A,1479.44,2565.00,2565.00,598.50,3253.30,,Hospital 78830,HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imag,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,75230.42,5793.00,45138.25,3475.80,N/A,811.02,6752.92,1253.77,12358.62,3221.94,N/A,1969.62,N/A,5186.26,5652.96,811.02,3934.00,1198.58,3934.00,1198.58,N/A,5793.00,12476.84,5186.26,12476.84,5186.26,12476.84,5186.26,12358.62,3221.94,13184.76,1198.58,N/A,811.02,14844.32,1879.22,14844.32,1879.22,N/A,811.02,6752.92,1198.58,6752.92,1253.77,6048.67,387.29,3934.00,45138.25,387.29,5793.00,,Hospital CPT 78831,HC Rp Loclzj Tumor/Dstrbj Agent Tomog Spect,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3195.00,3195.00,1917.00,1917.00,N/A,447.30,N/A,1192.45,N/A,1839.68,N/A,1086.30,N/A,2899.26,N/A,447.30,N/A,1198.58,N/A,1198.58,N/A,1804.84,N/A,2899.26,N/A,2899.26,N/A,2899.26,N/A,1839.68,N/A,1198.58,N/A,447.30,N/A,1712.52,N/A,1712.52,N/A,447.30,N/A,1198.58,N/A,1253.77,N/A,579.41,1917.00,1917.00,447.30,2899.26,,Hospital CPT 80050,HC General Health Profile,N/A,0301 - LABORATORY - CHEMISTRY,815.00,660.00,489.00,396.00,N/A,44.93,N/A,660.00,N/A,380.03,N/A,224.40,N/A,92.40,N/A,44.93,N/A,660.00,N/A,660.00,N/A,57.42,N/A,92.40,N/A,92.40,N/A,92.40,N/A,380.03,N/A,660.00,N/A,44.93,N/A,41.18,N/A,41.18,N/A,44.93,N/A,660.00,N/A,660.00,N/A,49.42,489.00,489.00,41.18,660.00,,Hospital CPT 80051,HC Electrolyte Panel,N/A,0301 - LABORATORY - CHEMISTRY,116.00,97.00,69.60,58.20,N/A,7.01,N/A,7.01,N/A,55.85,N/A,32.98,N/A,4.75,N/A,7.01,N/A,7.01,N/A,7.01,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,55.85,N/A,7.01,N/A,7.01,N/A,7.01,N/A,7.01,N/A,7.01,N/A,7.01,N/A,7.01,N/A,7.71,69.60,69.60,4.75,58.20,,Hospital CPT 80055,HC Obstetric Panel,N/A,0301 - LABORATORY - CHEMISTRY,1155.00,900.00,693.00,540.00,N/A,47.81,N/A,47.81,N/A,518.22,N/A,306.00,N/A,47.81,N/A,47.81,N/A,47.81,N/A,47.81,N/A,29.76,N/A,47.81,N/A,47.81,N/A,47.81,N/A,518.22,N/A,47.81,N/A,47.81,N/A,47.81,N/A,47.81,N/A,47.81,N/A,47.81,N/A,47.81,N/A,52.59,693.00,693.00,29.76,540.00,,Hospital CPT 80081,HC Obstetric Panel W/Hiv Screen,N/A,0301 - LABORATORY - CHEMISTRY,280.00,280.00,168.00,168.00,N/A,74.86,N/A,74.86,N/A,161.22,N/A,95.20,N/A,74.86,N/A,74.86,N/A,74.86,N/A,74.86,N/A,46.60,N/A,74.86,N/A,74.86,N/A,74.86,N/A,161.22,N/A,74.86,N/A,74.86,N/A,74.86,N/A,74.86,N/A,74.86,N/A,74.86,N/A,74.86,N/A,82.35,168.00,168.00,46.60,168.00,,Hospital CPT 80155,HC So Caffeine Level,N/A,0301 - LABORATORY - CHEMISTRY,98.00,98.00,58.80,58.80,N/A,38.57,N/A,38.57,N/A,56.43,N/A,33.32,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,24.01,N/A,38.57,N/A,38.57,N/A,38.57,N/A,56.43,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,42.43,58.80,58.80,24.01,58.80,,Hospital CPT 80157,HC So Carbamazepine Free,N/A,0301 - LABORATORY - CHEMISTRY,35.00,35.00,21.00,21.00,N/A,13.25,N/A,13.25,N/A,20.15,N/A,11.90,N/A,11.26,N/A,13.25,N/A,13.25,N/A,13.25,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,20.15,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,21.00,21.00,11.26,21.00,,Hospital CPT 80158,HC So Cyclosporine,N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,18.05,N/A,18.05,N/A,69.67,N/A,41.14,N/A,15.34,N/A,18.05,N/A,18.05,N/A,18.05,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,69.67,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,19.86,72.60,72.60,15.34,72.60,,Hospital CPT 80158,HC Cyclosporine,N/A,0301 - LABORATORY - CHEMISTRY,134.00,100.00,80.40,60.00,N/A,18.05,N/A,18.05,N/A,57.58,N/A,34.00,N/A,15.34,N/A,18.05,N/A,18.05,N/A,18.05,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,57.58,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,19.86,80.40,80.40,15.34,60.00,,Hospital CPT 80161,HC So Drug Assay Carbamazepine-10 11-Epoxide,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,18.64,N/A,18.64,N/A,43.19,N/A,25.50,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,11.60,N/A,18.64,N/A,18.64,N/A,18.64,N/A,43.19,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,45.00,45.00,11.60,45.00,,Hospital 80163,HC So Assay of Digoxin Free,N/A,0301 - LABORATORY - CHEMISTRY,39874.13,N/A,23924.48,N/A,7930.45,N/A,N/A,N/A,17871.91,N/A,13557.21,N/A,18042.86,N/A,8174.80,N/A,2248.00,N/A,2248.00,N/A,11231.26,N/A,18042.86,N/A,18042.86,N/A,18042.86,N/A,17871.91,N/A,9646.96,N/A,8174.80,N/A,21466.50,N/A,21466.50,N/A,8174.80,N/A,9646.96,N/A,9646.96,N/A,8747.03,N/A,2248.00,23924.48,N/A,N/A,,Hospital CPT 80169,HC So Everolimus Level,N/A,0301 - LABORATORY - CHEMISTRY,125.00,125.00,75.00,75.00,N/A,13.73,N/A,13.73,N/A,71.98,N/A,42.50,N/A,18.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,18.73,N/A,18.73,N/A,18.73,N/A,18.73,N/A,71.98,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,75.00,75.00,13.73,75.00,,Hospital CPT 80169,HC Everolimus Level,N/A,0301 - LABORATORY - CHEMISTRY,56.00,56.00,33.60,33.60,N/A,13.73,N/A,13.73,N/A,32.24,N/A,19.04,N/A,18.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,18.73,N/A,18.73,N/A,18.73,N/A,18.73,N/A,32.24,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,33.60,33.60,13.73,33.60,,Hospital CPT 80175,HC Lamotrigine,N/A,0301 - LABORATORY - CHEMISTRY,141.00,141.00,84.60,84.60,N/A,13.25,N/A,13.25,N/A,81.19,N/A,47.94,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,81.19,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,84.60,84.60,13.25,84.60,,Hospital CPT 80175,HC So Lamotrigine,N/A,0301 - LABORATORY - CHEMISTRY,141.00,141.00,84.60,84.60,N/A,13.25,N/A,13.25,N/A,81.19,N/A,47.94,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,81.19,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,84.60,84.60,13.25,84.60,,Hospital CPT 80180,HC Mycophenolate Level,N/A,0301 - LABORATORY - CHEMISTRY,76.00,76.00,45.60,45.60,N/A,18.05,N/A,18.05,N/A,43.76,N/A,25.84,N/A,24.63,N/A,18.05,N/A,18.05,N/A,18.05,N/A,24.63,N/A,24.63,N/A,24.63,N/A,24.63,N/A,43.76,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,19.86,45.60,45.60,18.05,45.60,,Hospital CPT 80180,HC So Mycophenolate Level,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,18.05,N/A,18.05,N/A,39.15,N/A,23.12,N/A,24.63,N/A,18.05,N/A,18.05,N/A,18.05,N/A,24.63,N/A,24.63,N/A,24.63,N/A,24.63,N/A,39.15,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,18.05,N/A,19.86,40.80,40.80,18.05,40.80,,Hospital CPT 80181,HC So Drug Assay Flecainide,N/A,0301 - LABORATORY - CHEMISTRY,105.00,105.00,63.00,63.00,N/A,18.64,N/A,18.64,N/A,60.46,N/A,35.70,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,11.60,N/A,18.64,N/A,18.64,N/A,18.64,N/A,60.46,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,63.00,63.00,11.60,63.00,,Hospital CPT 80192,HC So Napa,N/A,0301 - LABORATORY - CHEMISTRY,90.00,90.00,54.00,54.00,N/A,16.75,N/A,16.75,N/A,51.82,N/A,30.60,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,10.43,N/A,16.75,N/A,16.75,N/A,16.75,N/A,51.82,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,18.43,54.00,54.00,10.43,54.00,,Hospital CPT 80192,HC Napa,N/A,0301 - LABORATORY - CHEMISTRY,100.00,75.00,60.00,45.00,N/A,16.75,N/A,16.75,N/A,43.19,N/A,25.50,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,10.43,N/A,16.75,N/A,16.75,N/A,16.75,N/A,43.19,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,16.75,N/A,18.43,60.00,60.00,10.43,45.00,,Hospital CPT 80197,HC Tacrolimus,N/A,0301 - LABORATORY - CHEMISTRY,145.00,107.00,87.00,64.20,N/A,13.73,N/A,13.73,N/A,61.61,N/A,36.38,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,8.55,N/A,13.73,N/A,13.73,N/A,13.73,N/A,61.61,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,87.00,87.00,8.55,64.20,,Hospital CPT 80197,HC So Tacrolimus,N/A,0301 - LABORATORY - CHEMISTRY,131.00,131.00,78.60,78.60,N/A,13.73,N/A,13.73,N/A,75.43,N/A,44.54,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,8.55,N/A,13.73,N/A,13.73,N/A,13.73,N/A,75.43,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,78.60,78.60,8.55,78.60,,Hospital CPT 80199,HC So Tiagubine,N/A,0301 - LABORATORY - CHEMISTRY,190.00,190.00,114.00,114.00,N/A,27.11,N/A,27.11,N/A,109.40,N/A,64.60,N/A,24.63,N/A,27.11,N/A,27.11,N/A,27.11,N/A,24.63,N/A,24.63,N/A,24.63,N/A,24.63,N/A,109.40,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,29.82,114.00,114.00,24.63,114.00,,Hospital CPT 80203,HC So Zonisamide Level,N/A,0301 - LABORATORY - CHEMISTRY,126.00,126.00,75.60,75.60,N/A,13.25,N/A,13.25,N/A,72.55,N/A,42.84,N/A,18.09,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,72.55,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,75.60,75.60,13.25,75.60,,Hospital CPT 80235,HC So Lacosamide Level,N/A,0301 - LABORATORY - CHEMISTRY,343.00,343.00,205.80,205.80,N/A,27.11,N/A,27.11,N/A,197.50,N/A,116.62,N/A,10.84,N/A,27.11,N/A,27.11,N/A,27.11,N/A,10.84,N/A,10.84,N/A,10.84,N/A,10.84,N/A,197.50,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,27.11,N/A,29.82,205.80,205.80,10.84,205.80,,Hospital CPT 80280,HC So Drug Assay Vedolizumab,N/A,0301 - LABORATORY - CHEMISTRY,96.00,96.00,57.60,57.60,N/A,38.57,N/A,38.57,N/A,55.28,N/A,32.64,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,24.01,N/A,38.57,N/A,38.57,N/A,38.57,N/A,55.28,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,42.43,57.60,57.60,24.01,57.60,,Hospital 80323,"HC So Nicotine Metabolite, Serum",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,N/A,1884.00,N/A,1130.40,N/A,183.19,N/A,124.72,N/A,1084.81,N/A,568.48,N/A,125.56,N/A,183.19,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,1084.81,N/A,51.91,N/A,183.19,N/A,265.97,N/A,265.97,N/A,183.19,N/A,51.91,N/A,124.72,N/A,131.07,N/A,N/A,51.91,1130.40,,Hospital 80324,HC So Drug Screening Amphetamines 1/2,N/A,0309 - LABORATORY - OTHER LABORATORY,38232.27,416.00,22939.36,249.60,5483.99,85.80,6752.92,62.14,12358.62,239.53,12998.97,141.44,12476.84,85.80,N/A,85.80,2248.00,62.14,2248.00,62.14,N/A,53.38,12476.84,85.80,12476.84,85.80,12476.84,85.80,N/A,239.53,6752.92,62.14,5652.96,85.80,N/A,62.14,14844.32,62.14,5652.96,85.80,6752.92,62.14,N/A,62.14,6048.67,68.35,2248.00,22939.36,53.38,249.60,,Hospital 80337,HC Sotricyclic & Cyclicals 6/More,N/A,0309 - LABORATORY - OTHER LABORATORY,106210.32,N/A,63726.19,N/A,28615.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28615.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28615.96,N/A,N/A,N/A,N/A,N/A,28615.96,N/A,N/A,N/A,N/A,N/A,28615.96,N/A,28615.96,63726.19,N/A,N/A,,Hospital 80352,HC Cannabinoid Synthetic 7/More,N/A,0301 - LABORATORY - CHEMISTRY,74248.10,N/A,44548.86,N/A,32120.28,N/A,38262.30,N/A,72385.66,N/A,25244.35,N/A,37502.72,N/A,33109.97,N/A,38262.30,N/A,38262.30,N/A,23343.60,N/A,37502.72,N/A,37502.72,N/A,37502.72,N/A,72385.66,N/A,38262.30,N/A,33109.97,N/A,21840.00,N/A,21840.00,N/A,N/A,N/A,38262.30,N/A,38262.30,N/A,35427.66,N/A,21840.00,72385.66,N/A,N/A,,Hospital 80353,HC So Drug Screening Cocaine,N/A,0309 - LABORATORY - OTHER LABORATORY,131143.77,N/A,78686.26,N/A,20782.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20782.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20782.89,N/A,N/A,N/A,N/A,N/A,20782.89,N/A,N/A,N/A,N/A,N/A,20782.89,N/A,20782.89,78686.26,N/A,N/A,,Hospital 80359,HC So Methylenedioxyamphetamines,N/A,0309 - LABORATORY - OTHER LABORATORY,38232.27,N/A,22939.36,N/A,5483.99,N/A,6752.92,N/A,12358.62,N/A,N/A,N/A,12476.84,N/A,5652.96,N/A,2248.00,N/A,2248.00,N/A,7766.54,N/A,N/A,N/A,12476.84,N/A,12476.84,N/A,12358.62,N/A,6752.92,N/A,N/A,N/A,N/A,N/A,14844.32,N/A,N/A,N/A,6752.92,N/A,6752.92,N/A,N/A,N/A,2248.00,22939.36,N/A,N/A,,Hospital CPT 81002,"HC Non-Auto,Urine W/O Microscopy",N/A,0307 - LABORATORY - UROLOGY,25.00,21.00,15.00,12.60,N/A,3.48,N/A,3.48,N/A,12.09,N/A,7.14,N/A,3.48,N/A,3.48,N/A,3.48,N/A,3.48,N/A,2.17,N/A,3.48,N/A,3.48,N/A,3.48,N/A,12.09,N/A,3.48,N/A,3.48,N/A,3.48,N/A,3.48,N/A,3.48,N/A,3.48,N/A,3.48,N/A,3.83,15.00,15.00,2.17,12.60,,Hospital CPT 81107,HC So Hpa-3 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,60.36,N/A,122.22,N/A,122.22,N/A,122.22,N/A,60.36,N/A,60.36,N/A,60.36,N/A,60.36,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,60.36,183.60,,Hospital CPT 81108,HC So Hpa-4 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,60.36,N/A,122.22,N/A,122.22,N/A,122.22,N/A,60.36,N/A,60.36,N/A,60.36,N/A,60.36,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,60.36,183.60,,Hospital CPT 81110,HC So Hpa-6 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,60.36,N/A,122.22,N/A,122.22,N/A,122.22,N/A,60.36,N/A,60.36,N/A,60.36,N/A,60.36,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,60.36,183.60,,Hospital CPT 81121,HC So Idh2 Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,739.00,739.00,443.40,443.40,N/A,295.79,N/A,295.79,N/A,425.52,N/A,251.26,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,184.13,N/A,295.79,N/A,295.79,N/A,295.79,N/A,425.52,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,325.37,443.40,443.40,184.13,443.40,,Hospital 81168,HC So Ccnd1/Igh Translocation Alys Major Bp Qual&Quan,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,421848.33,16626.70,253109.00,9976.02,N/A,2476.95,27934.19,3077.66,N/A,9571.87,N/A,5653.08,N/A,7538.78,N/A,2476.95,27934.19,3104.47,27934.19,3104.47,N/A,4693.04,N/A,7538.78,N/A,7538.78,N/A,7538.78,N/A,9571.87,27934.19,3104.47,N/A,2476.95,N/A,3397.00,N/A,3397.00,N/A,2476.95,51202.02,3104.47,27934.19,3077.66,N/A,2666.23,27934.19,253109.00,2476.95,9976.02,,Hospital CPT 81170,HC So Abl1 Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1172.00,1172.00,703.20,703.20,N/A,300.00,N/A,300.00,N/A,674.84,N/A,398.48,N/A,69.13,N/A,300.00,N/A,300.00,N/A,300.00,N/A,69.13,N/A,69.13,N/A,69.13,N/A,69.13,N/A,674.84,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,330.00,703.20,703.20,69.13,703.20,,Hospital CPT 81177,HC So Atn1 Gene Detc Abnor Alleles,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,727.00,727.00,436.20,436.20,N/A,137.00,N/A,137.00,N/A,418.61,N/A,247.18,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,418.61,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,436.20,436.20,85.28,436.20,,Hospital CPT 81178,HC So Atxn1 Gene Detc Abnor Allele,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,200.00,200.00,120.00,120.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,68.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,120.00,120.00,68.00,150.70,,Hospital CPT 81185,HC Cacna1a Gene Analysis Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1175.00,1175.00,705.00,705.00,N/A,846.27,N/A,846.27,N/A,676.57,N/A,399.50,N/A,338.51,N/A,846.27,N/A,846.27,N/A,846.27,N/A,338.51,N/A,338.51,N/A,338.51,N/A,338.51,N/A,676.57,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,930.90,705.00,705.00,338.51,930.90,,Hospital 81187,HC So Cnbp Gene Analysis Eval Detect Abnormal Alleles,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,N/A,1450.00,N/A,870.00,N/A,296.17,N/A,296.17,N/A,834.91,N/A,493.00,N/A,124.94,N/A,296.17,N/A,296.17,N/A,296.17,N/A,124.94,N/A,124.94,N/A,124.94,N/A,124.94,N/A,834.91,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,296.17,N/A,325.79,N/A,N/A,124.94,870.00,,Hospital CPT 81201,HC So Apc Gene Seq,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1950.00,1950.00,1170.00,1170.00,N/A,780.00,N/A,780.00,N/A,1122.81,N/A,663.00,N/A,888.41,N/A,780.00,N/A,780.00,N/A,780.00,N/A,888.41,N/A,888.41,N/A,888.41,N/A,888.41,N/A,1122.81,N/A,780.00,N/A,780.00,N/A,780.00,N/A,780.00,N/A,780.00,N/A,780.00,N/A,780.00,N/A,858.00,1170.00,1170.00,663.00,1170.00,,Hospital CPT 81208,HC So Bcr/Abl1 Other Breakpnt Qual/Quant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,537.00,537.00,322.20,322.20,N/A,214.62,N/A,214.62,N/A,309.20,N/A,182.58,N/A,95.15,N/A,214.62,N/A,214.62,N/A,214.62,N/A,95.15,N/A,95.15,N/A,214.62,N/A,95.15,N/A,309.20,N/A,214.62,N/A,214.62,N/A,214.62,N/A,214.62,N/A,214.62,N/A,214.62,N/A,214.62,N/A,236.08,322.20,322.20,95.15,322.20,,Hospital CPT 81210,HC So Braf Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,532.00,532.00,319.20,319.20,N/A,175.40,N/A,175.40,N/A,306.33,N/A,180.88,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,109.19,N/A,175.40,N/A,175.40,N/A,175.40,N/A,306.33,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,192.94,319.20,319.20,109.19,319.20,,Hospital CPT 81210,HC Braf Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,587.00,587.00,352.20,352.20,N/A,175.40,N/A,175.40,N/A,337.99,N/A,199.58,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,109.19,N/A,175.40,N/A,175.40,N/A,175.40,N/A,337.99,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,192.94,352.20,352.20,109.19,352.20,,Hospital CPT 81218,HC So Cebpa Gene Full Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,975.00,975.00,585.00,585.00,N/A,241.90,N/A,241.90,N/A,561.41,N/A,331.50,N/A,241.90,N/A,241.90,N/A,241.90,N/A,241.90,N/A,150.58,N/A,241.90,N/A,241.90,N/A,241.90,N/A,561.41,N/A,241.90,N/A,241.90,N/A,241.90,N/A,241.90,N/A,241.90,N/A,241.90,N/A,241.90,N/A,266.09,585.00,585.00,150.58,585.00,,Hospital CPT 81220,HC Cystic Fibrosis Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1416.00,1416.00,849.60,849.60,N/A,556.60,N/A,556.60,N/A,815.33,N/A,481.44,N/A,332.71,N/A,556.60,N/A,556.60,N/A,556.60,N/A,332.71,N/A,332.71,N/A,332.71,N/A,332.71,N/A,815.33,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,612.26,849.60,849.60,332.71,849.60,,Hospital CPT 81220,HC So Cystic Fibrosis Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1416.00,1416.00,849.60,849.60,N/A,556.60,N/A,556.60,N/A,815.33,N/A,481.44,N/A,332.71,N/A,556.60,N/A,556.60,N/A,556.60,N/A,332.71,N/A,332.71,N/A,332.71,N/A,332.71,N/A,815.33,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,556.60,N/A,612.26,849.60,849.60,332.71,849.60,,Hospital CPT 81221,HC So Cftr Analysis; Know Familial Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,311.00,311.00,186.60,186.60,N/A,97.22,N/A,97.22,N/A,179.07,N/A,105.74,N/A,97.22,N/A,97.22,N/A,97.22,N/A,97.22,N/A,60.52,N/A,97.22,N/A,97.22,N/A,97.22,N/A,179.07,N/A,97.22,N/A,97.22,N/A,97.22,N/A,97.22,N/A,97.22,N/A,97.22,N/A,97.22,N/A,106.94,186.60,186.60,60.52,186.60,,Hospital CPT 81227,HC So Cyp2c9 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,438.00,438.00,262.80,262.80,N/A,174.81,N/A,174.81,N/A,252.20,N/A,148.92,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,108.82,N/A,174.81,N/A,174.81,N/A,174.81,N/A,252.20,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,262.80,262.80,108.82,262.80,,Hospital 81228,HC So Cytogen Micrarray Copy Nmbr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,299659.08,N/A,179795.45,N/A,N/A,N/A,49645.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,48583.25,N/A,48583.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49645.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49645.18,N/A,49645.18,N/A,N/A,N/A,48583.25,179795.45,N/A,N/A,,Hospital CPT 81242,HC So Fancc Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,99.00,99.00,59.40,59.40,N/A,36.62,N/A,36.62,N/A,57.00,N/A,33.66,N/A,36.62,N/A,36.62,N/A,36.62,N/A,36.62,N/A,22.80,N/A,36.62,N/A,36.62,N/A,36.62,N/A,57.00,N/A,36.62,N/A,36.62,N/A,36.62,N/A,36.62,N/A,36.62,N/A,36.62,N/A,36.62,N/A,40.28,59.40,59.40,22.80,59.40,,Hospital CPT 81245,HC So1 Flt3 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,413.00,413.00,247.80,247.80,N/A,165.51,N/A,165.51,N/A,237.81,N/A,140.42,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,103.03,N/A,165.51,N/A,165.51,N/A,165.51,N/A,237.81,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,182.06,247.80,247.80,103.03,247.80,,Hospital CPT 81245,HC So Flt3 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,406.00,406.00,243.60,243.60,N/A,165.51,N/A,165.51,N/A,233.77,N/A,138.04,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,103.03,N/A,165.51,N/A,165.51,N/A,165.51,N/A,233.77,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,165.51,N/A,182.06,243.60,243.60,103.03,243.60,,Hospital CPT 81246,HC So1 Flt3 Gene Analysis Tyorsine Kinase Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,208.00,208.00,124.80,124.80,N/A,83.00,N/A,83.00,N/A,119.77,N/A,70.72,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,51.67,N/A,83.00,N/A,83.00,N/A,83.00,N/A,119.77,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,91.30,124.80,124.80,51.67,124.80,,Hospital CPT 81246,HC So Flt3 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,406.00,406.00,243.60,243.60,N/A,83.00,N/A,83.00,N/A,233.77,N/A,138.04,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,51.67,N/A,83.00,N/A,83.00,N/A,83.00,N/A,233.77,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,91.30,243.60,243.60,51.67,243.60,,Hospital CPT 81250,HC So G6pc Gene Analysis Common Variant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,146.00,146.00,87.60,87.60,N/A,58.49,N/A,58.49,N/A,84.07,N/A,49.64,N/A,58.49,N/A,58.49,N/A,58.49,N/A,58.49,N/A,36.41,N/A,58.49,N/A,58.49,N/A,58.49,N/A,84.07,N/A,58.49,N/A,58.49,N/A,58.49,N/A,58.49,N/A,58.49,N/A,58.49,N/A,58.49,N/A,64.34,87.60,87.60,36.41,87.60,,Hospital CPT 81251,HC So Gba Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,502.00,502.00,301.20,301.20,N/A,47.25,N/A,47.25,N/A,289.05,N/A,170.68,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,29.41,N/A,47.25,N/A,47.25,N/A,47.25,N/A,289.05,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,51.98,301.20,301.20,29.41,301.20,,Hospital CPT 81252,HC So Gjb2 Full Gene Sequence,N/A,0301 - LABORATORY - CHEMISTRY,760.00,760.00,456.00,456.00,N/A,101.12,N/A,101.12,N/A,437.61,N/A,258.40,N/A,101.12,N/A,101.12,N/A,101.12,N/A,101.12,N/A,62.95,N/A,101.12,N/A,101.12,N/A,101.12,N/A,437.61,N/A,101.12,N/A,101.12,N/A,101.12,N/A,101.12,N/A,101.12,N/A,101.12,N/A,101.12,N/A,111.23,456.00,456.00,62.95,456.00,,Hospital CPT 81256,HC So Hemochromatosis Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1175.00,1175.00,705.00,705.00,N/A,65.36,N/A,65.36,N/A,676.57,N/A,399.50,N/A,31.01,N/A,65.36,N/A,65.36,N/A,65.36,N/A,31.01,N/A,31.01,N/A,31.01,N/A,31.01,N/A,676.57,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,71.90,705.00,705.00,31.01,705.00,,Hospital CPT 81256,HC Hfe Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1296.00,1101.00,777.60,660.60,N/A,65.36,N/A,65.36,N/A,633.96,N/A,374.34,N/A,31.01,N/A,65.36,N/A,65.36,N/A,65.36,N/A,31.01,N/A,31.01,N/A,31.01,N/A,31.01,N/A,633.96,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,65.36,N/A,71.90,777.60,777.60,31.01,660.60,,Hospital CPT 81259,HC So Hba1/Hba2 Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1500.00,1500.00,900.00,900.00,N/A,600.00,N/A,600.00,N/A,863.70,N/A,510.00,N/A,240.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,240.00,N/A,240.00,N/A,240.00,N/A,240.00,N/A,863.70,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,600.00,N/A,660.00,900.00,900.00,240.00,900.00,,Hospital CPT 81261,HC So Igh Gene Rearrange Am,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,550.00,550.00,330.00,330.00,N/A,197.99,N/A,197.99,N/A,316.69,N/A,187.00,N/A,197.99,N/A,197.99,N/A,197.99,N/A,197.99,N/A,123.25,N/A,197.99,N/A,197.99,N/A,197.99,N/A,316.69,N/A,197.99,N/A,197.99,N/A,197.99,N/A,197.99,N/A,197.99,N/A,197.99,N/A,197.99,N/A,217.79,330.00,330.00,123.25,330.00,,Hospital CPT 81263,HC So Igh Vari Regional Mutation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,800.00,800.00,480.00,480.00,N/A,294.52,N/A,294.52,N/A,460.64,N/A,272.00,N/A,294.52,N/A,294.52,N/A,294.52,N/A,294.52,N/A,183.34,N/A,294.52,N/A,294.52,N/A,294.52,N/A,460.64,N/A,294.52,N/A,294.52,N/A,294.52,N/A,294.52,N/A,294.52,N/A,294.52,N/A,294.52,N/A,323.97,480.00,480.00,183.34,480.00,,Hospital CPT 81264,HC So Igk Rearrangeabn Clonal Pop,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,430.00,430.00,258.00,258.00,N/A,172.73,N/A,172.73,N/A,247.59,N/A,146.20,N/A,172.73,N/A,172.73,N/A,172.73,N/A,172.73,N/A,107.52,N/A,172.73,N/A,172.73,N/A,172.73,N/A,247.59,N/A,172.73,N/A,172.73,N/A,172.73,N/A,172.73,N/A,172.73,N/A,172.73,N/A,172.73,N/A,190.00,258.00,258.00,107.52,258.00,,Hospital CPT 81269,HC So Hba1/Hba2 Gene Dup/Del Vrnts,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,637.00,637.00,382.20,382.20,N/A,202.40,N/A,202.40,N/A,366.78,N/A,216.58,N/A,80.96,N/A,202.40,N/A,202.40,N/A,202.40,N/A,80.96,N/A,80.96,N/A,80.96,N/A,202.40,N/A,366.78,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,222.64,382.20,382.20,80.96,382.20,,Hospital CPT 81271,HC So Huntington Disease Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,275.00,275.00,165.00,165.00,N/A,137.00,N/A,137.00,N/A,158.35,N/A,93.50,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,158.35,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,165.00,165.00,85.28,165.00,,Hospital CPT 81276,HC Kras Gene Analysis Additional Variant(S),N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,646.00,646.00,387.60,387.60,N/A,193.25,N/A,193.25,N/A,371.97,N/A,219.64,N/A,87.55,N/A,193.25,N/A,193.25,N/A,193.25,N/A,87.55,N/A,87.55,N/A,87.55,N/A,87.55,N/A,371.97,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,212.58,387.60,387.60,87.55,387.60,,Hospital CPT 81276,HC So Kras Gene Addl Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,585.00,585.00,351.00,351.00,N/A,193.25,N/A,193.25,N/A,336.84,N/A,198.90,N/A,87.55,N/A,193.25,N/A,193.25,N/A,193.25,N/A,87.55,N/A,87.55,N/A,87.55,N/A,87.55,N/A,336.84,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,212.58,351.00,351.00,87.55,351.00,,Hospital CPT 81279,HC So Jak2 Gene Trget Seq Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,740.00,740.00,444.00,444.00,N/A,185.20,N/A,185.20,N/A,426.09,N/A,251.60,N/A,74.08,N/A,185.20,N/A,185.20,N/A,185.20,N/A,74.08,N/A,74.08,N/A,185.20,N/A,74.08,N/A,426.09,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,203.72,444.00,444.00,74.08,444.00,,Hospital CPT 81283,HC Ifnl3 Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,253.00,253.00,151.80,151.80,N/A,73.37,N/A,73.37,N/A,145.68,N/A,86.02,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,45.67,N/A,73.37,N/A,73.37,N/A,73.37,N/A,145.68,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,80.71,151.80,151.80,45.67,151.80,,Hospital CPT 81283,HC So Ifnl3 Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,229.00,229.00,137.40,137.40,N/A,73.37,N/A,73.37,N/A,131.86,N/A,77.86,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,45.67,N/A,73.37,N/A,73.37,N/A,73.37,N/A,131.86,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,80.71,137.40,137.40,45.67,137.40,,Hospital CPT 81288,HC So Mlh1 Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,480.00,480.00,288.00,288.00,N/A,192.32,N/A,192.32,N/A,276.38,N/A,163.20,N/A,192.32,N/A,192.32,N/A,192.32,N/A,192.32,N/A,119.72,N/A,192.32,N/A,173.26,N/A,192.32,N/A,276.38,N/A,192.32,N/A,192.32,N/A,192.32,N/A,192.32,N/A,192.32,N/A,192.32,N/A,192.32,N/A,211.55,288.00,288.00,119.72,288.00,,Hospital CPT 81291,HC So Mthfr Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,207.00,207.00,124.20,124.20,N/A,65.34,N/A,65.34,N/A,119.19,N/A,70.38,N/A,26.30,N/A,65.34,N/A,65.34,N/A,65.34,N/A,26.30,N/A,26.30,N/A,26.30,N/A,65.34,N/A,119.19,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,71.87,124.20,124.20,26.30,124.20,,Hospital CPT 81291,HC Mthfr Mutation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,229.00,195.00,137.40,117.00,N/A,65.34,N/A,65.34,N/A,112.28,N/A,66.30,N/A,26.30,N/A,65.34,N/A,65.34,N/A,65.34,N/A,26.30,N/A,26.30,N/A,26.30,N/A,65.34,N/A,112.28,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,65.34,N/A,71.87,137.40,137.40,26.30,117.00,,Hospital CPT 81301,HC So Microsatellite Instability,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1163.00,1163.00,697.80,697.80,N/A,348.56,N/A,348.56,N/A,669.66,N/A,395.42,N/A,348.56,N/A,348.56,N/A,348.56,N/A,348.56,N/A,216.98,N/A,348.56,N/A,348.56,N/A,348.56,N/A,669.66,N/A,348.56,N/A,348.56,N/A,348.56,N/A,348.56,N/A,348.56,N/A,348.56,N/A,348.56,N/A,383.42,697.80,697.80,216.98,697.80,,Hospital CPT 81305,HC So Myd88 Gene P.Leu265 Varient,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,450.00,450.00,270.00,270.00,N/A,175.40,N/A,175.40,N/A,259.11,N/A,153.00,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,109.19,N/A,175.40,N/A,175.40,N/A,175.40,N/A,259.11,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,175.40,N/A,192.94,270.00,270.00,109.19,270.00,,Hospital CPT 81310,HC So Npm1 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,625.00,625.00,375.00,375.00,N/A,246.52,N/A,246.52,N/A,359.88,N/A,212.50,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,153.46,N/A,246.52,N/A,246.52,N/A,246.52,N/A,359.88,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,271.17,375.00,375.00,153.46,375.00,,Hospital CPT 81310,HC Npm1 Mutation Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,826.00,826.00,495.60,495.60,N/A,246.52,N/A,246.52,N/A,475.61,N/A,280.84,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,153.46,N/A,246.52,N/A,246.52,N/A,246.52,N/A,475.61,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,246.52,N/A,271.17,495.60,495.60,153.46,495.60,,Hospital CPT 81311,HC So Nras Gene Analysis Variants in Exon 2&3,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,850.00,850.00,510.00,510.00,N/A,295.79,N/A,295.79,N/A,489.43,N/A,289.00,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,184.13,N/A,295.79,N/A,295.79,N/A,295.79,N/A,489.43,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,295.79,N/A,325.37,510.00,510.00,184.13,510.00,,Hospital CPT 81324,HC So Pmp22 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1895.00,1895.00,1137.00,1137.00,N/A,758.36,N/A,758.36,N/A,1091.14,N/A,644.30,N/A,627.82,N/A,758.36,N/A,758.36,N/A,758.36,N/A,627.82,N/A,627.82,N/A,627.82,N/A,627.82,N/A,1091.14,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,834.20,1137.00,1137.00,627.82,1137.00,,Hospital CPT 81324,HC Pmp22 Gene Dup/Delet,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,3558.00,3558.00,2134.80,2134.80,N/A,758.36,N/A,758.36,N/A,2048.70,N/A,1209.72,N/A,627.82,N/A,758.36,N/A,758.36,N/A,758.36,N/A,627.82,N/A,627.82,N/A,627.82,N/A,627.82,N/A,2048.70,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,758.36,N/A,834.20,2134.80,2134.80,627.82,2134.80,,Hospital CPT 81350,HC So Ugt1a1 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,936.00,936.00,561.60,561.60,N/A,234.00,N/A,234.00,N/A,538.95,N/A,318.24,N/A,234.00,N/A,234.00,N/A,234.00,N/A,234.00,N/A,145.67,N/A,234.00,N/A,234.00,N/A,234.00,N/A,538.95,N/A,234.00,N/A,234.00,N/A,234.00,N/A,234.00,N/A,234.00,N/A,234.00,N/A,234.00,N/A,257.40,561.60,561.60,145.67,561.60,,Hospital 81352,HC So Tp53 Gene Analysis Targeted Sequence Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,363816.95,25308.68,218290.17,15185.21,33091.94,4524.66,N/A,1342.46,N/A,12041.82,N/A,8604.95,N/A,3280.38,33091.94,4524.66,N/A,1354.15,N/A,1354.15,N/A,2042.10,N/A,3280.38,N/A,3280.38,N/A,3280.38,N/A,12041.82,N/A,1354.15,33091.94,4524.66,N/A,1431.00,N/A,1431.00,33091.94,4524.66,N/A,1354.15,N/A,1342.46,33091.94,4620.42,33091.94,218290.17,1342.46,15185.21,,Hospital CPT 81400,HC Mopath Procedure Level 1,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,357.00,357.00,214.20,214.20,N/A,63.96,N/A,63.96,N/A,205.56,N/A,121.38,N/A,32.16,N/A,63.96,N/A,63.96,N/A,63.96,N/A,32.16,N/A,32.16,N/A,32.16,N/A,63.96,N/A,205.56,N/A,63.96,N/A,63.96,N/A,63.96,N/A,63.96,N/A,63.96,N/A,63.96,N/A,63.96,N/A,70.36,214.20,214.20,32.16,214.20,,Hospital CPT 81406,HC Mopath Procedure Level 7,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4762.00,4762.00,2857.20,2857.20,N/A,282.88,N/A,282.88,N/A,2741.96,N/A,1619.08,N/A,28.14,N/A,282.88,N/A,282.88,N/A,282.88,N/A,28.14,N/A,28.14,N/A,28.14,N/A,28.14,N/A,2741.96,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,311.17,2857.20,2857.20,28.14,2857.20,,Hospital CPT 81406,HC So Mopath Procedure Level 7,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4319.00,4319.00,2591.40,2591.40,N/A,282.88,N/A,282.88,N/A,2486.88,N/A,1468.46,N/A,28.14,N/A,282.88,N/A,282.88,N/A,282.88,N/A,28.14,N/A,28.14,N/A,28.14,N/A,28.14,N/A,2486.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,282.88,N/A,311.17,2591.40,2591.40,28.14,2591.40,,Hospital CPT 81408,HC So Molecular Pathology Level 9,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1200.00,1200.00,720.00,720.00,N/A,1200.00,N/A,2000.00,N/A,690.96,N/A,408.00,N/A,1200.00,N/A,1200.00,N/A,2000.00,N/A,2000.00,N/A,1200.00,N/A,1200.00,N/A,1200.00,N/A,1200.00,N/A,690.96,N/A,2000.00,N/A,1200.00,N/A,1200.00,N/A,1200.00,N/A,1200.00,N/A,2000.00,N/A,2000.00,N/A,2200.00,720.00,720.00,408.00,2200.00,,Hospital CPT 81410,HC So Aortic Dysfunction or Dilation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1500.00,1500.00,900.00,900.00,N/A,504.00,N/A,504.00,N/A,863.70,N/A,510.00,N/A,1500.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,1500.00,N/A,1500.00,N/A,1500.00,N/A,1500.00,N/A,863.70,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,504.00,N/A,554.40,900.00,900.00,504.00,1500.00,,Hospital CPT 81422,HC So Fetal Chrmoml Microdeltj,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2275.00,2275.00,1365.00,1365.00,N/A,759.05,N/A,759.05,N/A,1309.95,N/A,773.50,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,472.51,N/A,759.05,N/A,759.05,N/A,759.05,N/A,1309.95,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,834.96,1365.00,1365.00,472.51,1365.00,,Hospital CPT 81431,HC So1 Duplication/Deletion Analysis Panel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1700.00,1700.00,1020.00,1020.00,N/A,679.57,N/A,679.57,N/A,978.86,N/A,578.00,N/A,1700.00,N/A,679.57,N/A,679.57,N/A,679.57,N/A,1700.00,N/A,1700.00,N/A,1700.00,N/A,1700.00,N/A,978.86,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,747.53,1020.00,1020.00,578.00,1700.00,,Hospital CPT 81431,HC So Duplication/Deletion Analysis Panel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1700.00,1700.00,1020.00,1020.00,N/A,679.57,N/A,679.57,N/A,978.86,N/A,578.00,N/A,1700.00,N/A,679.57,N/A,679.57,N/A,679.57,N/A,1700.00,N/A,1700.00,N/A,1700.00,N/A,1700.00,N/A,978.86,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,679.57,N/A,747.53,1020.00,1020.00,578.00,1700.00,,Hospital CPT 81433,HC So1 Duplication/Deletion Analysis Panel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1220.00,1220.00,732.00,732.00,N/A,438.93,N/A,438.93,N/A,702.48,N/A,414.80,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,273.23,N/A,438.93,N/A,438.93,N/A,438.93,N/A,702.48,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,482.82,732.00,732.00,273.23,732.00,,Hospital CPT 81433,HC So Duplication/Deletion Analysis Panel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,5088.00,5088.00,3052.80,3052.80,N/A,438.93,N/A,438.93,N/A,2929.67,N/A,1729.92,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,273.23,N/A,438.93,N/A,438.93,N/A,438.93,N/A,2929.67,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,438.93,N/A,482.82,3052.80,3052.80,273.23,3052.80,,Hospital CPT 81442,HC So Noonan Spectrum Disorders,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,5359.00,5359.00,3215.40,3215.40,N/A,2143.60,N/A,2143.60,N/A,3085.71,N/A,1822.06,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,800.00,N/A,800.00,N/A,800.00,N/A,800.00,N/A,3085.71,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2357.96,3215.40,3215.40,800.00,3215.40,,Hospital CPT 81442,HC POC Placenta Alpha Micro Ig C/V,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,5359.00,5359.00,3215.40,3215.40,N/A,2143.60,N/A,2143.60,N/A,3085.71,N/A,1822.06,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,800.00,N/A,800.00,N/A,800.00,N/A,800.00,N/A,3085.71,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2357.96,3215.40,3215.40,800.00,3215.40,,Hospital CPT 81442,HC Placenta Alpha Micro Ig C/V,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,5359.00,5359.00,3215.40,3215.40,N/A,2143.60,N/A,2143.60,N/A,3085.71,N/A,1822.06,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,800.00,N/A,800.00,N/A,800.00,N/A,800.00,N/A,3085.71,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2143.60,N/A,2357.96,3215.40,3215.40,800.00,3215.40,,Hospital CPT 81443,HC So Genetic Testing for Severe Inherited Cond,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,25000.00,25000.00,15000.00,15000.00,N/A,2448.56,N/A,2448.56,N/A,14395.00,N/A,8500.00,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,1524.23,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,14395.00,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,2448.56,N/A,2693.42,15000.00,15000.00,1524.23,15000.00,,Hospital CPT 81448,HC So Hereditary Periph Neuropathy Gen Seq Pnl,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2372.00,2372.00,1423.20,1423.20,N/A,584.90,N/A,584.90,N/A,1365.80,N/A,806.48,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,364.10,N/A,584.90,N/A,584.90,N/A,584.90,N/A,1365.80,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,643.39,1423.20,1423.20,364.10,1423.20,,Hospital CPT 81455,HC So Targeted Genomic Seq Analys,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,5839.00,5839.00,3503.40,3503.40,N/A,2919.60,N/A,2919.60,N/A,3362.10,N/A,1985.26,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,1817.45,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,3362.10,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,2919.60,N/A,3211.56,3503.40,3503.40,1817.45,3503.40,,Hospital CPT 81470,HC So X-Linked Intellectual Dblt,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,3656.00,3656.00,2193.60,2193.60,N/A,914.00,N/A,914.00,N/A,2105.12,N/A,1243.04,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,568.97,N/A,914.00,N/A,914.00,N/A,914.00,N/A,2105.12,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,1005.40,2193.60,2193.60,568.97,2193.60,,Hospital CPT 81471,HC So X-Linked Intellectual Dblt Dup/Del Gene Analys,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,3656.00,3656.00,2193.60,2193.60,N/A,914.00,N/A,914.00,N/A,2105.12,N/A,1243.04,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,568.97,N/A,914.00,N/A,914.00,N/A,914.00,N/A,2105.12,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,914.00,N/A,1005.40,2193.60,2193.60,568.97,2193.60,,Hospital CPT 81511,HC So Maternal Screen Quad,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,175.00,175.00,105.00,105.00,N/A,153.50,N/A,153.50,N/A,100.77,N/A,59.50,N/A,46.48,N/A,153.50,N/A,153.50,N/A,153.50,N/A,46.48,N/A,46.48,N/A,46.48,N/A,46.48,N/A,100.77,N/A,153.50,N/A,153.50,N/A,153.50,N/A,153.50,N/A,153.50,N/A,153.50,N/A,153.50,N/A,168.85,105.00,105.00,46.48,168.85,,Hospital CPT 81540,HC So Oncology Tum Unkown Org Mrna 92 Genes,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,9375.00,9375.00,5625.00,5625.00,N/A,3750.00,N/A,3750.00,N/A,5398.13,N/A,3187.50,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,2334.38,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,5398.13,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,3750.00,N/A,4125.00,5625.00,5625.00,2334.38,5625.00,,Hospital CPT 82010,HC Acetone Assay,N/A,0307 - LABORATORY - UROLOGY,43.00,34.00,25.80,20.40,N/A,8.17,N/A,8.17,N/A,19.58,N/A,11.56,N/A,6.94,N/A,8.17,N/A,8.17,N/A,8.17,N/A,6.94,N/A,6.94,N/A,6.94,N/A,6.94,N/A,19.58,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.17,N/A,8.99,25.80,25.80,6.94,20.40,,Hospital CPT 82108,HC So Aluminum,N/A,0301 - LABORATORY - CHEMISTRY,66.00,66.00,39.60,39.60,N/A,25.48,N/A,25.48,N/A,38.00,N/A,22.44,N/A,21.65,N/A,25.48,N/A,25.48,N/A,25.48,N/A,21.65,N/A,21.65,N/A,21.65,N/A,21.65,N/A,38.00,N/A,25.48,N/A,25.48,N/A,25.48,N/A,25.48,N/A,25.48,N/A,25.48,N/A,25.48,N/A,28.03,39.60,39.60,21.65,39.60,,Hospital CPT 82157,HC Androstenedione,N/A,0301 - LABORATORY - CHEMISTRY,225.00,166.00,135.00,99.60,N/A,29.28,N/A,29.28,N/A,95.58,N/A,56.44,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,24.88,N/A,24.88,N/A,24.88,N/A,24.88,N/A,95.58,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,32.21,135.00,135.00,24.88,99.60,,Hospital CPT 82157,HC So Androstenedione,N/A,0301 - LABORATORY - CHEMISTRY,203.00,203.00,121.80,121.80,N/A,29.28,N/A,29.28,N/A,116.89,N/A,69.02,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,24.88,N/A,24.88,N/A,24.88,N/A,24.88,N/A,116.89,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,32.21,121.80,121.80,24.88,121.80,,Hospital CPT 82163,HC So Angiotensin II,N/A,0301 - LABORATORY - CHEMISTRY,202.00,202.00,121.20,121.20,N/A,20.52,N/A,20.52,N/A,116.31,N/A,68.68,N/A,14.83,N/A,20.52,N/A,20.52,N/A,20.52,N/A,14.83,N/A,14.83,N/A,14.83,N/A,14.83,N/A,116.31,N/A,20.52,N/A,20.52,N/A,20.52,N/A,20.52,N/A,20.52,N/A,20.52,N/A,20.52,N/A,22.57,121.20,121.20,14.83,121.20,,Hospital CPT 82175,HC So Arsenic,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,18.97,N/A,18.97,N/A,96.73,N/A,57.12,N/A,16.12,N/A,18.97,N/A,18.97,N/A,18.97,N/A,16.12,N/A,16.12,N/A,16.12,N/A,16.12,N/A,96.73,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,20.87,100.80,100.80,16.12,100.80,,Hospital CPT 82175,HC Arsenic,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,18.97,N/A,18.97,N/A,80.04,N/A,47.26,N/A,16.12,N/A,18.97,N/A,18.97,N/A,18.97,N/A,16.12,N/A,16.12,N/A,16.12,N/A,16.12,N/A,80.04,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,18.97,N/A,20.87,111.60,111.60,16.12,83.40,,Hospital CPT 82239,HC So Bile Acids Total,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,17.12,N/A,17.12,N/A,69.10,N/A,40.80,N/A,14.56,N/A,17.12,N/A,17.12,N/A,17.12,N/A,14.56,N/A,14.56,N/A,14.56,N/A,14.56,N/A,69.10,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,18.83,72.00,72.00,14.56,72.00,,Hospital CPT 82239,HC Bile Acids Total,N/A,0301 - LABORATORY - CHEMISTRY,132.00,99.00,79.20,59.40,N/A,17.12,N/A,17.12,N/A,57.00,N/A,33.66,N/A,14.56,N/A,17.12,N/A,17.12,N/A,17.12,N/A,14.56,N/A,14.56,N/A,14.56,N/A,14.56,N/A,57.00,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,17.12,N/A,18.83,79.20,79.20,14.56,59.40,,Hospital CPT 82247,HC So Bilirubin Total,N/A,0301 - LABORATORY - CHEMISTRY,150.00,150.00,90.00,90.00,N/A,5.02,N/A,5.02,N/A,86.37,N/A,51.00,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,3.12,N/A,4.26,N/A,5.02,N/A,4.26,N/A,86.37,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.52,90.00,90.00,3.12,90.00,,Hospital CPT 82247,HC Bilirubin Total,N/A,0301 - LABORATORY - CHEMISTRY,166.00,166.00,99.60,99.60,N/A,5.02,N/A,5.02,N/A,95.58,N/A,56.44,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,3.12,N/A,4.26,N/A,5.02,N/A,4.26,N/A,95.58,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.52,99.60,99.60,3.12,99.60,,Hospital CPT 82300,HC So Cadmium,N/A,0301 - LABORATORY - CHEMISTRY,133.00,133.00,79.80,79.80,N/A,23.64,N/A,23.64,N/A,76.58,N/A,45.22,N/A,19.67,N/A,23.64,N/A,23.64,N/A,23.64,N/A,19.67,N/A,19.67,N/A,19.67,N/A,19.67,N/A,76.58,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,26.00,79.80,79.80,19.67,79.80,,Hospital CPT 82300,HC Cadmium,N/A,0301 - LABORATORY - CHEMISTRY,147.00,110.00,88.20,66.00,N/A,23.64,N/A,23.64,N/A,63.34,N/A,37.40,N/A,19.67,N/A,23.64,N/A,23.64,N/A,23.64,N/A,19.67,N/A,19.67,N/A,19.67,N/A,19.67,N/A,63.34,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,23.64,N/A,26.00,88.20,88.20,19.67,66.00,,Hospital CPT 82308,HC So Calcitionin,N/A,0301 - LABORATORY - CHEMISTRY,268.00,268.00,160.80,160.80,N/A,26.79,N/A,26.79,N/A,154.31,N/A,91.12,N/A,22.76,N/A,26.79,N/A,26.79,N/A,26.79,N/A,22.76,N/A,22.76,N/A,22.76,N/A,22.76,N/A,154.31,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,29.47,160.80,160.80,22.76,160.80,,Hospital CPT 82308,HC Calcitionin,N/A,0301 - LABORATORY - CHEMISTRY,296.00,223.00,177.60,133.80,N/A,26.79,N/A,26.79,N/A,128.40,N/A,75.82,N/A,22.76,N/A,26.79,N/A,26.79,N/A,26.79,N/A,22.76,N/A,22.76,N/A,22.76,N/A,22.76,N/A,128.40,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,26.79,N/A,29.47,177.60,177.60,22.76,133.80,,Hospital CPT 82310,"HC Calcium,Serum",N/A,0301 - LABORATORY - CHEMISTRY,144.00,144.00,86.40,86.40,N/A,5.16,N/A,5.16,N/A,82.92,N/A,48.96,N/A,5.16,N/A,5.16,N/A,5.16,N/A,5.16,N/A,3.21,N/A,4.38,N/A,5.16,N/A,5.16,N/A,82.92,N/A,5.16,N/A,5.16,N/A,5.16,N/A,5.16,N/A,5.16,N/A,5.16,N/A,5.16,N/A,5.68,86.40,86.40,3.21,86.40,,Hospital CPT 82360,HC Stone Analysis,N/A,0301 - LABORATORY - CHEMISTRY,298.00,224.00,178.80,134.40,N/A,12.87,N/A,12.87,N/A,128.98,N/A,76.16,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,8.01,N/A,12.87,N/A,12.87,N/A,12.87,N/A,128.98,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,178.80,178.80,8.01,134.40,,Hospital CPT 82360,HC So Stone Analysis,N/A,0301 - LABORATORY - CHEMISTRY,270.00,270.00,162.00,162.00,N/A,12.87,N/A,12.87,N/A,155.47,N/A,91.80,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,8.01,N/A,12.87,N/A,12.87,N/A,12.87,N/A,155.47,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,162.00,162.00,8.01,162.00,,Hospital CPT 82378,HC Cea,N/A,0301 - LABORATORY - CHEMISTRY,231.00,172.00,138.60,103.20,N/A,18.96,N/A,18.96,N/A,99.04,N/A,58.48,N/A,16.12,N/A,18.96,N/A,18.96,N/A,18.96,N/A,11.80,N/A,18.96,N/A,18.96,N/A,18.96,N/A,99.04,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,20.86,138.60,138.60,11.80,103.20,,Hospital CPT 82378,HC So Cea,N/A,0301 - LABORATORY - CHEMISTRY,209.00,209.00,125.40,125.40,N/A,18.96,N/A,18.96,N/A,120.34,N/A,71.06,N/A,16.12,N/A,18.96,N/A,18.96,N/A,18.96,N/A,11.80,N/A,18.96,N/A,18.96,N/A,18.96,N/A,120.34,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,18.96,N/A,20.86,125.40,125.40,11.80,125.40,,Hospital CPT 82379,"HC So Carnitine,Total and Free",N/A,0301 - LABORATORY - CHEMISTRY,84.00,84.00,50.40,50.40,N/A,16.87,N/A,16.87,N/A,48.37,N/A,28.56,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,48.37,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,50.40,50.40,1.73,50.40,,Hospital CPT 82379,"HC Carnitine,Total and Free",N/A,0301 - LABORATORY - CHEMISTRY,93.00,70.00,55.80,42.00,N/A,16.87,N/A,16.87,N/A,40.31,N/A,23.80,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,40.31,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,55.80,55.80,1.73,42.00,,Hospital CPT 82380,HC Carotene,N/A,0301 - LABORATORY - CHEMISTRY,72.00,55.00,43.20,33.00,N/A,9.22,N/A,9.22,N/A,31.67,N/A,18.70,N/A,7.84,N/A,9.22,N/A,9.22,N/A,9.22,N/A,7.84,N/A,7.84,N/A,7.84,N/A,7.84,N/A,31.67,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,10.14,43.20,43.20,7.84,33.00,,Hospital CPT 82380,HC So Carotene,N/A,0301 - LABORATORY - CHEMISTRY,65.00,65.00,39.00,39.00,N/A,9.22,N/A,9.22,N/A,37.43,N/A,22.10,N/A,7.84,N/A,9.22,N/A,9.22,N/A,9.22,N/A,7.84,N/A,7.84,N/A,7.84,N/A,7.84,N/A,37.43,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,10.14,39.00,39.00,7.84,39.00,,Hospital CPT 82438,HC So Assay Other Fluid Chorides,N/A,0301 - LABORATORY - CHEMISTRY,19.00,19.00,11.40,11.40,N/A,5.00,N/A,5.00,N/A,10.94,N/A,6.46,N/A,4.16,N/A,5.00,N/A,5.00,N/A,5.00,N/A,4.16,N/A,4.16,N/A,4.16,N/A,4.16,N/A,10.94,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.00,N/A,5.50,11.40,11.40,4.16,11.40,,Hospital CPT 82465,"HC Cholesterol, Total",N/A,0301 - LABORATORY - CHEMISTRY,138.00,103.00,82.80,61.80,N/A,4.35,N/A,4.35,N/A,59.31,N/A,35.02,N/A,3.70,N/A,4.35,N/A,4.35,N/A,4.35,N/A,3.70,N/A,3.70,N/A,3.70,N/A,3.70,N/A,59.31,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.79,82.80,82.80,3.70,61.80,,Hospital CPT 82465,HC So Cholesterol,N/A,0301 - LABORATORY - CHEMISTRY,124.00,124.00,74.40,74.40,N/A,4.35,N/A,4.35,N/A,71.40,N/A,42.16,N/A,3.70,N/A,4.35,N/A,4.35,N/A,4.35,N/A,3.70,N/A,3.70,N/A,3.70,N/A,3.70,N/A,71.40,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.35,N/A,4.79,74.40,74.40,3.70,74.40,,Hospital CPT 82480,HC Pseudocholinesterase,N/A,0301 - LABORATORY - CHEMISTRY,70.00,59.00,42.00,35.40,N/A,7.87,N/A,7.87,N/A,33.97,N/A,20.06,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,4.90,N/A,7.87,N/A,7.87,N/A,7.87,N/A,33.97,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,8.66,42.00,42.00,4.90,35.40,,Hospital CPT 82480,HC So Pseudocholinesterase,N/A,0301 - LABORATORY - CHEMISTRY,63.00,63.00,37.80,37.80,N/A,7.87,N/A,7.87,N/A,36.28,N/A,21.42,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,4.90,N/A,7.87,N/A,7.87,N/A,7.87,N/A,36.28,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,7.87,N/A,8.66,37.80,37.80,4.90,37.80,,Hospital CPT 82533,"HC Cortisol,Serum",N/A,0301 - LABORATORY - CHEMISTRY,103.00,77.00,61.80,46.20,N/A,16.30,N/A,16.30,N/A,44.34,N/A,26.18,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,10.15,N/A,16.30,N/A,16.30,N/A,16.30,N/A,44.34,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,17.93,61.80,61.80,10.15,46.20,,Hospital CPT 82533,"HC So Cortisol,Serum",N/A,0301 - LABORATORY - CHEMISTRY,93.00,93.00,55.80,55.80,N/A,16.30,N/A,16.30,N/A,53.55,N/A,31.62,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,10.15,N/A,16.30,N/A,16.30,N/A,16.30,N/A,53.55,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,16.30,N/A,17.93,55.80,55.80,10.15,55.80,,Hospital CPT 82540,HC Creatine,N/A,0301 - LABORATORY - CHEMISTRY,113.00,113.00,67.80,67.80,N/A,4.64,N/A,4.64,N/A,65.07,N/A,38.42,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,2.89,N/A,4.64,N/A,4.64,N/A,4.64,N/A,65.07,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,5.10,67.80,67.80,2.89,67.80,,Hospital CPT 82540,HC So Creatine,N/A,0301 - LABORATORY - CHEMISTRY,113.00,113.00,67.80,67.80,N/A,4.64,N/A,4.64,N/A,65.07,N/A,38.42,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,2.89,N/A,4.64,N/A,4.64,N/A,4.64,N/A,65.07,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,4.64,N/A,5.10,67.80,67.80,2.89,67.80,,Hospital CPT 82575,HC Creatinine Clearance,N/A,0301 - LABORATORY - CHEMISTRY,180.00,134.00,108.00,80.40,N/A,9.46,N/A,9.46,N/A,77.16,N/A,45.56,N/A,7.27,N/A,9.46,N/A,9.46,N/A,9.46,N/A,7.27,N/A,7.27,N/A,7.27,N/A,7.27,N/A,77.16,N/A,9.46,N/A,9.46,N/A,9.46,N/A,9.46,N/A,9.46,N/A,9.46,N/A,9.46,N/A,10.41,108.00,108.00,7.27,80.40,,Hospital CPT 82585,HC So Plasma Cryofibrinogen,N/A,0301 - LABORATORY - CHEMISTRY,46.00,46.00,27.60,27.60,N/A,14.14,N/A,14.14,N/A,26.49,N/A,15.64,N/A,7.29,N/A,14.14,N/A,14.14,N/A,14.14,N/A,8.80,N/A,14.14,N/A,7.29,N/A,14.14,N/A,26.49,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,15.55,27.60,27.60,7.29,27.60,,Hospital CPT 82595,"HC So Cryoglobulin,Qualitative",N/A,0301 - LABORATORY - CHEMISTRY,51.00,51.00,30.60,30.60,N/A,6.47,N/A,6.47,N/A,29.37,N/A,17.34,N/A,5.06,N/A,6.47,N/A,6.47,N/A,6.47,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,29.37,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,30.60,30.60,5.06,30.60,,Hospital CPT 82595,"HC Cryoglobulin,Qualitative",N/A,0301 - LABORATORY - CHEMISTRY,57.00,43.00,34.20,25.80,N/A,6.47,N/A,6.47,N/A,24.76,N/A,14.62,N/A,5.06,N/A,6.47,N/A,6.47,N/A,6.47,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,24.76,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,34.20,34.20,5.06,25.80,,Hospital CPT 82608,HC So Vitamin B12 Binding Capacity,N/A,0301 - LABORATORY - CHEMISTRY,50.00,50.00,30.00,30.00,N/A,14.32,N/A,14.32,N/A,28.79,N/A,17.00,N/A,12.17,N/A,14.32,N/A,14.32,N/A,14.32,N/A,12.17,N/A,12.17,N/A,12.17,N/A,12.17,N/A,28.79,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,15.75,30.00,30.00,12.17,30.00,,Hospital CPT 82610,HC So Cystatin C,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,18.52,N/A,18.52,N/A,43.19,N/A,25.50,N/A,11.55,N/A,18.52,N/A,18.52,N/A,18.52,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,43.19,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,20.37,45.00,45.00,11.55,45.00,,Hospital CPT 82642,HC So Dihydrotestosterone (Dht),N/A,0301 - LABORATORY - CHEMISTRY,96.00,72.00,57.60,43.20,N/A,29.28,N/A,29.28,N/A,41.46,N/A,24.48,N/A,13.01,N/A,29.28,N/A,29.28,N/A,29.28,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,41.46,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,32.21,57.60,57.60,13.01,43.20,,Hospital CPT 82658,HC So Enzyme Act Blood Cells Ra Ea,N/A,0301 - LABORATORY - CHEMISTRY,931.00,931.00,558.60,558.60,N/A,44.03,N/A,44.03,N/A,536.07,N/A,316.54,N/A,44.03,N/A,44.03,N/A,44.03,N/A,44.03,N/A,27.41,N/A,44.03,N/A,44.03,N/A,44.03,N/A,536.07,N/A,44.03,N/A,44.03,N/A,44.03,N/A,44.03,N/A,44.03,N/A,44.03,N/A,44.03,N/A,48.43,558.60,558.60,27.41,558.60,,Hospital CPT 82670,HC Estradiol,N/A,0301 - LABORATORY - CHEMISTRY,182.00,135.00,109.20,81.00,N/A,27.94,N/A,27.94,N/A,77.73,N/A,45.90,N/A,23.75,N/A,27.94,N/A,27.94,N/A,27.94,N/A,23.75,N/A,23.75,N/A,23.75,N/A,23.75,N/A,77.73,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,30.73,109.20,109.20,23.75,81.00,,Hospital CPT 82670,HC So Estradiol,N/A,0301 - LABORATORY - CHEMISTRY,164.00,164.00,98.40,98.40,N/A,27.94,N/A,27.94,N/A,94.43,N/A,55.76,N/A,23.75,N/A,27.94,N/A,27.94,N/A,27.94,N/A,23.75,N/A,23.75,N/A,23.75,N/A,23.75,N/A,94.43,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,27.94,N/A,30.73,98.40,98.40,23.75,98.40,,Hospital CPT 82671,"HC So Estrogens,Fractionated",N/A,0301 - LABORATORY - CHEMISTRY,228.00,228.00,136.80,136.80,N/A,32.30,N/A,32.30,N/A,131.28,N/A,77.52,N/A,27.45,N/A,32.30,N/A,32.30,N/A,32.30,N/A,27.45,N/A,27.45,N/A,27.45,N/A,27.45,N/A,131.28,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,35.53,136.80,136.80,27.45,136.80,,Hospital CPT 82671,"HC Estrogens,Fractionated",N/A,0301 - LABORATORY - CHEMISTRY,252.00,189.00,151.20,113.40,N/A,32.30,N/A,32.30,N/A,108.83,N/A,64.26,N/A,27.45,N/A,32.30,N/A,32.30,N/A,32.30,N/A,27.45,N/A,27.45,N/A,27.45,N/A,27.45,N/A,108.83,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,32.30,N/A,35.53,151.20,151.20,27.45,113.40,,Hospital CPT 82679,HC So Assay of Estrone,N/A,0301 - LABORATORY - CHEMISTRY,173.00,173.00,103.80,103.80,N/A,24.95,N/A,24.95,N/A,99.61,N/A,58.82,N/A,21.21,N/A,24.95,N/A,24.95,N/A,24.95,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,99.61,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,27.45,103.80,103.80,21.21,103.80,,Hospital CPT 82679,HC Assay of Estrone,N/A,0301 - LABORATORY - CHEMISTRY,191.00,144.00,114.60,86.40,N/A,24.95,N/A,24.95,N/A,82.92,N/A,48.96,N/A,21.21,N/A,24.95,N/A,24.95,N/A,24.95,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,82.92,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,24.95,N/A,27.45,114.60,114.60,21.21,86.40,,Hospital CPT 82693,HC So Ethylene Glycol,N/A,0301 - LABORATORY - CHEMISTRY,133.00,133.00,79.80,79.80,N/A,14.90,N/A,14.90,N/A,76.58,N/A,45.22,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,9.28,N/A,14.90,N/A,14.90,N/A,14.90,N/A,76.58,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,16.39,79.80,79.80,9.28,79.80,,Hospital CPT 82693,HC Ethylene Glycol,N/A,0301 - LABORATORY - CHEMISTRY,147.00,110.00,88.20,66.00,N/A,14.90,N/A,14.90,N/A,63.34,N/A,37.40,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,9.28,N/A,14.90,N/A,14.90,N/A,14.90,N/A,63.34,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,14.90,N/A,16.39,88.20,88.20,9.28,66.00,,Hospital CPT 82731,HC Fetal Fibronectin,N/A,0301 - LABORATORY - CHEMISTRY,417.00,417.00,250.20,250.20,N/A,64.41,N/A,64.41,N/A,240.11,N/A,141.78,N/A,64.41,N/A,64.41,N/A,64.41,N/A,64.41,N/A,40.10,N/A,64.41,N/A,54.74,N/A,64.41,N/A,240.11,N/A,64.41,N/A,64.41,N/A,64.41,N/A,64.41,N/A,64.41,N/A,64.41,N/A,64.41,N/A,70.85,250.20,250.20,40.10,250.20,,Hospital CPT 82760,HC Galactose,N/A,0301 - LABORATORY - CHEMISTRY,320.00,320.00,192.00,192.00,N/A,11.20,N/A,11.20,N/A,184.26,N/A,108.80,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,6.97,N/A,11.20,N/A,11.20,N/A,11.20,N/A,184.26,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,12.32,192.00,192.00,6.97,192.00,,Hospital CPT 82760,HC So Assay of Galactose,N/A,0301 - LABORATORY - CHEMISTRY,223.00,223.00,133.80,133.80,N/A,11.20,N/A,11.20,N/A,128.40,N/A,75.82,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,6.97,N/A,11.20,N/A,11.20,N/A,11.20,N/A,128.40,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,11.20,N/A,12.32,133.80,133.80,6.97,133.80,,Hospital CPT 82787,HC So Immunoglob G Subclasses Each,N/A,0301 - LABORATORY - CHEMISTRY,144.00,144.00,86.40,86.40,N/A,8.02,N/A,8.02,N/A,82.92,N/A,48.96,N/A,6.50,N/A,8.02,N/A,8.02,N/A,8.02,N/A,6.50,N/A,8.02,N/A,6.50,N/A,8.02,N/A,82.92,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.82,86.40,86.40,6.50,86.40,,Hospital CPT 82787,HC Immunoglob G Subclasses Each,N/A,0301 - LABORATORY - CHEMISTRY,160.00,120.00,96.00,72.00,N/A,8.02,N/A,8.02,N/A,69.10,N/A,40.80,N/A,6.50,N/A,8.02,N/A,8.02,N/A,8.02,N/A,6.50,N/A,8.02,N/A,6.50,N/A,8.02,N/A,69.10,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.82,96.00,96.00,6.50,72.00,,Hospital CPT 82810,HC Blood Gas O2 Saturation,N/A,0301 - LABORATORY - CHEMISTRY,34.00,34.00,20.40,20.40,N/A,9.77,N/A,9.77,N/A,19.58,N/A,11.56,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,6.08,N/A,9.77,N/A,9.77,N/A,9.77,N/A,19.58,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,9.77,N/A,10.75,20.40,20.40,6.08,20.40,,Hospital CPT 82941,HC So Gastrin,N/A,0301 - LABORATORY - CHEMISTRY,159.00,159.00,95.40,95.40,N/A,17.63,N/A,17.63,N/A,91.55,N/A,54.06,N/A,14.99,N/A,17.63,N/A,17.63,N/A,17.63,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,91.55,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,19.39,95.40,95.40,14.99,95.40,,Hospital CPT 82941,HC Gastrin,N/A,0301 - LABORATORY - CHEMISTRY,175.00,130.00,105.00,78.00,N/A,17.63,N/A,17.63,N/A,74.85,N/A,44.20,N/A,14.99,N/A,17.63,N/A,17.63,N/A,17.63,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,74.85,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,17.63,N/A,19.39,105.00,105.00,14.99,78.00,,Hospital CPT 82948,HC Glucose Blood Rgnt Strip,N/A,0301 - LABORATORY - CHEMISTRY,25.00,18.00,15.00,10.80,N/A,5.04,N/A,5.04,N/A,10.36,N/A,6.12,N/A,5.04,N/A,5.04,N/A,5.04,N/A,5.04,N/A,2.69,N/A,2.69,N/A,2.69,N/A,5.04,N/A,10.36,N/A,5.04,N/A,5.04,N/A,5.04,N/A,5.04,N/A,5.04,N/A,5.04,N/A,5.04,N/A,5.54,15.00,15.00,2.69,10.80,,Hospital CPT 82952,"HC Tolerance Test, Addit.",N/A,0301 - LABORATORY - CHEMISTRY,30.00,24.00,18.00,14.40,N/A,3.92,N/A,3.92,N/A,13.82,N/A,8.16,N/A,3.33,N/A,3.92,N/A,3.92,N/A,3.92,N/A,2.44,N/A,3.92,N/A,3.33,N/A,3.33,N/A,13.82,N/A,3.92,N/A,3.92,N/A,3.92,N/A,3.92,N/A,3.92,N/A,3.92,N/A,3.92,N/A,4.31,18.00,18.00,2.44,14.40,,Hospital CPT 82955,HC Glucose 6 Phos Dehydro Quant,N/A,0301 - LABORATORY - CHEMISTRY,144.00,106.00,86.40,63.60,N/A,9.70,N/A,9.70,N/A,61.03,N/A,36.04,N/A,8.24,N/A,9.70,N/A,9.70,N/A,9.70,N/A,8.24,N/A,9.70,N/A,8.24,N/A,9.70,N/A,61.03,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,10.67,86.40,86.40,8.24,63.60,,Hospital CPT 82955,HC So Glucose 6 Phos Dehydro Quant,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,9.70,N/A,9.70,N/A,74.85,N/A,44.20,N/A,8.24,N/A,9.70,N/A,9.70,N/A,9.70,N/A,8.24,N/A,9.70,N/A,8.24,N/A,9.70,N/A,74.85,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,9.70,N/A,10.67,78.00,78.00,8.24,78.00,,Hospital CPT 82978,HC So Assay of Glutathione,N/A,0301 - LABORATORY - CHEMISTRY,138.00,138.00,82.80,82.80,N/A,15.45,N/A,15.45,N/A,79.46,N/A,46.92,N/A,12.11,N/A,15.45,N/A,15.45,N/A,15.45,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,79.46,N/A,15.45,N/A,15.45,N/A,15.45,N/A,15.45,N/A,15.45,N/A,15.45,N/A,15.45,N/A,17.00,82.80,82.80,12.11,82.80,,Hospital CPT 83002,HC Luteinizing Hormone,N/A,0301 - LABORATORY - CHEMISTRY,331.00,247.00,198.60,148.20,N/A,18.52,N/A,18.52,N/A,142.22,N/A,83.98,N/A,15.74,N/A,18.52,N/A,18.52,N/A,18.52,N/A,15.74,N/A,15.74,N/A,15.74,N/A,15.74,N/A,142.22,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,18.52,N/A,20.37,198.60,198.60,15.74,148.20,,Hospital CPT 83010,HC Haptoglobin,N/A,0301 - LABORATORY - CHEMISTRY,135.00,102.00,81.00,61.20,N/A,12.58,N/A,12.58,N/A,58.73,N/A,34.68,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,7.83,N/A,12.58,N/A,12.58,N/A,12.58,N/A,58.73,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,13.84,81.00,81.00,7.83,61.20,,Hospital CPT 83010,HC So Haptoglobin,N/A,0301 - LABORATORY - CHEMISTRY,122.00,122.00,73.20,73.20,N/A,12.58,N/A,12.58,N/A,70.25,N/A,41.48,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,7.83,N/A,12.58,N/A,12.58,N/A,12.58,N/A,70.25,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,12.58,N/A,13.84,73.20,73.20,7.83,73.20,,Hospital CPT 83014,HC So Pylori Breath Test/Sample,N/A,0301 - LABORATORY - CHEMISTRY,618.00,618.00,370.80,370.80,N/A,7.86,N/A,7.86,N/A,355.84,N/A,210.12,N/A,6.68,N/A,7.86,N/A,7.86,N/A,7.86,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,355.84,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,8.65,370.80,370.80,6.68,370.80,,Hospital CPT 83014,HC Pylori Breath Test/Sample,N/A,0301 - LABORATORY - CHEMISTRY,681.00,510.00,408.60,306.00,N/A,7.86,N/A,7.86,N/A,293.66,N/A,173.40,N/A,6.68,N/A,7.86,N/A,7.86,N/A,7.86,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,293.66,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,7.86,N/A,8.65,408.60,408.60,6.68,306.00,,Hospital CPT 83021,HC So1 Hemoglobin Chromatography,N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,18.06,N/A,18.06,N/A,63.34,N/A,37.40,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,11.24,N/A,18.06,N/A,15.34,N/A,15.34,N/A,63.34,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,19.87,66.00,66.00,11.24,66.00,,Hospital CPT 83021,HC Hemoglobin Chromatography,N/A,0301 - LABORATORY - CHEMISTRY,122.00,92.00,73.20,55.20,N/A,18.06,N/A,18.06,N/A,52.97,N/A,31.28,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,11.24,N/A,18.06,N/A,15.34,N/A,15.34,N/A,52.97,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,19.87,73.20,73.20,11.24,55.20,,Hospital CPT 83021,HC So Hemoglobin Chromatography,N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,18.06,N/A,18.06,N/A,63.34,N/A,37.40,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,11.24,N/A,18.06,N/A,15.34,N/A,15.34,N/A,63.34,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,19.87,66.00,66.00,11.24,66.00,,Hospital CPT 83030,HC Infant vs Maternal Blood Feces,N/A,0301 - LABORATORY - CHEMISTRY,45.00,45.00,27.00,27.00,N/A,10.74,N/A,10.74,N/A,25.91,N/A,15.30,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,6.69,N/A,10.74,N/A,10.74,N/A,10.74,N/A,25.91,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,11.81,27.00,27.00,6.69,27.00,,Hospital CPT 83036,HC Glycohemoglobin,N/A,0301 - LABORATORY - CHEMISTRY,76.00,56.00,45.60,33.60,N/A,9.71,N/A,9.71,N/A,32.24,N/A,19.04,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,6.04,N/A,8.25,N/A,9.71,N/A,9.71,N/A,32.24,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,10.68,45.60,45.60,6.04,33.60,,Hospital CPT 83036,HC So Glycohemoglobin,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,9.71,N/A,9.71,N/A,39.15,N/A,23.12,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,6.04,N/A,8.25,N/A,9.71,N/A,9.71,N/A,39.15,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,10.68,40.80,40.80,6.04,40.80,,Hospital 83037,HC Glyco Hemoglobin Home Dev,N/A,0301 - LABORATORY - CHEMISTRY,29263.00,32.00,17557.80,19.20,4602.71,9.71,5710.41,9.71,10372.58,18.43,9949.41,10.88,10879.05,8.25,4744.53,9.71,5710.41,9.71,5710.41,9.71,6772.12,8.25,10879.05,8.25,10879.05,8.25,10879.05,8.25,10372.58,18.43,5710.41,9.71,4744.53,9.71,12458.83,9.71,12458.83,9.71,N/A,9.71,5710.41,9.71,5710.41,9.71,5076.65,10.68,4602.71,17557.80,8.25,19.20,,Hospital CPT 83068,HC So Hemoglobin Unstable Screen,N/A,0301 - LABORATORY - CHEMISTRY,132.00,132.00,79.20,79.20,N/A,9.47,N/A,9.47,N/A,76.01,N/A,44.88,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,5.90,N/A,9.47,N/A,9.47,N/A,9.47,N/A,76.01,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,10.42,79.20,79.20,5.90,79.20,,Hospital CPT 83491,HC So Urine 17 Hydroxycorticosteroid,N/A,0301 - LABORATORY - CHEMISTRY,180.00,180.00,108.00,108.00,N/A,17.90,N/A,17.90,N/A,103.64,N/A,61.20,N/A,14.89,N/A,17.90,N/A,17.90,N/A,17.90,N/A,14.89,N/A,14.89,N/A,14.89,N/A,14.89,N/A,103.64,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,108.00,108.00,14.89,108.00,,Hospital CPT 83498,HC So 17-Hydroxyprogesterone,N/A,0301 - LABORATORY - CHEMISTRY,450.00,450.00,270.00,270.00,N/A,27.17,N/A,27.17,N/A,259.11,N/A,153.00,N/A,23.09,N/A,27.17,N/A,27.17,N/A,27.17,N/A,23.09,N/A,23.09,N/A,23.09,N/A,23.09,N/A,259.11,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,29.89,270.00,270.00,23.09,270.00,,Hospital CPT 83498,HC 17-Hydroxyprogesterone,N/A,0301 - LABORATORY - CHEMISTRY,146.00,108.00,87.60,64.80,N/A,27.17,N/A,27.17,N/A,62.19,N/A,36.72,N/A,23.09,N/A,27.17,N/A,27.17,N/A,27.17,N/A,23.09,N/A,23.09,N/A,23.09,N/A,23.09,N/A,62.19,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,27.17,N/A,29.89,87.60,87.60,23.09,64.80,,Hospital CPT 83605,HC So Lactic Acid,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,11.57,N/A,11.57,N/A,69.10,N/A,40.80,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,7.20,N/A,11.57,N/A,11.57,N/A,11.57,N/A,69.10,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,12.73,72.00,72.00,7.20,72.00,,Hospital CPT 83605,HC Lactic Acid,N/A,0301 - LABORATORY - CHEMISTRY,132.00,99.00,79.20,59.40,N/A,11.57,N/A,11.57,N/A,57.00,N/A,33.66,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,7.20,N/A,11.57,N/A,11.57,N/A,11.57,N/A,57.00,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,12.73,79.20,79.20,7.20,59.40,,Hospital CPT 83615,HC So Ldh,N/A,0301 - LABORATORY - CHEMISTRY,107.00,107.00,64.20,64.20,N/A,6.04,N/A,6.04,N/A,61.61,N/A,36.38,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,5.13,N/A,5.13,N/A,5.13,N/A,5.13,N/A,61.61,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.64,64.20,64.20,5.13,64.20,,Hospital CPT 83615,HC Ldh,N/A,0301 - LABORATORY - CHEMISTRY,119.00,90.00,71.40,54.00,N/A,6.04,N/A,6.04,N/A,51.82,N/A,30.60,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,5.13,N/A,5.13,N/A,5.13,N/A,5.13,N/A,51.82,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.04,N/A,6.64,71.40,71.40,5.13,54.00,,Hospital CPT 83631,HC So Lactoferrin Fecal (Quant),N/A,0301 - LABORATORY - CHEMISTRY,55.00,55.00,33.00,33.00,N/A,19.63,N/A,19.63,N/A,31.67,N/A,18.70,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,12.22,N/A,19.63,N/A,19.63,N/A,19.63,N/A,31.67,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,21.59,33.00,33.00,12.22,33.00,,Hospital CPT 83632,HC Lactogen Human Placental Hpl,N/A,0301 - LABORATORY - CHEMISTRY,357.00,357.00,214.20,214.20,N/A,20.22,N/A,20.22,N/A,205.56,N/A,121.38,N/A,20.22,N/A,20.22,N/A,20.22,N/A,20.22,N/A,12.59,N/A,20.22,N/A,20.22,N/A,20.22,N/A,205.56,N/A,20.22,N/A,20.22,N/A,20.22,N/A,20.22,N/A,20.22,N/A,20.22,N/A,20.22,N/A,22.24,214.20,214.20,12.59,214.20,,Hospital CPT 83695,HC So Lipoprotein A,N/A,0301 - LABORATORY - CHEMISTRY,55.00,55.00,33.00,33.00,N/A,14.32,N/A,14.32,N/A,31.67,N/A,18.70,N/A,11.00,N/A,14.32,N/A,14.32,N/A,14.32,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,31.67,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,14.32,N/A,15.75,33.00,33.00,11.00,33.00,,Hospital CPT 83721,HC Direct Ldl Cholesterol,N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,10.50,N/A,10.50,N/A,38.58,N/A,22.78,N/A,8.11,N/A,10.50,N/A,10.50,N/A,10.50,N/A,8.11,N/A,8.11,N/A,8.11,N/A,8.11,N/A,38.58,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,11.55,40.20,40.20,8.11,40.20,,Hospital CPT 83721,HC Direct Ldl Cholesterol,N/A,0301 - LABORATORY - CHEMISTRY,75.00,55.00,45.00,33.00,N/A,10.50,N/A,10.50,N/A,31.67,N/A,18.70,N/A,8.11,N/A,10.50,N/A,10.50,N/A,10.50,N/A,8.11,N/A,8.11,N/A,8.11,N/A,8.11,N/A,31.67,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,10.50,N/A,11.55,45.00,45.00,8.11,33.00,,Hospital CPT 83727,HC Luteinizing Releasing Factor,N/A,0301 - LABORATORY - CHEMISTRY,426.00,426.00,255.60,255.60,N/A,17.19,N/A,17.19,N/A,245.29,N/A,144.84,N/A,13.75,N/A,17.19,N/A,17.19,N/A,17.19,N/A,13.75,N/A,13.75,N/A,13.75,N/A,13.75,N/A,245.29,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,18.91,255.60,255.60,13.75,255.60,,Hospital CPT 83785,HC Assay of Manganese,N/A,0301 - LABORATORY - CHEMISTRY,144.00,106.00,86.40,63.60,N/A,26.65,N/A,26.65,N/A,61.03,N/A,36.04,N/A,20.90,N/A,26.65,N/A,26.65,N/A,26.65,N/A,20.90,N/A,20.90,N/A,20.90,N/A,20.90,N/A,61.03,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,29.32,86.40,86.40,20.90,63.60,,Hospital CPT 83785,HC So Assay of Manganese,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,26.65,N/A,26.65,N/A,74.85,N/A,44.20,N/A,20.90,N/A,26.65,N/A,26.65,N/A,26.65,N/A,20.90,N/A,20.90,N/A,20.90,N/A,20.90,N/A,74.85,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,26.65,N/A,29.32,78.00,78.00,20.90,78.00,,Hospital CPT 83789,HC So Gc/Ms Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,105.00,105.00,63.00,63.00,N/A,24.11,N/A,24.11,N/A,60.46,N/A,35.70,N/A,15.34,N/A,24.11,N/A,24.11,N/A,24.11,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,60.46,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,26.52,63.00,63.00,15.34,63.00,,Hospital CPT 83789,HC Gc/Ms Quatitative,N/A,0301 - LABORATORY - CHEMISTRY,117.00,85.00,70.20,51.00,N/A,24.11,N/A,24.11,N/A,48.94,N/A,28.90,N/A,15.34,N/A,24.11,N/A,24.11,N/A,24.11,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,48.94,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,24.11,N/A,26.52,70.20,70.20,15.34,51.00,,Hospital CPT 83873,HC So Myelin Basic Protein,N/A,0301 - LABORATORY - CHEMISTRY,263.00,263.00,157.80,157.80,N/A,17.20,N/A,17.20,N/A,151.44,N/A,89.42,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,10.71,N/A,17.20,N/A,17.20,N/A,17.20,N/A,151.44,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,18.92,157.80,157.80,10.71,157.80,,Hospital CPT 83873,HC Myelin Basic Protein,N/A,0301 - LABORATORY - CHEMISTRY,291.00,215.00,174.60,129.00,N/A,17.20,N/A,17.20,N/A,123.80,N/A,73.10,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,10.71,N/A,17.20,N/A,17.20,N/A,17.20,N/A,123.80,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,17.20,N/A,18.92,174.60,174.60,10.71,129.00,,Hospital CPT 83935,"HC So Osmolality, Urine",N/A,0301 - LABORATORY - CHEMISTRY,110.00,110.00,66.00,66.00,N/A,6.82,N/A,6.82,N/A,63.34,N/A,37.40,N/A,5.79,N/A,6.82,N/A,6.82,N/A,6.82,N/A,5.79,N/A,5.79,N/A,5.79,N/A,6.82,N/A,63.34,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,7.50,66.00,66.00,5.79,66.00,,Hospital CPT 83935,"HC Osmolality, Urine",N/A,0301 - LABORATORY - CHEMISTRY,122.00,92.00,73.20,55.20,N/A,6.82,N/A,6.82,N/A,52.97,N/A,31.28,N/A,5.79,N/A,6.82,N/A,6.82,N/A,6.82,N/A,5.79,N/A,5.79,N/A,5.79,N/A,6.82,N/A,52.97,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,7.50,73.20,73.20,5.79,55.20,,Hospital CPT 84105,"HC So Phosphorus, Urine 24 Hr",N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,5.78,N/A,5.78,N/A,39.15,N/A,23.12,N/A,4.40,N/A,5.78,N/A,5.78,N/A,5.78,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,39.15,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,6.36,40.80,40.80,4.40,40.80,,Hospital CPT 84105,"HC Phosphorus, Urine 24 Hr",N/A,0301 - LABORATORY - CHEMISTRY,76.00,56.00,45.60,33.60,N/A,5.78,N/A,5.78,N/A,32.24,N/A,19.04,N/A,4.40,N/A,5.78,N/A,5.78,N/A,5.78,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,32.24,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,5.78,N/A,6.36,45.60,45.60,4.40,33.60,,Hospital CPT 84140,HC So Pregnenolone,N/A,0301 - LABORATORY - CHEMISTRY,113.00,113.00,67.80,67.80,N/A,20.67,N/A,20.67,N/A,65.07,N/A,38.42,N/A,17.57,N/A,20.67,N/A,20.67,N/A,20.67,N/A,17.57,N/A,17.57,N/A,17.57,N/A,20.67,N/A,65.07,N/A,20.67,N/A,20.67,N/A,20.67,N/A,20.67,N/A,20.67,N/A,20.67,N/A,20.67,N/A,22.74,67.80,67.80,17.57,67.80,,Hospital CPT 84143,HC 17 - Hydroxyprynenolone,N/A,0301 - LABORATORY - CHEMISTRY,105.00,105.00,63.00,63.00,N/A,22.81,N/A,22.81,N/A,60.46,N/A,35.70,N/A,19.39,N/A,22.81,N/A,22.81,N/A,22.81,N/A,19.39,N/A,19.39,N/A,19.39,N/A,19.39,N/A,60.46,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,25.09,63.00,63.00,19.39,63.00,,Hospital CPT 84143,HC So 17 - Hydroxyprynenolone,N/A,0301 - LABORATORY - CHEMISTRY,95.00,95.00,57.00,57.00,N/A,22.81,N/A,22.81,N/A,54.70,N/A,32.30,N/A,19.39,N/A,22.81,N/A,22.81,N/A,22.81,N/A,19.39,N/A,19.39,N/A,19.39,N/A,19.39,N/A,54.70,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,22.81,N/A,25.09,57.00,57.00,19.39,57.00,,Hospital CPT 84150,HC So Assay of Prostaglandin,N/A,0301 - LABORATORY - CHEMISTRY,700.00,700.00,420.00,420.00,N/A,41.77,N/A,41.77,N/A,403.06,N/A,238.00,N/A,21.21,N/A,41.77,N/A,41.77,N/A,41.77,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,403.06,N/A,41.77,N/A,41.77,N/A,41.77,N/A,41.77,N/A,41.77,N/A,41.77,N/A,41.77,N/A,45.95,420.00,420.00,21.21,420.00,,Hospital CPT 84155,HC Total Protein,N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,3.67,N/A,3.67,N/A,50.67,N/A,29.92,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,2.28,N/A,3.67,N/A,3.67,N/A,3.67,N/A,50.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,4.04,52.80,52.80,2.28,52.80,,Hospital CPT 84155,HC So Total Protein,N/A,0301 - LABORATORY - CHEMISTRY,80.00,80.00,48.00,48.00,N/A,3.67,N/A,3.67,N/A,46.06,N/A,27.20,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,2.28,N/A,3.67,N/A,3.67,N/A,3.67,N/A,46.06,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,4.04,48.00,48.00,2.28,48.00,,Hospital CPT 84156,"HC Total Protein, Urine",N/A,0301 - LABORATORY - CHEMISTRY,88.00,65.00,52.80,39.00,N/A,3.67,N/A,3.67,N/A,37.43,N/A,22.10,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,2.28,N/A,3.67,N/A,3.67,N/A,3.67,N/A,37.43,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,4.04,52.80,52.80,2.28,39.00,,Hospital CPT 84156,"HC So Total Protein, Urine",N/A,0301 - LABORATORY - CHEMISTRY,80.00,80.00,48.00,48.00,N/A,3.67,N/A,3.67,N/A,46.06,N/A,27.20,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,2.28,N/A,3.67,N/A,3.67,N/A,3.67,N/A,46.06,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,3.67,N/A,4.04,48.00,48.00,2.28,48.00,,Hospital CPT 84163,HC Preg Assoc Plasma Prot-a Pappa,N/A,0301 - LABORATORY - CHEMISTRY,122.00,122.00,73.20,73.20,N/A,15.05,N/A,15.05,N/A,70.25,N/A,41.48,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,9.37,N/A,15.05,N/A,15.05,N/A,15.05,N/A,70.25,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,73.20,73.20,9.37,73.20,,Hospital CPT 84165,HC Protein Electrophoresis Serum,N/A,0301 - LABORATORY - CHEMISTRY,179.00,132.00,107.40,79.20,N/A,10.74,N/A,10.74,N/A,76.01,N/A,44.88,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,6.69,N/A,10.74,N/A,10.74,N/A,10.74,N/A,76.01,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,11.81,107.40,107.40,6.69,79.20,,Hospital CPT 84165,HC So Protein Electrophoresis Serum,N/A,0301 - LABORATORY - CHEMISTRY,161.00,161.00,96.60,96.60,N/A,10.74,N/A,10.74,N/A,92.70,N/A,54.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,6.69,N/A,10.74,N/A,10.74,N/A,10.74,N/A,92.70,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,11.81,96.60,96.60,6.69,96.60,,Hospital CPT 84166,HC Protein Electrophoresis Fluid,N/A,0301 - LABORATORY - CHEMISTRY,53.00,53.00,31.80,31.80,N/A,17.83,N/A,17.83,N/A,30.52,N/A,18.02,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,14.74,N/A,14.74,N/A,14.74,N/A,14.74,N/A,30.52,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,19.61,31.80,31.80,14.74,31.80,,Hospital CPT 84166,HC So Protein Electrophoresis Fluid,N/A,0301 - LABORATORY - CHEMISTRY,53.00,53.00,31.80,31.80,N/A,17.83,N/A,17.83,N/A,30.52,N/A,18.02,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,14.74,N/A,14.74,N/A,14.74,N/A,14.74,N/A,30.52,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,17.83,N/A,19.61,31.80,31.80,14.74,31.80,,Hospital CPT 84210,HC Pyruvic Acid,N/A,0301 - LABORATORY - CHEMISTRY,167.00,167.00,100.20,100.20,N/A,14.48,N/A,14.48,N/A,96.16,N/A,56.78,N/A,9.22,N/A,14.48,N/A,14.48,N/A,14.48,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,96.16,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,15.93,100.20,100.20,9.22,100.20,,Hospital CPT 84210,HC So Pyruvic Acid,N/A,0301 - LABORATORY - CHEMISTRY,65.00,65.00,39.00,39.00,N/A,14.48,N/A,14.48,N/A,37.43,N/A,22.10,N/A,9.22,N/A,14.48,N/A,14.48,N/A,14.48,N/A,9.22,N/A,9.22,N/A,9.22,N/A,9.22,N/A,37.43,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,14.48,N/A,15.93,39.00,39.00,9.22,39.00,,Hospital CPT 84244,HC Renin,N/A,0301 - LABORATORY - CHEMISTRY,337.00,251.00,202.20,150.60,N/A,21.99,N/A,21.99,N/A,144.53,N/A,85.34,N/A,18.69,N/A,21.99,N/A,21.99,N/A,21.99,N/A,18.69,N/A,18.69,N/A,18.69,N/A,18.69,N/A,144.53,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,24.19,202.20,202.20,18.69,150.60,,Hospital CPT 84244,HC So Renin,N/A,0301 - LABORATORY - CHEMISTRY,305.00,305.00,183.00,183.00,N/A,21.99,N/A,21.99,N/A,175.62,N/A,103.70,N/A,18.69,N/A,21.99,N/A,21.99,N/A,21.99,N/A,18.69,N/A,18.69,N/A,18.69,N/A,18.69,N/A,175.62,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,21.99,N/A,24.19,183.00,183.00,18.69,183.00,,Hospital CPT 84260,HC So Serotonin,N/A,0301 - LABORATORY - CHEMISTRY,245.00,245.00,147.00,147.00,N/A,30.98,N/A,30.98,N/A,141.07,N/A,83.30,N/A,26.32,N/A,30.98,N/A,30.98,N/A,30.98,N/A,19.29,N/A,30.98,N/A,30.98,N/A,26.32,N/A,141.07,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,34.08,147.00,147.00,19.29,147.00,,Hospital CPT 84260,HC Serotonin,N/A,0301 - LABORATORY - CHEMISTRY,271.00,203.00,162.60,121.80,N/A,30.98,N/A,30.98,N/A,116.89,N/A,69.02,N/A,26.32,N/A,30.98,N/A,30.98,N/A,30.98,N/A,19.29,N/A,30.98,N/A,30.98,N/A,26.32,N/A,116.89,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,34.08,162.60,162.60,19.29,121.80,,Hospital CPT 84295,"HC Sodium,Serum",N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,4.81,N/A,4.81,N/A,50.67,N/A,29.92,N/A,4.81,N/A,4.81,N/A,4.81,N/A,4.81,N/A,4.09,N/A,4.09,N/A,4.09,N/A,4.09,N/A,50.67,N/A,4.81,N/A,4.81,N/A,4.81,N/A,4.81,N/A,4.81,N/A,4.81,N/A,4.81,N/A,5.29,52.80,52.80,4.09,52.80,,Hospital CPT 84300,"HC Sodium,Urine Spot",N/A,0301 - LABORATORY - CHEMISTRY,56.00,44.00,33.60,26.40,N/A,5.06,N/A,5.06,N/A,25.34,N/A,14.96,N/A,4.13,N/A,5.06,N/A,5.06,N/A,5.06,N/A,4.13,N/A,4.13,N/A,4.13,N/A,4.13,N/A,25.34,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.57,33.60,33.60,4.13,26.40,,Hospital CPT 84300,"HC So Sodium,Urine Spot",N/A,0301 - LABORATORY - CHEMISTRY,53.00,53.00,31.80,31.80,N/A,5.06,N/A,5.06,N/A,30.52,N/A,18.02,N/A,4.13,N/A,5.06,N/A,5.06,N/A,5.06,N/A,4.13,N/A,4.13,N/A,4.13,N/A,4.13,N/A,30.52,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.06,N/A,5.57,31.80,31.80,4.13,31.80,,Hospital CPT 84311,HC Serum Porphyrins,N/A,0301 - LABORATORY - CHEMISTRY,79.00,59.00,47.40,35.40,N/A,8.10,N/A,8.10,N/A,33.97,N/A,20.06,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,5.04,N/A,8.10,N/A,8.10,N/A,5.94,N/A,33.97,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.91,47.40,47.40,5.04,35.40,,Hospital CPT 84311,"HC So Spectrophotometry, Analyte Nes",N/A,0301 - LABORATORY - CHEMISTRY,71.00,71.00,42.60,42.60,N/A,8.10,N/A,8.10,N/A,40.88,N/A,24.14,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,5.04,N/A,8.10,N/A,8.10,N/A,5.94,N/A,40.88,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.91,42.60,42.60,5.04,42.60,,Hospital CPT 84311,"HC So1 Spectrophotometry, Analyte Nes",N/A,0301 - LABORATORY - CHEMISTRY,71.00,71.00,42.60,42.60,N/A,8.10,N/A,8.10,N/A,40.88,N/A,24.14,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,5.04,N/A,8.10,N/A,8.10,N/A,5.94,N/A,40.88,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.10,N/A,8.91,42.60,42.60,5.04,42.60,,Hospital CPT 84376,HC So Sugars Single Qual,N/A,0301 - LABORATORY - CHEMISTRY,382.00,382.00,229.20,229.20,N/A,5.50,N/A,5.50,N/A,219.96,N/A,129.88,N/A,4.67,N/A,5.50,N/A,5.50,N/A,5.50,N/A,4.67,N/A,4.67,N/A,4.67,N/A,4.67,N/A,219.96,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.05,229.20,229.20,4.67,229.20,,Hospital CPT 84392,HC So Sulfate Urine,N/A,0301 - LABORATORY - CHEMISTRY,40.00,40.00,24.00,24.00,N/A,5.49,N/A,5.49,N/A,23.03,N/A,13.60,N/A,4.04,N/A,5.49,N/A,5.49,N/A,5.49,N/A,4.04,N/A,4.04,N/A,4.04,N/A,4.04,N/A,23.03,N/A,5.49,N/A,5.49,N/A,5.49,N/A,5.49,N/A,5.49,N/A,5.49,N/A,5.49,N/A,6.04,24.00,24.00,4.04,24.00,,Hospital CPT 84403,HC So Testosterone Total,N/A,0301 - LABORATORY - CHEMISTRY,176.00,176.00,105.60,105.60,N/A,25.81,N/A,25.81,N/A,101.34,N/A,59.84,N/A,21.94,N/A,25.81,N/A,25.81,N/A,25.81,N/A,21.94,N/A,25.81,N/A,21.94,N/A,21.94,N/A,101.34,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,28.39,105.60,105.60,21.94,105.60,,Hospital CPT 84403,HC Testosterone Total,N/A,0301 - LABORATORY - CHEMISTRY,194.00,146.00,116.40,87.60,N/A,25.81,N/A,25.81,N/A,84.07,N/A,49.64,N/A,21.94,N/A,25.81,N/A,25.81,N/A,25.81,N/A,21.94,N/A,25.81,N/A,21.94,N/A,21.94,N/A,84.07,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,25.81,N/A,28.39,116.40,116.40,21.94,87.60,,Hospital CPT 84425,HC Vitamin B-1,N/A,0301 - LABORATORY - CHEMISTRY,156.00,117.00,93.60,70.20,N/A,21.23,N/A,21.23,N/A,67.37,N/A,39.78,N/A,18.04,N/A,21.23,N/A,21.23,N/A,21.23,N/A,13.22,N/A,18.04,N/A,18.04,N/A,18.04,N/A,67.37,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,23.35,93.60,93.60,13.22,70.20,,Hospital CPT 84425,HC So Vitamin B-1,N/A,0301 - LABORATORY - CHEMISTRY,141.00,141.00,84.60,84.60,N/A,21.23,N/A,21.23,N/A,81.19,N/A,47.94,N/A,18.04,N/A,21.23,N/A,21.23,N/A,21.23,N/A,13.22,N/A,18.04,N/A,18.04,N/A,18.04,N/A,81.19,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,21.23,N/A,23.35,84.60,84.60,13.22,84.60,,Hospital 84433,HC So Assay Thiopurine S-Methyltransferase,N/A,0301 - LABORATORY - CHEMISTRY,75783.15,130.00,45469.89,78.00,8688.50,18.20,10543.69,22.17,42936.87,74.85,35669.79,44.20,35669.79,22.17,8956.20,18.20,3934.00,22.17,3934.00,22.17,12304.83,13.80,19767.53,22.17,35669.79,22.17,35669.79,22.17,42936.87,74.85,N/A,22.17,8956.20,18.20,23518.43,22.17,23518.43,22.17,8956.20,18.20,10543.69,22.17,10543.69,22.17,9583.14,N/A,3934.00,45469.89,13.80,78.00,,Hospital CPT 84437,"HC Thyroxine, Total Req Elution",N/A,0301 - LABORATORY - CHEMISTRY,40.00,29.00,24.00,17.40,N/A,6.47,N/A,6.47,N/A,16.70,N/A,9.86,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,4.03,N/A,6.47,N/A,6.47,N/A,6.47,N/A,16.70,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,24.00,24.00,4.03,17.40,,Hospital CPT 84442,HC Thyroxine Binding Globulin,N/A,0301 - LABORATORY - CHEMISTRY,190.00,163.00,114.00,97.80,N/A,14.78,N/A,14.78,N/A,163.00,N/A,55.42,N/A,12.57,N/A,14.78,N/A,14.78,N/A,14.78,N/A,12.57,N/A,12.57,N/A,12.57,N/A,14.78,N/A,93.86,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,16.26,114.00,114.00,12.57,163.00,,Hospital CPT 84442,HC So Thyroxine Binding Globulin,N/A,0301 - LABORATORY - CHEMISTRY,172.00,172.00,103.20,103.20,N/A,14.78,N/A,14.78,N/A,172.00,N/A,58.48,N/A,12.57,N/A,14.78,N/A,14.78,N/A,14.78,N/A,12.57,N/A,12.57,N/A,12.57,N/A,14.78,N/A,99.04,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,14.78,N/A,16.26,103.20,103.20,12.57,172.00,,Hospital CPT 84446,HC Vitamin E,N/A,0301 - LABORATORY - CHEMISTRY,71.00,54.00,42.60,32.40,N/A,14.18,N/A,14.18,N/A,31.09,N/A,18.36,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,9.51,N/A,9.51,N/A,14.18,N/A,9.51,N/A,31.09,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,15.60,42.60,42.60,9.51,32.40,,Hospital CPT 84446,HC So Vitamin E,N/A,0301 - LABORATORY - CHEMISTRY,64.00,64.00,38.40,38.40,N/A,14.18,N/A,14.18,N/A,36.85,N/A,21.76,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,9.51,N/A,9.51,N/A,14.18,N/A,9.51,N/A,36.85,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,15.60,38.40,38.40,9.51,38.40,,Hospital CPT 84450,HC So Sgot (Ast),N/A,0301 - LABORATORY - CHEMISTRY,148.00,148.00,88.80,88.80,N/A,5.18,N/A,5.18,N/A,85.22,N/A,50.32,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,85.22,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,88.80,88.80,4.40,88.80,,Hospital CPT 84450,HC Sgot (Ast),N/A,0301 - LABORATORY - CHEMISTRY,164.00,164.00,98.40,98.40,N/A,5.18,N/A,5.18,N/A,94.43,N/A,55.76,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,94.43,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,98.40,98.40,4.40,98.40,,Hospital CPT 84460,HC So Sgpt (Alt),N/A,0301 - LABORATORY - CHEMISTRY,148.00,148.00,88.80,88.80,N/A,5.30,N/A,5.30,N/A,85.22,N/A,50.32,N/A,4.50,N/A,5.30,N/A,5.30,N/A,5.30,N/A,4.50,N/A,4.50,N/A,4.50,N/A,4.50,N/A,85.22,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.83,88.80,88.80,4.50,88.80,,Hospital CPT 84460,HC Sgpt (Alt),N/A,0301 - LABORATORY - CHEMISTRY,164.00,164.00,98.40,98.40,N/A,5.30,N/A,5.30,N/A,94.43,N/A,55.76,N/A,4.50,N/A,5.30,N/A,5.30,N/A,5.30,N/A,4.50,N/A,4.50,N/A,4.50,N/A,4.50,N/A,94.43,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.30,N/A,5.83,98.40,98.40,4.50,98.40,,Hospital CPT 84478,HC Triglycerides,N/A,0301 - LABORATORY - CHEMISTRY,121.00,91.00,72.60,54.60,N/A,5.74,N/A,5.74,N/A,52.40,N/A,30.94,N/A,4.89,N/A,5.74,N/A,5.74,N/A,5.74,N/A,4.89,N/A,4.89,N/A,4.89,N/A,4.89,N/A,52.40,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,6.31,72.60,72.60,4.89,54.60,,Hospital CPT 84478,HC So Triglycerides,N/A,0301 - LABORATORY - CHEMISTRY,109.00,109.00,65.40,65.40,N/A,5.74,N/A,5.74,N/A,62.76,N/A,37.06,N/A,4.89,N/A,5.74,N/A,5.74,N/A,5.74,N/A,4.89,N/A,4.89,N/A,4.89,N/A,4.89,N/A,62.76,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,5.74,N/A,6.31,65.40,65.40,4.89,65.40,,Hospital CPT 84480,"HC T-3 by Ria,Total",N/A,0301 - LABORATORY - CHEMISTRY,148.00,113.00,88.80,67.80,N/A,14.18,N/A,14.18,N/A,65.07,N/A,38.42,N/A,12.05,N/A,14.18,N/A,14.18,N/A,14.18,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,65.07,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,14.18,N/A,15.60,88.80,88.80,12.05,67.80,,Hospital CPT 84481,"HC So Triiodothyronine T-3, Free",N/A,0301 - LABORATORY - CHEMISTRY,316.00,316.00,189.60,189.60,N/A,16.94,N/A,16.94,N/A,181.95,N/A,107.44,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,14.40,N/A,14.40,N/A,14.40,N/A,14.40,N/A,181.95,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,18.63,189.60,189.60,14.40,189.60,,Hospital CPT 84481,"HC Triiodothyronine T-3, Free",N/A,0301 - LABORATORY - CHEMISTRY,349.00,261.00,209.40,156.60,N/A,16.94,N/A,16.94,N/A,150.28,N/A,88.74,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,14.40,N/A,14.40,N/A,14.40,N/A,14.40,N/A,150.28,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,16.94,N/A,18.63,209.40,209.40,14.40,156.60,,Hospital CPT 84510,HC So Tyrosine,N/A,0301 - LABORATORY - CHEMISTRY,80.00,80.00,48.00,48.00,N/A,10.63,N/A,10.63,N/A,46.06,N/A,27.20,N/A,10.63,N/A,10.63,N/A,10.63,N/A,10.63,N/A,6.62,N/A,10.63,N/A,10.63,N/A,10.63,N/A,46.06,N/A,10.63,N/A,10.63,N/A,10.63,N/A,10.63,N/A,10.63,N/A,10.63,N/A,10.63,N/A,11.69,48.00,48.00,6.62,48.00,,Hospital CPT 84540,"HC So Urea Nitrogen, Urine",N/A,0301 - LABORATORY - CHEMISTRY,124.00,124.00,74.40,74.40,N/A,5.56,N/A,5.56,N/A,71.40,N/A,42.16,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,4.04,N/A,4.04,N/A,4.04,N/A,5.56,N/A,71.40,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,6.12,74.40,74.40,4.04,74.40,,Hospital CPT 84540,"HC Urea Nitrogen, Urine",N/A,0301 - LABORATORY - CHEMISTRY,138.00,103.00,82.80,61.80,N/A,5.56,N/A,5.56,N/A,59.31,N/A,35.02,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,4.04,N/A,4.04,N/A,4.04,N/A,5.56,N/A,59.31,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,6.12,82.80,82.80,4.04,61.80,,Hospital CPT 84585,HC Vma,N/A,0301 - LABORATORY - CHEMISTRY,85.00,64.00,51.00,38.40,N/A,15.50,N/A,15.50,N/A,36.85,N/A,21.76,N/A,3.46,N/A,15.50,N/A,15.50,N/A,15.50,N/A,3.46,N/A,3.46,N/A,3.46,N/A,3.46,N/A,36.85,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,17.05,51.00,51.00,3.46,38.40,,Hospital CPT 84585,HC So Vma,N/A,0301 - LABORATORY - CHEMISTRY,77.00,77.00,46.20,46.20,N/A,15.50,N/A,15.50,N/A,44.34,N/A,26.18,N/A,3.46,N/A,15.50,N/A,15.50,N/A,15.50,N/A,3.46,N/A,3.46,N/A,3.46,N/A,3.46,N/A,44.34,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,15.50,N/A,17.05,46.20,46.20,3.46,46.20,,Hospital CPT 84586,HC So Vip(Vasoact.Intest.Polypept.),N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,35.33,N/A,35.33,N/A,69.67,N/A,41.14,N/A,13.58,N/A,35.33,N/A,35.33,N/A,35.33,N/A,13.58,N/A,13.58,N/A,13.58,N/A,13.58,N/A,69.67,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,38.86,72.60,72.60,13.58,72.60,,Hospital CPT 84586,HC Vip(Vasoact.Intest.Polypept.),N/A,0301 - LABORATORY - CHEMISTRY,134.00,101.00,80.40,60.60,N/A,35.33,N/A,35.33,N/A,58.16,N/A,34.34,N/A,13.58,N/A,35.33,N/A,35.33,N/A,35.33,N/A,13.58,N/A,13.58,N/A,13.58,N/A,13.58,N/A,58.16,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,35.33,N/A,38.86,80.40,80.40,13.58,60.60,,Hospital CPT 84590,HC So Vitamin A,N/A,0301 - LABORATORY - CHEMISTRY,124.00,124.00,74.40,74.40,N/A,11.61,N/A,11.61,N/A,71.40,N/A,42.16,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,6.06,N/A,6.06,N/A,6.06,N/A,11.61,N/A,71.40,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,12.77,74.40,74.40,6.06,74.40,,Hospital CPT 84590,HC Vitamin A,N/A,0301 - LABORATORY - CHEMISTRY,138.00,103.00,82.80,61.80,N/A,11.61,N/A,11.61,N/A,59.31,N/A,35.02,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,6.06,N/A,6.06,N/A,6.06,N/A,11.61,N/A,59.31,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,12.77,82.80,82.80,6.06,61.80,,Hospital CPT 84591,HC Vitamin Nos,N/A,0301 - LABORATORY - CHEMISTRY,64.00,64.00,38.40,38.40,N/A,17.06,N/A,17.06,N/A,36.85,N/A,21.76,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,10.62,N/A,17.06,N/A,6.06,N/A,17.06,N/A,36.85,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,18.77,38.40,38.40,6.06,38.40,,Hospital CPT 84591,HC So Vitamin Nos,N/A,0301 - LABORATORY - CHEMISTRY,58.00,58.00,34.80,34.80,N/A,17.06,N/A,17.06,N/A,33.40,N/A,19.72,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,10.62,N/A,17.06,N/A,6.06,N/A,17.06,N/A,33.40,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,17.06,N/A,18.77,34.80,34.80,6.06,34.80,,Hospital CPT 84630,"HC Zinc, Serum",N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,11.39,N/A,11.39,N/A,80.04,N/A,47.26,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,7.09,N/A,9.67,N/A,9.67,N/A,9.67,N/A,80.04,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,12.53,111.60,111.60,7.09,83.40,,Hospital CPT 84630,"HC So Zinc, Serum",N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,11.39,N/A,11.39,N/A,96.73,N/A,57.12,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,7.09,N/A,9.67,N/A,9.67,N/A,9.67,N/A,96.73,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,12.53,100.80,100.80,7.09,100.80,,Hospital CPT 84681,"HC Peptide,C",N/A,0301 - LABORATORY - CHEMISTRY,129.00,97.00,77.40,58.20,N/A,20.81,N/A,20.81,N/A,55.85,N/A,32.98,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,16.31,N/A,16.31,N/A,16.31,N/A,16.31,N/A,55.85,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,77.40,77.40,16.31,58.20,,Hospital CPT 84681,"HC So Peptide,C",N/A,0301 - LABORATORY - CHEMISTRY,117.00,117.00,70.20,70.20,N/A,20.81,N/A,20.81,N/A,67.37,N/A,39.78,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,16.31,N/A,16.31,N/A,16.31,N/A,16.31,N/A,67.37,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,70.20,70.20,16.31,70.20,,Hospital 85046,HC Retic Auto Including 1 or More,N/A,0305 - LABORATORY - HEMATOLOGY,62896.10,550.00,37737.66,330.00,7358.04,153.46,8969.82,159.03,16581.94,316.69,21384.67,187.00,16740.56,159.03,7584.76,153.46,562.00,159.03,562.00,159.03,10420.61,98.99,16740.56,159.03,16740.56,159.03,16740.56,159.03,16581.94,316.69,8969.82,159.03,7584.76,153.46,19917.09,153.46,19917.09,153.46,5935.43,153.46,8969.82,159.03,8969.82,159.03,8115.69,168.82,562.00,37737.66,98.99,330.00,,Hospital CPT 85230,HC So Factor VII,N/A,0305 - LABORATORY - HEMATOLOGY,102.00,102.00,61.20,61.20,N/A,17.90,N/A,17.90,N/A,58.73,N/A,34.68,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,11.14,N/A,17.90,N/A,15.22,N/A,17.90,N/A,58.73,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,61.20,61.20,11.14,61.20,,Hospital CPT 85230,HC Factor VII,N/A,0305 - LABORATORY - HEMATOLOGY,113.00,96.00,67.80,57.60,N/A,17.90,N/A,17.90,N/A,55.28,N/A,32.64,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,11.14,N/A,17.90,N/A,15.22,N/A,17.90,N/A,55.28,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,67.80,67.80,11.14,57.60,,Hospital CPT 85240,HC So Factor VIII,N/A,0305 - LABORATORY - HEMATOLOGY,179.00,179.00,107.40,107.40,N/A,17.90,N/A,17.90,N/A,103.07,N/A,60.86,N/A,15.22,N/A,17.90,N/A,17.90,N/A,17.90,N/A,15.22,N/A,15.22,N/A,15.22,N/A,15.22,N/A,103.07,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,107.40,107.40,15.22,107.40,,Hospital CPT 85240,HC Factor VIII,N/A,0305 - LABORATORY - HEMATOLOGY,197.00,168.00,118.20,100.80,N/A,17.90,N/A,17.90,N/A,96.73,N/A,57.12,N/A,15.22,N/A,17.90,N/A,17.90,N/A,17.90,N/A,15.22,N/A,15.22,N/A,15.22,N/A,15.22,N/A,96.73,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,118.20,118.20,15.22,100.80,,Hospital CPT 85244,HC So Clot Factor VIII Reltd Antgn,N/A,0305 - LABORATORY - HEMATOLOGY,264.00,264.00,158.40,158.40,N/A,20.42,N/A,20.42,N/A,152.01,N/A,89.76,N/A,20.42,N/A,20.42,N/A,20.42,N/A,20.42,N/A,12.71,N/A,20.42,N/A,20.42,N/A,20.42,N/A,152.01,N/A,20.42,N/A,20.42,N/A,20.42,N/A,20.42,N/A,20.42,N/A,20.42,N/A,20.42,N/A,22.46,158.40,158.40,12.71,158.40,,Hospital CPT 85290,HC So Clot Factor XIII Fibrin Stab,N/A,0305 - LABORATORY - HEMATOLOGY,348.00,348.00,208.80,208.80,N/A,16.34,N/A,16.34,N/A,200.38,N/A,118.32,N/A,13.89,N/A,16.34,N/A,16.34,N/A,16.34,N/A,13.89,N/A,13.89,N/A,13.89,N/A,13.89,N/A,200.38,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,17.97,208.80,208.80,13.89,208.80,,Hospital CPT 85293,HC So Clot Factor Wght Kininogen,N/A,0305 - LABORATORY - HEMATOLOGY,303.00,303.00,181.80,181.80,N/A,18.93,N/A,18.93,N/A,174.47,N/A,103.02,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,11.78,N/A,18.93,N/A,18.93,N/A,18.93,N/A,174.47,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,18.93,N/A,20.82,181.80,181.80,11.78,181.80,,Hospital CPT 85300,HC So Antithrombin III Activity,N/A,0305 - LABORATORY - HEMATOLOGY,53.00,53.00,31.80,31.80,N/A,11.85,N/A,11.85,N/A,30.52,N/A,18.02,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,10.07,N/A,10.07,N/A,10.07,N/A,10.07,N/A,30.52,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,13.04,31.80,31.80,10.07,31.80,,Hospital CPT 85300,HC Antithrombin III Activity,N/A,0305 - LABORATORY - HEMATOLOGY,59.00,59.00,35.40,35.40,N/A,11.85,N/A,11.85,N/A,33.97,N/A,20.06,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,10.07,N/A,10.07,N/A,10.07,N/A,10.07,N/A,33.97,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,11.85,N/A,13.04,35.40,35.40,10.07,35.40,,Hospital CPT 85302,HC So Clot Inhibit Protein C Antigen,N/A,0305 - LABORATORY - HEMATOLOGY,53.00,53.00,31.80,31.80,N/A,12.01,N/A,12.01,N/A,30.52,N/A,18.02,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,7.48,N/A,12.01,N/A,12.01,N/A,10.22,N/A,30.52,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,13.21,31.80,31.80,7.48,31.80,,Hospital CPT 85302,HC Clot Inhibit Protein C Antigen,N/A,0305 - LABORATORY - HEMATOLOGY,59.00,59.00,35.40,35.40,N/A,12.01,N/A,12.01,N/A,33.97,N/A,20.06,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,7.48,N/A,12.01,N/A,12.01,N/A,10.22,N/A,33.97,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,12.01,N/A,13.21,35.40,35.40,7.48,35.40,,Hospital CPT 85305,HC Clot Inhibit Protein S Total,N/A,0305 - LABORATORY - HEMATOLOGY,59.00,59.00,35.40,35.40,N/A,11.61,N/A,11.61,N/A,33.97,N/A,20.06,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,7.23,N/A,11.61,N/A,9.86,N/A,9.86,N/A,33.97,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,12.77,35.40,35.40,7.23,35.40,,Hospital CPT 85305,HC So Clot Inhibit Protein S Total,N/A,0305 - LABORATORY - HEMATOLOGY,53.00,53.00,31.80,31.80,N/A,11.61,N/A,11.61,N/A,30.52,N/A,18.02,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,7.23,N/A,11.61,N/A,9.86,N/A,9.86,N/A,30.52,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,11.61,N/A,12.77,31.80,31.80,7.23,31.80,,Hospital CPT 85335,HC Factor Inhibitor Test,N/A,0305 - LABORATORY - HEMATOLOGY,49.00,49.00,29.40,29.40,N/A,12.87,N/A,12.87,N/A,28.21,N/A,16.66,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,8.01,N/A,12.87,N/A,12.87,N/A,10.94,N/A,28.21,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,29.40,29.40,8.01,29.40,,Hospital CPT 85335,HC So Factor Inhibitor Test,N/A,0305 - LABORATORY - HEMATOLOGY,44.00,44.00,26.40,26.40,N/A,12.87,N/A,12.87,N/A,25.34,N/A,14.96,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,8.01,N/A,12.87,N/A,12.87,N/A,12.87,N/A,25.34,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,26.40,26.40,8.01,26.40,,Hospital CPT 85420,HC So Plasminogen,N/A,0305 - LABORATORY - HEMATOLOGY,108.00,108.00,64.80,64.80,N/A,6.53,N/A,6.53,N/A,62.19,N/A,36.72,N/A,5.56,N/A,6.53,N/A,6.53,N/A,6.53,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,62.19,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,7.18,64.80,64.80,5.56,64.80,,Hospital CPT 85420,HC Plasminogen,N/A,0305 - LABORATORY - HEMATOLOGY,25.00,25.00,15.00,15.00,N/A,6.53,N/A,6.53,N/A,14.40,N/A,8.50,N/A,5.56,N/A,6.53,N/A,6.53,N/A,6.53,N/A,5.56,N/A,5.56,N/A,5.56,N/A,5.56,N/A,14.40,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,6.53,N/A,7.18,15.00,15.00,5.56,15.00,,Hospital CPT 85520,"HC So Factor Xa, Lmwh",N/A,0305 - LABORATORY - HEMATOLOGY,270.00,270.00,162.00,162.00,N/A,13.09,N/A,13.09,N/A,155.47,N/A,91.80,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,8.15,N/A,13.09,N/A,13.09,N/A,11.12,N/A,155.47,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,14.40,162.00,162.00,8.15,162.00,,Hospital CPT 85520,"HC Factor Xa, Lmwh",N/A,0305 - LABORATORY - HEMATOLOGY,298.00,252.00,178.80,151.20,N/A,13.09,N/A,13.09,N/A,145.10,N/A,85.68,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,8.15,N/A,13.09,N/A,13.09,N/A,11.12,N/A,145.10,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,14.40,178.80,178.80,8.15,151.20,,Hospital CPT 85530,"HC Heparin,Protamine,Assay,390200",N/A,0305 - LABORATORY - HEMATOLOGY,373.00,373.00,223.80,223.80,N/A,13.09,N/A,13.09,N/A,214.77,N/A,126.82,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,8.15,N/A,13.09,N/A,13.09,N/A,13.09,N/A,214.77,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,13.09,N/A,14.40,223.80,223.80,8.15,223.80,,Hospital CPT 85549,HC So Lysozyme,N/A,0305 - LABORATORY - HEMATOLOGY,38.00,38.00,22.80,22.80,N/A,18.75,N/A,18.75,N/A,21.88,N/A,12.92,N/A,18.75,N/A,18.75,N/A,18.75,N/A,18.75,N/A,11.67,N/A,18.75,N/A,15.94,N/A,18.75,N/A,21.88,N/A,18.75,N/A,18.75,N/A,18.75,N/A,18.75,N/A,18.75,N/A,18.75,N/A,18.75,N/A,20.63,22.80,22.80,11.67,22.80,,Hospital 85555,HC So RBC Osmotic Fragility,N/A,0305 - LABORATORY - HEMATOLOGY,N/A,900.00,N/A,540.00,N/A,70.79,N/A,51.64,N/A,518.23,N/A,306.00,N/A,125.56,N/A,70.79,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,518.23,N/A,51.91,N/A,70.79,N/A,70.79,N/A,70.79,N/A,70.79,N/A,51.91,N/A,51.64,N/A,77.87,N/A,N/A,51.64,540.00,,Hospital CPT 85576,HC So Platelet Aggr(Invitro) Ea Agnt,N/A,0305 - LABORATORY - HEMATOLOGY,197.00,197.00,118.20,118.20,N/A,24.91,N/A,24.91,N/A,113.43,N/A,66.98,N/A,18.26,N/A,24.91,N/A,24.91,N/A,24.91,N/A,15.51,N/A,24.91,N/A,24.91,N/A,18.26,N/A,113.43,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,27.40,118.20,118.20,15.51,118.20,,Hospital CPT 85576,HC Platelet Function Test,N/A,0305 - LABORATORY - HEMATOLOGY,121.00,103.00,72.60,61.80,N/A,24.91,N/A,24.91,N/A,59.31,N/A,35.02,N/A,18.26,N/A,24.91,N/A,24.91,N/A,24.91,N/A,15.51,N/A,24.91,N/A,24.91,N/A,18.26,N/A,59.31,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,27.40,72.60,72.60,15.51,61.80,,Hospital CPT 85576,HC Platelet Aggr(Invitro) Ea Agnt,N/A,0305 - LABORATORY - HEMATOLOGY,217.00,188.00,130.20,112.80,N/A,24.91,N/A,24.91,N/A,108.25,N/A,63.92,N/A,18.26,N/A,24.91,N/A,24.91,N/A,24.91,N/A,15.51,N/A,24.91,N/A,24.91,N/A,18.26,N/A,108.25,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,24.91,N/A,27.40,130.20,130.20,15.51,112.80,,Hospital CPT 85610,HC So Prothrombin Time,N/A,0305 - LABORATORY - HEMATOLOGY,61.00,61.00,36.60,36.60,N/A,4.29,N/A,4.29,N/A,35.12,N/A,20.74,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,3.34,N/A,3.34,N/A,4.29,N/A,3.34,N/A,35.12,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.72,36.60,36.60,3.34,36.60,,Hospital CPT 85610,HC Prothrombin Time,N/A,0305 - LABORATORY - HEMATOLOGY,68.00,56.00,40.80,33.60,N/A,4.29,N/A,4.29,N/A,32.24,N/A,19.04,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,3.34,N/A,3.34,N/A,4.29,N/A,3.34,N/A,32.24,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.29,N/A,4.72,40.80,40.80,3.34,33.60,,Hospital CPT 85660,HC So Sickling of RBC,N/A,0305 - LABORATORY - HEMATOLOGY,70.00,70.00,42.00,42.00,N/A,5.51,N/A,5.51,N/A,40.31,N/A,23.80,N/A,4.69,N/A,5.51,N/A,5.51,N/A,5.51,N/A,4.69,N/A,4.69,N/A,4.69,N/A,4.69,N/A,40.31,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,6.06,42.00,42.00,4.69,42.00,,Hospital CPT 85660,HC Sickle Cell Prep,N/A,0305 - LABORATORY - HEMATOLOGY,78.00,66.00,46.80,39.60,N/A,5.51,N/A,5.51,N/A,38.00,N/A,22.44,N/A,4.69,N/A,5.51,N/A,5.51,N/A,5.51,N/A,4.69,N/A,4.69,N/A,4.69,N/A,4.69,N/A,38.00,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,5.51,N/A,6.06,46.80,46.80,4.69,39.60,,Hospital CPT 86003,HC Allergen Specific,N/A,0305 - LABORATORY - HEMATOLOGY,40.00,30.00,24.00,18.00,N/A,5.22,N/A,5.22,N/A,17.27,N/A,10.20,N/A,4.43,N/A,5.22,N/A,5.22,N/A,5.22,N/A,4.43,N/A,4.43,N/A,4.43,N/A,4.43,N/A,17.27,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.74,24.00,24.00,4.43,18.00,,Hospital CPT 86003,HC So Allergen Specific,N/A,0305 - LABORATORY - HEMATOLOGY,36.00,36.00,21.60,21.60,N/A,5.22,N/A,5.22,N/A,20.73,N/A,12.24,N/A,4.43,N/A,5.22,N/A,5.22,N/A,5.22,N/A,4.43,N/A,4.43,N/A,4.43,N/A,4.43,N/A,20.73,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.22,N/A,5.74,21.60,21.60,4.43,21.60,,Hospital CPT 86022,HC So1 Heparin Asso1c Platelet Antibo,N/A,0302 - LABORATORY - IMMUNOLOGY,484.00,484.00,290.40,290.40,N/A,18.37,N/A,18.37,N/A,278.69,N/A,164.56,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,11.44,N/A,18.37,N/A,18.37,N/A,18.37,N/A,278.69,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,20.21,290.40,290.40,11.44,290.40,,Hospital CPT 86022,HC So Heparin Assoc Platelet Antibo,N/A,0302 - LABORATORY - IMMUNOLOGY,484.00,484.00,290.40,290.40,N/A,18.37,N/A,18.37,N/A,278.69,N/A,164.56,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,11.44,N/A,18.37,N/A,18.37,N/A,18.37,N/A,278.69,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,20.21,290.40,290.40,11.44,290.40,,Hospital CPT 86022,HC Heparin Assoc Platelet Antibo,N/A,0302 - LABORATORY - IMMUNOLOGY,534.00,406.00,320.40,243.60,N/A,18.37,N/A,18.37,N/A,233.77,N/A,138.04,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,11.44,N/A,18.37,N/A,18.37,N/A,18.37,N/A,233.77,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,18.37,N/A,20.21,320.40,320.40,11.44,243.60,,Hospital CPT 86023,HC So Platelet Assoc,N/A,0302 - LABORATORY - IMMUNOLOGY,109.00,109.00,65.40,65.40,N/A,12.46,N/A,12.46,N/A,62.76,N/A,37.06,N/A,10.58,N/A,12.46,N/A,12.46,N/A,12.46,N/A,10.58,N/A,10.58,N/A,12.46,N/A,10.58,N/A,62.76,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,13.71,65.40,65.40,10.58,65.40,,Hospital CPT 86023,HC Platelet Assoc,N/A,0302 - LABORATORY - IMMUNOLOGY,121.00,92.00,72.60,55.20,N/A,12.46,N/A,12.46,N/A,52.97,N/A,31.28,N/A,10.58,N/A,12.46,N/A,12.46,N/A,12.46,N/A,10.58,N/A,10.58,N/A,12.46,N/A,10.58,N/A,52.97,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,12.46,N/A,13.71,72.60,72.60,10.58,55.20,,Hospital 86037,"HC So Antineutrophil Cytoplasmic Ab Titer, Each",N/A,0302 - LABORATORY - IMMUNOLOGY,61899.27,2465.00,37139.56,1479.00,10440.92,220.80,12616.71,235.64,23529.46,1419.32,21045.75,838.10,23754.54,235.64,10762.62,220.80,5620.00,235.64,10206.95,235.64,14786.65,146.66,23754.54,235.64,23754.54,235.64,23754.54,235.64,23529.46,1419.32,12616.71,235.64,10762.62,220.80,28261.97,230.07,28261.97,230.07,9367.17,220.80,12616.71,235.64,12616.71,235.64,11516.01,213.33,5620.00,37139.56,146.66,1479.00,,Hospital CPT 86141,HC So Crp High Sensitivity,N/A,0302 - LABORATORY - IMMUNOLOGY,198.00,198.00,118.80,118.80,N/A,12.95,N/A,12.95,N/A,114.01,N/A,67.32,N/A,11.00,N/A,12.95,N/A,12.95,N/A,12.95,N/A,8.06,N/A,12.95,N/A,11.00,N/A,11.00,N/A,114.01,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,14.25,118.80,118.80,8.06,118.80,,Hospital CPT 86141,HC C-Reactive Protein Cardiac,N/A,0302 - LABORATORY - IMMUNOLOGY,218.00,168.00,130.80,100.80,N/A,12.95,N/A,12.95,N/A,96.73,N/A,57.12,N/A,11.00,N/A,12.95,N/A,12.95,N/A,12.95,N/A,8.06,N/A,12.95,N/A,11.00,N/A,11.00,N/A,96.73,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,14.25,130.80,130.80,8.06,100.80,,Hospital CPT 86147,HC Cardiolipin Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,351.00,270.00,210.60,162.00,N/A,25.45,N/A,25.45,N/A,155.47,N/A,91.80,N/A,21.62,N/A,25.45,N/A,25.45,N/A,25.45,N/A,15.84,N/A,21.62,N/A,21.62,N/A,21.62,N/A,155.47,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,28.00,210.60,210.60,15.84,162.00,,Hospital CPT 86147,HC So Cardiolipin Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,318.00,318.00,190.80,190.80,N/A,25.45,N/A,25.45,N/A,183.10,N/A,108.12,N/A,21.62,N/A,25.45,N/A,25.45,N/A,25.45,N/A,15.84,N/A,21.62,N/A,21.62,N/A,21.62,N/A,183.10,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,25.45,N/A,28.00,190.80,190.80,15.84,190.80,,Hospital CPT 86157,HC So Cold Agglutinin,N/A,0302 - LABORATORY - IMMUNOLOGY,131.00,131.00,78.60,78.60,N/A,8.06,N/A,8.06,N/A,75.43,N/A,44.54,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,5.02,N/A,8.06,N/A,8.06,N/A,8.06,N/A,75.43,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.87,78.60,78.60,5.02,78.60,,Hospital CPT 86157,HC Cold Agglutinin,N/A,0302 - LABORATORY - IMMUNOLOGY,145.00,109.00,87.00,65.40,N/A,8.06,N/A,8.06,N/A,62.76,N/A,37.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,5.02,N/A,8.06,N/A,8.06,N/A,8.06,N/A,62.76,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.06,N/A,8.87,87.00,87.00,5.02,65.40,,Hospital CPT 86200,"HC Cyclic Citrullinated Peptd,Ab",N/A,0302 - LABORATORY - IMMUNOLOGY,145.00,109.00,87.00,65.40,N/A,12.95,N/A,12.95,N/A,62.76,N/A,37.06,N/A,11.00,N/A,12.95,N/A,12.95,N/A,12.95,N/A,11.00,N/A,12.95,N/A,11.00,N/A,11.00,N/A,62.76,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,14.25,87.00,87.00,11.00,65.40,,Hospital CPT 86200,"HC So Cyclic Citrullinated Peptd,Ab",N/A,0302 - LABORATORY - IMMUNOLOGY,131.00,131.00,78.60,78.60,N/A,12.95,N/A,12.95,N/A,75.43,N/A,44.54,N/A,11.00,N/A,12.95,N/A,12.95,N/A,12.95,N/A,11.00,N/A,12.95,N/A,11.00,N/A,11.00,N/A,75.43,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,14.25,78.60,78.60,11.00,78.60,,Hospital CPT 86277,HC Human Growth Hormone Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,251.00,251.00,150.60,150.60,N/A,15.74,N/A,15.74,N/A,144.53,N/A,85.34,N/A,15.74,N/A,15.74,N/A,15.74,N/A,15.74,N/A,9.80,N/A,15.74,N/A,15.74,N/A,15.74,N/A,144.53,N/A,15.74,N/A,15.74,N/A,15.74,N/A,15.74,N/A,15.74,N/A,15.74,N/A,15.74,N/A,17.31,150.60,150.60,9.80,150.60,,Hospital CPT 86304,HC Ca 125,N/A,0302 - LABORATORY - IMMUNOLOGY,204.00,154.00,122.40,92.40,N/A,20.81,N/A,20.81,N/A,88.67,N/A,52.36,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,12.95,N/A,17.69,N/A,20.81,N/A,20.81,N/A,88.67,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,122.40,122.40,12.95,92.40,,Hospital CPT 86304,HC So Ca 125,N/A,0302 - LABORATORY - IMMUNOLOGY,184.00,184.00,110.40,110.40,N/A,20.81,N/A,20.81,N/A,105.95,N/A,62.56,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,12.95,N/A,17.69,N/A,20.81,N/A,20.81,N/A,105.95,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,110.40,110.40,12.95,110.40,,Hospital CPT 86317,HC Infectious Agent Ab Quant,N/A,0302 - LABORATORY - IMMUNOLOGY,90.00,68.00,54.00,40.80,N/A,14.99,N/A,14.99,N/A,39.15,N/A,23.12,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,12.74,N/A,12.74,N/A,12.74,N/A,12.74,N/A,39.15,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,16.49,54.00,54.00,12.74,40.80,,Hospital CPT 86317,"HC So Strep Pneumoniae Ab,Ea Serotyp",N/A,0302 - LABORATORY - IMMUNOLOGY,73.00,55.00,43.80,33.00,N/A,14.99,N/A,14.99,N/A,31.67,N/A,18.70,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,12.74,N/A,12.74,N/A,12.74,N/A,12.74,N/A,31.67,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,16.49,43.80,43.80,12.74,33.00,,Hospital 86318,HC Immuno Infest Agent Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,28727.90,2648.00,17236.74,1588.80,4653.92,209.73,5771.00,215.30,10487.99,1524.71,9767.49,900.32,7322.00,175.86,4797.32,209.73,5771.00,223.87,5771.00,223.87,4558.00,175.86,7322.00,175.86,7322.00,175.86,7322.00,175.86,10487.99,1524.71,5771.00,215.30,4797.32,209.73,12597.46,209.73,12597.46,209.73,4418.80,209.73,5771.00,215.30,5771.00,215.30,5133.13,230.72,4418.80,17236.74,175.86,1588.80,,Hospital 86320,HC Immunoelectrophoresis,N/A,0302 - LABORATORY - IMMUNOLOGY,81287.50,2241.00,48772.50,1344.60,11310.66,196.95,12015.36,118.26,16253.63,1290.35,12622.83,761.94,12622.83,264.01,11310.66,196.95,14092.38,109.14,14092.38,109.14,12622.83,164.35,12622.83,264.01,12622.83,264.01,12622.83,264.01,16253.63,1290.35,12015.36,109.14,11310.66,196.95,16253.63,152.15,16253.63,152.15,11310.66,196.95,8480.01,109.14,12015.36,118.26,11310.66,167.37,8480.01,48772.50,109.14,1344.60,,Hospital CPT 86329,HC So Immunodiffusion Nes,N/A,0302 - LABORATORY - IMMUNOLOGY,50.00,50.00,30.00,30.00,N/A,14.05,N/A,14.05,N/A,28.79,N/A,17.00,N/A,8.89,N/A,14.05,N/A,14.05,N/A,14.05,N/A,8.89,N/A,8.89,N/A,8.89,N/A,8.89,N/A,28.79,N/A,14.05,N/A,14.05,N/A,14.05,N/A,14.05,N/A,14.05,N/A,14.05,N/A,14.05,N/A,15.46,30.00,30.00,8.89,30.00,,Hospital CPT 86337,HC Insulin Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,229.00,174.00,137.40,104.40,N/A,21.41,N/A,21.41,N/A,100.19,N/A,59.16,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,13.33,N/A,21.41,N/A,18.20,N/A,21.41,N/A,100.19,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,23.55,137.40,137.40,13.33,104.40,,Hospital CPT 86337,HC So Insulin Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,207.00,207.00,124.20,124.20,N/A,21.41,N/A,21.41,N/A,119.19,N/A,70.38,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,13.33,N/A,21.41,N/A,18.20,N/A,21.41,N/A,119.19,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,21.41,N/A,23.55,124.20,124.20,13.33,124.20,,Hospital CPT 86356,"HC So Mononuclear Cell Antigen,Quan",N/A,0302 - LABORATORY - IMMUNOLOGY,161.00,161.00,96.60,96.60,N/A,26.78,N/A,26.78,N/A,92.70,N/A,54.74,N/A,22.75,N/A,26.78,N/A,26.78,N/A,26.78,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,92.70,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,29.46,96.60,96.60,22.75,96.60,,Hospital CPT 86356,"HC Mononuclear Cell Antigen,Quan",N/A,0302 - LABORATORY - IMMUNOLOGY,179.00,134.00,107.40,80.40,N/A,26.78,N/A,26.78,N/A,77.16,N/A,45.56,N/A,22.75,N/A,26.78,N/A,26.78,N/A,26.78,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,77.16,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,29.46,107.40,107.40,22.75,80.40,,Hospital CPT 86403,HC So Particle Agglut Antbdy Scrn,N/A,0302 - LABORATORY - IMMUNOLOGY,112.00,112.00,67.20,67.20,N/A,11.54,N/A,11.54,N/A,112.00,N/A,38.08,N/A,8.66,N/A,11.54,N/A,11.54,N/A,11.54,N/A,8.66,N/A,8.66,N/A,8.66,N/A,8.66,N/A,64.49,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,12.69,67.20,67.20,8.66,112.00,,Hospital CPT 86403,HC Particle Agglut Antbdy Scrn,N/A,0302 - LABORATORY - IMMUNOLOGY,124.00,96.00,74.40,57.60,N/A,11.54,N/A,11.54,N/A,96.00,N/A,32.64,N/A,8.66,N/A,11.54,N/A,11.54,N/A,11.54,N/A,8.66,N/A,8.66,N/A,8.66,N/A,8.66,N/A,55.28,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,11.54,N/A,12.69,74.40,74.40,8.66,96.00,,Hospital CPT 86430,"HC Rheumatoid Factor, Qual",N/A,0302 - LABORATORY - IMMUNOLOGY,22.00,22.00,13.20,13.20,N/A,6.14,N/A,6.14,N/A,12.67,N/A,7.48,N/A,4.82,N/A,6.14,N/A,6.14,N/A,6.14,N/A,4.82,N/A,6.14,N/A,4.82,N/A,4.82,N/A,12.67,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.75,13.20,13.20,4.82,13.20,,Hospital CPT 86430,HC So Rheumatoid Factor Test Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,20.00,20.00,12.00,12.00,N/A,6.14,N/A,6.14,N/A,11.52,N/A,6.80,N/A,4.82,N/A,6.14,N/A,6.14,N/A,6.14,N/A,4.82,N/A,6.14,N/A,4.82,N/A,4.82,N/A,11.52,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.14,N/A,6.75,12.00,12.00,4.82,12.00,,Hospital CPT 86592,HC Vdrl / Rpr,N/A,0302 - LABORATORY - IMMUNOLOGY,129.00,98.00,77.40,58.80,N/A,4.27,N/A,4.27,N/A,56.43,N/A,33.32,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,4.27,N/A,4.27,N/A,56.43,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,77.40,77.40,2.66,58.80,,Hospital CPT 86592,HC So Vdrl / Rpr,N/A,0302 - LABORATORY - IMMUNOLOGY,117.00,117.00,70.20,70.20,N/A,4.27,N/A,4.27,N/A,67.37,N/A,39.78,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,4.27,N/A,4.27,N/A,67.37,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,70.20,70.20,2.66,70.20,,Hospital CPT 86593,"HC Syphilis Test, Quantitative",N/A,0302 - LABORATORY - IMMUNOLOGY,156.00,119.00,93.60,71.40,N/A,4.40,N/A,4.40,N/A,68.52,N/A,40.46,N/A,3.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,3.74,N/A,3.74,N/A,3.74,N/A,3.74,N/A,68.52,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.84,93.60,93.60,3.74,71.40,,Hospital CPT 86593,HC So Vdrl (Titer),N/A,0302 - LABORATORY - IMMUNOLOGY,141.00,141.00,84.60,84.60,N/A,4.40,N/A,4.40,N/A,81.19,N/A,47.94,N/A,3.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,3.74,N/A,3.74,N/A,3.74,N/A,3.74,N/A,81.19,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.84,84.60,84.60,3.74,84.60,,Hospital CPT 86618,HC So1 Lyme Disease Total Anitbodies,N/A,0302 - LABORATORY - IMMUNOLOGY,87.00,87.00,52.20,52.20,N/A,17.03,N/A,17.03,N/A,50.09,N/A,29.58,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,10.60,N/A,17.03,N/A,17.03,N/A,17.03,N/A,50.09,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,18.73,52.20,52.20,10.60,52.20,,Hospital CPT 86618,HC Lyme Disease Total Anitbodies,N/A,0302 - LABORATORY - IMMUNOLOGY,489.00,372.00,293.40,223.20,N/A,17.03,N/A,17.03,N/A,214.20,N/A,126.48,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,10.60,N/A,17.03,N/A,17.03,N/A,17.03,N/A,214.20,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,18.73,293.40,293.40,10.60,223.20,,Hospital CPT 86618,HC So Lyme Disease Total Anitbodies,N/A,0302 - LABORATORY - IMMUNOLOGY,443.00,443.00,265.80,265.80,N/A,17.03,N/A,17.03,N/A,255.08,N/A,150.62,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,10.60,N/A,17.03,N/A,17.03,N/A,17.03,N/A,255.08,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,18.73,265.80,265.80,10.60,265.80,,Hospital CPT 86651,"HC Encephalitis, California",N/A,0302 - LABORATORY - IMMUNOLOGY,203.00,152.00,121.80,91.20,N/A,13.19,N/A,13.19,N/A,87.52,N/A,51.68,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,87.52,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,121.80,121.80,8.21,91.20,,Hospital CPT 86651,"HC So Encephalitis, California",N/A,0302 - LABORATORY - IMMUNOLOGY,183.00,183.00,109.80,109.80,N/A,13.19,N/A,13.19,N/A,105.37,N/A,62.22,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,105.37,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,109.80,109.80,8.21,109.80,,Hospital CPT 86682,"HC Helminth, Nos",N/A,0302 - LABORATORY - IMMUNOLOGY,463.00,351.00,277.80,210.60,N/A,13.01,N/A,13.01,N/A,202.11,N/A,119.34,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,8.10,N/A,13.01,N/A,11.06,N/A,11.06,N/A,202.11,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,14.31,277.80,277.80,8.10,210.60,,Hospital CPT 86682,"HC So Helminth, Nos",N/A,0302 - LABORATORY - IMMUNOLOGY,420.00,420.00,252.00,252.00,N/A,13.01,N/A,13.01,N/A,241.84,N/A,142.80,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,8.10,N/A,13.01,N/A,11.06,N/A,11.06,N/A,241.84,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,13.01,N/A,14.31,252.00,252.00,8.10,252.00,,Hospital CPT 86689,"HC So Htlv or Hiv Ab, Western Blot",N/A,0302 - LABORATORY - IMMUNOLOGY,393.00,393.00,235.80,235.80,N/A,19.35,N/A,19.35,N/A,226.29,N/A,133.62,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,12.05,N/A,19.35,N/A,16.45,N/A,19.35,N/A,226.29,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,235.80,235.80,12.05,235.80,,Hospital CPT 86689,"HC Htlv or Hiv Ab, Western Blot",N/A,0302 - LABORATORY - IMMUNOLOGY,434.00,329.00,260.40,197.40,N/A,19.35,N/A,19.35,N/A,189.44,N/A,111.86,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,12.05,N/A,19.35,N/A,16.45,N/A,19.35,N/A,189.44,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,260.40,260.40,12.05,197.40,,Hospital CPT 86695,"HC Herpes Simplex, Type 1",N/A,0302 - LABORATORY - IMMUNOLOGY,147.00,113.00,88.20,67.80,N/A,13.19,N/A,13.19,N/A,65.07,N/A,38.42,N/A,11.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,11.21,N/A,11.21,N/A,11.21,N/A,11.21,N/A,65.07,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,88.20,88.20,11.21,67.80,,Hospital CPT 86695,"HC So Herpes Simplex, Type 1",N/A,0302 - LABORATORY - IMMUNOLOGY,133.00,133.00,79.80,79.80,N/A,13.19,N/A,13.19,N/A,76.58,N/A,45.22,N/A,11.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,11.21,N/A,11.21,N/A,11.21,N/A,11.21,N/A,76.58,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,79.80,79.80,11.21,79.80,,Hospital CPT 86705,HC Hepatitis B Core Igm Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,143.00,108.00,85.80,64.80,N/A,11.77,N/A,11.77,N/A,62.19,N/A,36.72,N/A,10.00,N/A,11.77,N/A,11.77,N/A,11.77,N/A,7.33,N/A,11.77,N/A,10.00,N/A,10.00,N/A,62.19,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,12.95,85.80,85.80,7.33,64.80,,Hospital CPT 86705,HC So Hepatitis B Core Igm Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,129.00,129.00,77.40,77.40,N/A,11.77,N/A,11.77,N/A,74.28,N/A,43.86,N/A,10.00,N/A,11.77,N/A,11.77,N/A,11.77,N/A,7.33,N/A,11.77,N/A,10.00,N/A,10.00,N/A,74.28,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,11.77,N/A,12.95,77.40,77.40,7.33,77.40,,Hospital CPT 86706,HC Hepatitis B Surface Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,159.00,121.00,95.40,72.60,N/A,10.74,N/A,10.74,N/A,69.67,N/A,41.14,N/A,9.13,N/A,10.74,N/A,10.74,N/A,10.74,N/A,9.13,N/A,9.13,N/A,9.13,N/A,9.13,N/A,69.67,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,11.81,95.40,95.40,9.13,72.60,,Hospital CPT 86707,HC So Hepatitis Be Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,125.00,125.00,75.00,75.00,N/A,11.57,N/A,11.57,N/A,71.98,N/A,42.50,N/A,9.83,N/A,11.57,N/A,11.57,N/A,11.57,N/A,9.83,N/A,11.57,N/A,9.83,N/A,9.83,N/A,71.98,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,12.73,75.00,75.00,9.83,75.00,,Hospital CPT 86707,HC Hepatitis Be Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,139.00,106.00,83.40,63.60,N/A,11.57,N/A,11.57,N/A,61.03,N/A,36.04,N/A,9.83,N/A,11.57,N/A,11.57,N/A,11.57,N/A,9.83,N/A,11.57,N/A,9.83,N/A,9.83,N/A,61.03,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,11.57,N/A,12.73,83.40,83.40,9.83,63.60,,Hospital CPT 86710,HC Influenza a&B Titers,N/A,0302 - LABORATORY - IMMUNOLOGY,124.00,96.00,74.40,57.60,N/A,13.55,N/A,13.55,N/A,55.28,N/A,32.64,N/A,11.52,N/A,13.55,N/A,13.55,N/A,13.55,N/A,11.52,N/A,11.52,N/A,11.52,N/A,11.52,N/A,55.28,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,14.91,74.40,74.40,11.52,57.60,,Hospital CPT 86710,HC So Influenza a&B Titers,N/A,0302 - LABORATORY - IMMUNOLOGY,112.00,112.00,67.20,67.20,N/A,13.55,N/A,13.55,N/A,64.49,N/A,38.08,N/A,11.52,N/A,13.55,N/A,13.55,N/A,13.55,N/A,11.52,N/A,11.52,N/A,11.52,N/A,11.52,N/A,64.49,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,13.55,N/A,14.91,67.20,67.20,11.52,67.20,,Hospital CPT 86713,HC Legionnaires Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,175.00,134.00,105.00,80.40,N/A,15.30,N/A,15.30,N/A,77.16,N/A,45.56,N/A,13.00,N/A,15.30,N/A,15.30,N/A,15.30,N/A,13.00,N/A,13.00,N/A,13.00,N/A,13.00,N/A,77.16,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,16.83,105.00,105.00,13.00,80.40,,Hospital CPT 86713,HC So Legionnaires Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,159.00,159.00,95.40,95.40,N/A,15.30,N/A,15.30,N/A,91.55,N/A,54.06,N/A,13.00,N/A,15.30,N/A,15.30,N/A,15.30,N/A,13.00,N/A,13.00,N/A,13.00,N/A,13.00,N/A,91.55,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,16.83,95.40,95.40,13.00,95.40,,Hospital CPT 86757,HC Rickettsia,N/A,0302 - LABORATORY - IMMUNOLOGY,108.00,83.00,64.80,49.80,N/A,19.35,N/A,19.35,N/A,47.79,N/A,28.22,N/A,16.45,N/A,19.35,N/A,19.35,N/A,19.35,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,47.79,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,64.80,64.80,16.45,49.80,,Hospital CPT 86757,HC So Rickettsia Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,98.00,98.00,58.80,58.80,N/A,19.35,N/A,19.35,N/A,56.43,N/A,33.32,N/A,16.45,N/A,19.35,N/A,19.35,N/A,19.35,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,56.43,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,58.80,58.80,16.45,58.80,,Hospital CPT 86765,HC So Rubeola Igg / Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,213.00,213.00,127.80,127.80,N/A,12.88,N/A,12.88,N/A,122.65,N/A,72.42,N/A,10.95,N/A,12.88,N/A,12.88,N/A,12.88,N/A,10.95,N/A,10.95,N/A,10.95,N/A,10.95,N/A,122.65,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,127.80,127.80,10.95,127.80,,Hospital CPT 86765,HC Rubeola Igg / Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,235.00,179.00,141.00,107.40,N/A,12.88,N/A,12.88,N/A,103.07,N/A,60.86,N/A,10.95,N/A,12.88,N/A,12.88,N/A,12.88,N/A,10.95,N/A,10.95,N/A,10.95,N/A,10.95,N/A,103.07,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,141.00,141.00,10.95,107.40,,Hospital 86768,HC Salmonella Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,N/A,2883.00,N/A,1729.80,N/A,377.69,N/A,383.26,N/A,1660.04,N/A,980.22,N/A,320.38,N/A,377.69,N/A,383.26,N/A,383.26,N/A,320.38,N/A,320.38,N/A,320.38,N/A,320.38,N/A,1660.04,N/A,383.26,N/A,377.69,N/A,377.69,N/A,377.69,N/A,377.69,N/A,383.26,N/A,383.26,N/A,415.49,N/A,N/A,320.38,1729.80,,Hospital CPT 86778,HC So Toxoplasma Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,80.00,80.00,48.00,48.00,N/A,14.41,N/A,14.41,N/A,46.06,N/A,27.20,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,8.97,N/A,14.41,N/A,12.24,N/A,12.24,N/A,46.06,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,15.85,48.00,48.00,8.97,48.00,,Hospital CPT 86778,HC Toxoplasma Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,88.00,66.00,52.80,39.60,N/A,14.41,N/A,14.41,N/A,38.00,N/A,22.44,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,8.97,N/A,14.41,N/A,12.24,N/A,12.24,N/A,38.00,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,14.41,N/A,15.85,52.80,52.80,8.97,39.60,,Hospital CPT 86780,HC So Fta-Abs,N/A,0302 - LABORATORY - IMMUNOLOGY,108.00,108.00,64.80,64.80,N/A,13.24,N/A,13.24,N/A,62.19,N/A,36.72,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,5.42,N/A,5.42,N/A,5.42,N/A,5.42,N/A,62.19,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,14.56,64.80,64.80,5.42,64.80,,Hospital CPT 86780,HC Fta-Abs,N/A,0302 - LABORATORY - IMMUNOLOGY,120.00,92.00,72.00,55.20,N/A,13.24,N/A,13.24,N/A,52.97,N/A,31.28,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,5.42,N/A,5.42,N/A,5.42,N/A,5.42,N/A,52.97,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,14.56,72.00,72.00,5.42,55.20,,Hospital CPT 86787,HC So Varicella Igg Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,144.00,144.00,86.40,86.40,N/A,12.88,N/A,12.88,N/A,82.92,N/A,48.96,N/A,10.95,N/A,12.88,N/A,12.88,N/A,12.88,N/A,10.95,N/A,10.95,N/A,10.95,N/A,10.95,N/A,82.92,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,86.40,86.40,10.95,86.40,,Hospital CPT 86787,HC Varicella Igg Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,160.00,122.00,96.00,73.20,N/A,12.88,N/A,12.88,N/A,70.25,N/A,41.48,N/A,10.95,N/A,12.88,N/A,12.88,N/A,12.88,N/A,10.95,N/A,10.95,N/A,10.95,N/A,10.95,N/A,70.25,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,96.00,96.00,10.95,73.20,,Hospital CPT 86790,"HC Antibody Virus, Nos",N/A,0302 - LABORATORY - IMMUNOLOGY,76.00,56.00,45.60,33.60,N/A,12.88,N/A,12.88,N/A,32.24,N/A,19.04,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,8.02,N/A,12.88,N/A,10.95,N/A,12.88,N/A,32.24,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,45.60,45.60,8.02,33.60,,Hospital CPT 86790,"HC So Antibody Virus, Nos",N/A,0302 - LABORATORY - IMMUNOLOGY,68.00,68.00,40.80,40.80,N/A,12.88,N/A,12.88,N/A,39.15,N/A,23.12,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,8.02,N/A,12.88,N/A,10.95,N/A,12.88,N/A,39.15,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,40.80,40.80,8.02,40.80,,Hospital CPT 86793,HC So Yersinia Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,85.00,85.00,51.00,51.00,N/A,13.19,N/A,13.19,N/A,48.94,N/A,28.90,N/A,11.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,11.21,N/A,11.21,N/A,11.21,N/A,11.21,N/A,48.94,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,51.00,51.00,11.21,51.00,,Hospital 86794,HC So1 Zika Virus Igm Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,56202.22,N/A,33721.33,N/A,10440.92,N/A,12616.71,N/A,23529.46,N/A,19088.99,N/A,19549.37,N/A,10762.62,N/A,N/A,N/A,N/A,N/A,12172.03,N/A,19549.37,N/A,19549.37,N/A,19549.37,N/A,23529.46,N/A,12616.71,N/A,10762.62,N/A,28261.97,N/A,28261.97,N/A,10762.62,N/A,12616.71,N/A,12616.71,N/A,11516.01,N/A,10440.92,33721.33,N/A,N/A,,Hospital CPT 86803,HC So Hepatitis C Virus Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,318.00,318.00,190.80,190.80,N/A,14.27,N/A,14.27,N/A,183.10,N/A,108.12,N/A,12.13,N/A,14.27,N/A,14.27,N/A,14.27,N/A,12.13,N/A,12.13,N/A,12.13,N/A,14.27,N/A,183.10,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,15.70,190.80,190.80,12.13,190.80,,Hospital CPT 86803,HC Hepatitis C Virus Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,351.00,270.00,210.60,162.00,N/A,14.27,N/A,14.27,N/A,155.47,N/A,91.80,N/A,12.13,N/A,14.27,N/A,14.27,N/A,14.27,N/A,12.13,N/A,12.13,N/A,12.13,N/A,14.27,N/A,155.47,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,14.27,N/A,15.70,210.60,210.60,12.13,162.00,,Hospital CPT 86807,HC So Cytotoxic % Reactive Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,337.00,337.00,202.20,202.20,N/A,78.65,N/A,78.65,N/A,194.04,N/A,114.58,N/A,78.65,N/A,78.65,N/A,78.65,N/A,78.65,N/A,48.96,N/A,78.65,N/A,33.63,N/A,78.65,N/A,194.04,N/A,78.65,N/A,78.65,N/A,78.65,N/A,78.65,N/A,78.65,N/A,78.65,N/A,78.65,N/A,86.52,202.20,202.20,33.63,202.20,,Hospital CPT 86813,HC Hla Typing,N/A,0302 - LABORATORY - IMMUNOLOGY,598.00,598.00,358.80,358.80,N/A,58.00,N/A,58.00,N/A,344.33,N/A,203.32,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,36.11,N/A,58.00,N/A,58.00,N/A,58.00,N/A,344.33,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,63.80,358.80,358.80,36.11,358.80,,Hospital CPT 86860,HC Elution Procedure,N/A,0302 - LABORATORY - IMMUNOLOGY,268.00,201.00,160.80,120.60,N/A,28.14,N/A,150.49,N/A,115.74,N/A,68.34,N/A,201.00,N/A,28.14,N/A,142.00,N/A,142.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,115.74,N/A,142.00,N/A,28.14,N/A,152.32,N/A,152.32,N/A,28.14,N/A,142.00,N/A,150.49,N/A,201.00,160.80,160.80,28.14,201.00,,Hospital CPT 86860,HC So Elution Procedure,N/A,0302 - LABORATORY - IMMUNOLOGY,242.00,242.00,145.20,145.20,N/A,33.88,N/A,150.49,N/A,139.34,N/A,82.28,N/A,242.00,N/A,33.88,N/A,142.00,N/A,142.00,N/A,213.84,N/A,242.00,N/A,242.00,N/A,242.00,N/A,139.34,N/A,142.00,N/A,33.88,N/A,152.32,N/A,152.32,N/A,33.88,N/A,142.00,N/A,150.49,N/A,242.00,145.20,145.20,33.88,242.00,,Hospital CPT 86885,HC Coombs Test Indirect Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,314.00,265.00,188.40,159.00,N/A,5.72,N/A,144.96,N/A,152.59,N/A,90.10,N/A,265.00,N/A,5.72,N/A,142.00,N/A,142.00,N/A,213.84,N/A,265.00,N/A,265.00,N/A,265.00,N/A,152.59,N/A,142.00,N/A,5.72,N/A,5.72,N/A,5.72,N/A,5.72,N/A,142.00,N/A,144.96,N/A,6.29,188.40,188.40,5.72,265.00,,Hospital CPT 86885,HC So Indirect Coombs,N/A,0302 - LABORATORY - IMMUNOLOGY,284.00,284.00,170.40,170.40,N/A,5.72,N/A,144.96,N/A,163.53,N/A,96.56,N/A,284.00,N/A,5.72,N/A,142.00,N/A,142.00,N/A,213.84,N/A,284.00,N/A,284.00,N/A,284.00,N/A,163.53,N/A,142.00,N/A,5.72,N/A,5.72,N/A,5.72,N/A,5.72,N/A,142.00,N/A,144.96,N/A,6.29,170.40,170.40,5.72,284.00,,Hospital CPT 86890,HC Autologous Blood Process,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,254.00,254.00,152.40,152.40,N/A,35.56,N/A,143.54,N/A,146.25,N/A,86.36,N/A,254.00,N/A,35.56,N/A,142.00,N/A,142.00,N/A,213.84,N/A,254.00,N/A,254.00,N/A,254.00,N/A,146.25,N/A,142.00,N/A,35.56,N/A,152.32,N/A,152.32,N/A,35.56,N/A,142.00,N/A,143.54,N/A,254.00,152.40,152.40,35.56,254.00,,Hospital 86904,HC So Blood Typing Patient Serum,N/A,0309 - LABORATORY - OTHER LABORATORY,57892.48,19216.00,34735.49,11529.60,7930.45,892.75,9646.96,319.62,17871.91,11064.58,19683.44,6533.44,18042.86,720.74,8174.80,892.75,1686.00,292.68,1686.00,292.68,N/A,448.67,18042.86,720.74,18042.86,720.74,18042.86,720.74,17871.91,11064.58,9646.96,292.68,8174.80,892.75,21466.50,3199.66,21466.50,3199.66,8174.80,892.75,9646.96,305.44,9646.96,245.18,8747.03,447.31,1686.00,34735.49,245.18,11529.60,,Hospital CPT 86906,HC So Rh Phenotype Complete,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,164.00,164.00,98.40,98.40,N/A,7.75,N/A,32.50,N/A,94.43,N/A,55.76,N/A,74.18,N/A,7.75,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,94.43,N/A,30.67,N/A,7.75,N/A,7.75,N/A,7.75,N/A,7.75,N/A,30.67,N/A,32.50,N/A,8.53,98.40,98.40,7.75,98.40,,Hospital CPT 86920,"HC So Compatibility Test, Immed.Spin",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,267.00,267.00,160.20,160.20,N/A,37.38,N/A,267.00,N/A,153.74,N/A,90.78,N/A,267.00,N/A,37.38,N/A,142.00,N/A,142.00,N/A,213.84,N/A,267.00,N/A,267.00,N/A,267.00,N/A,153.74,N/A,142.00,N/A,37.38,N/A,152.32,N/A,152.32,N/A,37.38,N/A,142.00,N/A,267.00,N/A,267.00,160.20,160.20,37.38,267.00,,Hospital CPT 86920,"HC Compatibility Test, Immed.Spin",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,295.00,218.00,177.00,130.80,N/A,30.52,N/A,218.00,N/A,125.52,N/A,74.12,N/A,218.00,N/A,30.52,N/A,142.00,N/A,142.00,N/A,213.84,N/A,218.00,N/A,218.00,N/A,218.00,N/A,125.52,N/A,142.00,N/A,30.52,N/A,152.32,N/A,152.32,N/A,30.52,N/A,142.00,N/A,218.00,N/A,218.00,177.00,177.00,30.52,218.00,,Hospital CPT 86922,"HC Compatibility Test, Ahg Test",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,393.00,393.00,235.80,235.80,N/A,31.00,N/A,142.00,N/A,226.29,N/A,133.62,N/A,343.50,N/A,31.00,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,226.29,N/A,142.00,N/A,31.00,N/A,152.32,N/A,152.32,N/A,31.00,N/A,142.00,N/A,142.00,N/A,156.20,235.80,235.80,31.00,343.50,,Hospital CPT 86922,HC So Crossmatch Each Antiglobulin,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,141.00,141.00,84.60,84.60,N/A,31.00,N/A,142.00,N/A,81.19,N/A,47.94,N/A,141.00,N/A,31.00,N/A,142.00,N/A,142.00,N/A,141.00,N/A,141.00,N/A,141.00,N/A,141.00,N/A,81.19,N/A,142.00,N/A,31.00,N/A,141.00,N/A,141.00,N/A,31.00,N/A,142.00,N/A,142.00,N/A,156.20,84.60,84.60,31.00,156.20,,Hospital 86976,HC So RBC Serum Pretx ID Dilution,N/A,0302 - LABORATORY - IMMUNOLOGY,46564.18,N/A,27938.51,N/A,N/A,N/A,6481.56,N/A,N/A,N/A,15831.82,N/A,11954.95,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,7441.68,N/A,11954.95,N/A,11954.95,N/A,11954.95,N/A,11841.67,N/A,6481.56,N/A,5416.50,N/A,14223.40,N/A,14223.40,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,5795.66,N/A,5416.50,27938.51,N/A,N/A,,Hospital CPT 87015,"HC So Concentratn ,Any, Infect Agent",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,14.00,14.00,8.40,8.40,N/A,6.68,N/A,6.68,N/A,8.06,N/A,4.76,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,4.16,N/A,6.68,N/A,6.68,N/A,6.68,N/A,8.06,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,7.35,8.40,8.40,4.16,8.40,,Hospital CPT 87015,"HC Concentratn ,Any, Infect Agent",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,16.00,13.00,9.60,7.80,N/A,6.68,N/A,6.68,N/A,7.49,N/A,4.42,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,4.16,N/A,6.68,N/A,6.68,N/A,6.68,N/A,7.49,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,6.68,N/A,7.35,9.60,9.60,4.16,7.80,,Hospital CPT 87076,HC Anaerobic ID,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,42.00,33.00,25.20,19.80,N/A,8.08,N/A,8.08,N/A,19.00,N/A,11.22,N/A,6.87,N/A,8.08,N/A,8.08,N/A,8.08,N/A,6.87,N/A,6.87,N/A,8.08,N/A,6.87,N/A,19.00,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.89,25.20,25.20,6.87,19.80,,Hospital CPT 87076,HC So Anaerobic ID,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,38.00,38.00,22.80,22.80,N/A,8.08,N/A,8.08,N/A,21.88,N/A,12.92,N/A,6.87,N/A,8.08,N/A,8.08,N/A,8.08,N/A,6.87,N/A,6.87,N/A,8.08,N/A,6.87,N/A,21.88,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.89,22.80,22.80,6.87,22.80,,Hospital CPT 87101,HC So Fungus Culture Skin,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,28.00,28.00,16.80,16.80,N/A,7.71,N/A,7.71,N/A,16.12,N/A,9.52,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,4.80,N/A,7.71,N/A,7.71,N/A,7.71,N/A,16.12,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,8.48,16.80,16.80,4.80,16.80,,Hospital CPT 87101,HC Fungus Culture Skin,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,32.00,32.00,19.20,19.20,N/A,7.71,N/A,7.71,N/A,18.43,N/A,10.88,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,4.80,N/A,7.71,N/A,7.71,N/A,7.71,N/A,18.43,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,8.48,19.20,19.20,4.80,19.20,,Hospital CPT 87102,HC So Culture Fungus Other,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,182.00,182.00,109.20,109.20,N/A,8.41,N/A,8.41,N/A,104.80,N/A,61.88,N/A,7.14,N/A,8.41,N/A,8.41,N/A,8.41,N/A,7.14,N/A,8.41,N/A,8.41,N/A,8.41,N/A,104.80,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,9.25,109.20,109.20,7.14,109.20,,Hospital CPT 87102,"HC Culture,Fungus Other",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,202.00,160.00,121.20,96.00,N/A,8.41,N/A,8.41,N/A,92.13,N/A,54.40,N/A,7.14,N/A,8.41,N/A,8.41,N/A,8.41,N/A,7.14,N/A,8.41,N/A,8.41,N/A,8.41,N/A,92.13,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,8.41,N/A,9.25,121.20,121.20,7.14,96.00,,Hospital CPT 87150,HC So Dna/Rna Amplified Probe,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,1350.00,1350.00,810.00,810.00,N/A,35.09,N/A,35.09,N/A,777.33,N/A,459.00,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,777.33,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,810.00,810.00,21.84,810.00,,Hospital CPT 87150,HC Dna/Rna Amplified Probe,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,560.00,560.00,336.00,336.00,N/A,35.09,N/A,35.09,N/A,322.45,N/A,190.40,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,322.45,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,336.00,336.00,21.84,336.00,,Hospital CPT 87169,HC So Parasitic Identification,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,17.00,17.00,10.20,10.20,N/A,4.31,N/A,4.31,N/A,17.00,N/A,5.78,N/A,3.05,N/A,4.31,N/A,4.31,N/A,4.31,N/A,3.05,N/A,4.31,N/A,3.05,N/A,3.05,N/A,9.79,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.74,10.20,10.20,3.05,17.00,,Hospital CPT 87169,HC Macroscopic Exam Parasite,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,19.00,19.00,11.40,11.40,N/A,4.31,N/A,4.31,N/A,19.00,N/A,6.46,N/A,3.05,N/A,4.31,N/A,4.31,N/A,4.31,N/A,3.05,N/A,4.31,N/A,3.05,N/A,3.05,N/A,10.94,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.31,N/A,4.74,11.40,11.40,3.05,19.00,,Hospital CPT 87176,HC Tissue Homogenization,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,16.00,13.00,9.60,7.80,N/A,5.88,N/A,5.88,N/A,7.49,N/A,4.42,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,3.66,N/A,5.88,N/A,5.88,N/A,5.88,N/A,7.49,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,6.47,9.60,9.60,3.66,7.80,,Hospital CPT 87176,HC So Tissue Homogenization,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,14.00,14.00,8.40,8.40,N/A,5.88,N/A,5.88,N/A,8.06,N/A,4.76,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,3.66,N/A,5.88,N/A,5.88,N/A,5.88,N/A,8.06,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,5.88,N/A,6.47,8.40,8.40,3.66,8.40,,Hospital CPT 87177,HC So Ova and Parasites,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,133.00,133.00,79.80,79.80,N/A,8.90,N/A,8.90,N/A,76.58,N/A,45.22,N/A,7.42,N/A,8.90,N/A,8.90,N/A,8.90,N/A,7.42,N/A,7.42,N/A,7.42,N/A,7.42,N/A,76.58,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,9.79,79.80,79.80,7.42,79.80,,Hospital CPT 87177,HC Ova and Parasites,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,147.00,118.00,88.20,70.80,N/A,8.90,N/A,8.90,N/A,67.94,N/A,40.12,N/A,7.42,N/A,8.90,N/A,8.90,N/A,8.90,N/A,7.42,N/A,7.42,N/A,7.42,N/A,7.42,N/A,67.94,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,8.90,N/A,9.79,88.20,88.20,7.42,70.80,,Hospital CPT 87181,HC Microbe Susceptible Diffuse,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,51.00,51.00,30.60,30.60,N/A,4.75,N/A,4.75,N/A,29.37,N/A,17.34,N/A,N/A,N/A,4.75,N/A,4.75,N/A,4.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.75,N/A,29.37,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,30.60,30.60,4.75,30.60,,Hospital CPT 87181,HC So Microbe Susceptible Diffuse,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,46.00,46.00,27.60,27.60,N/A,4.75,N/A,4.75,N/A,26.49,N/A,15.64,N/A,N/A,N/A,4.75,N/A,4.75,N/A,4.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.75,N/A,26.49,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,27.60,27.60,4.75,27.60,,Hospital CPT 87184,HC Microbe Susceptible Disk,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,29.00,26.00,17.40,15.60,N/A,7.48,N/A,7.48,N/A,14.97,N/A,8.84,N/A,5.87,N/A,7.48,N/A,7.48,N/A,7.48,N/A,5.87,N/A,5.87,N/A,7.48,N/A,5.87,N/A,14.97,N/A,7.48,N/A,7.48,N/A,7.48,N/A,7.48,N/A,7.48,N/A,7.48,N/A,7.48,N/A,8.23,17.40,17.40,5.87,15.60,,Hospital CPT 87187,HC So Suscept Mlc Each Plate Addl,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,110.00,110.00,66.00,66.00,N/A,40.17,N/A,40.17,N/A,63.34,N/A,37.40,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,25.01,N/A,40.17,N/A,40.17,N/A,40.17,N/A,63.34,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,44.19,66.00,66.00,25.01,66.00,,Hospital CPT 87187,HC Microbe Susceptible Mlc,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,122.00,122.00,73.20,73.20,N/A,40.17,N/A,40.17,N/A,70.25,N/A,41.48,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,25.01,N/A,40.17,N/A,40.17,N/A,40.17,N/A,70.25,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,40.17,N/A,44.19,73.20,73.20,25.01,73.20,,Hospital CPT 87205,HC Gram Stain,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,108.00,87.00,64.80,52.20,N/A,4.27,N/A,4.27,N/A,50.09,N/A,29.58,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,4.27,N/A,4.27,N/A,50.09,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,64.80,64.80,2.66,52.20,,Hospital CPT 87205,HC So Gram Stain Smear,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,98.00,98.00,58.80,58.80,N/A,4.27,N/A,4.27,N/A,56.43,N/A,33.32,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,4.27,N/A,4.27,N/A,56.43,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,58.80,58.80,2.66,58.80,,Hospital CPT 87220,HC Koh Tissue Exam for Fungi,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,71.00,60.00,42.60,36.00,N/A,4.27,N/A,4.27,N/A,34.55,N/A,20.40,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,2.66,N/A,4.27,N/A,3.63,N/A,4.27,N/A,34.55,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,42.60,42.60,2.66,36.00,,Hospital CPT 87252,HC So Hsv Culture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,342.00,342.00,205.20,205.20,N/A,26.07,N/A,26.07,N/A,196.92,N/A,116.28,N/A,22.15,N/A,26.07,N/A,26.07,N/A,26.07,N/A,16.23,N/A,26.07,N/A,22.15,N/A,26.07,N/A,196.92,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,28.68,205.20,205.20,16.23,205.20,,Hospital CPT 87252,HC Viral/Hsv Culture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,378.00,300.00,226.80,180.00,N/A,26.07,N/A,26.07,N/A,172.74,N/A,102.00,N/A,22.15,N/A,26.07,N/A,26.07,N/A,26.07,N/A,16.23,N/A,26.07,N/A,22.15,N/A,26.07,N/A,172.74,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,28.68,226.80,226.80,16.23,180.00,,Hospital CPT 87253,"HC Virus Isolation,Tissue Cult",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,117.00,92.00,70.20,55.20,N/A,20.20,N/A,20.20,N/A,52.97,N/A,31.28,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,12.57,N/A,20.20,N/A,17.17,N/A,20.20,N/A,52.97,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,22.22,70.20,70.20,12.57,55.20,,Hospital CPT 87253,HC So Hsv IP Stain,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,105.00,105.00,63.00,63.00,N/A,20.20,N/A,20.20,N/A,60.46,N/A,35.70,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,12.57,N/A,20.20,N/A,17.17,N/A,20.20,N/A,60.46,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,20.20,N/A,22.22,63.00,63.00,12.57,63.00,,Hospital 87260,HC So Adenovirus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,66008.00,8291.80,39604.80,4975.08,5026.72,1247.75,11171.90,1431.09,13049.88,4773.66,N/A,2819.21,N/A,3498.95,5026.72,1247.75,11171.90,1443.56,11171.90,1443.56,N/A,2178.17,N/A,3498.95,N/A,3498.95,N/A,3498.95,17372.34,4773.66,11171.90,1443.56,5026.72,1247.75,15674.62,1871.00,15674.62,1871.00,5026.72,1247.75,7115.77,1443.56,11171.90,1431.09,5026.72,531.78,5026.72,39604.80,531.78,4975.08,,Hospital CPT 87272,HC Cryptospiridium Ag,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,194.00,194.00,116.40,116.40,N/A,11.98,N/A,11.98,N/A,111.71,N/A,65.96,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,111.71,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,116.40,116.40,7.46,116.40,,Hospital CPT 87273,HC So Herpes Simplex Type 2,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,41.00,41.00,24.60,24.60,N/A,11.98,N/A,11.98,N/A,23.61,N/A,13.94,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,23.61,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,24.60,24.60,7.46,24.60,,Hospital CPT 87273,HC Herpes Simplex Type 2,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,46.00,46.00,27.60,27.60,N/A,11.98,N/A,11.98,N/A,26.49,N/A,15.64,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,26.49,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,27.60,27.60,7.46,27.60,,Hospital CPT 87276,HC So Influenza a Virus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,61.00,61.00,36.60,36.60,N/A,16.07,N/A,16.07,N/A,35.12,N/A,20.74,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,10.00,N/A,16.07,N/A,16.07,N/A,16.07,N/A,35.12,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,17.68,36.60,36.60,10.00,36.60,,Hospital CPT 87276,HC Influenza a Virus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,68.00,53.00,40.80,31.80,N/A,16.07,N/A,16.07,N/A,30.52,N/A,18.02,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,10.00,N/A,16.07,N/A,16.07,N/A,16.07,N/A,30.52,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,17.68,40.80,40.80,10.00,31.80,,Hospital CPT 87280,"HC Respiratory Syncytial Virus, Ag If",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,48.00,48.00,28.80,28.80,N/A,13.42,N/A,13.42,N/A,27.64,N/A,16.32,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,8.35,N/A,13.42,N/A,13.42,N/A,13.42,N/A,27.64,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,14.76,28.80,28.80,8.35,28.80,,Hospital CPT 87280,"HC So Respiratory Syncytial Virus, Ag If",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,43.00,43.00,25.80,25.80,N/A,13.42,N/A,13.42,N/A,24.76,N/A,14.62,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,8.35,N/A,13.42,N/A,13.42,N/A,13.42,N/A,24.76,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,14.76,25.80,25.80,8.35,25.80,,Hospital CPT 87290,HC Varicella Zoster Virus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,46.00,46.00,27.60,27.60,N/A,13.42,N/A,13.42,N/A,26.49,N/A,15.64,N/A,9.73,N/A,13.42,N/A,13.42,N/A,13.42,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,26.49,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,14.76,27.60,27.60,9.73,27.60,,Hospital CPT 87290,HC So Varicella Zoster Virus,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,41.00,41.00,24.60,24.60,N/A,13.42,N/A,13.42,N/A,23.61,N/A,13.94,N/A,9.73,N/A,13.42,N/A,13.42,N/A,13.42,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,23.61,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,14.76,24.60,24.60,9.73,24.60,,Hospital CPT 87320,HC Chlamydia Trachomatis,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,145.00,145.00,87.00,87.00,N/A,15.00,N/A,15.00,N/A,83.49,N/A,49.30,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,9.34,N/A,15.00,N/A,15.00,N/A,15.00,N/A,83.49,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,16.50,87.00,87.00,9.34,87.00,,Hospital CPT 87328,HC Cryptosporidium,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,96.00,76.00,57.60,45.60,N/A,13.82,N/A,13.82,N/A,43.76,N/A,25.84,N/A,9.73,N/A,13.82,N/A,13.82,N/A,13.82,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,43.76,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,15.20,57.60,57.60,9.73,45.60,,Hospital CPT 87328,HC So Cryptosporidium Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,86.00,86.00,51.60,51.60,N/A,13.82,N/A,13.82,N/A,49.52,N/A,29.24,N/A,9.73,N/A,13.82,N/A,13.82,N/A,13.82,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,49.52,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,15.20,51.60,51.60,9.73,51.60,,Hospital CPT 87335,HC E.Coli 0157:H7,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,223.00,176.00,133.80,105.60,N/A,12.66,N/A,12.66,N/A,101.34,N/A,59.84,N/A,12.66,N/A,12.66,N/A,12.66,N/A,12.66,N/A,7.88,N/A,12.66,N/A,12.66,N/A,12.66,N/A,101.34,N/A,12.66,N/A,12.66,N/A,12.66,N/A,12.66,N/A,12.66,N/A,12.66,N/A,12.66,N/A,13.93,133.80,133.80,7.88,105.60,,Hospital 87336,HC Entamoeb Hist Dispr Ag Eia,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,44136.80,1737.00,26482.08,1042.20,5483.99,350.09,6752.92,113.42,12358.62,1000.16,15006.51,590.58,12476.84,262.27,5652.96,350.09,3934.00,108.43,3934.00,108.43,7766.54,163.27,12476.84,262.27,12476.84,262.27,12476.84,262.27,12358.62,1000.16,6752.92,108.43,5652.96,350.09,14844.32,444.34,14844.32,444.34,6088.33,350.09,6752.92,108.43,6752.92,113.42,6048.67,348.45,3934.00,26482.08,108.43,1042.20,,Hospital CPT 87338,HC So H.Pylori Stool Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,107.00,107.00,64.20,64.20,N/A,14.38,N/A,14.38,N/A,61.61,N/A,36.38,N/A,12.22,N/A,14.38,N/A,14.38,N/A,14.38,N/A,12.22,N/A,12.22,N/A,12.22,N/A,12.22,N/A,61.61,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,15.82,64.20,64.20,12.22,64.20,,Hospital CPT 87338,HC H.Pylori Stool Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,119.00,96.00,71.40,57.60,N/A,14.38,N/A,14.38,N/A,55.28,N/A,32.64,N/A,12.22,N/A,14.38,N/A,14.38,N/A,14.38,N/A,12.22,N/A,12.22,N/A,12.22,N/A,12.22,N/A,55.28,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,14.38,N/A,15.82,71.40,71.40,12.22,57.60,,Hospital CPT 87341,HC Hepatitis B Surface Ag Ia,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,43.00,43.00,25.80,25.80,N/A,10.33,N/A,10.33,N/A,24.76,N/A,14.62,N/A,8.78,N/A,10.33,N/A,10.33,N/A,10.33,N/A,8.78,N/A,8.78,N/A,10.33,N/A,10.33,N/A,24.76,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,11.36,25.80,25.80,8.78,25.80,,Hospital CPT 87341,HC So Hepatitis B Surface Ag Ia,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,39.00,39.00,23.40,23.40,N/A,10.33,N/A,10.33,N/A,22.46,N/A,13.26,N/A,8.78,N/A,10.33,N/A,10.33,N/A,10.33,N/A,8.78,N/A,8.78,N/A,10.33,N/A,10.33,N/A,22.46,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,11.36,23.40,23.40,8.78,23.40,,Hospital CPT 87380,HC So Hepatitis Delta Agent Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,213.00,213.00,127.80,127.80,N/A,18.36,N/A,18.36,N/A,122.65,N/A,72.42,N/A,18.36,N/A,18.36,N/A,18.36,N/A,18.36,N/A,11.43,N/A,18.36,N/A,18.36,N/A,18.36,N/A,122.65,N/A,18.36,N/A,18.36,N/A,18.36,N/A,18.36,N/A,18.36,N/A,18.36,N/A,18.36,N/A,20.20,127.80,127.80,11.43,127.80,,Hospital CPT 87420,HC Rsv (Eia),N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,275.00,217.00,165.00,130.20,N/A,13.91,N/A,13.91,N/A,124.95,N/A,73.78,N/A,13.91,N/A,13.91,N/A,13.91,N/A,13.91,N/A,8.66,N/A,13.91,N/A,13.91,N/A,13.91,N/A,124.95,N/A,13.91,N/A,13.91,N/A,13.91,N/A,13.91,N/A,13.91,N/A,13.91,N/A,13.91,N/A,15.30,165.00,165.00,8.66,130.20,,Hospital CPT 87427,HC Shiga-Like Toxin,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,46.00,46.00,27.60,27.60,N/A,11.98,N/A,11.98,N/A,46.00,N/A,15.64,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,26.49,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,27.60,27.60,9.73,46.00,,Hospital 87428,HC Iaad Ia Sarscov & Influenza Virus Types a&B,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,17548.40,244.00,10529.04,146.40,7445.53,96.30,8795.49,30.32,16779.11,140.50,5966.47,82.96,16939.61,N/A,7674.94,96.30,9073.32,73.49,9073.32,73.49,10544.51,N/A,16939.61,N/A,16939.61,N/A,16939.61,N/A,16779.11,140.50,9073.32,109.14,7674.94,96.30,17548.40,30.94,17548.40,30.94,N/A,96.30,9073.32,109.14,9073.32,115.66,8212.19,80.83,5966.47,17548.40,30.32,146.40,,Hospital CPT 87481,HC So Candida Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,101.00,101.00,60.60,60.60,N/A,35.09,N/A,35.09,N/A,58.16,N/A,34.34,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,58.16,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,60.60,60.60,29.83,60.60,,Hospital CPT 87491,HC So Chylmd Trach Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,188.00,188.00,112.80,112.80,N/A,35.09,N/A,35.09,N/A,188.00,N/A,63.92,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,108.25,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,112.80,112.80,29.83,188.00,,Hospital CPT 87491,"HC Chlamydia Amp Probe Tech, 1",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,208.00,166.00,124.80,99.60,N/A,35.09,N/A,35.09,N/A,166.00,N/A,56.44,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,95.58,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,124.80,124.80,29.83,166.00,,Hospital CPT 87498,"HC So Enterovirus,Amplified Probe",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,186.00,186.00,111.60,111.60,N/A,35.09,N/A,35.09,N/A,107.10,N/A,63.24,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,107.10,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,111.60,111.60,21.84,111.60,,Hospital CPT 87498,"HC Enterovirus,Amplified Probe",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,206.00,165.00,123.60,99.00,N/A,35.09,N/A,35.09,N/A,95.01,N/A,56.10,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,95.01,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,123.60,123.60,21.84,99.00,,Hospital CPT 87502,HC Infectious Agent Dna/Rna Influenza 1st 2 Types,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,299.00,299.00,179.40,179.40,N/A,95.80,N/A,95.80,N/A,172.16,N/A,101.66,N/A,72.31,N/A,95.80,N/A,95.80,N/A,95.80,N/A,72.31,N/A,72.31,N/A,95.80,N/A,95.80,N/A,172.16,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,105.38,179.40,179.40,72.31,179.40,,Hospital CPT 87502,HC So Inf Virusampl Probefirst 2 Typ,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,271.00,271.00,162.60,162.60,N/A,95.80,N/A,95.80,N/A,156.04,N/A,92.14,N/A,72.31,N/A,95.80,N/A,95.80,N/A,95.80,N/A,72.31,N/A,72.31,N/A,95.80,N/A,95.80,N/A,156.04,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,95.80,N/A,105.38,162.60,162.60,72.31,162.60,,Hospital CPT 87517,HC Hep B Ultraquant,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,373.00,297.00,223.80,178.20,N/A,42.84,N/A,42.84,N/A,171.01,N/A,100.98,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,42.84,N/A,36.40,N/A,42.84,N/A,171.01,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,223.80,223.80,36.40,178.20,,Hospital CPT 87517,HC So Hep B Ultraquant,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,338.00,338.00,202.80,202.80,N/A,42.84,N/A,42.84,N/A,194.62,N/A,114.92,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,42.84,N/A,36.40,N/A,42.84,N/A,194.62,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,202.80,202.80,36.40,202.80,,Hospital CPT 87520,HC Hepatitis C by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,374.00,374.00,224.40,224.40,N/A,31.22,N/A,31.22,N/A,215.35,N/A,127.16,N/A,31.22,N/A,31.22,N/A,31.22,N/A,31.22,N/A,19.43,N/A,31.22,N/A,31.22,N/A,31.22,N/A,215.35,N/A,31.22,N/A,31.22,N/A,31.22,N/A,31.22,N/A,31.22,N/A,31.22,N/A,31.22,N/A,34.34,224.40,224.40,19.43,224.40,,Hospital CPT 87521,HC So Hep C Rna Qual by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,132.00,132.00,79.20,79.20,N/A,35.09,N/A,35.09,N/A,76.01,N/A,44.88,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,76.01,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,79.20,79.20,21.84,79.20,,Hospital CPT 87521,HC Hep C Rna Qual by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,146.00,146.00,87.60,87.60,N/A,35.09,N/A,35.09,N/A,84.07,N/A,49.64,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,84.07,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,87.60,87.60,21.84,87.60,,Hospital 87530,HC So Hsv Dna Quant,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,524717.40,12253.00,314830.44,7351.80,33263.50,1382.01,47686.95,382.52,N/A,7052.21,N/A,4166.02,N/A,3499.33,33263.50,1382.01,47686.95,1443.56,47686.95,1443.56,N/A,2178.41,N/A,3499.33,N/A,3499.33,N/A,3499.33,N/A,7052.21,47686.95,1443.56,33263.50,1382.01,N/A,1871.00,N/A,1871.00,33263.50,1382.01,47686.95,1443.56,47686.95,382.52,33263.50,420.78,33263.50,314830.44,382.52,7351.80,,Hospital CPT 87535,"HC Hiv-1, Amplified Probe Tech",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,240.00,191.00,144.00,114.60,N/A,35.09,N/A,35.09,N/A,109.98,N/A,64.94,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,109.98,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,144.00,144.00,29.83,114.60,,Hospital CPT 87535,"HC So Hiv-1, Amplified Probe Tech",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,218.00,218.00,130.80,130.80,N/A,35.09,N/A,35.09,N/A,125.52,N/A,74.12,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,125.52,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,130.80,130.80,29.83,130.80,,Hospital CPT 87538,HC Hiv-2 Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,490.00,490.00,294.00,294.00,N/A,35.09,N/A,35.09,N/A,282.14,N/A,166.60,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,282.14,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,294.00,294.00,21.84,294.00,,Hospital CPT 87591,HC So N Gonorrhoeae Dna Amp Prob,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,174.00,174.00,104.40,104.40,N/A,35.09,N/A,35.09,N/A,174.00,N/A,59.16,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,100.19,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,104.40,104.40,29.83,174.00,,Hospital CPT 87591,"HC N.Gonorrhea, Dna, Amp Probe",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,192.00,154.00,115.20,92.40,N/A,35.09,N/A,35.09,N/A,154.00,N/A,52.36,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,88.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,115.20,115.20,29.83,154.00,,Hospital CPT 87593,HC So Iadna Orthopoxvirus Amp Probe Tech Ea,N/A,0302 - LABORATORY - IMMUNOLOGY,145.00,145.00,87.00,87.00,N/A,20.30,N/A,145.00,N/A,145.00,N/A,49.30,N/A,145.00,N/A,20.30,N/A,145.00,N/A,145.00,N/A,145.00,N/A,145.00,N/A,145.00,N/A,145.00,N/A,83.49,N/A,145.00,N/A,20.30,N/A,51.17,N/A,51.17,N/A,20.30,N/A,145.00,N/A,145.00,N/A,145.00,87.00,87.00,20.30,145.00,,Hospital CPT 87624,"HC Hpv, Dna, Amp Probe",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,205.00,163.00,123.00,97.80,N/A,35.09,N/A,35.09,N/A,163.00,N/A,55.42,N/A,16.76,N/A,35.09,N/A,35.09,N/A,35.09,N/A,16.76,N/A,16.76,N/A,16.76,N/A,35.09,N/A,93.86,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,123.00,123.00,16.76,163.00,,Hospital CPT 87624,HC So Hpv Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,185.00,185.00,111.00,111.00,N/A,35.09,N/A,35.09,N/A,185.00,N/A,62.90,N/A,16.76,N/A,35.09,N/A,35.09,N/A,35.09,N/A,16.76,N/A,16.76,N/A,16.76,N/A,35.09,N/A,106.52,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,111.00,111.00,16.76,185.00,,Hospital CPT 87631,HC Resp Virusampl Probe3-5 Target,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,482.00,482.00,289.20,289.20,N/A,142.63,N/A,142.63,N/A,277.54,N/A,163.88,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,88.79,N/A,142.63,N/A,142.63,N/A,142.63,N/A,277.54,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,156.89,289.20,289.20,88.79,289.20,,Hospital CPT 87631,HC So Resp Virusampl Probe3-5 Target,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,437.00,437.00,262.20,262.20,N/A,142.63,N/A,142.63,N/A,251.62,N/A,148.58,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,88.79,N/A,142.63,N/A,142.63,N/A,142.63,N/A,251.62,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,156.89,262.20,262.20,88.79,262.20,,Hospital CPT 87632,HC So Resp Virus 6-11 Targets,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1188.00,1188.00,712.80,712.80,N/A,218.06,N/A,218.06,N/A,684.05,N/A,403.92,N/A,218.06,N/A,218.06,N/A,218.06,N/A,218.06,N/A,135.74,N/A,218.06,N/A,218.06,N/A,218.06,N/A,684.05,N/A,218.06,N/A,218.06,N/A,218.06,N/A,218.06,N/A,218.06,N/A,218.06,N/A,218.06,N/A,239.87,712.80,712.80,135.74,712.80,,Hospital CPT 87633,HC So Respiratory Virus Panel by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,500.00,500.00,300.00,300.00,N/A,416.78,N/A,416.78,N/A,287.90,N/A,170.00,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,259.45,N/A,416.78,N/A,416.78,N/A,416.78,N/A,287.90,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,300.00,300.00,170.00,458.46,,Hospital CPT 87633,HC Respiratory Virus Panel by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,2120.00,1983.00,1272.00,1189.80,N/A,416.78,N/A,416.78,N/A,1141.81,N/A,674.22,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,259.45,N/A,416.78,N/A,416.78,N/A,416.78,N/A,1141.81,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,1272.00,1272.00,259.45,1189.80,,Hospital CPT 87633,HC So1 Respiratory Virus Panel by Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1042.00,1042.00,625.20,625.20,N/A,416.78,N/A,416.78,N/A,599.98,N/A,354.28,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,259.45,N/A,416.78,N/A,416.78,N/A,416.78,N/A,599.98,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,625.20,625.20,259.45,625.20,,Hospital CPT 87636,HC Iadna Sarscov2& Inf a&B Mult Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,393.00,393.00,235.80,235.80,N/A,142.63,N/A,142.63,N/A,226.29,N/A,133.62,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,63.35,N/A,63.35,N/A,63.35,N/A,63.35,N/A,226.29,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,142.63,N/A,156.89,235.80,235.80,63.35,235.80,,Hospital CPT 87651,HC Grp a Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,130.00,130.00,78.00,78.00,N/A,35.09,N/A,35.09,N/A,74.85,N/A,44.20,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,35.09,N/A,29.83,N/A,29.83,N/A,74.85,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,78.00,78.00,29.83,78.00,,Hospital CPT 87651,HC So Grp a Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,130.00,130.00,78.00,78.00,N/A,35.09,N/A,35.09,N/A,74.85,N/A,44.20,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,35.09,N/A,29.83,N/A,29.83,N/A,74.85,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,78.00,78.00,29.83,78.00,,Hospital CPT 87660,HC Trichomonas Vag Nuc Acd Direct Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,149.00,149.00,89.40,89.40,N/A,20.05,N/A,20.05,N/A,149.00,N/A,50.66,N/A,16.76,N/A,20.05,N/A,20.05,N/A,20.05,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,85.79,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,22.06,89.40,89.40,16.76,149.00,,Hospital CPT 87660,HC So Trichomonas Vag Nuc Acd Direct Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,149.00,149.00,89.40,89.40,N/A,20.05,N/A,20.05,N/A,149.00,N/A,50.66,N/A,16.76,N/A,20.05,N/A,20.05,N/A,20.05,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,85.79,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,22.06,89.40,89.40,16.76,149.00,,Hospital CPT 87798,"HC Detect Agent Nos, Dna, Amp",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,434.00,344.00,260.40,206.40,N/A,35.09,N/A,35.09,N/A,198.08,N/A,116.96,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,198.08,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,260.40,260.40,21.84,206.40,,Hospital CPT 87798,"HC So1 Detect Agent Nos, Dna, Amp",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,144.00,144.00,86.40,86.40,N/A,35.09,N/A,35.09,N/A,82.92,N/A,48.96,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,82.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,86.40,86.40,21.84,86.40,,Hospital CPT 87798,"HC So Detect Agent Nos, Dna, Amp",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,393.00,393.00,235.80,235.80,N/A,35.09,N/A,35.09,N/A,226.29,N/A,133.62,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,226.29,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,235.80,235.80,21.84,235.80,,Hospital CPT 87798,HC So Detect Agent Nos Dna Amp,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,356.00,283.00,213.60,169.80,N/A,35.09,N/A,35.09,N/A,162.95,N/A,96.22,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,162.95,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,213.60,213.60,21.84,169.80,,Hospital CPT 87801,"HC Detect, Agnt Mult, Dna Ampli",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,305.00,245.00,183.00,147.00,N/A,70.20,N/A,70.20,N/A,245.00,N/A,83.30,N/A,59.65,N/A,70.20,N/A,70.20,N/A,70.20,N/A,59.65,N/A,59.65,N/A,59.65,N/A,59.65,N/A,141.07,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,77.22,183.00,183.00,59.65,245.00,,Hospital CPT 87801,"HC So Detect, Agnt Mult, Dna Ampli",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,276.00,276.00,165.60,165.60,N/A,70.20,N/A,70.20,N/A,276.00,N/A,93.84,N/A,59.65,N/A,70.20,N/A,70.20,N/A,70.20,N/A,59.65,N/A,59.65,N/A,59.65,N/A,59.65,N/A,158.92,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,70.20,N/A,77.22,165.60,165.60,59.65,276.00,,Hospital CPT 87806,HC Hiv Antigen W/Hiv Antibodies,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,100.00,100.00,60.00,60.00,N/A,32.77,N/A,32.77,N/A,57.58,N/A,34.00,N/A,32.77,N/A,32.77,N/A,32.77,N/A,32.77,N/A,20.40,N/A,32.77,N/A,32.77,N/A,32.77,N/A,57.58,N/A,32.77,N/A,32.77,N/A,32.77,N/A,32.77,N/A,32.77,N/A,32.77,N/A,32.77,N/A,36.05,60.00,60.00,20.40,60.00,,Hospital CPT 87808,HC Trichomonas Assay W/Optic,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,96.00,96.00,57.60,57.60,N/A,15.29,N/A,15.29,N/A,96.00,N/A,32.64,N/A,9.73,N/A,15.29,N/A,15.29,N/A,15.29,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,55.28,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,16.82,57.60,57.60,9.73,96.00,,Hospital CPT 87900,HC So Phenotype Infect Agent Drug,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,973.00,973.00,583.80,583.80,N/A,130.35,N/A,130.35,N/A,560.25,N/A,330.82,N/A,110.77,N/A,130.35,N/A,130.35,N/A,130.35,N/A,110.77,N/A,110.77,N/A,110.77,N/A,110.77,N/A,560.25,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,143.39,583.80,583.80,110.77,583.80,,Hospital CPT 87900,HC Eer Hiv Phenosense Gt,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1073.00,1073.00,643.80,643.80,N/A,130.35,N/A,130.35,N/A,617.83,N/A,364.82,N/A,110.77,N/A,130.35,N/A,130.35,N/A,130.35,N/A,110.77,N/A,110.77,N/A,110.77,N/A,110.77,N/A,617.83,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,130.35,N/A,143.39,643.80,643.80,110.77,643.80,,Hospital CPT 87901,HC So Hiv Genotype for Retrov Resist,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1119.00,1119.00,671.40,671.40,N/A,257.45,N/A,257.45,N/A,644.32,N/A,380.46,N/A,218.78,N/A,257.45,N/A,257.45,N/A,257.45,N/A,218.78,N/A,218.78,N/A,218.78,N/A,218.78,N/A,644.32,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,671.40,671.40,218.78,671.40,,Hospital CPT 87901,HC Hiv Genotype for Retrov Resist,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1234.00,982.00,740.40,589.20,N/A,257.45,N/A,257.45,N/A,565.44,N/A,333.88,N/A,218.78,N/A,257.45,N/A,257.45,N/A,257.45,N/A,218.78,N/A,218.78,N/A,218.78,N/A,218.78,N/A,565.44,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,740.40,740.40,218.78,589.20,,Hospital CPT 87904,HC So Hiv Phenotype Ea Addl Drug,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,205.00,205.00,123.00,123.00,N/A,26.07,N/A,26.07,N/A,118.04,N/A,69.70,N/A,22.15,N/A,26.07,N/A,26.07,N/A,26.07,N/A,22.15,N/A,22.15,N/A,22.15,N/A,22.15,N/A,118.04,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,26.07,N/A,28.68,123.00,123.00,22.15,123.00,,Hospital CPT 87999,HC So Limulus,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,240.00,240.00,144.00,144.00,N/A,33.60,N/A,240.00,N/A,138.19,N/A,81.60,N/A,33.60,N/A,33.60,N/A,240.00,N/A,240.00,N/A,20.88,N/A,33.60,N/A,33.60,N/A,33.60,N/A,138.19,N/A,240.00,N/A,33.60,N/A,240.00,N/A,240.00,N/A,33.60,N/A,240.00,N/A,240.00,N/A,240.00,144.00,144.00,20.88,240.00,,Hospital CPT 88104,HC Cytology Consult.,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,92.00,92.00,55.20,55.20,N/A,12.88,N/A,32.08,N/A,52.97,N/A,31.28,N/A,74.18,N/A,12.88,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,52.97,N/A,30.67,N/A,12.88,N/A,34.57,N/A,34.57,N/A,12.88,N/A,30.67,N/A,32.08,N/A,39.02,55.20,55.20,12.88,74.18,,Hospital CPT 88108,HC Cytopath Concentrate Tech,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,212.00,212.00,127.20,127.20,N/A,29.68,N/A,31.31,N/A,122.07,N/A,72.08,N/A,74.18,N/A,29.68,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,122.07,N/A,30.67,N/A,29.68,N/A,34.57,N/A,34.57,N/A,29.68,N/A,30.67,N/A,33.23,N/A,41.01,127.20,127.20,29.68,127.20,,Hospital CPT 88177,HC So Eval of Fna Ea Addl Spec,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,173.00,173.00,103.80,103.80,N/A,24.22,N/A,173.00,N/A,99.61,N/A,58.82,N/A,173.00,N/A,24.22,N/A,173.00,N/A,173.00,N/A,173.00,N/A,173.00,N/A,173.00,N/A,173.00,N/A,99.61,N/A,173.00,N/A,24.22,N/A,7.27,N/A,7.27,N/A,24.22,N/A,173.00,N/A,173.00,N/A,173.00,103.80,103.80,7.27,173.00,,Hospital CPT 88177,HC Eval of Fna Ea Addl Spec,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,191.00,191.00,114.60,114.60,N/A,26.74,N/A,191.00,N/A,109.98,N/A,64.94,N/A,191.00,N/A,26.74,N/A,191.00,N/A,191.00,N/A,191.00,N/A,191.00,N/A,191.00,N/A,191.00,N/A,109.98,N/A,191.00,N/A,26.74,N/A,7.27,N/A,7.27,N/A,26.74,N/A,191.00,N/A,191.00,N/A,191.00,114.60,114.60,7.27,191.00,,Hospital 88187,HC So Flowcytometry/Read 2-8,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,N/A,968.00,N/A,580.80,N/A,163.40,N/A,175.25,N/A,557.38,N/A,329.12,N/A,809.83,N/A,163.40,N/A,327.25,N/A,327.25,N/A,504.13,N/A,809.83,N/A,809.83,N/A,809.83,N/A,557.38,N/A,327.25,N/A,163.40,N/A,411.33,N/A,411.33,N/A,163.40,N/A,327.25,N/A,175.25,N/A,186.66,N/A,N/A,163.40,809.83,,Hospital 88188,HC So Flowcytometry/Read 9-15,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,401195.82,1968.00,240717.49,1180.80,N/A,311.41,N/A,413.92,N/A,1133.18,N/A,669.12,N/A,812.98,N/A,311.41,N/A,352.74,N/A,352.74,N/A,545.73,N/A,812.98,N/A,812.98,N/A,812.98,N/A,1133.18,N/A,352.74,N/A,311.41,N/A,677.60,N/A,677.60,N/A,311.41,N/A,352.74,N/A,413.92,N/A,449.20,240717.49,240717.49,311.41,1180.80,,Hospital CPT 88235,HC Tissue Culture Placenta,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,826.00,826.00,495.60,495.60,N/A,150.30,N/A,150.30,N/A,475.61,N/A,280.84,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,93.56,N/A,150.30,N/A,150.30,N/A,150.30,N/A,475.61,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,165.33,495.60,495.60,93.56,495.60,,Hospital CPT 88235,HC So Tissue Culture Placenta,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,671.00,671.00,402.60,402.60,N/A,150.30,N/A,150.30,N/A,386.36,N/A,228.14,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,93.56,N/A,150.30,N/A,150.30,N/A,150.30,N/A,386.36,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,150.30,N/A,165.33,402.60,402.60,93.56,402.60,,Hospital CPT 88248,HC Chrom Anal Baseline Breakage,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,861.00,861.00,516.60,516.60,N/A,173.17,N/A,173.17,N/A,495.76,N/A,292.74,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,107.80,N/A,173.17,N/A,173.17,N/A,173.17,N/A,495.76,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,190.49,516.60,516.60,107.80,516.60,,Hospital CPT 88271,HC So Molec Cytogenics,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,181.00,181.00,108.60,108.60,N/A,21.42,N/A,21.42,N/A,104.22,N/A,61.54,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,12.30,N/A,12.30,N/A,12.30,N/A,12.30,N/A,104.22,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,23.56,108.60,108.60,12.30,108.60,,Hospital CPT 88271,HC Molec Cytogenics,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,201.00,201.00,120.60,120.60,N/A,21.42,N/A,21.42,N/A,115.74,N/A,68.34,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,12.30,N/A,12.30,N/A,12.30,N/A,12.30,N/A,115.74,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,21.42,N/A,23.56,120.60,120.60,12.30,120.60,,Hospital CPT 88273,HC Chrom in Situ Hybr 10-30 Cell,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,204.00,204.00,122.40,122.40,N/A,34.81,N/A,34.81,N/A,117.46,N/A,69.36,N/A,27.31,N/A,34.81,N/A,34.81,N/A,34.81,N/A,27.31,N/A,27.31,N/A,27.31,N/A,27.31,N/A,117.46,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,38.29,122.40,122.40,27.31,122.40,,Hospital CPT 88273,HC So Chrom in Situ Hybr 10-30 Cell,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,165.00,165.00,99.00,99.00,N/A,34.81,N/A,34.81,N/A,95.01,N/A,56.10,N/A,27.31,N/A,34.81,N/A,34.81,N/A,34.81,N/A,27.31,N/A,27.31,N/A,27.31,N/A,27.31,N/A,95.01,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,34.81,N/A,38.29,99.00,99.00,27.31,99.00,,Hospital CPT 88302,HC Tissue Level II,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,272.00,230.00,163.20,138.00,N/A,32.20,N/A,22.54,N/A,132.43,N/A,78.20,N/A,54.51,N/A,32.20,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,132.43,N/A,22.54,N/A,32.20,N/A,25.23,N/A,25.23,N/A,32.20,N/A,22.54,N/A,22.54,N/A,24.79,163.20,163.20,22.54,138.00,,Hospital CPT 88314,HC Histochemical Staining,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,249.00,249.00,149.40,149.40,N/A,34.86,N/A,68.85,N/A,143.37,N/A,84.66,N/A,245.43,N/A,34.86,N/A,68.85,N/A,68.85,N/A,152.78,N/A,245.43,N/A,245.43,N/A,245.43,N/A,143.37,N/A,68.85,N/A,34.86,N/A,79.25,N/A,79.25,N/A,34.86,N/A,68.85,N/A,68.85,N/A,75.74,149.40,149.40,34.86,245.43,,Hospital CPT 88314,HC So Histochemical Staining,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,225.00,225.00,135.00,135.00,N/A,31.50,N/A,68.85,N/A,129.56,N/A,76.50,N/A,225.00,N/A,31.50,N/A,68.85,N/A,68.85,N/A,152.78,N/A,225.00,N/A,225.00,N/A,225.00,N/A,129.56,N/A,68.85,N/A,31.50,N/A,79.25,N/A,79.25,N/A,31.50,N/A,68.85,N/A,68.85,N/A,75.74,135.00,135.00,31.50,225.00,,Hospital CPT 88321,HC So Consultation and Report on Referred Slides Prepared Elsewhere,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,828.00,828.00,496.80,496.80,N/A,115.92,N/A,30.67,N/A,476.76,N/A,281.52,N/A,74.18,N/A,115.92,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,476.76,N/A,30.67,N/A,115.92,N/A,34.57,N/A,34.57,N/A,115.92,N/A,30.67,N/A,30.67,N/A,33.73,496.80,496.80,30.67,496.80,,Hospital CPT 88321,HC Microslide Consultation,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,914.00,914.00,548.40,548.40,N/A,127.96,N/A,30.67,N/A,526.28,N/A,310.76,N/A,74.18,N/A,127.96,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,526.28,N/A,30.67,N/A,127.96,N/A,34.57,N/A,34.57,N/A,127.96,N/A,30.67,N/A,30.67,N/A,33.73,548.40,548.40,30.67,548.40,,Hospital CPT 88348,"HC Electron Microscopy, Diag",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1135.00,965.00,681.00,579.00,N/A,135.10,N/A,743.10,N/A,555.65,N/A,328.10,N/A,965.00,N/A,135.10,N/A,701.22,N/A,701.22,N/A,965.00,N/A,965.00,N/A,965.00,N/A,965.00,N/A,555.65,N/A,701.22,N/A,135.10,N/A,669.29,N/A,669.29,N/A,135.10,N/A,701.22,N/A,743.10,N/A,368.72,681.00,681.00,135.10,965.00,,Hospital CPT 88348,"HC So Electron Microscopy, Diag",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1029.00,1029.00,617.40,617.40,N/A,144.06,N/A,743.10,N/A,592.50,N/A,349.86,N/A,1029.00,N/A,144.06,N/A,701.22,N/A,701.22,N/A,1029.00,N/A,1029.00,N/A,1029.00,N/A,1029.00,N/A,592.50,N/A,701.22,N/A,144.06,N/A,669.29,N/A,669.29,N/A,144.06,N/A,701.22,N/A,743.10,N/A,368.72,617.40,617.40,144.06,1029.00,,Hospital CPT 88350,HC Immunofluor per Spec Ea Add Ab,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,188.00,160.00,112.80,96.00,N/A,22.40,N/A,160.00,N/A,92.13,N/A,54.40,N/A,160.00,N/A,22.40,N/A,160.00,N/A,160.00,N/A,160.00,N/A,160.00,N/A,160.00,N/A,160.00,N/A,92.13,N/A,160.00,N/A,22.40,N/A,91.01,N/A,91.01,N/A,22.40,N/A,160.00,N/A,160.00,N/A,86.99,112.80,112.80,22.40,160.00,,Hospital CPT 88350,HC So Immunofluor per Spec Ea Add Ab,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,170.00,170.00,102.00,102.00,N/A,23.80,N/A,170.00,N/A,97.89,N/A,57.80,N/A,170.00,N/A,23.80,N/A,170.00,N/A,170.00,N/A,170.00,N/A,170.00,N/A,170.00,N/A,170.00,N/A,97.89,N/A,170.00,N/A,23.80,N/A,91.01,N/A,91.01,N/A,23.80,N/A,170.00,N/A,170.00,N/A,86.99,102.00,102.00,23.80,170.00,,Hospital CPT 88720,"HC Bilirubin, Total, Transcutan",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,39.00,28.00,23.40,16.80,N/A,5.02,N/A,5.02,N/A,16.12,N/A,9.52,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,3.12,N/A,5.02,N/A,5.02,N/A,5.02,N/A,16.12,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.52,23.40,23.40,3.12,16.80,,Hospital CPT 88720,HC Transcutaneous Bilirubin Total,N/A,0301 - LABORATORY - CHEMISTRY,39.00,28.00,23.40,16.80,N/A,5.02,N/A,5.02,N/A,16.12,N/A,9.52,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,3.12,N/A,5.02,N/A,5.02,N/A,5.02,N/A,16.12,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.52,23.40,23.40,3.12,16.80,,Hospital 88741,HC Noninvasive Methemoglobin,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 89050,"HC Wbc,Dialysate Fluid",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,117.00,85.00,70.20,51.00,N/A,4.72,N/A,4.72,N/A,48.94,N/A,28.90,N/A,4.72,N/A,4.72,N/A,4.72,N/A,4.72,N/A,2.94,N/A,4.72,N/A,4.72,N/A,4.72,N/A,48.94,N/A,4.72,N/A,4.72,N/A,4.72,N/A,4.72,N/A,4.72,N/A,4.72,N/A,4.72,N/A,5.19,70.20,70.20,2.94,51.00,,Hospital CPT 89051,HC Fluid Cell Count,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,126.00,96.00,75.60,57.60,N/A,5.60,N/A,5.60,N/A,55.28,N/A,32.64,N/A,5.60,N/A,5.60,N/A,5.60,N/A,5.60,N/A,3.49,N/A,5.60,N/A,5.60,N/A,5.60,N/A,55.28,N/A,5.60,N/A,5.60,N/A,5.60,N/A,5.60,N/A,5.60,N/A,5.60,N/A,5.60,N/A,6.16,75.60,75.60,3.49,57.60,,Hospital 89055,HC Fecal Leukocytes,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,39455.78,891.00,23673.47,534.60,7528.22,72.75,9171.14,72.75,17441.41,513.03,13414.97,302.94,17127.73,55.45,7760.17,72.75,3934.00,72.75,3934.00,72.75,10661.62,55.45,17127.73,55.45,10328.59,55.45,17127.73,55.45,17441.41,513.03,9171.14,72.75,7760.17,72.75,20377.73,72.75,20377.73,72.75,4518.89,72.75,9171.14,72.75,9171.14,72.75,8303.39,80.03,3934.00,23673.47,55.45,534.60,,Hospital 89125,HC So Feces Smear for Fat,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,148731.83,N/A,89239.10,N/A,12807.46,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12807.46,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12807.46,N/A,N/A,N/A,N/A,N/A,12807.46,N/A,N/A,N/A,N/A,N/A,12807.46,N/A,12807.46,89239.10,N/A,N/A,,Hospital CPT 89320,HC Semen Analysis Complete,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,146.00,102.00,87.60,61.20,N/A,12.31,N/A,12.31,N/A,58.73,N/A,34.68,N/A,10.24,N/A,12.31,N/A,12.31,N/A,12.31,N/A,10.24,N/A,10.24,N/A,10.24,N/A,10.24,N/A,58.73,N/A,12.31,N/A,12.31,N/A,12.31,N/A,12.31,N/A,12.31,N/A,12.31,N/A,12.31,N/A,13.54,87.60,87.60,10.24,61.20,,Hospital 90384,"Rh Ig, Full-Dose, Im",N/A,N/A,N/A,1415.80,N/A,849.48,N/A,198.21,N/A,60.40,N/A,798.21,N/A,481.37,N/A,345.69,N/A,198.21,N/A,60.93,N/A,60.93,N/A,215.19,N/A,345.69,N/A,345.69,N/A,345.69,N/A,798.21,N/A,60.93,N/A,198.21,N/A,758.87,N/A,758.87,N/A,198.21,N/A,60.93,N/A,60.40,N/A,14.73,N/A,N/A,14.73,849.48,,Hospital 90460,Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 90461,HC Immune Admin Addl Inj<18 Years,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,N/A,194.00,N/A,116.40,N/A,27.16,N/A,27.28,N/A,110.21,N/A,65.96,N/A,186.95,N/A,27.16,N/A,27.28,N/A,27.28,N/A,146.25,N/A,186.95,N/A,186.95,N/A,186.95,N/A,110.21,N/A,27.28,N/A,27.16,N/A,103.99,N/A,103.99,N/A,27.16,N/A,27.28,N/A,27.28,N/A,30.01,N/A,N/A,27.16,186.95,,Hospital 90621,"HC Meningococcal B, Recombinant (Age 10y-25y) Im (Trumenba)",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,459.02,N/A,275.41,N/A,64.26,N/A,115.66,N/A,264.31,N/A,156.06,N/A,N/A,N/A,64.26,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,264.31,N/A,109.14,N/A,64.26,N/A,246.04,N/A,246.04,N/A,64.26,N/A,109.14,N/A,115.66,N/A,35.95,N/A,N/A,35.95,275.41,,Hospital 90634,Hepa Vaccine 3 Dose Schedule Ped/Adolesc Im Use,N/A,N/A,N/A,851.90,N/A,511.14,N/A,119.27,N/A,149.00,N/A,483.83,N/A,289.65,N/A,256.04,N/A,119.27,N/A,147.40,N/A,147.40,N/A,159.33,N/A,256.04,N/A,256.04,N/A,256.04,N/A,483.83,N/A,147.40,N/A,119.27,N/A,456.62,N/A,456.62,N/A,119.27,N/A,147.40,N/A,149.00,N/A,17.04,N/A,N/A,17.04,511.14,,Hospital 90647,HC Hib Prp-Omp Vacc 3 Dose Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),360398.83,580.00,216239.30,348.00,40040.43,71.42,34413.17,63.88,378392.87,332.83,400891.31,197.23,400891.31,232.37,40040.43,71.42,34413.17,60.93,34413.17,60.93,400891.31,577.36,400891.31,232.37,400891.31,232.37,400891.31,232.37,378392.87,332.82,34413.17,109.14,40040.43,71.42,378392.87,47.93,378392.87,47.93,40040.43,71.42,34413.17,109.14,34413.17,53.23,40040.43,58.56,34413.17,400891.31,47.93,577.36,,Hospital 90651,HC 9vhpv Vaccine 3 Dose Schedule for Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,459.00,N/A,275.40,N/A,64.26,N/A,116.10,N/A,261.75,N/A,156.06,N/A,187.00,N/A,64.26,N/A,109.14,N/A,109.14,N/A,408.88,N/A,187.00,N/A,187.00,N/A,187.00,N/A,261.75,N/A,109.14,N/A,64.26,N/A,246.02,N/A,246.02,N/A,64.26,N/A,109.14,N/A,116.10,N/A,17.04,N/A,N/A,17.04,408.88,,Hospital HCPCS 90670,PNEUMOCOCCAL 13-VAL CONJ VACC IM SUSP,00005-1971-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),509.50,509.50,305.70,305.70,N/A,71.33,N/A,509.50,N/A,286.44,N/A,173.23,N/A,509.50,N/A,71.33,N/A,509.50,N/A,509.50,N/A,415.96,N/A,509.50,N/A,509.50,N/A,509.50,N/A,286.44,N/A,509.50,N/A,71.33,N/A,273.09,N/A,273.09,N/A,71.33,N/A,509.50,N/A,509.50,N/A,509.50,305.70,305.70,71.33,509.50,,Hospital 90680,HC Rv5 Vaccine 3 Dose Schedule Live for Oral Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,321.00,N/A,192.60,N/A,44.97,N/A,40.55,N/A,183.70,N/A,109.17,N/A,232.37,N/A,44.97,N/A,38.26,N/A,38.26,N/A,321.00,N/A,232.37,N/A,232.37,N/A,232.37,N/A,183.70,N/A,38.26,N/A,44.97,N/A,172.06,N/A,172.06,N/A,44.97,N/A,38.26,N/A,40.55,N/A,42.98,N/A,N/A,38.26,321.00,,Hospital 90685,Iiv4 Vacc Prsrv Free 0.25 Ml Dos for Im Use,N/A,N/A,90299.40,N/A,54179.64,N/A,5031.61,N/A,6217.78,N/A,11339.15,N/A,30701.80,N/A,11447.62,N/A,5186.65,N/A,6217.78,N/A,6217.78,N/A,7125.88,N/A,11447.62,N/A,11447.62,N/A,11447.62,N/A,11339.15,N/A,6217.78,N/A,5186.65,N/A,13619.81,N/A,13619.81,N/A,6212.08,N/A,6217.78,N/A,6217.78,N/A,5549.71,N/A,5031.61,54179.64,N/A,N/A,,Hospital 90687,HC Iiv4 Vacc Split Virus 0.25 Ml Dos for Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,659.00,N/A,395.40,N/A,92.26,N/A,187.68,N/A,377.13,N/A,224.06,N/A,163.21,N/A,92.26,N/A,185.66,N/A,185.66,N/A,125.32,N/A,163.21,N/A,163.21,N/A,163.21,N/A,377.13,N/A,185.66,N/A,92.26,N/A,353.22,N/A,353.22,N/A,92.26,N/A,185.66,N/A,187.68,N/A,17.04,N/A,N/A,17.04,395.40,,Hospital 90698,HC Dtap-Ipv/Hib Vaccine Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,778.02,N/A,466.81,N/A,108.92,N/A,71.78,N/A,445.74,N/A,264.52,N/A,229.83,N/A,108.92,N/A,65.06,N/A,65.06,N/A,251.28,N/A,229.83,N/A,229.83,N/A,229.83,N/A,445.74,N/A,65.06,N/A,108.92,N/A,417.03,N/A,417.03,N/A,108.92,N/A,65.06,N/A,29.69,N/A,32.66,N/A,N/A,29.69,466.81,,Hospital HCPCS 90700,DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP,58160-0810-43,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),60.90,60.90,36.54,36.54,N/A,8.53,N/A,60.90,N/A,34.24,N/A,20.71,N/A,60.90,N/A,8.53,N/A,60.90,N/A,60.90,N/A,43.58,N/A,60.90,N/A,60.90,N/A,60.90,N/A,34.24,N/A,60.90,N/A,8.53,N/A,32.64,N/A,32.64,N/A,8.53,N/A,60.90,N/A,60.90,N/A,60.90,36.54,36.54,8.53,60.90,,Hospital HCPCS 90707,"MEASLES, MUMPS & RUBELLA VAC IJ SOLR",00006-4681-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),202.20,202.20,121.32,121.32,N/A,28.31,N/A,202.20,N/A,113.68,N/A,68.75,N/A,202.20,N/A,28.31,N/A,202.20,N/A,202.20,N/A,140.77,N/A,202.20,N/A,202.20,N/A,202.20,N/A,113.68,N/A,202.20,N/A,28.31,N/A,108.38,N/A,108.38,N/A,28.31,N/A,202.20,N/A,202.20,N/A,202.20,121.32,121.32,28.31,202.20,,Hospital 90710,"HC Combined Vaccine,Mmr+Varicella,Sub-Q",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,696.00,N/A,417.60,N/A,97.44,N/A,270.32,N/A,396.14,N/A,236.64,N/A,487.37,N/A,97.44,N/A,269.14,N/A,269.14,N/A,587.11,N/A,487.37,N/A,487.37,N/A,487.37,N/A,396.14,N/A,269.14,N/A,97.44,N/A,373.06,N/A,373.06,N/A,97.44,N/A,269.14,N/A,270.32,N/A,30.01,N/A,N/A,30.01,587.11,,Hospital 90716,HC Var Vaccine Live for Subcutaneous Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,580.00,N/A,348.00,N/A,71.42,N/A,63.88,N/A,332.83,N/A,197.23,N/A,232.37,N/A,71.42,N/A,60.93,N/A,60.93,N/A,577.36,N/A,232.37,N/A,232.37,N/A,232.37,N/A,332.82,N/A,109.14,N/A,71.42,N/A,47.93,N/A,47.93,N/A,71.42,N/A,109.14,N/A,53.23,N/A,58.56,N/A,N/A,47.93,577.36,,Hospital 90723,HC Dtap-Hepb-Ipv Vaccine Intramuscular,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),260539.88,567.02,156323.93,340.21,62794.53,79.38,N/A,40.12,N/A,325.90,400891.31,192.78,400891.31,190.37,62794.53,79.38,N/A,38.26,N/A,38.26,400891.31,136.97,400891.31,190.37,400891.31,190.37,400891.31,190.37,N/A,325.90,N/A,38.26,62794.53,79.38,N/A,303.94,N/A,303.94,62794.53,79.38,N/A,38.26,N/A,27.28,62794.53,30.01,62794.53,400891.31,27.28,340.21,,Hospital HCPCS 90732,PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ,00006-4943-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),263.50,263.50,158.10,158.10,N/A,36.89,N/A,263.50,N/A,148.14,N/A,89.59,N/A,263.50,N/A,36.89,N/A,263.50,N/A,263.50,N/A,215.19,N/A,263.50,N/A,263.50,N/A,263.50,N/A,148.14,N/A,263.50,N/A,36.89,N/A,141.24,N/A,141.24,N/A,36.89,N/A,263.50,N/A,263.50,N/A,263.50,158.10,158.10,36.89,263.50,,Hospital 90734,HC Meningococcal Conj Vaccine Quadravalent Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),220339.27,588.02,132203.56,352.81,9071.64,82.32,34413.17,120.40,171122.44,338.58,67233.09,199.92,67233.09,925.92,9071.64,82.32,34413.17,109.14,34413.17,109.14,67233.09,925.92,67233.09,925.92,67233.09,925.92,67233.09,925.92,171122.44,338.58,34413.17,109.14,9071.64,82.32,171122.44,315.19,171122.44,315.19,9071.64,82.32,34413.17,109.14,34413.17,27.28,9071.64,30.01,9071.64,171122.44,27.28,925.92,,Hospital HCPCS 90739,HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,43528-0003-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),300.20,300.20,180.12,180.12,N/A,42.03,N/A,300.20,N/A,168.77,N/A,102.07,N/A,300.20,N/A,42.03,N/A,300.20,N/A,300.20,N/A,232.51,N/A,300.20,N/A,300.20,N/A,300.20,N/A,168.77,N/A,300.20,N/A,42.03,N/A,160.91,N/A,160.91,N/A,42.03,N/A,300.20,N/A,300.20,N/A,300.20,180.12,180.12,42.03,300.20,,Hospital HCPCS 90740,HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSP,58160-0821-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),144.70,144.70,86.82,86.82,N/A,20.26,N/A,144.70,N/A,81.35,N/A,49.20,N/A,144.70,N/A,20.26,N/A,144.70,N/A,144.70,N/A,144.70,N/A,144.70,N/A,144.70,N/A,144.70,N/A,81.35,N/A,144.70,N/A,20.26,N/A,77.56,N/A,77.56,N/A,20.26,N/A,144.70,N/A,144.70,N/A,144.70,86.82,86.82,20.26,144.70,,Hospital HCPCS 90744,HEPATITIS B VAC RECOMBINANT 10 MCG/0.5ML IJ SUSY,58160-0820-52,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),177.80,177.80,106.68,106.68,N/A,24.89,N/A,177.80,N/A,99.96,N/A,60.45,N/A,75.21,N/A,24.89,N/A,177.80,N/A,177.80,N/A,46.82,N/A,75.21,N/A,75.21,N/A,75.21,N/A,99.96,N/A,177.80,N/A,24.89,N/A,95.30,N/A,95.30,N/A,24.89,N/A,177.80,N/A,177.80,N/A,177.80,106.68,106.68,24.89,177.80,,Hospital 90746,HC Hepatitis B Vaccine,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,496.00,N/A,297.60,N/A,69.44,N/A,149.00,N/A,283.43,N/A,77.18,N/A,227.00,N/A,69.44,N/A,147.40,N/A,147.40,N/A,205.21,N/A,227.00,N/A,227.00,N/A,227.00,N/A,283.43,N/A,147.40,N/A,69.44,N/A,265.85,N/A,265.85,N/A,69.44,N/A,147.40,N/A,149.00,N/A,88.48,N/A,N/A,69.44,297.60,,Hospital CPT 90832,HC Iop Tx 30 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,612.00,612.00,367.20,367.20,N/A,85.68,N/A,130.90,N/A,352.39,N/A,208.08,N/A,318.26,N/A,85.68,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,489.60,N/A,131.57,N/A,85.68,N/A,612.00,N/A,612.00,N/A,85.68,N/A,131.57,N/A,130.90,N/A,74.20,367.20,367.20,74.20,612.00,,Hospital CPT 90832,HC Php Psych Tx 30 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,612.00,612.00,367.20,367.20,N/A,85.68,N/A,130.90,N/A,352.39,N/A,208.08,N/A,318.26,N/A,85.68,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,489.60,N/A,131.57,N/A,85.68,N/A,612.00,N/A,612.00,N/A,85.68,N/A,131.57,N/A,130.90,N/A,74.20,367.20,367.20,74.20,612.00,,Hospital CPT 90832,HC OP Psych Tx 30 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,612.00,612.00,367.20,367.20,N/A,85.68,N/A,130.90,N/A,352.39,N/A,208.08,N/A,318.26,N/A,85.68,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,489.60,N/A,131.57,N/A,85.68,N/A,612.00,N/A,612.00,N/A,85.68,N/A,131.57,N/A,130.90,N/A,74.20,367.20,367.20,74.20,612.00,,Hospital CPT 90847,HC Iop Family Treatment,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,1058.00,1058.00,634.80,634.80,N/A,148.12,N/A,138.99,N/A,609.20,N/A,359.72,N/A,318.26,N/A,148.12,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,609.20,N/A,131.57,N/A,148.12,N/A,1058.00,N/A,1058.00,N/A,148.12,N/A,131.57,N/A,99.32,N/A,109.25,634.80,634.80,99.32,1058.00,,Hospital CPT 90847,HC Php Psych Family,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,1058.00,1058.00,634.80,634.80,N/A,148.12,N/A,138.99,N/A,609.20,N/A,359.72,N/A,318.26,N/A,148.12,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,609.20,N/A,131.57,N/A,148.12,N/A,1058.00,N/A,1058.00,N/A,148.12,N/A,131.57,N/A,99.32,N/A,109.25,634.80,634.80,99.32,1058.00,,Hospital 90869,HC Tcran Magn Stim Redetemine,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,730.00,N/A,438.00,N/A,102.20,N/A,255.64,N/A,420.33,N/A,248.20,N/A,611.76,N/A,102.20,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,420.33,N/A,252.91,N/A,102.20,N/A,391.28,N/A,391.28,N/A,102.20,N/A,252.91,N/A,255.64,N/A,N/A,N/A,N/A,102.20,611.76,,Hospital CPT 90870,HC Ect,N/A,0901 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - ELECTROSHOCK TREATMENT,2636.00,2636.00,1581.60,1581.60,N/A,369.04,N/A,451.52,N/A,1517.81,N/A,896.24,N/A,1055.99,N/A,369.04,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,880.23,N/A,436.56,N/A,369.04,N/A,2636.00,N/A,2636.00,N/A,369.04,N/A,436.56,N/A,448.22,N/A,114.87,1581.60,1581.60,114.87,2636.00,,Hospital 90940,"Hemodia Acc Flow,Hook Up,Disconnect",N/A,N/A,N/A,4289.00,N/A,2573.40,N/A,600.46,N/A,365.06,N/A,2469.61,N/A,1458.26,N/A,814.92,N/A,600.46,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,2469.61,N/A,336.90,N/A,600.46,N/A,527.00,N/A,527.00,N/A,600.46,N/A,336.90,N/A,365.06,N/A,63.06,N/A,N/A,63.06,2573.40,,Hospital CPT 90945,HC Capd,N/A,0881 - MISCELLANEOUS DIALYSIS - ULTRAFILTRATION,785.00,785.00,471.00,471.00,N/A,109.90,N/A,342.85,N/A,452.00,N/A,266.90,N/A,785.00,N/A,109.90,N/A,344.61,N/A,344.61,N/A,518.93,N/A,785.00,N/A,785.00,N/A,785.00,N/A,452.00,N/A,344.61,N/A,109.90,N/A,420.76,N/A,420.76,N/A,109.90,N/A,344.61,N/A,342.85,N/A,90.65,471.00,471.00,90.65,785.00,,Hospital CPT 90945,HC Dialysis Other Than Hemo (Crt/Peritoneal),N/A,0881 - MISCELLANEOUS DIALYSIS - ULTRAFILTRATION,785.00,785.00,471.00,471.00,N/A,109.90,N/A,342.85,N/A,452.00,N/A,266.90,N/A,785.00,N/A,109.90,N/A,344.61,N/A,344.61,N/A,518.93,N/A,785.00,N/A,785.00,N/A,785.00,N/A,452.00,N/A,344.61,N/A,109.90,N/A,420.76,N/A,420.76,N/A,109.90,N/A,344.61,N/A,342.85,N/A,90.65,471.00,471.00,90.65,785.00,,Hospital 90970,"Esrd Services, per Day,20+ Yr Old",N/A,0801 - INPATIENT RENAL DIALYSIS - INPATIENT HEMODIALYSIS,N/A,7355.80,N/A,4413.48,N/A,1024.55,N/A,226.52,N/A,4210.45,N/A,2500.97,N/A,3164.98,N/A,1024.55,N/A,1304.14,N/A,1304.14,N/A,1970.25,N/A,3164.98,N/A,3164.98,N/A,3164.98,N/A,3821.21,N/A,1304.14,N/A,1024.55,N/A,2138.32,N/A,2138.32,N/A,1024.55,N/A,1304.14,N/A,226.52,N/A,326.21,N/A,N/A,226.52,4413.48,,Hospital 90999,Dialysis Procedure,N/A,N/A,N/A,8303.30,N/A,4981.98,N/A,1162.46,N/A,106.15,N/A,4689.73,N/A,2823.12,N/A,1382.65,N/A,1162.46,N/A,106.15,N/A,106.15,N/A,860.46,N/A,1382.65,N/A,1382.65,N/A,1382.65,N/A,4689.73,N/A,106.15,N/A,1162.46,N/A,4450.57,N/A,4450.57,N/A,1162.46,N/A,106.15,N/A,106.15,N/A,392.62,N/A,N/A,106.15,4981.98,,Hospital 91013,Esophageal Motility Std W/I&R Stim/Perfusion,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,6947.40,N/A,4168.44,N/A,972.63,N/A,445.64,N/A,4000.32,N/A,2362.12,N/A,1055.99,N/A,972.63,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,4000.32,N/A,436.56,N/A,972.63,N/A,790.50,N/A,790.50,N/A,972.63,N/A,436.56,N/A,445.64,N/A,177.60,N/A,N/A,177.60,4168.44,,Hospital 91022,Duodenal Motility Study,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,3582.00,N/A,2149.20,N/A,501.48,N/A,456.66,N/A,2062.52,N/A,1217.88,N/A,1055.99,N/A,501.48,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,2062.52,N/A,436.56,N/A,501.48,N/A,527.00,N/A,527.00,N/A,501.48,N/A,436.56,N/A,456.66,N/A,100.20,N/A,N/A,100.20,2149.20,,Hospital 91034,Gerd Tst W/ Nasal Ph Electrod,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,5474.40,N/A,3284.64,N/A,766.42,N/A,445.64,N/A,3152.16,N/A,1861.30,N/A,1055.99,N/A,766.42,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,3152.16,N/A,436.56,N/A,766.42,N/A,527.00,N/A,527.00,N/A,766.42,N/A,436.56,N/A,445.64,N/A,144.21,N/A,N/A,144.21,3284.64,,Hospital 91299,Gastroenterology Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7521.02,N/A,4512.61,N/A,1052.95,N/A,144.87,N/A,4330.61,N/A,2531.85,N/A,317.67,N/A,1052.95,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,4330.61,N/A,131.33,N/A,1052.95,N/A,527.00,N/A,527.00,N/A,1052.95,N/A,131.33,N/A,133.10,N/A,N/A,N/A,N/A,131.33,4512.61,,Hospital 91303,Sarscov2 Vaccine Ad26 5x1010vp/0.5ml Im Use,N/A,N/A,180330.20,N/A,108198.12,N/A,N/A,N/A,40438.69,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,52452.26,N/A,52452.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,40438.69,N/A,N/A,N/A,36936.00,N/A,N/A,N/A,N/A,N/A,40438.69,N/A,40438.69,N/A,N/A,N/A,36936.00,108198.12,N/A,N/A,,Hospital 91307,HC Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,497.02,N/A,298.21,N/A,69.58,N/A,3.59,N/A,285.61,N/A,168.98,N/A,497.01,N/A,69.58,N/A,328.66,N/A,328.66,N/A,470.39,N/A,497.01,N/A,497.01,N/A,497.01,N/A,285.61,N/A,328.66,N/A,69.58,N/A,266.40,N/A,266.40,N/A,69.58,N/A,328.66,N/A,3.59,N/A,3.95,N/A,N/A,3.59,497.01,,Hospital 92002,"Eye Exam, New Patient,Intermed",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5559.60,N/A,3335.76,N/A,778.35,N/A,114.17,N/A,3201.06,N/A,1890.27,N/A,265.56,N/A,778.35,N/A,109.14,N/A,109.14,N/A,165.32,N/A,265.56,N/A,265.56,N/A,265.56,N/A,3201.06,N/A,109.14,N/A,778.35,N/A,N/A,N/A,N/A,N/A,778.35,N/A,109.14,N/A,114.17,N/A,49.31,N/A,N/A,49.31,3335.76,,Hospital 92083,HC Ophth Medical Xm&Eval Comprhnsv Estab Pt 1/>,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,621.00,N/A,372.60,N/A,86.94,N/A,111.11,N/A,357.58,N/A,211.14,N/A,N/A,N/A,86.94,N/A,104.85,N/A,104.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,357.58,N/A,104.85,N/A,86.94,N/A,332.86,N/A,332.86,N/A,86.94,N/A,104.85,N/A,111.11,N/A,50.91,N/A,N/A,50.91,372.60,,Hospital 92134,HC Cptr Ophth Dx Img Post Segmt,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,455.00,N/A,273.00,N/A,63.70,N/A,111.11,N/A,261.99,N/A,154.70,N/A,N/A,N/A,63.70,N/A,104.85,N/A,104.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,261.99,N/A,104.85,N/A,63.70,N/A,243.88,N/A,243.88,N/A,63.70,N/A,104.85,N/A,111.11,N/A,31.06,N/A,N/A,31.06,273.00,,Hospital 92250,HC Fundus Photography W/Interpretation & Report,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,475.00,N/A,285.00,N/A,66.50,N/A,115.66,N/A,273.51,N/A,161.50,N/A,N/A,N/A,66.50,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,273.51,N/A,109.14,N/A,66.50,N/A,254.60,N/A,254.60,N/A,66.50,N/A,109.14,N/A,115.66,N/A,15.86,N/A,N/A,15.86,285.00,,Hospital CPT 92521,HC Eval of Speech Fluency,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,368.00,368.00,220.80,220.80,N/A,51.52,N/A,109.06,N/A,211.89,N/A,125.12,N/A,368.00,N/A,51.52,N/A,109.06,N/A,109.06,N/A,368.00,N/A,368.00,N/A,368.00,N/A,368.00,N/A,211.89,N/A,129.37,N/A,51.52,N/A,197.25,N/A,197.25,N/A,51.52,N/A,109.06,N/A,109.06,N/A,119.97,220.80,220.80,51.52,368.00,,Hospital CPT 92523,HC Eval Speech Sound Lang Comprhension,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,620.00,620.00,372.00,372.00,N/A,86.80,N/A,186.92,N/A,357.00,N/A,210.80,N/A,620.00,N/A,86.80,N/A,186.92,N/A,186.92,N/A,620.00,N/A,620.00,N/A,620.00,N/A,620.00,N/A,357.00,N/A,221.81,N/A,86.80,N/A,332.32,N/A,332.32,N/A,86.80,N/A,186.92,N/A,186.92,N/A,205.61,372.00,372.00,86.80,620.00,,Hospital CPT 92526,HC Dysphagia Therapy,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,494.00,494.00,296.40,296.40,N/A,69.16,N/A,84.23,N/A,284.45,N/A,167.96,N/A,247.17,N/A,69.16,N/A,84.23,N/A,84.23,N/A,247.17,N/A,247.17,N/A,247.17,N/A,247.17,N/A,284.45,N/A,82.39,N/A,69.16,N/A,264.78,N/A,264.78,N/A,69.16,N/A,84.23,N/A,84.23,N/A,92.65,296.40,296.40,69.16,296.40,,Hospital 92542,HC Eng Positional Nystagmus Test,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,1970.00,N/A,1182.00,N/A,275.80,N/A,134.06,N/A,1134.33,N/A,669.80,N/A,317.67,N/A,275.80,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,1134.33,N/A,131.33,N/A,275.80,N/A,1055.92,N/A,1055.92,N/A,275.80,N/A,131.33,N/A,134.06,N/A,59.77,N/A,N/A,59.77,1182.00,,Hospital 92545,HC Eng Oscillating Tracking Test,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,1859.00,N/A,1115.40,N/A,260.26,N/A,392.22,N/A,1070.41,N/A,632.06,N/A,929.43,N/A,260.26,N/A,384.24,N/A,384.24,N/A,578.58,N/A,929.43,N/A,929.43,N/A,929.43,N/A,1070.41,N/A,384.24,N/A,260.26,N/A,996.42,N/A,996.42,N/A,260.26,N/A,384.24,N/A,392.22,N/A,52.82,N/A,N/A,52.82,1115.40,,Hospital 92558,HC Oae Screening,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,10528.70,656.00,6317.22,393.60,1079.73,91.84,1542.91,134.06,2433.25,377.72,3579.76,223.04,1589.00,357.43,1113.00,91.84,1542.91,131.33,1542.91,131.33,989.00,222.46,1589.00,357.43,1589.00,357.43,1589.00,357.43,2433.25,377.72,1542.91,131.33,1113.00,91.84,2704.00,351.61,2704.00,351.61,1620.16,91.84,1542.91,131.33,1542.91,134.06,1190.91,51.38,989.00,6317.22,51.38,393.60,,Hospital 92570,HC Acoustic Reflex Decay Test,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,4614.80,N/A,2768.88,N/A,1079.73,N/A,1542.91,N/A,2433.25,N/A,1569.03,N/A,1589.00,N/A,1113.00,N/A,1542.91,N/A,1542.91,N/A,989.00,N/A,1589.00,N/A,1589.00,N/A,1589.00,N/A,2433.25,N/A,1542.91,N/A,1113.00,N/A,2704.00,N/A,2704.00,N/A,1704.35,N/A,1542.91,N/A,1542.91,N/A,1190.91,N/A,989.00,2768.88,N/A,N/A,,Hospital 92579,HC Visual Audiometry (Vra),N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,656.00,N/A,393.60,N/A,91.84,N/A,134.06,N/A,377.72,N/A,223.04,N/A,357.43,N/A,91.84,N/A,131.33,N/A,131.33,N/A,222.46,N/A,357.43,N/A,357.43,N/A,357.43,N/A,377.72,N/A,131.33,N/A,91.84,N/A,351.61,N/A,351.61,N/A,91.84,N/A,131.33,N/A,134.06,N/A,51.38,N/A,N/A,51.38,393.60,,Hospital 92587,HC Otoacoutstic Emission Testing,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,5298.70,1044.00,3179.22,626.40,1079.73,146.16,1542.91,258.16,2433.25,601.13,1801.56,354.96,1589.00,611.76,1113.00,146.16,1542.91,252.91,1542.91,252.91,989.00,380.83,1589.00,611.76,1589.00,611.76,1589.00,611.76,2433.25,601.13,1542.91,252.91,1113.00,146.16,2704.00,559.59,2704.00,559.59,1704.35,146.16,1542.91,252.91,1542.91,258.16,1190.91,115.36,989.00,3179.22,115.36,626.40,,Hospital 92588,HC Otoacoustic Emissions Compr,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,6039.60,2023.00,3623.76,1213.80,1079.73,283.22,1542.91,250.72,2433.25,1164.84,2053.46,687.82,1589.00,611.76,1113.00,283.22,1542.91,252.91,1542.91,252.91,989.00,380.83,1589.00,611.76,1589.00,611.76,1589.00,611.76,2433.25,1164.84,1542.91,252.91,1113.00,283.22,1352.00,1084.33,1352.00,1084.33,1560.95,283.22,1542.91,252.91,1542.91,250.72,1190.91,56.66,989.00,3623.76,56.66,1213.80,,Hospital 92593,"HC Hearing Aid Check, Both Ears",N/A,0471 - AUDIOLOGY - DIAGNOSTIC,27458.60,22.00,16475.16,13.20,6749.90,3.08,8250.42,52.00,15211.44,12.67,9335.92,7.48,15356.95,3.08,6957.87,3.08,2810.00,52.00,2810.00,52.00,9559.34,1.91,15356.95,3.08,15356.95,3.08,15356.95,3.08,15211.44,12.67,8250.42,52.00,6957.87,3.08,18270.93,11.79,18270.93,11.79,N/A,3.08,8250.42,52.00,8250.42,52.00,7444.92,N/A,2810.00,18270.93,1.91,52.00,,Hospital CPT 92607,HC Speech Gen Device Eval 1 Hr,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,644.00,644.00,386.40,386.40,N/A,90.16,N/A,123.71,N/A,370.82,N/A,218.96,N/A,359.28,N/A,90.16,N/A,123.71,N/A,123.71,N/A,359.28,N/A,359.28,N/A,359.28,N/A,359.28,N/A,370.82,N/A,119.76,N/A,90.16,N/A,345.18,N/A,345.18,N/A,90.16,N/A,123.71,N/A,123.71,N/A,136.08,386.40,386.40,90.16,386.40,,Hospital CPT 92920,HC Prq Cardiac Angioplast 1 Art,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,10994.00,10994.00,6596.40,6596.40,N/A,1539.16,N/A,5103.37,N/A,6330.35,N/A,3737.96,N/A,10994.00,N/A,1539.16,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,10994.00,N/A,10994.00,N/A,10994.00,N/A,6330.35,N/A,4709.71,N/A,1539.16,N/A,7897.00,N/A,7897.00,N/A,1539.16,N/A,4709.71,N/A,4926.57,N/A,559.25,6596.40,6596.40,559.25,10994.00,,Hospital CPT 92921,HC Prq Cardiac Angio Addl Art,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3655.00,3655.00,2193.00,2193.00,N/A,511.70,N/A,3655.00,N/A,2104.55,N/A,1242.70,N/A,3655.00,N/A,511.70,N/A,3655.00,N/A,3655.00,N/A,3655.00,N/A,3655.00,N/A,3655.00,N/A,3655.00,N/A,2104.55,N/A,3655.00,N/A,511.70,N/A,7897.00,N/A,7897.00,N/A,511.70,N/A,3655.00,N/A,3655.00,N/A,3655.00,2193.00,2193.00,511.70,7897.00,,Hospital CPT 92925,HC Prq Card Angio/Athrect Addl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,29365.00,29365.00,17619.00,17619.00,N/A,4111.10,N/A,29365.00,N/A,16908.37,N/A,9984.10,N/A,29365.00,N/A,4111.10,N/A,29365.00,N/A,29365.00,N/A,29365.00,N/A,29365.00,N/A,29365.00,N/A,29365.00,N/A,16908.37,N/A,29365.00,N/A,4111.10,N/A,11660.00,N/A,11660.00,N/A,4111.10,N/A,29365.00,N/A,29365.00,N/A,29365.00,17619.00,17619.00,4111.10,29365.00,,Hospital CPT 92934,HC Prq Card Stent/Ath/Angio Addl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,26585.00,26585.00,15951.00,15951.00,N/A,3721.90,N/A,26585.00,N/A,15307.64,N/A,9038.90,N/A,3721.90,N/A,3721.90,N/A,26585.00,N/A,26585.00,N/A,2312.90,N/A,3721.90,N/A,3721.90,N/A,3721.90,N/A,15307.64,N/A,26585.00,N/A,3721.90,N/A,26585.00,N/A,26585.00,N/A,3721.90,N/A,26585.00,N/A,26585.00,N/A,26585.00,15951.00,15951.00,2312.90,26585.00,,Hospital CPT 92941,HC Prq Card Revasc Mi 1 Vsl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,17245.00,17245.00,10347.00,10347.00,N/A,2414.30,N/A,635.71,N/A,9929.67,N/A,5863.30,N/A,17245.00,N/A,2414.30,N/A,635.71,N/A,635.71,N/A,14434.61,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,9929.67,N/A,635.71,N/A,2414.30,N/A,7897.00,N/A,7897.00,N/A,2414.30,N/A,635.71,N/A,635.71,N/A,699.28,10347.00,10347.00,635.71,17245.00,,Hospital CPT 92960,HC Cardioversion,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,2423.00,2423.00,1453.80,1453.80,N/A,339.22,N/A,531.11,N/A,1395.16,N/A,823.82,N/A,1284.72,N/A,339.22,N/A,531.11,N/A,531.11,N/A,799.76,N/A,1284.72,N/A,1284.72,N/A,1284.72,N/A,1395.16,N/A,531.11,N/A,339.22,N/A,1298.73,N/A,1298.73,N/A,339.22,N/A,531.11,N/A,531.11,N/A,584.23,1453.80,1453.80,339.22,1453.80,,Hospital CPT 92960,HC Cardioversion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2423.00,2423.00,1453.80,1453.80,N/A,339.22,N/A,531.11,N/A,1395.16,N/A,823.82,N/A,1284.72,N/A,339.22,N/A,531.11,N/A,531.11,N/A,799.76,N/A,1284.72,N/A,1284.72,N/A,1284.72,N/A,1395.16,N/A,531.11,N/A,339.22,N/A,2423.00,N/A,2423.00,N/A,339.22,N/A,531.11,N/A,531.11,N/A,584.23,1453.80,1453.80,339.22,2423.00,,Hospital CPT 92961,HC Cardioversion Electric Internal,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,2457.00,2457.00,1474.20,1474.20,N/A,343.98,N/A,542.16,N/A,1414.74,N/A,835.38,N/A,1284.72,N/A,343.98,N/A,531.11,N/A,531.11,N/A,799.76,N/A,1284.72,N/A,1284.72,N/A,1284.72,N/A,1414.74,N/A,531.11,N/A,343.98,N/A,1316.95,N/A,1316.95,N/A,343.98,N/A,531.11,N/A,542.16,N/A,258.61,1474.20,1474.20,258.61,1474.20,,Hospital CPT 92973,HC Prq Coronary Mech Thrombect,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,10191.00,10191.00,6114.60,6114.60,N/A,1426.74,N/A,169.56,N/A,5867.98,N/A,3464.94,N/A,10191.00,N/A,1426.74,N/A,10191.00,N/A,169.56,N/A,10191.00,N/A,10191.00,N/A,10191.00,N/A,10191.00,N/A,5867.98,N/A,10191.00,N/A,1426.74,N/A,527.00,N/A,527.00,N/A,1426.74,N/A,10191.00,N/A,169.56,N/A,186.52,6114.60,6114.60,169.56,10191.00,,Hospital CPT 92979,HC Ivus Each Additional Vessel,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,6880.00,6880.00,4128.00,4128.00,N/A,963.20,N/A,6880.00,N/A,3961.50,N/A,2339.20,N/A,6880.00,N/A,963.20,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,3961.50,N/A,6880.00,N/A,963.20,N/A,527.00,N/A,527.00,N/A,963.20,N/A,6880.00,N/A,6880.00,N/A,6880.00,4128.00,4128.00,527.00,6880.00,,Hospital 93041,HC Rhythm Strip,N/A,0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION,63664.08,797.00,38198.45,478.20,10440.92,111.58,12616.71,54.30,23529.46,458.91,21645.78,152.66,23754.54,125.56,10762.62,111.58,5058.00,51.91,5058.00,51.91,14786.65,78.16,23754.54,125.56,23754.54,125.56,23754.54,125.56,23529.46,458.91,12616.71,51.91,10762.62,111.58,28261.97,427.19,28261.97,427.19,12889.63,111.58,12616.71,51.91,12616.71,54.30,11516.01,11.55,5058.00,38198.45,11.55,478.20,,Hospital CPT 93226,HC Holter Scan Analysis,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,1275.00,1275.00,765.00,765.00,N/A,178.50,N/A,111.11,N/A,734.15,N/A,433.50,N/A,253.64,N/A,178.50,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,734.15,N/A,104.85,N/A,178.50,N/A,683.40,N/A,683.40,N/A,178.50,N/A,104.85,N/A,111.54,N/A,65.65,765.00,765.00,65.65,765.00,,Hospital CPT 93229,HC Tele Mobile Monitor 30 Days,N/A,0732 - EKG/ECG (ELECTROCARDIOGRAM) - TELEMETRY,595.00,595.00,357.00,357.00,N/A,83.30,N/A,144.87,N/A,342.60,N/A,202.30,N/A,317.67,N/A,83.30,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,342.60,N/A,131.33,N/A,83.30,N/A,318.92,N/A,318.92,N/A,83.30,N/A,131.33,N/A,792.27,N/A,592.96,357.00,357.00,83.30,792.27,,Hospital 93260,HC Prgrmg Dev Eval Implantable Subq Lead Dfb System,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,105.00,N/A,63.00,N/A,14.70,N/A,34.87,N/A,60.46,N/A,35.70,N/A,76.46,N/A,14.70,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,60.46,N/A,31.61,N/A,14.70,N/A,56.28,N/A,56.28,N/A,14.70,N/A,31.61,N/A,31.86,N/A,35.05,N/A,N/A,14.70,76.46,,Hospital 93271,HC Event Monitor-Analysis Up to 30 Day,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,40995.63,1461.00,24597.38,876.60,3823.32,204.54,7818.69,93.64,8655.04,841.24,13938.52,496.74,9036.87,218.02,3941.13,204.54,1686.00,90.13,1686.00,90.13,5625.38,135.72,9036.87,218.02,9036.87,218.02,9036.87,218.02,8655.04,841.24,4788.44,90.13,3941.13,204.54,10349.15,783.10,10349.15,783.10,3941.13,204.54,4788.44,90.13,4788.44,93.64,4217.00,80.51,1686.00,24597.38,80.51,876.60,,Hospital 93278,HC Signal Average Ekg,N/A,0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION,196989.87,N/A,118193.92,N/A,31614.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31614.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31614.91,N/A,N/A,N/A,N/A,N/A,31614.91,N/A,N/A,N/A,N/A,N/A,31614.91,N/A,31614.91,118193.92,N/A,N/A,,Hospital 93280,HC Prog Eval Dual Lead Pacemaker,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,60900.60,250.00,36540.36,150.00,8595.67,35.00,10433.88,32.45,19371.05,143.95,11350.05,85.00,19556.35,76.46,8860.52,35.00,10433.88,31.61,10433.88,31.61,12173.37,47.60,19556.35,76.46,19556.35,76.46,19556.35,76.46,19371.05,143.95,10433.88,31.61,8860.52,35.00,23267.17,134.00,23267.17,134.00,3721.39,35.00,10433.88,31.61,10433.88,32.45,9480.76,43.65,3721.39,36540.36,31.61,150.00,,Hospital 93281,HC Prog Eval Mult Lead Pacemaker,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,81085.38,572.00,48651.23,343.20,17921.66,80.08,21466.05,120.40,60063.25,329.36,27569.03,194.48,42359.94,N/A,18473.86,80.08,3934.00,109.14,3934.00,109.14,26368.72,N/A,42359.94,N/A,42359.94,N/A,42359.94,N/A,60063.25,329.36,21466.05,109.14,18473.86,80.08,48511.18,306.59,48511.18,306.59,18473.86,80.08,21466.05,109.14,21466.05,40.28,19767.03,44.31,3934.00,60063.25,40.28,343.20,,Hospital CPT 93286,HC Peri-Proc Eval & Prog Pacemker,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,318.00,318.00,190.80,190.80,N/A,44.52,N/A,318.00,N/A,183.10,N/A,108.12,N/A,318.00,N/A,44.52,N/A,318.00,N/A,318.00,N/A,318.00,N/A,318.00,N/A,318.00,N/A,318.00,N/A,183.10,N/A,318.00,N/A,44.52,N/A,170.45,N/A,170.45,N/A,44.52,N/A,318.00,N/A,318.00,N/A,32.41,190.80,190.80,32.41,318.00,,Hospital CPT 93288,HC Pacemaker Interrogation,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,144.00,144.00,86.40,86.40,N/A,20.16,N/A,33.49,N/A,82.92,N/A,48.96,N/A,76.46,N/A,20.16,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,82.92,N/A,31.61,N/A,20.16,N/A,77.18,N/A,77.18,N/A,20.16,N/A,31.61,N/A,33.49,N/A,37.04,86.40,86.40,20.16,86.40,,Hospital 93290,HC Interr in Person Impl Cv Mon,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,785.00,N/A,471.00,N/A,109.90,N/A,84.28,N/A,452.00,N/A,266.90,N/A,N/A,N/A,109.90,N/A,76.40,N/A,76.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,452.00,N/A,43.66,N/A,109.90,N/A,420.76,N/A,420.76,N/A,109.90,N/A,76.40,N/A,67.63,N/A,74.40,N/A,N/A,43.66,471.00,,Hospital 93291,HC Interr in Person Loop Recorder,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,59441.02,34.00,35664.61,20.40,8360.52,4.76,7683.11,23.89,19862.62,19.58,20209.94,11.56,20255.10,34.00,8618.12,4.76,7683.11,22.54,7683.11,22.54,12608.63,33.94,20255.10,34.00,20255.10,34.00,20255.10,34.00,19862.62,19.58,7683.11,22.54,8618.12,4.76,23196.42,18.22,23196.42,18.22,4880.49,4.76,7683.11,22.54,7683.11,23.89,9221.39,32.74,4880.49,35664.61,4.76,34.00,,Hospital 93292,HC Interr in Person Wr Defibrillator,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,197.00,N/A,118.20,N/A,27.58,N/A,53.93,N/A,113.44,N/A,66.98,N/A,125.56,N/A,27.58,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,113.44,N/A,51.91,N/A,27.58,N/A,105.59,N/A,105.59,N/A,27.58,N/A,51.91,N/A,53.93,N/A,36.69,N/A,N/A,27.58,125.56,,Hospital CPT 93308,HC 2-D-Echo-Lmt,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,1012.00,1012.00,607.20,607.20,N/A,141.68,N/A,210.88,N/A,582.71,N/A,344.08,N/A,510.09,N/A,141.68,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,582.71,N/A,210.88,N/A,141.68,N/A,542.43,N/A,542.43,N/A,141.68,N/A,210.88,N/A,210.88,N/A,231.97,607.20,607.20,141.68,607.20,,Hospital CPT 93321,HC Echocardiogram Ltd Doppler,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,625.00,625.00,375.00,375.00,N/A,87.50,N/A,625.00,N/A,359.88,N/A,212.50,N/A,625.00,N/A,87.50,N/A,625.00,N/A,625.00,N/A,625.00,N/A,625.00,N/A,625.00,N/A,625.00,N/A,359.88,N/A,625.00,N/A,87.50,N/A,335.00,N/A,335.00,N/A,87.50,N/A,625.00,N/A,625.00,N/A,625.00,375.00,375.00,87.50,625.00,,Hospital CPT 93321,HC Doppler Echocard W/Spec F-Up/Lmt,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,625.00,625.00,375.00,375.00,N/A,87.50,N/A,625.00,N/A,359.88,N/A,212.50,N/A,625.00,N/A,87.50,N/A,625.00,N/A,625.00,N/A,625.00,N/A,625.00,N/A,625.00,N/A,625.00,N/A,359.88,N/A,625.00,N/A,87.50,N/A,335.00,N/A,335.00,N/A,87.50,N/A,625.00,N/A,625.00,N/A,625.00,375.00,375.00,87.50,625.00,,Hospital CPT 93356,HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech (Addon),N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,1381.00,1381.00,828.60,828.60,N/A,193.34,N/A,1381.00,N/A,795.18,N/A,469.54,N/A,1381.00,N/A,193.34,N/A,1381.00,N/A,1381.00,N/A,1381.00,N/A,1381.00,N/A,1381.00,N/A,1381.00,N/A,795.18,N/A,1381.00,N/A,193.34,N/A,740.22,N/A,740.22,N/A,193.34,N/A,1381.00,N/A,1381.00,N/A,1381.00,828.60,828.60,193.34,1381.00,,Hospital CPT 93452,HC L Heart W Lvgram,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9645.00,9645.00,5787.00,5787.00,N/A,1350.30,N/A,2775.63,N/A,9645.00,N/A,3279.30,N/A,6462.39,N/A,1350.30,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,9645.00,N/A,2671.61,N/A,1350.30,N/A,5963.00,N/A,5963.00,N/A,1350.30,N/A,2671.61,N/A,632.37,N/A,695.61,5787.00,5787.00,632.37,9645.00,,Hospital CPT 93459,HC L Heart Vgram W Graft,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,14139.00,14139.00,8483.40,8483.40,N/A,1979.46,N/A,2671.61,N/A,11012.00,N/A,4807.26,N/A,6462.39,N/A,1979.46,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,11012.00,N/A,2671.61,N/A,1979.46,N/A,5963.00,N/A,5963.00,N/A,1979.46,N/A,2671.61,N/A,2671.61,N/A,2938.77,8483.40,8483.40,1979.46,11012.00,,Hospital 93464,HC Physiologic Exercise Study & Hemodynamic Measu,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,64636.92,25145.40,38782.15,15087.24,4900.38,3513.71,6062.54,996.51,12721.54,14442.63,21976.55,8549.44,11582.63,6572.39,N/A,3513.71,7224.58,2671.61,3934.00,2671.61,7210.09,4091.44,11582.63,6572.39,11582.63,6572.39,11582.63,6572.39,12721.54,14442.63,6062.54,2671.61,5051.37,3513.71,13264.58,6810.25,N/A,6810.25,5051.37,3513.71,7224.58,2671.61,6062.54,996.51,5404.97,1096.18,3934.00,38782.15,996.51,15087.24,,Hospital CPT 93503,HC Insertion Swan-Ganz Catheter,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3593.00,3593.00,2155.80,2155.80,N/A,503.02,N/A,86.38,N/A,2068.85,N/A,1221.62,N/A,3250.03,N/A,503.02,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2068.85,N/A,1343.59,N/A,503.02,N/A,1431.00,N/A,1431.00,N/A,503.02,N/A,1343.59,N/A,86.38,N/A,95.02,2155.80,2155.80,86.38,3250.03,,Hospital 93531,HC Rt Lt Cath Cong Anom,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,94598.37,N/A,56759.02,N/A,17835.24,N/A,21363.81,N/A,40193.15,N/A,32163.45,N/A,42155.67,N/A,N/A,N/A,5058.00,N/A,23140.38,N/A,26241.56,N/A,N/A,N/A,N/A,N/A,42155.67,N/A,40193.15,N/A,21363.81,N/A,18384.77,N/A,48277.25,N/A,48277.25,N/A,N/A,N/A,21363.81,N/A,21363.81,N/A,19671.71,N/A,5058.00,56759.02,N/A,N/A,,Hospital CPT 93566,HC Inject R Ventr/Atrial Angio,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,1701.00,N/A,979.44,N/A,578.34,N/A,1701.00,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,979.44,N/A,1701.00,N/A,238.14,N/A,527.00,N/A,527.00,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,48.66,1020.60,1020.60,48.66,1701.00,,Hospital CPT 93568,"HC Pulm Angiogrm Inject, Heart Cath",N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,45.80,N/A,979.44,N/A,578.34,N/A,133.77,N/A,238.14,N/A,45.80,N/A,45.80,N/A,83.27,N/A,133.77,N/A,133.77,N/A,133.77,N/A,979.44,N/A,45.80,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,45.80,N/A,45.80,N/A,50.38,1020.60,1020.60,45.80,1701.00,,Hospital CPT 93572,HC Doppler Measure/Ffr Each Addl Vessel,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1972.00,1972.00,1183.20,1183.20,N/A,276.08,N/A,1972.00,N/A,1135.48,N/A,670.48,N/A,1972.00,N/A,276.08,N/A,1972.00,N/A,1972.00,N/A,1972.00,N/A,1972.00,N/A,1972.00,N/A,1972.00,N/A,1135.48,N/A,1972.00,N/A,276.08,N/A,527.00,N/A,527.00,N/A,276.08,N/A,1972.00,N/A,1972.00,N/A,1972.00,1183.20,1183.20,276.08,1972.00,,Hospital CPT 93580,HC Transcath Closure of Asd,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,42150.00,42150.00,25290.00,25290.00,N/A,5901.00,N/A,16226.30,N/A,24269.97,N/A,14331.00,N/A,37522.38,N/A,5901.00,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,37522.38,N/A,37522.38,N/A,37522.38,N/A,24269.97,N/A,15512.06,N/A,5901.00,N/A,16637.00,N/A,16637.00,N/A,5901.00,N/A,15512.06,N/A,16226.30,N/A,1027.37,25290.00,25290.00,1027.37,37522.38,,Hospital CPT 93590,HC Perq Transcath Cls Paravalvr Leak 1 Mitral Valve,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,46788.00,46788.00,28072.80,28072.80,N/A,6550.32,N/A,1038.06,N/A,26940.53,N/A,15907.92,N/A,3054.87,N/A,6550.32,N/A,1038.06,N/A,1038.06,N/A,1901.66,N/A,3054.87,N/A,3054.87,N/A,3054.87,N/A,26940.53,N/A,1038.06,N/A,6550.32,N/A,46788.00,N/A,46788.00,N/A,6550.32,N/A,1038.06,N/A,1038.06,N/A,1141.87,28072.80,28072.80,1038.06,46788.00,,Hospital 93592,HC Perq Transcath Cls Paravalvr Leak Each Occls Dev,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,115346.48,N/A,69207.89,N/A,27529.84,N/A,32832.03,N/A,63578.98,N/A,39217.80,N/A,65070.01,N/A,28378.09,N/A,32832.03,N/A,32832.03,N/A,40505.55,N/A,65070.01,N/A,65070.01,N/A,65070.01,N/A,63578.98,N/A,32832.03,N/A,28378.09,N/A,74519.06,N/A,74519.06,N/A,10972.41,N/A,32832.03,N/A,32832.03,N/A,30364.55,N/A,10972.41,74519.06,N/A,N/A,,Hospital CPT 93622,HC Electrophysiology Evaluation,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,8762.00,8762.00,5257.20,5257.20,N/A,1226.68,N/A,8762.00,N/A,5045.16,N/A,2979.08,N/A,8762.00,N/A,1226.68,N/A,8762.00,N/A,8762.00,N/A,8762.00,N/A,8762.00,N/A,8762.00,N/A,8762.00,N/A,5045.16,N/A,8762.00,N/A,1226.68,N/A,527.00,N/A,527.00,N/A,1226.68,N/A,8762.00,N/A,8762.00,N/A,8762.00,5257.20,5257.20,527.00,8762.00,,Hospital CPT 93641,HC Eval Icd Leads W/Testing,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,4238.00,4238.00,2542.80,2542.80,N/A,593.32,N/A,4238.00,N/A,2440.24,N/A,1440.92,N/A,4238.00,N/A,593.32,N/A,4238.00,N/A,4238.00,N/A,4238.00,N/A,4238.00,N/A,4238.00,N/A,4238.00,N/A,2440.24,N/A,4238.00,N/A,593.32,N/A,2271.57,N/A,2271.57,N/A,593.32,N/A,4238.00,N/A,4238.00,N/A,4238.00,2542.80,2542.80,593.32,4238.00,,Hospital CPT 93650,HC Ep Study Avn Ablation,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,563.85,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,6079.94,N/A,1842.26,N/A,7897.00,N/A,7897.00,N/A,1842.26,N/A,6079.94,N/A,563.85,N/A,620.24,7895.40,7895.40,563.85,13159.00,,Hospital CPT 93653,HC Ep Comp Eval W Svt Ablation,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,40777.00,40777.00,24466.20,24466.20,N/A,5708.78,N/A,21204.54,N/A,23479.40,N/A,13864.18,N/A,40777.00,N/A,5708.78,N/A,21204.54,N/A,21204.54,N/A,31930.27,N/A,40777.00,N/A,40777.00,N/A,40777.00,N/A,23479.40,N/A,21204.54,N/A,5708.78,N/A,16637.00,N/A,16637.00,N/A,5708.78,N/A,21204.54,N/A,21204.54,N/A,23325.00,24466.20,24466.20,5708.78,40777.00,,Hospital CPT 93654,HC Ep & Ablate Ventric Tachy,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,40777.00,40777.00,24466.20,24466.20,N/A,5708.78,N/A,22180.90,N/A,23479.40,N/A,13864.18,N/A,40777.00,N/A,5708.78,N/A,21204.54,N/A,21204.54,N/A,31930.27,N/A,40777.00,N/A,40777.00,N/A,40777.00,N/A,23479.40,N/A,21204.54,N/A,5708.78,N/A,16637.00,N/A,16637.00,N/A,5708.78,N/A,21204.54,N/A,1068.08,N/A,1174.89,24466.20,24466.20,1068.08,40777.00,,Hospital CPT 93656,HC Ep Tx Atrial Fib Pul Vn Isolat,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,40777.00,40777.00,24466.20,24466.20,N/A,5708.78,N/A,1071.16,N/A,23479.40,N/A,13864.18,N/A,40777.00,N/A,5708.78,N/A,21204.54,N/A,21204.54,N/A,31930.27,N/A,40777.00,N/A,40777.00,N/A,40777.00,N/A,23479.40,N/A,21204.54,N/A,5708.78,N/A,16637.00,N/A,16637.00,N/A,5708.78,N/A,21204.54,N/A,22180.90,N/A,1178.28,24466.20,24466.20,1071.16,40777.00,,Hospital CPT 93702,HC Bis Extracel Fluid Alys Lymphedema Assmnt,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,374.00,374.00,224.40,224.40,N/A,52.36,N/A,131.33,N/A,215.35,N/A,127.16,N/A,317.67,N/A,52.36,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,215.35,N/A,131.33,N/A,52.36,N/A,200.46,N/A,200.46,N/A,52.36,N/A,131.33,N/A,131.33,N/A,144.46,224.40,224.40,52.36,317.67,,Hospital 93786,HC Abpm Recording,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,17182.20,1288.00,10309.32,772.80,3606.74,180.32,4561.88,109.68,8128.07,741.63,4211.31,437.92,5349.54,253.64,3717.87,180.32,4532.23,104.85,4532.23,104.85,3331.13,157.89,5349.54,253.64,5349.54,253.64,5349.54,253.64,8128.07,741.63,4532.23,104.85,3717.87,180.32,9762.88,690.37,9762.88,690.37,N/A,180.32,4532.23,104.85,4561.88,109.68,3978.12,27.09,3331.13,10309.32,27.09,772.80,,Hospital CPT 93882,HC Extracranial Uni/Ltd Study,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,877.00,877.00,526.20,526.20,N/A,122.78,N/A,100.96,N/A,504.98,N/A,298.18,N/A,233.46,N/A,122.78,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,504.98,N/A,96.52,N/A,122.78,N/A,470.07,N/A,470.07,N/A,122.78,N/A,96.52,N/A,100.96,N/A,100.86,526.20,526.20,96.52,526.20,,Hospital 93888,HC Tcd Limited,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,239078.50,638.00,143447.10,382.80,N/A,89.32,N/A,102.67,N/A,367.36,N/A,216.92,N/A,233.46,N/A,89.32,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,367.36,N/A,96.52,N/A,89.32,N/A,341.97,N/A,341.97,N/A,89.32,N/A,96.52,N/A,102.67,N/A,134.94,143447.10,143447.10,89.32,382.80,,Hospital CPT 93931,HC Uni/Ltd Niv Arterial Upp Ext Duplex,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,2187.00,2187.00,1312.20,1312.20,N/A,306.18,N/A,96.52,N/A,1259.27,N/A,743.58,N/A,233.46,N/A,306.18,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1259.27,N/A,96.52,N/A,306.18,N/A,1172.23,N/A,1172.23,N/A,306.18,N/A,96.52,N/A,96.52,N/A,106.17,1312.20,1312.20,96.52,1312.20,,Hospital CPT 93978,HC US Duplex Scan of Aorta Complt,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,1364.00,1364.00,818.40,818.40,N/A,190.96,N/A,210.88,N/A,785.39,N/A,463.76,N/A,510.09,N/A,190.96,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,785.39,N/A,210.88,N/A,190.96,N/A,731.10,N/A,731.10,N/A,190.96,N/A,210.88,N/A,210.88,N/A,231.97,818.40,818.40,190.96,818.40,,Hospital CPT 93979,HC US Dup Scn Aorta Ivc Ltd,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,694.00,694.00,416.40,416.40,N/A,97.16,N/A,102.28,N/A,399.61,N/A,235.96,N/A,233.46,N/A,97.16,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,399.61,N/A,96.52,N/A,97.16,N/A,371.98,N/A,371.98,N/A,97.16,N/A,96.52,N/A,85.38,N/A,93.92,416.40,416.40,85.38,416.40,,Hospital CPT 94012,HC Meas Spiro Frcd Exp Flo Pre&Post Bronch Inf/2yrs,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,821.00,821.00,492.60,492.60,N/A,114.94,N/A,136.23,N/A,472.73,N/A,279.14,N/A,397.95,N/A,114.94,N/A,136.23,N/A,136.23,N/A,247.72,N/A,397.95,N/A,397.95,N/A,397.95,N/A,472.73,N/A,136.23,N/A,114.94,N/A,440.06,N/A,440.06,N/A,114.94,N/A,136.23,N/A,136.23,N/A,149.85,492.60,492.60,114.94,492.60,,Hospital CPT 94060,HC Before / After Bronchodilator,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,575.00,575.00,345.00,345.00,N/A,80.50,N/A,252.91,N/A,331.09,N/A,195.50,N/A,575.00,N/A,80.50,N/A,252.91,N/A,252.91,N/A,380.83,N/A,575.00,N/A,575.00,N/A,575.00,N/A,331.09,N/A,252.91,N/A,80.50,N/A,308.20,N/A,308.20,N/A,80.50,N/A,252.91,N/A,252.91,N/A,278.20,345.00,345.00,80.50,575.00,,Hospital CPT 94375,HC Flow Volume Loop,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,328.00,328.00,196.80,196.80,N/A,45.92,N/A,264.55,N/A,188.86,N/A,111.52,N/A,328.00,N/A,45.92,N/A,252.91,N/A,252.91,N/A,328.00,N/A,328.00,N/A,328.00,N/A,328.00,N/A,188.86,N/A,252.91,N/A,45.92,N/A,175.81,N/A,175.81,N/A,45.92,N/A,252.91,N/A,255.64,N/A,23.47,196.80,196.80,23.47,328.00,,Hospital CPT 94644,HC Continous Inhale Tx 1st Hour,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,305.00,305.00,183.00,183.00,N/A,42.70,N/A,54.72,N/A,175.62,N/A,103.70,N/A,253.64,N/A,42.70,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,175.62,N/A,104.85,N/A,42.70,N/A,163.48,N/A,163.48,N/A,42.70,N/A,104.85,N/A,54.72,N/A,60.19,183.00,183.00,42.70,253.64,,Hospital CPT 94668,HC Postural Drainage Sub,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,195.00,195.00,117.00,117.00,N/A,27.30,N/A,107.03,N/A,112.28,N/A,66.30,N/A,195.00,N/A,27.30,N/A,104.85,N/A,104.85,N/A,157.89,N/A,195.00,N/A,195.00,N/A,195.00,N/A,112.28,N/A,104.85,N/A,27.30,N/A,104.52,N/A,104.52,N/A,27.30,N/A,104.85,N/A,107.03,N/A,34.38,117.00,117.00,27.30,195.00,,Hospital CPT 94727,HC Gas Dilution or Washout,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,351.00,351.00,210.60,210.60,N/A,49.14,N/A,131.33,N/A,202.11,N/A,119.34,N/A,317.67,N/A,49.14,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,202.11,N/A,131.33,N/A,49.14,N/A,188.14,N/A,188.14,N/A,49.14,N/A,131.33,N/A,131.33,N/A,144.46,210.60,210.60,49.14,317.67,,Hospital CPT 94729,HC Diffusing Capacity,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,575.00,575.00,345.00,345.00,N/A,80.50,N/A,575.00,N/A,331.09,N/A,195.50,N/A,575.00,N/A,80.50,N/A,575.00,N/A,575.00,N/A,575.00,N/A,575.00,N/A,575.00,N/A,575.00,N/A,331.09,N/A,575.00,N/A,80.50,N/A,308.20,N/A,308.20,N/A,80.50,N/A,575.00,N/A,575.00,N/A,575.00,345.00,345.00,80.50,575.00,,Hospital 94750,HC Pulmonary Compliance Study,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,264538.20,N/A,158722.92,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,158722.92,158722.92,N/A,N/A,,Hospital CPT 94760,HC Oxygen Saturation Measurement,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,120.00,120.00,72.00,72.00,N/A,16.80,N/A,120.00,N/A,69.10,N/A,40.80,N/A,120.00,N/A,16.80,N/A,120.00,N/A,120.00,N/A,120.00,N/A,120.00,N/A,120.00,N/A,120.00,N/A,69.10,N/A,120.00,N/A,16.80,N/A,64.32,N/A,64.32,N/A,16.80,N/A,120.00,N/A,120.00,N/A,120.00,72.00,72.00,16.80,120.00,,Hospital CPT 94761,HC Pulse Ox Multiple Determine,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,164.00,164.00,98.40,98.40,N/A,22.96,N/A,164.00,N/A,94.43,N/A,55.76,N/A,164.00,N/A,22.96,N/A,164.00,N/A,164.00,N/A,164.00,N/A,164.00,N/A,164.00,N/A,164.00,N/A,94.43,N/A,164.00,N/A,22.96,N/A,87.90,N/A,87.90,N/A,22.96,N/A,164.00,N/A,164.00,N/A,164.00,98.40,98.40,22.96,164.00,,Hospital 94770,HC Etco2 Monitor Daily,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,427733.37,N/A,256640.02,N/A,N/A,N/A,53155.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7368.85,N/A,7368.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,53155.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,53155.14,N/A,53155.14,N/A,N/A,N/A,7368.85,256640.02,N/A,N/A,,Hospital 94772,HC Pneumogram/Area Hospital Study,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,10980.20,N/A,6588.12,N/A,10980.20,N/A,15923.46,N/A,10980.20,N/A,3733.27,N/A,5546.10,N/A,10980.20,N/A,15923.46,N/A,15923.46,N/A,3452.17,N/A,5546.10,N/A,5546.10,N/A,5546.10,N/A,10980.20,N/A,15923.46,N/A,10980.20,N/A,8320.00,N/A,8320.00,N/A,N/A,N/A,15923.46,N/A,15923.46,N/A,10980.20,N/A,3452.17,15923.46,N/A,N/A,,Hospital 95117,HC Allergy Injection 2 or Mo,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,14427.60,56.00,8656.56,33.60,5631.76,7.84,6927.73,39.75,12691.63,32.24,4905.39,19.04,12813.03,56.00,5805.28,7.84,1686.00,38.26,1686.00,38.26,7975.81,56.00,12813.03,56.00,12813.03,56.00,12813.03,56.00,12691.63,32.24,6927.73,38.26,5805.28,7.84,14427.60,30.02,14427.60,30.02,N/A,7.84,6927.73,38.26,6927.73,39.75,6211.65,11.23,1686.00,14427.60,7.84,56.00,,Hospital CPT 95700,HC Eeg Cont Rec W/Vid Eeg Tech,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,734.00,734.00,440.40,440.40,N/A,102.76,N/A,139.17,N/A,422.64,N/A,249.56,N/A,317.67,N/A,102.76,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,422.64,N/A,131.33,N/A,102.76,N/A,393.42,N/A,393.42,N/A,102.76,N/A,131.33,N/A,139.17,N/A,734.00,440.40,440.40,102.76,734.00,,Hospital 95707,HC Eeg W/O Video by Tech 2-12 Hr Cont R-T Monitoring,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,N/A,2023.00,N/A,1213.80,N/A,283.22,N/A,407.18,N/A,1164.85,N/A,687.82,N/A,929.43,N/A,283.22,N/A,384.24,N/A,384.24,N/A,578.58,N/A,929.43,N/A,929.43,N/A,929.43,N/A,1164.85,N/A,384.24,N/A,283.22,N/A,1084.32,N/A,1084.32,N/A,283.22,N/A,384.24,N/A,407.18,N/A,207.91,N/A,N/A,207.91,1213.80,,Hospital CPT 95782,HC Sleep Study Under 6 Years Old,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,10265.00,10265.00,6159.00,6159.00,N/A,1437.10,N/A,872.71,N/A,5910.59,N/A,3490.10,N/A,2041.05,N/A,1437.10,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,5910.59,N/A,843.78,N/A,1437.10,N/A,5502.04,N/A,5502.04,N/A,1437.10,N/A,843.78,N/A,872.71,N/A,803.81,6159.00,6159.00,803.81,6159.00,,Hospital CPT 95783,HC Cpap Under 6 Years Old,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,2709.00,2709.00,1625.40,1625.40,N/A,379.26,N/A,872.71,N/A,1559.84,N/A,921.06,N/A,2041.05,N/A,379.26,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,1559.84,N/A,843.78,N/A,379.26,N/A,1452.02,N/A,1452.02,N/A,379.26,N/A,843.78,N/A,872.71,N/A,847.79,1625.40,1625.40,379.26,2041.05,,Hospital CPT 95805,HC Multiple Sleep Latency or Maintenance Wakefulness Test,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,6200.00,6200.00,3720.00,3720.00,N/A,868.00,N/A,436.56,N/A,3569.96,N/A,2108.00,N/A,1055.99,N/A,868.00,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,3569.96,N/A,436.56,N/A,868.00,N/A,3323.20,N/A,3323.20,N/A,868.00,N/A,436.56,N/A,436.56,N/A,480.21,3720.00,3720.00,436.56,3720.00,,Hospital 95807,HC Pap-Nap,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,9931.00,N/A,5958.60,N/A,1390.34,N/A,685.93,N/A,5718.28,N/A,2951.20,N/A,1667.75,N/A,1390.34,N/A,689.47,N/A,689.47,N/A,1038.20,N/A,1667.75,N/A,1667.75,N/A,1667.75,N/A,5718.28,N/A,689.47,N/A,1390.34,N/A,5323.02,N/A,5323.02,N/A,1390.34,N/A,689.47,N/A,685.93,N/A,431.17,N/A,N/A,431.17,5958.60,,Hospital 95808,Polysom Any Age Sleep Stage 1-3 Addl Param Attnd,N/A,N/A,N/A,8548.00,N/A,5128.80,N/A,1196.72,N/A,872.71,N/A,4921.94,N/A,2906.32,N/A,2041.05,N/A,1196.72,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,4921.94,N/A,843.78,N/A,1196.72,N/A,4581.73,N/A,4581.73,N/A,1196.72,N/A,843.78,N/A,872.71,N/A,570.46,N/A,N/A,570.46,5128.80,,Hospital CPT 95812,HC Eeg 41-60 Min,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,914.00,914.00,548.40,548.40,N/A,127.96,N/A,252.91,N/A,526.28,N/A,310.76,N/A,611.76,N/A,127.96,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,526.28,N/A,252.91,N/A,127.96,N/A,489.90,N/A,489.90,N/A,127.96,N/A,252.91,N/A,252.91,N/A,278.20,548.40,548.40,127.96,611.76,,Hospital CPT 95824,HC Electro Cerebral Silence,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,823.00,823.00,493.80,493.80,N/A,115.22,N/A,823.00,N/A,473.88,N/A,279.82,N/A,115.22,N/A,115.22,N/A,823.00,N/A,823.00,N/A,71.60,N/A,115.22,N/A,115.22,N/A,115.22,N/A,473.88,N/A,823.00,N/A,115.22,N/A,441.13,N/A,441.13,N/A,115.22,N/A,823.00,N/A,823.00,N/A,823.00,493.80,493.80,71.60,823.00,,Hospital 95867,HC Emg Cranial Nerve Muscle Uni,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,N/A,2510.00,N/A,1506.00,N/A,351.40,N/A,388.39,N/A,1445.25,N/A,853.40,N/A,929.43,N/A,351.40,N/A,384.24,N/A,384.24,N/A,578.58,N/A,929.43,N/A,929.43,N/A,929.43,N/A,1445.25,N/A,384.24,N/A,351.40,N/A,1345.36,N/A,1345.36,N/A,351.40,N/A,384.24,N/A,388.39,N/A,158.40,N/A,N/A,158.40,1506.00,,Hospital 95870,HC Emg Limited Specific Muscle,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,124323.80,569.00,74594.28,341.40,16258.00,79.66,14343.29,107.65,68527.26,327.63,42270.09,193.46,62795.96,253.64,12267.15,79.66,14343.29,104.85,14343.29,104.85,13031.88,157.89,62795.96,253.64,62795.96,253.64,62795.96,253.64,68527.26,327.63,33325.53,104.85,12267.15,79.66,51300.00,304.98,51300.00,304.98,N/A,79.66,14343.29,104.85,24565.49,107.65,14255.75,66.14,12267.15,74594.28,66.14,341.40,,Hospital 95907,HC Nerve Conduction Studies 1-2 S,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,137431.23,1886.00,82458.74,1131.60,N/A,264.04,18479.75,362.64,75752.09,1085.95,46726.62,641.24,58111.96,827.76,26329.16,264.04,1686.00,342.21,1686.00,342.21,N/A,515.29,58111.96,827.76,58111.96,827.76,N/A,827.76,75752.09,1085.95,30480.71,342.21,26329.16,264.04,69138.72,1010.90,69138.72,1010.90,1944.22,264.04,30480.71,342.21,18479.75,362.64,28172.20,570.81,1686.00,82458.74,264.04,1131.60,,Hospital CPT 95911,HC Nerve Conduction 9-10 Studies,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,1230.00,1230.00,738.00,738.00,N/A,172.20,N/A,436.56,N/A,708.23,N/A,418.20,N/A,1055.99,N/A,172.20,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,708.23,N/A,436.56,N/A,172.20,N/A,659.28,N/A,659.28,N/A,172.20,N/A,436.56,N/A,436.56,N/A,480.21,738.00,738.00,172.20,1055.99,,Hospital CPT 95925,HC Somatosensory Testing Upr Limbs,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,752.00,752.00,451.20,451.20,N/A,105.28,N/A,255.64,N/A,433.00,N/A,255.68,N/A,611.76,N/A,105.28,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,433.00,N/A,252.91,N/A,105.28,N/A,403.07,N/A,403.07,N/A,105.28,N/A,252.91,N/A,255.64,N/A,153.76,451.20,451.20,105.28,611.76,,Hospital 95933,HC Blink Reflex Test,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,N/A,6687.00,N/A,4012.20,N/A,936.18,N/A,388.39,N/A,3850.37,N/A,2273.58,N/A,929.43,N/A,936.18,N/A,384.24,N/A,384.24,N/A,578.58,N/A,929.43,N/A,929.43,N/A,929.43,N/A,3850.37,N/A,384.24,N/A,936.18,N/A,3584.23,N/A,3584.23,N/A,936.18,N/A,384.24,N/A,388.39,N/A,198.43,N/A,N/A,198.43,4012.20,,Hospital CPT 95937,HC Neuromusc Junct Testing Ea Nrv,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,413.00,413.00,247.80,247.80,N/A,57.82,N/A,132.75,N/A,237.81,N/A,140.42,N/A,317.67,N/A,57.82,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,237.81,N/A,131.33,N/A,57.82,N/A,221.37,N/A,221.37,N/A,57.82,N/A,131.33,N/A,132.75,N/A,72.09,247.80,247.80,57.82,317.67,,Hospital 95951,HC Eeg Monitoring Video Recording,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,125782.70,N/A,75469.62,N/A,10247.81,N/A,12388.26,N/A,69331.42,N/A,42766.11,N/A,24010.58,N/A,10563.56,N/A,12388.26,N/A,12388.26,N/A,14947.30,N/A,24010.58,N/A,24010.58,N/A,24010.58,N/A,69331.42,N/A,12388.26,N/A,10563.56,N/A,27739.24,N/A,27739.24,N/A,N/A,N/A,12388.26,N/A,12388.26,N/A,11303.01,N/A,10247.81,75469.62,N/A,N/A,,Hospital 95957,HC Eeg Digital Analysis,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,135969.55,2303.00,81581.73,1381.80,22054.06,322.42,N/A,491.48,N/A,1326.06,N/A,783.02,N/A,1121.85,22054.06,322.42,N/A,463.79,N/A,463.79,N/A,698.37,N/A,1121.85,N/A,1121.85,N/A,1121.85,N/A,1326.06,N/A,463.79,22054.06,322.42,N/A,1234.41,N/A,1234.41,22054.06,322.42,N/A,463.79,N/A,491.48,22054.06,971.30,22054.06,81581.73,322.42,1381.80,,Hospital CPT 95992,HC Canalith Repositioning Proc,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,142.00,142.00,85.20,85.20,N/A,19.88,N/A,35.52,N/A,81.76,N/A,48.28,N/A,124.17,N/A,19.88,N/A,35.52,N/A,35.52,N/A,77.30,N/A,124.17,N/A,124.17,N/A,124.17,N/A,81.76,N/A,35.52,N/A,19.88,N/A,76.11,N/A,76.11,N/A,19.88,N/A,35.52,N/A,35.52,N/A,39.07,85.20,85.20,19.88,124.17,,Hospital CPT 95992,HC Canalith Reposit Epley Maneuv,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,142.00,142.00,85.20,85.20,N/A,19.88,N/A,35.52,N/A,81.76,N/A,48.28,N/A,124.17,N/A,19.88,N/A,35.52,N/A,35.52,N/A,77.30,N/A,124.17,N/A,124.17,N/A,124.17,N/A,81.76,N/A,35.52,N/A,19.88,N/A,142.00,N/A,142.00,N/A,19.88,N/A,35.52,N/A,35.52,N/A,39.07,85.20,85.20,19.88,142.00,,Hospital 96020,HC Test Select & Admin Functl Brain Map Phys/Qhp,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,3747.00,N/A,2248.20,N/A,524.58,N/A,220.59,N/A,1561.43,N/A,1273.98,N/A,510.09,N/A,524.58,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1561.43,N/A,210.88,N/A,524.58,N/A,1480.22,N/A,1480.22,N/A,524.58,N/A,210.88,N/A,220.59,N/A,N/A,N/A,N/A,210.88,2248.20,,Hospital 96113,HC Developmental Tst Admin Phys/Qhp Ea Addl 30 Min,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,1593.00,N/A,955.80,N/A,223.02,N/A,503.43,N/A,917.25,N/A,541.62,N/A,1490.43,N/A,223.02,N/A,513.68,N/A,513.68,N/A,1269.26,N/A,1490.43,N/A,1490.43,N/A,1490.43,N/A,917.25,N/A,543.72,N/A,223.02,N/A,853.86,N/A,853.86,N/A,223.02,N/A,513.68,N/A,503.43,N/A,553.78,N/A,N/A,223.02,1490.43,,Hospital CPT 96116,HC Cognitive Lang. Eval per Hour,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,1017.00,1017.00,610.20,610.20,N/A,142.38,N/A,80.18,N/A,585.59,N/A,345.78,N/A,268.05,N/A,142.38,N/A,80.18,N/A,80.18,N/A,166.86,N/A,268.05,N/A,268.05,N/A,268.05,N/A,585.59,N/A,80.18,N/A,142.38,N/A,545.11,N/A,545.11,N/A,142.38,N/A,80.18,N/A,80.18,N/A,88.20,610.20,610.20,80.18,610.20,,Hospital 96156,HC Hlth Bhv Assmt/Reassessment,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,551.03,N/A,330.62,N/A,77.14,N/A,154.55,N/A,317.29,N/A,187.34,N/A,151.15,N/A,77.14,N/A,147.40,N/A,147.40,N/A,94.09,N/A,151.15,N/A,151.15,N/A,151.15,N/A,317.29,N/A,147.40,N/A,77.14,N/A,295.37,N/A,295.37,N/A,77.14,N/A,147.40,N/A,27.28,N/A,30.01,N/A,N/A,27.28,330.62,,Hospital 96161,HC Caregiver Hlth Risk Assmt Score Doc Stnd Instrm,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,778.02,N/A,466.81,N/A,108.92,N/A,71.78,N/A,445.74,N/A,264.52,N/A,229.83,N/A,108.92,N/A,65.06,N/A,65.06,N/A,251.28,N/A,229.83,N/A,229.83,N/A,229.83,N/A,445.74,N/A,65.06,N/A,108.92,N/A,417.03,N/A,417.03,N/A,108.92,N/A,65.06,N/A,29.69,N/A,32.66,N/A,N/A,29.69,466.81,,Hospital CPT 96366,"HC Infusion Thrpy, Ea Add Hr, Other",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,645.00,645.00,387.00,387.00,N/A,90.30,N/A,38.26,N/A,371.39,N/A,219.30,N/A,92.56,N/A,90.30,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,371.39,N/A,38.26,N/A,90.30,N/A,345.72,N/A,345.72,N/A,90.30,N/A,38.26,N/A,38.26,N/A,42.09,387.00,387.00,38.26,387.00,,Hospital CPT 96366,HC IV Inf Ea Add Hour,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,645.00,645.00,387.00,387.00,N/A,90.30,N/A,38.26,N/A,371.39,N/A,219.30,N/A,92.56,N/A,90.30,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,371.39,N/A,38.26,N/A,90.30,N/A,345.72,N/A,345.72,N/A,90.30,N/A,38.26,N/A,38.26,N/A,42.09,387.00,387.00,38.26,387.00,,Hospital CPT 96372,HC Im Injection,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,291.00,291.00,174.60,174.60,N/A,40.74,N/A,60.93,N/A,167.56,N/A,98.94,N/A,147.37,N/A,40.74,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,167.56,N/A,60.93,N/A,40.74,N/A,155.98,N/A,155.98,N/A,40.74,N/A,60.93,N/A,60.93,N/A,67.02,174.60,174.60,40.74,174.60,,Hospital CPT 96372,HC Injection Im Sub Q,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,291.00,291.00,174.60,174.60,N/A,40.74,N/A,60.93,N/A,167.56,N/A,98.94,N/A,147.37,N/A,40.74,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,167.56,N/A,60.93,N/A,40.74,N/A,155.98,N/A,155.98,N/A,40.74,N/A,60.93,N/A,60.93,N/A,67.02,174.60,174.60,40.74,174.60,,Hospital CPT 96373,"HC Pain Mgt,Inj, Intra-Arterial",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,453.00,453.00,271.80,271.80,N/A,63.42,N/A,16.69,N/A,260.84,N/A,154.02,N/A,50.13,N/A,63.42,N/A,16.69,N/A,16.69,N/A,31.21,N/A,50.13,N/A,50.13,N/A,50.13,N/A,260.84,N/A,16.69,N/A,63.42,N/A,242.81,N/A,242.81,N/A,63.42,N/A,16.69,N/A,16.69,N/A,18.36,271.80,271.80,16.69,271.80,,Hospital CPT 96377,HC Applicaton on-Body Injector,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,172.00,172.00,103.20,103.20,N/A,24.08,N/A,38.26,N/A,99.04,N/A,58.48,N/A,92.56,N/A,24.08,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,99.04,N/A,38.26,N/A,24.08,N/A,92.19,N/A,92.19,N/A,24.08,N/A,38.26,N/A,38.26,N/A,42.09,103.20,103.20,24.08,103.20,,Hospital CPT 96401,HC Chemo Admin Subq/Intramusc,N/A,0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED,696.00,696.00,417.60,417.60,N/A,97.44,N/A,60.93,N/A,400.76,N/A,236.64,N/A,147.37,N/A,97.44,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,400.76,N/A,60.93,N/A,97.44,N/A,373.06,N/A,373.06,N/A,97.44,N/A,60.93,N/A,60.93,N/A,67.02,417.60,417.60,60.93,417.60,,Hospital CPT 96411,HC Chemo IV Push New Drug,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,677.00,677.00,406.20,406.20,N/A,94.78,N/A,60.93,N/A,389.82,N/A,230.18,N/A,147.37,N/A,94.78,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,389.82,N/A,60.93,N/A,94.78,N/A,362.87,N/A,362.87,N/A,94.78,N/A,60.93,N/A,60.93,N/A,67.02,406.20,406.20,60.93,406.20,,Hospital CPT 96411,HC Chemo Push Each Addt Drug,N/A,0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED,677.00,677.00,406.20,406.20,N/A,94.78,N/A,60.93,N/A,389.82,N/A,230.18,N/A,147.37,N/A,94.78,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,389.82,N/A,60.93,N/A,94.78,N/A,362.87,N/A,362.87,N/A,94.78,N/A,60.93,N/A,60.93,N/A,67.02,406.20,406.20,60.93,406.20,,Hospital CPT 96413,HC Chemo Infusion 1st Hour Chemo,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,2039.00,2039.00,1223.40,1223.40,N/A,285.46,N/A,300.37,N/A,1174.06,N/A,693.26,N/A,726.56,N/A,285.46,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,1174.06,N/A,300.37,N/A,285.46,N/A,1092.90,N/A,1092.90,N/A,285.46,N/A,300.37,N/A,300.37,N/A,330.41,1223.40,1223.40,285.46,1223.40,,Hospital CPT 96415,HC Chemo Infuse Addl Hour Chemo,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,289.00,289.00,173.40,173.40,N/A,40.46,N/A,60.93,N/A,166.41,N/A,98.26,N/A,147.37,N/A,40.46,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,166.41,N/A,60.93,N/A,40.46,N/A,154.90,N/A,154.90,N/A,40.46,N/A,60.93,N/A,60.93,N/A,67.02,173.40,173.40,40.46,173.40,,Hospital 96420,HC Chemo Push Technique Arterial,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,141317.60,N/A,84790.56,N/A,19731.77,N/A,27299.63,N/A,81164.94,N/A,48047.97,N/A,61846.16,N/A,19731.77,N/A,27195.81,N/A,27195.81,N/A,38500.44,N/A,61846.16,N/A,61846.16,N/A,61846.16,N/A,78420.70,N/A,27195.81,N/A,19731.77,N/A,11923.50,N/A,11923.50,N/A,19731.77,N/A,27195.81,N/A,27299.63,N/A,1414.77,N/A,N/A,1414.77,84790.56,,Hospital CPT 96521,HC Portable Pump - Refill/Maint,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,637.00,637.00,382.20,382.20,N/A,89.18,N/A,202.13,N/A,366.78,N/A,216.58,N/A,451.22,N/A,89.18,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,366.78,N/A,186.54,N/A,89.18,N/A,341.43,N/A,341.43,N/A,89.18,N/A,186.54,N/A,198.44,N/A,136.86,382.20,382.20,89.18,451.22,,Hospital CPT 96521,HC Portable Pump -Refill/Maint,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,637.00,637.00,382.20,382.20,N/A,89.18,N/A,202.13,N/A,366.78,N/A,216.58,N/A,451.22,N/A,89.18,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,366.78,N/A,186.54,N/A,89.18,N/A,341.43,N/A,341.43,N/A,89.18,N/A,186.54,N/A,198.44,N/A,136.86,382.20,382.20,89.18,451.22,,Hospital CPT 96523,HC Irrigation of Vad - Only,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,340.00,340.00,204.00,204.00,N/A,47.60,N/A,51.91,N/A,195.77,N/A,115.60,N/A,125.56,N/A,47.60,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,195.77,N/A,51.91,N/A,47.60,N/A,182.24,N/A,182.24,N/A,47.60,N/A,51.91,N/A,51.91,N/A,57.10,204.00,204.00,47.60,204.00,,Hospital CPT 96523,HC Irrigation of Vad - Only,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,340.00,340.00,204.00,204.00,N/A,47.60,N/A,51.91,N/A,195.77,N/A,115.60,N/A,125.56,N/A,47.60,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,195.77,N/A,51.91,N/A,47.60,N/A,340.00,N/A,340.00,N/A,47.60,N/A,51.91,N/A,51.91,N/A,57.10,204.00,204.00,47.60,340.00,,Hospital CPT 97012,HC OP Traction Intermittent,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,183.00,158.00,109.80,94.80,N/A,22.12,N/A,14.68,N/A,90.98,N/A,53.72,N/A,42.27,N/A,22.12,N/A,14.68,N/A,14.68,N/A,42.27,N/A,42.27,N/A,42.27,N/A,42.27,N/A,90.98,N/A,14.09,N/A,22.12,N/A,84.69,N/A,84.69,N/A,22.12,N/A,14.68,N/A,14.68,N/A,16.15,109.80,109.80,14.09,94.80,,Hospital 97016,HC Pt Vasopneumatic Device Therapy,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,34931.48,3990.00,20958.89,2394.00,5123.90,558.60,6326.96,479.80,11547.13,2297.45,11876.70,1356.60,11657.59,1375.95,5281.78,558.60,2248.00,479.80,2248.00,479.80,7256.58,1375.95,11657.59,1375.95,11657.59,1375.95,11657.59,1375.95,11547.13,2297.45,6326.96,458.65,5281.78,558.60,13869.62,2138.65,13869.62,2138.65,5281.78,558.60,6326.96,479.80,6326.96,479.80,5651.50,527.75,2248.00,20958.89,458.65,2394.00,,Hospital 97034,HC Ot Contrast Bath Therapy,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,73148.37,1143.00,43889.02,685.80,N/A,160.02,8429.71,158.12,18593.10,658.14,N/A,388.62,N/A,455.85,N/A,160.02,8429.71,158.12,8429.71,158.12,N/A,455.85,N/A,455.85,N/A,455.85,N/A,455.85,18593.10,658.14,8429.71,151.95,N/A,160.02,18593.10,612.66,18593.10,612.66,N/A,160.02,7504.51,158.12,8429.71,158.12,N/A,173.94,7504.51,43889.02,151.95,685.80,,Hospital CPT 97129,HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,48.00,48.00,28.80,28.80,N/A,6.72,N/A,22.39,N/A,27.64,N/A,16.32,N/A,48.00,N/A,6.72,N/A,22.39,N/A,22.39,N/A,41.03,N/A,48.00,N/A,48.00,N/A,48.00,N/A,27.64,N/A,22.39,N/A,6.72,N/A,25.73,N/A,25.73,N/A,6.72,N/A,22.39,N/A,22.39,N/A,24.63,28.80,28.80,6.72,48.00,,Hospital CPT 97129,HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,48.00,48.00,28.80,28.80,N/A,6.72,N/A,22.39,N/A,27.64,N/A,16.32,N/A,48.00,N/A,6.72,N/A,22.39,N/A,22.39,N/A,41.03,N/A,48.00,N/A,48.00,N/A,48.00,N/A,27.64,N/A,22.39,N/A,6.72,N/A,25.73,N/A,25.73,N/A,6.72,N/A,22.39,N/A,22.39,N/A,24.63,28.80,28.80,6.72,48.00,,Hospital CPT 97130,HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,48.00,48.00,28.80,28.80,N/A,6.72,N/A,21.39,N/A,27.64,N/A,16.32,N/A,48.00,N/A,6.72,N/A,21.39,N/A,21.39,N/A,39.22,N/A,48.00,N/A,48.00,N/A,48.00,N/A,27.64,N/A,21.39,N/A,6.72,N/A,25.73,N/A,25.73,N/A,6.72,N/A,21.39,N/A,21.39,N/A,23.53,28.80,28.80,6.72,48.00,,Hospital CPT 97130,HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,48.00,48.00,28.80,28.80,N/A,6.72,N/A,21.39,N/A,27.64,N/A,16.32,N/A,48.00,N/A,6.72,N/A,21.39,N/A,21.39,N/A,39.22,N/A,48.00,N/A,48.00,N/A,48.00,N/A,27.64,N/A,21.39,N/A,6.72,N/A,25.73,N/A,25.73,N/A,6.72,N/A,21.39,N/A,21.39,N/A,23.53,28.80,28.80,6.72,48.00,,Hospital CPT 97150,HC Group Exercise Pt,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,135.00,118.00,81.00,70.80,N/A,16.52,N/A,17.70,N/A,67.94,N/A,40.12,N/A,51.90,N/A,16.52,N/A,17.70,N/A,17.70,N/A,51.90,N/A,51.90,N/A,51.90,N/A,51.90,N/A,67.94,N/A,17.30,N/A,16.52,N/A,63.25,N/A,63.25,N/A,16.52,N/A,17.70,N/A,17.70,N/A,19.47,81.00,81.00,16.52,70.80,,Hospital CPT 97150,HC Ot Group Therapy,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,135.00,118.00,81.00,70.80,N/A,16.52,N/A,17.70,N/A,67.94,N/A,40.12,N/A,51.90,N/A,16.52,N/A,17.70,N/A,17.70,N/A,51.90,N/A,51.90,N/A,51.90,N/A,51.90,N/A,67.94,N/A,17.30,N/A,16.52,N/A,63.25,N/A,63.25,N/A,16.52,N/A,17.70,N/A,17.70,N/A,19.47,81.00,81.00,16.52,70.80,,Hospital 97151,HC Behavior ID Assessment by Phys/Qhp Ea 15 Min,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,71.00,N/A,42.60,N/A,9.94,N/A,71.65,N/A,40.88,N/A,24.14,N/A,71.00,N/A,9.94,N/A,68.50,N/A,68.50,N/A,71.00,N/A,71.00,N/A,71.00,N/A,71.00,N/A,40.88,N/A,68.50,N/A,9.94,N/A,38.06,N/A,38.06,N/A,9.94,N/A,68.50,N/A,71.65,N/A,N/A,N/A,N/A,9.94,71.65,,Hospital 97153,HC Adaptive Behavior Tx by Protocol Tech Ea 15 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,N/A,96478.00,N/A,57886.80,N/A,13506.92,N/A,4637.88,N/A,55552.03,N/A,32802.52,N/A,10546.20,N/A,13506.92,N/A,4359.78,N/A,4359.78,N/A,6565.14,N/A,10546.20,N/A,10546.20,N/A,10546.20,N/A,77182.40,N/A,4359.78,N/A,13506.92,N/A,N/A,N/A,N/A,N/A,13506.92,N/A,4359.78,N/A,4637.88,N/A,N/A,N/A,N/A,4359.78,77182.40,,Hospital CPT 97168,HC Ot Re-Eval Est Plan Care,N/A,0434 - OCCUPATIONAL THERAPY - EVALUATION OR REEVALUATION,194.00,194.00,116.40,116.40,N/A,27.16,N/A,59.50,N/A,111.71,N/A,65.96,N/A,194.00,N/A,27.16,N/A,59.50,N/A,59.50,N/A,194.00,N/A,194.00,N/A,194.00,N/A,194.00,N/A,111.71,N/A,67.04,N/A,27.16,N/A,103.98,N/A,103.98,N/A,27.16,N/A,59.50,N/A,59.50,N/A,65.45,116.40,116.40,27.16,194.00,,Hospital CPT 97535,HC Pt Adl Training 15mn,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,189.00,189.00,113.40,113.40,N/A,26.46,N/A,32.61,N/A,108.83,N/A,64.26,N/A,95.04,N/A,26.46,N/A,32.61,N/A,32.61,N/A,95.04,N/A,95.04,N/A,95.04,N/A,95.04,N/A,108.83,N/A,31.68,N/A,26.46,N/A,101.30,N/A,101.30,N/A,26.46,N/A,32.61,N/A,32.61,N/A,35.87,113.40,113.40,26.46,113.40,,Hospital CPT 97535,HC Ot Adl Training 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,182.00,182.00,109.20,109.20,N/A,25.48,N/A,32.61,N/A,104.80,N/A,61.88,N/A,95.04,N/A,25.48,N/A,32.61,N/A,32.61,N/A,95.04,N/A,95.04,N/A,95.04,N/A,95.04,N/A,104.80,N/A,31.68,N/A,25.48,N/A,97.55,N/A,97.55,N/A,25.48,N/A,32.61,N/A,32.61,N/A,35.87,109.20,109.20,25.48,109.20,,Hospital 97545,HC Pt Work Hardening/Simulation Init 2 Hrs,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,N/A,3870.00,N/A,2322.00,N/A,541.80,N/A,N/A,N/A,2228.30,N/A,1315.80,N/A,541.80,N/A,541.80,N/A,N/A,N/A,N/A,N/A,336.70,N/A,541.80,N/A,541.80,N/A,541.80,N/A,2228.30,N/A,N/A,N/A,541.80,N/A,2074.30,N/A,2074.30,N/A,541.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,336.70,2322.00,,Hospital CPT 97598,"HC Debrid,Open Wnd Ea Add 20sqcm (Selective)",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,1257.00,N/A,723.78,N/A,427.38,N/A,1257.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,723.78,N/A,1257.00,N/A,175.98,N/A,527.00,N/A,527.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,1257.00,754.20,754.20,175.98,1257.00,,Hospital CPT 97602,"HC Debride Skin,Non-Selective",N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,732.00,732.00,439.20,439.20,N/A,102.48,N/A,732.00,N/A,421.49,N/A,248.88,N/A,102.48,N/A,102.48,N/A,732.00,N/A,732.00,N/A,63.68,N/A,102.48,N/A,102.48,N/A,102.48,N/A,421.49,N/A,732.00,N/A,102.48,N/A,392.35,N/A,392.35,N/A,102.48,N/A,732.00,N/A,732.00,N/A,732.00,439.20,439.20,63.68,732.00,,Hospital CPT 97750,HC Phys Performnce Test Ea 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,108.00,108.00,64.80,64.80,N/A,15.12,N/A,33.24,N/A,62.19,N/A,36.72,N/A,97.83,N/A,15.12,N/A,33.24,N/A,33.24,N/A,97.83,N/A,97.83,N/A,97.83,N/A,97.83,N/A,62.19,N/A,32.61,N/A,15.12,N/A,57.89,N/A,57.89,N/A,15.12,N/A,33.24,N/A,33.24,N/A,36.56,64.80,64.80,15.12,97.83,,Hospital CPT 97750,HC Ot Performnce Test Ea 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,108.00,108.00,64.80,64.80,N/A,15.12,N/A,33.24,N/A,62.19,N/A,36.72,N/A,97.83,N/A,15.12,N/A,33.24,N/A,33.24,N/A,97.83,N/A,97.83,N/A,97.83,N/A,97.83,N/A,62.19,N/A,32.61,N/A,15.12,N/A,57.89,N/A,57.89,N/A,15.12,N/A,33.24,N/A,33.24,N/A,36.56,64.80,64.80,15.12,97.83,,Hospital CPT 97760,HC Splint Fitting/Training Ea 15,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,194.00,166.00,116.40,99.60,N/A,23.24,N/A,46.40,N/A,95.58,N/A,56.44,N/A,139.05,N/A,23.24,N/A,46.40,N/A,46.40,N/A,139.05,N/A,139.05,N/A,139.05,N/A,139.05,N/A,95.58,N/A,46.35,N/A,23.24,N/A,88.98,N/A,88.98,N/A,23.24,N/A,46.40,N/A,46.40,N/A,51.04,116.40,116.40,23.24,139.05,,Hospital 97814,HC Acupunct W/ Elec Stimul Addl 15m,N/A,2101 - ALTERNATIVE THERAPY SERVICES - ACUPUNCTURE,N/A,162.00,N/A,97.20,N/A,22.68,N/A,24.86,N/A,93.28,N/A,55.08,N/A,N/A,N/A,22.68,N/A,22.54,N/A,22.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,93.28,N/A,22.54,N/A,22.68,N/A,86.84,N/A,86.84,N/A,22.68,N/A,22.54,N/A,60.66,N/A,66.73,N/A,N/A,22.54,97.20,,Hospital CPT 98925,HC Omt 1-2 Body Regions,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,84.00,84.00,50.40,50.40,N/A,11.76,N/A,24.00,N/A,48.37,N/A,28.56,N/A,54.57,N/A,11.76,N/A,22.56,N/A,22.56,N/A,33.97,N/A,54.57,N/A,54.57,N/A,54.57,N/A,48.37,N/A,22.56,N/A,11.76,N/A,84.00,N/A,84.00,N/A,11.76,N/A,22.56,N/A,24.00,N/A,25.06,50.40,50.40,11.76,84.00,,Hospital 98926,HC Omt 3-4 Reg,N/A,0530 - OSTEOPATHIC SERVICES - GENERAL CLASSIFICATION,N/A,51.00,N/A,30.60,N/A,7.14,N/A,24.00,N/A,29.37,N/A,17.34,N/A,51.00,N/A,7.14,N/A,22.56,N/A,22.56,N/A,33.97,N/A,51.00,N/A,51.00,N/A,51.00,N/A,29.37,N/A,22.56,N/A,7.14,N/A,27.34,N/A,27.34,N/A,7.14,N/A,22.56,N/A,24.00,N/A,37.55,N/A,N/A,7.14,51.00,,Hospital CPT 99001,HC Collection Fee,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,42.00,32.00,25.20,19.20,N/A,4.48,N/A,32.00,N/A,18.43,N/A,10.88,N/A,6.00,N/A,4.48,N/A,32.00,N/A,32.00,N/A,6.00,N/A,6.00,N/A,6.00,N/A,4.48,N/A,18.43,N/A,32.00,N/A,4.48,N/A,6.58,N/A,6.58,N/A,4.48,N/A,32.00,N/A,32.00,N/A,32.00,25.20,25.20,4.48,32.00,,Hospital 9909779900,HC Physical Conditioning,N/A,0990 - PATIENT CONVENIENCE ITEMS - GENERAL CLASSIFICATION,141739.70,N/A,85043.82,N/A,7358.04,N/A,8969.82,N/A,78126.92,N/A,N/A,N/A,16740.56,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10420.61,N/A,16740.56,N/A,16740.56,N/A,16740.56,N/A,78126.92,N/A,8969.82,N/A,7584.76,N/A,19917.09,N/A,19917.09,N/A,2697.34,N/A,8969.82,N/A,8969.82,N/A,8115.69,N/A,2697.34,85043.82,N/A,N/A,,Hospital CPT 99152,HC Mod Sed Same Phys/Qhp 5/>Yrs,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,926.00,926.00,555.60,555.60,N/A,129.64,N/A,926.00,N/A,533.19,N/A,314.84,N/A,926.00,N/A,129.64,N/A,926.00,N/A,926.00,N/A,926.00,N/A,926.00,N/A,926.00,N/A,926.00,N/A,533.19,N/A,926.00,N/A,129.64,N/A,496.34,N/A,496.34,N/A,129.64,N/A,926.00,N/A,926.00,N/A,926.00,555.60,555.60,129.64,926.00,,Hospital CPT 99157,HC Mod Sed Other Phys/Qhp Ea Addl 15 Min,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,466.00,466.00,279.60,279.60,N/A,65.24,N/A,60.24,N/A,268.32,N/A,158.44,N/A,466.00,N/A,65.24,N/A,466.00,N/A,466.00,N/A,466.00,N/A,466.00,N/A,466.00,N/A,466.00,N/A,268.32,N/A,466.00,N/A,65.24,N/A,249.78,N/A,249.78,N/A,65.24,N/A,466.00,N/A,60.24,N/A,66.26,279.60,279.60,60.24,466.00,,Hospital CPT 99183,"HC Att&Supv Hbot/per Sess,Non-Med",N/A,0413 - RESPIRATORY SERVICES - HYPERBARIC OXYGEN THERAPY,5110.00,5110.00,3066.00,3066.00,N/A,715.40,N/A,103.63,N/A,2942.34,N/A,1737.40,N/A,305.85,N/A,715.40,N/A,103.63,N/A,103.63,N/A,190.39,N/A,305.85,N/A,305.85,N/A,305.85,N/A,2942.34,N/A,103.63,N/A,715.40,N/A,2738.96,N/A,2738.96,N/A,715.40,N/A,103.63,N/A,103.63,N/A,113.99,3066.00,3066.00,103.63,3066.00,,Hospital CPT 99195,HC Phlebotomy Therapeutic,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,667.00,667.00,400.20,400.20,N/A,93.38,N/A,104.85,N/A,384.06,N/A,226.78,N/A,253.64,N/A,93.38,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,384.06,N/A,104.85,N/A,93.38,N/A,357.51,N/A,357.51,N/A,93.38,N/A,104.85,N/A,104.85,N/A,115.34,400.20,400.20,93.38,400.20,,Hospital CPT 99195,"HC Phlebotomy,Tx",N/A,0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION,667.00,667.00,400.20,400.20,N/A,93.38,N/A,104.85,N/A,384.06,N/A,226.78,N/A,253.64,N/A,93.38,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,384.06,N/A,104.85,N/A,93.38,N/A,357.51,N/A,357.51,N/A,93.38,N/A,104.85,N/A,104.85,N/A,115.34,400.20,400.20,93.38,400.20,,Hospital CPT 99202,"HC New Pt, E/M Level 2",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,605.00,605.00,363.00,363.00,N/A,84.70,N/A,109.14,N/A,348.36,N/A,205.70,N/A,605.00,N/A,84.70,N/A,109.14,N/A,109.14,N/A,605.00,N/A,605.00,N/A,605.00,N/A,605.00,N/A,348.36,N/A,109.14,N/A,84.70,N/A,324.28,N/A,324.28,N/A,84.70,N/A,109.14,N/A,109.14,N/A,51.80,363.00,363.00,51.80,605.00,,Hospital CPT 99204,"HC New Pt, E/M Level 4",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,682.00,1029.00,409.20,617.40,N/A,144.06,N/A,109.14,N/A,592.50,N/A,349.86,N/A,1029.00,N/A,144.06,N/A,109.14,N/A,109.14,N/A,1029.00,N/A,1029.00,N/A,1029.00,N/A,1029.00,N/A,592.50,N/A,109.14,N/A,144.06,N/A,551.54,N/A,551.54,N/A,144.06,N/A,109.14,N/A,109.14,N/A,143.25,409.20,409.20,109.14,1029.00,,Hospital CPT 99214,"HC Est Pt, Outpt Visit Level 4",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,860.00,860.00,516.00,516.00,N/A,120.40,N/A,109.14,N/A,495.19,N/A,292.40,N/A,264.01,N/A,120.40,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,495.19,N/A,109.14,N/A,120.40,N/A,460.96,N/A,460.96,N/A,120.40,N/A,109.14,N/A,109.14,N/A,120.06,516.00,516.00,109.14,516.00,,Hospital CPT 99214,"HC Est Pt, E/M Level 4",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,860.00,860.00,516.00,516.00,N/A,120.40,N/A,109.14,N/A,495.19,N/A,292.40,N/A,860.00,N/A,120.40,N/A,109.14,N/A,109.14,N/A,860.00,N/A,860.00,N/A,860.00,N/A,860.00,N/A,495.19,N/A,109.14,N/A,120.40,N/A,460.96,N/A,460.96,N/A,120.40,N/A,109.14,N/A,109.14,N/A,120.06,516.00,516.00,109.14,860.00,,Hospital CPT 99215,"HC Est Pt, E/M Level 5",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,1029.00,1029.00,617.40,617.40,N/A,144.06,N/A,109.14,N/A,592.50,N/A,349.86,N/A,1029.00,N/A,144.06,N/A,109.14,N/A,109.14,N/A,1029.00,N/A,1029.00,N/A,1029.00,N/A,1029.00,N/A,592.50,N/A,109.14,N/A,144.06,N/A,551.54,N/A,551.54,N/A,144.06,N/A,109.14,N/A,109.14,N/A,120.06,617.40,617.40,109.14,1029.00,,Hospital CPT 99215,"HC Est Pt, Outpt Visit Level 5",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1029.00,1029.00,617.40,617.40,N/A,144.06,N/A,109.14,N/A,592.50,N/A,349.86,N/A,264.01,N/A,144.06,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,592.50,N/A,109.14,N/A,144.06,N/A,551.54,N/A,551.54,N/A,144.06,N/A,109.14,N/A,109.14,N/A,120.06,617.40,617.40,109.14,617.40,,Hospital CPT 99222,Initial Hospital Care/Day 50 Minutes,N/A,N/A,198.00,198.00,118.80,118.80,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,N/A,198.00,118.80,118.80,118.80,198.00,,Hospital CPT 99281,HC ER Level 1,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,455.00,455.00,273.00,273.00,N/A,63.70,N/A,21.35,N/A,261.99,N/A,154.70,N/A,164.03,N/A,63.70,N/A,67.81,N/A,67.81,N/A,102.11,N/A,164.03,N/A,164.03,N/A,164.03,N/A,261.99,N/A,67.81,N/A,63.70,N/A,455.00,N/A,455.00,N/A,63.70,N/A,67.81,N/A,21.35,N/A,23.49,273.00,273.00,21.35,455.00,,Hospital CPT 99283,HC ER Level 3,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1416.00,1416.00,849.60,849.60,N/A,198.24,N/A,70.45,N/A,815.33,N/A,481.44,N/A,535.24,N/A,198.24,N/A,221.27,N/A,221.27,N/A,333.20,N/A,535.24,N/A,535.24,N/A,535.24,N/A,815.33,N/A,221.27,N/A,198.24,N/A,1416.00,N/A,1416.00,N/A,198.24,N/A,221.27,N/A,70.45,N/A,77.50,849.60,849.60,70.45,1416.00,,Hospital CPT 99284,HC ER Level 4,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1813.00,1813.00,1087.80,1087.80,N/A,253.82,N/A,353.81,N/A,1043.93,N/A,616.42,N/A,833.59,N/A,253.82,N/A,344.61,N/A,344.61,N/A,518.93,N/A,833.59,N/A,833.59,N/A,833.59,N/A,1043.93,N/A,344.61,N/A,253.82,N/A,1813.00,N/A,1813.00,N/A,253.82,N/A,344.61,N/A,353.81,N/A,130.98,1087.80,1087.80,130.98,1813.00,,Hospital 99382,"HC Prev Visit New, Age1-4",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,424.00,N/A,254.40,N/A,59.36,N/A,33.83,N/A,244.14,N/A,144.16,N/A,74.18,N/A,59.36,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,244.14,N/A,30.67,N/A,59.36,N/A,227.27,N/A,227.27,N/A,59.36,N/A,30.67,N/A,10.21,N/A,11.23,N/A,N/A,10.21,254.40,,Hospital 99384,HC Prev Visit New Age12-17,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,410.02,N/A,246.01,N/A,57.40,N/A,67.21,N/A,236.08,N/A,139.40,N/A,147.37,N/A,57.40,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,236.08,N/A,60.93,N/A,57.40,N/A,219.77,N/A,219.77,N/A,57.40,N/A,60.93,N/A,15.49,N/A,17.04,N/A,N/A,15.49,246.01,,Hospital 99386,HC Prev Visit New Age40-64,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,9.71,N/A,185.98,N/A,109.82,N/A,N/A,N/A,45.22,N/A,9.71,N/A,9.71,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,185.98,N/A,9.71,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,9.71,N/A,9.71,N/A,141.59,N/A,N/A,9.71,193.80,,Hospital 99393,HC Prev Visit Est Age 5-11,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,164.96,N/A,185.98,N/A,109.82,N/A,N/A,N/A,45.22,N/A,164.96,N/A,164.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,185.98,N/A,164.96,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,164.96,N/A,164.96,N/A,139.02,N/A,N/A,45.22,193.80,,Hospital 99395,HC Prev Visit Est Age 18-39,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,174.00,N/A,185.98,N/A,109.82,N/A,63.43,N/A,45.22,N/A,174.00,N/A,174.00,N/A,63.43,N/A,63.43,N/A,63.43,N/A,63.43,N/A,185.98,N/A,174.00,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,174.00,N/A,174.00,N/A,141.59,N/A,N/A,45.22,193.80,,Hospital 99407,HC Smoking Cessatn 10/More Mins Symptomatic Pt,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,237.00,N/A,142.20,N/A,33.18,N/A,144.06,N/A,136.47,N/A,80.58,N/A,64.83,N/A,33.18,N/A,135.94,N/A,135.94,N/A,40.36,N/A,64.83,N/A,64.83,N/A,64.83,N/A,136.47,N/A,135.94,N/A,33.18,N/A,127.03,N/A,127.03,N/A,33.18,N/A,135.94,N/A,144.06,N/A,26.91,N/A,N/A,26.91,144.06,,Hospital CPT 99465,HC Neonatal Resusitation,N/A,0722 - LABOR ROOM/DELIVERY - DELIVERY ROOM,1557.00,1557.00,934.20,934.20,N/A,217.98,N/A,139.60,N/A,896.52,N/A,529.38,N/A,408.75,N/A,217.98,N/A,139.60,N/A,139.60,N/A,254.45,N/A,408.75,N/A,408.75,N/A,408.75,N/A,896.52,N/A,139.60,N/A,217.98,N/A,834.55,N/A,834.55,N/A,217.98,N/A,139.60,N/A,139.60,N/A,153.56,934.20,934.20,139.60,934.20,,Hospital 99495,HC Trans Care Mgmt 14 Day Disch,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,363.00,N/A,217.80,N/A,50.82,N/A,114.43,N/A,209.02,N/A,123.42,N/A,626.94,N/A,50.82,N/A,109.14,N/A,109.14,N/A,626.94,N/A,626.94,N/A,626.94,N/A,626.94,N/A,209.02,N/A,109.14,N/A,50.82,N/A,194.57,N/A,194.57,N/A,50.82,N/A,109.14,N/A,138.03,N/A,151.83,N/A,N/A,50.82,626.94,,Hospital 99606,HC Med Tx Mgmt Indiv Estab 15 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,333.00,N/A,199.80,N/A,46.62,N/A,116.10,N/A,191.74,N/A,113.22,N/A,264.01,N/A,46.62,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,191.74,N/A,109.14,N/A,46.62,N/A,178.49,N/A,178.49,N/A,46.62,N/A,109.14,N/A,116.10,N/A,49.95,N/A,N/A,46.62,264.01,,Hospital 99607,HC Med Tx Mgmt Indiv Ea Add 15 Mi,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,482.00,N/A,289.20,N/A,64.77,N/A,228.34,N/A,277.53,N/A,163.88,N/A,482.00,N/A,64.77,N/A,218.28,N/A,218.28,N/A,328.70,N/A,482.00,N/A,482.00,N/A,482.00,N/A,277.53,N/A,218.28,N/A,64.77,N/A,4.29,N/A,4.29,N/A,64.77,N/A,218.28,N/A,228.34,N/A,4.72,N/A,N/A,4.29,482.00,,Hospital Custom 999111,Miscellaneous Charge,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,275.00,275.00,165.00,165.00,N/A,38.50,N/A,275.00,N/A,154.61,N/A,93.50,N/A,38.50,N/A,38.50,N/A,275.00,N/A,275.00,N/A,23.93,N/A,38.50,N/A,38.50,N/A,38.50,N/A,154.61,N/A,275.00,N/A,38.50,N/A,147.40,N/A,147.40,N/A,38.50,N/A,275.00,N/A,275.00,N/A,275.00,165.00,165.00,23.93,275.00,,Hospital Custom 9991111,Miscellaneous Charge,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,114.00,114.00,68.40,68.40,N/A,15.96,N/A,114.00,N/A,65.64,N/A,38.76,N/A,15.96,N/A,15.96,N/A,114.00,N/A,114.00,N/A,9.92,N/A,15.96,N/A,15.96,N/A,15.96,N/A,65.64,N/A,114.00,N/A,15.96,N/A,61.10,N/A,61.10,N/A,15.96,N/A,114.00,N/A,114.00,N/A,114.00,68.40,68.40,9.92,114.00,,Hospital CPT A0425,"HC Ambulance, Mileage",N/A,0540 - AMBULANCE - GENERAL CLASSIFICATION,22.00,22.00,13.20,13.20,N/A,3.08,N/A,8.02,N/A,12.67,N/A,7.48,N/A,22.00,N/A,3.08,N/A,8.02,N/A,8.02,N/A,22.00,N/A,22.00,N/A,22.00,N/A,22.00,N/A,12.67,N/A,8.02,N/A,3.08,N/A,11.79,N/A,11.79,N/A,3.08,N/A,8.02,N/A,8.02,N/A,22.00,13.20,13.20,3.08,22.00,,Hospital CPT A0426,"HC Ambulance,Alc Non-Emergent,Par",N/A,0540 - AMBULANCE - GENERAL CLASSIFICATION,1017.00,1017.00,610.20,610.20,N/A,142.38,N/A,280.80,N/A,585.59,N/A,345.78,N/A,1017.00,N/A,142.38,N/A,280.80,N/A,280.80,N/A,1017.00,N/A,1017.00,N/A,1017.00,N/A,1017.00,N/A,585.59,N/A,280.80,N/A,142.38,N/A,545.11,N/A,545.11,N/A,142.38,N/A,280.80,N/A,280.80,N/A,1017.00,610.20,610.20,142.38,1017.00,,Hospital CPT A0427,"HC Ambulance,Als Emergency,Lev 1",N/A,0540 - AMBULANCE - GENERAL CLASSIFICATION,1338.00,1338.00,802.80,802.80,N/A,187.32,N/A,444.60,N/A,770.42,N/A,454.92,N/A,1338.00,N/A,187.32,N/A,444.60,N/A,444.60,N/A,1338.00,N/A,1338.00,N/A,1338.00,N/A,1338.00,N/A,770.42,N/A,444.60,N/A,187.32,N/A,717.17,N/A,717.17,N/A,187.32,N/A,444.60,N/A,444.60,N/A,1338.00,802.80,802.80,187.32,1338.00,,Hospital A2005,"Microlyte matrix, per sq cm",N/A,N/A,N/A,10757.58,N/A,6454.55,N/A,1506.06,N/A,1611.95,N/A,6189.21,N/A,3657.58,N/A,3769.94,N/A,1506.06,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,6189.21,N/A,1558.52,N/A,1506.06,N/A,1871.00,N/A,1871.00,N/A,1506.06,N/A,1558.52,N/A,1611.95,N/A,99.44,N/A,N/A,99.44,6454.55,,Hospital A2008,HC Theragenesis per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),948188.85,42454.23,568913.31,25472.54,125462.12,5941.75,N/A,144.35,N/A,24443.00,N/A,14434.45,N/A,4195.85,125462.12,5941.75,N/A,1726.97,N/A,1726.97,N/A,2611.98,N/A,4195.85,N/A,4195.85,N/A,4195.85,N/A,24443.02,N/A,1726.97,125462.12,5941.75,N/A,2134.50,N/A,2134.50,125462.12,5941.75,N/A,1726.97,N/A,144.35,125462.12,158.79,125462.12,568913.31,144.35,25472.54,,Hospital A4261,Cervical Cap Contraceptive,N/A,N/A,N/A,15564.30,N/A,9338.58,N/A,2179.00,N/A,190.42,N/A,8763.44,N/A,5291.87,N/A,535.40,N/A,2179.00,N/A,186.54,N/A,186.54,N/A,333.29,N/A,535.40,N/A,535.40,N/A,535.40,N/A,8763.45,N/A,186.54,N/A,2179.00,N/A,8342.46,N/A,8342.46,N/A,2179.00,N/A,186.54,N/A,190.42,N/A,67.14,N/A,N/A,67.14,9338.58,,Hospital A4315,1lyr 16fr 10ml 100%Sili Db Tra,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2489.63,N/A,1493.78,N/A,N/A,N/A,675.00,N/A,N/A,N/A,846.48,N/A,555.00,N/A,348.55,N/A,675.00,N/A,675.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1433.54,N/A,675.00,N/A,N/A,N/A,48.06,N/A,48.06,N/A,N/A,N/A,675.00,N/A,675.00,N/A,101.51,N/A,N/A,48.06,1493.78,,Hospital A4322,"Syringe,Piston,Irrigation,60ml,Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2070.68,N/A,1242.41,N/A,N/A,N/A,1603.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.25,N/A,1603.87,N/A,1603.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1603.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1603.87,N/A,1603.87,N/A,N/A,N/A,N/A,4.25,1603.87,,Hospital A4363,"Clamp,Pouch,Drainable,Quiet Film",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2686.62,N/A,1611.97,N/A,N/A,N/A,2740.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2740.35,N/A,2740.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2740.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2740.35,N/A,2740.35,N/A,N/A,N/A,N/A,1611.97,2740.35,,Hospital A4390,"Pouch,Drain W/Durahesive,1 Pc,1 3/8""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1833.75,N/A,1100.25,N/A,N/A,N/A,152.62,N/A,N/A,N/A,623.48,N/A,256.73,N/A,256.73,N/A,N/A,N/A,N/A,N/A,159.54,N/A,256.73,N/A,256.73,N/A,256.73,N/A,1055.87,N/A,N/A,N/A,N/A,N/A,982.88,N/A,982.88,N/A,N/A,N/A,N/A,N/A,152.62,N/A,167.89,N/A,N/A,152.62,1100.25,,Hospital A4396,"Belt,Support,Brava Ostomy,M",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5011.13,N/A,3006.68,N/A,N/A,N/A,140.43,N/A,N/A,N/A,1703.77,N/A,975.56,N/A,701.56,N/A,N/A,N/A,N/A,N/A,1187.19,N/A,975.56,N/A,975.56,N/A,975.56,N/A,2885.41,N/A,N/A,N/A,N/A,N/A,857.60,N/A,857.60,N/A,N/A,N/A,N/A,N/A,140.43,N/A,154.50,N/A,N/A,140.43,3006.68,,Hospital A4413,"Pouch,Natura,Trans,2 , 5/Bx",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1110.43,N/A,666.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,666.26,666.26,,Hospital A4416,"Pouch,Mio,1pc,Clsd,Maxi,Ctf,5/8-1 3/4",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4550.98,N/A,2730.59,N/A,N/A,N/A,79.88,N/A,1310.47,N/A,1547.33,N/A,1110.00,N/A,637.13,N/A,N/A,N/A,N/A,N/A,1110.00,N/A,1110.00,N/A,1110.00,N/A,1110.00,N/A,2620.47,N/A,N/A,N/A,N/A,N/A,295.33,N/A,295.33,N/A,N/A,N/A,N/A,N/A,79.88,N/A,87.89,N/A,N/A,79.88,2730.59,,Hospital A4430,"System,Pouch,Urostomy,1pc,Ceraplus,Soft",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1209.65,N/A,725.79,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,725.79,725.79,,Hospital A4432,"Pouch,Urostomy,W/Accuseal,2pc, 1 3/4",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2523.97,N/A,1514.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1514.38,1514.38,,Hospital A4561,"HC Pessary Rubber, Any Type",N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,714.00,N/A,428.40,N/A,88.19,N/A,30.23,N/A,411.12,N/A,242.75,N/A,30.23,N/A,88.19,N/A,30.23,N/A,30.23,N/A,18.81,N/A,30.23,N/A,30.23,N/A,30.23,N/A,411.12,N/A,270.00,N/A,88.19,N/A,30.23,N/A,30.23,N/A,88.19,N/A,270.00,N/A,286.13,N/A,81.85,N/A,N/A,18.81,428.40,,Hospital A4562,"HC Pessary, Non Rubber,Any Type",N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,660.82,N/A,396.49,N/A,92.51,N/A,286.13,N/A,377.14,N/A,224.68,N/A,N/A,N/A,92.51,N/A,270.00,N/A,270.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,377.14,N/A,270.00,N/A,92.51,N/A,354.20,N/A,354.20,N/A,92.51,N/A,270.00,N/A,286.13,N/A,117.47,N/A,N/A,92.51,396.49,,Hospital A4565,Slings,N/A,N/A,N/A,56489.32,N/A,33893.59,N/A,7640.98,N/A,3018.90,N/A,32327.10,N/A,19206.36,N/A,28860.88,N/A,7640.98,N/A,11864.95,N/A,11864.95,N/A,18076.89,N/A,28860.88,N/A,28860.88,N/A,28860.88,N/A,32327.06,N/A,11880.45,N/A,7640.98,N/A,14641.50,N/A,14641.50,N/A,7640.98,N/A,11864.95,N/A,3018.90,N/A,3302.44,N/A,N/A,3018.90,33893.59,,Hospital A4648,HC Implantable Tissue Marker,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,200816.62,11167.62,120489.97,6700.57,24624.16,1563.47,48465.90,1475.63,101596.24,6308.64,104734.28,3796.99,104734.28,3572.02,24624.16,1563.47,50212.52,1475.63,50212.52,1475.63,104734.28,2223.65,104734.28,3572.02,104734.28,3572.02,104734.28,3572.02,101596.24,6308.64,48465.90,1475.63,24624.16,1563.47,101596.24,5470.93,101596.24,5470.93,24624.16,1563.47,38937.23,1475.63,48465.90,1475.63,24624.16,1623.20,24624.16,120489.97,1475.63,6700.57,,Hospital A4722,Dialys Sol Fld Vol > 1999cc,N/A,N/A,88502.00,73894.72,53101.20,44336.83,11274.19,10323.61,13602.42,13083.92,25407.29,41995.91,30090.68,25124.20,25650.34,28951.15,11621.56,10323.61,13602.42,11868.88,13602.42,11868.88,15966.74,18133.09,23628.89,28951.15,25650.34,28951.15,25650.34,28951.15,25407.29,41995.95,14918.66,11884.38,11454.64,10323.61,30517.50,12507.25,21348.49,12507.25,11454.64,10323.61,13602.42,11868.88,13602.42,1708.38,12435.07,2033.29,11274.19,53101.20,1708.38,44336.83,,Hospital A4726,Dialys Sol Fld Vol > 5999cc,N/A,N/A,107427.32,N/A,64456.39,N/A,N/A,N/A,26315.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5058.00,N/A,5058.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,26315.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,26315.20,N/A,26315.20,N/A,N/A,N/A,5058.00,64456.39,N/A,N/A,,Hospital A5057,"Pouch,Convex, DRN,38mm,1 1/2"",Barrie,Ctf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1553.48,N/A,932.09,N/A,N/A,N/A,1553.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,65.83,N/A,1553.48,N/A,1553.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1553.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1553.48,N/A,1553.48,N/A,N/A,N/A,N/A,65.83,1553.48,,Hospital A5120,"Wipe,Protectant,Skin,Sureprep",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2780.38,N/A,1668.23,N/A,1176.63,N/A,1890.00,N/A,701.40,N/A,1018.74,N/A,1018.74,N/A,15.69,N/A,1260.00,N/A,1260.00,N/A,1018.74,N/A,1018.74,N/A,1018.74,N/A,1018.74,N/A,701.40,N/A,2443.02,N/A,1176.63,N/A,701.40,N/A,701.40,N/A,1176.63,N/A,1404.00,N/A,2359.49,N/A,1176.63,N/A,N/A,15.69,2443.02,,Hospital A6196,"Dressing, Alginate, Maxorb II, 4x4",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2960.08,N/A,1776.05,N/A,1203.80,N/A,1575.00,N/A,1080.00,N/A,453.13,N/A,453.13,N/A,79.60,N/A,1050.00,N/A,1050.00,N/A,453.13,N/A,453.13,N/A,453.13,N/A,453.13,N/A,1080.00,N/A,2303.35,N/A,1203.80,N/A,1080.00,N/A,1080.00,N/A,1203.80,N/A,1045.00,N/A,1575.00,N/A,1203.80,N/A,N/A,79.60,2303.35,,Hospital A6197,"Dressing, Gel Fiber, Opticell Ag+,4x5",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3548.12,N/A,2128.87,N/A,1218.80,N/A,1215.00,N/A,1300.00,N/A,1206.36,N/A,888.00,N/A,496.74,N/A,945.00,N/A,945.00,N/A,888.00,N/A,888.00,N/A,888.00,N/A,888.00,N/A,2043.01,N/A,2485.69,N/A,1218.80,N/A,186.60,N/A,186.60,N/A,1218.80,N/A,1140.00,N/A,1365.00,N/A,23.82,N/A,N/A,23.82,2485.69,,Hospital A6203,"Dressing,Stratasorb,Comp,Island,4x4",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2440.05,N/A,1464.03,N/A,N/A,N/A,58.65,N/A,1200.00,N/A,829.62,N/A,560.61,N/A,341.61,N/A,2200.00,N/A,2200.00,N/A,558.48,N/A,560.61,N/A,560.61,N/A,560.61,N/A,1404.98,N/A,2200.00,N/A,N/A,N/A,21.47,N/A,21.47,N/A,N/A,N/A,2200.00,N/A,58.65,N/A,64.52,N/A,N/A,21.47,2200.00,,Hospital A6204,"Dressing,Stratasorb,Comp,Island,4x14",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2091.32,N/A,1254.79,N/A,N/A,N/A,N/A,N/A,N/A,N/A,562.40,N/A,562.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,562.40,N/A,562.40,N/A,562.40,N/A,562.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,562.40,1254.79,,Hospital A6208,"Dressing,Adaptic Touch,Nonad,Sil,8x12.75",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3210.22,N/A,1926.13,N/A,N/A,N/A,760.00,N/A,N/A,N/A,1091.47,N/A,722.00,N/A,449.44,N/A,760.00,N/A,760.00,N/A,700.80,N/A,722.00,N/A,722.00,N/A,722.00,N/A,1848.45,N/A,760.00,N/A,N/A,N/A,219.88,N/A,219.88,N/A,N/A,N/A,760.00,N/A,760.00,N/A,6.87,N/A,N/A,6.87,1926.13,,Hospital A6212,"Optifoam Gentle Ex, Bordered, 3x3",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2668.28,N/A,1600.97,N/A,1201.62,N/A,1755.00,N/A,914.40,N/A,1177.00,N/A,1177.00,N/A,1201.62,N/A,1050.00,N/A,1050.00,N/A,1177.00,N/A,1177.00,N/A,1177.00,N/A,1177.00,N/A,914.40,N/A,2371.68,N/A,1201.62,N/A,914.40,N/A,600.00,N/A,1201.62,N/A,1296.00,N/A,2204.45,N/A,1201.62,N/A,N/A,600.00,2371.68,,Hospital A6213,"Dressing,Border,Post-OP,Mepilex,4x12",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3170.37,N/A,1902.22,N/A,1731.38,N/A,1915.00,N/A,1080.00,N/A,1028.37,N/A,1028.37,N/A,1731.38,N/A,1555.00,N/A,1555.00,N/A,1028.37,N/A,1028.37,N/A,1028.37,N/A,1028.37,N/A,1080.00,N/A,2366.06,N/A,1731.38,N/A,1080.00,N/A,1080.00,N/A,1731.38,N/A,1610.00,N/A,1805.00,N/A,1731.38,N/A,N/A,1028.37,2366.06,,Hospital A6222,"Dressing,Gauze,Xeroform,Curad,1x8,St",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2864.73,N/A,1718.84,N/A,1176.63,N/A,354.85,N/A,1300.00,N/A,974.01,N/A,731.07,N/A,401.07,N/A,1404.00,N/A,1404.00,N/A,706.43,N/A,731.07,N/A,731.07,N/A,731.07,N/A,1649.52,N/A,1404.00,N/A,1176.63,N/A,249.10,N/A,249.10,N/A,1176.63,N/A,864.00,N/A,354.85,N/A,390.34,N/A,N/A,249.10,1718.84,,Hospital A6248,"Hydrogel,Skintegrity,4 Oz Tube",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2171.77,N/A,1303.06,N/A,1444.56,N/A,564.00,N/A,N/A,N/A,738.41,N/A,447.48,N/A,304.05,N/A,564.00,N/A,564.00,N/A,446.16,N/A,447.48,N/A,447.48,N/A,447.48,N/A,1250.51,N/A,564.00,N/A,1444.56,N/A,306.49,N/A,306.49,N/A,1444.56,N/A,564.00,N/A,564.00,N/A,129.63,N/A,N/A,129.63,1444.56,,Hospital A6250,"Paste,Protectant,Zguard,Remedy Phyto,4oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2673.82,N/A,1604.29,N/A,1444.56,N/A,1728.00,N/A,638.60,N/A,1256.54,N/A,1256.54,N/A,1444.56,N/A,1728.00,N/A,1728.00,N/A,1256.54,N/A,1256.54,N/A,1256.54,N/A,1256.54,N/A,638.60,N/A,2530.95,N/A,1444.56,N/A,638.60,N/A,638.60,N/A,1444.56,N/A,1178.00,N/A,1728.00,N/A,1444.56,N/A,N/A,638.60,2530.95,,Hospital A6441,"Compression System,Threeflex,3-Layer",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3363.88,N/A,2018.33,N/A,724.08,N/A,17.99,N/A,N/A,N/A,1143.72,N/A,910.94,N/A,470.94,N/A,1045.00,N/A,1045.00,N/A,902.25,N/A,910.94,N/A,910.94,N/A,910.94,N/A,1936.94,N/A,1045.00,N/A,724.08,N/A,87.85,N/A,87.85,N/A,724.08,N/A,1045.00,N/A,17.99,N/A,19.80,N/A,N/A,17.99,2018.33,,Hospital A6445,"Bandage,Gauze,Conforming,2x75,Strl,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3326.43,N/A,1995.86,N/A,883.38,N/A,2004.25,N/A,N/A,N/A,1391.00,N/A,1391.00,N/A,883.38,N/A,2004.25,N/A,2004.25,N/A,1391.00,N/A,1391.00,N/A,1391.00,N/A,1391.00,N/A,N/A,N/A,2484.13,N/A,883.38,N/A,N/A,N/A,N/A,N/A,883.38,N/A,2004.25,N/A,2004.25,N/A,883.38,N/A,N/A,883.38,2484.13,,Hospital A6447,"Bandage,Gauze,Conforming,6x80,Strl,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2186.48,N/A,1311.89,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,174.53,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,174.53,2004.25,,Hospital A6454,"Dressing,Compression Sys,Coflex,2 Layer",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3067.52,N/A,1840.51,N/A,963.04,N/A,2295.00,N/A,2216.30,N/A,1042.95,N/A,779.77,N/A,429.45,N/A,1050.00,N/A,1050.00,N/A,778.72,N/A,779.77,N/A,779.77,N/A,779.77,N/A,1766.26,N/A,2303.35,N/A,963.04,N/A,143.38,N/A,143.38,N/A,963.04,N/A,760.00,N/A,1485.00,N/A,42.90,N/A,N/A,42.90,2303.35,,Hospital A9150,"Cream,Antifungal,Secura,Greaseless",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1848.68,N/A,1109.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1109.21,1109.21,,Hospital A9270,"Cleanser,Wound,Skintegrity,8oz,Spray",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,52980.93,3150.32,31788.56,1890.19,N/A,1176.63,11478.42,2025.00,N/A,760.00,N/A,1029.46,N/A,1029.46,N/A,1176.63,11478.42,953.00,11478.42,953.00,N/A,1029.46,N/A,1029.46,N/A,1029.46,N/A,1029.46,N/A,1159.00,11478.42,2303.35,N/A,1176.63,N/A,760.00,N/A,648.00,N/A,963.04,11478.42,1140.00,11478.42,1838.74,N/A,1176.63,11478.42,31788.56,648.00,2303.35,,Hospital A9284,"Incentive Spirometer,Post-Surg,2500ml,Ea",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1207.38,N/A,724.43,N/A,N/A,N/A,220.00,N/A,N/A,N/A,410.51,N/A,222.00,N/A,169.03,N/A,220.00,N/A,220.00,N/A,222.00,N/A,222.00,N/A,222.00,N/A,222.00,N/A,695.21,N/A,220.00,N/A,N/A,N/A,3.96,N/A,3.96,N/A,N/A,N/A,220.00,N/A,220.00,N/A,N/A,N/A,N/A,3.96,724.43,,Hospital A9503,Tc99m medronate,N/A,N/A,73852.83,3769.30,44311.70,2261.58,5984.79,527.70,10979.13,743.05,28106.61,2776.81,25109.96,1281.56,30889.97,1854.39,5984.79,527.70,7306.00,743.05,7306.00,743.05,30889.97,1154.39,30889.97,1854.39,31764.17,1854.39,32986.84,1854.39,20409.75,2776.81,10979.13,743.05,9335.63,527.70,24514.79,2218.45,31599.72,2218.45,9335.63,527.70,10979.13,743.05,11584.33,743.05,5984.79,817.36,5984.79,44311.70,527.70,2776.81,,Hospital A9512,Tc99m pertechnetate,N/A,N/A,83809.20,3383.00,50285.52,2029.80,8121.96,473.62,9873.49,97.56,18303.50,1940.48,4928.00,1150.22,4928.00,295.62,8372.21,473.62,8206.30,96.52,9873.49,96.52,4928.00,184.04,4928.00,295.62,4928.00,295.62,4928.00,295.62,18303.50,1940.48,8206.30,96.52,8372.21,473.62,21984.90,1732.89,16950.33,1732.89,9742.00,473.62,9873.49,96.52,9873.49,97.56,8958.27,84.67,4928.00,50285.52,84.67,2029.80,,Hospital A9537,Tc99m mebrofenin,N/A,N/A,48214.68,4056.00,28928.81,2433.60,5865.95,567.84,7204.75,455.58,13219.39,2329.48,16392.99,1379.04,13345.85,969.03,6046.69,567.84,7204.75,455.58,7204.75,455.58,8307.48,619.63,13345.85,969.03,13345.85,969.03,13345.85,969.03,13219.39,2329.48,7204.75,455.58,6046.69,567.84,15878.22,2109.70,15878.22,2109.70,5865.95,567.84,7204.75,455.58,2944.53,455.58,6469.96,501.14,2944.53,28928.81,455.58,2433.60,,Hospital A9539,Tc99m pentetate,N/A,N/A,62655.50,4654.92,37593.30,2792.95,7930.45,651.69,9646.96,539.83,17871.91,3554.19,21302.87,1582.67,18042.86,1369.53,8174.80,651.69,9646.96,534.04,9646.96,534.04,11231.26,852.57,18042.86,1369.53,18042.86,1369.53,18042.86,1369.53,17871.91,3554.19,9646.96,534.04,8174.80,651.69,21466.50,2751.52,21466.50,2751.52,8475.40,651.69,9646.96,534.04,9646.96,539.83,8747.03,285.39,7930.45,37593.30,285.39,3554.19,,Hospital A9540,Tc99m MAA,N/A,N/A,62184.20,2945.00,37310.52,1767.00,6827.25,412.30,8460.53,429.45,15385.76,1673.46,20255.10,1001.30,16137.00,1116.50,7037.61,412.30,8341.93,429.45,8341.93,429.45,10045.15,695.05,16137.00,1116.50,16137.00,1116.50,20255.10,1116.50,15385.76,1673.46,8341.93,429.45,7037.61,412.30,18480.31,1338.39,18480.31,1338.39,7037.61,412.30,8341.93,429.45,8341.93,429.45,7530.24,472.39,6827.25,37310.52,412.30,1767.00,,Hospital A9552,F18 fdg,N/A,N/A,72080.00,4727.00,43248.00,2836.20,6827.25,661.56,8341.93,1344.94,15385.76,4028.07,24507.20,1607.18,30674.29,3253.30,6667.21,661.56,5620.00,1344.94,11412.48,1344.94,30674.29,2025.24,30674.29,3253.30,30674.29,3253.30,30674.29,3253.30,13294.20,4028.07,8341.93,1344.94,7037.61,661.56,18480.31,1308.44,18480.31,1308.44,6667.21,661.56,8341.93,1344.94,8341.93,1344.94,7530.24,1479.44,5620.00,43248.00,661.56,4028.07,,Hospital A9557,Tc99m bicisate,N/A,N/A,114234.90,N/A,68540.94,N/A,14400.27,N/A,N/A,N/A,82432.65,N/A,N/A,N/A,N/A,N/A,14400.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,82432.65,N/A,N/A,N/A,14400.27,N/A,82432.65,N/A,82432.65,N/A,14400.27,N/A,N/A,N/A,N/A,N/A,14400.27,N/A,14400.27,82432.65,N/A,N/A,,Hospital A9560,Tc99m labeled rbc,N/A,N/A,68446.65,2733.10,41067.99,1639.86,9484.96,382.63,11485.86,350.99,21457.20,1572.13,23271.85,929.25,13217.19,881.13,3729.23,382.63,11485.86,350.99,11485.86,350.99,13217.19,689.77,13217.19,881.13,13217.19,881.13,21579.59,881.13,21457.20,1572.13,11485.86,350.99,9777.20,382.63,25674.32,1447.74,25674.32,1447.74,3729.23,382.63,11485.86,350.99,11485.86,350.99,10461.61,386.09,3729.23,41067.99,350.99,1639.86,,Hospital A9562,Tc99m mertiatide,N/A,N/A,53412.30,3360.10,32047.38,2016.06,6827.25,470.41,8341.93,455.58,15385.76,1917.79,18160.18,1142.43,16137.00,1105.12,7037.61,470.41,8341.93,455.58,8341.93,455.58,10045.15,687.96,16137.00,1105.12,16137.00,1105.12,16137.00,1105.12,15385.76,1917.79,8341.93,455.58,7037.61,470.41,18480.31,1612.29,18480.31,1612.29,7060.70,470.41,8341.93,455.58,8341.93,455.58,7530.24,501.14,6827.25,32047.38,455.58,2016.06,,Hospital A9585,Gadobutrol injection,N/A,N/A,78788.67,3303.40,47273.20,1982.04,10965.85,462.48,13237.68,332.71,24712.42,1240.66,26788.14,1123.16,46169.61,873.16,10166.90,462.48,2810.00,332.71,2810.00,332.71,46169.61,543.55,46169.61,873.16,46169.61,873.16,46169.61,873.16,24712.42,1240.66,6679.73,332.71,11303.72,462.48,29682.86,1060.00,29682.86,1060.00,11303.72,462.48,13237.68,332.71,13237.68,332.71,12094.98,365.98,2810.00,47273.20,332.71,1982.04,,Hospital HCPCS A9587,GALLIUM GA 68 DOTATATE IV KIT,69488-0001-40,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,10940.00,10940.00,6564.00,6564.00,N/A,1531.60,N/A,10940.00,N/A,5755.53,N/A,3719.60,N/A,10940.00,N/A,1531.60,N/A,10940.00,N/A,10940.00,N/A,8957.94,N/A,10940.00,N/A,10940.00,N/A,10940.00,N/A,5755.53,N/A,10940.00,N/A,1531.60,N/A,5863.84,N/A,5863.84,N/A,1531.60,N/A,10940.00,N/A,10940.00,N/A,10940.00,6564.00,6564.00,1531.60,10940.00,,Hospital A9588,Fluciclovine f-18,N/A,N/A,N/A,23774.80,N/A,14264.88,N/A,3328.47,N/A,1359.51,N/A,6463.61,N/A,8083.43,N/A,10177.10,N/A,3328.47,N/A,1344.94,N/A,1344.94,N/A,8990.38,N/A,10177.10,N/A,10177.10,N/A,10177.10,N/A,6463.61,N/A,1344.94,N/A,3328.47,N/A,9032.14,N/A,9032.14,N/A,3328.47,N/A,1344.94,N/A,1359.51,N/A,973.15,N/A,N/A,973.15,14264.88,,Hospital A9595,"Piflu f-18, dia 1 millicurie",N/A,N/A,47185.42,23948.05,28311.25,14368.83,9036.31,3352.73,10955.14,6908.12,20364.07,12614.48,16043.04,8142.34,20558.86,16888.10,9314.74,3352.73,2810.00,6893.42,2810.00,6893.42,12797.41,10513.03,20558.86,16888.10,20558.86,16888.10,20558.86,16888.10,20364.07,12614.48,10955.14,6893.42,9314.74,3352.73,24459.92,2859.02,24459.92,2859.02,9314.74,3352.73,10955.14,6893.42,10955.14,6908.12,9966.77,1083.27,2810.00,28311.25,1083.27,16888.10,,Hospital B4034,"Syringe,Piston,Feed Tray,Blister",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3340.48,N/A,2004.29,N/A,1345.64,N/A,N/A,N/A,N/A,N/A,1135.77,N/A,631.67,N/A,467.67,N/A,N/A,N/A,N/A,N/A,642.83,N/A,631.67,N/A,631.67,N/A,631.67,N/A,1923.45,N/A,N/A,N/A,1345.64,N/A,428.80,N/A,428.80,N/A,1345.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,428.80,2004.29,,Hospital B4035,"Set,Feed,Flush,Kangaroo Joey,1000ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,8894.52,N/A,5336.71,N/A,N/A,N/A,208.20,N/A,N/A,N/A,3024.14,N/A,1519.23,N/A,1245.23,N/A,N/A,N/A,N/A,N/A,1771.63,N/A,1519.23,N/A,1519.23,N/A,1519.23,N/A,5121.45,N/A,N/A,N/A,N/A,N/A,1500.80,N/A,1500.80,N/A,N/A,N/A,N/A,N/A,208.20,N/A,229.02,N/A,N/A,208.20,5336.71,,Hospital C1052,HC Hemostatic Agent GI Topical,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,112139.00,42882.03,67283.40,25729.22,8204.65,5980.74,7731.25,4602.87,61811.02,2552.00,38127.26,14579.90,19392.64,4461.35,8457.45,5980.74,7731.25,3855.45,7731.25,3855.45,31405.94,2777.93,19392.64,4461.35,19392.64,4461.35,31405.94,4461.35,61811.02,2552.00,7731.25,3855.45,8457.45,5980.74,22208.72,2806.50,22208.72,2806.50,10419.49,5980.74,7731.25,3855.45,14092.38,4602.87,9049.47,892.32,7731.25,67283.40,892.32,25729.22,,Hospital C1713,HC Misc Anchor,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,89286.77,55707.85,53572.06,33424.71,12760.07,7770.68,17170.99,11782.94,44582.88,31891.50,30357.50,18940.66,35998.34,28550.44,13153.23,7770.68,17170.99,11782.94,17170.99,11782.94,44007.55,17773.20,35998.34,28550.44,35998.34,28550.44,35998.34,28550.44,44582.88,31891.52,17170.99,11782.94,13153.23,7770.68,42829.04,10309.75,42829.04,10309.75,16887.40,7770.68,17170.99,11782.94,17170.99,11782.94,14073.95,12961.23,12760.07,53572.06,7770.68,33424.71,,Hospital C1714,"HC Misc Cath, Trans Atherectomy, Dir",N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,146349.92,87850.53,87809.95,52710.32,18584.75,12243.24,23373.11,15680.06,80668.07,50365.76,26288.71,29869.17,26288.71,37543.88,19157.38,12243.24,22250.45,15512.06,22250.45,15512.06,26288.71,23371.79,43927.23,37543.88,26288.71,37543.88,43927.23,37543.88,80668.07,50365.77,22250.45,15512.06,19157.38,12243.24,50306.07,15608.50,50306.07,15608.50,3503.20,12243.24,22250.45,15512.06,22250.45,15680.06,20498.40,1317.13,3503.20,87809.95,1317.13,52710.32,,Hospital C1719,"Brachytx Sour,Non-Hdr IR-192",N/A,N/A,N/A,30663.60,N/A,18398.16,N/A,4283.89,N/A,5614.02,N/A,17650.43,N/A,10425.62,N/A,13008.72,N/A,4283.89,N/A,5366.90,N/A,5366.90,N/A,8098.17,N/A,13008.72,N/A,13008.72,N/A,13008.72,N/A,17650.43,N/A,5366.90,N/A,4283.89,N/A,12390.50,N/A,12390.50,N/A,4283.89,N/A,5366.90,N/A,5614.02,N/A,1939.53,N/A,N/A,1939.53,18398.16,,Hospital C1722,HC Misc Cardio-Defib Generator Sgl,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,290464.13,154530.83,174278.48,92718.50,46302.32,21634.31,41577.28,12026.03,128524.33,87436.15,103282.43,52540.48,103282.43,22591.12,46302.32,21634.31,41577.28,11905.80,41577.28,11905.80,103282.43,14063.40,103282.43,22591.12,103282.43,22591.12,103282.43,22591.12,128524.33,87436.16,41577.28,11905.80,38983.44,21634.31,128524.33,11660.00,149604.91,11660.00,46302.32,21634.31,41577.28,11905.80,41577.28,474.20,46302.32,521.62,38983.44,174278.48,474.20,92718.50,,Hospital C1724,HC Cath Trans Atherec Rotation,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,203316.22,67603.83,121989.73,40562.30,14277.58,9390.55,19168.37,9586.05,112067.90,38648.43,69127.51,22985.31,70794.71,23345.00,16755.25,9390.55,19168.37,9586.05,19168.37,9586.05,44078.96,14532.70,70794.71,23345.00,70794.71,23345.00,70794.71,23345.00,112067.90,38648.43,19168.37,9586.05,16755.25,9390.55,108139.90,11660.00,108139.90,11660.00,13460.92,9390.55,19168.37,9586.05,19168.37,9586.05,17928.12,10544.65,13460.92,121989.73,9390.55,40562.30,,Hospital C1727,HC Cath Balloon Dissector Non Vasc,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,103259.93,39326.38,61955.96,23595.83,8843.20,5499.96,10726.69,418.36,29408.74,22527.13,35105.49,13370.97,20119.50,11494.68,9115.67,5499.96,562.00,4706.78,562.00,4706.78,12523.92,7155.66,20119.50,11494.68,20119.50,11494.68,20119.50,11494.68,29408.74,22527.14,10726.69,4706.78,9115.67,5499.96,23937.19,10178.00,23937.19,10178.00,9115.67,5499.96,10726.69,4706.78,10726.69,418.36,9753.77,460.20,562.00,61955.96,418.36,23595.83,,Hospital C1730,HC Cath Ep 19 or Few Elect,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,154878.93,77663.25,92927.36,46597.95,21407.83,10857.46,25590.01,21204.54,85369.27,44450.80,52658.84,26405.50,50599.92,51629.77,22067.44,10857.46,2810.00,21204.54,2810.00,21204.54,31498.04,32140.53,50599.92,51629.77,50599.92,51629.77,50599.92,51629.77,85369.27,44450.82,25590.01,21204.54,22067.44,10857.46,57947.72,16900.50,57947.72,16900.50,4994.08,10857.46,25590.01,21204.54,25590.01,21204.54,23612.17,23325.00,2810.00,92927.36,10857.46,51629.77,,Hospital C1731,HC Cath Ep 20 or More Elec,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,133314.13,151764.53,79988.48,91058.72,10440.92,21244.34,12616.71,23391.12,73482.75,86336.67,45326.81,51599.94,23754.54,51415.49,10762.62,21244.34,2248.00,21204.54,2248.00,21204.54,14786.65,32007.13,23754.54,51415.49,23754.54,51415.49,23754.54,51415.49,73482.75,86336.69,12616.71,21204.54,10762.62,21244.34,28261.97,16637.00,28261.97,16637.00,10762.62,21244.34,12616.71,21204.54,12616.71,1084.00,11516.01,1192.41,2248.00,79988.48,1084.00,91058.72,,Hospital C1755,"HC Misc Catheter, Intraspinal",N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,116478.82,72443.42,69887.29,43466.05,N/A,10142.08,N/A,16000.41,30602.73,41107.79,N/A,24630.77,N/A,37110.47,N/A,10142.08,N/A,15296.11,N/A,15296.11,N/A,23101.98,N/A,37110.47,N/A,37110.47,N/A,37110.47,30602.73,41107.78,N/A,15296.11,N/A,10142.08,17553.26,40081.50,30602.73,40081.50,N/A,10142.08,N/A,15296.11,N/A,16000.41,N/A,820.33,17553.26,69887.29,820.33,43466.05,,Hospital C1758,HC Misc Cath Ureteral,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,53903.27,22342.08,32341.96,13405.25,8862.41,3105.14,10749.41,4256.56,20854.67,12848.13,18327.11,7596.32,20163.20,10323.77,9135.47,3105.14,10749.41,4246.26,10749.41,4246.26,13082.47,6426.74,17127.73,10323.77,17127.73,10323.77,17127.73,10323.77,20854.67,12848.14,10749.41,4246.26,9135.47,3105.14,23989.17,5963.00,23989.17,5963.00,8303.39,3105.14,10749.41,4256.56,10749.41,4256.56,9774.95,4682.21,8303.39,32341.96,3105.14,13405.25,,Hospital C1761,HC Cath Translum Intravascular Lithotripsy Coronary,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,139105.67,105254.37,83463.40,63152.62,15979.32,14711.10,19168.37,24680.24,N/A,11012.00,47295.92,35786.50,N/A,32433.11,16471.67,14711.10,19168.37,18060.92,22194.00,18060.92,23510.89,20270.43,37769.00,32433.11,N/A,32433.11,37769.00,32433.11,76675.04,11012.00,19168.37,18060.92,16471.67,14711.10,43253.58,18980.75,43253.58,18980.75,2236.91,14711.10,19168.37,18060.92,19168.37,24680.24,17624.69,908.13,2236.91,83463.40,908.13,63152.62,,Hospital C1762,HC Graft Human,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,167626.90,65395.67,100576.14,39237.40,48837.38,9155.40,58037.75,6178.06,67103.82,7823.00,56993.15,22231.30,111111.81,14932.43,50342.15,9155.40,1686.00,5973.28,1686.00,5973.28,69164.51,9295.71,111111.81,14932.43,111111.81,14932.43,111111.81,14932.43,92395.95,7823.00,58037.75,5973.28,50342.15,9155.40,132195.31,8612.50,132195.31,8612.50,7222.42,9155.40,58037.75,5973.28,58037.75,6178.06,53866.10,1082.12,1686.00,132195.31,1082.12,39237.40,,Hospital C1763,HC Misc Graft Nonhuman,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,147327.07,51839.52,88396.24,31103.71,24221.84,7257.32,28918.84,5973.28,N/A,11735.00,50091.19,17625.43,38597.66,14547.26,24968.16,7257.32,28918.84,5973.28,28918.84,5973.28,38597.66,9055.96,38597.66,14547.26,38597.66,14547.26,38597.66,14547.26,N/A,11735.00,28918.84,5973.28,24968.16,7257.32,65564.82,13336.25,65564.82,13336.25,3674.01,7257.32,28918.84,5973.28,28918.84,5973.28,26715.93,6570.60,3674.01,88396.24,5973.28,31103.71,,Hospital C1765,HC Misc Adhesion Barrier,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,27510.48,47699.47,16506.29,28619.68,4653.92,6620.38,5771.00,1081.43,10976.54,27411.24,9353.57,16217.81,7322.00,19889.23,4797.32,6620.38,5771.00,8206.20,5771.00,8206.20,4558.00,12381.43,7322.00,19889.23,7322.00,19889.23,7322.00,19889.23,10976.54,27411.25,5771.00,8206.20,4797.32,6620.38,12597.46,7897.00,12597.46,7897.00,5133.13,6620.38,5771.00,8206.20,5771.00,1081.43,5133.13,1189.58,4558.00,16506.29,1081.43,28619.68,,Hospital C1772,HC Misc Infus Pump Programble/Impl,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,116478.82,75458.03,69887.29,45274.82,N/A,10564.12,N/A,15704.66,30602.73,42766.62,N/A,25655.74,N/A,37022.96,N/A,10564.12,N/A,15296.11,N/A,15296.11,N/A,23051.66,N/A,37022.96,N/A,37022.96,N/A,37022.96,30602.73,42766.63,N/A,15296.11,N/A,10564.12,17553.26,37100.00,30602.73,37100.00,N/A,10564.12,N/A,15296.11,N/A,15704.66,N/A,402.69,17553.26,69887.29,402.69,45274.82,,Hospital C1781,HC Misc Mesh,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,61275.78,37750.12,36765.47,22650.07,9148.48,5260.91,11223.06,7955.87,24230.67,21495.45,20833.76,12835.02,21334.42,19317.52,9430.36,5260.91,11223.06,7955.87,11223.06,7955.87,13280.18,12025.55,21334.42,19317.52,21334.42,19317.52,21334.42,19317.52,24230.67,21495.46,11223.06,7955.87,9430.36,5260.91,25382.63,11010.25,25382.63,11010.25,4797.32,5260.91,11223.06,7955.87,11223.06,7955.87,10090.49,8751.45,4797.32,36765.47,5260.91,22650.07,,Hospital C1782,HC Morcellator,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,N/A,42565.22,N/A,25539.13,N/A,5946.87,N/A,4684.12,N/A,24500.11,N/A,14472.17,N/A,10306.84,N/A,5946.87,N/A,4246.26,N/A,4246.26,N/A,6416.20,N/A,10306.84,N/A,10306.84,N/A,10306.84,N/A,22880.40,N/A,4246.26,N/A,5946.87,N/A,5963.00,N/A,5963.00,N/A,5946.87,N/A,4246.26,N/A,1013.34,N/A,1108.57,N/A,N/A,1013.34,25539.13,,Hospital C1785,HC Misc Pacemaker Dual Rate,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,122726.43,48339.72,73635.86,29003.83,12889.63,6759.77,16093.85,9327.29,N/A,27431.08,N/A,16435.50,N/A,22578.32,12889.63,6759.77,16093.85,9327.29,16093.85,9327.29,N/A,14055.44,N/A,22578.32,N/A,22578.32,N/A,22578.32,N/A,27431.08,24172.64,9327.29,12889.63,6759.77,N/A,11660.00,N/A,11660.00,12889.63,6759.77,16093.85,9327.29,16093.85,9327.29,12889.63,10260.02,12889.63,73635.86,6759.77,29003.83,,Hospital C1787,HC Misc Patient Programmer,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,239202.32,148563.33,143521.39,89138.00,25778.10,20785.30,30815.76,26515.81,131848.31,83950.21,81328.78,50511.55,83290.24,64318.02,22132.62,20785.30,30815.76,26515.81,30815.76,26515.81,26108.86,40039.21,83290.24,64318.02,83290.24,64318.02,83290.24,64318.02,131848.31,83950.21,30815.76,26515.81,22132.62,20785.30,165535.92,42930.00,165535.92,42930.00,19733.80,20785.30,30815.76,26515.81,30815.76,26515.81,23681.90,29167.39,19733.80,165535.92,20785.30,89138.00,,Hospital C1816,"Receiver/transmitter, neuro",N/A,N/A,N/A,73485.80,N/A,44091.48,N/A,10285.16,N/A,20323.84,N/A,41495.22,N/A,24985.17,N/A,47024.20,N/A,10285.16,N/A,19429.23,N/A,19429.23,N/A,29273.47,N/A,47024.20,N/A,47024.20,N/A,47024.20,N/A,41495.22,N/A,19429.23,N/A,10285.16,N/A,43022.75,N/A,43022.75,N/A,10285.16,N/A,19429.23,N/A,20323.84,N/A,907.28,N/A,N/A,907.28,47024.20,,Hospital C1825,HC Generator Neurostim Implantable,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,137670.82,N/A,82602.49,N/A,19273.92,N/A,26060.27,N/A,77934.52,N/A,46808.08,N/A,18045.55,N/A,19273.92,N/A,19612.05,N/A,19612.05,N/A,11221.79,N/A,18045.55,N/A,18045.55,N/A,18045.55,N/A,77902.85,N/A,19612.05,N/A,19273.92,N/A,4562.00,N/A,4562.00,N/A,19273.92,N/A,19612.05,N/A,26060.27,N/A,389.44,N/A,N/A,389.44,82602.49,,Hospital C1830,HC Powered Bone Marrow Biopsy Device,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,101860.98,20385.02,61116.59,12231.01,10656.65,2946.81,32303.13,2320.84,33517.05,9057.60,24559.61,6930.90,24559.61,5645.87,10656.65,2946.81,6182.00,2332.78,6182.00,2332.78,24559.61,3514.66,24559.61,5645.87,24559.61,5645.87,24559.61,5645.87,33517.05,9057.60,10703.67,2332.78,10656.65,2946.81,33517.05,1871.00,28482.64,1871.00,10656.65,2946.81,12928.17,2332.78,13469.64,2320.84,10656.65,1716.55,6182.00,61116.59,1716.55,12231.01,,Hospital C1831,Personalized interbody cage,N/A,N/A,N/A,54515.52,N/A,32709.31,N/A,7614.77,N/A,13564.80,N/A,31229.77,N/A,18535.28,N/A,29007.63,N/A,7614.77,N/A,12499.73,N/A,12499.73,N/A,18057.30,N/A,29007.63,N/A,29007.63,N/A,29007.63,N/A,31229.79,N/A,12499.73,N/A,7614.77,N/A,8292.25,N/A,8292.25,N/A,7614.77,N/A,12499.73,N/A,13564.80,N/A,2215.26,N/A,N/A,2215.26,32709.31,,Hospital C1874,HC Misc Stent Coated/Cvrd W Del Sys,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,107513.62,45493.98,64508.17,27296.39,10186.46,6365.89,12315.69,9586.05,59261.51,11012.00,36554.63,15467.97,24076.89,23605.94,10500.32,6365.89,12315.69,9586.05,12315.69,9586.05,14987.67,14695.13,24076.89,23605.94,24076.89,23605.94,24076.89,23605.94,59261.51,11012.00,12315.69,9586.05,10500.32,6365.89,27573.18,10878.50,27573.18,10878.50,16471.67,6365.89,12315.69,9586.05,12315.69,9586.05,11235.34,10544.65,10186.46,64508.17,6365.89,27296.39,,Hospital C1886,HC Catheter Ablation Extravascular Tissue,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,274482.38,14078.85,164689.43,8447.31,N/A,1971.04,22349.48,1572.73,141436.19,8051.93,161215.59,4786.82,161215.59,3821.37,N/A,1971.04,22349.48,1572.73,22349.48,1572.73,161215.59,2378.88,161215.59,3821.37,161215.59,3821.37,161215.59,3821.37,141436.19,8051.93,22349.48,1572.73,N/A,1971.04,141436.19,1871.00,141436.19,1871.00,N/A,1971.04,22349.48,1572.73,22349.48,1572.73,N/A,1730.00,22349.48,164689.43,1572.73,8447.31,,Hospital C1888,HC Misc Cath Ablat/Non-Card Endovasc,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,93310.22,13449.17,55986.13,8069.50,12504.35,1873.19,15057.65,2690.13,40616.06,7742.01,31725.47,4572.73,29555.50,6520.29,12889.63,1873.19,15057.65,2690.13,15057.65,2690.13,18398.06,4059.00,29555.50,6520.29,29555.50,6520.29,29555.50,6520.29,40616.06,7742.01,15057.65,2690.13,12889.63,1873.19,33847.36,4562.00,33847.36,4562.00,N/A,1873.19,15057.65,2690.13,15057.65,2690.13,13791.91,2959.14,12504.35,55986.13,1873.19,8069.50,,Hospital C1894,HC Misc Introducer/Sheath,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,110491.10,28246.72,66294.66,16948.03,9104.48,3863.53,28689.94,4729.36,60902.67,16201.85,37566.97,9603.88,55809.05,11448.79,13792.57,3863.53,28689.94,4709.71,28689.94,4709.71,5479.99,7127.10,55809.05,11448.79,55809.05,11448.79,55809.05,11448.79,60902.67,16201.86,28684.91,4709.71,13792.57,3863.53,28728.00,7897.00,28728.00,7897.00,10710.31,3863.53,28689.94,4729.36,28689.94,4729.36,14758.05,5202.31,5479.99,66294.66,3863.53,16948.03,,Hospital C1896,HC Misc Icd Lead Single or Dual,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,323289.50,195597.53,193973.70,117358.52,N/A,27275.48,41577.28,29568.60,N/A,111448.47,233130.44,66503.15,233130.44,70124.88,N/A,27275.48,40659.05,28966.21,40659.05,28966.21,233130.44,43654.11,233130.44,70124.88,233130.44,70124.88,233130.44,70124.88,N/A,111448.47,41577.28,28966.21,N/A,27275.48,N/A,29766.00,N/A,29766.00,N/A,27275.48,41577.28,28966.21,41577.28,29568.60,N/A,667.93,40659.05,233130.44,667.93,117358.52,,Hospital C1898,HC Misc Lead Pacemaker Not Vdd Sgl,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,165431.85,54532.23,99259.11,32719.34,12889.63,7621.75,28966.21,9327.29,N/A,30946.86,105105.86,18540.96,105105.86,22616.67,12889.63,7621.75,28966.21,9327.29,28966.21,9327.29,105105.86,14079.31,105105.86,22616.67,105105.86,22616.67,105105.86,22616.67,N/A,30946.87,28966.21,9327.29,12889.63,7621.75,N/A,1431.00,N/A,1431.00,12889.63,7621.75,28966.21,9327.29,28966.21,9327.29,12889.63,10260.02,12889.63,105105.86,1431.00,32719.34,,Hospital C2596,"HC Probe, Robotic, Water-Jet",N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,65939.25,64706.13,39563.55,38823.68,5111.63,9051.74,6312.44,12314.52,11519.48,37253.99,22411.93,22000.10,11629.67,20656.41,5269.13,9051.74,6312.44,10657.93,6312.44,10657.93,7239.20,12856.93,11629.67,20656.41,11629.67,20656.41,11629.67,20656.41,11519.48,37001.81,6312.44,10657.93,5269.13,9051.74,13836.41,5963.00,13836.41,5963.00,N/A,9051.74,6312.44,10657.93,6312.44,12314.52,5637.97,34.46,5111.63,39563.55,34.46,38823.68,,Hospital C2628,HC Misc Catheter Occlusion,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,180290.85,17120.90,108174.51,10272.54,22812.44,2371.67,27251.59,2690.13,99376.32,9856.79,61282.37,5821.10,53919.87,6532.21,23515.33,2371.67,27251.59,2690.13,27251.59,2690.13,33564.68,4066.41,53919.87,6532.21,53919.87,6532.21,53919.87,6532.21,99376.32,9856.79,27251.59,2690.13,23515.33,2371.67,61749.77,4562.00,61749.77,4562.00,9436.08,2371.67,27251.59,2690.13,27251.59,2690.13,25161.40,2959.14,9436.08,108174.51,2371.67,10272.54,,Hospital C2630,HC Cath Ep Cool-Tip Other,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,143149.90,119305.92,85889.94,71583.55,17609.05,16702.19,21096.24,23391.12,78904.22,68082.13,48670.97,40564.01,41621.05,51318.38,18151.61,16702.19,562.00,21204.54,562.00,21204.54,25908.76,31946.68,41621.05,51318.38,41621.05,51318.38,41621.05,51318.38,78904.22,68082.13,21096.24,21204.54,18151.61,16702.19,47665.00,16900.50,47665.00,16900.50,2943.84,16702.19,21096.24,21204.54,21096.24,801.67,19422.23,881.84,562.00,85889.94,801.67,71583.55,,Hospital C2640,HC Brachytx Stranded P 103,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,16568.92,N/A,9941.35,N/A,2305.59,N/A,1346.83,N/A,7110.62,N/A,5633.43,N/A,3130.33,N/A,2305.59,N/A,1299.31,N/A,1299.31,N/A,1948.68,N/A,3130.33,N/A,3130.33,N/A,3130.33,N/A,7110.62,N/A,1299.31,N/A,2305.59,N/A,4043.60,N/A,4043.60,N/A,2305.59,N/A,1305.32,N/A,1346.83,N/A,281.97,N/A,N/A,281.97,9941.35,,Hospital CPT C5275,"HC App Lc,H,H,F,1st 25sqcm or <",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2264.00,2264.00,1358.40,1358.40,N/A,316.96,N/A,538.63,N/A,1303.61,N/A,769.76,N/A,1269.02,N/A,316.96,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,1303.61,N/A,524.62,N/A,316.96,N/A,527.00,N/A,527.00,N/A,316.96,N/A,524.62,N/A,538.63,N/A,2264.00,1358.40,1358.40,316.96,2264.00,,Hospital CPT C5277,"HC App Lc,H,H,F,>= 100 Sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2063.00,2063.00,1237.80,1237.80,N/A,288.82,N/A,578.72,N/A,1187.88,N/A,701.42,N/A,1269.02,N/A,288.82,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,1187.88,N/A,524.62,N/A,288.82,N/A,527.00,N/A,527.00,N/A,288.82,N/A,524.62,N/A,2063.00,N/A,2063.00,1237.80,1237.80,288.82,2063.00,,Hospital CPT C8900,HC Mra Abdomen W/ Contrast,N/A,0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER,3920.00,3920.00,2352.00,2352.00,N/A,548.80,N/A,348.82,N/A,1110.00,N/A,1332.80,N/A,959.52,N/A,548.80,N/A,332.71,N/A,332.71,N/A,597.30,N/A,959.52,N/A,959.52,N/A,959.52,N/A,1110.00,N/A,332.71,N/A,548.80,N/A,1060.00,N/A,1060.00,N/A,548.80,N/A,332.71,N/A,3920.00,N/A,267.88,2352.00,2352.00,267.88,3920.00,,Hospital CPT C8901,HC Mra Abdomen W/O Contrast,N/A,0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER,3136.00,3136.00,1881.60,1881.60,N/A,439.04,N/A,213.16,N/A,1110.00,N/A,1066.24,N/A,959.52,N/A,439.04,N/A,210.88,N/A,210.88,N/A,597.30,N/A,959.52,N/A,959.52,N/A,959.52,N/A,1110.00,N/A,210.88,N/A,439.04,N/A,1060.00,N/A,1060.00,N/A,439.04,N/A,210.88,N/A,213.16,N/A,267.88,1881.60,1881.60,210.88,1881.60,,Hospital CPT C8908,HC MRI Breast W Cont Bilateral,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,332.71,N/A,1110.00,N/A,827.90,N/A,804.78,N/A,340.90,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,332.71,N/A,332.71,N/A,365.98,1461.00,1461.00,332.71,1461.00,,Hospital CPT C8908,HC MRI-Breast Bilat W & WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,332.71,N/A,1110.00,N/A,827.90,N/A,340.90,N/A,340.90,N/A,332.71,N/A,332.71,N/A,211.85,N/A,340.90,N/A,340.90,N/A,340.90,N/A,1110.00,N/A,332.71,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,332.71,N/A,332.71,N/A,2435.00,1461.00,1461.00,211.85,2435.00,,Hospital CPT C8908,HC MRI Breast W&WO Cont Incl Cad Bilateral,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2435.00,2435.00,1461.00,1461.00,N/A,340.90,N/A,332.71,N/A,1110.00,N/A,827.90,N/A,984.60,N/A,340.90,N/A,332.71,N/A,332.71,N/A,612.91,N/A,984.60,N/A,984.60,N/A,984.60,N/A,1110.00,N/A,332.71,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,332.71,N/A,332.71,N/A,365.98,1461.00,1461.00,332.71,1461.00,,Hospital C8909,HC Mra Chest W Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,N/A,4903.00,N/A,2941.80,N/A,686.42,N/A,240.82,N/A,1177.46,N/A,1667.02,N/A,900.61,N/A,686.42,N/A,240.82,N/A,240.82,N/A,560.65,N/A,900.61,N/A,900.61,N/A,900.61,N/A,1177.46,N/A,240.82,N/A,686.42,N/A,1060.00,N/A,1060.00,N/A,686.42,N/A,240.82,N/A,240.82,N/A,300.05,N/A,N/A,240.82,2941.80,,Hospital CPT C8911,HC MRI-Angio Chest WO & W Cont,N/A,0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER,4753.00,2435.00,2851.80,1461.00,N/A,340.90,N/A,348.82,N/A,1110.00,N/A,827.90,N/A,949.89,N/A,340.90,N/A,332.71,N/A,332.71,N/A,591.31,N/A,949.89,N/A,949.89,N/A,949.89,N/A,1110.00,N/A,332.71,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,332.71,N/A,2435.00,N/A,264.90,2851.80,2851.80,264.90,2435.00,,Hospital CPT C8914,HC Mra Lower Ext W/WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,241.43,N/A,1110.00,N/A,827.90,N/A,804.78,N/A,340.90,N/A,241.43,N/A,241.43,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,241.43,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,241.43,N/A,241.43,N/A,2435.00,1963.80,1963.80,241.43,2435.00,,Hospital C8918,HC Mra Pelvis With Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,N/A,6824.00,N/A,4094.40,N/A,955.36,N/A,784.12,N/A,3656.08,N/A,2320.16,N/A,2902.72,N/A,955.36,N/A,763.72,N/A,763.72,N/A,1806.98,N/A,2902.72,N/A,2902.72,N/A,2902.72,N/A,3656.08,N/A,763.72,N/A,955.36,N/A,1060.00,N/A,1060.00,N/A,955.36,N/A,763.72,N/A,784.12,N/A,267.88,N/A,N/A,267.88,4094.40,,Hospital C8924,HC 2-D Tte Lmt W/Contrast,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,73877.33,2410.00,44326.40,1446.00,11268.85,337.40,13596.12,367.02,37110.36,1384.28,25118.29,819.40,25638.20,510.09,11616.07,337.40,2810.00,332.71,2810.00,332.71,15959.18,317.54,25638.20,510.09,25638.20,510.09,25638.20,510.09,37110.36,1384.28,13596.12,332.71,11616.07,337.40,30503.06,1291.76,30503.06,1291.76,11616.07,337.40,13596.12,332.71,13596.12,18.65,12429.19,93.62,2810.00,44326.40,18.65,1446.00,,Hospital CPT C8957,HC Infusion Prolonged Req Pump,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,877.00,877.00,526.20,526.20,N/A,122.78,N/A,300.37,N/A,504.98,N/A,298.18,N/A,726.56,N/A,122.78,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,504.98,N/A,300.37,N/A,122.78,N/A,470.07,N/A,470.07,N/A,122.78,N/A,300.37,N/A,300.37,N/A,330.41,526.20,526.20,122.78,726.56,,Hospital C9047,"Injection, caplacizumab-yhdp",N/A,N/A,472941.50,N/A,283764.90,N/A,68761.50,N/A,57003.71,N/A,260685.35,N/A,160800.11,N/A,164678.23,N/A,63350.37,N/A,4496.00,N/A,4496.00,N/A,102533.72,N/A,164678.23,N/A,164678.23,N/A,164678.23,N/A,260685.35,N/A,57003.71,N/A,63350.37,N/A,336664.43,N/A,336664.43,N/A,60591.41,N/A,57003.71,N/A,57003.71,N/A,67784.89,N/A,4496.00,336664.43,N/A,N/A,,Hospital C9068,"Copper cu-64, dotatate, dx",N/A,N/A,N/A,11903.00,N/A,7141.80,N/A,1614.30,N/A,1511.72,N/A,7650.43,N/A,4047.02,N/A,4588.73,N/A,1614.30,N/A,1511.72,N/A,1511.72,N/A,2855.59,N/A,4588.73,N/A,4588.73,N/A,4588.73,N/A,7650.43,N/A,1511.72,N/A,1614.30,N/A,2059.08,N/A,2059.08,N/A,1614.30,N/A,1511.72,N/A,1511.72,N/A,1662.90,N/A,N/A,1511.72,7650.43,,Hospital C9085,Inj avalglucosid alfa-ngpt,N/A,N/A,N/A,278245.70,N/A,166947.42,N/A,38954.40,N/A,509.41,N/A,156451.58,N/A,94603.54,N/A,39937.42,N/A,38954.40,N/A,486.99,N/A,486.99,N/A,24819.58,N/A,39937.42,N/A,39937.42,N/A,39937.42,N/A,155687.50,N/A,486.99,N/A,38954.40,N/A,149139.70,N/A,149139.71,N/A,38954.40,N/A,486.99,N/A,509.41,N/A,168.75,N/A,N/A,168.75,166947.42,,Hospital C9132,"Kcentra, per i.u.",N/A,N/A,486040.22,N/A,291624.13,N/A,N/A,N/A,56872.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,46349.37,N/A,46349.37,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,46349.37,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,46349.37,N/A,46349.37,N/A,N/A,N/A,46349.37,291624.13,N/A,N/A,,Hospital C9147,"Injection, tremelimumab-actl, 1 mg",N/A,N/A,N/A,269388.02,N/A,161632.81,N/A,37714.32,N/A,183.07,N/A,151492.17,N/A,91591.93,N/A,58554.63,N/A,37714.32,N/A,12325.75,N/A,12325.75,N/A,36421.32,N/A,58554.63,N/A,58554.63,N/A,58554.63,N/A,151492.18,N/A,12325.75,N/A,37714.32,N/A,144391.98,N/A,144391.98,N/A,37714.32,N/A,12325.75,N/A,183.07,N/A,201.37,N/A,N/A,183.07,161632.81,,Hospital C9354,HC Veritas Collagen Matrix per Sq Cm,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,110211.18,N/A,66126.71,N/A,8843.20,N/A,10785.99,N/A,60748.41,N/A,37471.81,N/A,20119.50,N/A,9115.67,N/A,155112.00,N/A,155112.00,N/A,12523.92,N/A,20119.50,N/A,20119.50,N/A,20119.50,N/A,60748.41,N/A,10726.69,N/A,9115.67,N/A,23937.19,N/A,23937.19,N/A,9115.67,N/A,10726.69,N/A,10785.99,N/A,9753.77,N/A,8843.20,155112.00,N/A,N/A,,Hospital HCPCS C9399,SUGAMMADEX SODIUM 200 MG/2ML IV SOLN,00006-5423-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),779.10,779.10,467.46,467.46,N/A,109.07,N/A,779.10,N/A,438.01,N/A,264.89,N/A,109.07,N/A,109.07,N/A,779.10,N/A,779.10,N/A,67.78,N/A,109.07,N/A,109.07,N/A,109.07,N/A,438.01,N/A,779.10,N/A,109.07,N/A,417.60,N/A,417.60,N/A,109.07,N/A,779.10,N/A,779.10,N/A,779.10,467.46,467.46,67.78,779.10,,Hospital HCPCS C9399,SUGAMMADEX SODIUM 500 MG/5ML IV SOLN,00006-5425-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1427.00,1427.00,856.20,856.20,N/A,199.78,N/A,1427.00,N/A,802.26,N/A,485.18,N/A,199.78,N/A,199.78,N/A,1427.00,N/A,1427.00,N/A,124.15,N/A,199.78,N/A,199.78,N/A,199.78,N/A,802.26,N/A,1427.00,N/A,199.78,N/A,764.87,N/A,764.87,N/A,199.78,N/A,1427.00,N/A,1427.00,N/A,1427.00,856.20,856.20,124.15,1427.00,,Hospital CPT C9600,HC Perc Drug-El Cor Stent Sing,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,10832.00,10832.00,6499.20,6499.20,N/A,1516.48,N/A,9586.05,N/A,6237.07,N/A,3682.88,N/A,10832.00,N/A,1516.48,N/A,9586.05,N/A,9586.05,N/A,10832.00,N/A,10832.00,N/A,10832.00,N/A,10832.00,N/A,6237.07,N/A,9586.05,N/A,1516.48,N/A,11660.00,N/A,11660.00,N/A,1516.48,N/A,9586.05,N/A,9586.05,N/A,10544.65,6499.20,6499.20,1516.48,11660.00,,Hospital CPT C9601,HC Perc Drug-El Cor Stent Bran,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,16483.00,16483.00,9889.80,9889.80,N/A,2307.62,N/A,16483.00,N/A,9490.91,N/A,5604.22,N/A,16483.00,N/A,2307.62,N/A,16483.00,N/A,16483.00,N/A,16483.00,N/A,16483.00,N/A,16483.00,N/A,16483.00,N/A,9490.91,N/A,16483.00,N/A,2307.62,N/A,527.00,N/A,527.00,N/A,2307.62,N/A,16483.00,N/A,16483.00,N/A,16483.00,9889.80,9889.80,527.00,16483.00,,Hospital C9606,HC Perc D-E Cor Revasc W Ami S,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,113739.42,N/A,68243.65,N/A,10186.46,N/A,12315.69,N/A,62693.17,N/A,38671.40,N/A,24076.89,N/A,10500.32,N/A,12315.69,N/A,12315.69,N/A,14987.67,N/A,24076.89,N/A,24076.89,N/A,24076.89,N/A,62693.17,N/A,12315.69,N/A,10500.32,N/A,27573.18,N/A,27573.18,N/A,20529.41,N/A,12315.69,N/A,12315.69,N/A,11235.34,N/A,10186.46,68243.65,N/A,N/A,,Hospital C9608,HC Perc D-E Cor Revasc Chro Add,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,124595.48,N/A,74757.29,N/A,10186.46,N/A,12315.69,N/A,68677.03,N/A,42362.47,N/A,24076.89,N/A,10500.32,N/A,1686.00,N/A,1686.00,N/A,N/A,N/A,24076.89,N/A,24076.89,N/A,24076.89,N/A,68677.03,N/A,12315.69,N/A,10500.32,N/A,27573.18,N/A,27573.18,N/A,N/A,N/A,12315.69,N/A,12315.69,N/A,11235.34,N/A,1686.00,74757.29,N/A,N/A,,Hospital C9739,Cystoscopy prostatic imp 1-3,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34319.33,N/A,20591.60,N/A,4804.70,N/A,4441.77,N/A,19574.23,N/A,10128.72,N/A,10304.24,N/A,4804.70,N/A,4246.26,N/A,4246.26,N/A,6414.59,N/A,10304.24,N/A,10304.24,N/A,10304.24,N/A,19574.23,N/A,4246.26,N/A,4804.70,N/A,5095.50,N/A,5095.50,N/A,4804.70,N/A,4246.26,N/A,4441.77,N/A,185.50,N/A,N/A,185.50,20591.60,,Hospital C9753,Intraosseous destruct add'l,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81448.58,N/A,48869.15,N/A,11402.80,N/A,N/A,N/A,46494.21,N/A,27692.51,N/A,5184.73,N/A,11402.80,N/A,N/A,N/A,N/A,N/A,3221.98,N/A,5184.73,N/A,5184.73,N/A,5184.73,N/A,46494.20,N/A,N/A,N/A,11402.80,N/A,26834.39,N/A,26834.39,N/A,11402.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3221.98,48869.15,,Hospital C9761,"Cysto, litho, vacuum kidney",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47922.68,N/A,28753.61,N/A,6703.66,N/A,8220.71,N/A,27572.67,N/A,16293.71,N/A,18718.44,N/A,6703.66,N/A,7727.79,N/A,7727.79,N/A,11652.58,N/A,18718.44,N/A,18718.44,N/A,18718.44,N/A,27572.66,N/A,7727.79,N/A,6703.66,N/A,9793.75,N/A,9793.75,N/A,6703.66,N/A,7727.79,N/A,8220.71,N/A,470.41,N/A,N/A,470.41,28753.61,,Hospital CPT C9764,HC Revasc Intravasc Lithotripsy,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,26928.00,26928.00,16156.80,16156.80,N/A,3769.92,N/A,10027.43,N/A,15505.14,N/A,9155.52,N/A,23187.86,N/A,3769.92,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,23187.86,N/A,23187.86,N/A,23187.86,N/A,15505.14,N/A,9586.05,N/A,3769.92,N/A,7897.00,N/A,7897.00,N/A,3769.92,N/A,9586.05,N/A,10027.43,N/A,26928.00,16156.80,16156.80,3769.92,26928.00,,Hospital C9770,"Vitrec/mech pars, subret inj",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39869.68,N/A,23921.81,N/A,5576.08,N/A,3.28,N/A,22953.29,N/A,13241.75,N/A,3770.07,N/A,5576.08,N/A,3386.85,N/A,3386.85,N/A,3762.69,N/A,3770.07,N/A,3770.07,N/A,3770.07,N/A,22953.29,N/A,3386.85,N/A,5576.08,N/A,5963.00,N/A,5963.00,N/A,5576.08,N/A,3386.85,N/A,3.28,N/A,3.61,N/A,N/A,3.28,23921.81,,Hospital C9771,Nsl/sins cryo post nasal tis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14053.20,N/A,8431.92,N/A,1967.44,N/A,4821.94,N/A,8089.66,N/A,4778.08,N/A,11707.99,N/A,1967.44,N/A,4821.94,N/A,4821.94,N/A,7288.43,N/A,11707.99,N/A,11707.99,N/A,11707.99,N/A,8089.66,N/A,4821.94,N/A,1967.44,N/A,3397.00,N/A,3397.00,N/A,1967.44,N/A,4821.94,N/A,4821.94,N/A,5304.13,N/A,N/A,1967.44,11707.99,,Hospital HCPCS D9223,PR Deep Sedation/General Anesthesia - Ea 15 Min Increment,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital E0749,HC Elec Osteogen Stim Implanted,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,213288.88,150068.03,127973.33,90040.82,20190.86,21009.51,10726.75,12027.98,117564.84,85167.77,72518.22,51023.13,74267.19,28560.41,16715.81,21009.51,562.00,11902.60,562.00,11902.60,46241.03,17779.40,74267.19,28560.41,74267.19,28560.41,74267.19,28560.41,117564.84,85167.77,10726.75,11902.60,16715.81,21009.51,140135.16,7897.00,140135.16,7897.00,15204.14,21009.51,10726.75,11902.60,10726.75,12027.98,17885.92,1064.25,562.00,140135.16,1064.25,90040.82,,Hospital CPT G0009,HC Admin Pneumococcal Vaccine,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,40.55,N/A,70.25,N/A,41.48,N/A,122.00,N/A,17.08,N/A,38.26,N/A,38.26,N/A,91.74,N/A,122.00,N/A,122.00,N/A,122.00,N/A,70.25,N/A,38.26,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,38.26,N/A,40.70,N/A,122.00,73.20,73.20,17.08,122.00,,Hospital CPT G0123,HC Screen Cerv/Vag Thin Layer,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,56.00,48.00,33.60,28.80,N/A,20.26,N/A,20.26,N/A,48.00,N/A,16.32,N/A,17.22,N/A,20.26,N/A,20.26,N/A,20.26,N/A,17.22,N/A,17.22,N/A,17.22,N/A,17.22,N/A,27.64,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,22.29,33.60,33.60,16.32,48.00,,Hospital G0127,HC Trim Dystrophic Nails,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,314.00,N/A,188.40,N/A,43.96,N/A,55.22,N/A,180.80,N/A,106.76,N/A,N/A,N/A,43.96,N/A,51.91,N/A,51.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,180.80,N/A,51.91,N/A,43.96,N/A,168.30,N/A,168.30,N/A,43.96,N/A,51.91,N/A,55.22,N/A,23.86,N/A,N/A,23.86,188.40,,Hospital G0151,Pt Routine Visit,N/A,0421 - PHYSICAL THERAPY - VISIT,N/A,2514.73,N/A,1508.84,N/A,987.70,N/A,1215.00,N/A,828.60,N/A,925.52,N/A,925.52,N/A,987.70,N/A,1301.00,N/A,1301.00,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,960.00,N/A,2085.92,N/A,987.70,N/A,872.00,N/A,800.00,N/A,1152.16,N/A,760.00,N/A,2052.78,N/A,987.70,N/A,N/A,760.00,2085.92,,Hospital G0152,Ot Initial Visit,N/A,0431 - OCCUPATIONAL THERAPY - VISIT,N/A,2604.98,N/A,1562.99,N/A,1359.98,N/A,1890.00,N/A,1149.48,N/A,1246.91,N/A,1605.00,N/A,1359.98,N/A,1453.00,N/A,1453.00,N/A,1246.91,N/A,1246.91,N/A,1246.91,N/A,1246.91,N/A,1132.00,N/A,2327.67,N/A,1359.98,N/A,1132.00,N/A,1100.00,N/A,1251.36,N/A,1100.00,N/A,2158.36,N/A,1359.98,N/A,N/A,1100.00,2327.67,,Hospital G0155,Msw Routine Visit,N/A,0561 - HOME HEALTH (HH) - MEDICAL SOCIAL SERVICES - VISIT CHARGE,N/A,7073.62,N/A,4244.17,N/A,1789.59,N/A,2160.00,N/A,3899.07,N/A,2405.03,N/A,990.31,N/A,990.31,N/A,1567.29,N/A,1567.29,N/A,615.52,N/A,990.31,N/A,990.31,N/A,990.31,N/A,4073.01,N/A,2131.68,N/A,1789.59,N/A,1839.15,N/A,1839.15,N/A,1789.59,N/A,1370.00,N/A,2224.27,N/A,1789.59,N/A,N/A,615.52,4244.17,,Hospital G0157,Pt Pta Routine Visit,N/A,0421 - PHYSICAL THERAPY - VISIT,N/A,2593.67,N/A,1556.20,N/A,1183.65,N/A,1215.00,N/A,828.60,N/A,925.52,N/A,925.52,N/A,42.30,N/A,1448.00,N/A,1448.00,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,1011.00,N/A,2086.65,N/A,1183.65,N/A,872.00,N/A,800.00,N/A,1251.36,N/A,950.00,N/A,2052.78,N/A,1183.65,N/A,N/A,42.30,2086.65,,Hospital G0158,Ot Cota Routine Visit,N/A,0431 - OCCUPATIONAL THERAPY - VISIT,N/A,2848.47,N/A,1709.08,N/A,1710.41,N/A,2295.00,N/A,1532.64,N/A,1857.49,N/A,1857.49,N/A,1710.41,N/A,1419.00,N/A,1419.00,N/A,1857.49,N/A,1857.49,N/A,1857.49,N/A,1857.49,N/A,1532.64,N/A,2366.06,N/A,1710.41,N/A,1532.64,N/A,1532.64,N/A,1710.41,N/A,1100.00,N/A,2540.27,N/A,1710.41,N/A,N/A,1100.00,2540.27,,Hospital G0202,Scr mammo bi incl cad,N/A,N/A,N/A,2165.00,N/A,1299.00,N/A,303.10,N/A,45.70,N/A,876.11,N/A,736.10,N/A,297.36,N/A,303.10,N/A,117.57,N/A,117.57,N/A,185.12,N/A,297.36,N/A,297.36,N/A,297.36,N/A,876.11,N/A,117.57,N/A,303.10,N/A,944.58,N/A,944.58,N/A,303.10,N/A,117.57,N/A,45.70,N/A,50.28,N/A,N/A,45.70,1299.00,,Hospital G0237,HC Therapeutic Excercise/Imt,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,67263.02,2802.00,40357.81,1681.20,12504.35,392.28,15057.65,178.39,39210.74,1613.41,22869.43,952.68,29555.50,1094.78,12889.63,392.28,15057.65,452.65,15057.65,452.65,18398.06,681.52,29555.50,1094.78,29555.50,1094.78,29555.50,1094.78,39210.74,1613.41,15057.65,452.65,12889.63,392.28,33847.36,1501.86,33847.36,1501.86,N/A,392.28,15057.65,452.65,15057.65,178.39,13791.91,196.21,12504.35,40357.81,178.39,1681.20,,Hospital G0238,HC Educ/Instruc 1-1 15min,N/A,0419 - RESPIRATORY SERVICES - OTHER RESPIRATORY SERVICES,55141.45,1514.00,33084.87,908.40,4673.13,211.96,5793.71,346.80,10531.27,871.76,18748.09,513.06,10632.01,811.01,4817.11,211.96,5793.71,335.30,5793.71,335.30,6618.18,504.85,10632.01,811.01,10632.01,811.01,10632.01,811.01,10531.27,868.88,5793.71,335.30,4817.11,211.96,12649.44,808.82,12649.44,808.82,4817.11,211.96,5793.71,335.30,5793.71,346.80,5154.31,131.92,4673.13,33084.87,131.92,908.40,,Hospital CPT G0269,"HC Occl Dev in Vein Art, Angioseal, Vasc Plug",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2487.00,2487.00,1492.20,1492.20,N/A,348.18,N/A,2487.00,N/A,1432.01,N/A,845.58,N/A,2487.00,N/A,348.18,N/A,2487.00,N/A,2487.00,N/A,2487.00,N/A,2487.00,N/A,2487.00,N/A,2487.00,N/A,1432.01,N/A,2487.00,N/A,348.18,N/A,527.00,N/A,527.00,N/A,348.18,N/A,2487.00,N/A,2487.00,N/A,2487.00,1492.20,1492.20,348.18,2487.00,,Hospital CPT G0277,"HC Hbo,W/Press,Fullbdy Chmb,30min",N/A,0413 - RESPIRATORY SERVICES - HYPERBARIC OXYGEN THERAPY,1277.00,1277.00,766.20,766.20,N/A,178.78,N/A,112.94,N/A,735.30,N/A,434.18,N/A,273.19,N/A,178.78,N/A,112.94,N/A,112.94,N/A,170.07,N/A,273.19,N/A,273.19,N/A,273.19,N/A,735.30,N/A,112.94,N/A,178.78,N/A,684.47,N/A,684.47,N/A,178.78,N/A,112.94,N/A,112.94,N/A,124.24,766.20,766.20,112.94,766.20,,Hospital G0281,HC Pt E-Stim Stage III/IV Wound,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,N/A,64078.72,N/A,38447.23,N/A,8991.30,N/A,12325.48,N/A,36719.25,N/A,21786.78,N/A,28648.57,N/A,8991.30,N/A,11782.94,N/A,11782.94,N/A,17836.32,N/A,28648.57,N/A,28648.57,N/A,28648.57,N/A,36719.25,N/A,11782.94,N/A,8991.30,N/A,12375.50,N/A,12375.50,N/A,8991.30,N/A,11782.94,N/A,12325.48,N/A,906.85,N/A,N/A,906.85,38447.23,,Hospital G0282,Elect Stim Wound Care Not Pd,N/A,N/A,N/A,77234.80,N/A,46340.88,N/A,10812.86,N/A,10838.16,N/A,43721.61,N/A,26259.82,N/A,11604.00,N/A,10812.86,N/A,10478.88,N/A,10478.88,N/A,11604.00,N/A,11604.00,N/A,11604.00,N/A,11604.00,N/A,43721.61,N/A,10478.88,N/A,10812.86,N/A,41397.80,N/A,41397.80,N/A,10812.86,N/A,10478.88,N/A,10838.16,N/A,1233.76,N/A,N/A,1233.76,46340.88,,Hospital CPT G0288,HC Cta for Mms,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,3120.00,1426.00,1872.00,855.60,N/A,199.64,N/A,1426.00,N/A,914.00,N/A,484.84,N/A,189.77,N/A,199.64,N/A,1426.00,N/A,1426.00,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,914.00,N/A,1426.00,N/A,199.64,N/A,689.00,N/A,689.00,N/A,199.64,N/A,1426.00,N/A,1426.00,N/A,86.30,1872.00,1872.00,86.30,1426.00,,Hospital CPT G0288,HC Recon Cta Aorta/Vas Surg,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,3120.00,1426.00,1872.00,855.60,N/A,199.64,N/A,1426.00,N/A,914.00,N/A,484.84,N/A,1426.00,N/A,199.64,N/A,1426.00,N/A,1426.00,N/A,1426.00,N/A,1426.00,N/A,1426.00,N/A,1426.00,N/A,914.00,N/A,1426.00,N/A,199.64,N/A,689.00,N/A,689.00,N/A,199.64,N/A,1426.00,N/A,1426.00,N/A,1426.00,1872.00,1872.00,199.64,1426.00,,Hospital G0296,HC Counseling Visit for Ldct-Pbb,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,394.00,N/A,236.40,N/A,55.16,N/A,188.96,N/A,226.87,N/A,133.96,N/A,31.08,N/A,55.16,N/A,177.64,N/A,177.64,N/A,31.08,N/A,31.08,N/A,31.08,N/A,31.08,N/A,226.87,N/A,177.64,N/A,55.16,N/A,211.19,N/A,211.19,N/A,55.16,N/A,177.64,N/A,188.96,N/A,27.67,N/A,N/A,27.67,236.40,,Hospital G0297,HC CT Chest Screening Low Dose Wout Cont,N/A,0352 - CT SCAN - BODY SCAN,N/A,158.00,N/A,94.80,N/A,22.12,N/A,31.60,N/A,158.00,N/A,53.72,N/A,22.12,N/A,22.12,N/A,31.60,N/A,31.60,N/A,13.75,N/A,22.12,N/A,22.12,N/A,22.12,N/A,158.00,N/A,31.60,N/A,22.12,N/A,158.00,N/A,158.00,N/A,22.12,N/A,31.60,N/A,31.60,N/A,N/A,N/A,N/A,13.75,158.00,,Hospital G0299,Rn Routine Visit,N/A,0551 - HOME HEALTH (HH) - SKILLED NURSING - VISIT CHARGE,N/A,3007.40,N/A,1804.44,N/A,964.10,N/A,1215.00,N/A,1043.60,N/A,899.84,N/A,856.00,N/A,135.46,N/A,1055.00,N/A,1055.00,N/A,899.84,N/A,899.84,N/A,899.84,N/A,749.00,N/A,1100.00,N/A,2040.83,N/A,964.10,N/A,900.00,N/A,900.00,N/A,842.66,N/A,855.00,N/A,2052.78,N/A,964.10,N/A,N/A,135.46,2052.78,,Hospital CPT G0378,HC Observation per Hour Carve Out,N/A,0762 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM (A),43.00,43.00,25.80,25.80,N/A,6.02,N/A,43.00,N/A,24.76,N/A,14.62,N/A,43.00,N/A,6.02,N/A,43.00,N/A,43.00,N/A,43.00,N/A,43.00,N/A,43.00,N/A,43.00,N/A,24.76,N/A,43.00,N/A,6.02,N/A,23.05,N/A,23.05,N/A,6.02,N/A,43.00,N/A,43.00,N/A,43.00,25.80,25.80,6.02,43.00,,Hospital CPT G0378,HC Observation per Hour,N/A,0762 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM (A),43.00,43.00,25.80,25.80,N/A,6.02,N/A,43.00,N/A,24.76,N/A,14.62,N/A,43.00,N/A,6.02,N/A,43.00,N/A,43.00,N/A,43.00,N/A,43.00,N/A,43.00,N/A,43.00,N/A,24.76,N/A,43.00,N/A,6.02,N/A,23.05,N/A,23.05,N/A,6.02,N/A,43.00,N/A,43.00,N/A,43.00,25.80,25.80,6.02,43.00,,Hospital G0380,HC B-Level 1 Em,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT G0399,HC Home Sleep Study Type III,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,855.00,855.00,513.00,513.00,N/A,119.70,N/A,131.33,N/A,492.31,N/A,290.70,N/A,317.67,N/A,119.70,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,492.31,N/A,131.33,N/A,119.70,N/A,458.28,N/A,458.28,N/A,119.70,N/A,131.33,N/A,131.33,N/A,144.46,513.00,513.00,119.70,513.00,,Hospital G0438,"HC Ppps, Initial Visit",N/A,0770 - PREVENTIVE CARE SERVICES - GENERAL CLASSIFICATION,N/A,181.00,N/A,108.60,N/A,N/A,N/A,158.90,N/A,N/A,N/A,61.54,N/A,181.00,N/A,25.34,N/A,158.90,N/A,158.90,N/A,181.00,N/A,181.00,N/A,181.00,N/A,181.00,N/A,N/A,N/A,158.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,158.90,N/A,158.90,N/A,174.79,N/A,N/A,25.34,181.00,,Hospital G0439,"PPPS, subseq visit",N/A,N/A,N/A,186.00,N/A,111.60,N/A,26.04,N/A,123.72,N/A,107.10,N/A,63.24,N/A,N/A,N/A,26.04,N/A,123.72,N/A,123.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,107.10,N/A,123.72,N/A,26.04,N/A,99.70,N/A,99.70,N/A,26.04,N/A,123.72,N/A,123.72,N/A,136.09,N/A,N/A,26.04,136.09,,Hospital G0463,Hospital outpt clinic visit,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,N/A,2107.00,N/A,1264.20,N/A,294.98,N/A,240.47,N/A,1213.21,N/A,716.38,N/A,581.68,N/A,294.98,N/A,240.47,N/A,240.47,N/A,362.10,N/A,581.68,N/A,581.68,N/A,581.68,N/A,1213.21,N/A,240.47,N/A,294.98,N/A,1129.35,N/A,1129.35,N/A,294.98,N/A,240.47,N/A,240.47,N/A,264.52,N/A,N/A,240.47,1264.20,,Hospital G0463,Hospital outpt clinic visit,N/A,N/A,193260.62,N/A,115956.37,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,115956.37,115956.37,N/A,N/A,,Hospital G0482,"PR Drug Test(S), Definitive, 15-21 Drug Classes",N/A,N/A,N/A,2800.00,N/A,1680.00,N/A,470.02,N/A,52.99,N/A,1612.24,N/A,952.00,N/A,125.56,N/A,470.02,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,1612.24,N/A,51.91,N/A,470.02,N/A,614.16,N/A,614.16,N/A,470.02,N/A,51.91,N/A,52.99,N/A,466.90,N/A,N/A,51.91,1680.00,,Hospital G1011,HC Radiology Clinical Decision Support Mechanism - Nos,N/A,0359 - CT SCAN - OTHER CT SCAN,N/A,2145.02,N/A,1287.01,N/A,300.30,N/A,219.09,N/A,2145.01,N/A,729.30,N/A,510.09,N/A,300.30,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,2145.01,N/A,210.88,N/A,300.30,N/A,1923.74,N/A,1923.74,N/A,300.30,N/A,210.88,N/A,219.09,N/A,168.99,N/A,N/A,168.99,2145.01,,Hospital G2011,"Alcohol and/or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), and Brief Intervention, 5-14 Minutes",N/A,N/A,N/A,163.00,N/A,97.80,N/A,22.82,N/A,23.89,N/A,93.86,N/A,55.42,N/A,N/A,N/A,22.82,N/A,22.54,N/A,22.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,93.86,N/A,22.54,N/A,22.82,N/A,87.37,N/A,87.37,N/A,22.82,N/A,22.54,N/A,23.89,N/A,17.79,N/A,N/A,17.79,97.80,,Hospital G2066,HC Inter Devc Remote 30d,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,52591.30,195.00,31554.78,117.00,10440.92,27.30,7347.51,32.45,22507.59,112.28,17881.04,66.30,22722.89,76.46,10762.62,27.30,7288.21,31.61,7288.21,31.61,14144.47,47.60,22722.89,76.46,22722.89,76.46,22722.89,76.46,22507.59,112.28,7288.21,31.61,10762.62,27.30,27034.57,104.52,27034.57,104.52,N/A,27.30,7985.05,31.61,7347.51,32.45,11516.01,N/A,7288.21,31554.78,27.30,117.00,,Hospital H0048,HC Iop Uds Collect Handling Only,N/A,0906 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INTENSIVE OUTPATIENT SERVICES - CHEMICAL DEPENDENCY,N/A,2083.00,N/A,1249.80,N/A,291.62,N/A,409.94,N/A,1199.39,N/A,708.22,N/A,984.40,N/A,291.62,N/A,405.55,N/A,405.55,N/A,612.82,N/A,984.40,N/A,984.40,N/A,984.40,N/A,1964.62,N/A,405.55,N/A,291.62,N/A,190.28,N/A,190.28,N/A,291.62,N/A,405.55,N/A,409.94,N/A,269.13,N/A,N/A,190.28,1964.62,,Hospital H1001,HC Antepartum Management,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,N/A,66.00,N/A,39.60,N/A,9.36,N/A,3.48,N/A,38.00,N/A,22.44,N/A,9.36,N/A,9.36,N/A,3.48,N/A,3.48,N/A,5.82,N/A,9.36,N/A,9.36,N/A,9.36,N/A,38.00,N/A,3.48,N/A,9.36,N/A,3.48,N/A,3.48,N/A,9.36,N/A,3.48,N/A,3.48,N/A,3.83,N/A,N/A,3.48,39.60,,Hospital H1003,HC Prenatal at Risk Education,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,3701.00,N/A,2220.60,N/A,437.21,N/A,113.51,N/A,2131.03,N/A,1258.30,N/A,246.70,N/A,437.21,N/A,109.76,N/A,109.76,N/A,153.58,N/A,246.70,N/A,246.70,N/A,246.70,N/A,2131.04,N/A,218.90,N/A,437.21,N/A,950.48,N/A,950.48,N/A,437.21,N/A,218.90,N/A,226.90,N/A,311.87,N/A,N/A,109.76,2220.60,,Hospital H2020,HC Iop Mh Day Treatment,N/A,0905 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INTENSIVE OUTPATIENT SERVICES - PSYCHIATRIC,17076.20,1249.00,10245.72,749.40,5317.92,180.46,8441.00,176.26,12510.00,719.17,5805.91,424.66,9528.00,439.22,5317.92,180.46,8441.00,131.57,8441.00,131.57,5934.00,273.29,9528.00,439.22,9528.00,439.22,9528.00,439.22,8808.54,1249.00,5440.91,131.57,5424.30,180.46,17076.20,156.52,17076.20,156.52,17076.20,180.46,9294.00,1380.57,8441.00,176.26,4704.60,193.89,4704.60,17076.20,131.57,1380.57,,Hospital J0122,"Inj., eravacycline, 1 mg",N/A,N/A,118475.60,N/A,71085.36,N/A,N/A,N/A,12928.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12928.17,N/A,12928.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12928.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10941.90,N/A,12928.17,N/A,N/A,N/A,10941.90,71085.36,N/A,N/A,,Hospital HCPCS J0129,ABATACEPT 250 MG IV SOLR,00003-2187-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5859.00,5859.00,3515.40,3515.40,N/A,820.26,N/A,1081.78,N/A,3293.93,N/A,1992.06,N/A,2863.25,N/A,820.26,N/A,1081.78,N/A,1081.78,N/A,1782.40,N/A,2863.25,N/A,2863.25,N/A,2863.25,N/A,3293.93,N/A,1081.78,N/A,820.26,N/A,3140.42,N/A,3140.42,N/A,820.26,N/A,1081.78,N/A,1081.78,N/A,5859.00,3515.40,3515.40,820.26,5859.00,,Hospital HCPCS J0133,ACYCLOVIR SODIUM 50 MG/ML IV SOLN,63323-0325-14,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29.10,29.10,17.46,17.46,N/A,4.07,N/A,29.10,N/A,16.36,N/A,9.89,N/A,5.18,N/A,4.07,N/A,29.10,N/A,29.10,N/A,3.22,N/A,5.18,N/A,5.18,N/A,5.18,N/A,16.36,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,4.07,N/A,29.10,N/A,29.10,N/A,29.10,17.46,17.46,3.22,29.10,,Hospital HCPCS J0133,ACYCLOVIR SODIUM 50 MG/ML IV SOLN,63323-0325-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),236.30,236.30,141.78,141.78,N/A,33.08,N/A,236.30,N/A,132.85,N/A,80.34,N/A,10.36,N/A,33.08,N/A,236.30,N/A,236.30,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,132.85,N/A,236.30,N/A,33.08,N/A,126.66,N/A,126.66,N/A,33.08,N/A,236.30,N/A,236.30,N/A,236.30,141.78,141.78,6.45,236.30,,Hospital J0219,Inj aval alfa-nqpt 4mg,N/A,N/A,N/A,150489.30,N/A,90293.58,N/A,21068.50,N/A,37828.37,N/A,84622.67,N/A,51166.36,N/A,94849.50,N/A,21068.50,N/A,37820.33,N/A,37820.33,N/A,59044.73,N/A,94849.50,N/A,94849.50,N/A,94849.50,N/A,84622.67,N/A,37820.33,N/A,21068.50,N/A,80662.27,N/A,80662.27,N/A,21068.50,N/A,37820.33,N/A,37828.37,N/A,131.33,N/A,N/A,131.33,94849.50,,Hospital HCPCS J0248,REMDESIVIR 100 MG IV SOLR,61958-2901-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2600.00,2600.00,1560.00,1560.00,N/A,364.00,N/A,605.80,N/A,1461.72,N/A,884.00,N/A,1427.09,N/A,364.00,N/A,605.80,N/A,605.80,N/A,888.38,N/A,1427.09,N/A,1427.09,N/A,1427.09,N/A,1461.72,N/A,605.80,N/A,364.00,N/A,1393.60,N/A,1393.60,N/A,364.00,N/A,605.80,N/A,605.80,N/A,2600.00,1560.00,1560.00,364.00,2600.00,,Hospital J0256,Alpha 1 Proteinase Inhibitor,N/A,N/A,N/A,16480.00,N/A,9888.00,N/A,2307.20,N/A,61.04,N/A,9274.38,N/A,5603.20,N/A,6421.17,N/A,2307.20,N/A,2625.54,N/A,2625.54,N/A,3997.24,N/A,6421.17,N/A,6421.17,N/A,6421.17,N/A,9274.38,N/A,2625.54,N/A,2307.20,N/A,8833.28,N/A,8833.28,N/A,2307.20,N/A,2625.54,N/A,61.04,N/A,67.14,N/A,N/A,61.04,9888.00,,Hospital J0257,Glassia injection,N/A,N/A,N/A,11037.30,N/A,6622.38,N/A,1545.22,N/A,1719.99,N/A,6216.25,N/A,3752.68,N/A,4295.30,N/A,1545.22,N/A,1716.11,N/A,1716.11,N/A,2673.86,N/A,4295.30,N/A,4295.30,N/A,4295.30,N/A,6189.10,N/A,1716.11,N/A,1545.22,N/A,5915.99,N/A,5915.99,N/A,1545.22,N/A,1716.11,N/A,1719.99,N/A,67.14,N/A,N/A,67.14,6622.38,,Hospital HCPCS J0280,AMINOPHYLLINE 25 MG/ML IV SOLN,00409-5922-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0282,AMIODARONE HCL 900 MG/18ML IV SOLN,67457-0153-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.40,15.40,9.24,9.24,N/A,2.16,N/A,15.40,N/A,8.66,N/A,5.24,N/A,5.57,N/A,2.16,N/A,15.40,N/A,15.40,N/A,3.47,N/A,5.57,N/A,5.57,N/A,5.57,N/A,8.66,N/A,15.40,N/A,2.16,N/A,8.25,N/A,8.25,N/A,2.16,N/A,15.40,N/A,15.40,N/A,15.40,9.24,9.24,2.16,15.40,,Hospital HCPCS J0282,AMIODARONE HCL 150 MG/3ML IV SOLN,00143-9875-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,5.57,N/A,2.10,N/A,15.00,N/A,15.00,N/A,3.47,N/A,5.57,N/A,5.57,N/A,5.57,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0282,AMIODARONE HCL 450 MG/9ML IV SOLN,67457-0153-09,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.90,15.90,9.54,9.54,N/A,2.23,N/A,15.90,N/A,8.94,N/A,5.41,N/A,5.57,N/A,2.23,N/A,15.90,N/A,15.90,N/A,3.47,N/A,5.57,N/A,5.57,N/A,5.57,N/A,8.94,N/A,15.90,N/A,2.23,N/A,8.52,N/A,8.52,N/A,2.23,N/A,15.90,N/A,15.90,N/A,15.90,9.54,9.54,2.23,15.90,,Hospital HCPCS J0348,ANIDULAFUNGIN 50 MG IV SOLR,00049-0114-28,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),644.30,644.30,386.58,386.58,N/A,90.20,N/A,644.30,N/A,362.23,N/A,219.06,N/A,71.23,N/A,90.20,N/A,644.30,N/A,644.30,N/A,44.34,N/A,71.23,N/A,71.23,N/A,71.23,N/A,362.23,N/A,644.30,N/A,90.20,N/A,345.34,N/A,345.34,N/A,90.20,N/A,644.30,N/A,644.30,N/A,644.30,386.58,386.58,44.34,644.30,,Hospital HCPCS J0348,ANIDULAFUNGIN 100 MG IV SOLR,00049-0116-28,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1288.60,1288.60,773.16,773.16,N/A,180.40,N/A,1288.60,N/A,724.45,N/A,438.12,N/A,142.45,N/A,180.40,N/A,1288.60,N/A,1288.60,N/A,88.68,N/A,142.45,N/A,142.45,N/A,142.45,N/A,724.45,N/A,1288.60,N/A,180.40,N/A,690.69,N/A,690.69,N/A,180.40,N/A,1288.60,N/A,1288.60,N/A,1288.60,773.16,773.16,88.68,1288.60,,Hospital HCPCS J0401,ARIPIPRAZOLE ER 400 MG IM PRSY,59148-0072-80,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11489.80,11489.80,6893.88,6893.88,N/A,1608.57,N/A,2689.20,N/A,6459.57,N/A,3906.53,N/A,6537.16,N/A,1608.57,N/A,2689.20,N/A,2689.20,N/A,4069.45,N/A,6537.16,N/A,6537.16,N/A,6537.16,N/A,6459.57,N/A,2689.20,N/A,1608.57,N/A,6158.53,N/A,6158.53,N/A,1608.57,N/A,2689.20,N/A,2689.20,N/A,11489.80,6893.88,6893.88,1608.57,11489.80,,Hospital HCPCS J0401,ARIPIPRAZOLE ER 400 MG IM SRER,59148-0019-71,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),8617.30,8617.30,5170.38,5170.38,N/A,1206.42,N/A,2016.90,N/A,4844.65,N/A,2929.88,N/A,4902.87,N/A,1206.42,N/A,2016.90,N/A,2016.90,N/A,3052.08,N/A,4902.87,N/A,4902.87,N/A,4902.87,N/A,4844.65,N/A,2016.90,N/A,1206.42,N/A,4618.87,N/A,4618.87,N/A,1206.42,N/A,2016.90,N/A,2016.90,N/A,8617.30,5170.38,5170.38,1206.42,8617.30,,Hospital HCPCS J0461,ATROPINE SULFATE 8 MG/20ML IJ SOLN,00641-6006-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,4.14,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.58,N/A,4.14,N/A,4.14,N/A,4.14,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0461,ATROPINE SULFATE 1 MG/10ML IJ SOSY (MIXTURES ONLY),00409-4911-34,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),42.60,42.60,25.56,25.56,N/A,5.96,N/A,42.60,N/A,23.95,N/A,14.48,N/A,10.36,N/A,5.96,N/A,42.60,N/A,42.60,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,23.95,N/A,42.60,N/A,5.96,N/A,22.83,N/A,22.83,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,25.56,25.56,5.96,42.60,,Hospital HCPCS J0461,ATROPINE SULFATE 1 MG/ML IV SOLN,00517-1001-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),57.30,57.30,34.38,34.38,N/A,8.02,N/A,57.30,N/A,32.21,N/A,19.48,N/A,10.36,N/A,8.02,N/A,57.30,N/A,57.30,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,32.21,N/A,57.30,N/A,8.02,N/A,30.71,N/A,30.71,N/A,8.02,N/A,57.30,N/A,57.30,N/A,57.30,34.38,34.38,6.45,57.30,,Hospital HCPCS J0461,ATROPINE SULFATE 0.4 MG/ML IV SOLN,16729-0525-63,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),40.50,40.50,24.30,24.30,N/A,5.67,N/A,40.50,N/A,22.77,N/A,13.77,N/A,4.14,N/A,5.67,N/A,40.50,N/A,40.50,N/A,2.58,N/A,4.14,N/A,4.14,N/A,4.14,N/A,22.77,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,5.67,N/A,40.50,N/A,40.50,N/A,40.50,24.30,24.30,2.58,40.50,,Hospital HCPCS J0476,BACLOFEN 0.05 MG/ML IT SOLN,70257-0562-55,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),111.30,111.30,66.78,66.78,N/A,15.58,N/A,111.30,N/A,62.57,N/A,37.84,N/A,111.30,N/A,15.58,N/A,111.30,N/A,111.30,N/A,92.26,N/A,111.30,N/A,111.30,N/A,111.30,N/A,62.57,N/A,111.30,N/A,15.58,N/A,59.66,N/A,59.66,N/A,15.58,N/A,111.30,N/A,111.30,N/A,111.30,66.78,66.78,15.58,111.30,,Hospital HCPCS J0485,BELATACEPT 250 MG IV SOLR,00003-0371-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4258.00,4258.00,2554.80,2554.80,N/A,596.12,N/A,945.25,N/A,2393.85,N/A,1447.72,N/A,2447.55,N/A,596.12,N/A,945.25,N/A,945.25,N/A,1523.62,N/A,2447.55,N/A,2447.55,N/A,2447.55,N/A,2393.85,N/A,945.25,N/A,596.12,N/A,2282.29,N/A,2282.29,N/A,596.12,N/A,945.25,N/A,945.25,N/A,1039.78,2554.80,2554.80,596.12,2554.80,,Hospital HCPCS J0500,DICYCLOMINE HCL 10 MG/ML IM SOLN,58914-0080-52,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),131.70,131.70,79.02,79.02,N/A,18.44,N/A,131.70,N/A,74.04,N/A,44.78,N/A,70.50,N/A,18.44,N/A,131.70,N/A,131.70,N/A,43.89,N/A,70.50,N/A,70.50,N/A,70.50,N/A,74.04,N/A,131.70,N/A,18.44,N/A,70.59,N/A,70.59,N/A,18.44,N/A,131.70,N/A,131.70,N/A,131.70,79.02,79.02,18.44,131.70,,Hospital HCPCS J0561,PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,60793-0702-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2881.40,2881.40,1728.84,1728.84,N/A,403.40,N/A,484.03,N/A,1619.92,N/A,979.68,N/A,1024.40,N/A,403.40,N/A,484.03,N/A,484.03,N/A,637.70,N/A,1024.40,N/A,1024.40,N/A,1024.40,N/A,1619.92,N/A,484.03,N/A,403.40,N/A,1544.43,N/A,1544.43,N/A,403.40,N/A,484.03,N/A,484.03,N/A,2881.40,1728.84,1728.84,403.40,2881.40,,Hospital HCPCS J0561,PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,60793-0701-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1406.10,1406.10,843.66,843.66,N/A,196.85,N/A,242.02,N/A,790.51,N/A,478.07,N/A,512.20,N/A,196.85,N/A,242.02,N/A,242.02,N/A,318.85,N/A,512.20,N/A,512.20,N/A,512.20,N/A,790.51,N/A,242.02,N/A,196.85,N/A,753.67,N/A,753.67,N/A,196.85,N/A,242.02,N/A,242.02,N/A,1406.10,843.66,843.66,196.85,1406.10,,Hospital HCPCS J0574,BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM,12496-1208-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.30,20.30,12.18,12.18,N/A,2.84,N/A,20.30,N/A,11.41,N/A,6.90,N/A,2.84,N/A,2.84,N/A,20.30,N/A,20.30,N/A,1.77,N/A,2.84,N/A,2.84,N/A,2.84,N/A,11.41,N/A,20.30,N/A,2.84,N/A,10.88,N/A,10.88,N/A,2.84,N/A,20.30,N/A,20.30,N/A,20.30,12.18,12.18,1.77,20.30,,Hospital HCPCS J0574,BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,50268-0145-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11.30,11.30,6.78,6.78,N/A,1.58,N/A,11.30,N/A,6.35,N/A,3.84,N/A,1.58,N/A,1.58,N/A,11.30,N/A,11.30,N/A,N/A,N/A,1.58,N/A,1.58,N/A,1.58,N/A,6.35,N/A,11.30,N/A,1.58,N/A,6.06,N/A,6.06,N/A,1.58,N/A,11.30,N/A,11.30,N/A,11.30,6.78,6.78,1.58,11.30,,Hospital HCPCS J0585,ONABOTULINUMTOXINA 100 UNITS IJ SOLR,00023-1145-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1426.50,1426.50,855.90,855.90,N/A,199.71,N/A,319.70,N/A,801.98,N/A,485.01,N/A,804.20,N/A,199.71,N/A,319.70,N/A,319.70,N/A,500.62,N/A,804.20,N/A,804.20,N/A,804.20,N/A,801.98,N/A,319.70,N/A,199.71,N/A,764.60,N/A,764.60,N/A,199.71,N/A,319.70,N/A,319.70,N/A,351.67,855.90,855.90,199.71,855.90,,Hospital HCPCS J0585,BOTOX COSMETIC 100 UNITS IM SOLR,00023-9232-01,0250 - PHARMACY - GENERAL CLASSIFICATION,4279.50,4279.50,2567.70,2567.70,N/A,599.13,N/A,4279.50,N/A,2464.14,N/A,1455.03,N/A,4279.50,N/A,599.13,N/A,4279.50,N/A,4279.50,N/A,4279.50,N/A,4279.50,N/A,4279.50,N/A,4279.50,N/A,2464.14,N/A,4279.50,N/A,599.13,N/A,2293.81,N/A,2293.81,N/A,599.13,N/A,4279.50,N/A,4279.50,N/A,4279.50,2567.70,2567.70,599.13,4279.50,,Hospital HCPCS J0586,ABOBOTULINUMTOXINA 300 UNITS IM SOLR,15054-0530-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2319.80,2319.80,1391.88,1391.88,N/A,324.77,N/A,494.76,N/A,1304.19,N/A,788.73,N/A,1324.01,N/A,324.77,N/A,494.76,N/A,494.76,N/A,824.21,N/A,1324.01,N/A,1324.01,N/A,1324.01,N/A,1304.19,N/A,494.76,N/A,324.77,N/A,1243.41,N/A,1243.41,N/A,324.77,N/A,494.76,N/A,494.76,N/A,2319.80,1391.88,1391.88,324.77,2319.80,,Hospital HCPCS J0613,CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN,44567-0621-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),266.70,266.70,160.02,160.02,N/A,37.34,N/A,266.70,N/A,149.94,N/A,90.68,N/A,266.70,N/A,37.34,N/A,266.70,N/A,266.70,N/A,266.70,N/A,266.70,N/A,266.70,N/A,266.70,N/A,149.94,N/A,266.70,N/A,37.34,N/A,142.95,N/A,142.95,N/A,37.34,N/A,266.70,N/A,266.70,N/A,266.70,160.02,160.02,37.34,266.70,,Hospital J0670,Inj Mepivacaine Hcl/10 Ml,N/A,N/A,97514.05,78525.73,58508.43,47115.44,10199.26,10965.56,12330.85,1665.10,48921.77,44729.60,33154.77,26698.75,23204.73,29994.92,10513.52,10965.56,562.00,11933.08,562.00,11933.08,14444.40,18868.41,23204.73,29994.92,23204.73,29994.92,23204.73,29994.92,48921.77,44729.60,12330.85,11956.02,10513.52,10965.56,27607.84,12375.50,27607.84,12375.50,9734.88,10965.56,12330.85,11933.08,12330.85,1665.10,11249.46,1819.36,562.00,58508.43,1665.10,47115.44,,Hospital HCPCS J0689,CEFAZOLIN SODIUM-DEXTROSE 2-4 GM/100ML-% IV SOLN,00338-3508-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),62.80,62.80,37.68,37.68,N/A,8.79,N/A,62.80,N/A,35.31,N/A,21.35,N/A,62.80,N/A,8.79,N/A,62.80,N/A,62.80,N/A,62.80,N/A,62.80,N/A,62.80,N/A,62.80,N/A,35.31,N/A,62.80,N/A,8.79,N/A,33.66,N/A,33.66,N/A,8.79,N/A,62.80,N/A,62.80,N/A,62.80,37.68,37.68,8.79,62.80,,Hospital HCPCS J0692,CEFEPIME HCL 2 G IV SOLR,60505-6147-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),95.40,95.40,57.24,57.24,N/A,13.36,N/A,95.40,N/A,53.63,N/A,32.44,N/A,18.44,N/A,13.36,N/A,95.40,N/A,95.40,N/A,11.48,N/A,18.44,N/A,18.44,N/A,18.44,N/A,53.63,N/A,95.40,N/A,13.36,N/A,51.13,N/A,51.13,N/A,13.36,N/A,95.40,N/A,95.40,N/A,95.40,57.24,57.24,11.48,95.40,,Hospital J0693,"Inj., cefiderocol, 5 mg",N/A,N/A,129118.00,N/A,77470.80,N/A,9104.48,N/A,N/A,N/A,71169.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,71169.85,N/A,N/A,N/A,9481.36,N/A,28728.00,N/A,28728.00,N/A,N/A,N/A,N/A,N/A,33632.80,N/A,N/A,N/A,9104.48,77470.80,N/A,N/A,,Hospital J0695,Inj ceftolozane tazobactam,N/A,N/A,117925.42,N/A,70755.25,N/A,8655.72,N/A,43543.84,N/A,30610.22,N/A,21378.73,N/A,21378.73,N/A,8655.72,N/A,43543.84,N/A,43543.84,N/A,21378.73,N/A,21378.73,N/A,21378.73,N/A,21378.73,N/A,30610.22,N/A,43543.84,N/A,8655.72,N/A,30610.22,N/A,30610.22,N/A,8655.72,N/A,43543.84,N/A,43543.84,N/A,8655.72,N/A,8655.72,70755.25,N/A,N/A,,Hospital HCPCS J0696,CEFTRIAXONE SODIUM-DEXTROSE 2-2.22 GM-%(50ML) IV SOLR,00264-3155-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),164.30,164.30,98.58,98.58,N/A,23.00,N/A,164.30,N/A,92.37,N/A,55.86,N/A,10.57,N/A,23.00,N/A,164.30,N/A,164.30,N/A,6.58,N/A,10.57,N/A,10.57,N/A,10.57,N/A,92.37,N/A,164.30,N/A,23.00,N/A,88.06,N/A,88.06,N/A,23.00,N/A,164.30,N/A,164.30,N/A,164.30,98.58,98.58,6.58,164.30,,Hospital HCPCS J0696,CEFTRIAXONE SODIUM 500 MG IJ SOLR,00409-7338-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.64,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.64,N/A,2.64,N/A,2.64,N/A,2.64,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.64,15.00,,Hospital HCPCS J0696,CEFTRIAXONE SODIUM 250 MG IJ SOLR,00409-7337-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.32,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,1.32,N/A,1.32,N/A,1.32,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.32,15.00,,Hospital HCPCS J0696,CEFTRIAXONE SODIUM-DEXTROSE 1-3.74 GM-%(50ML) IV SOLR,00264-3153-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),115.00,115.00,69.00,69.00,N/A,16.10,N/A,115.00,N/A,64.65,N/A,39.10,N/A,5.28,N/A,16.10,N/A,115.00,N/A,115.00,N/A,3.29,N/A,5.28,N/A,5.28,N/A,5.28,N/A,64.65,N/A,115.00,N/A,16.10,N/A,61.64,N/A,61.64,N/A,16.10,N/A,115.00,N/A,115.00,N/A,115.00,69.00,69.00,3.29,115.00,,Hospital HCPCS J0696,CEFTRIAXONE SODIUM IN DEXTROSE 20 MG/ML IV SOLN,00338-5002-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),95.90,95.90,57.54,57.54,N/A,13.43,N/A,95.90,N/A,53.91,N/A,32.61,N/A,5.28,N/A,13.43,N/A,95.90,N/A,95.90,N/A,3.29,N/A,5.28,N/A,5.28,N/A,5.28,N/A,53.91,N/A,95.90,N/A,13.43,N/A,51.40,N/A,51.40,N/A,13.43,N/A,95.90,N/A,95.90,N/A,95.90,57.54,57.54,3.29,95.90,,Hospital HCPCS J0696,CEFTRIAXONE SODIUM 1 G IJ SOLR,00781-3208-85,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.64,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.64,N/A,2.64,N/A,2.64,N/A,2.64,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.64,15.00,,Hospital HCPCS J0703,CEFEPIME-DEXTROSE 1-5 GM-%(50ML) IV SOLR,00264-3193-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),115.00,115.00,69.00,69.00,N/A,16.10,N/A,115.00,N/A,64.65,N/A,39.10,N/A,16.10,N/A,16.10,N/A,115.00,N/A,115.00,N/A,10.01,N/A,16.10,N/A,16.10,N/A,16.10,N/A,64.65,N/A,115.00,N/A,16.10,N/A,61.64,N/A,61.64,N/A,16.10,N/A,115.00,N/A,115.00,N/A,115.00,69.00,69.00,10.01,115.00,,Hospital HCPCS J0712,CEFTAROLINE FOSAMIL 600 MG IV SOLR,00456-0600-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1000.80,1000.80,600.48,600.48,N/A,140.11,N/A,155.48,N/A,562.65,N/A,340.27,N/A,386.43,N/A,140.11,N/A,155.48,N/A,155.48,N/A,240.56,N/A,386.43,N/A,386.43,N/A,386.43,N/A,562.65,N/A,155.48,N/A,140.11,N/A,536.43,N/A,536.43,N/A,140.11,N/A,155.48,N/A,155.48,N/A,1000.80,600.48,600.48,140.11,1000.80,,Hospital J0740,Cidofovir Injection,N/A,N/A,N/A,16861.60,N/A,10116.96,N/A,2314.21,N/A,2785.31,N/A,9556.27,N/A,5732.94,N/A,6713.21,N/A,2314.21,N/A,2740.65,N/A,2740.65,N/A,4179.07,N/A,6713.21,N/A,6713.21,N/A,6713.21,N/A,9152.62,N/A,2849.79,N/A,2314.21,N/A,1852.08,N/A,1852.08,N/A,2314.21,N/A,2849.79,N/A,2899.48,N/A,289.25,N/A,N/A,289.25,10116.96,,Hospital J0744,Ciprofloxacin IV,N/A,N/A,35084.20,17202.80,21050.52,10321.68,4201.55,2387.64,5235.86,1572.73,9468.53,2552.00,11928.63,5848.95,9559.10,3834.79,4331.00,2387.64,5235.86,1572.73,5235.86,1572.73,11933.63,2387.23,12476.84,3834.79,9559.10,3834.79,12476.84,3834.79,9468.53,2552.00,5235.86,1572.73,4331.00,2387.64,2806.50,3274.25,11372.94,3274.25,5291.76,2387.64,5235.86,1572.73,5235.86,1572.73,4634.17,1730.00,2806.50,21050.52,1572.73,10321.68,,Hospital HCPCS J0780,PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN,23155-0294-42,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),30.40,30.40,18.24,18.24,N/A,4.26,N/A,30.40,N/A,17.09,N/A,10.34,N/A,10.36,N/A,4.26,N/A,30.40,N/A,30.40,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,17.09,N/A,30.40,N/A,4.26,N/A,16.29,N/A,16.29,N/A,4.26,N/A,30.40,N/A,30.40,N/A,30.40,18.24,18.24,4.26,30.40,,Hospital J0882,"Darbepoetin alfa, esrd use",N/A,N/A,39533.30,15378.50,23719.98,9227.10,8791.75,2153.00,12598.69,176.16,22229.88,8667.23,13441.32,5228.70,22442.53,2123.75,9062.64,2153.00,357994.00,176.16,357994.00,176.16,13969.95,1321.80,22442.53,2123.75,22442.53,2123.75,22442.53,2123.75,22229.88,8667.23,12480.09,176.16,9062.64,2153.00,26701.00,8242.88,26701.00,8242.88,N/A,2153.00,12480.09,176.16,12598.69,176.16,9697.03,387.85,8791.75,357994.00,176.16,9227.10,,Hospital HCPCS J0891,ARGATROBAN IN SODIUM CHLORIDE 50-0.9 MG/50ML-% IV SOLN,16729-0430-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1336.50,1336.50,801.90,801.90,N/A,187.11,N/A,23.00,N/A,751.38,N/A,454.41,N/A,20.75,N/A,187.11,N/A,23.00,N/A,23.00,N/A,20.75,N/A,20.75,N/A,20.75,N/A,20.75,N/A,751.38,N/A,23.00,N/A,187.11,N/A,716.36,N/A,716.36,N/A,187.11,N/A,23.00,N/A,23.00,N/A,25.30,801.90,801.90,20.75,801.90,,Hospital J1097,Phenylep ketorolac opth soln,N/A,N/A,N/A,30502.28,N/A,18301.37,N/A,4270.33,N/A,1990.61,N/A,17523.89,N/A,10370.79,N/A,5021.18,N/A,4270.33,N/A,1950.06,N/A,1950.06,N/A,3125.77,N/A,5021.18,N/A,5021.18,N/A,5021.18,N/A,17523.90,N/A,1950.06,N/A,4270.33,N/A,3397.00,N/A,3397.00,N/A,4270.33,N/A,1950.06,N/A,1990.61,N/A,556.44,N/A,N/A,556.44,18301.37,,Hospital HCPCS J1110,DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,00574-0850-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),443.40,443.40,266.04,266.04,N/A,62.08,N/A,443.40,N/A,249.28,N/A,150.76,N/A,150.84,N/A,62.08,N/A,443.40,N/A,443.40,N/A,93.90,N/A,150.84,N/A,150.84,N/A,150.84,N/A,249.28,N/A,443.40,N/A,62.08,N/A,237.66,N/A,237.66,N/A,62.08,N/A,443.40,N/A,443.40,N/A,443.40,266.04,266.04,62.08,443.40,,Hospital HCPCS J1120,ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,39822-0190-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),106.40,106.40,63.84,63.84,N/A,14.90,N/A,106.40,N/A,59.82,N/A,36.18,N/A,55.87,N/A,14.90,N/A,106.40,N/A,106.40,N/A,34.78,N/A,55.87,N/A,55.87,N/A,55.87,N/A,59.82,N/A,106.40,N/A,14.90,N/A,57.03,N/A,57.03,N/A,14.90,N/A,106.40,N/A,106.40,N/A,106.40,63.84,63.84,14.90,106.40,,Hospital HCPCS J1200,DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,63323-0664-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,3.91,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.43,N/A,3.91,N/A,3.91,N/A,3.91,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1265,DOPAMINE HCL 40 MG/ML IV SOLN,00409-5820-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,11.24,N/A,6.80,N/A,6.35,N/A,2.80,N/A,20.00,N/A,20.00,N/A,3.95,N/A,6.35,N/A,6.35,N/A,6.35,N/A,11.24,N/A,20.00,N/A,2.80,N/A,10.72,N/A,10.72,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,2.80,20.00,,Hospital HCPCS J1265,DOPAMINE IN D5W 1.6-5 MG/ML-% IV SOLN,00338-1007-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),89.50,89.50,53.70,53.70,N/A,12.53,N/A,89.50,N/A,50.32,N/A,30.43,N/A,12.69,N/A,12.53,N/A,89.50,N/A,89.50,N/A,7.90,N/A,12.69,N/A,12.69,N/A,12.69,N/A,50.32,N/A,89.50,N/A,12.53,N/A,47.97,N/A,47.97,N/A,12.53,N/A,89.50,N/A,89.50,N/A,89.50,53.70,53.70,7.90,89.50,,Hospital HCPCS J1265,DOPAMINE HCL 40 MG/ML IV SOLN,00409-9104-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.10,16.10,9.66,9.66,N/A,2.25,N/A,16.10,N/A,9.05,N/A,5.47,N/A,12.69,N/A,2.25,N/A,16.10,N/A,16.10,N/A,7.90,N/A,12.69,N/A,12.69,N/A,12.69,N/A,9.05,N/A,16.10,N/A,2.25,N/A,8.63,N/A,8.63,N/A,2.25,N/A,16.10,N/A,16.10,N/A,16.10,9.66,9.66,2.25,16.10,,Hospital HCPCS J1302,SUTIMLIMAB-JOME 1100 MG/22ML IV SOLN,80203-0347-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9000.00,9000.00,5400.00,5400.00,N/A,1260.00,N/A,9000.00,N/A,5059.80,N/A,3060.00,N/A,1260.00,N/A,1260.00,N/A,9000.00,N/A,9000.00,N/A,783.00,N/A,1260.00,N/A,1260.00,N/A,1260.00,N/A,5059.80,N/A,9000.00,N/A,1260.00,N/A,4824.00,N/A,4824.00,N/A,1260.00,N/A,9000.00,N/A,9000.00,N/A,9000.00,5400.00,5400.00,783.00,9000.00,,Hospital HCPCS J1327,EPTIFIBATIDE 75 MG/100ML IV SOLN,67457-0631-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),675.00,675.00,405.00,405.00,N/A,94.50,N/A,675.00,N/A,379.49,N/A,229.50,N/A,675.00,N/A,94.50,N/A,675.00,N/A,675.00,N/A,544.15,N/A,675.00,N/A,675.00,N/A,675.00,N/A,379.49,N/A,675.00,N/A,94.50,N/A,361.80,N/A,361.80,N/A,94.50,N/A,675.00,N/A,675.00,N/A,675.00,405.00,405.00,94.50,675.00,,Hospital HCPCS J1439,FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,00517-0650-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5604.10,5604.10,3362.46,3362.46,N/A,784.57,N/A,843.75,N/A,3150.63,N/A,1905.39,N/A,2156.18,N/A,784.57,N/A,843.75,N/A,843.75,N/A,1342.24,N/A,2156.18,N/A,2156.18,N/A,2156.18,N/A,3150.63,N/A,843.75,N/A,784.57,N/A,3003.80,N/A,3003.80,N/A,784.57,N/A,843.75,N/A,843.75,N/A,928.13,3362.46,3362.46,784.57,3362.46,,Hospital HCPCS J1442,FILGRASTIM 480 MCG/1.6ML IJ SOLN,55513-0546-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1576.80,1576.80,946.08,946.08,N/A,220.75,N/A,472.80,N/A,886.48,N/A,536.11,N/A,1243.20,N/A,220.75,N/A,472.80,N/A,472.80,N/A,773.90,N/A,1243.20,N/A,1243.20,N/A,1243.20,N/A,886.48,N/A,472.80,N/A,220.75,N/A,845.16,N/A,845.16,N/A,220.75,N/A,472.80,N/A,472.80,N/A,520.08,946.08,946.08,220.75,1243.20,,Hospital HCPCS J1442,FILGRASTIM 480 MCG/0.8ML IJ SOSY,55513-0209-91,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1576.80,1576.80,946.08,946.08,N/A,220.75,N/A,472.80,N/A,886.48,N/A,536.11,N/A,1243.20,N/A,220.75,N/A,472.80,N/A,472.80,N/A,773.90,N/A,1243.20,N/A,1243.20,N/A,1243.20,N/A,886.48,N/A,472.80,N/A,220.75,N/A,845.16,N/A,845.16,N/A,220.75,N/A,472.80,N/A,472.80,N/A,520.08,946.08,946.08,220.75,1243.20,,Hospital HCPCS J1448,TRILACICLIB DIHYDROCHLORIDE 300 MG IV SOLR,73462-0101-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6475.50,6475.50,3885.30,3885.30,N/A,906.57,N/A,1530.60,N/A,3640.53,N/A,2201.67,N/A,3838.38,N/A,906.57,N/A,1530.60,N/A,1530.60,N/A,2389.43,N/A,3838.38,N/A,3838.38,N/A,3838.38,N/A,3640.53,N/A,1530.60,N/A,906.57,N/A,3470.87,N/A,3470.87,N/A,906.57,N/A,1530.60,N/A,1530.60,N/A,1683.66,3885.30,3885.30,906.57,3885.30,,Hospital HCPCS J1453,FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,67457-0889-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),369.90,369.90,221.94,221.94,N/A,51.79,N/A,369.90,N/A,207.96,N/A,125.77,N/A,69.93,N/A,51.79,N/A,369.90,N/A,369.90,N/A,43.53,N/A,69.93,N/A,69.93,N/A,69.93,N/A,207.96,N/A,369.90,N/A,51.79,N/A,198.27,N/A,198.27,N/A,51.79,N/A,369.90,N/A,369.90,N/A,369.90,221.94,221.94,43.53,369.90,,Hospital J1454,"Inj fosnetupitant, palonoset",N/A,N/A,N/A,8665.90,N/A,5199.54,N/A,1213.23,N/A,707.56,N/A,4910.69,N/A,2946.41,N/A,2332.78,N/A,1213.23,N/A,809.82,N/A,809.82,N/A,1452.19,N/A,2332.78,N/A,2332.78,N/A,2332.78,N/A,4903.66,N/A,809.82,N/A,1213.23,N/A,4644.93,N/A,4644.93,N/A,1213.23,N/A,809.82,N/A,707.56,N/A,202.01,N/A,N/A,202.01,5199.54,,Hospital J1456,"Inj, fosaprepitant (teva)",N/A,N/A,74416.90,29572.70,44650.14,17743.62,4207.89,4144.85,12477.57,5290.39,29586.26,16710.50,20689.07,10054.72,20689.07,12765.90,4207.89,4144.85,12477.57,5290.39,12477.57,5290.39,20689.07,7946.91,20689.07,12765.90,20689.07,12765.90,20689.07,12765.90,29586.26,16710.49,12477.57,5290.39,4207.89,4144.85,29586.26,3189.63,29586.26,3189.63,4207.89,4144.85,12477.57,5290.39,12477.57,5290.39,4207.89,5819.44,4207.89,44650.14,3189.63,17743.62,,Hospital HCPCS J1570,GANCICLOVIR SODIUM 500 MG/10ML IV SOLN,25021-0185-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),405.00,405.00,243.00,243.00,N/A,56.70,N/A,405.00,N/A,227.69,N/A,137.70,N/A,122.12,N/A,56.70,N/A,405.00,N/A,405.00,N/A,76.02,N/A,122.12,N/A,122.12,N/A,122.12,N/A,227.69,N/A,405.00,N/A,56.70,N/A,217.08,N/A,217.08,N/A,56.70,N/A,405.00,N/A,405.00,N/A,405.00,243.00,243.00,56.70,405.00,,Hospital HCPCS J1570,GANCICLOVIR SODIUM 500 MG IV SOLR,63323-0315-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),656.60,656.60,393.96,393.96,N/A,91.92,N/A,656.60,N/A,369.14,N/A,223.24,N/A,122.12,N/A,91.92,N/A,656.60,N/A,656.60,N/A,76.02,N/A,122.12,N/A,122.12,N/A,122.12,N/A,369.14,N/A,656.60,N/A,91.92,N/A,351.94,N/A,351.94,N/A,91.92,N/A,656.60,N/A,656.60,N/A,656.60,393.96,393.96,76.02,656.60,,Hospital J1571,Hepagam B Im Injection,N/A,N/A,N/A,26391.30,N/A,15834.78,N/A,3694.78,N/A,1548.80,N/A,14852.39,N/A,8973.04,N/A,6205.23,N/A,3694.78,N/A,1549.94,N/A,1549.94,N/A,3860.90,N/A,6205.23,N/A,6205.23,N/A,6205.23,N/A,14852.39,N/A,1549.94,N/A,3694.78,N/A,14145.73,N/A,14145.73,N/A,3694.78,N/A,1549.94,N/A,1548.80,N/A,88.54,N/A,N/A,88.54,15834.78,,Hospital HCPCS J1595,GLATIRAMER ACETATE 20 MG/ML SC SOSY,68546-0317-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1067.10,1067.10,640.26,640.26,N/A,149.39,N/A,1067.10,N/A,599.92,N/A,362.81,N/A,168.35,N/A,149.39,N/A,1067.10,N/A,1067.10,N/A,104.80,N/A,168.35,N/A,168.35,N/A,168.35,N/A,599.92,N/A,1067.10,N/A,149.39,N/A,571.97,N/A,571.97,N/A,149.39,N/A,1067.10,N/A,1067.10,N/A,1067.10,640.26,640.26,104.80,1067.10,,Hospital J1640,"Hemin, 1 mg",N/A,N/A,348213.50,62126.80,208928.10,37276.08,N/A,8697.76,19060.46,8578.57,N/A,34947.15,N/A,21123.12,N/A,27712.16,N/A,8697.76,19060.46,11476.23,19060.46,11476.23,N/A,17251.09,N/A,27712.16,N/A,27712.16,N/A,27712.16,N/A,34937.10,19060.46,11476.23,N/A,8697.76,N/A,33299.96,N/A,33299.97,N/A,8697.76,19060.46,11476.23,19060.46,8578.57,N/A,156.64,19060.46,208928.10,156.64,37276.08,,Hospital J1741,Ibuprofen injection,N/A,N/A,1522306.43,N/A,913383.86,N/A,N/A,N/A,N/A,N/A,378392.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,378392.87,N/A,N/A,N/A,N/A,N/A,378392.87,N/A,378392.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,378392.87,913383.86,N/A,N/A,,Hospital J1744,Icatibant injection,N/A,N/A,40810.10,N/A,24486.06,N/A,3543.25,N/A,4457.13,N/A,7985.01,N/A,13875.43,N/A,8061.40,N/A,3652.43,N/A,4457.13,N/A,4457.13,N/A,5018.03,N/A,8061.40,N/A,8061.40,N/A,8061.40,N/A,7985.01,N/A,4457.13,N/A,3652.43,N/A,9591.05,N/A,9591.05,N/A,N/A,N/A,4457.13,N/A,4457.13,N/A,3908.10,N/A,3543.25,24486.06,N/A,N/A,,Hospital HCPCS J1745,INFLIXIMAB 100 MG IV SOLR,57894-0030-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3390.30,3390.30,2034.18,2034.18,N/A,474.64,N/A,329.07,N/A,1906.03,N/A,1152.70,N/A,924.89,N/A,474.64,N/A,329.07,N/A,329.07,N/A,575.75,N/A,924.89,N/A,924.89,N/A,924.89,N/A,1906.03,N/A,329.07,N/A,474.64,N/A,1817.20,N/A,1817.20,N/A,474.64,N/A,329.07,N/A,329.07,N/A,361.98,2034.18,2034.18,329.07,2034.18,,Hospital J1750,Iron Dextran,N/A,N/A,65994.77,1430.00,39596.86,858.00,6426.08,200.20,7867.36,220.89,14481.70,821.35,22438.22,486.20,14620.23,536.02,6624.08,200.20,2810.00,220.89,2810.00,220.89,9100.75,333.68,14620.23,536.02,14620.23,536.02,14620.23,536.02,14481.70,821.36,7867.36,220.89,6624.08,200.20,17394.42,766.48,17394.42,766.49,6624.08,200.20,7867.36,220.89,7867.36,220.89,7087.77,242.99,2810.00,39596.86,200.20,858.00,,Hospital HCPCS J1756,IRON SUCROSE 20 MG/ML IV SOLN,00517-2340-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,25.90,N/A,21.00,N/A,150.00,N/A,150.00,N/A,16.12,N/A,25.90,N/A,25.90,N/A,25.90,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,16.12,150.00,,Hospital HCPCS J1805,ESMOLOL HCL 100 MG/10ML IV SOLN,67457-0182-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1836,METRONIDAZOLE 500 MG/100ML IV SOLN,00338-9541-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1836,METRONIDAZOLE (FLAGYL) IVPB,99999-9913-19,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1885,KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN,00409-3793-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19.80,19.80,11.88,11.88,N/A,2.77,N/A,19.80,N/A,11.13,N/A,6.73,N/A,1.68,N/A,2.77,N/A,19.80,N/A,19.80,N/A,1.05,N/A,1.68,N/A,1.68,N/A,1.68,N/A,11.13,N/A,19.80,N/A,2.77,N/A,10.61,N/A,10.61,N/A,2.77,N/A,19.80,N/A,19.80,N/A,19.80,11.88,11.88,1.05,19.80,,Hospital HCPCS J1885,KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,00409-3795-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21.40,21.40,12.84,12.84,N/A,3.00,N/A,21.40,N/A,12.03,N/A,7.28,N/A,1.68,N/A,3.00,N/A,21.40,N/A,21.40,N/A,1.05,N/A,1.68,N/A,1.68,N/A,1.68,N/A,12.03,N/A,21.40,N/A,3.00,N/A,11.47,N/A,11.47,N/A,3.00,N/A,21.40,N/A,21.40,N/A,21.40,12.84,12.84,1.05,21.40,,Hospital J1932,"Inj, lanreotide, (cipla) 1mg",N/A,N/A,N/A,65333.50,N/A,39200.10,N/A,9146.69,N/A,6275.68,N/A,36736.17,N/A,22213.39,N/A,7258.92,N/A,9146.69,N/A,6274.50,N/A,6274.50,N/A,7258.92,N/A,7258.92,N/A,7258.92,N/A,7258.92,N/A,36736.17,N/A,6274.50,N/A,9146.69,N/A,35018.75,N/A,35018.75,N/A,9146.69,N/A,6274.50,N/A,6275.68,N/A,14.73,N/A,N/A,14.73,39200.10,,Hospital HCPCS J1944,ARIPIPRAZOLE LAUROXIL ER 1064 MG/3.9ML IM PRSY,65757-0404-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15808.00,15808.00,9484.80,9484.80,N/A,2213.12,N/A,3263.29,N/A,8887.26,N/A,5374.72,N/A,8046.82,N/A,2213.12,N/A,3263.29,N/A,3263.29,N/A,5009.22,N/A,8046.82,N/A,8046.82,N/A,8046.82,N/A,8887.26,N/A,3263.29,N/A,2213.12,N/A,8473.09,N/A,8473.09,N/A,2213.12,N/A,3263.29,N/A,3263.29,N/A,15808.00,9484.80,9484.80,2213.12,15808.00,,Hospital HCPCS J1944,ARIPIPRAZOLE LAUROXIL ER 882 MG/3.2ML IM PRSY,65757-0403-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),13103.90,13103.90,7862.34,7862.34,N/A,1834.55,N/A,2705.09,N/A,7367.01,N/A,4455.33,N/A,6670.39,N/A,1834.55,N/A,2705.09,N/A,2705.09,N/A,4152.38,N/A,6670.39,N/A,6670.39,N/A,6670.39,N/A,7367.01,N/A,2705.09,N/A,1834.55,N/A,7023.69,N/A,7023.69,N/A,1834.55,N/A,2705.09,N/A,2705.09,N/A,13103.90,7862.34,7862.34,1834.55,13103.90,,Hospital HCPCS J1944,ARIPIPRAZOLE LAUROXIL ER 662 MG/2.4ML IM PRSY,65757-0402-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9835.40,9835.40,5901.24,5901.24,N/A,1376.96,N/A,2030.35,N/A,5529.46,N/A,3344.04,N/A,5006.57,N/A,1376.96,N/A,2030.35,N/A,2030.35,N/A,3116.64,N/A,5006.57,N/A,5006.57,N/A,5006.57,N/A,5529.46,N/A,2030.35,N/A,1376.96,N/A,5271.77,N/A,5271.77,N/A,1376.96,N/A,2030.35,N/A,2030.35,N/A,9835.40,5901.24,5901.24,1376.96,9835.40,,Hospital HCPCS J1944,ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6ML IM PRSY,65757-0401-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6552.00,6552.00,3931.20,3931.20,N/A,917.28,N/A,1352.55,N/A,3683.53,N/A,2227.68,N/A,3335.19,N/A,917.28,N/A,1352.55,N/A,1352.55,N/A,2076.19,N/A,3335.19,N/A,3335.19,N/A,3335.19,N/A,3683.53,N/A,1352.55,N/A,917.28,N/A,3511.87,N/A,3511.87,N/A,917.28,N/A,1352.55,N/A,1352.55,N/A,6552.00,3931.20,3931.20,917.28,6552.00,,Hospital J1980,Hyoscyamine Sulfate Inj,N/A,N/A,76147.65,26427.77,45688.59,15856.66,8992.04,3674.53,10902.76,2894.35,20264.28,15193.50,25890.20,8985.45,20458.13,7173.41,9269.10,3674.53,10902.76,2894.35,10902.76,2894.35,12734.71,4465.58,20458.13,7173.41,20458.13,7173.41,20458.13,7173.41,20264.28,15193.50,10902.76,2894.35,9269.10,3674.53,24340.06,5944.75,24340.06,5944.75,10689.34,3674.53,10902.76,2894.35,10902.76,2894.35,9917.93,3183.79,8992.04,45688.59,2894.35,15856.66,,Hospital HCPCS J2210,METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,00517-0740-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),198.00,198.00,118.80,118.80,N/A,27.72,N/A,198.00,N/A,111.32,N/A,67.32,N/A,52.32,N/A,27.72,N/A,198.00,N/A,198.00,N/A,32.57,N/A,52.32,N/A,52.32,N/A,52.32,N/A,111.32,N/A,198.00,N/A,27.72,N/A,106.13,N/A,106.13,N/A,27.72,N/A,198.00,N/A,198.00,N/A,198.00,118.80,118.80,27.72,198.00,,Hospital HCPCS J2212,METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,65649-0551-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),653.20,653.20,391.92,391.92,N/A,91.45,N/A,653.20,N/A,367.23,N/A,222.09,N/A,250.71,N/A,91.45,N/A,653.20,N/A,653.20,N/A,156.07,N/A,250.71,N/A,250.71,N/A,250.71,N/A,367.23,N/A,653.20,N/A,91.45,N/A,350.12,N/A,350.12,N/A,91.45,N/A,653.20,N/A,653.20,N/A,653.20,391.92,391.92,91.45,653.20,,Hospital HCPCS J2247,MICAFUNGIN SODIUM 100 MG IV SOLR,00469-3211-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1262.30,1262.30,757.38,757.38,N/A,176.72,N/A,1262.30,N/A,709.67,N/A,429.18,N/A,124.32,N/A,176.72,N/A,1262.30,N/A,1262.30,N/A,77.39,N/A,124.32,N/A,124.32,N/A,124.32,N/A,709.67,N/A,1262.30,N/A,176.72,N/A,676.59,N/A,676.59,N/A,176.72,N/A,1262.30,N/A,1262.30,N/A,1262.30,757.38,757.38,77.39,1262.30,,Hospital HCPCS J2247,MICAFUNGIN SODIUM 50 MG IV SOLR,00469-3250-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),631.50,631.50,378.90,378.90,N/A,88.41,N/A,631.50,N/A,355.03,N/A,214.71,N/A,62.16,N/A,88.41,N/A,631.50,N/A,631.50,N/A,38.70,N/A,62.16,N/A,62.16,N/A,62.16,N/A,355.03,N/A,631.50,N/A,88.41,N/A,338.48,N/A,338.48,N/A,88.41,N/A,631.50,N/A,631.50,N/A,631.50,378.90,378.90,38.70,631.50,,Hospital J2248,Micafungin sodium injection,N/A,N/A,139718.60,3657.25,83831.16,2194.35,N/A,512.02,28122.93,75.61,N/A,2073.09,N/A,1243.47,N/A,802.79,N/A,512.02,29254.31,224.80,29254.31,224.80,N/A,499.73,N/A,802.79,N/A,802.79,N/A,802.79,N/A,2033.75,29254.31,224.80,N/A,512.02,N/A,1960.28,N/A,1960.28,N/A,512.02,29254.31,224.80,29254.31,75.61,N/A,83.17,28122.93,83831.16,75.61,2194.35,,Hospital HCPCS J2251,MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN,44567-0611-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),202.50,202.50,121.50,121.50,N/A,28.35,N/A,202.50,N/A,113.85,N/A,68.85,N/A,44.03,N/A,28.35,N/A,202.50,N/A,202.50,N/A,27.41,N/A,44.03,N/A,44.03,N/A,44.03,N/A,113.85,N/A,202.50,N/A,28.35,N/A,108.54,N/A,108.54,N/A,28.35,N/A,202.50,N/A,202.50,N/A,202.50,121.50,121.50,27.41,202.50,,Hospital HCPCS J2260,MILRINONE LACTATE 20 MG/20ML IV SOLN,63323-0617-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),533.30,533.30,319.98,319.98,N/A,74.66,N/A,533.30,N/A,299.82,N/A,181.32,N/A,17.72,N/A,74.66,N/A,533.30,N/A,533.30,N/A,11.03,N/A,17.72,N/A,17.72,N/A,17.72,N/A,299.82,N/A,533.30,N/A,74.66,N/A,285.85,N/A,285.85,N/A,74.66,N/A,533.30,N/A,533.30,N/A,533.30,319.98,319.98,11.03,533.30,,Hospital HCPCS J2260,MILRINONE LACTATE 10 MG/10ML IV SOLN,63323-0617-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),270.00,270.00,162.00,162.00,N/A,37.80,N/A,270.00,N/A,151.79,N/A,91.80,N/A,8.86,N/A,37.80,N/A,270.00,N/A,270.00,N/A,5.51,N/A,8.86,N/A,8.86,N/A,8.86,N/A,151.79,N/A,270.00,N/A,37.80,N/A,144.72,N/A,144.72,N/A,37.80,N/A,270.00,N/A,270.00,N/A,270.00,162.00,162.00,5.51,270.00,,Hospital HCPCS J2272,MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN,63323-0451-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20.60,20.60,12.36,12.36,N/A,2.88,N/A,20.60,N/A,11.58,N/A,7.00,N/A,13.29,N/A,2.88,N/A,20.60,N/A,20.60,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,11.58,N/A,20.60,N/A,2.88,N/A,11.04,N/A,11.04,N/A,2.88,N/A,20.60,N/A,20.60,N/A,20.60,12.36,12.36,2.88,20.60,,Hospital HCPCS J2272,MORPHINE SULFATE 2 MG/ML IJ SOLN,09999-9912-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,13.29,N/A,2.10,N/A,15.00,N/A,15.00,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2272,MORPHINE SULFATE (PF) 2 MG/ML IJ SOLN,63323-0452-00,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2272,MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN,63323-0454-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,13.29,N/A,2.10,N/A,15.00,N/A,15.00,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J2278,Ziconotide injection,N/A,N/A,N/A,122739.80,N/A,73643.88,N/A,17183.57,N/A,7573.07,N/A,69059.75,N/A,41731.53,N/A,19540.32,N/A,17183.57,N/A,7562.77,N/A,7562.77,N/A,12164.05,N/A,19540.32,N/A,19540.32,N/A,19540.32,N/A,69059.75,N/A,7562.77,N/A,17183.57,N/A,527.00,N/A,527.00,N/A,17183.57,N/A,7562.77,N/A,7573.07,N/A,88.92,N/A,N/A,88.92,73643.88,,Hospital HCPCS J2323,NATALIZUMAB 300 MG/15ML IV CONC,64406-0008-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),35351.40,35351.40,21210.84,21210.84,N/A,4949.20,N/A,7458.90,N/A,19874.56,N/A,12019.48,N/A,18780.09,N/A,4949.20,N/A,7458.90,N/A,7458.90,N/A,11690.79,N/A,18780.09,N/A,18780.09,N/A,18780.09,N/A,19874.56,N/A,7458.90,N/A,4949.20,N/A,18948.35,N/A,18948.35,N/A,4949.20,N/A,7458.90,N/A,7458.90,N/A,8204.79,21210.84,21210.84,4949.20,21210.84,,Hospital J2356,"Injection, Tezepelumab-Ekko, 1mg",N/A,N/A,N/A,24495.45,N/A,14697.27,N/A,3429.36,N/A,13.39,N/A,13776.93,N/A,8328.45,N/A,9556.84,N/A,3429.36,N/A,3994.02,N/A,3994.02,N/A,5949.23,N/A,9556.84,N/A,9556.84,N/A,9556.84,N/A,13776.93,N/A,3994.02,N/A,3429.36,N/A,13129.57,N/A,13129.57,N/A,3429.36,N/A,3994.02,N/A,13.39,N/A,14.73,N/A,N/A,13.39,14697.27,,Hospital J2370,Phenylephrine Hcl Injection,N/A,N/A,86538.47,41236.38,51923.08,24741.83,20090.18,5773.10,12616.71,5973.28,11280.41,7823.00,38597.66,14020.37,20739.71,14511.70,10762.62,5773.10,17867.74,5973.28,12616.71,5973.28,27344.35,9033.82,20739.71,14511.70,20739.71,14511.70,20739.71,14511.70,24050.97,7823.00,17170.99,5973.28,10762.62,5773.10,40930.85,10535.75,28261.97,10535.75,6356.92,5773.10,12616.71,5973.28,14215.10,5973.28,11516.01,6570.60,6356.92,51923.08,5773.10,24741.83,,Hospital J2372,"Injection, Phenylephrine Hydrochloride (Biorphen), 20 Micrograms",N/A,N/A,45284.27,46122.77,27170.56,27673.66,4653.92,6457.19,5771.00,396.96,10487.99,26533.75,15396.66,15666.44,7322.00,12497.33,4797.32,6457.19,2248.00,7600.71,2248.00,7600.71,4558.00,7777.43,7322.00,12497.33,7322.00,12497.33,7322.00,12497.33,10487.99,26533.77,5771.00,7600.71,4797.32,6457.19,12597.46,5963.00,12597.46,5963.00,6234.03,6457.19,5771.00,7600.71,5771.00,396.96,5133.13,436.66,2248.00,27170.56,396.96,27673.66,,Hospital J2400,Chloroprocaine Hcl Injection,N/A,N/A,31642.50,43343.40,18985.50,26006.04,8615.41,6068.07,10457.23,12849.82,19415.53,24725.87,10758.45,14736.76,7322.00,28853.02,8880.87,6068.07,10457.23,11864.95,10457.23,11864.95,4558.00,18107.46,7322.00,28853.02,7322.00,28853.02,7322.00,28853.02,19415.53,24725.89,10457.23,11880.45,8880.87,6068.07,23320.60,12375.50,23320.60,12375.50,5749.04,6068.07,10457.23,11864.95,10457.23,12849.82,9502.53,1572.42,4558.00,23320.60,1572.42,28853.02,,Hospital HCPCS J2401,CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,00143-9209-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),215.90,215.90,129.54,129.54,N/A,30.23,N/A,215.90,N/A,121.38,N/A,73.41,N/A,215.90,N/A,30.23,N/A,215.90,N/A,215.90,N/A,215.90,N/A,215.90,N/A,215.90,N/A,215.90,N/A,121.38,N/A,215.90,N/A,30.23,N/A,115.72,N/A,115.72,N/A,30.23,N/A,215.90,N/A,215.90,N/A,215.90,129.54,129.54,30.23,215.90,,Hospital HCPCS J2401,CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,00143-9210-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),151.10,151.10,90.66,90.66,N/A,21.15,N/A,151.10,N/A,84.95,N/A,51.37,N/A,151.10,N/A,21.15,N/A,151.10,N/A,151.10,N/A,151.10,N/A,151.10,N/A,151.10,N/A,151.10,N/A,84.95,N/A,151.10,N/A,21.15,N/A,80.99,N/A,80.99,N/A,21.15,N/A,151.10,N/A,151.10,N/A,151.10,90.66,90.66,21.15,151.10,,Hospital J2402,Chloroprocaine (clorotekal),N/A,N/A,N/A,15578.25,N/A,9346.95,N/A,2180.04,N/A,147.90,N/A,8969.33,N/A,5296.61,N/A,6176.19,N/A,2180.04,N/A,2553.29,N/A,2553.29,N/A,3844.80,N/A,6176.19,N/A,6176.19,N/A,6176.19,N/A,8969.33,N/A,2553.29,N/A,2180.04,N/A,3397.00,N/A,3397.00,N/A,2180.04,N/A,2553.29,N/A,147.90,N/A,162.69,N/A,N/A,147.90,9346.95,,Hospital J2406,"Injection, oritavancin 10 mg",N/A,N/A,N/A,29918.00,N/A,17950.80,N/A,4185.05,N/A,5203.21,N/A,16828.25,N/A,10172.12,N/A,13588.74,N/A,4185.05,N/A,5194.62,N/A,5194.62,N/A,8459.12,N/A,13588.74,N/A,13588.74,N/A,13588.74,N/A,16828.25,N/A,5194.62,N/A,4185.05,N/A,212.20,N/A,212.20,N/A,4185.05,N/A,5194.62,N/A,5203.21,N/A,95.98,N/A,N/A,95.98,17950.80,,Hospital J2407,"Injection, Oritavancin (Orbactiv), 10 Mg",N/A,N/A,59632.70,17374.10,35779.62,10424.46,6136.27,2432.37,7583.89,3490.34,15211.44,9802.81,20275.10,5907.19,15356.95,8592.30,6325.34,2432.37,7524.59,3490.34,7524.59,3490.34,9559.34,5348.79,15356.95,8592.30,15356.95,8592.30,15356.95,8592.30,15211.44,9791.51,7524.59,3490.34,6325.34,2432.37,18270.93,9312.52,18270.93,9312.52,3285.34,2432.37,7524.59,3490.34,7583.89,3490.34,6768.11,3839.39,3285.34,35779.62,2432.37,10424.46,,Hospital J2426,HC Sed Rate,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),50951.30,18538.22,30570.78,11122.93,18084.55,2595.35,8441.00,13.39,22935.00,10674.30,17323.44,6302.99,17468.00,147.37,18084.55,2595.35,8441.00,3942.17,8441.00,3942.17,10879.00,91.74,17468.00,147.37,17468.00,147.37,17468.00,147.37,16148.99,10674.30,9558.57,3942.17,18446.34,2595.35,50951.30,9936.49,50951.30,9936.49,6158.88,2595.35,17039.00,3942.17,8441.00,13.39,18446.23,14.73,6158.88,50951.30,13.39,11122.93,,Hospital HCPCS J2440,PAPAVERINE HCL 30 MG/ML IJ SOLN,00517-4002-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),139.80,139.80,83.88,83.88,N/A,19.57,N/A,139.80,N/A,78.60,N/A,47.53,N/A,97.13,N/A,19.57,N/A,139.80,N/A,139.80,N/A,60.46,N/A,97.13,N/A,97.13,N/A,97.13,N/A,78.60,N/A,139.80,N/A,19.57,N/A,74.93,N/A,74.93,N/A,19.57,N/A,139.80,N/A,139.80,N/A,139.80,83.88,83.88,19.57,139.80,,Hospital J2505,"Injection, Pegfilgrastim 6mg",N/A,N/A,N/A,115820.60,N/A,69492.36,N/A,16221.87,N/A,16217.09,N/A,65179.84,N/A,39379.02,N/A,43877.72,N/A,16221.87,N/A,16217.09,N/A,16217.09,N/A,27318.71,N/A,43877.72,N/A,43877.72,N/A,43877.72,N/A,63779.72,N/A,16217.09,N/A,16221.87,N/A,2399.24,N/A,2399.24,N/A,16221.87,N/A,16217.09,N/A,16217.09,N/A,17838.79,N/A,N/A,2399.24,69492.36,,Hospital J2547,"Injection, peramivir",N/A,N/A,79339.87,N/A,47603.92,N/A,10440.92,N/A,12616.71,N/A,23611.64,N/A,26975.55,N/A,N/A,N/A,10762.62,N/A,12616.71,N/A,12616.71,N/A,N/A,N/A,23754.54,N/A,N/A,N/A,N/A,N/A,23611.64,N/A,12616.71,N/A,10762.62,N/A,30818.07,N/A,28261.97,N/A,N/A,N/A,30983.31,N/A,30983.31,N/A,11516.01,N/A,10440.92,47603.92,N/A,N/A,,Hospital HCPCS J2550,PROMETHAZINE HCL 25 MG/ML IJ SOLN,00641-0928-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,7.20,N/A,2.10,N/A,15.00,N/A,15.00,N/A,4.48,N/A,7.20,N/A,7.20,N/A,7.20,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2550,PROMETHAZINE HCL 50 MG/ML IJ SOLN,00641-1496-31,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,7.20,N/A,2.10,N/A,15.00,N/A,15.00,N/A,4.48,N/A,7.20,N/A,7.20,N/A,7.20,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J2562,Plerixafor injection,N/A,N/A,N/A,81436.02,N/A,48861.61,N/A,11250.01,N/A,134.33,N/A,45814.60,N/A,27688.25,N/A,25856.12,N/A,11250.01,N/A,10619.92,N/A,10619.92,N/A,16095.68,N/A,25856.12,N/A,25856.12,N/A,25856.12,N/A,45814.60,N/A,10619.92,N/A,11250.01,N/A,350.89,N/A,350.89,N/A,11250.01,N/A,10619.92,N/A,134.33,N/A,147.77,N/A,N/A,134.33,48861.61,,Hospital HCPCS J2590,OXYTOCIN 10 UNIT/ML IJ SOLN,63323-0012-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.25,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.40,N/A,2.25,N/A,2.25,N/A,2.25,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.40,15.00,,Hospital HCPCS J2590,OXYTOCIN-LACTATED RINGERS 30 UNIT/500ML IV SOLN,09999-9900-87,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),77.70,77.70,46.62,46.62,N/A,10.88,N/A,77.70,N/A,43.68,N/A,26.42,N/A,6.76,N/A,10.88,N/A,77.70,N/A,77.70,N/A,4.21,N/A,6.76,N/A,6.76,N/A,6.76,N/A,43.68,N/A,77.70,N/A,10.88,N/A,41.65,N/A,41.65,N/A,10.88,N/A,77.70,N/A,77.70,N/A,77.70,46.62,46.62,4.21,77.70,,Hospital HCPCS J2590,OXYTOCIN 30 UNITS IN 500 ML INFUSION,09999-9900-87,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),77.70,77.70,46.62,46.62,N/A,10.88,N/A,77.70,N/A,43.68,N/A,26.42,N/A,6.76,N/A,10.88,N/A,77.70,N/A,77.70,N/A,4.21,N/A,6.76,N/A,6.76,N/A,6.76,N/A,43.68,N/A,77.70,N/A,10.88,N/A,41.65,N/A,41.65,N/A,10.88,N/A,77.70,N/A,77.70,N/A,77.70,46.62,46.62,4.21,77.70,,Hospital HCPCS J2590,OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,71266-5000-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),124.90,124.90,74.94,74.94,N/A,17.49,N/A,124.90,N/A,70.22,N/A,42.47,N/A,6.76,N/A,17.49,N/A,124.90,N/A,124.90,N/A,4.21,N/A,6.76,N/A,6.76,N/A,6.76,N/A,70.22,N/A,124.90,N/A,17.49,N/A,66.95,N/A,66.95,N/A,17.49,N/A,124.90,N/A,124.90,N/A,124.90,74.94,74.94,4.21,124.90,,Hospital J2599,"Injection, vasopressin (american regent) not therapeutically equivalent to j2598, 1 unit",N/A,N/A,87202.32,N/A,52321.39,N/A,14262.49,N/A,68722.21,N/A,23529.46,N/A,N/A,N/A,N/A,N/A,14262.49,N/A,68722.21,N/A,68722.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,68722.21,N/A,14262.49,N/A,N/A,N/A,N/A,N/A,14262.49,N/A,68722.21,N/A,68722.21,N/A,14262.49,N/A,14262.49,68722.21,N/A,N/A,,Hospital J2786,"Injection, reslizumab, 1mg",N/A,N/A,N/A,24692.60,N/A,14815.56,N/A,3456.97,N/A,3244.33,N/A,13896.54,N/A,8395.49,N/A,8182.38,N/A,3456.97,N/A,3245.94,N/A,3245.94,N/A,5093.60,N/A,8182.38,N/A,8182.38,N/A,8182.38,N/A,13896.54,N/A,3245.94,N/A,3456.97,N/A,13235.23,N/A,13235.23,N/A,3456.97,N/A,3245.94,N/A,3244.33,N/A,67.14,N/A,N/A,67.14,14815.56,,Hospital CPT J2790,HC Rh Immune Globulin,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),307.00,307.00,184.20,184.20,N/A,42.98,N/A,307.00,N/A,172.60,N/A,104.38,N/A,205.83,N/A,42.98,N/A,307.00,N/A,307.00,N/A,128.13,N/A,205.83,N/A,205.83,N/A,205.83,N/A,172.60,N/A,307.00,N/A,42.98,N/A,164.55,N/A,164.55,N/A,42.98,N/A,307.00,N/A,307.00,N/A,307.00,184.20,184.20,42.98,307.00,,Hospital HCPCS J2795,ROPIVACAINE HCL 2 MG/ML IJ SOLN,55150-0196-99,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),260.60,260.60,156.36,156.36,N/A,36.48,N/A,260.60,N/A,146.51,N/A,88.60,N/A,36.26,N/A,36.48,N/A,260.60,N/A,260.60,N/A,22.57,N/A,36.26,N/A,36.26,N/A,36.26,N/A,146.51,N/A,260.60,N/A,36.48,N/A,139.68,N/A,139.68,N/A,36.48,N/A,260.60,N/A,260.60,N/A,260.60,156.36,156.36,22.57,260.60,,Hospital HCPCS J2795,ROPIVACAINE HCL 5 MG/ML IJ SOLN,63323-0286-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),70.90,70.90,42.54,42.54,N/A,9.93,N/A,70.90,N/A,39.86,N/A,24.11,N/A,13.60,N/A,9.93,N/A,70.90,N/A,70.90,N/A,8.46,N/A,13.60,N/A,13.60,N/A,13.60,N/A,39.86,N/A,70.90,N/A,9.93,N/A,38.00,N/A,38.00,N/A,9.93,N/A,70.90,N/A,70.90,N/A,70.90,42.54,42.54,8.46,70.90,,Hospital HCPCS J2795,ROPIVACAINE HCL 10 MG/ML IJ SOLN,63323-0288-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),115.00,115.00,69.00,69.00,N/A,16.10,N/A,115.00,N/A,64.65,N/A,39.10,N/A,27.20,N/A,16.10,N/A,115.00,N/A,115.00,N/A,16.93,N/A,27.20,N/A,27.20,N/A,27.20,N/A,64.65,N/A,115.00,N/A,16.10,N/A,61.64,N/A,61.64,N/A,16.10,N/A,115.00,N/A,115.00,N/A,115.00,69.00,69.00,16.10,115.00,,Hospital HCPCS J2795,ROPIVACAINE 0.2% IN SODIUM CHLORIDE 0.9% (OB) EPIDURAL,63323-0285-64,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),549.50,549.50,329.70,329.70,N/A,76.93,N/A,549.50,N/A,308.93,N/A,186.83,N/A,72.52,N/A,76.93,N/A,549.50,N/A,549.50,N/A,45.14,N/A,72.52,N/A,72.52,N/A,72.52,N/A,308.93,N/A,549.50,N/A,76.93,N/A,294.53,N/A,294.53,N/A,76.93,N/A,549.50,N/A,549.50,N/A,549.50,329.70,329.70,45.14,549.50,,Hospital HCPCS J2795,ROPIVACAINE HCL 2 MG/ML IJ SOLN,63323-0285-64,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),549.50,549.50,329.70,329.70,N/A,76.93,N/A,549.50,N/A,308.93,N/A,186.83,N/A,72.52,N/A,76.93,N/A,549.50,N/A,549.50,N/A,45.14,N/A,72.52,N/A,72.52,N/A,72.52,N/A,308.93,N/A,549.50,N/A,76.93,N/A,294.53,N/A,294.53,N/A,76.93,N/A,549.50,N/A,549.50,N/A,549.50,329.70,329.70,45.14,549.50,,Hospital HCPCS J2795,ROPIVACAINE ELASTOMERIC INFUSION 0.2%,09999-9910-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),187.70,187.70,112.62,112.62,N/A,26.28,N/A,187.70,N/A,105.52,N/A,63.82,N/A,36.26,N/A,26.28,N/A,187.70,N/A,187.70,N/A,22.57,N/A,36.26,N/A,36.26,N/A,36.26,N/A,105.52,N/A,187.70,N/A,26.28,N/A,100.61,N/A,100.61,N/A,26.28,N/A,187.70,N/A,187.70,N/A,187.70,112.62,112.62,22.57,187.70,,Hospital HCPCS J2795,ROPIVACAINE HCL 2 MG/ML IJ SOLN,00143-9263-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),58.90,58.90,35.34,35.34,N/A,8.25,N/A,58.90,N/A,33.11,N/A,20.03,N/A,7.25,N/A,8.25,N/A,58.90,N/A,58.90,N/A,4.51,N/A,7.25,N/A,7.25,N/A,7.25,N/A,33.11,N/A,58.90,N/A,8.25,N/A,31.57,N/A,31.57,N/A,8.25,N/A,58.90,N/A,58.90,N/A,58.90,35.34,35.34,4.51,58.90,,Hospital HCPCS J2795,ROPIVACAINE 0.2% IN SODIUM CHLORIDE 0.9% 100 ML (OB) EPIDURAL,69374-4987-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),121.50,121.50,72.90,72.90,N/A,17.01,N/A,121.50,N/A,68.31,N/A,41.31,N/A,36.26,N/A,17.01,N/A,121.50,N/A,121.50,N/A,22.57,N/A,36.26,N/A,36.26,N/A,36.26,N/A,68.31,N/A,121.50,N/A,17.01,N/A,65.12,N/A,65.12,N/A,17.01,N/A,121.50,N/A,121.50,N/A,121.50,72.90,72.90,17.01,121.50,,Hospital HCPCS J2795,ROPIVACAINE HCL 10 MG/ML IJ SOLN,63323-0288-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),115.00,115.00,69.00,69.00,N/A,16.10,N/A,115.00,N/A,64.65,N/A,39.10,N/A,27.20,N/A,16.10,N/A,115.00,N/A,115.00,N/A,16.93,N/A,27.20,N/A,27.20,N/A,27.20,N/A,64.65,N/A,115.00,N/A,16.10,N/A,61.64,N/A,61.64,N/A,16.10,N/A,115.00,N/A,115.00,N/A,115.00,69.00,69.00,16.10,115.00,,Hospital HCPCS J2800,METHOCARBAMOL 1000 MG/10ML IJ SOLN,70069-0101-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),55.70,55.70,33.42,33.42,N/A,7.80,N/A,55.70,N/A,31.31,N/A,18.94,N/A,16.86,N/A,7.80,N/A,55.70,N/A,55.70,N/A,10.50,N/A,16.86,N/A,16.86,N/A,16.86,N/A,31.31,N/A,55.70,N/A,7.80,N/A,29.86,N/A,29.86,N/A,7.80,N/A,55.70,N/A,55.70,N/A,55.70,33.42,33.42,7.80,55.70,,Hospital J2850,Inj secretin synthetic human,N/A,N/A,N/A,22755.73,N/A,13653.44,N/A,3185.81,N/A,4950.49,N/A,13061.67,N/A,7736.96,N/A,12849.69,N/A,3185.81,N/A,4732.58,N/A,4732.58,N/A,7999.16,N/A,12849.69,N/A,12849.69,N/A,12849.69,N/A,13061.67,N/A,4732.58,N/A,3185.81,N/A,3397.00,N/A,3397.00,N/A,3185.81,N/A,4732.58,N/A,4950.49,N/A,494.29,N/A,N/A,494.29,13653.44,,Hospital HCPCS J2916,NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,00024-2792-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),214.70,214.70,128.82,128.82,N/A,30.06,N/A,214.70,N/A,120.70,N/A,73.00,N/A,24.09,N/A,30.06,N/A,214.70,N/A,214.70,N/A,14.99,N/A,24.09,N/A,24.09,N/A,24.09,N/A,120.70,N/A,214.70,N/A,30.06,N/A,115.08,N/A,115.08,N/A,30.06,N/A,214.70,N/A,214.70,N/A,214.70,128.82,128.82,14.99,214.70,,Hospital HCPCS J2920,METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR (MIXTURES ONLY),00009-0039-28,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20.50,20.50,12.30,12.30,N/A,2.87,N/A,20.50,N/A,11.53,N/A,6.97,N/A,10.85,N/A,2.87,N/A,20.50,N/A,20.50,N/A,6.76,N/A,10.85,N/A,10.85,N/A,10.85,N/A,11.53,N/A,20.50,N/A,2.87,N/A,10.99,N/A,10.99,N/A,2.87,N/A,20.50,N/A,20.50,N/A,20.50,12.30,12.30,2.87,20.50,,Hospital HCPCS J2920,METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR,00009-0039-28,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20.50,20.50,12.30,12.30,N/A,2.87,N/A,20.50,N/A,11.53,N/A,6.97,N/A,10.85,N/A,2.87,N/A,20.50,N/A,20.50,N/A,6.76,N/A,10.85,N/A,10.85,N/A,10.85,N/A,11.53,N/A,20.50,N/A,2.87,N/A,10.99,N/A,10.99,N/A,2.87,N/A,20.50,N/A,20.50,N/A,20.50,12.30,12.30,2.87,20.50,,Hospital HCPCS J3032,EPTINEZUMAB-JJMR 100 MG/ML IV SOLN,67386-0130-51,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7244.80,7244.80,4346.88,4346.88,N/A,1014.27,N/A,1744.30,N/A,4073.03,N/A,2463.23,N/A,4252.78,N/A,1014.27,N/A,1744.30,N/A,1744.30,N/A,2647.40,N/A,4252.78,N/A,4252.78,N/A,4252.78,N/A,4073.03,N/A,1744.30,N/A,1014.27,N/A,3883.21,N/A,3883.21,N/A,1014.27,N/A,1744.30,N/A,1744.30,N/A,1918.73,4346.88,4346.88,1014.27,4346.88,,Hospital J3110,Teriparatide injection,N/A,N/A,112130.30,N/A,67278.18,N/A,6749.90,N/A,8014.65,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8014.65,N/A,8014.65,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8014.65,N/A,6957.87,N/A,18270.93,N/A,18270.93,N/A,N/A,N/A,8250.42,N/A,8014.65,N/A,N/A,N/A,6749.90,67278.18,N/A,N/A,,Hospital HCPCS J3244,TIGECYCLINE 50 MG IV SOLR,00008-4990-19,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1072.40,1072.40,643.44,643.44,N/A,150.14,N/A,1072.40,N/A,602.90,N/A,364.62,N/A,1072.40,N/A,150.14,N/A,1072.40,N/A,1072.40,N/A,1072.40,N/A,1072.40,N/A,1072.40,N/A,1072.40,N/A,602.90,N/A,1072.40,N/A,150.14,N/A,574.81,N/A,574.81,N/A,150.14,N/A,1072.40,N/A,1072.40,N/A,1072.40,643.44,643.44,150.14,1072.40,,Hospital HCPCS J3262,TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),50242-0135-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2210.20,2210.20,1326.12,1326.12,N/A,309.43,N/A,472.80,N/A,1242.57,N/A,751.47,N/A,1201.76,N/A,309.43,N/A,472.80,N/A,472.80,N/A,748.11,N/A,1201.76,N/A,1201.76,N/A,1201.76,N/A,1242.57,N/A,472.80,N/A,309.43,N/A,1184.67,N/A,1184.67,N/A,309.43,N/A,472.80,N/A,472.80,N/A,2210.20,1326.12,1326.12,309.43,2210.20,,Hospital HCPCS J3262,TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),50242-0136-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5525.30,5525.30,3315.18,3315.18,N/A,773.54,N/A,1182.00,N/A,3106.32,N/A,1878.60,N/A,3004.40,N/A,773.54,N/A,1182.00,N/A,1182.00,N/A,1870.27,N/A,3004.40,N/A,3004.40,N/A,3004.40,N/A,3106.32,N/A,1182.00,N/A,773.54,N/A,2961.56,N/A,2961.56,N/A,773.54,N/A,1182.00,N/A,1182.00,N/A,5525.30,3315.18,3315.18,773.54,5525.30,,Hospital HCPCS J3262,TOCILIZUMAB 200 MG/10ML IV SOLN,50242-0136-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5525.30,5525.30,3315.18,3315.18,N/A,773.54,N/A,1182.00,N/A,3106.32,N/A,1878.60,N/A,3004.40,N/A,773.54,N/A,1182.00,N/A,1182.00,N/A,1870.27,N/A,3004.40,N/A,3004.40,N/A,3004.40,N/A,3106.32,N/A,1182.00,N/A,773.54,N/A,2961.56,N/A,2961.56,N/A,773.54,N/A,1182.00,N/A,1182.00,N/A,5525.30,3315.18,3315.18,773.54,5525.30,,Hospital HCPCS J3262,TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),50242-0137-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11050.60,11050.60,6630.36,6630.36,N/A,1547.08,N/A,2364.00,N/A,6212.65,N/A,3757.20,N/A,6008.80,N/A,1547.08,N/A,2364.00,N/A,2364.00,N/A,3740.54,N/A,6008.80,N/A,6008.80,N/A,6008.80,N/A,6212.65,N/A,2364.00,N/A,1547.08,N/A,5923.12,N/A,5923.12,N/A,1547.08,N/A,2364.00,N/A,2364.00,N/A,11050.60,6630.36,6630.36,1547.08,11050.60,,Hospital HCPCS J3262,TOCILIZUMAB 400 MG/20ML IV SOLN,50242-0137-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11050.60,11050.60,6630.36,6630.36,N/A,1547.08,N/A,2364.00,N/A,6212.65,N/A,3757.20,N/A,6008.80,N/A,1547.08,N/A,2364.00,N/A,2364.00,N/A,3740.54,N/A,6008.80,N/A,6008.80,N/A,6008.80,N/A,6212.65,N/A,2364.00,N/A,1547.08,N/A,5923.12,N/A,5923.12,N/A,1547.08,N/A,2364.00,N/A,2364.00,N/A,11050.60,6630.36,6630.36,1547.08,11050.60,,Hospital J3316,"Inj., triptorelin xr 3.75 mg",N/A,N/A,N/A,24351.30,N/A,14610.78,N/A,3412.89,N/A,9486.86,N/A,13694.66,N/A,8279.44,N/A,23704.53,N/A,3412.89,N/A,9486.86,N/A,9486.86,N/A,14756.30,N/A,23704.53,N/A,23704.53,N/A,23704.53,N/A,13694.66,N/A,9486.86,N/A,3412.89,N/A,163.75,N/A,163.75,N/A,3412.89,N/A,9486.86,N/A,9486.86,N/A,10435.55,N/A,N/A,163.75,23704.53,,Hospital HCPCS J3358,USTEKINUMAB 130 MG/26ML IV SOLN,57894-0054-27,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16685.40,16685.40,10011.24,10011.24,N/A,2335.96,N/A,3274.44,N/A,9380.53,N/A,5673.04,N/A,8276.09,N/A,2335.96,N/A,3274.44,N/A,3274.44,N/A,5151.94,N/A,8276.09,N/A,8276.09,N/A,8276.09,N/A,9380.53,N/A,3274.44,N/A,2335.96,N/A,8943.37,N/A,8943.37,N/A,2335.96,N/A,3274.44,N/A,3274.44,N/A,3601.88,10011.24,10011.24,2335.96,10011.24,,Hospital HCPCS J3370,VANCOMYCIN HCL 10 G IV SOLR,63323-0314-61,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1434.40,1434.40,860.64,860.64,N/A,200.82,N/A,1434.40,N/A,806.42,N/A,487.70,N/A,153.33,N/A,200.82,N/A,1434.40,N/A,1434.40,N/A,95.45,N/A,153.33,N/A,153.33,N/A,153.33,N/A,806.42,N/A,1434.40,N/A,200.82,N/A,768.84,N/A,768.84,N/A,200.82,N/A,1434.40,N/A,1434.40,N/A,1434.40,860.64,860.64,95.45,1434.40,,Hospital HCPCS J3370,VANCOMYCIN HCL 5 G IV SOLR,00409-6509-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),609.30,609.30,365.58,365.58,N/A,85.30,N/A,609.30,N/A,342.55,N/A,207.16,N/A,76.66,N/A,85.30,N/A,609.30,N/A,609.30,N/A,47.72,N/A,76.66,N/A,76.66,N/A,76.66,N/A,342.55,N/A,609.30,N/A,85.30,N/A,326.58,N/A,326.58,N/A,85.30,N/A,609.30,N/A,609.30,N/A,609.30,365.58,365.58,47.72,609.30,,Hospital HCPCS J3370,RIFAMPIN 600 MG IV SOLR,63323-0351-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1032.80,1032.80,619.68,619.68,N/A,144.59,N/A,1032.80,N/A,580.64,N/A,351.15,N/A,15.33,N/A,144.59,N/A,1032.80,N/A,1032.80,N/A,9.54,N/A,15.33,N/A,15.33,N/A,15.33,N/A,580.64,N/A,1032.80,N/A,144.59,N/A,553.58,N/A,553.58,N/A,144.59,N/A,1032.80,N/A,1032.80,N/A,1032.80,619.68,619.68,9.54,1032.80,,Hospital HCPCS J3370,VANCOMYCIN HCL 500 MG IV SOLR,00409-4332-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),55.10,55.10,33.06,33.06,N/A,7.71,N/A,55.10,N/A,30.98,N/A,18.73,N/A,7.67,N/A,7.71,N/A,55.10,N/A,55.10,N/A,4.77,N/A,7.67,N/A,7.67,N/A,7.67,N/A,30.98,N/A,55.10,N/A,7.71,N/A,29.53,N/A,29.53,N/A,7.71,N/A,55.10,N/A,55.10,N/A,55.10,33.06,33.06,4.77,55.10,,Hospital HCPCS J3370,VANCOMYCIN (VANCOCIN) 1000 MG IN SODIUM CHLORIDE 0.9% 250 ML IVPB,09999-9916-26,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),877.50,877.50,526.50,526.50,N/A,122.85,N/A,877.50,N/A,493.33,N/A,298.35,N/A,15.33,N/A,122.85,N/A,877.50,N/A,877.50,N/A,9.54,N/A,15.33,N/A,15.33,N/A,15.33,N/A,493.33,N/A,877.50,N/A,122.85,N/A,470.34,N/A,470.34,N/A,122.85,N/A,877.50,N/A,877.50,N/A,877.50,526.50,526.50,9.54,877.50,,Hospital HCPCS J3370,VANCOMYCIN HCL 1 G IV SOLR,63323-0284-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),107.40,107.40,64.44,64.44,N/A,15.04,N/A,107.40,N/A,60.38,N/A,36.52,N/A,15.33,N/A,15.04,N/A,107.40,N/A,107.40,N/A,9.54,N/A,15.33,N/A,15.33,N/A,15.33,N/A,60.38,N/A,107.40,N/A,15.04,N/A,57.57,N/A,57.57,N/A,15.04,N/A,107.40,N/A,107.40,N/A,107.40,64.44,64.44,9.54,107.40,,Hospital HCPCS J3370,VANCOMYCIN 50 MG/ML ORAL SOLUTION,09999-9900-34,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.30,11.30,6.78,6.78,N/A,1.58,N/A,11.30,N/A,6.35,N/A,3.84,N/A,7.67,N/A,1.58,N/A,11.30,N/A,11.30,N/A,4.77,N/A,7.67,N/A,7.67,N/A,7.67,N/A,6.35,N/A,11.30,N/A,1.58,N/A,6.06,N/A,6.06,N/A,1.58,N/A,11.30,N/A,11.30,N/A,11.30,6.78,6.78,1.58,11.30,,Hospital J3471,"Ovine, up to 999 USP units",N/A,N/A,56354.80,14788.53,33812.88,8873.12,7445.53,2070.41,9073.32,2151.15,16779.11,8481.26,19160.63,5028.10,16939.61,5037.75,7674.94,2070.41,9073.32,1950.06,9073.32,1950.06,10544.51,3136.10,16939.61,5037.75,16939.61,5037.75,16939.61,5037.75,16779.11,8481.28,9073.32,1950.06,7674.94,2070.41,20153.91,3397.00,20153.91,3397.00,N/A,2070.41,9073.32,1950.06,9073.32,630.95,8212.19,556.44,7445.53,33812.88,556.44,8873.12,,Hospital HCPCS J3473,HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,18657-0117-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.80,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.74,15.00,,Hospital HCPCS J3473,HYALURONIDASE HUMAN 15 UNITS/ML IJ SOLN,09999-9915-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),63.80,63.80,38.28,38.28,N/A,8.93,N/A,63.80,N/A,35.87,N/A,21.69,N/A,2.80,N/A,8.93,N/A,63.80,N/A,63.80,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,35.87,N/A,63.80,N/A,8.93,N/A,34.20,N/A,34.20,N/A,8.93,N/A,63.80,N/A,63.80,N/A,63.80,38.28,38.28,1.74,63.80,,Hospital HCPCS J3473,HYALURONIDASE HUMAN 15 UNITS/ML IJ SOLN,09999-9915-14,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),63.80,63.80,38.28,38.28,N/A,8.93,N/A,63.80,N/A,35.87,N/A,21.69,N/A,2.80,N/A,8.93,N/A,63.80,N/A,63.80,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,35.87,N/A,63.80,N/A,8.93,N/A,34.20,N/A,34.20,N/A,8.93,N/A,63.80,N/A,63.80,N/A,63.80,38.28,38.28,1.74,63.80,,Hospital HCPCS J3489,ZOLEDRONIC ACID 4 MG/100ML IV SOLN,25021-0826-82,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),607.50,607.50,364.50,364.50,N/A,85.05,N/A,607.50,N/A,341.54,N/A,206.55,N/A,64.80,N/A,85.05,N/A,607.50,N/A,607.50,N/A,40.34,N/A,64.80,N/A,64.80,N/A,64.80,N/A,341.54,N/A,607.50,N/A,85.05,N/A,325.62,N/A,325.62,N/A,85.05,N/A,607.50,N/A,607.50,N/A,607.50,364.50,364.50,40.34,607.50,,Hospital HCPCS J3489,ZOLEDRONIC ACID 4 MG/5ML IV CONC,25021-0801-66,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),810.00,810.00,486.00,486.00,N/A,113.40,N/A,810.00,N/A,455.38,N/A,275.40,N/A,86.40,N/A,113.40,N/A,810.00,N/A,810.00,N/A,53.79,N/A,86.40,N/A,86.40,N/A,86.40,N/A,455.38,N/A,810.00,N/A,113.40,N/A,434.16,N/A,434.16,N/A,113.40,N/A,810.00,N/A,810.00,N/A,810.00,486.00,486.00,53.79,810.00,,Hospital HCPCS J3489,ZOLEDRONIC ACID 5 MG/100ML IV SOLN,55111-0688-52,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1057.50,1057.50,634.50,634.50,N/A,148.05,N/A,1057.50,N/A,594.53,N/A,359.55,N/A,108.00,N/A,148.05,N/A,1057.50,N/A,1057.50,N/A,67.23,N/A,108.00,N/A,108.00,N/A,108.00,N/A,594.53,N/A,1057.50,N/A,148.05,N/A,566.82,N/A,566.82,N/A,148.05,N/A,1057.50,N/A,1057.50,N/A,1057.50,634.50,634.50,67.23,1057.50,,Hospital HCPCS J3590,IDARUCIZUMAB 2.5 GM/50ML IV SOLN,00597-0197-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),10013.40,10013.40,6008.04,6008.04,N/A,1401.88,N/A,10013.40,N/A,5629.53,N/A,3404.56,N/A,10013.40,N/A,1401.88,N/A,10013.40,N/A,10013.40,N/A,10013.40,N/A,10013.40,N/A,10013.40,N/A,10013.40,N/A,5629.53,N/A,10013.40,N/A,1401.88,N/A,5367.18,N/A,5367.18,N/A,1401.88,N/A,10013.40,N/A,10013.40,N/A,10013.40,6008.04,6008.04,1401.88,10013.40,,Hospital HCPCS J3590,RISANKIZUMAB-RZAA 600 MG/10ML IV SOLN,00074-5015-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),45682.00,45682.00,27409.20,27409.20,N/A,6395.48,N/A,9311.40,N/A,25682.42,N/A,15531.88,N/A,9439.20,N/A,6395.48,N/A,9311.40,N/A,9311.40,N/A,9439.20,N/A,9439.20,N/A,9439.20,N/A,9439.20,N/A,25682.42,N/A,9311.40,N/A,6395.48,N/A,24485.55,N/A,24485.55,N/A,6395.48,N/A,9311.40,N/A,9311.40,N/A,10242.54,27409.20,27409.20,6395.48,27409.20,,Hospital HCPCS J7131,SODIUM CHLORIDE 4 MEQ/ML IV SOLN,63323-0088-61,0258 - PHARMACY - IV SOLUTIONS,79.70,79.70,47.82,47.82,N/A,N/A,N/A,79.70,N/A,45.89,N/A,27.10,N/A,79.70,N/A,11.16,N/A,79.70,N/A,79.70,N/A,79.70,N/A,79.70,N/A,79.70,N/A,79.70,N/A,45.89,N/A,79.70,N/A,11.16,N/A,42.72,N/A,42.72,N/A,N/A,N/A,79.70,N/A,79.70,N/A,N/A,47.82,47.82,11.16,79.70,,Hospital HCPCS J7131,SODIUM CHLORIDE 3 % IV SOLN,00338-0054-03,0250 - PHARMACY - GENERAL CLASSIFICATION,43.90,43.90,N/A,N/A,N/A,6.15,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6.15,N/A,N/A,N/A,N/A,N/A,43.90,N/A,N/A,6.15,43.90,,Hospital HCPCS J7131,SODIUM CHLORIDE 4 MEQ/ML IV SOLN,63323-0088-61,0250 - PHARMACY - GENERAL CLASSIFICATION,79.70,79.70,N/A,N/A,N/A,11.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11.16,N/A,N/A,N/A,N/A,N/A,79.70,N/A,N/A,11.16,79.70,,Hospital HCPCS J7131,SODIUM CHLORIDE 3 % IV SOLN,00338-0054-03,0258 - PHARMACY - IV SOLUTIONS,43.90,43.90,26.34,26.34,N/A,N/A,N/A,43.90,N/A,25.28,N/A,14.93,N/A,43.90,N/A,6.15,N/A,43.90,N/A,43.90,N/A,43.90,N/A,43.90,N/A,43.90,N/A,43.90,N/A,25.28,N/A,43.90,N/A,6.15,N/A,23.53,N/A,23.53,N/A,N/A,N/A,43.90,N/A,43.90,N/A,N/A,26.34,26.34,6.15,43.90,,Hospital J7169,"Inj andexxa, 10 mg",N/A,N/A,663599.97,N/A,398159.98,N/A,99345.46,N/A,94576.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,99345.46,N/A,48477.42,N/A,48477.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,48477.42,N/A,99345.46,N/A,N/A,N/A,N/A,N/A,99345.46,N/A,48477.42,N/A,48477.42,N/A,99345.46,N/A,48477.42,398159.98,N/A,N/A,,Hospital J7183,Wilate injection,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital J7189,Factor viia recomb novoseven,N/A,N/A,496528.70,78940.32,297917.22,47364.19,44288.35,11046.08,69732.75,2813.99,157164.21,44989.74,105538.24,26839.72,105538.24,18790.98,44288.35,11046.08,64301.36,2690.13,64301.36,2690.13,105538.24,11697.51,105538.24,18790.98,105538.24,18790.98,105538.24,18790.98,157164.21,44989.77,64301.36,2690.13,44288.35,11046.08,157164.21,4562.00,157164.21,4562.00,44288.35,11046.08,73815.76,2690.13,64301.36,2813.99,44288.35,745.29,44288.35,297917.22,745.29,47364.19,,Hospital HCPCS J7192,ANTIHEMOPHIL FACTOR (RAHF-PFM) 500 UNITS IV SOLR,00944-3052-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4027.50,4027.50,2416.50,2416.50,N/A,563.85,N/A,753.00,N/A,2264.26,N/A,1369.35,N/A,1877.75,N/A,563.85,N/A,753.00,N/A,753.00,N/A,1168.92,N/A,1877.75,N/A,1877.75,N/A,1877.75,N/A,2264.26,N/A,755.00,N/A,563.85,N/A,2158.74,N/A,2158.74,N/A,563.85,N/A,753.00,N/A,753.00,N/A,828.30,2416.50,2416.50,563.85,2416.50,,Hospital HCPCS J7192,ANTIHEMOPHIL FACTOR (RAHF-PFM) 2000 UNITS IV SOLR,00944-3045-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16110.00,16110.00,9666.00,9666.00,N/A,2255.40,N/A,3012.00,N/A,9057.04,N/A,5477.40,N/A,7511.00,N/A,2255.40,N/A,3012.00,N/A,3012.00,N/A,4675.67,N/A,7511.00,N/A,7511.00,N/A,7511.00,N/A,9057.04,N/A,3020.00,N/A,2255.40,N/A,8634.96,N/A,8634.96,N/A,2255.40,N/A,3012.00,N/A,3012.00,N/A,3313.20,9666.00,9666.00,2255.40,9666.00,,Hospital HCPCS J7197,ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,13533-0602-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9000.00,9000.00,5400.00,5400.00,N/A,1260.00,N/A,9000.00,N/A,5059.80,N/A,3060.00,N/A,4649.05,N/A,1260.00,N/A,9000.00,N/A,9000.00,N/A,2894.08,N/A,4649.05,N/A,4649.05,N/A,4649.05,N/A,5059.80,N/A,9000.00,N/A,1260.00,N/A,4824.00,N/A,4824.00,N/A,1260.00,N/A,9000.00,N/A,9000.00,N/A,9000.00,5400.00,5400.00,1260.00,9000.00,,Hospital J7198,Anti-Inhibitor,N/A,N/A,150258.30,N/A,90154.98,N/A,8897.44,N/A,10351.21,N/A,82822.37,N/A,51087.82,N/A,51436.73,N/A,8606.47,N/A,10142.34,N/A,10142.34,N/A,11824.33,N/A,18995.62,N/A,18995.62,N/A,18995.62,N/A,82822.37,N/A,10142.34,N/A,8606.47,N/A,22600.04,N/A,22600.04,N/A,4186.39,N/A,10142.34,N/A,10505.31,N/A,9208.92,N/A,4186.39,90154.98,N/A,N/A,,Hospital J7204,Inj recombin esperoct per iu,N/A,N/A,N/A,40670.20,N/A,24402.12,N/A,5693.83,N/A,5775.89,N/A,22875.70,N/A,13827.87,N/A,14791.36,N/A,5693.83,N/A,5751.18,N/A,5751.18,N/A,9207.77,N/A,14791.36,N/A,14791.36,N/A,14791.36,N/A,22612.56,N/A,5756.36,N/A,5693.83,N/A,21799.23,N/A,21799.23,N/A,5693.83,N/A,5751.18,N/A,5775.89,N/A,39.24,N/A,N/A,39.24,24402.12,,Hospital J7307,HC Etonogestrel Implant System,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,1940.00,N/A,1164.00,N/A,267.19,N/A,64.81,N/A,1095.64,N/A,659.60,N/A,1722.37,N/A,267.19,N/A,60.93,N/A,60.93,N/A,1753.44,N/A,1722.37,N/A,1722.37,N/A,1722.37,N/A,1095.64,N/A,109.14,N/A,267.19,N/A,50.95,N/A,50.95,N/A,267.19,N/A,109.14,N/A,116.10,N/A,26.51,N/A,N/A,26.51,1753.44,,Hospital J7323,HC Euflexxa Inj per Dose,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,1648.00,N/A,988.80,N/A,230.72,N/A,768.79,N/A,939.80,N/A,560.32,N/A,670.00,N/A,230.72,N/A,740.27,N/A,740.27,N/A,422.52,N/A,670.00,N/A,670.00,N/A,670.00,N/A,939.80,N/A,740.27,N/A,230.72,N/A,883.32,N/A,883.32,N/A,230.72,N/A,740.27,N/A,768.79,N/A,95.48,N/A,N/A,95.48,988.80,,Hospital J7327,HC Monovisc Inj per Dose,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,1717.00,N/A,1030.20,N/A,240.38,N/A,495.93,N/A,988.65,N/A,583.78,N/A,64.83,N/A,240.38,N/A,490.61,N/A,490.61,N/A,40.36,N/A,64.83,N/A,64.83,N/A,64.83,N/A,154.89,N/A,490.61,N/A,240.38,N/A,920.31,N/A,920.31,N/A,240.38,N/A,490.61,N/A,495.93,N/A,60.48,N/A,N/A,40.36,1030.20,,Hospital HCPCS J7331,SODIUM HYALURONATE (VISCOSUP) 20 MG/2ML IX SOSY,55566-4100-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1575.60,1575.60,945.36,945.36,N/A,220.58,N/A,131.42,N/A,885.80,N/A,535.70,N/A,339.37,N/A,220.58,N/A,131.42,N/A,131.42,N/A,211.26,N/A,339.37,N/A,339.37,N/A,339.37,N/A,885.80,N/A,131.42,N/A,220.58,N/A,844.52,N/A,844.52,N/A,220.58,N/A,131.42,N/A,131.42,N/A,1575.60,945.36,945.36,131.42,1575.60,,Hospital HCPCS J7516,CYCLOSPORINE 50 MG/ML IV SOLN,00078-0109-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),426.60,426.60,255.96,255.96,N/A,59.72,N/A,426.60,N/A,239.83,N/A,145.04,N/A,161.69,N/A,59.72,N/A,426.60,N/A,426.60,N/A,100.66,N/A,161.69,N/A,161.69,N/A,161.69,N/A,239.83,N/A,426.60,N/A,59.72,N/A,228.66,N/A,228.66,N/A,59.72,N/A,426.60,N/A,426.60,N/A,426.60,255.96,255.96,59.72,426.60,,Hospital J7525,Tacrolimus Injection,N/A,N/A,119198.75,N/A,71519.25,N/A,16924.62,N/A,N/A,N/A,65702.35,N/A,40527.57,N/A,N/A,N/A,17446.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38505.85,N/A,65702.35,N/A,10620.48,N/A,17446.09,N/A,45812.34,N/A,45812.34,N/A,8308.05,N/A,10620.48,N/A,10620.48,N/A,18667.32,N/A,8308.05,71519.25,N/A,N/A,,Hospital J7527,Oral everolimus,N/A,N/A,29600.20,N/A,17760.12,N/A,6827.25,N/A,8341.93,N/A,15385.76,N/A,10064.07,N/A,16137.00,N/A,7037.61,N/A,1686.00,N/A,1686.00,N/A,10045.15,N/A,16137.00,N/A,16137.00,N/A,16137.00,N/A,15385.76,N/A,8341.93,N/A,7037.61,N/A,18480.31,N/A,18480.31,N/A,N/A,N/A,8341.93,N/A,8341.93,N/A,7530.24,N/A,1686.00,18480.31,N/A,N/A,,Hospital HCPCS J7606,FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,49502-0605-61,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),41.90,41.90,25.14,25.14,N/A,5.87,N/A,41.90,N/A,23.56,N/A,14.25,N/A,20.18,N/A,5.87,N/A,41.90,N/A,41.90,N/A,12.56,N/A,20.18,N/A,20.18,N/A,20.18,N/A,23.56,N/A,41.90,N/A,5.87,N/A,22.46,N/A,22.46,N/A,5.87,N/A,41.90,N/A,41.90,N/A,41.90,25.14,25.14,5.87,41.90,,Hospital J8610,Methotrexate Oral 2.5 Mg,N/A,N/A,46048.50,19404.20,27629.10,11642.52,N/A,2665.60,20434.51,56.25,12887.58,11172.08,13872.42,6597.43,13872.42,127.53,N/A,2665.60,20434.51,51.91,20434.51,51.91,13872.42,79.39,13872.42,127.53,13872.42,127.53,13872.42,127.53,12887.58,11172.09,20434.51,51.91,N/A,2665.60,N/A,10069.75,N/A,10069.75,N/A,2665.60,7030.58,51.91,20434.51,56.25,N/A,74.53,7030.58,27629.10,51.91,11642.52,,Hospital HCPCS J9025,AZACITIDINE 100 MG IJ SUSR,72485-0201-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),525.00,525.00,315.00,315.00,N/A,73.50,N/A,525.00,N/A,295.16,N/A,178.50,N/A,173.53,N/A,73.50,N/A,525.00,N/A,525.00,N/A,108.02,N/A,173.53,N/A,173.53,N/A,173.53,N/A,295.16,N/A,525.00,N/A,73.50,N/A,281.40,N/A,281.40,N/A,73.50,N/A,525.00,N/A,525.00,N/A,525.00,315.00,315.00,73.50,525.00,,Hospital HCPCS J9025,AZACITIDINE 100 MG IJ SUSR (MIXTURES ONLY),43598-0305-62,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1000.00,1000.00,600.00,600.00,N/A,140.00,N/A,1000.00,N/A,562.20,N/A,340.00,N/A,173.53,N/A,140.00,N/A,1000.00,N/A,1000.00,N/A,108.02,N/A,173.53,N/A,173.53,N/A,173.53,N/A,562.20,N/A,1000.00,N/A,140.00,N/A,536.00,N/A,536.00,N/A,140.00,N/A,1000.00,N/A,1000.00,N/A,1000.00,600.00,600.00,108.02,1000.00,,Hospital J9032,"Injection, belinostat, 10mg",N/A,N/A,N/A,51390.12,N/A,30834.07,N/A,7194.62,N/A,7541.43,N/A,28935.00,N/A,17472.64,N/A,18152.68,N/A,7194.62,N/A,7520.19,N/A,7520.19,N/A,11300.24,N/A,18152.68,N/A,18152.68,N/A,18152.68,N/A,28892.83,N/A,7520.19,N/A,7194.62,N/A,27545.10,N/A,27545.09,N/A,7194.62,N/A,7520.19,N/A,152.07,N/A,167.27,N/A,N/A,152.07,30834.07,,Hospital HCPCS J9033,BENDAMUSTINE HCL 25 MG IV SOLR,63459-0390-08,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3714.80,3714.80,2228.88,2228.88,N/A,520.07,N/A,3714.80,N/A,2088.46,N/A,1263.03,N/A,1146.08,N/A,520.07,N/A,3714.80,N/A,3714.80,N/A,713.44,N/A,1146.08,N/A,1146.08,N/A,1146.08,N/A,2088.46,N/A,3714.80,N/A,520.07,N/A,1991.13,N/A,1991.13,N/A,520.07,N/A,3714.80,N/A,3714.80,N/A,3714.80,2228.88,2228.88,520.07,3714.80,,Hospital HCPCS J9033,BENDAMUSTINE HCL 100 MG IV SOLR,63459-0391-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),14859.00,14859.00,8915.40,8915.40,N/A,2080.26,N/A,14859.00,N/A,8353.73,N/A,5052.06,N/A,4584.30,N/A,2080.26,N/A,14859.00,N/A,14859.00,N/A,2853.77,N/A,4584.30,N/A,4584.30,N/A,4584.30,N/A,8353.73,N/A,14859.00,N/A,2080.26,N/A,7964.42,N/A,7964.42,N/A,2080.26,N/A,14859.00,N/A,14859.00,N/A,14859.00,8915.40,8915.40,2080.26,14859.00,,Hospital HCPCS J9040,BLEOMYCIN SULFATE 15 UNITS IJ SOLR,61703-0332-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,62.47,N/A,21.00,N/A,150.00,N/A,150.00,N/A,38.89,N/A,62.47,N/A,62.47,N/A,62.47,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,21.00,150.00,,Hospital HCPCS J9040,BLEOMYCIN SULFATE 30 UNITS IJ SOLR,63323-0137-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,62.47,N/A,21.00,N/A,150.00,N/A,150.00,N/A,38.89,N/A,62.47,N/A,62.47,N/A,62.47,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,21.00,150.00,,Hospital HCPCS J9041,BORTEZOMIB 3.5 MG IJ SOLR,63020-0049-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),8015.00,8015.00,4809.00,4809.00,N/A,1122.10,N/A,106.09,N/A,4506.03,N/A,2725.10,N/A,3989.51,N/A,1122.10,N/A,106.09,N/A,106.09,N/A,2483.51,N/A,3989.51,N/A,3989.51,N/A,3989.51,N/A,4506.03,N/A,106.09,N/A,1122.10,N/A,4296.04,N/A,4296.04,N/A,1122.10,N/A,106.09,N/A,106.09,N/A,116.69,4809.00,4809.00,106.09,4809.00,,Hospital J9044,"Inj, bortezomib, nos, 0.1 mg",N/A,N/A,N/A,22371.20,N/A,13422.72,N/A,3164.81,N/A,64.81,N/A,12592.74,N/A,7606.20,N/A,1495.34,N/A,3164.81,N/A,60.93,N/A,60.93,N/A,930.86,N/A,1495.34,N/A,1495.34,N/A,1495.34,N/A,12592.74,N/A,60.93,N/A,3164.81,N/A,533.57,N/A,533.57,N/A,3164.81,N/A,60.93,N/A,64.81,N/A,138.17,N/A,N/A,60.93,13422.72,,Hospital J9049,"Inj, bortezomib, hospira",N/A,N/A,N/A,2388.60,N/A,1433.16,N/A,241.57,N/A,159.50,N/A,1359.68,N/A,812.12,N/A,289.17,N/A,241.57,N/A,158.23,N/A,158.23,N/A,233.54,N/A,289.17,N/A,289.17,N/A,289.17,N/A,1359.68,N/A,158.23,N/A,241.57,N/A,216.73,N/A,216.73,N/A,241.57,N/A,158.23,N/A,159.50,N/A,108.03,N/A,N/A,108.03,1433.16,,Hospital HCPCS J9060,CISPLATIN 200 MG/200ML IV SOLN,63323-0103-64,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),361.00,361.00,216.60,216.60,N/A,50.54,N/A,361.00,N/A,202.95,N/A,122.74,N/A,107.74,N/A,50.54,N/A,361.00,N/A,361.00,N/A,67.07,N/A,107.74,N/A,107.74,N/A,107.74,N/A,202.95,N/A,361.00,N/A,50.54,N/A,193.50,N/A,193.50,N/A,50.54,N/A,361.00,N/A,361.00,N/A,361.00,216.60,216.60,50.54,361.00,,Hospital HCPCS J9060,CISPLATIN 50 MG/50ML IV SOLN,63323-0103-51,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,26.94,N/A,21.00,N/A,150.00,N/A,150.00,N/A,16.77,N/A,26.94,N/A,26.94,N/A,26.94,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,16.77,150.00,,Hospital HCPCS J9070,CYCLOPHOSPHAMIDE 1 G IJ SOLR,00781-3244-94,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2801.80,2801.80,1681.08,1681.08,N/A,392.25,N/A,170.87,N/A,1575.17,N/A,952.61,N/A,695.93,N/A,392.25,N/A,170.87,N/A,170.87,N/A,433.23,N/A,695.93,N/A,695.93,N/A,695.93,N/A,1575.17,N/A,170.87,N/A,392.25,N/A,1501.76,N/A,1501.76,N/A,392.25,N/A,170.87,N/A,170.87,N/A,187.96,1681.08,1681.08,170.87,1681.08,,Hospital HCPCS J9070,CYCLOPHOSPHAMIDE 2 G IJ SOLR,10019-0957-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7325.00,7325.00,4395.00,4395.00,N/A,1025.50,N/A,341.74,N/A,4118.12,N/A,2490.50,N/A,1391.87,N/A,1025.50,N/A,341.74,N/A,341.74,N/A,866.45,N/A,1391.87,N/A,1391.87,N/A,1391.87,N/A,4118.12,N/A,341.74,N/A,1025.50,N/A,3926.20,N/A,3926.20,N/A,1025.50,N/A,341.74,N/A,341.74,N/A,375.91,4395.00,4395.00,341.74,4395.00,,Hospital HCPCS J9070,CYCLOPHOSPHAMIDE 500 MG IJ SOLR,10019-0943-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),925.00,925.00,555.00,555.00,N/A,129.50,N/A,85.44,N/A,520.04,N/A,314.50,N/A,347.97,N/A,129.50,N/A,85.44,N/A,85.44,N/A,216.61,N/A,347.97,N/A,347.97,N/A,347.97,N/A,520.04,N/A,85.44,N/A,129.50,N/A,495.80,N/A,495.80,N/A,129.50,N/A,85.44,N/A,85.44,N/A,93.98,555.00,555.00,85.44,555.00,,Hospital HCPCS J9119,CEMIPLIMAB-RWLC 350 MG/7ML IV SOLN,61755-0008-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),48048.30,48048.30,28828.98,28828.98,N/A,6726.76,N/A,9423.05,N/A,27012.75,N/A,16336.42,N/A,24702.13,N/A,6726.76,N/A,9423.05,N/A,9423.05,N/A,15377.31,N/A,24702.13,N/A,24702.13,N/A,24702.13,N/A,27012.75,N/A,9423.05,N/A,6726.76,N/A,25753.89,N/A,25753.89,N/A,6726.76,N/A,9423.05,N/A,9423.05,N/A,10365.36,28828.98,28828.98,6726.76,28828.98,,Hospital HCPCS J9176,ELOTUZUMAB 400 MG IV SOLR,00003-4522-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),13740.80,13740.80,8244.48,8244.48,N/A,1923.71,N/A,2876.40,N/A,7725.08,N/A,4671.87,N/A,7200.20,N/A,1923.71,N/A,2876.40,N/A,2876.40,N/A,4482.19,N/A,7200.20,N/A,7200.20,N/A,7200.20,N/A,7725.08,N/A,2876.40,N/A,1923.71,N/A,7365.07,N/A,7365.07,N/A,1923.71,N/A,2876.40,N/A,2876.40,N/A,13740.80,8244.48,8244.48,1923.71,13740.80,,Hospital HCPCS J9201,GEMCITABINE HCL 1 GM/26.3ML IV SOLN,67457-0617-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),192.70,192.70,115.62,115.62,N/A,26.98,N/A,192.70,N/A,108.34,N/A,65.52,N/A,48.69,N/A,26.98,N/A,192.70,N/A,192.70,N/A,30.31,N/A,48.69,N/A,48.69,N/A,48.69,N/A,108.34,N/A,192.70,N/A,26.98,N/A,103.29,N/A,103.29,N/A,26.98,N/A,192.70,N/A,192.70,N/A,192.70,115.62,115.62,26.98,192.70,,Hospital HCPCS J9201,GEMCITABINE HCL 200 MG/5.26ML IV SOLN,00409-0183-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,9.74,N/A,21.00,N/A,150.00,N/A,150.00,N/A,6.06,N/A,9.74,N/A,9.74,N/A,9.74,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,6.06,150.00,,Hospital HCPCS J9204,MOGAMULIZUMAB-KPKC 20 MG/5ML IV SOLN,42747-0761-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20822.90,20822.90,12493.74,12493.74,N/A,2915.21,N/A,20822.90,N/A,11706.63,N/A,7079.79,N/A,11201.75,N/A,2915.21,N/A,4534.12,N/A,4534.12,N/A,6973.20,N/A,11201.75,N/A,11201.75,N/A,11201.75,N/A,11706.63,N/A,4534.12,N/A,2915.21,N/A,11161.07,N/A,11161.07,N/A,2915.21,N/A,4534.12,N/A,20822.90,N/A,20822.90,12493.74,12493.74,2915.21,20822.90,,Hospital HCPCS J9208,IFOSFAMIDE 1 G IV SOLR,63323-0142-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),290.30,290.30,174.18,174.18,N/A,40.64,N/A,290.30,N/A,163.21,N/A,98.70,N/A,67.37,N/A,40.64,N/A,290.30,N/A,290.30,N/A,41.94,N/A,67.37,N/A,67.37,N/A,67.37,N/A,163.21,N/A,290.30,N/A,40.64,N/A,155.60,N/A,155.60,N/A,40.64,N/A,290.30,N/A,290.30,N/A,290.30,174.18,174.18,40.64,290.30,,Hospital J9214,Interferon Alfa-2b Inj,N/A,N/A,N/A,25820.30,N/A,15492.18,N/A,3612.83,N/A,600.73,N/A,14556.38,N/A,8778.90,N/A,5497.88,N/A,3612.83,N/A,564.71,N/A,564.71,N/A,3422.49,N/A,5497.88,N/A,5497.88,N/A,5497.88,N/A,14556.38,N/A,564.71,N/A,3612.83,N/A,3.17,N/A,3.17,N/A,3612.83,N/A,564.71,N/A,600.73,N/A,49.68,N/A,N/A,3.17,15492.18,,Hospital J9226,Supprelin La Implant,N/A,N/A,N/A,244448.10,N/A,146668.86,N/A,34222.73,N/A,17002.97,N/A,137678.64,N/A,83112.35,N/A,109824.89,N/A,34222.73,N/A,17002.13,N/A,17002.13,N/A,68367.04,N/A,109824.89,N/A,109824.89,N/A,109824.89,N/A,137678.63,N/A,17002.13,N/A,34222.73,N/A,527.00,N/A,527.00,N/A,34222.73,N/A,17002.13,N/A,17002.97,N/A,67.19,N/A,N/A,67.19,146668.86,,Hospital HCPCS J9227,ISATUXIMAB-IRFC 500 MG/25ML IV SOLN,00024-0656-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17926.50,17926.50,10755.90,10755.90,N/A,2509.71,N/A,3717.45,N/A,10078.28,N/A,6095.01,N/A,9129.75,N/A,2509.71,N/A,3717.45,N/A,3717.45,N/A,5683.36,N/A,9129.75,N/A,9129.75,N/A,9129.75,N/A,10078.28,N/A,3717.45,N/A,2509.71,N/A,9608.60,N/A,9608.60,N/A,2509.71,N/A,3717.45,N/A,3717.45,N/A,4089.20,10755.90,10755.90,2509.71,10755.90,,Hospital HCPCS J9227,ISATUXIMAB-IRFC 100 MG/5ML IV SOLN,00024-0654-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3585.30,3585.30,2151.18,2151.18,N/A,501.94,N/A,743.49,N/A,2015.66,N/A,1219.00,N/A,1825.95,N/A,501.94,N/A,743.49,N/A,743.49,N/A,1136.67,N/A,1825.95,N/A,1825.95,N/A,1825.95,N/A,2015.66,N/A,743.49,N/A,501.94,N/A,1921.72,N/A,1921.72,N/A,501.94,N/A,743.49,N/A,743.49,N/A,817.84,2151.18,2151.18,501.94,2151.18,,Hospital HCPCS J9228,IPILIMUMAB 50 MG/10ML IV SOLN,00003-2327-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),40201.80,40201.80,24121.08,24121.08,N/A,5628.25,N/A,8396.65,N/A,22601.45,N/A,13668.61,N/A,21193.97,N/A,5628.25,N/A,8396.65,N/A,8396.65,N/A,13193.45,N/A,21193.97,N/A,21193.97,N/A,21193.97,N/A,22601.45,N/A,8396.65,N/A,5628.25,N/A,21548.16,N/A,21548.16,N/A,5628.25,N/A,8396.65,N/A,8396.65,N/A,9236.32,24121.08,24121.08,5628.25,24121.08,,Hospital HCPCS J9228,IPILIMUMAB 200 MG/40ML IV SOLN,00003-2328-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),160806.80,160806.80,96484.08,96484.08,N/A,22512.95,N/A,33586.60,N/A,90405.58,N/A,54674.31,N/A,84775.88,N/A,22512.95,N/A,33586.60,N/A,33586.60,N/A,52773.80,N/A,84775.88,N/A,84775.88,N/A,84775.88,N/A,90405.58,N/A,33586.60,N/A,22512.95,N/A,86192.44,N/A,86192.44,N/A,22512.95,N/A,33586.60,N/A,33586.60,N/A,36945.26,96484.08,96484.08,22512.95,96484.08,,Hospital J9264,Paclitaxel injection,N/A,N/A,64783.87,21768.80,38870.32,13061.28,13098.63,3052.29,13857.87,2948.22,29518.82,12309.81,22026.51,7401.38,29801.19,8972.09,13502.22,3052.29,2810.00,2948.22,2810.00,2948.22,18550.55,5585.22,29801.19,8972.09,29801.19,8972.09,29801.19,8972.09,29518.82,12298.51,13857.87,2948.22,13502.22,3052.29,35455.98,2700.79,35455.98,2700.79,6607.69,3052.29,13857.87,2948.22,13857.87,2948.22,14447.37,3243.03,2810.00,38870.32,2700.79,13061.28,,Hospital J9296,"Injection, pemetrexed (accord) not therapeutically equivalent to j9305, 10 mg",N/A,N/A,N/A,65175.10,N/A,39105.06,N/A,9124.50,N/A,4785.10,N/A,36722.82,N/A,22159.52,N/A,12698.87,N/A,9124.50,N/A,4790.80,N/A,4790.80,N/A,8640.23,N/A,12698.87,N/A,12698.87,N/A,12698.87,N/A,36722.81,N/A,4790.80,N/A,9124.50,N/A,34933.85,N/A,34933.85,N/A,9124.50,N/A,4790.80,N/A,4785.10,N/A,343.28,N/A,N/A,343.28,39105.06,,Hospital HCPCS J9298,NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN,00003-7125-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),136942.80,136942.80,82165.68,82165.68,N/A,19171.99,N/A,734.52,N/A,76989.24,N/A,46560.55,N/A,721.35,N/A,19171.99,N/A,734.52,N/A,734.52,N/A,721.35,N/A,721.35,N/A,721.35,N/A,721.35,N/A,76989.24,N/A,734.52,N/A,19171.99,N/A,73401.34,N/A,73401.34,N/A,19171.99,N/A,734.52,N/A,734.52,N/A,807.97,82165.68,82165.68,721.35,82165.68,,Hospital J9305,"Injection, Pemetrexed, Not Otherwise Specified, 10 Mg",N/A,N/A,132642.03,66482.30,79585.22,39889.38,8791.75,9312.20,10665.54,12556.86,73112.29,37439.14,45098.29,22603.99,21602.65,36844.02,9062.64,9312.20,2248.00,12556.86,14797.00,12556.86,13447.14,32224.30,21602.65,36844.02,21602.65,36844.02,21602.65,36844.02,73112.29,37427.84,10665.54,12556.86,9062.64,9312.20,25701.76,2361.50,25701.76,2361.50,9062.64,9312.20,10665.54,12556.86,10665.54,12556.86,9697.03,13812.54,2248.00,79585.22,2361.50,39889.38,,Hospital HCPCS J9306,PERTUZUMAB 420 MG/14ML IV SOLN,50242-0145-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29473.00,29473.00,17683.80,17683.80,N/A,4126.22,N/A,6453.72,N/A,16569.72,N/A,10020.82,N/A,15392.37,N/A,4126.22,N/A,6453.72,N/A,6453.72,N/A,9581.90,N/A,15392.37,N/A,15392.37,N/A,15392.37,N/A,16569.72,N/A,6453.72,N/A,4126.22,N/A,15797.53,N/A,15797.53,N/A,4126.22,N/A,6453.72,N/A,6453.72,N/A,7099.09,17683.80,17683.80,4126.22,17683.80,,Hospital HCPCS J9312,RITUXIMAB (RITUXAN) 10 MG/ML IV SOLN (MIXTURES ONLY),50242-0051-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3584.00,3584.00,2150.40,2150.40,N/A,501.76,N/A,810.37,N/A,2014.92,N/A,1218.56,N/A,2180.00,N/A,501.76,N/A,810.37,N/A,810.37,N/A,1357.07,N/A,2180.00,N/A,2180.00,N/A,2180.00,N/A,2014.92,N/A,810.37,N/A,501.76,N/A,1921.02,N/A,1921.02,N/A,501.76,N/A,810.37,N/A,810.37,N/A,891.41,2150.40,2150.40,501.76,2180.00,,Hospital HCPCS J9312,RITUXIMAB 500 MG/50ML IV SOLN,50242-0053-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17920.00,17920.00,10752.00,10752.00,N/A,2508.80,N/A,4051.85,N/A,10074.62,N/A,6092.80,N/A,10900.02,N/A,2508.80,N/A,4051.85,N/A,4051.85,N/A,6785.36,N/A,10900.02,N/A,10900.02,N/A,10900.02,N/A,10074.62,N/A,4051.85,N/A,2508.80,N/A,9605.12,N/A,9605.12,N/A,2508.80,N/A,4051.85,N/A,4051.85,N/A,4457.04,10752.00,10752.00,2508.80,10900.02,,Hospital HCPCS J9312,RITUXIMAB (RITUXAN) 10 MG/ML IV SOLN (MIXTURES ONLY),50242-0053-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17920.00,17920.00,10752.00,10752.00,N/A,2508.80,N/A,4051.85,N/A,10074.62,N/A,6092.80,N/A,10900.02,N/A,2508.80,N/A,4051.85,N/A,4051.85,N/A,6785.36,N/A,10900.02,N/A,10900.02,N/A,10900.02,N/A,10074.62,N/A,4051.85,N/A,2508.80,N/A,9605.12,N/A,9605.12,N/A,2508.80,N/A,4051.85,N/A,4051.85,N/A,4457.04,10752.00,10752.00,2508.80,10900.02,,Hospital HCPCS J9312,RITUXIMAB 100 MG/10ML IV SOLN,50242-0051-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3584.00,3584.00,2150.40,2150.40,N/A,501.76,N/A,810.37,N/A,2014.92,N/A,1218.56,N/A,2180.00,N/A,501.76,N/A,810.37,N/A,810.37,N/A,1357.07,N/A,2180.00,N/A,2180.00,N/A,2180.00,N/A,2014.92,N/A,810.37,N/A,501.76,N/A,1921.02,N/A,1921.02,N/A,501.76,N/A,810.37,N/A,810.37,N/A,891.41,2150.40,2150.40,501.76,2180.00,,Hospital J9315,Romidepsin injection,N/A,N/A,N/A,136498.40,N/A,81899.04,N/A,19115.65,N/A,595.37,N/A,76817.48,N/A,46409.46,N/A,19519.69,N/A,19115.65,N/A,559.67,N/A,559.67,N/A,12131.60,N/A,19519.69,N/A,19519.69,N/A,19519.69,N/A,76082.44,N/A,559.67,N/A,19115.65,N/A,2838.23,N/A,2838.23,N/A,19115.65,N/A,559.67,N/A,595.37,N/A,301.63,N/A,N/A,301.63,81899.04,,Hospital HCPCS J9322,PEMETREXED DISODIUM 500 MG IV SOLR,00002-7623-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20215.00,20215.00,12129.00,12129.00,N/A,2830.10,N/A,396.65,N/A,11364.87,N/A,6873.10,N/A,10151.51,N/A,2830.10,N/A,396.65,N/A,396.65,N/A,6319.41,N/A,10151.51,N/A,10151.51,N/A,10151.51,N/A,11364.87,N/A,396.65,N/A,2830.10,N/A,10835.24,N/A,10835.24,N/A,2830.10,N/A,396.65,N/A,396.65,N/A,436.32,12129.00,12129.00,396.65,12129.00,,Hospital HCPCS J9322,PEMETREXED DISODIUM 100 MG IV SOLR,00002-7640-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4043.00,4043.00,2425.80,2425.80,N/A,566.02,N/A,79.33,N/A,2272.97,N/A,1374.62,N/A,2030.30,N/A,566.02,N/A,79.33,N/A,79.33,N/A,1263.88,N/A,2030.30,N/A,2030.30,N/A,2030.30,N/A,2272.97,N/A,79.33,N/A,566.02,N/A,2167.05,N/A,2167.05,N/A,566.02,N/A,79.33,N/A,79.33,N/A,87.26,2425.80,2425.80,79.33,2425.80,,Hospital J9340,Thiotepa Injection,N/A,N/A,651411.10,N/A,390846.66,N/A,N/A,N/A,83132.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,83132.18,N/A,83132.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,83132.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,83132.18,N/A,83132.18,N/A,N/A,N/A,83132.18,390846.66,N/A,N/A,,Hospital J9359,Inj lon tesirin-lpyl 0.075mg,N/A,N/A,N/A,123029.20,N/A,73817.52,N/A,17224.09,N/A,26463.42,N/A,69198.87,N/A,41829.93,N/A,65688.10,N/A,17224.09,N/A,26466.35,N/A,26466.35,N/A,40891.49,N/A,65688.10,N/A,65688.10,N/A,65688.10,N/A,69191.83,N/A,26466.35,N/A,17224.09,N/A,65943.64,N/A,65943.64,N/A,17224.09,N/A,26466.35,N/A,26463.42,N/A,151.25,N/A,N/A,151.25,73817.52,,Hospital L0180,HC Cerv Post Col Occ/Man Sup Adj,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,136635.30,94259.53,81981.18,56555.72,18231.60,13193.17,21832.68,13148.12,75313.38,53709.49,46456.00,32048.25,42716.58,29117.50,17170.59,13193.17,2810.00,11933.08,21658.61,11933.08,26592.35,18322.22,42716.58,29117.50,42716.58,29117.50,42716.58,29117.50,75313.38,53709.51,21832.68,11956.02,18793.35,13193.17,49350.14,13336.25,49350.14,13336.25,1805.09,13193.17,21658.61,11933.08,21832.68,3909.47,20108.88,3895.04,1805.09,81981.18,3895.04,56555.72,,Hospital L0190,HC Cerv Collar Supp Adj Cerv Ba,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,106265.38,115964.62,63759.23,69578.77,16382.62,16283.96,19645.44,11933.08,58573.48,66140.36,36130.23,39427.98,37272.73,29147.84,16887.40,16283.96,19645.44,11933.08,19645.44,11933.08,23201.41,18341.09,37272.73,29147.84,37272.73,29147.84,37272.73,29147.84,58573.48,66140.39,19645.44,11956.02,16887.40,16283.96,44345.24,13336.25,44345.24,13336.25,16887.40,16283.96,19645.44,11933.08,19645.44,11933.08,18069.51,13126.38,16382.62,63759.23,11933.08,69578.77,,Hospital L0472,HC Tlso Rigid Frame Hyperex Pre,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,30578.10,N/A,18346.86,N/A,4226.58,N/A,1860.05,N/A,17518.23,N/A,10396.55,N/A,5067.05,N/A,4226.58,N/A,1833.55,N/A,1833.55,N/A,3288.04,N/A,5067.05,N/A,5067.05,N/A,5067.05,N/A,17093.30,N/A,1848.16,N/A,4226.58,N/A,4704.15,N/A,4704.15,N/A,4226.58,N/A,1833.55,N/A,1860.05,N/A,968.74,N/A,N/A,968.74,18346.86,,Hospital L0627,HC Lo Sag Ri an/POS Pnl Pre Cst,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,111230.10,N/A,66738.06,N/A,10722.29,N/A,24647.95,N/A,27201.12,N/A,27890.87,N/A,27890.87,N/A,10722.29,N/A,24647.95,N/A,24647.95,N/A,27890.87,N/A,27890.87,N/A,27890.87,N/A,27890.87,N/A,27201.12,N/A,24647.95,N/A,10722.29,N/A,27201.12,N/A,27201.12,N/A,10722.29,N/A,24647.95,N/A,24647.95,N/A,10722.29,N/A,10722.29,66738.06,N/A,N/A,,Hospital L0637,HC Lso Sc R Ant/POS Pnl Pre Cst,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,301797.28,N/A,181078.37,N/A,41309.11,N/A,14831.53,N/A,166350.66,N/A,102611.07,N/A,105085.81,N/A,37314.66,N/A,14831.53,N/A,14831.53,N/A,N/A,N/A,105085.81,N/A,105085.81,N/A,105085.81,N/A,166350.66,N/A,38361.37,N/A,N/A,N/A,209698.00,N/A,N/A,N/A,37314.66,N/A,14831.53,N/A,38361.37,N/A,39926.69,N/A,14831.53,209698.00,N/A,N/A,,Hospital L1686,HC Ho Post-OP Hip Abduction,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,91647.58,N/A,54988.55,N/A,10199.26,N/A,12330.85,N/A,47023.07,N/A,31160.18,N/A,23204.73,N/A,10513.52,N/A,1686.00,N/A,12735.31,N/A,14444.40,N/A,23204.73,N/A,23204.73,N/A,23204.73,N/A,47023.07,N/A,12330.85,N/A,10513.52,N/A,27607.84,N/A,27607.84,N/A,N/A,N/A,12330.85,N/A,12330.85,N/A,11249.46,N/A,1686.00,54988.55,N/A,N/A,,Hospital L1810,HC Knee Orthosis Elastic W/.Joints Prefab Customized,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,122649.05,31246.37,73589.43,18747.82,7092.38,4374.49,8655.56,6354.28,67604.16,17978.12,41700.68,10623.76,16136.14,14523.30,7310.91,4374.49,9282.50,5973.28,9282.50,5973.28,10044.37,9041.02,16136.14,14523.30,16136.14,14523.30,16136.14,14523.30,55111.50,17978.13,8655.56,5973.28,7310.91,4374.49,19197.98,5277.50,19197.98,5277.50,7310.91,4374.49,8655.56,5973.28,8655.56,6354.28,7822.67,742.38,7092.38,73589.43,742.38,18747.82,,Hospital L1832,HC Ko Adj Jnt POS R Sup Pre Cst,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,81051.00,36666.52,48630.60,21999.91,11222.40,5133.32,13807.81,1689.99,32168.65,21091.88,22260.21,12466.62,22260.21,14855.28,11183.84,5133.32,13807.81,6055.29,13807.81,6055.29,22260.21,9358.12,22260.21,14855.28,22260.21,14855.28,22260.21,14855.28,32168.65,21091.88,13807.81,6070.79,11222.40,5133.32,29368.07,5277.50,29368.07,5277.50,11222.40,5133.32,13100.10,6055.29,13100.10,1689.99,11222.40,889.72,11183.84,48630.60,889.72,21999.91,,Hospital L1970,HC Afo Plastic Molded W/Ankle J,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,173092.40,N/A,103855.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,103855.44,103855.44,N/A,N/A,,Hospital L2200,HC Limited Ankle Motion Ea Jnt,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,247608.10,N/A,148564.86,N/A,11242.60,N/A,64580.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,11242.60,N/A,11242.60,148564.86,N/A,N/A,,Hospital L2570,HC Hip Clevic Type 2 Posit Jnt,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,91647.58,N/A,54988.55,N/A,10199.26,N/A,12330.85,N/A,47023.07,N/A,31160.18,N/A,23204.73,N/A,N/A,N/A,1686.00,N/A,1686.00,N/A,14444.40,N/A,23204.73,N/A,23204.73,N/A,23204.73,N/A,47023.07,N/A,12330.85,N/A,10513.52,N/A,27607.84,N/A,27607.84,N/A,N/A,N/A,12330.85,N/A,12330.85,N/A,11249.46,N/A,1686.00,54988.55,N/A,N/A,,Hospital L2785,HC Drop Lockretainer Each,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,338202.60,N/A,202921.56,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,11242.60,202921.56,N/A,N/A,,Hospital L3001,HC Foot Insert Remov Molded Spe,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,96300.68,N/A,57780.41,N/A,12576.90,N/A,15143.47,N/A,44274.63,N/A,32742.24,N/A,28614.19,N/A,12964.42,N/A,1686.00,N/A,1686.00,N/A,17811.67,N/A,28614.19,N/A,28614.19,N/A,28614.19,N/A,44274.63,N/A,N/A,N/A,N/A,N/A,34043.74,N/A,34043.74,N/A,12964.42,N/A,15143.47,N/A,15143.47,N/A,13871.93,N/A,1686.00,57780.41,N/A,N/A,,Hospital L3020,HC Foot Longitud/Metatarsal Sup,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,677.00,N/A,406.20,N/A,94.78,N/A,256.85,N/A,382.25,N/A,230.18,N/A,217.03,N/A,94.78,N/A,256.85,N/A,256.85,N/A,187.51,N/A,217.03,N/A,217.03,N/A,217.03,N/A,382.25,N/A,256.80,N/A,94.78,N/A,64.32,N/A,64.32,N/A,94.78,N/A,256.85,N/A,256.85,N/A,51.04,N/A,N/A,51.04,406.20,,Hospital L3260,HC Ambulatory Surgical Boot Eac,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,18535.88,N/A,11121.53,N/A,2589.35,N/A,2381.29,N/A,10647.01,N/A,6302.19,N/A,5663.94,N/A,2589.35,N/A,2332.78,N/A,2332.78,N/A,3525.91,N/A,5663.94,N/A,5663.94,N/A,5663.94,N/A,10575.03,N/A,2332.78,N/A,2589.35,N/A,3397.00,N/A,3397.00,N/A,2589.35,N/A,2332.78,N/A,2381.29,N/A,403.42,N/A,N/A,403.42,11121.53,,Hospital L3310,HC Shoe Lift Elev Heel/Sole Neo,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,85660.20,N/A,51396.12,N/A,N/A,N/A,31710.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,22376.16,N/A,22376.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31710.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31710.09,N/A,31710.09,N/A,N/A,N/A,22376.16,51396.12,N/A,N/A,,Hospital L3670,HC So Acro/Clav Can Web Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,95791.17,36735.72,57474.70,22041.43,12576.90,5143.00,15143.47,2029.60,57526.89,11735.00,32568.99,12490.13,28614.19,14487.53,12964.42,5143.00,1124.00,5973.28,1124.00,5973.28,17811.67,9018.77,28614.19,14487.53,28614.19,14487.53,28614.19,14487.53,57526.89,11735.00,15143.47,5973.28,N/A,5143.00,34043.74,12203.25,34043.74,12203.25,N/A,5143.00,15143.47,5973.28,15143.47,2029.60,13871.93,2080.45,1124.00,57526.89,2029.60,22041.43,,Hospital L3760,HC Eo Adj Jt Prefab Custom Fit (Non-Pmm),N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,13661.90,N/A,8197.14,N/A,4594.18,N/A,5700.32,N/A,11319.21,N/A,4645.05,N/A,10452.38,N/A,4735.73,N/A,2202.53,N/A,2202.53,N/A,6506.37,N/A,10452.38,N/A,10452.38,N/A,10452.38,N/A,11319.21,N/A,5700.32,N/A,4735.73,N/A,12435.73,N/A,12435.73,N/A,N/A,N/A,5700.32,N/A,5700.32,N/A,5067.23,N/A,2202.53,12435.73,N/A,N/A,,Hospital L3808,HC Whfo Ridig W/O Custom Fit,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,1208.00,N/A,724.80,N/A,169.12,N/A,483.40,N/A,690.90,N/A,410.72,N/A,554.57,N/A,169.12,N/A,483.40,N/A,483.40,N/A,536.39,N/A,554.57,N/A,554.57,N/A,554.57,N/A,690.90,N/A,491.29,N/A,169.12,N/A,463.65,N/A,463.65,N/A,169.12,N/A,483.40,N/A,483.40,N/A,177.05,N/A,N/A,169.12,724.80,,Hospital L3908,HC Who Cock-Up Nonmolde Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,39128.92,N/A,23477.35,N/A,5479.88,N/A,1381.99,N/A,22526.59,N/A,13303.83,N/A,3168.83,N/A,5479.88,N/A,1299.36,N/A,1299.36,N/A,1972.64,N/A,3168.83,N/A,3168.83,N/A,3168.83,N/A,22526.59,N/A,1299.36,N/A,5479.88,N/A,2718.25,N/A,2718.25,N/A,5479.88,N/A,1299.36,N/A,1381.99,N/A,2359.16,N/A,N/A,1299.36,23477.35,,Hospital L3925,HC Fo Pip Dip Jnt/Sprng Pre Ots (Non-Pmm),N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,3311.00,N/A,1986.60,N/A,463.54,N/A,656.74,N/A,1900.84,N/A,1125.74,N/A,1253.57,N/A,463.54,N/A,656.74,N/A,656.74,N/A,1231.73,N/A,1253.57,N/A,1253.57,N/A,1253.57,N/A,1900.84,N/A,655.59,N/A,463.54,N/A,1553.89,N/A,1553.89,N/A,463.54,N/A,656.74,N/A,656.74,N/A,439.73,N/A,N/A,439.73,1986.60,,Hospital L3960,HC Sewho Airplan Desig Abdu POS,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,46709.93,N/A,28025.96,N/A,6539.40,N/A,5942.72,N/A,11735.00,N/A,15881.04,N/A,14576.96,N/A,6539.40,N/A,5973.28,N/A,5973.28,N/A,9074.42,N/A,14576.96,N/A,14576.96,N/A,14576.96,N/A,11735.00,N/A,5973.28,N/A,6539.40,N/A,12203.25,N/A,12203.25,N/A,6539.40,N/A,5973.28,N/A,5942.72,N/A,2868.06,N/A,N/A,2868.06,28025.96,,Hospital L4360,HC Brace Walker Equalizer,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,67927.93,13388.92,40756.76,8033.35,8503.39,1874.46,10324.72,2674.29,22245.13,7703.08,23095.50,4552.24,19346.38,6528.01,8765.39,1874.46,2810.00,2688.04,13830.74,2688.04,N/A,4063.81,N/A,6528.01,19346.38,6528.01,19346.38,6528.01,22245.13,7703.08,10324.72,2688.04,8765.39,1874.46,25910.47,3397.00,23017.36,3397.00,1193.50,1874.46,10324.72,2688.04,10324.72,2674.29,1193.50,251.56,1193.50,40756.76,251.56,8033.35,,Hospital L4387,HC Non-Pneum Walk Boot Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,27635.50,N/A,16581.30,N/A,3864.56,N/A,1440.53,N/A,15907.24,N/A,9396.07,N/A,3308.43,N/A,3864.56,N/A,1354.15,N/A,1354.15,N/A,2059.56,N/A,3308.43,N/A,3308.43,N/A,3308.43,N/A,15907.24,N/A,1354.15,N/A,3864.56,N/A,2586.50,N/A,2586.50,N/A,3864.56,N/A,1354.15,N/A,1440.53,N/A,600.43,N/A,N/A,600.43,16581.30,,Hospital L8501,HC Trachesostomy Speaking Valve,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,198769.83,N/A,119261.90,N/A,51703.88,N/A,32911.24,N/A,449042.43,N/A,258870.15,N/A,258870.15,N/A,51703.88,N/A,32911.24,N/A,32911.24,N/A,258870.15,N/A,258870.15,N/A,258870.15,N/A,258870.15,N/A,449042.43,N/A,32911.24,N/A,51703.88,N/A,94811.60,N/A,449042.43,N/A,51703.88,N/A,32911.24,N/A,32911.24,N/A,51703.88,N/A,32911.24,449042.43,N/A,N/A,,Hospital L8606,HC Misc Syn Implant Urin per 1ml Syr,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,42298.73,29686.77,25379.24,17812.06,9613.52,4156.15,11637.93,3192.81,24794.64,16822.86,14381.57,10093.50,21872.09,7038.83,9909.73,4156.15,11637.93,2894.35,11637.93,2894.35,13614.87,4381.81,21872.09,7038.83,21872.09,7038.83,21872.09,7038.83,24794.64,16822.86,11637.93,2894.35,9909.73,4156.15,26022.32,4562.00,26022.32,4562.00,N/A,4156.15,11637.93,2894.35,11637.93,675.09,10603.41,210.33,9613.52,26022.32,210.33,17812.06,,Hospital L8610,HC Ocular Implant,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,20683.33,N/A,12410.00,N/A,2895.68,N/A,3774.30,N/A,11836.80,N/A,7032.34,N/A,9049.87,N/A,2895.68,N/A,3608.17,N/A,3608.17,N/A,5633.45,N/A,9049.87,N/A,9049.87,N/A,9049.87,N/A,11836.81,N/A,3608.17,N/A,2895.68,N/A,5963.00,N/A,5963.00,N/A,2895.68,N/A,3608.17,N/A,3774.30,N/A,1164.26,N/A,N/A,1164.26,12410.00,,Hospital L8614,HC Misc Cochlear Implant,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,198990.68,N/A,119394.41,N/A,27838.55,N/A,29844.64,N/A,112316.17,N/A,67656.84,N/A,72858.02,N/A,27838.55,N/A,30104.67,N/A,30104.67,N/A,45355.51,N/A,72858.02,N/A,72858.02,N/A,72858.02,N/A,112316.16,N/A,30104.67,N/A,27838.55,N/A,32047.00,N/A,32047.00,N/A,27838.55,N/A,30104.67,N/A,29844.64,N/A,46189.83,N/A,N/A,27838.55,119394.41,,Hospital L8689,HC Ext Rechg Sys Neurostim Repl,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,69200.57,N/A,41520.34,N/A,9688.08,N/A,20668.52,N/A,39104.97,N/A,23528.19,N/A,47016.12,N/A,9688.08,N/A,19429.23,N/A,19429.23,N/A,29268.44,N/A,47016.12,N/A,47016.12,N/A,47016.12,N/A,39104.97,N/A,19429.23,N/A,9688.08,N/A,37100.00,N/A,37100.00,N/A,9688.08,N/A,19429.23,N/A,20668.52,N/A,168.15,N/A,N/A,168.15,47016.12,,Hospital L8690,HC Misc Auditory Osseointegrated Dev,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,66675.40,N/A,40005.24,N/A,10199.26,N/A,12330.85,N/A,37637.37,N/A,22669.63,N/A,23204.73,N/A,10513.52,N/A,12330.85,N/A,12330.85,N/A,14444.40,N/A,23204.73,N/A,23204.73,N/A,23204.73,N/A,N/A,N/A,12330.85,N/A,10513.52,N/A,N/A,N/A,27607.84,N/A,N/A,N/A,12330.85,N/A,12330.85,N/A,N/A,N/A,10199.26,40005.24,N/A,N/A,,Hospital CPT M0220,HC Tixagev and Cilgav Inj,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,395.00,395.00,237.00,237.00,N/A,55.30,N/A,135.91,N/A,227.44,N/A,134.30,N/A,150.50,N/A,55.30,N/A,135.91,N/A,135.91,N/A,150.50,N/A,150.50,N/A,150.50,N/A,150.50,N/A,227.44,N/A,135.91,N/A,55.30,N/A,211.72,N/A,211.72,N/A,55.30,N/A,135.91,N/A,135.91,N/A,149.50,237.00,237.00,55.30,237.00,,Hospital CPT M0222,HC Bebtelovimab Injection,N/A,0250 - PHARMACY - GENERAL CLASSIFICATION,920.00,920.00,N/A,N/A,N/A,128.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,128.80,N/A,N/A,N/A,N/A,N/A,920.00,N/A,N/A,128.80,920.00,,Hospital CPT M0222,HC Bebtelovimab Injection,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,920.00,920.00,552.00,552.00,N/A,N/A,N/A,323.10,N/A,529.74,N/A,312.80,N/A,350.50,N/A,128.80,N/A,316.52,N/A,316.52,N/A,350.50,N/A,350.50,N/A,350.50,N/A,350.50,N/A,529.74,N/A,316.52,N/A,128.80,N/A,493.12,N/A,493.12,N/A,N/A,N/A,316.52,N/A,323.10,N/A,N/A,552.00,552.00,128.80,552.00,,Hospital M0239,HC IV Infusion Bamlanivimab W/Monitoring,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,N/A,1366.10,N/A,819.66,N/A,191.25,N/A,290.24,N/A,786.61,N/A,464.47,N/A,158.77,N/A,191.25,N/A,290.24,N/A,290.24,N/A,98.67,N/A,158.77,N/A,158.77,N/A,158.77,N/A,786.60,N/A,290.24,N/A,191.25,N/A,732.22,N/A,732.23,N/A,191.25,N/A,290.24,N/A,290.24,N/A,N/A,N/A,N/A,98.67,819.66,,Hospital CPT M0245,HC IV Infusion Bamlanivimab & Etesevimab W/Monitoring,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,2039.00,2039.00,1223.40,1223.40,N/A,285.46,N/A,425.55,N/A,1174.06,N/A,693.26,N/A,450.50,N/A,285.46,N/A,406.82,N/A,406.82,N/A,450.50,N/A,450.50,N/A,450.50,N/A,450.50,N/A,1174.06,N/A,406.82,N/A,285.46,N/A,1092.90,N/A,1092.90,N/A,285.46,N/A,406.82,N/A,425.55,N/A,2039.00,1223.40,1223.40,285.46,2039.00,,Hospital MED10045,"Swabstck, Benzoin Tincture, 1/Pk, Strl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2222.10,N/A,1333.26,N/A,N/A,N/A,1826.07,N/A,800.00,N/A,925.52,N/A,925.52,N/A,N/A,N/A,1826.07,N/A,1826.07,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,800.00,N/A,1931.46,N/A,N/A,N/A,800.00,N/A,800.00,N/A,N/A,N/A,1826.07,N/A,1826.07,N/A,N/A,N/A,N/A,800.00,1931.46,,Hospital MED10158,"Applicator, Cotton-Tip, Wood, 6, Strl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2841.28,N/A,1704.77,N/A,820.44,N/A,2004.25,N/A,700.00,N/A,966.02,N/A,777.00,N/A,397.77,N/A,2004.25,N/A,2004.25,N/A,777.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,1636.01,N/A,2304.31,N/A,820.44,N/A,22.12,N/A,22.12,N/A,820.44,N/A,1045.00,N/A,2004.25,N/A,26.91,N/A,N/A,22.12,2304.31,,Hospital MED10162,"Blade, Tongue, 6, Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2656.73,N/A,1594.04,N/A,N/A,N/A,2709.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2709.87,N/A,2709.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2709.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2709.87,N/A,2709.87,N/A,N/A,N/A,N/A,1594.04,2709.87,,Hospital MED10194,"Cream,Skin Repair, Remedy Ist,Phyto 4oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2516.40,N/A,1509.84,N/A,N/A,N/A,2566.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2566.73,N/A,2566.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2566.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2566.73,N/A,2566.73,N/A,N/A,N/A,N/A,1509.84,2566.73,,Hospital MED10196,"Paste,Calazime, Remedy Ist Phyto 2oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2054.55,N/A,1232.73,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,1232.73,2095.64,,Hospital MED10261,"Gauze, Border, 3x6, 1.5x4pad, Steril",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2453.08,N/A,1471.85,N/A,N/A,N/A,783.00,N/A,1037.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,783.00,N/A,783.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1037.00,N/A,783.00,N/A,N/A,N/A,1037.00,N/A,1037.00,N/A,N/A,N/A,783.00,N/A,783.00,N/A,N/A,N/A,N/A,783.00,1471.85,,Hospital MED10307,"Accuwrap,2 Layer,Compression Sys",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4476.35,N/A,2685.81,N/A,N/A,N/A,756.00,N/A,N/A,N/A,1521.96,N/A,778.39,N/A,626.69,N/A,756.00,N/A,756.00,N/A,777.86,N/A,778.39,N/A,778.39,N/A,778.39,N/A,2577.48,N/A,756.00,N/A,N/A,N/A,684.12,N/A,684.12,N/A,N/A,N/A,756.00,N/A,756.00,N/A,9.48,N/A,N/A,9.48,2685.81,,Hospital MED10308,"Accuwrap,2 Layer,Compression Sys",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2890.93,N/A,1734.56,N/A,N/A,N/A,1485.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1485.00,N/A,1485.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1485.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1485.00,N/A,1485.00,N/A,N/A,N/A,N/A,1485.00,1734.56,,Hospital MED10310,"Accuwrap Xl, 2 Layer, Compression Sys",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2004.25,N/A,1202.55,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,1202.55,2004.25,,Hospital MED10312,"Accuwrap Lite, 2 Layer, Compression Sys",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4206.03,N/A,2523.62,N/A,N/A,N/A,990.00,N/A,N/A,N/A,1430.05,N/A,999.00,N/A,588.85,N/A,990.00,N/A,990.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2421.84,N/A,990.00,N/A,N/A,N/A,110.43,N/A,110.43,N/A,N/A,N/A,990.00,N/A,990.00,N/A,21.62,N/A,N/A,21.62,2523.62,,Hospital MED10425,"Liner, Clear, 24x24, 10 Gal, 6 Mic, Roll",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2258.18,N/A,1354.91,N/A,N/A,N/A,2303.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2303.35,N/A,2303.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2303.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2303.35,N/A,2303.35,N/A,N/A,N/A,N/A,1354.91,2303.35,,Hospital MED10507,"Syringe, Luer Lock, Sterile, 3ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2504.33,N/A,1502.60,N/A,N/A,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,2554.42,N/A,N/A,N/A,N/A,1502.60,2554.42,,Hospital MED10597,"Kit,Pleurx Drainage 500 Ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,12641.28,N/A,7584.77,N/A,N/A,N/A,2462.00,N/A,N/A,N/A,4298.04,N/A,2056.00,N/A,1769.78,N/A,2462.00,N/A,2462.00,N/A,2361.00,N/A,2056.00,N/A,2056.00,N/A,2056.00,N/A,7278.85,N/A,2462.00,N/A,N/A,N/A,1072.00,N/A,1072.00,N/A,N/A,N/A,2462.00,N/A,2462.00,N/A,N/A,N/A,N/A,1072.00,7584.77,,Hospital MED10720,"Protectant, Ointment, Soothe&Cool, 4oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,7771.60,N/A,4662.96,N/A,1098.42,N/A,5.69,N/A,N/A,N/A,2642.35,N/A,999.00,N/A,1088.02,N/A,N/A,N/A,N/A,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,4474.90,N/A,N/A,N/A,1098.42,N/A,2021.56,N/A,2021.56,N/A,1098.42,N/A,N/A,N/A,5.69,N/A,6.26,N/A,N/A,5.69,4662.96,,Hospital MED10987,"Saline,.9%,3 Ml,Vial",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1981.98,N/A,1189.19,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1189.19,1189.19,,Hospital MED10999,"Syringe, Sterile, Field Flush 10 Ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,15765.10,N/A,9459.06,N/A,2207.11,N/A,1386.72,N/A,2552.00,N/A,5359.30,N/A,3287.50,N/A,2207.11,N/A,1350.64,N/A,1350.64,N/A,2046.54,N/A,3287.50,N/A,3287.50,N/A,3287.50,N/A,2552.00,N/A,1350.64,N/A,2207.11,N/A,2806.50,N/A,2806.50,N/A,2207.11,N/A,1350.64,N/A,1386.72,N/A,577.53,N/A,N/A,577.53,9459.06,,Hospital MED11025,"Jelly,Petroleum,Tube,4 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1732.30,N/A,1039.38,N/A,N/A,N/A,1766.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1766.95,N/A,1766.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1766.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1766.95,N/A,1766.95,N/A,N/A,N/A,N/A,1039.38,1766.95,,Hospital MED11061,"Saline,.9%,15 Ml,Vial",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2668.28,N/A,1600.97,N/A,N/A,N/A,1755.00,N/A,700.00,N/A,1256.54,N/A,1256.54,N/A,N/A,N/A,2200.00,N/A,2200.00,N/A,1256.54,N/A,1256.54,N/A,1256.54,N/A,1256.54,N/A,700.00,N/A,2378.56,N/A,N/A,N/A,700.00,N/A,600.00,N/A,N/A,N/A,2200.00,N/A,2200.00,N/A,N/A,N/A,N/A,600.00,2378.56,,Hospital MED11179,"Bandage,Elastic,Matrix,Strl,4x10yd,Lf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2853.68,N/A,1712.21,N/A,986.68,N/A,1755.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,986.68,N/A,1755.00,N/A,1755.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1755.00,N/A,986.68,N/A,N/A,N/A,N/A,N/A,986.68,N/A,1755.00,N/A,1755.00,N/A,986.68,N/A,N/A,986.68,1755.00,,Hospital MED11189,"Swabstick, Alcohol, 3/Pk, Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2720.58,N/A,1632.35,N/A,234.53,N/A,2775.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,234.53,N/A,2775.00,N/A,2775.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2775.00,N/A,234.53,N/A,N/A,N/A,N/A,N/A,234.53,N/A,2775.00,N/A,2775.00,N/A,234.53,N/A,N/A,234.53,2775.00,,Hospital MED11211,"Cleanser,Vashe-Dermal,Wound,16 Oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2574.73,N/A,1544.84,N/A,N/A,N/A,1296.00,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1296.00,N/A,1296.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,1296.00,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,N/A,N/A,1296.00,N/A,1296.00,N/A,N/A,N/A,N/A,1080.00,1544.84,,Hospital MED11261,"Gauze,Packing Strip,Iodoform,1/4x5yd,St",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3293.63,N/A,1976.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,90.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,90.26,1976.18,,Hospital MED11283,"Planner,7-Day,Med",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2481.32,N/A,1488.79,N/A,N/A,N/A,2530.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2530.95,N/A,2530.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2530.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2530.95,N/A,2530.95,N/A,N/A,N/A,N/A,1488.79,2530.95,,Hospital MED11331,"Mbo-Device,Stabilize,Foley,3 Wy,Statlock",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1603.87,N/A,962.32,N/A,N/A,N/A,1404.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1404.00,N/A,1404.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1404.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1404.00,N/A,1404.00,N/A,N/A,N/A,N/A,962.32,1404.00,,Hospital MED11332,Dressing Kit for Aspira Drain,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2414.15,N/A,1448.49,N/A,3080.31,N/A,375.00,N/A,N/A,N/A,820.81,N/A,555.00,N/A,337.99,N/A,375.00,N/A,375.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1390.07,N/A,375.00,N/A,3080.31,N/A,221.98,N/A,221.98,N/A,3080.31,N/A,375.00,N/A,375.00,N/A,94.46,N/A,N/A,94.46,3080.31,,Hospital MED11356,"Dbf-Gauze,Spnge,Dran,4x4,6ply,Strl,2s",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1187.42,N/A,712.45,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,712.45,712.45,,Hospital MED11433,"Moisturizer,Nourishing Skin CRM,Unsc,4oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3590.63,N/A,2154.38,N/A,N/A,N/A,840.00,N/A,N/A,N/A,1220.81,N/A,890.09,N/A,502.68,N/A,840.00,N/A,840.00,N/A,889.30,N/A,890.09,N/A,890.09,N/A,890.09,N/A,2067.49,N/A,840.00,N/A,N/A,N/A,209.38,N/A,209.38,N/A,N/A,N/A,840.00,N/A,840.00,N/A,25.34,N/A,N/A,25.34,2154.38,,Hospital MED11481,"Sterile Cotton-Tipped Wood Applicators,6",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2504.33,N/A,1502.60,N/A,N/A,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,2554.42,N/A,N/A,N/A,N/A,1502.60,2554.42,,Hospital MED11538,"Dressing,Hydrofiber,Advantage,4""X5""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2905.68,N/A,1743.41,N/A,975.12,N/A,7.40,N/A,N/A,N/A,987.94,N/A,778.39,N/A,406.80,N/A,1260.00,N/A,1260.00,N/A,777.86,N/A,778.39,N/A,778.39,N/A,778.39,N/A,1673.09,N/A,1260.00,N/A,975.12,N/A,56.66,N/A,56.66,N/A,975.12,N/A,1260.00,N/A,7.40,N/A,8.14,N/A,N/A,7.40,1743.41,,Hospital MED11610,"Swabstick,Betadine",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2071.92,N/A,1243.15,N/A,511.41,N/A,17.69,N/A,N/A,N/A,704.45,N/A,444.00,N/A,290.07,N/A,N/A,N/A,N/A,N/A,444.00,N/A,444.00,N/A,444.00,N/A,444.00,N/A,1193.02,N/A,N/A,N/A,511.41,N/A,38.55,N/A,38.55,N/A,511.41,N/A,N/A,N/A,17.69,N/A,19.46,N/A,N/A,17.69,1243.15,,Hospital MED11840,"Applicator,Cotton-Tip,Plastic,6,Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1575.25,N/A,945.15,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.15,945.15,,Hospital MED11929,"Saline,.9%,5 Ml,Addipak,Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6093.93,N/A,3656.36,N/A,N/A,N/A,7.27,N/A,N/A,N/A,2071.93,N/A,1567.14,N/A,853.14,N/A,N/A,N/A,N/A,N/A,1562.19,N/A,1567.14,N/A,1567.14,N/A,1567.14,N/A,3508.88,N/A,N/A,N/A,N/A,N/A,50.34,N/A,50.34,N/A,N/A,N/A,N/A,N/A,7.27,N/A,7.99,N/A,N/A,7.27,3656.36,,Hospital MED12016,"Solution,Scrub,Povidone Iodine,4 Oz Bt",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,523.12,N/A,313.87,N/A,N/A,N/A,135.88,N/A,N/A,N/A,177.86,N/A,128.24,N/A,73.24,N/A,N/A,N/A,N/A,N/A,121.70,N/A,128.24,N/A,128.24,N/A,128.24,N/A,301.21,N/A,N/A,N/A,N/A,N/A,66.00,N/A,66.00,N/A,N/A,N/A,N/A,N/A,135.88,N/A,149.47,N/A,N/A,66.00,313.87,,Hospital MED12032,"Xl Fabric, Curad, 10ct, 2""X4"", 24bx/",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1640.27,N/A,984.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,984.16,984.16,,Hospital MED12058,"Dressing,Hydrofera Blue,Ready,2.5""X2",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5357.00,N/A,3214.20,N/A,867.93,N/A,497.22,N/A,N/A,N/A,1821.39,N/A,1221.00,N/A,749.98,N/A,N/A,N/A,N/A,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,3084.55,N/A,N/A,N/A,867.93,N/A,512.95,N/A,512.95,N/A,867.93,N/A,N/A,N/A,497.22,N/A,546.95,N/A,N/A,497.22,3214.20,,Hospital MED12067,"Bandage,Fabric,Curad,30ct,Assrtd",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2872.30,N/A,1723.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1723.38,1723.38,,Hospital MED12091,"Cleanser,Foam,No Rinse,Remedy Phyto,8 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3386.23,N/A,2031.74,N/A,573.64,N/A,28.73,N/A,N/A,N/A,1151.33,N/A,613.39,N/A,474.08,N/A,1512.00,N/A,1512.00,N/A,713.66,N/A,613.39,N/A,613.39,N/A,613.39,N/A,1949.79,N/A,1512.00,N/A,573.64,N/A,428.80,N/A,428.80,N/A,573.64,N/A,1512.00,N/A,28.73,N/A,31.61,N/A,N/A,28.73,2031.74,,Hospital MED12206,"Triple Antibiotic Oin, 1 Oz Tube",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1925.72,N/A,1155.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1155.43,1155.43,,Hospital MED12239,"Dressing,Allevyn,Gentle Border,10x30",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,7403.77,N/A,4442.26,N/A,1444.56,N/A,211.35,N/A,N/A,N/A,2517.29,N/A,1332.00,N/A,1036.52,N/A,N/A,N/A,N/A,N/A,1332.00,N/A,1332.00,N/A,1332.00,N/A,1332.00,N/A,4263.08,N/A,N/A,N/A,1444.56,N/A,1395.59,N/A,1395.59,N/A,1444.56,N/A,N/A,N/A,211.35,N/A,232.49,N/A,N/A,211.35,4442.26,,Hospital MED12265,"Sol,Dakin .50%,Full Strength,No Return",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5106.08,N/A,3063.65,N/A,N/A,N/A,213.32,N/A,N/A,N/A,1736.06,N/A,1112.78,N/A,714.86,N/A,N/A,N/A,N/A,N/A,1111.72,N/A,1112.78,N/A,1112.78,N/A,1112.78,N/A,2940.07,N/A,N/A,N/A,N/A,N/A,378.46,N/A,378.46,N/A,N/A,N/A,N/A,N/A,213.32,N/A,234.66,N/A,N/A,213.32,3063.65,,Hospital MED12305,"Dressing,Zetuvit,Silicone,Plus,5x5"",Abs",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3799.28,N/A,2279.57,N/A,N/A,N/A,675.00,N/A,N/A,N/A,1291.76,N/A,1001.09,N/A,531.91,N/A,675.00,N/A,675.00,N/A,1000.30,N/A,1001.09,N/A,1001.09,N/A,1001.09,N/A,2187.64,N/A,675.00,N/A,N/A,N/A,106.81,N/A,106.81,N/A,N/A,N/A,675.00,N/A,675.00,N/A,49.56,N/A,N/A,49.56,2279.57,,Hospital MED12343,"Bandage,Elastic,Swiftwrap,4""X5yd,Hook&Lp",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2054.55,N/A,1232.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1232.73,1232.73,,Hospital MED12376,"Aegis 1"" Disk 4mm Hole, Peel Open",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3185.03,N/A,1911.02,N/A,234.53,N/A,2765.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,234.53,N/A,2765.00,N/A,2765.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2765.00,N/A,234.53,N/A,N/A,N/A,N/A,N/A,234.53,N/A,2765.00,N/A,2765.00,N/A,234.53,N/A,N/A,234.53,2765.00,,Hospital MED12453,"Barrier,Protective,Sensicare,4 Oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2366.07,N/A,1419.64,N/A,N/A,N/A,1536.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1536.00,N/A,1536.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1536.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1536.00,N/A,1536.00,N/A,N/A,N/A,N/A,1419.64,1536.00,,Hospital MED12480,"Aegis, 3/4"" Disk 1.5mm Hole, Sleeve",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2186.13,N/A,1311.68,N/A,N/A,N/A,N/A,N/A,994.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,994.00,N/A,N/A,N/A,N/A,N/A,994.00,N/A,994.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,994.00,1311.68,,Hospital MED12515,"Solution,Hydrogen Peroxide,3per,1-Oz Pk",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3204.53,N/A,1922.72,N/A,N/A,N/A,N/A,N/A,804.00,N/A,1089.54,N/A,448.63,N/A,448.63,N/A,1826.07,N/A,1826.07,N/A,819.40,N/A,448.63,N/A,448.63,N/A,448.63,N/A,1845.17,N/A,1826.07,N/A,N/A,N/A,1715.20,N/A,1715.20,N/A,N/A,N/A,1826.07,N/A,N/A,N/A,N/A,N/A,N/A,448.63,1922.72,,Hospital MED12556,"Can,Spray,7.1-Oz,Saline,Wound Wash,Strl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3003.07,N/A,1801.84,N/A,958.61,N/A,1610.00,N/A,N/A,N/A,856.00,N/A,856.00,N/A,73.88,N/A,1610.00,N/A,1610.00,N/A,856.00,N/A,856.00,N/A,856.00,N/A,856.00,N/A,N/A,N/A,1781.53,N/A,958.61,N/A,N/A,N/A,N/A,N/A,958.61,N/A,1430.00,N/A,1610.00,N/A,958.61,N/A,N/A,73.88,1801.84,,Hospital MED12605,"Protector,Heel/Elbow,Knit,Elastic,6cs",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,7013.37,N/A,4208.02,N/A,N/A,N/A,1728.00,N/A,N/A,N/A,2384.54,N/A,1116.00,N/A,981.87,N/A,1728.00,N/A,1728.00,N/A,1848.00,N/A,1116.00,N/A,1116.00,N/A,1116.00,N/A,4038.29,N/A,1728.00,N/A,N/A,N/A,2572.80,N/A,2572.80,N/A,N/A,N/A,1728.00,N/A,1728.00,N/A,6.59,N/A,N/A,6.59,4208.02,,Hospital MED12755,"Catheter,Hydrophilic,Infyna Chic,Ch 14",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2202.75,N/A,1321.65,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1321.65,1321.65,,Hospital MED12765,"Dressing,3.5x10"",Aquacel,W/Silver,Sp",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1980.35,N/A,1188.21,N/A,1703.87,N/A,N/A,N/A,N/A,N/A,925.52,N/A,925.52,N/A,1703.87,N/A,N/A,N/A,N/A,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,N/A,N/A,N/A,N/A,1703.87,N/A,N/A,N/A,N/A,N/A,1703.87,N/A,N/A,N/A,N/A,N/A,1703.87,N/A,N/A,925.52,1703.87,,Hospital MED12798,"Syringe, Luer Lock, Sterile, 1ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6220.50,N/A,3732.30,N/A,N/A,N/A,2113.20,N/A,N/A,N/A,2114.96,N/A,1280.00,N/A,870.86,N/A,2113.20,N/A,2113.20,N/A,1707.00,N/A,1280.00,N/A,1280.00,N/A,1280.00,N/A,3581.76,N/A,2113.20,N/A,N/A,N/A,1500.80,N/A,1500.80,N/A,N/A,N/A,2113.20,N/A,2113.20,N/A,252.87,N/A,N/A,252.87,3732.30,,Hospital MED12835,"Dressings,Strl,Silver Containing Calcium",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,10238.85,N/A,6143.31,N/A,N/A,N/A,2375.00,N/A,N/A,N/A,3481.20,N/A,1783.00,N/A,1433.43,N/A,2375.00,N/A,2375.00,N/A,2637.00,N/A,1783.00,N/A,1783.00,N/A,1783.00,N/A,5895.52,N/A,2375.00,N/A,N/A,N/A,3001.60,N/A,3001.60,N/A,N/A,N/A,2375.00,N/A,2375.00,N/A,78.68,N/A,N/A,78.68,6143.31,,Hospital MED12847,"Bandage,Coflex,Lf2,4""X5yd,Tan,Ns,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,9539.42,N/A,5723.65,N/A,2605.03,N/A,59.55,N/A,N/A,N/A,3243.40,N/A,1563.09,N/A,1335.52,N/A,N/A,N/A,N/A,N/A,2416.30,N/A,1563.09,N/A,1563.09,N/A,1563.09,N/A,5492.80,N/A,N/A,N/A,2605.03,N/A,3001.60,N/A,3001.60,N/A,2605.03,N/A,N/A,N/A,59.55,N/A,65.51,N/A,N/A,59.55,5723.65,,Hospital MED12859,"Catheter,Foley,Silastic,20fr,30ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,779.25,N/A,467.55,N/A,N/A,N/A,801.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,801.17,N/A,801.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,84.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,801.17,N/A,801.17,N/A,N/A,N/A,N/A,84.44,801.17,,Hospital MED12898,"Cotton Roll,Sterile,1lb,Large",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital MED12935,"Cream,Barrier,Baza Antifungal 5 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2669.20,N/A,1601.52,N/A,N/A,N/A,2823.63,N/A,N/A,N/A,N/A,N/A,N/A,N/A,109.36,N/A,2823.63,N/A,2823.63,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,529.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2823.63,N/A,2823.63,N/A,N/A,N/A,N/A,109.36,2823.63,,Hospital MED12938,"Prep,Chg,Liquid,4%,32 Oz,12 Ea/Cs",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3287.52,N/A,1972.51,N/A,625.59,N/A,22.91,N/A,N/A,N/A,1117.75,N/A,780.57,N/A,460.25,N/A,N/A,N/A,N/A,N/A,779.22,N/A,780.57,N/A,780.57,N/A,780.57,N/A,1892.95,N/A,N/A,N/A,625.59,N/A,46.90,N/A,46.90,N/A,625.59,N/A,N/A,N/A,22.91,N/A,25.22,N/A,N/A,22.91,1972.51,,Hospital MED12940,Tolnaftate 1% CRM 1.25oz,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2669.20,N/A,1601.52,N/A,N/A,N/A,2823.63,N/A,N/A,N/A,N/A,N/A,N/A,N/A,109.36,N/A,2823.63,N/A,2823.63,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,529.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2823.63,N/A,2823.63,N/A,N/A,N/A,N/A,109.36,2823.63,,Hospital MED12999,"Ndl,Huber,20gx0.75"",Safestep,Set,Cap",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4324.57,N/A,2594.74,N/A,1282.86,N/A,69.93,N/A,N/A,N/A,1470.36,N/A,890.00,N/A,605.44,N/A,N/A,N/A,N/A,N/A,1134.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,2490.09,N/A,N/A,N/A,1282.86,N/A,857.60,N/A,857.60,N/A,1282.86,N/A,N/A,N/A,69.93,N/A,76.92,N/A,N/A,69.93,2594.74,,Hospital MED13035,"Dressing, Suresite Select, 4"" X 6 1/8""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4318.07,N/A,2590.84,N/A,N/A,N/A,77.72,N/A,N/A,N/A,1468.14,N/A,1110.00,N/A,604.53,N/A,N/A,N/A,N/A,N/A,1110.00,N/A,1110.00,N/A,1110.00,N/A,1110.00,N/A,2486.34,N/A,N/A,N/A,N/A,N/A,170.49,N/A,170.49,N/A,N/A,N/A,N/A,N/A,77.72,N/A,85.50,N/A,N/A,77.72,2590.84,,Hospital MED13148,"Dbd-Unnaboot,Unnarite,W/Zinc,Calamine,3x",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3309.13,N/A,1985.48,N/A,N/A,N/A,2.82,N/A,N/A,N/A,1125.10,N/A,903.28,N/A,463.28,N/A,N/A,N/A,N/A,N/A,897.50,N/A,903.28,N/A,903.28,N/A,903.28,N/A,1905.40,N/A,N/A,N/A,N/A,N/A,58.50,N/A,58.50,N/A,N/A,N/A,N/A,N/A,2.82,N/A,3.10,N/A,N/A,2.82,1985.48,,Hospital MED13175,"Dressing,Covrsite,4""X4""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1915.00,N/A,1149.00,N/A,N/A,N/A,80.80,N/A,N/A,N/A,651.10,N/A,444.00,N/A,268.10,N/A,N/A,N/A,N/A,N/A,444.00,N/A,444.00,N/A,444.00,N/A,444.00,N/A,1102.66,N/A,N/A,N/A,N/A,N/A,168.85,N/A,168.85,N/A,N/A,N/A,N/A,N/A,80.80,N/A,88.88,N/A,N/A,80.80,1149.00,,Hospital MED13180,"Dbd-Slipper,Single Tread,Gray,Xxl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2463.47,N/A,1478.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,1478.08,,Hospital MED13210,"Tray,Foley,Latx,18fr,10ml,W/Sd",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2577.57,N/A,1546.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1546.54,1546.54,,Hospital MED13311,"Bandage,Elas,Ns,3"" X 5 Yards,Latex Free",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5975.37,N/A,3585.22,N/A,N/A,N/A,1404.00,N/A,N/A,N/A,2031.64,N/A,1444.39,N/A,836.55,N/A,1404.00,N/A,1404.00,N/A,1443.86,N/A,1444.39,N/A,1444.39,N/A,1444.39,N/A,3440.60,N/A,1404.00,N/A,N/A,N/A,201.19,N/A,201.19,N/A,N/A,N/A,1404.00,N/A,1404.00,N/A,49.17,N/A,N/A,49.17,3585.22,,Hospital MED13334,Medium Male External Catheter,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6743.63,N/A,4046.18,N/A,N/A,N/A,1419.00,N/A,N/A,N/A,2292.85,N/A,1471.00,N/A,944.12,N/A,1419.00,N/A,1419.00,N/A,1490.00,N/A,1471.00,N/A,1471.00,N/A,1471.00,N/A,3883.00,N/A,1419.00,N/A,N/A,N/A,720.17,N/A,720.17,N/A,N/A,N/A,1419.00,N/A,1419.00,N/A,291.87,N/A,N/A,291.87,4046.18,,Hospital MED13391,"Field,Sterile,Tissue-Poly-Tiss,18x26",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3053.02,N/A,1831.81,N/A,N/A,N/A,648.00,N/A,N/A,N/A,1038.02,N/A,666.00,N/A,427.43,N/A,648.00,N/A,648.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1757.92,N/A,648.00,N/A,N/A,N/A,135.63,N/A,135.63,N/A,N/A,N/A,648.00,N/A,648.00,N/A,159.98,N/A,N/A,135.63,1831.81,,Hospital MED13407,"Cleanser,Wound,Skintegrity,Ep,8oz,Spray",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2696.08,N/A,1617.65,N/A,724.08,N/A,1512.00,N/A,1054.00,N/A,449.92,N/A,449.92,N/A,724.08,N/A,1512.00,N/A,1512.00,N/A,449.92,N/A,449.92,N/A,449.92,N/A,449.92,N/A,1054.00,N/A,1512.00,N/A,724.08,N/A,1054.00,N/A,1054.00,N/A,724.08,N/A,1512.00,N/A,1512.00,N/A,724.08,N/A,N/A,449.92,1617.65,,Hospital MED13449,"Saline,.9%,Dualtop,Bottle,100ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1314.22,N/A,788.53,N/A,N/A,N/A,34.19,N/A,N/A,N/A,446.83,N/A,167.00,N/A,183.99,N/A,N/A,N/A,N/A,N/A,228.00,N/A,167.00,N/A,167.00,N/A,167.00,N/A,756.72,N/A,N/A,N/A,N/A,N/A,214.40,N/A,214.40,N/A,N/A,N/A,N/A,N/A,34.19,N/A,37.61,N/A,N/A,34.19,788.53,,Hospital MED13472,"Cleanser,Wound,Skintegrity,Ep,16oz,Spray",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1972.37,N/A,1183.42,N/A,N/A,N/A,334.70,N/A,N/A,N/A,670.60,N/A,496.15,N/A,276.14,N/A,N/A,N/A,N/A,N/A,476.39,N/A,496.15,N/A,496.15,N/A,496.15,N/A,1135.69,N/A,N/A,N/A,N/A,N/A,199.58,N/A,199.58,N/A,N/A,N/A,N/A,N/A,334.70,N/A,368.17,N/A,N/A,199.58,1183.42,,Hospital MED13492,"Dressing,4"" X 4"",Zetuvit Plus",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1298.28,N/A,778.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,778.97,778.97,,Hospital Custom MISC245,Pediflex Gel Bunion Splint,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISC350,"Retail Item, $350",N/A,N/A,350.00,350.00,210.00,210.00,N/A,49.00,N/A,350.00,N/A,350.00,N/A,119.00,N/A,49.00,N/A,49.00,N/A,350.00,N/A,350.00,N/A,30.45,N/A,49.00,N/A,49.00,N/A,49.00,N/A,350.00,N/A,350.00,N/A,49.00,N/A,350.00,N/A,350.00,N/A,49.00,N/A,350.00,N/A,350.00,N/A,350.00,210.00,210.00,30.45,350.00,,Hospital Custom MISC636,Half Foam Exercise Roller 6x36,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC87,Curette Podiatry,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISC901,Cold Pac Standard,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISC902,Cold Pac Oversized,N/A,N/A,40.00,40.00,24.00,24.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,24.00,24.00,3.48,40.00,,Hospital Custom MISC903,Cold Pac Cervical,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISC907,North Coast Elastic Putty,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISC908,Foam Slant Board (Each),N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC909,Xerosox Upper Arm,N/A,N/A,45.00,45.00,27.00,27.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,15.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,3.92,N/A,6.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,45.00,27.00,27.00,3.92,45.00,,Hospital Custom MISC913,Hallux Valgus,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC916,Thigh Sleeve,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC918,Full Foam Exercise Roller 6x18,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC921,Bionic Gloves Golf,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISC922,Bionic Gloves Gardening,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISC924,Biontic Gloves-Fitness Full Finger,N/A,N/A,50.00,50.00,30.00,30.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,17.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,50.00,30.00,30.00,4.35,50.00,,Hospital Custom MISC926,Equestrian Gloves,N/A,N/A,50.00,50.00,30.00,30.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,17.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,4.35,N/A,7.00,N/A,7.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,7.00,N/A,50.00,N/A,50.00,N/A,50.00,30.00,30.00,4.35,50.00,,Hospital Custom MISC967,Aircast Airheel Brace,N/A,N/A,51.00,51.00,30.60,30.60,N/A,7.14,N/A,51.00,N/A,51.00,N/A,17.34,N/A,7.14,N/A,7.14,N/A,51.00,N/A,51.00,N/A,4.44,N/A,7.14,N/A,7.14,N/A,7.14,N/A,51.00,N/A,51.00,N/A,7.14,N/A,51.00,N/A,51.00,N/A,7.14,N/A,51.00,N/A,51.00,N/A,51.00,30.60,30.60,4.44,51.00,,Hospital Custom MISCAMB,Miscamb,N/A,N/A,300.00,300.00,180.00,180.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,102.00,N/A,42.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,26.10,N/A,42.00,N/A,42.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,42.00,N/A,300.00,N/A,300.00,N/A,300.00,180.00,180.00,26.10,300.00,,Hospital Custom MISCATC1,Miscatc1,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCAUD2,Misc Audiology Supplies 2,N/A,N/A,200.00,200.00,120.00,120.00,N/A,28.00,N/A,200.00,N/A,200.00,N/A,68.00,N/A,28.00,N/A,28.00,N/A,200.00,N/A,200.00,N/A,17.40,N/A,28.00,N/A,28.00,N/A,28.00,N/A,200.00,N/A,200.00,N/A,28.00,N/A,200.00,N/A,200.00,N/A,28.00,N/A,200.00,N/A,200.00,N/A,200.00,120.00,120.00,17.40,200.00,,Hospital Custom MISCCALCIUMCRML,MISCCALCIUMCRML- 90ct Caramel,N/A,N/A,31.95,31.95,19.17,19.17,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,19.17,19.17,19.17,31.95,,Hospital Custom MISCCELEBRATEPSCVS,MISCCELEBRATEPROTEINSHAKE - Caramel Vanilla Swirl (Protein 20 Bag/Powder 15 Serv Bag),N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCCELEBRATEPSPBC,MISCCELEBRATEPROTEINSHAKE - Peanut Butter Cookie (Protein 20 Bag/Powder 15 Serv Bag),N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCCELEBRMRSBANBER,MISCCELEBRATEMEALREPLACEMENTSHAKE - Bananaberry (MR/TUB POWDER 15 SERV TUB),N/A,N/A,28.95,28.95,17.37,17.37,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,17.37,17.37,17.37,28.95,,Hospital Custom MISCD1101,Lateral Stabilizer Airmesh,N/A,N/A,65.00,65.00,39.00,39.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,22.10,N/A,9.10,N/A,9.10,N/A,65.00,N/A,65.00,N/A,5.66,N/A,9.10,N/A,9.10,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,9.10,N/A,65.00,N/A,65.00,N/A,65.00,39.00,39.00,5.66,65.00,,Hospital Custom MISCD114,Calf Sleeves,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCD124,Darco Post-OP Shoe Brace (Retail),N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCD284,Toe Combs,N/A,N/A,2.00,2.00,1.20,1.20,N/A,N/A,N/A,2.00,N/A,2.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.00,N/A,2.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.00,N/A,2.00,N/A,N/A,N/A,2.00,N/A,2.00,N/A,N/A,N/A,2.00,N/A,2.00,N/A,2.00,1.20,1.20,1.20,2.00,,Hospital Custom MISCD48,Neoprene Ankle-Mcdavid,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCD79,Kneed-It,N/A,N/A,35.00,35.00,21.00,21.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,11.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,3.05,N/A,4.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,35.00,21.00,21.00,3.05,35.00,,Hospital Custom MISCD84,Padded Elbow Sleeve-Mcdavid,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISCENSUREMAXHPBERRY,MISCENSUREMAXHIGHPROTEIN - Berry,N/A,N/A,2.75,2.75,1.65,1.65,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,1.65,1.65,1.65,2.75,,Hospital Custom MISCENSUREMAXHPCHOC,MISCENSUREMAXHIGHPROTEIN - Chocolate,N/A,N/A,2.75,2.75,1.65,1.65,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,1.65,1.65,1.65,2.75,,Hospital Custom MISCENSUREPRESURSTRW,MISCENSUREPRESURGERY - Strawberry,N/A,N/A,2.75,2.75,1.65,1.65,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,1.65,1.65,1.65,2.75,,Hospital Custom MISCFOM6X36,Full Foam Exercise Roller 6x36,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCFOMCVR,Full Foam 36 Cover Tote,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCKAYSPRETJHMIND,MISCKAYSNATURALPRETZELS - Jalapeno Honey Mustard (single bag),N/A,N/A,1.25,1.25,N/A,N/A,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,1.25,N/A,N/A,1.25,1.25,,Hospital Custom MISCKaysPretzels,MISCKAYSPRETZELS- Original,N/A,N/A,8.95,8.95,5.37,5.37,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,5.37,5.37,5.37,8.95,,Hospital Custom MISCLHANDLE,Breg L Handle,N/A,N/A,10.00,10.00,6.00,6.00,N/A,1.40,N/A,10.00,N/A,10.00,N/A,3.40,N/A,1.40,N/A,1.40,N/A,10.00,N/A,10.00,N/A,N/A,N/A,1.40,N/A,1.40,N/A,1.40,N/A,10.00,N/A,10.00,N/A,1.40,N/A,10.00,N/A,10.00,N/A,1.40,N/A,10.00,N/A,10.00,N/A,10.00,6.00,6.00,1.40,10.00,,Hospital Custom MISCMRTubCrml,MISCMRTUBCRML-Caramel Latte,N/A,N/A,28.95,28.95,17.37,17.37,N/A,4.05,N/A,28.95,N/A,28.95,N/A,9.84,N/A,4.05,N/A,4.05,N/A,28.95,N/A,28.95,N/A,2.52,N/A,4.05,N/A,4.05,N/A,4.05,N/A,28.95,N/A,28.95,N/A,4.05,N/A,28.95,N/A,28.95,N/A,4.05,N/A,28.95,N/A,28.95,N/A,28.95,17.37,17.37,2.52,28.95,,Hospital Custom MISCMRTubDChclt,MISCMRTUBDCHCLT- Deep Chocolate,N/A,N/A,28.95,28.95,17.37,17.37,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,N/A,28.95,17.37,17.37,17.37,28.95,,Hospital Custom MISCPILATES,Misc Pilates Class,N/A,N/A,35.00,35.00,21.00,21.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,11.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,3.05,N/A,4.90,N/A,4.90,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,4.90,N/A,35.00,N/A,35.00,N/A,35.00,21.00,21.00,3.05,35.00,,Hospital Custom MISCPULLYB&C,Pully's B&C,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISCPWRWBRED,Power Web Medium Red,N/A,N/A,60.00,60.00,36.00,36.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,20.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,5.22,N/A,8.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,60.00,36.00,36.00,5.22,60.00,,Hospital Custom MISCProtein20SglSv,MISCPROTEIN20SGLSV- Asst Flavored,N/A,N/A,31.95,31.95,19.17,19.17,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,19.17,19.17,19.17,31.95,,Hospital Custom MISCProtein20Unflvd,MISCPROTEIN20UNFLVD- Unflavored,N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCProteinWldbry,MISCPROTEIN20WLDBRY- Wild Berry,N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCRES,Misc Resident Nonbillable,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCRQBLGLVS,Raquetball Gloves,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCVES5,Ves Evaluation 14 or > Sheets,N/A,N/A,1200.00,1200.00,720.00,720.00,N/A,168.00,N/A,1200.00,N/A,1200.00,N/A,408.00,N/A,168.00,N/A,168.00,N/A,1200.00,N/A,1200.00,N/A,104.40,N/A,168.00,N/A,168.00,N/A,168.00,N/A,1200.00,N/A,1200.00,N/A,168.00,N/A,1200.00,N/A,1200.00,N/A,168.00,N/A,1200.00,N/A,1200.00,N/A,1200.00,720.00,720.00,104.40,1200.00,,Hospital CPT P3000,HC Screen Pap by Tech W MD Supv,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,143.00,122.00,85.80,73.20,N/A,15.15,N/A,17.31,N/A,70.25,N/A,41.48,N/A,8.98,N/A,15.15,N/A,17.31,N/A,17.31,N/A,8.98,N/A,8.98,N/A,8.98,N/A,8.98,N/A,70.25,N/A,17.31,N/A,15.15,N/A,15.92,N/A,15.92,N/A,15.15,N/A,17.31,N/A,17.31,N/A,16.67,85.80,85.80,8.98,73.20,,Hospital P9010,HC Whole Blood for Transfusion,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",N/A,1667.00,N/A,1000.20,N/A,233.38,N/A,612.78,N/A,959.86,N/A,566.78,N/A,1387.88,N/A,233.38,N/A,595.82,N/A,595.82,N/A,863.98,N/A,1387.88,N/A,1387.88,N/A,1387.88,N/A,959.87,N/A,595.82,N/A,233.38,N/A,242.81,N/A,242.81,N/A,233.38,N/A,595.82,N/A,612.78,N/A,37.35,N/A,N/A,37.35,1387.88,,Hospital P9019,HC Platelet Conc. Each Unit,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",28063.10,1707.50,16837.86,1024.50,N/A,239.05,N/A,442.26,N/A,983.18,N/A,580.55,N/A,1059.39,N/A,239.05,N/A,445.44,N/A,445.44,N/A,659.49,N/A,1059.39,N/A,1059.39,N/A,1059.39,N/A,983.18,N/A,445.44,N/A,239.05,N/A,190.28,N/A,190.28,N/A,239.05,N/A,445.44,N/A,442.26,N/A,37.35,16837.86,16837.86,37.35,1059.39,,Hospital P9021,HC Red Blood Cells Each Unit,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",74695.52,3382.30,44817.31,2029.38,13098.63,473.52,15760.65,682.21,N/A,1920.85,25396.48,1149.98,29801.19,1609.42,N/A,473.52,3372.00,660.21,10794.00,660.21,18550.55,1001.89,29801.19,1609.42,29801.19,1609.42,29801.19,1609.42,29518.82,1920.85,10794.00,660.21,N/A,473.52,N/A,393.43,35455.98,393.43,N/A,473.52,15760.65,660.21,15760.65,682.21,N/A,52.08,3372.00,44817.31,52.08,2029.38,,Hospital P9022,HC Washed Red Blood Cells Each,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",117969.90,N/A,70781.94,N/A,11310.66,N/A,3203.46,N/A,N/A,N/A,39117.78,N/A,23754.54,N/A,11310.66,N/A,3203.46,N/A,3203.46,N/A,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,N/A,N/A,3203.46,N/A,11310.66,N/A,N/A,N/A,28261.97,N/A,11310.66,N/A,3203.46,N/A,3203.46,N/A,11310.66,N/A,3203.46,70781.94,N/A,N/A,,Hospital CPT P9031,HC Platelets Leuko Red Ea Unit,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",416.00,416.00,249.60,249.60,N/A,58.24,N/A,130.89,N/A,239.53,N/A,141.44,N/A,285.92,N/A,58.24,N/A,130.89,N/A,130.89,N/A,177.99,N/A,285.92,N/A,285.92,N/A,285.92,N/A,239.53,N/A,130.89,N/A,58.24,N/A,222.98,N/A,222.98,N/A,58.24,N/A,130.89,N/A,130.89,N/A,416.00,249.60,249.60,58.24,416.00,,Hospital P9032,"HC Platelets, Irradiated",N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",N/A,13416.00,N/A,8049.60,N/A,1860.85,N/A,224.15,N/A,7657.82,N/A,4561.44,N/A,3449.70,N/A,1860.85,N/A,1383.29,N/A,1383.29,N/A,2147.50,N/A,3449.70,N/A,3449.70,N/A,3449.70,N/A,7657.83,N/A,1383.29,N/A,1860.85,N/A,3003.66,N/A,3003.66,N/A,1860.85,N/A,1383.29,N/A,224.15,N/A,246.56,N/A,N/A,224.15,8049.60,,Hospital HCPCS P9033,HC Platelets Leukoreduced Irrad,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",509.00,509.00,305.40,305.40,N/A,71.26,N/A,509.00,N/A,293.08,N/A,173.06,N/A,71.26,N/A,71.26,N/A,509.00,N/A,509.00,N/A,44.28,N/A,71.26,N/A,71.26,N/A,71.26,N/A,293.08,N/A,509.00,N/A,71.26,N/A,272.82,N/A,272.82,N/A,71.26,N/A,509.00,N/A,509.00,N/A,509.00,305.40,305.40,44.28,509.00,,Hospital P9054,HC Blood Lr Froz/Degly/Wash,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",33212.67,N/A,19927.60,N/A,7416.72,N/A,9039.24,N/A,16714.19,N/A,11292.30,N/A,16874.07,N/A,7645.25,N/A,562.00,N/A,562.00,N/A,10503.72,N/A,16874.07,N/A,16874.07,N/A,16874.07,N/A,16714.19,N/A,9039.24,N/A,7645.25,N/A,20075.93,N/A,20075.93,N/A,7645.25,N/A,9039.24,N/A,9039.24,N/A,8180.41,N/A,562.00,20075.93,N/A,N/A,,Hospital P9604,HC One-Way Allow Prorated Trip,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,41182.40,186.85,24709.44,112.11,10440.92,18.33,12616.71,23.50,23529.46,107.59,14002.02,63.53,23754.54,19.04,10762.62,18.33,3372.00,23.50,3372.00,23.50,14786.65,19.04,23754.54,19.04,23754.54,19.04,23754.54,19.04,23529.46,107.59,12616.71,23.50,10762.62,18.33,28261.97,17.93,28261.97,17.93,N/A,18.33,12616.71,23.50,12616.71,23.50,11516.01,19.73,3372.00,28261.97,17.93,112.11,,Hospital CPT Q0111,HC Wet Prep,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,78.00,54.00,46.80,32.40,N/A,5.82,N/A,17.31,N/A,31.09,N/A,18.36,N/A,5.82,N/A,5.82,N/A,17.31,N/A,17.31,N/A,3.62,N/A,5.82,N/A,5.82,N/A,5.82,N/A,31.09,N/A,17.31,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,17.31,N/A,17.31,N/A,6.40,46.80,46.80,3.62,32.40,,Hospital Q0113,HC Pinworm Ova Prep,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,N/A,40.00,N/A,24.00,N/A,8.54,N/A,8.54,N/A,N/A,N/A,13.60,N/A,9.20,N/A,8.54,N/A,8.54,N/A,8.54,N/A,9.20,N/A,9.20,N/A,9.20,N/A,9.20,N/A,23.04,N/A,8.54,N/A,8.54,N/A,8.54,N/A,8.54,N/A,8.54,N/A,8.54,N/A,8.54,N/A,9.40,N/A,N/A,8.54,24.00,,Hospital CPT Q0114,HC Fern Test,N/A,0301 - LABORATORY - CHEMISTRY,78.00,59.00,46.80,35.40,N/A,9.74,N/A,9.74,N/A,33.97,N/A,20.06,N/A,9.74,N/A,9.74,N/A,9.74,N/A,9.74,N/A,6.06,N/A,9.74,N/A,9.74,N/A,9.74,N/A,33.97,N/A,9.74,N/A,9.74,N/A,9.74,N/A,9.74,N/A,9.74,N/A,9.74,N/A,9.74,N/A,10.71,46.80,46.80,6.06,35.40,,Hospital Q0239,Bamlanivimab-xxxx,N/A,N/A,N/A,713.10,N/A,427.86,N/A,99.83,N/A,309.30,N/A,410.60,N/A,242.45,N/A,713.11,N/A,99.83,N/A,295.68,N/A,295.68,N/A,445.25,N/A,713.11,N/A,713.11,N/A,713.11,N/A,210.80,N/A,295.68,N/A,99.83,N/A,382.22,N/A,382.22,N/A,99.83,N/A,295.68,N/A,309.30,N/A,155.56,N/A,N/A,99.83,713.11,,Hospital HCPCS Q2050,DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,00338-0063-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3315.00,3315.00,1989.00,1989.00,N/A,464.10,N/A,175.96,N/A,1863.69,N/A,1127.10,N/A,673.35,N/A,464.10,N/A,175.96,N/A,175.96,N/A,419.17,N/A,673.35,N/A,673.35,N/A,673.35,N/A,1863.69,N/A,175.96,N/A,464.10,N/A,1776.84,N/A,1776.84,N/A,464.10,N/A,175.96,N/A,175.96,N/A,193.55,1989.00,1989.00,175.96,1989.00,,Hospital HCPCS Q2050,DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,00338-0067-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),8420.00,8420.00,5052.00,5052.00,N/A,1178.80,N/A,439.89,N/A,4733.72,N/A,2862.80,N/A,1683.37,N/A,1178.80,N/A,439.89,N/A,439.89,N/A,1047.91,N/A,1683.37,N/A,1683.37,N/A,1683.37,N/A,4733.72,N/A,439.89,N/A,1178.80,N/A,4513.12,N/A,4513.12,N/A,1178.80,N/A,439.89,N/A,439.89,N/A,483.88,5052.00,5052.00,439.89,5052.00,,Hospital Q3014,HC Telehealth Originating Site Facility Fee,N/A,0780 - TELEMEDICINE - GENERAL CLASSIFICATION,N/A,186.00,N/A,111.60,N/A,26.04,N/A,N/A,N/A,107.10,N/A,63.24,N/A,26.04,N/A,26.04,N/A,N/A,N/A,N/A,N/A,16.18,N/A,26.04,N/A,26.04,N/A,26.04,N/A,107.10,N/A,N/A,N/A,26.04,N/A,28.00,N/A,28.00,N/A,26.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16.18,111.60,,Hospital Q4100,"HC Skin Substitute, Nos",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),89788.43,52495.72,53873.06,31497.43,13074.01,7340.55,13781.09,6248.31,41517.82,29981.62,30528.07,17848.54,96677.55,14503.80,13074.01,7340.55,4496.00,5973.28,13781.09,5973.28,96677.55,9028.89,96677.55,14503.80,96677.55,14503.80,96677.55,14503.80,58919.82,29981.64,13781.09,5973.28,13074.01,7340.55,41517.82,4825.50,70770.44,4825.50,13074.01,7340.55,29260.78,5973.28,13781.09,6248.31,13074.01,651.36,4496.00,96677.55,651.36,31497.43,,Hospital Q4101,"HC Apligraf, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),87373.43,12448.93,52424.06,7469.36,8148.92,1742.85,9904.59,1545.06,40310.29,7057.89,29706.97,4232.63,41732.01,3769.94,8400.00,1742.85,1124.00,1558.52,1124.00,1558.52,25977.84,2346.86,41732.01,3769.94,41732.01,3769.94,41732.01,3769.94,40310.29,7057.89,9904.59,1558.52,8400.00,1742.85,47792.07,1871.00,47792.07,1871.00,N/A,1742.85,9904.59,1558.52,9904.59,1545.06,8988.00,99.44,1124.00,52424.06,99.44,7469.36,,Hospital Q4102,HC Oasis Dressing per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,8090.33,N/A,4854.20,N/A,1132.65,N/A,879.11,N/A,4641.36,N/A,2750.72,N/A,2032.91,N/A,1132.65,N/A,840.42,N/A,840.42,N/A,1265.52,N/A,2032.91,N/A,2032.91,N/A,2032.91,N/A,4641.36,N/A,840.42,N/A,1132.65,N/A,922.25,N/A,922.25,N/A,1132.65,N/A,840.42,N/A,879.11,N/A,131.29,N/A,N/A,131.29,4854.20,,Hospital Q4104,HC Integra Bmwd per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),134351.30,49062.52,80610.78,29437.51,14220.72,6868.76,25430.79,1619.20,39113.27,27807.01,45679.44,16681.26,25485.45,3769.94,14220.72,6868.76,31940.37,1558.52,31940.37,1558.52,25485.45,2346.86,25485.45,3769.94,25485.45,3769.94,25485.45,3769.94,39113.27,27807.01,25430.79,1558.52,14220.72,6868.76,39113.27,1871.00,39113.27,1871.00,14220.72,6868.76,25430.79,1558.52,25430.79,1619.20,14220.72,88.51,14220.72,80610.78,88.51,29437.51,,Hospital Q4110,"HC Primatrix, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),121479.38,39115.72,72887.63,23469.43,13514.19,5476.20,33272.93,1883.25,N/A,22163.43,41303.00,13299.34,30746.66,4404.45,6792.10,5476.20,3372.00,1820.83,3372.00,1820.83,43899.06,2741.85,43899.06,4404.45,30746.66,4404.45,30746.66,4404.45,N/A,22163.43,16252.24,1820.83,13930.59,5476.20,N/A,2938.25,36580.85,2938.25,6792.10,5476.20,16252.24,1820.83,16252.24,1883.25,14905.73,374.97,3372.00,72887.63,374.97,23469.43,,Hospital Q4114,HC Integra Flowable Wound Matrix per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),217760.08,N/A,130656.05,N/A,21614.02,N/A,N/A,N/A,N/A,N/A,74038.43,N/A,75824.06,N/A,18123.71,N/A,N/A,N/A,5620.00,N/A,47210.39,N/A,75824.06,N/A,75824.06,N/A,75824.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,135860.76,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5620.00,135860.76,N/A,N/A,,Hospital Q4116,HC Alloderm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),124884.72,163971.82,74930.83,98383.09,9261.97,22909.65,11222.07,15759.82,68836.45,93558.05,42460.80,55750.40,21072.26,38099.62,9547.35,22909.65,562.00,15066.11,562.00,15066.11,13116.99,24815.57,21072.26,38099.62,21072.26,38099.62,21072.26,38099.62,68836.45,93558.06,11222.07,15066.11,9547.35,22909.65,25070.73,12986.00,25070.73,12986.00,12740.53,22909.65,11222.07,15066.11,11222.07,15759.82,10215.66,5722.89,562.00,74930.83,5722.89,98383.09,,Hospital Q4118,HC Matristem Micromatrix 1mg,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),165810.08,50879.80,99486.05,30527.88,17238.29,7123.17,20716.96,1773.10,91394.52,28816.20,56375.43,17299.13,39219.50,4214.70,17769.43,7123.17,20657.66,1726.97,20657.66,1726.97,24413.23,2623.72,39219.50,4214.70,39219.50,4214.70,39219.50,4214.70,45313.55,28816.20,20657.66,1726.97,17769.43,7123.17,46661.42,2134.50,46661.42,2134.50,22444.87,7123.17,20657.66,1726.97,20657.66,1773.10,19013.30,181.00,17238.29,99486.05,181.00,30527.88,,Hospital Q4125,HC Arthroflex per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),171726.13,62530.93,103035.68,37518.56,13337.46,8754.33,13361.95,6178.06,94655.45,35694.07,58386.89,21260.52,24959.74,14464.43,11308.67,8754.33,3372.00,5973.28,3372.00,5973.28,N/A,9004.38,N/A,14464.43,24959.74,14464.43,24959.74,14464.43,N/A,35694.07,13243.35,5973.28,11308.67,8754.33,29695.86,4112.50,29695.86,4112.50,N/A,8754.33,13243.35,5973.28,13361.95,6178.06,12100.28,535.71,3372.00,103035.68,535.71,37518.56,,Hospital Q4155,"HC Neoxflo or Clarixflo, per 1 Mg",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,38011.35,N/A,22806.81,N/A,5315.92,N/A,2743.94,N/A,21759.78,N/A,12923.86,N/A,6528.17,N/A,5315.92,N/A,2688.04,N/A,2688.04,N/A,4063.91,N/A,6528.17,N/A,6528.17,N/A,6528.17,N/A,21759.78,N/A,2688.04,N/A,5315.92,N/A,3397.00,N/A,3397.00,N/A,5315.92,N/A,2688.04,N/A,2743.94,N/A,488.86,N/A,N/A,488.86,22806.81,,Hospital Q4181,"Amnio wound, per square cm",N/A,N/A,N/A,29861.30,N/A,17916.78,N/A,4180.59,N/A,1416.50,N/A,16983.72,N/A,10152.84,N/A,3297.58,N/A,4180.59,N/A,1354.15,N/A,1354.15,N/A,2052.80,N/A,3297.58,N/A,3297.58,N/A,3297.58,N/A,16983.73,N/A,1354.15,N/A,4180.59,N/A,2806.50,N/A,2806.50,N/A,4180.59,N/A,1354.15,N/A,1416.50,N/A,448.42,N/A,N/A,448.42,17916.78,,Hospital Q4195,HC Puraply 1 Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),132044.75,9807.00,79226.85,5884.20,28800.73,1372.98,N/A,1634.01,N/A,5539.64,N/A,3334.38,N/A,3769.94,28800.73,1372.98,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,5539.64,N/A,1558.52,28800.73,1372.98,N/A,1871.00,N/A,1871.00,28800.73,1372.98,N/A,1558.52,N/A,80.46,28800.73,88.51,28800.73,79226.85,80.46,5884.20,,Hospital Q4196,HC Puraply Am 1 Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),114595.93,9276.25,68757.56,5565.75,15378.08,1298.68,N/A,1545.06,N/A,5276.44,38962.64,3153.93,21540.75,3769.94,15378.08,1298.68,N/A,1558.52,N/A,1558.52,13408.61,2346.86,21540.75,3769.94,21540.75,3769.94,21540.75,3769.94,N/A,5276.44,N/A,1558.52,15378.08,1298.68,N/A,1871.00,N/A,1871.00,15378.08,1298.68,N/A,1558.52,N/A,1545.06,15378.08,88.51,13408.61,68757.56,88.51,5565.75,,Hospital Q4200,HC Skin Te 1 Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,19558.90,N/A,11735.34,N/A,2738.24,N/A,1630.28,N/A,11146.75,N/A,6650.02,N/A,3799.72,N/A,2738.24,N/A,1558.52,N/A,1558.52,N/A,2365.40,N/A,3799.72,N/A,3799.72,N/A,3799.72,N/A,11146.75,N/A,1558.52,N/A,2738.24,N/A,1871.00,N/A,1871.00,N/A,2738.24,N/A,1558.52,N/A,1630.28,N/A,119.93,N/A,N/A,119.93,11735.34,,Hospital Q4212,"Allogen, per cc",N/A,N/A,N/A,34720.70,N/A,20832.42,N/A,4860.90,N/A,2440.19,N/A,19791.36,N/A,11805.04,N/A,5670.12,N/A,4860.90,N/A,2332.78,N/A,2332.78,N/A,3529.75,N/A,5670.12,N/A,5670.12,N/A,5670.12,N/A,19791.36,N/A,2332.78,N/A,4860.90,N/A,3397.00,N/A,3397.00,N/A,4860.90,N/A,2332.78,N/A,2440.19,N/A,458.41,N/A,N/A,458.41,20832.42,,Hospital Q5002,Hospice/home hlth in asst lv,N/A,N/A,N/A,9150.00,N/A,5490.00,N/A,N/A,N/A,N/A,N/A,5043.60,N/A,3111.00,N/A,1281.00,N/A,1281.00,N/A,N/A,N/A,N/A,N/A,796.20,N/A,1281.00,N/A,1281.00,N/A,1281.00,N/A,5268.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,796.20,5490.00,,Hospital Q5004,Hospice in SNF,N/A,N/A,N/A,4880.00,N/A,2928.00,N/A,5925.60,N/A,N/A,N/A,2689.92,N/A,1659.20,N/A,683.20,N/A,683.20,N/A,N/A,N/A,N/A,N/A,424.64,N/A,683.20,N/A,683.20,N/A,683.20,N/A,2809.92,N/A,N/A,N/A,5925.60,N/A,N/A,N/A,N/A,N/A,5925.60,N/A,N/A,N/A,N/A,N/A,5925.60,N/A,N/A,424.64,5925.60,,Hospital HCPCS Q5101,FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,61314-0318-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),985.50,985.50,591.30,591.30,N/A,137.97,N/A,985.50,N/A,554.05,N/A,335.07,N/A,178.71,N/A,137.97,N/A,985.50,N/A,985.50,N/A,111.25,N/A,178.71,N/A,178.71,N/A,178.71,N/A,554.05,N/A,985.50,N/A,137.97,N/A,528.23,N/A,528.23,N/A,137.97,N/A,985.50,N/A,985.50,N/A,985.50,591.30,591.30,111.25,985.50,,Hospital HCPCS Q5101,FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,61314-0326-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1576.80,1576.80,946.08,946.08,N/A,220.75,N/A,1576.80,N/A,886.48,N/A,536.11,N/A,285.94,N/A,220.75,N/A,1576.80,N/A,1576.80,N/A,178.00,N/A,285.94,N/A,285.94,N/A,285.94,N/A,886.48,N/A,1576.80,N/A,220.75,N/A,845.16,N/A,845.16,N/A,220.75,N/A,1576.80,N/A,1576.80,N/A,1576.80,946.08,946.08,178.00,1576.80,,Hospital HCPCS Q5116,TRASTUZUMAB-QYYP 420 MG IV SOLR,00069-0305-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16955.40,16955.40,10173.24,10173.24,N/A,2373.76,N/A,972.47,N/A,9532.33,N/A,5764.84,N/A,4947.31,N/A,2373.76,N/A,972.47,N/A,972.47,N/A,3079.75,N/A,4947.31,N/A,4947.31,N/A,4947.31,N/A,9532.33,N/A,972.47,N/A,2373.76,N/A,9088.09,N/A,9088.09,N/A,2373.76,N/A,972.47,N/A,972.47,N/A,1069.71,10173.24,10173.24,972.47,10173.24,,Hospital HCPCS Q5120,PEGFILGRASTIM-BMEZ 6 MG/0.6ML SC SOSY,61314-0866-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17662.60,17662.60,10597.56,10597.56,N/A,2472.76,N/A,360.59,N/A,9929.91,N/A,6005.28,N/A,4765.50,N/A,2472.76,N/A,360.59,N/A,360.59,N/A,2966.57,N/A,4765.50,N/A,4765.50,N/A,4765.50,N/A,9929.91,N/A,360.59,N/A,2472.76,N/A,9467.15,N/A,9467.15,N/A,2472.76,N/A,360.59,N/A,360.59,N/A,396.65,10597.56,10597.56,360.59,10597.56,,Hospital CPT Q9001,HC Chaplain Assessment,N/A,0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION,10.00,10.00,6.00,6.00,N/A,1.40,N/A,10.00,N/A,5.76,N/A,3.40,N/A,1.40,N/A,1.40,N/A,10.00,N/A,10.00,N/A,N/A,N/A,1.40,N/A,1.40,N/A,1.40,N/A,5.76,N/A,10.00,N/A,1.40,N/A,5.36,N/A,5.36,N/A,1.40,N/A,10.00,N/A,10.00,N/A,10.00,6.00,6.00,1.40,10.00,,Hospital CPT Q9002,HC Chaplain Counsel Individual,N/A,0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION,10.00,10.00,6.00,6.00,N/A,1.40,N/A,10.00,N/A,5.76,N/A,3.40,N/A,1.40,N/A,1.40,N/A,10.00,N/A,10.00,N/A,N/A,N/A,1.40,N/A,1.40,N/A,1.40,N/A,5.76,N/A,10.00,N/A,1.40,N/A,5.36,N/A,5.36,N/A,1.40,N/A,10.00,N/A,10.00,N/A,10.00,6.00,6.00,1.40,10.00,,Hospital Q9964,"HOCM>= 400mg/ml iodine, 1ml",N/A,N/A,N/A,3062.00,N/A,1837.20,N/A,428.68,N/A,167.20,N/A,1739.21,N/A,1041.08,N/A,393.95,N/A,428.68,N/A,162.85,N/A,162.85,N/A,245.24,N/A,393.95,N/A,393.95,N/A,393.95,N/A,1739.21,N/A,162.85,N/A,428.68,N/A,699.48,N/A,699.48,N/A,428.68,N/A,162.85,N/A,167.20,N/A,166.71,N/A,N/A,162.85,1837.20,,Hospital Q9965,"Locm 100-199mg/Ml Iodine,1ml",N/A,N/A,63163.42,4615.40,37898.05,2769.24,12530.49,641.75,15088.57,618.98,28442.59,2655.91,21475.56,1569.24,28508.60,1414.03,12916.58,641.75,15088.57,581.86,15088.57,581.86,17745.94,880.26,28508.60,1414.03,28508.60,1414.03,28508.60,1414.03,28442.59,2655.91,15088.57,581.86,12916.58,641.75,33918.12,8.61,33918.12,8.61,5959.85,641.75,15088.57,581.86,15088.57,618.98,13820.74,114.41,5959.85,37898.05,8.61,2769.24,,Hospital S0020,"Injection, Bupivicaine Hydro",N/A,N/A,N/A,1618.63,N/A,971.18,N/A,226.60,N/A,270.85,N/A,924.73,N/A,550.34,N/A,630.33,N/A,226.60,N/A,245.53,N/A,245.53,N/A,392.40,N/A,630.33,N/A,630.33,N/A,630.33,N/A,924.74,N/A,245.53,N/A,226.60,N/A,527.00,N/A,527.00,N/A,226.60,N/A,245.53,N/A,43.40,N/A,47.74,N/A,N/A,43.40,971.18,,Hospital S0618,HC Audiometry -Hearing Aid,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,173.00,N/A,103.80,N/A,24.22,N/A,N/A,N/A,99.61,N/A,58.82,N/A,24.22,N/A,24.22,N/A,N/A,N/A,N/A,N/A,15.05,N/A,24.22,N/A,24.22,N/A,24.22,N/A,99.61,N/A,N/A,N/A,24.22,N/A,92.73,N/A,92.73,N/A,24.22,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15.05,103.80,,Hospital S1091,Stent non-coronary propel,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74185.90,N/A,44511.54,N/A,10180.50,N/A,1893.89,N/A,42425.98,N/A,25223.20,N/A,17306.93,N/A,10180.50,N/A,5587.18,N/A,5587.18,N/A,10773.87,N/A,17306.93,N/A,17306.93,N/A,17306.93,N/A,42425.99,N/A,5587.18,N/A,10180.50,N/A,7109.75,N/A,7109.75,N/A,10180.50,N/A,5587.18,N/A,1893.89,N/A,2083.29,N/A,N/A,1893.89,44511.54,,Hospital S5551,Insulin Most Rapid 5 U,N/A,N/A,N/A,25743.50,N/A,15446.10,N/A,3559.92,N/A,2516.66,N/A,14820.79,N/A,8746.32,N/A,5916.12,N/A,3559.92,N/A,2419.01,N/A,2419.01,N/A,3879.84,N/A,5916.12,N/A,5916.12,N/A,5916.12,N/A,13924.29,N/A,2439.53,N/A,3559.92,N/A,3541.57,N/A,3541.57,N/A,3559.92,N/A,2419.01,N/A,2516.66,N/A,1753.02,N/A,N/A,1753.02,15446.10,,Hospital S8037,MRCP,N/A,N/A,N/A,720.00,N/A,432.00,N/A,100.80,N/A,N/A,N/A,720.00,N/A,244.80,N/A,100.80,N/A,100.80,N/A,N/A,N/A,N/A,N/A,62.64,N/A,100.80,N/A,100.80,N/A,100.80,N/A,720.00,N/A,N/A,N/A,100.80,N/A,689.00,N/A,689.00,N/A,100.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62.64,720.00,,Hospital S8950,"Complex Lymphedema Therapy,",N/A,N/A,N/A,1141.00,N/A,684.60,N/A,159.74,N/A,134.60,N/A,656.98,N/A,387.94,N/A,485.76,N/A,159.74,N/A,134.60,N/A,134.60,N/A,470.18,N/A,485.76,N/A,485.76,N/A,485.76,N/A,656.98,N/A,148.20,N/A,159.74,N/A,611.57,N/A,611.57,N/A,159.74,N/A,134.60,N/A,134.60,N/A,148.06,N/A,N/A,134.60,684.60,,Hospital S9445,Pt Education Noc Individ,N/A,N/A,N/A,429.00,N/A,257.40,N/A,60.06,N/A,105.46,N/A,247.02,N/A,145.86,N/A,306.02,N/A,60.06,N/A,105.46,N/A,105.46,N/A,205.88,N/A,306.02,N/A,306.02,N/A,306.02,N/A,247.02,N/A,105.46,N/A,60.06,N/A,229.95,N/A,229.95,N/A,60.06,N/A,105.46,N/A,105.46,N/A,116.01,N/A,N/A,60.06,306.02,,Hospital S9473,Pulmonary Rehabilitation Pro,N/A,N/A,N/A,2700.00,N/A,1620.00,N/A,378.00,N/A,N/A,N/A,1554.70,N/A,918.00,N/A,378.00,N/A,378.00,N/A,N/A,N/A,N/A,N/A,234.90,N/A,378.00,N/A,378.00,N/A,378.00,N/A,1554.70,N/A,N/A,N/A,378.00,N/A,1447.20,N/A,1447.20,N/A,378.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,234.90,1620.00,,Hospital U0003,HC Covid-19 Amp Probe High Throughput Tech,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,80662.42,1705.00,48397.45,1023.00,10199.26,307.06,12419.80,252.91,36516.75,981.75,27425.23,579.70,29801.19,643.40,10513.52,307.06,12330.85,252.91,12330.85,252.91,14444.40,400.49,23204.73,643.40,29801.19,643.40,23204.73,643.40,36516.75,981.75,12330.85,252.91,10513.52,307.06,27607.84,890.06,27607.84,890.06,12964.42,307.06,12330.85,252.91,12419.80,252.91,11249.46,388.20,10199.26,48397.45,252.91,1023.00,,Hospital V2785,HC Corneal Tissue Processing,N/A,0810 - ACQUISITION OF BODY COMPONENTS - GENERAL CLASSIFICATION,N/A,20059.70,N/A,12035.82,N/A,2808.36,N/A,3774.30,N/A,11502.90,N/A,6820.30,N/A,9037.95,N/A,2808.36,N/A,3608.17,N/A,3608.17,N/A,5626.06,N/A,9037.95,N/A,9037.95,N/A,9037.95,N/A,11502.90,N/A,3608.17,N/A,2808.36,N/A,5963.00,N/A,5963.00,N/A,2808.36,N/A,3608.17,N/A,3774.30,N/A,1164.26,N/A,N/A,1164.26,12035.82,,Hospital HCPCS V2788,Presbyopia-correct function,N/A,0276 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - INTRAOCULAR LENS,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital V2790,HC Amniotic Membrane Surg Recon,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,310414.75,25733.12,186248.85,15439.87,39059.86,3599.58,28852.99,2759.84,171100.61,14698.31,105541.00,8749.28,108086.41,6527.60,34882.18,3599.58,28852.99,2688.04,28852.99,2688.04,67297.92,4063.55,108086.41,6527.60,108086.41,6527.60,108086.41,6527.60,171100.61,14698.32,28852.99,2688.04,34882.18,3599.58,147136.59,7109.75,147136.59,7109.75,32181.74,3599.58,28852.99,2688.04,28852.99,2759.84,37323.93,2580.01,28852.99,186248.85,2580.01,15439.87,,Hospital MS-DRG V40 (FY 2023) 021,Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,N/A,N/A,317595.12,N/A,190557.07,N/A,46480.45,N/A,N/A,N/A,262644.69,N/A,107982.34,N/A,110586.62,N/A,46480.45,N/A,N/A,N/A,N/A,N/A,68854.62,N/A,110586.62,N/A,110586.62,N/A,110586.62,N/A,262644.69,N/A,N/A,N/A,46480.45,N/A,262644.69,N/A,262644.69,N/A,46480.45,N/A,N/A,N/A,N/A,N/A,46480.45,N/A,46480.45,262644.69,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 023,Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,N/A,N/A,227578.20,N/A,136546.92,N/A,33468.93,N/A,38208.62,N/A,130830.50,N/A,92029.09,N/A,92029.09,N/A,33468.93,N/A,37275.72,N/A,37275.72,N/A,92029.09,N/A,92029.09,N/A,92029.09,N/A,92029.09,N/A,130830.50,N/A,36434.11,N/A,33468.93,N/A,130830.50,N/A,130830.50,N/A,34228.19,N/A,38208.62,N/A,38208.62,N/A,33468.93,N/A,33468.93,136546.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 024,Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,N/A,N/A,169601.58,N/A,101760.95,N/A,21065.35,N/A,25184.88,N/A,93484.39,N/A,51567.38,N/A,49356.05,N/A,21714.41,N/A,25184.88,N/A,25184.88,N/A,51567.38,N/A,49356.05,N/A,49356.05,N/A,49356.05,N/A,93484.39,N/A,25184.88,N/A,21714.41,N/A,57020.67,N/A,57020.67,N/A,7567.60,N/A,25184.88,N/A,25822.45,N/A,23234.42,N/A,7567.60,101760.95,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 031,Ventricular Shunt Procedures With McC,N/A,N/A,96129.52,N/A,57677.71,N/A,5758.99,N/A,26271.56,N/A,57178.79,N/A,32684.03,N/A,51508.38,N/A,22661.34,N/A,26271.56,N/A,26271.56,N/A,55728.28,N/A,55728.28,N/A,51508.38,N/A,51508.38,N/A,57178.79,N/A,26271.56,N/A,22661.34,N/A,59507.24,N/A,N/A,N/A,5758.99,N/A,26271.56,N/A,26271.56,N/A,24247.63,N/A,5758.99,59507.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 032,Ventricular Shunt Procedures With Cc,N/A,N/A,118246.43,N/A,70947.86,N/A,10959.98,N/A,13378.98,N/A,65177.43,N/A,26829.72,N/A,25679.20,N/A,11297.67,N/A,13230.73,N/A,13230.73,N/A,15986.06,N/A,25679.20,N/A,25679.20,N/A,25679.20,N/A,65177.43,N/A,13230.73,N/A,11297.67,N/A,29666.98,N/A,29666.98,N/A,9430.19,N/A,13230.73,N/A,13230.73,N/A,12088.51,N/A,9430.19,70947.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 033,Ventricular Shunt Procedures Without Cc/McC,N/A,N/A,129069.62,N/A,77441.77,N/A,9060.85,N/A,10984.17,N/A,71143.17,N/A,N/A,N/A,21229.55,N/A,9340.03,N/A,10984.17,N/A,10984.17,N/A,13216.03,N/A,21229.55,N/A,21229.55,N/A,21229.55,N/A,71143.17,N/A,10984.17,N/A,9340.03,N/A,24526.34,N/A,24526.34,N/A,482.61,N/A,10984.17,N/A,10984.17,N/A,9993.84,N/A,482.61,77441.77,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 034,Carotid Artery Stent Procedures With McC,N/A,N/A,144117.42,N/A,86470.45,N/A,21335.28,N/A,25504.18,N/A,79437.52,N/A,80023.99,N/A,49988.50,N/A,21992.66,N/A,25504.18,N/A,25504.18,N/A,31119.33,N/A,49988.50,N/A,49988.50,N/A,49988.50,N/A,79437.52,N/A,25504.18,N/A,21992.66,N/A,57751.34,N/A,57751.34,N/A,3112.97,N/A,25504.18,N/A,25504.18,N/A,23532.14,N/A,3112.97,86470.45,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 039,Extracranial Procedures Without Cc/McC,N/A,N/A,54048.17,N/A,32428.90,N/A,6149.22,N/A,7539.84,N/A,14538.04,N/A,18376.37,N/A,14407.60,N/A,6338.69,N/A,7539.84,N/A,7539.84,N/A,8969.16,N/A,14407.60,N/A,14407.60,N/A,14407.60,N/A,14538.04,N/A,7539.84,N/A,6338.69,N/A,16644.99,N/A,16644.99,N/A,N/A,N/A,7539.84,N/A,7539.84,N/A,6782.39,N/A,6149.22,32428.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 040,"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC",N/A,N/A,123275.45,N/A,73965.27,N/A,14644.69,N/A,20999.25,N/A,67949.43,N/A,41913.66,N/A,47351.21,N/A,15095.92,N/A,20880.65,N/A,20880.65,N/A,29477.54,N/A,47351.21,N/A,47351.21,N/A,47351.21,N/A,67949.43,N/A,20880.65,N/A,15095.92,N/A,54704.50,N/A,54704.50,N/A,14293.93,N/A,20880.65,N/A,20880.65,N/A,16152.64,N/A,14293.93,73965.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 052,Spinal Disorders And Injuries With Cc/McC,N/A,N/A,70184.70,N/A,42110.82,N/A,9497.22,N/A,11500.37,N/A,21402.77,N/A,N/A,N/A,22251.97,N/A,9789.85,N/A,11500.37,N/A,11500.37,N/A,13852.51,N/A,22251.97,N/A,22251.97,N/A,22251.97,N/A,21402.77,N/A,11500.37,N/A,9789.85,N/A,25707.53,N/A,25707.53,N/A,16657.60,N/A,1061.35,N/A,11500.37,N/A,10475.14,N/A,1061.35,42110.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 058,Multiple Sclerosis And Cerebellar Ataxia With McC,N/A,N/A,44830.10,N/A,26898.06,N/A,4552.24,N/A,11673.35,N/A,44830.10,N/A,15242.23,N/A,22643.69,N/A,9487.41,N/A,11673.35,N/A,11673.35,N/A,3648.93,N/A,22643.69,N/A,22643.69,N/A,22643.69,N/A,10339.00,N/A,11660.57,N/A,9487.41,N/A,14364.00,N/A,14364.00,N/A,7787.13,N/A,11673.35,N/A,11673.35,N/A,10151.53,N/A,3648.93,44830.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 061,"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC",N/A,N/A,95211.10,N/A,57126.66,N/A,15644.31,N/A,18890.66,N/A,35255.72,N/A,32371.77,N/A,36654.57,N/A,16126.34,N/A,18772.06,N/A,18772.06,N/A,22818.56,N/A,36654.57,N/A,36654.57,N/A,36654.57,N/A,35255.72,N/A,18772.06,N/A,16126.34,N/A,42346.74,N/A,42346.74,N/A,8719.11,N/A,18772.06,N/A,18772.06,N/A,17255.18,N/A,8719.11,57126.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 062,"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",N/A,N/A,80736.30,N/A,48441.78,N/A,10227.53,N/A,12364.28,N/A,23048.58,N/A,27450.34,N/A,23963.08,N/A,10542.66,N/A,2810.00,N/A,2810.00,N/A,14917.73,N/A,23963.08,N/A,23963.08,N/A,23963.08,N/A,23048.58,N/A,12364.28,N/A,10542.66,N/A,27684.37,N/A,27684.37,N/A,5992.12,N/A,12364.28,N/A,12364.28,N/A,11280.65,N/A,2810.00,48441.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 064,Intracranial Hemorrhage Or Cerebral Infarction With McC,N/A,N/A,47862.22,N/A,28717.33,N/A,10519.87,N/A,8750.27,N/A,23707.38,N/A,16273.15,N/A,24648.03,N/A,10844.01,N/A,8750.27,N/A,8750.27,N/A,15344.13,N/A,24648.03,N/A,24648.03,N/A,24648.03,N/A,23707.38,N/A,8750.27,N/A,10844.01,N/A,28475.68,N/A,28475.68,N/A,10844.01,N/A,8750.27,N/A,10002.64,N/A,11603.09,N/A,8750.27,28717.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 065,Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,N/A,N/A,36765.40,N/A,22059.24,N/A,5422.11,N/A,6679.73,N/A,12219.16,N/A,12500.24,N/A,12703.98,N/A,5589.17,N/A,6679.73,N/A,6679.73,N/A,7908.61,N/A,12703.98,N/A,12703.98,N/A,12703.98,N/A,12219.16,N/A,6679.73,N/A,5589.17,N/A,14676.82,N/A,14676.82,N/A,5589.17,N/A,6679.73,N/A,6679.73,N/A,5980.42,N/A,5422.11,22059.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 069,Transient Ischemia Without Thrombolytic,N/A,N/A,27581.50,N/A,16548.90,N/A,4256.49,N/A,5300.87,N/A,9592.35,N/A,9377.71,N/A,9972.95,N/A,4387.64,N/A,5300.87,N/A,5300.87,N/A,6208.46,N/A,9972.95,N/A,9972.95,N/A,9972.95,N/A,9592.35,N/A,5300.87,N/A,4387.64,N/A,11521.68,N/A,11521.68,N/A,N/A,N/A,5300.87,N/A,5300.87,N/A,4694.78,N/A,4256.49,16548.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 072,Nonspecific Cerebrovascular Disorders Without Cc/McC,N/A,N/A,25000.90,N/A,15000.54,N/A,4118.33,N/A,5137.41,N/A,9280.98,N/A,8500.31,N/A,9649.23,N/A,4245.22,N/A,3372.00,N/A,3372.00,N/A,6006.93,N/A,9649.23,N/A,9649.23,N/A,9649.23,N/A,9280.98,N/A,5137.41,N/A,4245.22,N/A,11147.68,N/A,11147.68,N/A,5088.98,N/A,5137.41,N/A,5137.41,N/A,4542.39,N/A,3372.00,15000.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 076,Viral Meningitis Without Cc/McC,N/A,N/A,34658.08,N/A,20794.85,N/A,5266.87,N/A,6496.07,N/A,14313.11,N/A,11783.75,N/A,12340.26,N/A,5429.15,N/A,1686.00,N/A,1686.00,N/A,7682.18,N/A,12340.26,N/A,12340.26,N/A,12340.26,N/A,14313.11,N/A,6496.07,N/A,5429.15,N/A,14256.61,N/A,14256.61,N/A,5429.15,N/A,6496.07,N/A,6496.07,N/A,5809.19,N/A,1686.00,20794.85,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 096,Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,N/A,N/A,113430.40,N/A,68058.24,N/A,12185.87,N/A,14680.91,N/A,62522.84,N/A,38566.34,N/A,28551.47,N/A,12561.34,N/A,14680.91,N/A,14680.91,N/A,17774.14,N/A,28551.47,N/A,28551.47,N/A,28551.47,N/A,62522.84,N/A,14680.91,N/A,12561.34,N/A,32985.29,N/A,32985.29,N/A,N/A,N/A,14680.91,N/A,14680.91,N/A,13440.64,N/A,12185.87,68058.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 100,Seizures With McC,N/A,N/A,35200.40,N/A,21120.24,N/A,9532.84,N/A,11542.11,N/A,23094.26,N/A,11968.14,N/A,24010.58,N/A,9826.57,N/A,11542.11,N/A,11542.11,N/A,14947.30,N/A,24010.58,N/A,24010.58,N/A,24010.58,N/A,23094.26,N/A,11542.11,N/A,9826.57,N/A,27739.24,N/A,27739.24,N/A,10563.56,N/A,11542.11,N/A,11542.11,N/A,10514.43,N/A,9532.84,27739.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 101,Seizures Without McC,N/A,N/A,20528.00,N/A,12316.80,N/A,4809.16,N/A,6013.93,N/A,10837.83,N/A,6979.52,N/A,11267.85,N/A,4957.34,N/A,5954.63,N/A,5954.63,N/A,7014.57,N/A,11267.85,N/A,11267.85,N/A,11267.85,N/A,10837.83,N/A,5954.63,N/A,4957.34,N/A,13017.66,N/A,13017.66,N/A,4957.34,N/A,5954.63,N/A,6013.93,N/A,1440.63,N/A,1440.63,13017.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 113,Orbital Procedures With Cc/McC,N/A,N/A,26970.70,N/A,16182.42,N/A,11977.82,N/A,14434.80,N/A,26970.70,N/A,9170.04,N/A,26970.70,N/A,12346.88,N/A,562.00,N/A,562.00,N/A,16963.24,N/A,26970.70,N/A,26970.70,N/A,26970.70,N/A,26970.70,N/A,14434.80,N/A,12346.88,N/A,26970.70,N/A,26970.70,N/A,11422.07,N/A,14434.80,N/A,14434.80,N/A,13211.16,N/A,562.00,26970.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 115,Extraocular Procedures Except Orbit,N/A,N/A,56083.20,N/A,33649.92,N/A,8103.82,N/A,9852.05,N/A,18262.62,N/A,19068.29,N/A,N/A,N/A,8353.51,N/A,9852.05,N/A,9852.05,N/A,11476.80,N/A,18437.32,N/A,18437.32,N/A,N/A,N/A,18262.62,N/A,9852.05,N/A,8353.51,N/A,21935.80,N/A,21935.80,N/A,12394.85,N/A,9852.05,N/A,10211.57,N/A,8938.26,N/A,8103.82,33649.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 122,Acute Major Eye Infections Without Cc/McC,N/A,N/A,21615.60,N/A,12969.36,N/A,3685.16,N/A,4624.99,N/A,8304.80,N/A,7349.31,N/A,8384.24,N/A,3798.70,N/A,4624.99,N/A,4624.99,N/A,5218.99,N/A,8384.24,N/A,8384.24,N/A,8384.24,N/A,8304.80,N/A,4624.99,N/A,3798.70,N/A,9975.15,N/A,9975.15,N/A,N/A,N/A,4624.99,N/A,4624.99,N/A,4064.61,N/A,3685.16,12969.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 123,Neurological Eye Disorders,N/A,N/A,29087.57,N/A,17452.54,N/A,4234.62,N/A,5334.28,N/A,9543.06,N/A,9889.77,N/A,9634.35,N/A,4365.10,N/A,56762.00,N/A,56762.00,N/A,5997.16,N/A,9634.35,N/A,9634.35,N/A,9634.35,N/A,9543.06,N/A,5274.98,N/A,4365.10,N/A,11462.47,N/A,11462.47,N/A,4365.10,N/A,2366.06,N/A,5334.28,N/A,4670.65,N/A,2366.06,56762.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 136,Sinus And Mastoid Procedures Without Cc/McC,N/A,N/A,66333.97,N/A,39800.38,N/A,6189.76,N/A,7587.81,N/A,13949.13,N/A,22553.55,N/A,14082.56,N/A,6380.48,N/A,562.00,N/A,562.00,N/A,8766.07,N/A,14082.56,N/A,14082.56,N/A,14082.56,N/A,13949.13,N/A,7587.81,N/A,6380.48,N/A,16754.73,N/A,16754.73,N/A,N/A,N/A,7587.81,N/A,7587.81,N/A,6827.11,N/A,562.00,39800.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 140,Major Head And Neck Procedures With McC,N/A,N/A,166393.97,N/A,99836.38,N/A,22172.28,N/A,27157.97,N/A,91716.36,N/A,N/A,N/A,N/A,N/A,24426.07,N/A,27157.97,N/A,27157.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,91716.36,N/A,27157.97,N/A,24426.07,N/A,60016.97,N/A,60016.97,N/A,24426.07,N/A,26494.31,N/A,27157.97,N/A,24426.07,N/A,22172.28,99836.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 143,"Other Ear, Nose, Mouth And Throat O.R. Procedures With McC",N/A,N/A,133685.08,N/A,80211.05,N/A,16924.62,N/A,20286.60,N/A,73687.22,N/A,45452.92,N/A,38505.85,N/A,8308.05,N/A,20835.34,N/A,20835.34,N/A,23968.99,N/A,38505.85,N/A,38505.85,N/A,38505.85,N/A,73687.22,N/A,20286.60,N/A,8308.05,N/A,45812.34,N/A,45812.34,N/A,1289.39,N/A,20286.60,N/A,20286.60,N/A,8308.05,N/A,1289.39,80211.05,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 152,Otitis Media And Uri With McC,N/A,N/A,37212.50,N/A,22327.50,N/A,6389.27,N/A,6778.77,N/A,12989.77,N/A,12652.25,N/A,13114.03,N/A,6586.14,N/A,224238.00,N/A,224238.00,N/A,8163.18,N/A,13114.03,N/A,13114.03,N/A,13114.03,N/A,12989.77,N/A,6749.12,N/A,6586.14,N/A,15602.42,N/A,15602.42,N/A,3656.62,N/A,7823.82,N/A,6778.77,N/A,7047.17,N/A,3656.62,224238.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 153,Otitis Media And Uri Without McC,N/A,N/A,18488.10,N/A,11092.86,N/A,3683.56,N/A,4623.10,N/A,8301.19,N/A,6285.95,N/A,8380.60,N/A,3797.05,N/A,4623.10,N/A,4623.10,N/A,5216.73,N/A,8380.60,N/A,8380.60,N/A,8380.60,N/A,8301.19,N/A,4623.10,N/A,3797.05,N/A,9970.82,N/A,9970.82,N/A,3766.51,N/A,4623.10,N/A,4623.10,N/A,4062.85,N/A,3683.56,11092.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 156,"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/McC",N/A,N/A,17416.50,N/A,10449.90,N/A,3636.61,N/A,4626.86,N/A,8195.40,N/A,5921.61,N/A,8273.79,N/A,3748.66,N/A,4567.56,N/A,4567.56,N/A,5150.24,N/A,8273.79,N/A,8273.79,N/A,8273.79,N/A,8195.40,N/A,4567.56,N/A,3748.66,N/A,9843.75,N/A,9843.75,N/A,3771.08,N/A,4567.56,N/A,4567.56,N/A,4011.07,N/A,3636.61,10449.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 157,Dental And Oral Diseases With McC,N/A,N/A,46673.70,N/A,28004.22,N/A,8918.42,N/A,10815.67,N/A,20098.38,N/A,15869.06,N/A,20290.64,N/A,9193.21,N/A,1124.00,N/A,1124.00,N/A,12630.45,N/A,20290.64,N/A,20290.64,N/A,20290.64,N/A,20098.38,N/A,10815.67,N/A,9193.21,N/A,24140.79,N/A,24140.79,N/A,3467.84,N/A,10815.67,N/A,10815.67,N/A,9836.74,N/A,1124.00,28004.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 163,Major Chest Procedures With McC,N/A,N/A,133758.63,N/A,80255.18,N/A,25839.30,N/A,30832.21,N/A,N/A,N/A,58787.99,N/A,58787.99,N/A,26635.46,N/A,30832.21,N/A,30832.21,N/A,58787.99,N/A,58787.99,N/A,58787.99,N/A,58787.99,N/A,N/A,N/A,30832.21,N/A,25839.30,N/A,N/A,N/A,69943.03,N/A,1302.25,N/A,30832.21,N/A,30832.21,N/A,25839.30,N/A,1302.25,80255.18,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 164,Major Chest Procedures With Cc,N/A,N/A,87802.03,N/A,52681.22,N/A,15196.40,N/A,16563.99,N/A,32613.90,N/A,31346.23,N/A,31346.23,N/A,15196.40,N/A,16563.99,N/A,16563.99,N/A,31346.23,N/A,31346.23,N/A,31346.23,N/A,31346.23,N/A,32613.90,N/A,16563.99,N/A,15196.40,N/A,32613.90,N/A,32613.90,N/A,15196.40,N/A,16563.99,N/A,16563.99,N/A,15196.40,N/A,15196.40,52681.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 165,Major Chest Procedures Without Cc/McC,N/A,N/A,124706.68,N/A,74824.01,N/A,13777.72,N/A,16563.99,N/A,68738.32,N/A,42400.27,N/A,31346.23,N/A,14202.24,N/A,16563.99,N/A,16563.99,N/A,19512.30,N/A,31346.23,N/A,31346.23,N/A,31346.23,N/A,68738.32,N/A,16563.99,N/A,14202.24,N/A,37294.19,N/A,37294.19,N/A,14202.24,N/A,16563.99,N/A,16563.99,N/A,15196.40,N/A,13777.72,74824.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 166,Other Respiratory System O.R. Procedures With McC,N/A,N/A,118174.83,N/A,70904.90,N/A,19555.65,N/A,23398.97,N/A,65137.97,N/A,40179.44,N/A,44491.81,N/A,20158.20,N/A,23398.97,N/A,23398.97,N/A,27695.12,N/A,44491.81,N/A,44491.81,N/A,44491.81,N/A,65137.97,N/A,23398.97,N/A,20158.20,N/A,52934.15,N/A,52934.15,N/A,11371.94,N/A,23398.97,N/A,23398.97,N/A,21569.27,N/A,11371.94,70904.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 167,Other Respiratory System O.R. Procedures With Cc,N/A,N/A,77702.93,N/A,46621.76,N/A,10391.63,N/A,12262.69,N/A,22855.02,N/A,26419.00,N/A,23073.65,N/A,10454.13,N/A,1124.00,N/A,1124.00,N/A,14362.81,N/A,23073.65,N/A,23073.65,N/A,23073.65,N/A,22855.02,N/A,12262.69,N/A,10454.13,N/A,27451.88,N/A,27451.88,N/A,10454.13,N/A,12262.69,N/A,12262.69,N/A,11185.92,N/A,1124.00,46621.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 176,Pulmonary Embolism Without McC,N/A,N/A,31257.90,N/A,18754.74,N/A,4361.59,N/A,5425.16,N/A,9829.19,N/A,10627.69,N/A,9923.21,N/A,4495.97,N/A,5425.16,N/A,5425.16,N/A,6176.97,N/A,9923.21,N/A,9923.21,N/A,9923.21,N/A,9829.19,N/A,5425.16,N/A,4495.97,N/A,11806.14,N/A,11806.14,N/A,N/A,N/A,5425.16,N/A,5425.16,N/A,4810.69,N/A,4361.59,18754.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 185,Major Chest Trauma Without Cc/McC,N/A,N/A,30810.30,N/A,18486.18,N/A,8013.67,N/A,2376.53,N/A,18059.45,N/A,10475.50,N/A,18232.20,N/A,8260.58,N/A,9745.39,N/A,9745.39,N/A,11349.12,N/A,18232.20,N/A,18232.20,N/A,18232.20,N/A,18059.45,N/A,9745.39,N/A,8260.58,N/A,21691.77,N/A,21691.77,N/A,1403.09,N/A,9745.39,N/A,9775.04,N/A,8838.82,N/A,1403.09,21691.77,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 186,Pleural Effusion With McC,N/A,N/A,45893.40,N/A,27536.04,N/A,8144.90,N/A,10236.42,N/A,18355.19,N/A,15603.76,N/A,20022.46,N/A,8395.86,N/A,3372.00,N/A,3372.00,N/A,20022.46,N/A,20022.46,N/A,20022.46,N/A,20022.46,N/A,18355.19,N/A,9900.64,N/A,8395.86,N/A,19476.60,N/A,22046.99,N/A,8395.86,N/A,10236.42,N/A,10236.42,N/A,8395.86,N/A,3372.00,27536.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 191,Chronic Obstructive Pulmonary Disease With Cc,N/A,N/A,25088.30,N/A,15052.98,N/A,4610.18,N/A,5719.23,N/A,10389.41,N/A,8530.02,N/A,10488.80,N/A,4752.23,N/A,5719.23,N/A,5719.23,N/A,6529.03,N/A,10488.80,N/A,10488.80,N/A,10488.80,N/A,10389.41,N/A,5719.23,N/A,4752.23,N/A,12479.05,N/A,12479.05,N/A,4610.18,N/A,5719.23,N/A,5719.23,N/A,5084.88,N/A,4610.18,15052.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 196,Interstitial Lung Disease With McC,N/A,N/A,44122.40,N/A,26473.44,N/A,9269.97,N/A,11231.54,N/A,20890.63,N/A,15001.62,N/A,21090.46,N/A,9555.59,N/A,11231.54,N/A,11231.54,N/A,13128.32,N/A,21090.46,N/A,21090.46,N/A,21090.46,N/A,20890.63,N/A,11231.54,N/A,9555.59,N/A,25092.39,N/A,25092.39,N/A,7958.76,N/A,11231.54,N/A,11231.54,N/A,10224.49,N/A,7958.76,26473.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 200,Pneumothorax With Cc,N/A,N/A,39409.00,N/A,23645.40,N/A,5718.71,N/A,7030.58,N/A,12887.58,N/A,13399.06,N/A,13010.86,N/A,5894.92,N/A,7030.58,N/A,7030.58,N/A,8098.96,N/A,13010.86,N/A,13010.86,N/A,13010.86,N/A,12887.58,N/A,7030.58,N/A,5894.92,N/A,15479.68,N/A,15479.68,N/A,N/A,N/A,7030.58,N/A,7030.58,N/A,6307.56,N/A,5718.71,23645.40,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 208,Respiratory System Diagnosis With Ventilator Support <=96 Hours,N/A,N/A,97702.13,N/A,58621.28,N/A,3221.03,N/A,16673.79,N/A,N/A,N/A,12899.38,N/A,12899.38,N/A,3221.03,N/A,16673.79,N/A,16673.79,N/A,12899.38,N/A,12899.38,N/A,12899.38,N/A,12899.38,N/A,N/A,N/A,16673.79,N/A,3221.03,N/A,N/A,N/A,N/A,N/A,3221.03,N/A,16673.79,N/A,16673.79,N/A,3221.03,N/A,3221.03,58621.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 220,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,N/A,N/A,219308.13,N/A,131584.88,N/A,N/A,N/A,34564.28,N/A,N/A,N/A,74564.76,N/A,76363.09,N/A,N/A,N/A,34564.28,N/A,34564.28,N/A,47546.00,N/A,76363.09,N/A,76363.09,N/A,76363.09,N/A,N/A,N/A,34564.28,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,34564.28,N/A,34564.28,N/A,N/A,N/A,34564.28,131584.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 221,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,N/A,N/A,213366.13,N/A,128019.68,N/A,18239.43,N/A,30851.97,N/A,117607.42,N/A,94674.58,N/A,94674.58,N/A,26019.02,N/A,30124.79,N/A,30124.79,N/A,94674.58,N/A,94674.58,N/A,94674.58,N/A,74294.09,N/A,117607.42,N/A,30124.79,N/A,26019.02,N/A,114297.75,N/A,114407.36,N/A,18239.43,N/A,30124.79,N/A,30851.97,N/A,18239.43,N/A,18239.43,128019.68,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 223,"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without McC",N/A,N/A,253169.20,N/A,151901.52,N/A,31566.50,N/A,33287.63,N/A,139546.86,N/A,86077.52,N/A,88153.52,N/A,28697.58,N/A,33198.68,N/A,33198.68,N/A,54887.08,N/A,88153.52,N/A,88153.52,N/A,88153.52,N/A,139546.86,N/A,33198.68,N/A,28697.58,N/A,153211.41,N/A,153211.41,N/A,22175.22,N/A,33198.68,N/A,33287.63,N/A,30706.41,N/A,22175.22,153211.41,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 233,Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,N/A,N/A,270297.92,N/A,162178.75,N/A,41316.10,N/A,47721.46,N/A,103174.60,N/A,N/A,N/A,N/A,N/A,41316.10,N/A,47721.46,N/A,47721.46,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,103174.60,N/A,47721.46,N/A,41316.10,N/A,103174.60,N/A,103174.60,N/A,41316.10,N/A,47721.46,N/A,47721.46,N/A,41316.10,N/A,41316.10,162178.75,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 236,Coronary Bypass Without Cardiac Catheterization Without McC,N/A,N/A,145871.02,N/A,87522.61,N/A,22427.08,N/A,26002.72,N/A,58892.10,N/A,49679.13,N/A,51424.55,N/A,22427.08,N/A,26002.72,N/A,26002.72,N/A,32011.36,N/A,51424.55,N/A,51424.55,N/A,51424.55,N/A,58892.10,N/A,26002.72,N/A,22427.08,N/A,58892.10,N/A,58892.10,N/A,22427.08,N/A,26002.72,N/A,26002.72,N/A,22427.08,N/A,22427.08,87522.61,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 240,Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,N/A,N/A,118078.70,N/A,70847.22,N/A,14925.36,N/A,17393.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14925.36,N/A,17393.82,N/A,17393.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,17393.82,N/A,14925.36,N/A,N/A,N/A,N/A,N/A,14925.36,N/A,17393.82,N/A,17393.82,N/A,14925.36,N/A,14925.36,70847.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 248,Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With McC Or 4+ Arteries Or Stents,N/A,N/A,186399.08,N/A,111839.45,N/A,7932.06,N/A,19552.58,N/A,N/A,N/A,60697.60,N/A,60697.60,N/A,7932.06,N/A,19552.58,N/A,19552.58,N/A,60697.60,N/A,60697.60,N/A,60697.60,N/A,60697.60,N/A,N/A,N/A,19552.58,N/A,7932.06,N/A,N/A,N/A,N/A,N/A,7932.06,N/A,19552.58,N/A,19552.58,N/A,7932.06,N/A,7932.06,111839.45,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 254,Other Vascular Procedures Without Cc/McC,N/A,N/A,62839.15,N/A,37703.49,N/A,9754.35,N/A,11804.54,N/A,25981.34,N/A,21365.31,N/A,23055.56,N/A,10054.90,N/A,11804.54,N/A,11804.54,N/A,14351.90,N/A,23055.56,N/A,23055.56,N/A,23055.56,N/A,25981.34,N/A,11804.54,N/A,10054.90,N/A,26403.54,N/A,26403.54,N/A,10054.90,N/A,11804.54,N/A,11804.54,N/A,10758.75,N/A,9754.35,37703.49,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 255,Upper Limb And Toe Amputation For Circulatory System Disorders With McC,N/A,N/A,63490.23,N/A,38094.14,N/A,13686.50,N/A,16456.08,N/A,30843.64,N/A,21586.68,N/A,32349.65,N/A,14108.21,N/A,2248.00,N/A,2248.00,N/A,20137.39,N/A,32349.65,N/A,32349.65,N/A,32349.65,N/A,30843.64,N/A,16456.08,N/A,14108.21,N/A,37047.26,N/A,46470.71,N/A,14108.21,N/A,16456.08,N/A,17294.26,N/A,15095.78,N/A,2248.00,46470.71,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 256,Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,N/A,N/A,54317.30,N/A,32590.38,N/A,8707.17,N/A,10565.78,N/A,19622.31,N/A,18467.88,N/A,20580.41,N/A,8975.45,N/A,3372.00,N/A,3372.00,N/A,12811.14,N/A,20580.41,N/A,20580.41,N/A,20580.41,N/A,19622.31,N/A,10565.78,N/A,8975.45,N/A,23568.97,N/A,23568.97,N/A,6733.32,N/A,10565.78,N/A,10565.78,N/A,9603.73,N/A,3372.00,32590.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 257,Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,N/A,N/A,41455.10,N/A,24873.06,N/A,5594.42,N/A,6883.54,N/A,12607.47,N/A,14094.73,N/A,13223.06,N/A,5766.79,N/A,2810.00,N/A,2810.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12607.47,N/A,6883.54,N/A,5766.79,N/A,15143.23,N/A,15143.23,N/A,7861.76,N/A,6883.54,N/A,6883.54,N/A,7861.76,N/A,2810.00,24873.06,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 266,Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,N/A,N/A,224936.47,N/A,134961.88,N/A,35212.23,N/A,41919.90,N/A,123984.98,N/A,76478.40,N/A,78322.88,N/A,36297.18,N/A,41919.90,N/A,41919.90,N/A,48766.23,N/A,78322.88,N/A,78322.88,N/A,78322.88,N/A,123984.98,N/A,41919.90,N/A,36297.18,N/A,165473.70,N/A,165473.70,N/A,17240.13,N/A,41919.90,N/A,41919.90,N/A,38837.98,N/A,17240.13,165473.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 267,Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,N/A,N/A,250089.27,N/A,150053.56,N/A,30942.73,N/A,32832.03,N/A,137849.20,N/A,85030.34,N/A,87081.08,N/A,28378.09,N/A,32832.03,N/A,32832.03,N/A,54219.35,N/A,87081.08,N/A,87081.08,N/A,87081.08,N/A,137849.20,N/A,32832.03,N/A,28378.09,N/A,186009.22,N/A,186009.22,N/A,21636.84,N/A,32832.03,N/A,32832.03,N/A,30364.55,N/A,21636.84,186009.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 274,Percutaneous And Other Intracardiac Procedures Without McC,N/A,N/A,138903.10,N/A,83341.86,N/A,17921.66,N/A,21466.05,N/A,76563.39,N/A,47227.05,N/A,42359.94,N/A,18473.86,N/A,1686.00,N/A,1686.00,N/A,26368.72,N/A,42359.94,N/A,42359.94,N/A,42359.94,N/A,76563.39,N/A,21466.05,N/A,18473.86,N/A,48511.18,N/A,48511.18,N/A,2201.50,N/A,21466.05,N/A,21466.05,N/A,19767.03,N/A,1686.00,83341.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 281,"Acute Myocardial Infarction, Discharged Alive With Cc",N/A,N/A,35036.00,N/A,21021.60,N/A,4900.38,N/A,6062.54,N/A,11043.41,N/A,11912.24,N/A,11582.63,N/A,5051.37,N/A,6062.54,N/A,6062.54,N/A,7210.09,N/A,11582.63,N/A,11582.63,N/A,11582.63,N/A,11043.41,N/A,6062.54,N/A,5051.37,N/A,13264.58,N/A,13264.58,N/A,5051.37,N/A,6062.54,N/A,6062.54,N/A,5404.97,N/A,4900.38,21021.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 284,"Acute Myocardial Infarction, Expired With Cc",N/A,N/A,28551.50,N/A,17130.90,N/A,3923.08,N/A,4906.45,N/A,8840.98,N/A,9707.51,N/A,9272.66,N/A,4043.96,N/A,4906.45,N/A,4906.45,N/A,5772.15,N/A,9272.66,N/A,9272.66,N/A,9272.66,N/A,8840.98,N/A,4906.45,N/A,4043.96,N/A,10619.18,N/A,10619.18,N/A,N/A,N/A,4906.45,N/A,4906.45,N/A,4327.03,N/A,3923.08,17130.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 286,"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC",N/A,N/A,66668.47,N/A,40001.08,N/A,11314.73,N/A,13650.39,N/A,38198.51,N/A,22667.28,N/A,26743.69,N/A,11663.36,N/A,13650.39,N/A,13650.39,N/A,16647.73,N/A,26743.69,N/A,26743.69,N/A,26743.69,N/A,25498.66,N/A,13650.39,N/A,11663.36,N/A,30627.24,N/A,30627.24,N/A,12441.59,N/A,13650.39,N/A,13650.39,N/A,12479.79,N/A,11314.73,40001.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 287,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC",N/A,N/A,48906.28,N/A,29343.77,N/A,5869.15,N/A,7208.54,N/A,13226.60,N/A,16628.13,N/A,13872.42,N/A,6049.99,N/A,7208.54,N/A,7208.54,N/A,8635.47,N/A,13872.42,N/A,13872.42,N/A,13872.42,N/A,13226.60,N/A,7208.54,N/A,6049.99,N/A,15886.89,N/A,15886.89,N/A,6049.99,N/A,7208.54,N/A,7208.54,N/A,6473.49,N/A,5869.15,29343.77,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 291,Heart Failure And Shock With McC,N/A,N/A,36308.70,N/A,21785.22,N/A,6827.25,N/A,8460.53,N/A,15385.76,N/A,12344.96,N/A,16137.00,N/A,7037.61,N/A,8341.93,N/A,8341.93,N/A,10045.15,N/A,16137.00,N/A,16137.00,N/A,16137.00,N/A,15385.76,N/A,8341.93,N/A,7037.61,N/A,18480.31,N/A,18480.31,N/A,7037.61,N/A,8341.93,N/A,8460.53,N/A,7530.24,N/A,6827.25,21785.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 293,Heart Failure And Shock Without Cc/McC,N/A,N/A,22642.60,N/A,13585.56,N/A,2988.99,N/A,3831.12,N/A,6735.93,N/A,7698.48,N/A,7064.82,N/A,3081.08,N/A,3801.47,N/A,3801.47,N/A,4397.79,N/A,7064.82,N/A,7064.82,N/A,7064.82,N/A,6735.93,N/A,3801.47,N/A,3081.08,N/A,8090.73,N/A,8090.73,N/A,1336.15,N/A,2202.53,N/A,3831.12,N/A,3296.76,N/A,1336.15,13585.56,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 294,Deep Vein Thrombophlebitis With Cc/McC,N/A,N/A,26228.27,N/A,15736.96,N/A,6158.82,N/A,7580.86,N/A,14350.35,N/A,8917.61,N/A,14557.09,N/A,6348.58,N/A,7551.21,N/A,7551.21,N/A,9061.67,N/A,14557.09,N/A,14557.09,N/A,14557.09,N/A,14350.35,N/A,7551.21,N/A,6348.58,N/A,16670.98,N/A,16670.98,N/A,N/A,N/A,7551.21,N/A,7580.86,N/A,6792.98,N/A,6158.82,16670.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 304,Hypertension With McC,N/A,N/A,41823.90,N/A,25094.34,N/A,5860.61,N/A,7198.44,N/A,13207.37,N/A,14220.13,N/A,13852.25,N/A,6041.19,N/A,7198.44,N/A,7198.44,N/A,8622.91,N/A,13852.25,N/A,13852.25,N/A,13852.25,N/A,13207.37,N/A,7198.44,N/A,6041.19,N/A,15863.78,N/A,15863.78,N/A,5860.61,N/A,7198.44,N/A,7198.44,N/A,6464.07,N/A,5860.61,25094.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 307,Cardiac Congenital And Valvular Disorders Without McC,N/A,N/A,34096.80,N/A,20458.08,N/A,4861.97,N/A,6017.11,N/A,10956.85,N/A,11592.91,N/A,11491.84,N/A,5011.78,N/A,6017.11,N/A,6017.11,N/A,7153.58,N/A,11491.84,N/A,11491.84,N/A,11491.84,N/A,10956.85,N/A,6017.11,N/A,5011.78,N/A,13160.62,N/A,13160.62,N/A,8476.26,N/A,6017.11,N/A,6017.11,N/A,5362.60,N/A,4861.97,20458.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 310,Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,N/A,N/A,19167.10,N/A,11500.26,N/A,2940.44,N/A,3773.68,N/A,6626.53,N/A,5413.64,N/A,5396.21,N/A,3031.04,N/A,3744.03,N/A,3744.03,N/A,3359.25,N/A,5396.21,N/A,5396.21,N/A,5396.21,N/A,6626.53,N/A,3744.03,N/A,3031.04,N/A,7959.33,N/A,7959.33,N/A,3031.04,N/A,3744.03,N/A,3773.68,N/A,3243.22,N/A,2940.44,11500.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 334,Rectal Resection Without Cc/McC,N/A,N/A,81851.02,N/A,49110.61,N/A,9146.21,N/A,11085.14,N/A,20649.75,N/A,27829.35,N/A,20808.89,N/A,9428.02,N/A,1124.00,N/A,1124.00,N/A,12953.05,N/A,20808.89,N/A,20808.89,N/A,20808.89,N/A,20649.75,N/A,11085.14,N/A,9428.02,N/A,24757.38,N/A,24757.38,N/A,9428.02,N/A,11085.14,N/A,11085.14,N/A,10087.98,N/A,1124.00,49110.61,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 337,Peritoneal Adhesiolysis Without Cc/McC,N/A,N/A,63533.67,N/A,38120.20,N/A,8404.69,N/A,10207.96,N/A,26296.75,N/A,21601.45,N/A,19121.84,N/A,8663.66,N/A,1686.00,N/A,1686.00,N/A,11902.90,N/A,19121.84,N/A,19121.84,N/A,19121.84,N/A,26296.75,N/A,10207.96,N/A,8663.66,N/A,22750.22,N/A,22750.22,N/A,8587.81,N/A,10207.96,N/A,10207.96,N/A,9270.11,N/A,1686.00,38120.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 340,Appendectomy With Complicated Principal Diagnosis Without Cc/McC,N/A,N/A,42633.20,N/A,25579.92,N/A,6401.01,N/A,7837.71,N/A,14425.20,N/A,14495.28,N/A,14563.19,N/A,6598.24,N/A,1124.00,N/A,1124.00,N/A,9065.24,N/A,14563.19,N/A,14563.19,N/A,14563.19,N/A,14425.20,N/A,7837.71,N/A,6598.24,N/A,17326.56,N/A,17326.56,N/A,6598.24,N/A,7837.71,N/A,7837.71,N/A,7060.11,N/A,1124.00,25579.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 346,Minor Small And Large Bowel Procedures Without Cc/McC,N/A,N/A,38907.50,N/A,23344.50,N/A,6672.01,N/A,8187.94,N/A,15035.92,N/A,13228.55,N/A,15179.75,N/A,6877.59,N/A,51142.00,N/A,51142.00,N/A,9449.04,N/A,15179.75,N/A,15179.75,N/A,15179.75,N/A,15035.92,N/A,8158.29,N/A,6877.59,N/A,18060.11,N/A,18060.11,N/A,6331.16,N/A,8158.29,N/A,8187.94,N/A,7359.02,N/A,6331.16,51142.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 348,Anal And Stomal Procedures With Cc,N/A,N/A,45361.50,N/A,27216.90,N/A,7367.11,N/A,9039.86,N/A,16602.38,N/A,15412.67,N/A,16761.20,N/A,7594.10,N/A,8980.56,N/A,8980.56,N/A,10433.46,N/A,16761.20,N/A,16761.20,N/A,16761.20,N/A,16602.38,N/A,8980.56,N/A,7594.10,N/A,19941.64,N/A,19941.64,N/A,6891.17,N/A,8980.56,N/A,9039.86,N/A,8125.69,N/A,6891.17,27216.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 349,Anal And Stomal Procedures Without Cc/McC,N/A,N/A,33208.60,N/A,19925.16,N/A,5319.68,N/A,6558.55,N/A,11988.34,N/A,11290.93,N/A,12103.02,N/A,5483.59,N/A,562.00,N/A,562.00,N/A,7533.85,N/A,12103.02,N/A,12103.02,N/A,12103.02,N/A,11988.34,N/A,6558.55,N/A,5483.59,N/A,14399.57,N/A,14399.57,N/A,6794.65,N/A,6558.55,N/A,6558.55,N/A,5867.44,N/A,562.00,19925.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 353,Hernia Procedures Except Inguinal And Femoral With McC,N/A,N/A,118932.47,N/A,71359.48,N/A,15298.62,N/A,18363.12,N/A,65555.58,N/A,40437.04,N/A,34806.49,N/A,15770.00,N/A,18363.12,N/A,18363.12,N/A,21666.23,N/A,34806.49,N/A,34806.49,N/A,34806.49,N/A,65555.58,N/A,18363.12,N/A,15770.00,N/A,41411.03,N/A,41411.03,N/A,12308.76,N/A,18363.12,N/A,18363.12,N/A,16873.90,N/A,12308.76,71359.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 357,Other Digestive System O.R. Procedures With Cc,N/A,N/A,78635.93,N/A,47181.56,N/A,11982.62,N/A,14440.47,N/A,30082.93,N/A,26736.22,N/A,27262.13,N/A,12351.83,N/A,14440.47,N/A,14440.47,N/A,16970.04,N/A,27262.13,N/A,27262.13,N/A,27262.13,N/A,30082.93,N/A,14440.47,N/A,12351.83,N/A,32435.13,N/A,32435.13,N/A,9821.13,N/A,14440.47,N/A,14440.47,N/A,13216.46,N/A,9821.13,47181.56,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 369,Major Esophageal Disorders With Cc,N/A,N/A,42421.60,N/A,25452.96,N/A,5452.52,N/A,6834.29,N/A,12287.69,N/A,14423.34,N/A,12405.23,N/A,5620.52,N/A,6715.69,N/A,6715.69,N/A,7721.97,N/A,12405.23,N/A,12405.23,N/A,12405.23,N/A,12287.69,N/A,6715.69,N/A,5620.52,N/A,14759.12,N/A,14759.12,N/A,5620.52,N/A,6715.69,N/A,6715.69,N/A,6013.95,N/A,5452.52,25452.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 370,Major Esophageal Disorders Without Cc/McC,N/A,N/A,28870.90,N/A,17322.54,N/A,3994.03,N/A,4990.37,N/A,9000.87,N/A,9816.11,N/A,9086.97,N/A,4117.09,N/A,1124.00,N/A,1124.00,N/A,5656.43,N/A,9086.97,N/A,9086.97,N/A,9086.97,N/A,9000.87,N/A,4990.37,N/A,4117.09,N/A,10811.23,N/A,10811.23,N/A,4385.47,N/A,4990.37,N/A,4990.37,N/A,4405.29,N/A,1124.00,17322.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 371,Major Gastrointestinal Disorders And Peritoneal Infections With McC,N/A,N/A,57860.90,N/A,34716.54,N/A,9025.11,N/A,1326.54,N/A,20338.82,N/A,19672.71,N/A,N/A,N/A,9025.11,N/A,10941.90,N/A,10941.90,N/A,N/A,N/A,20533.38,N/A,N/A,N/A,20533.38,N/A,20338.82,N/A,1326.54,N/A,9303.19,N/A,24429.59,N/A,24429.59,N/A,9025.11,N/A,1326.54,N/A,1326.54,N/A,9954.41,N/A,1326.54,34716.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 373,Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,N/A,N/A,20233.50,N/A,12140.10,N/A,3872.93,N/A,4847.13,N/A,8727.97,N/A,6879.39,N/A,8811.46,N/A,3992.27,N/A,4847.13,N/A,4847.13,N/A,5484.93,N/A,8811.46,N/A,8811.46,N/A,8811.46,N/A,8727.97,N/A,4847.13,N/A,3992.27,N/A,10483.44,N/A,10483.44,N/A,N/A,N/A,4847.13,N/A,4847.13,N/A,4271.73,N/A,3872.93,12140.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 378,Gastrointestinal Hemorrhage With Cc,N/A,N/A,35065.90,N/A,21039.54,N/A,5254.60,N/A,6481.56,N/A,11841.67,N/A,11922.41,N/A,11954.95,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,7441.68,N/A,11954.95,N/A,11954.95,N/A,11954.95,N/A,11841.67,N/A,6481.56,N/A,5416.50,N/A,14223.40,N/A,14223.40,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,5795.66,N/A,5254.60,21039.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 379,Gastrointestinal Hemorrhage Without Cc/McC,N/A,N/A,28702.50,N/A,17221.50,N/A,3381.08,N/A,4294.93,N/A,7619.54,N/A,9758.85,N/A,7692.43,N/A,3485.26,N/A,4265.28,N/A,4265.28,N/A,4788.36,N/A,7692.43,N/A,7692.43,N/A,7692.43,N/A,7619.54,N/A,4265.28,N/A,3485.26,N/A,9152.07,N/A,9152.07,N/A,3729.23,N/A,4265.28,N/A,2349.05,N/A,3729.23,N/A,2349.05,17221.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 380,Complicated Peptic Ulcer With McC,N/A,N/A,48823.20,N/A,29293.92,N/A,10157.65,N/A,12281.63,N/A,22891.09,N/A,16599.89,N/A,23110.06,N/A,10470.63,N/A,1686.00,N/A,1686.00,N/A,14385.48,N/A,23110.06,N/A,23110.06,N/A,23110.06,N/A,22891.09,N/A,12281.63,N/A,10470.63,N/A,27495.20,N/A,27495.20,N/A,6442.54,N/A,12281.63,N/A,12281.63,N/A,11203.57,N/A,1686.00,29293.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 383,Uncomplicated Peptic Ulcer With McC,N/A,N/A,44021.20,N/A,26412.72,N/A,7255.08,N/A,8936.98,N/A,16349.92,N/A,14967.21,N/A,16506.32,N/A,7478.63,N/A,138814.00,N/A,138814.00,N/A,10274.80,N/A,16506.32,N/A,16506.32,N/A,16506.32,N/A,16349.92,N/A,8848.03,N/A,7478.63,N/A,19638.40,N/A,19638.40,N/A,4723.73,N/A,8848.03,N/A,8936.98,N/A,8002.13,N/A,4723.73,138814.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 385,Inflammatory Bowel Disease With McC,N/A,N/A,42516.80,N/A,25510.08,N/A,8688.50,N/A,10543.69,N/A,19580.23,N/A,14455.71,N/A,19767.53,N/A,8956.20,N/A,2810.00,N/A,2810.00,N/A,12304.83,N/A,19767.53,N/A,19767.53,N/A,19767.53,N/A,19580.23,N/A,10543.69,N/A,8956.20,N/A,23518.43,N/A,26199.27,N/A,7206.52,N/A,10847.50,N/A,10543.69,N/A,9583.14,N/A,2810.00,26199.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 393,Other Digestive System Diagnoses With McC,N/A,N/A,42286.65,N/A,25371.99,N/A,8595.67,N/A,10493.18,N/A,19371.05,N/A,14377.46,N/A,19556.35,N/A,8860.52,N/A,10433.88,N/A,10433.88,N/A,12173.37,N/A,19556.35,N/A,19556.35,N/A,19556.35,N/A,19371.05,N/A,10433.88,N/A,8860.52,N/A,23267.17,N/A,23267.17,N/A,8860.52,N/A,10433.88,N/A,10493.18,N/A,9480.76,N/A,8595.67,25371.99,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 394,Other Digestive System Diagnoses With Cc,N/A,N/A,36199.50,N/A,21719.70,N/A,5030.55,N/A,6275.82,N/A,11336.75,N/A,12307.83,N/A,11445.19,N/A,5185.55,N/A,6216.52,N/A,6216.52,N/A,7124.37,N/A,11445.19,N/A,11445.19,N/A,11445.19,N/A,11336.75,N/A,6216.52,N/A,5185.55,N/A,13616.92,N/A,13616.92,N/A,5185.55,N/A,6216.52,N/A,6275.82,N/A,2443.43,N/A,2443.43,21719.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 407,"Pancreas, Liver And Shunt Procedures Without Cc/McC",N/A,N/A,95241.22,N/A,57144.73,N/A,11873.26,N/A,14311.10,N/A,26757.37,N/A,32382.01,N/A,27013.32,N/A,12239.10,N/A,1124.00,N/A,1124.00,N/A,16815.16,N/A,27013.32,N/A,27013.32,N/A,27013.32,N/A,26757.37,N/A,14311.10,N/A,12239.10,N/A,32139.11,N/A,32139.11,N/A,N/A,N/A,14311.10,N/A,14311.10,N/A,13095.84,N/A,1124.00,57144.73,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 410,Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,N/A,N/A,85723.47,N/A,51434.08,N/A,9056.59,N/A,10979.13,N/A,20409.75,N/A,29145.97,N/A,20604.98,N/A,9335.63,N/A,10979.13,N/A,10979.13,N/A,12826.12,N/A,20604.98,N/A,20604.98,N/A,20604.98,N/A,20409.75,N/A,10979.13,N/A,9335.63,N/A,24514.79,N/A,24514.79,N/A,12544.13,N/A,10979.13,N/A,10979.13,N/A,9989.13,N/A,9056.59,51434.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 411,Cholecystectomy With C.D.E. With McC,N/A,N/A,36930.90,N/A,22158.54,N/A,18021.41,N/A,21584.04,N/A,36930.90,N/A,12556.51,N/A,36930.90,N/A,18576.69,N/A,1686.00,N/A,1686.00,N/A,25522.30,N/A,36930.90,N/A,36930.90,N/A,36930.90,N/A,36930.90,N/A,21584.04,N/A,18576.69,N/A,36930.90,N/A,36930.90,N/A,N/A,N/A,21584.04,N/A,21584.04,N/A,19877.05,N/A,1686.00,36930.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 419,Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,N/A,N/A,48314.77,N/A,28988.86,N/A,6961.68,N/A,8530.60,N/A,15688.71,N/A,16427.03,N/A,15838.79,N/A,7176.18,N/A,8500.95,N/A,8500.95,N/A,9859.28,N/A,15838.79,N/A,15838.79,N/A,15838.79,N/A,15688.71,N/A,8500.95,N/A,7176.18,N/A,18844.20,N/A,18844.20,N/A,9026.81,N/A,8500.95,N/A,8530.60,N/A,7678.51,N/A,6961.68,28988.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 420,Hepatobiliary Diagnostic Procedures With McC,N/A,N/A,96307.40,N/A,57784.44,N/A,3346.70,N/A,22962.87,N/A,55572.89,N/A,32744.52,N/A,39581.18,N/A,3346.70,N/A,22962.87,N/A,22962.87,N/A,24638.37,N/A,39581.18,N/A,39581.18,N/A,39581.18,N/A,55572.89,N/A,22962.87,N/A,3346.70,N/A,55572.89,N/A,55572.89,N/A,3346.70,N/A,22962.87,N/A,22962.87,N/A,3346.70,N/A,3346.70,57784.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 422,Hepatobiliary Diagnostic Procedures Without Cc/McC,N/A,N/A,60457.32,N/A,36274.39,N/A,7391.65,N/A,9009.59,N/A,16657.68,N/A,20555.48,N/A,16817.03,N/A,7619.40,N/A,562.00,N/A,562.00,N/A,10468.21,N/A,16817.03,N/A,16817.03,N/A,16817.03,N/A,16657.68,N/A,9009.59,N/A,7619.40,N/A,20008.06,N/A,20008.06,N/A,N/A,N/A,9009.59,N/A,9009.59,N/A,8152.76,N/A,562.00,36274.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 434,Cirrhosis And Alcoholic Hepatitis Without Cc/McC,N/A,N/A,26132.43,N/A,15679.46,N/A,3348.54,N/A,4226.80,N/A,8627.75,N/A,8885.03,N/A,7618.39,N/A,3451.72,N/A,1686.00,N/A,1686.00,N/A,4742.27,N/A,7618.39,N/A,7618.39,N/A,7618.39,N/A,8627.75,N/A,4226.80,N/A,3451.72,N/A,9063.99,N/A,9063.99,N/A,3451.72,N/A,4226.80,N/A,4226.80,N/A,3693.34,N/A,1686.00,15679.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 435,Malignancy Of Hepatobiliary System Or Pancreas With McC,N/A,N/A,53621.38,N/A,32172.83,N/A,9325.98,N/A,11297.80,N/A,21370.77,N/A,18231.27,N/A,21217.90,N/A,9613.33,N/A,11297.80,N/A,11297.80,N/A,13207.65,N/A,21217.90,N/A,21217.90,N/A,21217.90,N/A,21370.77,N/A,11297.80,N/A,9613.33,N/A,25244.01,N/A,25244.01,N/A,N/A,N/A,11297.80,N/A,11297.80,N/A,10286.27,N/A,9325.98,32172.83,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 436,Malignancy Of Hepatobiliary System Or Pancreas With Cc,N/A,N/A,39941.33,N/A,23964.80,N/A,5870.22,N/A,7209.80,N/A,13297.73,N/A,13580.06,N/A,13355.55,N/A,6051.09,N/A,2248.00,N/A,2248.00,N/A,8313.52,N/A,13355.55,N/A,13355.55,N/A,13355.55,N/A,13297.73,N/A,7209.80,N/A,6051.09,N/A,15889.78,N/A,15889.78,N/A,5727.88,N/A,7681.26,N/A,7763.20,N/A,6474.66,N/A,2248.00,23964.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 437,Malignancy Of Hepatobiliary System Or Pancreas Without Cc/McC,N/A,N/A,12021.27,N/A,7212.76,N/A,4512.56,N/A,5603.76,N/A,10169.41,N/A,4087.23,N/A,10266.69,N/A,4651.60,N/A,1686.00,N/A,1686.00,N/A,6390.77,N/A,10266.69,N/A,10266.69,N/A,10266.69,N/A,10169.41,N/A,5603.76,N/A,4651.60,N/A,12021.27,N/A,12021.27,N/A,5798.59,N/A,5603.76,N/A,5603.76,N/A,4977.21,N/A,1686.00,12021.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 438,Disorders Of Pancreas Except Malignancy With McC,N/A,N/A,37976.73,N/A,22786.04,N/A,8841.60,N/A,9360.92,N/A,19925.26,N/A,12912.09,N/A,13223.50,N/A,9114.03,N/A,9360.92,N/A,9360.92,N/A,8233.36,N/A,13223.50,N/A,13223.50,N/A,13223.50,N/A,19925.26,N/A,9360.92,N/A,9114.03,N/A,23932.86,N/A,23932.86,N/A,8841.60,N/A,9360.92,N/A,9360.92,N/A,9752.01,N/A,8233.36,23932.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 444,Disorders Of The Biliary Tract With McC,N/A,N/A,50240.97,N/A,30144.58,N/A,8880.54,N/A,10770.87,N/A,20013.02,N/A,17081.93,N/A,N/A,N/A,1471.04,N/A,10770.87,N/A,10770.87,N/A,10892.24,N/A,17493.91,N/A,N/A,N/A,17493.91,N/A,20013.02,N/A,10770.87,N/A,9154.17,N/A,24038.27,N/A,24038.27,N/A,1471.04,N/A,10770.87,N/A,10770.87,N/A,9794.96,N/A,1471.04,30144.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 445,Disorders Of The Biliary Tract With Cc,N/A,N/A,40514.42,N/A,24308.65,N/A,5865.95,N/A,7204.75,N/A,13219.39,N/A,13774.90,N/A,13345.85,N/A,6046.69,N/A,7204.75,N/A,7204.75,N/A,8307.48,N/A,13345.85,N/A,13345.85,N/A,13345.85,N/A,13219.39,N/A,7204.75,N/A,6046.69,N/A,15878.22,N/A,15878.22,N/A,1127.64,N/A,7204.75,N/A,7204.75,N/A,6469.96,N/A,1127.64,24308.65,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 455,Combined Anterior And Posterior Spinal Fusion Without Cc/McC,N/A,N/A,176215.92,N/A,105729.55,N/A,25542.16,N/A,30480.71,N/A,97130.21,N/A,59913.41,N/A,58111.96,N/A,26329.16,N/A,31989.76,N/A,1124.00,N/A,36173.34,N/A,58111.96,N/A,58111.96,N/A,58111.96,N/A,97130.21,N/A,30480.71,N/A,26329.16,N/A,69138.72,N/A,69138.72,N/A,26329.16,N/A,30480.71,N/A,30480.71,N/A,28172.20,N/A,1124.00,105729.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 458,"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC",N/A,N/A,171059.57,N/A,102635.74,N/A,25676.06,N/A,30639.11,N/A,94288.03,N/A,58160.25,N/A,58416.59,N/A,26467.19,N/A,1124.00,N/A,1124.00,N/A,36362.97,N/A,58416.59,N/A,58416.59,N/A,58416.59,N/A,94288.03,N/A,30639.11,N/A,26467.19,N/A,69501.16,N/A,69501.16,N/A,26467.19,N/A,30639.11,N/A,30639.11,N/A,28319.89,N/A,1124.00,102635.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 459,Spinal Fusion Except Cervical With McC,N/A,N/A,223295.98,N/A,133977.59,N/A,25677.86,N/A,30596.01,N/A,123080.74,N/A,75920.64,N/A,77751.66,N/A,26431.01,N/A,2248.00,N/A,2248.00,N/A,48410.57,N/A,77751.66,N/A,77751.66,N/A,77751.66,N/A,123080.74,N/A,30596.01,N/A,26431.01,N/A,154168.01,N/A,154168.01,N/A,26431.01,N/A,30596.01,N/A,44005.08,N/A,28281.18,N/A,2248.00,154168.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 466,Revision Of Hip Or Knee Replacement With McC,N/A,N/A,154491.07,N/A,92694.64,N/A,12457.19,N/A,34164.70,N/A,54588.64,N/A,34260.00,N/A,34260.00,N/A,12457.19,N/A,34912.25,N/A,34912.25,N/A,34260.00,N/A,34260.00,N/A,34260.00,N/A,34260.00,N/A,54588.64,N/A,34845.85,N/A,12457.19,N/A,54588.64,N/A,54588.64,N/A,12457.19,N/A,34845.85,N/A,34845.85,N/A,12457.19,N/A,12457.19,92694.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 468,Revision Of Hip Or Knee Replacement Without Cc/McC,N/A,N/A,127064.97,N/A,76238.98,N/A,14879.86,N/A,17867.74,N/A,70038.21,N/A,43202.09,N/A,33853.73,N/A,15338.33,N/A,17867.74,N/A,17867.74,N/A,21073.16,N/A,33853.73,N/A,33853.73,N/A,33853.73,N/A,70038.21,N/A,17867.74,N/A,15338.33,N/A,40277.49,N/A,40277.49,N/A,132.20,N/A,17867.74,N/A,17867.74,N/A,16412.01,N/A,132.20,76238.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 471,Cervical Spinal Fusion With McC,N/A,N/A,174246.18,N/A,104547.71,N/A,26870.48,N/A,32052.05,N/A,96044.49,N/A,59243.70,N/A,61134.07,N/A,27698.41,N/A,32052.05,N/A,32052.05,N/A,38054.54,N/A,61134.07,N/A,61134.07,N/A,61134.07,N/A,96044.49,N/A,32052.05,N/A,27698.41,N/A,72734.28,N/A,72734.28,N/A,8379.47,N/A,32052.05,N/A,32052.05,N/A,29637.30,N/A,8379.47,104547.71,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 493,"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",N/A,N/A,64173.07,N/A,38503.84,N/A,9505.49,N/A,11539.80,N/A,32684.98,N/A,21815.00,N/A,28835.08,N/A,9798.37,N/A,11510.15,N/A,11510.15,N/A,17949.17,N/A,28835.08,N/A,28835.08,N/A,28835.08,N/A,32684.98,N/A,11510.15,N/A,9798.37,N/A,34306.55,N/A,34306.55,N/A,13979.01,N/A,11510.15,N/A,11539.80,N/A,10484.26,N/A,9505.49,38503.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 498,Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,N/A,N/A,88874.77,N/A,53324.86,N/A,13673.17,N/A,16440.29,N/A,30813.59,N/A,30217.42,N/A,31108.34,N/A,14094.46,N/A,18175.83,N/A,4496.00,N/A,19364.22,N/A,31108.34,N/A,31108.34,N/A,31108.34,N/A,30813.59,N/A,16440.29,N/A,14094.46,N/A,N/A,N/A,37011.16,N/A,14094.46,N/A,18175.83,N/A,16440.29,N/A,15081.07,N/A,4496.00,53324.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 500,Soft Tissue Procedures With McC,N/A,N/A,68102.93,N/A,40861.76,N/A,12828.52,N/A,20487.91,N/A,38590.18,N/A,23154.99,N/A,64118.84,N/A,12828.52,N/A,20976.43,N/A,4496.00,N/A,64118.84,N/A,64118.84,N/A,64118.84,N/A,64118.84,N/A,38590.18,N/A,20976.43,N/A,17621.51,N/A,25440.00,N/A,46272.98,N/A,17621.51,N/A,20487.91,N/A,20487.91,N/A,12828.52,N/A,4496.00,64118.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 503,Foot Procedures With McC,N/A,N/A,107573.97,N/A,64544.38,N/A,13514.19,N/A,17738.40,N/A,59294.77,N/A,36575.15,N/A,33241.96,N/A,13907.93,N/A,2810.00,N/A,2810.00,N/A,33241.96,N/A,33241.96,N/A,30746.66,N/A,30746.66,N/A,59294.77,N/A,16252.24,N/A,13930.59,N/A,36580.85,N/A,36580.85,N/A,13907.93,N/A,16252.24,N/A,16252.24,N/A,13907.93,N/A,2810.00,64544.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 507,Major Shoulder Or Elbow Joint Procedures With Cc/McC,N/A,N/A,45476.42,N/A,27285.85,N/A,9894.65,N/A,11970.51,N/A,22298.41,N/A,15461.98,N/A,22511.71,N/A,10199.53,N/A,4496.00,N/A,4496.00,N/A,24533.44,N/A,24533.44,N/A,22511.71,N/A,24533.44,N/A,22298.41,N/A,11970.51,N/A,9899.95,N/A,26783.31,N/A,26783.31,N/A,9899.95,N/A,11970.51,N/A,17312.67,N/A,10913.49,N/A,4496.00,27285.85,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 509,Arthroscopy,N/A,N/A,53755.83,N/A,32253.50,N/A,8097.42,N/A,9844.47,N/A,18909.90,N/A,18276.98,N/A,18422.75,N/A,8346.92,N/A,1686.00,N/A,1686.00,N/A,11467.73,N/A,18422.75,N/A,18422.75,N/A,18422.75,N/A,18909.90,N/A,9844.47,N/A,8346.92,N/A,21918.48,N/A,21918.48,N/A,N/A,N/A,9844.47,N/A,10794.81,N/A,8931.20,N/A,1686.00,32253.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 510,"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With McC",N/A,N/A,83387.82,N/A,50032.69,N/A,15406.92,N/A,18491.23,N/A,45255.33,N/A,28351.85,N/A,35052.87,N/A,15881.63,N/A,2810.00,N/A,2810.00,N/A,21819.60,N/A,35052.87,N/A,35052.87,N/A,35052.87,N/A,45255.33,N/A,18491.23,N/A,10988.74,N/A,41704.16,N/A,41704.16,N/A,10988.74,N/A,18491.23,N/A,19007.43,N/A,16993.35,N/A,2810.00,50032.69,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 515,Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,N/A,N/A,99512.33,N/A,59707.40,N/A,16632.28,N/A,20975.26,N/A,195546.04,N/A,33834.20,N/A,40830.71,N/A,16966.19,N/A,20279.17,N/A,20279.17,N/A,40830.71,N/A,40830.71,N/A,40830.71,N/A,40830.71,N/A,195546.04,N/A,19940.78,N/A,16966.19,N/A,195546.04,N/A,195546.04,N/A,16966.19,N/A,20474.95,N/A,20892.92,N/A,16966.19,N/A,16632.28,195546.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 517,Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,N/A,N/A,50672.58,N/A,30403.55,N/A,8054.74,N/A,9793.99,N/A,18671.88,N/A,17228.68,N/A,18325.66,N/A,8302.92,N/A,9793.99,N/A,9793.99,N/A,11407.29,N/A,18325.66,N/A,18325.66,N/A,18325.66,N/A,18671.88,N/A,9793.99,N/A,8302.92,N/A,21802.96,N/A,21802.96,N/A,N/A,N/A,9793.99,N/A,9793.99,N/A,8884.13,N/A,8054.74,30403.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 533,Fractures Of Femur With McC,N/A,N/A,58903.90,N/A,35342.34,N/A,N/A,N/A,9981.27,N/A,17146.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9981.27,N/A,9981.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9981.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9981.27,N/A,9981.27,N/A,8392.23,N/A,8392.23,35342.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 537,"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC",N/A,N/A,36722.10,N/A,22033.26,N/A,5299.41,N/A,6534.57,N/A,11942.65,N/A,12485.51,N/A,12056.90,N/A,5462.70,N/A,191642.00,N/A,191642.00,N/A,7505.14,N/A,12056.90,N/A,12056.90,N/A,12056.90,N/A,11942.65,N/A,6534.57,N/A,5462.70,N/A,14344.70,N/A,14344.70,N/A,N/A,N/A,6534.57,N/A,6534.57,N/A,5845.08,N/A,5299.41,191642.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 539,Osteomyelitis With McC,N/A,N/A,43427.50,N/A,26056.50,N/A,10647.37,N/A,12860.93,N/A,24565.34,N/A,14765.35,N/A,24224.24,N/A,10975.43,N/A,12860.93,N/A,12860.93,N/A,15079.02,N/A,24224.24,N/A,24224.24,N/A,24224.24,N/A,24565.34,N/A,12860.93,N/A,10975.43,N/A,28820.80,N/A,28820.80,N/A,8104.86,N/A,12860.93,N/A,12860.93,N/A,11743.71,N/A,8104.86,28820.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 541,Osteomyelitis Without Cc/McC,N/A,N/A,24423.50,N/A,14654.10,N/A,4363.72,N/A,3625.85,N/A,9834.00,N/A,8303.99,N/A,9928.07,N/A,4498.17,N/A,1686.00,N/A,1686.00,N/A,6179.99,N/A,9928.07,N/A,9928.07,N/A,9928.07,N/A,9834.00,N/A,3596.20,N/A,4498.17,N/A,11811.92,N/A,11811.92,N/A,6548.64,N/A,3596.20,N/A,3625.85,N/A,4813.05,N/A,1686.00,14654.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 543,Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,N/A,N/A,33210.60,N/A,19926.36,N/A,5809.40,N/A,7137.86,N/A,13091.96,N/A,11291.60,N/A,13217.19,N/A,5988.40,N/A,7137.86,N/A,7137.86,N/A,8227.40,N/A,13217.19,N/A,13217.19,N/A,13217.19,N/A,13091.96,N/A,7137.86,N/A,5988.40,N/A,15725.16,N/A,15725.16,N/A,N/A,N/A,7137.86,N/A,7137.86,N/A,6407.59,N/A,5809.40,19926.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 546,Connective Tissue Disorders With Cc,N/A,N/A,31898.00,N/A,19138.80,N/A,5512.64,N/A,6786.50,N/A,14493.72,N/A,10845.32,N/A,14632.37,N/A,5682.50,N/A,1124.00,N/A,1124.00,N/A,9108.31,N/A,14632.37,N/A,14632.37,N/A,14632.37,N/A,14493.72,N/A,6786.50,N/A,5682.50,N/A,17408.86,N/A,17408.86,N/A,8080.55,N/A,6786.50,N/A,6786.50,N/A,6080.27,N/A,1124.00,19138.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 553,Bone Diseases And Arthropathies With McC,N/A,N/A,39006.00,N/A,23403.60,N/A,5850.90,N/A,8632.84,N/A,15939.97,N/A,13262.04,N/A,16092.45,N/A,7291.11,N/A,8632.84,N/A,8632.84,N/A,10017.17,N/A,16092.45,N/A,16092.45,N/A,16092.45,N/A,15939.97,N/A,8632.84,N/A,7291.11,N/A,19146.00,N/A,19146.00,N/A,5850.90,N/A,8632.84,N/A,8632.84,N/A,7801.49,N/A,5850.90,23403.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 554,Bone Diseases And Arthropathies Without McC,N/A,N/A,22644.10,N/A,13586.46,N/A,4375.46,N/A,5441.59,N/A,9860.44,N/A,7698.99,N/A,9954.77,N/A,4510.27,N/A,2248.00,N/A,2248.00,N/A,6196.61,N/A,9954.77,N/A,9954.77,N/A,9954.77,N/A,9860.44,N/A,5441.59,N/A,4510.27,N/A,11843.69,N/A,11843.69,N/A,5729.62,N/A,5441.59,N/A,5441.59,N/A,4825.99,N/A,2248.00,13586.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 555,Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,N/A,N/A,51802.00,N/A,31081.20,N/A,7101.45,N/A,8666.29,N/A,16003.69,N/A,17612.68,N/A,16156.77,N/A,7320.25,N/A,3934.00,N/A,3934.00,N/A,10057.22,N/A,16156.77,N/A,16156.77,N/A,16156.77,N/A,16003.69,N/A,8666.29,N/A,7320.25,N/A,19222.53,N/A,19222.53,N/A,1160.19,N/A,8666.29,N/A,8666.29,N/A,7832.67,N/A,1160.19,31081.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 560,"Aftercare, Musculoskeletal System And Connective Tissue With Cc",N/A,N/A,50387.70,N/A,30232.62,N/A,9754.80,N/A,13038.32,N/A,50387.70,N/A,17131.82,N/A,25450.83,N/A,6024.69,N/A,13038.32,N/A,13038.32,N/A,13297.30,N/A,25450.83,N/A,25450.83,N/A,25450.83,N/A,22155.00,N/A,14948.15,N/A,6024.69,N/A,30780.00,N/A,30780.00,N/A,6024.69,N/A,13038.32,N/A,14948.15,N/A,6024.69,N/A,6024.69,50387.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 562,"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC",N/A,N/A,49748.00,N/A,29848.80,N/A,6296.22,N/A,2527.89,N/A,16789.77,N/A,N/A,N/A,N/A,N/A,6296.22,N/A,9796.72,N/A,9796.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16789.77,N/A,9796.72,N/A,6296.22,N/A,16789.77,N/A,21122.83,N/A,6296.22,N/A,9796.72,N/A,9796.72,N/A,6296.22,N/A,2527.89,29848.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 564,Other Musculoskeletal System And Connective Tissue Diagnoses With McC,N/A,N/A,50896.20,N/A,30537.72,N/A,8286.27,N/A,10067.87,N/A,18673.77,N/A,17304.71,N/A,18852.40,N/A,8541.58,N/A,10067.87,N/A,10067.87,N/A,11735.18,N/A,18852.40,N/A,18852.40,N/A,18852.40,N/A,18673.77,N/A,10067.87,N/A,8541.58,N/A,22429.65,N/A,22429.65,N/A,N/A,N/A,10067.87,N/A,10067.87,N/A,9139.49,N/A,8286.27,30537.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 573,Skin Graft For Skin Ulcer Or Cellulitis With McC,N/A,N/A,88912.15,N/A,53347.29,N/A,N/A,N/A,31136.30,N/A,70575.15,N/A,30230.13,N/A,N/A,N/A,N/A,N/A,4496.00,N/A,35374.52,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,70575.15,N/A,35374.52,N/A,26901.51,N/A,N/A,N/A,N/A,N/A,N/A,N/A,35374.52,N/A,35374.52,N/A,N/A,N/A,4496.00,70575.15,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 576,Skin Graft Except For Skin Ulcer Or Cellulitis With McC,N/A,N/A,409216.43,N/A,245529.86,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,245529.86,245529.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 580,"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",N/A,N/A,52273.40,N/A,31364.04,N/A,9261.97,N/A,11222.07,N/A,21346.31,N/A,17772.95,N/A,21072.26,N/A,9547.35,N/A,2248.00,N/A,2248.00,N/A,13116.99,N/A,21072.26,N/A,21072.26,N/A,21072.26,N/A,21346.31,N/A,11222.07,N/A,9547.35,N/A,25070.73,N/A,25070.73,N/A,6724.05,N/A,11222.07,N/A,11222.07,N/A,10215.66,N/A,2248.00,31364.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 596,Major Skin Disorders Without McC,N/A,N/A,23636.10,N/A,14181.66,N/A,5824.34,N/A,7155.54,N/A,11546.90,N/A,8036.28,N/A,13251.18,N/A,6003.80,N/A,2248.00,N/A,2248.00,N/A,8248.55,N/A,13251.18,N/A,13251.18,N/A,13251.18,N/A,13125.62,N/A,7155.54,N/A,6003.80,N/A,15765.59,N/A,15765.59,N/A,5072.06,N/A,7155.54,N/A,7155.54,N/A,6424.06,N/A,2248.00,15765.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 599,Malignant Breast Disorders Without Cc/McC,N/A,N/A,35257.30,N/A,21154.38,N/A,3988.16,N/A,5013.09,N/A,8987.65,N/A,11987.48,N/A,9073.62,N/A,4111.04,N/A,1686.00,N/A,1686.00,N/A,5648.12,N/A,9073.62,N/A,9073.62,N/A,9073.62,N/A,8987.65,N/A,4983.44,N/A,4111.04,N/A,10795.34,N/A,10795.34,N/A,N/A,N/A,4983.44,N/A,5013.09,N/A,4398.82,N/A,1686.00,21154.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 603,Cellulitis Without McC,N/A,N/A,25108.60,N/A,15065.16,N/A,4704.07,N/A,5830.32,N/A,10601.00,N/A,8536.92,N/A,10702.41,N/A,4849.01,N/A,5830.32,N/A,5830.32,N/A,6662.00,N/A,10702.41,N/A,10702.41,N/A,10702.41,N/A,10601.00,N/A,5830.32,N/A,4849.01,N/A,12733.19,N/A,12733.19,N/A,5040.61,N/A,5830.32,N/A,5830.32,N/A,5188.44,N/A,4704.07,15065.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 607,Minor Skin Disorders Without McC,N/A,N/A,20290.50,N/A,12174.30,N/A,4524.83,N/A,5618.27,N/A,10197.06,N/A,6898.77,N/A,10294.60,N/A,4664.24,N/A,1124.00,N/A,1124.00,N/A,6408.15,N/A,10294.60,N/A,10294.60,N/A,10294.60,N/A,10197.06,N/A,5618.27,N/A,4664.24,N/A,12248.01,N/A,12248.01,N/A,4454.09,N/A,5618.27,N/A,5618.27,N/A,4990.74,N/A,1124.00,12248.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 616,"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC",N/A,N/A,80357.62,N/A,48214.57,N/A,12281.27,N/A,24620.73,N/A,40767.38,N/A,41290.50,N/A,41290.50,N/A,12281.27,N/A,4496.00,N/A,4496.00,N/A,41290.50,N/A,41290.50,N/A,41290.50,N/A,41290.50,N/A,40767.38,N/A,24620.73,N/A,12281.27,N/A,40767.38,N/A,40767.38,N/A,12281.27,N/A,24620.73,N/A,24620.73,N/A,12281.27,N/A,4496.00,48214.57,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 622,"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With McC",N/A,N/A,66321.30,N/A,39792.78,N/A,19317.19,N/A,23116.89,N/A,43532.86,N/A,22549.24,N/A,43949.29,N/A,19912.39,N/A,3934.00,N/A,3934.00,N/A,27357.41,N/A,43949.29,N/A,43949.29,N/A,43949.29,N/A,43532.86,N/A,23116.89,N/A,19912.39,N/A,52288.68,N/A,52288.68,N/A,5836.82,N/A,23116.89,N/A,23116.89,N/A,21306.26,N/A,3934.00,52288.68,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 625,"Thyroid, Parathyroid And Thyroglossal Procedures With McC",N/A,N/A,183943.27,N/A,110365.96,N/A,N/A,N/A,19872.54,N/A,N/A,N/A,57569.89,N/A,57569.89,N/A,N/A,N/A,19872.54,N/A,19872.54,N/A,57569.89,N/A,57569.89,N/A,57569.89,N/A,57569.89,N/A,N/A,N/A,19872.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18422.44,N/A,19872.54,N/A,N/A,N/A,18422.44,110365.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 628,"Other Endocrine, Nutritional And Metabolic O.R. Procedures With McC",N/A,N/A,90587.05,N/A,54352.23,N/A,14372.95,N/A,23869.25,N/A,66018.26,N/A,30799.59,N/A,N/A,N/A,14372.95,N/A,24453.84,N/A,23866.33,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,66018.26,N/A,23869.25,N/A,14372.95,N/A,52630.91,N/A,52630.91,N/A,14372.95,N/A,23266.45,N/A,23869.25,N/A,21445.71,N/A,14372.95,66018.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 629,"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",N/A,N/A,54332.28,N/A,32599.37,N/A,11969.82,N/A,14454.97,N/A,32233.08,N/A,18472.99,N/A,27233.00,N/A,12338.63,N/A,121954.00,N/A,121954.00,N/A,16951.91,N/A,27233.00,N/A,27233.00,N/A,27233.00,N/A,32233.08,N/A,14425.32,N/A,12338.63,N/A,32400.47,N/A,32400.47,N/A,12136.36,N/A,14425.32,N/A,14454.97,N/A,13202.34,N/A,11969.82,121954.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 630,"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/McC",N/A,N/A,39232.48,N/A,23539.49,N/A,7490.87,N/A,9126.96,N/A,16881.29,N/A,13339.05,N/A,17042.78,N/A,7721.68,N/A,2810.00,N/A,2810.00,N/A,10608.73,N/A,17042.78,N/A,17042.78,N/A,17042.78,N/A,16881.29,N/A,9126.96,N/A,7721.68,N/A,20276.65,N/A,20276.65,N/A,7721.68,N/A,9126.96,N/A,9126.96,N/A,8262.20,N/A,2810.00,23539.49,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 639,Diabetes Without Cc/McC,N/A,N/A,20704.60,N/A,12422.76,N/A,3205.04,N/A,2191.29,N/A,7222.82,N/A,7039.56,N/A,7291.91,N/A,3303.79,N/A,4057.03,N/A,4057.03,N/A,4539.04,N/A,7291.91,N/A,7291.91,N/A,7291.91,N/A,7222.82,N/A,4057.03,N/A,3303.79,N/A,8675.55,N/A,8675.55,N/A,3535.06,N/A,4057.03,N/A,4057.03,N/A,3535.06,N/A,2191.29,12422.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 644,Endocrine Disorders With Cc,N/A,N/A,28851.90,N/A,17311.14,N/A,5436.51,N/A,6696.75,N/A,12251.62,N/A,9809.65,N/A,12368.82,N/A,5604.02,N/A,6696.75,N/A,6696.75,N/A,7699.30,N/A,12368.82,N/A,12368.82,N/A,12368.82,N/A,12251.62,N/A,6696.75,N/A,5604.02,N/A,14715.80,N/A,14715.80,N/A,3426.46,N/A,6696.75,N/A,6696.75,N/A,5996.30,N/A,3426.46,17311.14,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 645,Endocrine Disorders Without Cc/McC,N/A,N/A,21625.70,N/A,12975.42,N/A,3961.49,N/A,4951.87,N/A,8927.54,N/A,7352.74,N/A,9012.94,N/A,4083.55,N/A,4951.87,N/A,4951.87,N/A,5610.34,N/A,9012.94,N/A,9012.94,N/A,9012.94,N/A,8927.54,N/A,4951.87,N/A,4083.55,N/A,10723.14,N/A,10723.14,N/A,1559.15,N/A,4951.87,N/A,4951.87,N/A,4369.40,N/A,1559.15,12975.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 661,Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,N/A,N/A,27135.42,N/A,16281.25,N/A,5750.19,N/A,7067.82,N/A,13727.68,N/A,9226.05,N/A,13082.47,N/A,5927.36,N/A,7067.82,N/A,7067.82,N/A,8143.53,N/A,13082.47,N/A,13082.47,N/A,13082.47,N/A,13727.68,N/A,7067.82,N/A,5927.36,N/A,15564.88,N/A,15564.88,N/A,4670.88,N/A,7067.82,N/A,7067.82,N/A,6342.28,N/A,4670.88,16281.25,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 662,Minor Bladder Procedures With McC,N/A,N/A,75520.55,N/A,45312.33,N/A,16210.31,N/A,19441.60,N/A,36531.25,N/A,25676.98,N/A,36880.70,N/A,16709.78,N/A,6744.00,N/A,6744.00,N/A,22957.38,N/A,36880.70,N/A,36880.70,N/A,36880.70,N/A,36531.25,N/A,19441.60,N/A,16709.78,N/A,43878.83,N/A,43878.83,N/A,N/A,N/A,19441.60,N/A,19441.60,N/A,17879.46,N/A,6744.00,45312.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 663,Minor Bladder Procedures With Cc,N/A,N/A,47156.42,N/A,28293.85,N/A,8135.30,N/A,9889.28,N/A,18369.42,N/A,16033.18,N/A,18508.93,N/A,8385.96,N/A,1686.00,N/A,1686.00,N/A,11521.38,N/A,18508.93,N/A,18508.93,N/A,18508.93,N/A,18369.42,N/A,9889.28,N/A,8385.96,N/A,22021.00,N/A,22021.00,N/A,8135.30,N/A,9889.28,N/A,9889.28,N/A,8972.98,N/A,1686.00,28293.85,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 664,Minor Bladder Procedures Without Cc/McC,N/A,N/A,32789.18,N/A,19673.51,N/A,6010.52,N/A,7375.78,N/A,13545.19,N/A,11148.33,N/A,13674.76,N/A,6195.71,N/A,1124.00,N/A,1124.00,N/A,8512.22,N/A,13674.76,N/A,13674.76,N/A,13674.76,N/A,13545.19,N/A,7375.78,N/A,6195.71,N/A,16269.55,N/A,16269.55,N/A,6195.71,N/A,7375.78,N/A,7375.78,N/A,6629.41,N/A,1124.00,19673.51,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 682,Renal Failure With McC,N/A,N/A,34653.70,N/A,20792.22,N/A,7930.45,N/A,9646.96,N/A,17871.91,N/A,11782.26,N/A,18042.86,N/A,8174.80,N/A,9646.96,N/A,9646.96,N/A,11231.26,N/A,18042.86,N/A,18042.86,N/A,18042.86,N/A,17871.91,N/A,9646.96,N/A,8174.80,N/A,21466.50,N/A,21466.50,N/A,8174.80,N/A,9646.96,N/A,9646.96,N/A,8747.03,N/A,7930.45,21466.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 683,Renal Failure With Cc,N/A,N/A,27744.20,N/A,16646.52,N/A,4773.95,N/A,5604.84,N/A,10570.94,N/A,9433.03,N/A,10672.06,N/A,2791.94,N/A,5545.54,N/A,5545.54,N/A,6643.11,N/A,10672.06,N/A,10672.06,N/A,10672.06,N/A,10570.94,N/A,5545.54,N/A,4921.05,N/A,12697.09,N/A,12697.09,N/A,5241.82,N/A,5545.54,N/A,5604.84,N/A,5265.52,N/A,2791.94,16646.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 707,Major Male Pelvic Procedures With Cc/McC,N/A,N/A,97516.78,N/A,58510.07,N/A,10644.17,N/A,12857.15,N/A,32876.83,N/A,33155.69,N/A,24216.96,N/A,10972.13,N/A,2248.00,N/A,2248.00,N/A,15074.49,N/A,24216.96,N/A,24216.96,N/A,24216.96,N/A,32876.83,N/A,12857.15,N/A,10972.13,N/A,28812.13,N/A,28812.13,N/A,13704.53,N/A,12857.15,N/A,12857.15,N/A,11740.18,N/A,2248.00,58510.07,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 717,Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,N/A,N/A,48926.70,N/A,29356.02,N/A,9443.88,N/A,12241.58,N/A,21282.55,N/A,16635.08,N/A,21486.13,N/A,9734.86,N/A,3372.00,N/A,3372.00,N/A,13374.62,N/A,21486.13,N/A,21486.13,N/A,21486.13,N/A,21282.55,N/A,11437.26,N/A,9734.86,N/A,25563.13,N/A,25563.13,N/A,5488.75,N/A,11437.26,N/A,11437.26,N/A,10416.30,N/A,3372.00,29356.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 730,Other Male Reproductive System Diagnoses Without Cc/McC,N/A,N/A,16923.20,N/A,10153.92,N/A,3498.44,N/A,4433.78,N/A,7884.03,N/A,5753.89,N/A,7959.44,N/A,3606.24,N/A,85986.00,N/A,85986.00,N/A,4954.57,N/A,7959.44,N/A,7959.44,N/A,7959.44,N/A,7884.03,N/A,4404.13,N/A,3606.24,N/A,9469.75,N/A,9469.75,N/A,761.19,N/A,4404.13,N/A,4433.78,N/A,3858.67,N/A,761.19,85986.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 738,Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/McC,N/A,N/A,67382.20,N/A,40429.32,N/A,7488.74,N/A,9124.44,N/A,16876.48,N/A,22909.95,N/A,17037.92,N/A,7719.48,N/A,562.00,N/A,562.00,N/A,10605.71,N/A,17037.92,N/A,17037.92,N/A,17037.92,N/A,16876.48,N/A,9124.44,N/A,7719.48,N/A,20270.87,N/A,20270.87,N/A,7719.48,N/A,9124.44,N/A,9124.44,N/A,8259.85,N/A,562.00,40429.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 742,Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,N/A,N/A,59453.80,N/A,35672.28,N/A,9613.52,N/A,11637.93,N/A,21664.85,N/A,20214.29,N/A,21872.09,N/A,9909.73,N/A,11637.93,N/A,11637.93,N/A,13614.87,N/A,21872.09,N/A,21872.09,N/A,21872.09,N/A,21664.85,N/A,11637.93,N/A,9909.73,N/A,26022.32,N/A,26022.32,N/A,6993.71,N/A,11637.93,N/A,11637.93,N/A,10603.41,N/A,6993.71,35672.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 746,"Vagina, Cervix And Vulva Procedures With Cc/McC",N/A,N/A,51466.30,N/A,30879.78,N/A,8340.15,N/A,10131.60,N/A,18795.19,N/A,17498.54,N/A,18974.99,N/A,8597.12,N/A,2248.00,N/A,2248.00,N/A,11811.49,N/A,18974.99,N/A,18974.99,N/A,18974.99,N/A,18795.19,N/A,10131.60,N/A,8597.12,N/A,22575.50,N/A,22575.50,N/A,4689.32,N/A,10131.60,N/A,10131.60,N/A,9198.92,N/A,2248.00,30879.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 747,"Vagina, Cervix And Vulva Procedures Without Cc/McC",N/A,N/A,31411.00,N/A,18846.60,N/A,5822.79,N/A,6441.18,N/A,11764.73,N/A,10679.74,N/A,11877.27,N/A,5381.31,N/A,2248.00,N/A,2248.00,N/A,12892.08,N/A,11877.27,N/A,12892.08,N/A,12892.08,N/A,11764.73,N/A,6992.49,N/A,5381.31,N/A,14130.98,N/A,14130.98,N/A,5822.79,N/A,6441.18,N/A,6441.18,N/A,5758.00,N/A,2248.00,18846.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 750,Other Female Reproductive System O.R. Procedures Without Cc/McC,N/A,N/A,46271.77,N/A,27763.06,N/A,7612.50,N/A,9270.84,N/A,17155.39,N/A,15732.40,N/A,17319.50,N/A,7847.06,N/A,1124.00,N/A,1124.00,N/A,10780.99,N/A,17319.50,N/A,17319.50,N/A,17319.50,N/A,17155.39,N/A,9270.84,N/A,7847.06,N/A,20605.88,N/A,20605.88,N/A,6500.24,N/A,9270.84,N/A,9270.84,N/A,8396.35,N/A,1124.00,27763.06,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 755,"Malignancy, Female Reproductive System With Cc",N/A,N/A,39603.90,N/A,23762.34,N/A,8372.16,N/A,7088.02,N/A,12996.98,N/A,13465.33,N/A,13121.31,N/A,5944.96,N/A,2248.00,N/A,2248.00,N/A,8167.71,N/A,13121.31,N/A,13121.31,N/A,13121.31,N/A,12996.98,N/A,7088.02,N/A,5944.96,N/A,15611.08,N/A,15611.08,N/A,8372.16,N/A,7088.02,N/A,7088.02,N/A,6361.10,N/A,2248.00,23762.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 757,"Infections, Female Reproductive System With McC",N/A,N/A,45297.40,N/A,27178.44,N/A,7320.17,N/A,8925.02,N/A,16496.59,N/A,15401.12,N/A,16654.39,N/A,7545.71,N/A,3372.00,N/A,3372.00,N/A,10366.97,N/A,16654.39,N/A,16654.39,N/A,16654.39,N/A,16496.59,N/A,8925.02,N/A,7545.71,N/A,19814.57,N/A,19814.57,N/A,5467.86,N/A,8925.02,N/A,8925.02,N/A,8073.91,N/A,3372.00,27178.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 760,Menstrual And Other Female Reproductive System Disorders With Cc/McC,N/A,N/A,26995.20,N/A,16197.12,N/A,5156.44,N/A,7532.17,N/A,11620.47,N/A,9178.37,N/A,11731.62,N/A,5315.32,N/A,107904.00,N/A,107904.00,N/A,7302.66,N/A,11731.62,N/A,11731.62,N/A,11731.62,N/A,11620.47,N/A,7502.52,N/A,5315.32,N/A,13957.70,N/A,13957.70,N/A,4533.95,N/A,7502.52,N/A,7532.17,N/A,5687.40,N/A,4533.95,107904.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 761,Menstrual And Other Female Reproductive System Disorders Without Cc/McC,N/A,N/A,20252.10,N/A,12151.26,N/A,3017.79,N/A,3835.53,N/A,6800.85,N/A,6885.71,N/A,6865.90,N/A,3110.78,N/A,562.00,N/A,562.00,N/A,4273.86,N/A,6865.90,N/A,6865.90,N/A,6865.90,N/A,6800.85,N/A,3835.53,N/A,3110.78,N/A,8168.71,N/A,8168.71,N/A,2143.13,N/A,3835.53,N/A,3835.53,N/A,3328.53,N/A,562.00,12151.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 776,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,N/A,N/A,10790.30,N/A,6474.18,N/A,3718.76,N/A,4664.74,N/A,8380.54,N/A,3668.71,N/A,8460.70,N/A,3833.35,N/A,4664.74,N/A,4664.74,N/A,5266.59,N/A,8460.70,N/A,8460.70,N/A,8460.70,N/A,4404.27,N/A,4664.74,N/A,3833.35,N/A,10790.30,N/A,10790.30,N/A,3833.35,N/A,4647.00,N/A,4664.74,N/A,4101.68,N/A,3668.71,10790.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 779,Abortion Without D&C,N/A,N/A,13495.90,N/A,8097.54,N/A,5433.84,N/A,6693.60,N/A,12245.61,N/A,4588.61,N/A,12362.75,N/A,5601.27,N/A,6693.60,N/A,6693.60,N/A,7695.52,N/A,12362.75,N/A,12362.75,N/A,12362.75,N/A,12245.61,N/A,6693.60,N/A,5601.27,N/A,13495.90,N/A,13495.90,N/A,3032.19,N/A,6693.60,N/A,6693.60,N/A,5993.36,N/A,3032.19,13495.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 786,Cesarean Section Without Sterilization With McC,N/A,N/A,36329.40,N/A,21797.64,N/A,8615.41,N/A,10457.23,N/A,19415.53,N/A,12352.00,N/A,7322.00,N/A,8880.87,N/A,10457.23,N/A,10457.23,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,19415.53,N/A,10457.23,N/A,8880.87,N/A,23320.60,N/A,23320.60,N/A,6569.04,N/A,10457.23,N/A,10457.23,N/A,9502.53,N/A,4558.00,23320.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 788,Cesarean Section Without Sterilization Without Cc/McC,N/A,N/A,25062.68,N/A,15037.61,N/A,4653.92,N/A,5771.00,N/A,11280.41,N/A,8521.32,N/A,7322.00,N/A,4797.32,N/A,5771.00,N/A,5771.00,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,11280.41,N/A,5771.00,N/A,4797.32,N/A,12597.46,N/A,12597.46,N/A,5110.03,N/A,5771.00,N/A,5771.00,N/A,5133.13,N/A,4558.00,15037.61,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 799,Splenectomy With McC,N/A,N/A,166210.73,N/A,99726.44,N/A,27781.10,N/A,33129.25,N/A,91615.36,N/A,56511.65,N/A,63205.85,N/A,28637.09,N/A,33129.25,N/A,33129.25,N/A,39344.17,N/A,63205.85,N/A,63205.85,N/A,63205.85,N/A,91615.36,N/A,33129.25,N/A,28637.09,N/A,75199.19,N/A,75199.19,N/A,28637.09,N/A,33129.25,N/A,33129.25,N/A,30641.68,N/A,27781.10,99726.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 804,Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,N/A,N/A,52718.72,N/A,31631.23,N/A,6731.22,N/A,8228.33,N/A,15169.36,N/A,17924.36,N/A,15314.47,N/A,N/A,N/A,8228.33,N/A,8228.33,N/A,9532.90,N/A,15314.47,N/A,15314.47,N/A,15314.47,N/A,15169.36,N/A,8228.33,N/A,6938.62,N/A,18220.39,N/A,18220.39,N/A,N/A,N/A,8228.33,N/A,8228.33,N/A,7424.33,N/A,6731.22,31631.23,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 807,Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,N/A,N/A,13529.40,N/A,8117.64,N/A,3368.28,N/A,4250.13,N/A,7590.69,N/A,4600.00,N/A,4696.00,N/A,3472.06,N/A,4250.13,N/A,4250.13,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,7590.69,N/A,4250.13,N/A,3472.06,N/A,9117.42,N/A,9117.42,N/A,3698.38,N/A,4250.13,N/A,4250.13,N/A,3715.11,N/A,2923.00,9117.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 812,Red Blood Cell Disorders Without McC,N/A,N/A,34279.60,N/A,20567.76,N/A,4790.49,N/A,5932.54,N/A,10795.76,N/A,11655.06,N/A,10899.03,N/A,4938.09,N/A,5932.54,N/A,5932.54,N/A,6784.39,N/A,10899.03,N/A,10899.03,N/A,10899.03,N/A,10795.76,N/A,5932.54,N/A,4938.09,N/A,12967.12,N/A,12967.12,N/A,5283.76,N/A,5932.54,N/A,5932.54,N/A,5283.76,N/A,4790.49,20567.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 817,Other Antepartum Diagnoses With O.R. Procedures With McC,N/A,N/A,46494.85,N/A,27896.91,N/A,16696.30,N/A,20016.50,N/A,37626.46,N/A,46736.89,N/A,37986.38,N/A,17210.74,N/A,1124.00,N/A,1124.00,N/A,23645.64,N/A,37986.38,N/A,37986.38,N/A,37986.38,N/A,37626.46,N/A,20016.50,N/A,17210.74,N/A,45194.31,N/A,45194.31,N/A,6168.01,N/A,20016.50,N/A,20016.50,N/A,18415.49,N/A,1124.00,46736.89,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 819,Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,N/A,N/A,33285.12,N/A,19971.07,N/A,4739.81,N/A,5872.58,N/A,10681.55,N/A,11377.81,N/A,10783.72,N/A,4885.85,N/A,1124.00,N/A,1124.00,N/A,6712.62,N/A,10783.72,N/A,10783.72,N/A,10783.72,N/A,10681.55,N/A,5872.58,N/A,4885.85,N/A,12829.94,N/A,12829.94,N/A,4885.85,N/A,5872.58,N/A,5872.58,N/A,5227.86,N/A,1124.00,19971.07,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 821,Lymphoma And Leukemia With Major O.R. Procedures With Cc,N/A,N/A,88361.48,N/A,53016.89,N/A,11535.58,N/A,14483.18,N/A,25996.37,N/A,30042.91,N/A,26245.05,N/A,11891.01,N/A,13911.64,N/A,13911.64,N/A,31906.20,N/A,26245.05,N/A,26245.05,N/A,26245.05,N/A,25996.37,N/A,13911.64,N/A,11891.01,N/A,31225.06,N/A,31225.06,N/A,8535.98,N/A,13911.64,N/A,13911.64,N/A,12723.39,N/A,8535.98,53016.89,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 822,Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,N/A,N/A,73954.37,N/A,44372.62,N/A,6428.22,N/A,7869.88,N/A,14486.51,N/A,25144.48,N/A,14625.09,N/A,6626.28,N/A,7869.88,N/A,7869.88,N/A,9103.78,N/A,14625.09,N/A,14625.09,N/A,14625.09,N/A,14486.51,N/A,7869.88,N/A,6626.28,N/A,17400.20,N/A,17400.20,N/A,N/A,N/A,7869.88,N/A,7869.88,N/A,7090.12,N/A,6428.22,44372.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 829,Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,N/A,N/A,99994.40,N/A,59996.64,N/A,16882.47,N/A,20236.74,N/A,39027.17,N/A,33998.09,N/A,38409.96,N/A,17402.65,N/A,1686.00,N/A,1686.00,N/A,23909.31,N/A,38409.96,N/A,38409.96,N/A,38409.96,N/A,39027.17,N/A,20236.74,N/A,14957.07,N/A,45698.27,N/A,45698.27,N/A,14957.07,N/A,20236.74,N/A,20236.74,N/A,18620.84,N/A,1686.00,59996.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 830,Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,N/A,N/A,33262.13,N/A,19957.28,N/A,7844.56,N/A,9545.35,N/A,17678.35,N/A,11309.12,N/A,17847.46,N/A,8086.26,N/A,9545.35,N/A,9545.35,N/A,11109.63,N/A,17847.46,N/A,17847.46,N/A,17847.46,N/A,17678.35,N/A,9545.35,N/A,8086.26,N/A,21234.02,N/A,21234.02,N/A,8548.28,N/A,9545.35,N/A,9545.35,N/A,8652.30,N/A,7844.56,21234.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 831,Other Antepartum Diagnoses Without O.R. Procedures With McC,N/A,N/A,35149.30,N/A,21089.58,N/A,6373.80,N/A,7805.53,N/A,14363.89,N/A,11950.76,N/A,12238.99,N/A,6570.19,N/A,7805.53,N/A,7805.53,N/A,7620.37,N/A,12238.99,N/A,12238.99,N/A,12238.99,N/A,14363.89,N/A,7805.53,N/A,6570.19,N/A,17252.91,N/A,17252.91,N/A,7030.11,N/A,7805.53,N/A,7805.53,N/A,7030.11,N/A,6373.80,21089.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 835,Acute Leukemia Without Major O.R. Procedures With Cc,N/A,N/A,61780.20,N/A,37068.12,N/A,11187.23,N/A,13499.56,N/A,25211.34,N/A,21005.27,N/A,25452.50,N/A,11531.93,N/A,13499.56,N/A,13499.56,N/A,15843.59,N/A,25452.50,N/A,25452.50,N/A,25452.50,N/A,25211.34,N/A,13906.46,N/A,11531.93,N/A,30282.12,N/A,30282.12,N/A,18938.09,N/A,13499.56,N/A,13499.56,N/A,12339.17,N/A,11187.23,37068.12,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 837,Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC,N/A,N/A,252889.98,N/A,151733.99,N/A,21466.43,N/A,34857.00,N/A,N/A,N/A,61134.13,N/A,61134.13,N/A,21466.43,N/A,34857.00,N/A,34857.00,N/A,61134.13,N/A,61134.13,N/A,61134.13,N/A,61134.13,N/A,N/A,N/A,34857.00,N/A,21466.43,N/A,N/A,N/A,N/A,N/A,21466.43,N/A,34857.00,N/A,34857.00,N/A,21466.43,N/A,21466.43,151733.99,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 843,Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,N/A,N/A,48185.00,N/A,28911.00,N/A,10335.29,N/A,12491.76,N/A,23291.42,N/A,16382.90,N/A,23514.22,N/A,10653.74,N/A,12491.76,N/A,12491.76,N/A,14637.06,N/A,23514.22,N/A,23514.22,N/A,23514.22,N/A,23291.42,N/A,12491.76,N/A,10653.74,N/A,27976.06,N/A,27976.06,N/A,8750.69,N/A,12491.76,N/A,7294.79,N/A,11399.50,N/A,7294.79,28911.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 848,Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/McC,N/A,N/A,14009.83,N/A,8405.90,N/A,4956.40,N/A,6128.80,N/A,11169.64,N/A,4763.35,N/A,11276.49,N/A,5109.11,N/A,1124.00,N/A,1124.00,N/A,7019.35,N/A,11276.49,N/A,11276.49,N/A,11276.49,N/A,11169.64,N/A,6128.80,N/A,5109.11,N/A,13416.20,N/A,13416.20,N/A,5109.11,N/A,6128.80,N/A,6128.80,N/A,5466.75,N/A,1124.00,13416.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 854,Infectious And Parasitic Diseases With O.R. Procedures With Cc,N/A,N/A,52018.80,N/A,31211.28,N/A,11303.72,N/A,13237.68,N/A,24712.42,N/A,17686.39,N/A,11517.43,N/A,11303.72,N/A,13237.68,N/A,13237.68,N/A,11517.43,N/A,11517.43,N/A,11517.43,N/A,11517.43,N/A,24712.42,N/A,13237.68,N/A,11303.72,N/A,29682.86,N/A,29682.86,N/A,11303.72,N/A,13237.68,N/A,13237.68,N/A,12094.98,N/A,11303.72,31211.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 856,Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,N/A,N/A,78629.93,N/A,47177.96,N/A,N/A,N/A,N/A,N/A,40930.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,53261.22,N/A,N/A,N/A,N/A,N/A,40930.85,N/A,40930.85,N/A,N/A,N/A,35356.99,N/A,N/A,N/A,N/A,N/A,35356.99,53261.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 857,Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,N/A,N/A,60282.58,N/A,36169.55,N/A,8333.86,N/A,10123.62,N/A,26885.20,N/A,20496.08,N/A,25596.93,N/A,8590.64,N/A,1686.00,N/A,1686.00,N/A,15933.50,N/A,25596.93,N/A,25596.93,N/A,25596.93,N/A,26885.20,N/A,10123.62,N/A,8590.64,N/A,30453.96,N/A,30453.96,N/A,9876.51,N/A,10123.62,N/A,10123.62,N/A,9191.99,N/A,1686.00,36169.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 865,Viral Illness With McC,N/A,N/A,31261.00,N/A,18756.60,N/A,8923.75,N/A,10910.93,N/A,20110.40,N/A,10628.74,N/A,20302.77,N/A,9198.71,N/A,10821.98,N/A,10821.98,N/A,12638.00,N/A,20302.77,N/A,20302.77,N/A,20302.77,N/A,20110.40,N/A,10821.98,N/A,9198.71,N/A,24155.23,N/A,24155.23,N/A,N/A,N/A,10821.98,N/A,10821.98,N/A,9842.62,N/A,8923.75,24155.23,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 867,Other Infectious And Parasitic Diseases Diagnoses With McC,N/A,N/A,40197.00,N/A,24118.20,N/A,10249.26,N/A,12390.11,N/A,25407.29,N/A,13666.98,N/A,25650.34,N/A,10565.06,N/A,12390.11,N/A,12390.11,N/A,15966.74,N/A,25650.34,N/A,25650.34,N/A,25650.34,N/A,25407.29,N/A,12390.11,N/A,10565.06,N/A,30517.50,N/A,30517.50,N/A,22744.98,N/A,12390.11,N/A,12390.11,N/A,11304.61,N/A,10249.26,30517.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 870,Septicemia Or Severe Sepsis With Mv >96 Hours,N/A,N/A,164972.23,N/A,98983.34,N/A,3221.03,N/A,43120.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3221.03,N/A,43120.18,N/A,43120.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,43120.18,N/A,3221.03,N/A,N/A,N/A,N/A,N/A,3221.03,N/A,43120.18,N/A,43120.18,N/A,3221.03,N/A,3221.03,98983.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 871,Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,N/A,N/A,53057.00,N/A,31834.20,N/A,10762.62,N/A,12705.66,N/A,28261.97,N/A,23754.54,N/A,23754.54,N/A,10762.62,N/A,12616.71,N/A,12616.71,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,28261.97,N/A,12616.71,N/A,10762.62,N/A,28261.97,N/A,28261.97,N/A,10762.62,N/A,12616.71,N/A,12705.66,N/A,11516.01,N/A,10762.62,31834.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 876,O.R. Procedures With Principal Diagnosis Of Mental Illness,N/A,N/A,47406.40,N/A,28443.84,N/A,17051.05,N/A,20436.16,N/A,38425.92,N/A,16118.17,N/A,38793.49,N/A,17576.42,N/A,20436.16,N/A,20436.16,N/A,24148.05,N/A,38793.49,N/A,38793.49,N/A,38793.49,N/A,38425.92,N/A,6704.28,N/A,17576.42,N/A,46154.57,N/A,46154.57,N/A,5147.33,N/A,21611.34,N/A,20436.16,N/A,10061.58,N/A,5147.33,46154.57,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 880,Acute Adjustment Reaction And Psychosocial Dysfunction,N/A,N/A,18328.70,N/A,10997.22,N/A,4834.23,N/A,6013.95,N/A,18328.70,N/A,6231.76,N/A,1588.00,N/A,4983.18,N/A,5984.30,N/A,5984.30,N/A,989.00,N/A,1588.00,N/A,1588.00,N/A,1588.00,N/A,10894.34,N/A,1130.51,N/A,4983.18,N/A,13085.53,N/A,13085.53,N/A,2427.61,N/A,5984.30,N/A,6013.95,N/A,2427.61,N/A,989.00,18328.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 883,Disorders Of Personality And Impulse Control,N/A,N/A,12157.70,N/A,7294.62,N/A,2658.96,N/A,10454.07,N/A,6255.00,N/A,4133.62,N/A,4764.00,N/A,2658.96,N/A,10454.07,N/A,10454.07,N/A,2967.00,N/A,4764.00,N/A,4764.00,N/A,4764.00,N/A,4404.27,N/A,3266.21,N/A,2712.15,N/A,12157.70,N/A,12157.70,N/A,3786.29,N/A,4647.00,N/A,10454.07,N/A,2352.30,N/A,2352.30,12157.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 887,Other Mental Disorder Diagnoses,N/A,N/A,54341.50,N/A,32604.90,N/A,8643.55,N/A,8852.26,N/A,20850.00,N/A,18476.11,N/A,N/A,N/A,7129.44,N/A,5620.00,N/A,5620.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15586.52,N/A,2202.53,N/A,7129.44,N/A,N/A,N/A,18721.46,N/A,8643.55,N/A,2202.53,N/A,8852.26,N/A,16769.30,N/A,2202.53,32604.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 909,Other O.R. Procedures For Injuries Without Cc/McC,N/A,N/A,51596.38,N/A,30957.83,N/A,7280.16,N/A,8877.68,N/A,16406.42,N/A,17542.77,N/A,16563.36,N/A,7504.47,N/A,1686.00,N/A,1686.00,N/A,10310.31,N/A,16563.36,N/A,16563.36,N/A,16563.36,N/A,16406.42,N/A,8877.68,N/A,7504.47,N/A,19706.27,N/A,19706.27,N/A,7832.37,N/A,8877.68,N/A,8877.68,N/A,8029.78,N/A,1686.00,30957.83,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 913,Traumatic Injury With McC,N/A,N/A,62001.70,N/A,37201.02,N/A,8077.15,N/A,8072.02,N/A,18202.51,N/A,21080.58,N/A,18376.63,N/A,8326.02,N/A,134880.00,N/A,134880.00,N/A,11439.03,N/A,18376.63,N/A,18376.63,N/A,18376.63,N/A,18202.51,N/A,8012.72,N/A,8326.02,N/A,21863.60,N/A,N/A,N/A,24748.07,N/A,8012.72,N/A,8072.02,N/A,8908.84,N/A,8012.72,134880.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 923,"Other Injury, Poisoning And Toxic Effect Diagnoses Without McC",N/A,N/A,22715.65,N/A,13629.39,N/A,5031.61,N/A,6277.08,N/A,11339.15,N/A,6360.41,N/A,5396.70,N/A,5186.65,N/A,6217.78,N/A,6217.78,N/A,3359.56,N/A,5396.70,N/A,5396.70,N/A,5396.70,N/A,11339.15,N/A,6217.78,N/A,5186.65,N/A,13619.81,N/A,13619.81,N/A,5186.65,N/A,6217.78,N/A,6277.08,N/A,5549.71,N/A,3359.56,13629.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 929,Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/McC,N/A,N/A,92589.70,N/A,55553.82,N/A,15677.38,N/A,18811.17,N/A,35330.25,N/A,31480.50,N/A,46767.06,N/A,16160.43,N/A,3934.00,N/A,3934.00,N/A,29110.20,N/A,38377.79,N/A,46767.06,N/A,38377.79,N/A,35330.25,N/A,18811.17,N/A,16160.43,N/A,42436.27,N/A,N/A,N/A,18125.66,N/A,18811.17,N/A,20752.09,N/A,17291.66,N/A,3934.00,55553.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 933,Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,N/A,N/A,53058.20,N/A,31834.92,N/A,16179.90,N/A,19405.63,N/A,36462.73,N/A,18039.79,N/A,26799.70,N/A,16678.44,N/A,19405.63,N/A,19405.63,N/A,16681.50,N/A,26799.70,N/A,26799.70,N/A,26799.70,N/A,36462.73,N/A,19405.63,N/A,16678.44,N/A,43796.52,N/A,43796.52,N/A,5828.85,N/A,19405.63,N/A,19405.63,N/A,17845.93,N/A,5828.85,43796.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 939,O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,N/A,N/A,121633.80,N/A,72980.28,N/A,25027.98,N/A,20341.74,N/A,44983.76,N/A,41355.49,N/A,61437.24,N/A,25027.98,N/A,20341.74,N/A,20341.74,N/A,14413.04,N/A,61437.24,N/A,61437.24,N/A,61437.24,N/A,44983.76,N/A,20341.74,N/A,25027.98,N/A,44983.76,N/A,44983.76,N/A,25027.98,N/A,20341.74,N/A,20341.74,N/A,25027.98,N/A,14413.04,72980.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 940,O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,N/A,N/A,67770.42,N/A,40662.25,N/A,14871.72,N/A,14169.75,N/A,26488.07,N/A,23041.94,N/A,26741.45,N/A,12115.92,N/A,3372.00,N/A,3372.00,N/A,16645.93,N/A,26741.45,N/A,26741.45,N/A,26741.45,N/A,26488.07,N/A,14169.75,N/A,12115.92,N/A,31815.65,N/A,31815.65,N/A,14871.72,N/A,14951.54,N/A,14169.75,N/A,12964.04,N/A,3372.00,40662.25,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 941,O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,N/A,N/A,77695.90,N/A,46617.54,N/A,11733.28,N/A,13401.00,N/A,23282.46,N/A,16639.54,N/A,16639.54,N/A,11733.28,N/A,13401.00,N/A,13401.00,N/A,16639.54,N/A,16639.54,N/A,16639.54,N/A,16639.54,N/A,28385.66,N/A,13401.00,N/A,11733.28,N/A,28385.66,N/A,28385.66,N/A,11733.28,N/A,13401.00,N/A,13401.00,N/A,11733.28,N/A,11733.28,46617.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 948,Signs And Symptoms Without McC,N/A,N/A,27424.50,N/A,16454.70,N/A,4148.20,N/A,5202.40,N/A,9348.31,N/A,9324.33,N/A,9437.73,N/A,4276.01,N/A,5172.75,N/A,5172.75,N/A,5874.77,N/A,9437.73,N/A,9437.73,N/A,9437.73,N/A,9348.31,N/A,5172.75,N/A,4276.01,N/A,11228.54,N/A,11228.54,N/A,4041.95,N/A,5172.75,N/A,2366.06,N/A,4575.34,N/A,2366.06,16454.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 956,"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",N/A,N/A,122100.90,N/A,73260.54,N/A,21403.98,N/A,25605.67,N/A,89128.60,N/A,93050.73,N/A,93050.73,N/A,21403.98,N/A,24385.15,N/A,24385.15,N/A,93050.73,N/A,93050.73,N/A,93050.73,N/A,93050.73,N/A,89128.60,N/A,25504.60,N/A,21403.98,N/A,89128.60,N/A,89128.60,N/A,21403.98,N/A,25504.60,N/A,25504.60,N/A,21403.98,N/A,21403.98,93050.73,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 958,Other O.R. Procedures For Multiple Significant Trauma With Cc,N/A,N/A,186966.58,N/A,112179.95,N/A,24176.23,N/A,27249.35,N/A,114836.43,N/A,N/A,N/A,N/A,N/A,24176.23,N/A,27249.35,N/A,27249.35,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,114836.43,N/A,27249.35,N/A,24176.23,N/A,114836.43,N/A,114836.43,N/A,24176.23,N/A,26583.93,N/A,27249.35,N/A,24176.23,N/A,24176.23,114836.43,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 964,Other Multiple Significant Trauma With Cc,N/A,N/A,46790.50,N/A,28074.30,N/A,7812.55,N/A,9507.48,N/A,17606.22,N/A,15908.77,N/A,17774.64,N/A,8053.27,N/A,9860.74,N/A,9507.48,N/A,11064.30,N/A,17774.64,N/A,17774.64,N/A,17774.64,N/A,17606.22,N/A,9507.48,N/A,8053.27,N/A,21147.38,N/A,21147.38,N/A,5440.83,N/A,9507.48,N/A,9507.48,N/A,8617.00,N/A,5440.83,28074.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 970,Hiv With Extensive O.R. Procedures Without McC,N/A,N/A,41037.12,N/A,24622.27,N/A,16475.44,N/A,19755.24,N/A,N/A,N/A,13952.62,N/A,37483.91,N/A,16983.08,N/A,1686.00,N/A,N/A,N/A,23332.86,N/A,37483.91,N/A,37483.91,N/A,37483.91,N/A,N/A,N/A,19755.24,N/A,7265.74,N/A,41037.11,N/A,N/A,N/A,7265.74,N/A,19755.24,N/A,19755.24,N/A,18171.89,N/A,1686.00,41037.11,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 975,Hiv With Major Related Condition With Cc,N/A,N/A,45849.90,N/A,27509.94,N/A,7568.37,N/A,8947.11,N/A,N/A,N/A,15588.97,N/A,16696.87,N/A,7564.96,N/A,2810.00,N/A,9496.03,N/A,10393.41,N/A,16696.87,N/A,16696.87,N/A,16696.87,N/A,N/A,N/A,8947.11,N/A,7564.96,N/A,19865.11,N/A,N/A,N/A,7568.37,N/A,8947.11,N/A,8947.11,N/A,8094.51,N/A,2810.00,27509.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 982,Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,N/A,N/A,88687.03,N/A,53212.22,N/A,13380.30,N/A,14029.84,N/A,N/A,N/A,30153.59,N/A,30442.02,N/A,13792.57,N/A,7226.21,N/A,7226.21,N/A,18949.45,N/A,30442.02,N/A,30442.02,N/A,30442.02,N/A,31713.18,N/A,7147.75,N/A,8995.15,N/A,36218.41,N/A,N/A,N/A,8995.15,N/A,7147.75,N/A,7177.40,N/A,14758.05,N/A,7147.75,53212.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 983,Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,N/A,N/A,71111.10,N/A,42666.66,N/A,8909.88,N/A,10805.57,N/A,21050.96,N/A,24177.77,N/A,20271.22,N/A,9184.41,N/A,562.00,N/A,562.00,N/A,12618.36,N/A,20271.22,N/A,20271.22,N/A,20271.22,N/A,21050.96,N/A,10805.57,N/A,9184.41,N/A,24117.69,N/A,24117.69,N/A,7104.36,N/A,10805.57,N/A,10805.57,N/A,9827.32,N/A,562.00,42666.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 987,Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,N/A,N/A,88146.37,N/A,52887.82,N/A,11838.07,N/A,22413.64,N/A,52893.74,N/A,29969.76,N/A,40275.42,N/A,11838.07,N/A,21765.87,N/A,21772.11,N/A,40275.42,N/A,40275.42,N/A,40275.42,N/A,40275.42,N/A,39932.68,N/A,21206.68,N/A,11838.07,N/A,52893.74,N/A,52893.74,N/A,18247.85,N/A,21772.11,N/A,22372.28,N/A,11838.07,N/A,11838.07,52893.74,N/A,N/A,,Hospital V5060,HC Behind Ear Hearing Aid,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1040.00,N/A,624.00,N/A,N/A,N/A,208.00,N/A,598.83,N/A,353.60,N/A,145.60,N/A,145.60,N/A,208.00,N/A,208.00,N/A,90.48,N/A,145.60,N/A,145.60,N/A,145.60,N/A,598.83,N/A,208.00,N/A,N/A,N/A,557.44,N/A,557.44,N/A,N/A,N/A,208.00,N/A,208.00,N/A,N/A,N/A,N/A,90.48,624.00,,Hospital V5090,"HC Dispensing Fee, Unspec Hearing Aid",N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,500.00,N/A,300.00,N/A,70.00,N/A,N/A,N/A,287.90,N/A,170.00,N/A,70.00,N/A,70.00,N/A,N/A,N/A,N/A,N/A,43.50,N/A,70.00,N/A,70.00,N/A,70.00,N/A,287.90,N/A,N/A,N/A,70.00,N/A,268.00,N/A,268.00,N/A,70.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,43.50,300.00,,Hospital V5160,HC Hearing Aid Disp Binaural,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,4300.00,N/A,2580.00,N/A,1018.50,N/A,1455.00,N/A,900.00,N/A,1462.00,N/A,602.00,N/A,602.00,N/A,1455.00,N/A,1455.00,N/A,374.10,N/A,602.00,N/A,602.00,N/A,602.00,N/A,900.00,N/A,1455.00,N/A,1018.50,N/A,900.00,N/A,900.00,N/A,1018.50,N/A,1455.00,N/A,1455.00,N/A,1018.50,N/A,N/A,374.10,2580.00,,Hospital V5240,HC Hearing Aid Disp Fee Contralat Binau,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,1794.00,N/A,1076.40,N/A,1229.10,N/A,N/A,N/A,1032.99,N/A,609.96,N/A,251.16,N/A,251.16,N/A,N/A,N/A,N/A,N/A,156.08,N/A,251.16,N/A,251.16,N/A,251.16,N/A,1032.99,N/A,N/A,N/A,1229.10,N/A,961.58,N/A,961.58,N/A,1229.10,N/A,N/A,N/A,N/A,N/A,1229.10,N/A,N/A,156.08,1229.10,,Hospital V5247,"HC Hearing Aid, Prog, Mon, Bte",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1967.00,N/A,1180.20,N/A,223.47,N/A,N/A,N/A,1132.60,N/A,668.78,N/A,275.38,N/A,275.38,N/A,N/A,N/A,N/A,N/A,171.13,N/A,275.38,N/A,275.38,N/A,275.38,N/A,1132.60,N/A,N/A,N/A,223.47,N/A,1054.31,N/A,1054.31,N/A,223.47,N/A,N/A,N/A,N/A,N/A,223.47,N/A,N/A,171.13,1180.20,,Hospital V5256,"HC Hearing Aid, Digit, Mon, Ite",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3166.00,N/A,1899.60,N/A,N/A,N/A,921.50,N/A,1822.98,N/A,1076.44,N/A,443.24,N/A,443.24,N/A,921.50,N/A,921.50,N/A,275.44,N/A,443.24,N/A,443.24,N/A,443.24,N/A,1822.98,N/A,921.50,N/A,N/A,N/A,1696.98,N/A,1696.98,N/A,N/A,N/A,921.50,N/A,921.50,N/A,N/A,N/A,N/A,275.44,1899.60,,Hospital CPT 0001U,HC RBC Dna Hea 35 Ag 11 Bld Grp Whl Bld Cmn Allel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,395.00,395.00,237.00,237.00,N/A,395.00,N/A,720.00,N/A,227.44,N/A,134.30,N/A,395.00,N/A,395.00,N/A,720.00,N/A,720.00,N/A,395.00,N/A,395.00,N/A,395.00,N/A,395.00,N/A,227.44,N/A,720.00,N/A,395.00,N/A,395.00,N/A,395.00,N/A,395.00,N/A,720.00,N/A,720.00,N/A,792.00,237.00,237.00,134.30,792.00,,Hospital CPT 0001U,HC So RBC Dna Hea 35 Ag 11 Bld Grp Whl Bld Cmn Allel,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,358.00,358.00,214.80,214.80,N/A,358.00,N/A,720.00,N/A,206.14,N/A,121.72,N/A,358.00,N/A,358.00,N/A,720.00,N/A,720.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,206.14,N/A,720.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,720.00,N/A,720.00,N/A,792.00,214.80,214.80,121.72,792.00,,Hospital CPT 0002A,HC Imm Admin Sarscov2 30mcg/0.3ml Dil Recon 2nd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,122.00,N/A,70.25,N/A,41.48,N/A,17.08,N/A,17.08,N/A,122.00,N/A,122.00,N/A,10.61,N/A,17.08,N/A,17.08,N/A,17.08,N/A,70.25,N/A,122.00,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,122.00,N/A,122.00,N/A,122.00,73.20,73.20,10.61,122.00,,Hospital 00103,PR Anesthesia Eyelid Reconstructive Procedure,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,9736.90,N/A,5842.14,N/A,1363.16,N/A,2445.42,N/A,5606.07,N/A,3310.54,N/A,5662.32,N/A,1363.16,N/A,2337.78,N/A,2337.78,N/A,3524.90,N/A,5662.32,N/A,5662.32,N/A,5662.32,N/A,5606.07,N/A,2337.78,N/A,1363.16,N/A,2806.50,N/A,2806.50,N/A,1363.16,N/A,2337.78,N/A,2445.42,N/A,566.25,N/A,N/A,566.25,5842.14,,Hospital 00120,PR Anesthesia for Ear Surgery,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,34371.40,N/A,20622.84,N/A,4812.00,N/A,3171.05,N/A,19790.01,N/A,10622.76,N/A,7342.97,N/A,4812.00,N/A,3031.47,N/A,3031.47,N/A,4571.14,N/A,7342.97,N/A,7342.97,N/A,7342.97,N/A,19790.03,N/A,3031.47,N/A,4812.00,N/A,4825.50,N/A,4825.50,N/A,4812.00,N/A,3031.47,N/A,3171.05,N/A,1193.77,N/A,N/A,1193.77,20622.84,,Hospital CPT 0012A,HC Imm Admin Sarscov2 100mcg/0.5 Ml 2nd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,122.00,N/A,70.25,N/A,41.48,N/A,17.08,N/A,17.08,N/A,122.00,N/A,122.00,N/A,10.61,N/A,17.08,N/A,17.08,N/A,17.08,N/A,70.25,N/A,122.00,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,122.00,N/A,122.00,N/A,122.00,73.20,73.20,10.61,122.00,,Hospital 00145,"Anesth,Vitrectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18736.63,N/A,11241.98,N/A,2623.12,N/A,3577.00,N/A,10786.91,N/A,6370.46,N/A,8747.26,N/A,2623.12,N/A,3608.17,N/A,3608.17,N/A,5445.35,N/A,8747.26,N/A,8747.26,N/A,8747.26,N/A,10786.91,N/A,3608.17,N/A,2623.12,N/A,5963.00,N/A,5963.00,N/A,2623.12,N/A,3608.17,N/A,3577.00,N/A,1220.60,N/A,N/A,1220.60,11241.98,,Hospital 00147,"Anesth,Iridectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,46865.17,N/A,28119.10,N/A,6553.43,N/A,2074.44,N/A,26978.36,N/A,15934.15,N/A,4747.36,N/A,6553.43,N/A,1950.06,N/A,1950.06,N/A,2955.31,N/A,4747.36,N/A,4747.36,N/A,4747.36,N/A,26978.37,N/A,1950.06,N/A,6553.43,N/A,5277.50,N/A,5277.50,N/A,6553.43,N/A,1950.06,N/A,2074.44,N/A,1374.96,N/A,N/A,1374.96,28119.10,,Hospital 00160,"Anesth,Nose,Sinus Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,50201.42,15729.27,30120.85,9437.56,9651.93,2202.09,10904.66,4821.94,21364.36,9053.42,17068.48,5347.94,21379.33,11675.63,9949.32,2202.09,216370.00,4821.94,216370.00,4821.94,13308.13,7268.30,N/A,11675.63,21379.33,11675.63,21379.33,11675.63,21364.36,9053.42,10845.36,4821.94,9949.32,2202.09,25436.06,6898.50,3660.50,6898.50,238.28,2202.09,10845.36,4821.94,10904.66,4821.94,10645.77,5304.13,238.28,216370.00,2202.09,11675.63,,Hospital 00172,"Anesth,Cleft Palate Repair",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,24018.50,N/A,14411.10,N/A,3343.33,N/A,4874.16,N/A,13753.59,N/A,8166.29,N/A,11675.79,N/A,3343.33,N/A,4821.94,N/A,4821.94,N/A,7268.40,N/A,11675.79,N/A,11675.79,N/A,11675.79,N/A,13753.59,N/A,4821.94,N/A,3343.33,N/A,5963.00,N/A,5963.00,N/A,3343.33,N/A,4821.94,N/A,4874.16,N/A,991.87,N/A,N/A,991.87,14411.10,,Hospital 00210,"Anesth,Open Head Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,56143.73,28815.42,33686.24,17289.25,6443.15,4034.16,7917.20,351.18,14606.19,15663.84,19088.87,9797.25,14659.07,841.99,6641.68,4034.16,129822.00,342.05,129822.00,342.05,9124.93,524.16,14659.07,841.99,14659.07,841.99,14659.07,841.99,29664.72,15663.84,7887.55,342.05,6641.68,4034.16,17440.63,527.00,17440.63,527.00,N/A,4034.16,7887.55,342.05,7917.20,351.18,7106.60,748.10,6443.15,129822.00,342.05,17289.25,,Hospital 00212,"Anesth,Skull Surg Subdur Tap",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,41419.68,N/A,24851.81,N/A,12489.41,N/A,15039.99,N/A,28851.52,N/A,14082.69,N/A,29262.66,N/A,12874.23,N/A,1245.43,N/A,1245.43,N/A,18216.88,N/A,29262.66,N/A,29262.66,N/A,29262.66,N/A,28851.52,N/A,15039.99,N/A,12874.23,N/A,33806.93,N/A,33806.93,N/A,N/A,N/A,15039.99,N/A,15039.99,N/A,13775.43,N/A,1245.43,33806.93,N/A,N/A,,Hospital 00214,"Anesth,Skull Surg Burr Hole",N/A,N/A,N/A,28815.42,N/A,17289.25,N/A,4034.16,N/A,351.18,N/A,15663.84,N/A,9797.25,N/A,841.99,N/A,4034.16,N/A,342.05,N/A,342.05,N/A,524.16,N/A,841.99,N/A,841.99,N/A,841.99,N/A,15663.84,N/A,342.05,N/A,4034.16,N/A,527.00,N/A,527.00,N/A,4034.16,N/A,342.05,N/A,351.18,N/A,748.10,N/A,N/A,342.05,17289.25,,Hospital CPT 0021A,HC Imm Admin Sarscov2 5x10/.5ml 1st Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,122.00,N/A,70.25,N/A,41.48,N/A,17.08,N/A,17.08,N/A,122.00,N/A,122.00,N/A,10.61,N/A,17.08,N/A,17.08,N/A,17.08,N/A,70.25,N/A,122.00,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,122.00,N/A,122.00,N/A,122.00,73.20,73.20,10.61,122.00,,Hospital 00220,"Anesth,Intracran Proc; CSF Shunt Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,55212.20,68760.13,33127.32,41256.08,10959.98,9568.63,13260.38,5986.31,24699.20,39552.87,18772.15,23378.46,25679.20,14733.95,11297.67,9568.63,146120.00,5729.40,146120.00,5729.40,15986.06,9375.43,25679.20,14733.95,25679.20,14733.95,25679.20,14733.95,24699.20,39552.92,13230.73,5752.65,11297.67,9568.63,29666.98,5963.00,29666.98,5963.00,2985.08,9568.63,13230.73,5729.40,13260.38,5986.31,12088.51,1282.14,2985.08,146120.00,1282.14,41256.08,,Hospital 0023U,HC So Onc Aml Dna Detcj/Nondetcj,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,105580.90,27249.28,63348.54,16349.57,10440.92,4995.79,12616.71,2440.19,88955.58,15691.24,35897.50,9264.75,23754.54,5648.56,18938.09,4995.79,12616.71,2332.78,12616.71,2332.78,193550.81,3516.34,23754.54,5648.56,23754.54,5648.56,23754.54,5648.56,58196.19,15685.62,12616.71,2332.78,10762.62,4995.79,28261.97,1871.00,28261.97,1871.00,18938.09,4995.79,12616.71,2332.78,12616.71,2440.19,11516.01,4496.87,10440.92,193550.81,1871.00,16349.57,,Hospital 00300,"Anesth,Skin Surg Head/Neck",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,30117.50,19069.90,18070.50,11441.94,4704.07,2660.92,5830.32,1354.15,10601.00,10978.03,10239.95,6483.76,10702.41,3299.42,4849.01,2660.24,562.00,1354.15,562.00,1354.15,6662.00,2053.95,10702.41,3299.42,10702.41,3299.42,10702.41,3299.42,10601.00,10978.03,5830.32,1354.15,4849.01,2660.92,12733.19,2504.25,12733.19,2504.25,1897.28,2660.92,5830.32,1354.15,5830.32,1354.15,5188.44,1489.57,562.00,18070.50,1354.15,11441.94,,Hospital 00320,"Anesth,Neck Org Proc; Nos, Age 1 Yr/Old",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,60956.87,15647.55,36574.12,9388.53,10141.65,2190.64,12262.69,3010.42,22855.02,9006.55,20725.34,5320.15,23073.65,7323.42,10454.13,2190.64,12262.69,3010.42,12262.69,3010.42,14362.81,4558.96,23073.65,7323.42,23073.65,7323.42,23073.65,7323.42,22855.02,9006.55,12262.69,3010.42,10454.13,2190.64,27451.88,3397.00,27451.88,3397.00,N/A,2190.64,12262.69,3010.42,12262.69,3010.42,11185.92,3311.46,10141.65,36574.12,2190.64,9388.53,,Hospital 00322,"Anesth,Needle Bx Thyroid",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,4813.30,N/A,2887.98,N/A,673.86,N/A,902.55,N/A,2770.88,N/A,1636.52,N/A,2130.39,N/A,673.86,N/A,879.07,N/A,879.07,N/A,1326.21,N/A,2130.39,N/A,2130.39,N/A,2130.39,N/A,2770.88,N/A,879.07,N/A,673.86,N/A,2146.50,N/A,2146.50,N/A,673.86,N/A,879.07,N/A,902.55,N/A,223.50,N/A,N/A,223.50,2887.98,,Hospital CPT 0034A,PR Adm Janssen Sarscov2 5x10/0.5ml Booster,N/A,N/A,101.00,101.00,60.60,60.60,N/A,14.14,N/A,101.00,N/A,101.00,N/A,34.34,N/A,14.14,N/A,14.14,N/A,101.00,N/A,101.00,N/A,8.79,N/A,14.14,N/A,14.14,N/A,14.14,N/A,101.00,N/A,101.00,N/A,14.14,N/A,101.00,N/A,101.00,N/A,14.14,N/A,101.00,N/A,101.00,N/A,101.00,60.60,60.60,8.79,101.00,,Hospital 00352,"Anesth,Neck Vessel Surg Simpl Ligat",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,17719.70,N/A,10631.82,N/A,2470.89,N/A,1354.15,N/A,10199.47,N/A,6024.69,N/A,3329.28,N/A,2470.89,N/A,1354.15,N/A,1354.15,N/A,2072.54,N/A,3329.28,N/A,3329.28,N/A,3329.28,N/A,10199.47,N/A,1354.15,N/A,2470.89,N/A,1871.00,N/A,1871.00,N/A,2470.89,N/A,1354.15,N/A,1354.15,N/A,1489.57,N/A,N/A,1354.15,10631.82,,Hospital 00400,"Anesth,Skin Surg Thorax/Extr",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,38926.90,17796.45,23356.14,10677.87,6420.75,2491.50,7890.70,3104.47,14469.68,10238.28,13235.15,6050.79,14608.09,7595.16,6618.58,2491.50,66316.00,3104.47,66316.00,3104.47,9093.20,4728.14,14608.09,7595.16,14608.09,7595.16,14608.09,7595.16,14469.68,10238.28,7861.05,3104.47,6618.58,2491.50,17379.98,3397.00,17379.98,3397.00,1652.97,2491.50,7861.05,3104.47,7890.70,3104.47,7081.88,3414.92,1652.97,66316.00,2491.50,10677.87,,Hospital 00402,"Anesth,Surg Breast Reconstructive",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,65639.73,37750.12,39383.84,22650.07,11393.68,5260.91,11341.25,7955.87,22080.81,21495.45,22317.52,12835.02,22292.03,19317.52,11744.74,5260.91,255710.00,7955.87,255710.00,7955.87,13876.27,12025.55,22292.03,19317.52,22292.03,19317.52,22292.03,19317.52,22080.81,21495.46,11311.60,7955.87,11744.74,5260.91,26521.95,11010.25,26521.95,11010.25,N/A,5260.91,5366.90,7955.87,11341.25,7955.87,12566.87,8751.45,5366.90,255710.00,5260.91,22650.07,,Hospital 00404,"Anesth,Surg Breast Rad Mastec",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,58784.77,47203.53,35270.86,28322.12,4518.03,6598.47,5639.84,5578.34,20872.60,27143.71,19986.82,16049.21,21072.26,13315.30,4657.24,6598.47,5366.90,5466.73,5366.90,5466.73,13116.99,8289.04,21072.26,13315.30,21072.26,13315.30,21072.26,13315.30,20872.60,27143.70,5610.19,5466.73,4657.24,6598.47,25070.73,6678.50,25070.73,6678.50,N/A,6598.47,5610.19,5466.73,5639.84,5578.34,4983.25,1893.89,4518.03,35270.86,1893.89,28322.12,,Hospital 00410,"Anesth,Correct Heart Rhythm",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,18601.30,5435.70,11160.78,3261.42,3934.82,762.04,4949.97,526.53,8867.43,3128.97,6324.44,1848.14,9300.40,1294.04,4056.05,762.04,130384.00,531.11,130384.00,531.11,5789.42,805.56,9300.40,1294.04,9300.40,1294.04,9300.40,1294.04,8867.43,3128.97,4920.32,531.11,4056.05,762.04,10650.94,1128.34,10650.94,1128.34,166.68,762.04,4920.32,531.11,4949.97,526.53,4339.98,117.89,166.68,130384.00,117.89,3261.42,,Hospital 0042T,HC CT Cerebral Perfusion,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,51003.20,33245.52,30601.92,19947.31,10247.81,4526.01,12388.26,1562.95,23094.26,19126.61,17341.09,11303.47,24010.58,816.00,10563.56,4526.01,12388.26,1441.65,12388.26,1441.65,14947.30,816.00,24010.58,816.00,24010.58,816.00,24010.58,816.00,23094.26,18868.69,12388.26,1462.93,10563.56,4526.01,27488.87,2012.36,27739.24,2012.36,5418.06,4526.01,12388.26,1441.65,12388.26,1120.98,11303.01,1220.84,5418.06,30601.92,816.00,19947.31,,Hospital 00450,"Anesth,Surg Clavicle/Scapula",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,31551.70,28339.73,18931.02,17003.84,4594.18,3967.55,5700.32,5973.28,10353.35,16269.30,10727.58,9635.50,10452.38,14486.77,4735.73,3967.55,562.00,5973.28,562.00,5973.28,6506.37,9018.29,10452.38,14486.77,10452.38,14486.77,10452.38,14486.77,10353.35,16269.29,5700.32,5973.28,4735.73,3967.55,12435.73,8612.50,12435.73,8612.50,N/A,3967.55,5700.32,5973.28,5700.32,5973.28,5067.23,6570.60,562.00,18931.02,3967.55,17003.84,,Hospital 00522,"Anesth,Chest Pleural Biopsy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,35945.40,N/A,21567.24,N/A,5032.36,N/A,3149.03,N/A,20696.87,N/A,12221.44,N/A,7285.99,N/A,5032.36,N/A,3010.42,N/A,3010.42,N/A,4535.66,N/A,7285.99,N/A,7285.99,N/A,7285.99,N/A,20696.87,N/A,3010.42,N/A,5032.36,N/A,4332.50,N/A,4332.50,N/A,5032.36,N/A,3010.42,N/A,3149.03,N/A,1778.14,N/A,N/A,1778.14,21567.24,,Hospital 00524,"Anesth,Chest Drainage",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,24120.62,N/A,14472.37,N/A,6047.86,N/A,7419.94,N/A,13629.34,N/A,8201.01,N/A,13759.72,N/A,6234.20,N/A,7419.94,N/A,7419.94,N/A,8565.10,N/A,13759.72,N/A,13759.72,N/A,13759.72,N/A,13629.34,N/A,7419.94,N/A,6234.20,N/A,16370.63,N/A,16370.63,N/A,N/A,N/A,7419.94,N/A,7419.94,N/A,6670.60,N/A,6047.86,16370.63,N/A,N/A,,Hospital 00532,"Anesth,Centrl Vascular Access",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,46531.23,15745.98,27918.74,9447.59,20335.57,2207.23,24351.23,2690.13,46044.34,9047.28,15820.61,5353.64,N/A,6551.44,20962.15,2207.23,24321.58,2690.13,24321.58,2690.13,28799.66,4078.39,46266.24,6551.44,46266.24,6551.44,46266.24,6551.44,46044.34,9047.28,24321.58,2690.13,20962.15,2207.23,46531.23,4562.00,46531.23,4562.00,2512.17,2207.23,24321.58,2690.13,24351.23,2690.13,22429.50,2959.14,2512.17,46531.23,2207.23,9447.59,,Hospital 00541,"Anesth,Thoracotomy Proc, W/1 Lung Vent",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,64767.43,N/A,38860.46,N/A,13777.72,N/A,16563.99,N/A,31049.22,N/A,22020.93,N/A,31346.23,N/A,14202.24,N/A,16563.99,N/A,16563.99,N/A,19512.30,N/A,31346.23,N/A,31346.23,N/A,31346.23,N/A,N/A,N/A,16563.99,N/A,N/A,N/A,37294.19,N/A,37294.19,N/A,N/A,N/A,16563.99,N/A,16563.99,N/A,15196.40,N/A,13777.72,38860.46,N/A,N/A,,Hospital 00548,"Anesth,Trach,Bronchi Intrathor Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,44560.22,N/A,26736.13,N/A,6238.41,N/A,244.87,N/A,25635.37,N/A,15150.46,N/A,697.37,N/A,6238.41,N/A,239.88,N/A,239.88,N/A,434.13,N/A,697.37,N/A,697.37,N/A,697.37,N/A,25491.42,N/A,239.88,N/A,6238.41,N/A,527.00,N/A,527.00,N/A,6238.41,N/A,239.88,N/A,244.87,N/A,95.16,N/A,N/A,95.16,26736.13,,Hospital 0054A,HC Imm Admn Sarscov2 30mcg/0.3ml Tris-Sucrose Bst,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,27758.10,N/A,16654.86,N/A,5254.60,N/A,6481.56,N/A,11841.67,N/A,9437.75,N/A,11954.95,N/A,5416.50,N/A,2927.88,N/A,2927.88,N/A,7441.68,N/A,11954.95,N/A,11954.95,N/A,11954.95,N/A,11841.67,N/A,6481.56,N/A,5416.50,N/A,14223.40,N/A,14223.40,N/A,N/A,N/A,6481.56,N/A,6481.56,N/A,5795.66,N/A,2927.88,16654.86,N/A,N/A,,Hospital 00560,"Anesth,Open Heart; W/O Pump Oxyegenator",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,257169.97,N/A,154301.98,N/A,35756.73,N/A,16303.44,N/A,145816.18,N/A,87437.78,N/A,3920.25,N/A,35756.73,N/A,16299.81,N/A,16299.81,N/A,2439.82,N/A,3920.25,N/A,3920.25,N/A,3920.25,N/A,145816.17,N/A,16299.81,N/A,35756.73,N/A,1643.00,N/A,1643.00,N/A,35756.73,N/A,16299.81,N/A,16303.44,N/A,1107.45,N/A,N/A,1107.45,154301.98,,Hospital 00562,"Anesth,Open Heart Surgery+Pump",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,181391.48,N/A,108834.89,N/A,25351.00,N/A,8273.77,N/A,102688.08,N/A,61673.09,N/A,6238.44,N/A,25351.00,N/A,8228.55,N/A,8228.55,N/A,3903.19,N/A,6238.44,N/A,6238.44,N/A,6238.44,N/A,102688.08,N/A,8228.55,N/A,25351.00,N/A,1643.00,N/A,1643.00,N/A,25351.00,N/A,8228.55,N/A,8273.77,N/A,1611.70,N/A,N/A,1611.70,108834.89,,Hospital 00563,"Anesth,Open Heart,Pump+Hypotherm",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,233098.52,N/A,139859.11,N/A,N/A,N/A,N/A,N/A,56894.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56894.90,N/A,N/A,N/A,N/A,N/A,56894.90,N/A,56894.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56894.90,139859.11,N/A,N/A,,Hospital 0058U,HC So Merkel Smt Oncoprotein Ab Titer,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,N/A,524.00,N/A,314.40,N/A,333.73,N/A,339.30,N/A,301.72,N/A,178.16,N/A,339.30,N/A,333.73,N/A,339.30,N/A,339.30,N/A,211.21,N/A,339.30,N/A,339.30,N/A,339.30,N/A,301.72,N/A,339.30,N/A,333.73,N/A,333.73,N/A,333.73,N/A,333.73,N/A,339.30,N/A,339.30,N/A,367.11,N/A,N/A,178.16,367.11,,Hospital 00620,"Anesth,Thor Spine,Cord Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,105328.32,122445.88,63196.99,73467.53,N/A,17142.43,6458.17,26799.01,N/A,69246.45,N/A,41549.29,N/A,64186.18,N/A,17142.43,6458.17,26511.88,6458.17,26511.88,N/A,39957.13,N/A,64186.18,N/A,64186.18,N/A,64186.18,N/A,69246.45,6458.17,26511.88,N/A,17142.43,N/A,42930.00,N/A,42930.00,N/A,17142.43,6458.17,26511.88,6458.17,26799.01,N/A,1251.17,6458.17,63196.99,1251.17,73467.53,,Hospital 00626,"Anesth,Transthoracic Spine Surg W/ 1 Lung Vent",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,52433.63,N/A,31460.18,N/A,7340.73,N/A,12079.30,N/A,29908.05,N/A,17827.45,N/A,29248.67,N/A,7340.73,N/A,11951.69,N/A,11951.69,N/A,18428.71,N/A,29248.67,N/A,29248.67,N/A,29248.67,N/A,29908.11,N/A,11977.96,N/A,7340.73,N/A,13336.25,N/A,13336.25,N/A,7340.73,N/A,11951.69,N/A,12079.30,N/A,3775.66,N/A,N/A,3775.66,31460.18,,Hospital 00630,"Anesth,Lumbar Spine,Cord Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,77739.07,29104.52,46643.44,17462.71,7894.17,4074.63,9604.05,5973.28,17790.16,16753.99,26431.28,9895.52,17960.33,14536.72,8137.40,4074.63,3372.00,5973.28,3372.00,5973.28,11179.89,9049.39,17960.33,14536.72,17960.33,14536.72,17960.33,14536.72,17790.16,16754.00,9604.05,5973.28,8137.40,4074.63,21368.31,7897.00,21368.31,7897.00,4259.70,4074.63,6123.11,5973.28,9604.05,5973.28,4259.70,6570.60,3372.00,46643.44,4074.63,17462.71,,Hospital 0064A,HC Imm Admn Sarscov2 50 Mcg/0.25 Ml Booster Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,N/A,317.02,N/A,190.21,N/A,43.87,N/A,39.73,N/A,182.54,N/A,107.78,N/A,90.69,N/A,43.87,N/A,37.49,N/A,37.49,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,182.54,N/A,37.49,N/A,43.87,N/A,113.57,N/A,113.57,N/A,43.87,N/A,37.49,N/A,39.73,N/A,38.20,N/A,N/A,37.49,190.21,,Hospital 0065U,HC Syphilis Tst Non Treponemal Antib Ia Qual Rpr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,32100.90,3569.00,19260.54,2141.40,5682.97,419.99,6988.30,286.37,12807.04,2055.01,10914.31,1213.46,7322.00,657.04,5858.07,419.99,6988.30,273.93,6988.30,273.93,4558.00,409.02,7322.00,657.04,7322.00,657.04,7322.00,657.04,12807.04,2055.01,6988.30,273.93,5858.07,419.99,15382.93,886.32,15382.93,886.32,5096.20,419.99,6988.30,273.93,6988.30,286.37,6268.14,264.80,4558.00,19260.54,264.80,2141.40,,Hospital 00700,"Anesth,Abd Wall,Uper Anter,Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,69357.50,15924.10,41614.50,9554.46,9377.20,2229.38,11358.38,1440.53,27496.38,9163.72,23581.55,5414.20,21334.42,3299.26,9666.12,2229.38,562.00,1354.15,562.00,1354.15,13280.18,2053.85,21334.42,3299.26,21334.42,3299.26,21334.42,3299.26,27496.38,9163.72,11358.38,1354.15,9666.12,2229.38,25382.63,2134.50,25382.63,2134.50,9699.75,2229.38,11358.38,1354.15,11358.38,1440.53,10342.75,635.60,562.00,41614.50,635.60,9554.46,,Hospital CPT 0071A,HC Imm Admn Sarscov2 10mcg/0.2ml Tris-Sucrose 1st,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,110.00,N/A,63.34,N/A,37.40,N/A,90.69,N/A,15.40,N/A,37.49,N/A,37.49,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,63.34,N/A,37.49,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,37.49,N/A,110.00,N/A,110.00,66.00,66.00,15.40,110.00,,Hospital 00730,"Anesth,Abd Wall,Upper Post,Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,49667.30,12926.10,29800.38,7755.66,4201.55,1809.66,5295.16,2440.19,9468.53,7442.13,16886.88,4394.88,9559.10,5656.90,4331.00,1809.66,175344.00,2332.78,175344.00,2332.78,5950.32,3521.53,9559.10,5656.90,9559.10,5656.90,9559.10,5656.90,9468.53,7442.14,5235.86,2332.78,4331.00,1809.66,11372.94,3397.00,11372.94,3397.00,2696.81,1809.66,5235.86,2332.78,5295.16,2440.19,4634.17,493.87,2696.81,175344.00,493.87,7755.66,,Hospital 00731,Anesthesia Upper GI Endoscopic Px Nos,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,34908.00,6781.80,20944.80,4069.08,4640.05,949.46,5754.58,1572.73,10456.74,3903.86,11868.72,2305.82,10556.76,3815.47,4783.02,949.46,5754.58,1572.73,5754.58,1572.73,6571.34,2375.20,10556.76,3815.47,10556.76,3815.47,10556.76,3815.47,10456.74,3893.52,2077.71,1572.73,4783.02,949.46,12559.91,1871.00,12559.91,1871.00,1471.04,949.46,5754.58,1572.73,5754.58,1572.73,5117.83,1730.00,1471.04,20944.80,949.46,4069.08,,Hospital 00732,Anesthesia Upper GI Endoscopic Px Ercp,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,57511.70,13916.98,34507.02,8350.19,4330.11,1948.15,5447.24,2944.53,3635.37,8012.39,19553.98,4731.78,9851.60,7130.80,4463.53,1948.15,107342.00,2944.53,107342.00,2944.53,6132.39,4439.05,9851.60,7130.80,9851.60,7130.80,9851.60,7130.80,10059.23,8012.39,5387.94,2944.53,4463.53,1948.15,11720.95,3397.00,11720.95,3397.00,6135.88,1948.15,4732.58,2944.53,5447.24,2944.53,4775.98,3238.99,3635.37,107342.00,1948.15,8350.19,,Hospital CPT 0073A,HC Adm Sarscv2 10 Mcg/0.2 Ml Trs-Sucr 3rd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital CPT 0074A,HC Adm Sarscv2 10 Mcg/0.2 Ml Trs-Sucr Booster,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital 00750,"Anesth,Repair Upper Abd Hernia Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,61154.48,36984.40,36692.69,22190.64,5879.29,5169.42,7250.18,4706.78,14402.06,21176.34,20792.53,12574.71,13376.19,12381.62,6060.44,5169.42,153426.00,4706.78,153426.00,4706.78,8326.37,7707.80,13376.19,12381.62,13376.19,12381.62,13376.19,12381.62,14402.06,21176.33,7220.53,4706.78,6060.44,5169.42,15914.32,8160.50,15914.32,8160.50,N/A,5169.42,7220.53,4706.78,7250.18,4706.78,6484.67,5177.46,5879.29,153426.00,4706.78,22190.64,,Hospital 00752,"Anesth,Repair Up Hernia Lumbar/Ventr",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,85142.28,41551.50,51085.37,24930.90,7320.70,5815.78,8925.66,3198.50,17091.25,23807.22,28948.37,14127.51,16655.61,8718.21,7546.26,5815.78,562.00,3198.50,562.00,3198.50,10367.73,5427.23,16655.61,8718.21,16655.61,8718.21,16655.61,8718.21,17091.25,23807.21,8925.66,3198.50,7546.26,5815.78,19816.01,4562.00,19816.01,4562.00,N/A,5815.78,8925.66,3198.50,8925.66,3198.50,8074.50,3518.35,562.00,51085.37,3198.50,24930.90,,Hospital CPT 0075T,HC Insert Verterbral Stent Init,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,45499.00,45499.00,27299.40,27299.40,N/A,6369.86,N/A,45499.00,N/A,26198.32,N/A,15469.66,N/A,1263.78,N/A,6369.86,N/A,45499.00,N/A,45499.00,N/A,786.73,N/A,1263.78,N/A,1263.78,N/A,1263.78,N/A,26198.32,N/A,45499.00,N/A,6369.86,N/A,45499.00,N/A,45499.00,N/A,6369.86,N/A,45499.00,N/A,45499.00,N/A,45499.00,27299.40,27299.40,786.73,45499.00,,Hospital 00792,"Anesth,Partial Liver Removal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,76083.03,N/A,45649.82,N/A,10617.58,N/A,2558.07,N/A,43806.22,N/A,25868.21,N/A,9283.28,N/A,10617.58,N/A,2544.59,N/A,2544.59,N/A,5782.90,N/A,9283.28,N/A,9283.28,N/A,9283.28,N/A,43806.22,N/A,2544.59,N/A,10617.58,N/A,1643.00,N/A,1643.00,N/A,10617.58,N/A,2544.59,N/A,2558.07,N/A,3102.18,N/A,N/A,1643.00,45649.82,,Hospital 00794,"Anesth,Pancreas Removal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,146533.12,N/A,87919.87,N/A,18671.96,N/A,20214.76,N/A,80769.06,N/A,49821.26,N/A,65869.93,N/A,19247.27,N/A,31344.19,N/A,31344.19,N/A,41002.50,N/A,65869.93,N/A,65869.93,N/A,65869.93,N/A,80769.06,N/A,31344.19,N/A,19247.27,N/A,78368.77,N/A,78368.77,N/A,N/A,N/A,31344.19,N/A,N/A,N/A,20594.58,N/A,18671.96,87919.87,N/A,N/A,,Hospital 00797,"Anesth,Gastric Restrict, Morbid Obesity",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,65329.38,57954.58,39197.63,34772.75,8295.33,8119.55,10108.24,1395.43,18694.21,33362.41,22211.99,19704.60,18873.04,12204.90,8550.93,8119.55,157922.00,1370.96,157922.00,1370.96,11748.03,7597.77,18873.04,12204.90,18873.04,12204.90,18873.04,12204.90,18694.21,32673.20,10078.59,1370.96,8550.93,8119.55,22454.20,7897.00,22454.20,7897.00,3493.40,8119.55,10078.59,1370.96,10108.24,1395.43,9149.49,1469.37,3493.40,157922.00,1370.96,34772.75,,Hospital 00802,"Anesth,Fat Layer Removal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,52802.47,48980.30,31681.48,29388.18,6420.75,6857.26,7890.70,5709.23,14469.68,28195.40,17952.84,16653.31,14608.09,13042.10,6618.58,6857.26,5366.90,5366.90,5366.90,5366.90,9093.20,8118.95,14608.09,13042.10,14608.09,13042.10,14608.09,13042.10,14469.68,28195.41,7861.05,5366.90,6618.58,6857.26,17379.98,6226.50,17379.98,6226.50,N/A,6857.26,7861.05,5366.90,7890.70,5709.23,7081.88,1226.48,5366.90,31681.48,1226.48,29388.18,,Hospital 00812,Anesthesia Lower Intst Endoscopic Px Scr Colsc,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,43624.00,5520.30,26174.40,3312.18,5254.60,772.62,6481.56,977.91,13234.52,2552.00,14832.16,1876.90,11954.95,2384.13,5416.50,772.62,1686.00,977.91,1686.00,977.91,7441.68,1484.16,11954.95,2384.13,11954.95,2384.13,11954.95,2384.13,13234.52,2552.00,6481.56,977.91,5416.50,772.62,14223.40,1871.00,14223.40,1871.00,6310.65,772.62,6481.56,977.91,6481.56,977.91,5795.66,1075.70,1686.00,26174.40,772.62,3312.18,,Hospital 00813,Anesthesia Combined Upper&Lower GI Endoscopic Px,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,40508.90,10326.00,24305.34,6195.60,8595.67,1445.64,10493.18,1839.60,19371.05,2552.00,13773.03,3510.83,19556.35,4462.26,8860.52,1445.64,72498.00,1839.60,72498.00,1839.60,12173.37,2777.85,19556.35,4462.26,19556.35,4462.26,19556.35,4462.26,19371.05,2552.00,10433.88,1839.60,8860.52,1445.64,23267.17,3274.25,23267.17,3274.25,1579.72,1445.64,10433.88,1839.60,10493.18,1839.60,9480.76,2023.56,1579.72,72498.00,1445.64,6195.60,,Hospital CPT 0082A,HC Imm Admn Sarscov2 3 Mcg/0.2 Ml 2nd Dose,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital 00830,"Anesth,Repair Lo Abd Hernia Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,39049.18,26742.02,23429.51,16045.21,7320.70,3743.88,8925.66,3198.50,17715.22,15347.01,13276.72,9092.28,16655.61,8446.72,7546.26,3743.88,562.00,3198.50,562.00,3198.50,10367.73,5258.24,16655.61,8446.72,16655.61,8446.72,16655.61,8446.72,17715.22,15347.02,8925.66,3198.50,7546.26,3743.88,19816.01,4825.50,19816.01,4825.50,N/A,3743.88,8925.66,3198.50,8925.66,3198.50,8074.50,3518.35,562.00,23429.51,3198.50,16045.21,,Hospital 00832,"Anesth,Repair Lo Hernia Ventr/Incis",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,58980.53,38208.90,35388.32,22925.34,11346.74,5339.55,13717.89,3198.50,27862.34,21881.16,20053.39,12991.03,25815.40,8736.41,11696.35,5339.55,59010.00,3198.50,59010.00,3198.50,16069.49,5438.57,25815.40,8736.41,25815.40,8736.41,25815.40,8736.41,27862.34,21881.17,13688.24,3198.50,11696.35,5339.55,30713.88,4562.00,30713.88,4562.00,N/A,5339.55,13688.24,3198.50,13717.89,3198.50,12515.10,3518.35,11346.74,59010.00,3198.50,22925.34,,Hospital 00834,PR Anes Hernia Repair Lower Abdomen Nos & 1yr Age,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,50284.30,N/A,30170.58,N/A,7039.80,N/A,3402.52,N/A,28952.72,N/A,17096.66,N/A,7743.24,N/A,7039.80,N/A,3198.50,N/A,3198.50,N/A,4820.30,N/A,7743.24,N/A,7743.24,N/A,7743.24,N/A,28952.71,N/A,3198.50,N/A,7039.80,N/A,6843.00,N/A,6843.00,N/A,7039.80,N/A,3198.50,N/A,3402.52,N/A,456.40,N/A,N/A,456.40,30170.58,,Hospital 00836,"Anesth,Rep Lo Abd Hern Nos, Prem <50 Wks",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,46769.30,N/A,28061.58,N/A,6547.70,N/A,3402.52,N/A,26929.43,N/A,15901.56,N/A,7751.09,N/A,6547.70,N/A,3198.50,N/A,3198.50,N/A,4859.82,N/A,7751.09,N/A,7751.09,N/A,7751.09,N/A,26929.42,N/A,3198.50,N/A,6547.70,N/A,6843.00,N/A,6843.00,N/A,6547.70,N/A,3198.50,N/A,3402.52,N/A,895.01,N/A,N/A,895.01,28061.58,,Hospital 00846,"Anesth,Radical Hysterectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,86661.82,N/A,51997.09,N/A,12065.73,N/A,2547.15,N/A,49896.53,N/A,29465.01,N/A,13017.17,N/A,12065.73,N/A,2514.86,N/A,2514.86,N/A,8102.21,N/A,13017.17,N/A,13017.17,N/A,13017.17,N/A,49896.56,N/A,2514.86,N/A,12065.73,N/A,5963.00,N/A,5963.00,N/A,12065.73,N/A,2514.86,N/A,2547.15,N/A,2534.83,N/A,N/A,2514.86,51997.09,,Hospital 00851,"Anesth,Tubal Ligation/Transection",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,50208.57,N/A,30125.14,N/A,7023.53,N/A,4804.66,N/A,28906.50,N/A,17070.92,N/A,11400.44,N/A,7023.53,N/A,4706.78,N/A,4706.78,N/A,7097.00,N/A,11400.44,N/A,11400.44,N/A,11400.44,N/A,28834.51,N/A,4706.78,N/A,7023.53,N/A,10178.00,N/A,10178.00,N/A,7023.53,N/A,4706.78,N/A,4804.66,N/A,697.62,N/A,N/A,697.62,30125.14,,Hospital 00866,"Anesth,Removal of Adrenal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,90444.37,N/A,54266.62,N/A,12650.93,N/A,1462.17,N/A,52058.24,N/A,30751.10,N/A,12895.54,N/A,12650.93,N/A,1443.50,N/A,1443.50,N/A,8026.98,N/A,12895.54,N/A,12895.54,N/A,12895.54,N/A,51885.49,N/A,1443.50,N/A,12650.93,N/A,5963.00,N/A,5963.00,N/A,12650.93,N/A,1443.50,N/A,1462.17,N/A,1803.56,N/A,N/A,1443.50,54266.62,,Hospital 00870,"Anesth,Bladder Stone Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,82725.22,N/A,49635.13,N/A,11474.55,N/A,4334.56,N/A,47623.59,N/A,28126.58,N/A,10325.23,N/A,11474.55,N/A,4246.26,N/A,4246.26,N/A,6427.63,N/A,10325.23,N/A,10325.23,N/A,10325.23,N/A,47623.57,N/A,4246.26,N/A,11474.55,N/A,3397.00,N/A,3397.00,N/A,11474.55,N/A,4246.26,N/A,4334.56,N/A,551.91,N/A,N/A,551.91,49635.13,,Hospital 00873,"Anesth,Kid Stone Destruct",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,131732.23,68881.50,79039.34,41328.90,5750.19,9620.47,7097.47,2894.35,72610.81,39657.49,44788.96,23419.71,13082.47,7068.39,5927.36,9620.47,7067.82,2894.35,7067.82,2894.35,8143.53,4400.21,13082.47,7068.39,13082.47,7068.39,13082.47,7068.39,72610.81,39657.48,7067.82,2894.35,5927.36,9620.47,15564.88,7897.00,15564.88,7897.00,948.04,9620.47,N/A,2894.35,7097.47,2894.35,4670.88,3183.79,948.04,79039.34,2894.35,41328.90,,Hospital 00902,"Anesth,Anorectal Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,35900.30,15164.20,21540.18,9098.52,3440.30,2122.76,4335.33,2320.33,7752.99,8730.13,12206.10,5155.82,7827.15,5624.25,3546.30,2122.76,1684.52,2320.33,1684.52,2320.33,4872.22,3501.20,7827.15,5624.25,7827.15,5624.25,7827.15,5624.25,7752.99,8730.13,4335.33,2320.33,3546.30,2122.76,9312.36,3397.00,9312.36,3397.00,2877.62,2122.76,2345.46,2320.33,4335.33,2320.33,3794.54,2552.37,1684.52,21540.18,2122.76,9098.52,,Hospital 00904,"Anesth,Radical Perineal Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,42727.60,N/A,25636.56,N/A,5915.07,N/A,1656.90,N/A,24598.60,N/A,14527.42,N/A,12509.27,N/A,5915.07,N/A,1624.61,N/A,1624.61,N/A,7786.59,N/A,12509.27,N/A,12509.27,N/A,12509.27,N/A,24346.46,N/A,1624.61,N/A,5915.07,N/A,4562.00,N/A,4562.00,N/A,5915.07,N/A,1624.61,N/A,1656.90,N/A,1370.24,N/A,N/A,1370.24,25636.56,,Hospital 00918,"Anesth,Stone Rmvoval",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,41367.87,23840.27,24820.72,14304.16,7528.22,3310.19,9230.44,4246.26,17266.58,13711.71,14065.07,8105.70,17127.73,10377.03,7760.17,3312.29,3044.18,4246.26,3044.18,4246.26,10661.62,6459.90,17127.73,10377.03,17127.73,10377.03,17127.73,10377.03,17266.58,13711.71,9171.14,4246.26,7760.17,3312.29,20377.73,5963.00,25091.48,5963.00,3379.26,3312.29,9171.14,4246.26,9230.44,4246.26,8303.39,4670.88,3044.18,25091.48,3310.19,14304.16,,Hospital 00928,"Anesth,Radical Remv Testis,Abdominal",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,36442.20,N/A,21865.32,N/A,5101.91,N/A,3027.62,N/A,20975.44,N/A,12390.34,N/A,7139.84,N/A,5101.91,N/A,2894.35,N/A,2894.35,N/A,4444.68,N/A,7139.84,N/A,7139.84,N/A,7139.84,N/A,20975.45,N/A,2894.35,N/A,5101.91,N/A,4562.00,N/A,4562.00,N/A,5101.91,N/A,2894.35,N/A,3027.62,N/A,816.52,N/A,N/A,816.52,21865.32,,Hospital 00940,"Anesth,Vaginal Procedures",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,35569.03,13167.00,21341.42,7900.20,10068.56,1843.38,12176.23,2553.29,22690.32,7576.76,12093.47,4476.78,22907.37,6272.59,10378.79,1843.38,562.00,2553.29,562.00,2553.29,14259.31,3904.81,22907.37,6272.59,22907.37,6272.59,22907.37,6272.59,22690.32,7576.76,12176.23,2553.29,10378.79,1843.38,27254.06,3397.00,27254.06,3397.00,2733.65,1843.38,635.26,2553.29,12176.23,2553.29,11105.31,2808.62,562.00,27254.06,1843.38,7900.20,,Hospital 00944,"Anesth,Vaginal Hysterectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,73152.42,47672.12,43891.45,28603.27,24434.70,6619.16,29170.64,8584.05,55065.57,27443.32,24871.82,16015.05,55592.31,19974.17,25187.57,6619.16,1686.00,8206.20,1686.00,8206.20,34604.92,12434.31,25924.59,19974.17,25924.59,19974.17,55592.31,19974.17,55065.57,27443.32,29170.64,8206.20,25187.57,6619.16,66140.98,7897.00,66140.98,7897.00,3045.27,6619.16,29170.64,8206.20,29170.64,8584.05,26950.70,1271.52,1686.00,66140.98,1271.52,28603.27,,Hospital 00952,"Anesth,Hysteroscopy/Vag Bx",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,77539.13,13809.27,46523.48,8285.56,10126.71,1926.60,12304.32,4185.69,22821.36,7948.83,26363.30,4695.14,23039.67,10147.64,10438.73,1926.60,2553.29,4185.69,2553.29,4185.69,14341.66,6317.10,23039.67,10147.64,23039.67,10147.64,23039.67,10147.64,22821.36,7948.83,12245.02,4185.69,10438.73,1926.60,27411.45,4562.00,27411.45,4562.00,1811.59,1926.60,12245.02,4185.69,12304.32,4185.69,11169.44,4604.26,1811.59,46523.48,1926.60,10147.64,,Hospital 0098U,HC Respirpthgn Mult Rev Trans & Amp Prb Tech 14 Trgt,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,N/A,22280.00,N/A,13368.00,N/A,3463.74,N/A,1882.57,N/A,12825.21,N/A,7575.20,N/A,5490.42,N/A,3463.74,N/A,1844.20,N/A,1844.20,N/A,3416.79,N/A,5490.42,N/A,5490.42,N/A,5490.42,N/A,11059.83,N/A,1844.20,N/A,3463.74,N/A,5387.55,N/A,5387.55,N/A,3463.74,N/A,1844.20,N/A,1882.57,N/A,1627.22,N/A,N/A,1627.22,13368.00,,Hospital 0099U,HC Respirpthgn Mult Rev Trans & Amp Prb Tech 20 Trgt,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,329237.33,N/A,197542.40,N/A,N/A,N/A,41009.32,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,43120.18,N/A,43120.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,41009.32,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,41009.32,N/A,41009.32,N/A,N/A,N/A,41009.32,197542.40,N/A,N/A,,Hospital 0101T,Extracorporeal Shock Wave Muscskel Sys Nos,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7925.10,N/A,4755.06,N/A,1109.52,N/A,2674.29,N/A,4561.94,N/A,2694.53,N/A,6513.56,N/A,1109.52,N/A,2688.04,N/A,2688.04,N/A,4054.81,N/A,6513.56,N/A,6513.56,N/A,6513.56,N/A,4561.94,N/A,2688.04,N/A,1109.52,N/A,4562.00,N/A,4562.00,N/A,1109.52,N/A,2688.04,N/A,2674.29,N/A,N/A,N/A,N/A,1109.52,6513.56,,Hospital 0107U,HC C Diff Tox Ag Detcj Ia Tech Stool Qual,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,44682.20,N/A,26809.32,N/A,8700.77,N/A,10557.80,N/A,23529.46,N/A,15191.95,N/A,23754.54,N/A,8968.85,N/A,1686.00,N/A,1686.00,N/A,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,23529.46,N/A,10557.80,N/A,8968.85,N/A,28261.97,N/A,28261.97,N/A,N/A,N/A,10557.80,N/A,10557.80,N/A,9596.67,N/A,1686.00,28261.97,N/A,N/A,,Hospital 01112,"Anesth,Bone Marrow Asp/Bx Iliac Crst",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,54600.72,N/A,32760.43,N/A,7635.24,N/A,2112.34,N/A,31299.06,N/A,18564.25,N/A,16646.43,N/A,7635.24,N/A,2072.14,N/A,2072.14,N/A,10362.72,N/A,16646.43,N/A,16646.43,N/A,16646.43,N/A,31299.09,N/A,2072.14,N/A,7635.24,N/A,8970.25,N/A,8970.25,N/A,7635.24,N/A,2072.14,N/A,2112.34,N/A,1464.08,N/A,N/A,1464.08,32760.43,,Hospital 01120,"Anesth,Bony Pelvis Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,24829.50,N/A,14897.70,N/A,3435.26,N/A,1416.50,N/A,14295.02,N/A,8442.03,N/A,3316.69,N/A,3435.26,N/A,1354.15,N/A,1354.15,N/A,2064.69,N/A,3316.69,N/A,3316.69,N/A,3316.69,N/A,14295.03,N/A,1354.15,N/A,3435.26,N/A,1694.50,N/A,1694.50,N/A,3435.26,N/A,1354.15,N/A,1416.50,N/A,423.16,N/A,N/A,423.16,14897.70,,Hospital 01130,"Anesth,Body Cast Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,8503.50,N/A,5102.10,N/A,1190.49,N/A,130.49,N/A,4894.43,N/A,2891.19,N/A,334.35,N/A,1190.49,N/A,131.63,N/A,131.63,N/A,208.14,N/A,334.35,N/A,334.35,N/A,334.35,N/A,4894.43,N/A,131.63,N/A,1190.49,N/A,527.00,N/A,527.00,N/A,1190.49,N/A,131.63,N/A,130.49,N/A,450.93,N/A,N/A,130.49,5102.10,,Hospital 01160,"Anesth,Pubis,Sacroiliac Open Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,59520.50,N/A,35712.30,N/A,8327.75,N/A,20452.39,N/A,33869.75,N/A,20236.96,N/A,47868.15,N/A,8327.75,N/A,19774.44,N/A,19774.44,N/A,29798.84,N/A,47868.15,N/A,47868.15,N/A,47868.15,N/A,33869.74,N/A,19774.44,N/A,8327.75,N/A,11660.00,N/A,11660.00,N/A,8327.75,N/A,19774.44,N/A,20452.39,N/A,887.79,N/A,N/A,887.79,47868.15,,Hospital 01200,"Anesth,Hip Joint Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,27836.70,7692.60,16702.02,4615.56,3122.53,1076.96,3959.23,378.13,9499.78,4426.18,9464.48,2615.48,9590.66,959.05,3218.74,1076.96,562.00,368.29,562.00,368.29,5969.96,597.03,9590.66,959.05,9590.66,959.05,9590.66,959.05,9499.78,4426.18,3959.23,368.29,3218.74,1076.96,11410.49,790.50,11410.49,790.50,N/A,1076.96,3959.23,368.29,3959.23,378.13,3444.05,47.74,562.00,16702.02,47.74,4615.56,,Hospital 01202,"Anesth,Arthroscopy of Hip",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,82374.53,N/A,49424.72,N/A,11523.60,N/A,12325.48,N/A,47341.02,N/A,28003.94,N/A,28614.88,N/A,11523.60,N/A,11782.94,N/A,11782.94,N/A,17813.30,N/A,28614.88,N/A,28614.88,N/A,28614.88,N/A,47341.03,N/A,11782.94,N/A,11523.60,N/A,13819.75,N/A,13819.75,N/A,11523.60,N/A,11782.94,N/A,12325.48,N/A,3285.11,N/A,N/A,3285.11,49424.72,,Hospital 01210,"Anesth,Hip Joint Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,67711.42,29593.17,40626.85,17755.90,11308.88,4146.62,12198.40,295.83,30859.70,16963.57,23021.88,10061.68,26372.49,986.33,11657.32,4146.62,127574.00,295.83,127574.00,295.83,16416.26,753.29,26372.49,986.33,26372.49,986.33,26372.49,986.33,30859.70,16963.57,12139.10,309.92,11657.32,4146.62,31376.68,527.00,31376.68,527.00,N/A,4146.62,12139.10,295.83,12198.40,295.83,12473.33,325.41,11308.88,127574.00,295.83,17755.90,,Hospital 01214,"Anesth,Total Hip Arthroplasty",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,72186.60,62100.82,43311.96,37260.49,10199.26,8657.38,11709.91,11933.08,34105.94,35355.63,24543.45,21114.28,23063.94,29095.54,10513.52,8657.38,241098.00,11933.08,241098.00,11933.08,14356.77,18308.54,23063.94,29095.54,23063.94,29095.54,23063.94,29095.54,34105.94,35355.68,11680.26,11956.02,10513.52,8657.38,27440.33,11660.00,27440.33,11660.00,3627.14,8657.38,11680.26,11933.08,11709.91,11933.08,11249.46,13126.38,3627.14,241098.00,8657.38,37260.49,,Hospital 01220,"Anesth,Closed Proc Upper 2/3 Femur",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,46178.13,5996.30,27706.88,3597.78,5322.01,839.48,8636.72,244.27,22049.00,3451.19,15700.56,2038.74,19978.72,615.24,5485.99,839.48,143872.00,245.53,143872.00,245.53,12436.29,382.99,19978.72,615.24,19978.72,615.24,19978.72,615.24,22049.00,3451.19,8607.07,245.53,5485.99,839.48,23769.68,527.00,23769.68,527.00,N/A,839.48,8607.07,245.53,8636.72,244.27,5870.01,47.74,5322.01,143872.00,47.74,3597.78,,Hospital 01230,"Anesth,Open Proc Upper 2/3 Femur",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,55967.27,52891.08,33580.36,31734.65,7861.99,7404.75,11580.55,1138.28,31855.73,30366.64,19028.87,17982.98,25638.20,14499.10,8104.23,7404.75,1124.00,1138.28,1124.00,1138.28,15959.18,9025.97,25638.20,14499.10,25638.20,14499.10,25638.20,14499.10,31855.73,30366.65,11580.55,1138.28,8104.23,7404.75,30503.06,7897.00,30503.06,7897.00,N/A,7404.75,11580.55,1138.28,11580.55,1138.28,8671.53,1252.11,1124.00,33580.36,1138.28,31734.65,,Hospital 01234,"Anesth,Radical Femur Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,86659.47,N/A,51995.68,N/A,10482.65,N/A,12522.23,N/A,38362.14,N/A,29464.21,N/A,25440.37,N/A,10805.64,N/A,388342.00,N/A,388342.00,N/A,15836.04,N/A,25440.37,N/A,25440.37,N/A,25440.37,N/A,38362.14,N/A,12433.28,N/A,10805.64,N/A,30267.68,N/A,30267.68,N/A,N/A,N/A,2352.36,N/A,12522.23,N/A,11562.04,N/A,2352.36,388342.00,N/A,N/A,,Hospital 01260,"Anesth,Upper Leg Veins Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,20850.40,N/A,12510.24,N/A,2898.77,N/A,2719.26,N/A,12001.31,N/A,7038.83,N/A,6551.03,N/A,2898.77,N/A,2690.13,N/A,2690.13,N/A,4078.14,N/A,6551.03,N/A,6551.03,N/A,6551.03,N/A,12001.31,N/A,2690.13,N/A,2898.77,N/A,6843.00,N/A,6843.00,N/A,2898.77,N/A,2690.13,N/A,2719.26,N/A,592.09,N/A,N/A,592.09,12510.24,,Hospital 01270,"Anesth,Thigh Arteries Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,48031.50,58062.63,28818.90,34837.58,9754.35,8075.79,11834.19,4709.71,22008.62,33399.04,16330.71,19741.30,23055.56,11435.85,10054.90,8075.79,11804.54,4709.71,11804.54,4709.71,14351.90,7119.01,23055.56,11435.85,23055.56,11435.85,23055.56,11435.85,22008.62,33399.04,11804.54,4709.71,10054.90,8075.79,26403.54,7897.00,26403.54,7897.00,6356.92,8075.79,11804.54,4709.71,11834.19,4709.71,10758.75,5180.69,6356.92,28818.90,4709.71,34837.58,,Hospital 01340,"Anesth,Lower 1/3 Femur,Closed Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,16789.50,N/A,10073.70,N/A,2298.53,N/A,1368.82,N/A,7000.03,N/A,5708.43,N/A,3290.20,N/A,2298.53,N/A,1354.15,N/A,1354.15,N/A,2048.21,N/A,3290.20,N/A,3290.20,N/A,3290.20,N/A,7000.03,N/A,1354.15,N/A,2298.53,N/A,1871.00,N/A,1871.00,N/A,2298.53,N/A,1354.15,N/A,1368.82,N/A,454.32,N/A,N/A,454.32,10073.70,,Hospital 01360,"Anesth,Lower 1/3 Femur,Open Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,36539.67,N/A,21923.80,N/A,5106.70,N/A,1034.47,N/A,21012.96,N/A,12423.48,N/A,14771.13,N/A,5106.70,N/A,1030.86,N/A,1030.86,N/A,9195.31,N/A,14771.13,N/A,14771.13,N/A,14771.13,N/A,21012.97,N/A,1030.86,N/A,5106.70,N/A,5963.00,N/A,5963.00,N/A,5106.70,N/A,1030.86,N/A,1034.47,N/A,1076.73,N/A,N/A,1030.86,21923.80,,Hospital 01382,"Anesth,Dx Arthroscopic Proc Knee Joint",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18022.00,N/A,10813.20,N/A,2523.08,N/A,2811.81,N/A,7823.00,N/A,6127.48,N/A,6530.65,N/A,2523.08,N/A,2688.04,N/A,2688.04,N/A,4065.45,N/A,6530.65,N/A,6530.65,N/A,6530.65,N/A,7823.00,N/A,2688.04,N/A,2523.08,N/A,4562.00,N/A,4562.00,N/A,2523.08,N/A,2688.04,N/A,2811.81,N/A,425.23,N/A,N/A,425.23,10813.20,,Hospital 01390,"Anesth,Upper Leg,Closed Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,15264.90,N/A,9158.94,N/A,2070.79,N/A,1368.82,N/A,8787.14,N/A,5190.07,N/A,3314.60,N/A,2070.79,N/A,1354.15,N/A,1354.15,N/A,2063.40,N/A,3314.60,N/A,3314.60,N/A,3314.60,N/A,8787.15,N/A,1354.15,N/A,2070.79,N/A,2586.50,N/A,2586.50,N/A,2070.79,N/A,1354.15,N/A,1368.82,N/A,657.64,N/A,N/A,657.64,9158.94,,Hospital 01402,"Anesth,Total Knee Arthroplasty",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,75216.67,64270.10,45130.00,38562.06,10199.26,8983.35,12360.50,11864.95,36516.75,36702.97,25573.67,21851.84,23204.73,29784.69,10513.52,8983.35,24195.80,11864.95,24195.80,11864.95,14444.40,18651.96,23204.73,29784.69,N/A,29784.69,23204.73,29784.69,36516.75,35934.29,12330.85,11880.45,10513.52,8983.35,27607.84,11660.00,27607.84,11660.00,N/A,8983.35,12330.85,11864.95,12360.50,11864.95,11249.46,13051.44,10199.26,45130.00,8983.35,38562.06,,Hospital 01440,"Anesth,Knee Arteries Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,60719.95,N/A,36431.97,N/A,8407.66,N/A,4709.71,N/A,34876.34,N/A,20644.78,N/A,11468.47,N/A,8407.66,N/A,4709.71,N/A,4709.71,N/A,7139.33,N/A,11468.47,N/A,11468.47,N/A,11468.47,N/A,34876.34,N/A,4709.71,N/A,8407.66,N/A,7897.00,N/A,7897.00,N/A,8407.66,N/A,4709.71,N/A,4709.71,N/A,5180.69,N/A,N/A,4709.71,36431.97,,Hospital 01442,"Anesth,Poplit Thromboendartectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,85490.18,N/A,51294.11,N/A,18584.75,N/A,21503.13,N/A,44022.29,N/A,29066.67,N/A,44946.04,N/A,19157.38,N/A,15512.06,N/A,15512.06,N/A,27978.55,N/A,44946.04,N/A,44946.04,N/A,44946.04,N/A,44022.29,N/A,21443.83,N/A,19157.38,N/A,51472.82,N/A,51472.82,N/A,N/A,N/A,21443.83,N/A,21503.13,N/A,20498.40,N/A,15512.06,51472.82,N/A,N/A,,Hospital 01444,"Anesth,Poplit Artery Excision",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,56617.50,N/A,33970.50,N/A,9754.35,N/A,11215.97,N/A,21830.75,N/A,19249.95,N/A,22896.68,N/A,10054.90,N/A,11186.32,N/A,11186.32,N/A,14253.00,N/A,22896.68,N/A,22896.68,N/A,22896.68,N/A,21830.75,N/A,11186.32,N/A,10054.90,N/A,26221.60,N/A,26221.60,N/A,N/A,N/A,11186.32,N/A,11215.97,N/A,10758.75,N/A,9754.35,33970.50,N/A,N/A,,Hospital 01464,"Anesth,Arthroscop Proc,Ankle &/or Foot",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,29207.20,N/A,17524.32,N/A,4089.00,N/A,2743.94,N/A,16811.62,N/A,9930.44,N/A,6561.57,N/A,4089.00,N/A,2688.04,N/A,2688.04,N/A,4087.03,N/A,6561.57,N/A,6561.57,N/A,6561.57,N/A,16811.61,N/A,2688.04,N/A,4089.00,N/A,5095.50,N/A,5095.50,N/A,4089.00,N/A,2688.04,N/A,2743.94,N/A,760.78,N/A,N/A,760.78,17524.32,,Hospital 01470,"Anesth,Lower Leg,Open Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,63785.50,24565.43,38271.30,14739.26,10965.85,3439.16,13237.68,2811.81,24712.42,14138.19,N/A,8352.25,24948.82,6602.47,11303.72,3439.16,3934.00,2688.04,1414.42,2688.04,15530.06,4110.16,N/A,6602.47,N/A,6602.47,24948.82,6602.47,24712.42,14138.20,2861.12,2688.04,11303.72,3439.16,29682.86,5095.50,29682.86,5095.50,N/A,3439.16,1414.42,2688.04,13237.68,2811.81,12094.98,823.81,1414.42,38271.30,823.81,14739.26,,Hospital 01474,"Anesth,Gastrocnemius Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,37236.90,N/A,22342.14,N/A,5213.16,N/A,2780.20,N/A,21433.74,N/A,12660.55,N/A,6532.32,N/A,5213.16,N/A,2688.04,N/A,2688.04,N/A,4066.49,N/A,6532.32,N/A,6532.32,N/A,6532.32,N/A,21433.73,N/A,2688.04,N/A,5213.16,N/A,4562.00,N/A,4562.00,N/A,5213.16,N/A,2688.04,N/A,2780.20,N/A,475.38,N/A,N/A,475.38,22342.14,,Hospital 01486,"Anesth,Ankle Replacement",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,127473.93,123457.18,76484.36,74074.31,17238.29,17274.85,2805.07,20684.94,70263.63,70359.30,N/A,41975.42,39219.50,47881.04,17769.43,17274.85,65192.00,19774.44,65192.00,19774.44,24413.23,29806.88,39219.50,47881.04,39219.50,47881.04,39219.50,47881.04,70263.63,70359.30,20657.66,19774.44,17769.43,17274.85,46661.42,11027.25,46661.42,11027.25,203.68,17274.85,20657.66,19774.44,20776.26,20684.94,19013.30,2139.15,203.68,76484.36,2139.15,74074.31,,Hospital 01490,"Anesth,Lower Leg Casting",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18864.70,N/A,11318.82,N/A,2641.06,N/A,137.69,N/A,10861.56,N/A,6414.00,N/A,328.18,N/A,2641.06,N/A,131.63,N/A,131.63,N/A,204.30,N/A,328.18,N/A,328.18,N/A,328.18,N/A,10861.56,N/A,131.63,N/A,2641.06,N/A,527.00,N/A,527.00,N/A,2641.06,N/A,131.63,N/A,137.69,N/A,77.21,N/A,N/A,77.21,11318.82,,Hospital 01500,"Anesth,Lower Leg Arteries Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,66831.52,N/A,40098.91,N/A,9283.51,N/A,15512.06,N/A,38333.66,N/A,22722.71,N/A,37588.55,N/A,9283.51,N/A,15512.06,N/A,15512.06,N/A,23399.59,N/A,37588.55,N/A,37588.55,N/A,37588.55,N/A,38333.67,N/A,15512.06,N/A,9283.51,N/A,12375.50,N/A,12375.50,N/A,9283.51,N/A,15512.06,N/A,15512.06,N/A,17063.27,N/A,N/A,9283.51,40098.91,,Hospital 01622,"Anesth,Dx Arthrosc Proc,Shoulder Joint",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,23340.23,N/A,14004.14,N/A,3269.25,N/A,2792.70,N/A,11735.00,N/A,7935.68,N/A,6551.06,N/A,3269.25,N/A,2688.04,N/A,2688.04,N/A,4078.16,N/A,6551.06,N/A,6551.06,N/A,6551.06,N/A,11735.00,N/A,2688.04,N/A,3269.25,N/A,5277.50,N/A,5277.50,N/A,3269.25,N/A,2688.04,N/A,2792.70,N/A,566.87,N/A,N/A,566.87,14004.14,,Hospital 01712,"Anesth,Upperarm Tendon Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18624.20,N/A,11174.52,N/A,2607.39,N/A,2743.94,N/A,10722.76,N/A,6332.24,N/A,6512.67,N/A,2607.39,N/A,2688.04,N/A,2688.04,N/A,4054.27,N/A,6512.67,N/A,6512.67,N/A,6512.67,N/A,10722.77,N/A,2688.04,N/A,2607.39,N/A,4562.00,N/A,4562.00,N/A,2607.39,N/A,2688.04,N/A,2743.94,N/A,553.50,N/A,N/A,553.50,11174.52,,Hospital 01740,"Anesth,Elbow,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,89110.02,32690.72,53466.01,19614.43,10076.03,4576.71,12185.08,11782.94,30176.84,18711.21,30297.40,11114.85,22924.37,28518.25,10386.49,4576.71,2248.00,11782.94,2248.00,11782.94,14269.88,17753.16,22924.37,28518.25,22924.37,28518.25,22924.37,28518.25,30176.84,18711.20,12053.53,11782.94,10386.49,4576.71,27274.27,7897.00,27274.27,7897.00,N/A,4576.71,12185.08,11782.94,12185.08,11782.94,11113.55,12961.23,2248.00,53466.01,4576.71,28518.25,,Hospital 01742,"Anesth,Humerus Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,18893.10,N/A,11335.86,N/A,2645.04,N/A,2664.83,N/A,10875.37,N/A,6423.65,N/A,6553.46,N/A,2645.04,N/A,2688.04,N/A,2688.04,N/A,4079.67,N/A,6553.46,N/A,6553.46,N/A,6553.46,N/A,10875.38,N/A,2688.04,N/A,2645.04,N/A,7109.75,N/A,7109.75,N/A,2645.04,N/A,2688.04,N/A,2664.83,N/A,1852.59,N/A,N/A,1852.59,11335.86,,Hospital 01744,"Anesth,Humerus Repair",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,64658.37,N/A,38795.02,N/A,9052.17,N/A,11910.55,N/A,37109.42,N/A,21983.84,N/A,28605.23,N/A,9052.17,N/A,11782.94,N/A,11782.94,N/A,17807.29,N/A,28605.23,N/A,28605.23,N/A,28605.23,N/A,37109.43,N/A,11782.94,N/A,9052.17,N/A,8612.50,N/A,8612.50,N/A,9052.17,N/A,11782.94,N/A,11910.55,N/A,1014.77,N/A,N/A,1014.77,38795.02,,Hospital 01772,"Anesth,Upperarm Embolectomy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,38481.53,N/A,23088.92,N/A,5364.61,N/A,4855.12,N/A,22137.70,N/A,13083.72,N/A,11340.24,N/A,5364.61,N/A,4641.41,N/A,4641.41,N/A,7059.49,N/A,11340.24,N/A,11340.24,N/A,11340.24,N/A,22137.69,N/A,4641.41,N/A,5364.61,N/A,7897.00,N/A,7897.00,N/A,5364.61,N/A,4641.41,N/A,4855.12,N/A,741.17,N/A,N/A,741.17,23088.92,,Hospital 01780,"Anesth,Upper Arm Vein Surg",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,60280.40,N/A,36168.24,N/A,8396.27,N/A,4737.93,N/A,34696.20,N/A,20495.35,N/A,11327.09,N/A,8396.27,N/A,4641.41,N/A,4641.41,N/A,7051.33,N/A,11327.09,N/A,11327.09,N/A,11327.09,N/A,34696.21,N/A,4641.41,N/A,8396.27,N/A,7897.00,N/A,7897.00,N/A,8396.27,N/A,4641.41,N/A,4737.93,N/A,739.74,N/A,N/A,739.74,36168.24,,Hospital 01810,"Anesth,Lower Arm Surgery",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,28527.10,11090.30,17116.26,6654.18,9377.20,1552.64,11388.03,1623.23,21132.27,6383.79,9699.21,3770.70,21334.42,3945.79,9666.12,1552.64,58448.00,1623.23,58448.00,1623.23,13280.18,2456.34,21334.42,3945.79,21334.42,3945.79,21334.42,3945.79,21132.27,6383.79,11358.38,1623.23,9666.12,1552.64,25382.63,3397.00,25382.63,3397.00,2636.76,1552.64,633.51,1623.23,11388.03,1623.23,10342.75,1785.56,633.51,58448.00,1552.64,6654.18,,Hospital 01830,"Anesth,Distal Radius/Ulna Wrist/Hand,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,54047.28,25366.45,32428.37,15219.87,8570.07,3551.30,10403.59,2688.04,21219.14,14531.76,18376.08,8624.59,19498.09,6529.93,8834.13,3551.30,562.00,2688.04,562.00,2688.04,12137.11,4065.01,19498.09,6529.93,19498.09,6529.93,19498.09,6529.93,21219.14,14531.76,10403.59,2688.04,8834.13,3551.30,23197.86,9595.50,23197.86,9595.50,2987.65,3551.30,10403.59,2688.04,10403.59,2688.04,9452.52,2956.85,562.00,32428.37,2688.04,15219.87,,Hospital 01852,"Anesth,Lower Arm Vein Repair",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,34346.80,N/A,20608.08,N/A,4837.48,N/A,5935.46,N/A,19767.03,N/A,11677.90,N/A,13521.25,N/A,4837.48,N/A,5579.57,N/A,5579.57,N/A,8417.25,N/A,13521.25,N/A,13521.25,N/A,13521.25,N/A,19767.02,N/A,5579.57,N/A,4837.48,N/A,9384.50,N/A,9384.50,N/A,4837.48,N/A,5579.57,N/A,5935.46,N/A,4109.42,N/A,N/A,4109.42,20608.08,,Hospital 01860,"Anesth,Lower Arm Casting",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,16861.30,N/A,10116.78,N/A,2389.51,N/A,160.99,N/A,9706.91,N/A,5732.85,N/A,337.90,N/A,2389.51,N/A,156.16,N/A,156.16,N/A,212.38,N/A,337.90,N/A,337.90,N/A,337.90,N/A,9706.91,N/A,156.16,N/A,2389.51,N/A,527.00,N/A,527.00,N/A,2389.51,N/A,156.16,N/A,160.99,N/A,97.51,N/A,N/A,97.51,10116.78,,Hospital 01916,"Anesth,Dx Arteriography/Venography",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,31942.52,31378.68,19165.51,18827.21,3820.66,4298.75,4785.27,2690.13,9876.05,18065.73,10860.46,10668.75,9030.57,6539.59,3938.38,4298.75,4785.27,2690.13,4785.27,2690.13,5621.45,4071.01,9030.57,6539.59,9030.57,6539.59,9030.57,6539.59,9876.05,18065.74,4785.27,2690.13,3938.38,4298.75,10341.93,527.00,10341.93,527.00,N/A,4298.75,4785.27,2690.13,4785.27,2690.13,4214.06,2959.14,3820.66,19165.51,527.00,18827.21,,Hospital 01920,"Anesth,Cardiac Cath W/Coron Art & Vent",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,44537.12,26238.02,26722.27,15742.81,5869.15,3665.61,7238.19,2808.01,15223.45,11012.00,15142.62,8920.92,13872.42,6493.76,6049.99,3665.61,7208.54,2685.00,7208.54,2685.00,8635.47,4042.49,13872.42,6493.76,13872.42,6493.76,13872.42,6493.76,15223.45,11012.00,7208.54,2685.00,6049.99,3665.61,15886.89,5963.00,15886.89,5963.00,N/A,3665.61,4723.10,2685.00,7238.19,2808.01,6473.49,914.72,4723.10,26722.27,914.72,15742.81,,Hospital 01922,"Anesth,Cat/MRI Scan,Radiatn Therapy",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,9501.50,N/A,5700.90,N/A,1330.21,N/A,459.27,N/A,5469.82,N/A,3230.51,N/A,1115.80,N/A,1330.21,N/A,454.35,N/A,454.35,N/A,694.61,N/A,1115.80,N/A,1115.80,N/A,1115.80,N/A,5469.82,N/A,454.35,N/A,1330.21,N/A,5092.80,N/A,5092.80,N/A,1330.21,N/A,454.35,N/A,459.27,N/A,171.00,N/A,N/A,171.00,5700.90,,Hospital 01924,"Anesth,Inter Rad,Arterial Sys,Nos",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,106949.77,70902.32,64169.86,42541.39,19443.62,9899.99,23266.45,15512.06,58950.71,40312.79,36362.92,24106.78,44236.94,37570.18,20042.72,9899.99,2810.00,15512.06,2810.00,15512.06,27536.46,23388.15,44236.94,37570.18,44236.94,37570.18,44236.94,37570.18,58950.71,40312.79,23266.45,15512.06,10566.27,9899.99,52630.91,17490.00,52630.91,17490.00,10566.27,9899.99,23266.45,15512.06,23266.45,15512.06,21445.71,17063.27,2810.00,64169.86,9899.99,42541.39,,Hospital 01926,"Anesth,Inter Rad,Intracra/Intracar/Aort",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,186007.22,109896.72,111604.33,65938.03,26783.53,15386.43,31949.18,30299.94,102527.17,62487.68,63242.45,37364.87,64767.71,70108.05,27608.78,15386.43,31949.18,28966.21,31949.18,28966.21,40326.36,43643.63,64767.71,70108.05,64767.71,70108.05,64767.71,70108.05,102527.17,62487.68,31949.18,28966.21,27608.78,15386.43,72498.91,29766.00,72498.91,29766.00,10435.30,15386.43,31949.18,28966.21,31949.18,30299.94,29541.39,1012.91,10435.30,111604.33,1012.91,70108.05,,Hospital 01932,"Anesth,Inter Rad,Intrathoracic/Jugular",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,49525.10,42197.47,29715.06,25318.48,17835.24,5869.43,20283.77,2813.99,44641.30,24282.66,16838.53,14024.82,41933.75,6546.93,18384.77,5869.43,20254.12,2690.13,20254.12,2690.13,26103.42,4075.56,41933.75,6546.93,41933.75,6546.93,41933.75,6546.93,44641.30,24282.66,20254.12,2690.13,18384.77,5869.43,48023.11,6843.00,48023.11,6843.00,N/A,5869.43,20254.12,2690.13,9593.91,2813.99,19671.71,939.31,9593.91,48023.11,939.31,25318.48,,Hospital 01937,Anes Perq Img Njx Drg/Aspir Px Spi/Sp Crv/Thrc,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10094.50,N/A,6056.70,N/A,1413.23,N/A,785.56,N/A,5811.64,N/A,3432.13,N/A,1865.99,N/A,1413.23,N/A,769.55,N/A,769.55,N/A,1161.61,N/A,1865.99,N/A,1865.99,N/A,1865.99,N/A,5811.64,N/A,769.55,N/A,1413.23,N/A,1431.00,N/A,1431.00,N/A,1413.23,N/A,769.55,N/A,785.56,N/A,138.09,N/A,N/A,138.09,6056.70,,Hospital 01939,Anes Perq Img Dstrj Px Nulyt Agt Spi/Sp Crv/Thrc,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,10862.80,N/A,6517.68,N/A,1520.79,N/A,1656.99,N/A,6254.05,N/A,3693.35,N/A,3931.76,N/A,1520.79,N/A,1623.23,N/A,1623.23,N/A,2447.59,N/A,3931.76,N/A,3931.76,N/A,3931.76,N/A,6254.05,N/A,1623.23,N/A,1520.79,N/A,3660.50,N/A,3660.50,N/A,1520.79,N/A,1623.23,N/A,1656.99,N/A,273.17,N/A,N/A,273.17,6517.68,,Hospital 01942,Anes Perq Img Neuromd/Ntrvrt Px Spi/Sp Lmbr/Sac,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,68216.62,28070.88,40929.97,16842.53,7894.17,3929.93,9604.05,5973.28,26767.21,16144.66,23193.65,9544.10,17960.33,14504.22,8137.40,3929.93,1686.00,5973.28,1686.00,5973.28,11179.89,9029.14,17960.33,14504.22,17960.33,14504.22,17960.33,14504.22,26767.21,16144.67,9604.05,5973.28,8137.40,3929.93,21368.31,7897.00,21368.31,7897.00,2990.80,3929.93,9604.05,5973.28,9604.05,5973.28,8707.02,6570.60,1686.00,40929.97,3929.93,16842.53,,Hospital 01951,"Anesth,Burn Tx, <4% Tbsa",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,23558.30,N/A,14134.98,N/A,3298.18,N/A,2486.90,N/A,13561.99,N/A,8009.82,N/A,5671.90,N/A,3298.18,N/A,2337.78,N/A,2337.78,N/A,3530.86,N/A,5671.90,N/A,5671.90,N/A,5671.90,N/A,13562.00,N/A,2337.78,N/A,3298.18,N/A,2938.25,N/A,2938.25,N/A,3298.18,N/A,2337.78,N/A,2486.90,N/A,1471.36,N/A,N/A,1471.36,14134.98,,Hospital 01953,"Anesth,Burn Tx, Additional 9% Tbsa",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,40880.12,N/A,24528.07,N/A,5723.22,N/A,2445.42,N/A,23326.03,N/A,13899.24,N/A,6056.31,N/A,5723.22,N/A,2337.78,N/A,2337.78,N/A,3770.72,N/A,6056.31,N/A,6056.31,N/A,6056.31,N/A,23326.07,N/A,2337.78,N/A,5723.22,N/A,2806.50,N/A,2806.50,N/A,5723.22,N/A,2337.78,N/A,2445.42,N/A,351.76,N/A,N/A,351.76,24528.07,,Hospital 01958,"Anesth, Antepartum Manipul",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,12051.50,N/A,7230.90,N/A,1633.83,N/A,2606.39,N/A,6939.03,N/A,4097.17,N/A,6184.48,N/A,1633.83,N/A,2553.29,N/A,2553.29,N/A,3849.96,N/A,6184.48,N/A,6184.48,N/A,6184.48,N/A,6939.03,N/A,2553.29,N/A,1633.83,N/A,4680.60,N/A,4680.60,N/A,1633.83,N/A,2553.29,N/A,2606.39,N/A,182.69,N/A,N/A,182.69,7230.90,,Hospital 01961,"Anesth,Cesarean Delivery Only",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,36843.68,20660.90,22106.21,12396.54,4653.92,2858.03,5712.93,1190.57,11142.47,11894.02,12526.85,6308.61,7322.00,6920.57,4797.32,2858.03,5594.33,1166.10,5594.33,1166.10,4558.00,4319.01,7322.00,6920.57,7322.00,6920.57,7322.00,6920.57,11142.47,11894.03,5594.33,1166.10,4797.32,2858.03,12814.06,196.01,12814.06,196.01,1763.50,2858.03,5594.33,1166.10,5712.93,1190.57,1763.50,1259.76,1763.50,22106.21,196.01,12396.54,,Hospital 01965,"Anesth, Incomp/Missed Ab Proc",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,16805.90,10407.70,10083.54,6244.62,4618.71,1434.03,5729.34,2553.29,10408.65,5987.46,5714.00,3538.61,10508.21,6278.19,4761.03,1434.03,5729.34,2553.29,5729.34,2553.29,6541.12,3908.29,10508.21,6278.19,10508.21,6278.19,10508.21,6278.19,10408.65,5987.45,5729.34,2553.29,4761.03,1434.03,12502.15,3397.00,12502.15,3397.00,2808.62,1434.03,5729.34,2553.29,5729.34,2553.29,5094.30,2808.62,2808.62,12502.15,1434.03,6278.19,,Hospital 01966,"Anesth, Induced Ab Procedure",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,31821.50,N/A,19092.90,N/A,4454.53,N/A,2716.15,N/A,18131.12,N/A,10819.30,N/A,8963.92,N/A,4454.53,N/A,2553.29,N/A,2553.29,N/A,5580.19,N/A,8963.92,N/A,8963.92,N/A,8963.92,N/A,18131.12,N/A,2553.29,N/A,4454.53,N/A,3660.50,N/A,3660.50,N/A,4454.53,N/A,2553.29,N/A,2716.15,N/A,534.99,N/A,N/A,534.99,19092.90,,Hospital 01967,"Neuraxial Labor Anal/Anes, Plan Vag Del",N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,37158.80,N/A,22295.28,N/A,3722.50,N/A,4703.72,N/A,8831.36,N/A,12633.99,N/A,4696.00,N/A,3837.19,N/A,4674.07,N/A,4674.07,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,8831.36,N/A,4674.07,N/A,3837.19,N/A,10607.62,N/A,10607.62,N/A,112.79,N/A,4674.07,N/A,4703.72,N/A,4105.80,N/A,112.79,22295.28,N/A,N/A,,Hospital 0200T,HC Sacroplasty,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,121875.97,47893.50,73125.58,28736.10,12530.49,6705.09,15088.57,6097.50,67178.03,27178.52,41437.83,16283.79,28508.60,14465.88,12916.58,6705.09,15088.57,5973.28,15088.57,5973.28,17745.94,9005.29,28508.60,14465.88,28508.60,14465.88,28508.60,14465.88,67178.03,27178.53,15088.57,5973.28,12916.58,6705.09,33918.12,4562.00,33918.12,4562.00,N/A,6705.09,15088.57,5973.28,15088.57,6097.50,13820.74,N/A,12530.49,73125.58,4562.00,28736.10,,Hospital 0201T,HC Sacroplasty Bilat,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,67508.02,40123.32,40504.81,24073.99,25652.89,5617.27,N/A,6589.23,N/A,23069.34,22952.72,13641.93,N/A,14471.60,17144.75,5617.27,56200.00,5973.28,56200.00,5973.28,N/A,9008.86,N/A,14471.60,37840.74,14471.60,N/A,14471.60,38368.78,23069.34,19940.78,5973.28,17144.75,5617.27,45021.03,4562.00,45021.03,4562.00,17144.75,5617.27,19940.78,5973.28,20118.68,12.20,25652.89,13.42,17144.75,56200.00,12.20,24073.99,,Hospital CPT 0202U,HC Jfct Ds Dna/Rna 22 Trgt Sars-Cov 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,863.00,863.00,517.80,517.80,N/A,416.78,N/A,416.78,N/A,496.92,N/A,293.42,N/A,166.71,N/A,416.78,N/A,416.78,N/A,416.78,N/A,166.71,N/A,166.71,N/A,166.71,N/A,166.71,N/A,496.92,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,517.80,517.80,166.71,517.80,,Hospital CPT 0202U,HC So Jfct Ds Dna/Rna 22 Trgt Sars-Cov 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,745.00,745.00,447.00,447.00,N/A,416.78,N/A,416.78,N/A,428.97,N/A,253.30,N/A,166.71,N/A,416.78,N/A,416.78,N/A,416.78,N/A,166.71,N/A,166.71,N/A,166.71,N/A,166.71,N/A,428.97,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,447.00,447.00,166.71,458.46,,Hospital 0263T,Auto Bone Marrw Cell Rx Complt Bone Marrw Harvst,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51863.50,N/A,31118.10,N/A,7203.16,N/A,2811.81,N/A,29858.09,N/A,17633.59,N/A,6599.04,N/A,7203.16,N/A,2688.04,N/A,2688.04,N/A,4110.07,N/A,6599.04,N/A,6599.04,N/A,6599.04,N/A,29858.11,N/A,2688.04,N/A,7203.16,N/A,8711.75,N/A,8711.75,N/A,7203.16,N/A,2688.04,N/A,2811.81,N/A,1496.08,N/A,N/A,1496.08,31118.10,,Hospital 0275T,Perc Lamino-/Laminectomy Indir Imag Guide Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31275.00,N/A,18765.00,N/A,4371.69,N/A,6248.31,N/A,18006.22,N/A,10633.49,N/A,14520.30,N/A,4371.69,N/A,5973.28,N/A,5973.28,N/A,9039.15,N/A,14520.30,N/A,14520.30,N/A,14520.30,N/A,18006.22,N/A,5973.28,N/A,4371.69,N/A,7897.00,N/A,7897.00,N/A,4371.69,N/A,5973.28,N/A,6248.31,N/A,9.31,N/A,N/A,9.31,18765.00,,Hospital 0335T,Insertion of Sinus Tarsi Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31230.87,N/A,18738.52,N/A,4372.32,N/A,6248.31,N/A,17854.87,N/A,10618.50,N/A,14473.50,N/A,4372.32,N/A,5973.28,N/A,5973.28,N/A,9010.03,N/A,14473.50,N/A,14473.50,N/A,14473.50,N/A,17854.86,N/A,5973.28,N/A,4372.32,N/A,3397.00,N/A,3397.00,N/A,4372.32,N/A,5973.28,N/A,6248.31,N/A,20.49,N/A,N/A,20.49,18738.52,,Hospital 0355T,GI Tract Imaging Intraluminal Colon With I&R,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,6518.00,N/A,3910.80,N/A,912.52,N/A,1509.38,N/A,3753.06,N/A,2216.12,N/A,912.52,N/A,912.52,N/A,1509.38,N/A,1509.38,N/A,567.07,N/A,912.52,N/A,912.52,N/A,912.52,N/A,3753.06,N/A,1509.38,N/A,912.52,N/A,N/A,N/A,N/A,N/A,912.52,N/A,1509.38,N/A,1509.38,N/A,N/A,N/A,N/A,567.07,3910.80,,Hospital 0404T,Transcervical Uterine Fibroid Abltj W/US Gdn Rf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24064.07,N/A,14438.44,N/A,3360.11,N/A,6542.02,N/A,13854.93,N/A,8181.79,N/A,15144.30,N/A,3360.11,N/A,6254.06,N/A,6254.06,N/A,9427.62,N/A,15144.30,N/A,15144.30,N/A,15144.30,N/A,13854.93,N/A,6254.06,N/A,3360.11,N/A,5963.00,N/A,5963.00,N/A,3360.11,N/A,6254.06,N/A,6542.02,N/A,8.27,N/A,N/A,8.27,15144.30,,Hospital 0414T,HC Rmvl & Rpl Card Modulj Sys Pls Gen Only,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,246943.07,N/A,148165.84,N/A,26672.82,N/A,16942.11,N/A,136115.01,N/A,83960.64,N/A,85985.57,N/A,22952.58,N/A,2810.00,N/A,2810.00,N/A,53537.26,N/A,85985.57,N/A,85985.57,N/A,85985.57,N/A,136115.01,N/A,16942.11,N/A,22952.58,N/A,139272.93,N/A,139272.93,N/A,21086.89,N/A,16942.11,N/A,16942.11,N/A,24559.26,N/A,2810.00,148165.84,N/A,N/A,,Hospital 0421T,Transurethral Waterjet Ablation Prostate Compl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,61145.05,64706.13,36687.03,38823.68,7905.37,9051.74,12160.87,12314.52,17815.40,37253.99,20789.32,22000.10,17985.82,20656.41,8148.95,9051.74,159046.00,10657.93,159046.00,10657.93,11195.75,12856.93,17985.82,20656.41,17985.82,20656.41,17985.82,20656.41,17815.40,37001.81,9617.28,10657.93,8148.95,9051.74,21398.64,5963.00,21398.64,5963.00,N/A,9051.74,9617.28,10657.93,9646.93,12314.52,8719.38,34.46,7905.37,159046.00,34.46,38823.68,,Hospital CPT 0483T,HC Tmvi W/Prosthetic Valve Percutaneous Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,43173.00,43173.00,25903.80,25903.80,N/A,6044.22,N/A,43173.00,N/A,24859.01,N/A,14678.82,N/A,6044.22,N/A,6044.22,N/A,43173.00,N/A,43173.00,N/A,3756.05,N/A,6044.22,N/A,6044.22,N/A,6044.22,N/A,24859.01,N/A,43173.00,N/A,6044.22,N/A,43173.00,N/A,43173.00,N/A,6044.22,N/A,43173.00,N/A,43173.00,N/A,43173.00,25903.80,25903.80,3756.05,43173.00,,Hospital 0517T,HC Insertion Wrls Car Stimulator Lv Pacg Pg Compnt,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,282134.53,N/A,169280.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,169280.72,169280.72,N/A,N/A,,Hospital 0523T,HC Intrapx Coronary Ffr W/3d Funcjl Map,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,75684.32,N/A,45410.59,N/A,11314.73,N/A,13650.39,N/A,25498.66,N/A,25732.67,N/A,26743.69,N/A,11663.36,N/A,13650.39,N/A,13650.39,N/A,16647.73,N/A,26743.69,N/A,26743.69,N/A,26743.69,N/A,25498.66,N/A,13650.39,N/A,11663.36,N/A,30627.24,N/A,30627.24,N/A,N/A,N/A,13650.39,N/A,13650.39,N/A,12479.79,N/A,11314.73,45410.59,N/A,N/A,,Hospital 0527T,HC Insertion/Rplcmt Iims Implantable Mntr Only,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,N/A,48781.60,N/A,29268.96,N/A,6825.14,N/A,7987.43,N/A,27843.65,N/A,16585.74,N/A,17830.58,N/A,6825.14,N/A,7371.31,N/A,7371.31,N/A,11099.88,N/A,17830.58,N/A,17830.58,N/A,17830.58,N/A,27843.65,N/A,7371.31,N/A,6825.14,N/A,17490.00,N/A,17490.00,N/A,6825.14,N/A,7371.31,N/A,7987.43,N/A,96.04,N/A,N/A,96.04,29268.96,,Hospital 0537T,HC Car-T Therapy Hrvg Bld Drv T Lmphcyt PR Day,N/A,0871 - CELL/GENE THERAPY - CELL COLLECTION,N/A,3823.00,N/A,2293.80,N/A,539.60,N/A,109.68,N/A,2201.30,N/A,1299.82,N/A,701.50,N/A,539.60,N/A,104.85,N/A,104.85,N/A,436.20,N/A,701.50,N/A,701.50,N/A,701.50,N/A,2201.30,N/A,104.85,N/A,539.60,N/A,32.80,N/A,32.80,N/A,539.60,N/A,104.85,N/A,109.68,N/A,94.28,N/A,N/A,32.80,2293.80,,Hospital 0539T,HC Cart-T Therapy Receipt & Prep Car-T Cells F/Admin,N/A,0873 - CELL/GENE THERAPY - STORAGE & PROCESSING AFTER RECEIPT OF CELLS FROM R,2891559.10,2549521.00,1734935.46,1529712.60,545805.04,356893.53,N/A,449754.20,1593827.38,1468014.05,983130.09,866837.14,1006840.88,1233.46,523118.19,356893.53,516730.31,449740.37,516730.31,449740.37,626890.01,767.30,N/A,1233.46,1006840.88,1233.46,1006840.88,1233.46,1593827.38,1468008.44,516730.31,449740.37,523118.19,356893.53,1393724.34,71.75,1393724.34,71.75,N/A,356893.53,516730.31,449740.37,516730.31,449754.20,559736.46,108.03,516730.31,1734935.46,71.75,1529712.60,,Hospital 0546T,Rf Spectrsc R-T Intraop Mrgn Assmt at Prtl Mast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36676.97,N/A,22006.18,N/A,5134.15,N/A,5920.33,N/A,20959.69,N/A,12470.16,N/A,13001.30,N/A,5134.15,N/A,5366.90,N/A,5366.90,N/A,8093.56,N/A,13001.30,N/A,13001.30,N/A,13001.30,N/A,20959.71,N/A,5366.90,N/A,5134.15,N/A,11455.00,N/A,11455.00,N/A,5134.15,N/A,5366.90,N/A,1604.45,N/A,1764.89,N/A,N/A,1604.45,22006.18,,Hospital 0565T,Autol Cell Implt Adps Tiss Hrvg Cell Implt Crtj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34533.50,N/A,20720.10,N/A,4834.69,N/A,82.07,N/A,19878.18,N/A,11741.39,N/A,2748.80,N/A,4834.69,N/A,78.46,N/A,78.46,N/A,1708.51,N/A,2748.80,N/A,2748.80,N/A,2748.80,N/A,19878.19,N/A,78.46,N/A,4834.69,N/A,527.00,N/A,527.00,N/A,4834.69,N/A,78.46,N/A,82.07,N/A,25.78,N/A,N/A,25.78,20720.10,,Hospital 0650T,Prgrmg Dev Eval Scrms Phys/Qhp Remote,N/A,N/A,N/A,195.00,N/A,117.00,N/A,27.30,N/A,32.45,N/A,112.28,N/A,66.30,N/A,76.46,N/A,27.30,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,112.28,N/A,31.61,N/A,27.30,N/A,104.52,N/A,104.52,N/A,27.30,N/A,31.61,N/A,32.45,N/A,N/A,N/A,N/A,27.30,117.00,,Hospital 0673T,Abltj B9 Thyr Ndul Perq Lasr,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,26593.52,N/A,15956.11,N/A,3723.09,N/A,31.38,N/A,15306.44,N/A,9041.79,N/A,3283.44,N/A,3723.09,N/A,1354.15,N/A,1354.15,N/A,2044.00,N/A,3283.44,N/A,3283.44,N/A,3283.44,N/A,15306.44,N/A,1354.15,N/A,3723.09,N/A,1871.00,N/A,1871.00,N/A,3723.09,N/A,1354.15,N/A,31.38,N/A,34.52,N/A,N/A,31.38,15956.11,,Hospital CPT 0715T,HC Perq Trluml Coronry Lithotrp,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13288.00,13288.00,7972.80,7972.80,N/A,1860.32,N/A,13288.00,N/A,7651.23,N/A,4517.92,N/A,13288.00,N/A,1860.32,N/A,13288.00,N/A,13288.00,N/A,13288.00,N/A,13288.00,N/A,13288.00,N/A,13288.00,N/A,7651.23,N/A,13288.00,N/A,1860.32,N/A,527.00,N/A,527.00,N/A,1860.32,N/A,13288.00,N/A,13288.00,N/A,13288.00,7972.80,7972.80,527.00,13288.00,,Hospital CPT 0715T,Percutaneous Transluminal Coronary Lithotripsy,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 10005,HC Fna Bx W/US Gdn 1st Les,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1352.00,1352.00,811.20,811.20,N/A,189.28,N/A,586.05,N/A,778.48,N/A,459.68,N/A,1352.00,N/A,189.28,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1352.00,N/A,1352.00,N/A,1352.00,N/A,778.48,N/A,586.05,N/A,189.28,N/A,1431.00,N/A,1431.00,N/A,189.28,N/A,586.05,N/A,586.05,N/A,644.65,811.20,811.20,189.28,1431.00,,Hospital CPT 10006,HC Fna Bx W/US Gdn Ea Addl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1352.00,1352.00,811.20,811.20,N/A,189.28,N/A,1352.00,N/A,778.48,N/A,459.68,N/A,1352.00,N/A,189.28,N/A,1352.00,N/A,1352.00,N/A,1352.00,N/A,1352.00,N/A,1352.00,N/A,1352.00,N/A,778.48,N/A,1352.00,N/A,189.28,N/A,527.00,N/A,527.00,N/A,189.28,N/A,1352.00,N/A,48.90,N/A,53.79,811.20,811.20,48.90,1352.00,,Hospital 10007,HC Fna Bx W/Fluor Gdn 1st Les,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,149982.85,3305.00,89989.71,1983.00,N/A,462.70,N/A,606.14,82670.55,1903.01,49978.79,1123.70,59483.44,1417.60,N/A,462.70,N/A,586.05,N/A,586.05,37027.06,882.49,59483.44,1417.60,59483.44,1417.60,59483.44,1417.60,N/A,1903.01,N/A,586.05,N/A,462.70,70770.44,1431.00,70770.44,1431.00,N/A,462.70,N/A,586.05,N/A,606.14,18023.18,234.22,18023.18,89989.71,234.22,1983.00,,Hospital 10008,HC Fna Bx W/Fluor Gdn Ea Addl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,5087.00,N/A,3052.20,N/A,712.18,N/A,333.24,N/A,2929.10,N/A,1306.62,N/A,1417.60,N/A,712.18,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,2929.10,N/A,586.05,N/A,712.18,N/A,1694.50,N/A,1694.50,N/A,712.18,N/A,586.05,N/A,333.24,N/A,366.57,N/A,N/A,333.24,3052.20,,Hospital CPT 10021,HC Fna W/O Guidance,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,392.00,392.00,235.20,235.20,N/A,54.88,N/A,371.64,N/A,225.71,N/A,133.28,N/A,392.00,N/A,54.88,N/A,336.90,N/A,336.90,N/A,392.00,N/A,392.00,N/A,392.00,N/A,392.00,N/A,225.71,N/A,336.90,N/A,54.88,N/A,527.00,N/A,527.00,N/A,54.88,N/A,336.90,N/A,52.61,N/A,57.87,235.20,235.20,52.61,527.00,,Hospital CPT 10021,HC Fna WO Imaging Guidance,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,392.00,392.00,235.20,235.20,N/A,54.88,N/A,371.64,N/A,225.71,N/A,133.28,N/A,392.00,N/A,54.88,N/A,336.90,N/A,336.90,N/A,392.00,N/A,392.00,N/A,392.00,N/A,392.00,N/A,225.71,N/A,336.90,N/A,54.88,N/A,392.00,N/A,392.00,N/A,54.88,N/A,336.90,N/A,52.61,N/A,57.87,235.20,235.20,52.61,392.00,,Hospital CPT 10030,HC Guide Cathet Fluid Drainage,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1745.00,1745.00,1047.00,1047.00,N/A,244.30,N/A,613.03,N/A,1004.77,N/A,593.30,N/A,1417.60,N/A,244.30,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1004.77,N/A,586.05,N/A,244.30,N/A,1431.00,N/A,1431.00,N/A,244.30,N/A,586.05,N/A,130.59,N/A,143.65,1047.00,1047.00,130.59,1431.00,,Hospital CPT 10036,HC Perq Dev Soft Tiss Add Imag,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1745.00,1745.00,1047.00,1047.00,N/A,244.30,N/A,41.30,N/A,1004.77,N/A,593.30,N/A,831.90,N/A,244.30,N/A,41.30,N/A,41.30,N/A,517.86,N/A,831.90,N/A,831.90,N/A,831.90,N/A,1004.77,N/A,41.30,N/A,244.30,N/A,1745.00,N/A,1745.00,N/A,244.30,N/A,41.30,N/A,41.30,N/A,45.43,1047.00,1047.00,41.30,1745.00,,Hospital CPT 10060,HC I & D Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1768.00,1768.00,1060.80,1060.80,N/A,247.52,N/A,162.24,N/A,1018.01,N/A,601.12,N/A,394.46,N/A,247.52,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,1018.01,N/A,163.07,N/A,247.52,N/A,1768.00,N/A,1768.00,N/A,247.52,N/A,163.07,N/A,172.81,N/A,107.78,1060.80,1060.80,107.78,1768.00,,Hospital CPT 10060,HC I&D Simple,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1768.00,1768.00,1060.80,1060.80,N/A,247.52,N/A,162.24,N/A,1018.01,N/A,601.12,N/A,394.46,N/A,247.52,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,1018.01,N/A,163.07,N/A,247.52,N/A,947.65,N/A,947.65,N/A,247.52,N/A,163.07,N/A,172.81,N/A,107.78,1060.80,1060.80,107.78,1060.80,,Hospital CPT 10060,HC Incision & Drainage-Simple,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1768.00,1768.00,1060.80,1060.80,N/A,247.52,N/A,162.24,N/A,1018.01,N/A,601.12,N/A,394.46,N/A,247.52,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,1018.01,N/A,163.07,N/A,247.52,N/A,527.00,N/A,527.00,N/A,247.52,N/A,163.07,N/A,172.81,N/A,107.78,1060.80,1060.80,107.78,1060.80,,Hospital CPT 10061,HC I&D Abcess Complic Multiple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1893.00,1893.00,1135.80,1135.80,N/A,265.02,N/A,350.01,N/A,1089.99,N/A,643.62,N/A,814.92,N/A,265.02,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1089.99,N/A,336.90,N/A,265.02,N/A,1893.00,N/A,1893.00,N/A,265.02,N/A,336.90,N/A,350.01,N/A,190.33,1135.80,1135.80,190.33,1893.00,,Hospital CPT 10061,HC Incision & Drainage-Comlex,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1893.00,1893.00,1135.80,1135.80,N/A,265.02,N/A,350.01,N/A,1089.99,N/A,643.62,N/A,814.92,N/A,265.02,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1089.99,N/A,336.90,N/A,265.02,N/A,527.00,N/A,527.00,N/A,265.02,N/A,336.90,N/A,350.01,N/A,190.33,1135.80,1135.80,190.33,1135.80,,Hospital CPT 10081,HC Drain Pilonidal Cyst,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2020.00,2020.00,1212.00,1212.00,N/A,282.80,N/A,621.05,N/A,1163.12,N/A,686.80,N/A,1417.60,N/A,282.80,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1163.12,N/A,586.05,N/A,282.80,N/A,2020.00,N/A,2020.00,N/A,282.80,N/A,586.05,N/A,621.05,N/A,178.87,1212.00,1212.00,178.87,2020.00,,Hospital CPT 10120,HC Removal FB Skin,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1485.00,1485.00,891.00,891.00,N/A,207.90,N/A,357.02,N/A,855.06,N/A,504.90,N/A,814.92,N/A,207.90,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,855.06,N/A,336.90,N/A,207.90,N/A,1485.00,N/A,1485.00,N/A,207.90,N/A,336.90,N/A,357.02,N/A,106.46,891.00,891.00,106.46,1485.00,,Hospital CPT 10120,Incision & Removal Foreign Body Subq Tiss Simple,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,252.00,252.00,151.20,151.20,N/A,35.28,N/A,357.02,N/A,145.10,N/A,85.68,N/A,252.00,N/A,35.28,N/A,336.90,N/A,336.90,N/A,252.00,N/A,252.00,N/A,252.00,N/A,252.00,N/A,145.10,N/A,336.90,N/A,35.28,N/A,252.00,N/A,252.00,N/A,35.28,N/A,336.90,N/A,357.02,N/A,106.46,151.20,151.20,35.28,357.02,,Hospital CPT 10121,HC Remove FB,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4290.00,4290.00,2574.00,2574.00,N/A,600.60,N/A,174.55,N/A,2470.18,N/A,1458.60,N/A,739.05,N/A,600.60,N/A,174.55,N/A,174.55,N/A,460.06,N/A,739.05,N/A,739.05,N/A,739.05,N/A,2470.18,N/A,174.55,N/A,600.60,N/A,4290.00,N/A,4290.00,N/A,600.60,N/A,174.55,N/A,174.55,N/A,192.01,2574.00,2574.00,174.55,4290.00,,Hospital CPT 10121,HC Incise & Rmvl FB Sq Complic,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4290.00,4290.00,2574.00,2574.00,N/A,600.60,N/A,174.55,N/A,2470.18,N/A,1458.60,N/A,739.05,N/A,600.60,N/A,174.55,N/A,174.55,N/A,460.06,N/A,739.05,N/A,739.05,N/A,739.05,N/A,2470.18,N/A,174.55,N/A,600.60,N/A,4290.00,N/A,4290.00,N/A,600.60,N/A,174.55,N/A,174.55,N/A,192.01,2574.00,2574.00,174.55,4290.00,,Hospital CPT 10140,HC I&D Hematoma Seroma Fluid,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,6009.00,6009.00,3605.40,3605.40,N/A,841.26,N/A,1467.34,N/A,3459.98,N/A,2043.06,N/A,3275.59,N/A,841.26,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3459.98,N/A,1354.15,N/A,841.26,N/A,6009.00,N/A,6009.00,N/A,841.26,N/A,1354.15,N/A,1390.32,N/A,122.33,3605.40,3605.40,122.33,6009.00,,Hospital CPT 10140,HC Evacuation of Hematoma,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6009.00,6009.00,3605.40,3605.40,N/A,841.26,N/A,1467.34,N/A,3459.98,N/A,2043.06,N/A,3275.59,N/A,841.26,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3459.98,N/A,1354.15,N/A,841.26,N/A,1871.00,N/A,1871.00,N/A,841.26,N/A,1354.15,N/A,1390.32,N/A,122.33,3605.40,3605.40,122.33,3605.40,,Hospital CPT 10160,HC Puncture Drainage of Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,933.00,933.00,559.80,559.80,N/A,130.62,N/A,336.90,N/A,537.22,N/A,317.22,N/A,814.92,N/A,130.62,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,537.22,N/A,336.90,N/A,130.62,N/A,933.00,N/A,933.00,N/A,130.62,N/A,336.90,N/A,336.90,N/A,370.59,559.80,559.80,130.62,933.00,,Hospital CPT 10160,HC Punct Aspir Abcess/Hemat/Cyst,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,933.00,933.00,559.80,559.80,N/A,130.62,N/A,336.90,N/A,537.22,N/A,317.22,N/A,814.92,N/A,130.62,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,537.22,N/A,336.90,N/A,130.62,N/A,527.00,N/A,527.00,N/A,130.62,N/A,336.90,N/A,336.90,N/A,370.59,559.80,559.80,130.62,814.92,,Hospital CPT 10160,HC Puncture/Aspiration Hematoma,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,933.00,933.00,559.80,559.80,N/A,130.62,N/A,336.90,N/A,537.22,N/A,317.22,N/A,814.92,N/A,130.62,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,537.22,N/A,336.90,N/A,130.62,N/A,527.00,N/A,527.00,N/A,130.62,N/A,336.90,N/A,336.90,N/A,370.59,559.80,559.80,130.62,814.92,,Hospital 11008,Removal Prosthetic Matrl Abdl Wall for Infection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18725.80,N/A,11235.48,N/A,2621.61,N/A,2440.19,N/A,10769.80,N/A,6366.77,N/A,6601.77,N/A,2621.61,N/A,2332.78,N/A,2332.78,N/A,4109.63,N/A,6601.77,N/A,6601.77,N/A,6601.77,N/A,10769.80,N/A,2332.78,N/A,2621.61,N/A,6260.50,N/A,6260.50,N/A,2621.61,N/A,2332.78,N/A,2440.19,N/A,485.87,N/A,N/A,485.87,11235.48,,Hospital 11010,Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15025.80,N/A,9015.48,N/A,2156.29,N/A,2674.29,N/A,8651.31,N/A,5108.77,N/A,6510.03,N/A,2156.29,N/A,2688.04,N/A,2688.04,N/A,4052.62,N/A,6510.03,N/A,6510.03,N/A,6510.03,N/A,8651.31,N/A,2688.04,N/A,2156.29,N/A,5453.25,N/A,5453.25,N/A,2156.29,N/A,2688.04,N/A,2674.29,N/A,1366.29,N/A,N/A,1366.29,9015.48,,Hospital CPT 11042,Debridement Subcutaneous Tissue 20 Sq Cm/<,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,214.00,214.00,128.40,128.40,N/A,29.96,N/A,336.90,N/A,123.22,N/A,72.76,N/A,214.00,N/A,29.96,N/A,336.90,N/A,336.90,N/A,214.00,N/A,214.00,N/A,214.00,N/A,214.00,N/A,123.22,N/A,336.90,N/A,29.96,N/A,214.00,N/A,214.00,N/A,29.96,N/A,336.90,N/A,336.90,N/A,370.59,128.40,128.40,29.96,370.59,,Hospital CPT 11042,HC Debride Skin and Subcu,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3185.00,3185.00,1911.00,1911.00,N/A,445.90,N/A,336.90,N/A,1833.92,N/A,1082.90,N/A,814.92,N/A,445.90,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1833.92,N/A,336.90,N/A,445.90,N/A,3185.00,N/A,3185.00,N/A,445.90,N/A,336.90,N/A,336.90,N/A,370.59,1911.00,1911.00,336.90,3185.00,,Hospital CPT 11042,HC Debride Subq First 20 Sq Cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3185.00,3185.00,1911.00,1911.00,N/A,445.90,N/A,336.90,N/A,1833.92,N/A,1082.90,N/A,814.92,N/A,445.90,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1833.92,N/A,336.90,N/A,445.90,N/A,527.00,N/A,527.00,N/A,445.90,N/A,336.90,N/A,336.90,N/A,370.59,1911.00,1911.00,336.90,1911.00,,Hospital CPT 11045,"HC Debrid,Subq Ea Addt'l 20sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2292.00,2292.00,1375.20,1375.20,N/A,320.88,N/A,2292.00,N/A,1319.73,N/A,779.28,N/A,2292.00,N/A,320.88,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,2292.00,N/A,1319.73,N/A,2292.00,N/A,320.88,N/A,527.00,N/A,527.00,N/A,320.88,N/A,2292.00,N/A,2292.00,N/A,2292.00,1375.20,1375.20,320.88,2292.00,,Hospital CPT 11056,HC Paring of Callus 2-4 Lesions,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,805.00,805.00,483.00,483.00,N/A,112.70,N/A,172.81,N/A,463.52,N/A,273.70,N/A,394.46,N/A,112.70,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,463.52,N/A,163.07,N/A,112.70,N/A,527.00,N/A,527.00,N/A,112.70,N/A,163.07,N/A,172.81,N/A,23.94,483.00,483.00,23.94,527.00,,Hospital CPT 11103,HC Tangential Biopsy Skin Ea Sep/Additional Lesion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,1257.00,N/A,723.78,N/A,427.38,N/A,1257.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,1257.00,N/A,723.78,N/A,1257.00,N/A,175.98,N/A,527.00,N/A,527.00,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,23.00,754.20,754.20,23.00,1257.00,,Hospital CPT 11103,HC Tangential Biopsy Skin Ea Sep/Additional Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,763.00,763.00,457.80,457.80,N/A,106.82,N/A,763.00,N/A,439.34,N/A,259.42,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,763.00,N/A,439.34,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,106.82,N/A,763.00,N/A,763.00,N/A,23.00,457.80,457.80,23.00,763.00,,Hospital CPT 11104,HC Punch Biopsy Skin Single Lesion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,336.90,N/A,723.78,N/A,427.38,N/A,814.92,N/A,175.98,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,723.78,N/A,336.90,N/A,175.98,N/A,527.00,N/A,527.00,N/A,175.98,N/A,336.90,N/A,336.90,N/A,370.59,754.20,754.20,175.98,814.92,,Hospital CPT 11104,HC Punch Biopsy Skin Single Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,336.90,N/A,723.78,N/A,427.38,N/A,814.92,N/A,175.98,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,723.78,N/A,336.90,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,175.98,N/A,336.90,N/A,336.90,N/A,370.59,754.20,754.20,175.98,1257.00,,Hospital CPT 11300,HC Shaving Les Tr/AR/Le .5 Cm-<,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,436.00,436.00,261.60,261.60,N/A,61.04,N/A,350.01,N/A,251.05,N/A,148.24,N/A,436.00,N/A,61.04,N/A,336.90,N/A,336.90,N/A,436.00,N/A,436.00,N/A,436.00,N/A,436.00,N/A,251.05,N/A,336.90,N/A,61.04,N/A,436.00,N/A,436.00,N/A,61.04,N/A,336.90,N/A,350.01,N/A,35.96,261.60,261.60,35.96,436.00,,Hospital 11301,HC Shaving Les 0.6 to 1.0 Cm,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,451.00,N/A,270.60,N/A,63.14,N/A,173.47,N/A,259.69,N/A,153.34,N/A,N/A,N/A,63.14,N/A,163.07,N/A,163.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,259.69,N/A,163.07,N/A,63.14,N/A,241.74,N/A,241.74,N/A,63.14,N/A,163.07,N/A,173.47,N/A,53.64,N/A,N/A,53.64,270.60,,Hospital 11303,"HC Shav Skin Les >21mm Trunk,Arm,Leg",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,933.00,N/A,559.80,N/A,130.62,N/A,350.01,N/A,537.22,N/A,317.22,N/A,N/A,N/A,130.62,N/A,336.90,N/A,336.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,537.22,N/A,336.90,N/A,130.62,N/A,500.09,N/A,500.09,N/A,130.62,N/A,336.90,N/A,350.01,N/A,74.18,N/A,N/A,74.18,559.80,,Hospital CPT 11305,Shaving Skin Lesion 1 S/N/H/F/G Diam 0.5 Cm/<,N/A,N/A,178.00,178.00,106.80,106.80,N/A,24.92,N/A,37.19,N/A,178.00,N/A,60.52,N/A,178.00,N/A,24.92,N/A,37.19,N/A,37.19,N/A,178.00,N/A,178.00,N/A,178.00,N/A,178.00,N/A,178.00,N/A,37.19,N/A,24.92,N/A,178.00,N/A,178.00,N/A,24.92,N/A,37.19,N/A,37.19,N/A,40.91,106.80,106.80,24.92,178.00,,Hospital 11307,Shaving Skin Lesion 1 S/N/H/F/G Diam 1.1-2.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45695.92,N/A,27417.55,N/A,6397.42,N/A,1069.56,N/A,26281.36,N/A,15536.61,N/A,3020.96,N/A,6397.42,N/A,1063.21,N/A,1063.21,N/A,1910.93,N/A,3020.96,N/A,3020.96,N/A,3020.96,N/A,26281.37,N/A,1063.21,N/A,6397.42,N/A,790.50,N/A,790.50,N/A,6397.42,N/A,1063.21,N/A,1069.56,N/A,1131.10,N/A,N/A,790.50,27417.55,,Hospital 11310,HC Shaving Les Fa/Ie/No 0.5cm,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,18633.50,N/A,11180.10,N/A,2608.69,N/A,1674.16,N/A,10726.81,N/A,6335.39,N/A,3983.44,N/A,2608.69,N/A,1640.06,N/A,1640.06,N/A,2479.76,N/A,3983.44,N/A,3983.44,N/A,3983.44,N/A,10726.81,N/A,1640.06,N/A,2608.69,N/A,2134.50,N/A,2134.50,N/A,2608.69,N/A,1640.06,N/A,1674.16,N/A,952.26,N/A,N/A,952.26,11180.10,,Hospital 11312,HC Shave Lesion Face Dia 1.1-2.0,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,18597.30,N/A,11158.38,N/A,2603.62,N/A,3170.67,N/A,10706.76,N/A,6323.08,N/A,7525.88,N/A,2603.62,N/A,3106.08,N/A,3106.08,N/A,4685.00,N/A,7525.88,N/A,7525.88,N/A,7525.88,N/A,10706.77,N/A,3106.08,N/A,2603.62,N/A,4825.50,N/A,4825.50,N/A,2603.62,N/A,3106.08,N/A,3170.67,N/A,830.01,N/A,N/A,830.01,11158.38,,Hospital CPT 11400,HC Exc Tr-Ext B9+Marg 0.5 Cm<,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,613.03,N/A,1017.44,N/A,600.78,N/A,1417.60,N/A,247.38,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1017.44,N/A,586.05,N/A,247.38,N/A,1767.00,N/A,1767.00,N/A,247.38,N/A,586.05,N/A,613.03,N/A,85.36,1060.20,1060.20,85.36,1767.00,,Hospital CPT 11401,Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,257.00,257.00,154.20,154.20,N/A,35.98,N/A,357.02,N/A,147.98,N/A,87.38,N/A,257.00,N/A,35.98,N/A,336.90,N/A,336.90,N/A,257.00,N/A,257.00,N/A,257.00,N/A,257.00,N/A,147.98,N/A,336.90,N/A,35.98,N/A,257.00,N/A,257.00,N/A,35.98,N/A,336.90,N/A,357.02,N/A,108.66,154.20,154.20,35.98,357.02,,Hospital CPT 11401,HC Exc Tr-Ext B9+Marg 0.6-1 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3279.00,3279.00,1967.40,1967.40,N/A,459.06,N/A,357.02,N/A,1888.05,N/A,1114.86,N/A,814.92,N/A,459.06,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1888.05,N/A,336.90,N/A,459.06,N/A,3279.00,N/A,3279.00,N/A,459.06,N/A,336.90,N/A,357.02,N/A,108.66,1967.40,1967.40,108.66,3279.00,,Hospital CPT 11401,HC Exc Tr-Ext B9+Marg 0.6-1 Cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3279.00,3279.00,1967.40,1967.40,N/A,459.06,N/A,357.02,N/A,1888.05,N/A,1114.86,N/A,814.92,N/A,459.06,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1888.05,N/A,336.90,N/A,459.06,N/A,527.00,N/A,527.00,N/A,459.06,N/A,336.90,N/A,357.02,N/A,108.66,1967.40,1967.40,108.66,1967.40,,Hospital CPT 11402,Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,283.00,283.00,169.80,169.80,N/A,39.62,N/A,608.86,N/A,162.95,N/A,96.22,N/A,283.00,N/A,39.62,N/A,586.05,N/A,586.05,N/A,283.00,N/A,283.00,N/A,283.00,N/A,283.00,N/A,162.95,N/A,586.05,N/A,39.62,N/A,283.00,N/A,283.00,N/A,39.62,N/A,586.05,N/A,608.86,N/A,119.38,169.80,169.80,39.62,608.86,,Hospital CPT 11403,Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,326.00,326.00,195.60,195.60,N/A,45.64,N/A,621.05,N/A,187.71,N/A,110.84,N/A,326.00,N/A,45.64,N/A,586.05,N/A,586.05,N/A,326.00,N/A,326.00,N/A,326.00,N/A,326.00,N/A,187.71,N/A,586.05,N/A,45.64,N/A,326.00,N/A,326.00,N/A,45.64,N/A,586.05,N/A,621.05,N/A,152.67,195.60,195.60,45.64,621.05,,Hospital 11404,"HC Exc Lesion 3.1 - 4.0 Cm Trunk, Arms, or Legs",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,13594.60,N/A,8156.76,N/A,1896.38,N/A,1354.15,N/A,7825.60,N/A,4622.17,N/A,3301.56,N/A,1896.38,N/A,1354.15,N/A,1354.15,N/A,2055.29,N/A,3301.56,N/A,3301.56,N/A,3301.56,N/A,7825.62,N/A,1354.15,N/A,1896.38,N/A,1871.00,N/A,1871.00,N/A,1896.38,N/A,1354.15,N/A,1354.15,N/A,1489.57,N/A,N/A,1354.15,8156.76,,Hospital 11406,HC Excis Benign Les > 4.0cm,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,79445.82,15249.90,47667.49,9149.94,8404.69,2134.98,10207.96,1354.15,18940.66,8774.28,27011.57,5184.96,19121.84,3397.73,8663.66,2134.98,5405.73,1354.15,5405.73,1354.15,11902.90,2115.16,19121.84,3397.73,19121.84,3397.73,19121.84,3397.73,18940.66,8774.29,10207.96,1354.15,8663.66,2134.98,22750.22,1871.00,22750.22,1871.00,N/A,2134.98,10207.96,1354.15,10207.96,1354.15,9270.11,1489.57,5405.73,47667.49,1354.15,9149.94,,Hospital CPT 11420,Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,N/A,N/A,212.00,212.00,127.20,127.20,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,127.20,127.20,127.20,212.00,,Hospital CPT 11420,HC Exc Sebaceous Cyst,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4914.00,4914.00,2948.40,2948.40,N/A,687.96,N/A,1406.88,N/A,2829.48,N/A,1670.76,N/A,3275.59,N/A,687.96,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2829.48,N/A,1354.15,N/A,687.96,N/A,1431.00,N/A,1431.00,N/A,687.96,N/A,1354.15,N/A,1406.88,N/A,84.70,2948.40,2948.40,84.70,3275.59,,Hospital CPT 11420,HC Excis Benign Lesion 0.5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4914.00,4914.00,2948.40,2948.40,N/A,687.96,N/A,1406.88,N/A,2829.48,N/A,1670.76,N/A,3275.59,N/A,687.96,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2829.48,N/A,1354.15,N/A,687.96,N/A,4914.00,N/A,4914.00,N/A,687.96,N/A,1354.15,N/A,1406.88,N/A,84.70,2948.40,2948.40,84.70,4914.00,,Hospital 11421,HC Exc Skin Benig 0.6-1cm Remaindr Body,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,11165.30,N/A,6699.18,N/A,1564.18,N/A,1842.07,N/A,6425.69,N/A,3796.20,N/A,4521.01,N/A,1564.18,N/A,1851.54,N/A,1851.54,N/A,2814.40,N/A,4521.01,N/A,4521.01,N/A,4521.01,N/A,6425.69,N/A,1851.54,N/A,1564.18,N/A,2586.50,N/A,2586.50,N/A,1564.18,N/A,1851.54,N/A,1842.07,N/A,964.45,N/A,N/A,964.45,6699.18,,Hospital CPT 11426,Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,N/A,N/A,553.00,553.00,331.80,331.80,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,N/A,553.00,331.80,331.80,331.80,553.00,,Hospital 11441,"HC Exc Lesion 0.6 - 1.0 Cm - Face, Ears, Eyelids, Nose, Lips, Mucous Membr",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,11522.80,N/A,6913.68,N/A,1613.19,N/A,802.62,N/A,6633.62,N/A,3917.75,N/A,1833.43,N/A,1613.19,N/A,754.50,N/A,754.50,N/A,1141.35,N/A,1833.43,N/A,1833.43,N/A,1833.43,N/A,6633.62,N/A,754.50,N/A,1613.19,N/A,1694.50,N/A,1694.50,N/A,1613.19,N/A,754.50,N/A,802.62,N/A,339.99,N/A,N/A,339.99,6913.68,,Hospital 11444,Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 3.1-4.0cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16049.08,N/A,9629.45,N/A,2223.17,N/A,399.40,N/A,9238.03,N/A,5456.69,N/A,3284.09,N/A,2223.17,N/A,1354.15,N/A,1354.15,N/A,2044.41,N/A,3284.09,N/A,3284.09,N/A,3284.09,N/A,9238.05,N/A,1354.15,N/A,2223.17,N/A,2146.50,N/A,2146.50,N/A,2223.17,N/A,1354.15,N/A,399.40,N/A,439.35,N/A,N/A,399.40,9629.45,,Hospital 11446,Exc B9 Lesion Mrgn Xcp Sk Tg F/E/E/N/L/M > 4.0cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16055.80,N/A,9633.48,N/A,2244.66,N/A,2440.19,N/A,9243.64,N/A,5458.97,N/A,5659.33,N/A,2244.66,N/A,2332.78,N/A,2332.78,N/A,3523.04,N/A,5659.33,N/A,5659.33,N/A,5659.33,N/A,9243.63,N/A,2332.78,N/A,2244.66,N/A,3660.50,N/A,3660.50,N/A,2244.66,N/A,2332.78,N/A,2440.19,N/A,709.54,N/A,N/A,709.54,9633.48,,Hospital 11462,Excision Hidradenitis Inguinal Smpl/Intrm Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19575.23,N/A,11745.14,N/A,2729.18,N/A,268.19,N/A,11264.06,N/A,6655.58,N/A,5694.09,N/A,2729.18,N/A,2332.78,N/A,2332.78,N/A,3544.68,N/A,5694.09,N/A,5694.09,N/A,5694.09,N/A,11264.08,N/A,2332.78,N/A,2729.18,N/A,3397.00,N/A,3397.00,N/A,2729.18,N/A,2332.78,N/A,268.19,N/A,295.02,N/A,N/A,268.19,11745.14,,Hospital 11603,Excision Mal Lesion Trunk/Arm/Leg 2.1-3.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18093.45,N/A,10856.07,N/A,2533.09,N/A,2180.26,N/A,10411.61,N/A,6151.78,N/A,4546.65,N/A,2533.09,N/A,2141.75,N/A,2141.75,N/A,2830.30,N/A,4546.65,N/A,4546.65,N/A,4546.65,N/A,10411.61,N/A,2141.75,N/A,2533.09,N/A,2586.50,N/A,2586.50,N/A,2533.09,N/A,2141.75,N/A,2180.26,N/A,900.91,N/A,N/A,900.91,10856.07,,Hospital 11620,Excision Malignant Lesion S/N/H/F/G 0.5 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11883.20,N/A,7129.92,N/A,1663.65,N/A,1400.58,N/A,6842.36,N/A,4040.29,N/A,3275.59,N/A,1663.65,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,6842.36,N/A,1354.15,N/A,1663.65,N/A,1431.00,N/A,1431.00,N/A,1663.65,N/A,1354.15,N/A,1400.58,N/A,224.82,N/A,N/A,224.82,7129.92,,Hospital 11621,Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6577.70,N/A,3946.62,N/A,920.88,N/A,802.62,N/A,3787.44,N/A,2236.42,N/A,1825.06,N/A,920.88,N/A,754.50,N/A,754.50,N/A,1136.14,N/A,1825.06,N/A,1825.06,N/A,1825.06,N/A,3787.44,N/A,754.50,N/A,920.88,N/A,1694.50,N/A,1694.50,N/A,920.88,N/A,754.50,N/A,802.62,N/A,389.56,N/A,N/A,389.56,3946.62,,Hospital 11626,Excision Malignant Lesion S/N/H/F/G >4.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21056.10,N/A,12633.66,N/A,2948.14,N/A,2381.29,N/A,12121.96,N/A,7159.07,N/A,5660.01,N/A,2948.14,N/A,2332.78,N/A,2332.78,N/A,3523.46,N/A,5660.01,N/A,5660.01,N/A,5660.01,N/A,12121.96,N/A,2332.78,N/A,2948.14,N/A,3397.00,N/A,3397.00,N/A,2948.14,N/A,2332.78,N/A,2381.29,N/A,344.54,N/A,N/A,344.54,12633.66,,Hospital 11640,Excision Malignant Lesion F/E/E/N/L 0.5 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9451.00,N/A,5670.60,N/A,1323.14,N/A,613.03,N/A,5441.40,N/A,3213.34,N/A,1423.82,N/A,1323.14,N/A,586.05,N/A,586.05,N/A,886.36,N/A,1423.82,N/A,1423.82,N/A,1423.82,N/A,5441.41,N/A,586.05,N/A,1323.14,N/A,1431.00,N/A,1431.00,N/A,1323.14,N/A,586.05,N/A,613.03,N/A,163.45,N/A,N/A,163.45,5670.60,,Hospital 11641,Excision Malignant Lesion F/E/E/N/L 0.6-1.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11826.10,N/A,7095.66,N/A,1655.66,N/A,1969.64,N/A,6809.47,N/A,4020.87,N/A,4478.74,N/A,1655.66,N/A,1851.54,N/A,1851.54,N/A,2788.10,N/A,4478.74,N/A,4478.74,N/A,4478.74,N/A,6809.47,N/A,1851.54,N/A,1655.66,N/A,2586.50,N/A,2586.50,N/A,1655.66,N/A,1851.54,N/A,1969.64,N/A,1064.69,N/A,N/A,1064.69,7095.66,,Hospital 11642,Excision Malignant Lesion F/E/E/N/L 1.1-2.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16248.20,N/A,9748.92,N/A,2274.76,N/A,1333.60,N/A,9351.01,N/A,5524.39,N/A,3049.27,N/A,2274.76,N/A,1253.64,N/A,1253.64,N/A,1898.23,N/A,3049.27,N/A,3049.27,N/A,3049.27,N/A,9351.02,N/A,1253.64,N/A,2274.76,N/A,2504.25,N/A,2504.25,N/A,2274.76,N/A,1253.64,N/A,1333.60,N/A,725.59,N/A,N/A,725.59,9748.92,,Hospital 11643,HC Exc Skin Malig 2.1-3cm Face Facial,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,16161.00,N/A,9696.60,N/A,2262.54,N/A,1382.32,N/A,9305.50,N/A,5494.74,N/A,3275.59,N/A,2262.54,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,9305.50,N/A,1354.15,N/A,2262.54,N/A,1431.00,N/A,1431.00,N/A,2262.54,N/A,1354.15,N/A,1382.32,N/A,392.79,N/A,N/A,392.79,9696.60,,Hospital 11719,HC Trim Nondystrophic Nails,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,52303.08,4267.00,31381.85,2560.20,8859.61,597.38,13703.72,89.99,26755.67,2456.94,N/A,1450.78,N/A,814.92,8859.61,597.38,13703.72,336.90,13703.72,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,26755.67,2456.94,13703.72,336.90,8859.61,597.38,26755.67,922.25,26755.67,922.25,8859.61,597.38,13703.72,336.90,13703.72,89.99,8859.61,98.99,8859.61,31381.85,89.99,2560.20,,Hospital 11721,HC Debride Nails 6+ Only,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,57609.50,339.00,34565.70,203.40,10293.73,47.46,10288.28,172.81,N/A,195.20,N/A,115.26,N/A,304.98,10293.73,47.46,10288.28,163.07,10288.28,163.07,N/A,304.98,N/A,304.98,N/A,135.60,N/A,304.98,N/A,195.20,10288.28,163.07,10293.73,47.46,N/A,181.71,N/A,181.71,10293.73,47.46,10288.28,163.07,10288.28,172.81,10293.73,43.01,10288.28,34565.70,43.01,304.98,,Hospital CPT 11732,HC Remove Nail Plate +,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1481.00,1481.00,888.60,888.60,N/A,207.34,N/A,1481.00,N/A,852.76,N/A,503.54,N/A,1481.00,N/A,207.34,N/A,1481.00,N/A,1481.00,N/A,1481.00,N/A,1481.00,N/A,1481.00,N/A,1481.00,N/A,852.76,N/A,1481.00,N/A,207.34,N/A,1481.00,N/A,1481.00,N/A,207.34,N/A,1481.00,N/A,1481.00,N/A,18.70,888.60,888.60,18.70,1481.00,,Hospital CPT 11732,HC Avulsion of Addtl. Nail Plate,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,670.00,670.00,402.00,402.00,N/A,93.80,N/A,670.00,N/A,385.79,N/A,227.80,N/A,670.00,N/A,93.80,N/A,670.00,N/A,670.00,N/A,670.00,N/A,670.00,N/A,670.00,N/A,670.00,N/A,385.79,N/A,670.00,N/A,93.80,N/A,527.00,N/A,527.00,N/A,93.80,N/A,670.00,N/A,670.00,N/A,18.70,402.00,402.00,18.70,670.00,,Hospital CPT 11750,HC Excision of Nail & Nail Matrix,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3408.00,3408.00,2044.80,2044.80,N/A,477.12,N/A,357.02,N/A,1962.33,N/A,1158.72,N/A,814.92,N/A,477.12,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1962.33,N/A,336.90,N/A,477.12,N/A,527.00,N/A,527.00,N/A,477.12,N/A,336.90,N/A,357.02,N/A,105.93,2044.80,2044.80,105.93,2044.80,,Hospital CPT 11750,HC Excis Nail Matrix Perm Rmvl,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4264.00,4264.00,2558.40,2558.40,N/A,596.96,N/A,357.02,N/A,2455.21,N/A,1449.76,N/A,814.92,N/A,596.96,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,2455.21,N/A,336.90,N/A,596.96,N/A,4264.00,N/A,4264.00,N/A,596.96,N/A,336.90,N/A,357.02,N/A,105.93,2558.40,2558.40,105.93,4264.00,,Hospital 11755,HC Biopsy Nail Unit Separate Procedure,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,1940.00,N/A,1164.00,N/A,271.60,N/A,727.20,N/A,1117.05,N/A,659.60,N/A,1417.60,N/A,271.60,N/A,695.19,N/A,695.19,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1117.05,N/A,695.19,N/A,271.60,N/A,1431.00,N/A,1431.00,N/A,271.60,N/A,695.19,N/A,727.20,N/A,64.63,N/A,N/A,64.63,1431.00,,Hospital CPT 11765,HC Wedge Excision Skin Nail Fold,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,620.00,620.00,372.00,372.00,N/A,86.80,N/A,353.22,N/A,357.00,N/A,210.80,N/A,620.00,N/A,86.80,N/A,336.90,N/A,336.90,N/A,507.30,N/A,620.00,N/A,620.00,N/A,620.00,N/A,357.00,N/A,336.90,N/A,86.80,N/A,620.00,N/A,620.00,N/A,86.80,N/A,336.90,N/A,86.28,N/A,94.91,372.00,372.00,86.28,620.00,,Hospital 11770,HC Remove Pilonidal Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,36201.50,14167.40,21720.90,8500.44,4704.07,1972.63,2466.84,2332.78,N/A,8154.82,N/A,4816.91,10702.41,5696.32,4849.01,1972.63,182088.00,2332.78,182088.00,2332.78,6662.00,3546.07,10702.41,5696.32,10702.41,5696.32,10702.41,5696.32,10601.00,8154.83,5830.32,2332.78,4849.01,1972.63,12733.19,3397.00,N/A,3397.00,N/A,1972.63,2376.01,2332.78,5919.27,2332.78,5188.44,2566.06,2376.01,182088.00,1972.63,8500.44,,Hospital 11772,Excision Pilonidal Cyst/Sinus Complicated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20209.17,N/A,12125.50,N/A,2829.29,N/A,579.13,N/A,11630.35,N/A,6871.12,N/A,5683.90,N/A,2829.29,N/A,2332.78,N/A,2332.78,N/A,3538.34,N/A,5683.90,N/A,5683.90,N/A,5683.90,N/A,11630.37,N/A,2332.78,N/A,2829.29,N/A,3397.00,N/A,3397.00,N/A,2829.29,N/A,2332.78,N/A,579.13,N/A,637.05,N/A,N/A,579.13,12125.50,,Hospital Custom 1180000000,HC Rehab R&B,N/A,0118 - ROOM & BOARD - PRIVATE (MEDICAL OR GENERAL) - REHABILITATION,1245.00,1245.00,747.00,747.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,747.00,747.00,747.00,747.00,,Hospital 11920,Tattooing Incl Micropigmentation 6.0 Cm/<,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,19526.70,N/A,11716.02,N/A,2733.75,N/A,1808.80,N/A,2552.00,N/A,6639.08,N/A,4201.38,N/A,2733.75,N/A,1729.18,N/A,1729.18,N/A,2615.44,N/A,4201.38,N/A,4201.38,N/A,4201.38,N/A,2552.00,N/A,1729.18,N/A,2733.75,N/A,2938.25,N/A,2938.25,N/A,2733.75,N/A,1729.18,N/A,1808.80,N/A,659.58,N/A,N/A,659.58,11716.02,,Hospital 11951,Subcutaneous Injection Filling Matrl 1.1-5.0 Cc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25125.60,N/A,15075.36,N/A,3517.58,N/A,520.09,N/A,14466.49,N/A,8542.70,N/A,1281.19,N/A,3517.58,N/A,524.62,N/A,524.62,N/A,797.56,N/A,1281.19,N/A,1281.19,N/A,1281.19,N/A,14466.49,N/A,524.62,N/A,3517.58,N/A,527.00,N/A,527.00,N/A,3517.58,N/A,524.62,N/A,520.09,N/A,76.70,N/A,N/A,76.70,15075.36,,Hospital 11952,Subcutaneous Injection Filling Matrl 5.1-10.0cc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36344.52,N/A,21806.71,N/A,5088.23,N/A,520.09,N/A,20524.08,N/A,12357.14,N/A,1278.75,N/A,5088.23,N/A,524.62,N/A,524.62,N/A,796.05,N/A,1278.75,N/A,1278.75,N/A,1278.75,N/A,20524.08,N/A,524.62,N/A,5088.23,N/A,527.00,N/A,527.00,N/A,5088.23,N/A,524.62,N/A,520.09,N/A,108.16,N/A,N/A,108.16,21806.71,,Hospital 11960,HC Insert Tissue Expander(S),N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,125584.00,N/A,75350.40,N/A,17563.91,N/A,15759.82,N/A,71616.37,N/A,42698.54,N/A,39033.03,N/A,17563.91,N/A,15066.11,N/A,15066.11,N/A,25396.62,N/A,39033.03,N/A,39033.03,N/A,39033.03,N/A,71616.38,N/A,15066.11,N/A,17563.91,N/A,12986.00,N/A,12986.00,N/A,17563.91,N/A,15066.11,N/A,15759.82,N/A,5702.11,N/A,N/A,5702.11,75350.40,,Hospital CPT 11970,Replacement Tissue Expander W/Permanent Implant,N/A,N/A,1209.00,1209.00,725.40,725.40,N/A,169.26,N/A,531.46,N/A,1209.00,N/A,411.06,N/A,1209.00,N/A,169.26,N/A,531.46,N/A,531.46,N/A,989.76,N/A,1209.00,N/A,1209.00,N/A,1209.00,N/A,1209.00,N/A,531.46,N/A,169.26,N/A,1209.00,N/A,1209.00,N/A,169.26,N/A,531.46,N/A,531.46,N/A,584.61,725.40,725.40,169.26,1209.00,,Hospital 11971,Removal Tissue Expander W/O Insertion Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28018.03,N/A,16810.82,N/A,3844.15,N/A,2440.19,N/A,16130.52,N/A,9526.13,N/A,5704.99,N/A,3844.15,N/A,2332.78,N/A,2332.78,N/A,3551.47,N/A,5704.99,N/A,5704.99,N/A,5704.99,N/A,16130.54,N/A,2332.78,N/A,3844.15,N/A,3397.00,N/A,3397.00,N/A,3844.15,N/A,2332.78,N/A,2440.19,N/A,692.31,N/A,N/A,692.31,16810.82,,Hospital 11983,HC Remove/Insert Drug Dlvr Implant,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,10401.00,N/A,6240.60,N/A,1446.27,N/A,108.51,N/A,5987.96,N/A,3536.34,N/A,827.81,N/A,1446.27,N/A,340.96,N/A,340.96,N/A,515.32,N/A,827.81,N/A,827.81,N/A,827.81,N/A,5987.95,N/A,340.96,N/A,1446.27,N/A,527.00,N/A,527.00,N/A,1446.27,N/A,340.96,N/A,108.51,N/A,119.36,N/A,N/A,108.51,6240.60,,Hospital CPT 12001,HC Rep Lac Smp Not Face <2.5cm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1422.00,1422.00,853.20,853.20,N/A,199.08,N/A,172.81,N/A,818.79,N/A,483.48,N/A,394.46,N/A,199.08,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,818.79,N/A,163.07,N/A,199.08,N/A,527.00,N/A,527.00,N/A,199.08,N/A,163.07,N/A,172.81,N/A,47.92,853.20,853.20,47.92,853.20,,Hospital CPT 12001,HC Rep Lac Smp Not Face <2.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1422.00,1422.00,853.20,853.20,N/A,199.08,N/A,172.81,N/A,818.79,N/A,483.48,N/A,394.46,N/A,199.08,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,818.79,N/A,163.07,N/A,199.08,N/A,1422.00,N/A,1422.00,N/A,199.08,N/A,163.07,N/A,172.81,N/A,47.92,853.20,853.20,47.92,1422.00,,Hospital CPT 12002,HC Repr Smp Not Face 2.6-7.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1444.00,1444.00,866.40,866.40,N/A,202.16,N/A,164.84,N/A,831.46,N/A,490.96,N/A,394.46,N/A,202.16,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,831.46,N/A,163.07,N/A,202.16,N/A,1444.00,N/A,1444.00,N/A,202.16,N/A,163.07,N/A,164.84,N/A,62.89,866.40,866.40,62.89,1444.00,,Hospital CPT 12004,HC Repr Smp Nt Face 7.6-12.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1461.00,1461.00,876.60,876.60,N/A,204.54,N/A,70.79,N/A,841.24,N/A,496.74,N/A,370.86,N/A,204.54,N/A,70.79,N/A,70.79,N/A,230.86,N/A,370.86,N/A,370.86,N/A,370.86,N/A,841.24,N/A,70.79,N/A,204.54,N/A,1461.00,N/A,1461.00,N/A,204.54,N/A,70.79,N/A,70.79,N/A,77.87,876.60,876.60,70.79,1461.00,,Hospital CPT 12011,HC Simple Rep Wnd Face <2.5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1363.00,1363.00,817.80,817.80,N/A,190.82,N/A,172.81,N/A,784.82,N/A,463.42,N/A,394.46,N/A,190.82,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,784.82,N/A,163.07,N/A,190.82,N/A,1363.00,N/A,1363.00,N/A,190.82,N/A,163.07,N/A,172.81,N/A,58.92,817.80,817.80,58.92,1363.00,,Hospital CPT 12013,HC Rep Lac Smp Face 2.6-5.0 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1363.00,1363.00,817.80,817.80,N/A,190.82,N/A,56.91,N/A,784.82,N/A,463.42,N/A,329.85,N/A,190.82,N/A,56.91,N/A,56.91,N/A,205.33,N/A,329.85,N/A,329.85,N/A,329.85,N/A,784.82,N/A,56.91,N/A,190.82,N/A,1363.00,N/A,1363.00,N/A,190.82,N/A,56.91,N/A,56.91,N/A,62.60,817.80,817.80,56.91,1363.00,,Hospital CPT 12014,HC Rep Lac Smp Face 5.1-7.5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1363.00,1363.00,817.80,817.80,N/A,190.82,N/A,73.13,N/A,784.82,N/A,463.42,N/A,401.82,N/A,190.82,N/A,73.13,N/A,73.13,N/A,250.13,N/A,401.82,N/A,401.82,N/A,401.82,N/A,784.82,N/A,73.13,N/A,190.82,N/A,1363.00,N/A,1363.00,N/A,190.82,N/A,73.13,N/A,73.13,N/A,80.44,817.80,817.80,73.13,1363.00,,Hospital CPT 12017,HC Rep Lac Simple Face 20.1-30.0c,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1547.00,1547.00,928.20,928.20,N/A,216.58,N/A,149.09,N/A,890.76,N/A,525.98,N/A,446.46,N/A,216.58,N/A,149.09,N/A,149.09,N/A,277.92,N/A,446.46,N/A,446.46,N/A,446.46,N/A,890.76,N/A,149.09,N/A,216.58,N/A,1547.00,N/A,1547.00,N/A,216.58,N/A,149.09,N/A,149.09,N/A,164.00,928.20,928.20,149.09,1547.00,,Hospital CPT 12018,HC Rpr F/E/E/N/L/M >30.0 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1547.00,1547.00,928.20,928.20,N/A,216.58,N/A,169.22,N/A,890.76,N/A,525.98,N/A,504.33,N/A,216.58,N/A,169.22,N/A,169.22,N/A,313.95,N/A,504.33,N/A,504.33,N/A,504.33,N/A,890.76,N/A,169.22,N/A,216.58,N/A,1547.00,N/A,1547.00,N/A,216.58,N/A,169.22,N/A,169.22,N/A,186.14,928.20,928.20,169.22,1547.00,,Hospital CPT 12020,"HC Trtmnt Supfic Wnd,Dehisc,Simp",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1129.00,1129.00,677.40,677.40,N/A,158.06,N/A,177.51,N/A,650.08,N/A,383.86,N/A,1129.00,N/A,158.06,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1129.00,N/A,1129.00,N/A,1129.00,N/A,650.08,N/A,524.62,N/A,158.06,N/A,527.00,N/A,527.00,N/A,158.06,N/A,524.62,N/A,177.51,N/A,195.26,677.40,677.40,158.06,1129.00,,Hospital CPT 12020,HC Treatment Dehiscence Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1129.00,1129.00,677.40,677.40,N/A,158.06,N/A,177.51,N/A,650.08,N/A,383.86,N/A,1129.00,N/A,158.06,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1129.00,N/A,1129.00,N/A,1129.00,N/A,650.08,N/A,524.62,N/A,158.06,N/A,1129.00,N/A,1129.00,N/A,158.06,N/A,524.62,N/A,177.51,N/A,195.26,677.40,677.40,158.06,1129.00,,Hospital 12021,HC Closure of Split Wound,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,24064.70,N/A,14438.82,N/A,3244.62,N/A,822.48,N/A,13851.94,N/A,8182.00,N/A,2323.55,N/A,3244.62,N/A,843.07,N/A,822.48,N/A,1801.80,N/A,2323.55,N/A,2323.55,N/A,2323.55,N/A,N/A,N/A,843.07,N/A,3244.62,N/A,527.00,N/A,527.00,N/A,3244.62,N/A,822.48,N/A,822.48,N/A,898.32,N/A,N/A,527.00,14438.82,,Hospital CPT 12035,HC Lyr Clos Sc Tk Ext 12.6-20,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1915.00,1915.00,1149.00,1149.00,N/A,268.10,N/A,228.15,N/A,1102.66,N/A,651.10,N/A,1084.26,N/A,268.10,N/A,228.15,N/A,228.15,N/A,674.95,N/A,1084.26,N/A,1084.26,N/A,1084.26,N/A,1102.66,N/A,228.15,N/A,268.10,N/A,1915.00,N/A,1915.00,N/A,268.10,N/A,228.15,N/A,228.15,N/A,250.97,1149.00,1149.00,228.15,1915.00,,Hospital 12046,HC Intmd Wnd Repair N-Hg/Gen,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,21823.93,N/A,13094.36,N/A,3055.36,N/A,587.33,N/A,12552.59,N/A,7404.83,N/A,5730.07,N/A,3055.36,N/A,2332.78,N/A,2332.78,N/A,3567.07,N/A,5730.07,N/A,5730.07,N/A,5730.07,N/A,12552.61,N/A,2332.78,N/A,3055.36,N/A,4112.50,N/A,4112.50,N/A,3055.36,N/A,2332.78,N/A,587.33,N/A,646.07,N/A,N/A,587.33,13094.36,,Hospital 12047,Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15338.30,N/A,9202.98,N/A,2144.93,N/A,1416.50,N/A,8831.25,N/A,5215.02,N/A,3291.13,N/A,2144.93,N/A,1354.15,N/A,1354.15,N/A,2048.79,N/A,3291.13,N/A,3291.13,N/A,3291.13,N/A,8831.27,N/A,1354.15,N/A,2144.93,N/A,2806.50,N/A,2806.50,N/A,2144.93,N/A,1354.15,N/A,1416.50,N/A,592.30,N/A,N/A,592.30,9202.98,,Hospital CPT 12055,HC ED Layer Clos Face 12.6-20,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1908.00,1908.00,1144.80,1144.80,N/A,267.12,N/A,282.99,N/A,1098.63,N/A,648.72,N/A,1414.86,N/A,267.12,N/A,282.99,N/A,282.99,N/A,880.75,N/A,1414.86,N/A,1414.86,N/A,1414.86,N/A,1098.63,N/A,282.99,N/A,267.12,N/A,1908.00,N/A,1908.00,N/A,267.12,N/A,282.99,N/A,282.99,N/A,311.29,1144.80,1144.80,267.12,1908.00,,Hospital CPT 12056,HC Repair Wounds 20.1cm to 30.0cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3632.00,3632.00,2179.20,2179.20,N/A,508.48,N/A,363.06,N/A,2091.31,N/A,1234.88,N/A,1617.72,N/A,508.48,N/A,363.06,N/A,363.06,N/A,1007.03,N/A,1617.72,N/A,1617.72,N/A,1617.72,N/A,2091.31,N/A,363.06,N/A,508.48,N/A,3632.00,N/A,3632.00,N/A,508.48,N/A,363.06,N/A,363.06,N/A,399.37,2179.20,2179.20,363.06,3632.00,,Hospital 12057,HC Intmd Wnd Repair Face/Mm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom 1210000000,HC Med Surg R&B,N/A,0121 - ROOM & BOARD - SEMI-PRIVATE TWO BED (MEDICAL OR GENERAL) - MEDICAL/SURGICAL/GYN,2100.00,2100.00,1260.00,1260.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1260.00,1260.00,1260.00,1260.00,,Hospital Custom 1240000000,HC Emotional Wellness R&B,N/A,0124 - ROOM & BOARD - SEMI-PRIVATE TWO BED (MEDICAL OR GENERAL) - PSYCHIATRIC,1834.00,1834.00,1100.40,1100.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1100.40,1100.40,1100.40,1100.40,,Hospital CPT 13102,HC Repair Complex Trunk Ea Add'l 5 Cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1025.00,1025.00,615.00,615.00,N/A,143.50,N/A,69.09,N/A,590.20,N/A,348.50,N/A,326.58,N/A,143.50,N/A,69.09,N/A,69.09,N/A,203.30,N/A,326.58,N/A,326.58,N/A,326.58,N/A,590.20,N/A,69.09,N/A,143.50,N/A,1025.00,N/A,1025.00,N/A,143.50,N/A,69.09,N/A,69.09,N/A,76.00,615.00,615.00,69.09,1025.00,,Hospital CPT 13131,HC Rep Cpx Face H Ft 1.1-2.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1951.00,1951.00,1170.60,1170.60,N/A,273.14,N/A,357.02,N/A,1123.39,N/A,663.34,N/A,814.92,N/A,273.14,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,1123.39,N/A,336.90,N/A,273.14,N/A,1951.00,N/A,1951.00,N/A,273.14,N/A,336.90,N/A,357.02,N/A,251.47,1170.60,1170.60,251.47,1951.00,,Hospital 14001,Adjnt Tis Transfr/Rearrange Trunk 10.1-30.0 Sqcm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39285.07,N/A,23571.04,N/A,5492.45,N/A,5614.02,N/A,22586.03,N/A,13356.91,N/A,13660.15,N/A,5492.45,N/A,5366.90,N/A,5366.90,N/A,9610.26,N/A,13660.15,N/A,13660.15,N/A,13660.15,N/A,22586.04,N/A,5366.90,N/A,5492.45,N/A,12522.25,N/A,12522.25,N/A,5492.45,N/A,5366.90,N/A,5614.02,N/A,2445.66,N/A,N/A,2445.66,23571.04,,Hospital 14021,Adjt/Rearrgmt Scalp/Arm/Leg 10.1-30.0 Sq Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19222.30,N/A,11533.38,N/A,2691.12,N/A,1762.88,N/A,11067.17,N/A,6535.58,N/A,4187.45,N/A,2691.12,N/A,1726.97,N/A,1726.97,N/A,2606.76,N/A,4187.45,N/A,4187.45,N/A,4187.45,N/A,11067.18,N/A,1726.97,N/A,2691.12,N/A,2134.50,N/A,2134.50,N/A,2691.12,N/A,1726.97,N/A,1762.88,N/A,914.69,N/A,N/A,914.69,11533.38,,Hospital CPT 14301,Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,N/A,N/A,1774.00,1774.00,1064.40,1064.40,N/A,248.36,N/A,820.48,N/A,1774.00,N/A,603.16,N/A,1774.00,N/A,248.36,N/A,820.48,N/A,820.48,N/A,1774.00,N/A,1774.00,N/A,1774.00,N/A,1774.00,N/A,1774.00,N/A,820.48,N/A,248.36,N/A,1774.00,N/A,1774.00,N/A,248.36,N/A,820.48,N/A,820.48,N/A,902.53,1064.40,1064.40,248.36,1774.00,,Hospital CPT 15002,HC Surg Prep Trunk/Arms/Legs 100,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2469.00,2469.00,1481.40,1481.40,N/A,345.66,N/A,209.57,N/A,1421.65,N/A,839.46,N/A,965.49,N/A,345.66,N/A,209.57,N/A,209.57,N/A,601.02,N/A,965.49,N/A,965.49,N/A,965.49,N/A,1421.65,N/A,209.57,N/A,345.66,N/A,2469.00,N/A,2469.00,N/A,345.66,N/A,209.57,N/A,209.57,N/A,230.53,1481.40,1481.40,209.57,2469.00,,Hospital CPT 15003,HC Surg Prep Ea Addtl 100sqcm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2725.00,2725.00,1635.00,1635.00,N/A,381.50,N/A,43.66,N/A,1569.06,N/A,926.50,N/A,194.88,N/A,381.50,N/A,43.66,N/A,43.66,N/A,121.31,N/A,194.88,N/A,194.88,N/A,194.88,N/A,1569.06,N/A,43.66,N/A,381.50,N/A,2725.00,N/A,2725.00,N/A,381.50,N/A,43.66,N/A,43.66,N/A,48.03,1635.00,1635.00,43.66,2725.00,,Hospital 15040,Harvest Skin Tissue Cltr Skin Agrft 100 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31809.40,N/A,19085.64,N/A,4403.07,N/A,2445.42,N/A,18286.80,N/A,10815.21,N/A,6605.13,N/A,4403.07,N/A,2337.78,N/A,2337.78,N/A,4111.80,N/A,6605.13,N/A,6605.13,N/A,6605.13,N/A,18286.81,N/A,2337.78,N/A,4403.07,N/A,2806.50,N/A,2806.50,N/A,4403.07,N/A,2337.78,N/A,2445.42,N/A,928.98,N/A,N/A,928.98,19085.64,,Hospital CPT 15050,"HC Wcc, Skin Pinch Graft",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1265.00,1265.00,759.00,759.00,N/A,177.10,N/A,434.83,N/A,728.39,N/A,430.10,N/A,1265.00,N/A,177.10,N/A,434.83,N/A,434.83,N/A,1029.09,N/A,1265.00,N/A,1265.00,N/A,1265.00,N/A,728.39,N/A,434.83,N/A,177.10,N/A,1265.00,N/A,1265.00,N/A,177.10,N/A,434.83,N/A,434.83,N/A,478.31,759.00,759.00,177.10,1265.00,,Hospital CPT 15110,HC Epidrm Autogrft Trnk/Arm/Leg 1st 100,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1820.00,1820.00,1092.00,1092.00,N/A,254.80,N/A,677.81,N/A,1047.96,N/A,618.80,N/A,1820.00,N/A,254.80,N/A,677.81,N/A,677.81,N/A,1466.75,N/A,1820.00,N/A,1820.00,N/A,1820.00,N/A,1047.96,N/A,677.81,N/A,254.80,N/A,1820.00,N/A,1820.00,N/A,254.80,N/A,677.81,N/A,677.81,N/A,745.59,1092.00,1092.00,254.80,1820.00,,Hospital CPT 15111,HC Epidrm Autogrft T/a/L Add-On,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,345.00,345.00,207.00,207.00,N/A,48.30,N/A,98.31,N/A,198.65,N/A,117.30,N/A,321.96,N/A,48.30,N/A,98.31,N/A,98.31,N/A,200.42,N/A,321.96,N/A,321.96,N/A,321.96,N/A,198.65,N/A,98.31,N/A,48.30,N/A,345.00,N/A,345.00,N/A,48.30,N/A,98.31,N/A,98.31,N/A,108.14,207.00,207.00,48.30,345.00,,Hospital CPT 15116,HC Epidrm a-Grft F/N/Hf/G Addl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,512.00,512.00,307.20,307.20,N/A,71.68,N/A,142.41,N/A,294.81,N/A,174.08,N/A,441.24,N/A,71.68,N/A,142.41,N/A,142.41,N/A,274.67,N/A,441.24,N/A,441.24,N/A,441.24,N/A,294.81,N/A,142.41,N/A,71.68,N/A,512.00,N/A,512.00,N/A,71.68,N/A,142.41,N/A,142.41,N/A,156.65,307.20,307.20,71.68,512.00,,Hospital 15130,Dermal Autograft Trunk/Arm/Leg 1st 100 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10953.40,N/A,6572.04,N/A,1533.48,N/A,1835.55,N/A,6305.41,N/A,3724.16,N/A,4501.30,N/A,1533.48,N/A,1851.54,N/A,1851.54,N/A,2802.13,N/A,4501.30,N/A,4501.30,N/A,4501.30,N/A,6305.42,N/A,1851.54,N/A,1533.48,N/A,4112.50,N/A,4112.50,N/A,1533.48,N/A,1851.54,N/A,1835.55,N/A,877.48,N/A,N/A,877.48,6572.04,,Hospital 15150,Cltr Skin Autograft T/a/L 1st 25 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64209.67,N/A,38525.80,N/A,8983.61,N/A,1783.40,N/A,36833.02,N/A,21815.97,N/A,14513.63,N/A,8983.61,N/A,5973.28,N/A,5973.28,N/A,9034.99,N/A,14513.63,N/A,14513.63,N/A,14513.63,N/A,36833.04,N/A,5973.28,N/A,8983.61,N/A,10085.00,N/A,10085.00,N/A,8983.61,N/A,5973.28,N/A,1783.40,N/A,1961.75,N/A,N/A,1783.40,38525.80,,Hospital 15155,Cltr Skin Agrft F/S/N/H/F/G/M/D Gt 1st 25cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27136.70,N/A,16282.02,N/A,3799.14,N/A,2743.94,N/A,15505.66,N/A,9226.48,N/A,6522.10,N/A,3799.14,N/A,2688.04,N/A,2688.04,N/A,4060.13,N/A,6522.10,N/A,6522.10,N/A,6522.10,N/A,15505.66,N/A,2688.04,N/A,3799.14,N/A,6260.50,N/A,6260.50,N/A,3799.14,N/A,2688.04,N/A,2743.94,N/A,1211.59,N/A,N/A,1211.59,16282.02,,Hospital 15220,Fth/Gft Free W/Direct Closure S/a/L 20 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19043.90,N/A,11426.34,N/A,2666.14,N/A,1762.88,N/A,10963.22,N/A,6474.92,N/A,4193.17,N/A,2666.14,N/A,1726.97,N/A,1726.97,N/A,2610.33,N/A,4193.17,N/A,4193.17,N/A,4193.17,N/A,10963.23,N/A,1726.97,N/A,2666.14,N/A,2134.50,N/A,2134.50,N/A,2666.14,N/A,1726.97,N/A,1762.88,N/A,867.87,N/A,N/A,867.87,11426.34,,Hospital 15261,Fth/Gft Free W/Dir Clsr N/E/E/L Ea 20 Sq Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24556.50,N/A,14733.90,N/A,3437.91,N/A,1590.93,N/A,14139.63,N/A,8349.21,N/A,3769.94,N/A,3437.91,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,14139.63,N/A,1558.52,N/A,3437.91,N/A,2134.50,N/A,2134.50,N/A,3437.91,N/A,1558.52,N/A,1590.93,N/A,1306.63,N/A,N/A,1306.63,14733.90,,Hospital 15570,Frmj Direct/Tubed Pedicle W/WO Transfer Trunk,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34420.18,N/A,20652.11,N/A,4803.22,N/A,5626.86,N/A,19798.45,N/A,11702.86,N/A,13080.68,N/A,4803.22,N/A,5366.90,N/A,5366.90,N/A,8142.97,N/A,13080.68,N/A,13080.68,N/A,13080.68,N/A,19798.47,N/A,5366.90,N/A,4803.22,N/A,7310.75,N/A,7310.75,N/A,4803.22,N/A,5366.90,N/A,1514.08,N/A,1665.48,N/A,N/A,1514.08,20652.11,,Hospital 15610,Delay Flap/Sectioning Flap Scalp Arms/Legs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22718.10,N/A,13630.86,N/A,3180.54,N/A,1590.93,N/A,13076.10,N/A,7724.16,N/A,3782.47,N/A,3180.54,N/A,1558.52,N/A,1558.52,N/A,2354.66,N/A,3782.47,N/A,3782.47,N/A,3782.47,N/A,13076.10,N/A,1558.52,N/A,3180.54,N/A,3397.00,N/A,3397.00,N/A,3180.54,N/A,1558.52,N/A,1590.93,N/A,248.08,N/A,N/A,248.08,13630.86,,Hospital 15620,Delay Flap/Sectioning Flap F/C/C/N/Ax/G/H/F,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17791.30,N/A,10674.78,N/A,2490.77,N/A,2486.90,N/A,10232.40,N/A,6049.04,N/A,5687.39,N/A,2490.77,N/A,2337.78,N/A,2337.78,N/A,3540.52,N/A,5687.39,N/A,5687.39,N/A,5687.39,N/A,10232.39,N/A,2337.78,N/A,2490.77,N/A,2806.50,N/A,2806.50,N/A,2490.77,N/A,2337.78,N/A,2486.90,N/A,1105.55,N/A,N/A,1105.55,10674.78,,Hospital CPT 15630,Delay Flap/Sctj Flap Eyelids Nose Ears/Lips,N/A,N/A,766.00,766.00,459.60,459.60,N/A,107.24,N/A,320.21,N/A,766.00,N/A,260.44,N/A,766.00,N/A,107.24,N/A,320.21,N/A,320.21,N/A,766.00,N/A,766.00,N/A,766.00,N/A,766.00,N/A,766.00,N/A,320.21,N/A,107.24,N/A,766.00,N/A,766.00,N/A,107.24,N/A,320.21,N/A,320.21,N/A,352.23,459.60,459.60,107.24,766.00,,Hospital 15650,Transfer Any Pedicle Flap Any Location,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20305.70,N/A,12183.42,N/A,2842.81,N/A,1969.64,N/A,11686.56,N/A,6903.93,N/A,4499.31,N/A,2842.81,N/A,1851.54,N/A,1851.54,N/A,2800.90,N/A,4499.31,N/A,4499.31,N/A,4499.31,N/A,11686.56,N/A,1851.54,N/A,2842.81,N/A,2586.50,N/A,2586.50,N/A,2842.81,N/A,1851.54,N/A,1969.64,N/A,677.88,N/A,N/A,677.88,12183.42,,Hospital 15730,Midface Flap W/Preservation of Vascular Pedicles,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,84203.00,N/A,50521.80,N/A,11788.42,N/A,6184.27,N/A,48475.45,N/A,28629.01,N/A,6246.73,N/A,11788.42,N/A,6173.26,N/A,6173.26,N/A,3888.71,N/A,6246.73,N/A,6246.73,N/A,6246.73,N/A,48475.46,N/A,6173.26,N/A,11788.42,N/A,7109.75,N/A,7109.75,N/A,11788.42,N/A,6173.26,N/A,6184.27,N/A,3206.86,N/A,N/A,3206.86,50521.80,,Hospital 15736,Musc Myocutaneous/Fasciocutaneous Flap Uxtr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17872.62,N/A,10723.57,N/A,2502.17,N/A,1721.53,N/A,10285.63,N/A,6076.69,N/A,3953.87,N/A,2502.17,N/A,1623.23,N/A,1623.23,N/A,2461.37,N/A,3953.87,N/A,3953.87,N/A,3953.87,N/A,10285.63,N/A,1623.23,N/A,2502.17,N/A,4332.50,N/A,4332.50,N/A,2502.17,N/A,1623.23,N/A,1721.53,N/A,1893.68,N/A,N/A,1623.23,10723.57,,Hospital 15740,Flap Island Pedicle Anatomic Named Axial Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20459.50,N/A,12275.70,N/A,2864.33,N/A,3447.00,N/A,11778.44,N/A,6956.23,N/A,8272.35,N/A,2864.33,N/A,3410.06,N/A,3410.06,N/A,5149.69,N/A,8272.35,N/A,8272.35,N/A,8272.35,N/A,11778.44,N/A,3410.06,N/A,2864.33,N/A,3274.25,N/A,3274.25,N/A,2864.33,N/A,3410.06,N/A,3447.00,N/A,2840.97,N/A,N/A,2840.97,12275.70,,Hospital 15750,Flap Neurovascular Pedicle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33834.80,N/A,20300.88,N/A,4736.86,N/A,3436.71,N/A,19474.52,N/A,11503.83,N/A,7834.43,N/A,4736.86,N/A,3230.65,N/A,3230.65,N/A,4877.10,N/A,7834.43,N/A,7834.43,N/A,7834.43,N/A,19474.52,N/A,3230.65,N/A,4736.86,N/A,5277.50,N/A,5277.50,N/A,4736.86,N/A,3230.65,N/A,3436.71,N/A,1335.21,N/A,N/A,1335.21,20300.88,,Hospital 15760,Graft Composite W/Primary Closure Donor Area,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,66086.70,N/A,39652.02,N/A,9252.16,N/A,2805.02,N/A,38044.16,N/A,22469.48,N/A,6522.45,N/A,9252.16,N/A,2683.88,N/A,2683.88,N/A,4060.36,N/A,6522.45,N/A,6522.45,N/A,6522.45,N/A,38044.17,N/A,2683.88,N/A,9252.16,N/A,3164.25,N/A,3164.25,N/A,9252.16,N/A,2683.88,N/A,2805.02,N/A,1728.08,N/A,N/A,1728.08,39652.02,,Hospital 15769,Grafting of Autologous Soft Tiss by Direct Exc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47232.93,N/A,28339.76,N/A,6612.60,N/A,5043.96,N/A,27176.64,N/A,16059.19,N/A,11691.68,N/A,6612.60,N/A,4821.94,N/A,4821.94,N/A,7278.30,N/A,11691.68,N/A,11691.68,N/A,11691.68,N/A,27176.64,N/A,4821.94,N/A,6612.60,N/A,8244.00,N/A,8244.00,N/A,6612.60,N/A,4821.94,N/A,5043.96,N/A,1472.97,N/A,N/A,1472.97,28339.76,,Hospital 15773,Grafting of Autologous Fat by Lipo 25 Cc or Less,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19872.30,N/A,11923.38,N/A,2777.73,N/A,1657.93,N/A,11433.20,N/A,6756.59,N/A,3840.62,N/A,2777.73,N/A,1558.52,N/A,1558.52,N/A,2390.85,N/A,3840.62,N/A,3840.62,N/A,3840.62,N/A,11433.21,N/A,1558.52,N/A,2777.73,N/A,1871.00,N/A,1871.00,N/A,2777.73,N/A,1558.52,N/A,1657.93,N/A,536.61,N/A,N/A,536.61,11923.38,,Hospital 15777,Implnt Bio Implnt for Soft Tissue Reinforcement,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48713.65,44656.90,29228.19,26794.14,12645.72,6212.76,15224.87,5366.90,30729.33,25561.85,16562.64,15183.35,28770.76,14394.15,13035.35,6212.76,1124.00,5366.90,1124.00,5366.90,17909.13,8960.62,28770.76,14394.15,28770.76,14394.15,28770.76,14394.15,30729.33,25561.86,15224.87,5366.90,13035.35,6212.76,34230.02,11850.25,34230.02,11850.25,N/A,6212.76,15224.87,5366.90,15224.87,5366.90,13947.83,5903.59,1124.00,34230.02,5366.90,26794.14,,Hospital 15788,Chemical Peel Facial Epidermal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,86371.80,N/A,51823.08,N/A,12092.06,N/A,6335.00,N/A,49717.44,N/A,29366.44,N/A,6269.41,N/A,12092.06,N/A,6323.99,N/A,6323.99,N/A,3902.83,N/A,6269.41,N/A,6269.41,N/A,6269.41,N/A,49717.44,N/A,6323.99,N/A,12092.06,N/A,3274.25,N/A,3274.25,N/A,12092.06,N/A,6323.99,N/A,6335.00,N/A,1563.82,N/A,N/A,1563.82,51823.08,,Hospital 15789,Chemical Peel Facial Dermal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,84203.00,N/A,50521.80,N/A,11788.42,N/A,6184.27,N/A,48475.45,N/A,28629.01,N/A,6246.73,N/A,11788.42,N/A,6173.26,N/A,6173.26,N/A,3888.71,N/A,6246.73,N/A,6246.73,N/A,6246.73,N/A,48475.46,N/A,6173.26,N/A,11788.42,N/A,7109.75,N/A,7109.75,N/A,11788.42,N/A,6173.26,N/A,6184.27,N/A,3206.86,N/A,N/A,3206.86,50521.80,,Hospital 15822,Blepharoplasty Upper Eyelid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28332.10,N/A,16999.26,N/A,3966.50,N/A,3876.37,N/A,16310.40,N/A,9632.92,N/A,9468.49,N/A,3966.50,N/A,3896.30,N/A,3896.30,N/A,5894.31,N/A,9468.49,N/A,9468.49,N/A,9468.49,N/A,16310.40,N/A,3896.30,N/A,3966.50,N/A,3274.25,N/A,3274.25,N/A,3966.50,N/A,3896.30,N/A,3876.37,N/A,939.57,N/A,N/A,939.57,16999.26,,Hospital 15825,Rhytidectomy Neck W/Platysmal Tightening,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62297.13,N/A,37378.28,N/A,8661.07,N/A,14.93,N/A,35847.91,N/A,21181.02,N/A,9121.88,N/A,8661.07,N/A,3716.89,N/A,3716.89,N/A,5678.53,N/A,9121.88,N/A,9121.88,N/A,9121.88,N/A,35847.95,N/A,3716.89,N/A,8661.07,N/A,5497.50,N/A,5497.50,N/A,8661.07,N/A,3716.89,N/A,14.93,N/A,16.43,N/A,N/A,14.93,37378.28,,Hospital 15828,Rhytidectomy Cheek Chin & Neck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57034.22,N/A,34220.53,N/A,7984.80,N/A,2320.84,N/A,32836.44,N/A,19391.63,N/A,5699.79,N/A,7984.80,N/A,2332.78,N/A,2332.78,N/A,3548.71,N/A,5699.79,N/A,5699.79,N/A,5699.79,N/A,32836.44,N/A,2332.78,N/A,7984.80,N/A,7310.75,N/A,7310.75,N/A,7984.80,N/A,2332.78,N/A,2320.84,N/A,672.89,N/A,N/A,672.89,34220.53,,Hospital 15835,Excision Excessive Skin & Subq Tissue Buttock,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67839.20,N/A,40703.52,N/A,9481.88,N/A,5920.33,N/A,38992.28,N/A,23065.33,N/A,14030.75,N/A,9481.88,N/A,5366.90,N/A,5366.90,N/A,8734.40,N/A,14030.75,N/A,14030.75,N/A,14030.75,N/A,38992.30,N/A,5366.90,N/A,9481.88,N/A,7793.25,N/A,7793.25,N/A,9481.88,N/A,5366.90,N/A,2005.43,N/A,2205.97,N/A,N/A,2005.43,40703.52,,Hospital 15838,Exc Excsv Skin & Subq Tissue Submental Fat Pad,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57034.22,N/A,34220.53,N/A,7984.80,N/A,2320.84,N/A,32836.44,N/A,19391.63,N/A,5699.79,N/A,7984.80,N/A,2332.78,N/A,2332.78,N/A,3548.71,N/A,5699.79,N/A,5699.79,N/A,5699.79,N/A,32836.44,N/A,2332.78,N/A,7984.80,N/A,7310.75,N/A,7310.75,N/A,7984.80,N/A,2332.78,N/A,2320.84,N/A,672.89,N/A,N/A,672.89,34220.53,,Hospital 15876,Suction Assisted Lipectomy Head & Neck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36591.30,N/A,21954.78,N/A,5123.05,N/A,4498.08,N/A,21065.09,N/A,12441.04,N/A,10679.74,N/A,5123.05,N/A,4406.44,N/A,4406.44,N/A,6648.34,N/A,10679.74,N/A,10679.74,N/A,10679.74,N/A,21065.09,N/A,4406.44,N/A,5123.05,N/A,6843.00,N/A,6843.00,N/A,5123.05,N/A,4406.44,N/A,4498.08,N/A,135.00,N/A,N/A,135.00,21954.78,,Hospital CPT 16000,HC 1st Deg Burn Trtmnt,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,523.00,523.00,313.80,313.80,N/A,73.22,N/A,43.56,N/A,301.14,N/A,177.82,N/A,220.02,N/A,73.22,N/A,43.56,N/A,43.56,N/A,136.96,N/A,220.02,N/A,220.02,N/A,220.02,N/A,301.14,N/A,43.56,N/A,73.22,N/A,523.00,N/A,523.00,N/A,73.22,N/A,43.56,N/A,43.56,N/A,47.92,313.80,313.80,43.56,523.00,,Hospital CPT 16020,HC Burn Dress/Debrid 5% or Less,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,820.00,820.00,492.00,492.00,N/A,114.80,N/A,170.58,N/A,472.16,N/A,278.80,N/A,394.46,N/A,114.80,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,472.16,N/A,163.07,N/A,114.80,N/A,527.00,N/A,527.00,N/A,114.80,N/A,163.07,N/A,161.66,N/A,56.30,492.00,492.00,56.30,527.00,,Hospital CPT 16020,HC Dress or Debride Burn Small,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,820.00,820.00,492.00,492.00,N/A,114.80,N/A,170.58,N/A,472.16,N/A,278.80,N/A,394.46,N/A,114.80,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,472.16,N/A,163.07,N/A,114.80,N/A,820.00,N/A,820.00,N/A,114.80,N/A,163.07,N/A,161.66,N/A,56.30,492.00,492.00,56.30,820.00,,Hospital Custom 1710000000,HC Nursery Level I R&B,N/A,0171 - NURSERY - NEWBORN - LEVEL I,2100.00,2100.00,1260.00,1260.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1260.00,1260.00,1260.00,1260.00,,Hospital 17111,HC Destruction 15+ Lesions,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,15957.40,N/A,9574.44,N/A,2234.03,N/A,170.58,N/A,9186.59,N/A,5425.51,N/A,416.16,N/A,2234.03,N/A,163.07,N/A,163.07,N/A,259.07,N/A,416.16,N/A,416.16,N/A,416.16,N/A,9186.59,N/A,163.07,N/A,2234.03,N/A,790.50,N/A,790.50,N/A,2234.03,N/A,163.07,N/A,170.58,N/A,166.82,N/A,N/A,163.07,9574.44,,Hospital Custom 1720000000,HC Nursery Level II R&B,N/A,0172 - NURSERY - NEWBORN - LEVEL II,3675.00,3675.00,2205.00,2205.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2205.00,2205.00,2205.00,2205.00,,Hospital 17261,HC Shav Skin Les >21mm Trunk Arm Leg,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,427.00,N/A,256.20,N/A,59.78,N/A,115.66,N/A,245.87,N/A,145.18,N/A,N/A,N/A,59.78,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,245.87,N/A,109.14,N/A,59.78,N/A,228.87,N/A,228.87,N/A,59.78,N/A,109.14,N/A,115.66,N/A,88.94,N/A,N/A,59.78,256.20,,Hospital 17262,HC Shav Skin Les 6-10mm Remaindr Body,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1357.00,N/A,814.20,N/A,189.98,N/A,651.19,N/A,781.36,N/A,461.38,N/A,N/A,N/A,189.98,N/A,614.49,N/A,614.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,781.36,N/A,614.49,N/A,189.98,N/A,727.35,N/A,727.35,N/A,189.98,N/A,614.49,N/A,651.19,N/A,475.18,N/A,N/A,189.98,814.20,,Hospital 17271,HC Shav Skin Les 11-20mm Remaindr Body,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,645.00,N/A,387.00,N/A,90.30,N/A,288.47,N/A,371.40,N/A,219.30,N/A,N/A,N/A,90.30,N/A,272.21,N/A,272.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,371.40,N/A,272.21,N/A,90.30,N/A,345.72,N/A,345.72,N/A,90.30,N/A,272.21,N/A,288.47,N/A,107.69,N/A,N/A,90.30,387.00,,Hospital 17281,HC Shav Skin Les <5mm Face Facial,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,645.00,N/A,387.00,N/A,90.30,N/A,472.68,N/A,371.39,N/A,219.30,N/A,N/A,N/A,90.30,N/A,446.04,N/A,446.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,371.39,N/A,446.04,N/A,90.30,N/A,345.72,N/A,345.72,N/A,90.30,N/A,446.04,N/A,472.68,N/A,122.00,N/A,N/A,90.30,472.68,,Hospital 17282,Destruction Mal Lesion F/E/E/N/L/M 1.1-2.0cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24507.10,N/A,14704.26,N/A,3431.00,N/A,1382.32,N/A,14102.42,N/A,8332.41,N/A,3289.68,N/A,3431.00,N/A,1354.15,N/A,1354.15,N/A,2047.89,N/A,3289.68,N/A,3289.68,N/A,3289.68,N/A,14102.42,N/A,1354.15,N/A,3431.00,N/A,2718.25,N/A,2718.25,N/A,3431.00,N/A,1354.15,N/A,1382.32,N/A,1331.98,N/A,N/A,1331.98,14704.26,,Hospital 17284,HC Dest Mal Lesion F/E/E/N/L/M 3.1-4.0cm,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,722.00,N/A,433.20,N/A,101.08,N/A,555.96,N/A,415.73,N/A,245.48,N/A,N/A,N/A,101.08,N/A,524.62,N/A,524.62,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,415.73,N/A,524.62,N/A,101.08,N/A,386.99,N/A,386.99,N/A,101.08,N/A,524.62,N/A,555.96,N/A,206.65,N/A,N/A,101.08,555.96,,Hospital CPT 17999,Unlisted Px Skin Muc Membrane & Subq Tissue,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 19084,HC Bx Breast Add Lesion US Img,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9519.00,9519.00,5711.40,5711.40,N/A,1332.66,N/A,9519.00,N/A,5481.04,N/A,3236.46,N/A,9519.00,N/A,1332.66,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,9519.00,N/A,5481.04,N/A,9519.00,N/A,1332.66,N/A,527.00,N/A,527.00,N/A,1332.66,N/A,9519.00,N/A,9519.00,N/A,9519.00,5711.40,5711.40,527.00,9519.00,,Hospital 19101,Biopsy Breast Open Incisional,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21458.20,N/A,12874.92,N/A,2995.28,N/A,3247.41,N/A,12354.31,N/A,7295.78,N/A,7527.03,N/A,2995.28,N/A,3104.47,N/A,3104.47,N/A,4685.72,N/A,7527.03,N/A,7527.03,N/A,7527.03,N/A,12354.33,N/A,3104.47,N/A,2995.28,N/A,3397.00,N/A,3397.00,N/A,2995.28,N/A,3104.47,N/A,3247.41,N/A,277.19,N/A,N/A,277.19,12874.92,,Hospital CPT 19125,Exc Breast Les Preop Plmt Rad Marker Open 1 Les,N/A,N/A,943.00,943.00,565.80,565.80,N/A,132.02,N/A,442.62,N/A,943.00,N/A,320.62,N/A,943.00,N/A,132.02,N/A,442.62,N/A,442.62,N/A,943.00,N/A,943.00,N/A,943.00,N/A,943.00,N/A,943.00,N/A,442.62,N/A,132.02,N/A,943.00,N/A,943.00,N/A,132.02,N/A,442.62,N/A,442.62,N/A,486.88,565.80,565.80,132.02,943.00,,Hospital CPT 19281,HC Perq Device Breast 1st Image,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1599.00,3749.00,959.40,2249.40,N/A,524.86,N/A,1354.15,N/A,2158.67,N/A,1274.66,N/A,3275.59,N/A,524.86,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2158.67,N/A,1354.15,N/A,524.86,N/A,1871.00,N/A,1871.00,N/A,524.86,N/A,1354.15,N/A,1354.15,N/A,1489.57,959.40,959.40,524.86,3275.59,,Hospital CPT 19285,HC Perq Dev Breast 1st US Image,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1084.00,1084.00,650.40,650.40,N/A,151.76,N/A,586.05,N/A,624.17,N/A,368.56,N/A,1084.00,N/A,151.76,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1084.00,N/A,1084.00,N/A,1084.00,N/A,624.17,N/A,586.05,N/A,151.76,N/A,581.02,N/A,581.02,N/A,151.76,N/A,586.05,N/A,586.05,N/A,644.65,650.40,650.40,151.76,1084.00,,Hospital 19294,Prepj Tumor Cavity Iort W/Partial Mastectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63996.42,N/A,38397.85,N/A,8959.47,N/A,6944.89,N/A,36752.36,N/A,21758.78,N/A,16854.44,N/A,8959.47,N/A,6944.89,N/A,6944.89,N/A,10492.22,N/A,16854.44,N/A,16854.44,N/A,16854.44,N/A,36752.35,N/A,6944.89,N/A,8959.47,N/A,10192.50,N/A,10192.50,N/A,8959.47,N/A,6944.89,N/A,6944.89,N/A,7639.38,N/A,N/A,6944.89,38397.85,,Hospital 19297,Plmt Expandable Cath Brst Concurrent Prtl Mast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58876.88,N/A,35326.13,N/A,8242.76,N/A,6944.89,N/A,33817.07,N/A,20018.14,N/A,16856.61,N/A,8242.76,N/A,6944.89,N/A,6944.89,N/A,10493.58,N/A,16856.61,N/A,16856.61,N/A,16856.61,N/A,33817.07,N/A,6944.89,N/A,8242.76,N/A,20035.25,N/A,20035.25,N/A,8242.76,N/A,6944.89,N/A,6944.89,N/A,7639.38,N/A,N/A,6944.89,35326.13,,Hospital 19302,Mastectomy Partial W/Axillary Lymphadenectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,67731.12,54198.63,40638.67,32519.18,9261.97,7574.23,5425.03,5370.83,21401.37,30901.91,23028.57,18427.54,21072.26,14337.59,9547.35,7574.23,96664.00,5370.83,96664.00,5370.83,13116.99,8925.41,21072.26,14337.59,21072.26,14337.59,21072.26,14337.59,21401.37,30901.92,11222.07,5370.83,9547.35,7574.23,25070.73,6358.25,25070.73,6358.25,N/A,7574.23,11222.07,5370.83,11251.72,5370.83,10215.66,5907.91,5425.03,96664.00,5370.83,32519.18,,Hospital CPT 19318,Breast Reduction,N/A,N/A,2520.00,2520.00,1512.00,1512.00,N/A,352.80,N/A,1040.58,N/A,2520.00,N/A,856.80,N/A,2520.00,N/A,352.80,N/A,1040.58,N/A,1040.58,N/A,1934.86,N/A,2520.00,N/A,2520.00,N/A,2520.00,N/A,2520.00,N/A,1040.58,N/A,352.80,N/A,2520.00,N/A,2520.00,N/A,352.80,N/A,1040.58,N/A,1040.58,N/A,1144.64,1512.00,1512.00,352.80,2520.00,,Hospital 19325,Breast Augmentation With Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44959.87,N/A,26975.92,N/A,6278.78,N/A,8771.93,N/A,25805.97,N/A,15286.34,N/A,20218.32,N/A,6278.78,N/A,7951.94,N/A,7951.94,N/A,12586.29,N/A,20218.32,N/A,20218.32,N/A,20218.32,N/A,25805.99,N/A,7951.94,N/A,6278.78,N/A,11845.50,N/A,11845.50,N/A,6278.78,N/A,7951.94,N/A,636.20,N/A,648.98,N/A,N/A,636.20,26975.92,,Hospital 19330,Rmvl Ruptured Breast Implant W/Implant Contents,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38887.60,N/A,23332.56,N/A,5444.27,N/A,8459.15,N/A,22381.54,N/A,13221.78,N/A,19334.56,N/A,5444.27,N/A,7951.94,N/A,7951.94,N/A,12036.15,N/A,19334.56,N/A,19334.56,N/A,19334.56,N/A,22381.53,N/A,7951.94,N/A,5444.27,N/A,12986.00,N/A,12986.00,N/A,5444.27,N/A,7951.94,N/A,8459.15,N/A,1314.53,N/A,N/A,1314.53,23332.56,,Hospital 19350,Nipple/Areola Reconstruction,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36224.90,N/A,21734.94,N/A,5071.50,N/A,5425.03,N/A,20854.34,N/A,12316.47,N/A,13064.48,N/A,5071.50,N/A,5366.90,N/A,5366.90,N/A,8132.88,N/A,13064.48,N/A,13064.48,N/A,13064.48,N/A,20763.65,N/A,5366.90,N/A,5071.50,N/A,7692.25,N/A,7692.25,N/A,5071.50,N/A,5366.90,N/A,5425.03,N/A,2114.46,N/A,N/A,2114.46,21734.94,,Hospital 19361,Breast Reconstruction W/Latissimus Dorsi Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55430.38,N/A,33258.23,N/A,7696.26,N/A,1578.73,N/A,31901.21,N/A,18846.33,N/A,13354.99,N/A,7696.26,N/A,1545.72,N/A,1545.72,N/A,8313.57,N/A,13354.99,N/A,13354.99,N/A,13354.99,N/A,31639.80,N/A,1545.72,N/A,7696.26,N/A,1643.00,N/A,1643.00,N/A,7696.26,N/A,1545.72,N/A,1578.73,N/A,1730.50,N/A,N/A,1545.72,33258.23,,Hospital 19366,Breast Reconstruc W Othr Techniq,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,130353.43,N/A,78212.06,N/A,18245.61,N/A,10087.63,N/A,74684.80,N/A,44320.15,N/A,20271.23,N/A,18245.61,N/A,10053.56,N/A,10053.56,N/A,12619.22,N/A,20271.23,N/A,20271.23,N/A,20271.23,N/A,74684.78,N/A,10053.56,N/A,18245.61,N/A,11845.50,N/A,11845.50,N/A,18245.61,N/A,10053.56,N/A,10087.63,N/A,803.59,N/A,N/A,803.59,78212.06,,Hospital 19370,Revision Peri-Implant Capsule Breast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57327.70,N/A,34396.62,N/A,8010.28,N/A,6262.60,N/A,32817.10,N/A,19477.09,N/A,14576.71,N/A,8010.28,N/A,5973.28,N/A,5973.28,N/A,9074.26,N/A,14576.71,N/A,14576.71,N/A,14576.71,N/A,32817.12,N/A,5973.28,N/A,8010.28,N/A,10085.00,N/A,10085.00,N/A,8010.28,N/A,5973.28,N/A,2355.72,N/A,2591.31,N/A,N/A,2355.72,34396.62,,Hospital Custom 2000000000,HC Icu R&B,N/A,0200 - INTENSIVE CARE - GENERAL CLASSIFICATION,3426.00,3426.00,2055.60,2055.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2055.60,2055.60,2055.60,2055.60,,Hospital 20200,HC Muscle Biopsy,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,34252.40,N/A,20551.44,N/A,4310.37,N/A,5364.60,N/A,10839.98,N/A,11645.82,N/A,9806.70,N/A,4443.18,N/A,2248.00,N/A,2248.00,N/A,6104.44,N/A,9806.70,N/A,9806.70,N/A,9806.70,N/A,10839.98,N/A,5364.60,N/A,4443.18,N/A,11667.52,N/A,11667.52,N/A,N/A,N/A,5364.60,N/A,5364.60,N/A,4754.21,N/A,2248.00,20551.44,N/A,N/A,,Hospital CPT 20206,HC Needle Biopsy Muscle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2873.00,2873.00,1723.80,1723.80,N/A,402.22,N/A,54.58,N/A,1654.27,N/A,976.82,N/A,2873.00,N/A,402.22,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,2873.00,N/A,2873.00,N/A,2873.00,N/A,1654.27,N/A,1354.15,N/A,402.22,N/A,1871.00,N/A,1871.00,N/A,402.22,N/A,1354.15,N/A,1400.58,N/A,60.04,1723.80,1723.80,54.58,2873.00,,Hospital CPT 20220,HC Bx Bone Troc or Needle Superfi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2873.00,2873.00,1723.80,1723.80,N/A,402.22,N/A,1382.32,N/A,1654.27,N/A,976.82,N/A,2873.00,N/A,402.22,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,2873.00,N/A,2873.00,N/A,2873.00,N/A,1654.27,N/A,1354.15,N/A,402.22,N/A,1431.00,N/A,1431.00,N/A,402.22,N/A,1354.15,N/A,1400.58,N/A,92.03,1723.80,1723.80,92.03,2873.00,,Hospital CPT 20225,HC Bx Bone Trocar/Needle Deep,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4253.00,4253.00,2551.80,2551.80,N/A,595.42,N/A,1368.82,N/A,2448.88,N/A,1446.02,N/A,3275.59,N/A,595.42,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2448.88,N/A,1354.15,N/A,595.42,N/A,1871.00,N/A,1871.00,N/A,595.42,N/A,1354.15,N/A,1382.32,N/A,137.23,2551.80,2551.80,137.23,3275.59,,Hospital 20245,Biopsy Bone Open Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42005.42,N/A,25203.25,N/A,5880.76,N/A,6248.31,N/A,24001.43,N/A,14281.84,N/A,14474.46,N/A,5880.76,N/A,5973.28,N/A,5973.28,N/A,9010.62,N/A,14474.46,N/A,14474.46,N/A,14474.46,N/A,24001.43,N/A,5973.28,N/A,5880.76,N/A,9595.50,N/A,9595.50,N/A,5880.76,N/A,5973.28,N/A,6248.31,N/A,1464.60,N/A,N/A,1464.60,25203.25,,Hospital CPT 20501,HC Inject Sinus Tract Diagnostic,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,371.00,371.00,222.60,222.60,N/A,51.94,N/A,36.11,N/A,213.62,N/A,126.14,N/A,371.00,N/A,51.94,N/A,371.00,N/A,371.00,N/A,371.00,N/A,371.00,N/A,371.00,N/A,371.00,N/A,213.62,N/A,371.00,N/A,51.94,N/A,527.00,N/A,527.00,N/A,51.94,N/A,371.00,N/A,36.11,N/A,39.72,222.60,222.60,36.11,527.00,,Hospital 20525,Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13118.63,N/A,7871.18,N/A,1836.62,N/A,234.65,N/A,7547.70,N/A,4460.08,N/A,5663.99,N/A,1836.62,N/A,2332.78,N/A,2332.78,N/A,3525.95,N/A,5663.99,N/A,5663.99,N/A,5663.99,N/A,7547.70,N/A,2332.78,N/A,1836.62,N/A,3397.00,N/A,3397.00,N/A,1836.62,N/A,2332.78,N/A,234.65,N/A,258.12,N/A,N/A,234.65,7871.18,,Hospital CPT 20553,HC Inject Trigger Point 3/> Muscle,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1761.00,1761.00,1056.60,1056.60,N/A,246.54,N/A,245.53,N/A,1013.98,N/A,598.74,N/A,593.92,N/A,246.54,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1013.98,N/A,245.53,N/A,246.54,N/A,1761.00,N/A,1761.00,N/A,246.54,N/A,245.53,N/A,245.53,N/A,270.08,1056.60,1056.60,245.53,1761.00,,Hospital CPT 20553,HC Trigger Point 3 or More,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1761.00,1761.00,1056.60,1056.60,N/A,246.54,N/A,245.53,N/A,1013.98,N/A,598.74,N/A,593.92,N/A,246.54,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,1013.98,N/A,245.53,N/A,246.54,N/A,943.90,N/A,943.90,N/A,246.54,N/A,245.53,N/A,245.53,N/A,270.08,1056.60,1056.60,245.53,1056.60,,Hospital Custom 2060000000,HC Icu Intermediate R&B,N/A,0206 - INTENSIVE CARE - INTERMEDIATE ICU,3047.00,3047.00,1828.20,1828.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1828.20,1828.20,1828.20,1828.20,,Hospital CPT 20612,HC Ganglion Cyst Inj,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,862.00,862.00,517.20,517.20,N/A,120.68,N/A,260.19,N/A,496.34,N/A,293.08,N/A,593.92,N/A,120.68,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,496.34,N/A,245.53,N/A,120.68,N/A,462.03,N/A,462.03,N/A,120.68,N/A,245.53,N/A,260.19,N/A,43.36,517.20,517.20,43.36,593.92,,Hospital CPT 20670,HC Rem Superficial Implant,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6809.00,6809.00,4085.40,4085.40,N/A,953.26,N/A,1368.82,N/A,3920.62,N/A,2315.06,N/A,3275.59,N/A,953.26,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3920.62,N/A,1354.15,N/A,953.26,N/A,1871.00,N/A,1871.00,N/A,953.26,N/A,1354.15,N/A,1368.82,N/A,149.08,4085.40,4085.40,149.08,4085.40,,Hospital 20692,Application Multiplane External Fixation System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,151358.27,N/A,90814.96,N/A,21062.98,N/A,12190.84,N/A,87053.32,N/A,51461.80,N/A,28998.34,N/A,21062.98,N/A,11991.19,N/A,11991.19,N/A,18052.03,N/A,28998.34,N/A,28998.34,N/A,28998.34,N/A,87053.32,N/A,11991.19,N/A,21062.98,N/A,7983.50,N/A,7983.50,N/A,21062.98,N/A,11991.19,N/A,12190.84,N/A,3271.39,N/A,N/A,3271.39,90814.96,,Hospital 20693,Adjustment/Revj Xtrnl Fixation System Req Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37569.82,N/A,22541.89,N/A,5207.35,N/A,479.85,N/A,21583.90,N/A,12773.73,N/A,14533.18,N/A,5207.35,N/A,5973.28,N/A,5973.28,N/A,9047.18,N/A,14533.18,N/A,14533.18,N/A,14533.18,N/A,21583.90,N/A,5973.28,N/A,5207.35,N/A,4562.00,N/A,4562.00,N/A,5207.35,N/A,5973.28,N/A,479.85,N/A,521.73,N/A,N/A,479.85,22541.89,,Hospital 20697,"HC Comp Assist Multiplane Ext Fixation, Change",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,4516.00,N/A,2709.60,N/A,632.24,N/A,1309.46,N/A,2600.31,N/A,1535.44,N/A,252.15,N/A,632.24,N/A,1295.43,N/A,1295.43,N/A,252.15,N/A,252.15,N/A,252.15,N/A,252.15,N/A,2600.31,N/A,1295.43,N/A,632.24,N/A,293.19,N/A,293.19,N/A,632.24,N/A,1295.43,N/A,1309.46,N/A,1892.43,N/A,N/A,252.15,2709.60,,Hospital 20700,Manual Prep and Insertion Deep Drug Delivery Dev,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,22966.88,N/A,13780.13,N/A,3215.35,N/A,2440.19,N/A,13181.83,N/A,7808.74,N/A,5730.19,N/A,3215.35,N/A,2332.78,N/A,2332.78,N/A,3567.16,N/A,5730.19,N/A,5730.19,N/A,5730.19,N/A,13181.83,N/A,2332.78,N/A,3215.35,N/A,1431.00,N/A,1431.00,N/A,3215.35,N/A,2332.78,N/A,2440.19,N/A,597.91,N/A,N/A,597.91,13780.13,,Hospital 20701,Removal Deep Drug Delivery Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15150.73,N/A,9090.44,N/A,2121.11,N/A,1719.23,N/A,8715.49,N/A,5151.25,N/A,3810.09,N/A,2121.11,N/A,1558.52,N/A,1558.52,N/A,2371.85,N/A,3810.09,N/A,3810.09,N/A,3810.09,N/A,8715.49,N/A,1558.52,N/A,2121.11,N/A,2134.50,N/A,2134.50,N/A,2121.11,N/A,1558.52,N/A,822.29,N/A,904.52,N/A,N/A,822.29,9090.44,,Hospital 20900,Bone Graft Any Donor Area Minor/Small,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,77521.37,N/A,46512.82,N/A,10836.42,N/A,3391.11,N/A,44036.00,N/A,23889.62,N/A,28550.17,N/A,10836.42,N/A,11782.94,N/A,11782.94,N/A,17773.04,N/A,28550.17,N/A,28550.17,N/A,28550.17,N/A,44036.02,N/A,11782.94,N/A,10836.42,N/A,7692.25,N/A,7692.25,N/A,10836.42,N/A,11782.94,N/A,3391.11,N/A,3730.20,N/A,N/A,3391.11,46512.82,,Hospital 20924,Tendon Graft From a Distance,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64854.08,N/A,38912.45,N/A,9079.56,N/A,5921.68,N/A,36827.86,N/A,22050.38,N/A,14479.25,N/A,9079.56,N/A,5973.28,N/A,5973.28,N/A,9013.61,N/A,14479.25,N/A,14479.25,N/A,14479.25,N/A,36827.86,N/A,5973.28,N/A,9079.56,N/A,6843.00,N/A,6843.00,N/A,9079.56,N/A,5973.28,N/A,5921.68,N/A,908.13,N/A,N/A,908.13,38912.45,,Hospital 20930,Allograft for Spine Surgery Only Morselized,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,134383.47,102853.12,80630.08,61711.87,6037.91,14342.30,20138.05,3340.33,22625.90,58667.12,40142.11,34970.06,40142.11,29162.26,6037.91,14342.30,11932.77,11933.08,11932.77,11933.08,40142.11,18350.08,40142.11,29162.26,40142.11,29162.26,40142.11,29162.26,74072.16,58667.16,20138.05,11956.02,6037.91,14342.30,22625.90,13819.75,44095.43,13819.75,1411.47,14342.30,20138.05,11933.08,20138.05,3340.33,6037.91,3674.37,1411.47,80630.08,3340.33,61711.87,,Hospital 20939,Bone Marrow Aspiration Bone Grfg Spi Surg Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,154035.30,132859.02,92421.18,79715.41,14881.62,18556.29,17868.86,3079.06,84904.26,75318.82,52372.00,45172.07,45707.94,48994.58,15340.14,18556.29,562.00,19774.44,562.00,19774.44,28452.13,30499.87,45707.94,48994.58,45707.94,48994.58,45707.94,48994.58,84904.26,75318.83,17868.86,19774.44,15340.14,18556.29,54381.04,19049.75,54381.04,19049.75,15340.14,18556.29,17868.86,19774.44,17868.86,3079.06,16413.95,3380.85,562.00,92421.18,3079.06,79715.41,,Hospital CPT 20950,HC Fluid Pressure Muscle,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,83.25,N/A,1017.44,N/A,600.78,N/A,720.00,N/A,247.38,N/A,83.25,N/A,83.25,N/A,448.20,N/A,720.00,N/A,720.00,N/A,720.00,N/A,1017.44,N/A,83.25,N/A,247.38,N/A,1767.00,N/A,1767.00,N/A,247.38,N/A,83.25,N/A,83.25,N/A,91.58,1060.20,1060.20,83.25,1767.00,,Hospital 20982,HC CT Ablation Bone,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,157263.13,105466.52,94357.88,63279.91,N/A,14765.31,28012.49,6354.28,N/A,60455.34,N/A,35858.61,N/A,14475.26,N/A,14765.31,15911.33,8076.58,15911.33,8076.58,N/A,9011.13,N/A,14475.26,N/A,14475.26,N/A,14475.26,N/A,60455.34,15911.33,8076.58,N/A,14765.31,N/A,8244.00,N/A,8244.00,N/A,14765.31,15911.33,8076.58,15911.33,6354.28,N/A,1326.10,15911.33,94357.88,1326.10,63279.91,,Hospital 20983,HC Ablate Bone Tumor(S) Perq,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,101776.82,N/A,61066.09,N/A,14248.75,N/A,6589.23,N/A,58562.98,N/A,34604.12,N/A,14474.94,N/A,14248.75,N/A,5973.28,N/A,5973.28,N/A,9010.93,N/A,14474.94,N/A,14474.94,N/A,14474.94,N/A,58562.98,N/A,5973.28,N/A,14248.75,N/A,11845.50,N/A,11845.50,N/A,14248.75,N/A,5973.28,N/A,827.90,N/A,910.70,N/A,N/A,827.90,61066.09,,Hospital 20999,Unlisted Procedure Muscskeletal System General,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59738.78,N/A,35843.27,N/A,8234.44,N/A,185.82,N/A,34077.89,N/A,20311.19,N/A,4944.19,N/A,8234.44,N/A,1651.99,N/A,1651.99,N/A,3077.83,N/A,4944.19,N/A,4944.19,N/A,4944.19,N/A,34077.88,N/A,1651.99,N/A,8234.44,N/A,2134.50,N/A,2134.50,N/A,8234.44,N/A,1651.99,N/A,185.82,N/A,204.41,N/A,N/A,185.82,35843.27,,Hospital 21012,Excision Tumor Soft Tiss Face/Scalp Subq 2 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17737.00,N/A,10642.20,N/A,2484.23,N/A,2358.04,N/A,10210.15,N/A,6030.59,N/A,5673.63,N/A,2484.23,N/A,2332.78,N/A,2332.78,N/A,3531.94,N/A,5673.63,N/A,5673.63,N/A,5673.63,N/A,10210.15,N/A,2332.78,N/A,2484.23,N/A,4690.25,N/A,4690.25,N/A,2484.23,N/A,2332.78,N/A,2358.04,N/A,1264.31,N/A,N/A,1264.31,10642.20,,Hospital 21014,Exc Tumor Soft Tiss Face&Scalp Subfascial 2 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15827.40,N/A,9496.44,N/A,2215.83,N/A,2440.19,N/A,9111.93,N/A,5381.31,N/A,5671.61,N/A,2215.83,N/A,2332.78,N/A,2332.78,N/A,3530.69,N/A,5671.61,N/A,5671.61,N/A,5671.61,N/A,9111.94,N/A,2332.78,N/A,2215.83,N/A,1694.50,N/A,1694.50,N/A,2215.83,N/A,2332.78,N/A,2440.19,N/A,902.14,N/A,N/A,902.14,9496.44,,Hospital 21029,Removal Contouring Benign Tumor Facial Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24598.90,N/A,14759.34,N/A,3444.13,N/A,2622.61,N/A,14159.49,N/A,8363.62,N/A,6239.11,N/A,3444.13,N/A,2569.18,N/A,2569.18,N/A,3883.98,N/A,6239.11,N/A,6239.11,N/A,6239.11,N/A,14159.49,N/A,2569.18,N/A,3444.13,N/A,4464.25,N/A,4464.25,N/A,3444.13,N/A,2569.18,N/A,2622.61,N/A,1577.84,N/A,N/A,1577.84,14759.34,,Hospital 21048,Exc Benign Tumor/Cyst Maxl Intra-Oral Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15314.30,N/A,9188.58,N/A,2144.01,N/A,4797.27,N/A,8813.14,N/A,5206.87,N/A,11695.95,N/A,2144.01,N/A,4821.94,N/A,4821.94,N/A,7280.94,N/A,11695.95,N/A,11695.95,N/A,11695.95,N/A,8813.14,N/A,4821.94,N/A,2144.01,N/A,5963.00,N/A,5963.00,N/A,2144.01,N/A,4821.94,N/A,4797.27,N/A,1265.87,N/A,N/A,1265.87,11695.95,,Hospital 21120,Genioplasty Augmentation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40262.58,N/A,24157.55,N/A,5621.15,N/A,5055.49,N/A,23162.20,N/A,13689.28,N/A,11786.11,N/A,5621.15,N/A,4821.94,N/A,4821.94,N/A,7337.07,N/A,11786.11,N/A,11786.11,N/A,11786.11,N/A,23162.22,N/A,4821.94,N/A,5621.15,N/A,7109.75,N/A,7109.75,N/A,5621.15,N/A,4821.94,N/A,1958.85,N/A,2154.74,N/A,N/A,1958.85,24157.55,,Hospital 21121,Genioplasty Sliding Osteotomy Single Piece,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,101551.18,N/A,60930.71,N/A,14200.05,N/A,7688.30,N/A,58213.24,N/A,34527.40,N/A,11861.29,N/A,14200.05,N/A,7660.55,N/A,7660.55,N/A,7383.89,N/A,11861.29,N/A,11861.29,N/A,11861.29,N/A,58213.26,N/A,7660.55,N/A,14200.05,N/A,7661.50,N/A,7661.50,N/A,14200.05,N/A,7660.55,N/A,7688.30,N/A,2013.17,N/A,N/A,2013.17,60930.71,,Hospital 21122,Genioplasty 2/> Sliding Osteotomies,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15300.00,N/A,9180.00,N/A,2142.00,N/A,707.78,N/A,8809.74,N/A,5202.00,N/A,11663.87,N/A,2142.00,N/A,4821.94,N/A,4821.94,N/A,7260.98,N/A,11663.87,N/A,11663.87,N/A,11663.87,N/A,8809.74,N/A,4821.94,N/A,2142.00,N/A,3397.00,N/A,3397.00,N/A,2142.00,N/A,4821.94,N/A,707.78,N/A,778.56,N/A,N/A,707.78,11663.87,,Hospital 21141,Rcnstj Midface Lefort I 1 Piece W/O Bone Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,142983.77,N/A,85790.26,N/A,20012.60,N/A,10560.78,N/A,81670.02,N/A,48614.48,N/A,11807.49,N/A,20012.60,N/A,10540.11,N/A,10540.11,N/A,7350.38,N/A,11807.49,N/A,11807.49,N/A,11807.49,N/A,80672.74,N/A,10540.11,N/A,20012.60,N/A,5963.00,N/A,5963.00,N/A,20012.60,N/A,10540.11,N/A,10560.78,N/A,1460.05,N/A,N/A,1460.05,85790.26,,Hospital 21142,Rcnstj Midface Lefort I 2 Pieces W/O Bone Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33753.85,N/A,20252.31,N/A,4709.93,N/A,5319.17,N/A,19356.12,N/A,10432.51,N/A,11702.42,N/A,4709.93,N/A,4821.94,N/A,4821.94,N/A,7284.99,N/A,11702.42,N/A,11702.42,N/A,11702.42,N/A,19356.15,N/A,4821.94,N/A,4709.93,N/A,5963.00,N/A,5963.00,N/A,4709.93,N/A,4821.94,N/A,1311.77,N/A,1442.95,N/A,N/A,1311.77,20252.31,,Hospital 21147,Rcnstj Midface Lefort I 3/> Piece W/Bone Grafts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,117268.18,N/A,70360.91,N/A,16402.86,N/A,8780.63,N/A,67143.27,N/A,39871.17,N/A,23401.13,N/A,16402.86,N/A,8752.88,N/A,8752.88,N/A,14567.66,N/A,23401.13,N/A,23401.13,N/A,23401.13,N/A,67143.27,N/A,8752.88,N/A,16402.86,N/A,10435.25,N/A,10435.25,N/A,16402.86,N/A,8752.88,N/A,8780.63,N/A,5855.22,N/A,N/A,5855.22,70360.91,,Hospital 21154,Rcnstj Midface Lefort III W/O Lefort I,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,199327.00,N/A,119596.20,N/A,27880.32,N/A,14483.72,N/A,113214.65,N/A,67771.14,N/A,23534.83,N/A,27880.32,N/A,14455.97,N/A,14455.97,N/A,14650.89,N/A,23534.83,N/A,23534.83,N/A,23534.83,N/A,113186.09,N/A,14455.97,N/A,27880.32,N/A,9076.25,N/A,9076.25,N/A,27880.32,N/A,14455.97,N/A,14483.72,N/A,2864.20,N/A,N/A,2864.20,119596.20,,Hospital 21196,Rcnstj Mndblr Rami&/Bdy Sgtl Splt W/Int Rgd Fi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,117268.18,N/A,70360.91,N/A,16402.86,N/A,8780.63,N/A,67143.27,N/A,39871.17,N/A,23401.13,N/A,16402.86,N/A,8752.88,N/A,8752.88,N/A,14567.66,N/A,23401.13,N/A,23401.13,N/A,23401.13,N/A,67143.27,N/A,8752.88,N/A,16402.86,N/A,10435.25,N/A,10435.25,N/A,16402.86,N/A,8752.88,N/A,8780.63,N/A,5855.22,N/A,N/A,5855.22,70360.91,,Hospital 21198,Osteotomy Mandible Segmental,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56525.78,N/A,33915.47,N/A,7913.62,N/A,5043.96,N/A,32545.61,N/A,19218.76,N/A,11684.02,N/A,7913.62,N/A,4821.94,N/A,4821.94,N/A,7273.53,N/A,11684.02,N/A,11684.02,N/A,11684.02,N/A,32545.61,N/A,4821.94,N/A,7913.62,N/A,3397.00,N/A,3397.00,N/A,7913.62,N/A,4821.94,N/A,5043.96,N/A,1088.48,N/A,N/A,1088.48,33915.47,,Hospital 21199,Osteotomy Mandible Sgmtl W/Genioglossus Advmnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,162204.02,N/A,97322.41,N/A,22664.60,N/A,11903.67,N/A,92757.54,N/A,55149.35,N/A,11726.58,N/A,22664.60,N/A,11875.92,N/A,11875.92,N/A,7300.04,N/A,11726.58,N/A,11726.58,N/A,11726.58,N/A,92757.58,N/A,11875.92,N/A,22664.60,N/A,8944.50,N/A,8944.50,N/A,22664.60,N/A,11875.92,N/A,11903.67,N/A,2496.75,N/A,N/A,2496.75,97322.41,,Hospital 21215,Graft Bone Mandible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,117268.18,N/A,70360.91,N/A,16402.86,N/A,8780.63,N/A,67143.27,N/A,39871.17,N/A,23401.13,N/A,16402.86,N/A,8752.88,N/A,8752.88,N/A,14567.66,N/A,23401.13,N/A,23401.13,N/A,23401.13,N/A,67143.27,N/A,8752.88,N/A,16402.86,N/A,10435.25,N/A,10435.25,N/A,16402.86,N/A,8752.88,N/A,8780.63,N/A,5855.22,N/A,N/A,5855.22,70360.91,,Hospital 21230,Graft Rib Crtlg Autogenous Face/Chin/Nose/Ear,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45191.23,N/A,27114.74,N/A,6325.50,N/A,5319.17,N/A,26006.87,N/A,15365.05,N/A,11702.42,N/A,6325.50,N/A,4821.94,N/A,4821.94,N/A,7284.99,N/A,11702.42,N/A,11702.42,N/A,11702.42,N/A,26006.89,N/A,4821.94,N/A,6325.50,N/A,10435.25,N/A,10435.25,N/A,6325.50,N/A,4821.94,N/A,2036.53,N/A,2240.19,N/A,N/A,2036.53,27114.74,,Hospital CPT 21235,Graft Ear Crtlg Autogenous Nose/Ear,N/A,N/A,1218.00,1218.00,730.80,730.80,N/A,170.52,N/A,536.27,N/A,1218.00,N/A,414.12,N/A,1218.00,N/A,170.52,N/A,536.27,N/A,536.27,N/A,1218.00,N/A,1218.00,N/A,1218.00,N/A,1218.00,N/A,1218.00,N/A,536.27,N/A,170.52,N/A,1218.00,N/A,1218.00,N/A,170.52,N/A,536.27,N/A,536.27,N/A,589.90,730.80,730.80,170.52,1218.00,,Hospital 21244,Rcnstj Mndbl Xtroral W/Transosteal Bone Plate,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72015.88,N/A,43209.53,N/A,10082.22,N/A,4874.16,N/A,41159.57,N/A,24485.40,N/A,11726.96,N/A,10082.22,N/A,4821.94,N/A,4821.94,N/A,7300.26,N/A,11726.96,N/A,11726.96,N/A,11726.96,N/A,41159.56,N/A,4821.94,N/A,10082.22,N/A,6898.50,N/A,6898.50,N/A,10082.22,N/A,4821.94,N/A,4874.16,N/A,1759.41,N/A,N/A,1759.41,43209.53,,Hospital 21282,Lateral Canthopexy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27879.18,N/A,16727.51,N/A,3903.09,N/A,5055.49,N/A,16037.77,N/A,9478.92,N/A,11726.23,N/A,3903.09,N/A,4821.94,N/A,4821.94,N/A,7299.81,N/A,11726.23,N/A,11726.23,N/A,11726.23,N/A,16037.78,N/A,4821.94,N/A,3903.09,N/A,5563.25,N/A,5563.25,N/A,3903.09,N/A,4821.94,N/A,798.86,N/A,878.74,N/A,N/A,798.86,16727.51,,Hospital 21310,HC Treatment of Nose Fractur,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 21315,HC Clsd Tx Nasal Bone Fracture,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5943.00,5943.00,3565.80,3565.80,N/A,832.02,N/A,56.48,N/A,3421.98,N/A,2020.62,N/A,417.06,N/A,832.02,N/A,56.48,N/A,56.48,N/A,259.62,N/A,417.06,N/A,417.06,N/A,417.06,N/A,3421.98,N/A,56.48,N/A,832.02,N/A,5943.00,N/A,5943.00,N/A,832.02,N/A,56.48,N/A,56.48,N/A,62.13,3565.80,3565.80,56.48,5943.00,,Hospital 21335,Open Tx Nasal Fx W/Concomitant Optx Fxd Septum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23806.93,N/A,14284.16,N/A,3332.96,N/A,849.52,N/A,13699.71,N/A,8026.18,N/A,6258.85,N/A,3332.96,N/A,2569.18,N/A,2569.18,N/A,3896.26,N/A,6258.85,N/A,6258.85,N/A,6258.85,N/A,13699.72,N/A,2569.18,N/A,3332.96,N/A,5944.75,N/A,5944.75,N/A,3332.96,N/A,2569.18,N/A,849.52,N/A,934.48,N/A,N/A,849.52,14284.16,,Hospital 21337,Closed Tx Nasal Septal Fract W/WO Stabilization,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15276.65,N/A,9165.99,N/A,2166.30,N/A,400.28,N/A,8792.53,N/A,5194.07,N/A,6237.25,N/A,2166.30,N/A,2569.18,N/A,2569.18,N/A,3882.81,N/A,6237.25,N/A,6237.25,N/A,6237.25,N/A,8792.53,N/A,2569.18,N/A,2166.30,N/A,2806.50,N/A,2806.50,N/A,2166.30,N/A,2569.18,N/A,400.28,N/A,440.31,N/A,N/A,400.28,9165.99,,Hospital 21356,Open Tx Depressed Zygomatic Arch Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13241.30,N/A,7944.78,N/A,1834.68,N/A,4780.29,N/A,7621.50,N/A,4502.05,N/A,11701.43,N/A,1834.68,N/A,4821.94,N/A,4821.94,N/A,7284.36,N/A,11701.43,N/A,11701.43,N/A,11701.43,N/A,7621.50,N/A,4821.94,N/A,1834.68,N/A,3397.00,N/A,3397.00,N/A,1834.68,N/A,4821.94,N/A,4780.29,N/A,442.30,N/A,N/A,442.30,11701.43,,Hospital 21385,Open Tx Orbital Floor Blowout Fx Transantral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58892.68,N/A,35335.61,N/A,8244.99,N/A,4874.16,N/A,33468.44,N/A,20023.52,N/A,11743.59,N/A,8244.99,N/A,4821.94,N/A,4821.94,N/A,7310.61,N/A,11743.59,N/A,11743.59,N/A,11743.59,N/A,33468.44,N/A,4821.94,N/A,8244.99,N/A,8129.25,N/A,8129.25,N/A,8244.99,N/A,4821.94,N/A,4874.16,N/A,1640.63,N/A,N/A,1640.63,35335.61,,Hospital 21390,Optx Orb Floor Blwt Fx Pri/Bital Appr W/Allplstc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50471.85,N/A,30283.11,N/A,7066.05,N/A,5319.17,N/A,28882.45,N/A,17160.43,N/A,11787.65,N/A,7066.05,N/A,4821.94,N/A,4821.94,N/A,7337.93,N/A,11787.65,N/A,11787.65,N/A,11787.65,N/A,28882.46,N/A,4821.94,N/A,7066.05,N/A,6898.50,N/A,6898.50,N/A,7066.05,N/A,4821.94,N/A,852.84,N/A,938.13,N/A,N/A,852.84,30283.11,,Hospital CPT 21400,HC Treat Eye Socket Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1247.00,1247.00,748.20,748.20,N/A,174.58,N/A,153.19,N/A,718.02,N/A,423.98,N/A,593.49,N/A,174.58,N/A,153.19,N/A,153.19,N/A,369.45,N/A,593.49,N/A,593.49,N/A,593.49,N/A,718.02,N/A,153.19,N/A,174.58,N/A,1247.00,N/A,1247.00,N/A,174.58,N/A,153.19,N/A,153.19,N/A,168.51,748.20,748.20,153.19,1247.00,,Hospital 21422,Open Treatment Palatal/Maxillary Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47914.73,N/A,28748.84,N/A,6703.65,N/A,5129.50,N/A,27479.44,N/A,16291.01,N/A,11792.08,N/A,6703.65,N/A,4821.94,N/A,4821.94,N/A,7340.78,N/A,11792.08,N/A,11792.08,N/A,11792.08,N/A,27479.44,N/A,4821.94,N/A,6703.65,N/A,5963.00,N/A,5963.00,N/A,6703.65,N/A,4821.94,N/A,5129.50,N/A,663.79,N/A,N/A,663.79,28748.84,,Hospital 21445,Optx Mandibular/Maxillary Alveolar Ridge Fx Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64869.60,N/A,38921.76,N/A,9081.76,N/A,5129.50,N/A,37119.66,N/A,22055.67,N/A,11762.00,N/A,9081.76,N/A,4821.94,N/A,4821.94,N/A,7322.07,N/A,11762.00,N/A,11762.00,N/A,11762.00,N/A,37119.66,N/A,4821.94,N/A,9081.76,N/A,8944.50,N/A,8944.50,N/A,9081.76,N/A,4821.94,N/A,5129.50,N/A,1766.37,N/A,N/A,1766.37,38921.76,,Hospital 21461,Open Tx Mandibular Fx W/O Interdental Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40192.07,N/A,24115.24,N/A,5604.44,N/A,4874.16,N/A,23068.67,N/A,13665.30,N/A,11693.25,N/A,5604.44,N/A,4821.94,N/A,4821.94,N/A,7279.26,N/A,11693.25,N/A,11693.25,N/A,11693.25,N/A,23068.68,N/A,4821.94,N/A,5604.44,N/A,5963.00,N/A,5963.00,N/A,5604.44,N/A,4821.94,N/A,4874.16,N/A,1109.23,N/A,N/A,1109.23,24115.24,,Hospital 21462,Open Tx Mandibular Fx W/Interdental Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44192.48,N/A,26515.49,N/A,6186.95,N/A,4874.16,N/A,25247.06,N/A,14507.66,N/A,11729.07,N/A,6186.95,N/A,4821.94,N/A,4821.94,N/A,7301.56,N/A,11729.07,N/A,11729.07,N/A,11729.07,N/A,25247.06,N/A,4821.94,N/A,6186.95,N/A,5963.00,N/A,5963.00,N/A,6186.95,N/A,4821.94,N/A,4874.16,N/A,1237.58,N/A,N/A,1237.58,26515.49,,Hospital 21465,Open Treatment Mandibular Condylar Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15062.28,N/A,9037.37,N/A,2104.33,N/A,5129.50,N/A,8634.03,N/A,5121.19,N/A,11728.39,N/A,2104.33,N/A,4821.94,N/A,4821.94,N/A,7301.14,N/A,11728.39,N/A,11728.39,N/A,11728.39,N/A,8634.03,N/A,4821.94,N/A,2104.33,N/A,5963.00,N/A,5963.00,N/A,2104.33,N/A,4821.94,N/A,5129.50,N/A,846.77,N/A,N/A,846.77,11728.39,,Hospital CPT 21480,HC ED Closed Tx Tmj Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1422.00,1422.00,853.20,853.20,N/A,199.08,N/A,29.97,N/A,818.79,N/A,483.48,N/A,387.69,N/A,199.08,N/A,29.97,N/A,29.97,N/A,241.34,N/A,387.69,N/A,387.69,N/A,387.69,N/A,818.79,N/A,29.97,N/A,199.08,N/A,1422.00,N/A,1422.00,N/A,199.08,N/A,29.97,N/A,29.97,N/A,32.97,853.20,853.20,29.97,1422.00,,Hospital 21501,I&D Deep Absc/Hmtma Soft Tissue Neck/Thorax,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28377.52,N/A,17026.51,N/A,3972.87,N/A,3254.84,N/A,16203.98,N/A,9648.34,N/A,10039.46,N/A,3972.87,N/A,3104.47,N/A,3104.47,N/A,8500.68,N/A,10039.46,N/A,10039.46,N/A,10039.46,N/A,16203.98,N/A,3104.47,N/A,3972.87,N/A,5227.25,N/A,5227.25,N/A,3972.87,N/A,3104.47,N/A,1664.96,N/A,1831.46,N/A,N/A,1664.96,17026.51,,Hospital 21550,HC Biopsy Soft Tissue Neck/T,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,44413.60,8482.50,26648.16,5089.50,11969.82,1187.55,14425.32,1368.82,26974.96,4884.23,15100.62,2884.05,27233.00,3275.59,12338.63,1187.55,3934.00,1354.15,3934.00,1354.15,16951.91,2039.12,27233.00,3275.59,27233.00,3275.59,27233.00,3275.59,26974.96,4884.23,14425.32,1354.15,12338.63,1187.55,32400.47,1871.00,32400.47,1871.00,N/A,1187.55,14425.32,1354.15,14425.32,1368.82,13202.34,479.13,3934.00,32400.47,479.13,5089.50,,Hospital CPT 21554,Exc Tumor Soft Tissue Neck/Thorax Subfasc 5 Cm/>,N/A,N/A,1468.00,1468.00,880.80,880.80,N/A,205.52,N/A,701.08,N/A,1468.00,N/A,499.12,N/A,1468.00,N/A,205.52,N/A,701.08,N/A,701.08,N/A,1301.12,N/A,1468.00,N/A,1468.00,N/A,1468.00,N/A,1468.00,N/A,701.08,N/A,205.52,N/A,1468.00,N/A,1468.00,N/A,205.52,N/A,701.08,N/A,701.08,N/A,771.19,880.80,880.80,205.52,1468.00,,Hospital CPT 21555,Exc Tumor Soft Tissue Neck/Ant Thorax Subq <3cm,N/A,N/A,724.00,724.00,434.40,434.40,N/A,101.36,N/A,291.07,N/A,724.00,N/A,246.16,N/A,724.00,N/A,101.36,N/A,291.07,N/A,291.07,N/A,724.00,N/A,724.00,N/A,724.00,N/A,724.00,N/A,724.00,N/A,291.07,N/A,101.36,N/A,724.00,N/A,724.00,N/A,101.36,N/A,291.07,N/A,291.07,N/A,320.18,434.40,434.40,101.36,724.00,,Hospital 21620,Ostectomy Sternum Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,23499.60,N/A,14099.76,N/A,8054.74,N/A,9793.99,N/A,18152.02,N/A,7989.86,N/A,18325.66,N/A,8302.92,N/A,9793.99,N/A,9793.99,N/A,11407.29,N/A,18325.66,N/A,18325.66,N/A,18325.66,N/A,18152.02,N/A,9793.99,N/A,8302.92,N/A,21802.96,N/A,21802.96,N/A,N/A,N/A,9793.99,N/A,9793.99,N/A,8884.13,N/A,7989.86,21802.96,N/A,N/A,,Hospital 21627,Sternal Debridement,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26332.70,N/A,15799.62,N/A,3664.85,N/A,627.63,N/A,15147.38,N/A,8953.11,N/A,14765.38,N/A,3664.85,N/A,620.94,N/A,620.94,N/A,9191.72,N/A,14765.38,N/A,14765.38,N/A,14765.38,N/A,15147.38,N/A,620.94,N/A,3664.85,N/A,7897.00,N/A,7897.00,N/A,3664.85,N/A,620.94,N/A,627.63,N/A,661.10,N/A,N/A,620.94,15799.62,,Hospital 21685,Hyoid Myotomy & Suspension,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50357.43,N/A,30214.46,N/A,7027.78,N/A,1791.79,N/A,28722.42,N/A,17121.52,N/A,11719.28,N/A,7027.78,N/A,4821.94,N/A,4821.94,N/A,7295.45,N/A,11719.28,N/A,11719.28,N/A,11719.28,N/A,28722.43,N/A,4821.94,N/A,7027.78,N/A,5095.50,N/A,5095.50,N/A,7027.78,N/A,4821.94,N/A,1791.79,N/A,1829.03,N/A,N/A,1791.79,30214.46,,Hospital 21750,Close Median Sternotomy Sep W/WO Debridement Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64387.30,N/A,38632.38,N/A,8973.28,N/A,784.44,N/A,36883.42,N/A,21891.67,N/A,15761.47,N/A,8973.28,N/A,780.83,N/A,780.83,N/A,9817.96,N/A,15761.47,N/A,15761.47,N/A,15761.47,N/A,36883.44,N/A,780.83,N/A,8973.28,N/A,7897.00,N/A,7897.00,N/A,8973.28,N/A,780.83,N/A,784.44,N/A,910.01,N/A,N/A,780.83,38632.38,,Hospital 21825,Open Tx Sternum Fracture W/WO Skeletal Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23719.20,N/A,14231.52,N/A,3285.63,N/A,753.04,N/A,13616.42,N/A,8064.52,N/A,14995.75,N/A,3285.63,N/A,735.42,N/A,735.42,N/A,9335.13,N/A,14995.75,N/A,14995.75,N/A,14995.75,N/A,13616.43,N/A,735.42,N/A,3285.63,N/A,7897.00,N/A,7897.00,N/A,3285.63,N/A,735.42,N/A,753.04,N/A,620.87,N/A,N/A,620.87,14995.75,,Hospital 21899,Unlisted Procedure Neck/Thorax,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22377.40,N/A,13426.44,N/A,3125.66,N/A,1676.73,N/A,12879.98,N/A,7608.32,N/A,4064.53,N/A,3125.66,N/A,1652.36,N/A,1652.36,N/A,2530.24,N/A,4064.53,N/A,4064.53,N/A,4064.53,N/A,12879.97,N/A,1652.36,N/A,3125.66,N/A,4464.25,N/A,4464.25,N/A,3125.66,N/A,1658.83,N/A,1676.73,N/A,1245.58,N/A,N/A,1245.58,13426.44,,Hospital CPT 21930,Excision Tumor Soft Tissue Back/Flank Subq <3cm,N/A,N/A,832.00,832.00,499.20,499.20,N/A,116.48,N/A,346.27,N/A,832.00,N/A,282.88,N/A,832.00,N/A,116.48,N/A,346.27,N/A,346.27,N/A,832.00,N/A,832.00,N/A,832.00,N/A,832.00,N/A,832.00,N/A,346.27,N/A,116.48,N/A,832.00,N/A,832.00,N/A,116.48,N/A,346.27,N/A,346.27,N/A,380.90,499.20,499.20,116.48,832.00,,Hospital CPT 21932,Exc Tumor Soft Tiss Back/Flank Subfascial <5cm,N/A,N/A,1329.00,1329.00,797.40,797.40,N/A,186.06,N/A,635.82,N/A,1329.00,N/A,451.86,N/A,1329.00,N/A,186.06,N/A,635.82,N/A,635.82,N/A,1182.33,N/A,1329.00,N/A,1329.00,N/A,1329.00,N/A,1329.00,N/A,635.82,N/A,186.06,N/A,1329.00,N/A,1329.00,N/A,186.06,N/A,635.82,N/A,635.82,N/A,699.40,797.40,797.40,186.06,1329.00,,Hospital 22015,I&D Deep Abscess Pst Spine Lumbar Sac/Lumbosac,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,76899.18,46345.92,46139.51,27807.55,10849.55,6488.43,19321.87,1792.35,25544.03,26680.19,26145.73,15757.61,24684.23,20992.61,11183.84,6488.43,13100.10,1792.35,13100.10,1792.35,15365.36,13068.31,24684.23,20992.61,24684.23,20992.61,24684.23,20992.61,25544.03,26680.19,13100.10,1792.35,11183.84,6488.43,29368.07,8718.50,29368.07,8718.50,N/A,6488.43,13100.10,1792.35,13100.10,1792.35,11966.71,1971.59,10849.55,46139.51,1792.35,27807.55,,Hospital 22100,Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Crv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19748.70,N/A,11849.22,N/A,2764.82,N/A,6037.97,N/A,11367.03,N/A,6714.55,N/A,14521.41,N/A,2764.82,N/A,5973.28,N/A,5973.28,N/A,9039.86,N/A,14521.41,N/A,14521.41,N/A,14521.41,N/A,11367.04,N/A,5973.28,N/A,2764.82,N/A,7897.00,N/A,7897.00,N/A,2764.82,N/A,5973.28,N/A,6037.97,N/A,899.79,N/A,N/A,899.79,14521.41,,Hospital 22110,Prtl Exc Vrt Bdy B1y Les W/O Spi Cord 1 Sgm Crv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28958.58,N/A,17375.15,N/A,4054.19,N/A,1135.13,N/A,16668.19,N/A,9845.91,N/A,15003.40,N/A,4054.19,N/A,1135.13,N/A,1135.13,N/A,9339.90,N/A,15003.40,N/A,15003.40,N/A,15003.40,N/A,16547.28,N/A,1135.13,N/A,4054.19,N/A,8160.50,N/A,8160.50,N/A,4054.19,N/A,1135.13,N/A,1135.13,N/A,1248.65,N/A,N/A,1135.13,17375.15,,Hospital 22116,Prtl Exc Vrt Bdy B1y Les W/O Spi Cord 1 Sgm Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28958.58,N/A,17375.15,N/A,4054.19,N/A,1135.13,N/A,16668.19,N/A,9845.91,N/A,15003.40,N/A,4054.19,N/A,1135.13,N/A,1135.13,N/A,9339.90,N/A,15003.40,N/A,15003.40,N/A,15003.40,N/A,16547.28,N/A,1135.13,N/A,4054.19,N/A,8160.50,N/A,8160.50,N/A,4054.19,N/A,1135.13,N/A,1135.13,N/A,1248.65,N/A,N/A,1135.13,17375.15,,Hospital 22216,Osteot Spi Pst/Pstlat Appr 1 Vrt Sgm Ea Vrt Sgm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,369404.73,N/A,221642.84,N/A,N/A,N/A,N/A,N/A,178995.23,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,178995.23,N/A,N/A,N/A,N/A,N/A,178995.23,N/A,178995.23,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,178995.23,221642.84,N/A,N/A,,Hospital 22220,Osteotomy Spine W/Dsc Ant Appr 1 Vrt Sgm Crv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47367.20,N/A,28420.32,N/A,6605.44,N/A,12325.48,N/A,27137.29,N/A,16104.83,N/A,43030.80,N/A,6605.44,N/A,11782.94,N/A,11782.94,N/A,26787.51,N/A,43030.80,N/A,43030.80,N/A,43030.80,N/A,27137.29,N/A,11782.94,N/A,6605.44,N/A,12986.00,N/A,12986.00,N/A,6605.44,N/A,11782.94,N/A,12325.48,N/A,3977.84,N/A,N/A,3977.84,43030.80,,Hospital 22310,Closed Tx Vert Fx W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,804.00,N/A,482.40,N/A,112.56,N/A,299.28,N/A,462.94,N/A,273.36,N/A,N/A,N/A,112.56,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,462.94,N/A,296.08,N/A,112.56,N/A,430.94,N/A,430.94,N/A,112.56,N/A,296.08,N/A,299.28,N/A,360.23,N/A,N/A,112.56,482.40,,Hospital 22505,Manipulation Spine Requiring Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50872.42,N/A,30523.45,N/A,7066.13,N/A,1408.80,N/A,29276.62,N/A,17296.63,N/A,3481.44,N/A,7066.13,N/A,1381.86,N/A,1381.86,N/A,2277.67,N/A,3481.44,N/A,3481.44,N/A,3481.44,N/A,29276.65,N/A,1392.94,N/A,7066.13,N/A,1871.00,N/A,1871.00,N/A,7066.13,N/A,1381.86,N/A,1408.80,N/A,320.12,N/A,N/A,320.12,30523.45,,Hospital 22512,HC Vertebroplasty Addl Inject,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,107268.95,20276.40,64361.37,12165.84,N/A,2832.57,24973.51,6097.50,N/A,11656.25,36471.44,6893.98,N/A,14469.79,N/A,2832.57,24973.51,5973.28,24973.51,5973.28,N/A,9007.72,N/A,14469.79,N/A,14469.79,N/A,14469.79,59126.65,11656.25,24973.51,5973.28,N/A,2832.57,N/A,4825.50,66140.98,4825.50,N/A,2832.57,24973.51,5973.28,24973.51,6097.50,N/A,1210.57,24973.51,66140.98,1210.57,14469.79,,Hospital 22513,HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,101185.58,43314.28,60711.35,25988.57,8054.74,6064.00,9596.87,6589.23,20962.82,24906.73,34403.10,14726.85,18325.66,14467.39,8302.92,6064.00,108466.00,5973.28,108466.00,5973.28,11407.29,9006.22,18325.66,14467.39,18325.66,14467.39,18325.66,14467.39,20962.82,24906.75,9567.22,5973.28,8302.92,6064.00,21802.96,7897.00,21802.96,7897.00,14805.18,6064.00,9567.22,5973.28,9596.87,488.35,8884.13,537.19,8054.74,108466.00,488.35,25988.57,,Hospital 22514,HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,102082.72,28070.88,61249.63,16842.53,18765.14,3929.93,13834.20,5973.28,162751.85,16144.66,N/A,9544.10,N/A,14504.22,18765.14,3929.93,13834.20,5973.28,13834.20,5973.28,N/A,9029.14,N/A,14504.22,N/A,14504.22,N/A,14504.22,162751.85,16144.67,13834.20,5973.28,18765.14,3929.93,162751.85,7897.00,162751.85,7897.00,18765.14,3929.93,13834.20,5973.28,13834.20,5973.28,18765.14,6570.60,13834.20,162751.85,3929.93,16842.53,,Hospital 22515,HC Vertebroplasty Addl Inject,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,124126.48,64286.67,74475.89,38572.00,8054.74,9000.13,9912.59,12997.98,68418.52,36987.25,42203.00,21857.47,18325.66,28519.71,8302.92,9000.13,38778.00,11782.94,38778.00,11782.94,11407.29,17754.08,18325.66,28519.71,N/A,28519.71,18325.66,28519.71,N/A,36987.25,9793.99,11782.94,8302.92,9000.13,21802.96,8160.50,21802.96,8160.50,8302.92,9000.13,9793.99,11782.94,9912.59,686.14,8884.13,754.76,8054.74,74475.89,686.14,38572.00,,Hospital 22551,Arthrd Ant Interbody Decompress Cervical Belw C2,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,88832.87,59615.20,53299.72,35769.12,16382.62,8317.70,18700.42,11782.94,47810.35,34070.74,30203.18,20269.15,37062.76,28656.04,16887.40,8317.70,11933.08,11782.94,11933.08,11782.94,23070.70,17838.94,37062.76,28656.04,37062.76,28656.04,37062.76,28656.04,47810.35,34070.74,18641.12,11782.94,16887.40,8317.70,44095.43,13336.25,44095.43,13336.25,6037.91,8317.70,18641.12,11782.94,18700.42,11782.94,18069.51,12961.23,6037.91,53299.72,8317.70,35769.12,,Hospital 22552,Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,88832.87,67133.20,53299.72,40279.92,16382.62,9372.31,18700.42,11782.94,47810.35,38457.80,30203.18,22825.26,37062.76,28590.87,16887.40,9372.31,11933.08,11782.94,11933.08,11782.94,23070.70,17798.36,37062.76,28590.87,37062.76,28590.87,37062.76,28590.87,47810.35,38457.79,18641.12,11782.94,16887.40,9372.31,44095.43,12019.00,44095.43,12019.00,N/A,9372.31,18641.12,11782.94,18700.42,11782.94,18069.51,12961.23,11933.08,53299.72,9372.31,40279.92,,Hospital 22595,Arthrodesis Posterior Atlas-Axis C1-C2,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,145568.50,N/A,87341.10,N/A,13523.80,N/A,15570.94,N/A,80237.36,N/A,49493.29,N/A,30815.84,N/A,13940.49,N/A,387218.00,N/A,387218.00,N/A,19182.15,N/A,30815.84,N/A,30815.84,N/A,30815.84,N/A,80237.36,N/A,15541.29,N/A,13940.49,N/A,36663.16,N/A,36663.16,N/A,3366.61,N/A,15541.29,N/A,15570.94,N/A,14916.32,N/A,3366.61,387218.00,N/A,N/A,,Hospital 22600,Arthrd Pst/Pstlat Tq 1ntrspc Crv Belw C2 Segment,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,78372.00,N/A,47023.20,N/A,10898.83,N/A,6195.35,N/A,44729.49,N/A,26646.48,N/A,48562.10,N/A,10898.83,N/A,6194.75,N/A,6194.75,N/A,30230.53,N/A,48562.10,N/A,48562.10,N/A,48562.10,N/A,44729.52,N/A,6194.75,N/A,10898.83,N/A,12055.25,N/A,12055.25,N/A,10898.83,N/A,6194.75,N/A,6195.35,N/A,2294.95,N/A,N/A,2294.95,48562.10,,Hospital 22634,Arthrodesis Cmbn Tq 1ntrspc Each Additional,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,250873.22,217127.68,150523.93,130276.61,N/A,30340.25,78413.68,4838.93,N/A,122970.91,N/A,73823.41,N/A,49400.89,N/A,30340.25,79432.85,19924.58,79432.85,19924.58,N/A,30949.02,N/A,49400.89,N/A,49400.89,N/A,49400.89,N/A,120136.24,79432.85,19947.52,N/A,30340.25,N/A,19049.75,N/A,19049.75,N/A,30340.25,79432.85,19924.58,79432.85,4838.93,N/A,5310.59,78413.68,150523.93,4838.93,130276.61,,Hospital 22840,Posterior Non-Segmental Instrumentation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,156532.48,145271.27,93919.49,87162.76,N/A,20308.98,29075.45,20835.08,86280.70,82739.56,53221.04,49392.22,58030.64,48448.57,26329.16,20308.98,323150.00,19924.58,323150.00,19924.58,36122.72,30356.17,58030.64,48448.57,58030.64,48448.57,58030.64,48448.57,86280.70,82739.61,29045.80,19947.52,26329.16,20308.98,69041.97,19049.75,69041.97,19049.75,26329.16,20308.98,29045.80,19924.58,29075.45,20835.08,28172.20,4225.52,26329.16,323150.00,4225.52,87162.76,,Hospital 22842,Posterior Segmental Instrumentation 3-6 Vrt Seg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,104547.48,150009.50,62728.49,90005.70,14881.62,21003.91,17868.86,20602.22,74748.92,85746.32,35546.14,51003.26,45707.94,48473.28,15340.14,21003.91,562.00,19924.27,562.00,19924.27,28452.13,30371.56,45707.94,48473.28,45707.94,48473.28,45707.94,48473.28,74748.92,85746.31,17868.86,19947.52,15340.14,21003.91,54381.04,12055.25,54381.04,12055.25,15340.14,21003.91,17868.86,19924.27,17868.86,20602.22,16413.95,3076.26,562.00,74748.92,3076.26,90005.70,,Hospital 22845,Anterior Instrumentation 2-3 Vertebral Segments,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,80354.03,59615.20,48212.42,35769.12,16382.62,8317.70,19645.44,11782.94,43730.00,34070.74,27320.38,20269.15,37272.73,28656.04,16887.40,8317.70,1124.00,11782.94,1124.00,11782.94,23201.41,17838.94,37272.73,28656.04,37272.73,28656.04,37272.73,28656.04,43730.00,34070.74,19645.44,11782.94,16887.40,8317.70,44345.24,13336.25,44345.24,13336.25,N/A,8317.70,19645.44,11782.94,19645.44,11782.94,18069.51,12961.23,1124.00,48212.42,8317.70,35769.12,,Hospital 22849,Reinsertion Spinal Fixation Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,113675.87,98846.28,68205.52,59307.77,20090.18,13791.87,17898.51,1519.23,62658.14,56398.80,38649.80,33607.73,45707.94,49002.89,20709.19,13791.87,17868.86,6047.17,17868.86,6047.17,28452.13,30785.70,45707.94,49002.89,45707.94,49002.89,45707.94,49002.89,62658.14,56398.81,17868.86,6066.21,20709.19,13791.87,54381.04,11660.00,54381.04,11660.00,N/A,13791.87,17868.86,6047.17,17898.51,1519.23,22158.84,1671.16,17868.86,68205.52,1519.23,59307.77,,Hospital 22850,Removal Posterior Nonsegmental Instrumentation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20531.68,N/A,12319.01,N/A,2874.46,N/A,722.05,N/A,11819.78,N/A,6980.78,N/A,20531.68,N/A,2874.46,N/A,721.81,N/A,721.81,N/A,17799.51,N/A,20531.68,N/A,20531.68,N/A,20531.68,N/A,11819.79,N/A,721.81,N/A,2874.46,N/A,7897.00,N/A,7897.00,N/A,2874.46,N/A,721.81,N/A,722.05,N/A,779.77,N/A,N/A,721.81,20531.68,,Hospital 22852,Removal Posterior Segmental Instrumentation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,129288.43,N/A,77573.06,N/A,17996.80,N/A,20335.50,N/A,73673.60,N/A,43958.08,N/A,77019.53,N/A,17996.80,N/A,19924.27,N/A,19924.27,N/A,48142.13,N/A,77019.53,N/A,77019.53,N/A,77019.53,N/A,73512.43,N/A,19947.52,N/A,17996.80,N/A,22559.75,N/A,22559.75,N/A,17996.80,N/A,19924.27,N/A,20335.50,N/A,5188.10,N/A,N/A,5188.10,77573.06,,Hospital 22855,Removal Anterior Instrumentation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58833.62,N/A,35300.17,N/A,8159.01,N/A,1418.14,N/A,33860.51,N/A,20003.44,N/A,29909.84,N/A,8159.01,N/A,1413.76,N/A,1413.76,N/A,18754.40,N/A,29909.84,N/A,29909.84,N/A,29909.84,N/A,33860.54,N/A,1428.37,N/A,8159.01,N/A,7897.00,N/A,7897.00,N/A,8159.01,N/A,1413.76,N/A,1418.14,N/A,1541.01,N/A,N/A,1413.76,35300.17,,Hospital 22861,Revj W/Rplcmt Tot Disc Arthrp Ant 1 Ntrspc Crv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,90594.82,N/A,54356.89,N/A,12652.35,N/A,6962.37,N/A,51524.52,N/A,30597.13,N/A,49631.25,N/A,12652.35,N/A,6960.17,N/A,6960.17,N/A,31146.28,N/A,49631.25,N/A,49631.25,N/A,49631.25,N/A,51524.55,N/A,6980.81,N/A,12652.35,N/A,11660.00,N/A,11660.00,N/A,12652.35,N/A,6960.17,N/A,6962.37,N/A,2724.82,N/A,N/A,2724.82,54356.89,,Hospital 22869,Insj Stablj Dev W/O Dcmprn Lumbar Single Level,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82692.10,N/A,49615.26,N/A,11572.14,N/A,11726.95,N/A,46816.29,N/A,28115.31,N/A,28544.99,N/A,11572.14,N/A,11782.94,N/A,11782.94,N/A,17769.81,N/A,28544.99,N/A,28544.99,N/A,28544.99,N/A,46816.29,N/A,11782.94,N/A,11572.14,N/A,7897.00,N/A,7897.00,N/A,11572.14,N/A,11787.23,N/A,11726.95,N/A,466.02,N/A,N/A,466.02,49615.26,,Hospital 22870,Insj Stablj Dev W/O Dcmprn Lumbar Second Level,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81231.50,N/A,48738.90,N/A,11372.41,N/A,12186.91,N/A,46183.26,N/A,27618.71,N/A,28522.46,N/A,11372.41,N/A,11782.94,N/A,11782.94,N/A,17755.79,N/A,28522.46,N/A,28522.46,N/A,28522.46,N/A,46183.27,N/A,11782.94,N/A,11372.41,N/A,8160.50,N/A,8160.50,N/A,11372.41,N/A,11782.94,N/A,12186.91,N/A,585.06,N/A,N/A,585.06,48738.90,,Hospital 22899,Unlisted Procedure Spine,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,194592.72,N/A,116755.63,N/A,27214.79,N/A,8797.03,N/A,109941.50,N/A,66161.53,N/A,49603.89,N/A,27214.79,N/A,8789.35,N/A,8789.35,N/A,30879.38,N/A,49603.89,N/A,49603.89,N/A,49603.89,N/A,109941.52,N/A,8789.35,N/A,27214.79,N/A,12055.25,N/A,12055.25,N/A,27214.79,N/A,8789.35,N/A,8796.99,N/A,1852.06,N/A,N/A,1852.06,116755.63,,Hospital 22901,Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11722.00,N/A,7033.20,N/A,1641.08,N/A,2358.04,N/A,2552.00,N/A,3985.48,N/A,5663.99,N/A,1641.08,N/A,2332.78,N/A,2332.78,N/A,3525.94,N/A,5663.99,N/A,5663.99,N/A,5663.99,N/A,2552.00,N/A,2332.78,N/A,1641.08,N/A,4332.50,N/A,4332.50,N/A,1641.08,N/A,2332.78,N/A,2358.04,N/A,979.66,N/A,N/A,979.66,7033.20,,Hospital CPT 22903,Exc Tumor Soft Tissue Abdominal Wall Subq 3 Cm/>,N/A,N/A,880.00,880.00,528.00,528.00,N/A,123.20,N/A,422.22,N/A,880.00,N/A,299.20,N/A,880.00,N/A,123.20,N/A,422.22,N/A,422.22,N/A,782.54,N/A,880.00,N/A,880.00,N/A,880.00,N/A,880.00,N/A,422.22,N/A,123.20,N/A,880.00,N/A,880.00,N/A,123.20,N/A,422.22,N/A,422.22,N/A,464.44,528.00,528.00,123.20,880.00,,Hospital 22904,Rad Resection Tumor Soft Tissue Abdl Wall <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,53582.20,N/A,32149.32,N/A,5769.53,N/A,7326.26,N/A,27546.01,N/A,18217.94,N/A,27809.51,N/A,5947.30,N/A,296174.00,N/A,296174.00,N/A,17310.77,N/A,27809.51,N/A,27809.51,N/A,27809.51,N/A,27546.01,N/A,7266.96,N/A,5947.30,N/A,33086.37,N/A,33086.37,N/A,2236.64,N/A,7266.96,N/A,7326.26,N/A,6363.61,N/A,2236.64,296174.00,N/A,N/A,,Hospital 22905,Rad Resection Tumor Soft Tissue Abdl Wall 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,69357.50,30034.52,41614.50,18020.71,9377.20,4204.84,11358.38,4682.70,27496.38,17290.22,23581.55,10211.74,21334.42,11432.51,9666.12,4204.84,562.00,4706.78,562.00,4706.78,13280.18,7116.96,21334.42,11432.51,21334.42,11432.51,21334.42,11432.51,27496.38,17290.23,11358.38,4706.78,9666.12,4204.84,25382.63,10444.75,25382.63,10444.75,N/A,4204.84,11358.38,4706.78,11358.38,4682.70,10342.75,2876.43,562.00,41614.50,2876.43,18020.71,,Hospital 23020,Capsular Contracture Release,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,75788.50,N/A,45473.10,N/A,10537.86,N/A,12475.31,N/A,43419.67,N/A,25768.09,N/A,29556.16,N/A,10537.86,N/A,11932.77,N/A,11932.77,N/A,18602.29,N/A,29556.16,N/A,29556.16,N/A,29556.16,N/A,43419.68,N/A,11956.02,N/A,10537.86,N/A,14298.75,N/A,14298.75,N/A,10537.86,N/A,11932.77,N/A,12475.31,N/A,2413.99,N/A,N/A,2413.99,45473.10,,Hospital 23030,I&D Shoulder Deep Abscess/Hematoma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15814.40,N/A,9488.64,N/A,2125.59,N/A,2332.78,N/A,9103.05,N/A,5376.90,N/A,5723.93,N/A,2125.59,N/A,2332.78,N/A,2332.78,N/A,3563.25,N/A,5723.93,N/A,5723.93,N/A,5723.93,N/A,9103.06,N/A,2332.78,N/A,2125.59,N/A,3397.00,N/A,3397.00,N/A,2125.59,N/A,2332.78,N/A,2332.78,N/A,2566.06,N/A,N/A,2125.59,9488.64,,Hospital 23040,Arthrotomy Glenohumeral Jt Expl/Drg/Rmvl FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25590.80,N/A,15354.48,N/A,3253.66,N/A,1664.33,N/A,14735.17,N/A,8700.87,N/A,20951.53,N/A,3253.66,N/A,2688.04,N/A,2688.04,N/A,13042.73,N/A,20951.53,N/A,20951.53,N/A,20951.53,N/A,14735.19,N/A,2688.04,N/A,3253.66,N/A,8244.00,N/A,8244.00,N/A,3253.66,N/A,2688.04,N/A,1664.33,N/A,1830.76,N/A,N/A,1664.33,20951.53,,Hospital 23044,Arthrt Acromclav Strnclav Jt Expl/Drg/Rmvl FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33216.60,N/A,19929.96,N/A,4584.62,N/A,2811.81,N/A,19123.20,N/A,11293.66,N/A,6565.24,N/A,4584.62,N/A,2688.04,N/A,2688.04,N/A,4086.99,N/A,6565.24,N/A,6565.24,N/A,6565.24,N/A,19123.23,N/A,2688.04,N/A,4584.62,N/A,4825.50,N/A,4825.50,N/A,4584.62,N/A,2688.04,N/A,2811.81,N/A,953.67,N/A,N/A,953.67,19929.96,,Hospital 23066,Biopsy Soft Tissue Shoulder Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76094.62,N/A,45656.77,N/A,10682.17,N/A,2440.19,N/A,43758.24,N/A,25872.16,N/A,6586.26,N/A,10682.17,N/A,2332.78,N/A,2332.78,N/A,4100.07,N/A,6586.26,N/A,6586.26,N/A,6586.26,N/A,43758.23,N/A,2332.78,N/A,10682.17,N/A,3397.00,N/A,3397.00,N/A,10682.17,N/A,2332.78,N/A,2440.19,N/A,1362.64,N/A,N/A,1362.64,45656.77,,Hospital 23078,Rad Resection Tumor Soft Tissue Shoulder 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17237.80,N/A,10342.68,N/A,2413.29,N/A,1398.51,N/A,9912.92,N/A,5860.85,N/A,5688.55,N/A,2413.29,N/A,2332.78,N/A,2332.78,N/A,3541.23,N/A,5688.55,N/A,5688.55,N/A,5688.55,N/A,9912.92,N/A,2332.78,N/A,2413.29,N/A,3397.00,N/A,3397.00,N/A,2413.29,N/A,2332.78,N/A,1398.51,N/A,1538.37,N/A,N/A,1398.51,10342.68,,Hospital 23105,Arthrt Glenohumrl Jt W/Synovectomy W/WO Biopsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,79694.90,N/A,47816.94,N/A,11130.71,N/A,12475.31,N/A,45580.24,N/A,27096.25,N/A,30045.87,N/A,11130.71,N/A,11932.77,N/A,11932.77,N/A,18900.13,N/A,30045.87,N/A,30045.87,N/A,30045.87,N/A,45580.26,N/A,11956.02,N/A,11130.71,N/A,15782.00,N/A,15782.00,N/A,11130.71,N/A,11932.77,N/A,12475.31,N/A,3456.55,N/A,N/A,3456.55,47816.94,,Hospital 23107,Arthrt Glenohmrl Jt W/Jt Expl W/WO Rmvl Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,85336.70,N/A,51202.02,N/A,11876.87,N/A,12412.22,N/A,48716.73,N/A,29014.48,N/A,29323.00,N/A,11876.87,N/A,11869.68,N/A,11869.68,N/A,18364.55,N/A,29323.00,N/A,29323.00,N/A,29323.00,N/A,48716.76,N/A,11880.45,N/A,11876.87,N/A,14298.75,N/A,14298.75,N/A,11876.87,N/A,11869.68,N/A,12412.22,N/A,2489.41,N/A,N/A,2489.41,51202.02,,Hospital CPT 23120,Claviculectomy Partial,N/A,N/A,1157.00,1157.00,694.20,694.20,N/A,161.98,N/A,557.91,N/A,1157.00,N/A,393.38,N/A,1157.00,N/A,161.98,N/A,557.91,N/A,557.91,N/A,1041.41,N/A,1157.00,N/A,1157.00,N/A,1157.00,N/A,1157.00,N/A,557.91,N/A,161.98,N/A,1157.00,N/A,1157.00,N/A,161.98,N/A,557.91,N/A,557.91,N/A,613.70,694.20,694.20,161.98,1157.00,,Hospital 23130,Partial Repair or Removal of Shoulder Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46936.92,N/A,28162.15,N/A,6571.19,N/A,6248.31,N/A,26945.78,N/A,15958.54,N/A,14569.64,N/A,6571.19,N/A,5973.28,N/A,5973.28,N/A,9069.87,N/A,14569.64,N/A,14569.64,N/A,14569.64,N/A,26945.78,N/A,5973.28,N/A,6571.19,N/A,10085.00,N/A,10085.00,N/A,6571.19,N/A,5973.28,N/A,6248.31,N/A,2188.25,N/A,N/A,2188.25,28162.15,,Hospital 23150,Exc/Curtg Bone Cyst/Benign Tumor Prox Humerus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61696.87,N/A,37018.12,N/A,8637.59,N/A,12325.48,N/A,35372.37,N/A,20976.94,N/A,28544.91,N/A,8637.59,N/A,11782.94,N/A,11782.94,N/A,17769.77,N/A,28544.91,N/A,28544.91,N/A,28544.91,N/A,35372.36,N/A,11782.94,N/A,8637.59,N/A,10178.00,N/A,10178.00,N/A,8637.59,N/A,11782.94,N/A,12325.48,N/A,1850.59,N/A,N/A,1850.59,37018.12,,Hospital 23330,Removal Foreign Body Shoulder Subcutaneous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61984.48,N/A,37190.69,N/A,8677.82,N/A,6248.31,N/A,35646.81,N/A,21074.71,N/A,14944.23,N/A,8677.82,N/A,5973.28,N/A,5973.28,N/A,9310.07,N/A,14944.23,N/A,14944.23,N/A,14944.23,N/A,35646.82,N/A,5973.28,N/A,8677.82,N/A,7256.25,N/A,7256.25,N/A,8677.82,N/A,5973.28,N/A,6248.31,N/A,1945.65,N/A,N/A,1945.65,37190.69,,Hospital CPT 23350,HC Inj Proc Shoulder Arthro,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,612.00,612.00,367.20,367.20,N/A,85.68,N/A,612.00,N/A,352.39,N/A,208.08,N/A,612.00,N/A,85.68,N/A,612.00,N/A,612.00,N/A,612.00,N/A,612.00,N/A,612.00,N/A,612.00,N/A,352.39,N/A,612.00,N/A,85.68,N/A,527.00,N/A,527.00,N/A,85.68,N/A,612.00,N/A,612.00,N/A,53.14,367.20,367.20,53.14,612.00,,Hospital 23397,Muscle Transfer Shoulder/Upper Arm Multiple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,119251.58,N/A,71550.95,N/A,16372.83,N/A,12110.30,N/A,67787.20,N/A,40545.54,N/A,29193.45,N/A,16372.83,N/A,11951.38,N/A,11951.38,N/A,18394.33,N/A,29193.45,N/A,29193.45,N/A,29193.45,N/A,67787.18,N/A,11977.96,N/A,16372.83,N/A,14999.25,N/A,14999.25,N/A,16372.83,N/A,11951.38,N/A,3507.35,N/A,3833.62,N/A,N/A,3507.35,71550.95,,Hospital 23405,Tenotomy Shoulder Area 1 Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43005.87,N/A,25803.52,N/A,6020.83,N/A,6248.31,N/A,11735.00,N/A,14622.01,N/A,14486.18,N/A,6020.83,N/A,5973.28,N/A,5973.28,N/A,9017.93,N/A,14486.18,N/A,14486.18,N/A,14486.18,N/A,11735.00,N/A,5973.28,N/A,6020.83,N/A,12986.00,N/A,12986.00,N/A,6020.83,N/A,5973.28,N/A,6248.31,N/A,2730.53,N/A,N/A,2730.53,25803.52,,Hospital 23410,Open Repair of Rotator Cuff Acute,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46936.92,N/A,28162.15,N/A,6571.19,N/A,6248.31,N/A,26945.78,N/A,15958.54,N/A,14569.64,N/A,6571.19,N/A,5973.28,N/A,5973.28,N/A,9069.87,N/A,14569.64,N/A,14569.64,N/A,14569.64,N/A,26945.78,N/A,5973.28,N/A,6571.19,N/A,10085.00,N/A,10085.00,N/A,6571.19,N/A,5973.28,N/A,6248.31,N/A,2188.25,N/A,N/A,2188.25,28162.15,,Hospital CPT 23430,Tenodesis Long Tendon Biceps,N/A,N/A,1482.00,1482.00,889.20,889.20,N/A,207.48,N/A,709.60,N/A,1482.00,N/A,503.88,N/A,1482.00,N/A,207.48,N/A,709.60,N/A,709.60,N/A,1320.57,N/A,1482.00,N/A,1482.00,N/A,1482.00,N/A,1482.00,N/A,709.60,N/A,207.48,N/A,1482.00,N/A,1482.00,N/A,207.48,N/A,709.60,N/A,709.60,N/A,780.56,889.20,889.20,207.48,1482.00,,Hospital 23440,Resection/Transplantation Long Tendon Biceps,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,77104.68,N/A,46262.81,N/A,10716.35,N/A,12475.31,N/A,44062.69,N/A,26215.59,N/A,29557.31,N/A,10716.35,N/A,11932.77,N/A,11932.77,N/A,18596.00,N/A,29557.31,N/A,29557.31,N/A,29557.31,N/A,44062.71,N/A,11956.02,N/A,10716.35,N/A,10535.75,N/A,10535.75,N/A,10716.35,N/A,11932.77,N/A,12475.31,N/A,2248.31,N/A,N/A,2248.31,46262.81,,Hospital 23472,Arthroplasty Glenohumeral Joint Total Shoulder,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,103786.27,68317.03,62271.76,40990.22,12576.90,9564.38,15143.47,11782.94,56762.28,38772.72,35287.33,23227.79,28614.19,28987.41,12964.42,9564.38,562.00,11782.94,562.00,11782.94,17811.67,18045.21,28614.19,28987.41,28614.19,28987.41,28614.19,28987.41,56762.28,38772.72,15143.47,11782.94,12964.42,9564.38,34043.74,12375.50,34043.74,12375.50,12964.42,9564.38,15143.47,11782.94,15143.47,11782.94,13871.93,12961.23,562.00,62271.76,9564.38,40990.22,,Hospital 23473,Revis Shoulder Arthrplsty Humeral/Glenoid Compnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,95300.22,76284.53,57180.13,45770.72,12576.90,10562.47,15143.47,12325.48,49784.09,43754.93,32402.07,25936.73,28614.19,29140.53,12964.42,10562.47,15143.47,11782.94,15143.47,11782.94,17811.67,18140.53,28614.19,29140.53,28614.19,29140.53,28614.19,29140.53,49784.09,43754.94,15143.47,11782.94,12964.42,10562.47,34043.74,6678.50,34043.74,6678.50,N/A,10562.47,15143.47,11782.94,15143.47,12325.48,13871.93,1997.74,12576.90,57180.13,1997.74,45770.72,,Hospital 23480,Osteotomy Clavicle W/WO Internal Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38668.45,N/A,23201.07,N/A,5318.25,N/A,6097.50,N/A,22255.69,N/A,13147.28,N/A,14508.01,N/A,5318.25,N/A,5973.28,N/A,5973.28,N/A,9031.51,N/A,14508.01,N/A,14508.01,N/A,14508.01,N/A,22255.68,N/A,5973.28,N/A,5318.25,N/A,5963.00,N/A,5963.00,N/A,5318.25,N/A,5973.28,N/A,6097.50,N/A,995.75,N/A,N/A,995.75,23201.07,,Hospital 23485,Osteotomy Clav W/WO Int Fixj W/Bone Grf Non/Mal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44172.62,N/A,26503.57,N/A,6184.16,N/A,11910.55,N/A,25322.87,N/A,15018.67,N/A,28629.25,N/A,6184.16,N/A,11782.94,N/A,11782.94,N/A,17822.26,N/A,28629.25,N/A,28629.25,N/A,28629.25,N/A,25262.41,N/A,11782.94,N/A,6184.16,N/A,8612.50,N/A,8612.50,N/A,6184.16,N/A,11782.94,N/A,11910.55,N/A,1066.51,N/A,N/A,1066.51,28629.25,,Hospital CPT 23505,HC Closed Treat of Clavicular Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4030.00,4030.00,2418.00,2418.00,N/A,564.20,N/A,318.78,N/A,2320.47,N/A,1370.20,N/A,1028.13,N/A,564.20,N/A,318.78,N/A,318.78,N/A,640.01,N/A,1028.13,N/A,1028.13,N/A,1028.13,N/A,2320.47,N/A,318.78,N/A,564.20,N/A,4030.00,N/A,4030.00,N/A,564.20,N/A,318.78,N/A,318.78,N/A,350.66,2418.00,2418.00,318.78,4030.00,,Hospital 23520,HC Treat Clavicle Disloc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 23525,HC Treat Clavicle Disloc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 23550,Open Tx Acromioclavicular Dislc Acute/Chronic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58019.60,N/A,34811.76,N/A,8122.76,N/A,1186.45,N/A,32995.47,N/A,19726.67,N/A,14502.27,N/A,8122.76,N/A,5973.28,N/A,5973.28,N/A,9027.94,N/A,14502.27,N/A,14502.27,N/A,14502.27,N/A,32995.48,N/A,5973.28,N/A,8122.76,N/A,10535.75,N/A,10535.75,N/A,8122.76,N/A,5973.28,N/A,1186.45,N/A,1305.09,N/A,N/A,1186.45,34811.76,,Hospital CPT 23575,HC Treat Shoulder Blade Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3586.00,3586.00,2151.60,2151.60,N/A,502.04,N/A,361.31,N/A,2064.82,N/A,1219.24,N/A,1171.74,N/A,502.04,N/A,361.31,N/A,361.31,N/A,729.41,N/A,1171.74,N/A,1171.74,N/A,1171.74,N/A,2064.82,N/A,361.31,N/A,502.04,N/A,3586.00,N/A,3586.00,N/A,502.04,N/A,361.31,N/A,361.31,N/A,397.44,2151.60,2151.60,361.31,3586.00,,Hospital 23600,HC Cltx Proximal Humeral Fracture W/O Manipulation,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,32199.50,488.00,19319.70,292.80,4108.72,68.32,5126.05,313.76,9259.34,280.99,10947.85,165.92,9347.92,N/A,4235.32,68.32,1686.00,296.08,1686.00,296.08,5818.86,N/A,9347.92,N/A,9347.92,N/A,9347.92,N/A,9259.34,280.99,5126.05,296.08,4235.32,68.32,11121.69,261.56,11121.69,261.56,N/A,68.32,5126.05,296.08,5126.05,313.76,4531.79,328.59,1686.00,19319.70,68.32,328.59,,Hospital CPT 23605,HC ED Clsd Tx Prox Hum Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3384.00,3384.00,2030.40,2030.40,N/A,473.76,N/A,406.99,N/A,1948.51,N/A,1150.56,N/A,1343.91,N/A,473.76,N/A,406.99,N/A,406.99,N/A,836.58,N/A,1343.91,N/A,1343.91,N/A,1343.91,N/A,1948.51,N/A,406.99,N/A,473.76,N/A,3384.00,N/A,3384.00,N/A,473.76,N/A,406.99,N/A,406.99,N/A,447.69,2030.40,2030.40,406.99,3384.00,,Hospital 23615,Optx Prox Humeral Fx W/Int Fixj Rpr Tuberosity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59537.42,N/A,35722.45,N/A,8335.24,N/A,12325.48,N/A,34049.18,N/A,20242.72,N/A,28543.31,N/A,8335.24,N/A,11782.94,N/A,11782.94,N/A,17768.77,N/A,28543.31,N/A,28543.31,N/A,28543.31,N/A,34049.19,N/A,11782.94,N/A,8335.24,N/A,8612.50,N/A,8612.50,N/A,8335.24,N/A,11782.94,N/A,12325.48,N/A,1017.26,N/A,N/A,1017.26,35722.45,,Hospital 23620,HC Cltx Gr Hmrl Tbrs Fx WO Mnpj,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 23650,HC ED Clsd Tx Shoulder WO Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1914.00,1914.00,1148.40,1148.40,N/A,267.96,N/A,282.29,N/A,1102.08,N/A,650.76,N/A,951.51,N/A,267.96,N/A,282.29,N/A,282.29,N/A,592.31,N/A,951.51,N/A,951.51,N/A,951.51,N/A,1102.08,N/A,282.29,N/A,267.96,N/A,1914.00,N/A,1914.00,N/A,267.96,N/A,282.29,N/A,282.29,N/A,310.52,1148.40,1148.40,267.96,1914.00,,Hospital CPT 23655,HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4030.00,4030.00,2418.00,2418.00,N/A,564.20,N/A,389.19,N/A,2320.47,N/A,1370.20,N/A,3133.53,N/A,564.20,N/A,1295.43,N/A,1295.43,N/A,1950.68,N/A,3133.53,N/A,3133.53,N/A,3133.53,N/A,2320.47,N/A,1295.43,N/A,564.20,N/A,4030.00,N/A,4030.00,N/A,564.20,N/A,1295.43,N/A,389.19,N/A,428.11,2418.00,2418.00,389.19,4030.00,,Hospital CPT 23665,HC ED Clsd Tx Shdr W Fx WO Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1705.00,1705.00,1023.00,1023.00,N/A,238.70,N/A,380.92,N/A,981.74,N/A,579.70,N/A,1241.16,N/A,238.70,N/A,380.92,N/A,380.92,N/A,772.62,N/A,1241.16,N/A,1241.16,N/A,1241.16,N/A,981.74,N/A,380.92,N/A,238.70,N/A,1705.00,N/A,1705.00,N/A,238.70,N/A,380.92,N/A,380.92,N/A,419.01,1023.00,1023.00,238.70,1705.00,,Hospital 23800,Arthrodesis Glenohumeral Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42730.68,N/A,25638.41,N/A,5982.31,N/A,6248.31,N/A,24526.29,N/A,14528.43,N/A,14506.44,N/A,5982.31,N/A,5973.28,N/A,5973.28,N/A,9030.53,N/A,14506.44,N/A,14506.44,N/A,14506.44,N/A,24526.30,N/A,5973.28,N/A,5982.31,N/A,12203.25,N/A,12203.25,N/A,5982.31,N/A,5973.28,N/A,6248.31,N/A,2255.69,N/A,N/A,2255.69,25638.41,,Hospital CPT 23931,HC Drain Arm Bursa,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3791.00,3791.00,2274.60,2274.60,N/A,530.74,N/A,150.99,N/A,2182.86,N/A,1288.94,N/A,838.38,N/A,530.74,N/A,150.99,N/A,150.99,N/A,521.89,N/A,838.38,N/A,838.38,N/A,838.38,N/A,2182.86,N/A,150.99,N/A,530.74,N/A,3791.00,N/A,3791.00,N/A,530.74,N/A,150.99,N/A,150.99,N/A,166.09,2274.60,2274.60,150.99,3791.00,,Hospital 23935,Inc Deep W/Opening Bone Cortex Humerus/Elbow,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39754.50,N/A,23852.70,N/A,5395.65,N/A,2811.81,N/A,22839.09,N/A,13516.53,N/A,6545.86,N/A,5395.65,N/A,2688.04,N/A,2688.04,N/A,4074.91,N/A,6545.86,N/A,6545.86,N/A,6545.86,N/A,22839.09,N/A,2688.04,N/A,5395.65,N/A,3397.00,N/A,3397.00,N/A,5395.65,N/A,2688.04,N/A,2811.81,N/A,716.51,N/A,N/A,716.51,23852.70,,Hospital 24065,Biopsy Soft Tissue Upper Arm/Elbow Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10010.10,N/A,6006.06,N/A,1401.41,N/A,1406.88,N/A,5762.08,N/A,3403.43,N/A,3306.98,N/A,1401.41,N/A,1354.15,N/A,1354.15,N/A,2058.65,N/A,3306.98,N/A,3306.98,N/A,3306.98,N/A,5762.09,N/A,1354.15,N/A,1401.41,N/A,1871.00,N/A,1871.00,N/A,1401.41,N/A,1354.15,N/A,1406.88,N/A,199.67,N/A,N/A,199.67,6006.06,,Hospital 24066,Biopsy Soft Tissue Upper Arm/Elbow Area Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8974.60,N/A,5384.76,N/A,1246.15,N/A,2527.76,N/A,5165.83,N/A,3051.36,N/A,5665.60,N/A,1246.15,N/A,2332.78,N/A,2332.78,N/A,3526.94,N/A,5665.60,N/A,5665.60,N/A,5665.60,N/A,5134.16,N/A,2332.78,N/A,1246.15,N/A,1871.00,N/A,1871.00,N/A,1246.15,N/A,2332.78,N/A,2527.76,N/A,476.90,N/A,N/A,476.90,5665.60,,Hospital CPT 24075,Exc Tumor Soft Tiss Upper Arm/Elbow Subq <3cm,N/A,N/A,890.00,890.00,534.00,534.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,890.00,534.00,534.00,534.00,890.00,,Hospital CPT 24076,Exc Tumor Soft Tiss Upr Arm/Elbow Subfasc <5cm,N/A,N/A,1082.00,1082.00,649.20,649.20,N/A,151.48,N/A,520.02,N/A,1082.00,N/A,367.88,N/A,1082.00,N/A,151.48,N/A,520.02,N/A,520.02,N/A,971.40,N/A,1082.00,N/A,1082.00,N/A,1082.00,N/A,1082.00,N/A,520.02,N/A,151.48,N/A,1082.00,N/A,1082.00,N/A,151.48,N/A,520.02,N/A,520.02,N/A,572.02,649.20,649.20,151.48,1082.00,,Hospital 24077,Rad Rescj Tumor Soft Tiss Upper Arm/Elbow <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38279.88,N/A,22967.93,N/A,5355.34,N/A,2481.57,N/A,22036.86,N/A,13011.66,N/A,5667.83,N/A,5355.34,N/A,2332.78,N/A,2332.78,N/A,3528.34,N/A,5667.83,N/A,5667.83,N/A,5667.83,N/A,22036.86,N/A,2332.78,N/A,5355.34,N/A,2806.50,N/A,2806.50,N/A,5355.34,N/A,2332.78,N/A,2481.57,N/A,2817.40,N/A,N/A,2332.78,22967.93,,Hospital 24102,Arthrotomy Elbow W/Synovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23895.83,N/A,14337.50,N/A,3345.42,N/A,1283.09,N/A,13675.93,N/A,8124.59,N/A,6528.37,N/A,3345.42,N/A,2688.04,N/A,2688.04,N/A,4064.03,N/A,6528.37,N/A,6528.37,N/A,6528.37,N/A,13675.93,N/A,2688.04,N/A,3345.42,N/A,7200.75,N/A,7200.75,N/A,3345.42,N/A,2688.04,N/A,1283.09,N/A,1411.41,N/A,N/A,1283.09,14337.50,,Hospital 24149,Rad Rescj Capsl Tiss&Htrtpc B1 Elbw Contrct Rls,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38838.28,N/A,23302.97,N/A,5421.19,N/A,1756.70,N/A,22354.38,N/A,12171.17,N/A,14497.06,N/A,5421.19,N/A,5973.28,N/A,5973.28,N/A,9024.70,N/A,14497.06,N/A,14497.06,N/A,14497.06,N/A,22354.40,N/A,5973.28,N/A,5421.19,N/A,6618.25,N/A,6618.25,N/A,5421.19,N/A,5973.28,N/A,1756.70,N/A,1932.38,N/A,N/A,1756.70,23302.97,,Hospital 24200,Rmvl Foreign Body Upper Arm/Elbow Subcutaneous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7177.30,N/A,4306.38,N/A,1004.82,N/A,1347.23,N/A,4131.10,N/A,2440.28,N/A,3295.22,N/A,1004.82,N/A,1354.15,N/A,1354.15,N/A,2051.34,N/A,3295.22,N/A,3295.22,N/A,3295.22,N/A,4131.10,N/A,1354.15,N/A,1004.82,N/A,1431.00,N/A,1431.00,N/A,1004.82,N/A,1354.15,N/A,1347.23,N/A,176.89,N/A,N/A,176.89,4306.38,,Hospital 24220,HC Inj Proc Elbow Arthrography,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,6629.02,N/A,3977.41,N/A,928.06,N/A,701.33,N/A,1984.69,N/A,2253.87,N/A,1629.20,N/A,928.06,N/A,668.93,N/A,668.93,N/A,1014.21,N/A,1629.20,N/A,1629.20,N/A,1629.20,N/A,1984.69,N/A,668.93,N/A,928.06,N/A,527.00,N/A,527.00,N/A,928.06,N/A,668.93,N/A,294.44,N/A,323.88,N/A,N/A,294.44,3977.41,,Hospital 24301,Muscle/Tendon Transfer Upper Arm/Elbow Single,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,126531.17,N/A,75918.70,N/A,17469.63,N/A,2687.71,N/A,71818.73,N/A,43020.62,N/A,29167.11,N/A,17469.63,N/A,11864.95,N/A,11864.95,N/A,18267.51,N/A,29167.11,N/A,29167.11,N/A,29167.11,N/A,70926.85,N/A,11880.45,N/A,17469.63,N/A,14298.75,N/A,14298.75,N/A,17469.63,N/A,11864.95,N/A,2687.71,N/A,2944.26,N/A,N/A,2687.71,75918.70,,Hospital 24310,Tenotomy Open Elbow to Shoulder Each Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10892.20,N/A,6535.32,N/A,1524.91,N/A,2664.83,N/A,6269.60,N/A,3703.35,N/A,6523.66,N/A,1524.91,N/A,2688.04,N/A,2688.04,N/A,4061.10,N/A,6523.66,N/A,6523.66,N/A,6523.66,N/A,6269.60,N/A,2688.04,N/A,1524.91,N/A,5095.50,N/A,5095.50,N/A,1524.91,N/A,2688.04,N/A,2664.83,N/A,923.22,N/A,N/A,923.22,6535.32,,Hospital 24340,Tenodesis Biceps Tendon Elbow Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61360.68,N/A,36816.41,N/A,8579.14,N/A,2700.59,N/A,11735.00,N/A,20831.80,N/A,15008.79,N/A,8579.14,N/A,5973.28,N/A,5973.28,N/A,9343.26,N/A,15008.79,N/A,15008.79,N/A,15008.79,N/A,11735.00,N/A,5973.28,N/A,8579.14,N/A,13336.25,N/A,13336.25,N/A,8579.14,N/A,5973.28,N/A,2700.59,N/A,2970.65,N/A,N/A,2700.59,36816.41,,Hospital 24341,Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36304.10,N/A,21782.46,N/A,5082.58,N/A,1137.82,N/A,20801.92,N/A,12343.40,N/A,14483.69,N/A,5082.58,N/A,5973.28,N/A,5973.28,N/A,9016.38,N/A,14483.69,N/A,14483.69,N/A,14483.69,N/A,20801.92,N/A,5973.28,N/A,5082.58,N/A,7661.50,N/A,7661.50,N/A,5082.58,N/A,5973.28,N/A,1137.82,N/A,1188.05,N/A,N/A,1137.82,21782.46,,Hospital 24346,Rcnstj Medial Coltrl Ligm Elbw W/Tdn Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26847.12,N/A,16108.27,N/A,3758.59,N/A,12534.51,N/A,15400.45,N/A,9128.01,N/A,26847.11,N/A,3758.59,N/A,11782.94,N/A,11782.94,N/A,17777.63,N/A,26847.11,N/A,26847.11,N/A,26847.11,N/A,15400.46,N/A,11782.94,N/A,3758.59,N/A,5963.00,N/A,5963.00,N/A,3758.59,N/A,11782.94,N/A,12534.51,N/A,1155.54,N/A,N/A,1155.54,26847.11,,Hospital 24357,Tenotomy Elbow Lateral/Medial Percutaneous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12678.98,N/A,7607.39,N/A,1775.06,N/A,2811.81,N/A,7300.29,N/A,4310.86,N/A,6504.78,N/A,1775.06,N/A,2688.04,N/A,2688.04,N/A,4049.34,N/A,6504.78,N/A,6504.78,N/A,6504.78,N/A,7300.29,N/A,2688.04,N/A,1775.06,N/A,3397.00,N/A,3397.00,N/A,1775.06,N/A,2688.04,N/A,2811.81,N/A,463.43,N/A,N/A,463.43,7607.39,,Hospital 24358,Tnot Elbow Lateral/Medial Debride Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18624.20,N/A,11174.52,N/A,2607.39,N/A,2743.94,N/A,10722.76,N/A,6332.24,N/A,6512.67,N/A,2607.39,N/A,2688.04,N/A,2688.04,N/A,4054.27,N/A,6512.67,N/A,6512.67,N/A,6512.67,N/A,10722.77,N/A,2688.04,N/A,2607.39,N/A,4562.00,N/A,4562.00,N/A,2607.39,N/A,2688.04,N/A,2743.94,N/A,553.50,N/A,N/A,553.50,11174.52,,Hospital 24359,Tnot Elbow Lateral/Medial Debride Open Tdn Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,39598.70,30006.48,23759.22,18003.89,13380.30,4200.91,16123.50,631.55,30153.58,17175.94,13463.56,10202.19,30442.02,6557.08,13792.57,4200.91,110152.00,2688.04,110152.00,2688.04,18949.45,4081.92,30442.02,6557.08,30442.02,6557.08,30442.02,6557.08,30153.58,17175.96,16093.85,2688.04,13792.57,4200.91,36218.41,4562.00,36218.41,4562.00,N/A,4200.91,16093.85,2688.04,16123.50,631.55,14758.05,694.71,13380.30,110152.00,631.55,18003.89,,Hospital 24363,Arthrp Elbow W/Distal Hum&Prox UR Prostc Rplcm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,91795.35,82831.58,55077.21,49698.95,12576.90,11596.43,15143.47,20955.59,55035.67,46931.65,31210.41,28162.75,28614.19,47919.71,12964.42,11596.43,19924.58,19774.44,19924.58,19774.44,17811.67,29830.95,28614.19,47919.71,28614.19,47919.71,28614.19,47919.71,55035.67,46931.67,15143.47,19774.44,12964.42,11596.43,34043.74,11660.00,34043.74,11660.00,N/A,11596.43,15143.47,19774.44,15143.47,20955.59,13871.93,1540.17,12576.90,55077.21,1540.17,49698.95,,Hospital 24365,Arthroplasty Radial Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,73743.38,N/A,44246.03,N/A,10324.08,N/A,1351.96,N/A,41882.62,N/A,25072.75,N/A,28588.59,N/A,10324.08,N/A,11782.94,N/A,11782.94,N/A,17796.96,N/A,28588.59,N/A,28588.59,N/A,28588.59,N/A,41882.64,N/A,11782.94,N/A,10324.08,N/A,8601.75,N/A,8601.75,N/A,10324.08,N/A,11782.94,N/A,1351.96,N/A,1487.16,N/A,N/A,1351.96,44246.03,,Hospital 24435,Repair Non/Malunion Humerus W/Iliac/Oth Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,96826.98,N/A,58096.19,N/A,13381.57,N/A,1283.87,N/A,55026.92,N/A,32921.19,N/A,28912.53,N/A,13381.57,N/A,11864.95,N/A,11864.95,N/A,18109.03,N/A,28912.53,N/A,28912.53,N/A,28912.53,N/A,55026.92,N/A,11880.45,N/A,13381.57,N/A,8612.50,N/A,8612.50,N/A,13381.57,N/A,11864.95,N/A,1283.87,N/A,1412.28,N/A,N/A,1283.87,58096.19,,Hospital 24498,Proph Tx W/WO Methylmethacrylate Humeral Shaft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57445.13,N/A,34467.08,N/A,8052.94,N/A,12325.48,N/A,32964.24,N/A,19531.36,N/A,28574.91,N/A,8052.94,N/A,11782.94,N/A,11782.94,N/A,17791.04,N/A,28574.91,N/A,28574.91,N/A,28574.91,N/A,32964.24,N/A,11782.94,N/A,8052.94,N/A,7897.00,N/A,7897.00,N/A,8052.94,N/A,11782.94,N/A,12325.48,N/A,1571.03,N/A,N/A,1571.03,34467.08,,Hospital CPT 24500,HC Treat Humerus Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,316.72,N/A,327.05,N/A,193.12,N/A,568.00,N/A,79.52,N/A,316.72,N/A,316.72,N/A,568.00,N/A,568.00,N/A,568.00,N/A,568.00,N/A,327.05,N/A,316.72,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,316.72,N/A,316.72,N/A,348.39,340.80,340.80,79.52,568.00,,Hospital 24530,HC Cltx Sprcndylr/Transcndylr Humeral Fx W/WO Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,977.00,N/A,586.20,N/A,136.78,N/A,313.76,N/A,562.56,N/A,332.18,N/A,N/A,N/A,136.78,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,562.56,N/A,296.08,N/A,136.78,N/A,268.00,N/A,268.00,N/A,136.78,N/A,296.08,N/A,313.76,N/A,442.16,N/A,N/A,136.78,586.20,,Hospital CPT 24535,HC Clsd Tx Hum Suprcndyl Fx Man,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4030.00,4030.00,2418.00,2418.00,N/A,564.20,N/A,542.29,N/A,2320.47,N/A,1370.20,N/A,1771.41,N/A,564.20,N/A,542.29,N/A,542.29,N/A,1102.70,N/A,1771.41,N/A,1771.41,N/A,1771.41,N/A,2320.47,N/A,542.29,N/A,564.20,N/A,4030.00,N/A,4030.00,N/A,564.20,N/A,542.29,N/A,542.29,N/A,596.52,2418.00,2418.00,542.29,4030.00,,Hospital 24538,Prq Skel Fixj Sprcndylr/Transcndylr Humeral Fx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27587.30,N/A,16552.38,N/A,3862.22,N/A,6097.50,N/A,15883.71,N/A,9379.68,N/A,14489.92,N/A,3862.22,N/A,5973.28,N/A,5973.28,N/A,9021.71,N/A,14489.92,N/A,14489.92,N/A,14489.92,N/A,14734.42,N/A,5973.28,N/A,3862.22,N/A,3397.00,N/A,3397.00,N/A,3862.22,N/A,5973.28,N/A,6097.50,N/A,952.59,N/A,N/A,952.59,16552.38,,Hospital 24546,Open Tx Humeral Supracondylar Fracture W/Xtn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44294.93,N/A,26576.96,N/A,6201.30,N/A,11910.55,N/A,25398.55,N/A,15060.28,N/A,28600.62,N/A,6201.30,N/A,11782.94,N/A,11782.94,N/A,17804.44,N/A,28600.62,N/A,28600.62,N/A,28600.62,N/A,25338.09,N/A,11782.94,N/A,6201.30,N/A,8612.50,N/A,8612.50,N/A,6201.30,N/A,11782.94,N/A,11910.55,N/A,1175.67,N/A,N/A,1175.67,28600.62,,Hospital 24566,Prq Skel Fixj Humrl Epcndylr Fx Medial/Lat Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31503.05,N/A,18901.83,N/A,4439.35,N/A,1378.06,N/A,18134.20,N/A,10711.04,N/A,3153.51,N/A,4439.35,N/A,1295.43,N/A,1295.43,N/A,1963.11,N/A,3153.51,N/A,3153.51,N/A,3153.51,N/A,18134.19,N/A,1295.43,N/A,4439.35,N/A,3397.00,N/A,3397.00,N/A,4439.35,N/A,1295.43,N/A,1378.06,N/A,809.25,N/A,N/A,809.25,18901.83,,Hospital 24576,HC Cltx Humeral Condylar Fx Medial/Lat W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,995.00,N/A,597.00,N/A,139.30,N/A,313.76,N/A,572.92,N/A,338.30,N/A,N/A,N/A,139.30,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,572.92,N/A,296.08,N/A,139.30,N/A,268.00,N/A,268.00,N/A,139.30,N/A,296.08,N/A,313.76,N/A,350.05,N/A,N/A,139.30,597.00,,Hospital CPT 24577,HC Treat Humerus Fracture,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4100.00,4100.00,2460.00,2460.00,N/A,574.00,N/A,483.75,N/A,2360.78,N/A,1394.00,N/A,1587.75,N/A,574.00,N/A,483.75,N/A,483.75,N/A,988.37,N/A,1587.75,N/A,1587.75,N/A,1587.75,N/A,2360.78,N/A,483.75,N/A,574.00,N/A,4100.00,N/A,4100.00,N/A,574.00,N/A,483.75,N/A,483.75,N/A,532.13,2460.00,2460.00,483.75,4100.00,,Hospital 24579,Open Treatment Humeral Condylar Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72542.93,N/A,43525.76,N/A,10147.99,N/A,12325.48,N/A,41535.03,N/A,24664.60,N/A,28604.12,N/A,10147.99,N/A,11782.94,N/A,11782.94,N/A,17806.62,N/A,28604.12,N/A,28604.12,N/A,28604.12,N/A,41535.04,N/A,11782.94,N/A,10147.99,N/A,11845.50,N/A,11845.50,N/A,10147.99,N/A,11782.94,N/A,12325.48,N/A,1828.78,N/A,N/A,1828.78,43525.76,,Hospital 24582,Prq Skel Fixj Humrl Cndylr Fx Medial/Lat W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29768.52,N/A,17861.11,N/A,4167.59,N/A,6097.50,N/A,17133.52,N/A,10120.37,N/A,14454.82,N/A,4167.59,N/A,5973.28,N/A,5973.28,N/A,8998.41,N/A,14454.82,N/A,14454.82,N/A,14454.82,N/A,17133.52,N/A,5973.28,N/A,4167.59,N/A,3397.00,N/A,3397.00,N/A,4167.59,N/A,5973.28,N/A,6097.50,N/A,872.55,N/A,N/A,872.55,17861.11,,Hospital 24586,Optx Periarticular Fracture &/Dislocation Elbo,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,89110.02,54769.05,53466.01,32861.43,10076.03,7667.68,12185.08,1723.37,30176.84,31290.04,30297.40,18621.46,22924.37,28553.96,10386.49,7667.68,2248.00,11782.94,2248.00,11782.94,14269.88,17775.37,22924.37,28553.96,22924.37,28553.96,22924.37,28553.96,30176.84,31290.06,12053.53,11782.94,10386.49,7667.68,27274.27,12203.25,27274.27,12203.25,N/A,7667.68,12185.08,11782.94,12185.08,1723.37,11113.55,1895.70,2248.00,53466.01,1723.37,32861.43,,Hospital CPT 24600,HC ED Clsd Tx Elbow Disclocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,863.00,863.00,517.80,517.80,N/A,120.82,N/A,325.25,N/A,496.92,N/A,293.42,N/A,863.00,N/A,120.82,N/A,325.25,N/A,325.25,N/A,676.93,N/A,863.00,N/A,863.00,N/A,863.00,N/A,496.92,N/A,325.25,N/A,120.82,N/A,863.00,N/A,863.00,N/A,120.82,N/A,325.25,N/A,325.25,N/A,357.78,517.80,517.80,120.82,863.00,,Hospital CPT 24605,HC Treat Elbow Dislocation W Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4474.00,4474.00,2684.40,2684.40,N/A,626.36,N/A,454.88,N/A,2576.13,N/A,1521.16,N/A,1364.67,N/A,626.36,N/A,454.88,N/A,454.88,N/A,849.51,N/A,1364.67,N/A,1364.67,N/A,1364.67,N/A,2576.13,N/A,454.88,N/A,626.36,N/A,4474.00,N/A,4474.00,N/A,626.36,N/A,454.88,N/A,454.88,N/A,500.37,2684.40,2684.40,454.88,4474.00,,Hospital 24615,Open Tx Acute/Chronic Elbow Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49171.33,N/A,29502.80,N/A,6864.13,N/A,11910.55,N/A,28138.07,N/A,16718.26,N/A,28580.08,N/A,6864.13,N/A,11782.94,N/A,11782.94,N/A,17791.64,N/A,28580.08,N/A,28580.08,N/A,28580.08,N/A,28047.38,N/A,11782.94,N/A,6864.13,N/A,12203.25,N/A,12203.25,N/A,6864.13,N/A,11782.94,N/A,11910.55,N/A,1635.66,N/A,N/A,1635.66,29502.80,,Hospital 24635,Open Tx Monteggia Fracture Dislocation Elbow,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44060.77,N/A,26436.46,N/A,6168.51,N/A,703.13,N/A,25133.55,N/A,14980.67,N/A,14508.29,N/A,6168.51,N/A,5973.28,N/A,5973.28,N/A,9031.68,N/A,14508.29,N/A,14508.29,N/A,14508.29,N/A,25133.56,N/A,5973.28,N/A,6168.51,N/A,8612.50,N/A,8612.50,N/A,6168.51,N/A,5973.28,N/A,703.13,N/A,773.44,N/A,N/A,703.13,26436.46,,Hospital CPT 24650,HC Treat Radius Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,198.10,N/A,327.05,N/A,193.12,N/A,452.19,N/A,79.52,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,327.05,N/A,186.94,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,186.94,N/A,198.10,N/A,254.63,340.80,340.80,79.52,568.00,,Hospital CPT 24655,HC ED Clsd Tx Radial Head/Neck Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4474.00,4474.00,2684.40,2684.40,N/A,626.36,N/A,384.38,N/A,2576.13,N/A,1521.16,N/A,1279.68,N/A,626.36,N/A,384.38,N/A,384.38,N/A,796.60,N/A,1279.68,N/A,1279.68,N/A,1279.68,N/A,2576.13,N/A,384.38,N/A,626.36,N/A,4474.00,N/A,4474.00,N/A,626.36,N/A,384.38,N/A,384.38,N/A,422.82,2684.40,2684.40,384.38,4474.00,,Hospital 24670,HC Treat Ulnar Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 24675,HC ED Clsd Tx Prox Ulnar Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,401.23,N/A,979.44,N/A,578.34,N/A,1316.25,N/A,238.14,N/A,401.23,N/A,401.23,N/A,819.37,N/A,1316.25,N/A,1316.25,N/A,1316.25,N/A,979.44,N/A,401.23,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,401.23,N/A,401.23,N/A,441.35,1020.60,1020.60,238.14,1701.00,,Hospital 24685,Open Treatment Ulnar Fracture Proximal End,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48725.12,N/A,29235.07,N/A,6803.57,N/A,6398.14,N/A,27902.92,N/A,16566.52,N/A,15046.14,N/A,6803.57,N/A,6123.11,N/A,6123.11,N/A,9562.50,N/A,15046.14,N/A,15046.14,N/A,15046.14,N/A,27902.93,N/A,6146.36,N/A,6803.57,N/A,7897.00,N/A,7897.00,N/A,6803.57,N/A,6123.11,N/A,6398.14,N/A,1009.19,N/A,N/A,1009.19,29235.07,,Hospital CPT 25000,Incision Extensor Tendon Sheath Wrist,N/A,N/A,658.00,658.00,394.80,394.80,N/A,92.12,N/A,324.88,N/A,658.00,N/A,223.72,N/A,658.00,N/A,92.12,N/A,324.88,N/A,324.88,N/A,610.17,N/A,658.00,N/A,658.00,N/A,658.00,N/A,658.00,N/A,324.88,N/A,92.12,N/A,658.00,N/A,658.00,N/A,92.12,N/A,324.88,N/A,324.88,N/A,357.37,394.80,394.80,92.12,658.00,,Hospital 25028,I&D Forearm&/Wrist Deep Abscess/Hematoma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,28552.40,21247.50,17131.44,12748.50,4704.07,2974.64,5830.32,2859.50,10601.00,12232.16,9707.82,7224.15,10702.41,6516.25,4849.01,2974.64,562.00,2688.04,562.00,2688.04,6662.00,4056.48,10702.41,6516.25,10702.41,6516.25,10702.41,6516.25,10601.00,12232.15,5830.32,2688.04,4849.01,2974.64,12733.19,3660.50,12733.19,3660.50,N/A,2974.64,5830.32,2688.04,5830.32,2859.50,5188.44,982.04,562.00,17131.44,982.04,12748.50,,Hospital 25065,Biopsy Soft Tissue Forearm&/Wrist Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15229.90,N/A,9137.94,N/A,2132.19,N/A,1440.53,N/A,8769.39,N/A,5178.17,N/A,3275.59,N/A,2132.19,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,8769.39,N/A,1354.15,N/A,2132.19,N/A,1431.00,N/A,1431.00,N/A,2132.19,N/A,1354.15,N/A,1440.53,N/A,958.39,N/A,N/A,958.39,9137.94,,Hospital 25066,Biopsy Soft Tissue Forearm&/Wrist Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20152.50,N/A,12091.50,N/A,2705.17,N/A,2440.19,N/A,11602.32,N/A,6851.85,N/A,5656.23,N/A,2705.17,N/A,2332.78,N/A,2332.78,N/A,3521.11,N/A,5656.23,N/A,5656.23,N/A,5656.23,N/A,11602.32,N/A,2332.78,N/A,2705.17,N/A,3397.00,N/A,3397.00,N/A,2705.17,N/A,2332.78,N/A,2440.19,N/A,602.11,N/A,N/A,602.11,12091.50,,Hospital CPT 25071,Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,N/A,N/A,849.00,849.00,509.40,509.40,N/A,118.86,N/A,405.07,N/A,849.00,N/A,288.66,N/A,849.00,N/A,118.86,N/A,405.07,N/A,405.07,N/A,752.77,N/A,849.00,N/A,849.00,N/A,849.00,N/A,849.00,N/A,405.07,N/A,118.86,N/A,849.00,N/A,849.00,N/A,118.86,N/A,405.07,N/A,405.07,N/A,445.58,509.40,509.40,118.86,849.00,,Hospital 25073,Exc Tumor Sft Tiss Forearm&/Wrist Subfasc 3cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18181.40,N/A,10908.84,N/A,2534.10,N/A,2440.19,N/A,10468.61,N/A,6181.67,N/A,5645.92,N/A,2534.10,N/A,2332.78,N/A,2332.78,N/A,3514.69,N/A,5645.92,N/A,5645.92,N/A,5645.92,N/A,10468.62,N/A,2332.78,N/A,2534.10,N/A,3397.00,N/A,3397.00,N/A,2534.10,N/A,2332.78,N/A,2440.19,N/A,607.85,N/A,N/A,607.85,10908.84,,Hospital CPT 25076,Exc Tumor Soft Tiss Forearm&/Wrist Subfasc <3cm,N/A,N/A,1027.00,1027.00,616.20,616.20,N/A,143.78,N/A,491.80,N/A,1027.00,N/A,349.18,N/A,1027.00,N/A,143.78,N/A,491.80,N/A,491.80,N/A,921.31,N/A,1027.00,N/A,1027.00,N/A,1027.00,N/A,1027.00,N/A,491.80,N/A,143.78,N/A,1027.00,N/A,1027.00,N/A,143.78,N/A,491.80,N/A,491.80,N/A,540.98,616.20,616.20,143.78,1027.00,,Hospital 25077,Rad Resect Tumor Soft Tiss Forearm&/Wrist <3 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16366.58,N/A,9819.95,N/A,2291.32,N/A,881.26,N/A,9417.51,N/A,5549.33,N/A,5690.88,N/A,2291.32,N/A,2332.78,N/A,2332.78,N/A,3542.68,N/A,5690.88,N/A,5690.88,N/A,5690.88,N/A,9417.52,N/A,2332.78,N/A,2291.32,N/A,1871.00,N/A,1871.00,N/A,2291.32,N/A,2332.78,N/A,881.26,N/A,969.39,N/A,N/A,881.26,9819.95,,Hospital 25115,Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33837.43,N/A,20302.46,N/A,4738.28,N/A,1609.21,N/A,19232.00,N/A,11504.73,N/A,3982.53,N/A,4738.28,N/A,1623.23,N/A,1623.23,N/A,2479.19,N/A,3982.53,N/A,3982.53,N/A,3982.53,N/A,19232.01,N/A,1623.23,N/A,4738.28,N/A,5563.25,N/A,5563.25,N/A,4738.28,N/A,1623.23,N/A,1609.21,N/A,1946.15,N/A,N/A,1609.21,20302.46,,Hospital 25118,Synovectomy Extensor Tendon Shth Wrist 1 Cmprt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11423.43,N/A,6854.06,N/A,1599.28,N/A,935.00,N/A,6571.88,N/A,3883.97,N/A,6525.53,N/A,1599.28,N/A,2688.04,N/A,2688.04,N/A,4062.26,N/A,6525.53,N/A,6525.53,N/A,6525.53,N/A,6571.89,N/A,2688.04,N/A,1599.28,N/A,5095.50,N/A,5095.50,N/A,1599.28,N/A,2688.04,N/A,935.00,N/A,1028.50,N/A,N/A,935.00,6854.06,,Hospital 25119,Synvct Xtnsr Tdn Shth Wrst 1 Rescj Dstl Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16899.80,N/A,10139.88,N/A,2365.54,N/A,2759.84,N/A,9727.17,N/A,5745.93,N/A,6560.44,N/A,2365.54,N/A,2688.04,N/A,2688.04,N/A,4083.99,N/A,6560.44,N/A,6560.44,N/A,6560.44,N/A,9727.17,N/A,2688.04,N/A,2365.54,N/A,6618.25,N/A,6618.25,N/A,2365.54,N/A,2688.04,N/A,2759.84,N/A,1240.95,N/A,N/A,1240.95,10139.88,,Hospital 25120,Excision/Curettage Cyst/Tumor Radius/Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36004.50,N/A,21602.70,N/A,5025.31,N/A,1068.16,N/A,20637.73,N/A,11207.69,N/A,6563.65,N/A,5025.31,N/A,2688.04,N/A,2688.04,N/A,4086.00,N/A,6563.65,N/A,6563.65,N/A,6563.65,N/A,20637.73,N/A,2688.04,N/A,5025.31,N/A,7200.75,N/A,7200.75,N/A,5025.31,N/A,2688.04,N/A,1068.16,N/A,1174.98,N/A,N/A,1068.16,21602.70,,Hospital 25130,Excision/Curettage Cyst/Tumor Carpal Bones,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26084.13,N/A,15650.48,N/A,3651.79,N/A,514.20,N/A,15010.48,N/A,8868.61,N/A,6548.16,N/A,3651.79,N/A,2688.04,N/A,2688.04,N/A,4076.35,N/A,6548.16,N/A,6548.16,N/A,6548.16,N/A,15010.49,N/A,2688.04,N/A,3651.79,N/A,5277.50,N/A,5277.50,N/A,3651.79,N/A,2688.04,N/A,514.20,N/A,565.63,N/A,N/A,514.20,15650.48,,Hospital 25136,Exc/Curtg Cyst/Tumor Carpal Bones W/Allograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83475.33,N/A,50085.20,N/A,11686.76,N/A,6097.50,N/A,47863.26,N/A,28381.62,N/A,14544.79,N/A,11686.76,N/A,5973.28,N/A,5973.28,N/A,9054.42,N/A,14544.79,N/A,14544.79,N/A,14544.79,N/A,47863.25,N/A,5973.28,N/A,11686.76,N/A,7200.75,N/A,7200.75,N/A,11686.76,N/A,5973.28,N/A,6097.50,N/A,1157.32,N/A,N/A,1157.32,50085.20,,Hospital 25145,Sequestrectomy Forearm &/Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44617.40,N/A,26770.44,N/A,6097.53,N/A,2811.81,N/A,25687.52,N/A,15169.92,N/A,6559.97,N/A,6097.53,N/A,2688.04,N/A,2688.04,N/A,4083.70,N/A,6559.97,N/A,6559.97,N/A,6559.97,N/A,25687.53,N/A,2688.04,N/A,6097.53,N/A,4562.00,N/A,4562.00,N/A,6097.53,N/A,2688.04,N/A,2811.81,N/A,735.23,N/A,N/A,735.23,26770.44,,Hospital 25150,Partial Excision Bone Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39535.50,N/A,23721.30,N/A,5536.77,N/A,2863.43,N/A,22762.63,N/A,13442.07,N/A,6523.29,N/A,5536.77,N/A,2691.97,N/A,2691.97,N/A,4060.86,N/A,6523.29,N/A,6523.29,N/A,6523.29,N/A,22762.63,N/A,2691.97,N/A,5536.77,N/A,4562.00,N/A,4562.00,N/A,5536.77,N/A,2691.97,N/A,2863.43,N/A,609.19,N/A,N/A,609.19,23721.30,,Hospital 25210,Carpectomy 1 Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42197.23,N/A,25318.34,N/A,5907.62,N/A,2297.65,N/A,24158.93,N/A,14347.06,N/A,14512.35,N/A,5907.62,N/A,5973.28,N/A,5973.28,N/A,9034.22,N/A,14512.35,N/A,14512.35,N/A,14512.35,N/A,24158.93,N/A,5973.28,N/A,5907.62,N/A,9093.25,N/A,9093.25,N/A,5907.62,N/A,5973.28,N/A,2297.65,N/A,2527.41,N/A,N/A,2297.65,25318.34,,Hospital 25215,Carpectomy All Bones Proximal Row,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23120.20,N/A,13872.12,N/A,3225.47,N/A,656.81,N/A,13299.63,N/A,7860.87,N/A,6586.14,N/A,3225.47,N/A,2688.04,N/A,2688.04,N/A,4100.00,N/A,6586.14,N/A,6586.14,N/A,6586.14,N/A,13299.65,N/A,2688.04,N/A,3225.47,N/A,5277.50,N/A,5277.50,N/A,3225.47,N/A,2688.04,N/A,656.81,N/A,722.50,N/A,N/A,656.81,13872.12,,Hospital CPT 25246,HC Inj Proc Wrist,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,326.00,326.00,195.60,195.60,N/A,45.64,N/A,326.00,N/A,187.71,N/A,110.84,N/A,326.00,N/A,45.64,N/A,326.00,N/A,326.00,N/A,326.00,N/A,326.00,N/A,326.00,N/A,326.00,N/A,187.71,N/A,326.00,N/A,45.64,N/A,527.00,N/A,527.00,N/A,45.64,N/A,326.00,N/A,326.00,N/A,77.50,195.60,195.60,45.64,527.00,,Hospital 25263,Rpr Tdn/Musc Flxr F/Arm&/Wrist Sec 1 Ea Tdn/Mus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33804.10,N/A,20282.46,N/A,4729.42,N/A,6354.28,N/A,19456.21,N/A,11493.40,N/A,14478.58,N/A,4729.42,N/A,5973.28,N/A,5973.28,N/A,9013.19,N/A,14478.58,N/A,14478.58,N/A,14478.58,N/A,19456.20,N/A,5973.28,N/A,4729.42,N/A,7983.50,N/A,7983.50,N/A,4729.42,N/A,5973.28,N/A,6354.28,N/A,2787.79,N/A,N/A,2787.79,20282.46,,Hospital 25265,Rpr Tdn/Musc Flxr F/Arm&/Wristsec Fr Grf Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33804.10,N/A,20282.46,N/A,4729.42,N/A,6354.28,N/A,19456.21,N/A,11493.40,N/A,14478.58,N/A,4729.42,N/A,5973.28,N/A,5973.28,N/A,9013.19,N/A,14478.58,N/A,14478.58,N/A,14478.58,N/A,19456.20,N/A,5973.28,N/A,4729.42,N/A,7983.50,N/A,7983.50,N/A,4729.42,N/A,5973.28,N/A,6354.28,N/A,2787.79,N/A,N/A,2787.79,20282.46,,Hospital CPT 25270,Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn,N/A,N/A,967.00,967.00,580.20,580.20,N/A,135.38,N/A,469.56,N/A,967.00,N/A,328.78,N/A,967.00,N/A,135.38,N/A,469.56,N/A,469.56,N/A,878.08,N/A,967.00,N/A,967.00,N/A,967.00,N/A,967.00,N/A,469.56,N/A,135.38,N/A,967.00,N/A,967.00,N/A,135.38,N/A,469.56,N/A,469.56,N/A,516.52,580.20,580.20,135.38,967.00,,Hospital CPT 25270,HC Repair Forearm Tendon/Muscle Prim 1 Ea Tdn,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7593.00,7593.00,4555.80,4555.80,N/A,1063.02,N/A,469.56,N/A,4372.05,N/A,2581.62,N/A,1410.57,N/A,1063.02,N/A,469.56,N/A,469.56,N/A,878.08,N/A,1410.57,N/A,1410.57,N/A,1410.57,N/A,4372.05,N/A,469.56,N/A,1063.02,N/A,7593.00,N/A,7593.00,N/A,1063.02,N/A,469.56,N/A,469.56,N/A,516.52,4555.80,4555.80,469.56,7593.00,,Hospital 25280,Lngth/Shrt Flxr/Xtnsr Tdn F/Arm&/Wrist 1 Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,113928.23,N/A,68356.94,N/A,15949.95,N/A,8609.43,N/A,64529.81,N/A,38735.59,N/A,13537.24,N/A,15949.95,N/A,8615.46,N/A,8615.46,N/A,8427.20,N/A,13537.24,N/A,13537.24,N/A,13537.24,N/A,64477.99,N/A,8615.46,N/A,15949.95,N/A,9093.25,N/A,9093.25,N/A,15949.95,N/A,8615.46,N/A,8609.43,N/A,3834.75,N/A,N/A,3834.75,68356.94,,Hospital 25301,Tenodesis Wrist Extensors Fingers,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33762.12,N/A,20257.27,N/A,4726.69,N/A,2818.24,N/A,19330.29,N/A,11479.12,N/A,6558.00,N/A,4726.69,N/A,2688.04,N/A,2688.04,N/A,4082.48,N/A,6558.00,N/A,6558.00,N/A,6558.00,N/A,19330.30,N/A,2688.04,N/A,4726.69,N/A,8244.00,N/A,8244.00,N/A,4726.69,N/A,2688.04,N/A,1401.91,N/A,1542.10,N/A,N/A,1401.91,20257.27,,Hospital 25360,Osteotomy Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28610.17,N/A,17166.10,N/A,3989.83,N/A,5921.68,N/A,16387.04,N/A,9666.02,N/A,14542.86,N/A,3989.83,N/A,5973.28,N/A,5973.28,N/A,9053.21,N/A,14542.86,N/A,14542.86,N/A,14542.86,N/A,16387.04,N/A,5973.28,N/A,3989.83,N/A,7661.50,N/A,7661.50,N/A,3989.83,N/A,5973.28,N/A,5921.68,N/A,1199.15,N/A,N/A,1199.15,17166.10,,Hospital 25405,Rpr Nonunion/Malunion Radius/Ulna W/Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42420.12,N/A,25452.07,N/A,5912.60,N/A,6037.97,N/A,24389.12,N/A,14422.85,N/A,14558.04,N/A,5912.60,N/A,5973.28,N/A,5973.28,N/A,9062.65,N/A,14558.04,N/A,14558.04,N/A,14558.04,N/A,24389.11,N/A,5973.28,N/A,5912.60,N/A,12203.25,N/A,12203.25,N/A,5912.60,N/A,5973.28,N/A,6037.97,N/A,2516.29,N/A,N/A,2516.29,25452.07,,Hospital 25415,Rpr Nonunion/Malunion Radius&Ulna W/O Autograf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43600.22,N/A,26160.13,N/A,6065.01,N/A,6037.97,N/A,24959.25,N/A,14824.07,N/A,14602.99,N/A,6065.01,N/A,5973.28,N/A,5973.28,N/A,9090.61,N/A,14602.99,N/A,14602.99,N/A,14602.99,N/A,24959.24,N/A,5973.28,N/A,6065.01,N/A,8612.50,N/A,8612.50,N/A,6065.01,N/A,5973.28,N/A,6037.97,N/A,1201.23,N/A,N/A,1201.23,26160.13,,Hospital 25420,Rpr Nonunion/Malunion Radius&Ulna W/Autograft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42420.12,N/A,25452.07,N/A,5912.60,N/A,6037.97,N/A,24389.12,N/A,14422.85,N/A,14558.04,N/A,5912.60,N/A,5973.28,N/A,5973.28,N/A,9062.65,N/A,14558.04,N/A,14558.04,N/A,14558.04,N/A,24389.11,N/A,5973.28,N/A,5912.60,N/A,12203.25,N/A,12203.25,N/A,5912.60,N/A,5973.28,N/A,6037.97,N/A,2516.29,N/A,N/A,2516.29,25452.07,,Hospital 25425,Repair Defect W/Autograft Radius/Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,100237.83,N/A,60142.70,N/A,14021.98,N/A,6362.14,N/A,57684.87,N/A,33956.95,N/A,14516.16,N/A,14021.98,N/A,5981.14,N/A,5981.14,N/A,9036.60,N/A,14516.16,N/A,14516.16,N/A,14516.16,N/A,57684.87,N/A,5981.14,N/A,14021.98,N/A,11727.75,N/A,11727.75,N/A,14021.98,N/A,5981.14,N/A,6362.14,N/A,2206.34,N/A,N/A,2206.34,60142.70,,Hospital 25430,Insertion Vascular Pedicle Carpal Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26580.00,N/A,15948.00,N/A,3721.20,N/A,5921.68,N/A,15286.68,N/A,9037.22,N/A,14473.45,N/A,3721.20,N/A,5973.28,N/A,5973.28,N/A,9009.99,N/A,14473.45,N/A,14473.45,N/A,14473.45,N/A,15286.69,N/A,5973.28,N/A,3721.20,N/A,9093.25,N/A,9093.25,N/A,3721.20,N/A,5973.28,N/A,5921.68,N/A,1773.01,N/A,N/A,1773.01,15948.00,,Hospital 25431,Repair Nonunion Carpal Bone Each Bone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52643.43,N/A,31586.06,N/A,7370.07,N/A,6248.31,N/A,30140.11,N/A,17898.76,N/A,14459.77,N/A,7370.07,N/A,5973.28,N/A,5973.28,N/A,9001.49,N/A,14459.77,N/A,14459.77,N/A,14459.77,N/A,30140.10,N/A,5973.28,N/A,7370.07,N/A,10435.25,N/A,10435.25,N/A,7370.07,N/A,5973.28,N/A,6248.31,N/A,4537.91,N/A,N/A,4537.91,31586.06,,Hospital 25445,Arthroplasty W/Prosthetic Replacement Trapezium,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33991.40,N/A,20394.84,N/A,4758.80,N/A,5942.72,N/A,19451.79,N/A,11557.08,N/A,14474.74,N/A,4758.80,N/A,5973.28,N/A,5973.28,N/A,9010.81,N/A,14474.74,N/A,14474.74,N/A,14474.74,N/A,19451.79,N/A,5973.28,N/A,4758.80,N/A,5963.00,N/A,5963.00,N/A,4758.80,N/A,5973.28,N/A,5942.72,N/A,858.69,N/A,N/A,858.69,20394.84,,Hospital 25492,Proph Tx N/P/Pltwr W/WO Methylmecrylate Rad&Ul,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,53565.88,N/A,32139.53,N/A,7494.10,N/A,2780.20,N/A,30692.90,N/A,18212.38,N/A,7453.34,N/A,7494.10,N/A,2688.04,N/A,2688.04,N/A,4639.84,N/A,7453.34,N/A,7453.34,N/A,7453.34,N/A,30692.91,N/A,2688.04,N/A,7494.10,N/A,6678.50,N/A,6678.50,N/A,7494.10,N/A,2688.04,N/A,2780.20,N/A,1046.61,N/A,N/A,1046.61,32139.53,,Hospital 25500,HC Treat Radius Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 25505,HC Clsed Tx Radial W Manipulation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,437.23,N/A,979.44,N/A,578.34,N/A,1451.01,N/A,238.14,N/A,437.23,N/A,437.23,N/A,903.25,N/A,1451.01,N/A,1451.01,N/A,1451.01,N/A,979.44,N/A,437.23,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,437.23,N/A,437.23,N/A,480.95,1020.60,1020.60,238.14,1701.00,,Hospital 25520,HC Treat Radius Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 25525,Open Rdl Shaft Fx Closed Rad/Uln Jt Dislocate,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41134.57,N/A,24680.74,N/A,5749.97,N/A,6248.31,N/A,23583.52,N/A,13985.74,N/A,14584.25,N/A,5749.97,N/A,5973.28,N/A,5973.28,N/A,9078.89,N/A,14584.25,N/A,14584.25,N/A,14584.25,N/A,23583.52,N/A,5973.28,N/A,5749.97,N/A,7897.00,N/A,7897.00,N/A,5749.97,N/A,5973.28,N/A,6248.31,N/A,858.75,N/A,N/A,858.75,24680.74,,Hospital 25526,Open Rdl Shaft Fx Open Rad/Uln Jt Dislocate,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41143.83,N/A,24686.30,N/A,5760.13,N/A,6248.31,N/A,23606.79,N/A,13988.89,N/A,14492.74,N/A,5760.13,N/A,5973.28,N/A,5973.28,N/A,9025.63,N/A,14492.74,N/A,14492.74,N/A,14492.74,N/A,23606.80,N/A,5973.28,N/A,5760.13,N/A,7897.00,N/A,7897.00,N/A,5760.13,N/A,5973.28,N/A,6248.31,N/A,1027.50,N/A,N/A,1027.50,24686.30,,Hospital CPT 25535,HC Closed Tx Ulnar Shaft Frac Man,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4117.00,4117.00,2470.20,2470.20,N/A,576.38,N/A,435.69,N/A,2370.57,N/A,1399.78,N/A,1415.25,N/A,576.38,N/A,435.69,N/A,435.69,N/A,880.99,N/A,1415.25,N/A,1415.25,N/A,1415.25,N/A,2370.57,N/A,435.69,N/A,576.38,N/A,4117.00,N/A,4117.00,N/A,576.38,N/A,435.69,N/A,435.69,N/A,479.26,2470.20,2470.20,435.69,4117.00,,Hospital CPT 25560,HC Treat Radius & Ulna Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,570.00,570.00,342.00,342.00,N/A,79.80,N/A,245.27,N/A,328.21,N/A,193.80,N/A,570.00,N/A,79.80,N/A,245.27,N/A,245.27,N/A,515.73,N/A,570.00,N/A,570.00,N/A,570.00,N/A,328.21,N/A,245.27,N/A,79.80,N/A,570.00,N/A,570.00,N/A,79.80,N/A,245.27,N/A,245.27,N/A,269.80,342.00,342.00,79.80,570.00,,Hospital CPT 25565,HC ED Cltx Rad Ulnr Shft Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,445.49,N/A,979.44,N/A,578.34,N/A,1492.53,N/A,238.14,N/A,445.49,N/A,445.49,N/A,929.10,N/A,1492.53,N/A,1492.53,N/A,1492.53,N/A,979.44,N/A,445.49,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,445.49,N/A,445.49,N/A,490.04,1020.60,1020.60,238.14,1701.00,,Hospital 25575,Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54047.28,47104.63,32428.37,28262.78,8570.07,6565.68,10403.59,5942.72,21219.14,26998.46,18376.08,16015.56,19498.09,14564.91,8834.13,6565.68,562.00,5973.28,562.00,5973.28,12137.11,9066.94,19498.09,14564.91,19498.09,14564.91,19498.09,14564.91,21219.14,26998.46,10403.59,5973.28,8834.13,6565.68,23197.86,8612.50,23197.86,8612.50,3201.27,6565.68,10403.59,5973.28,10403.59,5942.72,9452.52,1035.99,562.00,32428.37,1035.99,28262.78,,Hospital CPT 25600,HC Treat Radius/Ulna Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,568.00,568.00,340.80,340.80,N/A,79.52,N/A,188.96,N/A,327.05,N/A,193.12,N/A,452.19,N/A,79.52,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,327.05,N/A,186.94,N/A,79.52,N/A,568.00,N/A,568.00,N/A,79.52,N/A,186.94,N/A,198.10,N/A,335.51,340.80,340.80,79.52,568.00,,Hospital 25607,Optx Dstl Radl X-Artic Fx/Epiphysl Sep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26767.32,N/A,16060.39,N/A,3740.55,N/A,5973.28,N/A,15294.46,N/A,9100.89,N/A,14537.05,N/A,3740.55,N/A,5973.28,N/A,5973.28,N/A,9049.59,N/A,14537.05,N/A,14537.05,N/A,14537.05,N/A,15294.46,N/A,5973.28,N/A,3740.55,N/A,8612.50,N/A,8612.50,N/A,3740.55,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,3740.55,16060.39,,Hospital 25608,Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,64201.12,40786.20,38520.67,24471.72,15406.92,5710.07,18491.23,6132.82,38927.79,23387.22,21828.36,13867.31,35052.87,14501.10,15881.63,5710.07,3934.00,5973.28,3934.00,5973.28,21819.60,9027.22,35052.87,14501.10,35052.87,14501.10,35052.87,14501.10,38927.79,23387.21,18491.23,5973.28,15881.63,5710.07,41704.16,8612.50,41704.16,8612.50,N/A,5710.07,6123.11,5973.28,18491.23,6132.82,16993.35,932.92,3934.00,41704.16,932.92,24471.72,,Hospital 25622,Closed Tx Carpal Scaphoid Fracture W/O Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22302.62,N/A,13381.57,N/A,3151.30,N/A,246.86,N/A,12820.28,N/A,7582.89,N/A,566.56,N/A,3151.30,N/A,238.25,N/A,238.25,N/A,364.94,N/A,566.56,N/A,566.56,N/A,566.56,N/A,12820.28,N/A,238.25,N/A,3151.30,N/A,527.00,N/A,527.00,N/A,3151.30,N/A,238.25,N/A,246.86,N/A,384.43,N/A,N/A,238.25,13381.57,,Hospital 25630,HC Cltx Carpal Bone Fx W/O Manj Each Bone,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1996.10,N/A,1197.66,N/A,279.45,N/A,635.16,N/A,1148.75,N/A,678.67,N/A,6.17,N/A,279.45,N/A,630.95,N/A,630.95,N/A,3.84,N/A,6.17,N/A,6.17,N/A,6.17,N/A,1148.75,N/A,630.95,N/A,279.45,N/A,273.36,N/A,273.36,N/A,279.45,N/A,630.95,N/A,635.16,N/A,716.42,N/A,N/A,3.84,1197.66,,Hospital 25645,Open Tx Carpal Bone Fracture Oth/Thn Scaphoid Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18547.88,N/A,11128.73,N/A,2596.71,N/A,2811.81,N/A,10677.51,N/A,6306.29,N/A,6538.39,N/A,2596.71,N/A,2688.04,N/A,2688.04,N/A,4070.27,N/A,6538.39,N/A,6538.39,N/A,6538.39,N/A,10677.51,N/A,2688.04,N/A,2596.71,N/A,11845.50,N/A,11845.50,N/A,2596.71,N/A,2688.04,N/A,2811.81,N/A,1200.04,N/A,N/A,1200.04,11845.50,,Hospital CPT 25650,Closed Treatment Ulnar Styloid Fracture,N/A,N/A,547.00,547.00,328.20,328.20,N/A,76.58,N/A,290.43,N/A,547.00,N/A,185.98,N/A,547.00,N/A,76.58,N/A,290.43,N/A,290.43,N/A,547.00,N/A,547.00,N/A,547.00,N/A,547.00,N/A,547.00,N/A,290.43,N/A,76.58,N/A,547.00,N/A,547.00,N/A,76.58,N/A,290.43,N/A,290.43,N/A,319.47,328.20,328.20,76.58,547.00,,Hospital 25651,Prq Skeletal Fixation Ulnar Styloid Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64470.18,N/A,38682.11,N/A,9025.82,N/A,6354.28,N/A,37017.48,N/A,21919.86,N/A,14535.81,N/A,9025.82,N/A,5973.28,N/A,5973.28,N/A,9048.81,N/A,14535.81,N/A,14535.81,N/A,14535.81,N/A,37017.48,N/A,5973.28,N/A,9025.82,N/A,9953.25,N/A,9953.25,N/A,9025.82,N/A,5973.28,N/A,6354.28,N/A,1374.90,N/A,N/A,1374.90,38682.11,,Hospital 25660,HC Treat Wrist Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,138195.43,N/A,82917.26,N/A,15822.48,N/A,18982.83,N/A,76173.32,N/A,46986.44,N/A,N/A,N/A,16310.00,N/A,3372.00,N/A,3372.00,N/A,22408.13,N/A,35998.34,N/A,35998.34,N/A,35998.34,N/A,76173.32,N/A,18982.83,N/A,16310.00,N/A,42829.04,N/A,42829.04,N/A,2077.80,N/A,18982.83,N/A,19498.07,N/A,17451.70,N/A,2077.80,82917.26,N/A,N/A,,Hospital CPT 25675,HC Treat Wrist Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,873.00,873.00,523.80,523.80,N/A,122.22,N/A,387.92,N/A,502.67,N/A,296.82,N/A,873.00,N/A,122.22,N/A,387.92,N/A,387.92,N/A,813.69,N/A,873.00,N/A,873.00,N/A,873.00,N/A,502.67,N/A,387.92,N/A,122.22,N/A,873.00,N/A,873.00,N/A,122.22,N/A,387.92,N/A,387.92,N/A,426.71,523.80,523.80,122.22,873.00,,Hospital 25695,Open Treatment Lunate Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46770.30,N/A,28062.18,N/A,6547.84,N/A,6248.31,N/A,26892.93,N/A,15901.90,N/A,14481.75,N/A,6547.84,N/A,5973.28,N/A,5973.28,N/A,9015.16,N/A,14481.75,N/A,14481.75,N/A,14481.75,N/A,26892.93,N/A,5973.28,N/A,6547.84,N/A,5095.50,N/A,5095.50,N/A,6547.84,N/A,5973.28,N/A,6248.31,N/A,1145.88,N/A,N/A,1145.88,28062.18,,Hospital 25800,Arthrodesis Wrist Complete W/O Bone Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68641.08,N/A,41184.65,N/A,9609.75,N/A,6178.06,N/A,39332.41,N/A,23337.97,N/A,14523.50,N/A,9609.75,N/A,5973.28,N/A,5973.28,N/A,9041.15,N/A,14523.50,N/A,14523.50,N/A,14523.50,N/A,39332.41,N/A,5973.28,N/A,9609.75,N/A,8612.50,N/A,8612.50,N/A,9609.75,N/A,5973.28,N/A,6178.06,N/A,866.83,N/A,N/A,866.83,41184.65,,Hospital 25922,Disarticulation Thru Wrist Sec Closure/Scar Revj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45592.30,N/A,27355.38,N/A,6411.83,N/A,1378.06,N/A,26240.11,N/A,15501.38,N/A,3181.50,N/A,6411.83,N/A,1295.43,N/A,1295.43,N/A,1980.54,N/A,3181.50,N/A,3181.50,N/A,3181.50,N/A,26240.12,N/A,1295.43,N/A,6411.83,N/A,3397.00,N/A,3397.00,N/A,6411.83,N/A,1295.43,N/A,1378.06,N/A,941.49,N/A,N/A,941.49,27355.38,,Hospital 25999,Unlisted Procedure Forearm/Wrist,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,37189.90,45636.32,22313.94,27381.79,8570.07,6388.45,10433.24,1429.01,19313.34,26012.15,12644.57,15516.09,19498.09,3195.56,8834.13,6388.45,191642.00,1295.43,191642.00,1295.43,12137.11,1989.29,19498.09,3195.56,19498.09,3195.56,19498.09,3195.56,19313.34,26012.16,10403.59,1295.43,8834.13,6388.45,23197.86,4825.50,23197.86,4825.50,N/A,6388.45,10403.59,1295.43,N/A,487.61,9452.52,536.37,8570.07,191642.00,487.61,27381.79,,Hospital 26020,Drainage Tendon Sheath Digit&/Palm Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,50883.15,21337.00,30529.89,12802.20,5366.09,2811.54,6613.46,572.75,14103.36,12276.69,17300.28,7239.28,12208.61,6546.92,5531.43,2811.54,2810.00,2688.04,2810.00,2688.04,7599.57,4075.57,12208.61,6546.92,12208.61,6546.92,12208.61,6546.92,14103.36,12276.70,6613.46,2688.04,5531.43,2811.54,14525.20,1871.00,14525.20,1871.00,5531.43,2811.54,6613.46,2688.04,6613.46,572.75,5918.63,630.03,2810.00,30529.89,572.75,12802.20,,Hospital 26037,Decompressive Fasciotomy Hand,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10190.80,N/A,6114.48,N/A,1408.00,N/A,2674.29,N/A,5865.50,N/A,3464.87,N/A,6529.59,N/A,1408.00,N/A,2688.04,N/A,2688.04,N/A,4064.79,N/A,6529.59,N/A,6529.59,N/A,6529.59,N/A,5865.50,N/A,2688.04,N/A,1408.00,N/A,1871.00,N/A,1871.00,N/A,1408.00,N/A,2688.04,N/A,2674.29,N/A,622.61,N/A,N/A,622.61,6529.59,,Hospital 26040,Fasciotomy Palmar Percutaneous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24762.90,N/A,14857.74,N/A,3466.80,N/A,1288.80,N/A,14255.90,N/A,8419.38,N/A,3166.49,N/A,3466.80,N/A,1295.43,N/A,1295.43,N/A,1971.19,N/A,3166.49,N/A,3166.49,N/A,3166.49,N/A,14255.89,N/A,1295.43,N/A,3466.80,N/A,1871.00,N/A,1871.00,N/A,3466.80,N/A,1295.43,N/A,1288.80,N/A,357.64,N/A,N/A,357.64,14857.74,,Hospital 26045,Fasciotomy Palmar Open Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18804.00,N/A,11282.40,N/A,2632.56,N/A,509.69,N/A,10819.23,N/A,6393.36,N/A,6548.25,N/A,2632.56,N/A,2688.04,N/A,2688.04,N/A,4076.41,N/A,6548.25,N/A,6548.25,N/A,6548.25,N/A,10819.23,N/A,2688.04,N/A,2632.56,N/A,5277.50,N/A,5277.50,N/A,2632.56,N/A,2688.04,N/A,509.69,N/A,560.66,N/A,N/A,509.69,11282.40,,Hospital CPT 26055,Tendon Sheath Incision,N/A,N/A,987.00,987.00,592.20,592.20,N/A,138.18,N/A,274.56,N/A,987.00,N/A,335.58,N/A,987.00,N/A,138.18,N/A,274.56,N/A,274.56,N/A,987.00,N/A,987.00,N/A,987.00,N/A,987.00,N/A,987.00,N/A,274.56,N/A,138.18,N/A,987.00,N/A,987.00,N/A,138.18,N/A,274.56,N/A,274.56,N/A,302.02,592.20,592.20,138.18,987.00,,Hospital CPT 26055,HC Incise Finger Tendon Sheath,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4474.00,4474.00,2684.40,2684.40,N/A,626.36,N/A,274.56,N/A,2576.13,N/A,1521.16,N/A,1630.38,N/A,626.36,N/A,274.56,N/A,274.56,N/A,1014.91,N/A,1630.38,N/A,1630.38,N/A,1630.38,N/A,2576.13,N/A,274.56,N/A,626.36,N/A,4474.00,N/A,4474.00,N/A,626.36,N/A,274.56,N/A,274.56,N/A,302.02,2684.40,2684.40,274.56,4474.00,,Hospital 26060,Tenotomy Percutaneous Single Each Digit,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17954.60,N/A,10772.76,N/A,2513.65,N/A,1322.37,N/A,10336.25,N/A,6104.58,N/A,3145.44,N/A,2513.65,N/A,1295.43,N/A,1295.43,N/A,1958.10,N/A,3145.44,N/A,3145.44,N/A,3145.44,N/A,10336.25,N/A,1295.43,N/A,2513.65,N/A,4800.25,N/A,4800.25,N/A,2513.65,N/A,1295.43,N/A,1322.37,N/A,1506.76,N/A,N/A,1295.43,10772.76,,Hospital 26113,Ex Tum/Vasc Mal Sft Tis Hand/Fngr Subfsc 1.5cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10988.90,N/A,6593.34,N/A,1538.44,N/A,1347.23,N/A,6326.08,N/A,3736.22,N/A,3289.18,N/A,1538.44,N/A,1354.15,N/A,1354.15,N/A,2047.57,N/A,3289.18,N/A,3289.18,N/A,3289.18,N/A,6326.08,N/A,1354.15,N/A,1538.44,N/A,3397.00,N/A,3397.00,N/A,1538.44,N/A,1354.15,N/A,1347.23,N/A,600.10,N/A,N/A,600.10,6593.34,,Hospital 26116,Exc Tum/Vas Mal Sft Tis Hand/Fngr Subfasc<1.5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7355.80,N/A,4413.48,N/A,1029.81,N/A,1390.32,N/A,4234.84,N/A,2500.97,N/A,3283.46,N/A,1029.81,N/A,1354.15,N/A,1354.15,N/A,2044.02,N/A,3283.46,N/A,3283.46,N/A,3283.46,N/A,4234.84,N/A,1354.15,N/A,1029.81,N/A,1871.00,N/A,1871.00,N/A,1029.81,N/A,1354.15,N/A,1390.32,N/A,581.06,N/A,N/A,581.06,4413.48,,Hospital CPT 26123,Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr,N/A,N/A,1653.00,1653.00,991.80,991.80,N/A,231.42,N/A,794.01,N/A,1653.00,N/A,562.02,N/A,1653.00,N/A,231.42,N/A,794.01,N/A,794.01,N/A,1484.27,N/A,1653.00,N/A,1653.00,N/A,1653.00,N/A,1653.00,N/A,794.01,N/A,231.42,N/A,1653.00,N/A,1653.00,N/A,231.42,N/A,794.01,N/A,794.01,N/A,873.41,991.80,991.80,231.42,1653.00,,Hospital 26135,Synvct Mtcarphlngl Jt W/Intrnsc Rls&Xtnsr Hood,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51564.13,N/A,30938.48,N/A,7208.48,N/A,1121.63,N/A,29384.48,N/A,17531.81,N/A,6557.12,N/A,7208.48,N/A,2688.04,N/A,2688.04,N/A,4081.92,N/A,6557.12,N/A,6557.12,N/A,6557.12,N/A,29384.48,N/A,2688.04,N/A,7208.48,N/A,7200.75,N/A,7200.75,N/A,7208.48,N/A,2688.04,N/A,1121.63,N/A,1233.80,N/A,N/A,1121.63,30938.48,,Hospital 26145,Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10674.85,N/A,6404.91,N/A,1494.48,N/A,1614.93,N/A,6144.50,N/A,3629.45,N/A,3948.85,N/A,1494.48,N/A,1623.23,N/A,1623.23,N/A,2458.24,N/A,3948.85,N/A,3948.85,N/A,3948.85,N/A,6144.51,N/A,1623.23,N/A,1494.48,N/A,4332.50,N/A,4332.50,N/A,1494.48,N/A,1623.23,N/A,1614.93,N/A,991.45,N/A,N/A,991.45,6404.91,,Hospital 26170,Excision Tendon Palm Flexor/Extensor Single Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26813.27,N/A,16087.96,N/A,3756.09,N/A,2674.29,N/A,15365.20,N/A,9116.51,N/A,6530.62,N/A,3756.09,N/A,2688.04,N/A,2688.04,N/A,4065.44,N/A,6530.62,N/A,6530.62,N/A,6530.62,N/A,15365.21,N/A,2688.04,N/A,3756.09,N/A,7310.75,N/A,7310.75,N/A,3756.09,N/A,2688.04,N/A,2674.29,N/A,2088.69,N/A,N/A,2088.69,16087.96,,Hospital 26200,Excision/Curettage Cyst/Tumor Metacarpal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15091.50,N/A,9054.90,N/A,1934.72,N/A,1282.19,N/A,8687.50,N/A,5131.10,N/A,6520.75,N/A,1934.72,N/A,2688.04,N/A,2688.04,N/A,4059.29,N/A,6520.75,N/A,6520.75,N/A,6520.75,N/A,8687.50,N/A,2688.04,N/A,1934.72,N/A,5563.25,N/A,5563.25,N/A,1934.72,N/A,2688.04,N/A,1282.19,N/A,1410.44,N/A,N/A,1282.19,9054.90,,Hospital 26215,Exc/Curettage Cyst/Tumor Phalanx Finger W/Agraft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31571.73,N/A,18943.04,N/A,4420.04,N/A,2859.50,N/A,18132.91,N/A,10734.41,N/A,6535.43,N/A,4420.04,N/A,2688.04,N/A,2688.04,N/A,4068.44,N/A,6535.43,N/A,6535.43,N/A,6535.43,N/A,18132.91,N/A,2688.04,N/A,4420.04,N/A,4332.50,N/A,4332.50,N/A,4420.04,N/A,2688.04,N/A,2859.50,N/A,1256.84,N/A,N/A,1256.84,18943.04,,Hospital 26235,Partial Excision Proximal/Middle Phalanx Finger,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13365.20,N/A,8019.12,N/A,1871.12,N/A,1355.08,N/A,7694.64,N/A,4544.16,N/A,3151.50,N/A,1871.12,N/A,1295.43,N/A,1295.43,N/A,1961.87,N/A,3151.50,N/A,3151.50,N/A,3151.50,N/A,7694.65,N/A,1295.43,N/A,1871.12,N/A,1871.00,N/A,1871.00,N/A,1871.12,N/A,1295.43,N/A,1355.08,N/A,514.98,N/A,N/A,514.98,8019.12,,Hospital 26250,Radical Resection Tumor Metacarpal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23848.60,N/A,14309.16,N/A,3330.07,N/A,2674.29,N/A,13726.30,N/A,8108.52,N/A,6552.15,N/A,3330.07,N/A,2688.04,N/A,2688.04,N/A,4078.83,N/A,6552.15,N/A,6552.15,N/A,6552.15,N/A,13726.29,N/A,2688.04,N/A,3330.07,N/A,3164.25,N/A,3164.25,N/A,3330.07,N/A,2688.04,N/A,2674.29,N/A,2033.00,N/A,N/A,2033.00,14309.16,,Hospital 26262,Radical Resection Tumor Distal Phalanx Finger,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7964.00,N/A,4778.40,N/A,1114.96,N/A,636.84,N/A,4585.67,N/A,2707.76,N/A,3133.53,N/A,1114.96,N/A,1295.43,N/A,1295.43,N/A,1950.68,N/A,3133.53,N/A,3133.53,N/A,3133.53,N/A,4585.67,N/A,1295.43,N/A,1114.96,N/A,1871.00,N/A,1871.00,N/A,1114.96,N/A,1295.43,N/A,636.84,N/A,700.53,N/A,N/A,636.84,4778.40,,Hospital 26340,Manipulation Finger Joint Under Anes Each Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23034.50,N/A,13820.70,N/A,3225.56,N/A,1339.84,N/A,13258.39,N/A,7831.73,N/A,3160.93,N/A,3225.56,N/A,1295.43,N/A,1295.43,N/A,1967.73,N/A,3160.93,N/A,3160.93,N/A,3160.93,N/A,13258.39,N/A,1295.43,N/A,3225.56,N/A,3660.50,N/A,3660.50,N/A,3225.56,N/A,1295.43,N/A,1339.84,N/A,806.50,N/A,N/A,806.50,13820.70,,Hospital CPT 26350,HC Repair Finger/Hand Tendon,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7802.00,7802.00,4681.20,4681.20,N/A,1092.28,N/A,708.20,N/A,4492.39,N/A,2652.68,N/A,2098.02,N/A,1092.28,N/A,708.20,N/A,708.20,N/A,1306.02,N/A,2098.02,N/A,2098.02,N/A,2098.02,N/A,4492.39,N/A,708.20,N/A,1092.28,N/A,7802.00,N/A,7802.00,N/A,1092.28,N/A,708.20,N/A,708.20,N/A,779.02,4681.20,4681.20,708.20,7802.00,,Hospital 26352,Rpr/Advmnt Flxr Tdn N/Z/2 W/Fr Graft Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34460.90,N/A,20676.54,N/A,4824.53,N/A,6248.31,N/A,19840.83,N/A,11716.71,N/A,14480.30,N/A,4824.53,N/A,5973.28,N/A,5973.28,N/A,9014.27,N/A,14480.30,N/A,14480.30,N/A,14480.30,N/A,19809.16,N/A,5973.28,N/A,4824.53,N/A,4562.00,N/A,4562.00,N/A,4824.53,N/A,5973.28,N/A,6248.31,N/A,882.78,N/A,N/A,882.78,20676.54,,Hospital 26357,Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29275.70,N/A,17565.42,N/A,4098.59,N/A,2861.72,N/A,16855.36,N/A,9953.74,N/A,6518.81,N/A,4098.59,N/A,2690.13,N/A,2690.13,N/A,4058.08,N/A,6518.81,N/A,6518.81,N/A,6518.81,N/A,16855.36,N/A,2690.13,N/A,4098.59,N/A,7983.50,N/A,7983.50,N/A,4098.59,N/A,2690.13,N/A,2861.72,N/A,4885.47,N/A,N/A,2690.13,17565.42,,Hospital 26370,Rpr/Advmnt Tdn W/Ntc Supfcis Tdn Prim Ea Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22899.80,N/A,13739.88,N/A,3205.97,N/A,5836.48,N/A,13183.76,N/A,7785.95,N/A,13534.26,N/A,3205.97,N/A,5579.57,N/A,5579.57,N/A,8425.34,N/A,13534.26,N/A,13534.26,N/A,13534.26,N/A,13120.43,N/A,5579.57,N/A,3205.97,N/A,9384.50,N/A,9384.50,N/A,3205.97,N/A,5579.57,N/A,5836.48,N/A,2751.76,N/A,N/A,2751.76,13739.88,,Hospital 26372,Rpr/Advmnt Tdn W/Ntc Supfcis Tdn W/Free Graft Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31627.57,N/A,18976.54,N/A,4427.85,N/A,5921.68,N/A,18045.91,N/A,10753.37,N/A,14483.16,N/A,4427.85,N/A,5973.28,N/A,5973.28,N/A,9016.04,N/A,14483.16,N/A,14483.16,N/A,14483.16,N/A,18045.91,N/A,5973.28,N/A,4427.85,N/A,6843.00,N/A,6843.00,N/A,4427.85,N/A,5973.28,N/A,5921.68,N/A,1684.39,N/A,N/A,1684.39,18976.54,,Hospital CPT 26418,HC Repair Finger Tendon,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,9632.00,9632.00,5779.20,5779.20,N/A,1348.48,N/A,589.51,N/A,5546.11,N/A,3274.88,N/A,1748.16,N/A,1348.48,N/A,589.51,N/A,589.51,N/A,1088.23,N/A,1748.16,N/A,1748.16,N/A,1748.16,N/A,5546.11,N/A,589.51,N/A,1348.48,N/A,9632.00,N/A,9632.00,N/A,1348.48,N/A,589.51,N/A,589.51,N/A,648.46,5779.20,5779.20,589.51,9632.00,,Hospital 26432,Cltx Dstl Xtnsr Tdn Insj W/WO Percutan Pinning,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7467.02,N/A,4480.21,N/A,1045.38,N/A,1330.03,N/A,4299.03,N/A,2538.78,N/A,3135.29,N/A,1045.38,N/A,1295.43,N/A,1295.43,N/A,1951.78,N/A,3135.29,N/A,3135.29,N/A,3135.29,N/A,4299.03,N/A,1295.43,N/A,1045.38,N/A,1871.00,N/A,1871.00,N/A,1045.38,N/A,1295.43,N/A,1330.03,N/A,567.33,N/A,N/A,567.33,4480.21,,Hospital 26433,Repair Extensor Tendon Distal Insertion W/O Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9383.18,N/A,5629.91,N/A,1313.65,N/A,2859.50,N/A,5402.66,N/A,3190.28,N/A,6502.16,N/A,1313.65,N/A,2688.04,N/A,2688.04,N/A,4047.72,N/A,6502.16,N/A,6502.16,N/A,6502.16,N/A,5402.66,N/A,2688.04,N/A,1313.65,N/A,5497.50,N/A,5497.50,N/A,1313.65,N/A,2688.04,N/A,2859.50,N/A,1235.47,N/A,N/A,1235.47,6502.16,,Hospital 26445,Tenolysis Extensor Tendon Hand/Finger Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21324.60,N/A,12794.76,N/A,2985.45,N/A,2859.50,N/A,12274.52,N/A,7250.36,N/A,6521.97,N/A,2985.45,N/A,2688.04,N/A,2688.04,N/A,4060.05,N/A,6521.97,N/A,6521.97,N/A,6521.97,N/A,12274.52,N/A,2688.04,N/A,2985.45,N/A,3274.25,N/A,3274.25,N/A,2985.45,N/A,2688.04,N/A,2859.50,N/A,2028.92,N/A,N/A,2028.92,12794.76,,Hospital 26449,Tenolysis Cplx Xtnsr Tendon Finger W/Forearm Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,58605.40,N/A,35163.24,N/A,N/A,N/A,9986.72,N/A,19272.47,N/A,19925.83,N/A,19456.82,N/A,9547.35,N/A,9927.42,N/A,9927.42,N/A,12111.42,N/A,19456.82,N/A,19456.82,N/A,19456.82,N/A,19272.47,N/A,9927.42,N/A,9547.35,N/A,23148.76,N/A,23148.76,N/A,N/A,N/A,9927.42,N/A,9986.72,N/A,10215.66,N/A,9547.35,35163.24,N/A,N/A,,Hospital 26455,Tenotomy Flexor Finger Open Each Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13100.48,N/A,7860.29,N/A,1834.07,N/A,2664.83,N/A,7540.86,N/A,4454.17,N/A,6526.14,N/A,1834.07,N/A,2688.04,N/A,2688.04,N/A,4062.65,N/A,6526.14,N/A,6526.14,N/A,6526.14,N/A,7540.86,N/A,2688.04,N/A,1834.07,N/A,5965.25,N/A,5965.25,N/A,1834.07,N/A,2688.04,N/A,2664.83,N/A,1959.16,N/A,N/A,1834.07,7860.29,,Hospital 26474,Tenodesis Distal Joint Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29595.92,N/A,17757.55,N/A,4143.45,N/A,2818.24,N/A,17030.31,N/A,10000.58,N/A,6572.25,N/A,4143.45,N/A,2688.04,N/A,2688.04,N/A,4091.34,N/A,6572.25,N/A,6572.25,N/A,6572.25,N/A,17030.32,N/A,2688.04,N/A,4143.45,N/A,8711.75,N/A,8711.75,N/A,4143.45,N/A,2688.04,N/A,2265.99,N/A,2492.59,N/A,N/A,2265.99,17757.55,,Hospital 26476,Lengthening Tendon Extensor Hand/Finger Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12096.60,N/A,7257.96,N/A,1694.84,N/A,2664.83,N/A,6962.98,N/A,4112.86,N/A,6531.20,N/A,1694.84,N/A,2688.04,N/A,2688.04,N/A,4065.78,N/A,6531.20,N/A,6531.20,N/A,6531.20,N/A,6962.98,N/A,2688.04,N/A,1694.84,N/A,5563.25,N/A,5563.25,N/A,1694.84,N/A,2688.04,N/A,2664.83,N/A,2115.52,N/A,N/A,1694.84,7257.96,,Hospital 26483,Tendon Transfer Transplant Carp/Mtcrpl Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19932.22,N/A,11959.33,N/A,2790.52,N/A,1717.82,N/A,11472.18,N/A,6776.95,N/A,6558.22,N/A,2790.52,N/A,2688.04,N/A,2688.04,N/A,4082.61,N/A,6558.22,N/A,6558.22,N/A,6558.22,N/A,11472.17,N/A,2688.04,N/A,2790.52,N/A,8244.00,N/A,8244.00,N/A,2790.52,N/A,2688.04,N/A,1717.82,N/A,1780.47,N/A,N/A,1717.82,11959.33,,Hospital 26496,Opponensplasty Other Methods,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17102.00,N/A,10261.20,N/A,2395.46,N/A,2664.83,N/A,9841.79,N/A,5814.70,N/A,6577.89,N/A,2395.46,N/A,2688.04,N/A,2688.04,N/A,4094.86,N/A,6577.89,N/A,6577.89,N/A,6577.89,N/A,9841.78,N/A,2688.04,N/A,2395.46,N/A,6728.25,N/A,6728.25,N/A,2395.46,N/A,2688.04,N/A,2664.83,N/A,2013.17,N/A,N/A,2013.17,10261.20,,Hospital 26500,Rcnstj Tendon Pulley Each W/Local Tissues Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37642.70,N/A,22585.62,N/A,5266.83,N/A,6354.28,N/A,21663.67,N/A,12798.53,N/A,14537.92,N/A,5266.83,N/A,5973.28,N/A,5973.28,N/A,9050.12,N/A,14537.92,N/A,14537.92,N/A,14537.92,N/A,21663.67,N/A,5973.28,N/A,5266.83,N/A,5497.50,N/A,5497.50,N/A,5266.83,N/A,5973.28,N/A,6354.28,N/A,1621.24,N/A,N/A,1621.24,22585.62,,Hospital 26516,Capsulodesis Mtcarphlngl Joint Single Digit,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46417.02,N/A,27850.21,N/A,6498.38,N/A,3207.46,N/A,26440.87,N/A,15781.80,N/A,14512.71,N/A,6498.38,N/A,5973.28,N/A,5973.28,N/A,9034.44,N/A,14512.71,N/A,14512.71,N/A,14512.71,N/A,26440.88,N/A,5973.28,N/A,6498.38,N/A,9384.50,N/A,9384.50,N/A,6498.38,N/A,5973.28,N/A,3207.46,N/A,3528.20,N/A,N/A,3207.46,27850.21,,Hospital 26517,Capsulodesis Mtcarphlngl Joint 2 Digits,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23836.98,N/A,14302.19,N/A,3337.19,N/A,2664.83,N/A,13649.95,N/A,8104.57,N/A,6527.54,N/A,3337.19,N/A,2688.04,N/A,2688.04,N/A,4063.52,N/A,6527.54,N/A,6527.54,N/A,6527.54,N/A,13598.14,N/A,2688.04,N/A,3337.19,N/A,5965.25,N/A,5965.25,N/A,3337.19,N/A,2688.04,N/A,2664.83,N/A,2340.73,N/A,N/A,2340.73,14302.19,,Hospital CPT 26525,Capsulectomy/Capsulotomy Iphal Joint Each,N/A,N/A,1246.00,1246.00,747.60,747.60,N/A,174.44,N/A,650.18,N/A,1246.00,N/A,423.64,N/A,1246.00,N/A,174.44,N/A,650.18,N/A,650.18,N/A,1199.23,N/A,1246.00,N/A,1246.00,N/A,1246.00,N/A,1246.00,N/A,650.18,N/A,174.44,N/A,1246.00,N/A,1246.00,N/A,174.44,N/A,650.18,N/A,650.18,N/A,715.20,747.60,747.60,174.44,1246.00,,Hospital 26530,Arthroplasty Metacarpophalangeal Joint Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29652.83,N/A,17791.70,N/A,4151.38,N/A,5942.72,N/A,16946.09,N/A,10081.96,N/A,14470.29,N/A,4151.38,N/A,5973.28,N/A,5973.28,N/A,9008.03,N/A,14470.29,N/A,14470.29,N/A,14470.29,N/A,16946.09,N/A,5973.28,N/A,4151.38,N/A,6898.50,N/A,6898.50,N/A,4151.38,N/A,5973.28,N/A,5942.72,N/A,1299.07,N/A,N/A,1299.07,17791.70,,Hospital 26535,Arthroplasty Interphalangeal Joint Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26490.02,N/A,15894.01,N/A,3695.40,N/A,773.06,N/A,15105.82,N/A,9006.61,N/A,6525.09,N/A,3695.40,N/A,2688.04,N/A,2688.04,N/A,4061.98,N/A,6525.09,N/A,6525.09,N/A,6525.09,N/A,15105.84,N/A,2688.04,N/A,3695.40,N/A,5963.00,N/A,5963.00,N/A,3695.40,N/A,2688.04,N/A,773.06,N/A,850.37,N/A,N/A,773.06,15894.01,,Hospital 26548,Rpr & Rcnstj Finger Volar Plate Interphalangeal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13100.48,N/A,7860.29,N/A,1834.07,N/A,2664.83,N/A,7540.86,N/A,4454.17,N/A,6526.14,N/A,1834.07,N/A,2688.04,N/A,2688.04,N/A,4062.65,N/A,6526.14,N/A,6526.14,N/A,6526.14,N/A,7540.86,N/A,2688.04,N/A,1834.07,N/A,5965.25,N/A,5965.25,N/A,1834.07,N/A,2688.04,N/A,2664.83,N/A,1959.16,N/A,N/A,1834.07,7860.29,,Hospital CPT 26615,Open Tx Metacarpal Fracture Single Ea Bone,N/A,N/A,1136.00,1136.00,681.60,681.60,N/A,159.04,N/A,545.87,N/A,1136.00,N/A,386.24,N/A,1136.00,N/A,159.04,N/A,545.87,N/A,545.87,N/A,1019.52,N/A,1136.00,N/A,1136.00,N/A,1136.00,N/A,1136.00,N/A,545.87,N/A,159.04,N/A,1136.00,N/A,1136.00,N/A,159.04,N/A,545.87,N/A,545.87,N/A,600.46,681.60,681.60,159.04,1136.00,,Hospital CPT 26641,HC Clsd Tx Cmc Disl Thumb W/Man,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,804.00,804.00,482.40,482.40,N/A,112.56,N/A,363.61,N/A,462.94,N/A,273.36,N/A,804.00,N/A,112.56,N/A,363.61,N/A,363.61,N/A,744.07,N/A,804.00,N/A,804.00,N/A,804.00,N/A,462.94,N/A,363.61,N/A,112.56,N/A,804.00,N/A,804.00,N/A,112.56,N/A,363.61,N/A,363.61,N/A,399.97,482.40,482.40,112.56,804.00,,Hospital CPT 26645,HC Treat Thumb Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3988.00,3988.00,2392.80,2392.80,N/A,558.32,N/A,376.95,N/A,2296.29,N/A,1355.92,N/A,1238.34,N/A,558.32,N/A,376.95,N/A,376.95,N/A,770.87,N/A,1238.34,N/A,1238.34,N/A,1238.34,N/A,2296.29,N/A,376.95,N/A,558.32,N/A,3988.00,N/A,3988.00,N/A,558.32,N/A,376.95,N/A,376.95,N/A,414.65,2392.80,2392.80,376.95,3988.00,,Hospital CPT 26670,HC Clsd Tx Cmc Disl WO Anesth,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,725.00,725.00,435.00,435.00,N/A,101.50,N/A,299.23,N/A,417.46,N/A,246.50,N/A,725.00,N/A,101.50,N/A,299.23,N/A,299.23,N/A,623.45,N/A,725.00,N/A,725.00,N/A,725.00,N/A,417.46,N/A,299.23,N/A,101.50,N/A,725.00,N/A,725.00,N/A,101.50,N/A,299.23,N/A,299.23,N/A,329.15,435.00,435.00,101.50,725.00,,Hospital 26685,Open Tx Carpometacarpal Dislocate Not Thumb,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17619.80,N/A,10571.88,N/A,2466.77,N/A,2759.84,N/A,10142.41,N/A,5990.73,N/A,6548.84,N/A,2466.77,N/A,2688.04,N/A,2688.04,N/A,4076.78,N/A,6548.84,N/A,6548.84,N/A,6548.84,N/A,10142.41,N/A,2688.04,N/A,2466.77,N/A,9953.25,N/A,9953.25,N/A,2466.77,N/A,2688.04,N/A,2759.84,N/A,1269.31,N/A,N/A,1269.31,10571.88,,Hospital CPT 26700,HC ED Clsd Tx Mcp Disl WO Anesth,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1692.00,1692.00,1015.20,1015.20,N/A,236.88,N/A,298.04,N/A,974.25,N/A,575.28,N/A,979.32,N/A,236.88,N/A,298.04,N/A,298.04,N/A,609.63,N/A,979.32,N/A,979.32,N/A,979.32,N/A,974.25,N/A,298.04,N/A,236.88,N/A,1692.00,N/A,1692.00,N/A,236.88,N/A,298.04,N/A,298.04,N/A,327.84,1015.20,1015.20,236.88,1692.00,,Hospital 26720,HC Treat Finger Fx Each,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,34556.00,1111.00,20733.60,666.60,4108.72,155.54,5126.05,474.90,9259.34,639.49,11749.04,377.74,9347.92,13.36,4235.32,155.54,3934.00,448.14,3934.00,448.14,5818.86,8.32,9347.92,13.36,9347.92,13.36,9347.92,13.36,9259.34,639.49,5126.05,448.14,4235.32,155.54,11121.69,113.10,11121.69,113.10,N/A,155.54,5126.05,448.14,5126.05,474.90,4531.79,270.99,3934.00,20733.60,8.32,666.60,,Hospital CPT 26727,Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T,N/A,N/A,922.00,922.00,553.20,553.20,N/A,129.08,N/A,449.84,N/A,922.00,N/A,313.48,N/A,922.00,N/A,129.08,N/A,449.84,N/A,449.84,N/A,841.70,N/A,922.00,N/A,922.00,N/A,922.00,N/A,922.00,N/A,449.84,N/A,129.08,N/A,922.00,N/A,922.00,N/A,129.08,N/A,449.84,N/A,449.84,N/A,494.82,553.20,553.20,129.08,922.00,,Hospital 26740,HC Treat Finger Fx Each,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,9448.72,N/A,5669.23,N/A,1322.82,N/A,191.93,N/A,5440.31,N/A,3212.56,N/A,452.19,N/A,1322.82,N/A,186.94,N/A,186.94,N/A,281.50,N/A,452.19,N/A,452.19,N/A,452.19,N/A,5440.31,N/A,186.94,N/A,1322.82,N/A,527.00,N/A,527.00,N/A,1322.82,N/A,186.94,N/A,191.93,N/A,229.02,N/A,N/A,186.94,5669.23,,Hospital CPT 26742,HC Clsd Tx Mcp IP Fx W Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,321.02,N/A,979.44,N/A,578.34,N/A,1073.70,N/A,238.14,N/A,321.02,N/A,321.02,N/A,668.38,N/A,1073.70,N/A,1073.70,N/A,1073.70,N/A,979.44,N/A,321.02,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,238.14,N/A,321.02,N/A,321.02,N/A,353.12,1020.60,1020.60,238.14,1701.00,,Hospital 26756,Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11297.28,N/A,6778.37,N/A,1581.62,N/A,2811.81,N/A,6504.32,N/A,3841.08,N/A,6502.16,N/A,1581.62,N/A,2688.04,N/A,2688.04,N/A,4047.72,N/A,6502.16,N/A,6502.16,N/A,6502.16,N/A,6504.32,N/A,2688.04,N/A,1581.62,N/A,3397.00,N/A,3397.00,N/A,1581.62,N/A,2688.04,N/A,2811.81,N/A,442.56,N/A,N/A,442.56,6778.37,,Hospital 26765,Open Tx Distal Phalangeal Fracture Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16497.90,N/A,9898.74,N/A,2309.71,N/A,2859.50,N/A,9494.98,N/A,5609.29,N/A,6526.98,N/A,2309.71,N/A,2688.04,N/A,2688.04,N/A,4063.17,N/A,6526.98,N/A,6526.98,N/A,6526.98,N/A,9494.99,N/A,2688.04,N/A,2309.71,N/A,3660.50,N/A,3660.50,N/A,2309.71,N/A,2688.04,N/A,2859.50,N/A,639.00,N/A,N/A,639.00,9898.74,,Hospital CPT 26770,HC ED Clsd Tx IP Disloc WO Anesth,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1135.00,1135.00,681.00,681.00,N/A,158.90,N/A,248.56,N/A,653.53,N/A,385.90,N/A,827.70,N/A,158.90,N/A,248.56,N/A,248.56,N/A,515.24,N/A,827.70,N/A,827.70,N/A,827.70,N/A,653.53,N/A,248.56,N/A,158.90,N/A,1135.00,N/A,1135.00,N/A,158.90,N/A,248.56,N/A,248.56,N/A,273.42,681.00,681.00,158.90,1135.00,,Hospital 26775,Cltx Iphal Jt Dislc W/Manj Req Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15886.40,N/A,9531.84,N/A,2224.10,N/A,327.58,N/A,9349.10,N/A,5401.38,N/A,770.22,N/A,2224.10,N/A,313.17,N/A,313.17,N/A,479.48,N/A,770.22,N/A,770.22,N/A,770.22,N/A,9349.10,N/A,313.17,N/A,2224.10,N/A,527.00,N/A,527.00,N/A,2224.10,N/A,313.17,N/A,327.58,N/A,519.07,N/A,N/A,313.17,9531.84,,Hospital 26820,Fusion Opposition Thumb W/Autogenous Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28282.73,N/A,16969.64,N/A,3959.59,N/A,5942.72,N/A,16191.55,N/A,9616.14,N/A,14468.47,N/A,3959.59,N/A,5973.28,N/A,5973.28,N/A,9006.89,N/A,14468.47,N/A,14468.47,N/A,14468.47,N/A,16191.56,N/A,5973.28,N/A,3959.59,N/A,4562.00,N/A,4562.00,N/A,3959.59,N/A,5973.28,N/A,5942.72,N/A,871.66,N/A,N/A,871.66,16969.64,,Hospital 26842,Arthrd Crp/Mtacrpl Jt Thmb W/WO Int Fixj W/Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34788.80,N/A,20873.28,N/A,4871.75,N/A,5946.00,N/A,19911.88,N/A,11828.19,N/A,14477.90,N/A,4871.75,N/A,5973.28,N/A,5973.28,N/A,9012.76,N/A,14477.90,N/A,14477.90,N/A,14477.90,N/A,19911.89,N/A,5973.28,N/A,4871.75,N/A,4562.00,N/A,4562.00,N/A,4871.75,N/A,5976.56,N/A,5946.00,N/A,982.24,N/A,N/A,982.24,20873.28,,Hospital CPT 26951,Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr,N/A,N/A,1255.00,1255.00,753.00,753.00,N/A,175.70,N/A,662.32,N/A,1255.00,N/A,426.70,N/A,1255.00,N/A,175.70,N/A,662.32,N/A,662.32,N/A,1226.74,N/A,1255.00,N/A,1255.00,N/A,1255.00,N/A,1255.00,N/A,662.32,N/A,175.70,N/A,1255.00,N/A,1255.00,N/A,175.70,N/A,662.32,N/A,662.32,N/A,728.55,753.00,753.00,175.70,1255.00,,Hospital CPT 26951,HC ED Amputation Finger Thumb,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,8837.00,8837.00,5302.20,5302.20,N/A,1237.18,N/A,662.32,N/A,5088.34,N/A,3004.58,N/A,1970.67,N/A,1237.18,N/A,662.32,N/A,662.32,N/A,1226.74,N/A,1970.67,N/A,1970.67,N/A,1970.67,N/A,5088.34,N/A,662.32,N/A,1237.18,N/A,8837.00,N/A,8837.00,N/A,1237.18,N/A,662.32,N/A,662.32,N/A,728.55,5302.20,5302.20,662.32,8837.00,,Hospital CPT 26952,HC Amputation of Finger/Thumb With Flaps,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,8035.00,8035.00,4821.00,4821.00,N/A,1124.90,N/A,650.73,N/A,4626.55,N/A,2731.90,N/A,1932.87,N/A,1124.90,N/A,650.73,N/A,650.73,N/A,1203.21,N/A,1932.87,N/A,1932.87,N/A,1932.87,N/A,4626.55,N/A,650.73,N/A,1124.90,N/A,8035.00,N/A,8035.00,N/A,1124.90,N/A,650.73,N/A,650.73,N/A,715.80,4821.00,4821.00,650.73,8035.00,,Hospital CPT 26952,Amp F/Th 1/2 Jt/Phalanx W/Neurect Local Flap,N/A,N/A,1243.00,1243.00,745.80,745.80,N/A,174.02,N/A,650.73,N/A,1243.00,N/A,422.62,N/A,1243.00,N/A,174.02,N/A,650.73,N/A,650.73,N/A,1203.21,N/A,1243.00,N/A,1243.00,N/A,1243.00,N/A,1243.00,N/A,650.73,N/A,174.02,N/A,1243.00,N/A,1243.00,N/A,174.02,N/A,650.73,N/A,650.73,N/A,715.80,745.80,745.80,174.02,1243.00,,Hospital 26990,I&D Pelvis/Hip Jt Area Deep Abscess/Hematoma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48478.80,16539.40,29087.28,9923.64,10417.33,2262.77,5224.95,2688.04,25354.40,9519.75,16482.79,5623.40,25596.93,6569.75,10738.30,2262.77,4374.04,2688.04,4374.04,2688.04,15933.50,4089.79,25596.93,6569.75,25596.93,6569.75,25596.93,6569.75,25354.40,9519.74,5195.30,2688.04,10738.30,2262.77,30453.96,3397.00,30453.96,3397.00,N/A,2262.77,5195.30,2688.04,5224.95,2688.04,11489.99,2956.85,4374.04,30453.96,2262.77,9923.64,,Hospital Custom 2700000000,HC Oxygen Therapy per Day,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,292.00,292.00,175.20,175.20,N/A,40.88,N/A,292.00,N/A,168.13,N/A,99.28,N/A,40.88,N/A,40.88,N/A,292.00,N/A,292.00,N/A,25.40,N/A,40.88,N/A,40.88,N/A,40.88,N/A,168.13,N/A,292.00,N/A,40.88,N/A,156.51,N/A,156.51,N/A,40.88,N/A,292.00,N/A,292.00,N/A,292.00,175.20,175.20,25.40,292.00,,Hospital 27041,HC Bx Soft Tissue Pelvis/Hip Deep,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,29639.35,19985.12,17783.61,11991.07,11913.27,2797.92,14358.44,1197.78,26847.53,11499.46,10077.38,6794.94,27104.35,5669.15,12280.34,2797.92,2248.00,2320.33,2248.00,2320.33,16871.83,3529.16,27104.35,5669.15,27104.35,5669.15,27104.35,5669.15,26847.53,11499.48,14358.44,2320.33,12280.34,2797.92,29639.35,2586.50,29639.35,2586.50,12280.34,2797.92,14358.44,2320.33,14358.44,1197.78,13139.97,1317.57,2248.00,29639.35,1197.78,11991.07,,Hospital 27043,Excision Tumor Soft Tissue Pelvis&Hip Subq 3cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15389.20,N/A,9233.52,N/A,2154.49,N/A,2440.19,N/A,8859.76,N/A,5232.33,N/A,5681.04,N/A,2154.49,N/A,2332.78,N/A,2332.78,N/A,3536.55,N/A,5681.04,N/A,5681.04,N/A,5681.04,N/A,8859.76,N/A,2332.78,N/A,2154.49,N/A,3397.00,N/A,3397.00,N/A,2154.49,N/A,2332.78,N/A,2440.19,N/A,523.94,N/A,N/A,523.94,9233.52,,Hospital 27045,Exc Tumor Soft Tissue Pelvis & Hip Subfasc 5cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19319.42,N/A,11591.65,N/A,2704.71,N/A,2381.29,N/A,11123.14,N/A,6568.60,N/A,5652.86,N/A,2704.71,N/A,2332.78,N/A,2332.78,N/A,3519.01,N/A,5652.86,N/A,5652.86,N/A,5652.86,N/A,11123.15,N/A,2332.78,N/A,2704.71,N/A,3397.00,N/A,3397.00,N/A,2704.71,N/A,2332.78,N/A,2381.29,N/A,803.93,N/A,N/A,803.93,11591.65,,Hospital 27048,Exc Tumor Soft Tissue Pelvis & Hip Subfasc <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81550.13,N/A,48930.08,N/A,11415.31,N/A,2146.53,N/A,46417.45,N/A,27704.42,N/A,30104.87,N/A,11415.31,N/A,11933.08,N/A,11933.08,N/A,18936.86,N/A,30104.87,N/A,30104.87,N/A,30104.87,N/A,46417.49,N/A,11956.02,N/A,11415.31,N/A,12953.25,N/A,12953.25,N/A,11415.31,N/A,11933.08,N/A,2146.53,N/A,2361.20,N/A,N/A,2146.53,48930.08,,Hospital 27065,Excision Bone Cyst/Bnign Tumor Superficial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16841.90,N/A,10105.14,N/A,2349.00,N/A,6248.31,N/A,9689.20,N/A,5726.24,N/A,14549.44,N/A,2349.00,N/A,5973.28,N/A,5973.28,N/A,9057.30,N/A,14549.44,N/A,14549.44,N/A,14549.44,N/A,9689.19,N/A,5973.28,N/A,2349.00,N/A,3397.00,N/A,3397.00,N/A,2349.00,N/A,5973.28,N/A,6248.31,N/A,599.15,N/A,N/A,599.15,14549.44,,Hospital 27091,Rmvl Hip Prosth Comp W/Tot Hip Prosth Mma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,100735.18,N/A,60441.11,N/A,15935.58,N/A,19264.86,N/A,39209.64,N/A,N/A,N/A,36255.65,N/A,16426.58,N/A,8436.67,N/A,100598.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,39209.64,N/A,19116.61,N/A,16426.58,N/A,N/A,N/A,43135.17,N/A,N/A,N/A,19116.61,N/A,19264.86,N/A,17576.44,N/A,8436.67,100598.00,N/A,N/A,,Hospital CPT 27093,HC Inj Proc Hip,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1083.00,1083.00,649.80,649.80,N/A,151.62,N/A,65.26,N/A,623.59,N/A,368.22,N/A,1083.00,N/A,151.62,N/A,1083.00,N/A,1083.00,N/A,1083.00,N/A,1083.00,N/A,1083.00,N/A,1083.00,N/A,623.59,N/A,1083.00,N/A,151.62,N/A,527.00,N/A,527.00,N/A,151.62,N/A,1083.00,N/A,65.26,N/A,71.79,649.80,649.80,65.26,1083.00,,Hospital 27095,HC Arthrography Hip With Anesth,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,6006.60,N/A,3603.96,N/A,840.92,N/A,261.97,N/A,3457.10,N/A,2042.24,N/A,18.28,N/A,840.92,N/A,261.97,N/A,261.97,N/A,11.38,N/A,18.28,N/A,18.28,N/A,18.28,N/A,3457.10,N/A,261.97,N/A,840.92,N/A,527.00,N/A,527.00,N/A,840.92,N/A,261.97,N/A,261.97,N/A,87.81,N/A,N/A,11.38,3603.96,,Hospital CPT 27096,HC Inject Sacroiliac Joint,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2822.00,2822.00,1693.20,1693.20,N/A,395.08,N/A,79.01,N/A,1624.91,N/A,959.48,N/A,451.29,N/A,395.08,N/A,79.01,N/A,79.01,N/A,280.93,N/A,451.29,N/A,451.29,N/A,451.29,N/A,1624.91,N/A,79.01,N/A,395.08,N/A,527.00,N/A,527.00,N/A,395.08,N/A,79.01,N/A,79.01,N/A,86.91,1693.20,1693.20,79.01,1693.20,,Hospital 27097,Release/Recession Hamstring Proximal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54935.82,N/A,32961.49,N/A,7682.15,N/A,2811.81,N/A,31479.00,N/A,18678.17,N/A,6724.79,N/A,7682.15,N/A,2688.04,N/A,2688.04,N/A,4252.33,N/A,6724.79,N/A,6724.79,N/A,6724.79,N/A,31479.00,N/A,2688.04,N/A,7682.15,N/A,4562.00,N/A,4562.00,N/A,7682.15,N/A,2688.04,N/A,2811.81,N/A,725.91,N/A,N/A,725.91,32961.49,,Hospital 27132,Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,86977.70,N/A,52186.62,N/A,254.06,N/A,8534.01,N/A,N/A,N/A,39090.00,N/A,39090.00,N/A,254.06,N/A,8534.01,N/A,8534.01,N/A,39090.00,N/A,39090.00,N/A,39090.00,N/A,39090.00,N/A,N/A,N/A,8534.01,N/A,254.06,N/A,N/A,N/A,N/A,N/A,254.06,N/A,8534.01,N/A,8534.01,N/A,254.06,N/A,N/A,254.06,52186.62,,Hospital 27134,Revj Tot Hip Arthrp Bth W/WO Agrft/Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,102411.45,103549.23,61446.87,62129.54,7092.38,14343.60,8655.56,2200.27,54732.38,58639.68,34819.89,35206.74,16136.14,29814.78,7310.91,14343.60,1686.00,8054.94,1686.00,8054.94,10044.37,18920.78,16136.14,29814.78,16136.14,29814.78,16136.14,29814.78,54732.38,58639.69,8655.56,8069.20,7310.91,14343.60,19197.98,11660.00,19197.98,11660.00,7310.91,14343.60,8655.56,8054.94,8655.56,2200.27,7822.67,2414.16,1686.00,61446.87,2200.27,62129.54,,Hospital 27137,Revj Tot Hip Arthrp Actblr W/WO Agrft/Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62841.42,N/A,37704.85,N/A,8756.13,N/A,1641.28,N/A,35808.42,N/A,21241.49,N/A,29545.47,N/A,8756.13,N/A,1702.78,N/A,1702.78,N/A,18640.42,N/A,29545.47,N/A,29545.47,N/A,29545.47,N/A,35808.42,N/A,1723.75,N/A,8756.13,N/A,11660.00,N/A,11660.00,N/A,8756.13,N/A,1702.78,N/A,1641.28,N/A,1805.41,N/A,N/A,1641.28,37704.85,,Hospital 27165,Osteot Intertrchntric/Subtrchntric W/Int/Xtrnl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,89027.22,N/A,53416.33,N/A,12438.51,N/A,6585.53,N/A,51067.09,N/A,30094.09,N/A,20671.95,N/A,12438.51,N/A,6555.46,N/A,6555.46,N/A,13064.70,N/A,20671.95,N/A,20671.95,N/A,20671.95,N/A,50689.39,N/A,6578.40,N/A,12438.51,N/A,9595.50,N/A,9595.50,N/A,12438.51,N/A,6555.46,N/A,1976.68,N/A,2168.23,N/A,N/A,1976.68,53416.33,,Hospital 27170,B1 Grf Fem H/N Intertrchntric/Subtrchntric Area,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57033.78,N/A,34220.27,N/A,7976.71,N/A,2440.19,N/A,32623.23,N/A,19391.50,N/A,21113.60,N/A,7976.71,N/A,2332.78,N/A,2332.78,N/A,13143.60,N/A,21113.60,N/A,21113.60,N/A,21113.60,N/A,32623.23,N/A,2332.78,N/A,7976.71,N/A,9595.50,N/A,9595.50,N/A,7976.71,N/A,2332.78,N/A,2440.19,N/A,1708.18,N/A,N/A,1708.18,34220.27,,Hospital 27197,HC Clsd Tx Pelvic Ring Fx W/O Man,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1533.00,N/A,919.80,N/A,214.62,N/A,299.28,N/A,882.70,N/A,521.22,N/A,N/A,N/A,214.62,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,882.70,N/A,296.08,N/A,214.62,N/A,309.81,N/A,309.81,N/A,214.62,N/A,296.08,N/A,299.28,N/A,246.72,N/A,N/A,214.62,919.80,,Hospital 27198,Clsd Tx Pelvic Ring Fx W/Manipulation W/Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10592.60,N/A,6355.56,N/A,1482.97,N/A,92.66,N/A,6095.57,N/A,3601.49,N/A,257.75,N/A,1482.97,N/A,93.47,N/A,93.47,N/A,160.44,N/A,257.75,N/A,257.75,N/A,257.75,N/A,6095.57,N/A,93.47,N/A,1482.97,N/A,263.50,N/A,263.50,N/A,1482.97,N/A,93.47,N/A,92.66,N/A,335.24,N/A,N/A,92.66,6355.56,,Hospital 27220,HC Cltx Acetabulum Hip/Sockt Fx W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1505.00,N/A,903.00,N/A,210.70,N/A,299.28,N/A,866.58,N/A,511.70,N/A,N/A,N/A,210.70,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,866.58,N/A,296.08,N/A,210.70,N/A,322.14,N/A,322.14,N/A,210.70,N/A,296.08,N/A,299.28,N/A,462.96,N/A,N/A,210.70,903.00,,Hospital 27235,Prq Skel Fixj Femoral Fx Prox End Neck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,46178.13,30153.32,27706.88,18091.99,5322.01,4208.58,8636.72,6739.37,22049.00,17272.73,15700.56,10252.12,19978.72,15023.00,5485.99,4208.58,143872.00,6123.42,143872.00,6123.42,12436.29,9548.11,19978.72,15023.00,19978.72,15023.00,19978.72,15023.00,22049.00,17272.74,8607.07,6146.36,5485.99,4208.58,23769.68,4562.00,23769.68,4562.00,N/A,4208.58,8607.07,6123.42,8636.72,1101.85,5870.01,1205.91,5322.01,143872.00,1101.85,18091.99,,Hospital 27257,Tx Spon Hip Dislc Abdct Splnt/Trcj W/Manj Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,77856.23,N/A,46713.74,N/A,10899.88,N/A,1342.91,N/A,44168.52,N/A,26471.12,N/A,28575.98,N/A,10899.88,N/A,11782.94,N/A,11782.94,N/A,17789.10,N/A,28575.98,N/A,28575.98,N/A,28575.98,N/A,44168.53,N/A,11782.94,N/A,10899.88,N/A,10535.75,N/A,10535.75,N/A,10899.88,N/A,11782.94,N/A,1342.91,N/A,1477.21,N/A,N/A,1342.91,46713.74,,Hospital CPT 27265,HC Clsd Tx Hip Dislo Postarth,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,765.00,765.00,459.00,459.00,N/A,107.10,N/A,391.49,N/A,440.49,N/A,260.10,N/A,765.00,N/A,107.10,N/A,391.49,N/A,391.49,N/A,741.90,N/A,765.00,N/A,765.00,N/A,765.00,N/A,440.49,N/A,391.49,N/A,107.10,N/A,765.00,N/A,765.00,N/A,107.10,N/A,391.49,N/A,391.49,N/A,430.64,459.00,459.00,107.10,765.00,,Hospital 27269,Open Tx Femoral Fracture Proximal End Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,110808.78,N/A,66485.27,N/A,15541.05,N/A,1855.15,N/A,63715.67,N/A,37674.99,N/A,4727.47,N/A,15541.05,N/A,1818.03,N/A,1818.03,N/A,2942.93,N/A,4727.47,N/A,4727.47,N/A,4727.47,N/A,63715.67,N/A,1818.03,N/A,15541.05,N/A,2586.50,N/A,2586.50,N/A,15541.05,N/A,1818.03,N/A,1855.15,N/A,1478.93,N/A,N/A,1478.93,66485.27,,Hospital 27299,Unlisted Procedure Pelvis/Hip Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51847.38,N/A,31108.43,N/A,7258.65,N/A,206.22,N/A,29445.35,N/A,17628.11,N/A,519.59,N/A,7258.65,N/A,186.94,N/A,186.94,N/A,323.45,N/A,519.59,N/A,519.59,N/A,519.59,N/A,29445.38,N/A,186.94,N/A,7258.65,N/A,527.00,N/A,527.00,N/A,7258.65,N/A,186.94,N/A,4611.98,N/A,N/A,N/A,N/A,186.94,31108.43,,Hospital 27301,I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29580.40,N/A,17748.24,N/A,3994.75,N/A,2562.90,N/A,17028.64,N/A,10057.33,N/A,6205.72,N/A,3994.75,N/A,2482.92,N/A,2482.92,N/A,4059.19,N/A,6205.72,N/A,6205.72,N/A,6205.72,N/A,17028.64,N/A,2505.86,N/A,3994.75,N/A,3660.50,N/A,3660.50,N/A,3994.75,N/A,2482.92,N/A,2562.90,N/A,873.98,N/A,N/A,873.98,17748.24,,Hospital 27303,Inc Deep W/Opng Bone Cortex Femur/Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29181.58,N/A,17508.95,N/A,4061.99,N/A,2184.13,N/A,16611.54,N/A,9921.75,N/A,18246.39,N/A,4061.99,N/A,2167.25,N/A,2167.25,N/A,11358.72,N/A,18246.39,N/A,18246.39,N/A,18246.39,N/A,16581.31,N/A,2167.25,N/A,4061.99,N/A,6898.50,N/A,6898.50,N/A,4061.99,N/A,2167.25,N/A,2184.13,N/A,815.28,N/A,N/A,815.28,18246.39,,Hospital 27306,Tenotomy Prq Adductor/Hamstring 1 Tendon Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45655.70,N/A,27393.42,N/A,6391.81,N/A,2811.81,N/A,26187.29,N/A,15522.95,N/A,6536.03,N/A,6391.81,N/A,2688.04,N/A,2688.04,N/A,4068.80,N/A,6536.03,N/A,6536.03,N/A,6536.03,N/A,26187.29,N/A,2688.04,N/A,6391.81,N/A,6260.50,N/A,6260.50,N/A,6391.81,N/A,2688.04,N/A,2811.81,N/A,1107.83,N/A,N/A,1107.83,27393.42,,Hospital 27310,Arthrt Kne W/Expl Drg/Rmvl FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,26752.80,22675.92,16051.68,13605.55,5366.09,3099.24,6613.46,756.69,12092.93,13054.04,9095.95,7709.81,12208.61,6522.73,5531.43,3099.24,562.00,2688.04,562.00,2688.04,7599.57,4060.52,12208.61,6522.73,12208.61,6522.73,12208.61,6522.73,12092.93,13054.06,6613.46,2688.04,5531.43,3099.24,14525.20,4562.00,14525.20,4562.00,N/A,3099.24,6613.46,2688.04,6613.46,756.69,5918.63,832.37,562.00,16051.68,756.69,13605.55,,Hospital 27347,Excision Lesion Meniscus/Capsule Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33092.32,N/A,19855.39,N/A,4539.43,N/A,553.05,N/A,19033.81,N/A,11251.39,N/A,6616.53,N/A,4539.43,N/A,2688.04,N/A,2688.04,N/A,4118.92,N/A,6616.53,N/A,6616.53,N/A,6616.53,N/A,19033.84,N/A,2688.04,N/A,4539.43,N/A,3397.00,N/A,3397.00,N/A,4539.43,N/A,2688.04,N/A,553.05,N/A,608.37,N/A,N/A,553.05,19855.39,,Hospital 27355,Excision/Curettage Cyst/Tumor Femur,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24790.00,N/A,14874.00,N/A,3463.80,N/A,2893.82,N/A,14270.17,N/A,8428.61,N/A,6857.29,N/A,3463.80,N/A,2770.05,N/A,2770.05,N/A,4379.22,N/A,6857.29,N/A,6857.29,N/A,6857.29,N/A,14270.18,N/A,2785.55,N/A,3463.80,N/A,4562.00,N/A,4562.00,N/A,3463.80,N/A,2770.05,N/A,2893.82,N/A,859.16,N/A,N/A,859.16,14874.00,,Hospital 27360,Prtl Exc Bone Femur Prox Tibia&/Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25325.10,N/A,15195.06,N/A,3519.86,N/A,2743.94,N/A,14578.84,N/A,8610.53,N/A,6537.22,N/A,3519.86,N/A,2688.04,N/A,2688.04,N/A,4069.55,N/A,6537.22,N/A,6537.22,N/A,6537.22,N/A,14578.84,N/A,2688.04,N/A,3519.86,N/A,4562.00,N/A,4562.00,N/A,3519.86,N/A,2688.04,N/A,2743.94,N/A,1004.14,N/A,N/A,1004.14,15195.06,,Hospital 27364,Rad Resection Tumor Soft Tis Thigh/Knee 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22846.02,N/A,13707.61,N/A,3198.45,N/A,2520.24,N/A,13132.22,N/A,7767.64,N/A,7840.88,N/A,3198.45,N/A,3104.47,N/A,3104.47,N/A,5119.21,N/A,7840.88,N/A,7840.88,N/A,7840.88,N/A,13132.24,N/A,3104.47,N/A,3198.45,N/A,6392.25,N/A,6392.25,N/A,3198.45,N/A,3104.47,N/A,2520.24,N/A,2772.27,N/A,N/A,2520.24,13707.61,,Hospital 27380,Suture Infrapatellar Tendon Primary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,44533.10,33446.80,26719.86,20068.08,7332.44,4651.80,6398.45,5921.68,16524.24,19099.72,15141.25,11371.91,16682.31,14544.13,7558.36,4651.80,97788.00,5973.28,97788.00,5973.28,10384.35,9054.00,16682.31,14544.13,16682.31,14544.13,16682.31,14544.13,16524.24,19099.73,8939.53,5973.28,7558.36,4651.80,19847.78,5277.50,19847.78,5277.50,N/A,4651.80,8939.53,5973.28,8969.18,5921.68,8087.45,742.27,6398.45,97788.00,742.27,20068.08,,Hospital 27381,Sutr Infrapatellar Tdn 2 Rcnstj W/Fscal/Tdn Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52580.20,N/A,31548.12,N/A,7361.21,N/A,6248.31,N/A,30134.62,N/A,17877.25,N/A,14631.10,N/A,7361.21,N/A,5973.28,N/A,5973.28,N/A,9174.27,N/A,14631.10,N/A,14631.10,N/A,14631.10,N/A,30134.64,N/A,5973.28,N/A,7361.21,N/A,4562.00,N/A,4562.00,N/A,7361.21,N/A,5973.28,N/A,6248.31,N/A,862.96,N/A,N/A,862.96,31548.12,,Hospital 27403,Arthrotomy W/Meniscus Repair Knee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55849.17,N/A,33509.50,N/A,7810.01,N/A,6248.31,N/A,31957.70,N/A,18985.32,N/A,14707.75,N/A,7810.01,N/A,5973.28,N/A,5973.28,N/A,9217.34,N/A,14707.75,N/A,14707.75,N/A,14707.75,N/A,31957.71,N/A,5973.28,N/A,7810.01,N/A,5277.50,N/A,5277.50,N/A,7810.01,N/A,5973.28,N/A,6248.31,N/A,740.87,N/A,N/A,740.87,33509.50,,Hospital 27407,Repair Primary Torn Ligm&/Capsule Knee Cruciat,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42613.58,N/A,25568.15,N/A,5960.08,N/A,6178.06,N/A,24388.83,N/A,14488.63,N/A,15390.49,N/A,5960.08,N/A,5973.28,N/A,5973.28,N/A,9580.86,N/A,15390.49,N/A,15390.49,N/A,15390.49,N/A,24388.83,N/A,5973.28,N/A,5960.08,N/A,7897.00,N/A,7897.00,N/A,5960.08,N/A,5973.28,N/A,6178.06,N/A,845.33,N/A,N/A,845.33,25568.15,,Hospital 27409,Rpr 1 Torn Ligm&/Capsl Kne Coltrl&Cruciate,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23027.10,N/A,13816.26,N/A,3005.68,N/A,5973.28,N/A,13240.18,N/A,7829.21,N/A,14548.19,N/A,3005.68,N/A,5973.28,N/A,5973.28,N/A,9056.53,N/A,14548.19,N/A,14548.19,N/A,14548.19,N/A,13240.19,N/A,5973.28,N/A,3005.68,N/A,5963.00,N/A,5963.00,N/A,3005.68,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,3005.68,14548.19,,Hospital 27415,Osteochondral Allograft Knee Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,102041.43,N/A,61224.86,N/A,14285.80,N/A,12325.48,N/A,7823.00,N/A,34694.09,N/A,28539.64,N/A,14285.80,N/A,11782.94,N/A,11782.94,N/A,17766.48,N/A,28539.64,N/A,28539.64,N/A,28539.64,N/A,7823.00,N/A,11782.94,N/A,14285.80,N/A,10178.00,N/A,10178.00,N/A,14285.80,N/A,11782.94,N/A,12325.48,N/A,1863.41,N/A,N/A,1863.41,61224.86,,Hospital 27416,Osteochondral Autograft Knee Open Mosaicplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55602.68,N/A,33361.61,N/A,7775.53,N/A,6248.31,N/A,7823.00,N/A,18904.91,N/A,14535.18,N/A,7775.53,N/A,5973.28,N/A,5973.28,N/A,9081.49,N/A,14535.18,N/A,14535.18,N/A,14535.18,N/A,7823.00,N/A,5973.28,N/A,7775.53,N/A,9384.50,N/A,9384.50,N/A,7775.53,N/A,5973.28,N/A,6248.31,N/A,2443.65,N/A,N/A,2443.65,33361.61,,Hospital 27418,Anterior Tibial Tubercleplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82675.38,N/A,49605.23,N/A,11574.56,N/A,2364.92,N/A,47219.71,N/A,28094.27,N/A,14666.71,N/A,11574.56,N/A,5973.28,N/A,5973.28,N/A,9130.31,N/A,14666.71,N/A,14666.71,N/A,14666.71,N/A,47219.73,N/A,5973.28,N/A,11574.56,N/A,10878.50,N/A,10878.50,N/A,11574.56,N/A,5973.28,N/A,2364.92,N/A,2601.41,N/A,N/A,2364.92,49605.23,,Hospital 27425,Lateral Retinacular Release Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55088.68,N/A,33053.21,N/A,7703.57,N/A,2811.81,N/A,7823.00,N/A,17285.84,N/A,6570.84,N/A,7703.57,N/A,2688.04,N/A,2688.04,N/A,4090.46,N/A,6570.84,N/A,6570.84,N/A,6570.84,N/A,7823.00,N/A,2688.04,N/A,7703.57,N/A,7200.75,N/A,7200.75,N/A,7703.57,N/A,2688.04,N/A,2811.81,N/A,1056.95,N/A,N/A,1056.95,33053.21,,Hospital 27427,Ligamentous Reconstruction Knee Extra-Articular,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83952.48,N/A,50371.49,N/A,11753.36,N/A,1713.54,N/A,7823.00,N/A,28517.70,N/A,14566.12,N/A,11753.36,N/A,5973.28,N/A,5973.28,N/A,9067.68,N/A,14566.12,N/A,14566.12,N/A,14566.12,N/A,7823.00,N/A,5973.28,N/A,11753.36,N/A,12203.25,N/A,12203.25,N/A,11753.36,N/A,5973.28,N/A,1713.54,N/A,1884.90,N/A,N/A,1713.54,50371.49,,Hospital 27437,Arthroplasty Patella W/O Prosthesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59844.78,N/A,35906.87,N/A,8331.85,N/A,6248.31,N/A,34227.82,N/A,20338.62,N/A,14573.28,N/A,8331.85,N/A,5973.28,N/A,5973.28,N/A,9098.87,N/A,14573.28,N/A,14573.28,N/A,14573.28,N/A,34227.85,N/A,5973.28,N/A,8331.85,N/A,6678.50,N/A,6678.50,N/A,8331.85,N/A,5973.28,N/A,6248.31,N/A,792.06,N/A,N/A,792.06,35906.87,,Hospital 27443,Arthrp Fem Condyles/Tibl Platu Kne Dbrdmt&Prtl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72863.02,N/A,43717.81,N/A,10194.67,N/A,12340.67,N/A,41699.40,N/A,24773.43,N/A,29160.87,N/A,10194.67,N/A,11936.70,N/A,11936.70,N/A,18349.22,N/A,29160.87,N/A,29160.87,N/A,29160.87,N/A,41699.40,N/A,11959.95,N/A,10194.67,N/A,6678.50,N/A,6678.50,N/A,10194.67,N/A,11936.70,N/A,12340.67,N/A,1244.61,N/A,N/A,1244.61,43717.81,,Hospital 27447,Arthrp Kne Condyle&Platu Medial&Lat Compartments,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,75216.67,64579.70,45130.00,38747.82,10199.26,8959.36,12360.50,11864.95,36516.75,36845.37,25573.67,21834.72,23204.73,29810.74,10513.52,8959.36,24195.80,11864.95,24195.80,11864.95,14444.40,18668.18,23204.73,29810.74,23204.73,29810.74,23204.73,29810.74,36516.75,36845.41,11979.20,11880.45,10513.52,8959.36,27607.84,11660.00,27607.84,11660.00,N/A,8959.36,12330.85,11864.95,11979.20,11864.95,11249.46,13051.44,10199.26,45130.00,8959.36,38747.82,,Hospital 27454,Osteot Mlt W/Relignmt Imed Rod Fem Shft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,116340.07,N/A,69804.04,N/A,16290.85,N/A,1611.02,N/A,66617.06,N/A,39555.63,N/A,16452.71,N/A,16290.85,N/A,1611.02,N/A,1611.02,N/A,10658.38,N/A,16452.71,N/A,16452.71,N/A,16452.71,N/A,66617.04,N/A,1625.41,N/A,16290.85,N/A,7897.00,N/A,7897.00,N/A,16290.85,N/A,1611.02,N/A,1611.02,N/A,1766.00,N/A,N/A,1611.02,69804.04,,Hospital 27455,Osteot Prox Tibia Fib Exc/Osteot Before Epiphysl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,98516.77,N/A,59110.06,N/A,13784.32,N/A,12407.49,N/A,56263.42,N/A,33495.70,N/A,43384.30,N/A,13784.32,N/A,11864.95,N/A,11864.95,N/A,27184.11,N/A,43384.30,N/A,43384.30,N/A,43384.30,N/A,56263.45,N/A,11880.45,N/A,13784.32,N/A,11845.50,N/A,11845.50,N/A,13784.32,N/A,11864.95,N/A,12407.49,N/A,2125.09,N/A,N/A,2125.09,59110.06,,Hospital 27465,Osteoplasty Femur Shortening Excluding 64876,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87193.37,N/A,52316.02,N/A,12171.72,N/A,12247.49,N/A,49593.19,N/A,29645.73,N/A,43657.51,N/A,12171.72,N/A,11932.77,N/A,11932.77,N/A,27373.65,N/A,43657.51,N/A,43657.51,N/A,43657.51,N/A,49593.21,N/A,11956.02,N/A,12171.72,N/A,15608.50,N/A,15608.50,N/A,12171.72,N/A,11932.77,N/A,12247.49,N/A,2966.92,N/A,N/A,2966.92,52316.02,,Hospital 27470,Rpr Non/Mal Femur Dstl H/N W/O Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67995.23,N/A,40797.14,N/A,9444.20,N/A,1480.17,N/A,38829.27,N/A,23118.39,N/A,15571.14,N/A,9444.20,N/A,1475.09,N/A,1475.09,N/A,9992.92,N/A,15571.14,N/A,15571.14,N/A,15571.14,N/A,38829.29,N/A,1493.94,N/A,9444.20,N/A,7897.00,N/A,7897.00,N/A,9444.20,N/A,1475.09,N/A,1457.99,N/A,1591.54,N/A,N/A,1457.99,40797.14,,Hospital 27475,Arrest Epiphyseal Distal Femur,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72194.15,N/A,43316.49,N/A,10136.11,N/A,6354.28,N/A,41487.08,N/A,24546.02,N/A,14473.74,N/A,10136.11,N/A,5973.28,N/A,5973.28,N/A,9010.17,N/A,14473.74,N/A,14473.74,N/A,14473.74,N/A,41487.07,N/A,5973.28,N/A,10136.11,N/A,4562.00,N/A,4562.00,N/A,10136.11,N/A,5973.28,N/A,6354.28,N/A,752.71,N/A,N/A,752.71,43316.49,,Hospital 27479,Arrst Epiphysl Cmbn Dstl Femur Prox Tibfib,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71045.33,N/A,42627.20,N/A,9946.35,N/A,6671.24,N/A,40392.00,N/A,24140.29,N/A,14759.85,N/A,9946.35,N/A,6055.29,N/A,6055.29,N/A,9298.70,N/A,14759.85,N/A,14759.85,N/A,14759.85,N/A,40392.00,N/A,6070.79,N/A,9946.35,N/A,4562.00,N/A,4562.00,N/A,9946.35,N/A,6055.29,N/A,981.71,N/A,1079.88,N/A,N/A,981.71,42627.20,,Hospital 27486,Revj Total Knee Arthrp W/WO Algrft 1 Component,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,79042.27,44708.68,47425.36,26825.21,11128.02,6039.92,2435.34,1938.64,30373.20,25539.56,N/A,15200.96,26087.27,29995.64,11470.89,6039.92,2435.34,1938.64,220866.00,1938.64,N/A,18672.87,26087.27,29995.64,N/A,29995.64,26087.27,29995.64,30373.20,25539.56,13178.60,1938.64,11470.89,6039.92,31037.34,12375.50,N/A,12375.50,1341.94,6039.92,2435.34,1938.64,13386.15,1938.64,1341.94,2113.27,1341.94,220866.00,1938.64,29995.64,,Hospital 27496,Decompression Fasciotomy Thigh&/Knee 1 Component,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19126.30,N/A,11475.78,N/A,2677.68,N/A,2811.81,N/A,11007.03,N/A,6472.28,N/A,6608.91,N/A,2677.68,N/A,2688.04,N/A,2688.04,N/A,4114.18,N/A,6608.91,N/A,6608.91,N/A,6608.91,N/A,11007.04,N/A,2688.04,N/A,2677.68,N/A,6260.50,N/A,6260.50,N/A,2677.68,N/A,2688.04,N/A,2811.81,N/A,1096.83,N/A,N/A,1096.83,11475.78,,Hospital CPT 27502,HC Clsd Tx Femur W or W/O Mani,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2700.00,2700.00,1620.00,1620.00,N/A,378.00,N/A,727.76,N/A,1554.66,N/A,918.00,N/A,2165.04,N/A,378.00,N/A,727.76,N/A,727.76,N/A,1347.74,N/A,2165.04,N/A,2165.04,N/A,2165.04,N/A,1554.66,N/A,727.76,N/A,378.00,N/A,2700.00,N/A,2700.00,N/A,378.00,N/A,727.76,N/A,727.76,N/A,800.54,1620.00,1620.00,378.00,2700.00,,Hospital CPT 27503,HC Supracondylar Femur Fx Cls Red,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3444.00,3444.00,2066.40,2066.40,N/A,482.16,N/A,762.89,N/A,1983.06,N/A,1170.96,N/A,2288.13,N/A,482.16,N/A,762.89,N/A,762.89,N/A,1424.36,N/A,2288.13,N/A,2288.13,N/A,2288.13,N/A,1983.06,N/A,762.89,N/A,482.16,N/A,3444.00,N/A,3444.00,N/A,482.16,N/A,762.89,N/A,762.89,N/A,839.18,2066.40,2066.40,482.16,3444.00,,Hospital 27506,Optx Fem Shft Fx W/Insj Imed Implt W/WO Screw,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,124219.88,N/A,74531.93,N/A,17213.37,N/A,8909.78,N/A,71338.95,N/A,42234.76,N/A,18395.51,N/A,17213.37,N/A,8898.98,N/A,8898.98,N/A,11647.55,N/A,18395.51,N/A,18395.51,N/A,18395.51,N/A,71338.93,N/A,8922.23,N/A,17213.37,N/A,7036.25,N/A,7036.25,N/A,17213.37,N/A,7195.06,N/A,8909.78,N/A,2832.42,N/A,N/A,2832.42,74531.93,,Hospital 27508,HC Cltx Fem Fx Dstl End Medial/Lat Condyle W/O Manj,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1176.00,N/A,705.60,N/A,164.64,N/A,313.76,N/A,677.13,N/A,399.84,N/A,N/A,N/A,164.64,N/A,296.08,N/A,296.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,677.13,N/A,296.08,N/A,164.64,N/A,244.42,N/A,244.42,N/A,164.64,N/A,296.08,N/A,313.76,N/A,554.22,N/A,N/A,164.64,705.60,,Hospital 27511,Open Tx Femoral Supracondylar Fracture W/O Xtn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36539.67,N/A,21923.80,N/A,5106.70,N/A,1034.47,N/A,21012.96,N/A,12423.48,N/A,14771.13,N/A,5106.70,N/A,1030.86,N/A,1030.86,N/A,9195.31,N/A,14771.13,N/A,14771.13,N/A,14771.13,N/A,21012.97,N/A,1030.86,N/A,5106.70,N/A,5963.00,N/A,5963.00,N/A,5106.70,N/A,1030.86,N/A,1034.47,N/A,1076.73,N/A,N/A,1030.86,21923.80,,Hospital 27535,Open Tx Tibial Fracture Proximal Unicondylar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,68571.47,56897.27,41142.88,34138.36,9505.49,7965.61,1834.71,1021.25,33358.57,32574.41,23314.27,19345.06,28228.23,14706.95,N/A,7965.61,242784.00,1017.64,242784.00,1017.64,17571.42,9155.34,28228.23,14706.95,28228.23,14706.95,28228.23,14706.95,N/A,32574.42,10742.21,1017.64,9798.37,7965.61,N/A,5963.00,33584.55,5963.00,N/A,7965.61,10742.21,1017.64,10771.86,1021.25,10484.26,966.92,1834.71,242784.00,966.92,34138.36,,Hospital CPT 27550,HC Clsd Tx Knee Disl WO Anesth,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,873.00,873.00,523.80,523.80,N/A,122.22,N/A,452.34,N/A,502.67,N/A,296.82,N/A,873.00,N/A,122.22,N/A,452.34,N/A,452.34,N/A,873.00,N/A,873.00,N/A,873.00,N/A,873.00,N/A,502.67,N/A,452.34,N/A,122.22,N/A,873.00,N/A,873.00,N/A,122.22,N/A,452.34,N/A,452.34,N/A,497.57,523.80,523.80,122.22,873.00,,Hospital 27590,Amputation Thigh Through Femur Any Level,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,321889.82,23931.37,193133.89,14358.82,N/A,3328.53,N/A,951.73,N/A,13744.99,N/A,8136.67,N/A,24141.42,N/A,3328.53,N/A,1105.19,N/A,1105.19,N/A,24061.90,N/A,24141.42,N/A,24141.42,N/A,24141.42,N/A,13745.02,N/A,1105.19,N/A,3328.53,N/A,11660.00,N/A,11660.00,N/A,3328.53,N/A,1105.19,N/A,951.73,N/A,1046.91,193133.89,193133.89,951.73,24141.42,,Hospital 27601,Dcmprn Fasct Leg Post Compartment Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18516.00,N/A,11109.60,N/A,2594.13,N/A,2792.70,N/A,10659.75,N/A,6295.45,N/A,6525.42,N/A,2594.13,N/A,2688.04,N/A,2688.04,N/A,4062.20,N/A,6525.42,N/A,6525.42,N/A,6525.42,N/A,10659.76,N/A,2688.04,N/A,2594.13,N/A,3397.00,N/A,3397.00,N/A,2594.13,N/A,2688.04,N/A,2792.70,N/A,478.35,N/A,N/A,478.35,11109.60,,Hospital 27602,Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12236.20,N/A,7341.72,N/A,1662.79,N/A,2674.29,N/A,7044.01,N/A,4160.31,N/A,6518.32,N/A,1662.79,N/A,2688.04,N/A,2688.04,N/A,4057.77,N/A,6518.32,N/A,6518.32,N/A,6518.32,N/A,7044.01,N/A,2688.04,N/A,1662.79,N/A,4562.00,N/A,4562.00,N/A,1662.79,N/A,2688.04,N/A,2674.29,N/A,662.17,N/A,N/A,662.17,7341.72,,Hospital 27603,Incision & Drainage Leg/Ankle Abscess/Hematoma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16192.47,N/A,9715.48,N/A,2240.66,N/A,2358.04,N/A,9321.57,N/A,5505.44,N/A,5684.20,N/A,2240.66,N/A,2332.78,N/A,2332.78,N/A,3538.53,N/A,5684.20,N/A,5684.20,N/A,5684.20,N/A,9291.35,N/A,2332.78,N/A,2240.66,N/A,3397.00,N/A,3397.00,N/A,2240.66,N/A,2332.78,N/A,2358.04,N/A,538.88,N/A,N/A,538.88,9715.48,,Hospital 27606,Tenotomy Prq Achilles Tendon Spx General Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72319.18,N/A,43391.51,N/A,10114.59,N/A,12060.69,N/A,41395.56,N/A,24588.53,N/A,29238.43,N/A,10114.59,N/A,11933.08,N/A,11933.08,N/A,18397.49,N/A,29238.43,N/A,29238.43,N/A,29238.43,N/A,39894.54,N/A,11956.02,N/A,10114.59,N/A,9953.25,N/A,9953.25,N/A,10114.59,N/A,11933.08,N/A,12060.69,N/A,1921.65,N/A,N/A,1921.65,43391.51,,Hospital 27610,Arthrotomy Ankle W/Expl Drainage/Removal FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35859.22,N/A,21515.53,N/A,4933.04,N/A,2811.81,N/A,20472.00,N/A,12192.14,N/A,6521.59,N/A,4933.04,N/A,2688.04,N/A,2688.04,N/A,4059.81,N/A,6521.59,N/A,6521.59,N/A,6521.59,N/A,20472.00,N/A,2688.04,N/A,4933.04,N/A,5497.50,N/A,5497.50,N/A,4933.04,N/A,2688.04,N/A,2811.81,N/A,1413.02,N/A,N/A,1413.02,21515.53,,Hospital 27612,Arthrt Pst Capsul Rls Ankle W/WO Achll Tdn Lngth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,106640.75,N/A,63984.45,N/A,14929.70,N/A,6354.28,N/A,61097.33,N/A,36257.84,N/A,14494.14,N/A,14929.70,N/A,8158.19,N/A,8158.19,N/A,9022.87,N/A,14494.14,N/A,14494.14,N/A,14494.14,N/A,61097.34,N/A,8158.19,N/A,14929.70,N/A,7983.50,N/A,7983.50,N/A,14929.70,N/A,8158.19,N/A,6354.28,N/A,2463.38,N/A,N/A,2463.38,63984.45,,Hospital 27614,Biopsy Soft Tissue Leg/Ankle Area Deep,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22891.80,N/A,13735.08,N/A,3196.84,N/A,2440.19,N/A,13073.98,N/A,7783.21,N/A,5721.35,N/A,3196.84,N/A,2332.78,N/A,2332.78,N/A,3561.65,N/A,5721.35,N/A,5721.35,N/A,5721.35,N/A,13042.32,N/A,2332.78,N/A,3196.84,N/A,3397.00,N/A,3397.00,N/A,3196.84,N/A,2332.78,N/A,2440.19,N/A,473.55,N/A,N/A,473.55,13735.08,,Hospital 27616,Rad Resection Tumor Soft Tissue Leg/Ankle 5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29500.67,N/A,17700.40,N/A,4120.31,N/A,2981.38,N/A,16966.00,N/A,10030.23,N/A,7844.93,N/A,4120.31,N/A,3104.47,N/A,3104.47,N/A,5121.72,N/A,7844.93,N/A,7844.93,N/A,7844.93,N/A,16966.01,N/A,3104.47,N/A,4120.31,N/A,7692.25,N/A,7692.25,N/A,4120.31,N/A,3104.47,N/A,3789.66,N/A,4168.64,N/A,N/A,2981.38,17700.40,,Hospital 27618,Exc Tumor Soft Tissue Leg/Ankle Subq <3cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18770.90,N/A,11262.54,N/A,2622.26,N/A,1382.32,N/A,10805.80,N/A,6382.11,N/A,3294.96,N/A,2622.26,N/A,1354.15,N/A,1354.15,N/A,2051.18,N/A,3294.96,N/A,3294.96,N/A,3294.96,N/A,10805.80,N/A,1354.15,N/A,2622.26,N/A,1871.00,N/A,1871.00,N/A,2622.26,N/A,1354.15,N/A,1382.32,N/A,358.45,N/A,N/A,358.45,11262.54,,Hospital 27619,Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22309.18,N/A,13385.51,N/A,3113.20,N/A,11722.66,N/A,12802.04,N/A,7585.13,N/A,22309.18,N/A,3113.20,N/A,11782.94,N/A,11782.94,N/A,17792.45,N/A,22309.18,N/A,22309.18,N/A,22309.18,N/A,12802.04,N/A,11782.94,N/A,3113.20,N/A,10063.25,N/A,10063.25,N/A,3113.20,N/A,11782.94,N/A,11722.66,N/A,1987.99,N/A,N/A,1987.99,22309.18,,Hospital 27635,Excision/Curettage Bone Cyst/Tumor Tibia/Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42666.40,N/A,25599.84,N/A,5973.29,N/A,2811.81,N/A,24391.59,N/A,14506.58,N/A,6524.90,N/A,5973.29,N/A,2688.04,N/A,2688.04,N/A,4061.88,N/A,6524.90,N/A,6524.90,N/A,6524.90,N/A,24391.60,N/A,2688.04,N/A,5973.29,N/A,6843.00,N/A,6843.00,N/A,5973.29,N/A,2688.04,N/A,2811.81,N/A,1197.88,N/A,N/A,1197.88,25599.84,,Hospital 27647,Radical Resection of Tumor Talus or Calcaneus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24763.05,N/A,14857.83,N/A,3428.36,N/A,2664.83,N/A,14255.10,N/A,8419.43,N/A,6530.34,N/A,3428.36,N/A,2688.04,N/A,2688.04,N/A,4065.26,N/A,6530.34,N/A,6530.34,N/A,6530.34,N/A,14229.19,N/A,2688.04,N/A,3428.36,N/A,7692.25,N/A,7692.25,N/A,3428.36,N/A,2688.04,N/A,2664.83,N/A,2664.67,N/A,N/A,2664.67,14857.83,,Hospital CPT 27650,Repair Primary Open/Prq Ruptured Achilles Tendon,N/A,N/A,1308.00,1308.00,784.80,784.80,N/A,183.12,N/A,627.58,N/A,1308.00,N/A,444.72,N/A,1308.00,N/A,183.12,N/A,627.58,N/A,627.58,N/A,1165.99,N/A,1308.00,N/A,1308.00,N/A,1308.00,N/A,1308.00,N/A,627.58,N/A,183.12,N/A,1308.00,N/A,1308.00,N/A,183.12,N/A,627.58,N/A,627.58,N/A,690.34,784.80,784.80,183.12,1308.00,,Hospital 27654,Repair Secondary Achilles Tendon W/WO Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,43530.40,47536.65,26118.24,28521.99,13380.30,6643.76,16093.85,2331.45,N/A,27121.98,14800.34,16147.16,30442.02,14524.49,N/A,6643.76,2810.00,5973.28,2810.00,5973.28,18949.45,9041.78,30442.02,14524.49,30442.02,14524.49,30442.02,14524.49,30962.92,27122.00,16093.85,5973.28,N/A,6643.76,36218.41,10085.00,36218.41,10085.00,N/A,6643.76,16093.85,5973.28,16093.85,2331.45,14758.05,2564.61,2810.00,36218.41,2331.45,28521.99,,Hospital CPT 27656,Repair Fascial Defect Leg,N/A,N/A,1063.00,1063.00,637.80,637.80,N/A,148.82,N/A,334.87,N/A,1063.00,N/A,361.42,N/A,1063.00,N/A,148.82,N/A,334.87,N/A,334.87,N/A,930.52,N/A,1063.00,N/A,1063.00,N/A,1063.00,N/A,1063.00,N/A,334.87,N/A,148.82,N/A,1063.00,N/A,1063.00,N/A,148.82,N/A,334.87,N/A,334.87,N/A,368.36,637.80,637.80,148.82,1063.00,,Hospital 27659,Rpr Flexor Tendon Leg Secondary W/O Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47113.23,N/A,28267.94,N/A,6595.63,N/A,5973.28,N/A,26838.82,N/A,16018.50,N/A,14525.29,N/A,6595.63,N/A,5973.28,N/A,5973.28,N/A,9042.26,N/A,14525.29,N/A,14525.29,N/A,14525.29,N/A,26838.82,N/A,5973.28,N/A,6595.63,N/A,4112.50,N/A,4112.50,N/A,6595.63,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,4112.50,28267.94,,Hospital 27665,Rpr Extensor Tendon Leg Secondry W/WO Graft Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36313.92,N/A,21788.35,N/A,5083.31,N/A,6589.23,N/A,20830.25,N/A,12346.74,N/A,28950.02,N/A,5083.31,N/A,5973.28,N/A,5973.28,N/A,18021.94,N/A,28950.02,N/A,28950.02,N/A,28950.02,N/A,20830.26,N/A,5973.28,N/A,5083.31,N/A,8601.75,N/A,8601.75,N/A,5083.31,N/A,5973.28,N/A,1231.39,N/A,1354.53,N/A,N/A,1231.39,28950.02,,Hospital 27675,Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50773.38,N/A,30464.03,N/A,7108.27,N/A,5921.68,N/A,28855.08,N/A,17262.96,N/A,14464.90,N/A,7108.27,N/A,5973.28,N/A,5973.28,N/A,9004.67,N/A,14464.90,N/A,14464.90,N/A,14464.90,N/A,28855.07,N/A,5973.28,N/A,7108.27,N/A,6260.50,N/A,6260.50,N/A,7108.27,N/A,5973.28,N/A,5921.68,N/A,1193.71,N/A,N/A,1193.71,30464.03,,Hospital 27676,Repair Dislocating Peroneal Tendon W/Fib Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35435.22,N/A,21261.13,N/A,4960.93,N/A,2176.21,N/A,20175.23,N/A,12047.74,N/A,14486.14,N/A,4960.93,N/A,5973.28,N/A,5973.28,N/A,9017.89,N/A,14486.14,N/A,14486.14,N/A,14486.14,N/A,20175.24,N/A,5973.28,N/A,4960.93,N/A,7983.50,N/A,7983.50,N/A,4960.93,N/A,5973.28,N/A,2176.21,N/A,2393.84,N/A,N/A,2176.21,21261.13,,Hospital 27681,Tnols Flxr/Xtnsr Tdn Leg&/Ankle Mlt Tdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30336.20,N/A,18201.72,N/A,4247.07,N/A,2780.20,N/A,17459.25,N/A,10314.32,N/A,6556.66,N/A,4247.07,N/A,2688.04,N/A,2688.04,N/A,4081.64,N/A,6556.66,N/A,6556.66,N/A,6556.66,N/A,17459.25,N/A,2688.04,N/A,4247.07,N/A,6618.25,N/A,6618.25,N/A,4247.07,N/A,2688.04,N/A,2780.20,N/A,1027.45,N/A,N/A,1027.45,18201.72,,Hospital 27690,Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Supfc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52602.42,N/A,31561.45,N/A,7364.34,N/A,2210.83,N/A,29956.77,N/A,17884.57,N/A,14496.92,N/A,7364.34,N/A,5973.28,N/A,5973.28,N/A,9024.59,N/A,14496.92,N/A,14496.92,N/A,14496.92,N/A,29956.78,N/A,5973.28,N/A,7364.34,N/A,9384.50,N/A,9384.50,N/A,7364.34,N/A,5973.28,N/A,2210.83,N/A,2431.93,N/A,N/A,2210.83,31561.45,,Hospital 27691,Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,228062.85,52238.43,136837.71,31343.06,24866.80,7307.72,24087.43,2348.38,125708.24,29703.72,77541.37,17761.07,79411.48,28570.46,21340.51,7307.72,121392.00,11782.94,121392.00,11782.94,49444.03,17785.67,79411.48,28570.46,79411.48,28570.46,79411.48,28570.46,125708.24,29703.73,24057.78,11782.94,21340.51,7307.72,136752.46,13336.25,136752.46,13336.25,17786.63,7307.72,24057.78,11782.94,24087.43,2348.38,22834.35,2583.23,17786.63,136837.71,2348.38,31343.06,,Hospital 27702,Arthroplasty Ankle W/Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,228062.85,127443.93,136837.71,76466.36,24866.80,17830.77,24087.43,20684.94,125708.24,72533.49,77541.37,43330.94,79411.48,47922.40,21340.51,17830.77,121392.00,19774.44,121392.00,19774.44,49444.03,29832.62,79411.48,47922.40,79411.48,47922.40,79411.48,47922.40,125708.24,72533.51,24057.78,19774.44,21340.51,17830.77,136752.46,10535.75,136752.46,10535.75,17786.63,17830.77,24057.78,19774.44,24087.43,20684.94,22834.35,1663.30,17786.63,136837.71,1663.30,76466.36,,Hospital 27703,Arthroplasty Ankle Revision Total Ankle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,127473.93,107400.65,76484.36,64440.39,17238.29,15022.07,2805.07,1972.89,70263.63,61289.42,43341.14,36516.20,39219.50,30670.17,17769.43,15022.07,65192.00,1932.69,65192.00,1932.69,24413.23,19092.77,39219.50,30670.17,39219.50,30670.17,39219.50,30670.17,70263.63,61226.08,20657.66,1932.69,17769.43,15022.07,46661.42,8970.25,46661.42,8970.25,203.68,15022.07,20657.66,1932.69,20776.26,1972.89,19013.30,1325.72,203.68,76484.36,1325.72,64440.39,,Hospital 27704,Removal Ankle Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17560.60,N/A,10536.36,N/A,2386.76,N/A,2674.29,N/A,10107.18,N/A,5970.60,N/A,6568.10,N/A,2386.76,N/A,2688.04,N/A,2688.04,N/A,4088.78,N/A,6568.10,N/A,6568.10,N/A,6568.10,N/A,10107.18,N/A,2688.04,N/A,2386.76,N/A,4562.00,N/A,4562.00,N/A,2386.76,N/A,2688.04,N/A,2674.29,N/A,709.52,N/A,N/A,709.52,10536.36,,Hospital 27705,Osteotomy Tibia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,78938.13,N/A,47362.88,N/A,11051.34,N/A,6248.31,N/A,45278.17,N/A,26837.27,N/A,14516.92,N/A,11051.34,N/A,5973.28,N/A,5973.28,N/A,9046.49,N/A,14516.92,N/A,14516.92,N/A,14516.92,N/A,45278.18,N/A,5973.28,N/A,11051.34,N/A,11236.25,N/A,11236.25,N/A,11051.34,N/A,5973.28,N/A,6248.31,N/A,1624.91,N/A,N/A,1624.91,47362.88,,Hospital 27715,Osteoplasty Tibia & Fibula Lengthening/Shortenin,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,105569.67,N/A,63341.80,N/A,14770.88,N/A,7514.15,N/A,60354.97,N/A,35893.68,N/A,31921.29,N/A,14770.88,N/A,7506.36,N/A,7506.36,N/A,19937.73,N/A,31921.29,N/A,31921.29,N/A,31921.29,N/A,60355.00,N/A,7506.36,N/A,14770.88,N/A,8612.50,N/A,8612.50,N/A,14770.88,N/A,7506.36,N/A,7514.15,N/A,1206.02,N/A,N/A,1206.02,63341.80,,Hospital 27724,Rpr Non/Mal Tibia W/Iliac/Oth Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28827.92,N/A,17296.75,N/A,4035.91,N/A,1281.42,N/A,16576.05,N/A,9801.49,N/A,14707.17,N/A,4035.91,N/A,1277.81,N/A,1277.81,N/A,9155.49,N/A,14707.17,N/A,14707.17,N/A,14707.17,N/A,16576.05,N/A,1277.81,N/A,4035.91,N/A,7897.00,N/A,7897.00,N/A,4035.91,N/A,1277.81,N/A,1281.42,N/A,1343.42,N/A,N/A,1277.81,17296.75,,Hospital 27750,HC Treat Tibia Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,1059.00,N/A,635.40,N/A,148.26,N/A,444.30,N/A,609.77,N/A,360.06,N/A,N/A,N/A,148.26,N/A,419.26,N/A,419.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,609.77,N/A,419.26,N/A,148.26,N/A,567.63,N/A,567.63,N/A,148.26,N/A,419.26,N/A,444.30,N/A,396.66,N/A,N/A,148.26,635.40,,Hospital 27758,Optx Tibial Shft Fx W/Plate/Screws W/WO Cerclage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,68024.80,54239.43,40814.88,32543.66,10076.03,7585.50,12214.73,12325.48,32730.55,31195.51,23128.43,18441.41,22924.37,28643.15,10386.49,7585.50,12185.08,11782.94,12185.08,11782.94,14269.88,17859.13,22924.37,28643.15,22924.37,28643.15,22924.37,28643.15,32730.55,31192.64,12185.08,11782.94,10386.49,7585.50,27274.27,8970.25,27274.27,8970.25,2823.45,7585.50,12185.08,11782.94,12214.73,12325.48,11113.55,1163.19,2823.45,40814.88,1163.19,32543.66,,Hospital 27759,Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,113127.02,66518.22,67876.21,39910.93,10076.03,9312.54,11417.58,12325.48,62355.61,38044.88,38463.18,22616.19,22474.08,28575.51,10386.49,9312.54,247280.00,11782.94,247280.00,11782.94,13989.59,17788.81,22474.08,28575.51,22474.08,28575.51,22474.08,28575.51,62355.61,38044.88,11387.93,11782.94,10386.49,9312.54,26738.55,7897.00,26738.55,7897.00,3464.92,9312.54,11387.93,11782.94,11417.58,12325.48,11113.55,1070.30,3464.92,247280.00,1070.30,39910.93,,Hospital CPT 27768,HC Cltx Post Ankle Fx W/Mnpj,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3839.00,3839.00,2303.40,2303.40,N/A,537.46,N/A,424.75,N/A,2210.50,N/A,1305.26,N/A,1278.39,N/A,537.46,N/A,424.75,N/A,424.75,N/A,795.80,N/A,1278.39,N/A,1278.39,N/A,1278.39,N/A,2210.50,N/A,424.75,N/A,537.46,N/A,3839.00,N/A,3839.00,N/A,537.46,N/A,424.75,N/A,424.75,N/A,467.23,2303.40,2303.40,424.75,3839.00,,Hospital 27769,Open Treatment Posterior Malleolus Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36297.22,N/A,21778.33,N/A,5065.02,N/A,1950.60,N/A,20867.80,N/A,12341.06,N/A,14512.82,N/A,5065.02,N/A,5973.28,N/A,5973.28,N/A,9034.51,N/A,14512.82,N/A,14512.82,N/A,14512.82,N/A,20867.81,N/A,5973.28,N/A,5065.02,N/A,12986.00,N/A,12986.00,N/A,5065.02,N/A,5973.28,N/A,1950.60,N/A,2145.66,N/A,N/A,1950.60,21778.33,,Hospital CPT 27784,Open Treatment Proximal Fibula/Shaft Fracture,N/A,N/A,1422.00,1422.00,853.20,853.20,N/A,199.08,N/A,674.20,N/A,1422.00,N/A,483.48,N/A,1422.00,N/A,199.08,N/A,674.20,N/A,674.20,N/A,1260.21,N/A,1422.00,N/A,1422.00,N/A,1422.00,N/A,1422.00,N/A,674.20,N/A,199.08,N/A,1422.00,N/A,1422.00,N/A,199.08,N/A,674.20,N/A,674.20,N/A,741.62,853.20,853.20,199.08,1422.00,,Hospital CPT 27788,HC ED Clsd Tx Distal Fib Fx Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,704.00,704.00,422.40,422.40,N/A,98.56,N/A,367.37,N/A,405.36,N/A,239.36,N/A,704.00,N/A,98.56,N/A,367.37,N/A,367.37,N/A,704.00,N/A,704.00,N/A,704.00,N/A,704.00,N/A,405.36,N/A,367.37,N/A,98.56,N/A,704.00,N/A,704.00,N/A,98.56,N/A,367.37,N/A,367.37,N/A,404.11,422.40,422.40,98.56,704.00,,Hospital CPT 27810,HC Clsd Tx Bimall Fx W Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1547.00,1547.00,928.20,928.20,N/A,216.58,N/A,406.61,N/A,890.76,N/A,525.98,N/A,1357.92,N/A,216.58,N/A,406.61,N/A,406.61,N/A,845.31,N/A,1357.92,N/A,1357.92,N/A,1357.92,N/A,890.76,N/A,406.61,N/A,216.58,N/A,1547.00,N/A,1547.00,N/A,216.58,N/A,406.61,N/A,406.61,N/A,447.27,928.20,928.20,216.58,1547.00,,Hospital CPT 27818,HC Clsd Tx Trimall Fx W Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1547.00,1547.00,928.20,928.20,N/A,216.58,N/A,418.42,N/A,890.76,N/A,525.98,N/A,1410.60,N/A,216.58,N/A,418.42,N/A,418.42,N/A,878.10,N/A,1410.60,N/A,1410.60,N/A,1410.60,N/A,890.76,N/A,418.42,N/A,216.58,N/A,1547.00,N/A,1547.00,N/A,216.58,N/A,418.42,N/A,418.42,N/A,460.26,928.20,928.20,216.58,1547.00,,Hospital CPT 27825,HC Treat Lower Leg Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3823.00,3823.00,2293.80,2293.80,N/A,535.22,N/A,469.86,N/A,2201.28,N/A,1299.82,N/A,1561.02,N/A,535.22,N/A,469.86,N/A,469.86,N/A,971.73,N/A,1561.02,N/A,1561.02,N/A,1561.02,N/A,2201.28,N/A,469.86,N/A,535.22,N/A,3823.00,N/A,3823.00,N/A,535.22,N/A,469.86,N/A,469.86,N/A,516.85,2293.80,2293.80,469.86,3823.00,,Hospital 27828,Open Treatment Fracture Distal Tibia & Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50362.20,N/A,30217.32,N/A,7048.33,N/A,11722.66,N/A,28826.04,N/A,17123.16,N/A,28573.10,N/A,7048.33,N/A,11782.94,N/A,11782.94,N/A,17787.31,N/A,28573.10,N/A,28573.10,N/A,28573.10,N/A,28826.04,N/A,11782.94,N/A,7048.33,N/A,8612.50,N/A,8612.50,N/A,7048.33,N/A,11782.94,N/A,11722.66,N/A,1491.79,N/A,N/A,1491.79,30217.32,,Hospital 27846,Optx Ankle Dislocation W/O Repair/Internal Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,231901.73,N/A,139141.04,N/A,32466.25,N/A,17657.86,N/A,131705.11,N/A,78846.57,N/A,28578.87,N/A,32466.25,N/A,17590.04,N/A,17590.04,N/A,17790.91,N/A,28578.87,N/A,28578.87,N/A,28578.87,N/A,131705.11,N/A,17590.04,N/A,32466.25,N/A,13819.75,N/A,13819.75,N/A,32466.25,N/A,17456.46,N/A,17657.86,N/A,3998.67,N/A,N/A,3998.67,139141.04,,Hospital 27848,Optx Ankle Dislocation W/Repair/Int/Xtrnl Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33262.73,N/A,19957.64,N/A,4656.78,N/A,6248.31,N/A,19078.79,N/A,11309.33,N/A,14486.45,N/A,4656.78,N/A,5973.28,N/A,5973.28,N/A,9018.08,N/A,14486.45,N/A,14486.45,N/A,14486.45,N/A,19078.79,N/A,5973.28,N/A,4656.78,N/A,11845.50,N/A,11845.50,N/A,4656.78,N/A,5973.28,N/A,6248.31,N/A,1597.52,N/A,N/A,1597.52,19957.64,,Hospital 27860,Manipulation Ankle Under General Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18009.30,N/A,10805.58,N/A,2521.31,N/A,2848.60,N/A,10359.52,N/A,6123.17,N/A,6621.75,N/A,2521.31,N/A,2688.04,N/A,2688.04,N/A,4122.05,N/A,6621.75,N/A,6621.75,N/A,6621.75,N/A,10359.52,N/A,2688.04,N/A,2521.31,N/A,1871.00,N/A,1871.00,N/A,2521.31,N/A,2688.04,N/A,2848.60,N/A,190.63,N/A,N/A,190.63,10805.58,,Hospital 27880,Amputation Leg Through Tibia&Fibula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60121.63,N/A,36072.98,N/A,N/A,N/A,1918.46,N/A,34595.74,N/A,9788.75,N/A,9788.75,N/A,7801.18,N/A,3950.03,N/A,1936.16,N/A,9788.75,N/A,9788.75,N/A,9788.75,N/A,9788.75,N/A,33811.48,N/A,3950.03,N/A,7801.18,N/A,11660.00,N/A,11660.00,N/A,7801.18,N/A,3950.03,N/A,3950.03,N/A,2377.94,N/A,N/A,1918.46,36072.98,,Hospital 28003,I&D Below Fascia Foot Multiple Areas,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,74194.70,33996.73,44516.82,20398.04,24434.70,4759.53,28189.47,2811.81,56284.86,19300.18,N/A,11558.88,N/A,6533.37,25187.57,4759.53,28041.22,2688.04,28041.22,2688.04,34862.55,4067.15,N/A,6533.37,56006.19,6533.37,N/A,6533.37,56284.86,19300.18,N/A,2688.04,25187.57,4759.53,66633.38,4464.25,7227.50,4464.25,N/A,4759.53,28041.22,2688.04,28189.47,2811.81,26950.70,655.66,7227.50,66633.38,655.66,20398.04,,Hospital 28008,Fasciotomy Foot&/Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26584.20,N/A,15950.52,N/A,3721.79,N/A,2792.70,N/A,15305.29,N/A,9038.63,N/A,6570.18,N/A,3721.79,N/A,2688.04,N/A,2688.04,N/A,4090.07,N/A,6570.18,N/A,6570.18,N/A,6570.18,N/A,15305.30,N/A,2688.04,N/A,3721.79,N/A,5453.25,N/A,5453.25,N/A,3721.79,N/A,2688.04,N/A,2792.70,N/A,736.53,N/A,N/A,736.53,15950.52,,Hospital CPT 28010,HC Tenotomy Toe Single Tend Perc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3839.00,3839.00,2303.40,2303.40,N/A,537.46,N/A,195.94,N/A,2210.50,N/A,1305.26,N/A,655.98,N/A,537.46,N/A,195.94,N/A,195.94,N/A,408.35,N/A,655.98,N/A,655.98,N/A,655.98,N/A,2210.50,N/A,195.94,N/A,537.46,N/A,3839.00,N/A,3839.00,N/A,537.46,N/A,195.94,N/A,195.94,N/A,215.53,2303.40,2303.40,195.94,3839.00,,Hospital 28022,Arthrt W/Expl Drg/Rmvl Loose/FB Mttarphlngl Jt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,118603.33,N/A,71162.00,N/A,16628.94,N/A,21037.60,N/A,67283.62,N/A,40302.03,N/A,48298.19,N/A,16628.94,N/A,19856.45,N/A,19856.45,N/A,30176.97,N/A,48298.19,N/A,48298.19,N/A,48298.19,N/A,66842.01,N/A,19871.95,N/A,16628.94,N/A,11027.25,N/A,11027.25,N/A,16628.94,N/A,19856.45,N/A,21037.60,N/A,2340.83,N/A,N/A,2340.83,71162.00,,Hospital CPT 28024,HC Exploration of Toe Joint,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3988.00,3988.00,2392.80,2392.80,N/A,558.32,N/A,288.42,N/A,2296.29,N/A,1355.92,N/A,1270.56,N/A,558.32,N/A,288.42,N/A,288.42,N/A,790.92,N/A,1270.56,N/A,1270.56,N/A,1270.56,N/A,2296.29,N/A,288.42,N/A,558.32,N/A,3988.00,N/A,3988.00,N/A,558.32,N/A,288.42,N/A,288.42,N/A,317.26,2392.80,2392.80,288.42,3988.00,,Hospital 28035,Release Tarsal Tunnel,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32714.00,N/A,19628.40,N/A,4565.48,N/A,1697.97,N/A,18640.17,N/A,11122.76,N/A,3955.58,N/A,4565.48,N/A,1623.23,N/A,1623.23,N/A,2462.43,N/A,3955.58,N/A,3955.58,N/A,3955.58,N/A,18608.50,N/A,1623.23,N/A,4565.48,N/A,3397.00,N/A,3397.00,N/A,4565.48,N/A,1623.23,N/A,1697.97,N/A,395.06,N/A,N/A,395.06,19628.40,,Hospital 28041,Exc Tumor Soft Tissue Foot/Toe Subfasc 1.5 Cm/>,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13989.90,N/A,8393.94,N/A,1958.58,N/A,2440.19,N/A,8052.65,N/A,4756.56,N/A,5700.52,N/A,1958.58,N/A,2332.78,N/A,2332.78,N/A,3548.68,N/A,5700.52,N/A,5700.52,N/A,5700.52,N/A,8052.65,N/A,2332.78,N/A,1958.58,N/A,3397.00,N/A,3397.00,N/A,1958.58,N/A,2332.78,N/A,2440.19,N/A,501.94,N/A,N/A,501.94,8393.94,,Hospital 28050,Arthrt W/Bx Intertarsal/Tarsometatarsal Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,151358.27,N/A,90814.96,N/A,21062.98,N/A,12190.84,N/A,87053.32,N/A,51461.80,N/A,28998.34,N/A,21062.98,N/A,11991.19,N/A,11991.19,N/A,18052.03,N/A,28998.34,N/A,28998.34,N/A,28998.34,N/A,87053.32,N/A,11991.19,N/A,21062.98,N/A,7983.50,N/A,7983.50,N/A,21062.98,N/A,11991.19,N/A,12190.84,N/A,3271.39,N/A,N/A,3271.39,90814.96,,Hospital 28054,Arthrtomy W/Bx Interphalangeal Joint,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10022.90,N/A,6013.74,N/A,1366.09,N/A,2664.83,N/A,5769.20,N/A,3407.78,N/A,6520.09,N/A,1366.09,N/A,2688.04,N/A,2688.04,N/A,4058.88,N/A,6520.09,N/A,6520.09,N/A,6520.09,N/A,5769.20,N/A,2688.04,N/A,1366.09,N/A,5095.50,N/A,5095.50,N/A,1366.09,N/A,2688.04,N/A,2664.83,N/A,1265.82,N/A,N/A,1265.82,6520.09,,Hospital 28080,Excision Interdigital Morton Neuroma Single Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24169.62,N/A,14501.77,N/A,3373.88,N/A,518.62,N/A,13871.41,N/A,8217.67,N/A,4073.18,N/A,3373.88,N/A,1295.43,N/A,1295.43,N/A,2535.62,N/A,4073.18,N/A,4073.18,N/A,4073.18,N/A,13871.41,N/A,1295.43,N/A,3373.88,N/A,4112.50,N/A,4112.50,N/A,3373.88,N/A,1295.43,N/A,518.62,N/A,570.49,N/A,N/A,518.62,14501.77,,Hospital 28103,Exc/Curettage Cyst/Tumor Talus/Calcaneus Algrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61019.23,N/A,36611.54,N/A,8537.02,N/A,1726.63,N/A,34783.32,N/A,20746.27,N/A,14490.85,N/A,8537.02,N/A,5973.28,N/A,5973.28,N/A,9020.82,N/A,14490.85,N/A,14490.85,N/A,14490.85,N/A,34783.34,N/A,5973.28,N/A,8537.02,N/A,12986.00,N/A,12986.00,N/A,8537.02,N/A,5973.28,N/A,1726.63,N/A,1899.30,N/A,N/A,1726.63,36611.54,,Hospital 28104,Exc/Curtg Bone Cyst/B9 Tumortarsal/Metatarsal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29080.17,N/A,17448.10,N/A,4071.23,N/A,2811.81,N/A,16672.04,N/A,9887.25,N/A,6522.93,N/A,4071.23,N/A,2688.04,N/A,2688.04,N/A,4060.65,N/A,6522.93,N/A,6522.93,N/A,6522.93,N/A,16672.04,N/A,2688.04,N/A,4071.23,N/A,5944.75,N/A,5944.75,N/A,4071.23,N/A,2688.04,N/A,2811.81,N/A,1085.99,N/A,N/A,1085.99,17448.10,,Hospital 28108,Exc/Curtg Cst/B9 Tum Phalanges Foot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16111.30,N/A,9666.78,N/A,2255.57,N/A,2811.81,N/A,9275.44,N/A,5477.83,N/A,6520.34,N/A,2255.57,N/A,2688.04,N/A,2688.04,N/A,4059.04,N/A,6520.34,N/A,6520.34,N/A,6520.34,N/A,9275.45,N/A,2688.04,N/A,2255.57,N/A,5095.50,N/A,5095.50,N/A,2255.57,N/A,2688.04,N/A,2811.81,N/A,485.41,N/A,N/A,485.41,9666.78,,Hospital 28111,Ostectomy Complete 1st Metatarsal Head,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34807.93,N/A,20884.76,N/A,4873.12,N/A,2811.81,N/A,19932.64,N/A,11834.71,N/A,6519.87,N/A,4873.12,N/A,2688.04,N/A,2688.04,N/A,4058.74,N/A,6519.87,N/A,6519.87,N/A,6519.87,N/A,19932.65,N/A,2688.04,N/A,4873.12,N/A,4112.50,N/A,4112.50,N/A,4873.12,N/A,2688.04,N/A,2811.81,N/A,453.19,N/A,N/A,453.19,20884.76,,Hospital 28112,Ostectomy Complete Other Metatarsal Head 2/3/4,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18258.63,N/A,10955.18,N/A,2452.94,N/A,2965.23,N/A,10508.01,N/A,6207.94,N/A,6537.70,N/A,2452.94,N/A,2688.04,N/A,2688.04,N/A,4069.84,N/A,6537.70,N/A,6537.70,N/A,6537.70,N/A,10508.03,N/A,2688.04,N/A,2452.94,N/A,3397.00,N/A,3397.00,N/A,2452.94,N/A,2688.04,N/A,668.83,N/A,735.74,N/A,N/A,668.83,10955.18,,Hospital 28119,Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45235.15,N/A,27141.09,N/A,6332.92,N/A,5921.68,N/A,25732.12,N/A,15379.61,N/A,14495.45,N/A,6332.92,N/A,5973.28,N/A,5973.28,N/A,9023.71,N/A,14495.45,N/A,14495.45,N/A,14495.45,N/A,25732.13,N/A,5973.28,N/A,6332.92,N/A,7661.50,N/A,7661.50,N/A,6332.92,N/A,5973.28,N/A,5921.68,N/A,1196.87,N/A,N/A,1196.87,27141.09,,Hospital 28120,Partial Excision Bone Talus/Calcaneus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43437.17,N/A,26062.30,N/A,6081.20,N/A,6330.07,N/A,24823.80,N/A,14768.66,N/A,14471.17,N/A,6081.20,N/A,5973.28,N/A,5973.28,N/A,9008.58,N/A,14471.17,N/A,14471.17,N/A,14471.17,N/A,24823.81,N/A,5973.28,N/A,6081.20,N/A,9093.25,N/A,9093.25,N/A,6081.20,N/A,5973.28,N/A,6330.07,N/A,2253.70,N/A,N/A,2253.70,26062.30,,Hospital CPT 28122,Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus,N/A,N/A,1002.00,1002.00,601.20,601.20,N/A,140.28,N/A,416.62,N/A,1002.00,N/A,340.68,N/A,1002.00,N/A,140.28,N/A,416.62,N/A,416.62,N/A,1002.00,N/A,1002.00,N/A,1002.00,N/A,1002.00,N/A,1002.00,N/A,416.62,N/A,140.28,N/A,1002.00,N/A,1002.00,N/A,140.28,N/A,416.62,N/A,416.62,N/A,458.28,601.20,601.20,140.28,1002.00,,Hospital 28124,Partical Excision Bone Phalanx Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21158.87,N/A,12695.32,N/A,2961.33,N/A,655.39,N/A,12180.55,N/A,7194.02,N/A,6529.55,N/A,2961.33,N/A,2688.04,N/A,2688.04,N/A,4064.78,N/A,6529.55,N/A,6529.55,N/A,6529.55,N/A,12180.56,N/A,2688.04,N/A,2961.33,N/A,5095.50,N/A,5095.50,N/A,2961.33,N/A,2688.04,N/A,655.39,N/A,743.39,N/A,N/A,655.39,12695.32,,Hospital 28126,Resection Partial/Complete Phalangeal Base Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14270.02,N/A,8562.01,N/A,1995.04,N/A,608.26,N/A,8213.35,N/A,4851.81,N/A,6517.05,N/A,1995.04,N/A,2688.04,N/A,2688.04,N/A,4056.99,N/A,6517.05,N/A,6517.05,N/A,6517.05,N/A,8213.34,N/A,2688.04,N/A,1995.04,N/A,5095.50,N/A,5095.50,N/A,1995.04,N/A,2688.04,N/A,608.26,N/A,669.09,N/A,N/A,608.26,8562.01,,Hospital 28173,Radical Resection Tumor Metatarsal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41353.48,N/A,24812.09,N/A,5789.50,N/A,804.98,N/A,23791.45,N/A,14060.18,N/A,6600.99,N/A,5789.50,N/A,2688.04,N/A,2688.04,N/A,4109.24,N/A,6600.99,N/A,6600.99,N/A,6600.99,N/A,23791.46,N/A,2688.04,N/A,5789.50,N/A,4470.25,N/A,4470.25,N/A,5789.50,N/A,2688.04,N/A,804.98,N/A,885.48,N/A,N/A,804.98,24812.09,,Hospital CPT 28190,HC Removal FB Foot Subcutaneous,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2102.00,2102.00,1261.20,1261.20,N/A,294.28,N/A,613.03,N/A,1210.33,N/A,714.68,N/A,1417.60,N/A,294.28,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1210.33,N/A,586.05,N/A,294.28,N/A,2102.00,N/A,2102.00,N/A,294.28,N/A,586.05,N/A,613.03,N/A,138.38,1261.20,1261.20,138.38,2102.00,,Hospital 28193,Removal Foreign Body Foot Complicated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9926.10,N/A,5955.66,N/A,1389.65,N/A,1342.46,N/A,5714.09,N/A,3374.87,N/A,3288.80,N/A,1389.65,N/A,1354.15,N/A,1354.15,N/A,2047.34,N/A,3288.80,N/A,3288.80,N/A,3288.80,N/A,5714.09,N/A,1354.15,N/A,1389.65,N/A,1431.00,N/A,1431.00,N/A,1389.65,N/A,1354.15,N/A,1342.46,N/A,413.63,N/A,N/A,413.63,5955.66,,Hospital CPT 28200,Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon,N/A,N/A,816.00,816.00,489.60,489.60,N/A,114.24,N/A,310.88,N/A,816.00,N/A,277.44,N/A,816.00,N/A,114.24,N/A,310.88,N/A,310.88,N/A,816.00,N/A,816.00,N/A,816.00,N/A,816.00,N/A,816.00,N/A,310.88,N/A,114.24,N/A,816.00,N/A,816.00,N/A,114.24,N/A,310.88,N/A,310.88,N/A,341.97,489.60,489.60,114.24,816.00,,Hospital CPT 28208,HC Repair of Foot Tendon 1/2 Each,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7967.00,7967.00,4780.20,4780.20,N/A,1115.38,N/A,302.62,N/A,4587.40,N/A,2708.78,N/A,1346.73,N/A,1115.38,N/A,302.62,N/A,302.62,N/A,838.34,N/A,1346.73,N/A,1346.73,N/A,1346.73,N/A,4587.40,N/A,302.62,N/A,1115.38,N/A,7967.00,N/A,7967.00,N/A,1115.38,N/A,302.62,N/A,302.62,N/A,332.88,4780.20,4780.20,302.62,7967.00,,Hospital 28210,Rpr Tendon Xtnsr Foot Sec W/Free Graft Ea Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63371.63,N/A,38022.98,N/A,8872.03,N/A,6178.06,N/A,36234.71,N/A,21546.36,N/A,14888.11,N/A,8872.03,N/A,5973.28,N/A,5973.28,N/A,9267.68,N/A,14888.11,N/A,14888.11,N/A,14888.11,N/A,36234.71,N/A,5973.28,N/A,8872.03,N/A,9953.25,N/A,9953.25,N/A,8872.03,N/A,5973.28,N/A,6178.06,N/A,864.29,N/A,N/A,864.29,38022.98,,Hospital 28225,Tenolysis Extensor Foot Single Tendon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40312.80,N/A,24187.68,N/A,5643.81,N/A,2780.20,N/A,23139.82,N/A,13706.36,N/A,6980.82,N/A,5643.81,N/A,2688.04,N/A,2688.04,N/A,4345.69,N/A,6980.82,N/A,6980.82,N/A,6980.82,N/A,23139.81,N/A,2688.04,N/A,5643.81,N/A,5944.75,N/A,5944.75,N/A,5643.81,N/A,2688.04,N/A,2780.20,N/A,1268.53,N/A,N/A,1268.53,24187.68,,Hospital 28238,Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,98937.17,N/A,59362.30,N/A,13842.34,N/A,6248.31,N/A,56351.92,N/A,33636.96,N/A,14570.94,N/A,13842.34,N/A,5973.28,N/A,5973.28,N/A,9070.68,N/A,14570.94,N/A,14570.94,N/A,14570.94,N/A,56351.92,N/A,5973.28,N/A,13842.34,N/A,12203.25,N/A,12203.25,N/A,13842.34,N/A,5973.28,N/A,6248.31,N/A,1318.44,N/A,N/A,1318.44,59362.30,,Hospital 28240,Tenotomy Lengthening/Rls Abductor Hallucis Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,100400.40,N/A,60240.24,N/A,14056.05,N/A,6248.31,N/A,57150.51,N/A,34136.12,N/A,14527.05,N/A,14056.05,N/A,5973.28,N/A,5973.28,N/A,9043.36,N/A,14527.05,N/A,14527.05,N/A,14527.05,N/A,57150.52,N/A,5973.28,N/A,14056.05,N/A,10444.75,N/A,10444.75,N/A,14056.05,N/A,5973.28,N/A,6248.31,N/A,1377.37,N/A,N/A,1377.37,60240.24,,Hospital 28250,Division Plantar Fascia & Muscle Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71267.43,N/A,42760.46,N/A,9977.44,N/A,3453.39,N/A,40484.83,N/A,24230.91,N/A,28610.47,N/A,9977.44,N/A,11782.94,N/A,11782.94,N/A,17810.57,N/A,28610.47,N/A,28610.47,N/A,28610.47,N/A,40484.85,N/A,11782.94,N/A,9977.44,N/A,13336.25,N/A,13336.25,N/A,9977.44,N/A,11782.94,N/A,3453.39,N/A,3798.74,N/A,N/A,3453.39,42760.46,,Hospital 28261,Capsulotomy Midfoot W/Tendon Lengthening,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,133661.32,N/A,80196.79,N/A,18706.91,N/A,2299.60,N/A,75708.61,N/A,45444.85,N/A,47882.56,N/A,18706.91,N/A,19774.44,N/A,19774.44,N/A,29807.82,N/A,47882.56,N/A,47882.56,N/A,47882.56,N/A,75708.61,N/A,19774.44,N/A,18706.91,N/A,11027.25,N/A,11027.25,N/A,18706.91,N/A,19774.44,N/A,2299.60,N/A,2529.56,N/A,N/A,2299.60,80196.79,,Hospital CPT 28272,HC Capsulotomy Iphal Joint Each Joint Spx,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3922.00,3922.00,2353.20,2353.20,N/A,549.08,N/A,238.34,N/A,2258.29,N/A,1333.48,N/A,1057.83,N/A,549.08,N/A,238.34,N/A,238.34,N/A,658.50,N/A,1057.83,N/A,1057.83,N/A,1057.83,N/A,2258.29,N/A,238.34,N/A,549.08,N/A,3922.00,N/A,3922.00,N/A,549.08,N/A,238.34,N/A,238.34,N/A,262.17,2353.20,2353.20,238.34,3922.00,,Hospital 28280,Syndactylization Toes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23030.05,N/A,13818.03,N/A,3224.21,N/A,2780.20,N/A,13247.23,N/A,7830.22,N/A,6544.17,N/A,3224.21,N/A,2688.04,N/A,2688.04,N/A,4073.86,N/A,6544.17,N/A,6544.17,N/A,6544.17,N/A,13247.23,N/A,2688.04,N/A,3224.21,N/A,5095.50,N/A,5095.50,N/A,3224.21,N/A,2688.04,N/A,2780.20,N/A,764.29,N/A,N/A,764.29,13818.03,,Hospital 28295,Corrj Hallux Valgus W/Sesmdc W/Prox Metar Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38962.18,N/A,23377.31,N/A,5454.70,N/A,2780.20,N/A,22399.79,N/A,13247.14,N/A,6526.35,N/A,5454.70,N/A,2688.04,N/A,2688.04,N/A,4062.78,N/A,6526.35,N/A,6526.35,N/A,6526.35,N/A,22399.80,N/A,2688.04,N/A,5454.70,N/A,4562.00,N/A,4562.00,N/A,5454.70,N/A,2688.04,N/A,2780.20,N/A,643.02,N/A,N/A,643.02,23377.31,,Hospital CPT 28296,Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot,N/A,0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION,1492.00,1492.00,895.20,895.20,N/A,208.88,N/A,488.58,N/A,859.09,N/A,507.28,N/A,1492.00,N/A,208.88,N/A,488.58,N/A,488.58,N/A,1492.00,N/A,1492.00,N/A,1492.00,N/A,1492.00,N/A,859.09,N/A,488.58,N/A,208.88,N/A,1492.00,N/A,1492.00,N/A,208.88,N/A,488.58,N/A,488.58,N/A,537.44,895.20,895.20,208.88,1492.00,,Hospital 28297,Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,83593.93,N/A,50156.36,N/A,11703.17,N/A,11941.86,N/A,47414.01,N/A,28421.96,N/A,28570.46,N/A,11703.17,N/A,11782.94,N/A,11782.94,N/A,17785.67,N/A,28570.46,N/A,28570.46,N/A,28570.46,N/A,47414.02,N/A,11782.94,N/A,11703.17,N/A,7692.25,N/A,7692.25,N/A,11703.17,N/A,11782.94,N/A,1580.98,N/A,1739.07,N/A,N/A,1580.98,50156.36,,Hospital 28298,Corrj Hallux Valgus W/Sesmdc W/Prox Phlnx Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,57072.05,32258.97,34243.23,19355.38,N/A,4505.78,13515.98,3579.78,30276.31,18498.55,19404.49,10968.04,N/A,14516.74,11546.23,4505.78,6225.80,5973.28,2810.00,5973.28,15863.23,9036.96,25484.06,14516.74,25484.06,14516.74,25484.06,14516.74,30276.31,18498.55,13515.98,5973.28,11546.23,4505.78,30319.67,7109.75,30319.67,7109.75,11546.23,4505.78,13515.98,5973.28,13515.98,3579.78,N/A,3937.77,2810.00,34243.23,3579.78,19355.38,,Hospital 28299,Corrj Hallux Valgus W/Sesmdc W/2 Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52495.72,N/A,31497.43,N/A,7340.55,N/A,6248.31,N/A,29981.62,N/A,17848.54,N/A,14503.80,N/A,7340.55,N/A,5973.28,N/A,5973.28,N/A,9028.89,N/A,14503.80,N/A,14503.80,N/A,14503.80,N/A,29981.64,N/A,5973.28,N/A,7340.55,N/A,4825.50,N/A,4825.50,N/A,7340.55,N/A,5973.28,N/A,6248.31,N/A,651.36,N/A,N/A,651.36,31497.43,,Hospital 28300,Osteotomy Calcaneus W/WO Internal Fixation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64924.57,N/A,38954.74,N/A,9078.07,N/A,12325.48,N/A,37317.19,N/A,22074.37,N/A,28578.64,N/A,9078.07,N/A,11782.94,N/A,11782.94,N/A,17790.77,N/A,28578.64,N/A,28578.64,N/A,28578.64,N/A,37317.20,N/A,11782.94,N/A,9078.07,N/A,12019.00,N/A,12019.00,N/A,9078.07,N/A,11782.94,N/A,12325.48,N/A,2621.07,N/A,N/A,2621.07,38954.74,,Hospital 28304,Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61090.97,N/A,36654.58,N/A,8552.76,N/A,3057.35,N/A,34795.45,N/A,20770.94,N/A,28601.76,N/A,8552.76,N/A,11782.94,N/A,11782.94,N/A,17805.16,N/A,28601.76,N/A,28601.76,N/A,28601.76,N/A,34795.45,N/A,11782.94,N/A,8552.76,N/A,13336.25,N/A,13336.25,N/A,8552.76,N/A,11782.94,N/A,3057.35,N/A,3363.10,N/A,N/A,3057.35,36654.58,,Hospital 28305,Osteot Tarsal Oth/Thn Calcaneus/Talus W/Agrft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,185780.52,N/A,111468.31,N/A,26000.42,N/A,13692.79,N/A,105315.81,N/A,63165.40,N/A,14475.51,N/A,26000.42,N/A,13658.41,N/A,13658.41,N/A,9011.28,N/A,14475.51,N/A,14475.51,N/A,14475.51,N/A,105284.14,N/A,13658.41,N/A,26000.42,N/A,12986.00,N/A,12986.00,N/A,26000.42,N/A,13658.41,N/A,13692.79,N/A,2397.29,N/A,N/A,2397.29,111468.31,,Hospital 28306,Osteot W/WO Lngth Shrt/Corrj 1st Metar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71824.18,N/A,43094.51,N/A,10055.41,N/A,3435.61,N/A,40797.85,N/A,24419.97,N/A,28595.14,N/A,10055.41,N/A,11782.94,N/A,11782.94,N/A,17801.04,N/A,28595.14,N/A,28595.14,N/A,28595.14,N/A,40797.88,N/A,11782.94,N/A,10055.41,N/A,11318.50,N/A,11318.50,N/A,10055.41,N/A,11782.94,N/A,3435.61,N/A,3779.19,N/A,N/A,3435.61,43094.51,,Hospital 28309,Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46067.95,N/A,27640.77,N/A,6449.51,N/A,6248.31,N/A,26305.38,N/A,15663.11,N/A,14476.81,N/A,6449.51,N/A,5973.28,N/A,5973.28,N/A,9012.09,N/A,14476.81,N/A,14476.81,N/A,14476.81,N/A,26305.38,N/A,5973.28,N/A,6449.51,N/A,8832.50,N/A,8832.50,N/A,6449.51,N/A,5973.28,N/A,6248.31,N/A,1602.22,N/A,N/A,1602.22,27640.77,,Hospital 28312,Osteot Shrt Corrj Oth Phalanges Any Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26198.63,N/A,15719.18,N/A,3667.80,N/A,2420.71,N/A,15039.30,N/A,8819.57,N/A,14493.83,N/A,3667.80,N/A,5973.28,N/A,5973.28,N/A,9022.70,N/A,14493.83,N/A,14493.83,N/A,14493.83,N/A,15039.30,N/A,5973.28,N/A,3667.80,N/A,5944.75,N/A,5944.75,N/A,3667.80,N/A,5973.28,N/A,2420.71,N/A,2662.80,N/A,N/A,2420.71,15719.18,,Hospital 28320,Repair Nonunion/Malunion Tarsal Bones,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16387.08,N/A,9832.25,N/A,2294.19,N/A,648.20,N/A,9427.78,N/A,5571.61,N/A,16387.09,N/A,2294.19,N/A,11782.94,N/A,11782.94,N/A,16387.09,N/A,16387.09,N/A,16387.09,N/A,16387.09,N/A,9427.77,N/A,11782.94,N/A,2294.19,N/A,8612.50,N/A,8612.50,N/A,2294.19,N/A,11782.94,N/A,648.20,N/A,713.03,N/A,N/A,648.20,16387.09,,Hospital CPT 28405,HC Treat Heel Fx,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,736.00,736.00,441.60,441.60,N/A,103.04,N/A,335.38,N/A,423.79,N/A,250.24,N/A,736.00,N/A,103.04,N/A,335.38,N/A,335.38,N/A,736.00,N/A,736.00,N/A,736.00,N/A,736.00,N/A,423.79,N/A,335.38,N/A,103.04,N/A,736.00,N/A,736.00,N/A,103.04,N/A,335.38,N/A,335.38,N/A,368.92,441.60,441.60,103.04,736.00,,Hospital 28406,Prq Skeletal Fixj Calcaneal Fracture W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,128327.28,N/A,76996.37,N/A,17959.58,N/A,12475.62,N/A,73377.96,N/A,43631.26,N/A,29155.43,N/A,17959.58,N/A,11933.08,N/A,11933.08,N/A,18345.82,N/A,29155.43,N/A,29155.43,N/A,29155.43,N/A,72925.98,N/A,11956.02,N/A,17959.58,N/A,6728.25,N/A,6728.25,N/A,17959.58,N/A,11933.08,N/A,12475.62,N/A,2351.66,N/A,N/A,2351.66,76996.37,,Hospital 28415,Open Treatment Calcaneal Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67601.67,N/A,40561.00,N/A,9176.13,N/A,1248.25,N/A,38773.63,N/A,22984.56,N/A,14496.34,N/A,9176.13,N/A,5973.28,N/A,5973.28,N/A,9024.25,N/A,14496.34,N/A,14496.34,N/A,14496.34,N/A,38773.65,N/A,5973.28,N/A,9176.13,N/A,8612.50,N/A,8612.50,N/A,9176.13,N/A,5973.28,N/A,1248.25,N/A,1373.08,N/A,N/A,1248.25,40561.00,,Hospital 28445,Open Treatment Talus Fracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63180.45,N/A,37908.27,N/A,8845.27,N/A,6132.82,N/A,36227.44,N/A,21481.35,N/A,14495.31,N/A,8845.27,N/A,5973.28,N/A,5973.28,N/A,9023.60,N/A,14495.31,N/A,14495.31,N/A,14495.31,N/A,36227.44,N/A,5973.28,N/A,8845.27,N/A,12369.25,N/A,12369.25,N/A,8845.27,N/A,5973.28,N/A,6132.82,N/A,2659.53,N/A,N/A,2659.53,37908.27,,Hospital 28455,HC Treat Midfoot Fx Each,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,66989.53,N/A,40193.72,N/A,9378.53,N/A,6037.97,N/A,38479.34,N/A,22776.45,N/A,14550.66,N/A,9378.53,N/A,5973.28,N/A,5973.28,N/A,9058.05,N/A,14550.66,N/A,14550.66,N/A,14550.66,N/A,38479.35,N/A,5973.28,N/A,9378.53,N/A,11027.25,N/A,11027.25,N/A,9378.53,N/A,5973.28,N/A,6037.97,N/A,3221.14,N/A,N/A,3221.14,40193.72,,Hospital 28485,Open Treatment Metatarsal Fracture Each,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44459.57,N/A,26675.74,N/A,6224.32,N/A,5921.68,N/A,25304.94,N/A,15116.25,N/A,14470.08,N/A,6224.32,N/A,5973.28,N/A,5973.28,N/A,9007.89,N/A,14470.08,N/A,14470.08,N/A,14470.08,N/A,25304.93,N/A,5973.28,N/A,6224.32,N/A,11845.50,N/A,11845.50,N/A,6224.32,N/A,5973.28,N/A,5921.68,N/A,1172.72,N/A,N/A,1172.72,26675.74,,Hospital CPT 28495,HC Clsd Tx Fx Great Toe W Manip,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,633.00,633.00,379.80,379.80,N/A,88.62,N/A,139.95,N/A,364.48,N/A,215.22,N/A,500.88,N/A,88.62,N/A,139.95,N/A,139.95,N/A,311.80,N/A,500.88,N/A,500.88,N/A,500.88,N/A,364.48,N/A,139.95,N/A,88.62,N/A,633.00,N/A,633.00,N/A,88.62,N/A,139.95,N/A,139.95,N/A,153.95,379.80,379.80,88.62,633.00,,Hospital 28505,Open Tx Fracture Great Toe/Phalanx/Phalanges,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20578.73,N/A,12347.24,N/A,2881.02,N/A,539.33,N/A,11840.82,N/A,6981.47,N/A,6545.83,N/A,2881.02,N/A,2688.04,N/A,2688.04,N/A,4074.91,N/A,6545.83,N/A,6545.83,N/A,6545.83,N/A,11840.83,N/A,2688.04,N/A,2881.02,N/A,4112.50,N/A,4112.50,N/A,2881.02,N/A,2688.04,N/A,539.33,N/A,593.26,N/A,N/A,539.33,12347.24,,Hospital 28525,Open Tx Fracture Phalanx/Phalanges Not Great Toe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23156.63,N/A,13893.98,N/A,3241.93,N/A,2811.81,N/A,13332.06,N/A,7873.26,N/A,6516.35,N/A,3241.93,N/A,2688.04,N/A,2688.04,N/A,4056.56,N/A,6516.35,N/A,6516.35,N/A,6516.35,N/A,13300.39,N/A,2688.04,N/A,3241.93,N/A,3397.00,N/A,3397.00,N/A,3241.93,N/A,2688.04,N/A,2811.81,N/A,445.01,N/A,N/A,445.01,13893.98,,Hospital 28540,HC Treat Foot Disloc,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,41614.88,N/A,24968.93,N/A,5826.07,N/A,6037.97,N/A,23911.26,N/A,14149.03,N/A,14561.51,N/A,5826.07,N/A,5973.28,N/A,5973.28,N/A,9064.82,N/A,14561.51,N/A,14561.51,N/A,14561.51,N/A,23911.26,N/A,5973.28,N/A,5826.07,N/A,9953.25,N/A,9953.25,N/A,5826.07,N/A,5973.28,N/A,6037.97,N/A,2093.89,N/A,N/A,2093.89,24968.93,,Hospital 28545,Cltx Tarsal Dislc Oth/Thn Talotarsal W/Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19060.00,N/A,11436.00,N/A,2668.40,N/A,2674.29,N/A,10971.21,N/A,6480.39,N/A,6550.36,N/A,2668.40,N/A,2688.04,N/A,2688.04,N/A,4077.73,N/A,6550.36,N/A,6550.36,N/A,6550.36,N/A,10971.21,N/A,2688.04,N/A,2668.40,N/A,3397.00,N/A,3397.00,N/A,2668.40,N/A,2688.04,N/A,2674.29,N/A,280.04,N/A,N/A,280.04,11436.00,,Hospital 28555,Open Treatment Tarsal Bone Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63076.70,N/A,37846.02,N/A,8824.94,N/A,6178.06,N/A,36204.69,N/A,21446.11,N/A,14501.58,N/A,8824.94,N/A,5973.28,N/A,5973.28,N/A,9027.51,N/A,14501.58,N/A,14501.58,N/A,14501.58,N/A,36204.68,N/A,5973.28,N/A,8824.94,N/A,13819.75,N/A,13819.75,N/A,8824.94,N/A,5973.28,N/A,6178.06,N/A,3344.19,N/A,N/A,3344.19,37846.02,,Hospital 28606,Prq Skel Fixj Tars Jt Dislc W/Manj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65616.15,N/A,39369.69,N/A,9174.56,N/A,1735.04,N/A,37520.84,N/A,22309.50,N/A,14510.30,N/A,9174.56,N/A,5973.28,N/A,5973.28,N/A,9032.93,N/A,14510.30,N/A,14510.30,N/A,14510.30,N/A,37520.84,N/A,5973.28,N/A,9174.56,N/A,10444.75,N/A,10444.75,N/A,9174.56,N/A,5973.28,N/A,1735.04,N/A,1908.56,N/A,N/A,1735.04,39369.69,,Hospital 28615,Open Treatment Tarsometatarsal Joint Dislocation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,64476.37,N/A,38685.82,N/A,9026.72,N/A,4693.18,N/A,37031.06,N/A,21921.94,N/A,28559.92,N/A,9026.72,N/A,11782.94,N/A,11782.94,N/A,17779.11,N/A,28559.92,N/A,28559.92,N/A,28559.92,N/A,37031.07,N/A,11782.94,N/A,9026.72,N/A,13819.75,N/A,13819.75,N/A,9026.72,N/A,11782.94,N/A,4693.18,N/A,5162.50,N/A,N/A,4693.18,38685.82,,Hospital CPT 28630,HC ED Closed Tx Mtp Dislocation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1619.00,1619.00,971.40,971.40,N/A,226.66,N/A,105.61,N/A,932.22,N/A,550.46,N/A,435.21,N/A,226.66,N/A,105.61,N/A,105.61,N/A,270.92,N/A,435.21,N/A,435.21,N/A,435.21,N/A,932.22,N/A,105.61,N/A,226.66,N/A,1619.00,N/A,1619.00,N/A,226.66,N/A,105.61,N/A,105.61,N/A,116.17,971.40,971.40,105.61,1619.00,,Hospital CPT 28660,HC Clsd Tx IP Disloc WO Anes,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1410.00,1410.00,846.00,846.00,N/A,197.40,N/A,88.17,N/A,811.88,N/A,479.40,N/A,350.16,N/A,197.40,N/A,88.17,N/A,88.17,N/A,217.97,N/A,350.16,N/A,350.16,N/A,350.16,N/A,811.88,N/A,88.17,N/A,197.40,N/A,1410.00,N/A,1410.00,N/A,197.40,N/A,88.17,N/A,88.17,N/A,96.99,846.00,846.00,88.17,1410.00,,Hospital 28705,Arthrodesis Pantalar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,121316.63,131757.77,72789.98,79054.66,7463.73,18440.70,10640.30,20835.08,66869.73,75161.72,41247.65,44312.81,22924.37,48513.46,7693.70,18440.70,562.00,19924.58,562.00,19924.58,14269.88,30396.58,22924.37,48513.46,22924.37,48513.46,22924.37,48513.46,66869.73,74976.95,10640.30,19947.52,7693.70,18440.70,27274.27,10535.75,27274.27,10535.75,N/A,18440.70,10640.30,19924.58,10640.30,20835.08,8232.26,2124.99,562.00,72789.98,2124.99,79054.66,,Hospital 28730,Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,106879.17,N/A,64127.50,N/A,14963.08,N/A,12534.51,N/A,61053.83,N/A,36338.91,N/A,28501.95,N/A,14963.08,N/A,11782.94,N/A,11782.94,N/A,17743.02,N/A,28501.95,N/A,28501.95,N/A,28501.95,N/A,61053.83,N/A,11782.94,N/A,14963.08,N/A,10178.00,N/A,10178.00,N/A,14963.08,N/A,11782.94,N/A,12534.51,N/A,984.45,N/A,N/A,984.45,64127.50,,Hospital 28735,Arthrd Midtarsl/Tars Mlt/Transvrs W/Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,177375.13,N/A,106425.08,N/A,24832.49,N/A,15739.60,N/A,100909.21,N/A,60307.53,N/A,29783.57,N/A,24832.49,N/A,14999.59,N/A,14999.59,N/A,18539.57,N/A,29783.57,N/A,29783.57,N/A,29783.57,N/A,100909.21,N/A,14999.59,N/A,24832.49,N/A,13819.75,N/A,13819.75,N/A,24832.49,N/A,14999.59,N/A,15739.60,N/A,3502.37,N/A,N/A,3502.37,106425.08,,Hospital 28737,Arthrd W/Tdn Lngth&Advmnt Tarsl Nvclr-Cuneifor,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,113117.52,N/A,67870.51,N/A,15831.35,N/A,12186.91,N/A,64754.33,N/A,38459.96,N/A,28591.72,N/A,15831.35,N/A,11782.94,N/A,11782.94,N/A,17798.90,N/A,28591.72,N/A,28591.72,N/A,28591.72,N/A,64754.33,N/A,11782.94,N/A,15831.35,N/A,9595.50,N/A,9595.50,N/A,15831.35,N/A,11782.94,N/A,12186.91,N/A,1133.29,N/A,N/A,1133.29,67870.51,,Hospital 28760,Arthrd W/Xtnsr Hallucis Longus Tr 1st Metar Nck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,97293.30,N/A,58375.98,N/A,13622.24,N/A,5942.72,N/A,55274.31,N/A,33079.71,N/A,14503.36,N/A,13622.24,N/A,5973.28,N/A,5973.28,N/A,9028.62,N/A,14503.36,N/A,14503.36,N/A,14503.36,N/A,55274.31,N/A,5973.28,N/A,13622.24,N/A,8612.50,N/A,8612.50,N/A,13622.24,N/A,5973.28,N/A,5942.72,N/A,684.24,N/A,N/A,684.24,58375.98,,Hospital CPT 28810,Amputation Metatarsal W/Toe Single,N/A,N/A,866.00,866.00,519.60,519.60,N/A,121.24,N/A,405.69,N/A,866.00,N/A,294.44,N/A,866.00,N/A,121.24,N/A,405.69,N/A,405.69,N/A,748.74,N/A,866.00,N/A,866.00,N/A,866.00,N/A,866.00,N/A,405.69,N/A,121.24,N/A,866.00,N/A,866.00,N/A,121.24,N/A,405.69,N/A,405.69,N/A,446.26,519.60,519.60,121.24,866.00,,Hospital CPT 28820,"HC Amputation Toe,Metatphal Jnt",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,14062.00,14062.00,8437.20,8437.20,N/A,1968.68,N/A,173.18,N/A,8096.90,N/A,4781.08,N/A,834.18,N/A,1968.68,N/A,173.18,N/A,173.18,N/A,519.28,N/A,834.18,N/A,834.18,N/A,834.18,N/A,8096.90,N/A,173.18,N/A,1968.68,N/A,14062.00,N/A,14062.00,N/A,1968.68,N/A,173.18,N/A,173.18,N/A,190.50,8437.20,8437.20,173.18,14062.00,,Hospital 28890,Eswt Hi Nrg Phys/Qhp W/US Gdn Invg Plntar Fascia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7971.70,N/A,4783.02,N/A,1117.08,N/A,1288.80,N/A,4588.35,N/A,2710.38,N/A,3153.24,N/A,1117.08,N/A,1295.43,N/A,1295.43,N/A,1962.94,N/A,3153.24,N/A,3153.24,N/A,3153.24,N/A,4588.35,N/A,1295.43,N/A,1117.08,N/A,4562.00,N/A,4562.00,N/A,1117.08,N/A,1295.43,N/A,1288.80,N/A,233.40,N/A,N/A,233.40,4783.02,,Hospital 28899,Unlisted Procedure Foot/Toes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35424.00,N/A,21254.40,N/A,4988.29,N/A,1105.62,N/A,20297.61,N/A,12044.16,N/A,2686.68,N/A,4988.29,N/A,1111.04,N/A,1111.04,N/A,1672.49,N/A,2686.68,N/A,2686.68,N/A,2686.68,N/A,20297.61,N/A,1111.04,N/A,4988.29,N/A,2278.25,N/A,2278.25,N/A,4988.29,N/A,1111.04,N/A,1105.62,N/A,325.38,N/A,N/A,325.38,21254.40,,Hospital CPT 29065,HC Apply Long Arm Cast,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,812.00,812.00,487.20,487.20,N/A,113.68,N/A,218.99,N/A,467.55,N/A,276.08,N/A,524.06,N/A,113.68,N/A,216.65,N/A,216.65,N/A,326.24,N/A,524.06,N/A,524.06,N/A,524.06,N/A,467.55,N/A,216.65,N/A,113.68,N/A,812.00,N/A,812.00,N/A,113.68,N/A,216.65,N/A,218.99,N/A,70.54,487.20,487.20,70.54,812.00,,Hospital CPT 29075,HC Cast - Short Arm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,516.00,516.00,309.60,309.60,N/A,72.24,N/A,218.99,N/A,297.11,N/A,175.44,N/A,516.00,N/A,72.24,N/A,216.65,N/A,216.65,N/A,326.24,N/A,516.00,N/A,516.00,N/A,516.00,N/A,297.11,N/A,216.65,N/A,72.24,N/A,516.00,N/A,516.00,N/A,72.24,N/A,216.65,N/A,218.99,N/A,63.49,309.60,309.60,63.49,516.00,,Hospital CPT 29126,HC Appl Splint Fa-Hand Dynamic,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,337.00,337.00,202.20,202.20,N/A,47.18,N/A,46.24,N/A,194.04,N/A,114.58,N/A,215.55,N/A,47.18,N/A,46.24,N/A,46.24,N/A,134.18,N/A,215.55,N/A,215.55,N/A,215.55,N/A,194.04,N/A,46.24,N/A,47.18,N/A,337.00,N/A,337.00,N/A,47.18,N/A,46.24,N/A,46.24,N/A,50.86,202.20,202.20,46.24,337.00,,Hospital CPT 29345,HC Cast - Long Leg,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1230.00,1230.00,738.00,738.00,N/A,172.20,N/A,93.77,N/A,708.23,N/A,418.20,N/A,380.10,N/A,172.20,N/A,93.77,N/A,93.77,N/A,236.61,N/A,380.10,N/A,380.10,N/A,380.10,N/A,708.23,N/A,93.77,N/A,172.20,N/A,1230.00,N/A,1230.00,N/A,172.20,N/A,93.77,N/A,93.77,N/A,103.15,738.00,738.00,93.77,1230.00,,Hospital 29365,HC Apply Long Leg Cast,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 29425,HC Apply Short Leg Cast Walker,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,N/A,5414.00,N/A,3248.40,N/A,757.96,N/A,1040.80,N/A,3117.39,N/A,1840.76,N/A,2661.48,N/A,757.96,N/A,1027.28,N/A,1027.28,N/A,2068.00,N/A,2661.48,N/A,2661.48,N/A,2661.48,N/A,3117.39,N/A,1013.04,N/A,757.96,N/A,2901.90,N/A,2901.90,N/A,757.96,N/A,1027.28,N/A,1040.80,N/A,527.27,N/A,N/A,527.27,3248.40,,Hospital CPT 29445,HC Apply Total Contact Leg Cast Uni,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2134.00,2134.00,1280.40,1280.40,N/A,298.76,N/A,216.65,N/A,1228.76,N/A,725.56,N/A,524.06,N/A,298.76,N/A,216.65,N/A,216.65,N/A,326.24,N/A,524.06,N/A,524.06,N/A,524.06,N/A,1228.76,N/A,216.65,N/A,298.76,N/A,527.00,N/A,527.00,N/A,298.76,N/A,216.65,N/A,216.65,N/A,238.31,1280.40,1280.40,216.65,1280.40,,Hospital CPT 29515,HC Splint App/Short Leg,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1233.00,1233.00,739.80,739.80,N/A,172.62,N/A,139.49,N/A,709.96,N/A,419.22,N/A,318.39,N/A,172.62,N/A,131.63,N/A,131.63,N/A,198.21,N/A,318.39,N/A,318.39,N/A,318.39,N/A,709.96,N/A,131.63,N/A,172.62,N/A,1233.00,N/A,1233.00,N/A,172.62,N/A,131.63,N/A,139.49,N/A,51.10,739.80,739.80,51.10,1233.00,,Hospital CPT 29530,HC Strapping Knee,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,853.00,853.00,511.80,511.80,N/A,119.42,N/A,17.68,N/A,491.16,N/A,290.02,N/A,84.03,N/A,119.42,N/A,17.68,N/A,17.68,N/A,52.31,N/A,84.03,N/A,84.03,N/A,84.03,N/A,491.16,N/A,17.68,N/A,119.42,N/A,853.00,N/A,853.00,N/A,119.42,N/A,17.68,N/A,17.68,N/A,19.45,511.80,511.80,17.68,853.00,,Hospital 29705,Removal/Bivalving Full Arm/Full Leg Cast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12153.00,N/A,7291.80,N/A,1701.42,N/A,238.99,N/A,6994.66,N/A,4132.02,N/A,526.86,N/A,1701.42,N/A,216.65,N/A,216.65,N/A,327.98,N/A,526.86,N/A,526.86,N/A,526.86,N/A,6994.66,N/A,216.65,N/A,1701.42,N/A,527.00,N/A,527.00,N/A,1701.42,N/A,216.65,N/A,42.68,N/A,46.95,N/A,N/A,42.68,7291.80,,Hospital 29804,Arthroscopy Temporomandibular Joint Surgical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31178.32,N/A,18706.99,N/A,4355.78,N/A,2965.23,N/A,17940.71,N/A,10600.63,N/A,6578.67,N/A,4355.78,N/A,2688.04,N/A,2688.04,N/A,4095.35,N/A,6578.67,N/A,6578.67,N/A,6578.67,N/A,17940.75,N/A,2688.04,N/A,4355.78,N/A,4825.50,N/A,4825.50,N/A,4355.78,N/A,2688.04,N/A,633.57,N/A,690.80,N/A,N/A,633.57,18706.99,,Hospital 29805,Diagnostic Arthroscopy Shoulder +- Synovial Bx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24318.57,N/A,14591.14,N/A,3395.74,N/A,2811.81,N/A,11735.00,N/A,8268.31,N/A,6525.11,N/A,3395.74,N/A,2688.04,N/A,2688.04,N/A,4062.00,N/A,6525.11,N/A,6525.11,N/A,6525.11,N/A,11735.00,N/A,2688.04,N/A,3395.74,N/A,4562.00,N/A,4562.00,N/A,3395.74,N/A,2688.04,N/A,2811.81,N/A,498.25,N/A,N/A,498.25,14591.14,,Hospital 29807,Surgical Arthroscopy Shoulder Repair Slap Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51589.47,N/A,30953.68,N/A,7222.53,N/A,12325.48,N/A,11735.00,N/A,17540.42,N/A,28563.80,N/A,7222.53,N/A,11782.94,N/A,11782.94,N/A,17781.52,N/A,28563.80,N/A,28563.80,N/A,28563.80,N/A,11735.00,N/A,11782.94,N/A,7222.53,N/A,12203.25,N/A,12203.25,N/A,7222.53,N/A,11782.94,N/A,12325.48,N/A,2288.29,N/A,N/A,2288.29,30953.68,,Hospital 29819,Surgical Arthroscopy Shoulder Removal Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26981.77,N/A,16189.06,N/A,3777.43,N/A,2811.81,N/A,11735.00,N/A,9173.79,N/A,6554.58,N/A,3777.43,N/A,2688.04,N/A,2688.04,N/A,4080.35,N/A,6554.58,N/A,6554.58,N/A,6554.58,N/A,11735.00,N/A,2688.04,N/A,3777.43,N/A,8612.50,N/A,8612.50,N/A,3777.43,N/A,2688.04,N/A,2811.81,N/A,682.05,N/A,N/A,682.05,16189.06,,Hospital 29821,Surgical Arthroscopy Shoulder Compl Synovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48626.67,N/A,29176.00,N/A,6717.99,N/A,2811.81,N/A,11735.00,N/A,16533.07,N/A,7029.29,N/A,6717.99,N/A,2688.04,N/A,2688.04,N/A,4375.85,N/A,7029.29,N/A,7029.29,N/A,7029.29,N/A,11735.00,N/A,2688.04,N/A,6717.99,N/A,12203.25,N/A,12203.25,N/A,6717.99,N/A,2688.04,N/A,2811.81,N/A,1426.27,N/A,N/A,1426.27,29176.00,,Hospital CPT 29826,Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls,N/A,N/A,358.00,358.00,214.80,214.80,N/A,50.12,N/A,166.10,N/A,358.00,N/A,121.72,N/A,358.00,N/A,50.12,N/A,166.10,N/A,166.10,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,166.10,N/A,50.12,N/A,358.00,N/A,358.00,N/A,50.12,N/A,166.10,N/A,166.10,N/A,182.71,214.80,214.80,50.12,358.00,,Hospital 29834,Arthroscopy Elbow Surgical W/Removal Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44990.67,N/A,26994.40,N/A,6298.72,N/A,6248.31,N/A,25888.08,N/A,15296.82,N/A,14959.73,N/A,6298.72,N/A,5973.28,N/A,5973.28,N/A,9312.71,N/A,14959.73,N/A,14959.73,N/A,14959.73,N/A,25888.09,N/A,5973.28,N/A,6298.72,N/A,11318.50,N/A,11318.50,N/A,6298.72,N/A,5973.28,N/A,6248.31,N/A,1816.47,N/A,N/A,1816.47,26994.40,,Hospital CPT 29835,Arthroscopy Elbow Surgical Synovectomy Partial,N/A,N/A,994.00,994.00,596.40,596.40,N/A,139.16,N/A,484.83,N/A,994.00,N/A,337.96,N/A,994.00,N/A,139.16,N/A,484.83,N/A,484.83,N/A,903.22,N/A,994.00,N/A,994.00,N/A,994.00,N/A,994.00,N/A,484.83,N/A,139.16,N/A,994.00,N/A,994.00,N/A,139.16,N/A,484.83,N/A,484.83,N/A,533.31,596.40,596.40,139.16,994.00,,Hospital 29837,Arthroscopy Elbow Surgical Debridement Limited,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34888.00,N/A,20932.80,N/A,4884.32,N/A,2811.81,N/A,20084.83,N/A,11861.92,N/A,6588.85,N/A,4884.32,N/A,2688.04,N/A,2688.04,N/A,4101.67,N/A,6588.85,N/A,6588.85,N/A,6588.85,N/A,20084.83,N/A,2688.04,N/A,4884.32,N/A,6260.50,N/A,6260.50,N/A,4884.32,N/A,2688.04,N/A,2811.81,N/A,1179.17,N/A,N/A,1179.17,20932.80,,Hospital 29838,Arthroscopy Elbow Surgical Debridement Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44990.67,N/A,26994.40,N/A,6298.72,N/A,6248.31,N/A,25888.08,N/A,15296.82,N/A,14959.73,N/A,6298.72,N/A,5973.28,N/A,5973.28,N/A,9312.71,N/A,14959.73,N/A,14959.73,N/A,14959.73,N/A,25888.09,N/A,5973.28,N/A,6298.72,N/A,11318.50,N/A,11318.50,N/A,6298.72,N/A,5973.28,N/A,6248.31,N/A,1816.47,N/A,N/A,1816.47,26994.40,,Hospital 29851,Arthroscopy Aid Tx Spine&/Fx Knee W/Fixj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59201.75,N/A,35521.05,N/A,8288.25,N/A,6248.31,N/A,7823.00,N/A,20128.58,N/A,14498.35,N/A,8288.25,N/A,5973.28,N/A,5973.28,N/A,9025.50,N/A,14498.35,N/A,14498.35,N/A,14498.35,N/A,7823.00,N/A,5973.28,N/A,8288.25,N/A,9302.25,N/A,9302.25,N/A,8288.25,N/A,5973.28,N/A,6248.31,N/A,1740.33,N/A,N/A,1740.33,35521.05,,Hospital 29860,Arthroscopy Hip Diagnostic W/WO Synovial Byp Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67071.65,N/A,40242.99,N/A,9390.03,N/A,6248.31,N/A,7823.00,N/A,22804.36,N/A,14676.45,N/A,9390.03,N/A,5973.28,N/A,5973.28,N/A,9136.36,N/A,14676.45,N/A,14676.45,N/A,14676.45,N/A,7823.00,N/A,5973.28,N/A,9390.03,N/A,9595.50,N/A,9595.50,N/A,9390.03,N/A,5973.28,N/A,6248.31,N/A,1173.91,N/A,N/A,1173.91,40242.99,,Hospital 29861,Arthroscopy Hip Surgical W/Removal Loose/FB,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,110196.10,N/A,66117.66,N/A,15418.59,N/A,8439.67,N/A,63160.05,N/A,37466.31,N/A,14644.65,N/A,15418.59,N/A,8405.29,N/A,8405.29,N/A,9116.57,N/A,14644.65,N/A,14644.65,N/A,14644.65,N/A,63160.07,N/A,8405.29,N/A,15418.59,N/A,13819.75,N/A,13819.75,N/A,15418.59,N/A,8405.29,N/A,8439.67,N/A,3002.71,N/A,N/A,3002.71,66117.66,,Hospital 29862,Arthrs Hip Debridement/Shaving Articular Crtlg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20058.45,N/A,12035.07,N/A,2792.01,N/A,783.51,N/A,11545.59,N/A,6819.88,N/A,14463.80,N/A,2792.01,N/A,5973.28,N/A,5973.28,N/A,9004.00,N/A,14463.80,N/A,14463.80,N/A,14463.80,N/A,11545.62,N/A,5973.28,N/A,2792.01,N/A,7897.00,N/A,7897.00,N/A,2792.01,N/A,5973.28,N/A,783.51,N/A,861.87,N/A,N/A,783.51,14463.80,,Hospital 29863,Arthroscopy Hip Surgical W/Synovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,120825.50,N/A,72495.30,N/A,16905.13,N/A,9178.41,N/A,69028.69,N/A,41080.66,N/A,14599.41,N/A,16905.13,N/A,9144.03,N/A,9144.03,N/A,9241.02,N/A,14599.41,N/A,14599.41,N/A,14599.41,N/A,69028.71,N/A,9144.03,N/A,16905.13,N/A,12203.25,N/A,12203.25,N/A,16905.13,N/A,9144.03,N/A,9178.41,N/A,2047.51,N/A,N/A,2047.51,72495.30,,Hospital CPT 29866,Arthroscopy Knee Osteochondral Agrft Mosaicplast,N/A,N/A,2070.00,2070.00,1242.00,1242.00,N/A,289.80,N/A,1001.29,N/A,2070.00,N/A,703.80,N/A,2070.00,N/A,289.80,N/A,1001.29,N/A,1001.29,N/A,1862.61,N/A,2070.00,N/A,2070.00,N/A,2070.00,N/A,2070.00,N/A,1001.29,N/A,289.80,N/A,2070.00,N/A,2070.00,N/A,289.80,N/A,1001.29,N/A,1001.29,N/A,1101.42,1242.00,1242.00,289.80,2070.00,,Hospital CPT 29873,Arthroscopy Knee Lateral Release,N/A,N/A,1035.00,1035.00,621.00,621.00,N/A,144.90,N/A,508.21,N/A,1035.00,N/A,351.90,N/A,1035.00,N/A,144.90,N/A,508.21,N/A,508.21,N/A,945.48,N/A,1035.00,N/A,1035.00,N/A,1035.00,N/A,1035.00,N/A,508.21,N/A,144.90,N/A,1035.00,N/A,1035.00,N/A,144.90,N/A,508.21,N/A,508.21,N/A,559.03,621.00,621.00,144.90,1035.00,,Hospital 29874,Arthroscopy Knee Removal Loose/Foreign Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23732.28,N/A,14239.37,N/A,3322.52,N/A,2811.81,N/A,7823.00,N/A,8068.97,N/A,6530.97,N/A,3322.52,N/A,2688.04,N/A,2688.04,N/A,4065.65,N/A,6530.97,N/A,6530.97,N/A,6530.97,N/A,7823.00,N/A,2688.04,N/A,3322.52,N/A,4562.00,N/A,4562.00,N/A,3322.52,N/A,2688.04,N/A,2811.81,N/A,599.22,N/A,N/A,599.22,14239.37,,Hospital 29876,Arthroscopy Knee Synovectomy 2/>Compartments,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25498.82,N/A,15299.29,N/A,3569.83,N/A,1156.41,N/A,7823.00,N/A,8669.60,N/A,6520.24,N/A,3569.83,N/A,2688.04,N/A,2688.04,N/A,4058.97,N/A,6520.24,N/A,6520.24,N/A,6520.24,N/A,7823.00,N/A,2688.04,N/A,3569.83,N/A,6843.00,N/A,6843.00,N/A,3569.83,N/A,2688.04,N/A,1156.41,N/A,1272.05,N/A,N/A,1156.41,15299.29,,Hospital CPT 29877,Arthrs Knee Debridement/Shaving Artclr Crtlg,N/A,N/A,1236.00,1236.00,741.60,741.60,N/A,173.04,N/A,591.23,N/A,1236.00,N/A,420.24,N/A,1236.00,N/A,173.04,N/A,591.23,N/A,591.23,N/A,1100.63,N/A,1236.00,N/A,1236.00,N/A,1236.00,N/A,1236.00,N/A,591.23,N/A,173.04,N/A,1236.00,N/A,1236.00,N/A,173.04,N/A,591.23,N/A,591.23,N/A,650.35,741.60,741.60,173.04,1236.00,,Hospital 29879,Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23743.07,N/A,14245.84,N/A,3308.42,N/A,2965.23,N/A,7823.00,N/A,8072.64,N/A,6525.83,N/A,3308.42,N/A,2688.04,N/A,2688.04,N/A,4062.45,N/A,6525.83,N/A,6525.83,N/A,6525.83,N/A,7823.00,N/A,2688.04,N/A,3308.42,N/A,5277.50,N/A,5277.50,N/A,3308.42,N/A,2688.04,N/A,689.42,N/A,758.36,N/A,N/A,689.42,14245.84,,Hospital CPT 29881,Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,N/A,N/A,1075.00,1075.00,645.00,645.00,N/A,150.50,N/A,514.59,N/A,1075.00,N/A,365.50,N/A,1075.00,N/A,150.50,N/A,514.59,N/A,514.59,N/A,958.44,N/A,1075.00,N/A,1075.00,N/A,1075.00,N/A,1075.00,N/A,514.59,N/A,150.50,N/A,1075.00,N/A,1075.00,N/A,150.50,N/A,514.59,N/A,514.59,N/A,566.05,645.00,645.00,150.50,1075.00,,Hospital CPT 29882,Arthroscopy Knee W/Meniscus Rpr Medial/Lateral,N/A,N/A,1399.00,1399.00,839.40,839.40,N/A,195.86,N/A,656.39,N/A,1399.00,N/A,475.66,N/A,1399.00,N/A,195.86,N/A,656.39,N/A,656.39,N/A,1223.19,N/A,1399.00,N/A,1399.00,N/A,1399.00,N/A,1399.00,N/A,656.39,N/A,195.86,N/A,1399.00,N/A,1399.00,N/A,195.86,N/A,656.39,N/A,656.39,N/A,722.03,839.40,839.40,195.86,1399.00,,Hospital CPT 29883,Arthroscopy Knee W/Meniscus Rpr Medial&Lateral,N/A,N/A,1686.00,1686.00,1011.60,1011.60,N/A,236.04,N/A,800.82,N/A,1686.00,N/A,573.24,N/A,1686.00,N/A,236.04,N/A,800.82,N/A,800.82,N/A,1495.21,N/A,1686.00,N/A,1686.00,N/A,1686.00,N/A,1686.00,N/A,800.82,N/A,236.04,N/A,1686.00,N/A,1686.00,N/A,236.04,N/A,800.82,N/A,800.82,N/A,880.90,1011.60,1011.60,236.04,1686.00,,Hospital CPT 29884,Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,N/A,N/A,1221.00,1221.00,732.60,732.60,N/A,170.94,N/A,588.18,N/A,1221.00,N/A,415.14,N/A,1221.00,N/A,170.94,N/A,588.18,N/A,588.18,N/A,1097.70,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,588.18,N/A,170.94,N/A,1221.00,N/A,1221.00,N/A,170.94,N/A,588.18,N/A,588.18,N/A,647.00,732.60,732.60,170.94,1221.00,,Hospital 29886,Arthrs Knee Drilling Osteochond Dissecans Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28786.47,N/A,17271.88,N/A,4030.10,N/A,2965.23,N/A,7823.00,N/A,9787.40,N/A,6552.58,N/A,4030.10,N/A,2688.04,N/A,2688.04,N/A,4079.11,N/A,6552.58,N/A,6552.58,N/A,6552.58,N/A,7823.00,N/A,2688.04,N/A,4030.10,N/A,6260.50,N/A,6260.50,N/A,4030.10,N/A,2688.04,N/A,1003.06,N/A,1103.37,N/A,N/A,1003.06,17271.88,,Hospital 29891,Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42723.47,N/A,25634.08,N/A,5981.29,N/A,1323.35,N/A,24446.52,N/A,14510.68,N/A,14562.70,N/A,5981.29,N/A,5973.28,N/A,5973.28,N/A,9065.55,N/A,14562.70,N/A,14562.70,N/A,14562.70,N/A,24446.53,N/A,5973.28,N/A,5981.29,N/A,12203.25,N/A,12203.25,N/A,5981.29,N/A,5973.28,N/A,1323.35,N/A,1455.69,N/A,N/A,1323.35,25634.08,,Hospital CPT 29893,Endoscopic Plantar Fasciotomy,N/A,N/A,1085.00,1085.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1085.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1085.00,N/A,1085.00,N/A,1085.00,N/A,1085.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1085.00,1085.00,,Hospital 29895,Arthroscopy Ankle Surgical Synovectomy Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24958.85,N/A,14975.31,N/A,3492.40,N/A,1178.76,N/A,14363.12,N/A,8480.91,N/A,6545.80,N/A,3492.40,N/A,2688.04,N/A,2688.04,N/A,4074.88,N/A,6545.80,N/A,6545.80,N/A,6545.80,N/A,14363.11,N/A,2688.04,N/A,3492.40,N/A,6260.50,N/A,6260.50,N/A,3492.40,N/A,2688.04,N/A,1178.76,N/A,1296.65,N/A,N/A,1178.76,14975.31,,Hospital 29897,Arthroscopy Ankle Surgical Debridement Limited,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45602.90,N/A,27361.74,N/A,6384.41,N/A,6205.85,N/A,26075.96,N/A,15505.00,N/A,14497.04,N/A,6384.41,N/A,5973.28,N/A,5973.28,N/A,9024.69,N/A,14497.04,N/A,14497.04,N/A,14497.04,N/A,26075.97,N/A,5973.28,N/A,6384.41,N/A,7200.75,N/A,7200.75,N/A,6384.41,N/A,5973.28,N/A,6205.85,N/A,1076.20,N/A,N/A,1076.20,27361.74,,Hospital 29904,Arthrs Subtalar Joint Remove Loose/Foreign Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48728.92,N/A,29237.35,N/A,6805.48,N/A,1865.64,N/A,27817.49,N/A,16567.83,N/A,14473.04,N/A,6805.48,N/A,5973.28,N/A,5973.28,N/A,9009.73,N/A,14473.04,N/A,14473.04,N/A,14473.04,N/A,27817.51,N/A,5973.28,N/A,6805.48,N/A,7983.50,N/A,7983.50,N/A,6805.48,N/A,5973.28,N/A,1865.64,N/A,2052.21,N/A,N/A,1865.64,29237.35,,Hospital 29905,Arthroscopy Subtalar Joint With Synovectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25958.98,N/A,15575.39,N/A,3634.26,N/A,1025.65,N/A,14925.07,N/A,6358.42,N/A,14550.46,N/A,3634.26,N/A,5973.28,N/A,5973.28,N/A,9057.94,N/A,14550.46,N/A,14550.46,N/A,14550.46,N/A,14925.08,N/A,5973.28,N/A,3634.26,N/A,7200.75,N/A,7200.75,N/A,3634.26,N/A,5973.28,N/A,1025.65,N/A,1128.22,N/A,N/A,1025.65,15575.39,,Hospital 29907,Arthroscopy Subtalar Joint Subtalar Arthrodesis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39124.72,N/A,23474.83,N/A,5474.58,N/A,11722.66,N/A,22396.05,N/A,13302.40,N/A,28537.77,N/A,5474.58,N/A,11782.94,N/A,11782.94,N/A,17765.32,N/A,28537.77,N/A,28537.77,N/A,28537.77,N/A,22396.05,N/A,11782.94,N/A,5474.58,N/A,9595.50,N/A,9595.50,N/A,5474.58,N/A,11782.94,N/A,11722.66,N/A,1269.92,N/A,N/A,1269.92,28537.77,,Hospital 29916,Arthroscopy Hip W/Labral Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76048.18,N/A,45628.91,N/A,10637.89,N/A,12325.48,N/A,43670.58,N/A,25856.37,N/A,28803.85,N/A,10637.89,N/A,11782.94,N/A,11782.94,N/A,17934.57,N/A,28803.85,N/A,28803.85,N/A,28803.85,N/A,43670.60,N/A,11782.94,N/A,10637.89,N/A,12203.25,N/A,12203.25,N/A,10637.89,N/A,11782.94,N/A,12325.48,N/A,2207.19,N/A,N/A,2207.19,45628.91,,Hospital 30000,Drainage Abscess/Hematoma Nasal Int Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26600.50,N/A,15960.30,N/A,3724.07,N/A,191.58,N/A,15306.30,N/A,9044.17,N/A,488.10,N/A,3724.07,N/A,187.68,N/A,187.68,N/A,303.87,N/A,488.10,N/A,488.10,N/A,488.10,N/A,15306.29,N/A,187.68,N/A,3724.07,N/A,527.00,N/A,527.00,N/A,3724.07,N/A,187.68,N/A,191.58,N/A,124.81,N/A,N/A,124.81,15960.30,,Hospital 30110,Excision Nasal Polyp Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72547.88,N/A,43528.73,N/A,10156.70,N/A,2622.61,N/A,41767.06,N/A,24666.29,N/A,6243.95,N/A,10156.70,N/A,2569.18,N/A,2569.18,N/A,3887.00,N/A,6243.95,N/A,6243.95,N/A,6243.95,N/A,41767.05,N/A,2569.18,N/A,10156.70,N/A,4800.25,N/A,4800.25,N/A,10156.70,N/A,2569.18,N/A,2622.61,N/A,1187.82,N/A,N/A,1187.82,43528.73,,Hospital 30115,Excision Nasal Polyp Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,77030.02,N/A,46218.01,N/A,10784.19,N/A,5538.92,N/A,44038.27,N/A,26190.18,N/A,13577.85,N/A,10784.19,N/A,5587.18,N/A,5587.18,N/A,8452.48,N/A,13577.85,N/A,13577.85,N/A,13577.85,N/A,44038.27,N/A,5587.18,N/A,10784.19,N/A,7983.50,N/A,7983.50,N/A,10784.19,N/A,5587.18,N/A,5538.92,N/A,1511.07,N/A,N/A,1511.07,46218.01,,Hospital 30118,Excision/Destruction Intranasal Lesion Xtrnl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6418.30,N/A,3850.98,N/A,895.70,N/A,2556.03,N/A,3694.79,N/A,2182.23,N/A,6223.58,N/A,895.70,N/A,2569.18,N/A,2569.18,N/A,3874.30,N/A,6223.58,N/A,6223.58,N/A,6223.58,N/A,3694.80,N/A,2569.18,N/A,895.70,N/A,3397.00,N/A,3397.00,N/A,895.70,N/A,2569.18,N/A,2556.03,N/A,878.40,N/A,N/A,878.40,6223.58,,Hospital 30220,Insertion Nasal Septal Prosthesis Button,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21161.08,N/A,12696.65,N/A,2953.69,N/A,1311.26,N/A,12167.13,N/A,7194.77,N/A,3127.48,N/A,2953.69,N/A,1253.55,N/A,1253.55,N/A,1946.91,N/A,3127.48,N/A,3127.48,N/A,3127.48,N/A,12072.12,N/A,1253.55,N/A,2953.69,N/A,1871.00,N/A,1871.00,N/A,2953.69,N/A,1253.55,N/A,1311.26,N/A,140.55,N/A,N/A,140.55,12696.65,,Hospital CPT 30300,HC Remove Foreign Body/Intranasal,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,263.00,263.00,157.80,157.80,N/A,36.82,N/A,116.01,N/A,151.44,N/A,89.42,N/A,263.00,N/A,36.82,N/A,116.01,N/A,116.01,N/A,263.00,N/A,263.00,N/A,263.00,N/A,263.00,N/A,151.44,N/A,116.01,N/A,36.82,N/A,263.00,N/A,263.00,N/A,36.82,N/A,116.01,N/A,116.01,N/A,127.61,157.80,157.80,36.82,263.00,,Hospital 30320,Rmvl Foreign Body Intranasal Lateral Rhinotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20704.00,N/A,12422.40,N/A,2900.25,N/A,674.61,N/A,11913.30,N/A,7039.36,N/A,1548.32,N/A,2900.25,N/A,634.63,N/A,634.63,N/A,963.87,N/A,1548.32,N/A,1548.32,N/A,1548.32,N/A,11913.30,N/A,634.63,N/A,2900.25,N/A,935.50,N/A,935.50,N/A,2900.25,N/A,634.63,N/A,674.61,N/A,518.01,N/A,N/A,518.01,12422.40,,Hospital 30462,Rhinp Dfrm Colum Lngth Tip Septum Osteot,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76689.70,N/A,46013.82,N/A,10739.35,N/A,5137.36,N/A,44152.13,N/A,26074.50,N/A,11710.30,N/A,10739.35,N/A,4829.80,N/A,4829.80,N/A,7289.88,N/A,11710.30,N/A,11710.30,N/A,11710.30,N/A,44152.14,N/A,4829.80,N/A,10739.35,N/A,9793.75,N/A,9793.75,N/A,10739.35,N/A,4829.80,N/A,5137.36,N/A,2891.43,N/A,N/A,2891.43,46013.82,,Hospital 30465,Repair Nasal Vestibular Stenosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35334.92,N/A,21200.95,N/A,4946.90,N/A,5055.49,N/A,20262.01,N/A,12013.87,N/A,11895.19,N/A,4946.90,N/A,4821.94,N/A,4821.94,N/A,7404.84,N/A,11895.19,N/A,11895.19,N/A,11895.19,N/A,20262.03,N/A,4821.94,N/A,4946.90,N/A,8510.75,N/A,8510.75,N/A,4946.90,N/A,4821.94,N/A,1794.37,N/A,1973.81,N/A,N/A,1794.37,21200.95,,Hospital 30560,Lysis Intranasal Synechia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23763.38,N/A,14258.03,N/A,3324.28,N/A,204.97,N/A,13598.30,N/A,8079.56,N/A,1015.57,N/A,3324.28,N/A,412.53,N/A,412.53,N/A,632.22,N/A,1015.57,N/A,1015.57,N/A,1015.57,N/A,13598.31,N/A,412.53,N/A,3324.28,N/A,790.50,N/A,790.50,N/A,3324.28,N/A,412.53,N/A,204.97,N/A,225.47,N/A,N/A,204.97,14258.03,,Hospital 30580,Repair Fistula Oromaxillary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27084.90,N/A,16250.94,N/A,3791.88,N/A,5043.96,N/A,15594.31,N/A,9208.86,N/A,11678.12,N/A,3791.88,N/A,4821.94,N/A,4821.94,N/A,7269.85,N/A,11678.12,N/A,11678.12,N/A,11678.12,N/A,15594.33,N/A,4821.94,N/A,3791.88,N/A,5963.00,N/A,5963.00,N/A,3791.88,N/A,4821.94,N/A,5043.96,N/A,482.80,N/A,N/A,482.80,16250.94,,Hospital 30630,Repair Nasal Septal Perforations,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33897.78,N/A,20338.67,N/A,4736.84,N/A,5043.96,N/A,19516.73,N/A,11525.24,N/A,11692.54,N/A,4736.84,N/A,4821.94,N/A,4821.94,N/A,7278.82,N/A,11692.54,N/A,11692.54,N/A,11692.54,N/A,19516.74,N/A,4821.94,N/A,4736.84,N/A,5944.75,N/A,5944.75,N/A,4736.84,N/A,4821.94,N/A,5043.96,N/A,1603.69,N/A,N/A,1603.69,20338.67,,Hospital CPT 30901,HC Anterior Epitaxis Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1265.00,1265.00,759.00,759.00,N/A,177.10,N/A,108.93,N/A,728.39,N/A,430.10,N/A,253.64,N/A,177.10,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,728.39,N/A,104.85,N/A,177.10,N/A,1265.00,N/A,1265.00,N/A,177.10,N/A,104.85,N/A,108.93,N/A,60.42,759.00,759.00,60.42,1265.00,,Hospital CPT 30905,HC Control Nosebleed Posterior,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,882.00,882.00,529.20,529.20,N/A,123.48,N/A,101.96,N/A,507.86,N/A,299.88,N/A,882.00,N/A,123.48,N/A,101.96,N/A,101.96,N/A,603.59,N/A,882.00,N/A,882.00,N/A,882.00,N/A,507.86,N/A,101.96,N/A,123.48,N/A,882.00,N/A,882.00,N/A,123.48,N/A,101.96,N/A,101.96,N/A,112.16,529.20,529.20,101.96,882.00,,Hospital 30920,Ligation Arteries Int Maxillary Transantral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10526.58,N/A,6315.95,N/A,1473.72,N/A,2666.89,N/A,6048.43,N/A,3579.03,N/A,6530.21,N/A,1473.72,N/A,2690.13,N/A,2690.13,N/A,4065.18,N/A,6530.21,N/A,6530.21,N/A,6530.21,N/A,6048.43,N/A,2690.13,N/A,1473.72,N/A,4562.00,N/A,4562.00,N/A,1473.72,N/A,2690.13,N/A,2666.89,N/A,920.70,N/A,N/A,920.70,6530.21,,Hospital 30930,Fracture Nasal Inferior Turbinate Therapeutic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,73481.72,9895.12,44089.03,5937.07,6806.44,1385.31,8346.96,2569.18,15564.84,5696.01,24983.79,3364.33,15485.60,6227.31,7016.16,1379.01,175344.00,2569.18,175344.00,2569.18,9639.42,3876.62,15485.60,6227.31,15485.60,6227.31,15485.60,6227.31,15564.84,5696.01,8317.31,2569.18,7016.16,1385.31,18424.00,3397.00,18424.00,3397.00,N/A,1385.31,4706.78,2569.18,8346.96,2569.18,7507.29,2826.09,4706.78,175344.00,1379.01,6227.31,,Hospital 30999,Unlisted Procedure Nose,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47629.63,N/A,28577.78,N/A,6668.15,N/A,962.50,N/A,27415.02,N/A,14848.29,N/A,6251.01,N/A,6668.15,N/A,2569.18,N/A,2569.18,N/A,3891.37,N/A,6251.01,N/A,6251.01,N/A,6251.01,N/A,27415.05,N/A,2569.18,N/A,6668.15,N/A,5944.75,N/A,5944.75,N/A,6668.15,N/A,2569.18,N/A,962.50,N/A,1058.75,N/A,N/A,962.50,28577.78,,Hospital 31020,Sinusotomy Maxillary Antrotomy Intranasal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,50201.42,62383.77,30120.85,37430.26,9651.93,8734.03,10904.66,5703.37,21364.36,35913.50,17068.48,21210.49,21379.33,13540.76,9949.32,8734.03,216370.00,5587.18,216370.00,5587.18,13308.13,8429.39,21379.33,13540.76,21379.33,13540.76,21379.33,13540.76,21364.36,35913.50,10845.36,5587.18,9949.32,8734.03,25436.06,7692.25,3660.50,7692.25,N/A,8734.03,10845.36,5587.18,10904.66,5703.37,10645.77,1095.65,3660.50,216370.00,1095.65,37430.26,,Hospital 31030,Sinusotomy Maxillary Rad W/O Rmvl Antroch Polyps,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21171.20,N/A,12702.72,N/A,2963.97,N/A,5319.17,N/A,12181.55,N/A,7198.21,N/A,11698.06,N/A,2963.97,N/A,4821.94,N/A,4821.94,N/A,7282.26,N/A,11698.06,N/A,11698.06,N/A,11698.06,N/A,12181.58,N/A,4821.94,N/A,2963.97,N/A,5963.00,N/A,5963.00,N/A,2963.97,N/A,4821.94,N/A,486.10,N/A,534.71,N/A,N/A,486.10,12702.72,,Hospital 31070,Sinusotomy Frontal External Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58538.93,N/A,35123.36,N/A,8165.68,N/A,4922.21,N/A,33695.61,N/A,19903.23,N/A,11746.70,N/A,8165.68,N/A,4821.94,N/A,4821.94,N/A,7312.54,N/A,11746.70,N/A,11746.70,N/A,11746.70,N/A,33695.61,N/A,4821.94,N/A,8165.68,N/A,5563.25,N/A,5563.25,N/A,8165.68,N/A,4821.94,N/A,4922.21,N/A,1106.62,N/A,N/A,1106.62,35123.36,,Hospital 31200,Ethmoidectomy Intranasal Anterior,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58803.50,N/A,35282.10,N/A,8223.53,N/A,4780.29,N/A,33646.78,N/A,19993.18,N/A,11693.29,N/A,8223.53,N/A,4821.94,N/A,4821.94,N/A,7279.30,N/A,11693.29,N/A,11693.29,N/A,11693.29,N/A,33646.79,N/A,4821.94,N/A,8223.53,N/A,9384.50,N/A,9384.50,N/A,8223.53,N/A,4821.94,N/A,4780.29,N/A,2057.81,N/A,N/A,2057.81,35282.10,,Hospital 31233,Nasal/Sinus Endoscopy Dx Maxillary Sinusoscopy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60166.18,N/A,36099.71,N/A,8406.68,N/A,163.88,N/A,34301.90,N/A,19774.12,N/A,1419.28,N/A,8406.68,N/A,510.86,N/A,510.86,N/A,883.51,N/A,1419.28,N/A,1419.28,N/A,1419.28,N/A,34301.94,N/A,510.86,N/A,8406.68,N/A,790.50,N/A,790.50,N/A,8406.68,N/A,510.86,N/A,163.88,N/A,180.27,N/A,N/A,163.88,36099.71,,Hospital 31235,Nasal/Sinus Endoscopy Dx Sphenoid Sinusoscopy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36645.28,N/A,21987.17,N/A,5130.35,N/A,279.85,N/A,21086.97,N/A,12459.40,N/A,3568.05,N/A,5130.35,N/A,1443.56,N/A,1443.56,N/A,2221.19,N/A,3568.05,N/A,3568.05,N/A,3568.05,N/A,21086.99,N/A,1443.56,N/A,5130.35,N/A,2134.50,N/A,2134.50,N/A,5130.35,N/A,1443.56,N/A,279.85,N/A,307.83,N/A,N/A,279.85,21987.17,,Hospital CPT 31237,Nasal/Sinus Ndsc Surg W/Bx Polypect/Dbrdmt Spx,N/A,N/A,724.00,724.00,434.40,434.40,N/A,101.36,N/A,151.99,N/A,724.00,N/A,246.16,N/A,718.62,N/A,101.36,N/A,151.99,N/A,151.99,N/A,447.34,N/A,718.62,N/A,718.62,N/A,718.62,N/A,724.00,N/A,151.99,N/A,101.36,N/A,724.00,N/A,724.00,N/A,101.36,N/A,151.99,N/A,151.99,N/A,167.19,434.40,434.40,101.36,724.00,,Hospital CPT 31238,HC ED Nasal Sinus Endoscopy Cntrl Hemorrhage,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3618.00,3618.00,2170.80,2170.80,N/A,506.52,N/A,159.21,N/A,2083.24,N/A,1230.12,N/A,703.56,N/A,506.52,N/A,159.21,N/A,159.21,N/A,437.97,N/A,703.56,N/A,703.56,N/A,703.56,N/A,2083.24,N/A,159.21,N/A,506.52,N/A,3618.00,N/A,3618.00,N/A,506.52,N/A,159.21,N/A,159.21,N/A,175.13,2170.80,2170.80,159.21,3618.00,,Hospital CPT 31254,Nasal/Sinus Ndsc W/Partial Ethmoidectomy,N/A,N/A,740.00,740.00,444.00,444.00,N/A,103.60,N/A,233.21,N/A,740.00,N/A,251.60,N/A,740.00,N/A,103.60,N/A,233.21,N/A,233.21,N/A,740.00,N/A,740.00,N/A,740.00,N/A,740.00,N/A,740.00,N/A,233.21,N/A,103.60,N/A,740.00,N/A,740.00,N/A,103.60,N/A,233.21,N/A,233.21,N/A,256.53,444.00,444.00,103.60,740.00,,Hospital CPT 31257,Nasal/Sinus Ndsc Total With Sphenoidotomy,N/A,N/A,727.00,727.00,436.20,436.20,N/A,101.78,N/A,428.31,N/A,727.00,N/A,247.18,N/A,727.00,N/A,101.78,N/A,428.31,N/A,428.31,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,428.31,N/A,101.78,N/A,727.00,N/A,727.00,N/A,101.78,N/A,428.31,N/A,428.31,N/A,471.14,436.20,436.20,101.78,727.00,,Hospital CPT 31259,Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl,N/A,N/A,769.00,769.00,461.40,461.40,N/A,107.66,N/A,453.51,N/A,769.00,N/A,261.46,N/A,769.00,N/A,107.66,N/A,453.51,N/A,453.51,N/A,769.00,N/A,769.00,N/A,769.00,N/A,769.00,N/A,769.00,N/A,453.51,N/A,107.66,N/A,769.00,N/A,769.00,N/A,107.66,N/A,453.51,N/A,453.51,N/A,498.86,461.40,461.40,107.66,769.00,,Hospital CPT 31276,Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus,N/A,N/A,1011.00,1011.00,606.60,606.60,N/A,141.54,N/A,363.03,N/A,1011.00,N/A,343.74,N/A,1011.00,N/A,141.54,N/A,363.03,N/A,363.03,N/A,674.50,N/A,1011.00,N/A,1011.00,N/A,1011.00,N/A,1011.00,N/A,363.03,N/A,141.54,N/A,1011.00,N/A,1011.00,N/A,141.54,N/A,363.03,N/A,363.03,N/A,399.33,606.60,606.60,141.54,1011.00,,Hospital 31296,Nasal/Sinus Ndsc Surg W/Dilation Frontal Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47565.95,N/A,28539.57,N/A,6659.23,N/A,1237.22,N/A,27381.32,N/A,16172.43,N/A,13559.57,N/A,6659.23,N/A,5587.18,N/A,5587.18,N/A,8441.10,N/A,13559.57,N/A,13559.57,N/A,13559.57,N/A,27381.33,N/A,5587.18,N/A,6659.23,N/A,7692.25,N/A,7692.25,N/A,6659.23,N/A,5587.18,N/A,1237.22,N/A,1360.94,N/A,N/A,1237.22,28539.57,,Hospital 31297,Nasal/Sinus Ndsc Surg W/Dilation Sphenoid Sinus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54071.58,N/A,32442.95,N/A,7560.05,N/A,5538.92,N/A,30751.64,N/A,18384.33,N/A,13585.62,N/A,7560.05,N/A,5587.18,N/A,5587.18,N/A,8457.32,N/A,13585.62,N/A,13585.62,N/A,13585.62,N/A,30751.64,N/A,5587.18,N/A,7560.05,N/A,7983.50,N/A,7983.50,N/A,7560.05,N/A,5587.18,N/A,5538.92,N/A,792.92,N/A,N/A,792.92,32442.95,,Hospital 31300,Laryngotomy W/Rmvl Tumor/Laryngocele Cordectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33671.63,N/A,20202.98,N/A,4742.76,N/A,4757.75,N/A,19380.80,N/A,11448.36,N/A,11466.44,N/A,4742.76,N/A,4706.78,N/A,4706.78,N/A,7138.07,N/A,11466.44,N/A,11466.44,N/A,11466.44,N/A,19320.34,N/A,4706.78,N/A,4742.76,N/A,9595.50,N/A,9595.50,N/A,4742.76,N/A,4706.78,N/A,4757.75,N/A,2564.43,N/A,N/A,2564.43,20202.98,,Hospital 31420,Epiglottidectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72088.30,N/A,43252.98,N/A,10084.42,N/A,4922.21,N/A,41482.83,N/A,24510.03,N/A,11854.56,N/A,10084.42,N/A,4821.94,N/A,4821.94,N/A,7379.68,N/A,11854.56,N/A,11854.56,N/A,11854.56,N/A,41482.86,N/A,4821.94,N/A,10084.42,N/A,5963.00,N/A,5963.00,N/A,10084.42,N/A,4821.94,N/A,4922.21,N/A,922.00,N/A,N/A,922.00,43252.98,,Hospital CPT 31500,HC Intubation Emergent,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1309.00,1309.00,785.40,785.40,N/A,183.26,N/A,189.71,N/A,753.72,N/A,445.06,N/A,453.97,N/A,183.26,N/A,187.68,N/A,187.68,N/A,282.61,N/A,453.97,N/A,453.97,N/A,453.97,N/A,753.72,N/A,187.68,N/A,183.26,N/A,701.62,N/A,701.62,N/A,183.26,N/A,187.68,N/A,189.71,N/A,151.57,785.40,785.40,151.57,785.40,,Hospital CPT 31500,HC Airway Insertion Emergent,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,1309.00,1309.00,785.40,785.40,N/A,183.26,N/A,189.71,N/A,753.72,N/A,445.06,N/A,453.97,N/A,183.26,N/A,187.68,N/A,187.68,N/A,282.61,N/A,453.97,N/A,453.97,N/A,453.97,N/A,753.72,N/A,187.68,N/A,183.26,N/A,701.62,N/A,701.62,N/A,183.26,N/A,187.68,N/A,189.71,N/A,151.57,785.40,785.40,151.57,785.40,,Hospital CPT 31500,HC Intubation/Endotracheal/Emerg,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1309.00,1309.00,785.40,785.40,N/A,183.26,N/A,189.71,N/A,753.72,N/A,445.06,N/A,453.97,N/A,183.26,N/A,187.68,N/A,187.68,N/A,282.61,N/A,453.97,N/A,453.97,N/A,453.97,N/A,753.72,N/A,187.68,N/A,183.26,N/A,1309.00,N/A,1309.00,N/A,183.26,N/A,187.68,N/A,189.71,N/A,151.57,785.40,785.40,151.57,1309.00,,Hospital CPT 31502,HC Trach Change,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1231.00,1231.00,738.60,738.60,N/A,172.34,N/A,191.58,N/A,708.81,N/A,418.54,N/A,453.97,N/A,172.34,N/A,187.68,N/A,187.68,N/A,282.61,N/A,453.97,N/A,453.97,N/A,453.97,N/A,708.81,N/A,187.68,N/A,172.34,N/A,659.82,N/A,659.82,N/A,172.34,N/A,187.68,N/A,191.58,N/A,37.17,738.60,738.60,37.17,738.60,,Hospital CPT 31502,HC Replacement Tracheostomy Tube,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1231.00,1231.00,738.60,738.60,N/A,172.34,N/A,191.58,N/A,708.81,N/A,418.54,N/A,453.97,N/A,172.34,N/A,187.68,N/A,187.68,N/A,282.61,N/A,453.97,N/A,453.97,N/A,453.97,N/A,708.81,N/A,187.68,N/A,172.34,N/A,1231.00,N/A,1231.00,N/A,172.34,N/A,187.68,N/A,191.58,N/A,37.17,738.60,738.60,37.17,1231.00,,Hospital 31505,"HC Laryngoscopy,Indirect,Dx",N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,24482.00,N/A,14689.20,N/A,N/A,N/A,6066.96,N/A,11051.82,N/A,8323.88,N/A,11157.54,N/A,N/A,N/A,2810.00,N/A,2810.00,N/A,6945.31,N/A,11157.54,N/A,11157.54,N/A,11157.54,N/A,11051.82,N/A,6066.96,N/A,5055.22,N/A,13274.69,N/A,13274.69,N/A,N/A,N/A,6066.96,N/A,6066.96,N/A,N/A,N/A,2810.00,14689.20,N/A,N/A,,Hospital 31512,Laryngoscopy Indirect W/Removal Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43789.02,N/A,26273.41,N/A,6130.11,N/A,3073.03,N/A,25186.62,N/A,14888.27,N/A,7456.15,N/A,6130.11,N/A,3010.42,N/A,3010.42,N/A,4641.59,N/A,7456.15,N/A,7456.15,N/A,7456.15,N/A,25186.62,N/A,3010.42,N/A,6130.11,N/A,4332.50,N/A,4332.50,N/A,6130.11,N/A,3010.42,N/A,3073.03,N/A,335.14,N/A,N/A,335.14,26273.41,,Hospital 31526,Laryngoscopy W/WO Tracheoscopy W/Micro/Telescope,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34419.20,N/A,20651.52,N/A,4818.70,N/A,2597.00,N/A,19815.10,N/A,11702.53,N/A,6283.09,N/A,4818.70,N/A,2569.18,N/A,2569.18,N/A,3911.35,N/A,6283.09,N/A,6283.09,N/A,6283.09,N/A,19815.09,N/A,2569.18,N/A,4818.70,N/A,3274.25,N/A,3274.25,N/A,4818.70,N/A,2569.18,N/A,2597.00,N/A,806.69,N/A,N/A,806.69,20651.52,,Hospital 31528,Laryngoscopy W/WO Tracheoscopy W/Dilation In,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,59320.48,33494.73,35592.29,20096.84,9651.93,4689.25,11683.38,3043.02,21751.40,19283.08,20168.97,11388.21,21959.47,7323.27,9949.32,4689.25,562.00,3010.42,562.00,3010.42,13669.26,4558.86,21959.47,7323.27,21959.47,7323.27,21959.47,7323.27,21751.40,19283.09,11683.38,3010.42,9949.32,4689.25,26126.29,3397.00,26126.29,3397.00,N/A,4689.25,11683.38,3010.42,11683.38,3043.02,10645.77,150.23,562.00,35592.29,150.23,20096.84,,Hospital 31529,Laryngoscopy W/WO Tracheoscopy Dilation Subsq,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22031.60,N/A,13218.96,N/A,3084.44,N/A,3149.03,N/A,12640.35,N/A,7490.75,N/A,7319.14,N/A,3084.44,N/A,3010.42,N/A,3010.42,N/A,4556.30,N/A,7319.14,N/A,7319.14,N/A,7319.14,N/A,12640.35,N/A,3010.42,N/A,3084.44,N/A,5095.50,N/A,5095.50,N/A,3084.44,N/A,3010.42,N/A,3149.03,N/A,429.99,N/A,N/A,429.99,13218.96,,Hospital 31530,Laryngoscopy W/Foreign Body Removal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 31535,Laryngoscopy Direct Operative W/Biopsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,31117.17,17522.35,18670.30,10513.41,6443.15,2453.12,7917.20,3010.42,14520.17,10085.57,10579.84,5957.60,14659.07,7322.12,6641.68,2453.12,80366.00,3010.42,80366.00,3010.42,9124.93,4558.15,14659.07,7322.12,14659.07,7322.12,14659.07,7322.12,14520.17,10085.58,7887.55,3010.42,6641.68,2453.12,17440.63,3397.00,17440.63,3397.00,N/A,2453.12,3010.42,3010.42,7917.20,3010.42,7106.60,3311.46,3010.42,80366.00,2453.12,10513.41,,Hospital 31540,Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27750.33,N/A,16650.20,N/A,3885.05,N/A,260.78,N/A,15971.80,N/A,9435.12,N/A,7315.16,N/A,3885.05,N/A,3010.42,N/A,3010.42,N/A,4553.82,N/A,7315.16,N/A,7315.16,N/A,7315.16,N/A,15971.82,N/A,3010.42,N/A,3885.05,N/A,3397.00,N/A,3397.00,N/A,3885.05,N/A,3010.42,N/A,260.78,N/A,286.86,N/A,N/A,260.78,16650.20,,Hospital 31546,Largsc Micro/Telescope Rmvl Les Vocal Cord Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,73557.73,N/A,44134.64,N/A,6443.15,N/A,7917.20,N/A,14520.17,N/A,25009.64,N/A,14659.07,N/A,6641.68,N/A,5587.18,N/A,5587.18,N/A,9124.93,N/A,14659.07,N/A,14659.07,N/A,14659.07,N/A,14520.17,N/A,7887.55,N/A,6641.68,N/A,17440.63,N/A,17440.63,N/A,N/A,N/A,7887.55,N/A,7917.20,N/A,7106.60,N/A,5587.18,44134.64,N/A,N/A,,Hospital 31561,Largsc Arytenoidectomy Microscope/Telescope,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,73557.73,56707.72,44134.64,34024.63,6443.15,7915.14,7917.20,5703.37,14520.17,32635.44,25009.64,19280.62,14659.07,13634.23,6641.68,7915.14,5587.18,5587.18,5587.18,5587.18,9124.93,8487.58,14659.07,13634.23,14659.07,13634.23,14659.07,13634.23,14520.17,32635.44,7887.55,5587.18,6641.68,7915.14,17440.63,6392.25,17440.63,6392.25,N/A,7915.14,7887.55,5587.18,7917.20,5703.37,7106.60,704.26,5587.18,44134.64,704.26,34024.63,,Hospital 31571,Largsc W/Njx Vocal Cord Ther W/Micro/Telescope,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20917.48,N/A,12550.49,N/A,2928.45,N/A,282.97,N/A,11941.41,N/A,7111.94,N/A,7318.38,N/A,2928.45,N/A,3010.42,N/A,3010.42,N/A,4555.83,N/A,7318.38,N/A,7318.38,N/A,7318.38,N/A,11941.42,N/A,3010.42,N/A,2928.45,N/A,3397.00,N/A,3397.00,N/A,2928.45,N/A,3010.42,N/A,282.97,N/A,261.11,N/A,N/A,261.11,12550.49,,Hospital 31572,Laryngoscopy Flexible Ablatj Destj Lesion(S) Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60956.87,25458.70,36574.12,15275.22,10141.65,3564.22,12262.69,3149.03,22855.02,14654.90,20725.34,8655.96,23073.65,7366.57,10454.13,3564.22,12262.69,3010.42,12262.69,3010.42,14362.81,4585.82,23073.65,7366.57,23073.65,7366.57,23073.65,7366.57,22855.02,14654.91,12262.69,3010.42,10454.13,3564.22,27451.88,5095.50,27451.88,5095.50,N/A,3564.22,12262.69,3010.42,12262.69,3149.03,11185.92,531.37,10141.65,36574.12,531.37,15275.22,,Hospital 31576,Laryngoscopy Flexible W/Biopsy(Ies),N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17243.70,N/A,10346.22,N/A,2414.13,N/A,1510.03,N/A,9928.22,N/A,5862.86,N/A,3501.95,N/A,2414.13,N/A,1443.56,N/A,1443.56,N/A,2180.04,N/A,3501.95,N/A,3501.95,N/A,3501.95,N/A,9928.22,N/A,1443.56,N/A,2414.13,N/A,1871.00,N/A,1871.00,N/A,2414.13,N/A,1443.56,N/A,1510.03,N/A,156.89,N/A,N/A,156.89,10346.22,,Hospital 31578,Laryngoscopy Flexible Rmvl Lesion(S) Non-Laser,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,82319.88,N/A,49391.93,N/A,9651.93,N/A,11713.03,N/A,21751.40,N/A,27988.76,N/A,21959.47,N/A,9949.32,N/A,11683.38,N/A,11683.38,N/A,13669.26,N/A,21959.47,N/A,21959.47,N/A,21959.47,N/A,21751.40,N/A,11683.38,N/A,9949.32,N/A,26126.29,N/A,26126.29,N/A,3506.71,N/A,11683.38,N/A,11713.03,N/A,10645.77,N/A,3506.71,49391.93,N/A,N/A,,Hospital 31579,HC Diagnostic Laryngoscopy,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,N/A,1851.00,N/A,1110.60,N/A,259.14,N/A,456.46,N/A,1065.81,N/A,629.34,N/A,1145.23,N/A,259.14,N/A,427.99,N/A,427.99,N/A,834.26,N/A,1145.23,N/A,1145.23,N/A,1145.23,N/A,1065.81,N/A,447.71,N/A,259.14,N/A,992.14,N/A,992.14,N/A,259.14,N/A,427.99,N/A,456.46,N/A,220.58,N/A,N/A,220.58,1145.23,,Hospital 31580,Laryngoplasty Laryn Web W/Keel Stent Insertion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,47674.83,N/A,28604.90,N/A,6669.91,N/A,4922.21,N/A,27431.75,N/A,16209.46,N/A,12052.95,N/A,6669.91,N/A,4821.94,N/A,4821.94,N/A,7503.18,N/A,12052.95,N/A,12052.95,N/A,12052.95,N/A,27287.80,N/A,4821.94,N/A,6669.91,N/A,8129.25,N/A,8129.25,N/A,6669.91,N/A,4821.94,N/A,4922.21,N/A,2172.83,N/A,N/A,2172.83,28604.90,,Hospital 31584,Laryngoplasty W/Open Reduction Fracture W/Trachs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,73849.37,N/A,44309.62,N/A,10338.91,N/A,4922.21,N/A,42145.56,N/A,25108.77,N/A,11708.61,N/A,10338.91,N/A,4821.94,N/A,4821.94,N/A,7288.82,N/A,11708.61,N/A,11708.61,N/A,11708.61,N/A,42145.55,N/A,4821.94,N/A,10338.91,N/A,4562.00,N/A,4562.00,N/A,10338.91,N/A,4821.94,N/A,4922.21,N/A,1484.30,N/A,N/A,1484.30,44309.62,,Hospital 31587,Laryngoplasty Cricoid Split W/O Graft Placement,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,69027.20,N/A,41416.32,N/A,9664.08,N/A,4922.21,N/A,39722.41,N/A,23469.24,N/A,11798.08,N/A,9664.08,N/A,4821.94,N/A,4821.94,N/A,7344.51,N/A,11798.08,N/A,11798.08,N/A,11798.08,N/A,39722.43,N/A,4821.94,N/A,9664.08,N/A,8510.75,N/A,8510.75,N/A,9664.08,N/A,4821.94,N/A,4922.21,N/A,2919.95,N/A,N/A,2919.95,41416.32,,Hospital 31592,Cricotracheal Resection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,79620.72,N/A,47772.43,N/A,11149.36,N/A,4922.21,N/A,45833.08,N/A,27071.06,N/A,11759.80,N/A,11149.36,N/A,4821.94,N/A,4821.94,N/A,7320.68,N/A,11759.80,N/A,11759.80,N/A,11759.80,N/A,45129.48,N/A,4821.94,N/A,11149.36,N/A,10085.00,N/A,10085.00,N/A,11149.36,N/A,4821.94,N/A,4922.21,N/A,3434.88,N/A,N/A,3434.88,47772.43,,Hospital 31599,Unlisted Procedure Larynx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38275.18,N/A,22965.11,N/A,5350.51,N/A,196.32,N/A,21998.55,N/A,13013.57,N/A,515.00,N/A,5350.51,N/A,187.68,N/A,187.68,N/A,320.59,N/A,515.00,N/A,515.00,N/A,515.00,N/A,21998.57,N/A,187.68,N/A,5350.51,N/A,527.00,N/A,527.00,N/A,5350.51,N/A,187.68,N/A,196.32,N/A,35.69,N/A,N/A,35.69,22965.11,,Hospital CPT 31603,HC Tracheostomy Emergency Transtracheal,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3886.00,3886.00,2331.60,2331.60,N/A,544.04,N/A,310.10,N/A,2237.56,N/A,1321.24,N/A,921.15,N/A,544.04,N/A,310.10,N/A,310.10,N/A,573.42,N/A,921.15,N/A,921.15,N/A,921.15,N/A,2237.56,N/A,310.10,N/A,544.04,N/A,3886.00,N/A,3886.00,N/A,544.04,N/A,310.10,N/A,310.10,N/A,341.11,2331.60,2331.60,310.10,3886.00,,Hospital 31613,Tracheostoma Revj Smpl W/O Flap Rotation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,27514.80,N/A,16508.88,N/A,13870.55,N/A,16703.44,N/A,27514.80,N/A,9355.03,N/A,27514.80,N/A,14297.92,N/A,16673.79,N/A,16673.79,N/A,19643.76,N/A,27514.80,N/A,27514.80,N/A,27514.80,N/A,27514.80,N/A,16673.79,N/A,14297.92,N/A,27514.80,N/A,27514.80,N/A,N/A,N/A,2607.44,N/A,16703.44,N/A,15298.78,N/A,2607.44,27514.80,N/A,N/A,,Hospital 31614,Tracheostoma Revj Cplx W/Flap Rotation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30233.00,N/A,18139.80,N/A,4232.62,N/A,4922.21,N/A,17400.24,N/A,10279.22,N/A,11705.78,N/A,4232.62,N/A,4821.94,N/A,4821.94,N/A,7287.07,N/A,11705.78,N/A,11705.78,N/A,11705.78,N/A,17400.25,N/A,4821.94,N/A,4232.62,N/A,5963.00,N/A,5963.00,N/A,4232.62,N/A,4821.94,N/A,4922.21,N/A,815.34,N/A,N/A,815.34,18139.80,,Hospital CPT 31615,HC Tracheobrnchsc Thru Est Trachs,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1254.00,1254.00,752.40,752.40,N/A,175.56,N/A,416.99,N/A,722.05,N/A,426.36,N/A,997.86,N/A,175.56,N/A,412.53,N/A,412.53,N/A,621.19,N/A,997.86,N/A,997.86,N/A,997.86,N/A,722.05,N/A,412.53,N/A,175.56,N/A,1254.00,N/A,1254.00,N/A,175.56,N/A,412.53,N/A,416.99,N/A,120.58,752.40,752.40,120.58,1254.00,,Hospital 31624,HC Rt Bronchoscopy Alveolar Lavage,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,227704.60,16752.60,136622.76,10051.56,20782.89,2345.15,32282.49,3010.42,43587.41,9645.13,91833.34,5695.89,91833.34,7290.60,20782.89,2345.15,34487.03,3010.42,32899.10,3010.42,91833.34,4538.53,91833.34,7290.60,91833.34,7290.60,91833.34,7290.60,43587.41,9645.13,34487.03,3010.42,20782.89,2345.15,43587.41,5497.50,43587.41,5497.50,20782.89,2345.15,20652.20,3010.42,32899.10,3010.42,20782.89,3311.46,20652.20,136622.76,2345.15,10051.56,,Hospital 31625,HC Rt Bronch Dx W/Biopsy(S),N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,98895.30,26294.25,59337.18,15776.55,7138.16,3707.03,13703.72,1780.83,2660.70,15136.58,274751.00,8940.04,274751.00,13537.97,7138.16,3707.03,13703.72,5587.18,13703.72,5587.18,274751.00,8427.65,274751.00,13537.97,274751.00,13537.97,274751.00,13537.97,2660.70,15136.59,13703.72,5587.18,7138.16,3707.03,2660.70,4800.25,2660.70,4800.25,7138.16,3707.03,23398.97,5587.18,13703.72,1780.83,7138.16,1958.92,2660.70,274751.00,1780.83,15776.55,,Hospital 31626,Bronchoscopy W/Plmt Fiducial Markers Single/Mult,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,21480.10,N/A,12888.06,N/A,2904.07,N/A,5736.41,N/A,12350.72,N/A,7303.27,N/A,13534.75,N/A,2904.07,N/A,5587.18,N/A,5587.18,N/A,8425.65,N/A,13534.75,N/A,13534.75,N/A,13534.75,N/A,12350.73,N/A,5587.18,N/A,2904.07,N/A,7310.75,N/A,7310.75,N/A,2904.07,N/A,5587.18,N/A,5736.41,N/A,1844.07,N/A,N/A,1844.07,13534.75,,Hospital 31629,HC Rt Bronchoscopy W/Transb Needle Bx,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,62891.57,29646.83,37734.94,17788.10,10141.65,4150.56,12292.34,5844.44,22855.02,17069.89,21383.11,10079.91,23073.65,13523.81,10454.13,4150.56,5587.18,5587.18,5587.18,5587.18,14362.81,8418.85,23073.65,13523.81,23073.65,13523.81,23073.65,13523.81,22855.02,17069.89,12262.69,5587.18,10454.13,4150.56,27451.88,6728.25,27451.88,6728.25,2593.58,4150.56,12262.69,5587.18,12292.34,5844.44,11185.92,1253.58,2593.58,37734.94,1253.58,17788.10,,Hospital 31631,Bronchoscopy W/Placement Tracheal Stent,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,20775.12,N/A,12465.07,N/A,2898.72,N/A,222.55,N/A,11911.52,N/A,7063.54,N/A,13521.34,N/A,2898.72,N/A,5587.18,N/A,5587.18,N/A,8417.30,N/A,13521.34,N/A,13521.34,N/A,13521.34,N/A,11911.53,N/A,5587.18,N/A,2898.72,N/A,4562.00,N/A,4562.00,N/A,2898.72,N/A,5587.18,N/A,222.55,N/A,244.81,N/A,N/A,222.55,13521.34,,Hospital 31632,Bronchoscopy W/Transbronchial Lung Bx Each Lobe,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,83288.48,19246.88,49973.09,11548.13,6047.86,2642.99,7419.94,5736.41,13629.34,11081.70,28318.09,6543.96,13759.72,13522.06,6234.20,2642.99,1124.00,5587.18,1124.00,5587.18,8565.10,8417.75,13759.72,13522.06,13759.72,13522.06,13759.72,13522.06,13629.34,11081.71,7419.94,5587.18,6234.20,2642.99,16370.63,4800.25,16370.63,4800.25,7138.16,2642.99,7419.94,5587.18,7419.94,5736.41,6670.60,1948.90,1124.00,49973.09,1948.90,13522.06,,Hospital 31635,HC Rt Bronchoscopy Foreign Body Removal,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,38127.00,N/A,22876.20,N/A,4904.12,N/A,6066.96,N/A,11051.82,N/A,12963.18,N/A,11157.54,N/A,5055.22,N/A,6066.96,N/A,6066.96,N/A,6945.31,N/A,11157.54,N/A,11157.54,N/A,11157.54,N/A,11051.82,N/A,6066.96,N/A,5055.22,N/A,13274.69,N/A,13274.69,N/A,5302.65,N/A,6066.96,N/A,6066.96,N/A,5409.09,N/A,4904.12,22876.20,N/A,N/A,,Hospital 31645,HC Rt Bronch Dx Clear Airway,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,206222.48,23006.90,123733.49,13804.14,10080.46,3161.37,25929.56,3262.04,52925.16,13244.79,46538.46,7822.34,46538.46,7319.66,10080.46,3161.37,34487.03,3010.42,34487.03,3010.42,46538.46,4556.63,46538.46,7319.66,46538.46,7319.66,46538.46,7319.66,52925.16,13244.79,31193.81,3010.42,10080.46,3161.37,52925.16,3274.25,52925.16,3274.25,10080.46,3161.37,14092.38,3010.42,25929.56,3262.04,10080.46,1314.40,10080.46,123733.49,1314.40,13804.14,,Hospital 31649,Brnchsc Removal Bronchial Valve Ea Addl,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,18383.40,N/A,11030.04,N/A,2573.68,N/A,3073.03,N/A,10583.83,N/A,6250.36,N/A,7294.17,N/A,2573.68,N/A,3010.42,N/A,3010.42,N/A,4540.76,N/A,7294.17,N/A,7294.17,N/A,7294.17,N/A,10583.83,N/A,3010.42,N/A,2573.68,N/A,5497.50,N/A,5497.50,N/A,2573.68,N/A,3010.42,N/A,3073.03,N/A,282.12,N/A,N/A,282.12,11030.04,,Hospital 31652,HC Rt Bronch Ebus Samplng 1/2 Node,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,71631.12,14019.30,42978.67,8411.58,26144.98,1962.72,8924.96,3010.42,58919.82,8067.27,24354.58,4766.57,N/A,7382.49,26950.55,1962.72,2248.00,3010.42,2248.00,3010.42,N/A,4595.74,N/A,7382.49,N/A,7382.49,N/A,7382.49,58919.82,8067.26,31193.81,3010.42,26950.55,1962.72,70770.44,3397.00,70770.44,3397.00,2663.02,1962.72,8924.96,3010.42,31193.81,3010.42,28837.09,3311.46,2248.00,70770.44,1962.72,8411.58,,Hospital 31654,Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,83288.48,44214.15,49973.09,26528.49,6047.86,6147.65,7419.94,1463.49,13629.34,25529.43,28318.09,15032.81,13759.72,3506.97,6234.20,6147.65,1124.00,1443.56,1124.00,1443.56,8565.10,2183.16,13759.72,3506.97,13759.72,3506.97,13759.72,3506.97,13629.34,25529.43,7419.94,1443.56,6234.20,6147.65,16370.63,2134.50,16370.63,2134.50,2663.02,6147.65,7419.94,1447.85,7419.94,1463.49,6670.60,642.72,1124.00,49973.09,642.72,26528.49,,Hospital 31660,Bronchoscopic Thermoplasty One Lobe,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,33113.30,N/A,19867.98,N/A,4590.66,N/A,5647.69,N/A,18924.02,N/A,11258.52,N/A,13577.18,N/A,4590.66,N/A,5587.18,N/A,5587.18,N/A,8452.06,N/A,13577.18,N/A,13577.18,N/A,13577.18,N/A,18924.02,N/A,5587.18,N/A,4590.66,N/A,5965.25,N/A,5965.25,N/A,4590.66,N/A,5587.18,N/A,5647.69,N/A,771.92,N/A,N/A,771.92,19867.98,,Hospital CPT 31720,HC Nasotracheal Catheter Aspiration,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,238.00,238.00,142.80,142.80,N/A,33.32,N/A,56.99,N/A,137.04,N/A,80.92,N/A,140.58,N/A,33.32,N/A,56.99,N/A,56.99,N/A,87.51,N/A,140.58,N/A,140.58,N/A,140.58,N/A,137.04,N/A,56.99,N/A,33.32,N/A,127.57,N/A,127.57,N/A,33.32,N/A,56.99,N/A,56.99,N/A,62.69,142.80,142.80,33.32,142.80,,Hospital 31781,Exc Tracheal Stenosis&Anast Cervicothoracic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,269968.82,N/A,161981.29,N/A,N/A,N/A,13990.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13990.82,N/A,13990.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13990.82,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13990.82,N/A,13990.82,N/A,N/A,N/A,13990.82,161981.29,N/A,N/A,,Hospital 31820,Surg Clsr Tracheostomy/Fistula W/O Plastic Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81454.88,N/A,48872.93,N/A,11409.26,N/A,4922.21,N/A,46864.28,N/A,27694.65,N/A,11844.69,N/A,11409.26,N/A,4821.94,N/A,4821.94,N/A,7373.52,N/A,11844.69,N/A,11844.69,N/A,11844.69,N/A,41109.75,N/A,4821.94,N/A,11409.26,N/A,7661.50,N/A,7661.50,N/A,11409.26,N/A,4821.94,N/A,4922.21,N/A,2010.29,N/A,N/A,2010.29,48872.93,,Hospital 31825,Surg Clsr Tracheostomy/Fistula W/Plastic Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26411.40,N/A,15846.84,N/A,3726.53,N/A,3149.03,N/A,15205.06,N/A,8979.88,N/A,7388.58,N/A,3726.53,N/A,3010.42,N/A,3010.42,N/A,4615.88,N/A,7388.58,N/A,7388.58,N/A,7388.58,N/A,15205.05,N/A,3010.42,N/A,3726.53,N/A,5095.50,N/A,5095.50,N/A,3726.53,N/A,3010.42,N/A,3149.03,N/A,751.78,N/A,N/A,751.78,15846.84,,Hospital 32098,Thoracotomy W/Biopsy of Pleura,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17573.10,N/A,10543.86,N/A,2459.94,N/A,871.45,N/A,10116.39,N/A,5974.86,N/A,2762.75,N/A,2459.94,N/A,867.65,N/A,867.65,N/A,1719.57,N/A,2762.75,N/A,2762.75,N/A,2762.75,N/A,10116.39,N/A,867.65,N/A,2459.94,N/A,1643.00,N/A,1643.00,N/A,2459.94,N/A,867.65,N/A,871.45,N/A,1390.97,N/A,N/A,867.65,10543.86,,Hospital CPT 32408,HC Core Needle Bx Lung/Mediastinum Perq W/Img,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8848.00,8848.00,5308.80,5308.80,N/A,1238.72,N/A,1354.15,N/A,5094.68,N/A,3008.32,N/A,3275.59,N/A,1238.72,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,5094.68,N/A,1354.15,N/A,1238.72,N/A,1871.00,N/A,1871.00,N/A,1238.72,N/A,1354.15,N/A,1354.15,N/A,1489.57,5308.80,5308.80,1238.72,5308.80,,Hospital CPT 32551,HC Insertion of Chest Tube,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2886.00,2886.00,1731.60,1731.60,N/A,404.04,N/A,1371.53,N/A,1661.76,N/A,981.24,N/A,2886.00,N/A,404.04,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,2886.00,N/A,2886.00,N/A,2886.00,N/A,1661.76,N/A,1343.59,N/A,404.04,N/A,2886.00,N/A,2886.00,N/A,404.04,N/A,1343.59,N/A,1371.53,N/A,166.78,1731.60,1731.60,166.78,2886.00,,Hospital CPT 32551,HC Chest Tube Insertion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2886.00,2886.00,1731.60,1731.60,N/A,404.04,N/A,1371.53,N/A,1661.76,N/A,981.24,N/A,2886.00,N/A,404.04,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,2886.00,N/A,2886.00,N/A,2886.00,N/A,1661.76,N/A,1343.59,N/A,404.04,N/A,1431.00,N/A,1431.00,N/A,404.04,N/A,1343.59,N/A,1371.53,N/A,166.78,1731.60,1731.60,166.78,2886.00,,Hospital CPT 32551,HC Chest Tube Insertion,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2886.00,2886.00,1731.60,1731.60,N/A,404.04,N/A,1371.53,N/A,1661.76,N/A,981.24,N/A,2886.00,N/A,404.04,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,2886.00,N/A,2886.00,N/A,2886.00,N/A,1661.76,N/A,1343.59,N/A,404.04,N/A,1546.90,N/A,1546.90,N/A,404.04,N/A,1343.59,N/A,1371.53,N/A,166.78,1731.60,1731.60,166.78,2886.00,,Hospital CPT 32552,HC Remove Lung Catheter,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1884.00,1884.00,1130.40,1130.40,N/A,263.76,N/A,533.27,N/A,1084.81,N/A,640.56,N/A,1263.67,N/A,263.76,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1084.81,N/A,522.41,N/A,263.76,N/A,1431.00,N/A,1431.00,N/A,263.76,N/A,522.41,N/A,542.75,N/A,164.89,1130.40,1130.40,164.89,1431.00,,Hospital CPT 32555,HC Aspirate Pleura W/ Imaging,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,4463.00,4463.00,2677.80,2677.80,N/A,624.82,N/A,522.41,N/A,914.00,N/A,1517.42,N/A,1263.67,N/A,624.82,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,914.00,N/A,522.41,N/A,624.82,N/A,689.00,N/A,689.00,N/A,624.82,N/A,522.41,N/A,522.41,N/A,574.65,2677.80,2677.80,522.41,2677.80,,Hospital CPT 32555,HC Aspirate Pleura W/ Imaging,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4463.00,4463.00,2677.80,2677.80,N/A,624.82,N/A,522.41,N/A,2569.80,N/A,1517.42,N/A,1263.67,N/A,624.82,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,2569.80,N/A,522.41,N/A,624.82,N/A,2392.17,N/A,2392.17,N/A,624.82,N/A,522.41,N/A,522.41,N/A,574.65,2677.80,2677.80,522.41,2677.80,,Hospital 32557,HC Insert Cath Pleura W/ Image,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,149561.68,11661.67,89737.01,6997.00,9381.46,1632.64,11719.24,1408.67,26815.09,6713.78,90571.84,3964.97,90571.84,3252.21,14257.38,1632.64,11363.44,1343.59,12268.24,1343.59,13286.22,2024.56,90571.84,3252.21,66665.32,3252.21,90571.84,3252.21,82438.40,6713.78,11363.44,1343.59,14257.38,1632.64,26815.09,1431.00,26146.45,1431.00,14257.38,1632.64,11363.44,1343.59,11363.44,144.87,10347.46,159.36,9381.46,90571.84,144.87,6997.00,,Hospital 32562,HC Lyse Chest Fibrin Subq Day,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,218892.82,N/A,131335.69,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,131335.69,131335.69,N/A,N/A,,Hospital 32601,Thorsc Dx Lungs/Pericar/Med/Pleural Space W/O Bx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46188.20,N/A,27712.92,N/A,6345.70,N/A,4757.75,N/A,26590.91,N/A,15703.99,N/A,11508.62,N/A,6345.70,N/A,4706.78,N/A,4706.78,N/A,7164.34,N/A,11508.62,N/A,11508.62,N/A,11508.62,N/A,26530.44,N/A,4706.78,N/A,6345.70,N/A,6916.25,N/A,6916.25,N/A,6345.70,N/A,4706.78,N/A,4757.75,N/A,1749.77,N/A,N/A,1749.77,27712.92,,Hospital 32607,Thoracoscopy W/Dx Bx of Lung Infiltrate Unilatrl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,50676.27,N/A,30405.76,N/A,7562.36,N/A,4832.50,N/A,18987.64,N/A,17229.93,N/A,17205.41,N/A,7795.37,N/A,9211.52,N/A,9211.52,N/A,10709.97,N/A,17205.41,N/A,17205.41,N/A,17205.41,N/A,18987.64,N/A,9211.52,N/A,7795.37,N/A,20470.14,N/A,20470.14,N/A,N/A,N/A,9211.52,N/A,9270.82,N/A,8341.04,N/A,4832.50,30405.76,N/A,N/A,,Hospital 32609,Thoracoscopy With Biopsyies of Pleura,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,24120.62,N/A,14472.37,N/A,6047.86,N/A,7419.94,N/A,13629.34,N/A,8201.01,N/A,13759.72,N/A,6234.20,N/A,7419.94,N/A,7419.94,N/A,8565.10,N/A,13759.72,N/A,13759.72,N/A,13759.72,N/A,13629.34,N/A,7419.94,N/A,6234.20,N/A,16370.63,N/A,16370.63,N/A,N/A,N/A,7419.94,N/A,7419.94,N/A,6670.60,N/A,6047.86,16370.63,N/A,N/A,,Hospital 32663,Thoracoscopy W/Lobectomy Single Lobe,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,64767.43,N/A,38860.46,N/A,13777.72,N/A,16563.99,N/A,N/A,N/A,22020.93,N/A,31346.23,N/A,14202.24,N/A,16563.99,N/A,16563.99,N/A,19512.30,N/A,31346.23,N/A,31346.23,N/A,31346.23,N/A,31049.22,N/A,16563.99,N/A,14202.24,N/A,37294.19,N/A,37294.19,N/A,N/A,N/A,16563.99,N/A,16563.99,N/A,15196.40,N/A,13777.72,38860.46,N/A,N/A,,Hospital 32666,Thoracoscopy W/Thera Wedge Resexn Initial Unilat,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40331.95,N/A,24199.17,N/A,5346.25,N/A,4832.50,N/A,23217.60,N/A,13712.88,N/A,11462.22,N/A,5346.25,N/A,4706.78,N/A,4706.78,N/A,7135.46,N/A,11462.22,N/A,11462.22,N/A,11462.22,N/A,22962.53,N/A,4706.78,N/A,5346.25,N/A,7309.25,N/A,7309.25,N/A,5346.25,N/A,4706.78,N/A,4832.50,N/A,2997.21,N/A,N/A,2997.21,24199.17,,Hospital 32999,HC Unlisted Proc Lungs and Pleura,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,42659.48,N/A,25595.69,N/A,N/A,N/A,9900.64,N/A,18355.19,N/A,14504.23,N/A,N/A,N/A,8395.86,N/A,4496.00,N/A,4496.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18355.19,N/A,9900.64,N/A,8395.86,N/A,N/A,N/A,N/A,N/A,8395.86,N/A,9900.64,N/A,9900.64,N/A,8983.57,N/A,4496.00,25595.69,N/A,N/A,,Hospital CPT 33017,HC Perq Prcrd Drg 6yr+ W/O Congenital Car Anomaly,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4158.00,4158.00,2494.80,2494.80,N/A,582.12,N/A,236.63,N/A,2394.18,N/A,1413.72,N/A,3249.19,N/A,582.12,N/A,236.63,N/A,236.63,N/A,2022.68,N/A,3249.19,N/A,3249.19,N/A,3249.19,N/A,2394.18,N/A,236.63,N/A,582.12,N/A,4158.00,N/A,4158.00,N/A,582.12,N/A,236.63,N/A,236.63,N/A,260.29,2494.80,2494.80,236.63,4158.00,,Hospital CPT 33020,HC Incis Heart Sac Remv Clot/FB,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2443.00,2443.00,1465.80,1465.80,N/A,342.02,N/A,793.13,N/A,1406.68,N/A,830.62,N/A,2342.13,N/A,342.02,N/A,793.13,N/A,793.13,N/A,1457.98,N/A,2342.13,N/A,2342.13,N/A,2342.13,N/A,1406.68,N/A,793.13,N/A,342.02,N/A,2443.00,N/A,2443.00,N/A,342.02,N/A,793.13,N/A,793.13,N/A,872.44,1465.80,1465.80,342.02,2443.00,,Hospital CPT 33206,HC Inital Atrial Lead Insertion,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11559.00,11559.00,6935.40,6935.40,N/A,1618.26,N/A,9576.42,N/A,6655.67,N/A,3930.06,N/A,11559.00,N/A,1618.26,N/A,9327.29,N/A,9327.29,N/A,11559.00,N/A,11559.00,N/A,11559.00,N/A,11559.00,N/A,6655.67,N/A,9327.29,N/A,1618.26,N/A,11660.00,N/A,11660.00,N/A,1618.26,N/A,9327.29,N/A,9576.42,N/A,479.57,6935.40,6935.40,479.57,11660.00,,Hospital CPT 33208,HC Ins New/Rplcmt Prm Pm W/Transv Eltrd Atrial&Vent,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,13449.00,13449.00,8069.40,8069.40,N/A,1882.86,N/A,9327.29,N/A,7743.93,N/A,4572.66,N/A,13449.00,N/A,1882.86,N/A,9327.29,N/A,9327.29,N/A,13449.00,N/A,13449.00,N/A,13449.00,N/A,13449.00,N/A,7743.93,N/A,9327.29,N/A,1882.86,N/A,7208.66,N/A,7208.66,N/A,1882.86,N/A,9327.29,N/A,9327.29,N/A,10260.02,8069.40,8069.40,1882.86,13449.00,,Hospital CPT 33213,HC Generator Change-Dual,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11078.00,11078.00,6646.80,6646.80,N/A,1550.92,N/A,322.02,N/A,6378.71,N/A,3766.52,N/A,11078.00,N/A,1550.92,N/A,9327.29,N/A,9327.29,N/A,11078.00,N/A,11078.00,N/A,11078.00,N/A,11078.00,N/A,6378.71,N/A,9327.29,N/A,1550.92,N/A,11660.00,N/A,11660.00,N/A,1550.92,N/A,9327.29,N/A,322.02,N/A,354.22,6646.80,6646.80,322.02,11660.00,,Hospital CPT 33214,HC Pacer Upgrade,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,16836.00,16836.00,10101.60,10101.60,N/A,2357.04,N/A,458.64,N/A,9694.17,N/A,5724.24,N/A,1356.87,N/A,2357.04,N/A,458.64,N/A,458.64,N/A,844.65,N/A,1356.87,N/A,1356.87,N/A,1356.87,N/A,9694.17,N/A,458.64,N/A,2357.04,N/A,16836.00,N/A,16836.00,N/A,2357.04,N/A,458.64,N/A,458.64,N/A,504.50,10101.60,10101.60,458.64,16836.00,,Hospital CPT 33215,HC Reposition a/V Lead,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3650.00,3650.00,2190.00,2190.00,N/A,511.00,N/A,2813.99,N/A,2101.67,N/A,1241.00,N/A,3650.00,N/A,511.00,N/A,2690.13,N/A,2690.13,N/A,3650.00,N/A,3650.00,N/A,3650.00,N/A,3650.00,N/A,2101.67,N/A,2690.13,N/A,511.00,N/A,4562.00,N/A,4562.00,N/A,511.00,N/A,2690.13,N/A,2813.99,N/A,326.08,2190.00,2190.00,326.08,4562.00,,Hospital CPT 33228,HC Remv & Replc Pm Gen Dual,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,14362.00,14362.00,8617.20,8617.20,N/A,2010.68,N/A,9327.29,N/A,8269.64,N/A,4883.08,N/A,14362.00,N/A,2010.68,N/A,9327.29,N/A,9327.29,N/A,14045.25,N/A,14362.00,N/A,14362.00,N/A,14362.00,N/A,8269.64,N/A,9327.29,N/A,2010.68,N/A,11660.00,N/A,11660.00,N/A,2010.68,N/A,9327.29,N/A,9327.29,N/A,10260.02,8617.20,8617.20,2010.68,14362.00,,Hospital CPT 33229,HC Rmv&Rplc Pm Gen Multi Leads,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,19551.00,19551.00,11730.60,11730.60,N/A,2737.14,N/A,17044.18,N/A,11257.47,N/A,6647.34,N/A,19551.00,N/A,2737.14,N/A,16861.57,N/A,16861.57,N/A,19551.00,N/A,19551.00,N/A,19551.00,N/A,19551.00,N/A,11257.47,N/A,16861.57,N/A,2737.14,N/A,11660.00,N/A,11660.00,N/A,2737.14,N/A,16861.57,N/A,17311.94,N/A,394.59,11730.60,11730.60,394.59,19551.00,,Hospital CPT 33231,HC Ins Icd Gen Only Exist Mult Ld,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,62484.00,62484.00,37490.40,37490.40,N/A,8747.76,N/A,30299.94,N/A,35978.29,N/A,21244.56,N/A,62484.00,N/A,8747.76,N/A,28966.21,N/A,28966.21,N/A,43617.96,N/A,62484.00,N/A,62484.00,N/A,62484.00,N/A,35978.29,N/A,28966.21,N/A,8747.76,N/A,29766.00,N/A,29766.00,N/A,8747.76,N/A,28966.21,N/A,29568.60,N/A,420.66,37490.40,37490.40,420.66,62484.00,,Hospital CPT 33233,HC Removal of Ppm Generator Only,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,20407.00,20407.00,12244.20,12244.20,N/A,2856.98,N/A,7524.60,N/A,11750.35,N/A,6938.38,N/A,17830.58,N/A,2856.98,N/A,7371.31,N/A,7371.31,N/A,11099.88,N/A,17830.58,N/A,17830.58,N/A,17830.58,N/A,11750.35,N/A,7371.31,N/A,2856.98,N/A,10938.15,N/A,10938.15,N/A,2856.98,N/A,7371.31,N/A,7568.19,N/A,243.74,12244.20,12244.20,243.74,17830.58,,Hospital CPT 33235,HC Rmvl Transvns Pm Eltrd Dual Lead Sys,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,4293.00,4293.00,2575.80,2575.80,N/A,601.02,N/A,3088.95,N/A,2471.91,N/A,1459.62,N/A,4293.00,N/A,601.02,N/A,3026.02,N/A,3026.02,N/A,4293.00,N/A,4293.00,N/A,4293.00,N/A,4293.00,N/A,2471.91,N/A,3026.02,N/A,601.02,N/A,2301.05,N/A,2301.05,N/A,601.02,N/A,3026.02,N/A,3165.36,N/A,670.59,2575.80,2575.80,601.02,4293.00,,Hospital CPT 33240,HC Replace Single/Dual Cd Gen Only,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,23855.00,23855.00,14313.00,14313.00,N/A,3339.70,N/A,21920.19,N/A,13735.71,N/A,8110.70,N/A,23855.00,N/A,3339.70,N/A,20605.86,N/A,20605.86,N/A,23855.00,N/A,23855.00,N/A,23855.00,N/A,23855.00,N/A,13735.71,N/A,20605.86,N/A,3339.70,N/A,29766.00,N/A,29766.00,N/A,3339.70,N/A,20605.86,N/A,21920.19,N/A,386.33,14313.00,14313.00,386.33,29766.00,,Hospital CPT 33249,HC Ins/Repos Leads/Gen Cd Sin/Dual,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,32307.00,32307.00,19384.20,19384.20,N/A,4522.98,N/A,28966.21,N/A,18602.37,N/A,10984.38,N/A,32307.00,N/A,4522.98,N/A,28966.21,N/A,28966.21,N/A,32307.00,N/A,32307.00,N/A,32307.00,N/A,32307.00,N/A,18602.37,N/A,28966.21,N/A,4522.98,N/A,29766.00,N/A,29766.00,N/A,4522.98,N/A,28966.21,N/A,28966.21,N/A,31862.83,19384.20,19384.20,4522.98,32307.00,,Hospital CPT 33262,HC Remv & Replc Cd Gen Sing,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,31764.00,31764.00,19058.40,19058.40,N/A,4446.96,N/A,21034.38,N/A,18289.71,N/A,10799.76,N/A,31764.00,N/A,4446.96,N/A,20605.86,N/A,20605.86,N/A,31028.76,N/A,31764.00,N/A,31764.00,N/A,31764.00,N/A,18289.71,N/A,20605.86,N/A,4446.96,N/A,29766.00,N/A,29766.00,N/A,4446.96,N/A,20605.86,N/A,21034.38,N/A,393.37,19058.40,19058.40,393.37,31764.00,,Hospital CPT 33263,HC Remv & Replc Cd Gen Dual,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,31764.00,31764.00,19058.40,19058.40,N/A,4446.96,N/A,20829.02,N/A,18289.71,N/A,10799.76,N/A,31764.00,N/A,4446.96,N/A,5967.86,N/A,20605.86,N/A,31028.76,N/A,31764.00,N/A,31764.00,N/A,31764.00,N/A,18289.71,N/A,20605.86,N/A,4446.96,N/A,17025.50,N/A,17025.50,N/A,4446.96,N/A,20605.86,N/A,21312.31,N/A,409.17,19058.40,19058.40,409.17,31764.00,,Hospital 33270,HC Ins/Rep Subq Defibrillator,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,320385.87,273882.17,192231.52,164329.30,N/A,38255.75,40659.05,29279.92,176596.69,155454.80,108931.19,93119.93,111558.36,70206.67,40964.38,38255.75,3372.00,28966.21,3372.00,28966.21,69459.65,43705.00,111558.36,70206.67,111558.36,70206.67,111558.36,70206.67,176596.69,155454.83,40659.05,28966.21,40964.38,38255.75,216256.18,29766.00,216256.18,29766.00,40964.38,38255.75,41577.28,28966.21,41577.28,29279.92,43831.89,716.53,3372.00,216256.18,716.53,164329.30,,Hospital 33273,HC Repos Prev Impltbl Subq Dfb,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,9308.20,N/A,5584.92,N/A,1303.14,N/A,3210.92,N/A,5356.68,N/A,3164.79,N/A,7519.54,N/A,1303.14,N/A,3104.48,N/A,3104.48,N/A,4681.06,N/A,7519.54,N/A,7519.54,N/A,7519.54,N/A,5356.68,N/A,3104.48,N/A,1303.14,N/A,4671.24,N/A,4671.24,N/A,1303.14,N/A,3104.48,N/A,3210.92,N/A,437.19,N/A,N/A,437.19,7519.54,,Hospital CPT 33289,HC Tcat Impl Wrls P-Art Prs Snr L-T Hemodyn,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,79423.00,79423.00,47653.80,47653.80,N/A,11119.22,N/A,25793.01,N/A,45731.76,N/A,27003.82,N/A,59644.81,N/A,11119.22,N/A,24657.66,N/A,24657.66,N/A,37130.05,N/A,59644.81,N/A,59644.81,N/A,59644.81,N/A,45731.76,N/A,24657.66,N/A,11119.22,N/A,42570.73,N/A,42570.73,N/A,11119.22,N/A,24657.66,N/A,25793.01,N/A,352.89,47653.80,47653.80,352.89,59644.81,,Hospital 33320,Sutr Rpr Aorta/Grt Vsl W/O Shunt/Card Byp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 33321,Sutr Rpr Aorta/Great Vessel W/Shunt Bypass,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 33361,HC Replace Aortic Valve Perq (Tavr/Tavi),N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,16409.00,16409.00,9845.40,9845.40,N/A,2297.26,N/A,1161.85,N/A,9448.30,N/A,5579.06,N/A,3422.34,N/A,2297.26,N/A,1161.85,N/A,1161.85,N/A,2130.41,N/A,3422.34,N/A,3422.34,N/A,3422.34,N/A,9448.30,N/A,1161.85,N/A,2297.26,N/A,1643.00,N/A,1643.00,N/A,2297.26,N/A,1161.85,N/A,1161.85,N/A,1278.04,9845.40,9845.40,1161.85,9845.40,,Hospital CPT 33362,HC Replace Aortic Valve Open Fem,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,17616.00,17616.00,10569.60,10569.60,N/A,2466.24,N/A,1266.72,N/A,10143.29,N/A,5989.44,N/A,3733.80,N/A,2466.24,N/A,1266.72,N/A,1266.72,N/A,2324.29,N/A,3733.80,N/A,3733.80,N/A,3733.80,N/A,10143.29,N/A,1266.72,N/A,2466.24,N/A,17616.00,N/A,17616.00,N/A,2466.24,N/A,1266.72,N/A,1266.72,N/A,1393.39,10569.60,10569.60,1266.72,17616.00,,Hospital CPT 33366,HC Trcath Replace Aortic Valve (Tavr/Tavi),N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15495.00,15495.00,9297.00,9297.00,N/A,2169.30,N/A,1510.39,N/A,8922.02,N/A,5268.30,N/A,4452.33,N/A,2169.30,N/A,1510.39,N/A,1510.39,N/A,2771.58,N/A,4452.33,N/A,4452.33,N/A,4452.33,N/A,8922.02,N/A,1510.39,N/A,2169.30,N/A,15495.00,N/A,15495.00,N/A,2169.30,N/A,1510.39,N/A,1510.39,N/A,1661.43,9297.00,9297.00,1510.39,15495.00,,Hospital 33370,HC Transcatheter Placement&Sbsq Removal Cepd Perq,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,271349.98,N/A,162809.99,N/A,34820.68,N/A,32920.98,N/A,149568.11,N/A,92259.00,N/A,94484.06,N/A,31028.83,N/A,32832.03,N/A,32832.03,N/A,58828.68,N/A,94484.06,N/A,94484.06,N/A,94484.06,N/A,149568.11,N/A,32832.03,N/A,31028.83,N/A,183701.59,N/A,183701.59,N/A,25353.22,N/A,32832.03,N/A,32832.03,N/A,33200.85,N/A,25353.22,183701.59,N/A,N/A,,Hospital 33430,Replacement Mitral Valve W/Cardiopulmonary Byp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34140.73,N/A,20484.44,N/A,4779.72,N/A,2823.25,N/A,19641.21,N/A,11607.86,N/A,8856.10,N/A,4779.72,N/A,2816.70,N/A,2816.70,N/A,5515.06,N/A,8856.10,N/A,8856.10,N/A,8856.10,N/A,19641.24,N/A,2816.70,N/A,4779.72,N/A,1643.00,N/A,1643.00,N/A,4779.72,N/A,2816.70,N/A,2823.25,N/A,2970.53,N/A,N/A,1643.00,20484.44,,Hospital 33508,Ndsc Surg W/Video-Assisted Harvest Vein Cabg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,219255.20,N/A,131553.12,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76596.93,131553.12,N/A,N/A,,Hospital 33512,Coronary Artery Bypass 3 Coronary Venous Grafts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,219255.20,N/A,131553.12,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,76596.93,N/A,76596.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,76596.93,131553.12,N/A,N/A,,Hospital 33518,Coronary Artery Byp W/Vein & Artery Graft 2 Vein,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,231765.73,N/A,139059.44,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9658.67,139059.44,N/A,N/A,,Hospital 33533,Cabg W/Arterial Graft Single Arterial Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,231765.73,N/A,139059.44,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,9658.67,N/A,9658.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9658.67,139059.44,N/A,N/A,,Hospital 33866,Aortic Hemiarch Graft W/Isol & Ctrl Arch Vessels,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 33946,HC Ecmo/Eclx Initiation Veno-Venous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1569915.92,N/A,941949.55,N/A,183651.12,N/A,336855.67,N/A,N/A,N/A,894020.97,N/A,894020.97,N/A,183651.12,N/A,336855.67,N/A,336855.67,N/A,894020.97,N/A,894020.97,N/A,894020.97,N/A,894020.97,N/A,N/A,N/A,336855.67,N/A,183651.12,N/A,N/A,N/A,N/A,N/A,183651.12,N/A,336855.67,N/A,336855.67,N/A,183651.12,N/A,183651.12,941949.55,N/A,N/A,,Hospital 33949,HC Ecmo/Ecls Daily Mgmt Artery,N/A,0947 - OTHER THERAPEUTIC SERVICES - COMPLEX MEDICAL EQUIPMENT - ANCILLARY,930732.53,N/A,558439.52,N/A,N/A,N/A,136920.01,N/A,57156.61,N/A,372140.60,N/A,372140.60,N/A,N/A,N/A,158123.27,N/A,158123.27,N/A,372140.60,N/A,372140.60,N/A,372140.60,N/A,372140.60,N/A,57156.61,N/A,136920.01,N/A,N/A,N/A,57156.61,N/A,57156.61,N/A,N/A,N/A,136920.01,N/A,136920.01,N/A,N/A,N/A,57156.61,558439.52,N/A,N/A,,Hospital 33952,HC Ecmo/Ecls Insj of Prph Cannula 6 Yrs&Older Perq,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1069086.88,N/A,641452.13,N/A,N/A,N/A,173671.32,N/A,57156.61,N/A,624966.22,N/A,624966.22,N/A,N/A,N/A,173671.32,N/A,173671.32,N/A,624966.22,N/A,624966.22,N/A,624966.22,N/A,624966.22,N/A,57156.61,N/A,173671.32,N/A,N/A,N/A,57156.61,N/A,57156.61,N/A,N/A,N/A,173671.32,N/A,173671.32,N/A,N/A,N/A,57156.61,641452.13,N/A,N/A,,Hospital 33962,HC Ecmo/Ecls Repos Cnula Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1502391.35,N/A,901434.81,N/A,N/A,N/A,152987.03,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,152987.03,N/A,152987.03,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,152987.03,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,256918.20,N/A,152987.03,N/A,N/A,N/A,152987.03,901434.81,N/A,N/A,,Hospital CPT 33971,"HC Rem Aortic Circulation Assist Device,Include Rpr Art W or W/O Graft",N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,26083.00,26083.00,15649.80,15649.80,N/A,3651.62,N/A,676.67,N/A,15018.59,N/A,8868.22,N/A,7319.09,N/A,3651.62,N/A,676.67,N/A,676.67,N/A,4556.28,N/A,7319.09,N/A,7319.09,N/A,7319.09,N/A,15018.59,N/A,676.67,N/A,3651.62,N/A,26083.00,N/A,26083.00,N/A,3651.62,N/A,676.67,N/A,676.67,N/A,744.34,15649.80,15649.80,676.67,26083.00,,Hospital 33984,HC Ecmo/Ecls Rmvl Cannula Open,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,930732.53,N/A,558439.52,N/A,N/A,N/A,139370.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,158123.27,N/A,158123.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,139370.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,139370.89,N/A,139370.89,N/A,N/A,N/A,139370.89,558439.52,N/A,N/A,,Hospital CPT 33990,HC Insert Vent Assist Device; Artery Access Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,15610.00,15610.00,9366.00,9366.00,N/A,2185.40,N/A,347.13,N/A,8988.24,N/A,5307.40,N/A,1022.13,N/A,2185.40,N/A,347.13,N/A,347.13,N/A,636.28,N/A,1022.13,N/A,1022.13,N/A,1022.13,N/A,8988.24,N/A,347.13,N/A,2185.40,N/A,1643.00,N/A,1643.00,N/A,2185.40,N/A,347.13,N/A,347.13,N/A,381.84,9366.00,9366.00,347.13,9366.00,,Hospital CPT 33992,HC Remove Vad Different Session,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4142.00,4142.00,2485.20,2485.20,N/A,579.88,N/A,181.49,N/A,2384.96,N/A,1408.28,N/A,531.06,N/A,579.88,N/A,181.49,N/A,181.49,N/A,330.58,N/A,531.06,N/A,531.06,N/A,531.06,N/A,2384.96,N/A,181.49,N/A,579.88,N/A,4142.00,N/A,4142.00,N/A,579.88,N/A,181.49,N/A,181.49,N/A,199.64,2485.20,2485.20,181.49,4142.00,,Hospital 33995,HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,329292.13,N/A,197575.28,N/A,54963.66,N/A,65314.49,N/A,181505.83,N/A,111959.32,N/A,114659.52,N/A,56657.19,N/A,65284.84,N/A,65284.84,N/A,71390.54,N/A,114659.52,N/A,185373.83,N/A,114659.52,N/A,181505.83,N/A,65284.84,N/A,56657.19,N/A,193236.97,N/A,193236.97,N/A,35481.51,N/A,65284.84,N/A,65284.84,N/A,60623.19,N/A,35481.51,197575.28,N/A,N/A,,Hospital HCPCS 340B,ASCORBIC ACID 25000 MG/50ML IV SOLN,67157-0101-50,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 340B,INSULIN DETEMIR 100 UNIT/ML SC SOLN,00169-3687-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),847.40,847.40,508.44,508.44,N/A,118.64,N/A,847.40,N/A,476.41,N/A,288.12,N/A,118.64,N/A,118.64,N/A,847.40,N/A,847.40,N/A,73.72,N/A,118.64,N/A,118.64,N/A,118.64,N/A,476.41,N/A,847.40,N/A,118.64,N/A,454.21,N/A,454.21,N/A,118.64,N/A,847.40,N/A,847.40,N/A,847.40,508.44,508.44,73.72,847.40,,Hospital 34703,Evasc Rpr Dplmnt Aorto-Un-Iliac Ndgft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,633777.48,N/A,380266.49,N/A,101220.33,N/A,88431.98,N/A,349338.15,N/A,215484.34,N/A,220681.32,N/A,94683.06,N/A,88431.98,N/A,88431.98,N/A,137402.96,N/A,220681.32,N/A,220681.32,N/A,220681.32,N/A,349338.15,N/A,88431.98,N/A,94683.06,N/A,469644.43,N/A,469644.43,N/A,N/A,N/A,88431.98,N/A,88431.98,N/A,101310.87,N/A,88431.98,469644.43,N/A,N/A,,Hospital 34704,HC Evasc Rpr a-Unilac Ndgft Rpt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,776570.38,N/A,465942.23,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,465942.23,465942.23,N/A,N/A,,Hospital 34710,Dlyd Placement Xtn Prosth for Evasc Rpr 1st Vsl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,110806.02,N/A,66483.61,N/A,15489.01,N/A,824.12,N/A,63103.09,N/A,37674.06,N/A,11653.84,N/A,15489.01,N/A,775.71,N/A,775.71,N/A,7254.72,N/A,11653.84,N/A,11653.84,N/A,11653.84,N/A,63103.10,N/A,775.71,N/A,15489.01,N/A,1643.00,N/A,1643.00,N/A,15489.01,N/A,775.71,N/A,824.12,N/A,906.54,N/A,N/A,775.71,66483.61,,Hospital CPT 34713,HC Perq Access & Clsr Fem Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1205.00,1205.00,723.00,723.00,N/A,168.70,N/A,119.02,N/A,693.84,N/A,409.70,N/A,350.70,N/A,168.70,N/A,119.02,N/A,119.02,N/A,218.31,N/A,350.70,N/A,350.70,N/A,350.70,N/A,693.84,N/A,119.02,N/A,168.70,N/A,1205.00,N/A,1205.00,N/A,168.70,N/A,119.02,N/A,119.02,N/A,130.92,723.00,723.00,119.02,1205.00,,Hospital 34717,HC Evasc Rpr Iliac Art Tm of a-Iliac Art Ndgft Uni (Addon),N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,192802.93,N/A,115681.76,N/A,17840.69,N/A,17140.14,N/A,106272.98,N/A,65553.00,N/A,67133.98,N/A,14704.30,N/A,17140.14,N/A,17140.14,N/A,41799.68,N/A,N/A,N/A,N/A,N/A,67133.98,N/A,106272.98,N/A,17140.14,N/A,14704.30,N/A,38612.56,N/A,38612.56,N/A,N/A,N/A,17140.14,N/A,17140.14,N/A,15733.60,N/A,14704.30,115681.76,N/A,N/A,,Hospital CPT 34718,HC Evasc Rpr Iliac Art N/a a-Iliac Art Ndgft Uni (Addon),N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,11868.00,11868.00,7120.80,7120.80,N/A,1661.52,N/A,1188.81,N/A,6833.59,N/A,4035.12,N/A,11868.00,N/A,1661.52,N/A,1188.81,N/A,1188.81,N/A,11868.00,N/A,11868.00,N/A,11868.00,N/A,11868.00,N/A,6833.59,N/A,1188.81,N/A,1661.52,N/A,11868.00,N/A,11868.00,N/A,1661.52,N/A,1188.81,N/A,1188.81,N/A,1307.69,7120.80,7120.80,1188.81,11868.00,,Hospital 34808,HC Endovas Iliac a Device Addon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,157578.22,N/A,94546.93,N/A,27273.78,N/A,32529.13,N/A,86857.11,N/A,53576.59,N/A,64464.77,N/A,28114.13,N/A,32529.13,N/A,32529.13,N/A,40128.80,N/A,N/A,N/A,N/A,N/A,64464.77,N/A,86857.11,N/A,32529.13,N/A,28114.13,N/A,73825.94,N/A,73825.94,N/A,5465.91,N/A,32529.13,N/A,32529.13,N/A,30082.12,N/A,5465.91,94546.93,N/A,N/A,,Hospital 34813,HC Femoral Endovas Graft Add-On,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,776570.38,N/A,465942.23,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,465942.23,465942.23,N/A,N/A,,Hospital 35045,Dir Rpr Ruptd Aneurysm Radial/Ulnar Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,57394.37,19930.00,34436.62,11958.00,10970.65,2790.20,4855.12,935.69,24723.24,11465.54,19514.09,6776.20,24959.74,11274.38,11308.67,2790.20,13243.35,4641.41,13243.35,4641.41,15536.86,7018.51,24959.74,11274.38,24959.74,11274.38,24959.74,11274.38,24723.24,11465.57,13243.35,4641.41,11308.67,2790.20,29695.86,7897.00,29695.86,7897.00,N/A,2790.20,13243.35,4641.41,13273.00,935.69,12100.28,1029.26,4855.12,34436.62,935.69,11958.00,,Hospital 35141,Dir Rpr Aneurysm & Graft Common Femoral Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,82596.33,N/A,49557.80,N/A,11562.64,N/A,1831.31,N/A,47536.49,N/A,28082.74,N/A,5691.39,N/A,11562.64,N/A,1791.28,N/A,1791.28,N/A,3653.42,N/A,5691.39,N/A,5691.39,N/A,5691.39,N/A,47069.52,N/A,1805.37,N/A,11562.64,N/A,1643.00,N/A,1643.00,N/A,11562.64,N/A,1791.28,N/A,1831.31,N/A,1634.19,N/A,N/A,1634.19,49557.80,,Hospital 35151,Dir Rpr Aneurysm & Graft Popliteal Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,56617.50,N/A,33970.50,N/A,9754.35,N/A,11215.97,N/A,21830.75,N/A,19249.95,N/A,22896.68,N/A,10054.90,N/A,11186.32,N/A,11186.32,N/A,14253.00,N/A,22896.68,N/A,22896.68,N/A,22896.68,N/A,21830.75,N/A,11186.32,N/A,10054.90,N/A,26221.60,N/A,26221.60,N/A,N/A,N/A,11186.32,N/A,11215.97,N/A,10758.75,N/A,9754.35,33970.50,N/A,N/A,,Hospital 35201,Repair Blood Vessel Direct Neck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51275.80,N/A,30765.48,N/A,7097.00,N/A,8038.06,N/A,29518.54,N/A,17433.76,N/A,30990.79,N/A,7097.00,N/A,7951.94,N/A,7951.94,N/A,19292.37,N/A,30990.79,N/A,30990.79,N/A,30990.79,N/A,29518.58,N/A,7951.94,N/A,7097.00,N/A,10063.25,N/A,10063.25,N/A,7097.00,N/A,7951.94,N/A,8038.06,N/A,4322.72,N/A,N/A,4322.72,30990.79,,Hospital 35207,Repair Blood Vessel Direct Hand Finger,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38526.55,N/A,23115.93,N/A,5393.73,N/A,2861.72,N/A,22179.27,N/A,13099.05,N/A,6529.94,N/A,5393.73,N/A,2690.13,N/A,2690.13,N/A,4065.02,N/A,6529.94,N/A,6529.94,N/A,6529.94,N/A,22179.27,N/A,2690.13,N/A,5393.73,N/A,7983.50,N/A,7983.50,N/A,5393.73,N/A,2690.13,N/A,2861.72,N/A,3474.59,N/A,N/A,2690.13,23115.93,,Hospital 35261,Repair Blood Vessel W/Graft Other/Than Vein Neck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,100810.62,N/A,60486.37,N/A,14116.89,N/A,7354.13,N/A,57871.49,N/A,34275.62,N/A,13105.25,N/A,14116.89,N/A,7342.60,N/A,7342.60,N/A,8158.27,N/A,13105.25,N/A,13105.25,N/A,13105.25,N/A,57871.47,N/A,7342.60,N/A,14116.89,N/A,5383.50,N/A,5383.50,N/A,14116.89,N/A,7342.60,N/A,7354.13,N/A,2390.34,N/A,N/A,2390.34,60486.37,,Hospital 35266,Rpr Blood Vsl Grf Oth/Thn Vein Upper Extremity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80648.83,N/A,48389.30,N/A,11412.23,N/A,5027.82,N/A,46400.91,N/A,27420.62,N/A,11667.72,N/A,11412.23,N/A,4731.77,N/A,4731.77,N/A,7373.79,N/A,11667.72,N/A,11667.72,N/A,11667.72,N/A,45533.77,N/A,4742.85,N/A,11412.23,N/A,7897.00,N/A,7897.00,N/A,11412.23,N/A,4731.77,N/A,5027.82,N/A,1833.12,N/A,N/A,1833.12,48389.30,,Hospital 35301,Teaec W/Patch Grf Carotid Vertb Subclav Neck Inc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,59534.23,N/A,35720.54,N/A,8724.77,N/A,10616.24,N/A,20180.69,N/A,20241.64,N/A,20442.11,N/A,8993.60,N/A,10586.59,N/A,10586.59,N/A,12725.83,N/A,20442.11,N/A,20442.11,N/A,20442.11,N/A,20180.69,N/A,10586.59,N/A,8993.60,N/A,23616.62,N/A,23616.62,N/A,N/A,N/A,10586.59,N/A,10616.24,N/A,9623.15,N/A,8724.77,35720.54,N/A,N/A,,Hospital 35321,Teaec W/WO Patch Grf Axillary-Brachial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37239.20,N/A,22343.52,N/A,5146.83,N/A,4691.68,N/A,21341.31,N/A,12661.32,N/A,11335.32,N/A,5146.83,N/A,4641.41,N/A,4641.41,N/A,7056.44,N/A,11335.32,N/A,11335.32,N/A,11335.32,N/A,21341.32,N/A,4641.41,N/A,5146.83,N/A,8612.50,N/A,8612.50,N/A,5146.83,N/A,4641.41,N/A,4691.68,N/A,1072.49,N/A,N/A,1072.49,22343.52,,Hospital 35351,Teaec W/WO Patch Graft Iliac,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,51734.47,N/A,31040.68,N/A,13850.81,N/A,16650.44,N/A,33619.57,N/A,17589.72,N/A,32738.01,N/A,14277.58,N/A,16650.44,N/A,16650.44,N/A,20379.14,N/A,32738.01,N/A,32738.01,N/A,32738.01,N/A,33619.57,N/A,16650.44,N/A,14277.58,N/A,37492.02,N/A,37492.02,N/A,N/A,N/A,16650.44,N/A,16650.44,N/A,15277.01,N/A,13850.81,37492.02,N/A,N/A,,Hospital 35371,Teaec W/WO Patch Graft Common Femoral,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,321889.82,119544.43,193133.89,71726.66,N/A,16723.90,N/A,10201.42,N/A,68408.64,N/A,40645.11,N/A,24554.11,N/A,16723.90,N/A,9589.98,N/A,9589.98,N/A,15285.42,N/A,24554.11,N/A,24554.11,N/A,24554.11,N/A,68063.18,N/A,9589.98,N/A,16723.90,N/A,12481.50,N/A,12481.50,N/A,16723.90,N/A,9589.98,N/A,10201.42,N/A,1658.31,193133.89,193133.89,1658.31,71726.66,,Hospital 35372,Teaec W/WO Patch Graft Deep Profunda Femoral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48031.50,60272.60,28818.90,36163.56,9754.35,8418.01,11834.19,959.92,22008.62,34658.60,16330.71,20492.70,23055.56,11370.30,10054.90,8418.01,11804.54,959.92,11804.54,959.92,14351.90,7078.23,23055.56,11370.30,23055.56,11370.30,23055.56,11370.30,22008.62,34658.62,11804.54,959.92,10054.90,8418.01,26403.54,7897.00,26403.54,7897.00,6356.92,8418.01,11804.54,959.92,11834.19,1003.12,10758.75,1097.31,6356.92,28818.90,959.92,36163.56,,Hospital 35390,Roprtj Crtd Teaec > 1 Mo After Original Opratio,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,85064.88,N/A,51038.93,N/A,6149.22,N/A,7232.23,N/A,14952.38,N/A,28922.06,N/A,14236.36,N/A,6338.69,N/A,7202.58,N/A,7202.58,N/A,8862.56,N/A,14236.36,N/A,14236.36,N/A,14236.36,N/A,14952.38,N/A,7202.58,N/A,6338.69,N/A,16447.16,N/A,16447.16,N/A,N/A,N/A,1448.15,N/A,7232.23,N/A,6782.39,N/A,1448.15,51038.93,N/A,N/A,,Hospital 35702,Exploration N/Flwd Surg Upper Extremity Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,56953.42,N/A,34172.05,N/A,24434.70,N/A,28065.61,N/A,55857.62,N/A,19364.16,N/A,56006.19,N/A,25187.57,N/A,28006.31,N/A,28006.31,N/A,34862.55,N/A,56006.19,N/A,56006.19,N/A,56006.19,N/A,55857.62,N/A,28006.31,N/A,25187.57,N/A,56953.41,N/A,56953.41,N/A,N/A,N/A,4706.78,N/A,28065.61,N/A,26950.70,N/A,4706.78,56953.41,N/A,N/A,,Hospital 35800,Expl Po Hemrrg Thrombosis/Infctj Nck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19252.00,N/A,11551.20,N/A,2695.28,N/A,731.60,N/A,11085.31,N/A,6545.68,N/A,11680.32,N/A,2695.28,N/A,885.49,N/A,885.49,N/A,7271.23,N/A,11680.32,N/A,11680.32,N/A,11680.32,N/A,11085.31,N/A,885.49,N/A,2695.28,N/A,8160.50,N/A,8160.50,N/A,2695.28,N/A,885.49,N/A,731.60,N/A,804.76,N/A,N/A,731.60,11680.32,,Hospital 35840,Expl Po Hemrrg Thrombosis/Infctj Abd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,92878.30,N/A,55726.98,N/A,11982.62,N/A,13925.13,N/A,27581.97,N/A,31578.62,N/A,27353.16,N/A,12351.83,N/A,441170.00,N/A,441170.00,N/A,17026.70,N/A,27353.16,N/A,27353.16,N/A,27353.16,N/A,27581.97,N/A,13747.23,N/A,12351.83,N/A,32543.43,N/A,32543.43,N/A,N/A,N/A,13747.23,N/A,13925.13,N/A,13216.46,N/A,11982.62,441170.00,N/A,N/A,,Hospital 35860,Expl Po Hemrrg Thrombosis/Infctj Xtr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22051.60,N/A,13230.96,N/A,3087.23,N/A,2782.36,N/A,12676.42,N/A,7497.55,N/A,6579.66,N/A,3087.23,N/A,2690.13,N/A,2690.13,N/A,4095.95,N/A,6579.66,N/A,6579.66,N/A,6579.66,N/A,12676.42,N/A,2690.13,N/A,3087.23,N/A,4562.00,N/A,4562.00,N/A,3087.23,N/A,2690.13,N/A,2782.36,N/A,886.15,N/A,N/A,886.15,13230.96,,Hospital 35879,Revj Lxtr Artl Byp Opn Vein Patch Angiop,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58005.40,N/A,34803.24,N/A,8095.40,N/A,4855.12,N/A,33390.26,N/A,19721.85,N/A,11402.88,N/A,8095.40,N/A,4641.41,N/A,4641.41,N/A,7098.50,N/A,11402.88,N/A,11402.88,N/A,11402.88,N/A,33138.08,N/A,4641.41,N/A,8095.40,N/A,7897.00,N/A,7897.00,N/A,8095.40,N/A,4641.41,N/A,4855.12,N/A,1024.24,N/A,N/A,1024.24,34803.24,,Hospital 35881,Revj Lxtr Artl Byp Opn W/Sgmtl Vein Interpos,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,90955.33,N/A,54573.20,N/A,9754.35,N/A,11245.62,N/A,22080.61,N/A,30924.82,N/A,22896.68,N/A,10054.90,N/A,4791.24,N/A,4791.24,N/A,14253.00,N/A,22896.68,N/A,22896.68,N/A,22896.68,N/A,22080.61,N/A,11186.32,N/A,10054.90,N/A,26221.60,N/A,26221.60,N/A,N/A,N/A,11186.32,N/A,11245.62,N/A,10758.75,N/A,4791.24,54573.20,N/A,N/A,,Hospital Custom 3600000000,HC Injection Steroid Major Jnt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1373.00,1373.00,823.80,823.80,N/A,192.22,N/A,1373.00,N/A,790.57,N/A,466.82,N/A,192.22,N/A,192.22,N/A,1373.00,N/A,1373.00,N/A,119.45,N/A,192.22,N/A,192.22,N/A,192.22,N/A,790.57,N/A,1373.00,N/A,192.22,N/A,1373.00,N/A,1373.00,N/A,192.22,N/A,1373.00,N/A,1373.00,N/A,1373.00,823.80,823.80,119.45,1373.00,,Hospital Custom 3600000004,HC Surgery Level 4 Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5256.00,5256.00,3153.60,3153.60,N/A,735.84,N/A,5256.00,N/A,3026.40,N/A,1787.04,N/A,735.84,N/A,735.84,N/A,5256.00,N/A,5256.00,N/A,457.27,N/A,735.84,N/A,735.84,N/A,735.84,N/A,3026.40,N/A,5256.00,N/A,735.84,N/A,5256.00,N/A,5256.00,N/A,735.84,N/A,5256.00,N/A,5256.00,N/A,5256.00,3153.60,3153.60,457.27,5256.00,,Hospital Custom 3600000005,HC Surgery Level 5 Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5731.00,5731.00,3438.60,3438.60,N/A,802.34,N/A,5731.00,N/A,3299.91,N/A,1948.54,N/A,802.34,N/A,802.34,N/A,5731.00,N/A,5731.00,N/A,498.60,N/A,802.34,N/A,802.34,N/A,802.34,N/A,3299.91,N/A,5731.00,N/A,802.34,N/A,5731.00,N/A,5731.00,N/A,802.34,N/A,5731.00,N/A,5731.00,N/A,5731.00,3438.60,3438.60,498.60,5731.00,,Hospital Custom 3600000007,HC Surgery Hybrid Base,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5735.00,5735.00,3441.00,3441.00,N/A,802.90,N/A,5735.00,N/A,3302.21,N/A,1949.90,N/A,802.90,N/A,802.90,N/A,5735.00,N/A,5735.00,N/A,498.95,N/A,802.90,N/A,802.90,N/A,802.90,N/A,3302.21,N/A,5735.00,N/A,802.90,N/A,5735.00,N/A,5735.00,N/A,802.90,N/A,5735.00,N/A,5735.00,N/A,5735.00,3441.00,3441.00,498.95,5735.00,,Hospital Custom 3600000011,HC Surgery Level 1 Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1055.00,1055.00,633.00,633.00,N/A,147.70,N/A,1055.00,N/A,607.47,N/A,358.70,N/A,147.70,N/A,147.70,N/A,1055.00,N/A,1055.00,N/A,91.79,N/A,147.70,N/A,147.70,N/A,147.70,N/A,607.47,N/A,1055.00,N/A,147.70,N/A,1055.00,N/A,1055.00,N/A,147.70,N/A,1055.00,N/A,1055.00,N/A,1055.00,633.00,633.00,91.79,1055.00,,Hospital Custom 3600000012,HC Surgery Level 2 Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1445.00,1445.00,867.00,867.00,N/A,202.30,N/A,1445.00,N/A,832.03,N/A,491.30,N/A,202.30,N/A,202.30,N/A,1445.00,N/A,1445.00,N/A,125.72,N/A,202.30,N/A,202.30,N/A,202.30,N/A,832.03,N/A,1445.00,N/A,202.30,N/A,1445.00,N/A,1445.00,N/A,202.30,N/A,1445.00,N/A,1445.00,N/A,1445.00,867.00,867.00,125.72,1445.00,,Hospital Custom 3600000013,HC Surgery Level 3 Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1757.00,1757.00,1054.20,1054.20,N/A,245.98,N/A,1757.00,N/A,1011.68,N/A,597.38,N/A,245.98,N/A,245.98,N/A,1757.00,N/A,1757.00,N/A,152.86,N/A,245.98,N/A,245.98,N/A,245.98,N/A,1011.68,N/A,1757.00,N/A,245.98,N/A,1757.00,N/A,1757.00,N/A,245.98,N/A,1757.00,N/A,1757.00,N/A,1757.00,1054.20,1054.20,152.86,1757.00,,Hospital Custom 3600000014,HC Surgery Level 4 Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2065.00,2065.00,1239.00,1239.00,N/A,289.10,N/A,2065.00,N/A,1189.03,N/A,702.10,N/A,289.10,N/A,289.10,N/A,2065.00,N/A,2065.00,N/A,179.66,N/A,289.10,N/A,289.10,N/A,289.10,N/A,1189.03,N/A,2065.00,N/A,289.10,N/A,2065.00,N/A,2065.00,N/A,289.10,N/A,2065.00,N/A,2065.00,N/A,2065.00,1239.00,1239.00,179.66,2065.00,,Hospital Custom 3600000016,HC Surgery Level 6 Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3241.00,3241.00,1944.60,1944.60,N/A,453.74,N/A,3241.00,N/A,1866.17,N/A,1101.94,N/A,453.74,N/A,453.74,N/A,3241.00,N/A,3241.00,N/A,281.97,N/A,453.74,N/A,453.74,N/A,453.74,N/A,1866.17,N/A,3241.00,N/A,453.74,N/A,3241.00,N/A,3241.00,N/A,453.74,N/A,3241.00,N/A,3241.00,N/A,3241.00,1944.60,1944.60,281.97,3241.00,,Hospital Custom 3600000019,HC Surgery Robot Addtl 15min,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3649.00,3649.00,2189.40,2189.40,N/A,510.86,N/A,3649.00,N/A,2101.09,N/A,1240.66,N/A,510.86,N/A,510.86,N/A,3649.00,N/A,3649.00,N/A,317.46,N/A,510.86,N/A,510.86,N/A,510.86,N/A,2101.09,N/A,3649.00,N/A,510.86,N/A,3649.00,N/A,3649.00,N/A,510.86,N/A,3649.00,N/A,3649.00,N/A,3649.00,2189.40,2189.40,317.46,3649.00,,Hospital Custom 3600000090,HC Perfusion Pump On,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,11532.00,11532.00,6919.20,6919.20,N/A,1614.48,N/A,11532.00,N/A,6640.13,N/A,3920.88,N/A,1614.48,N/A,1614.48,N/A,11532.00,N/A,11532.00,N/A,1003.28,N/A,1614.48,N/A,1614.48,N/A,1614.48,N/A,6640.13,N/A,11532.00,N/A,1614.48,N/A,11532.00,N/A,11532.00,N/A,1614.48,N/A,11532.00,N/A,11532.00,N/A,11532.00,6919.20,6919.20,1003.28,11532.00,,Hospital Custom 3600000091,HC Perfusion Pump Off,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,8721.00,8721.00,5232.60,5232.60,N/A,1220.94,N/A,8721.00,N/A,5021.55,N/A,2965.14,N/A,1220.94,N/A,1220.94,N/A,8721.00,N/A,8721.00,N/A,758.73,N/A,1220.94,N/A,1220.94,N/A,1220.94,N/A,5021.55,N/A,8721.00,N/A,1220.94,N/A,8721.00,N/A,8721.00,N/A,1220.94,N/A,8721.00,N/A,8721.00,N/A,8721.00,5232.60,5232.60,758.73,8721.00,,Hospital Custom 3600000101,HC Manip Shoulder Under Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5482.00,5482.00,3289.20,3289.20,N/A,767.48,N/A,5482.00,N/A,3156.54,N/A,1863.88,N/A,767.48,N/A,767.48,N/A,5482.00,N/A,5482.00,N/A,476.93,N/A,767.48,N/A,767.48,N/A,767.48,N/A,3156.54,N/A,5482.00,N/A,767.48,N/A,5482.00,N/A,5482.00,N/A,767.48,N/A,5482.00,N/A,5482.00,N/A,5482.00,3289.20,3289.20,476.93,5482.00,,Hospital CPT 36011,HC Selective Cath,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,805.00,805.00,483.00,483.00,N/A,112.70,N/A,151.21,N/A,463.52,N/A,273.70,N/A,805.00,N/A,112.70,N/A,805.00,N/A,805.00,N/A,805.00,N/A,805.00,N/A,805.00,N/A,805.00,N/A,463.52,N/A,805.00,N/A,112.70,N/A,527.00,N/A,527.00,N/A,112.70,N/A,805.00,N/A,151.21,N/A,166.33,483.00,483.00,112.70,805.00,,Hospital CPT 36012,HC Sel Cath Plcmt 2nd Ord Venous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,564.00,564.00,338.40,338.40,N/A,78.96,N/A,564.00,N/A,324.75,N/A,191.76,N/A,564.00,N/A,78.96,N/A,564.00,N/A,564.00,N/A,564.00,N/A,564.00,N/A,564.00,N/A,564.00,N/A,324.75,N/A,564.00,N/A,78.96,N/A,527.00,N/A,527.00,N/A,78.96,N/A,564.00,N/A,564.00,N/A,183.98,338.40,338.40,78.96,564.00,,Hospital 36013,HC Intro Cath Rt Hrt or Main Pulm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,131897.70,N/A,79138.62,N/A,25221.85,N/A,15357.91,N/A,31400.47,N/A,364332.00,N/A,364332.00,N/A,25221.85,N/A,15357.91,N/A,15357.91,N/A,364332.00,N/A,364332.00,N/A,364332.00,N/A,364332.00,N/A,31400.47,N/A,15357.91,N/A,25221.85,N/A,31400.47,N/A,69943.03,N/A,25221.85,N/A,15357.91,N/A,15357.91,N/A,25221.85,N/A,15357.91,364332.00,N/A,N/A,,Hospital Custom 3603165200,HC Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,6674.00,6674.00,4004.40,4004.40,N/A,934.36,N/A,6674.00,N/A,3842.89,N/A,2269.16,N/A,934.36,N/A,934.36,N/A,6674.00,N/A,6674.00,N/A,580.64,N/A,934.36,N/A,934.36,N/A,934.36,N/A,3842.89,N/A,6674.00,N/A,934.36,N/A,6674.00,N/A,6674.00,N/A,934.36,N/A,6674.00,N/A,6674.00,N/A,6674.00,4004.40,4004.40,580.64,6674.00,,Hospital Custom 3609008700,HC Sigmoidoscopy Polyp Ablation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2197.00,2197.00,1318.20,1318.20,N/A,307.58,N/A,2197.00,N/A,1265.03,N/A,746.98,N/A,307.58,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,191.14,N/A,307.58,N/A,307.58,N/A,307.58,N/A,1265.03,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,2197.00,1318.20,1318.20,191.14,2197.00,,Hospital Custom 3609008800,HC Sigmoidoscopy Polyp Forcep Cautery,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2197.00,2197.00,1318.20,1318.20,N/A,307.58,N/A,2197.00,N/A,1265.03,N/A,746.98,N/A,307.58,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,191.14,N/A,307.58,N/A,307.58,N/A,307.58,N/A,1265.03,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,2197.00,1318.20,1318.20,191.14,2197.00,,Hospital Custom 3609008900,HC Sigmoidoscopy Polyp Snare,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3256.00,3256.00,1953.60,1953.60,N/A,455.84,N/A,3256.00,N/A,1874.80,N/A,1107.04,N/A,455.84,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,283.27,N/A,455.84,N/A,455.84,N/A,455.84,N/A,1874.80,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,455.84,N/A,3256.00,N/A,3256.00,N/A,3256.00,1953.60,1953.60,283.27,3256.00,,Hospital Custom 3609009300,HC Colonoscopy Biopsy/Stoma,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609009400,HC Colonoscopy With Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609009600,HC Colonoscopy Stoma Dx Including Collj Spec Spx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609009700,HC Colonoscopy W/Removal of Foreign Body(S),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609009800,HC Colonoscopy Stoma W/Rmvl Foreign Body,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010600,HC Colonoscopy Polypectomy Snare/Cold Biopsy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010700,HC Colonoscopy Polypectomy Removal Snare/Stoma,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609010800,HC Bronchoscopy Alveolar Lavage,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609011300,HC Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609011700,HC Bronchoscopy/Transbronchial Lung Biopsy Addl Lobe,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2974.00,2974.00,1784.40,1784.40,N/A,416.36,N/A,2974.00,N/A,1712.43,N/A,1011.16,N/A,416.36,N/A,416.36,N/A,2974.00,N/A,2974.00,N/A,258.74,N/A,416.36,N/A,416.36,N/A,416.36,N/A,1712.43,N/A,2974.00,N/A,416.36,N/A,2974.00,N/A,2974.00,N/A,416.36,N/A,2974.00,N/A,2974.00,N/A,2974.00,1784.40,1784.40,258.74,2974.00,,Hospital Custom 3609011800,HC Bronchoscopy/Transbronchial Lung Biopsy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3976.00,3976.00,2385.60,2385.60,N/A,556.64,N/A,3976.00,N/A,2289.38,N/A,1351.84,N/A,556.64,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,345.91,N/A,556.64,N/A,556.64,N/A,556.64,N/A,2289.38,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,556.64,N/A,3976.00,N/A,3976.00,N/A,3976.00,2385.60,2385.60,345.91,3976.00,,Hospital Custom 3609011900,HC Bronchoscopy Needle Bx Trachea Main Stem&/Bron,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7782.00,7782.00,4669.20,4669.20,N/A,1089.48,N/A,7782.00,N/A,4480.88,N/A,2645.88,N/A,1089.48,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,677.03,N/A,1089.48,N/A,1089.48,N/A,1089.48,N/A,4480.88,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,7782.00,4669.20,4669.20,677.03,7782.00,,Hospital Custom 3609012200,HC Bronchoscopy Revise Tracheal/Brncl Stent Ins Prev Sess,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7782.00,7782.00,4669.20,4669.20,N/A,1089.48,N/A,7782.00,N/A,4480.88,N/A,2645.88,N/A,1089.48,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,677.03,N/A,1089.48,N/A,1089.48,N/A,1089.48,N/A,4480.88,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,1089.48,N/A,7782.00,N/A,7782.00,N/A,7782.00,4669.20,4669.20,677.03,7782.00,,Hospital Custom 3609012300,HC Egd Band Ligation Esophgeal/Gastric Varices,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4007.00,4007.00,2404.20,2404.20,N/A,560.98,N/A,4007.00,N/A,2307.23,N/A,1362.38,N/A,560.98,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,348.61,N/A,560.98,N/A,560.98,N/A,560.98,N/A,2307.23,N/A,4007.00,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,4007.00,2404.20,2404.20,348.61,4007.00,,Hospital Custom 3609012400,HC Egd Transoral Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609012900,HC Egd Foreign Body Removal,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609013000,HC Egd Transoral Control Bleeding Any Method,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2617.00,2617.00,1570.20,1570.20,N/A,366.38,N/A,2617.00,N/A,1506.87,N/A,889.78,N/A,366.38,N/A,366.38,N/A,2617.00,N/A,2617.00,N/A,227.68,N/A,366.38,N/A,366.38,N/A,366.38,N/A,1506.87,N/A,2617.00,N/A,366.38,N/A,2617.00,N/A,2617.00,N/A,366.38,N/A,2617.00,N/A,2617.00,N/A,2617.00,1570.20,1570.20,227.68,2617.00,,Hospital Custom 3609013700,HC Egd Stent Placement,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,11325.00,11325.00,6795.00,6795.00,N/A,1585.50,N/A,11325.00,N/A,6520.94,N/A,3850.50,N/A,1585.50,N/A,1585.50,N/A,11325.00,N/A,11325.00,N/A,985.28,N/A,1585.50,N/A,1585.50,N/A,1585.50,N/A,6520.94,N/A,11325.00,N/A,1585.50,N/A,11325.00,N/A,11325.00,N/A,1585.50,N/A,11325.00,N/A,11325.00,N/A,11325.00,6795.00,6795.00,985.28,11325.00,,Hospital Custom 3609013800,HC Egd Submucosal/Botox Injection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609013900,HC Enteroscopy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3335.00,3335.00,2001.00,2001.00,N/A,466.90,N/A,3335.00,N/A,1920.29,N/A,1133.90,N/A,466.90,N/A,466.90,N/A,3335.00,N/A,3335.00,N/A,290.15,N/A,466.90,N/A,466.90,N/A,466.90,N/A,1920.29,N/A,3335.00,N/A,466.90,N/A,3335.00,N/A,3335.00,N/A,466.90,N/A,3335.00,N/A,3335.00,N/A,3335.00,2001.00,2001.00,290.15,3335.00,,Hospital Custom 3609014100,HC Enteroscopy > 2nd Prtn W/Control Bleeding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4591.00,4591.00,2754.60,2754.60,N/A,642.74,N/A,4591.00,N/A,2643.50,N/A,1560.94,N/A,642.74,N/A,642.74,N/A,4591.00,N/A,4591.00,N/A,399.42,N/A,642.74,N/A,642.74,N/A,642.74,N/A,2643.50,N/A,4591.00,N/A,642.74,N/A,4591.00,N/A,4591.00,N/A,642.74,N/A,4591.00,N/A,4591.00,N/A,4591.00,2754.60,2754.60,399.42,4591.00,,Hospital Custom 3609014300,HC Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609014600,HC Ercp Destruction/Lithotripsy Calculi Any Method,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609014900,HC Ercp W/Sphincterotomy &/or Papillotomy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609015000,HC Ercp Remove Foreign Body/Stent Biliary/Panc Duct,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,7453.00,7453.00,4471.80,4471.80,N/A,1043.42,N/A,7453.00,N/A,4291.44,N/A,2534.02,N/A,1043.42,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,648.41,N/A,1043.42,N/A,1043.42,N/A,1043.42,N/A,4291.44,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,1043.42,N/A,7453.00,N/A,7453.00,N/A,7453.00,4471.80,4471.80,648.41,7453.00,,Hospital Custom 3609015100,HC Ercp Stent Placement Biliary/Pancreatic Duct,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,11325.00,11325.00,6795.00,6795.00,N/A,1585.50,N/A,11325.00,N/A,6520.94,N/A,3850.50,N/A,1585.50,N/A,1585.50,N/A,11325.00,N/A,11325.00,N/A,985.28,N/A,1585.50,N/A,1585.50,N/A,1585.50,N/A,6520.94,N/A,11325.00,N/A,1585.50,N/A,11325.00,N/A,11325.00,N/A,1585.50,N/A,11325.00,N/A,11325.00,N/A,11325.00,6795.00,6795.00,985.28,11325.00,,Hospital Custom 3609015300,HC Esophageal Dilation Maloney,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609015400,HC Esophageal Dilation Other,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609015500,HC Gastric/Duodenal Motility &/or Manometry Study,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2308.00,2308.00,1384.80,1384.80,N/A,323.12,N/A,2308.00,N/A,1328.95,N/A,784.72,N/A,323.12,N/A,323.12,N/A,2308.00,N/A,2308.00,N/A,200.80,N/A,323.12,N/A,323.12,N/A,323.12,N/A,1328.95,N/A,2308.00,N/A,323.12,N/A,2308.00,N/A,2308.00,N/A,323.12,N/A,2308.00,N/A,2308.00,N/A,2308.00,1384.80,1384.80,200.80,2308.00,,Hospital Custom 3609015700,HC Esophagoscopy Band Ligation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609015800,HC Esophagoscopy Biopsy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609016300,HC Esophagoscopy Removal Polypoid,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4640.00,4640.00,2784.00,2784.00,N/A,649.60,N/A,4640.00,N/A,2671.71,N/A,1577.60,N/A,649.60,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,403.68,N/A,649.60,N/A,649.60,N/A,649.60,N/A,2671.71,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,649.60,N/A,4640.00,N/A,4640.00,N/A,4640.00,2784.00,2784.00,403.68,4640.00,,Hospital Custom 3609017100,HC Egd,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609018500,HC Egd US Scope W/Adjacent Structures,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4844.00,4844.00,2906.40,2906.40,N/A,678.16,N/A,4844.00,N/A,2789.18,N/A,1646.96,N/A,678.16,N/A,678.16,N/A,4844.00,N/A,4844.00,N/A,421.43,N/A,678.16,N/A,678.16,N/A,678.16,N/A,2789.18,N/A,4844.00,N/A,678.16,N/A,4844.00,N/A,4844.00,N/A,678.16,N/A,4844.00,N/A,4844.00,N/A,4844.00,2906.40,2906.40,421.43,4844.00,,Hospital Custom 3609019100,HC Esophageal Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4007.00,4007.00,2404.20,2404.20,N/A,560.98,N/A,4007.00,N/A,2307.23,N/A,1362.38,N/A,560.98,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,348.61,N/A,560.98,N/A,560.98,N/A,560.98,N/A,2307.23,N/A,4007.00,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,4007.00,2404.20,2404.20,348.61,4007.00,,Hospital Custom 3609019600,HC Esophagoscopy Dilation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4211.00,4211.00,2526.60,2526.60,N/A,589.54,N/A,4211.00,N/A,2424.69,N/A,1431.74,N/A,589.54,N/A,589.54,N/A,4211.00,N/A,4211.00,N/A,366.36,N/A,589.54,N/A,589.54,N/A,589.54,N/A,2424.69,N/A,4211.00,N/A,589.54,N/A,4211.00,N/A,4211.00,N/A,589.54,N/A,4211.00,N/A,4211.00,N/A,4211.00,2526.60,2526.60,366.36,4211.00,,Hospital Custom 3609019800,HC Colonoscopy With Submucosal Injection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2939.00,2939.00,1763.40,1763.40,N/A,411.46,N/A,2939.00,N/A,1692.28,N/A,999.26,N/A,411.46,N/A,411.46,N/A,2939.00,N/A,2939.00,N/A,255.69,N/A,411.46,N/A,411.46,N/A,411.46,N/A,1692.28,N/A,2939.00,N/A,411.46,N/A,2939.00,N/A,2939.00,N/A,411.46,N/A,2939.00,N/A,2939.00,N/A,2939.00,1763.40,1763.40,255.69,2939.00,,Hospital Custom 3609020000,HC Bronchoscopy W/Ebus Fna,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4362.00,4362.00,2617.20,2617.20,N/A,610.68,N/A,4362.00,N/A,2511.64,N/A,1483.08,N/A,610.68,N/A,610.68,N/A,4362.00,N/A,4362.00,N/A,379.49,N/A,610.68,N/A,610.68,N/A,610.68,N/A,2511.64,N/A,4362.00,N/A,610.68,N/A,4362.00,N/A,4362.00,N/A,610.68,N/A,4362.00,N/A,4362.00,N/A,4362.00,2617.20,2617.20,379.49,4362.00,,Hospital Custom 3609020100,HC Colonoscopy W/Eus Fna,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4401.00,4401.00,2640.60,2640.60,N/A,616.14,N/A,4401.00,N/A,2534.10,N/A,1496.34,N/A,616.14,N/A,616.14,N/A,4401.00,N/A,4401.00,N/A,382.89,N/A,616.14,N/A,616.14,N/A,616.14,N/A,2534.10,N/A,4401.00,N/A,616.14,N/A,4401.00,N/A,4401.00,N/A,616.14,N/A,4401.00,N/A,4401.00,N/A,4401.00,2640.60,2640.60,382.89,4401.00,,Hospital Custom 3609020400,HC Ileoscopy Dx W/Collj Spec When Prfmd,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609020800,HC Egd W/Eus Fna,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3629.00,3629.00,2177.40,2177.40,N/A,508.06,N/A,3629.00,N/A,2089.58,N/A,1233.86,N/A,508.06,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,315.72,N/A,508.06,N/A,508.06,N/A,508.06,N/A,2089.58,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,508.06,N/A,3629.00,N/A,3629.00,N/A,3629.00,2177.40,2177.40,315.72,3629.00,,Hospital Custom 3609079900,HC Cesarean Section,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,11822.00,11822.00,7093.20,7093.20,N/A,1655.08,N/A,11822.00,N/A,6807.11,N/A,4019.48,N/A,1655.08,N/A,1655.08,N/A,11822.00,N/A,11822.00,N/A,1028.51,N/A,1655.08,N/A,1655.08,N/A,1655.08,N/A,6807.11,N/A,11822.00,N/A,1655.08,N/A,11822.00,N/A,11822.00,N/A,1655.08,N/A,11822.00,N/A,11822.00,N/A,11822.00,7093.20,7093.20,1028.51,11822.00,,Hospital Custom 3609154900,HC Rectal Exam Under Anesthesia,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2837.00,2837.00,1702.20,1702.20,N/A,397.18,N/A,2837.00,N/A,1633.54,N/A,964.58,N/A,397.18,N/A,397.18,N/A,2837.00,N/A,2837.00,N/A,246.82,N/A,397.18,N/A,397.18,N/A,397.18,N/A,1633.54,N/A,2837.00,N/A,397.18,N/A,2837.00,N/A,2837.00,N/A,397.18,N/A,2837.00,N/A,2837.00,N/A,2837.00,1702.20,1702.20,246.82,2837.00,,Hospital Custom 3609155000,HC Colonoscopy Fecal Transplant,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3589.00,3589.00,2153.40,2153.40,N/A,502.46,N/A,3589.00,N/A,2066.55,N/A,1220.26,N/A,502.46,N/A,502.46,N/A,3589.00,N/A,3589.00,N/A,312.24,N/A,502.46,N/A,502.46,N/A,502.46,N/A,2066.55,N/A,3589.00,N/A,502.46,N/A,3589.00,N/A,3589.00,N/A,502.46,N/A,3589.00,N/A,3589.00,N/A,3589.00,2153.40,2153.40,312.24,3589.00,,Hospital Custom 3609155200,HC Colonoscopy W/Endoscopic Stent Placement,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3768.00,3768.00,2260.80,2260.80,N/A,527.52,N/A,3768.00,N/A,2169.61,N/A,1281.12,N/A,527.52,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,327.82,N/A,527.52,N/A,527.52,N/A,527.52,N/A,2169.61,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,527.52,N/A,3768.00,N/A,3768.00,N/A,3768.00,2260.80,2260.80,327.82,3768.00,,Hospital Custom 3609155300,HC Egd W Endoscopic Mucosal Resection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4007.00,4007.00,2404.20,2404.20,N/A,560.98,N/A,4007.00,N/A,2307.23,N/A,1362.38,N/A,560.98,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,348.61,N/A,560.98,N/A,560.98,N/A,560.98,N/A,2307.23,N/A,4007.00,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,560.98,N/A,4007.00,N/A,4007.00,N/A,4007.00,2404.20,2404.20,348.61,4007.00,,Hospital Custom 3609155600,HC Colonoscopy With Decompression,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,3949.00,3949.00,2369.40,2369.40,N/A,552.86,N/A,3949.00,N/A,2273.83,N/A,1342.66,N/A,552.86,N/A,552.86,N/A,3949.00,N/A,3949.00,N/A,343.56,N/A,552.86,N/A,552.86,N/A,552.86,N/A,2273.83,N/A,3949.00,N/A,552.86,N/A,3949.00,N/A,3949.00,N/A,552.86,N/A,3949.00,N/A,3949.00,N/A,3949.00,2369.40,2369.40,343.56,3949.00,,Hospital Custom 3609155800,HC Enteroscopy With Intervention,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,4591.00,4591.00,2754.60,2754.60,N/A,642.74,N/A,4591.00,N/A,2643.50,N/A,1560.94,N/A,642.74,N/A,642.74,N/A,4591.00,N/A,4591.00,N/A,399.42,N/A,642.74,N/A,642.74,N/A,642.74,N/A,2643.50,N/A,4591.00,N/A,642.74,N/A,4591.00,N/A,4591.00,N/A,642.74,N/A,4591.00,N/A,4591.00,N/A,4591.00,2754.60,2754.60,399.42,4591.00,,Hospital Custom 3609155900,HC Anoscopy Hemorroid Banding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2197.00,2197.00,1318.20,1318.20,N/A,307.58,N/A,2197.00,N/A,1265.03,N/A,746.98,N/A,307.58,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,191.14,N/A,307.58,N/A,307.58,N/A,307.58,N/A,1265.03,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,307.58,N/A,2197.00,N/A,2197.00,N/A,2197.00,1318.20,1318.20,191.14,2197.00,,Hospital Custom 3609156700,HC Proctosigmoidoscopy Dx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,2188.00,2188.00,1312.80,1312.80,N/A,306.32,N/A,2188.00,N/A,1259.85,N/A,743.92,N/A,306.32,N/A,306.32,N/A,2188.00,N/A,2188.00,N/A,190.36,N/A,306.32,N/A,306.32,N/A,306.32,N/A,1259.85,N/A,2188.00,N/A,306.32,N/A,2188.00,N/A,2188.00,N/A,306.32,N/A,2188.00,N/A,2188.00,N/A,2188.00,1312.80,1312.80,190.36,2188.00,,Hospital CPT 36140,HC Intro Ndl/Intracath in Ext Art,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,2082.00,2082.00,1249.20,1249.20,N/A,291.48,N/A,2082.00,N/A,1198.82,N/A,707.88,N/A,2082.00,N/A,291.48,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,1198.82,N/A,2082.00,N/A,291.48,N/A,527.00,N/A,527.00,N/A,291.48,N/A,2082.00,N/A,2082.00,N/A,94.56,1249.20,1249.20,94.56,2082.00,,Hospital CPT 36140,"HC Intro Catheter,Ext Artery",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2082.00,2082.00,1249.20,1249.20,N/A,291.48,N/A,2082.00,N/A,1198.82,N/A,707.88,N/A,2082.00,N/A,291.48,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,2082.00,N/A,1198.82,N/A,2082.00,N/A,291.48,N/A,527.00,N/A,527.00,N/A,291.48,N/A,2082.00,N/A,2082.00,N/A,94.56,1249.20,1249.20,94.56,2082.00,,Hospital CPT 36200,HC Intro Catheter Aorta,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3428.00,3428.00,2056.80,2056.80,N/A,479.92,N/A,3428.00,N/A,1973.84,N/A,1165.52,N/A,3428.00,N/A,479.92,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,1973.84,N/A,3428.00,N/A,479.92,N/A,527.00,N/A,527.00,N/A,479.92,N/A,3428.00,N/A,3428.00,N/A,3428.00,2056.80,2056.80,479.92,3428.00,,Hospital CPT 36200,HC Introduction of Catheter Aorta,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3428.00,3428.00,2056.80,2056.80,N/A,479.92,N/A,3428.00,N/A,1973.84,N/A,1165.52,N/A,3428.00,N/A,479.92,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,3428.00,N/A,1973.84,N/A,3428.00,N/A,479.92,N/A,527.00,N/A,527.00,N/A,479.92,N/A,3428.00,N/A,3428.00,N/A,3428.00,2056.80,2056.80,479.92,3428.00,,Hospital CPT 36215,HC Sel Cath Plcmt 1st Ord Thor Br,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2615.00,2615.00,1569.00,1569.00,N/A,366.10,N/A,2615.00,N/A,1505.72,N/A,889.10,N/A,2615.00,N/A,366.10,N/A,2615.00,N/A,2615.00,N/A,2615.00,N/A,2615.00,N/A,2615.00,N/A,2615.00,N/A,1505.72,N/A,2615.00,N/A,366.10,N/A,527.00,N/A,527.00,N/A,366.10,N/A,2615.00,N/A,2615.00,N/A,224.98,1569.00,1569.00,224.98,2615.00,,Hospital CPT 36218,HC Sel Cath Plcmt Add 2/3 Brach,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,296.00,296.00,177.60,177.60,N/A,41.44,N/A,296.00,N/A,170.44,N/A,100.64,N/A,296.00,N/A,41.44,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,296.00,N/A,170.44,N/A,296.00,N/A,41.44,N/A,527.00,N/A,527.00,N/A,41.44,N/A,296.00,N/A,296.00,N/A,54.37,177.60,177.60,41.44,527.00,,Hospital CPT 36221,HC Arch & Nonsel Car or Vert,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,10326.00,10326.00,6195.60,6195.60,N/A,1445.64,N/A,2782.36,N/A,5945.71,N/A,3510.84,N/A,6507.21,N/A,1445.64,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5945.71,N/A,2690.13,N/A,1445.64,N/A,4562.00,N/A,4562.00,N/A,1445.64,N/A,2690.13,N/A,2813.99,N/A,213.30,6195.60,6195.60,213.30,6507.21,,Hospital CPT 36221,HC Place Cath Thoracic Aorta,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,10326.00,10326.00,6195.60,6195.60,N/A,1445.64,N/A,2782.36,N/A,5945.71,N/A,3510.84,N/A,6507.21,N/A,1445.64,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5945.71,N/A,2690.13,N/A,1445.64,N/A,4562.00,N/A,4562.00,N/A,1445.64,N/A,2690.13,N/A,2813.99,N/A,213.30,6195.60,6195.60,213.30,6507.21,,Hospital CPT 36222,HC Arch & Uni Carotid Cervical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,12292.00,12292.00,7375.20,7375.20,N/A,1720.88,N/A,2746.07,N/A,7077.73,N/A,4179.28,N/A,6507.21,N/A,1720.88,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,7077.73,N/A,2690.13,N/A,1720.88,N/A,4562.00,N/A,4562.00,N/A,1720.88,N/A,2690.13,N/A,2813.99,N/A,299.87,7375.20,7375.20,299.87,7375.20,,Hospital CPT 36222,HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,12292.00,12292.00,7375.20,7375.20,N/A,1720.88,N/A,2746.07,N/A,7077.73,N/A,4179.28,N/A,6507.21,N/A,1720.88,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,7077.73,N/A,2690.13,N/A,1720.88,N/A,4562.00,N/A,4562.00,N/A,1720.88,N/A,2690.13,N/A,2813.99,N/A,299.87,7375.20,7375.20,299.87,7375.20,,Hospital CPT 36223,HC Arch & Car Cerv & Cerebral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,12292.00,12292.00,7375.20,7375.20,N/A,1720.88,N/A,4855.12,N/A,7077.73,N/A,4179.28,N/A,11227.17,N/A,1720.88,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,11227.17,N/A,11227.17,N/A,11227.17,N/A,7077.73,N/A,4641.41,N/A,1720.88,N/A,7897.00,N/A,7897.00,N/A,1720.88,N/A,4641.41,N/A,5029.36,N/A,338.65,7375.20,7375.20,338.65,11227.17,,Hospital CPT 36226,HC Place Cath Vertebral Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7943.00,7943.00,4765.80,4765.80,N/A,1112.02,N/A,4855.12,N/A,4573.58,N/A,2700.62,N/A,7943.00,N/A,1112.02,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,7943.00,N/A,7943.00,N/A,7943.00,N/A,4573.58,N/A,4641.41,N/A,1112.02,N/A,7897.00,N/A,7897.00,N/A,1112.02,N/A,4641.41,N/A,4855.12,N/A,377.84,4765.80,4765.80,377.84,7943.00,,Hospital CPT 36226,HC Arch Selected Vert,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,7943.00,7943.00,4765.80,4765.80,N/A,1112.02,N/A,4855.12,N/A,4573.58,N/A,2700.62,N/A,7943.00,N/A,1112.02,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,7943.00,N/A,7943.00,N/A,7943.00,N/A,4573.58,N/A,4641.41,N/A,1112.02,N/A,7897.00,N/A,7897.00,N/A,1112.02,N/A,4641.41,N/A,4855.12,N/A,377.84,4765.80,4765.80,377.84,7943.00,,Hospital CPT 36228,HC Add'l Internal Carotid/Vertebral Imaging,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,12339.00,12339.00,7403.40,7403.40,N/A,1727.46,N/A,12339.00,N/A,7104.80,N/A,4195.26,N/A,12339.00,N/A,1727.46,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,12339.00,N/A,7104.80,N/A,12339.00,N/A,1727.46,N/A,527.00,N/A,527.00,N/A,1727.46,N/A,12339.00,N/A,232.27,N/A,255.50,7403.40,7403.40,232.27,12339.00,,Hospital CPT 36247,HC 3rd Order Sel Abd/Lower Ext,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2126.00,2126.00,1275.60,1275.60,N/A,297.64,N/A,2126.00,N/A,1224.15,N/A,722.84,N/A,2126.00,N/A,297.64,N/A,2126.00,N/A,2126.00,N/A,2126.00,N/A,2126.00,N/A,2126.00,N/A,2126.00,N/A,1224.15,N/A,2126.00,N/A,297.64,N/A,527.00,N/A,527.00,N/A,297.64,N/A,2126.00,N/A,2126.00,N/A,2126.00,1275.60,1275.60,297.64,2126.00,,Hospital CPT 36248,HC Add 2nd/3rd Order Abd/Le,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,926.00,926.00,555.60,555.60,N/A,129.64,N/A,926.00,N/A,533.19,N/A,314.84,N/A,926.00,N/A,129.64,N/A,926.00,N/A,926.00,N/A,926.00,N/A,926.00,N/A,926.00,N/A,926.00,N/A,533.19,N/A,926.00,N/A,129.64,N/A,527.00,N/A,527.00,N/A,129.64,N/A,926.00,N/A,926.00,N/A,51.17,555.60,555.60,51.17,926.00,,Hospital CPT 36251,HC Renal Art 1st Order Uni,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,5461.00,5461.00,3276.60,3276.60,N/A,764.54,N/A,2813.99,N/A,3144.44,N/A,1856.74,N/A,5461.00,N/A,764.54,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5461.00,N/A,5461.00,N/A,5461.00,N/A,3144.44,N/A,2690.13,N/A,764.54,N/A,4562.00,N/A,4562.00,N/A,764.54,N/A,2690.13,N/A,2813.99,N/A,271.45,3276.60,3276.60,271.45,5461.00,,Hospital CPT 36251,HC Renal Art 1st Order Uni,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,5461.00,5461.00,3276.60,3276.60,N/A,764.54,N/A,2813.99,N/A,3144.44,N/A,1856.74,N/A,5461.00,N/A,764.54,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5461.00,N/A,5461.00,N/A,5461.00,N/A,3144.44,N/A,2690.13,N/A,764.54,N/A,4562.00,N/A,4562.00,N/A,764.54,N/A,2690.13,N/A,2813.99,N/A,271.45,3276.60,3276.60,271.45,5461.00,,Hospital CPT 36253,HC Renal Art 2nd Order Uni,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,5461.00,5461.00,3276.60,3276.60,N/A,764.54,N/A,4737.93,N/A,3144.44,N/A,1856.74,N/A,5461.00,N/A,764.54,N/A,4641.41,N/A,4641.41,N/A,5461.00,N/A,5461.00,N/A,5461.00,N/A,5461.00,N/A,3144.44,N/A,4641.41,N/A,764.54,N/A,7897.00,N/A,7897.00,N/A,764.54,N/A,4641.41,N/A,4737.93,N/A,375.77,3276.60,3276.60,375.77,7897.00,,Hospital CPT 36254,HC Renal Art 2nd Order Bil,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9090.00,9090.00,5454.00,5454.00,N/A,1272.60,N/A,2782.36,N/A,5234.02,N/A,3090.60,N/A,6507.21,N/A,1272.60,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5234.02,N/A,2690.13,N/A,1272.60,N/A,4562.00,N/A,4562.00,N/A,1272.60,N/A,2690.13,N/A,2782.36,N/A,434.12,5454.00,5454.00,434.12,6507.21,,Hospital 36261,Revj Implanted Intra-Arterial Infusion Pump,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16368.80,N/A,9821.28,N/A,2291.64,N/A,3058.80,N/A,9414.13,N/A,5565.40,N/A,7366.88,N/A,2291.64,N/A,3026.02,N/A,3026.02,N/A,4586.02,N/A,7366.88,N/A,7366.88,N/A,7366.88,N/A,9404.46,N/A,3026.02,N/A,2291.64,N/A,4562.00,N/A,4562.00,N/A,2291.64,N/A,3026.02,N/A,3058.80,N/A,432.38,N/A,N/A,432.38,9821.28,,Hospital CPT 36416,HC Capillary Puncture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,32.00,32.00,19.20,19.20,N/A,4.48,N/A,32.00,N/A,18.43,N/A,10.88,N/A,32.00,N/A,4.48,N/A,32.00,N/A,32.00,N/A,32.00,N/A,32.00,N/A,32.00,N/A,32.00,N/A,18.43,N/A,32.00,N/A,4.48,N/A,3.11,N/A,3.11,N/A,4.48,N/A,32.00,N/A,32.00,N/A,32.00,19.20,19.20,3.11,32.00,,Hospital 36455,"HC Exchange Transfusion, Blood",N/A,"0391 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - ADMINISTRATION (E.G., TRANS",N/A,11593.10,N/A,6955.86,N/A,1395.82,N/A,1629.93,N/A,6648.21,N/A,3941.65,N/A,3691.65,N/A,1395.82,N/A,1568.61,N/A,1568.61,N/A,2298.11,N/A,3691.65,N/A,3691.65,N/A,3691.65,N/A,6535.10,N/A,1568.61,N/A,1395.82,N/A,1746.80,N/A,1746.80,N/A,1395.82,N/A,1568.61,N/A,1629.93,N/A,357.75,N/A,N/A,357.75,6955.86,,Hospital CPT 36475,HC Endovenous Rf 1st Vein,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7674.00,7674.00,4604.40,4604.40,N/A,1074.36,N/A,2690.13,N/A,4418.69,N/A,2609.16,N/A,6507.21,N/A,1074.36,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,4418.69,N/A,2690.13,N/A,1074.36,N/A,4562.00,N/A,4562.00,N/A,1074.36,N/A,2690.13,N/A,2690.13,N/A,2959.14,4604.40,4604.40,1074.36,6507.21,,Hospital 36478,Endoven Abltj Incmptnt Vein Xtr Laser 1st Vein,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35410.97,N/A,21246.58,N/A,4922.22,N/A,2865.65,N/A,20388.08,N/A,12039.73,N/A,6520.42,N/A,4922.22,N/A,2694.06,N/A,2694.06,N/A,4059.08,N/A,6520.42,N/A,6520.42,N/A,6520.42,N/A,20388.08,N/A,2694.06,N/A,4922.22,N/A,4562.00,N/A,4562.00,N/A,4922.22,N/A,2694.06,N/A,2865.65,N/A,340.58,N/A,N/A,340.58,21246.58,,Hospital 36481,HC Portal Vein Catheterization,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,359606.28,52130.90,215763.77,31278.54,63230.84,7277.84,N/A,2139.25,55340.16,29954.36,N/A,17724.51,N/A,5178.54,63230.84,7277.84,N/A,2043.35,N/A,2043.35,N/A,3475.34,N/A,5178.54,N/A,5178.54,N/A,5178.54,55340.16,28907.55,N/A,1568.83,63230.84,7277.84,55340.16,2134.50,201117.72,2134.50,63230.84,7277.84,N/A,2043.35,N/A,2139.25,63230.84,1111.95,55340.16,215763.77,1111.95,31278.54,,Hospital 36522,HC Photopheresis,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,13798.00,N/A,8278.80,N/A,1931.72,N/A,3929.62,N/A,7944.89,N/A,4691.32,N/A,9087.02,N/A,1931.72,N/A,3756.65,N/A,3756.65,N/A,5656.85,N/A,9087.02,N/A,9087.02,N/A,9087.02,N/A,7944.89,N/A,3756.65,N/A,1931.72,N/A,7395.73,N/A,7395.73,N/A,1931.72,N/A,3756.65,N/A,3929.62,N/A,102.17,N/A,N/A,102.17,9087.02,,Hospital CPT 36555,HC Cv Cath Plac Nontun <5yr,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3650.00,3650.00,2190.00,2190.00,N/A,511.00,N/A,83.08,N/A,2101.67,N/A,1241.00,N/A,528.96,N/A,511.00,N/A,83.08,N/A,83.08,N/A,329.28,N/A,528.96,N/A,528.96,N/A,528.96,N/A,2101.67,N/A,83.08,N/A,511.00,N/A,3650.00,N/A,3650.00,N/A,511.00,N/A,83.08,N/A,83.08,N/A,91.39,2190.00,2190.00,83.08,3650.00,,Hospital CPT 36555,HC Central Ven Cath Under 5 Yrs,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3650.00,3650.00,2190.00,2190.00,N/A,511.00,N/A,83.08,N/A,2101.67,N/A,1241.00,N/A,528.96,N/A,511.00,N/A,83.08,N/A,83.08,N/A,329.28,N/A,528.96,N/A,528.96,N/A,528.96,N/A,2101.67,N/A,83.08,N/A,511.00,N/A,3650.00,N/A,3650.00,N/A,511.00,N/A,83.08,N/A,83.08,N/A,91.39,2190.00,2190.00,83.08,3650.00,,Hospital CPT 36556,HC Placement Central Venous Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5828.00,5828.00,3496.80,3496.80,N/A,815.92,N/A,2761.98,N/A,3355.76,N/A,1981.52,N/A,5828.00,N/A,815.92,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5828.00,N/A,5828.00,N/A,5828.00,N/A,3355.76,N/A,2690.13,N/A,815.92,N/A,1431.00,N/A,1431.00,N/A,815.92,N/A,2690.13,N/A,2690.13,N/A,2959.14,3496.80,3496.80,815.92,5828.00,,Hospital CPT 36556,HC Central Ven Cath 5+ Yrs,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5828.00,5828.00,3496.80,3496.80,N/A,815.92,N/A,2761.98,N/A,3355.76,N/A,1981.52,N/A,5828.00,N/A,815.92,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5828.00,N/A,5828.00,N/A,5828.00,N/A,3355.76,N/A,2690.13,N/A,815.92,N/A,5828.00,N/A,5828.00,N/A,815.92,N/A,2690.13,N/A,2690.13,N/A,2959.14,3496.80,3496.80,815.92,5828.00,,Hospital CPT 36556,HC Insert Central Line,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,5828.00,5828.00,3496.80,3496.80,N/A,815.92,N/A,2761.98,N/A,3355.76,N/A,1981.52,N/A,5828.00,N/A,815.92,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5828.00,N/A,5828.00,N/A,5828.00,N/A,3355.76,N/A,2690.13,N/A,815.92,N/A,3123.81,N/A,3123.81,N/A,815.92,N/A,2690.13,N/A,2690.13,N/A,2959.14,3496.80,3496.80,815.92,5828.00,,Hospital 36557,HC Cv Cath Plac WO Port <5yr(Tun),N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,85490.65,9232.00,51294.39,5539.20,5401.75,1291.56,15123.39,409.77,25037.02,5314.22,29066.82,3138.88,149103.86,9232.00,11452.20,1291.56,13408.05,4641.41,13408.05,4641.41,149103.86,6996.03,149103.86,9232.00,149103.86,9232.00,149103.86,9232.00,40536.14,5294.54,13408.05,4641.41,11452.20,1291.56,40536.14,7897.00,30072.74,7897.00,11452.20,1291.56,13408.05,4641.41,15123.39,409.77,12253.85,450.76,5401.75,149103.86,409.77,9232.00,,Hospital CPT 36558,HC Insert Tun Vad No Port or Pump,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,13524.00,13524.00,8114.40,8114.40,N/A,1893.36,N/A,2690.13,N/A,7787.12,N/A,4598.16,N/A,6507.21,N/A,1893.36,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,7787.12,N/A,2690.13,N/A,1893.36,N/A,4562.00,N/A,4562.00,N/A,1893.36,N/A,2690.13,N/A,2690.13,N/A,2959.14,8114.40,8114.40,1893.36,8114.40,,Hospital 36560,HC Cv Cath Plac W/Port Tun <5,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,226978.42,15803.30,136187.05,9481.98,10376.71,2212.46,13175.98,2967.53,166691.73,9063.98,220532.14,5373.12,220532.14,6521.27,10376.71,2212.46,13175.98,2690.13,13175.98,2690.13,220532.14,4059.61,220532.14,6521.27,220532.14,6521.27,220532.14,6521.27,166691.73,9021.82,13175.98,2690.13,10376.71,2212.46,166691.73,4562.00,166691.73,4562.00,10376.71,2212.46,13175.98,2690.13,13175.98,465.14,10376.71,511.66,10376.71,220532.14,465.14,9481.98,,Hospital CPT 36568,"HC Insert Picc Cath, <5 Yrs",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4635.00,4635.00,2781.00,2781.00,N/A,648.90,N/A,89.55,N/A,2668.83,N/A,1575.90,N/A,3250.03,N/A,648.90,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2668.83,N/A,1343.59,N/A,648.90,N/A,1431.00,N/A,1431.00,N/A,648.90,N/A,1343.59,N/A,89.55,N/A,98.51,2781.00,2781.00,89.55,3250.03,,Hospital CPT 36569,HC Insert Picc Cath,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4239.00,4239.00,2543.40,2543.40,N/A,593.46,N/A,1343.59,N/A,2440.82,N/A,1441.26,N/A,3250.03,N/A,593.46,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2440.82,N/A,1343.59,N/A,593.46,N/A,4239.00,N/A,4239.00,N/A,593.46,N/A,1343.59,N/A,1343.59,N/A,1477.95,2543.40,2543.40,593.46,4239.00,,Hospital CPT 36569,"HC Insert Picc Cath, 5/> Yrs",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4239.00,4239.00,2543.40,2543.40,N/A,593.46,N/A,1343.59,N/A,2440.82,N/A,1441.26,N/A,3250.03,N/A,593.46,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2440.82,N/A,1343.59,N/A,593.46,N/A,1431.00,N/A,1431.00,N/A,593.46,N/A,1343.59,N/A,1343.59,N/A,1477.95,2543.40,2543.40,593.46,3250.03,,Hospital CPT 36575,HC Repair Cv Cath WO Subq Port or Pump,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1974.00,1974.00,1184.40,1184.40,N/A,276.36,N/A,536.36,N/A,1136.63,N/A,671.16,N/A,1263.67,N/A,276.36,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1136.63,N/A,522.41,N/A,276.36,N/A,1974.00,N/A,1974.00,N/A,276.36,N/A,522.41,N/A,536.36,N/A,35.96,1184.40,1184.40,35.96,1974.00,,Hospital CPT 36575,HC Repair Vad,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2028.00,2028.00,1216.80,1216.80,N/A,283.92,N/A,536.36,N/A,1167.72,N/A,689.52,N/A,1263.67,N/A,283.92,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,1167.72,N/A,522.41,N/A,283.92,N/A,1431.00,N/A,1431.00,N/A,283.92,N/A,522.41,N/A,536.36,N/A,35.96,1216.80,1216.80,35.96,1431.00,,Hospital CPT 36578,HC Replace Cv Cath Only,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7572.00,7572.00,4543.20,4543.20,N/A,1060.08,N/A,193.86,N/A,4359.96,N/A,2574.48,N/A,1198.71,N/A,1060.08,N/A,193.86,N/A,193.86,N/A,746.20,N/A,1198.71,N/A,1198.71,N/A,1198.71,N/A,4359.96,N/A,193.86,N/A,1060.08,N/A,7572.00,N/A,7572.00,N/A,1060.08,N/A,193.86,N/A,193.86,N/A,213.25,4543.20,4543.20,193.86,7572.00,,Hospital CPT 36581,HC Replace Tunneled Catheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,12298.00,12298.00,7378.80,7378.80,N/A,1721.72,N/A,2690.13,N/A,7081.19,N/A,4181.32,N/A,6507.21,N/A,1721.72,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,7081.19,N/A,2690.13,N/A,1721.72,N/A,4562.00,N/A,4562.00,N/A,1721.72,N/A,2690.13,N/A,2690.13,N/A,2959.14,7378.80,7378.80,1721.72,7378.80,,Hospital CPT 36582,HC Replac Central Tun Cath W/Port,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6939.00,6939.00,4163.40,4163.40,N/A,971.46,N/A,276.09,N/A,3995.48,N/A,2359.26,N/A,6507.21,N/A,971.46,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,3995.48,N/A,2690.13,N/A,971.46,N/A,4562.00,N/A,4562.00,N/A,971.46,N/A,2690.13,N/A,276.09,N/A,303.70,4163.40,4163.40,276.09,6507.21,,Hospital CPT 36582,Rplcmt Compl Tun Ctr Vad W/Subq Port,N/A,N/A,1890.00,1890.00,1134.00,1134.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,N/A,1890.00,1134.00,1134.00,1134.00,1890.00,,Hospital 36583,Rplcmt Compl Tun Ctr Vad W/Subq Pmp,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65731.60,N/A,39438.96,N/A,9201.29,N/A,4765.38,N/A,37228.32,N/A,22348.74,N/A,11272.54,N/A,9201.29,N/A,4641.41,N/A,4641.41,N/A,7017.38,N/A,11272.54,N/A,11272.54,N/A,11272.54,N/A,37228.32,N/A,4641.41,N/A,9201.29,N/A,7897.00,N/A,7897.00,N/A,9201.29,N/A,4641.41,N/A,4765.38,N/A,370.41,N/A,N/A,370.41,39438.96,,Hospital CPT 36584,HC Replace Picc via Same Access,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4919.00,4919.00,2951.40,2951.40,N/A,688.66,N/A,1482.14,N/A,2832.36,N/A,1672.46,N/A,3250.03,N/A,688.66,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2832.36,N/A,1343.59,N/A,688.66,N/A,1431.00,N/A,1431.00,N/A,688.66,N/A,1343.59,N/A,56.70,N/A,62.37,2951.40,2951.40,56.70,3250.03,,Hospital CPT 36584,HC Replace Picc Same Access,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4919.00,4919.00,2951.40,2951.40,N/A,688.66,N/A,1482.14,N/A,2832.36,N/A,1672.46,N/A,3250.03,N/A,688.66,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2832.36,N/A,1343.59,N/A,688.66,N/A,1431.00,N/A,1431.00,N/A,688.66,N/A,1343.59,N/A,56.70,N/A,62.37,2951.40,2951.40,56.70,3250.03,,Hospital 36585,Rplcmt Compl Prph Ctr Vad W/Subq Port,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16500.08,N/A,9900.05,N/A,2310.01,N/A,2967.53,N/A,9464.95,N/A,5601.86,N/A,6539.11,N/A,2310.01,N/A,2690.13,N/A,2690.13,N/A,4070.72,N/A,6539.11,N/A,6539.11,N/A,6539.11,N/A,9464.97,N/A,2690.13,N/A,2310.01,N/A,4562.00,N/A,4562.00,N/A,2310.01,N/A,2690.13,N/A,269.87,N/A,296.86,N/A,N/A,269.87,9900.05,,Hospital CPT 36589,HC Rem Central Venous Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7201.00,7201.00,4320.60,4320.60,N/A,1008.14,N/A,522.41,N/A,4146.34,N/A,2448.34,N/A,1263.67,N/A,1008.14,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,4146.34,N/A,522.41,N/A,1008.14,N/A,1431.00,N/A,1431.00,N/A,1008.14,N/A,522.41,N/A,522.41,N/A,574.65,4320.60,4320.60,522.41,4320.60,,Hospital CPT 36589,HC Remove Tunneled Central Cath,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,7201.00,7201.00,4320.60,4320.60,N/A,1008.14,N/A,522.41,N/A,4146.34,N/A,2448.34,N/A,1263.67,N/A,1008.14,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,4146.34,N/A,522.41,N/A,1008.14,N/A,1431.00,N/A,1431.00,N/A,1008.14,N/A,522.41,N/A,522.41,N/A,574.65,4320.60,4320.60,522.41,4320.60,,Hospital CPT 36592,HC Blood Draw per Picc/Cl,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,370.00,370.00,222.00,222.00,N/A,51.80,N/A,104.85,N/A,213.05,N/A,125.80,N/A,253.64,N/A,51.80,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,213.05,N/A,104.85,N/A,51.80,N/A,198.32,N/A,198.32,N/A,51.80,N/A,104.85,N/A,104.85,N/A,115.34,222.00,222.00,51.80,253.64,,Hospital 36596,HC Mech Rem Intracath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,28650.88,N/A,17190.53,N/A,4011.11,N/A,2861.72,N/A,16474.58,N/A,9741.29,N/A,6523.72,N/A,4011.11,N/A,2690.13,N/A,2690.13,N/A,4061.12,N/A,6523.72,N/A,6523.72,N/A,6523.72,N/A,16474.58,N/A,2690.13,N/A,4011.11,N/A,5277.50,N/A,5277.50,N/A,4011.11,N/A,2690.13,N/A,2861.72,N/A,548.56,N/A,N/A,548.56,17190.53,,Hospital CPT 36600,HC Arterial Puncture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,139.00,139.00,83.40,83.40,N/A,19.46,N/A,104.85,N/A,80.04,N/A,47.26,N/A,139.00,N/A,19.46,N/A,104.85,N/A,104.85,N/A,139.00,N/A,139.00,N/A,139.00,N/A,139.00,N/A,80.04,N/A,104.85,N/A,19.46,N/A,139.00,N/A,139.00,N/A,19.46,N/A,104.85,N/A,104.85,N/A,115.34,83.40,83.40,19.46,139.00,,Hospital CPT 36620,HC Arterial Line Insertion,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,1339.00,1339.00,803.40,803.40,N/A,187.46,N/A,43.20,N/A,771.00,N/A,455.26,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,771.00,N/A,1339.00,N/A,187.46,N/A,717.70,N/A,717.70,N/A,187.46,N/A,1339.00,N/A,43.20,N/A,47.52,803.40,803.40,43.20,1339.00,,Hospital CPT 36620,HC a Line Insertion,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1339.00,1339.00,803.40,803.40,N/A,187.46,N/A,43.20,N/A,771.00,N/A,455.26,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,771.00,N/A,1339.00,N/A,187.46,N/A,717.70,N/A,717.70,N/A,187.46,N/A,1339.00,N/A,43.20,N/A,47.52,803.40,803.40,43.20,1339.00,,Hospital CPT 36620,HC Arterial Line Insertion,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1339.00,1339.00,803.40,803.40,N/A,187.46,N/A,43.20,N/A,771.00,N/A,455.26,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,771.00,N/A,1339.00,N/A,187.46,N/A,527.00,N/A,527.00,N/A,187.46,N/A,1339.00,N/A,43.20,N/A,47.52,803.40,803.40,43.20,1339.00,,Hospital CPT 36620,HC Arterial Sampling/Monitoring,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1339.00,1339.00,803.40,803.40,N/A,187.46,N/A,43.20,N/A,771.00,N/A,455.26,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,1339.00,N/A,771.00,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,1339.00,N/A,187.46,N/A,1339.00,N/A,43.20,N/A,47.52,803.40,803.40,43.20,1339.00,,Hospital 36640,Artl Cathj Prolng Nfs Ther Chemotx Cutdown,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,21876.03,N/A,13125.62,N/A,3977.49,N/A,4970.81,N/A,10571.46,N/A,7437.85,N/A,9401.27,N/A,4100.05,N/A,4970.81,N/A,4970.81,N/A,5852.21,N/A,9401.27,N/A,9401.27,N/A,9401.27,N/A,10571.46,N/A,4970.81,N/A,4100.05,N/A,10766.46,N/A,10766.46,N/A,N/A,N/A,4970.81,N/A,5000.46,N/A,4387.05,N/A,3977.49,13125.62,N/A,N/A,,Hospital CPT 36660,HC Cath Umbil Cord Artery,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,189.00,189.00,113.40,113.40,N/A,26.46,N/A,66.66,N/A,108.83,N/A,64.26,N/A,189.00,N/A,26.46,N/A,66.66,N/A,66.66,N/A,189.00,N/A,189.00,N/A,189.00,N/A,189.00,N/A,108.83,N/A,66.66,N/A,26.46,N/A,189.00,N/A,189.00,N/A,26.46,N/A,66.66,N/A,66.66,N/A,73.33,113.40,113.40,26.46,189.00,,Hospital 36819,Arven Anast Opn Upr Arm Basilic Vein Trpos,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28951.50,N/A,17370.90,N/A,4035.57,N/A,4641.41,N/A,16666.92,N/A,9843.51,N/A,11321.70,N/A,4035.57,N/A,4641.41,N/A,4641.41,N/A,7047.98,N/A,11321.70,N/A,11321.70,N/A,11321.70,N/A,16666.92,N/A,4641.41,N/A,4035.57,N/A,7897.00,N/A,7897.00,N/A,4035.57,N/A,4641.41,N/A,4641.41,N/A,5105.55,N/A,N/A,4035.57,17370.90,,Hospital 36838,Dstl Revsc&Interval Lig Uxtr Hemo Access,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24115.90,N/A,14469.54,N/A,3332.46,N/A,1922.31,N/A,13871.70,N/A,8199.41,N/A,11284.72,N/A,3332.46,N/A,4641.41,N/A,4641.41,N/A,7024.94,N/A,11284.72,N/A,11284.72,N/A,11284.72,N/A,13871.72,N/A,4641.41,N/A,3332.46,N/A,11845.50,N/A,11845.50,N/A,3332.46,N/A,4641.41,N/A,1922.31,N/A,2108.42,N/A,N/A,1922.31,14469.54,,Hospital 36861,Xtrnl Cannula Decltng Spx W/Balo Cath,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24102.30,N/A,14461.38,N/A,3359.28,N/A,160.68,N/A,13866.81,N/A,8194.78,N/A,11268.66,N/A,3359.28,N/A,4641.41,N/A,4641.41,N/A,7014.96,N/A,11268.66,N/A,11268.66,N/A,11268.66,N/A,13866.81,N/A,4641.41,N/A,3359.28,N/A,7897.00,N/A,7897.00,N/A,3359.28,N/A,4641.41,N/A,160.68,N/A,176.76,N/A,N/A,160.68,14461.38,,Hospital CPT 36903,HC Intro Cath Dialysis Circuit W Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,20160.00,20160.00,12096.00,12096.00,N/A,2822.40,N/A,10027.43,N/A,11608.13,N/A,6854.40,N/A,20160.00,N/A,2822.40,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,20160.00,N/A,20160.00,N/A,20160.00,N/A,11608.13,N/A,9586.05,N/A,2822.40,N/A,11660.00,N/A,11660.00,N/A,2822.40,N/A,9586.05,N/A,9586.05,N/A,334.62,12096.00,12096.00,334.62,20160.00,,Hospital CPT 36903,HC Intro Cath Dialysis Circuit W Stent -Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,20160.00,20160.00,12096.00,12096.00,N/A,2822.40,N/A,10027.43,N/A,11608.13,N/A,6854.40,N/A,20160.00,N/A,2822.40,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,20160.00,N/A,20160.00,N/A,20160.00,N/A,11608.13,N/A,9586.05,N/A,2822.40,N/A,11660.00,N/A,11660.00,N/A,2822.40,N/A,9586.05,N/A,9586.05,N/A,334.62,12096.00,12096.00,334.62,20160.00,,Hospital CPT 36905,HC Thrmbc/Nfs Dialysis W Pta,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,18563.00,17632.00,11137.80,10579.20,N/A,2468.48,N/A,427.60,N/A,10152.51,N/A,5994.88,N/A,17632.00,N/A,2468.48,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,17632.00,N/A,17632.00,N/A,17632.00,N/A,10152.51,N/A,9586.05,N/A,2468.48,N/A,11660.00,N/A,11660.00,N/A,2468.48,N/A,9586.05,N/A,427.60,N/A,470.36,11137.80,11137.80,427.60,17632.00,,Hospital CPT 36905,HC Thrmbc/Nfs Dialysis W Pta - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,18563.00,17632.00,11137.80,10579.20,N/A,2468.48,N/A,427.60,N/A,10152.51,N/A,5994.88,N/A,17632.00,N/A,2468.48,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,17632.00,N/A,17632.00,N/A,17632.00,N/A,10152.51,N/A,9586.05,N/A,2468.48,N/A,11660.00,N/A,11660.00,N/A,2468.48,N/A,9586.05,N/A,427.60,N/A,470.36,11137.80,11137.80,427.60,17632.00,,Hospital CPT 36906,HC Thrmbc/Nfs Dialysis W Stent - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,24971.00,24971.00,14982.60,14982.60,N/A,3495.94,N/A,15834.66,N/A,14378.30,N/A,8490.14,N/A,24971.00,N/A,3495.94,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,24971.00,N/A,24971.00,N/A,24971.00,N/A,14378.30,N/A,15512.06,N/A,3495.94,N/A,37100.00,N/A,37100.00,N/A,3495.94,N/A,15512.06,N/A,15834.66,N/A,540.94,14982.60,14982.60,540.94,37100.00,,Hospital CPT 36906,HC Thrmbc/Nfs Dialysis W Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,24971.00,24971.00,14982.60,14982.60,N/A,3495.94,N/A,15834.66,N/A,14378.30,N/A,8490.14,N/A,24971.00,N/A,3495.94,N/A,15512.06,N/A,15512.06,N/A,23358.41,N/A,24971.00,N/A,24971.00,N/A,24971.00,N/A,14378.30,N/A,15512.06,N/A,3495.94,N/A,37100.00,N/A,37100.00,N/A,3495.94,N/A,15512.06,N/A,15834.66,N/A,540.94,14982.60,14982.60,540.94,37100.00,,Hospital Custom 3700000000,HC Anesthesia Attended Care,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,702.00,702.00,421.20,421.20,N/A,98.28,N/A,702.00,N/A,404.21,N/A,238.68,N/A,98.28,N/A,98.28,N/A,702.00,N/A,702.00,N/A,61.07,N/A,98.28,N/A,98.28,N/A,98.28,N/A,404.21,N/A,702.00,N/A,98.28,N/A,376.27,N/A,376.27,N/A,98.28,N/A,702.00,N/A,702.00,N/A,702.00,421.20,421.20,61.07,702.00,,Hospital Custom 3700000025,HC Labor and Delivery Epidural,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,704.00,704.00,422.40,422.40,N/A,98.56,N/A,704.00,N/A,405.36,N/A,239.36,N/A,98.56,N/A,98.56,N/A,704.00,N/A,704.00,N/A,61.25,N/A,98.56,N/A,98.56,N/A,98.56,N/A,405.36,N/A,704.00,N/A,98.56,N/A,377.34,N/A,377.34,N/A,98.56,N/A,704.00,N/A,704.00,N/A,704.00,422.40,422.40,61.25,704.00,,Hospital 37182,HC Tips,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,169274.47,120038.73,101564.68,72023.24,23417.33,16474.41,25261.10,1014.75,110171.98,68282.09,54788.32,40813.17,54788.32,27406.75,23417.33,16474.41,25261.10,2370.02,25261.10,2370.02,54788.32,17060.98,54788.32,27406.75,54788.32,27406.75,54788.32,27406.75,110171.98,68056.97,25261.10,2370.02,23417.33,16474.41,110171.98,12595.50,110171.98,12595.50,23417.33,16474.41,25261.10,2370.02,25261.10,1014.75,23417.33,1103.99,23417.33,110171.98,1014.75,72023.24,,Hospital 37183,HC Tips Revision,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,96350.43,40200.07,57810.26,24120.04,18584.75,5613.06,22250.45,401.51,41882.24,23139.08,32759.15,13668.02,N/A,11418.21,19157.38,5613.06,2810.00,4709.71,2810.00,4709.71,27344.35,7108.06,43927.23,11418.21,43927.23,11418.21,43927.23,11418.21,41882.24,23139.08,22250.45,4709.71,19157.38,5613.06,50306.07,11660.00,50306.07,11660.00,19157.38,5613.06,22250.45,4709.71,22250.45,401.51,20498.40,441.67,2810.00,57810.26,401.51,24120.04,,Hospital CPT 37184,HC Thromb Mech 1st Vssl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,12892.00,12892.00,7735.20,7735.20,N/A,1804.88,N/A,10027.43,N/A,7423.21,N/A,4383.28,N/A,12892.00,N/A,1804.88,N/A,9586.05,N/A,9586.05,N/A,12892.00,N/A,12892.00,N/A,12892.00,N/A,12892.00,N/A,7423.21,N/A,9586.05,N/A,1804.88,N/A,7897.00,N/A,7897.00,N/A,1804.88,N/A,9586.05,N/A,10027.43,N/A,454.81,7735.20,7735.20,454.81,12892.00,,Hospital CPT 37187,HC Thromb Mech Vein,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,10842.00,10842.00,6505.20,6505.20,N/A,1517.88,N/A,10027.43,N/A,6242.82,N/A,3686.28,N/A,10842.00,N/A,1517.88,N/A,9586.05,N/A,9586.05,N/A,10842.00,N/A,10842.00,N/A,10842.00,N/A,10842.00,N/A,6242.82,N/A,9586.05,N/A,1517.88,N/A,7897.00,N/A,7897.00,N/A,1517.88,N/A,9586.05,N/A,377.26,N/A,414.99,6505.20,6505.20,377.26,10842.00,,Hospital CPT 37193,HC Remove Ivc Filter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,6325.00,6325.00,3795.00,3795.00,N/A,885.50,N/A,2761.98,N/A,3641.94,N/A,2150.50,N/A,6325.00,N/A,885.50,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6325.00,N/A,6325.00,N/A,6325.00,N/A,3641.94,N/A,2690.13,N/A,885.50,N/A,4562.00,N/A,4562.00,N/A,885.50,N/A,2690.13,N/A,333.88,N/A,367.27,3795.00,3795.00,333.88,6325.00,,Hospital CPT 37195,HC Thrombolytic Ther Stroke,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1475.00,1475.00,885.00,885.00,N/A,206.50,N/A,1475.00,N/A,849.31,N/A,501.50,N/A,206.50,N/A,206.50,N/A,1475.00,N/A,1475.00,N/A,128.33,N/A,206.50,N/A,206.50,N/A,206.50,N/A,849.31,N/A,1475.00,N/A,206.50,N/A,1475.00,N/A,1475.00,N/A,206.50,N/A,1475.00,N/A,1475.00,N/A,1475.00,885.00,885.00,128.33,1475.00,,Hospital CPT 37211,HC Trancath Thx Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,12849.00,12849.00,7709.40,7709.40,N/A,1798.86,N/A,371.42,N/A,7398.45,N/A,4368.66,N/A,11227.17,N/A,1798.86,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,11227.17,N/A,11227.17,N/A,11227.17,N/A,7398.45,N/A,4641.41,N/A,1798.86,N/A,7897.00,N/A,7897.00,N/A,1798.86,N/A,4641.41,N/A,371.42,N/A,408.56,7709.40,7709.40,371.42,11227.17,,Hospital CPT 37213,HC Trancath Art or Vein @ Add,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4767.00,4767.00,2860.20,2860.20,N/A,667.38,N/A,223.39,N/A,2744.84,N/A,1620.78,N/A,657.48,N/A,667.38,N/A,223.39,N/A,223.39,N/A,409.28,N/A,657.48,N/A,657.48,N/A,657.48,N/A,2744.84,N/A,223.39,N/A,667.38,N/A,4767.00,N/A,4767.00,N/A,667.38,N/A,223.39,N/A,223.39,N/A,245.73,2860.20,2860.20,223.39,4767.00,,Hospital CPT 37214,HC Trancath Thx Cessation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,4767.00,4767.00,2860.20,2860.20,N/A,667.38,N/A,117.15,N/A,2744.84,N/A,1620.78,N/A,347.97,N/A,667.38,N/A,117.15,N/A,117.15,N/A,216.61,N/A,347.97,N/A,347.97,N/A,347.97,N/A,2744.84,N/A,117.15,N/A,667.38,N/A,4767.00,N/A,4767.00,N/A,667.38,N/A,117.15,N/A,117.15,N/A,128.87,2860.20,2860.20,117.15,4767.00,,Hospital CPT 37215,HC Transcath Stent Cca W/Eps,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,32382.00,32382.00,19429.20,19429.20,N/A,4533.48,N/A,950.65,N/A,18645.56,N/A,11009.88,N/A,6462.86,N/A,4533.48,N/A,950.65,N/A,950.65,N/A,4023.26,N/A,6462.86,N/A,6462.86,N/A,6462.86,N/A,18645.56,N/A,950.65,N/A,4533.48,N/A,1643.00,N/A,1643.00,N/A,4533.48,N/A,950.65,N/A,950.65,N/A,1045.72,19429.20,19429.20,950.65,19429.20,,Hospital CPT 37216,"HC Transcath Stent Cerv,Carotid W/O Eps",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,34104.00,34104.00,20462.40,20462.40,N/A,4774.56,N/A,34104.00,N/A,19637.08,N/A,11595.36,N/A,4774.56,N/A,4774.56,N/A,34104.00,N/A,34104.00,N/A,2967.05,N/A,4774.56,N/A,4774.56,N/A,4774.56,N/A,19637.08,N/A,34104.00,N/A,4774.56,N/A,34104.00,N/A,34104.00,N/A,4774.56,N/A,34104.00,N/A,34104.00,N/A,34104.00,20462.40,20462.40,2967.05,34104.00,,Hospital CPT 37218,HC Stent Placemnt Innominate Artery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,28032.00,28032.00,16819.20,16819.20,N/A,3924.48,N/A,782.24,N/A,16140.83,N/A,9530.88,N/A,6462.86,N/A,3924.48,N/A,782.24,N/A,782.24,N/A,4023.26,N/A,6462.86,N/A,6462.86,N/A,6462.86,N/A,16140.83,N/A,782.24,N/A,3924.48,N/A,28032.00,N/A,28032.00,N/A,3924.48,N/A,782.24,N/A,782.24,N/A,860.46,16819.20,16819.20,782.24,28032.00,,Hospital CPT 37221,HC Plasty Iliac W Stent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,17160.00,17160.00,10296.00,10296.00,N/A,2402.40,N/A,9586.05,N/A,9880.73,N/A,5834.40,N/A,17160.00,N/A,2402.40,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,17160.00,N/A,17160.00,N/A,17160.00,N/A,9880.73,N/A,9586.05,N/A,2402.40,N/A,11660.00,N/A,11660.00,N/A,2402.40,N/A,9586.05,N/A,9586.05,N/A,10544.65,10296.00,10296.00,2402.40,17160.00,,Hospital CPT 37225,HC Atherectomy Fem/Pop,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,16255.00,16255.00,9753.00,9753.00,N/A,2275.70,N/A,9586.05,N/A,9359.63,N/A,5526.70,N/A,16255.00,N/A,2275.70,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,16255.00,N/A,16255.00,N/A,16255.00,N/A,9359.63,N/A,9586.05,N/A,2275.70,N/A,11660.00,N/A,11660.00,N/A,2275.70,N/A,9586.05,N/A,9586.05,N/A,10544.65,9753.00,9753.00,2275.70,16255.00,,Hospital CPT 37226,HC Fempop Plasty & Stent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,19589.00,19589.00,11753.40,11753.40,N/A,2742.46,N/A,9586.05,N/A,11279.35,N/A,6660.26,N/A,19589.00,N/A,2742.46,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,19589.00,N/A,19589.00,N/A,19589.00,N/A,11279.35,N/A,9586.05,N/A,2742.46,N/A,11660.00,N/A,11660.00,N/A,2742.46,N/A,9586.05,N/A,9586.05,N/A,10544.65,11753.40,11753.40,2742.46,19589.00,,Hospital CPT 37230,HC Tib/per Plasty & Stent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,19589.00,19589.00,11753.40,11753.40,N/A,2742.46,N/A,15834.66,N/A,11279.35,N/A,6660.26,N/A,19589.00,N/A,2742.46,N/A,15512.06,N/A,15512.06,N/A,19589.00,N/A,19589.00,N/A,19589.00,N/A,19589.00,N/A,11279.35,N/A,15512.06,N/A,2742.46,N/A,11660.00,N/A,11660.00,N/A,2742.46,N/A,15512.06,N/A,15834.66,N/A,735.30,11753.40,11753.40,735.30,19589.00,,Hospital 37231,HC Tib per Terr Ather and Stent,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,92984.97,N/A,55790.98,N/A,13011.26,N/A,873.71,N/A,53468.61,N/A,31614.89,N/A,38456.31,N/A,13011.26,N/A,15512.06,N/A,15512.06,N/A,23939.78,N/A,38456.31,N/A,38456.31,N/A,38456.31,N/A,53468.61,N/A,15512.06,N/A,13011.26,N/A,37100.00,N/A,37100.00,N/A,13011.26,N/A,15512.06,N/A,873.71,N/A,961.09,N/A,N/A,873.71,55790.98,,Hospital CPT 37232,HC Plasty Tibper Ea Addl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,7985.00,7985.00,4791.00,4791.00,N/A,1117.90,N/A,7985.00,N/A,4597.76,N/A,2714.90,N/A,7985.00,N/A,1117.90,N/A,7985.00,N/A,7985.00,N/A,7985.00,N/A,7985.00,N/A,7985.00,N/A,7985.00,N/A,4597.76,N/A,7985.00,N/A,1117.90,N/A,7897.00,N/A,7897.00,N/A,1117.90,N/A,7985.00,N/A,7985.00,N/A,210.55,4791.00,4791.00,210.55,7985.00,,Hospital CPT 37242,HC Embolization Artery Angio,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,21819.00,21819.00,13091.40,13091.40,N/A,3054.66,N/A,9842.09,N/A,12563.38,N/A,7418.46,N/A,21819.00,N/A,3054.66,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,21819.00,N/A,21819.00,N/A,21819.00,N/A,12563.38,N/A,9586.05,N/A,3054.66,N/A,11660.00,N/A,11660.00,N/A,3054.66,N/A,9586.05,N/A,457.04,N/A,502.74,13091.40,13091.40,457.04,21819.00,,Hospital CPT 37243,HC Vasc Embolize Occlude Organ,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,29287.00,29287.00,17572.20,17572.20,N/A,4100.18,N/A,10027.43,N/A,16863.45,N/A,9957.58,N/A,23187.86,N/A,4100.18,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,23187.86,N/A,23187.86,N/A,23187.86,N/A,16863.45,N/A,9586.05,N/A,4100.18,N/A,11660.00,N/A,11660.00,N/A,4100.18,N/A,9586.05,N/A,537.61,N/A,591.37,17572.20,17572.20,537.61,23187.86,,Hospital CPT 37247,HC Trluml Balo Angiop Addl Art,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,11168.00,9842.00,6700.80,5905.20,N/A,1377.88,N/A,9842.00,N/A,5667.02,N/A,3346.28,N/A,9842.00,N/A,1377.88,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,5667.02,N/A,9842.00,N/A,1377.88,N/A,527.00,N/A,527.00,N/A,1377.88,N/A,9842.00,N/A,9842.00,N/A,180.37,6700.80,6700.80,180.37,9842.00,,Hospital CPT 37247,HC Trluml Balo Angiop Addl Art - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11168.00,9842.00,6700.80,5905.20,N/A,1377.88,N/A,9842.00,N/A,5667.02,N/A,3346.28,N/A,9842.00,N/A,1377.88,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,9842.00,N/A,5667.02,N/A,9842.00,N/A,1377.88,N/A,527.00,N/A,527.00,N/A,1377.88,N/A,9842.00,N/A,9842.00,N/A,180.37,6700.80,6700.80,180.37,9842.00,,Hospital CPT 37248,HC Trluml Balo Angiop 1st Vein - Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,9291.00,8360.00,5574.60,5016.00,N/A,1170.40,N/A,286.08,N/A,4813.69,N/A,2842.40,N/A,8360.00,N/A,1170.40,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,4813.69,N/A,4709.71,N/A,1170.40,N/A,7897.00,N/A,7897.00,N/A,1170.40,N/A,4709.71,N/A,4871.18,N/A,314.69,5574.60,5574.60,286.08,8360.00,,Hospital CPT 37248,HC Trluml Balo Angiop 1st Vein,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9291.00,8360.00,5574.60,5016.00,N/A,1170.40,N/A,286.08,N/A,4813.69,N/A,2842.40,N/A,8360.00,N/A,1170.40,N/A,4709.71,N/A,4709.71,N/A,7092.00,N/A,8360.00,N/A,8360.00,N/A,8360.00,N/A,4813.69,N/A,4709.71,N/A,1170.40,N/A,7897.00,N/A,7897.00,N/A,1170.40,N/A,4709.71,N/A,4871.18,N/A,314.69,5574.60,5574.60,286.08,8360.00,,Hospital CPT 37252,HC Intrvasc US Noncoronary 1st,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,973.00,973.00,583.80,583.80,N/A,136.22,N/A,973.00,N/A,560.25,N/A,330.82,N/A,973.00,N/A,136.22,N/A,973.00,N/A,973.00,N/A,973.00,N/A,973.00,N/A,973.00,N/A,973.00,N/A,560.25,N/A,973.00,N/A,136.22,N/A,521.53,N/A,521.53,N/A,136.22,N/A,973.00,N/A,973.00,N/A,973.00,583.80,583.80,136.22,973.00,,Hospital CPT 37253,HC Intrvasc US Noncoronary Addl,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,973.00,973.00,583.80,583.80,N/A,136.22,N/A,973.00,N/A,560.25,N/A,330.82,N/A,973.00,N/A,136.22,N/A,973.00,N/A,973.00,N/A,973.00,N/A,973.00,N/A,973.00,N/A,973.00,N/A,560.25,N/A,973.00,N/A,136.22,N/A,521.53,N/A,521.53,N/A,136.22,N/A,973.00,N/A,973.00,N/A,74.59,583.80,583.80,74.59,973.00,,Hospital CPT 37605,HC Ligation Internal/Common Carotid Artery,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,7888.00,7888.00,4732.80,4732.80,N/A,1104.32,N/A,710.64,N/A,4541.91,N/A,2681.92,N/A,2099.43,N/A,1104.32,N/A,710.64,N/A,710.64,N/A,1306.90,N/A,2099.43,N/A,2099.43,N/A,2099.43,N/A,4541.91,N/A,710.64,N/A,1104.32,N/A,7888.00,N/A,7888.00,N/A,1104.32,N/A,710.64,N/A,710.64,N/A,781.70,4732.80,4732.80,710.64,7888.00,,Hospital 37618,Ligation Major Artery Extremity,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32840.40,N/A,19704.24,N/A,4575.58,N/A,1368.82,N/A,18902.93,N/A,11165.75,N/A,4647.75,N/A,4575.58,N/A,1354.15,N/A,1354.15,N/A,2893.30,N/A,4647.75,N/A,4647.75,N/A,4647.75,N/A,18087.04,N/A,1354.15,N/A,4575.58,N/A,2490.25,N/A,2490.25,N/A,4575.58,N/A,1354.15,N/A,1368.82,N/A,1420.88,N/A,N/A,1354.15,19704.24,,Hospital 37722,Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27173.67,N/A,16304.20,N/A,3766.02,N/A,2690.13,N/A,15644.57,N/A,9239.04,N/A,6539.63,N/A,3766.02,N/A,2690.13,N/A,2690.13,N/A,4071.04,N/A,6539.63,N/A,6539.63,N/A,6539.63,N/A,15644.57,N/A,2690.13,N/A,3766.02,N/A,4562.00,N/A,4562.00,N/A,3766.02,N/A,2690.13,N/A,2690.13,N/A,2959.14,N/A,N/A,2690.13,16304.20,,Hospital 37735,Ligj & Divj Radical Strip Long/Short Saphenous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54060.48,N/A,32436.29,N/A,7565.73,N/A,2782.36,N/A,31122.37,N/A,18375.70,N/A,6520.79,N/A,7565.73,N/A,2690.13,N/A,2690.13,N/A,4059.31,N/A,6520.79,N/A,6520.79,N/A,6520.79,N/A,31122.37,N/A,2690.13,N/A,7565.73,N/A,5277.50,N/A,5277.50,N/A,7565.73,N/A,2690.13,N/A,2782.36,N/A,1220.46,N/A,N/A,1220.46,32436.29,,Hospital 37761,Lig Prfratr Vein Subfscal Open Incl US Gid 1 Leg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46458.43,N/A,27875.06,N/A,6503.92,N/A,2782.36,N/A,26742.10,N/A,15795.88,N/A,6556.13,N/A,6503.92,N/A,2690.13,N/A,2690.13,N/A,4081.31,N/A,6556.13,N/A,6556.13,N/A,6556.13,N/A,26742.09,N/A,2690.13,N/A,6503.92,N/A,5277.50,N/A,5277.50,N/A,6503.92,N/A,2690.13,N/A,2782.36,N/A,823.85,N/A,N/A,823.85,27875.06,,Hospital 37766,Stab Phlebt Varicose Veins 1 Xtr > 20 Incs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,40222.53,N/A,24133.52,N/A,5631.18,N/A,4855.12,N/A,23158.30,N/A,13673.97,N/A,11276.35,N/A,5631.18,N/A,4641.41,N/A,4641.41,N/A,7019.75,N/A,11276.35,N/A,11276.35,N/A,11276.35,N/A,23158.32,N/A,4641.41,N/A,5631.18,N/A,6974.75,N/A,6974.75,N/A,5631.18,N/A,4641.41,N/A,4855.12,N/A,786.91,N/A,N/A,786.91,24133.52,,Hospital 37780,Ligj & Div Short Saph Vein Saphenopop Junct Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11025.90,N/A,6615.54,N/A,1543.63,N/A,2666.89,N/A,6346.72,N/A,3748.81,N/A,6533.68,N/A,1543.63,N/A,2690.13,N/A,2690.13,N/A,4067.33,N/A,6533.68,N/A,6533.68,N/A,6533.68,N/A,6346.72,N/A,2690.13,N/A,1543.63,N/A,2146.50,N/A,2146.50,N/A,1543.63,N/A,2690.13,N/A,2666.89,N/A,276.71,N/A,N/A,276.71,6615.54,,Hospital CPT 37799,HC Unlisted Procedure Vascular Surgery,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1505.00,1505.00,903.00,903.00,N/A,210.70,N/A,566.07,N/A,866.58,N/A,511.70,N/A,1263.67,N/A,210.70,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,866.58,N/A,522.41,N/A,210.70,N/A,1431.00,N/A,1431.00,N/A,210.70,N/A,522.41,N/A,566.07,N/A,1505.00,903.00,903.00,210.70,1505.00,,Hospital CPT 37799,HC Unlisted Procedure Vascular Surgery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1505.00,1505.00,903.00,903.00,N/A,210.70,N/A,566.07,N/A,866.58,N/A,511.70,N/A,1263.67,N/A,210.70,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,866.58,N/A,522.41,N/A,210.70,N/A,1431.00,N/A,1431.00,N/A,210.70,N/A,522.41,N/A,566.07,N/A,1505.00,903.00,903.00,210.70,1505.00,,Hospital CPT 37799,HC Collect Blood From Arterial Line,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1505.00,1505.00,903.00,903.00,N/A,210.70,N/A,566.07,N/A,866.58,N/A,511.70,N/A,1263.67,N/A,210.70,N/A,522.41,N/A,522.41,N/A,786.66,N/A,1263.67,N/A,1263.67,N/A,1263.67,N/A,866.58,N/A,522.41,N/A,210.70,N/A,806.68,N/A,806.68,N/A,210.70,N/A,522.41,N/A,566.07,N/A,1505.00,903.00,903.00,210.70,1505.00,,Hospital 38100,Splenectomy Total Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 38101,Splenectomy Partial Separate Procedure,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 38120,Laparoscopic Surgical Splenectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,129165.12,N/A,77499.07,N/A,14881.53,N/A,10024.08,N/A,74360.54,N/A,43916.12,N/A,19907.79,N/A,14881.53,N/A,10002.75,N/A,10002.75,N/A,12392.99,N/A,19907.79,N/A,19907.79,N/A,19907.79,N/A,74360.54,N/A,10002.75,N/A,14881.53,N/A,7897.00,N/A,7897.00,N/A,14881.53,N/A,10002.75,N/A,10024.08,N/A,1560.97,N/A,N/A,1560.97,77499.07,,Hospital 38204,HC Bl Donor Search Management,N/A,0815 - ACQUISITION OF BODY COMPONENTS - ALLOGENIC STEM CELL,114632.57,8733.00,68779.54,5239.80,193911.48,1222.62,19645.44,342.75,63185.47,5028.45,38975.08,2969.22,37272.73,486.71,16887.40,1222.62,19645.44,337.92,19645.44,337.92,23201.41,302.98,37272.73,486.71,37272.73,486.71,37272.73,486.71,63185.47,5028.45,19645.44,337.92,16887.40,1222.62,44345.24,3703.92,44345.24,3703.92,193911.48,1222.62,19645.44,337.92,19645.44,342.75,18069.51,479.89,16887.40,193911.48,302.98,5239.80,,Hospital 38206,HC Harvest Auto Stem Cells,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,N/A,21682.62,N/A,13009.57,N/A,2816.08,N/A,246.26,N/A,12371.90,N/A,7372.09,N/A,6004.67,N/A,2816.08,N/A,2477.81,N/A,2477.81,N/A,3738.01,N/A,6004.67,N/A,6004.67,N/A,6004.67,N/A,12371.92,N/A,2477.81,N/A,2816.08,N/A,905.15,N/A,905.15,N/A,2816.08,N/A,2477.81,N/A,246.26,N/A,270.90,N/A,N/A,246.26,13009.57,,Hospital 38208,HC Thawing of Cryo Hpc No Wash,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,211263.30,6089.40,126757.98,3653.64,N/A,841.52,40535.58,2180.03,145771.72,3504.03,N/A,2070.40,N/A,5094.50,N/A,841.52,40535.58,2084.07,40535.58,2084.07,N/A,3171.42,N/A,5094.50,N/A,5094.50,N/A,5094.50,145771.72,2885.39,40535.58,2084.07,N/A,841.52,145771.72,573.05,145771.72,573.05,N/A,841.52,40535.58,2084.07,40535.58,2180.03,N/A,357.34,40535.58,145771.72,357.34,5094.50,,Hospital CPT 38220,HC Aspiration Bone Marrow,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1698.00,1698.00,1018.80,1018.80,N/A,237.72,N/A,1467.34,N/A,977.71,N/A,577.32,N/A,1698.00,N/A,237.72,N/A,1354.15,N/A,1354.15,N/A,1698.00,N/A,1698.00,N/A,1698.00,N/A,1698.00,N/A,977.71,N/A,1354.15,N/A,237.72,N/A,910.13,N/A,910.13,N/A,237.72,N/A,1354.15,N/A,1467.34,N/A,71.67,1018.80,1018.80,71.67,1698.00,,Hospital CPT 38221,HC Biopsy Bone Marrow,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,5719.00,5719.00,3431.40,3431.40,N/A,800.66,N/A,1390.32,N/A,3293.00,N/A,1944.46,N/A,3275.59,N/A,800.66,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3293.00,N/A,1354.15,N/A,800.66,N/A,3065.38,N/A,3065.38,N/A,800.66,N/A,1354.15,N/A,1382.32,N/A,74.71,3431.40,3431.40,74.71,3431.40,,Hospital CPT 38221,HC Bone Marrow Biopsy-CT,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5719.00,5719.00,3431.40,3431.40,N/A,800.66,N/A,1390.32,N/A,3293.00,N/A,1944.46,N/A,3275.59,N/A,800.66,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3293.00,N/A,1354.15,N/A,800.66,N/A,1431.00,N/A,1431.00,N/A,800.66,N/A,1354.15,N/A,1382.32,N/A,74.71,3431.40,3431.40,74.71,3431.40,,Hospital CPT 38222,HC Dx Bone Marrow Bx & Aspir,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,5719.00,5719.00,3431.40,3431.40,N/A,800.66,N/A,2320.84,N/A,3293.00,N/A,1944.46,N/A,5642.81,N/A,800.66,N/A,2332.78,N/A,2332.78,N/A,3512.76,N/A,5642.81,N/A,5642.81,N/A,5642.81,N/A,3293.00,N/A,2332.78,N/A,800.66,N/A,3065.38,N/A,3065.38,N/A,800.66,N/A,2332.78,N/A,2358.04,N/A,80.77,3431.40,3431.40,80.77,5642.81,,Hospital 38230,Bone Marrow Harvest Transplantation Allogeneic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26662.80,N/A,15997.68,N/A,3670.82,N/A,1284.53,N/A,15335.25,N/A,9065.36,N/A,3195.16,N/A,3670.82,N/A,1227.99,N/A,1227.99,N/A,1988.94,N/A,3195.16,N/A,3195.16,N/A,3195.16,N/A,15335.26,N/A,1227.99,N/A,3670.82,N/A,1871.00,N/A,1871.00,N/A,3670.82,N/A,1227.99,N/A,1284.53,N/A,260.24,N/A,N/A,260.24,15997.68,,Hospital 38232,Bone Marrow Harvest Transplantation Autologous,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,160129.97,N/A,96077.98,N/A,22288.55,N/A,11923.32,N/A,91656.85,N/A,54444.17,N/A,14494.59,N/A,22288.55,N/A,11875.69,N/A,11875.69,N/A,9028.25,N/A,14494.59,N/A,14494.59,N/A,14494.59,N/A,91656.86,N/A,11875.69,N/A,22288.55,N/A,12019.00,N/A,12019.00,N/A,22288.55,N/A,11875.69,N/A,11923.32,N/A,2944.95,N/A,N/A,2944.95,96077.98,,Hospital 38243,HC Allo Hpc Boost,N/A,0362 - OPERATING ROOM SERVICES - ORGAN TRANSPLANT - OTHER THAN KIDNEY,N/A,140356.30,N/A,84213.78,N/A,19655.34,N/A,3079.39,N/A,80814.61,N/A,47650.43,N/A,7188.49,N/A,19655.34,N/A,2943.85,N/A,2943.85,N/A,4474.97,N/A,7188.49,N/A,7188.49,N/A,7188.49,N/A,80140.88,N/A,3052.99,N/A,19655.34,N/A,1871.00,N/A,1871.00,N/A,19655.34,N/A,3052.99,N/A,3193.56,N/A,526.27,N/A,N/A,526.27,84213.78,,Hospital 38308,Lymphangiotomy/Oth Oprations Lymphatic Channels,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36780.72,N/A,22068.43,N/A,5147.44,N/A,3187.39,N/A,20745.85,N/A,12505.46,N/A,12400.35,N/A,5147.44,N/A,3104.47,N/A,3104.47,N/A,7719.41,N/A,12400.35,N/A,12400.35,N/A,12400.35,N/A,20745.85,N/A,3104.47,N/A,5147.44,N/A,13511.25,N/A,13511.25,N/A,5147.44,N/A,3104.47,N/A,3187.39,N/A,2685.41,N/A,N/A,2685.41,22068.43,,Hospital CPT 38505,HC Biopsy/Exc Lymph Node Needle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3951.00,3951.00,2370.60,2370.60,N/A,553.14,N/A,1354.15,N/A,2274.99,N/A,1343.34,N/A,3275.59,N/A,553.14,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2274.99,N/A,1354.15,N/A,553.14,N/A,1871.00,N/A,1871.00,N/A,553.14,N/A,1354.15,N/A,1354.15,N/A,1489.57,2370.60,2370.60,553.14,3275.59,,Hospital CPT 38510,Bx/Exc Lymph Node Open Deep Cervical Node,N/A,N/A,880.00,880.00,528.00,528.00,N/A,123.20,N/A,402.18,N/A,880.00,N/A,299.20,N/A,880.00,N/A,123.20,N/A,402.18,N/A,402.18,N/A,880.00,N/A,880.00,N/A,880.00,N/A,880.00,N/A,880.00,N/A,402.18,N/A,123.20,N/A,880.00,N/A,880.00,N/A,123.20,N/A,402.18,N/A,402.18,N/A,442.40,528.00,528.00,123.20,880.00,,Hospital 38525,Bx/Exc Lymph Node Open Deep Axillary Node,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,61147.37,48105.73,36688.42,28863.44,9261.97,6734.81,11251.72,5366.90,20872.60,27453.31,20790.10,16355.96,21072.26,14353.64,9547.35,6734.81,5366.90,5366.90,5366.90,5366.90,13116.99,8935.34,21072.26,14353.64,21072.26,14353.64,21072.26,14353.64,20872.60,27453.31,11222.07,5366.90,9547.35,6734.81,25070.73,11718.50,25070.73,11718.50,N/A,6734.81,11222.07,5366.90,11251.72,5366.90,10215.66,5903.59,5366.90,36688.42,5366.90,28863.44,,Hospital 38542,Dissection Deep Jugular Node,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8434.40,N/A,5060.64,N/A,1181.85,N/A,4666.13,N/A,4854.35,N/A,2867.69,N/A,8434.40,N/A,1181.85,N/A,4706.78,N/A,4706.78,N/A,7101.90,N/A,8434.40,N/A,8434.40,N/A,8434.40,N/A,4828.44,N/A,4706.78,N/A,1181.85,N/A,7897.00,N/A,7897.00,N/A,1181.85,N/A,4706.78,N/A,4666.13,N/A,623.25,N/A,N/A,623.25,8434.40,,Hospital 38570,Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52479.00,51636.92,31487.40,30982.15,6244.71,7155.65,7652.80,8584.05,14072.95,29728.85,17842.86,17556.54,14207.57,19929.09,6437.12,7155.65,562.00,8206.20,562.00,8206.20,8843.88,12406.26,14207.57,19929.09,14207.57,19929.09,14207.57,19929.09,14072.95,29728.89,7652.80,8206.20,6437.12,7155.65,16903.46,11845.50,16903.46,11845.50,6437.12,7155.65,7652.80,8206.20,7652.80,8584.05,6887.72,2576.83,562.00,31487.40,2576.83,30982.15,,Hospital 38589,Unlisted Laparoscopy Px Lymphatic System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46979.58,N/A,28187.75,N/A,6382.09,N/A,1472.17,N/A,27033.70,N/A,15850.42,N/A,19966.59,N/A,6382.09,N/A,8206.20,N/A,8206.20,N/A,12429.59,N/A,19966.59,N/A,19966.59,N/A,19966.59,N/A,26616.31,N/A,8206.20,N/A,6382.09,N/A,10878.50,N/A,10878.50,N/A,6382.09,N/A,8206.20,N/A,1472.17,N/A,1613.29,N/A,N/A,1472.17,28187.75,,Hospital 38700,Suprahyoid Lymphadenectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43552.37,N/A,26131.42,N/A,6098.09,N/A,5478.51,N/A,25070.68,N/A,14807.80,N/A,13021.20,N/A,6098.09,N/A,5366.90,N/A,5366.90,N/A,8105.95,N/A,13021.20,N/A,13021.20,N/A,13021.20,N/A,24926.73,N/A,5366.90,N/A,6098.09,N/A,3397.00,N/A,3397.00,N/A,6098.09,N/A,5366.90,N/A,5478.51,N/A,1066.79,N/A,N/A,1066.79,26131.42,,Hospital 38720,Cervical Lymphadenectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67709.18,N/A,40625.51,N/A,9461.98,N/A,8038.06,N/A,38982.22,N/A,23021.11,N/A,19299.66,N/A,9461.98,N/A,7951.94,N/A,7951.94,N/A,12014.41,N/A,19299.66,N/A,19299.66,N/A,19299.66,N/A,38982.22,N/A,7951.94,N/A,9461.98,N/A,7661.50,N/A,7661.50,N/A,9461.98,N/A,7951.94,N/A,8038.06,N/A,2788.68,N/A,N/A,2788.68,40625.51,,Hospital 38724,Cervical Lymphadec Modified Radical Neck Dsj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,86968.07,67474.08,52180.84,40484.45,12988.20,9544.88,4801.89,4757.75,30062.21,38842.02,29569.14,22941.20,30349.78,22910.63,13388.39,9544.88,212436.00,4706.78,212436.00,4706.78,18892.03,14262.30,30349.78,22910.63,30349.78,22910.63,30349.78,22910.63,30062.21,38842.07,15291.10,4706.78,13388.39,9544.88,36108.66,9595.50,36108.66,9595.50,13388.39,9544.88,15291.10,4706.78,15320.75,4757.75,14325.58,3861.37,4801.89,212436.00,3861.37,40484.45,,Hospital 38747,Abdl Lmphadec Reg Celiac Gstr Portal Pripncrtc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32841.75,N/A,19705.05,N/A,4597.85,N/A,4923.50,N/A,11012.00,N/A,11166.19,N/A,22855.63,N/A,4597.85,N/A,4706.78,N/A,4706.78,N/A,14228.07,N/A,22855.63,N/A,22855.63,N/A,22855.63,N/A,11012.00,N/A,4706.78,N/A,4597.85,N/A,8718.50,N/A,8718.50,N/A,4597.85,N/A,4706.78,N/A,4923.50,N/A,1109.83,N/A,N/A,1109.83,22855.63,,Hospital 38760,Inguinofem Lmphadec Supfc W/Cloquets Node Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23390.10,N/A,14034.06,N/A,3274.90,N/A,5478.51,N/A,13465.22,N/A,7952.63,N/A,12995.04,N/A,3274.90,N/A,5366.90,N/A,5366.90,N/A,8089.67,N/A,12995.04,N/A,12995.04,N/A,12995.04,N/A,13465.22,N/A,5366.90,N/A,3274.90,N/A,3397.00,N/A,3397.00,N/A,3274.90,N/A,5366.90,N/A,5478.51,N/A,919.38,N/A,N/A,919.38,14034.06,,Hospital 38770,Pel Lmphadec W/Xtrnl Iliac Hypogstr&Obturator,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80094.52,N/A,48056.71,N/A,11182.19,N/A,8584.05,N/A,46114.66,N/A,27232.14,N/A,31301.79,N/A,11182.19,N/A,8206.20,N/A,8206.20,N/A,19485.95,N/A,31301.79,N/A,31301.79,N/A,31301.79,N/A,45736.36,N/A,8206.20,N/A,11182.19,N/A,11289.25,N/A,11289.25,N/A,11182.19,N/A,8206.20,N/A,8584.05,N/A,2416.67,N/A,N/A,2416.67,48056.71,,Hospital 38780,Rpr Tabdl Lmphadec Extnsv W/Pel Aortic&Rnl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,107297.50,N/A,64378.50,N/A,15017.11,N/A,1309.82,N/A,61770.31,N/A,36481.15,N/A,13662.20,N/A,15017.11,N/A,1291.15,N/A,1291.15,N/A,8503.38,N/A,13662.20,N/A,13662.20,N/A,13662.20,N/A,61597.59,N/A,1291.15,N/A,15017.11,N/A,1643.00,N/A,1643.00,N/A,15017.11,N/A,1291.15,N/A,1309.82,N/A,1442.51,N/A,N/A,1291.15,64378.50,,Hospital CPT 38792,HC Inj Lympho for Sentinal Node,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1011.00,1011.00,606.60,606.60,N/A,141.54,N/A,350.99,N/A,582.13,N/A,343.74,N/A,849.03,N/A,141.54,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,582.13,N/A,350.99,N/A,141.54,N/A,527.00,N/A,527.00,N/A,141.54,N/A,350.99,N/A,350.99,N/A,386.09,606.60,606.60,141.54,849.03,,Hospital 39010,Mediast W/Expl Drg Rmvl FB/Bx Tthrc Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21005.80,N/A,12603.48,N/A,2916.01,N/A,801.30,N/A,12093.15,N/A,7141.98,N/A,11965.21,N/A,2916.01,N/A,799.22,N/A,799.22,N/A,7448.10,N/A,11965.21,N/A,11965.21,N/A,11965.21,N/A,12093.16,N/A,799.22,N/A,2916.01,N/A,1643.00,N/A,1643.00,N/A,2916.01,N/A,799.22,N/A,801.30,N/A,920.60,N/A,N/A,799.22,12603.48,,Hospital 39401,Mediastinoscopy Includes Mediastinal Mass Biopsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,46793.00,N/A,28075.80,N/A,19555.65,N/A,22834.12,N/A,45579.01,N/A,13714.24,N/A,11730.38,N/A,20158.20,N/A,22774.82,N/A,22774.82,N/A,7320.27,N/A,11730.38,N/A,11730.38,N/A,11730.38,N/A,45579.01,N/A,22774.82,N/A,20158.20,N/A,46793.00,N/A,46793.00,N/A,N/A,N/A,22774.82,N/A,22834.12,N/A,21569.27,N/A,7320.27,46793.00,N/A,N/A,,Hospital 39499,Unlisted Procedure Mediastinum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21631.40,N/A,12978.84,N/A,3057.33,N/A,2813.99,N/A,12435.94,N/A,7354.68,N/A,6538.23,N/A,3057.33,N/A,2690.13,N/A,2690.13,N/A,4070.17,N/A,6538.23,N/A,6538.23,N/A,6538.23,N/A,12429.76,N/A,2690.13,N/A,3057.33,N/A,5383.50,N/A,5383.50,N/A,3057.33,N/A,2690.13,N/A,2813.99,N/A,509.19,N/A,N/A,509.19,12978.84,,Hospital 40490,Biopsy of Lip,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15916.00,N/A,9549.60,N/A,2228.23,N/A,713.51,N/A,9162.39,N/A,5396.14,N/A,7288.17,N/A,2228.23,N/A,3010.42,N/A,3010.42,N/A,4537.02,N/A,7288.17,N/A,7288.17,N/A,7288.17,N/A,9162.40,N/A,3010.42,N/A,2228.23,N/A,4800.25,N/A,4800.25,N/A,2228.23,N/A,3010.42,N/A,713.51,N/A,784.86,N/A,N/A,713.51,9549.60,,Hospital 40520,Exc Lip V-Exc W/Prim Dir Linr Clsr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20043.00,N/A,12025.80,N/A,2806.02,N/A,2622.61,N/A,11540.76,N/A,6814.62,N/A,6214.61,N/A,2806.02,N/A,2569.18,N/A,2569.18,N/A,3868.72,N/A,6214.61,N/A,6214.61,N/A,6214.61,N/A,11540.76,N/A,2569.18,N/A,2806.02,N/A,1871.00,N/A,1871.00,N/A,2806.02,N/A,2569.18,N/A,2622.61,N/A,516.92,N/A,N/A,516.92,12025.80,,Hospital 40525,Exc Lip Full Thkns Rcnstj W/Local Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6378.60,N/A,3827.16,N/A,893.00,N/A,2546.98,N/A,3672.13,N/A,2168.72,N/A,6220.77,N/A,893.00,N/A,2569.18,N/A,2569.18,N/A,3872.56,N/A,6220.77,N/A,6220.77,N/A,6220.77,N/A,3672.13,N/A,2569.18,N/A,893.00,N/A,3397.00,N/A,3397.00,N/A,893.00,N/A,2569.18,N/A,2546.98,N/A,609.88,N/A,N/A,609.88,6220.77,,Hospital 40530,Rescj Lip > One-Fourth W/O Rcnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18678.10,N/A,11206.86,N/A,2549.54,N/A,786.03,N/A,10739.85,N/A,6350.55,N/A,6303.18,N/A,2549.54,N/A,2569.18,N/A,2569.18,N/A,3923.86,N/A,6303.18,N/A,6303.18,N/A,6303.18,N/A,10739.85,N/A,2569.18,N/A,2549.54,N/A,3660.50,N/A,3660.50,N/A,2549.54,N/A,2569.18,N/A,786.03,N/A,864.64,N/A,N/A,786.03,11206.86,,Hospital CPT 40650,HC Repair Liphc Repair Lip Full Thickness Vermilion Only,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,294.25,N/A,884.43,N/A,522.24,N/A,1336.35,N/A,215.04,N/A,294.25,N/A,294.25,N/A,831.88,N/A,1336.35,N/A,1336.35,N/A,1336.35,N/A,884.43,N/A,294.25,N/A,215.04,N/A,1536.00,N/A,1536.00,N/A,215.04,N/A,294.25,N/A,294.25,N/A,323.68,921.60,921.60,215.04,1536.00,,Hospital 40701,Plstc Rpr Cl Lip/Nsl Dfrm Prim Bi 1 Stg Px,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76507.40,N/A,45904.44,N/A,10711.03,N/A,5129.50,N/A,44050.84,N/A,26010.21,N/A,11709.46,N/A,10711.03,N/A,4821.94,N/A,4821.94,N/A,7289.36,N/A,11709.46,N/A,11709.46,N/A,11709.46,N/A,44050.82,N/A,4821.94,N/A,10711.03,N/A,8944.50,N/A,8944.50,N/A,10711.03,N/A,4821.94,N/A,5129.50,N/A,2215.13,N/A,N/A,2215.13,45904.44,,Hospital 40720,Plstc Rpr Cl Lip/Nsl Dfrm Sec Recrtj Dfct & Recl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76689.70,N/A,46013.82,N/A,10739.35,N/A,5137.36,N/A,44152.13,N/A,26074.50,N/A,11710.30,N/A,10739.35,N/A,4829.80,N/A,4829.80,N/A,7289.88,N/A,11710.30,N/A,11710.30,N/A,11710.30,N/A,44152.14,N/A,4829.80,N/A,10739.35,N/A,9793.75,N/A,9793.75,N/A,10739.35,N/A,4829.80,N/A,5137.36,N/A,2891.43,N/A,N/A,2891.43,46013.82,,Hospital CPT 40799,HC Lip Surgery Procedure,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,542.00,542.00,325.20,325.20,N/A,75.88,N/A,542.00,N/A,312.08,N/A,184.28,N/A,75.88,N/A,75.88,N/A,542.00,N/A,542.00,N/A,47.15,N/A,75.88,N/A,75.88,N/A,75.88,N/A,312.08,N/A,542.00,N/A,75.88,N/A,542.00,N/A,542.00,N/A,75.88,N/A,542.00,N/A,542.00,N/A,542.00,325.20,325.20,47.15,542.00,,Hospital CPT 40804,"HC Removal of Embedded Foreign Body, Vestible of Mouth, Simple",N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2484.00,2484.00,1490.40,1490.40,N/A,347.76,N/A,104.93,N/A,1430.29,N/A,844.56,N/A,516.39,N/A,347.76,N/A,104.93,N/A,104.93,N/A,321.45,N/A,516.39,N/A,516.39,N/A,516.39,N/A,1430.29,N/A,104.93,N/A,347.76,N/A,2484.00,N/A,2484.00,N/A,347.76,N/A,104.93,N/A,104.93,N/A,115.42,1490.40,1490.40,104.93,2484.00,,Hospital 40806,HC Incision Labial Frenum Frenotomy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,5356.00,N/A,3213.60,N/A,749.84,N/A,410.42,N/A,3083.98,N/A,1821.04,N/A,997.86,N/A,749.84,N/A,412.53,N/A,412.53,N/A,621.19,N/A,997.86,N/A,997.86,N/A,997.86,N/A,3083.98,N/A,412.53,N/A,749.84,N/A,527.00,N/A,527.00,N/A,749.84,N/A,412.53,N/A,410.42,N/A,28.94,N/A,N/A,28.94,3213.60,,Hospital 40812,Exc Lesion Mucosa & Sbmcsl Vestibule Smpl Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19003.80,N/A,11402.28,N/A,2654.86,N/A,1279.62,N/A,10938.52,N/A,6461.29,N/A,3050.87,N/A,2654.86,N/A,1253.55,N/A,1253.55,N/A,1899.21,N/A,3050.87,N/A,3050.87,N/A,3050.87,N/A,10866.54,N/A,1253.55,N/A,2654.86,N/A,1871.00,N/A,1871.00,N/A,2654.86,N/A,1253.55,N/A,1279.62,N/A,234.91,N/A,N/A,234.91,11402.28,,Hospital 40816,Exc Lesion Mucosa&Sbmcsl Vestibule Cplx Exc Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11045.70,N/A,6627.42,N/A,1546.41,N/A,2733.05,N/A,6354.53,N/A,3755.54,N/A,6236.06,N/A,1546.41,N/A,2569.18,N/A,2569.18,N/A,3882.07,N/A,6236.06,N/A,6236.06,N/A,6236.06,N/A,6354.54,N/A,2569.18,N/A,1546.41,N/A,3397.00,N/A,3397.00,N/A,1546.41,N/A,2569.18,N/A,2733.05,N/A,346.27,N/A,N/A,346.27,6627.42,,Hospital 40818,Exc Mucosa Vestibule Mouth as Don Grf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46132.12,N/A,27679.27,N/A,6458.48,N/A,4391.84,N/A,26481.64,N/A,15684.91,N/A,10291.42,N/A,6458.48,N/A,4246.26,N/A,4246.26,N/A,6406.61,N/A,10291.42,N/A,10291.42,N/A,10291.42,N/A,26481.64,N/A,4246.26,N/A,6458.48,N/A,4825.50,N/A,4825.50,N/A,6458.48,N/A,4246.26,N/A,4391.84,N/A,1307.11,N/A,N/A,1307.11,27679.27,,Hospital 40843,Vestibuloplasty Posterior Bilateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55474.53,N/A,33284.72,N/A,7766.45,N/A,4922.21,N/A,31933.94,N/A,18861.36,N/A,11723.11,N/A,7766.45,N/A,4821.94,N/A,4821.94,N/A,7297.85,N/A,11723.11,N/A,11723.11,N/A,11723.11,N/A,31933.94,N/A,4821.94,N/A,7766.45,N/A,5944.75,N/A,5944.75,N/A,7766.45,N/A,4821.94,N/A,4922.21,N/A,1914.81,N/A,N/A,1914.81,33284.72,,Hospital 40845,Vestibuloplasty Cplx W/Ridge Xtn Musc Rpsg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28189.12,N/A,16913.47,N/A,3946.46,N/A,5043.96,N/A,16228.14,N/A,9584.30,N/A,11682.88,N/A,3946.46,N/A,4821.94,N/A,4821.94,N/A,7272.81,N/A,11682.88,N/A,11682.88,N/A,11682.88,N/A,16228.15,N/A,4821.94,N/A,3946.46,N/A,5963.00,N/A,5963.00,N/A,3946.46,N/A,4821.94,N/A,5043.96,N/A,1276.47,N/A,N/A,1276.47,16913.47,,Hospital CPT 41000,HC Drain Mouth Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1247.00,1247.00,748.20,748.20,N/A,174.58,N/A,100.30,N/A,718.02,N/A,423.98,N/A,411.42,N/A,174.58,N/A,100.30,N/A,100.30,N/A,256.11,N/A,411.42,N/A,411.42,N/A,411.42,N/A,718.02,N/A,100.30,N/A,174.58,N/A,1247.00,N/A,1247.00,N/A,174.58,N/A,100.30,N/A,100.30,N/A,110.33,748.20,748.20,100.30,1247.00,,Hospital 41108,Biopsy Floor Mouth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13850.00,N/A,8310.00,N/A,1939.00,N/A,1416.50,N/A,7974.14,N/A,4709.00,N/A,3285.28,N/A,1939.00,N/A,1354.15,N/A,1354.15,N/A,2045.15,N/A,3285.28,N/A,3285.28,N/A,3285.28,N/A,7974.14,N/A,1354.15,N/A,1939.00,N/A,1431.00,N/A,1431.00,N/A,1939.00,N/A,1354.15,N/A,1416.50,N/A,263.90,N/A,N/A,263.90,8310.00,,Hospital 41113,Exc Lesion Tongue W/Clsr Posterior One-Third,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26185.50,N/A,15711.30,N/A,3649.73,N/A,323.68,N/A,15066.16,N/A,8903.07,N/A,6285.22,N/A,3649.73,N/A,2569.18,N/A,2569.18,N/A,3912.68,N/A,6285.22,N/A,6285.22,N/A,6285.22,N/A,15066.19,N/A,2569.18,N/A,3649.73,N/A,1871.00,N/A,1871.00,N/A,3649.73,N/A,2569.18,N/A,323.68,N/A,356.06,N/A,N/A,323.68,15711.30,,Hospital 41114,Exc Lesion Tongue W/Clsr W/Local Tongue Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36654.22,N/A,21992.53,N/A,5131.61,N/A,1241.02,N/A,21094.43,N/A,12462.44,N/A,6289.64,N/A,5131.61,N/A,2569.18,N/A,2569.18,N/A,3915.44,N/A,6289.64,N/A,6289.64,N/A,6289.64,N/A,21094.45,N/A,2569.18,N/A,5131.61,N/A,3397.00,N/A,3397.00,N/A,5131.61,N/A,2569.18,N/A,1241.02,N/A,1365.14,N/A,N/A,1241.02,21992.53,,Hospital CPT 41115,Excision Lingual Frenum Frenectomy,N/A,N/A,453.00,453.00,271.80,271.80,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,N/A,453.00,271.80,271.80,271.80,453.00,,Hospital 41116,Excision Lesion Floor Mouth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23983.40,N/A,14390.04,N/A,3357.68,N/A,2733.05,N/A,13809.31,N/A,8154.36,N/A,6217.41,N/A,3357.68,N/A,2569.18,N/A,2569.18,N/A,3870.46,N/A,6217.41,N/A,6217.41,N/A,6217.41,N/A,13809.31,N/A,2569.18,N/A,3357.68,N/A,3397.00,N/A,3397.00,N/A,3357.68,N/A,2569.18,N/A,2733.05,N/A,251.87,N/A,N/A,251.87,14390.04,,Hospital 41130,Glossectomy Hemiglossectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19474.28,N/A,11684.57,N/A,2726.41,N/A,2017.45,N/A,11183.09,N/A,6621.25,N/A,13589.95,N/A,2726.41,N/A,1945.14,N/A,1945.14,N/A,8459.83,N/A,13589.95,N/A,13589.95,N/A,13589.95,N/A,11183.12,N/A,1945.14,N/A,2726.41,N/A,1643.00,N/A,1643.00,N/A,2726.41,N/A,1945.14,N/A,1559.30,N/A,1715.23,N/A,N/A,1559.30,13589.95,,Hospital CPT 41250,HC Rep Lac Floor Mouth 0-2.5cm,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,630.00,630.00,378.00,378.00,N/A,88.20,N/A,144.28,N/A,362.75,N/A,214.20,N/A,630.00,N/A,88.20,N/A,144.28,N/A,144.28,N/A,490.82,N/A,630.00,N/A,630.00,N/A,630.00,N/A,362.75,N/A,144.28,N/A,88.20,N/A,630.00,N/A,630.00,N/A,88.20,N/A,144.28,N/A,144.28,N/A,158.71,378.00,378.00,88.20,630.00,,Hospital CPT 41251,HC Repair Tongue Laceration,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,651.00,651.00,390.60,390.60,N/A,91.14,N/A,170.68,N/A,374.85,N/A,221.34,N/A,651.00,N/A,91.14,N/A,170.68,N/A,170.68,N/A,546.17,N/A,651.00,N/A,651.00,N/A,651.00,N/A,374.85,N/A,170.68,N/A,91.14,N/A,651.00,N/A,651.00,N/A,91.14,N/A,170.68,N/A,170.68,N/A,187.75,390.60,390.60,91.14,651.00,,Hospital 41805,HC Rmvl Embedded FB From Dentalvlr Struxs Soft Tiss,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 41825,Exc Lesion/Tumor Dentoalveolar Strux W/O Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30928.40,N/A,18557.04,N/A,4329.98,N/A,2687.47,N/A,17807.54,N/A,10515.66,N/A,6228.19,N/A,4329.98,N/A,2569.18,N/A,2569.18,N/A,3877.17,N/A,6228.19,N/A,6228.19,N/A,6228.19,N/A,17807.55,N/A,2569.18,N/A,4329.98,N/A,1871.00,N/A,1871.00,N/A,4329.98,N/A,2569.18,N/A,2687.47,N/A,129.18,N/A,N/A,129.18,18557.04,,Hospital 41826,Exc Lesion/Tumor Dentoalveolar Strux W/Smpl Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6441.40,N/A,3864.84,N/A,901.79,N/A,2597.00,N/A,3707.65,N/A,2190.07,N/A,6236.89,N/A,901.79,N/A,2569.18,N/A,2569.18,N/A,3882.58,N/A,6236.89,N/A,6236.89,N/A,6236.89,N/A,3707.64,N/A,2569.18,N/A,901.79,N/A,3397.00,N/A,3397.00,N/A,901.79,N/A,2569.18,N/A,2597.00,N/A,238.55,N/A,N/A,238.55,6236.89,,Hospital 41830,Alveolectomy W/Curtg Osteitis/Sequestrectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,48620.60,N/A,29172.36,N/A,6799.42,N/A,2687.47,N/A,27994.52,N/A,16530.99,N/A,6238.62,N/A,6799.42,N/A,2569.18,N/A,2569.18,N/A,3883.66,N/A,6238.62,N/A,6238.62,N/A,6238.62,N/A,27994.54,N/A,2569.18,N/A,6799.42,N/A,3792.25,N/A,3792.25,N/A,6799.42,N/A,2569.18,N/A,2687.47,N/A,340.95,N/A,N/A,340.95,29172.36,,Hospital CPT 41899,HC Dental Surgery Procedure,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,542.00,542.00,325.20,325.20,N/A,75.88,N/A,542.00,N/A,312.08,N/A,184.28,N/A,75.88,N/A,75.88,N/A,542.00,N/A,542.00,N/A,47.15,N/A,75.88,N/A,75.88,N/A,75.88,N/A,312.08,N/A,542.00,N/A,75.88,N/A,542.00,N/A,542.00,N/A,75.88,N/A,542.00,N/A,542.00,N/A,542.00,325.20,325.20,47.15,542.00,,Hospital CPT 42000,HC Drainage Mouth Roof Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1133.00,1133.00,679.80,679.80,N/A,158.62,N/A,101.16,N/A,652.38,N/A,385.22,N/A,448.68,N/A,158.62,N/A,101.16,N/A,101.16,N/A,279.30,N/A,448.68,N/A,448.68,N/A,448.68,N/A,652.38,N/A,101.16,N/A,158.62,N/A,1133.00,N/A,1133.00,N/A,158.62,N/A,101.16,N/A,101.16,N/A,111.28,679.80,679.80,101.16,1133.00,,Hospital 42100,Biopsy Palate Uvula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34032.82,N/A,20419.69,N/A,4758.92,N/A,2622.61,N/A,19588.74,N/A,11540.24,N/A,6244.14,N/A,4758.92,N/A,2569.18,N/A,2569.18,N/A,3887.11,N/A,6244.14,N/A,6244.14,N/A,6244.14,N/A,19588.73,N/A,2569.18,N/A,4758.92,N/A,4332.50,N/A,4332.50,N/A,4758.92,N/A,2569.18,N/A,2622.61,N/A,481.22,N/A,N/A,481.22,20419.69,,Hospital 42106,Exc Lesion Palate Uvula W/Smpl Prim Closure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19483.47,N/A,11690.08,N/A,2717.19,N/A,189.47,N/A,11206.92,N/A,6624.38,N/A,6288.89,N/A,2717.19,N/A,2569.18,N/A,2569.18,N/A,3914.96,N/A,6288.89,N/A,6288.89,N/A,6288.89,N/A,11206.95,N/A,2569.18,N/A,2717.19,N/A,1871.00,N/A,1871.00,N/A,2717.19,N/A,2569.18,N/A,189.47,N/A,208.43,N/A,N/A,189.47,11690.08,,Hospital 42107,Exc Lesion Palate Uvula W/Local Flap Closure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,68171.62,N/A,40902.97,N/A,9544.04,N/A,1541.67,N/A,38916.23,N/A,23178.36,N/A,11721.37,N/A,9544.04,N/A,4821.94,N/A,4821.94,N/A,7296.78,N/A,11721.37,N/A,11721.37,N/A,11721.37,N/A,38916.23,N/A,4821.94,N/A,9544.04,N/A,4332.50,N/A,4332.50,N/A,9544.04,N/A,4821.94,N/A,1541.67,N/A,1695.85,N/A,N/A,1541.67,40902.97,,Hospital 42200,Palatop Cl Palate Soft&/Hard Palate Only,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,33558.07,24905.00,20134.84,14943.00,4717.40,3486.70,5846.09,5319.17,10631.05,14331.17,11409.74,8467.70,10732.75,11678.07,4862.76,3486.70,5846.09,4821.94,5846.09,4821.94,6680.89,7269.84,10732.75,11678.07,10732.75,11678.07,10732.75,11678.07,10631.05,14331.20,5846.09,4821.94,4862.76,3486.70,12769.29,6898.50,12769.29,6898.50,49.50,3486.70,5846.09,4821.94,5846.09,983.30,5203.15,1081.63,49.50,20134.84,983.30,14943.00,,Hospital 42210,Palatop Clsr Alveolar Ridge Grf Alveolar Ridge,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,53812.52,N/A,32287.51,N/A,7533.74,N/A,4987.25,N/A,30739.47,N/A,18296.24,N/A,11672.37,N/A,7533.74,N/A,4821.94,N/A,4821.94,N/A,7266.27,N/A,11672.37,N/A,11672.37,N/A,11672.37,N/A,30739.46,N/A,4821.94,N/A,7533.74,N/A,5963.00,N/A,5963.00,N/A,7533.74,N/A,4821.94,N/A,4987.25,N/A,1127.78,N/A,N/A,1127.78,32287.51,,Hospital 42215,Palatoplasty Cleft Palate Major Revj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,80276.60,N/A,48165.96,N/A,11235.57,N/A,5129.50,N/A,46211.66,N/A,27294.04,N/A,11714.55,N/A,11235.57,N/A,4821.94,N/A,4821.94,N/A,7292.53,N/A,11714.55,N/A,11714.55,N/A,11714.55,N/A,46211.64,N/A,4821.94,N/A,11235.57,N/A,9793.75,N/A,9793.75,N/A,11235.57,N/A,4821.94,N/A,5129.50,N/A,2741.35,N/A,N/A,2741.35,48165.96,,Hospital 42226,Lengthening Palate & Pharyngeal Flap,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29952.95,N/A,17971.77,N/A,4193.42,N/A,5043.96,N/A,17245.20,N/A,10184.00,N/A,11689.67,N/A,4193.42,N/A,4821.94,N/A,4821.94,N/A,7277.04,N/A,11689.67,N/A,11689.67,N/A,11689.67,N/A,17245.21,N/A,4821.94,N/A,4193.42,N/A,5963.00,N/A,5963.00,N/A,4193.42,N/A,4821.94,N/A,5043.96,N/A,943.09,N/A,N/A,943.09,17971.77,,Hospital 42235,Repair Anterior Palate W/Vomer Flap,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8562.90,N/A,5137.74,N/A,1198.81,N/A,4950.73,N/A,4930.20,N/A,2911.39,N/A,8562.90,N/A,1198.81,N/A,4821.94,N/A,4821.94,N/A,7263.88,N/A,8562.90,N/A,8562.90,N/A,8562.90,N/A,4930.20,N/A,4821.94,N/A,1198.81,N/A,5963.00,N/A,5963.00,N/A,1198.81,N/A,4821.94,N/A,4950.73,N/A,770.88,N/A,N/A,770.88,8562.90,,Hospital 42335,Sialolithotomy Submndblr Submax Comp Intraoral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49993.28,N/A,29995.97,N/A,6980.24,N/A,4987.25,N/A,28773.86,N/A,16997.72,N/A,11696.28,N/A,6980.24,N/A,4821.94,N/A,4821.94,N/A,7281.17,N/A,11696.28,N/A,11696.28,N/A,11696.28,N/A,28773.87,N/A,4821.94,N/A,6980.24,N/A,7661.50,N/A,7661.50,N/A,6980.24,N/A,4821.94,N/A,4987.25,N/A,775.98,N/A,N/A,775.98,29995.97,,Hospital 42400,HC Biopsy of Salivary Gland,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,39989.70,7469.00,23993.82,4481.40,10744.99,1045.66,12976.41,613.03,24214.71,4300.64,13596.50,2539.46,24446.35,1417.60,11076.06,1045.66,1686.00,586.05,1686.00,586.05,15217.28,882.49,24446.35,1417.60,24446.35,1417.60,24446.35,1417.60,24214.71,4300.64,12976.41,586.05,11076.06,1045.66,29085.05,1431.00,29085.05,1431.00,N/A,1045.66,12976.41,586.05,12976.41,613.03,11851.39,642.49,1686.00,29085.05,586.05,4481.40,,Hospital 42408,Exc Sublingual Salivary Cyst Ranula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21068.70,N/A,12641.22,N/A,2949.60,N/A,2546.98,N/A,12125.54,N/A,7163.36,N/A,6282.97,N/A,2949.60,N/A,2569.18,N/A,2569.18,N/A,3911.28,N/A,6282.97,N/A,6282.97,N/A,6282.97,N/A,12125.55,N/A,2569.18,N/A,2949.60,N/A,3397.00,N/A,3397.00,N/A,2949.60,N/A,2569.18,N/A,2546.98,N/A,391.39,N/A,N/A,391.39,12641.22,,Hospital 42426,Exc Prtd Tum/Prtd Glnd Tot W/Uni Rad Nck Dsj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62709.45,N/A,37625.67,N/A,8779.32,N/A,1600.70,N/A,36075.15,N/A,21321.21,N/A,12491.54,N/A,8779.32,N/A,1590.66,N/A,1590.66,N/A,7776.22,N/A,12491.54,N/A,12491.54,N/A,12491.54,N/A,36075.12,N/A,1590.66,N/A,8779.32,N/A,3397.00,N/A,3397.00,N/A,8779.32,N/A,1590.66,N/A,1600.70,N/A,1865.62,N/A,N/A,1590.66,37625.67,,Hospital 42550,HC Inj Procedure for Sialography,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,2838.00,N/A,1702.80,N/A,387.87,N/A,228.50,N/A,1632.76,N/A,964.92,N/A,518.90,N/A,387.87,N/A,210.88,N/A,210.88,N/A,323.02,N/A,518.90,N/A,518.90,N/A,518.90,N/A,1632.76,N/A,210.88,N/A,387.87,N/A,527.00,N/A,527.00,N/A,387.87,N/A,210.88,N/A,228.50,N/A,154.47,N/A,N/A,154.47,1702.80,,Hospital 42725,I&D Absc Rtrphrngl/Parapharyngeal Xtrnl Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,142659.67,N/A,85595.80,N/A,N/A,N/A,10572.65,N/A,12009.52,N/A,N/A,N/A,2448.00,N/A,19596.37,N/A,10560.11,N/A,N/A,N/A,2448.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,77404.30,N/A,10583.36,N/A,19596.37,N/A,6898.50,N/A,6898.50,N/A,N/A,N/A,N/A,N/A,10572.65,N/A,3425.62,N/A,N/A,2448.00,85595.80,,Hospital 42806,Bx Nasopharynx Survey Unknown Primary Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44896.27,N/A,26937.76,N/A,6268.13,N/A,4923.50,N/A,25848.04,N/A,15264.75,N/A,11433.92,N/A,6268.13,N/A,4706.78,N/A,4706.78,N/A,7117.84,N/A,11433.92,N/A,11433.92,N/A,11433.92,N/A,25848.03,N/A,4706.78,N/A,6268.13,N/A,10444.75,N/A,10444.75,N/A,6268.13,N/A,4706.78,N/A,4923.50,N/A,1887.63,N/A,N/A,1887.63,26937.76,,Hospital CPT 42808,Excision/Destruction Lesion Pharynx Any Method,N/A,N/A,389.00,389.00,233.40,233.40,N/A,54.46,N/A,157.23,N/A,389.00,N/A,132.26,N/A,389.00,N/A,54.46,N/A,157.23,N/A,157.23,N/A,389.00,N/A,389.00,N/A,389.00,N/A,389.00,N/A,389.00,N/A,157.23,N/A,54.46,N/A,389.00,N/A,389.00,N/A,54.46,N/A,157.23,N/A,157.23,N/A,172.95,233.40,233.40,54.46,389.00,,Hospital 42810,Exc Branchial Cleft Cyst Confined Skn&Subq Tis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31126.68,N/A,18676.01,N/A,4329.14,N/A,2546.98,N/A,17918.03,N/A,10583.07,N/A,6284.38,N/A,4329.14,N/A,2569.18,N/A,2569.18,N/A,3912.16,N/A,6284.38,N/A,6284.38,N/A,6284.38,N/A,17668.70,N/A,2569.18,N/A,4329.14,N/A,3397.00,N/A,3397.00,N/A,4329.14,N/A,2569.18,N/A,2546.98,N/A,356.86,N/A,N/A,356.86,18676.01,,Hospital CPT 42820,Tonsillectomy & Adenoidectomy ,N/A,N/A,501.00,501.00,300.60,300.60,N/A,70.14,N/A,242.26,N/A,501.00,N/A,170.34,N/A,501.00,N/A,70.14,N/A,242.26,N/A,242.26,N/A,453.60,N/A,501.00,N/A,501.00,N/A,501.00,N/A,501.00,N/A,242.26,N/A,70.14,N/A,501.00,N/A,501.00,N/A,70.14,N/A,242.26,N/A,242.26,N/A,266.49,300.60,300.60,70.14,501.00,,Hospital CPT 42831,Adenoidectomy Primary Age 12/>,N/A,N/A,444.00,444.00,266.40,266.40,N/A,62.16,N/A,217.25,N/A,444.00,N/A,150.96,N/A,444.00,N/A,62.16,N/A,217.25,N/A,217.25,N/A,407.58,N/A,444.00,N/A,444.00,N/A,444.00,N/A,444.00,N/A,217.25,N/A,62.16,N/A,444.00,N/A,444.00,N/A,62.16,N/A,217.25,N/A,217.25,N/A,238.98,266.40,266.40,62.16,444.00,,Hospital 42860,Excision Tonsil Tags,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20738.30,N/A,12442.98,N/A,2894.50,N/A,2687.47,N/A,11935.13,N/A,7051.02,N/A,6305.37,N/A,2894.50,N/A,2569.18,N/A,2569.18,N/A,3925.21,N/A,6305.37,N/A,6305.37,N/A,6305.37,N/A,11935.13,N/A,2569.18,N/A,2894.50,N/A,3397.00,N/A,3397.00,N/A,2894.50,N/A,2569.18,N/A,2687.47,N/A,241.17,N/A,N/A,241.17,12442.98,,Hospital 42870,Exc/Dstrj Lingual Tonsil Any Method Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25261.45,N/A,15156.87,N/A,3530.45,N/A,4991.18,N/A,14540.70,N/A,8588.90,N/A,11680.50,N/A,3530.45,N/A,4825.87,N/A,4825.87,N/A,7271.33,N/A,11680.50,N/A,11680.50,N/A,11680.50,N/A,14540.71,N/A,4825.87,N/A,3530.45,N/A,5095.50,N/A,5095.50,N/A,3530.45,N/A,4825.87,N/A,4991.18,N/A,846.19,N/A,N/A,846.19,15156.87,,Hospital 42890,Limited Pharyngectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28782.50,N/A,17269.50,N/A,4012.63,N/A,5043.96,N/A,16569.82,N/A,9786.04,N/A,11715.79,N/A,4012.63,N/A,4821.94,N/A,4821.94,N/A,7293.29,N/A,11715.79,N/A,11715.79,N/A,11715.79,N/A,16569.82,N/A,4821.94,N/A,4012.63,N/A,7793.25,N/A,7793.25,N/A,4012.63,N/A,4821.94,N/A,5043.96,N/A,1839.35,N/A,N/A,1839.35,17269.50,,Hospital 43130,Diverticulectomy Hypopharynx/Esoph Crv Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,63937.88,N/A,38362.73,N/A,4201.55,N/A,5265.51,N/A,9468.53,N/A,21738.88,N/A,9559.10,N/A,4331.00,N/A,4972.08,N/A,4972.08,N/A,5950.32,N/A,9559.10,N/A,9559.10,N/A,9559.10,N/A,9468.53,N/A,5235.86,N/A,4331.00,N/A,11372.94,N/A,11372.94,N/A,N/A,N/A,5235.86,N/A,5265.51,N/A,4634.17,N/A,4201.55,38362.73,N/A,N/A,,Hospital 43191,Esophagoscopy Rigid Transoral Diagnostic Brush,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18996.40,N/A,11397.84,N/A,2659.51,N/A,3149.03,N/A,10937.44,N/A,6458.77,N/A,7296.82,N/A,2659.51,N/A,3010.42,N/A,3010.42,N/A,4542.40,N/A,7296.82,N/A,7296.82,N/A,7296.82,N/A,10937.45,N/A,3010.42,N/A,2659.51,N/A,4464.25,N/A,4464.25,N/A,2659.51,N/A,3010.42,N/A,3149.03,N/A,538.13,N/A,N/A,538.13,11397.84,,Hospital 43193,Esophagoscopy Rigid Transoral With Biopsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25052.67,N/A,15031.60,N/A,3507.37,N/A,490.33,N/A,14418.09,N/A,8517.91,N/A,7315.41,N/A,3507.37,N/A,3010.42,N/A,3010.42,N/A,4553.98,N/A,7315.41,N/A,7315.41,N/A,7315.41,N/A,14418.10,N/A,3010.42,N/A,3507.37,N/A,4332.50,N/A,4332.50,N/A,3507.37,N/A,3010.42,N/A,490.33,N/A,539.36,N/A,N/A,490.33,15031.60,,Hospital 43200,HC Esophagoscopy Flexible Transoral Diagnostic,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,11067.93,N/A,6640.76,N/A,1549.51,N/A,1463.54,N/A,2552.00,N/A,3763.09,N/A,3288.33,N/A,1549.51,N/A,1350.64,N/A,1350.64,N/A,2047.05,N/A,3288.33,N/A,3288.33,N/A,3288.33,N/A,2552.00,N/A,1350.64,N/A,1549.51,N/A,2806.50,N/A,2806.50,N/A,1549.51,N/A,1350.64,N/A,1463.54,N/A,393.21,N/A,N/A,393.21,6640.76,,Hospital CPT 43202,HC Esophagoscopy Flex Biopsy,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2038.00,2038.00,1222.80,1222.80,N/A,285.32,N/A,1605.43,N/A,1173.48,N/A,692.92,N/A,2038.00,N/A,285.32,N/A,1572.73,N/A,1572.73,N/A,2038.00,N/A,2038.00,N/A,2038.00,N/A,2038.00,N/A,1173.48,N/A,1572.73,N/A,285.32,N/A,2038.00,N/A,2038.00,N/A,285.32,N/A,1572.73,N/A,1605.43,N/A,108.11,1222.80,1222.80,108.11,2038.00,,Hospital 43214,Esophagoscopy Dilate Esophagus Balloon 30 Mm,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8464.00,N/A,5078.40,N/A,1176.49,N/A,1704.18,N/A,4869.72,N/A,2877.76,N/A,3835.36,N/A,1176.49,N/A,1572.73,N/A,1572.73,N/A,2387.59,N/A,3835.36,N/A,3835.36,N/A,3835.36,N/A,4869.72,N/A,1572.73,N/A,1176.49,N/A,1871.00,N/A,1871.00,N/A,1176.49,N/A,1572.73,N/A,1704.18,N/A,212.63,N/A,N/A,212.63,5078.40,,Hospital CPT 43215,HC Esophagoscopy W Removal FB,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2974.00,2974.00,1784.40,1784.40,N/A,416.36,N/A,135.33,N/A,1712.43,N/A,1011.16,N/A,1083.09,N/A,416.36,N/A,135.33,N/A,135.33,N/A,674.22,N/A,1083.09,N/A,1083.09,N/A,1083.09,N/A,1712.43,N/A,135.33,N/A,416.36,N/A,2974.00,N/A,2974.00,N/A,416.36,N/A,135.33,N/A,135.33,N/A,148.86,1784.40,1784.40,135.33,2974.00,,Hospital 43220,HC Esophagoscopy Flex Balloon Dilat <30 Mm Diam,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,9584.37,N/A,5750.62,N/A,1341.81,N/A,1614.73,N/A,5518.24,N/A,3258.69,N/A,3810.50,N/A,1341.81,N/A,1572.73,N/A,1572.73,N/A,2372.11,N/A,3810.50,N/A,3810.50,N/A,3810.50,N/A,5518.25,N/A,1572.73,N/A,1341.81,N/A,1871.00,N/A,1871.00,N/A,1341.81,N/A,1572.73,N/A,1614.73,N/A,123.70,N/A,N/A,123.70,5750.62,,Hospital 43226,Esophagoscopy Flexible Guide Wire Dilation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18743.30,N/A,11245.98,N/A,2624.06,N/A,1645.14,N/A,10791.81,N/A,6372.72,N/A,3822.36,N/A,2624.06,N/A,1572.73,N/A,1572.73,N/A,2379.49,N/A,3822.36,N/A,3822.36,N/A,3822.36,N/A,10791.81,N/A,1572.73,N/A,2624.06,N/A,1871.00,N/A,1871.00,N/A,2624.06,N/A,1572.73,N/A,1645.14,N/A,153.86,N/A,N/A,153.86,11245.98,,Hospital 43227,Esophagoscopy Flexible W/Bleeding Control,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,9702.73,N/A,5821.64,N/A,1358.38,N/A,1645.14,N/A,5586.42,N/A,3298.93,N/A,3811.02,N/A,1358.38,N/A,1572.73,N/A,1572.73,N/A,2372.43,N/A,3811.02,N/A,3811.02,N/A,3811.02,N/A,5586.42,N/A,1572.73,N/A,1358.38,N/A,1871.00,N/A,1871.00,N/A,1358.38,N/A,1572.73,N/A,1645.14,N/A,173.32,N/A,N/A,173.32,5821.64,,Hospital 43229,Esophagoscopy Flex Transoral Lesion Ablation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8196.42,N/A,4917.85,N/A,1147.49,N/A,3190.65,N/A,4718.44,N/A,2786.78,N/A,7135.02,N/A,1147.49,N/A,2944.53,N/A,2944.53,N/A,4441.69,N/A,7135.02,N/A,7135.02,N/A,7135.02,N/A,4718.44,N/A,2944.53,N/A,1147.49,N/A,3397.00,N/A,3397.00,N/A,1147.49,N/A,2944.53,N/A,3190.65,N/A,206.95,N/A,N/A,206.95,7135.02,,Hospital 43235,Esophagogastroduodenoscopy Transoral Diagnostic,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,34936.80,6095.50,20962.08,3657.30,3381.08,853.37,4141.94,1118.20,7660.42,3509.37,11878.51,2072.47,7733.70,2709.50,3485.26,853.37,3073.57,1118.20,3073.57,1118.20,4814.05,1686.71,7733.70,2709.50,7733.70,2709.50,7733.70,2709.50,7660.42,3509.37,4082.64,1118.20,3485.26,853.37,9201.17,2806.50,9201.17,2806.50,4951.99,853.37,4082.64,1118.20,4141.94,1118.20,3729.23,1230.03,3073.57,20962.08,853.37,3657.30,,Hospital 43236,Esophagogastroduodenoscopy Submucosal Injection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,37253.08,8259.50,22351.85,4955.70,6749.90,1156.32,8250.42,1212.94,15211.44,4716.28,12666.04,2808.23,15356.95,3417.21,6957.87,1156.32,1686.00,1384.87,1686.00,1384.87,9559.34,2127.26,15356.95,3417.21,15356.95,3417.21,15356.95,3417.21,15211.44,4716.28,8250.42,1384.87,6957.87,1156.32,18270.93,1871.00,18270.93,1871.00,N/A,1156.32,8250.42,1384.87,8250.42,1212.94,7444.92,1523.36,1686.00,22351.85,1156.32,4955.70,,Hospital 43237,Esophagogastroduodenoscopy US Scope W/Adj Strxrs,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,41392.28,9160.80,24835.37,5496.48,3234.91,1282.51,4151.67,1572.73,7371.78,5274.11,14073.37,3114.67,7359.88,3812.05,3334.59,1282.51,4092.37,1572.73,4092.37,1572.73,4581.35,2373.08,7359.88,3812.05,7359.88,3812.05,7359.88,3812.05,7371.78,5274.11,4092.37,1572.73,3334.59,1282.51,8756.42,1871.00,8756.42,1871.00,2014.33,1282.51,1584.21,1572.73,4151.67,1572.73,3568.01,1730.00,1584.21,24835.37,1282.51,5496.48,,Hospital 43238,Egd Intrmural US Needle Aspirate/Biopsy Esophags,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,58930.02,11988.43,35358.01,7193.06,8841.60,1678.16,9890.35,1572.73,19383.09,6900.73,20036.20,4076.06,19392.50,3829.14,9114.03,1678.16,234916.00,1572.73,234916.00,1572.73,12071.38,2383.72,19392.50,3829.14,19392.50,3829.14,19392.50,3829.14,19383.09,6900.73,9860.70,1572.73,9114.03,1678.16,23072.23,1871.00,23072.23,1871.00,9114.03,1678.16,9860.70,1572.73,9890.35,1572.73,9752.01,1730.00,8841.60,234916.00,1572.73,7193.06,,Hospital 43241,Egd Intraluminal Tube/Catheter Insertion,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,12686.10,N/A,7611.66,N/A,1776.06,N/A,1645.14,N/A,7303.28,N/A,4313.28,N/A,3837.75,N/A,1776.06,N/A,1572.73,N/A,1572.73,N/A,2389.07,N/A,3837.75,N/A,3837.75,N/A,3837.75,N/A,7303.29,N/A,1572.73,N/A,1776.06,N/A,1871.00,N/A,1871.00,N/A,1776.06,N/A,1572.73,N/A,1645.14,N/A,149.86,N/A,N/A,149.86,7611.66,,Hospital 43243,Egd Injection Sclerosis Esophgl/Gastric Varices,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,16339.00,N/A,9803.40,N/A,2287.46,N/A,1645.14,N/A,9307.69,N/A,5555.26,N/A,7030.38,N/A,2287.46,N/A,1572.73,N/A,1572.73,N/A,4376.52,N/A,7030.38,N/A,7030.38,N/A,7030.38,N/A,9307.69,N/A,1572.73,N/A,2287.46,N/A,1871.00,N/A,1871.00,N/A,2287.46,N/A,1572.73,N/A,1645.14,N/A,249.74,N/A,N/A,249.74,9803.40,,Hospital 43245,Egd Dilation Gastric/Duodenal Stricture,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,42733.60,10593.72,25640.16,6356.23,5030.55,1473.42,6216.52,1572.73,11336.75,2552.00,14529.43,3601.86,11445.19,3816.71,5185.55,1473.42,2248.00,1572.73,2248.00,1572.73,7124.37,2375.98,11445.19,3816.71,11445.19,3816.71,11445.19,3816.71,11336.75,2552.00,6216.52,1572.73,5185.55,1473.42,13616.92,2806.50,13616.92,2806.50,N/A,1473.42,6216.52,1572.73,6216.52,1572.73,5548.54,1730.00,2248.00,25640.16,1473.42,6356.23,,Hospital 43250,Egd Flex Removal Lesion(S) by Hot Biopsy Forceps,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,12435.20,N/A,7461.12,N/A,1740.93,N/A,1626.65,N/A,7157.04,N/A,4227.97,N/A,3813.60,N/A,1740.93,N/A,1572.73,N/A,1572.73,N/A,2374.04,N/A,3813.60,N/A,3813.60,N/A,3813.60,N/A,7157.04,N/A,1572.73,N/A,1740.93,N/A,1871.00,N/A,1871.00,N/A,1740.93,N/A,1572.73,N/A,1626.65,N/A,211.95,N/A,N/A,211.95,7461.12,,Hospital 43251,Egd Removal Tumor Polyp/Other Lesion Snare Tech,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,38109.95,5879.20,22865.97,3527.52,5254.60,823.08,6481.56,1572.73,12305.95,3384.03,12957.38,1998.93,11954.95,3815.11,5416.50,823.08,1686.00,1572.73,1686.00,1572.73,7441.68,2374.98,11954.95,3815.11,11954.95,3815.11,11954.95,3815.11,12305.95,3384.03,6481.56,1572.73,5416.50,823.08,14223.40,2806.50,14223.40,2806.50,N/A,823.08,6481.56,1572.73,6481.56,1572.73,5795.66,1730.00,1686.00,22865.97,823.08,3815.11,,Hospital 43261,Ercp W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,30861.57,N/A,18516.94,N/A,4320.62,N/A,4732.58,N/A,17759.26,N/A,10492.93,N/A,11460.04,N/A,4320.62,N/A,4732.58,N/A,4732.58,N/A,7134.10,N/A,11460.04,N/A,11460.04,N/A,11460.04,N/A,17759.26,N/A,4732.58,N/A,4320.62,N/A,5944.75,N/A,5944.75,N/A,4320.62,N/A,4732.58,N/A,4732.58,N/A,5205.84,N/A,N/A,4320.62,18516.94,,Hospital 43264,Ercp Remove Calculi/Debris Biliary/Pancreas Duct,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,72053.80,13908.78,43232.28,8345.27,5865.95,1947.22,7293.70,2944.53,13219.39,8007.85,24498.29,4728.99,13345.85,7131.91,6046.69,1947.22,112400.00,2944.53,112400.00,2944.53,8307.48,4439.75,13345.85,7131.91,13345.85,7131.91,13345.85,7131.91,13219.39,8007.85,7204.75,2944.53,6046.69,1947.22,15878.22,5095.50,15878.22,5095.50,6135.88,1947.22,7204.75,2944.53,7293.70,2944.53,6469.96,3238.99,5865.95,112400.00,1947.22,8345.27,,Hospital 43266,Egd Endoscopic Stent Placement W/Wire& Dilation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33649.90,N/A,20189.94,N/A,4710.99,N/A,5220.60,N/A,19038.77,N/A,11440.97,N/A,11495.99,N/A,4710.99,N/A,4732.58,N/A,4732.58,N/A,7156.47,N/A,11495.99,N/A,11495.99,N/A,11495.99,N/A,19038.78,N/A,4732.58,N/A,4710.99,N/A,5965.25,N/A,5965.25,N/A,4710.99,N/A,4732.58,N/A,729.35,N/A,802.28,N/A,N/A,729.35,20189.94,,Hospital 43270,Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,41797.57,11621.70,25078.54,6973.02,5254.60,1617.33,7878.60,1572.73,19112.64,6689.85,14211.17,3951.38,12058.11,3826.04,5416.50,1617.33,215246.00,1572.73,215246.00,1572.73,7505.89,2381.78,12058.11,3826.04,12058.11,3826.04,12058.11,3826.04,19112.64,6689.85,7819.30,1572.73,5416.50,1617.33,14346.14,1871.00,1871.00,1871.00,1631.33,1617.33,7819.30,1572.73,7878.60,1572.73,5795.66,1730.00,1631.33,215246.00,1572.73,6973.02,,Hospital 43275,Ercp Remove Foreign Body/Stent Biliary/Panc Duct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,14061.05,13541.38,8436.63,8124.83,3440.30,1895.79,2929.47,2944.53,7752.99,7795.79,4780.76,4604.08,7827.15,7134.97,3546.30,1895.79,562.00,2944.53,562.00,2944.53,4872.22,4441.65,7827.15,7134.97,7827.15,7134.97,7827.15,7134.97,7752.99,7795.79,4335.33,2944.53,3546.30,1895.79,9312.36,5095.50,9312.36,5095.50,N/A,1895.79,4335.33,2944.53,4335.33,2944.53,3794.54,3238.99,562.00,9312.36,1895.79,8124.83,,Hospital 43276,Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,32638.90,27090.87,19583.34,16254.52,6484.76,3783.01,7936.79,4732.58,14762.31,15425.85,11097.23,9210.89,14753.74,11478.06,6684.57,3783.01,562.00,4732.58,562.00,4732.58,9183.86,7145.31,14753.74,11478.06,14753.74,11478.06,14753.74,11478.06,14762.31,15425.85,7936.79,4732.58,6684.57,3783.01,17553.26,3397.00,17553.26,3397.00,N/A,3783.01,7936.79,4732.58,7936.79,4732.58,7152.49,5205.84,562.00,19583.34,3397.00,16254.52,,Hospital 43278,Ercp Tumor/Polyp/Lesion Ablation W/Dilation&Wire,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,38508.23,N/A,23104.94,N/A,5373.98,N/A,4732.58,N/A,22162.50,N/A,12680.04,N/A,11472.63,N/A,5373.98,N/A,4732.58,N/A,4732.58,N/A,7141.93,N/A,11472.63,N/A,11472.63,N/A,11472.63,N/A,22162.50,N/A,4732.58,N/A,5373.98,N/A,5944.75,N/A,5944.75,N/A,5373.98,N/A,4732.58,N/A,4732.58,N/A,5205.84,N/A,N/A,4732.58,23104.94,,Hospital 43284,Laps Esophgl Sphnctr Agmntj Plmt Dev Crrpl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,100194.10,N/A,60116.46,N/A,14027.18,N/A,8376.85,N/A,57279.28,N/A,34065.99,N/A,19912.44,N/A,14027.18,N/A,8206.20,N/A,8206.20,N/A,12398.21,N/A,19912.44,N/A,19912.44,N/A,19912.44,N/A,57279.28,N/A,8206.20,N/A,14027.18,N/A,7897.00,N/A,7897.00,N/A,14027.18,N/A,8206.20,N/A,8376.85,N/A,691.17,N/A,N/A,691.17,60116.46,,Hospital 43285,Removal Esophageal Sphincter Agmntj Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16126.90,N/A,9676.14,N/A,2255.45,N/A,4682.70,N/A,9280.97,N/A,5465.14,N/A,11463.40,N/A,2255.45,N/A,4706.78,N/A,4706.78,N/A,7136.19,N/A,11463.40,N/A,11463.40,N/A,11463.40,N/A,9280.98,N/A,4706.78,N/A,2255.45,N/A,7897.00,N/A,7897.00,N/A,2255.45,N/A,4706.78,N/A,4682.70,N/A,731.92,N/A,N/A,731.92,11463.40,,Hospital 43305,Esphgp Crv Appr W/Rpr Tracheoesophgl Fstl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17603.10,N/A,10561.86,N/A,2464.44,N/A,1589.76,N/A,10131.56,N/A,5985.06,N/A,15496.02,N/A,2464.44,N/A,1572.73,N/A,1572.73,N/A,9646.56,N/A,15496.02,N/A,15496.02,N/A,15496.02,N/A,10131.57,N/A,1572.73,N/A,2464.44,N/A,3217.25,N/A,3217.25,N/A,2464.44,N/A,1572.73,N/A,1589.76,N/A,1535.44,N/A,N/A,1535.44,15496.02,,Hospital 43500,Gastrotomy W/Exploration/Foreign Body Removal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14297.70,N/A,8578.62,N/A,2001.67,N/A,2719.26,N/A,8216.16,N/A,4861.20,N/A,14265.84,N/A,2001.67,N/A,2690.13,N/A,2690.13,N/A,8880.74,N/A,14265.84,N/A,14265.84,N/A,14265.84,N/A,8209.12,N/A,2690.13,N/A,2001.67,N/A,5383.50,N/A,5383.50,N/A,2001.67,N/A,2690.13,N/A,2719.26,N/A,1204.54,N/A,N/A,1204.54,14265.84,,Hospital 43644,Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,72530.13,85651.40,43518.08,51390.84,8295.33,11962.13,10108.24,3366.28,20681.58,49250.92,24660.24,29121.49,18873.04,32395.36,8550.93,11962.13,123640.00,8206.20,123640.00,8206.20,11748.03,20166.73,18873.04,32395.36,18873.04,32395.36,18873.04,32395.36,20681.58,48462.09,10078.59,8206.20,8550.93,11962.13,22454.20,11845.50,22454.20,11845.50,8550.93,11962.13,10078.59,8206.20,10108.24,3366.28,9149.49,3690.66,8295.33,123640.00,3366.28,51390.84,,Hospital 43647,Laps Impltj/Rplcmt Gastric Nstim Eltrd Antrum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,93485.93,N/A,56091.56,N/A,5460.52,N/A,6408.84,N/A,46488.40,N/A,31785.21,N/A,12736.48,N/A,5628.77,N/A,214122.00,N/A,214122.00,N/A,7928.84,N/A,12736.48,N/A,12736.48,N/A,12736.48,N/A,46488.40,N/A,6379.19,N/A,5628.77,N/A,14714.36,N/A,14714.36,N/A,14400.21,N/A,6379.19,N/A,6408.84,N/A,6022.78,N/A,5460.52,214122.00,N/A,N/A,,Hospital 43653,Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30034.52,N/A,18020.71,N/A,4204.84,N/A,4682.70,N/A,17290.22,N/A,10211.74,N/A,11432.51,N/A,4204.84,N/A,4706.78,N/A,4706.78,N/A,7116.96,N/A,11432.51,N/A,11432.51,N/A,11432.51,N/A,17290.23,N/A,4706.78,N/A,4204.84,N/A,10444.75,N/A,10444.75,N/A,4204.84,N/A,4706.78,N/A,4682.70,N/A,2876.43,N/A,N/A,2876.43,18020.71,,Hospital CPT 43753,HC Gastric Lavage/Decomp by Phys,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,604.00,604.00,362.40,362.40,N/A,84.56,N/A,21.46,N/A,347.78,N/A,205.36,N/A,62.58,N/A,84.56,N/A,21.46,N/A,21.46,N/A,38.96,N/A,62.58,N/A,62.58,N/A,62.58,N/A,347.78,N/A,21.46,N/A,84.56,N/A,604.00,N/A,604.00,N/A,84.56,N/A,21.46,N/A,21.46,N/A,23.61,362.40,362.40,21.46,604.00,,Hospital 43761,HC Reposition Gastric Tube Duod,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,331360.57,3951.30,198816.34,2370.78,N/A,553.18,34045.41,309.48,N/A,2274.92,110122.08,1343.44,110122.08,748.13,N/A,553.18,22905.29,303.18,22905.29,303.18,110122.08,465.72,110122.08,748.13,110122.08,748.13,110122.08,748.13,N/A,2274.92,22905.29,303.18,N/A,553.18,N/A,790.50,N/A,790.50,N/A,553.18,22905.29,303.18,22905.29,309.48,N/A,153.67,22905.29,198816.34,153.67,2370.78,,Hospital 43772,Laps Gastric Restrictive Px Remove Device,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38477.68,N/A,23086.61,N/A,5386.88,N/A,3248.17,N/A,22139.84,N/A,13082.41,N/A,7188.84,N/A,5386.88,N/A,2944.53,N/A,2944.53,N/A,4475.20,N/A,7188.84,N/A,7188.84,N/A,7188.84,N/A,22139.86,N/A,2944.53,N/A,5386.88,N/A,4562.00,N/A,4562.00,N/A,5386.88,N/A,2944.53,N/A,919.26,N/A,1011.19,N/A,N/A,919.26,23086.61,,Hospital 43870,Closure Gastrostomy Surg,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30034.52,N/A,18020.71,N/A,4204.84,N/A,4682.70,N/A,17290.22,N/A,10211.74,N/A,11432.51,N/A,4204.84,N/A,4706.78,N/A,4706.78,N/A,7116.96,N/A,11432.51,N/A,11432.51,N/A,11432.51,N/A,17290.23,N/A,4706.78,N/A,4204.84,N/A,10444.75,N/A,10444.75,N/A,4204.84,N/A,4706.78,N/A,4682.70,N/A,2876.43,N/A,N/A,2876.43,18020.71,,Hospital 44050,Rdctj Volvulus Intussusception Int Hrna Lapt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,23672.70,22169.55,14203.62,13301.73,14043.39,3051.72,16907.90,937.47,23672.70,12760.35,8048.72,7537.65,23672.70,8047.15,14476.09,3051.72,145558.00,1009.39,145558.00,1009.39,19888.54,5009.49,23672.70,8047.15,23672.70,8047.15,23672.70,8047.15,23672.70,12760.37,16878.25,1009.39,14476.09,3051.72,23672.70,1643.00,23672.70,1643.00,151.09,3051.72,16878.25,1009.39,16907.90,937.47,15489.42,1025.09,151.09,145558.00,937.47,13301.73,,Hospital 44055,Corrj Malrotation Bands&/Rdctj Volvulus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25963.17,N/A,15577.90,N/A,3632.52,N/A,1484.76,N/A,14944.15,N/A,8827.48,N/A,7930.36,N/A,3632.52,N/A,1484.99,N/A,1484.99,N/A,4936.80,N/A,7930.36,N/A,7930.36,N/A,7930.36,N/A,14944.15,N/A,1484.99,N/A,3632.52,N/A,1643.00,N/A,1643.00,N/A,3632.52,N/A,1484.99,N/A,1484.76,N/A,1622.58,N/A,N/A,1484.76,15577.90,,Hospital 44120,Entrc Rescj Small Intestine 1 Rescj & Anast,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,120833.72,35262.27,72500.23,21157.36,24663.55,4936.73,29471.00,1405.45,66603.54,20300.81,41083.46,11989.17,56112.99,11061.29,25423.48,4936.73,205130.00,1343.59,205130.00,1343.59,34929.03,6889.48,56112.99,11061.29,56112.99,11061.29,56112.99,11061.29,66603.54,20048.63,29441.35,1343.59,25423.48,4936.73,66760.45,2692.50,66760.45,2692.50,N/A,4936.73,31801.57,1343.59,34827.09,1405.45,27203.12,1553.59,24663.55,205130.00,1343.59,21157.36,,Hospital 44140,Colectomy Partial W/Anastomosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49061.22,N/A,29436.73,N/A,6868.58,N/A,2024.06,N/A,28192.91,N/A,16680.82,N/A,9509.39,N/A,6868.58,N/A,1996.76,N/A,1996.76,N/A,5919.78,N/A,9509.39,N/A,9509.39,N/A,9509.39,N/A,28142.25,N/A,1996.76,N/A,6868.58,N/A,1906.50,N/A,1906.50,N/A,6868.58,N/A,1996.76,N/A,2024.06,N/A,1797.87,N/A,N/A,1797.87,29436.73,,Hospital 44143,Colectomy Prtl W/End Colostomy & Clsr Dstl Sgmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42853.27,N/A,25711.96,N/A,5999.46,N/A,2133.21,N/A,24671.89,N/A,14570.12,N/A,9025.21,N/A,5999.46,N/A,2122.30,N/A,2122.30,N/A,5618.37,N/A,9025.21,N/A,9025.21,N/A,9025.21,N/A,24671.89,N/A,2122.30,N/A,5999.46,N/A,2038.25,N/A,2038.25,N/A,5999.46,N/A,2122.30,N/A,2133.21,N/A,2539.92,N/A,N/A,2038.25,25711.96,,Hospital 44186,Laparoscopy Surgical Jejunostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52194.03,26465.33,31316.42,15879.20,6943.01,3688.35,8508.51,696.29,15646.63,15234.96,17139.57,8998.22,11473.15,11442.38,7156.93,3688.35,41588.00,4706.78,41588.00,4706.78,7142.27,7123.08,11473.15,11442.38,11473.15,11442.38,11473.15,11442.38,15646.63,14854.95,6718.94,4706.78,7156.93,3688.35,18793.66,7897.00,18793.66,7897.00,7156.93,3688.35,8478.86,4706.78,8508.51,696.29,784.10,759.80,784.10,41588.00,696.29,15879.20,,Hospital 44202,Laps Enterect Rescj 1 Small Intest Rescj & Ana,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19955.05,N/A,11973.03,N/A,2793.72,N/A,4682.70,N/A,11486.40,N/A,6784.72,N/A,19955.05,N/A,2793.72,N/A,4706.78,N/A,4706.78,N/A,14220.91,N/A,19955.05,N/A,19955.05,N/A,19955.05,N/A,11486.41,N/A,4706.78,N/A,2793.72,N/A,7921.50,N/A,7921.50,N/A,2793.72,N/A,4706.78,N/A,4682.70,N/A,1634.24,N/A,N/A,1634.24,19955.05,,Hospital 44204,Laparoscopy Colectomy Partial W/Anastomosis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,121081.32,32281.77,72648.79,19369.06,9115.80,4510.59,11049.17,1787.48,66740.02,18586.08,41167.65,10975.80,20739.71,12119.55,9396.67,4510.59,2810.00,1774.00,2810.00,1774.00,12909.98,7544.66,20739.71,12119.55,N/A,12119.55,20739.71,12119.55,66740.02,18586.10,11049.17,1774.00,9396.67,4510.59,24675.07,5963.00,24675.07,5963.00,N/A,4510.59,11049.17,1774.00,11049.17,1787.48,10054.44,1836.80,2810.00,72648.79,1774.00,19369.06,,Hospital 44206,Laps Colectomy Prtl W/End Clst & Clsr Dstl Sgm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,141373.57,N/A,84824.14,N/A,19156.16,N/A,18090.52,N/A,77925.11,N/A,N/A,N/A,N/A,N/A,19746.39,N/A,185460.00,N/A,185460.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,77925.11,N/A,18031.22,N/A,19746.39,N/A,66760.45,N/A,66760.45,N/A,2633.34,N/A,18031.22,N/A,18090.52,N/A,21128.64,N/A,2633.34,185460.00,N/A,N/A,,Hospital 44320,Colostomy/Skin Level Cecostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,71205.17,N/A,42723.10,N/A,9920.21,N/A,2746.07,N/A,40673.88,N/A,24209.80,N/A,19857.63,N/A,9920.21,N/A,2690.13,N/A,2690.13,N/A,12361.71,N/A,19857.63,N/A,19857.63,N/A,19857.63,N/A,40673.89,N/A,2690.13,N/A,9920.21,N/A,3103.25,N/A,3103.25,N/A,9920.21,N/A,2690.13,N/A,2746.07,N/A,3456.08,N/A,N/A,2690.13,42723.10,,Hospital 44340,Revj Colostomy Smpl Rls Supfc Scar Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17830.10,N/A,10698.06,N/A,2496.21,N/A,599.98,N/A,10255.73,N/A,6046.94,N/A,7168.77,N/A,2496.21,N/A,2937.63,N/A,2937.63,N/A,4462.69,N/A,7168.77,N/A,7168.77,N/A,7168.77,N/A,10255.75,N/A,2937.63,N/A,2496.21,N/A,4562.00,N/A,4562.00,N/A,2496.21,N/A,2937.63,N/A,599.98,N/A,659.98,N/A,N/A,599.98,10698.06,,Hospital 44345,Revj Colostomy Comp Rcnstj in-Depth Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33230.43,N/A,19938.26,N/A,4599.96,N/A,1059.17,N/A,19118.24,N/A,11298.35,N/A,8092.01,N/A,4599.96,N/A,1114.96,N/A,1114.96,N/A,5037.42,N/A,8092.01,N/A,8092.01,N/A,8092.01,N/A,19118.26,N/A,1114.96,N/A,4599.96,N/A,4562.00,N/A,4562.00,N/A,4599.96,N/A,1114.96,N/A,1059.17,N/A,1165.10,N/A,N/A,1059.17,19938.26,,Hospital 44361,Endoscopy Upper Small Intestine W/Biopsy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,9671.20,N/A,5802.72,N/A,1345.11,N/A,1645.14,N/A,5567.85,N/A,3288.21,N/A,3812.57,N/A,1345.11,N/A,1572.73,N/A,1572.73,N/A,2373.40,N/A,3812.57,N/A,3812.57,N/A,3812.57,N/A,5567.85,N/A,1572.73,N/A,1345.11,N/A,1871.00,N/A,1871.00,N/A,1345.11,N/A,1572.73,N/A,1645.14,N/A,208.14,N/A,N/A,208.14,5802.72,,Hospital 44366,Enteroscopy > 2nd Prtn W/Control Bleeding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,9858.43,N/A,5915.06,N/A,1380.19,N/A,1645.14,N/A,5676.33,N/A,3351.87,N/A,3809.87,N/A,1380.19,N/A,1572.73,N/A,1572.73,N/A,2371.72,N/A,3809.87,N/A,3809.87,N/A,3809.87,N/A,5676.33,N/A,1572.73,N/A,1380.19,N/A,1871.00,N/A,1871.00,N/A,1380.19,N/A,1572.73,N/A,1645.14,N/A,251.96,N/A,N/A,251.96,5915.06,,Hospital 44370,Enteroscopy > 2nd Prtn Tndsc Stent Plmt,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10792.90,N/A,6475.74,N/A,1511.01,N/A,4708.37,N/A,6213.94,N/A,3669.59,N/A,10792.90,N/A,1511.01,N/A,4732.58,N/A,4732.58,N/A,7130.68,N/A,10792.90,N/A,10792.90,N/A,10792.90,N/A,6213.94,N/A,4732.58,N/A,1511.01,N/A,5497.50,N/A,5497.50,N/A,1511.01,N/A,4732.58,N/A,4708.37,N/A,976.56,N/A,N/A,976.56,10792.90,,Hospital 44377,Enterosc >2nd Prtn W/Ileum W/Bx Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,12543.90,N/A,7526.34,N/A,1756.14,N/A,1645.14,N/A,7222.34,N/A,4264.92,N/A,3813.91,N/A,1756.14,N/A,1572.73,N/A,1572.73,N/A,2374.23,N/A,3813.91,N/A,3813.91,N/A,3813.91,N/A,7222.35,N/A,1572.73,N/A,1756.14,N/A,1871.00,N/A,1871.00,N/A,1756.14,N/A,1572.73,N/A,1645.14,N/A,785.51,N/A,N/A,785.51,7526.34,,Hospital 44378,Enteroscopy > 2nd Prtn Ileum Control Bleeding,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,50278.73,10944.73,30167.24,6566.84,5254.60,1532.28,6481.56,1645.14,11841.67,6299.17,17094.77,3721.22,11954.95,3841.58,5416.50,1532.28,6481.56,1572.73,6481.56,1572.73,7441.68,2391.46,11954.95,3841.58,11954.95,3841.58,11954.95,3841.58,11841.67,6299.17,6481.56,1572.73,5416.50,1532.28,14223.40,1871.00,14223.40,1871.00,N/A,1532.28,6481.56,1572.73,6481.56,1645.14,5795.66,405.92,5254.60,30167.24,405.92,6566.84,,Hospital 44382,Ileoscopy Stoma W/Bx Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8532.30,N/A,5119.38,N/A,1185.66,N/A,779.79,N/A,4912.43,N/A,2900.98,N/A,1814.42,N/A,1185.66,N/A,745.47,N/A,745.47,N/A,1129.50,N/A,1814.42,N/A,1814.42,N/A,1814.42,N/A,4912.44,N/A,745.47,N/A,1185.66,N/A,1871.00,N/A,1871.00,N/A,1185.66,N/A,745.47,N/A,779.79,N/A,117.44,N/A,N/A,117.44,5119.38,,Hospital 44386,Ndsc Eval Intstinal Pouch W/Bx Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,9228.20,N/A,5536.92,N/A,1291.95,N/A,785.02,N/A,5313.00,N/A,3137.59,N/A,1823.07,N/A,1291.95,N/A,750.46,N/A,750.46,N/A,1134.90,N/A,1823.07,N/A,1823.07,N/A,1823.07,N/A,5313.00,N/A,750.46,N/A,1291.95,N/A,1871.00,N/A,1871.00,N/A,1291.95,N/A,750.46,N/A,785.02,N/A,193.03,N/A,N/A,193.03,5536.92,,Hospital 44394,Colonoscopy Stoma W/Rmvl Tum Polyp/Oth Les Snare,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,44834.93,10552.90,26900.96,6331.74,8349.21,1477.42,10142.34,1826.18,18815.63,6075.30,15243.88,3587.99,18995.62,4467.06,8606.47,1477.42,2248.00,1842.10,2248.00,1842.10,11824.33,2780.84,18995.62,4467.06,18995.62,4467.06,18995.62,4467.06,18815.63,6075.30,10142.34,1842.10,8606.47,1477.42,22600.04,3164.25,22600.04,3164.25,N/A,1477.42,4557.60,1842.10,10142.34,1826.18,9208.92,659.03,2248.00,26900.96,659.03,6331.74,,Hospital 44403,Colonoscopy Stoma W/Endoscopic Mucosal Rescj,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,24146.55,N/A,14487.93,N/A,3380.52,N/A,1022.94,N/A,13875.55,N/A,8209.83,N/A,2379.47,N/A,3380.52,N/A,977.91,N/A,977.91,N/A,1481.27,N/A,2379.47,N/A,2379.47,N/A,2379.47,N/A,13875.55,N/A,977.91,N/A,3380.52,N/A,1871.00,N/A,1871.00,N/A,3380.52,N/A,977.91,N/A,1022.94,N/A,353.29,N/A,N/A,353.29,14487.93,,Hospital 44404,Colonoscopy Stoma W/Submucosal Injection,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8074.70,N/A,4844.82,N/A,1130.46,N/A,1826.18,N/A,4648.53,N/A,2745.40,N/A,4465.19,N/A,1130.46,N/A,1842.10,N/A,1842.10,N/A,2779.67,N/A,4465.19,N/A,4465.19,N/A,4465.19,N/A,4648.53,N/A,1842.10,N/A,1130.46,N/A,3164.25,N/A,3164.25,N/A,1130.46,N/A,1842.10,N/A,1826.18,N/A,453.32,N/A,N/A,453.32,4844.82,,Hospital 44407,Colonoscopy Stoma W/US Gid Ndl Aspir/Bx,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,11904.92,N/A,7142.95,N/A,1666.68,N/A,1534.41,N/A,2552.00,N/A,4047.68,N/A,3625.33,N/A,1666.68,N/A,1466.87,N/A,1466.87,N/A,2256.84,N/A,3625.33,N/A,3625.33,N/A,3625.33,N/A,2552.00,N/A,1466.87,N/A,1666.68,N/A,2806.50,N/A,2806.50,N/A,1666.68,N/A,1466.87,N/A,1534.41,N/A,555.64,N/A,N/A,555.64,7142.95,,Hospital 44604,Sutr Lg Intestine 1/Mult Perforat W/O Colostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,65026.23,N/A,39015.74,N/A,9097.93,N/A,1682.22,N/A,37382.43,N/A,22005.02,N/A,19660.89,N/A,9097.93,N/A,4706.78,N/A,4706.78,N/A,12238.76,N/A,19660.89,N/A,19660.89,N/A,19660.89,N/A,37382.43,N/A,4706.78,N/A,9097.93,N/A,12256.25,N/A,12256.25,N/A,9097.93,N/A,4706.78,N/A,1682.22,N/A,1850.45,N/A,N/A,1682.22,39015.74,,Hospital 44615,Intstinal Stricturoplasty W/WO Dilat Obstrcj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67343.32,N/A,40405.99,N/A,9360.04,N/A,4682.70,N/A,38763.06,N/A,22896.72,N/A,19203.65,N/A,9360.04,N/A,4706.78,N/A,4706.78,N/A,11954.63,N/A,19203.65,N/A,19203.65,N/A,19203.65,N/A,38042.11,N/A,4706.78,N/A,9360.04,N/A,7309.25,N/A,7309.25,N/A,9360.04,N/A,4706.78,N/A,4682.70,N/A,1469.30,N/A,N/A,1469.30,40405.99,,Hospital 44620,Closure Enterostomy Lg/Small Intestine,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,88132.57,N/A,52879.54,N/A,12171.24,N/A,1155.06,N/A,50640.71,N/A,29887.82,N/A,8901.93,N/A,12171.24,N/A,1095.41,N/A,1095.41,N/A,5541.55,N/A,8901.93,N/A,8901.93,N/A,8901.93,N/A,47548.17,N/A,1095.41,N/A,12171.24,N/A,1906.50,N/A,1906.50,N/A,12171.24,N/A,1095.41,N/A,1155.06,N/A,1258.34,N/A,N/A,1095.41,52879.54,,Hospital 44701,Intraoperative Colonic Lavage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,373664.52,N/A,224198.71,N/A,N/A,N/A,18541.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18541.49,N/A,18541.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18541.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18541.49,N/A,18541.49,N/A,N/A,N/A,18541.49,224198.71,N/A,N/A,,Hospital 44705,Prepare Fecal Microbiota for Instillation,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,11377.50,N/A,6826.50,N/A,1592.85,N/A,176.59,N/A,2552.00,N/A,3865.44,N/A,2390.45,N/A,1592.85,N/A,750.46,N/A,750.46,N/A,1487.49,N/A,2390.45,N/A,2390.45,N/A,2390.45,N/A,2552.00,N/A,750.46,N/A,1592.85,N/A,1871.00,N/A,1871.00,N/A,1592.85,N/A,750.46,N/A,176.59,N/A,194.25,N/A,N/A,176.59,6826.50,,Hospital 44960,Appendec Rptd Appendix Absc/Pritonitis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,120833.72,N/A,72500.23,N/A,24663.55,N/A,29471.00,N/A,66603.54,N/A,41083.46,N/A,56112.99,N/A,25423.48,N/A,205130.00,N/A,205130.00,N/A,N/A,N/A,56112.99,N/A,56112.99,N/A,56112.99,N/A,66603.54,N/A,34827.09,N/A,25423.48,N/A,66760.45,N/A,66760.45,N/A,N/A,N/A,31801.57,N/A,29471.00,N/A,27203.12,N/A,24663.55,205130.00,N/A,N/A,,Hospital 44979,Unlisted Laparoscopy Procedure Appendix,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49806.72,N/A,29884.03,N/A,6967.19,N/A,632.15,N/A,28663.11,N/A,16934.27,N/A,11476.84,N/A,6967.19,N/A,4706.78,N/A,4706.78,N/A,7144.56,N/A,11476.84,N/A,11476.84,N/A,11476.84,N/A,28663.14,N/A,4706.78,N/A,6967.19,N/A,11346.25,N/A,11346.25,N/A,6967.19,N/A,4706.78,N/A,632.15,N/A,695.37,N/A,N/A,632.15,29884.03,,Hospital CPT 45005,HC Drain Rectal Abscess,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,3288.00,3288.00,1972.80,1972.80,N/A,460.32,N/A,159.68,N/A,1893.23,N/A,1117.92,N/A,876.15,N/A,460.32,N/A,159.68,N/A,159.68,N/A,545.40,N/A,876.15,N/A,876.15,N/A,876.15,N/A,1893.23,N/A,159.68,N/A,460.32,N/A,3288.00,N/A,3288.00,N/A,460.32,N/A,159.68,N/A,159.68,N/A,175.65,1972.80,1972.80,159.68,3288.00,,Hospital 45130,Exc Rct Procidentia W/Anast Perineal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,30149.10,48128.40,18089.46,28877.04,13098.63,6732.95,15760.65,1553.71,29518.82,27701.87,10250.69,16363.65,29801.19,6846.49,13502.22,6732.95,562.00,1536.81,562.00,1536.81,18550.55,4262.08,29801.19,6846.49,29801.19,6846.49,29801.19,6846.49,29518.82,25510.95,15760.65,1536.81,13502.22,6732.95,30149.10,1643.00,30149.10,1643.00,N/A,6732.95,15760.65,1536.81,15760.65,1553.71,14447.37,1368.55,562.00,30149.10,1368.55,28877.04,,Hospital CPT 45171,Exc Rct Tum Not Incl Muscularis Propria,N/A,N/A,1202.00,1202.00,721.20,721.20,N/A,168.28,N/A,589.79,N/A,1202.00,N/A,408.68,N/A,1202.00,N/A,168.28,N/A,589.79,N/A,589.79,N/A,1088.23,N/A,1202.00,N/A,1202.00,N/A,1202.00,N/A,1202.00,N/A,589.79,N/A,168.28,N/A,1202.00,N/A,1202.00,N/A,168.28,N/A,589.79,N/A,589.79,N/A,648.77,721.20,721.20,168.28,1202.00,,Hospital 45305,Proctosgmdsc Rigid W/Bx Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,5758.92,N/A,3455.35,N/A,806.25,N/A,969.46,N/A,3307.75,N/A,1958.03,N/A,2942.15,N/A,806.25,N/A,977.91,N/A,977.91,N/A,1873.70,N/A,2942.15,N/A,2942.15,N/A,2942.15,N/A,3307.75,N/A,977.91,N/A,806.25,N/A,1871.00,N/A,1871.00,N/A,806.25,N/A,977.91,N/A,969.46,N/A,217.43,N/A,N/A,217.43,3455.35,,Hospital 45331,Sigmoidoscopy Flx W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,38380.50,6066.70,23028.30,3640.02,5430.64,849.33,6530.09,750.46,12637.97,3491.47,13049.37,2062.67,12492.61,1834.88,5597.97,849.33,219742.00,750.46,219742.00,750.46,7776.36,1142.25,12492.61,1834.88,12492.61,1834.88,12492.61,1834.88,12637.97,3491.47,6441.14,750.46,5597.97,849.33,14863.09,1431.00,1431.00,1431.00,N/A,849.33,6441.14,750.46,6530.09,750.46,5989.83,825.51,1431.00,219742.00,750.46,3640.02,,Hospital 45333,Sigmoidoscopy Flx W/Rmvl Tumor by Hot Bx Forceps,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8974.40,N/A,5384.64,N/A,1256.42,N/A,1433.96,N/A,5166.90,N/A,3051.30,N/A,3284.01,N/A,1256.42,N/A,1353.14,N/A,1353.14,N/A,2044.36,N/A,3284.01,N/A,3284.01,N/A,3284.01,N/A,5166.90,N/A,1353.14,N/A,1256.42,N/A,2586.50,N/A,2586.50,N/A,1256.42,N/A,1353.14,N/A,1433.96,N/A,257.69,N/A,N/A,257.69,5384.64,,Hospital 45340,Sigmoidoscopy Flx Tndsc Balo Dilat,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,9224.80,N/A,5534.88,N/A,1285.66,N/A,1399.54,N/A,5310.60,N/A,3136.43,N/A,3280.90,N/A,1285.66,N/A,1353.14,N/A,1353.14,N/A,2042.43,N/A,3280.90,N/A,3280.90,N/A,3280.90,N/A,5310.60,N/A,1353.14,N/A,1285.66,N/A,2586.50,N/A,2586.50,N/A,1285.66,N/A,1353.14,N/A,1399.54,N/A,231.95,N/A,N/A,231.95,5534.88,,Hospital 45341,Sigmoidoscopy Flx Ndsc US Xm,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10571.97,N/A,6343.18,N/A,1472.05,N/A,746.62,N/A,6083.92,N/A,3594.47,N/A,1823.38,N/A,1472.05,N/A,750.46,N/A,750.46,N/A,1135.09,N/A,1823.38,N/A,1823.38,N/A,1823.38,N/A,6083.92,N/A,750.46,N/A,1472.05,N/A,1871.00,N/A,1871.00,N/A,1472.05,N/A,750.46,N/A,746.62,N/A,166.17,N/A,N/A,166.17,6343.18,,Hospital 45350,Sigmoidoscopy Flx With With Band Ligation(S),N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,11866.20,N/A,7119.72,N/A,1637.74,N/A,1645.14,N/A,6832.16,N/A,4034.51,N/A,3817.64,N/A,1637.74,N/A,1572.73,N/A,1572.73,N/A,2376.56,N/A,3817.64,N/A,3817.64,N/A,3817.64,N/A,6832.16,N/A,1572.73,N/A,1637.74,N/A,2806.50,N/A,2806.50,N/A,1637.74,N/A,1572.73,N/A,1645.14,N/A,376.41,N/A,N/A,376.41,7119.72,,Hospital 45378,Colonoscopy Flx Dx W/Collj Spec When Pfrmd,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,36199.50,9515.10,21719.70,5709.06,5030.55,1332.11,6275.82,1123.19,11336.75,2552.00,12307.83,3235.13,11445.19,2729.03,5185.55,1332.11,6216.52,1123.19,6216.52,1123.19,7124.37,1698.88,11445.19,2729.03,11445.19,2729.03,11445.19,2729.03,11336.75,2552.00,6216.52,1123.19,5185.55,1332.11,13616.92,2806.50,13616.92,2806.50,2443.43,1332.11,6216.52,1123.19,6275.82,1123.19,2443.43,1235.52,2443.43,21719.70,1123.19,5709.06,,Hospital 45380,Colonoscopy W/Biopsy Single/Multiple,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,44151.70,6293.00,26491.02,3775.80,5097.23,880.80,6149.29,1955.83,11657.73,2552.00,15011.58,2139.62,11769.25,4742.77,5254.28,880.80,284934.00,1955.83,284934.00,1955.83,7326.08,2952.47,11769.25,4742.77,11769.25,4742.77,11769.25,4742.77,11657.73,2552.00,6089.99,1955.83,5254.28,880.80,14002.47,3274.25,14002.47,3274.25,2426.16,880.80,6089.99,1955.83,6149.29,1955.83,5622.08,2151.40,2426.16,284934.00,880.80,4742.77,,Hospital 45381,Colsc Flx With Directed Submucosal Njx Any Sbst,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,43624.00,9563.60,26174.40,5738.16,5254.60,1338.90,6481.56,1955.83,13234.52,2552.00,14832.16,3251.61,11954.95,4749.61,5416.50,1338.90,1686.00,1955.83,1686.00,1955.83,7441.68,2956.73,11954.95,4749.61,11954.95,4749.61,11954.95,4749.61,13234.52,2552.00,6481.56,1955.83,5416.50,1338.90,14223.40,3274.25,14223.40,3274.25,N/A,1338.90,6481.56,1955.83,6481.56,1955.83,5795.66,2151.40,1686.00,26174.40,1338.90,5738.16,,Hospital 45382,Colsc Flexible W/Control Bleeding Any Method,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,32499.32,13901.33,19499.59,8340.80,5254.60,1946.19,6481.56,1365.27,11841.67,2552.00,11049.77,4726.45,11954.95,3282.84,5416.50,1946.19,6481.56,1350.64,6481.56,1350.64,7441.68,2043.64,11954.95,3282.84,11954.95,3282.84,11954.95,3282.84,11841.67,2552.00,6481.56,1350.64,5416.50,1946.19,14223.40,2806.50,14223.40,2806.50,N/A,1946.19,6481.56,1350.64,6481.56,1365.27,5795.66,633.87,5254.60,19499.59,633.87,8340.80,,Hospital 45386,Colsc Flexible W/Transendoscopic Balloon Dilat,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,14601.37,N/A,8760.82,N/A,2044.19,N/A,1534.41,N/A,2552.00,N/A,4964.46,N/A,3559.41,N/A,2044.19,N/A,1466.87,N/A,1466.87,N/A,2215.81,N/A,3559.41,N/A,3559.41,N/A,3559.41,N/A,2552.00,N/A,1466.87,N/A,2044.19,N/A,2806.50,N/A,2806.50,N/A,2044.19,N/A,1466.87,N/A,1534.41,N/A,532.68,N/A,N/A,532.68,8760.82,,Hospital 45389,Colonoscopy Flx With Endoscopic Stent Placement,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,9315.60,N/A,5589.36,N/A,1304.62,N/A,807.76,N/A,2552.00,N/A,3167.30,N/A,9315.60,N/A,1304.62,N/A,4736.51,N/A,4736.51,N/A,7134.29,N/A,9315.60,N/A,9315.60,N/A,9315.60,N/A,2552.00,N/A,4736.51,N/A,1304.62,N/A,3274.25,N/A,3274.25,N/A,1304.62,N/A,4736.51,N/A,807.76,N/A,888.54,N/A,N/A,807.76,9315.60,,Hospital 45391,Colsc Flx W/Ndsc US Xm Rctm Et Al Lmtd&Adj Strux,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,8678.80,N/A,5207.28,N/A,1215.03,N/A,1022.94,N/A,2552.00,N/A,2950.79,N/A,2369.52,N/A,1215.03,N/A,977.91,N/A,977.91,N/A,1475.07,N/A,2369.52,N/A,2369.52,N/A,2369.52,N/A,2552.00,N/A,977.91,N/A,1215.03,N/A,1871.00,N/A,1871.00,N/A,1215.03,N/A,977.91,N/A,1022.94,N/A,271.74,N/A,N/A,271.74,5207.28,,Hospital 45399,Unlisted Procedure Colon,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15084.57,N/A,9050.74,N/A,2091.69,N/A,743.98,N/A,8684.81,N/A,5128.75,N/A,1824.62,N/A,2091.69,N/A,750.46,N/A,750.46,N/A,1135.86,N/A,1824.62,N/A,1824.62,N/A,1824.62,N/A,8684.81,N/A,750.46,N/A,2091.69,N/A,1871.00,N/A,1871.00,N/A,2091.69,N/A,750.46,N/A,743.98,N/A,25.67,N/A,N/A,25.67,9050.74,,Hospital CPT 45900,HC Reduction Rectal Prolapse W Anesthe,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2263.00,2263.00,1357.80,1357.80,N/A,316.82,N/A,203.71,N/A,1303.04,N/A,769.42,N/A,604.59,N/A,316.82,N/A,203.71,N/A,203.71,N/A,376.36,N/A,604.59,N/A,604.59,N/A,604.59,N/A,1303.04,N/A,203.71,N/A,316.82,N/A,2263.00,N/A,2263.00,N/A,316.82,N/A,203.71,N/A,203.71,N/A,224.08,1357.80,1357.80,203.71,2263.00,,Hospital 45910,Dilat Rct Strix Spx Under Anes Oth/Thn Local,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6760.20,N/A,4056.12,N/A,946.43,N/A,972.91,N/A,3891.03,N/A,2298.47,N/A,2382.62,N/A,946.43,N/A,977.91,N/A,977.91,N/A,1483.23,N/A,2382.62,N/A,2382.62,N/A,2382.62,N/A,3891.03,N/A,977.91,N/A,946.43,N/A,1871.00,N/A,1871.00,N/A,946.43,N/A,977.91,N/A,972.91,N/A,203.29,N/A,N/A,203.29,4056.12,,Hospital 45999,Unlisted Procedure Rectum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13700.25,N/A,8220.15,N/A,1918.04,N/A,N/A,N/A,7881.16,N/A,4642.78,N/A,1844.06,N/A,1918.04,N/A,750.46,N/A,750.46,N/A,1147.96,N/A,1844.06,N/A,1844.06,N/A,1844.06,N/A,7881.18,N/A,750.46,N/A,1918.04,N/A,1431.00,N/A,1431.00,N/A,1918.04,N/A,750.46,N/A,N/A,N/A,N/A,N/A,N/A,750.46,8220.15,,Hospital 46020,Placement Seton,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22731.70,N/A,13639.02,N/A,3182.43,N/A,2368.59,N/A,13083.50,N/A,7728.77,N/A,5648.59,N/A,3182.43,N/A,2320.33,N/A,2320.33,N/A,3516.35,N/A,5648.59,N/A,5648.59,N/A,5648.59,N/A,13083.50,N/A,2320.33,N/A,3182.43,N/A,3397.00,N/A,3397.00,N/A,3182.43,N/A,2320.33,N/A,2368.59,N/A,121.87,N/A,N/A,121.87,13639.02,,Hospital 46030,Removal Anal Seton Other Marker,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24614.00,N/A,14768.40,N/A,3429.94,N/A,2427.17,N/A,14171.71,N/A,8368.76,N/A,5630.09,N/A,3429.94,N/A,2320.33,N/A,2320.33,N/A,3504.84,N/A,5630.09,N/A,5630.09,N/A,5630.09,N/A,14171.72,N/A,2320.33,N/A,3429.94,N/A,4332.50,N/A,4332.50,N/A,3429.94,N/A,2320.33,N/A,2427.17,N/A,531.84,N/A,N/A,531.84,14768.40,,Hospital CPT 46050,HC I&D Perianal Absc Superficial,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2597.00,2597.00,1558.20,1558.20,N/A,363.58,N/A,795.29,N/A,1495.35,N/A,882.98,N/A,1815.30,N/A,363.58,N/A,750.46,N/A,750.46,N/A,1130.06,N/A,1815.30,N/A,1815.30,N/A,1815.30,N/A,1495.35,N/A,750.46,N/A,363.58,N/A,2597.00,N/A,2597.00,N/A,363.58,N/A,750.46,N/A,795.29,N/A,104.38,1558.20,1558.20,104.38,2597.00,,Hospital 46060,I&D Ischiorct/Intramural Absc W/WO Seton,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,31936.90,19781.48,19162.14,11868.89,8276.66,2769.40,10086.16,463.85,18652.13,11374.81,10858.55,6725.70,18830.56,5725.93,8531.68,2769.40,126450.00,2320.33,126450.00,2320.33,11721.58,3564.49,18830.56,5725.93,18830.56,5725.93,18830.56,5725.93,18652.13,11374.82,10056.51,2320.33,8531.68,2769.40,22403.66,1871.00,22403.66,1871.00,10762.62,2769.40,2320.33,2320.33,10086.16,463.85,9128.90,510.24,2320.33,126450.00,463.85,11868.89,,Hospital CPT 46080,Sphincterotomy Anal Division Sphincter Spx,N/A,N/A,480.00,480.00,288.00,288.00,N/A,67.20,N/A,151.74,N/A,480.00,N/A,163.20,N/A,480.00,N/A,67.20,N/A,151.74,N/A,151.74,N/A,480.00,N/A,480.00,N/A,480.00,N/A,480.00,N/A,480.00,N/A,151.74,N/A,67.20,N/A,480.00,N/A,480.00,N/A,67.20,N/A,151.74,N/A,151.74,N/A,166.91,288.00,288.00,67.20,480.00,,Hospital CPT 46200,Fissurectomy Incl Sphincterotomy When Performed,N/A,N/A,795.00,795.00,477.00,477.00,N/A,111.30,N/A,317.91,N/A,795.00,N/A,270.30,N/A,795.00,N/A,111.30,N/A,317.91,N/A,317.91,N/A,795.00,N/A,795.00,N/A,795.00,N/A,795.00,N/A,795.00,N/A,317.91,N/A,111.30,N/A,795.00,N/A,795.00,N/A,111.30,N/A,317.91,N/A,317.91,N/A,349.70,477.00,477.00,111.30,795.00,,Hospital CPT 46220,Excision Single External Papilla or Tag Anus,N/A,N/A,419.00,419.00,251.40,251.40,N/A,58.66,N/A,114.84,N/A,419.00,N/A,142.46,N/A,419.00,N/A,58.66,N/A,114.84,N/A,114.84,N/A,419.00,N/A,419.00,N/A,419.00,N/A,419.00,N/A,419.00,N/A,114.84,N/A,58.66,N/A,419.00,N/A,419.00,N/A,58.66,N/A,114.84,N/A,114.84,N/A,126.32,251.40,251.40,58.66,419.00,,Hospital 46250,Hemorrhoidectomy Xtrnl 2/> Column/Group,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,51783.22,23870.83,31069.93,14322.50,11753.77,3341.92,14169.75,2399.88,26488.07,13738.25,17606.29,8116.09,26741.45,5654.13,12115.92,3341.92,N/A,2320.33,3372.00,2320.33,N/A,3519.80,26741.45,5654.13,26741.45,5654.13,26741.45,5654.13,26488.07,13738.24,14169.75,2320.33,12115.92,3341.92,31815.65,3397.00,31815.65,3397.00,14871.72,3341.92,N/A,2320.33,14169.75,2399.88,12964.04,364.97,3372.00,31815.65,364.97,14322.50,,Hospital 46257,Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30105.90,N/A,18063.54,N/A,4214.84,N/A,2427.17,N/A,17267.53,N/A,10236.02,N/A,7736.09,N/A,4214.84,N/A,2320.33,N/A,2320.33,N/A,4818.67,N/A,7736.09,N/A,7736.09,N/A,7736.09,N/A,17267.55,N/A,2320.33,N/A,4214.84,N/A,4332.50,N/A,4332.50,N/A,4214.84,N/A,2320.33,N/A,2427.17,N/A,733.84,N/A,N/A,733.84,18063.54,,Hospital 46258,Hrhc 1 Col/Grp W/Fstulectmy Incl Fssrectomy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,22363.30,N/A,13417.98,N/A,3098.83,N/A,2472.27,N/A,12802.65,N/A,7603.52,N/A,6576.27,N/A,3098.83,N/A,2324.26,N/A,2324.26,N/A,4093.85,N/A,6576.27,N/A,6576.27,N/A,6576.27,N/A,12802.65,N/A,2324.26,N/A,3098.83,N/A,5095.50,N/A,5095.50,N/A,3098.83,N/A,2324.26,N/A,2472.27,N/A,740.31,N/A,N/A,740.31,13417.98,,Hospital CPT 46260,Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,N/A,N/A,951.00,951.00,570.60,570.60,N/A,133.14,N/A,462.84,N/A,951.00,N/A,323.34,N/A,951.00,N/A,133.14,N/A,462.84,N/A,462.84,N/A,853.82,N/A,951.00,N/A,951.00,N/A,951.00,N/A,951.00,N/A,462.84,N/A,133.14,N/A,951.00,N/A,951.00,N/A,133.14,N/A,462.84,N/A,462.84,N/A,509.12,570.60,570.60,133.14,951.00,,Hospital 46261,Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7953.10,N/A,4771.86,N/A,1113.43,N/A,2308.46,N/A,4578.04,N/A,2704.06,N/A,5629.21,N/A,1113.43,N/A,2320.33,N/A,2320.33,N/A,3504.29,N/A,5629.21,N/A,5629.21,N/A,5629.21,N/A,4578.05,N/A,2320.33,N/A,1113.43,N/A,3397.00,N/A,3397.00,N/A,1113.43,N/A,2320.33,N/A,2308.46,N/A,587.92,N/A,N/A,587.92,5629.21,,Hospital 46262,Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,19740.70,N/A,11844.42,N/A,2763.69,N/A,2308.46,N/A,11363.97,N/A,6711.83,N/A,5644.48,N/A,2763.69,N/A,2320.33,N/A,2320.33,N/A,3513.79,N/A,5644.48,N/A,5644.48,N/A,5644.48,N/A,10859.56,N/A,2320.33,N/A,2763.69,N/A,5095.50,N/A,5095.50,N/A,2763.69,N/A,2320.33,N/A,2308.46,N/A,950.02,N/A,N/A,950.02,11844.42,,Hospital 46275,Surg Tx Anal Fistula Intersphincteric,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,17037.40,24347.40,10222.44,14608.44,5319.68,3408.64,6558.55,2427.17,11988.34,13990.00,5792.72,8278.12,12103.02,6554.08,5483.59,3408.64,1124.00,2320.33,1124.00,2320.33,7533.85,4080.03,12103.02,6554.08,12103.02,6554.08,12103.02,6554.08,11988.34,13990.01,6558.55,2320.33,5483.59,3408.64,14399.57,4332.50,14399.57,4332.50,N/A,3408.64,6558.55,2320.33,6558.55,2427.17,5867.44,534.62,1124.00,14399.57,534.62,14608.44,,Hospital 46280,Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21289.47,N/A,12773.68,N/A,2978.16,N/A,2427.17,N/A,12228.94,N/A,7238.42,N/A,6560.22,N/A,2978.16,N/A,2320.33,N/A,2320.33,N/A,4083.85,N/A,6560.22,N/A,6560.22,N/A,6560.22,N/A,12228.95,N/A,2320.33,N/A,2978.16,N/A,3397.00,N/A,3397.00,N/A,2978.16,N/A,2320.33,N/A,2427.17,N/A,512.81,N/A,N/A,512.81,12773.68,,Hospital 46505,Chemodenervation Internal Anal Sphincter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21840.80,N/A,13104.48,N/A,3057.71,N/A,2427.17,N/A,12535.24,N/A,7425.87,N/A,6886.90,N/A,3057.71,N/A,2320.33,N/A,2320.33,N/A,4287.21,N/A,6886.90,N/A,6886.90,N/A,6886.90,N/A,12535.27,N/A,2320.33,N/A,3057.71,N/A,4332.50,N/A,4332.50,N/A,3057.71,N/A,2320.33,N/A,2427.17,N/A,613.43,N/A,N/A,613.43,13104.48,,Hospital 46608,HC Anoscopy Remove FB,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 46910,Dstrj Lesion Anus Smpl Eltrdsiccation,N/A,N/A,448.00,448.00,268.80,268.80,N/A,62.72,N/A,128.50,N/A,448.00,N/A,152.32,N/A,448.00,N/A,62.72,N/A,128.50,N/A,128.50,N/A,448.00,N/A,448.00,N/A,448.00,N/A,448.00,N/A,448.00,N/A,128.50,N/A,62.72,N/A,448.00,N/A,448.00,N/A,62.72,N/A,128.50,N/A,128.50,N/A,141.35,268.80,268.80,62.72,448.00,,Hospital CPT 46922,Dstrj Lesion Anus Simple Surg Excision,N/A,N/A,525.00,525.00,315.00,315.00,N/A,73.50,N/A,130.56,N/A,525.00,N/A,178.50,N/A,525.00,N/A,73.50,N/A,130.56,N/A,130.56,N/A,525.00,N/A,525.00,N/A,525.00,N/A,525.00,N/A,525.00,N/A,130.56,N/A,73.50,N/A,525.00,N/A,525.00,N/A,73.50,N/A,130.56,N/A,130.56,N/A,143.62,315.00,315.00,73.50,525.00,,Hospital 46930,Destruction Internal Hemorrhoid Thermal Energy,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,10548.93,N/A,6329.36,N/A,1476.85,N/A,1439.46,N/A,2552.00,N/A,3586.64,N/A,3281.52,N/A,1476.85,N/A,1353.14,N/A,1353.14,N/A,2042.81,N/A,3281.52,N/A,3281.52,N/A,3281.52,N/A,2552.00,N/A,1353.14,N/A,1476.85,N/A,2586.50,N/A,2586.50,N/A,1476.85,N/A,1353.14,N/A,1439.46,N/A,352.44,N/A,N/A,352.44,6329.36,,Hospital CPT 46940,Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,N/A,N/A,440.00,440.00,264.00,264.00,N/A,61.60,N/A,138.28,N/A,440.00,N/A,149.60,N/A,440.00,N/A,61.60,N/A,138.28,N/A,138.28,N/A,440.00,N/A,440.00,N/A,440.00,N/A,440.00,N/A,440.00,N/A,138.28,N/A,61.60,N/A,440.00,N/A,440.00,N/A,61.60,N/A,138.28,N/A,138.28,N/A,152.11,264.00,264.00,61.60,440.00,,Hospital CPT 46945,Int Hrhc by Ligation Single Hroid W/O Img Gdn,N/A,N/A,560.00,560.00,336.00,336.00,N/A,78.40,N/A,321.40,N/A,560.00,N/A,190.40,N/A,560.00,N/A,78.40,N/A,321.40,N/A,321.40,N/A,560.00,N/A,560.00,N/A,560.00,N/A,560.00,N/A,560.00,N/A,321.40,N/A,78.40,N/A,560.00,N/A,560.00,N/A,78.40,N/A,321.40,N/A,321.40,N/A,353.54,336.00,336.00,78.40,560.00,,Hospital 46947,Hemorrhoidopexy Stapling,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16692.50,N/A,10015.50,N/A,2336.95,N/A,2382.31,N/A,9609.76,N/A,5675.45,N/A,5643.78,N/A,2336.95,N/A,2320.33,N/A,2320.33,N/A,3513.37,N/A,5643.78,N/A,5643.78,N/A,5643.78,N/A,9609.78,N/A,2320.33,N/A,2336.95,N/A,4562.00,N/A,4562.00,N/A,2336.95,N/A,2320.33,N/A,2382.31,N/A,439.02,N/A,N/A,439.02,10015.50,,Hospital CPT 47000,HC Biopsy Liver Percutan Needle,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5268.00,5268.00,3160.80,3160.80,N/A,737.52,N/A,1354.15,N/A,3033.31,N/A,1791.12,N/A,3275.59,N/A,737.52,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,3033.31,N/A,1354.15,N/A,737.52,N/A,1871.00,N/A,1871.00,N/A,737.52,N/A,1354.15,N/A,1354.15,N/A,1489.57,3160.80,3160.80,737.52,3275.59,,Hospital 47010,HC CT Liver Abscess,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,134788.15,N/A,80872.89,N/A,N/A,N/A,12853.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12616.71,N/A,11853.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12616.71,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1482.21,N/A,11853.42,N/A,12616.71,N/A,N/A,N/A,1482.21,80872.89,N/A,N/A,,Hospital 47361,Mgmt Lvr Hemrrg Expl Wnd Dbrdmt Coagj/Sutr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 47379,Unlisted Laparoscopic Procedure Liver,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,99065.60,31424.75,59439.36,18854.85,4369.60,4399.47,11846.13,1150.79,23195.91,7923.00,33682.31,10654.58,21987.39,11429.39,4369.60,4399.47,188270.00,4706.78,188270.00,4706.78,13686.64,7115.03,N/A,11429.39,21987.39,11429.39,21987.39,11429.39,23195.91,7923.00,11697.88,4706.78,9961.97,4399.47,13671.96,10878.50,10435.25,10878.50,4369.60,4399.47,11697.88,4706.78,11846.13,1150.79,10659.31,1265.88,4369.60,188270.00,1150.79,18854.85,,Hospital 47383,HC Ablation 1/> Liver Tumor Perq Cryoablation,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,19673.97,N/A,11804.38,N/A,2754.36,N/A,5192.14,N/A,11305.43,N/A,6689.14,N/A,11436.04,N/A,2754.36,N/A,4706.78,N/A,4706.78,N/A,7119.17,N/A,11436.04,N/A,11436.04,N/A,11436.04,N/A,11305.43,N/A,4706.78,N/A,2754.36,N/A,7897.00,N/A,7897.00,N/A,2754.36,N/A,4706.78,N/A,479.64,N/A,527.61,N/A,N/A,479.64,11804.38,,Hospital CPT 47531,HC Injection for Cholangiogram,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3667.00,3667.00,2200.20,2200.20,N/A,513.38,N/A,66.78,N/A,2111.46,N/A,1246.78,N/A,3667.00,N/A,513.38,N/A,3198.50,N/A,3198.50,N/A,3667.00,N/A,3667.00,N/A,3667.00,N/A,3667.00,N/A,2111.46,N/A,3198.50,N/A,513.38,N/A,4562.00,N/A,4562.00,N/A,513.38,N/A,3198.50,N/A,66.78,N/A,73.46,2200.20,2200.20,66.78,4562.00,,Hospital 47532,HC Inj for Cholangiogram New Acc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,63869.50,23700.83,38321.70,14220.50,8880.54,3318.12,10770.87,3528.33,20013.02,13625.64,21715.63,8058.29,20204.46,7800.92,9154.17,3318.12,2248.00,3198.50,2248.00,3198.50,12576.81,4856.23,20204.46,7800.92,N/A,7800.92,20204.46,7800.92,6391.09,13625.66,11333.91,3198.50,9154.17,3318.12,24038.27,4825.50,24038.27,4825.50,9154.17,3318.12,10770.87,3198.50,10770.87,352.47,9794.96,387.72,2248.00,38321.70,352.47,14220.50,,Hospital CPT 47536,HC Exchange Biliary Drng Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,6684.00,6684.00,4010.40,4010.40,N/A,935.76,N/A,125.76,N/A,3848.65,N/A,2272.56,N/A,6684.00,N/A,935.76,N/A,3198.50,N/A,3198.50,N/A,4816.37,N/A,6684.00,N/A,6684.00,N/A,6684.00,N/A,3848.65,N/A,3198.50,N/A,935.76,N/A,4562.00,N/A,4562.00,N/A,935.76,N/A,3198.50,N/A,3170.88,N/A,138.34,4010.40,4010.40,125.76,6684.00,,Hospital CPT 47537,HC Removal Biliary Drng Cath,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1482.00,1482.00,889.20,889.20,N/A,207.48,N/A,771.03,N/A,853.34,N/A,503.88,N/A,1482.00,N/A,207.48,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1482.00,N/A,1482.00,N/A,1482.00,N/A,853.34,N/A,745.47,N/A,207.48,N/A,1871.00,N/A,1871.00,N/A,207.48,N/A,745.47,N/A,739.03,N/A,101.18,889.20,889.20,101.18,1871.00,,Hospital 47542,HC Dilate Biliary Duct/Ampulla,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,94458.28,15970.22,56674.97,9582.13,4814.85,2235.82,11683.52,346.26,N/A,9187.99,102686.10,5429.86,102686.10,7750.71,4814.85,2235.82,11683.52,3198.50,11683.52,3198.50,102686.10,4824.96,102686.10,7750.71,102686.10,7750.71,102686.10,7750.71,N/A,9187.99,11683.52,3198.50,9498.95,2235.82,N/A,4957.25,24943.66,4957.25,4814.85,2235.82,11166.54,3198.50,11683.52,346.26,10163.88,380.89,4814.85,102686.10,346.26,9582.13,,Hospital 47543,HC Endoluminal Bx Biliary Tree,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,46998.18,30727.57,28198.91,18436.54,9568.18,4301.87,11613.95,541.67,21562.66,17684.80,15979.38,10447.38,21768.92,7785.68,9862.99,4301.87,64630.00,3198.50,64630.00,3198.50,13550.65,4846.73,21768.92,7785.68,21768.92,7785.68,21768.92,7785.68,21562.66,17684.83,11584.30,3198.50,9862.99,4301.87,25899.58,4825.50,25899.58,4825.50,N/A,4301.87,11584.30,3198.50,11613.95,541.67,10553.40,595.83,9568.18,64630.00,541.67,18436.54,,Hospital 47544,HC Removal Duct Glbldr Calculi,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,89096.42,22179.55,53457.85,13307.73,9757.55,3102.76,11808.33,4950.49,N/A,12768.09,30292.78,7541.05,22199.79,11490.28,10058.20,3102.76,11808.33,4732.58,11808.33,4732.58,13818.85,7152.93,N/A,11490.28,22199.79,11490.28,22199.79,11490.28,21989.44,12768.09,11808.33,4732.58,10058.20,3102.76,26412.20,4825.50,26412.20,4825.50,N/A,3102.76,11808.33,4732.58,11808.33,4950.49,10762.28,311.09,9757.55,53457.85,311.09,13307.73,,Hospital 47600,Cholecystectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42280.88,N/A,25368.53,N/A,5911.32,N/A,1116.01,N/A,24337.11,N/A,14375.51,N/A,8225.13,N/A,5911.32,N/A,1206.21,N/A,1206.21,N/A,5120.28,N/A,8225.13,N/A,8225.13,N/A,8225.13,N/A,24337.13,N/A,1206.21,N/A,5911.32,N/A,1643.00,N/A,1643.00,N/A,5911.32,N/A,1206.21,N/A,1116.01,N/A,1221.50,N/A,N/A,1116.01,25368.53,,Hospital 47999,Unlisted Procedure Biliary Tract,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25033.42,N/A,15020.05,N/A,3504.69,N/A,3248.17,N/A,14392.19,N/A,8511.36,N/A,7182.64,N/A,3504.69,N/A,2944.53,N/A,2944.53,N/A,4471.32,N/A,7182.64,N/A,7182.64,N/A,7182.64,N/A,14392.20,N/A,2944.53,N/A,3504.69,N/A,5563.25,N/A,5563.25,N/A,3504.69,N/A,2944.53,N/A,691.94,N/A,761.14,N/A,N/A,691.94,15020.05,,Hospital 48999,Unlisted Procedure Pancreas,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,14367.67,N/A,8620.60,N/A,2011.47,N/A,613.03,N/A,8271.57,N/A,4885.00,N/A,1437.00,N/A,2011.47,N/A,586.05,N/A,586.05,N/A,894.57,N/A,1437.00,N/A,1437.00,N/A,1437.00,N/A,8271.57,N/A,586.05,N/A,2011.47,N/A,1431.00,N/A,1431.00,N/A,2011.47,N/A,586.05,N/A,613.03,N/A,N/A,N/A,N/A,586.05,8620.60,,Hospital CPT 49082,HC Paracentesis W/O Imaging,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1386.00,1386.00,831.60,831.60,N/A,194.04,N/A,70.30,N/A,798.06,N/A,471.24,N/A,1386.00,N/A,194.04,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1386.00,N/A,1386.00,N/A,1386.00,N/A,798.06,N/A,745.47,N/A,194.04,N/A,742.90,N/A,742.90,N/A,194.04,N/A,745.47,N/A,70.30,N/A,77.33,831.60,831.60,70.30,1386.00,,Hospital CPT 49082,HC Paracentesis WO Img Gd,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1386.00,1386.00,831.60,831.60,N/A,194.04,N/A,70.30,N/A,798.06,N/A,471.24,N/A,1386.00,N/A,194.04,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1386.00,N/A,1386.00,N/A,1386.00,N/A,798.06,N/A,745.47,N/A,194.04,N/A,1386.00,N/A,1386.00,N/A,194.04,N/A,745.47,N/A,70.30,N/A,77.33,831.60,831.60,70.30,1386.00,,Hospital 49185,HC Sclerotx Fluid Collection,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,177116.30,15487.87,106269.78,9292.72,14148.10,2149.92,N/A,2358.04,97626.50,8916.69,60219.54,5265.87,22997.19,5673.01,10965.07,2149.92,3372.00,2332.78,N/A,2332.78,14315.21,3531.55,22997.19,5673.01,N/A,5673.01,22997.19,5673.01,97626.50,8916.69,12222.94,2332.78,10965.07,2149.92,27360.91,2586.50,27360.91,2586.50,10965.07,2149.92,N/A,2332.78,12222.94,2358.04,11732.62,410.73,3372.00,106269.78,410.73,9292.72,,Hospital 49203,Excision/Destruction Open Abdominal Tumor 5 Cm/<,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14189.80,N/A,8513.88,N/A,1986.57,N/A,1213.42,N/A,8167.88,N/A,4824.53,N/A,7870.33,N/A,1986.57,N/A,1198.58,N/A,1198.58,N/A,4899.43,N/A,7870.33,N/A,7870.33,N/A,7870.33,N/A,8167.89,N/A,1198.58,N/A,1986.57,N/A,3397.00,N/A,3397.00,N/A,1986.57,N/A,1198.58,N/A,1213.42,N/A,1334.77,N/A,N/A,1198.58,8513.88,,Hospital 49204,Exc/Destruction Open Abdmnl Tumors 5.1-10.0 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17525.90,N/A,10515.54,N/A,2453.61,N/A,1512.42,N/A,10087.24,N/A,5958.80,N/A,7932.86,N/A,2453.61,N/A,1512.81,N/A,1512.81,N/A,4938.36,N/A,7932.86,N/A,7932.86,N/A,7932.86,N/A,10061.33,N/A,1512.81,N/A,2453.61,N/A,7897.00,N/A,7897.00,N/A,2453.61,N/A,1512.81,N/A,1512.42,N/A,1647.35,N/A,N/A,1512.42,10515.54,,Hospital CPT 49320,Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,N/A,N/A,657.00,657.00,394.20,394.20,N/A,91.98,N/A,316.00,N/A,657.00,N/A,223.38,N/A,657.00,N/A,91.98,N/A,316.00,N/A,316.00,N/A,584.71,N/A,657.00,N/A,657.00,N/A,657.00,N/A,657.00,N/A,316.00,N/A,91.98,N/A,657.00,N/A,657.00,N/A,91.98,N/A,316.00,N/A,316.00,N/A,347.60,394.20,394.20,91.98,657.00,,Hospital 49324,Laps Insertion Tunneled Intraperitoneal Catheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,37868.02,16083.70,22720.81,9650.22,7528.22,2220.44,9171.14,4706.78,17153.79,9257.67,12875.13,5468.45,17127.73,11404.12,7760.17,2220.44,1124.00,4706.78,1124.00,4706.78,10661.62,7099.29,17127.73,11404.12,17127.73,11404.12,17127.73,11404.12,17153.79,9257.67,9171.14,4706.78,7760.17,2220.44,20377.73,5963.00,20377.73,5963.00,N/A,2220.44,9171.14,4706.78,9171.14,4706.78,8303.39,5177.46,1124.00,22720.81,2220.44,11404.12,,Hospital CPT 49400,HC Inject Peritoneal Cavity,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,664.00,664.00,398.40,398.40,N/A,92.96,N/A,664.00,N/A,382.33,N/A,225.76,N/A,664.00,N/A,92.96,N/A,664.00,N/A,664.00,N/A,664.00,N/A,664.00,N/A,664.00,N/A,664.00,N/A,382.33,N/A,664.00,N/A,92.96,N/A,527.00,N/A,527.00,N/A,92.96,N/A,664.00,N/A,664.00,N/A,96.72,398.40,398.40,92.96,664.00,,Hospital CPT 49405,HC Image Cath Fluid Colxn Visc,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3772.00,3772.00,2263.20,2263.20,N/A,528.08,N/A,1467.34,N/A,2171.92,N/A,1282.48,N/A,3275.59,N/A,528.08,N/A,1354.15,N/A,1354.15,N/A,2039.12,N/A,3275.59,N/A,3275.59,N/A,3275.59,N/A,2171.92,N/A,1354.15,N/A,528.08,N/A,1871.00,N/A,1871.00,N/A,528.08,N/A,1354.15,N/A,1467.34,N/A,206.62,2263.20,2263.20,206.62,3275.59,,Hospital 49407,HC Image Cath Fluid Trns/Vgnl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,53234.90,11962.52,31940.94,7177.51,4878.64,1674.75,12928.17,1440.53,23529.46,6888.01,10438.82,4067.25,10438.82,3275.59,4878.64,1674.75,3934.00,1354.15,12928.17,1354.15,10438.82,2039.12,10438.82,3275.59,10438.82,3275.59,10438.82,3275.59,23529.46,6888.01,12616.71,1354.15,4878.64,1674.75,N/A,1871.00,N/A,1871.00,4878.64,1674.75,12616.71,1354.15,12928.17,1440.53,11516.01,245.81,3934.00,31940.94,245.81,7177.51,,Hospital 49411,HC Place Percu-Abd/Plv-No Prost,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,16718.72,N/A,10031.23,N/A,2340.62,N/A,2953.65,N/A,2552.00,N/A,5676.15,N/A,6493.74,N/A,2340.62,N/A,2677.55,N/A,2677.55,N/A,4042.49,N/A,6493.74,N/A,6493.74,N/A,6493.74,N/A,2552.00,N/A,2677.55,N/A,2340.62,N/A,3274.25,N/A,3274.25,N/A,2340.62,N/A,2677.55,N/A,671.89,N/A,739.09,N/A,N/A,671.89,10031.23,,Hospital CPT 49423,HC Drainage Catheter Exchange,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4506.00,4506.00,2703.60,2703.60,N/A,630.84,N/A,67.49,N/A,2594.55,N/A,1532.04,N/A,3804.28,N/A,630.84,N/A,1572.73,N/A,1572.73,N/A,2368.24,N/A,3804.28,N/A,3804.28,N/A,3804.28,N/A,2594.55,N/A,1572.73,N/A,630.84,N/A,1871.00,N/A,1871.00,N/A,630.84,N/A,1572.73,N/A,67.49,N/A,74.24,2703.60,2703.60,67.49,3804.28,,Hospital 49424,HC Abscess Catheter Injection,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,114088.80,2159.95,68453.28,1295.97,8582.09,302.39,13184.76,68.57,26146.45,1241.99,38790.22,734.38,22199.79,1102.13,8582.09,302.39,13026.36,454.35,13026.36,454.35,26401.97,686.09,26401.97,1102.13,26401.97,1102.13,22199.79,1102.13,26146.45,1241.99,13184.76,454.35,8582.09,302.39,26146.45,527.00,26146.45,527.00,8582.09,302.39,16907.71,454.35,13184.76,68.57,8582.09,75.43,8582.09,68453.28,68.57,1295.97,,Hospital 49435,Insj Subq Extension Intraperitoneal Catheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,50169.50,N/A,30101.70,N/A,24434.70,N/A,29170.64,N/A,50169.50,N/A,17057.63,N/A,50169.50,N/A,25187.57,N/A,562.00,N/A,562.00,N/A,34604.92,N/A,50169.50,N/A,50169.50,N/A,50169.50,N/A,50169.50,N/A,29170.64,N/A,25187.57,N/A,50169.50,N/A,50169.50,N/A,N/A,N/A,29170.64,N/A,29170.64,N/A,26950.70,N/A,562.00,50169.50,N/A,N/A,,Hospital 49436,Delayed Creation Exit Site Embedded Catheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8639.90,N/A,5183.94,N/A,1190.56,N/A,1559.14,N/A,4974.25,N/A,2937.57,N/A,3810.45,N/A,1190.56,N/A,1572.73,N/A,1572.73,N/A,2372.07,N/A,3810.45,N/A,3810.45,N/A,3810.45,N/A,4974.25,N/A,1572.73,N/A,1190.56,N/A,1871.00,N/A,1871.00,N/A,1190.56,N/A,1572.73,N/A,1559.14,N/A,218.14,N/A,N/A,218.14,5183.94,,Hospital 49441,HC J Tube Plcmt,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,66505.43,20627.32,39903.26,12376.39,11982.62,2883.23,14529.42,2854.74,27517.79,11861.39,22611.84,7013.29,27262.13,6551.62,12351.83,2883.23,119144.00,2694.06,119144.00,2694.06,16970.04,4078.50,27262.13,6551.62,27262.13,6551.62,27262.13,6551.62,27517.79,11861.41,14440.47,2694.06,12351.83,2883.23,32435.13,5497.50,32435.13,5497.50,N/A,2883.23,2690.13,2694.06,14529.42,2854.74,13216.46,615.75,2690.13,119144.00,615.75,12376.39,,Hospital 49446,HC Change G to Gj Tube,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,90117.23,21841.67,54070.34,13105.00,6271.65,3057.83,13371.61,3005.77,18324.08,12295.57,149103.86,7426.16,149103.86,7127.51,6271.65,3057.83,12616.71,2944.53,12616.71,2944.53,149103.86,4437.01,149103.86,7127.51,149103.86,7127.51,149103.86,7127.51,18324.08,12295.57,13371.61,2944.53,6271.65,3057.83,18324.08,3274.25,18324.08,3274.25,6271.65,3057.83,13371.61,2944.53,13371.61,3005.77,6271.65,1140.61,6271.65,149103.86,1140.61,13105.00,,Hospital 49460,HC Mech Rem/Obst GI Tube,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,85142.37,2276.92,51085.42,1366.15,N/A,318.77,14257.79,760.97,N/A,1310.66,N/A,774.15,N/A,1816.18,N/A,318.77,14257.79,745.47,14257.79,745.47,N/A,1130.60,N/A,1816.18,N/A,1816.18,N/A,1816.18,N/A,1310.66,14257.79,745.47,N/A,318.77,N/A,1871.00,N/A,1871.00,N/A,318.77,14257.79,745.47,13734.20,760.97,N/A,51.59,13734.20,51085.42,51.59,1871.00,,Hospital CPT 49465,HC Fluoro Exam Gtube Jtube,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,702.00,557.00,421.20,334.20,N/A,77.98,N/A,215.26,N/A,320.72,N/A,189.38,N/A,510.09,N/A,77.98,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,320.72,N/A,210.88,N/A,77.98,N/A,298.55,N/A,298.55,N/A,77.98,N/A,210.88,N/A,215.26,N/A,32.12,421.20,421.20,32.12,510.09,,Hospital 49495,Rpr 1st Ingun Hrna Full Term Inft <6 Mo Rdc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32823.70,N/A,19694.22,N/A,4595.32,N/A,3402.52,N/A,18899.73,N/A,11160.06,N/A,7749.41,N/A,4595.32,N/A,3198.50,N/A,3198.50,N/A,4858.77,N/A,7749.41,N/A,7749.41,N/A,7749.41,N/A,18899.74,N/A,3198.50,N/A,4595.32,N/A,6843.00,N/A,6843.00,N/A,4595.32,N/A,3198.50,N/A,3402.52,N/A,433.00,N/A,N/A,433.00,19694.22,,Hospital 49501,Rpr 1st Ingun Hrna Age 6 Mo-5 Yrs Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26006.10,N/A,15603.66,N/A,3669.78,N/A,3402.52,N/A,14973.46,N/A,8842.07,N/A,7740.49,N/A,3669.78,N/A,3198.50,N/A,3198.50,N/A,4818.59,N/A,7740.49,N/A,7740.49,N/A,7740.49,N/A,14973.45,N/A,3198.50,N/A,3669.78,N/A,6843.00,N/A,6843.00,N/A,3669.78,N/A,3198.50,N/A,3402.52,N/A,1157.16,N/A,N/A,1157.16,15603.66,,Hospital 49525,Rpr Ingun Hernia Sliding Any Age,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32409.40,N/A,19445.64,N/A,4537.32,N/A,3308.16,N/A,18657.76,N/A,11019.20,N/A,7751.41,N/A,4537.32,N/A,3198.50,N/A,3198.50,N/A,4825.41,N/A,7751.41,N/A,7751.41,N/A,7751.41,N/A,18657.75,N/A,3198.50,N/A,4537.32,N/A,4562.00,N/A,4562.00,N/A,4537.32,N/A,3198.50,N/A,3308.16,N/A,619.90,N/A,N/A,619.90,19445.64,,Hospital 49553,Rpr 1st Fem Hernia Any Age Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,34646.85,25597.98,20788.11,15358.79,7842.96,3583.72,9573.11,3170.88,17817.07,14706.91,11779.93,8703.32,17843.82,7768.42,8084.61,3583.72,9543.46,3198.50,9543.46,3198.50,11107.36,4835.99,17843.82,7768.42,17843.82,7768.42,17843.82,7768.42,17817.07,14706.91,9543.46,3198.50,8084.61,3583.72,21229.69,4562.00,21229.69,4562.00,N/A,3583.72,4788.79,3198.50,9573.11,3170.88,8650.54,672.42,4788.79,21229.69,672.42,15358.79,,Hospital 49557,Rpr Recrt Fem Hrna Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21425.30,N/A,12855.18,N/A,2999.55,N/A,3265.02,N/A,12326.34,N/A,7284.59,N/A,7761.69,N/A,2999.55,N/A,3198.50,N/A,3198.50,N/A,4831.80,N/A,7761.69,N/A,7761.69,N/A,7761.69,N/A,12326.33,N/A,3198.50,N/A,2999.55,N/A,4562.00,N/A,4562.00,N/A,2999.55,N/A,3198.50,N/A,3265.02,N/A,770.51,N/A,N/A,770.51,12855.18,,Hospital 49560,Repair First Abdominal Wall Hernia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31665.05,N/A,18999.03,N/A,4433.11,N/A,970.61,N/A,18149.97,N/A,10766.12,N/A,2306.75,N/A,4433.11,N/A,970.61,N/A,970.61,N/A,1433.52,N/A,2306.75,N/A,2306.75,N/A,2306.75,N/A,18149.97,N/A,970.61,N/A,4433.11,N/A,5611.30,N/A,5611.30,N/A,4433.11,N/A,970.61,N/A,970.61,N/A,1067.67,N/A,N/A,970.61,18999.03,,Hospital 49561,Rpr 1st Incal/Vnt Hernia Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32842.37,N/A,19705.42,N/A,4577.27,N/A,1167.12,N/A,18806.43,N/A,11166.40,N/A,2156.55,N/A,4577.27,N/A,1167.12,N/A,1167.12,N/A,1340.32,N/A,2156.55,N/A,2156.55,N/A,2156.55,N/A,18806.44,N/A,1167.12,N/A,4577.27,N/A,12057.52,N/A,12057.52,N/A,4577.27,N/A,1167.12,N/A,1167.12,N/A,1283.84,N/A,N/A,1167.12,19705.42,,Hospital 49565,Rpr Recrt Incal/Vnt Hernia Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34896.92,N/A,20938.15,N/A,4881.79,N/A,1033.28,N/A,19998.60,N/A,11864.95,N/A,2998.27,N/A,4881.79,N/A,1022.98,N/A,1022.98,N/A,1863.29,N/A,2998.27,N/A,2998.27,N/A,2998.27,N/A,19998.60,N/A,1022.98,N/A,4881.79,N/A,7401.78,N/A,7401.78,N/A,4881.79,N/A,1033.28,N/A,1033.28,N/A,1130.48,N/A,N/A,1022.98,20938.15,,Hospital 49568,Implant Mesh Opn Hernia Rpr/Debridement Closure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,49993.92,32842.37,29996.35,19705.42,11346.74,4577.27,14079.13,1167.12,28677.72,18806.43,16495.74,11166.40,11541.98,2156.55,11696.35,4577.27,269198.00,1167.12,269198.00,1167.12,7185.10,1340.32,11541.98,2156.55,11541.98,2156.55,11541.98,2156.55,28677.72,18806.44,14049.48,1167.12,11696.35,4577.27,33086.37,12057.52,33086.37,12057.52,N/A,4577.27,14049.48,1167.12,14079.13,1167.12,12515.10,1283.84,7185.10,269198.00,1167.12,19705.42,,Hospital 49570,Rpr Epigastric Hernia Reducible Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24794.70,N/A,14876.82,N/A,3471.27,N/A,426.86,N/A,14251.34,N/A,8430.20,N/A,1810.76,N/A,3471.27,N/A,425.82,N/A,425.82,N/A,1125.38,N/A,1810.76,N/A,1810.76,N/A,1810.76,N/A,14251.35,N/A,425.82,N/A,3471.27,N/A,4753.00,N/A,4753.00,N/A,3471.27,N/A,425.82,N/A,426.86,N/A,467.74,N/A,N/A,425.82,14876.82,,Hospital 49585,Rpr Umbilical Hrna 5 Yrs/> Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26211.07,N/A,15726.64,N/A,3637.15,N/A,441.10,N/A,15001.47,N/A,8911.76,N/A,1492.55,N/A,3637.15,N/A,441.10,N/A,441.10,N/A,927.59,N/A,1492.55,N/A,1492.55,N/A,1492.55,N/A,15001.47,N/A,441.10,N/A,3637.15,N/A,9053.12,N/A,9053.12,N/A,3637.15,N/A,441.10,N/A,441.10,N/A,485.21,N/A,N/A,441.10,15726.64,,Hospital 49587,Rpr Umbilical Hernia Age 5 Yrs/> Incarcerated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,50539.13,25053.92,30323.48,15032.35,7320.70,3507.55,8925.66,4752.51,18749.53,14363.28,17183.31,8518.33,16655.61,7757.48,7546.26,3507.55,562.00,3198.50,562.00,3198.50,10367.73,4829.17,16655.61,7757.48,16655.61,7757.48,16655.61,7757.48,18749.53,14363.28,8925.66,3198.50,7546.26,3507.55,19816.01,4562.00,19816.01,4562.00,N/A,3507.55,914.29,3198.50,8925.66,964.37,8074.50,1060.81,562.00,30323.48,964.37,15032.35,,Hospital CPT 49591,Rpr Aa Hernia 1st < 3 Cm Reducible,N/A,N/A,561.00,561.00,336.60,336.60,N/A,78.54,N/A,561.00,N/A,561.00,N/A,190.74,N/A,561.00,N/A,78.54,N/A,561.00,N/A,561.00,N/A,561.00,N/A,561.00,N/A,561.00,N/A,561.00,N/A,561.00,N/A,561.00,N/A,78.54,N/A,561.00,N/A,561.00,N/A,78.54,N/A,561.00,N/A,561.00,N/A,561.00,336.60,336.60,78.54,561.00,,Hospital 49593,Rpr Aa Hernia 1st 3-10 Cm Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,66622.97,38208.90,39973.78,22925.34,11346.74,5339.55,13717.89,3198.50,28446.89,21881.16,22651.81,12991.03,25815.40,8736.41,11696.35,5339.55,106780.00,3198.50,106780.00,3198.50,16069.49,5438.57,25815.40,8736.41,25815.40,8736.41,25815.40,8736.41,28446.89,21881.17,13688.24,3198.50,11696.35,5339.55,30713.88,4562.00,30713.88,4562.00,N/A,5339.55,13688.24,3198.50,13717.89,3198.50,12515.10,3518.35,11346.74,106780.00,3198.50,22925.34,,Hospital 49594,Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,41030.83,37843.80,24618.50,22706.28,7320.70,5298.14,8955.31,4706.78,19000.17,21671.57,13950.48,12866.89,16655.61,12337.11,7546.26,5298.14,105656.00,4706.78,105656.00,4706.78,10367.73,7680.09,16655.61,12337.11,16655.61,12337.11,16655.61,12337.11,19000.17,21671.58,8925.66,4706.78,7546.26,5298.14,19816.01,7897.00,19816.01,7897.00,2664.73,5298.14,8925.66,4706.78,8955.31,4706.78,8074.50,5177.46,2664.73,105656.00,4706.78,22706.28,,Hospital 49595,Rpr Aa Hernia 1st > 10 Cm Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,41908.48,50814.23,25145.09,30488.54,7320.70,7113.99,8955.31,3465.85,18659.33,29252.61,14248.89,17276.83,16655.61,7769.15,7546.26,7113.99,3198.50,3198.50,3198.50,3198.50,10367.73,4836.45,16655.61,7769.15,16655.61,7769.15,16655.61,7769.15,18659.33,29252.60,8925.66,3198.50,7546.26,7113.99,19816.01,4562.00,19816.01,4562.00,N/A,7113.99,8925.66,3198.50,8955.31,3465.85,8074.50,1944.57,3198.50,25145.09,1944.57,30488.54,,Hospital 49596,Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,79979.68,59626.38,47987.81,35775.83,9346.26,8347.70,11351.43,1024.13,24055.63,33974.31,27193.09,20257.67,21264.02,7850.78,9634.23,8347.70,76432.00,1024.13,76432.00,1024.13,13236.36,4887.27,21264.02,7850.78,21264.02,7850.78,21264.02,7850.78,24055.63,33974.33,11321.78,1024.13,9634.23,8347.70,25298.88,7897.00,25298.88,7897.00,N/A,8347.70,11321.78,1024.13,11351.43,1024.13,10308.63,N/A,9346.26,76432.00,1024.13,35775.83,,Hospital 49613,Rpr Aa Hernia Recr < 3 Cm Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35781.17,N/A,21468.70,N/A,5009.37,N/A,3198.50,N/A,20481.02,N/A,12165.60,N/A,7875.49,N/A,5009.37,N/A,3198.50,N/A,3198.50,N/A,4902.64,N/A,7875.49,N/A,7875.49,N/A,7875.49,N/A,20481.03,N/A,3198.50,N/A,5009.37,N/A,4562.00,N/A,4562.00,N/A,5009.37,N/A,3198.50,N/A,3198.50,N/A,2003.88,N/A,N/A,2003.88,21468.70,,Hospital 49615,Rpr Aa Hernia Recr 3-10 Cm Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,40629.62,39452.45,24377.77,23671.47,24434.70,5485.26,29200.29,3241.65,40482.95,22691.13,13814.07,13413.83,40629.62,7843.74,25187.57,5485.26,124202.00,3198.50,124202.00,3198.50,34604.92,4882.87,40629.62,7843.74,40629.62,7843.74,40629.62,7843.74,40482.95,22691.14,29170.64,3198.50,25187.57,5485.26,40629.62,4562.00,40629.62,4562.00,N/A,5485.26,29170.64,3198.50,29200.29,47.52,26950.70,46.15,13814.07,124202.00,46.15,23671.47,,Hospital 49616,Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,76629.43,44987.12,45977.66,26992.27,9346.26,6298.21,11381.08,857.19,23121.89,25706.11,25042.16,15295.62,17125.45,11484.97,9634.23,6298.21,73060.00,857.19,73060.00,857.19,10660.90,7149.62,17125.45,11484.97,17125.45,11484.97,17125.45,11484.97,23121.89,25706.15,11321.78,857.19,9634.23,6298.21,25298.88,7897.00,25298.88,7897.00,N/A,6298.21,11321.78,857.19,11381.08,857.19,10308.63,N/A,9346.26,73060.00,857.19,26992.27,,Hospital 49650,Laparoscopy Surg Rpr Initial Inguinal Hernia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,61154.48,37751.92,36692.69,22651.15,5879.29,5285.26,7250.18,4706.78,14402.06,21686.95,20792.53,12835.65,13376.19,12371.58,6060.44,5285.26,153426.00,4706.78,153426.00,4706.78,8326.37,7701.55,13376.19,12371.58,13376.19,12371.58,13376.19,12371.58,14402.06,21686.94,7220.53,4706.78,6060.44,5285.26,15914.32,7897.00,15914.32,7897.00,N/A,5285.26,7220.53,4706.78,7250.18,4706.78,6484.67,5177.46,5879.29,153426.00,4706.78,22651.15,,Hospital 49652,Laps Repair Hernia Except Incal/Ingun Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,75359.37,N/A,45215.62,N/A,10550.29,N/A,718.57,N/A,43301.78,N/A,25592.73,N/A,8676.49,N/A,10550.29,N/A,718.57,N/A,718.57,N/A,5391.87,N/A,8676.49,N/A,8676.49,N/A,8676.49,N/A,43301.77,N/A,718.57,N/A,10550.29,N/A,57309.51,N/A,57309.51,N/A,10550.29,N/A,718.57,N/A,718.57,N/A,790.43,N/A,N/A,718.57,57309.51,,Hospital 49653,Lap Rpr Hrna Xcpt Incal/Ingun Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,61154.48,47288.87,36692.69,28373.32,5879.29,6612.42,7250.18,907.66,14402.06,27169.43,20792.53,16078.21,13376.19,3550.22,6060.44,6612.42,153426.00,907.66,153426.00,907.66,8326.37,2206.31,13376.19,3550.22,13376.19,3550.22,13376.19,3550.22,14402.06,27169.42,7220.53,907.66,6060.44,6612.42,15914.32,527.00,15914.32,527.00,N/A,6612.42,7220.53,907.66,7250.18,907.66,6484.67,1058.50,5879.29,153426.00,527.00,28373.32,,Hospital 49655,Laps Rpr Incisional Hernia Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52211.37,57776.48,31326.82,34665.89,7320.70,8088.71,8461.18,1022.06,20795.71,33028.79,17751.86,19644.00,16508.75,11568.86,7546.26,8088.71,218056.00,4706.78,218056.00,4706.78,10276.31,7201.84,16508.75,11568.86,16508.75,11568.86,16508.75,11568.86,28779.74,33028.81,8431.53,4706.78,7546.26,8088.71,19641.29,5963.00,19641.29,5963.00,N/A,8088.71,8431.53,4706.78,8461.18,1022.06,8074.50,1124.26,7320.70,218056.00,1022.06,34665.89,,Hospital 49656,Laps Rpr Recurrent Incisional Hernia Reducible,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,84217.13,92517.38,50530.28,55510.43,8404.69,12958.35,10207.96,1130.81,23655.46,53255.23,28633.83,31455.90,19121.84,9421.97,8663.66,12958.35,562.00,1112.02,562.00,1112.02,11902.90,5855.85,19121.84,9421.97,19121.84,9421.97,19121.84,9421.97,23655.46,51204.24,10207.96,1112.02,8663.66,12958.35,22750.22,527.00,22750.22,527.00,N/A,12958.35,10207.96,1112.02,10207.96,1130.81,9270.11,1184.81,562.00,50530.28,527.00,55510.43,,Hospital 49657,Laps Rpr Recurrent Incal Hrna Ncrc8/Strangulated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,85142.28,41762.87,51085.37,25057.72,7320.70,5820.80,8925.66,1327.59,17091.25,23932.04,28948.37,14199.37,16655.61,5067.09,7546.26,5820.80,562.00,1327.59,562.00,1327.59,10367.73,3149.99,16655.61,5067.09,16655.61,5067.09,16655.61,5067.09,17091.25,23932.08,8925.66,1327.59,7546.26,5820.80,19816.01,23932.08,19816.01,23932.08,N/A,5820.80,8925.66,1327.59,8925.66,1327.59,8074.50,1460.35,562.00,51085.37,1327.59,25057.72,,Hospital 49900,Sec Abdominal Wall Suture Evisceration/Dehsn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14858.73,N/A,8915.24,N/A,2080.22,N/A,815.56,N/A,8549.53,N/A,4964.01,N/A,7864.94,N/A,2080.22,N/A,834.09,N/A,834.09,N/A,4896.07,N/A,7864.94,N/A,7864.94,N/A,7864.94,N/A,8549.53,N/A,834.09,N/A,2080.22,N/A,1643.00,N/A,1643.00,N/A,2080.22,N/A,834.09,N/A,815.56,N/A,897.12,N/A,N/A,815.56,8915.24,,Hospital 49905,Omental Flap Intra-Abdominal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,53514.48,N/A,32108.69,N/A,7469.91,N/A,1698.31,N/A,30783.48,N/A,18194.92,N/A,19477.14,N/A,7469.91,N/A,2767.24,N/A,2767.24,N/A,12124.40,N/A,19477.14,N/A,19477.14,N/A,19477.14,N/A,29014.59,N/A,2767.24,N/A,7469.91,N/A,3103.25,N/A,3103.25,N/A,7469.91,N/A,2767.24,N/A,1411.87,N/A,1868.16,N/A,N/A,1411.87,32108.69,,Hospital 50081,Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,100256.87,73227.10,60154.12,43936.26,5750.19,10187.18,7067.82,8083.61,13122.37,42157.86,34087.33,24897.19,13082.47,18803.80,5927.36,10187.18,562.00,7727.79,562.00,7727.79,8143.53,11705.72,13082.47,18803.80,13082.47,18803.80,13082.47,18803.80,13122.37,42157.88,7067.82,7727.79,5927.36,10187.18,15564.88,8129.25,15564.88,8129.25,4404.67,10187.18,7067.82,7727.79,7067.82,8083.61,6342.28,1812.38,562.00,60154.12,1812.38,43936.26,,Hospital 50220,Nephrectomy W/Prtl Ureterectomy W/Open Rib Rescj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 50386,HC Remove Indwelling Stent via Transurethra,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,85855.83,38763.05,51513.50,23257.83,7528.22,5327.35,9171.14,2954.54,17425.85,22240.20,29190.99,13179.43,17127.73,7024.13,7760.17,5327.35,562.00,2894.35,562.00,2894.35,10661.62,4372.63,17127.73,7024.13,17127.73,7024.13,17127.73,7024.13,17425.85,22240.21,9171.14,2894.35,7760.17,5327.35,20377.73,7109.75,20377.73,7109.75,N/A,5327.35,9171.14,2894.35,9171.14,2954.54,8303.39,674.01,562.00,51513.50,674.01,23257.83,,Hospital 50389,HC Rem Neph Tube,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,105370.73,2282.00,63222.44,1369.20,13746.78,319.48,16527.37,600.73,43922.66,1313.98,14813.58,775.88,14813.58,1365.97,9523.67,319.48,7306.00,564.71,11242.28,564.71,14813.58,850.34,14813.58,1365.97,14813.58,1365.97,14813.58,1365.97,31038.23,1313.98,11242.28,564.71,9523.67,319.48,37210.44,2146.50,43922.66,2146.50,9523.67,319.48,16527.37,564.71,11242.28,600.73,9523.67,112.54,7306.00,63222.44,112.54,2146.50,,Hospital CPT 50390,HC Renal Cyst Aspiration,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3224.00,3224.00,1934.40,1934.40,N/A,451.36,N/A,646.48,N/A,1856.38,N/A,1096.16,N/A,1417.60,N/A,451.36,N/A,586.05,N/A,586.05,N/A,882.49,N/A,1417.60,N/A,1417.60,N/A,1417.60,N/A,1856.38,N/A,586.05,N/A,451.36,N/A,1431.00,N/A,1431.00,N/A,451.36,N/A,586.05,N/A,91.91,N/A,101.10,1934.40,1934.40,91.91,1934.40,,Hospital 50391,Instlj Ther Agent Renal Pelvis&/Ureter via Tub,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,117454.00,N/A,70472.40,N/A,16437.83,N/A,23898.46,N/A,66176.45,N/A,39934.36,N/A,59599.89,N/A,16437.83,N/A,23887.88,N/A,23887.88,N/A,37101.51,N/A,59599.89,N/A,59599.89,N/A,59599.89,N/A,66176.45,N/A,23887.88,N/A,16437.83,N/A,527.00,N/A,527.00,N/A,16437.83,N/A,23891.81,N/A,23898.46,N/A,108.01,N/A,N/A,108.01,70472.40,,Hospital CPT 50430,HC Njx Px Nfrosgrm &/Urtrgrm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1708.00,1708.00,1024.80,1024.80,N/A,239.12,N/A,590.71,N/A,983.47,N/A,580.72,N/A,1365.97,N/A,239.12,N/A,564.71,N/A,564.71,N/A,850.34,N/A,1365.97,N/A,1365.97,N/A,1365.97,N/A,983.47,N/A,564.71,N/A,239.12,N/A,1431.00,N/A,1431.00,N/A,239.12,N/A,564.71,N/A,590.71,N/A,161.22,1024.80,1024.80,161.22,1431.00,,Hospital CPT 50432,"HC Plmt Nephrostomy Catheter,Perc",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4624.00,4624.00,2774.40,2774.40,N/A,647.36,N/A,1666.46,N/A,2662.50,N/A,1572.16,N/A,4051.75,N/A,647.36,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,2662.50,N/A,1675.03,N/A,647.36,N/A,3397.00,N/A,3397.00,N/A,647.36,N/A,1675.03,N/A,1752.16,N/A,214.90,2774.40,2774.40,214.90,4051.75,,Hospital CPT 50435,"HC Exchange Nephrostomy Cath, Perc",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2136.00,2136.00,1281.60,1281.60,N/A,299.04,N/A,1752.16,N/A,1229.91,N/A,726.24,N/A,2136.00,N/A,299.04,N/A,1675.03,N/A,1675.03,N/A,2136.00,N/A,2136.00,N/A,2136.00,N/A,2136.00,N/A,1229.91,N/A,1675.03,N/A,299.04,N/A,1431.00,N/A,1431.00,N/A,299.04,N/A,1675.03,N/A,1781.87,N/A,104.39,1281.60,1281.60,104.39,2136.00,,Hospital CPT 50436,HC Perq Dilation Xst Trc Endourologic Px W/Img,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,8480.00,8480.00,5088.00,5088.00,N/A,1187.20,N/A,143.33,N/A,4882.78,N/A,2883.20,N/A,422.76,N/A,1187.20,N/A,143.33,N/A,143.33,N/A,263.17,N/A,422.76,N/A,422.76,N/A,422.76,N/A,4882.78,N/A,143.33,N/A,1187.20,N/A,8480.00,N/A,8480.00,N/A,1187.20,N/A,143.33,N/A,143.33,N/A,157.66,5088.00,5088.00,143.33,8480.00,,Hospital 50543,Laparoscopy Surg Partial Nephrectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,122507.63,112814.32,73504.58,67688.59,8423.37,15644.53,10230.05,8376.85,67526.21,64941.54,41652.59,38356.88,19164.32,20028.55,8682.90,15644.53,1124.00,8206.20,1124.00,8206.20,11929.35,12468.15,19164.32,20028.55,19164.32,20028.55,19164.32,20028.55,67526.21,64941.53,10230.05,8206.20,8682.90,15644.53,22800.76,7897.00,22800.76,7897.00,N/A,15644.53,8206.20,8206.20,10230.05,8376.85,9290.71,1850.58,1124.00,73504.58,1850.58,67688.59,,Hospital 50544,Laparoscopy Surg Pyeloplasty,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,91197.53,117607.70,54718.52,70564.62,5750.19,16454.16,7097.47,8733.55,13500.10,67696.12,31007.16,39986.62,13082.47,19957.95,5927.36,16454.16,100598.00,8210.13,100598.00,8210.13,8143.53,12424.22,13082.47,19957.95,13082.47,19957.95,13082.47,19957.95,13500.10,67696.11,7067.82,8210.13,5927.36,16454.16,15564.88,7897.00,15564.88,7897.00,N/A,16454.16,7067.82,8210.13,7097.47,8733.55,6342.28,1370.37,5750.19,100598.00,1370.37,70564.62,,Hospital 50545,Laparoscopy Radical Nephrectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,88764.83,114937.00,53258.90,68962.20,10018.42,15988.25,12176.21,1579.01,22577.32,66145.72,30180.04,39078.57,22793.29,12268.32,10327.10,15988.25,91606.00,1572.92,91606.00,1572.92,14188.29,7637.28,22793.29,12268.32,22793.29,12268.32,22793.29,12268.32,22577.32,65641.89,12116.91,1572.92,10327.10,15988.25,27118.32,1643.00,27118.32,1643.00,N/A,15988.25,12116.91,1572.92,12176.21,1579.01,11050.00,1649.66,10018.42,91606.00,1572.92,68962.20,,Hospital 50548,Laparoscopy Nephrectomy W/Total Ureterectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,198455.77,N/A,119073.46,N/A,27793.19,N/A,1619.17,N/A,114260.22,N/A,67474.98,N/A,12220.55,N/A,27793.19,N/A,1600.50,N/A,1600.50,N/A,7607.52,N/A,12220.55,N/A,12220.55,N/A,12220.55,N/A,114087.48,N/A,1600.50,N/A,27793.19,N/A,1643.00,N/A,1643.00,N/A,27793.19,N/A,1600.50,N/A,1619.17,N/A,1796.78,N/A,N/A,1600.50,119073.46,,Hospital 50549,Unlisted Laparoscopy Procedure Renal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60092.12,N/A,36055.27,N/A,8392.47,N/A,8603.67,N/A,34586.04,N/A,20431.32,N/A,19921.09,N/A,8392.47,N/A,8206.20,N/A,8206.20,N/A,12401.27,N/A,19921.09,N/A,19921.09,N/A,19921.09,N/A,34586.06,N/A,8206.20,N/A,8392.47,N/A,14641.50,N/A,14641.50,N/A,8392.47,N/A,8206.20,N/A,1635.11,N/A,1792.50,N/A,N/A,1635.11,36055.27,,Hospital 50553,Renal Ndsc Nephrost W/Ureteral Cath W/WO Dila,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,90200.68,N/A,54120.41,N/A,5750.19,N/A,6677.72,N/A,13242.41,N/A,29720.01,N/A,10506.62,N/A,5927.36,N/A,236040.00,N/A,236040.00,N/A,6540.56,N/A,10506.62,N/A,10506.62,N/A,10506.62,N/A,13242.41,N/A,6648.07,N/A,5927.36,N/A,15359.83,N/A,15359.83,N/A,N/A,N/A,6648.07,N/A,6677.72,N/A,6342.28,N/A,5750.19,236040.00,N/A,N/A,,Hospital CPT 50590,HC Lithotripsy,N/A,0790 - EXTRA-CORPOREAL SHOCK WAVE THERAPY (FORMERLY LITHOTRIPSY) - GENERAL CLASSIFICATION,62962.00,62962.00,37777.20,37777.20,N/A,8814.68,N/A,2894.35,N/A,36253.52,N/A,21407.08,N/A,7001.20,N/A,8814.68,N/A,2894.35,N/A,2894.35,N/A,4358.38,N/A,7001.20,N/A,7001.20,N/A,7001.20,N/A,36253.52,N/A,2894.35,N/A,8814.68,N/A,7897.00,N/A,7897.00,N/A,8814.68,N/A,2894.35,N/A,2894.35,N/A,3183.79,37777.20,37777.20,2894.35,37777.20,,Hospital 50592,HC Rfa Renal Tumor(S),N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,43043.22,N/A,25825.93,N/A,6018.79,N/A,8376.85,N/A,23074.68,N/A,14634.69,N/A,19902.89,N/A,6018.79,N/A,8206.20,N/A,8206.20,N/A,12389.95,N/A,19902.89,N/A,19902.89,N/A,19902.89,N/A,23074.68,N/A,8206.20,N/A,6018.79,N/A,8832.50,N/A,8832.50,N/A,6018.79,N/A,8206.20,N/A,8376.85,N/A,615.98,N/A,N/A,615.98,25825.93,,Hospital 50606,HC Endoluminal Bx Urtr Rnl Plvs,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21238.48,N/A,12743.09,N/A,2973.38,N/A,445.99,N/A,12219.66,N/A,7221.08,N/A,4065.94,N/A,2973.38,N/A,1675.03,N/A,1675.03,N/A,2531.13,N/A,4065.94,N/A,4065.94,N/A,4065.94,N/A,12219.66,N/A,1675.03,N/A,2973.38,N/A,3660.50,N/A,3660.50,N/A,2973.38,N/A,1675.03,N/A,445.99,N/A,490.60,N/A,N/A,445.99,12743.09,,Hospital 50690,HC Inj Ileal Conduit Ureteropyelo,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1006575.52,N/A,603945.31,N/A,N/A,N/A,N/A,N/A,N/A,N/A,437664.43,N/A,437664.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,437664.43,N/A,437664.43,N/A,437664.43,N/A,437664.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,437664.43,603945.31,N/A,N/A,,Hospital CPT 50693,HC Insert Ureteral Tube,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7026.00,7026.00,4215.60,4215.60,N/A,983.64,N/A,2954.54,N/A,4045.57,N/A,2388.84,N/A,7001.20,N/A,983.64,N/A,2894.35,N/A,2894.35,N/A,4358.38,N/A,7001.20,N/A,7001.20,N/A,7001.20,N/A,4045.57,N/A,2894.35,N/A,983.64,N/A,4562.00,N/A,4562.00,N/A,983.64,N/A,2894.35,N/A,2954.54,N/A,213.37,4215.60,4215.60,213.37,7001.20,,Hospital 50695,HC Plmt Ureteral Stent Prq,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,84057.18,21400.12,50434.31,12840.07,5483.99,2996.02,6752.92,2993.58,13475.24,12310.35,28579.44,7276.04,12476.84,7015.91,5652.96,2996.02,4496.00,2894.35,4496.00,2894.35,7766.54,4367.53,12476.84,7015.91,12476.84,7015.91,12476.84,7015.91,13475.24,12303.32,6752.92,2894.35,5652.96,2996.02,14844.32,5277.50,14844.32,5277.50,3804.13,2996.02,6752.92,2894.35,6752.92,2993.58,6048.67,472.70,3804.13,50434.31,472.70,12840.07,,Hospital 50760,Ureteroureterostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,90320.70,N/A,54192.42,N/A,12576.25,N/A,6655.74,N/A,51954.19,N/A,30702.56,N/A,15133.05,N/A,12576.25,N/A,6639.08,N/A,6639.08,N/A,9420.54,N/A,15133.05,N/A,15133.05,N/A,15133.05,N/A,51954.21,N/A,6639.08,N/A,12576.25,N/A,5506.25,N/A,5506.25,N/A,12576.25,N/A,6639.08,N/A,6655.74,N/A,1963.79,N/A,N/A,1963.79,54192.42,,Hospital 50782,Ureteroneocystostomy Anast Duplicate Ureter Bldr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,120249.55,N/A,72149.73,N/A,16834.95,N/A,8580.08,N/A,69210.00,N/A,40884.84,N/A,11069.58,N/A,16834.95,N/A,8566.72,N/A,8566.72,N/A,6891.02,N/A,11069.58,N/A,11069.58,N/A,11069.58,N/A,68743.02,N/A,8566.72,N/A,16834.95,N/A,4218.50,N/A,4218.50,N/A,16834.95,N/A,8566.72,N/A,8580.08,N/A,1378.39,N/A,N/A,1378.39,72149.73,,Hospital 50945,Laparoscopy Urtrolithotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,98415.18,N/A,59049.11,N/A,13752.66,N/A,7474.50,N/A,56642.93,N/A,33461.15,N/A,11431.66,N/A,13752.66,N/A,7436.97,N/A,7436.97,N/A,7116.45,N/A,11431.66,N/A,11431.66,N/A,11431.66,N/A,56642.94,N/A,7436.97,N/A,13752.66,N/A,9595.50,N/A,9595.50,N/A,13752.66,N/A,7436.97,N/A,7474.50,N/A,1270.59,N/A,N/A,1270.59,59049.11,,Hospital 50951,Ureteral Endoscopy via Ureterostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,77712.85,N/A,46627.71,N/A,10875.06,N/A,4941.81,N/A,44727.48,N/A,26422.36,N/A,8041.61,N/A,10875.06,N/A,4452.21,N/A,4452.21,N/A,5004.95,N/A,8041.61,N/A,8041.61,N/A,8041.61,N/A,44727.49,N/A,4452.21,N/A,10875.06,N/A,5277.50,N/A,5277.50,N/A,10875.06,N/A,4452.21,N/A,4941.81,N/A,544.67,N/A,N/A,544.67,46627.71,,Hospital 51101,Aspiration Bladder Trocar/Intracatheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34477.20,N/A,20686.32,N/A,4828.52,N/A,913.32,N/A,19849.51,N/A,11722.24,N/A,2077.34,N/A,4828.52,N/A,859.50,N/A,859.50,N/A,1293.18,N/A,2077.34,N/A,2077.34,N/A,2077.34,N/A,19849.52,N/A,859.50,N/A,4828.52,N/A,1871.00,N/A,1871.00,N/A,4828.52,N/A,859.50,N/A,913.32,N/A,71.16,N/A,N/A,71.16,20686.32,,Hospital Custom 5130000000,HC Bridge Appointment,N/A,0513 - CLINIC - PSYCHIATRIC CLINIC,251.00,251.00,150.60,150.60,N/A,35.14,N/A,251.00,N/A,144.53,N/A,85.34,N/A,35.14,N/A,35.14,N/A,251.00,N/A,251.00,N/A,21.84,N/A,35.14,N/A,35.14,N/A,35.14,N/A,144.53,N/A,251.00,N/A,35.14,N/A,251.00,N/A,251.00,N/A,35.14,N/A,251.00,N/A,251.00,N/A,251.00,150.60,150.60,21.84,251.00,,Hospital 51500,Exc Urachal Cyst/Sinus W/WO Umbilical Hernia Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12544.80,N/A,7526.88,N/A,1753.40,N/A,4682.70,N/A,7218.91,N/A,4265.23,N/A,11433.72,N/A,1753.40,N/A,4706.78,N/A,4706.78,N/A,7117.70,N/A,11433.72,N/A,11433.72,N/A,11433.72,N/A,7218.91,N/A,4706.78,N/A,1753.40,N/A,4562.00,N/A,4562.00,N/A,1753.40,N/A,4706.78,N/A,4682.70,N/A,704.53,N/A,N/A,704.53,11433.72,,Hospital 51525,Cystotomy Excise Bladder Diverticulum 1/Multiple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,103612.62,N/A,62167.57,N/A,14420.14,N/A,1321.98,N/A,59650.85,N/A,35221.84,N/A,8244.16,N/A,14420.14,N/A,1300.02,N/A,1300.02,N/A,5132.13,N/A,8244.16,N/A,8244.16,N/A,8244.16,N/A,59466.01,N/A,1300.02,N/A,14420.14,N/A,4825.50,N/A,4825.50,N/A,14420.14,N/A,1300.02,N/A,1321.98,N/A,1481.91,N/A,N/A,1300.02,62167.57,,Hospital CPT 51600,HC Inj Proc Cysto or Void,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,987.00,987.00,592.20,592.20,N/A,138.18,N/A,987.00,N/A,568.31,N/A,335.58,N/A,987.00,N/A,138.18,N/A,987.00,N/A,987.00,N/A,987.00,N/A,987.00,N/A,987.00,N/A,987.00,N/A,568.31,N/A,987.00,N/A,138.18,N/A,527.00,N/A,527.00,N/A,138.18,N/A,987.00,N/A,987.00,N/A,46.59,592.20,592.20,46.59,987.00,,Hospital 51727,Complex Cystometrogram Urethral Press Profile,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17725.00,N/A,10635.00,N/A,2481.50,N/A,584.07,N/A,10206.06,N/A,6026.50,N/A,1365.97,N/A,2481.50,N/A,564.71,N/A,564.71,N/A,850.34,N/A,1365.97,N/A,1365.97,N/A,1365.97,N/A,10206.06,N/A,564.71,N/A,2481.50,N/A,1431.00,N/A,1431.00,N/A,2481.50,N/A,564.71,N/A,584.07,N/A,261.97,N/A,N/A,261.97,10635.00,,Hospital 51784,HC Anal Urinary Muscle Study,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1141.00,N/A,684.60,N/A,159.74,N/A,399.19,N/A,656.99,N/A,387.94,N/A,611.76,N/A,159.74,N/A,384.24,N/A,384.24,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,656.99,N/A,384.24,N/A,159.74,N/A,611.57,N/A,611.57,N/A,159.74,N/A,384.24,N/A,399.19,N/A,214.30,N/A,N/A,159.74,684.60,,Hospital 51800,Cstoplasty/Cstourtp Plstc Any,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,153162.02,N/A,91897.21,N/A,21413.30,N/A,2651.83,N/A,88187.58,N/A,52075.07,N/A,14068.09,N/A,21413.30,N/A,2552.42,N/A,2552.42,N/A,8757.65,N/A,14068.09,N/A,14068.09,N/A,14068.09,N/A,88187.58,N/A,2552.42,N/A,21413.30,N/A,2692.50,N/A,2692.50,N/A,21413.30,N/A,2552.42,N/A,2651.83,N/A,2017.61,N/A,N/A,2017.61,91897.21,,Hospital 51980,Cutaneous Vesicostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63598.10,N/A,38158.86,N/A,8941.98,N/A,907.37,N/A,36760.81,N/A,21623.36,N/A,7527.53,N/A,8941.98,N/A,893.92,N/A,893.92,N/A,4686.03,N/A,7527.53,N/A,7527.53,N/A,7527.53,N/A,36760.81,N/A,893.92,N/A,8941.98,N/A,3397.00,N/A,3397.00,N/A,8941.98,N/A,893.92,N/A,907.37,N/A,957.34,N/A,N/A,893.92,38158.86,,Hospital 51990,Laparoscopy Urethral Suspension Stress Incont,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76029.72,N/A,45617.83,N/A,10644.16,N/A,8525.70,N/A,43775.00,N/A,25850.10,N/A,19918.34,N/A,10644.16,N/A,8206.20,N/A,8206.20,N/A,12399.55,N/A,19918.34,N/A,19918.34,N/A,19918.34,N/A,43775.00,N/A,8206.20,N/A,10644.16,N/A,11977.25,N/A,11977.25,N/A,10644.16,N/A,8206.20,N/A,8525.70,N/A,1857.19,N/A,N/A,1857.19,45617.83,,Hospital 51992,Laparoscopy Sling Operation Stress Incont,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76841.98,N/A,46105.19,N/A,10716.95,N/A,2750.54,N/A,43941.35,N/A,26126.28,N/A,20026.49,N/A,10716.95,N/A,8206.20,N/A,8206.20,N/A,12466.87,N/A,20026.49,N/A,20026.49,N/A,20026.49,N/A,43941.38,N/A,8206.20,N/A,10716.95,N/A,13819.75,N/A,13819.75,N/A,10716.95,N/A,8206.20,N/A,2750.54,N/A,3025.60,N/A,N/A,2750.54,46105.19,,Hospital 51999,Unlisted Laparoscopy Procedure Bladder,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,95348.92,128939.92,57209.35,77363.95,3951.89,18051.36,4999.83,9591.17,8905.90,74240.20,30496.41,43839.56,11433.30,11418.25,4073.65,18051.36,137690.00,9545.57,137690.00,9545.57,7117.45,7108.10,11433.30,11418.25,11433.30,11418.25,11433.30,11418.25,8905.90,74240.20,4940.53,9545.57,4073.65,18051.36,10697.15,5963.00,10697.15,5963.00,N/A,18051.36,4940.53,9553.64,4999.83,9591.17,4358.81,153.27,3951.89,137690.00,153.27,77363.95,,Hospital CPT 52000,HC Cystourethroscopy (Separate Procedure),N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1548.00,1548.00,928.80,928.80,N/A,216.72,N/A,598.44,N/A,891.34,N/A,526.32,N/A,1365.97,N/A,216.72,N/A,564.71,N/A,564.71,N/A,850.34,N/A,1365.97,N/A,1365.97,N/A,1365.97,N/A,891.34,N/A,564.71,N/A,216.72,N/A,1548.00,N/A,1548.00,N/A,216.72,N/A,564.71,N/A,598.44,N/A,85.06,928.80,928.80,85.06,1548.00,,Hospital 52001,Cysto W/Irrig & Evac Multple Obstructing Clots,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,36344.80,24217.50,21806.88,14530.50,8135.30,3369.15,3147.34,3005.37,18333.55,13940.50,12357.23,8233.95,18508.93,7036.22,8385.96,3369.15,42150.00,2906.14,42150.00,2906.14,11521.38,4380.17,18508.93,7036.22,18508.93,7036.22,18508.93,7036.22,18333.55,13940.50,9889.28,2906.14,8385.96,3369.15,22021.00,1871.00,22021.00,1871.00,N/A,3369.15,9889.28,2906.14,9918.93,3005.37,8972.98,1017.99,3147.34,42150.00,1017.99,14530.50,,Hospital CPT 52005,HC Cysto Bladder W/Ureteral Catheterization,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5149.00,5149.00,3089.40,3089.40,N/A,720.86,N/A,126.12,N/A,2964.79,N/A,1750.66,N/A,838.14,N/A,720.86,N/A,126.12,N/A,126.12,N/A,521.74,N/A,838.14,N/A,838.14,N/A,838.14,N/A,2964.79,N/A,126.12,N/A,720.86,N/A,5149.00,N/A,5149.00,N/A,720.86,N/A,126.12,N/A,126.12,N/A,138.73,3089.40,3089.40,126.12,5149.00,,Hospital 52007,Cysto W/Urtrl Cathj Brush Bx Urtr&/Renal Pelvis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25698.65,N/A,15419.19,N/A,3588.01,N/A,340.24,N/A,14772.72,N/A,8737.54,N/A,7032.08,N/A,3588.01,N/A,2894.35,N/A,2894.35,N/A,4377.60,N/A,7032.08,N/A,7032.08,N/A,7032.08,N/A,14772.74,N/A,2894.35,N/A,3588.01,N/A,5944.75,N/A,5944.75,N/A,3588.01,N/A,2894.35,N/A,340.24,N/A,374.27,N/A,N/A,340.24,15419.19,,Hospital 52234,Cysto W/Removal of Tumors Small,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54121.30,21409.07,32472.78,12845.44,8397.76,2965.23,7811.48,445.55,27862.78,12319.03,18401.24,7191.12,19106.07,7043.91,8656.51,2965.23,10199.76,2894.35,10199.76,2894.35,11893.08,4384.96,19106.07,7043.91,19106.07,7043.91,19106.07,7043.91,27862.78,12319.04,10199.76,2894.35,8656.51,2965.23,22731.45,5095.50,22731.45,5095.50,N/A,2965.23,10199.76,2894.35,10229.41,445.55,9262.46,490.12,7811.48,32472.78,445.55,12845.44,,Hospital 52235,Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,39648.23,20161.13,23788.94,12096.68,7905.37,2822.56,9617.28,2894.35,17815.40,11606.63,N/A,6854.79,17985.82,7014.26,8148.95,2822.56,1686.00,2894.35,1686.00,2894.35,11195.75,4366.51,17985.82,7014.26,17985.82,7014.26,17985.82,7014.26,17815.40,11606.62,9617.28,2894.35,8148.95,2822.56,21398.64,5095.50,21398.64,5095.50,N/A,2822.56,9617.28,2894.35,9617.28,2894.35,8719.38,3183.79,1686.00,23788.94,2822.56,12096.68,,Hospital 52260,Cystourethroscopy W/Dil Bladder General Anesth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18023.20,N/A,10813.92,N/A,2523.24,N/A,1752.16,N/A,10371.11,N/A,6127.88,N/A,4176.44,N/A,2523.24,N/A,1675.03,N/A,1675.03,N/A,2599.92,N/A,4176.44,N/A,4176.44,N/A,4176.44,N/A,10371.11,N/A,1675.03,N/A,2523.24,N/A,1871.00,N/A,1871.00,N/A,2523.24,N/A,1675.03,N/A,1752.16,N/A,221.14,N/A,N/A,221.14,10813.92,,Hospital 52283,Cystourethroscopy W/Steroid Injection Stricture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17635.72,N/A,10581.43,N/A,2469.01,N/A,557.00,N/A,10120.28,N/A,5892.25,N/A,4235.73,N/A,2469.01,N/A,1675.03,N/A,1675.03,N/A,2636.83,N/A,4235.73,N/A,4235.73,N/A,4235.73,N/A,10120.27,N/A,1675.03,N/A,2469.01,N/A,5563.25,N/A,5563.25,N/A,2469.01,N/A,1675.03,N/A,557.00,N/A,612.70,N/A,N/A,557.00,10581.43,,Hospital 52285,Cystourethroscopy Tx Female Urethral Syndrome,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67695.82,N/A,40617.49,N/A,9477.43,N/A,6542.02,N/A,38968.66,N/A,23016.57,N/A,15279.57,N/A,9477.43,N/A,6254.06,N/A,6254.06,N/A,9511.82,N/A,15279.57,N/A,15279.57,N/A,15279.57,N/A,38968.69,N/A,6254.06,N/A,9477.43,N/A,11346.25,N/A,11346.25,N/A,9477.43,N/A,6254.06,N/A,6542.02,N/A,1670.87,N/A,N/A,1670.87,40617.49,,Hospital 52290,Cystourethroscopy W/Ureteral Meatotomy Uni/Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8004.40,N/A,4802.64,N/A,1120.62,N/A,1660.56,N/A,4606.79,N/A,2721.50,N/A,4081.12,N/A,1120.62,N/A,1675.03,N/A,1675.03,N/A,2540.57,N/A,4081.12,N/A,4081.12,N/A,4081.12,N/A,4606.79,N/A,1675.03,N/A,1120.62,N/A,3397.00,N/A,3397.00,N/A,1120.62,N/A,1675.03,N/A,1660.56,N/A,255.82,N/A,N/A,255.82,4802.64,,Hospital 52300,Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43578.40,N/A,26147.04,N/A,6100.97,N/A,3078.97,N/A,25091.95,N/A,14816.66,N/A,7005.78,N/A,6100.97,N/A,2894.35,N/A,2894.35,N/A,4361.24,N/A,7005.78,N/A,7005.78,N/A,7005.78,N/A,25091.95,N/A,2894.35,N/A,6100.97,N/A,3397.00,N/A,3397.00,N/A,6100.97,N/A,2894.35,N/A,3078.97,N/A,314.54,N/A,N/A,314.54,26147.04,,Hospital 52305,Cysto Inc/Rescj Orifice Bldr Diverticulum 1/Mlt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,147756.98,N/A,88654.19,N/A,20335.21,N/A,11316.22,N/A,85033.51,N/A,50237.37,N/A,20033.33,N/A,20335.21,N/A,11281.68,N/A,11281.68,N/A,12471.15,N/A,20033.33,N/A,20033.33,N/A,20033.33,N/A,85033.53,N/A,11294.88,N/A,20335.21,N/A,10444.75,N/A,10444.75,N/A,20335.21,N/A,11294.88,N/A,11316.22,N/A,1155.18,N/A,N/A,1155.18,88654.19,,Hospital CPT 52310,HC Cysto Remove FB Simple,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4117.00,4117.00,2470.20,2470.20,N/A,576.38,N/A,1709.87,N/A,2370.57,N/A,1399.78,N/A,4051.75,N/A,576.38,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,2370.57,N/A,1675.03,N/A,576.38,N/A,4117.00,N/A,4117.00,N/A,576.38,N/A,1675.03,N/A,1740.25,N/A,158.69,2470.20,2470.20,158.69,4117.00,,Hospital CPT 52315,HC Cysto W Rmvlfb Urthr Bldr Cmpl,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4117.00,4117.00,2470.20,2470.20,N/A,576.38,N/A,261.75,N/A,2370.57,N/A,1399.78,N/A,1313.88,N/A,576.38,N/A,261.75,N/A,261.75,N/A,817.89,N/A,1313.88,N/A,1313.88,N/A,1313.88,N/A,2370.57,N/A,261.75,N/A,576.38,N/A,4117.00,N/A,4117.00,N/A,576.38,N/A,261.75,N/A,261.75,N/A,287.93,2470.20,2470.20,261.75,4117.00,,Hospital 52330,Cysto Manj W/O Rmvl Ureteral Stone,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35309.72,15714.22,21185.83,9428.53,5750.19,2199.98,7097.47,2971.66,13213.68,9039.87,12005.30,5342.83,13082.47,7036.38,5927.36,2199.98,133194.00,2894.35,133194.00,2894.35,8143.53,4380.28,13082.47,7036.38,13082.47,7036.38,13082.47,7036.38,13213.68,9039.88,7067.82,2894.35,5927.36,2199.98,15564.88,5095.50,15564.88,5095.50,N/A,2199.98,2894.35,2894.35,7097.47,2971.66,6342.28,466.69,2894.35,133194.00,466.69,9428.53,,Hospital 52332,Cysto W/Insert Ureteral Stent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,35818.58,22315.83,21491.15,13389.50,5750.19,3089.16,7067.82,2894.35,13332.77,12829.29,12178.33,7567.67,13082.47,7099.75,5927.36,3089.16,2906.14,2894.35,2906.14,2894.35,8143.53,4419.73,13082.47,7099.75,13082.47,7099.75,13082.47,7099.75,13332.77,12829.29,7067.82,2894.35,5927.36,3089.16,15564.88,5095.50,15564.88,5095.50,2588.70,3089.16,7067.82,2894.35,7067.82,2894.35,6342.28,3183.79,2588.70,21491.15,2894.35,13389.50,,Hospital 52341,HC Cysto W/Tx Ureteral Stricture,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,24116.12,N/A,14469.67,N/A,3346.84,N/A,2869.35,N/A,13868.53,N/A,8199.48,N/A,7048.98,N/A,3346.84,N/A,2894.35,N/A,2894.35,N/A,4388.11,N/A,7048.98,N/A,7048.98,N/A,7048.98,N/A,13868.53,N/A,2894.35,N/A,3346.84,N/A,5944.75,N/A,5944.75,N/A,3346.84,N/A,2894.35,N/A,2869.35,N/A,721.95,N/A,N/A,721.95,14469.67,,Hospital 52342,Cysto W/Tx Ureteropelvic Junction Stricture,N/A,N/A,N/A,19246.95,N/A,11548.17,N/A,2694.59,N/A,1709.87,N/A,11066.98,N/A,6543.96,N/A,4111.43,N/A,2694.59,N/A,1675.03,N/A,1675.03,N/A,2559.44,N/A,4111.43,N/A,4111.43,N/A,4111.43,N/A,11066.98,N/A,1675.03,N/A,2694.59,N/A,3397.00,N/A,3397.00,N/A,2694.59,N/A,1675.03,N/A,1709.87,N/A,190.65,N/A,N/A,190.65,11548.17,,Hospital 52343,Cysto W/Tx Intra-Renal Stricture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33363.95,N/A,20018.37,N/A,4600.26,N/A,489.75,N/A,19204.85,N/A,11343.75,N/A,7019.60,N/A,4600.26,N/A,2894.35,N/A,2894.35,N/A,4369.83,N/A,7019.60,N/A,7019.60,N/A,7019.60,N/A,19204.86,N/A,2894.35,N/A,4600.26,N/A,5095.50,N/A,5095.50,N/A,4600.26,N/A,2894.35,N/A,489.75,N/A,538.72,N/A,N/A,489.75,20018.37,,Hospital 52353,Cysto W/Ureteroscopy W/Lithotripsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,37973.07,21131.17,22783.84,12678.70,4252.23,2940.51,5325.46,6560.23,9582.74,12162.89,12910.84,7184.59,9674.40,11199.15,4383.24,2940.51,105094.00,5598.63,105094.00,5598.63,6022.09,6970.70,9674.40,11199.15,9674.40,11199.15,9674.40,11199.15,9582.74,12162.89,5295.81,5598.63,4383.24,2940.51,11510.12,5963.00,11510.12,5963.00,2968.03,2940.51,5295.81,5598.63,5325.46,6560.23,4690.07,473.40,2968.03,105094.00,473.40,12678.70,,Hospital 52354,Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33774.48,N/A,20264.69,N/A,4716.13,N/A,4399.70,N/A,19425.33,N/A,11483.32,N/A,10299.07,N/A,4716.13,N/A,4254.12,N/A,4254.12,N/A,6411.38,N/A,10299.07,N/A,10299.07,N/A,10299.07,N/A,19425.33,N/A,4254.12,N/A,4716.13,N/A,5095.50,N/A,5095.50,N/A,4716.13,N/A,4254.12,N/A,4399.70,N/A,704.64,N/A,N/A,704.64,20264.69,,Hospital 52450,Transurethral Incision Prostate,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,40648.80,15040.83,24389.28,9024.50,5111.63,2090.09,6312.44,2925.70,11519.48,8657.29,13820.59,5113.88,11629.67,7032.29,5269.13,2090.09,1124.00,2894.35,1124.00,2894.35,7239.20,4377.73,11629.67,7032.29,11629.67,7032.29,11629.67,7032.29,11519.48,8657.29,6312.44,2894.35,5269.13,2090.09,13836.41,3397.00,13836.41,3397.00,5269.13,2090.09,6312.44,2894.35,6312.44,2925.70,5637.97,568.01,1124.00,24389.28,568.01,9024.50,,Hospital 52500,Transurethral Resection Bladder Neck,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21373.93,N/A,12824.36,N/A,2906.78,N/A,1234.14,N/A,12301.94,N/A,7267.13,N/A,10286.15,N/A,2906.78,N/A,4246.26,N/A,4246.26,N/A,6403.32,N/A,10286.15,N/A,10286.15,N/A,10286.15,N/A,12301.96,N/A,4246.26,N/A,2906.78,N/A,7661.50,N/A,7661.50,N/A,2906.78,N/A,4246.26,N/A,1234.14,N/A,1351.46,N/A,N/A,1234.14,12824.36,,Hospital 52601,Trurl Electrosurg Rescj Prostate Bleed Complete,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,38205.15,30893.12,22923.09,18535.87,7905.37,4314.79,9303.32,4292.24,17983.46,17780.31,12989.75,10503.66,18125.40,10335.05,8148.95,4314.79,4396.40,4246.26,4396.40,4246.26,11282.64,6433.75,18125.40,10335.05,18125.40,10335.05,18125.40,10335.05,17983.46,15458.68,9244.02,4246.26,8148.95,4314.79,21564.70,7661.50,21564.70,7661.50,N/A,4314.79,9244.02,4246.26,9303.32,4292.24,8719.38,1569.40,4396.40,22923.09,1569.40,18535.87,,Hospital 52640,Trurl Rescj Postop Bladder Neck Contracture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18791.50,N/A,11274.90,N/A,2630.81,N/A,2954.54,N/A,10815.12,N/A,6389.11,N/A,7023.70,N/A,2630.81,N/A,2894.35,N/A,2894.35,N/A,4372.38,N/A,7023.70,N/A,7023.70,N/A,7023.70,N/A,10815.12,N/A,2894.35,N/A,2630.81,N/A,3397.00,N/A,3397.00,N/A,2630.81,N/A,2894.35,N/A,2954.54,N/A,334.26,N/A,N/A,334.26,11274.90,,Hospital 53020,HC Meatotomy Cutting Meatus Spx Except Infant,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,11597.63,N/A,6958.58,N/A,1621.83,N/A,98.78,N/A,6674.23,N/A,3943.20,N/A,4076.04,N/A,1621.83,N/A,1675.03,N/A,1675.03,N/A,2537.41,N/A,4076.04,N/A,4076.04,N/A,4076.04,N/A,6674.23,N/A,1675.03,N/A,1621.83,N/A,3397.00,N/A,3397.00,N/A,1621.83,N/A,1675.03,N/A,98.78,N/A,108.66,N/A,N/A,98.78,6958.58,,Hospital 53235,Exc Urethral Diverticulum Spx Male,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37002.98,N/A,22201.79,N/A,5180.44,N/A,4441.77,N/A,21304.05,N/A,12581.03,N/A,10306.73,N/A,5180.44,N/A,4246.26,N/A,4246.26,N/A,6416.14,N/A,10306.73,N/A,10306.73,N/A,10306.73,N/A,21304.04,N/A,4246.26,N/A,5180.44,N/A,5563.25,N/A,5563.25,N/A,5180.44,N/A,4246.26,N/A,4441.77,N/A,1512.53,N/A,N/A,1512.53,22201.79,,Hospital 53400,Urethroplasty 1st Stg Fistula/Diverticulum/Strix,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28247.00,N/A,16948.20,N/A,3954.56,N/A,4334.56,N/A,16258.34,N/A,9603.96,N/A,10332.89,N/A,3954.56,N/A,4246.26,N/A,4246.26,N/A,6432.42,N/A,10332.89,N/A,10332.89,N/A,10332.89,N/A,16258.34,N/A,4246.26,N/A,3954.56,N/A,5497.50,N/A,5497.50,N/A,3954.56,N/A,4246.26,N/A,4334.56,N/A,1660.31,N/A,N/A,1660.31,16948.20,,Hospital 53415,Urtp Transpubic/Prnl 1 Stg Rcnstj/Rpr Urt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44913.00,N/A,26947.80,N/A,6287.80,N/A,2993.58,N/A,25856.72,N/A,15270.41,N/A,17292.43,N/A,6287.80,N/A,2894.35,N/A,2894.35,N/A,10764.88,N/A,17292.43,N/A,17292.43,N/A,17292.43,N/A,25856.70,N/A,2894.35,N/A,6287.80,N/A,7661.50,N/A,7661.50,N/A,6287.80,N/A,2894.35,N/A,2993.58,N/A,1579.31,N/A,N/A,1579.31,26947.80,,Hospital 53425,Urtp 2-Stg Rcnstj/Rpr Prostat/Urethra 2nd Stage,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58744.23,N/A,35246.54,N/A,8215.19,N/A,4441.77,N/A,33817.73,N/A,19973.03,N/A,10359.69,N/A,8215.19,N/A,4246.26,N/A,4246.26,N/A,6449.08,N/A,10359.69,N/A,10359.69,N/A,10359.69,N/A,33313.35,N/A,4246.26,N/A,8215.19,N/A,4562.00,N/A,4562.00,N/A,8215.19,N/A,4246.26,N/A,4441.77,N/A,1066.24,N/A,N/A,1066.24,35246.54,,Hospital 53440,Sling Opration Corrj Male Urinary Incontinence,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,91496.22,N/A,54897.73,N/A,12798.96,N/A,11554.65,N/A,52264.36,N/A,31108.71,N/A,26376.43,N/A,12798.96,N/A,10861.83,N/A,10861.83,N/A,16419.84,N/A,26376.43,N/A,26376.43,N/A,26376.43,N/A,51797.39,N/A,10861.83,N/A,12798.96,N/A,11660.00,N/A,11660.00,N/A,12798.96,N/A,10861.83,N/A,11554.65,N/A,895.73,N/A,N/A,895.73,54897.73,,Hospital 53447,Rmvl & Rplcmt Nfltl Urethral/Bladder Neck Sphinc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,99227.83,40603.93,59536.70,24362.36,4908.34,5684.54,6072.00,18213.89,52463.90,23297.16,33737.47,13805.33,12283.86,40603.93,5059.57,5684.54,17494.17,17412.16,17494.17,17412.16,7646.42,26285.75,12283.86,40603.93,12283.86,40603.93,12283.86,40603.93,52463.90,23297.17,6072.00,17412.16,5059.57,5684.54,14614.72,18918.00,14614.72,18918.00,N/A,5684.54,6072.00,17412.16,6072.00,18213.89,5413.74,1226.78,4908.34,59536.70,1226.78,40603.93,,Hospital 53449,Rpr Nfltbl Urethral/Bladder Neck Sphincter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62606.52,N/A,37563.91,N/A,8764.92,N/A,8083.61,N/A,35964.53,N/A,21286.21,N/A,18710.91,N/A,8764.92,N/A,7727.79,N/A,7727.79,N/A,11647.90,N/A,18710.91,N/A,18710.91,N/A,18710.91,N/A,35964.53,N/A,7727.79,N/A,8764.92,N/A,10178.00,N/A,10178.00,N/A,8764.92,N/A,7727.79,N/A,8083.61,N/A,1102.66,N/A,N/A,1102.66,37563.91,,Hospital 53500,Urethrolss Trvg Sec Opn W/Csto,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,74487.95,N/A,44692.77,N/A,10428.31,N/A,4452.67,N/A,42824.07,N/A,25325.90,N/A,10165.89,N/A,10428.31,N/A,4185.69,N/A,4185.69,N/A,6328.46,N/A,10165.89,N/A,10165.89,N/A,10165.89,N/A,42824.08,N/A,4185.69,N/A,10428.31,N/A,9093.25,N/A,9093.25,N/A,10428.31,N/A,4185.69,N/A,4452.67,N/A,2109.72,N/A,N/A,2109.72,44692.77,,Hospital CPT 53620,HC Dil Ure Strc Fil/Fol Male Init,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1686.00,1686.00,1011.60,1011.60,N/A,236.04,N/A,83.44,N/A,970.80,N/A,573.24,N/A,472.59,N/A,236.04,N/A,83.44,N/A,83.44,N/A,294.19,N/A,472.59,N/A,472.59,N/A,472.59,N/A,970.80,N/A,83.44,N/A,236.04,N/A,1686.00,N/A,1686.00,N/A,236.04,N/A,83.44,N/A,83.44,N/A,91.78,1011.60,1011.60,83.44,1686.00,,Hospital 54057,Dstrj Lesion Penis Simple Laser,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18523.00,N/A,11113.80,N/A,2587.54,N/A,94.03,N/A,10659.42,N/A,6267.22,N/A,3793.88,N/A,2587.54,N/A,1558.52,N/A,1558.52,N/A,2361.76,N/A,3793.88,N/A,3793.88,N/A,3793.88,N/A,10659.42,N/A,1558.52,N/A,2587.54,N/A,1871.00,N/A,1871.00,N/A,2587.54,N/A,1558.52,N/A,94.03,N/A,103.44,N/A,N/A,94.03,11113.80,,Hospital 54065,Dstrj Lesion Penis Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,65196.80,13205.30,39118.08,7923.18,4809.16,1848.75,5630.00,1657.93,16811.47,7603.62,22166.91,4489.80,11104.11,3769.94,4957.34,1848.75,287744.00,1558.52,287744.00,1558.52,6912.64,2346.86,11104.11,3769.94,11104.11,3769.94,11104.11,3769.94,16811.47,7603.62,5600.35,1558.52,4957.34,1848.75,12828.50,1871.00,12828.50,1871.00,N/A,1848.75,5600.35,1558.52,5630.00,1657.93,5304.35,176.99,4809.16,287744.00,176.99,7923.18,,Hospital 54105,Biopsy Penis Deep Structures,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21273.90,N/A,12764.34,N/A,2980.04,N/A,2816.01,N/A,12243.23,N/A,7233.13,N/A,7122.32,N/A,2980.04,N/A,2340.64,N/A,2340.64,N/A,4433.76,N/A,7122.32,N/A,7122.32,N/A,7122.32,N/A,12243.22,N/A,2340.64,N/A,2980.04,N/A,5095.50,N/A,5095.50,N/A,2980.04,N/A,2667.22,N/A,2816.01,N/A,845.79,N/A,N/A,845.79,12764.34,,Hospital 54110,Excision of Penile Plaque,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,104288.23,N/A,62572.94,N/A,14592.88,N/A,18213.89,N/A,59299.25,N/A,35458.00,N/A,42192.82,N/A,14592.88,N/A,17412.16,N/A,17412.16,N/A,26265.83,N/A,42192.82,N/A,42192.82,N/A,42192.82,N/A,59299.24,N/A,17412.16,N/A,14592.88,N/A,19618.50,N/A,19618.50,N/A,14592.88,N/A,17412.16,N/A,18213.89,N/A,1534.73,N/A,N/A,1534.73,62572.94,,Hospital 54120,Amputation Penis Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57798.70,N/A,34679.22,N/A,8094.01,N/A,3082.90,N/A,33271.20,N/A,19651.56,N/A,7062.60,N/A,8094.01,N/A,2898.28,N/A,2898.28,N/A,4396.60,N/A,7062.60,N/A,7062.60,N/A,7062.60,N/A,33271.17,N/A,2898.28,N/A,8094.01,N/A,4562.00,N/A,4562.00,N/A,8094.01,N/A,2898.28,N/A,3082.90,N/A,1087.83,N/A,N/A,1087.83,34679.22,,Hospital CPT 54150,HC Circumcision W/Clamp/Oth Dev W/Block,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,4713.00,4713.00,2827.80,2827.80,N/A,659.82,N/A,1675.03,N/A,2713.75,N/A,1602.42,N/A,4051.75,N/A,659.82,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,2713.75,N/A,1675.03,N/A,659.82,N/A,3397.00,N/A,3397.00,N/A,659.82,N/A,1675.03,N/A,1675.03,N/A,1842.53,2827.80,2827.80,659.82,4051.75,,Hospital CPT 54161,HC Circum 28 Days or Older,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5665.00,5665.00,3399.00,3399.00,N/A,793.10,N/A,1709.87,N/A,3261.91,N/A,1926.10,N/A,4051.75,N/A,793.10,N/A,1675.03,N/A,1675.03,N/A,2522.29,N/A,4051.75,N/A,4051.75,N/A,4051.75,N/A,3261.91,N/A,1675.03,N/A,793.10,N/A,5665.00,N/A,5665.00,N/A,793.10,N/A,1675.03,N/A,1709.87,N/A,207.12,3399.00,3399.00,207.12,5665.00,,Hospital 54162,HC Lysis/Exc Penile Postcirc Adhesions,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,11885.10,N/A,7131.06,N/A,1663.90,N/A,1740.25,N/A,6841.41,N/A,4040.92,N/A,4093.18,N/A,1663.90,N/A,1675.03,N/A,1675.03,N/A,2554.20,N/A,4093.18,N/A,4093.18,N/A,4093.18,N/A,6841.43,N/A,1675.03,N/A,1663.90,N/A,3397.00,N/A,3397.00,N/A,1663.90,N/A,1675.03,N/A,1740.25,N/A,210.10,N/A,N/A,210.10,7131.06,,Hospital 54200,HC Injection Peyronie Disease,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,623.00,N/A,373.80,N/A,87.22,N/A,386.44,N/A,357.53,N/A,211.82,N/A,87.00,N/A,87.22,N/A,368.33,N/A,368.33,N/A,94.92,N/A,87.00,N/A,87.00,N/A,87.00,N/A,357.53,N/A,368.33,N/A,87.22,N/A,333.93,N/A,333.93,N/A,87.22,N/A,368.33,N/A,386.44,N/A,88.37,N/A,N/A,87.00,386.44,,Hospital 54300,Penis Straightening Chordee,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15389.93,N/A,9233.96,N/A,2154.59,N/A,3192.81,N/A,8860.51,N/A,5226.82,N/A,7002.13,N/A,2154.59,N/A,2894.35,N/A,2894.35,N/A,4358.96,N/A,7002.13,N/A,7002.13,N/A,7002.13,N/A,8860.52,N/A,2894.35,N/A,2154.59,N/A,7661.50,N/A,7661.50,N/A,2154.59,N/A,2894.35,N/A,807.27,N/A,888.00,N/A,N/A,807.27,9233.96,,Hospital 54304,Penis Corrj Chordee/1st Stage Hypospadias Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,73751.57,N/A,44250.94,N/A,10325.22,N/A,3078.97,N/A,42462.73,N/A,25075.53,N/A,7008.82,N/A,10325.22,N/A,2894.35,N/A,2894.35,N/A,4363.12,N/A,7008.82,N/A,7008.82,N/A,7008.82,N/A,42462.73,N/A,2894.35,N/A,10325.22,N/A,5963.00,N/A,5963.00,N/A,10325.22,N/A,2894.35,N/A,3078.97,N/A,788.14,N/A,N/A,788.14,44250.94,,Hospital 54324,1 Stg Dstl Hypospadias Rpr W/Urtp Skin Flaps,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43442.70,N/A,26065.62,N/A,6081.98,N/A,3078.97,N/A,25013.65,N/A,14770.52,N/A,7004.31,N/A,6081.98,N/A,2894.35,N/A,2894.35,N/A,4360.31,N/A,7004.31,N/A,7004.31,N/A,7004.31,N/A,25013.63,N/A,2894.35,N/A,6081.98,N/A,5963.00,N/A,5963.00,N/A,6081.98,N/A,2894.35,N/A,3078.97,N/A,1020.36,N/A,N/A,1020.36,26065.62,,Hospital 54328,1 Stage Dstl Hypospadias Rpr W/Extensive Dsj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58497.60,N/A,35098.56,N/A,8189.67,N/A,3078.97,N/A,33677.82,N/A,19889.19,N/A,7023.12,N/A,8189.67,N/A,2894.35,N/A,2894.35,N/A,4372.01,N/A,7023.12,N/A,7023.12,N/A,7023.12,N/A,33677.82,N/A,2894.35,N/A,8189.67,N/A,5963.00,N/A,5963.00,N/A,8189.67,N/A,2894.35,N/A,3078.97,N/A,986.74,N/A,N/A,986.74,35098.56,,Hospital 54332,1 Stage Prox Penile/Penoscrotal Hypospadias Rpr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,54496.20,N/A,32697.72,N/A,7629.47,N/A,3078.97,N/A,31378.55,N/A,18528.70,N/A,7005.06,N/A,7629.47,N/A,2894.35,N/A,2894.35,N/A,4360.78,N/A,7005.06,N/A,7005.06,N/A,7005.06,N/A,31378.55,N/A,2894.35,N/A,7629.47,N/A,6260.50,N/A,6260.50,N/A,7629.47,N/A,2894.35,N/A,3078.97,N/A,1272.10,N/A,N/A,1272.10,32697.72,,Hospital 54401,Insj Penile Prosthesos Inflatable Self-Contained,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,107772.72,N/A,64663.63,N/A,15072.19,N/A,17261.76,N/A,60898.77,N/A,36642.72,N/A,42221.84,N/A,15072.19,N/A,17412.16,N/A,17412.16,N/A,26283.90,N/A,42221.84,N/A,42221.84,N/A,42221.84,N/A,60708.77,N/A,17412.16,N/A,15072.19,N/A,16637.00,N/A,16637.00,N/A,15072.19,N/A,17412.16,N/A,17261.76,N/A,756.77,N/A,N/A,756.77,64663.63,,Hospital 54405,Insj Multi-Component Inflatable Penile Prosth,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,104288.23,N/A,62572.94,N/A,14592.88,N/A,18213.89,N/A,59299.25,N/A,35458.00,N/A,42192.82,N/A,14592.88,N/A,17412.16,N/A,17412.16,N/A,26265.83,N/A,42192.82,N/A,42192.82,N/A,42192.82,N/A,59299.24,N/A,17412.16,N/A,14592.88,N/A,19618.50,N/A,19618.50,N/A,14592.88,N/A,17412.16,N/A,18213.89,N/A,1534.73,N/A,N/A,1534.73,62572.94,,Hospital CPT 54435,HC Revision of Penis,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5495.00,5495.00,3297.00,3297.00,N/A,769.30,N/A,394.51,N/A,3164.02,N/A,1868.30,N/A,1177.53,N/A,769.30,N/A,394.51,N/A,394.51,N/A,733.01,N/A,1177.53,N/A,1177.53,N/A,1177.53,N/A,3164.02,N/A,394.51,N/A,769.30,N/A,5495.00,N/A,5495.00,N/A,769.30,N/A,394.51,N/A,394.51,N/A,433.96,3297.00,3297.00,394.51,5495.00,,Hospital 54440,Plastic Operation Penis Injury,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23783.00,N/A,14269.80,N/A,3329.62,N/A,1776.47,N/A,13686.08,N/A,8070.92,N/A,7044.01,N/A,3329.62,N/A,2894.35,N/A,2894.35,N/A,4385.03,N/A,7044.01,N/A,7044.01,N/A,7044.01,N/A,13686.09,N/A,2894.35,N/A,3329.62,N/A,4562.00,N/A,4562.00,N/A,3329.62,N/A,2894.35,N/A,1776.47,N/A,1954.12,N/A,N/A,1776.47,14269.80,,Hospital CPT 54450,HC Preputial Stretching,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,704.00,704.00,422.40,422.40,N/A,98.56,N/A,54.52,N/A,405.36,N/A,239.36,N/A,194.58,N/A,98.56,N/A,54.52,N/A,54.52,N/A,121.13,N/A,194.58,N/A,194.58,N/A,194.58,N/A,405.36,N/A,54.52,N/A,98.56,N/A,704.00,N/A,704.00,N/A,98.56,N/A,54.52,N/A,54.52,N/A,59.97,422.40,422.40,54.52,704.00,,Hospital 54505,Biopsy Testis Incisional Separate Procedure,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 54520,Orchiectomy Simple Scrotal/Inguinal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24090.57,N/A,14454.34,N/A,3372.69,N/A,3027.62,N/A,13868.30,N/A,8190.80,N/A,7059.29,N/A,3372.69,N/A,2894.35,N/A,2894.35,N/A,4394.54,N/A,7059.29,N/A,7059.29,N/A,7059.29,N/A,13836.64,N/A,2894.35,N/A,3372.69,N/A,4562.00,N/A,4562.00,N/A,3372.69,N/A,2894.35,N/A,3027.62,N/A,377.27,N/A,N/A,377.27,14454.34,,Hospital 54530,Orchiectomy Radical Tumor Inguinal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26624.95,N/A,15974.97,N/A,3727.50,N/A,515.29,N/A,15323.81,N/A,9052.49,N/A,7785.64,N/A,3727.50,N/A,3198.50,N/A,3198.50,N/A,4846.71,N/A,7785.64,N/A,7785.64,N/A,7785.64,N/A,15323.83,N/A,3198.50,N/A,3727.50,N/A,4562.00,N/A,4562.00,N/A,3727.50,N/A,3198.50,N/A,515.29,N/A,566.82,N/A,N/A,515.29,15974.97,,Hospital 54650,Orchiopexy Abdl Approach Intra-Abdominal Testis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46966.20,N/A,28179.72,N/A,6575.27,N/A,3402.52,N/A,27042.39,N/A,15968.51,N/A,7739.94,N/A,6575.27,N/A,3198.50,N/A,3198.50,N/A,4818.26,N/A,7739.94,N/A,7739.94,N/A,7739.94,N/A,27042.38,N/A,3198.50,N/A,6575.27,N/A,5277.50,N/A,5277.50,N/A,6575.27,N/A,3198.50,N/A,3402.52,N/A,859.88,N/A,N/A,859.88,28179.72,,Hospital 54690,Laparoscopy Surgical Orchiectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33004.57,N/A,19802.74,N/A,4620.64,N/A,5007.00,N/A,19003.29,N/A,11221.56,N/A,11388.78,N/A,4620.64,N/A,4706.78,N/A,4706.78,N/A,7089.74,N/A,11388.78,N/A,11388.78,N/A,11388.78,N/A,19003.28,N/A,4706.78,N/A,4620.64,N/A,7897.00,N/A,7897.00,N/A,4620.64,N/A,4706.78,N/A,5007.00,N/A,724.31,N/A,N/A,724.31,19802.74,,Hospital 54830,Excision Local Lesion Epididymis,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55458.32,N/A,33274.99,N/A,7615.96,N/A,1380.81,N/A,31919.85,N/A,17637.23,N/A,10354.92,N/A,7615.96,N/A,4246.26,N/A,4246.26,N/A,6446.14,N/A,10354.92,N/A,10354.92,N/A,10354.92,N/A,31789.15,N/A,4246.26,N/A,7615.96,N/A,8510.75,N/A,8510.75,N/A,7615.96,N/A,4246.26,N/A,1380.81,N/A,1512.80,N/A,N/A,1380.81,33274.99,,Hospital 54860,Epididymectomy Unilateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23655.70,N/A,14193.42,N/A,3311.80,N/A,2993.58,N/A,13612.54,N/A,8042.94,N/A,7041.24,N/A,3311.80,N/A,2894.35,N/A,2894.35,N/A,4383.31,N/A,7041.24,N/A,7041.24,N/A,7041.24,N/A,13612.54,N/A,2894.35,N/A,3311.80,N/A,3397.00,N/A,3397.00,N/A,3311.80,N/A,2894.35,N/A,2993.58,N/A,469.63,N/A,N/A,469.63,14193.42,,Hospital 55040,Excision Hydrocele Unilateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21690.75,N/A,13014.45,N/A,3009.20,N/A,330.71,N/A,12483.89,N/A,7344.00,N/A,7765.73,N/A,3009.20,N/A,3198.50,N/A,3198.50,N/A,4834.30,N/A,7765.73,N/A,7765.73,N/A,7765.73,N/A,12483.89,N/A,3198.50,N/A,3009.20,N/A,4562.00,N/A,4562.00,N/A,3009.20,N/A,3198.50,N/A,330.71,N/A,363.78,N/A,N/A,330.71,13014.45,,Hospital 55041,Excision Hydrocele Bilateral,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41084.90,N/A,24650.94,N/A,5691.32,N/A,3406.45,N/A,23651.78,N/A,13968.87,N/A,7781.45,N/A,5691.32,N/A,3198.50,N/A,3198.50,N/A,4844.11,N/A,7781.45,N/A,7781.45,N/A,7781.45,N/A,23651.78,N/A,3198.50,N/A,5691.32,N/A,5277.50,N/A,5277.50,N/A,5691.32,N/A,3202.43,N/A,3406.45,N/A,689.40,N/A,N/A,689.40,24650.94,,Hospital CPT 55100,HC I&D Abscess Scrotal Wall,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,4763.00,4763.00,2857.80,2857.80,N/A,666.82,N/A,158.56,N/A,2742.54,N/A,1619.42,N/A,643.02,N/A,666.82,N/A,158.56,N/A,158.56,N/A,400.28,N/A,643.02,N/A,643.02,N/A,643.02,N/A,2742.54,N/A,158.56,N/A,666.82,N/A,4763.00,N/A,4763.00,N/A,666.82,N/A,158.56,N/A,158.56,N/A,174.42,2857.80,2857.80,158.56,4763.00,,Hospital 55175,Scrotoplasty Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28119.60,N/A,16871.76,N/A,3936.74,N/A,3345.78,N/A,16189.17,N/A,9560.66,N/A,7766.72,N/A,3936.74,N/A,3198.50,N/A,3198.50,N/A,4834.92,N/A,7766.72,N/A,7766.72,N/A,7766.72,N/A,16189.18,N/A,3198.50,N/A,3936.74,N/A,8244.00,N/A,8244.00,N/A,3936.74,N/A,3198.50,N/A,3345.78,N/A,737.95,N/A,N/A,737.95,16871.76,,Hospital 55180,Scrotoplasty Complicated,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,56355.68,N/A,33813.41,N/A,7830.30,N/A,4441.77,N/A,32447.62,N/A,19160.92,N/A,10315.26,N/A,7830.30,N/A,4246.26,N/A,4246.26,N/A,6421.44,N/A,10315.26,N/A,10315.26,N/A,10315.26,N/A,32447.67,N/A,4246.26,N/A,7830.30,N/A,7692.25,N/A,7692.25,N/A,7830.30,N/A,4246.26,N/A,4441.77,N/A,1779.29,N/A,N/A,1779.29,33813.41,,Hospital 55530,Exc Varicocele/Ligation Spermatic Veins Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28028.40,N/A,16817.04,N/A,3923.98,N/A,3027.62,N/A,16137.60,N/A,9529.65,N/A,7020.93,N/A,3923.98,N/A,2894.35,N/A,2894.35,N/A,4370.66,N/A,7020.93,N/A,7020.93,N/A,7020.93,N/A,16137.61,N/A,2894.35,N/A,3923.98,N/A,5227.25,N/A,5227.25,N/A,3923.98,N/A,2894.35,N/A,3027.62,N/A,943.15,N/A,N/A,943.15,16817.04,,Hospital 55706,Bx Prostate Strtctc Saturation Sampling Img Gid,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17836.90,N/A,10702.14,N/A,2497.17,N/A,3078.97,N/A,10269.40,N/A,6064.55,N/A,7013.73,N/A,2497.17,N/A,2894.35,N/A,2894.35,N/A,4366.18,N/A,7013.73,N/A,7013.73,N/A,7013.73,N/A,10269.40,N/A,2894.35,N/A,2497.17,N/A,1871.00,N/A,1871.00,N/A,2497.17,N/A,2894.35,N/A,3078.97,N/A,953.22,N/A,N/A,953.22,10702.14,,Hospital 55821,Prostatectomy Suprapubic Subtotal 1/2 Stages,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,63030.83,N/A,37818.50,N/A,8790.69,N/A,945.58,N/A,36290.04,N/A,21430.48,N/A,7310.21,N/A,8790.69,N/A,940.75,N/A,940.75,N/A,4550.74,N/A,7310.21,N/A,7310.21,N/A,7310.21,N/A,36290.05,N/A,940.75,N/A,8790.69,N/A,1643.00,N/A,1643.00,N/A,8790.69,N/A,940.75,N/A,945.58,N/A,1006.45,N/A,N/A,940.75,37818.50,,Hospital 55842,Prostect Retropubic Rad W/WO Nrv Spar W/Lymph Bx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,108537.22,N/A,65122.33,N/A,15195.06,N/A,1866.05,N/A,62487.01,N/A,36902.66,N/A,12030.61,N/A,15195.06,N/A,1821.32,N/A,1821.32,N/A,7489.30,N/A,12030.61,N/A,12030.61,N/A,12030.61,N/A,62487.01,N/A,1821.32,N/A,15195.06,N/A,1643.00,N/A,1643.00,N/A,15195.06,N/A,1821.32,N/A,1866.05,N/A,1634.86,N/A,N/A,1634.86,65122.33,,Hospital 55867,Laps Surg Prst8ect Smpl Stot Robotic Assistance,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,80712.22,90858.93,48427.33,54515.36,10644.17,12689.85,12886.80,8487.54,23987.50,52304.15,27442.15,30892.02,24216.96,19938.28,10972.13,12689.85,114086.00,8206.20,114086.00,8206.20,15074.49,12411.95,24216.96,19938.28,24216.96,19938.28,24216.96,19938.28,23987.50,52304.15,12857.15,8206.20,10972.13,12689.85,28812.13,7897.00,28812.13,7897.00,N/A,12689.85,12857.15,8206.20,12886.80,8487.54,11740.18,119.16,10644.17,114086.00,119.16,54515.36,,Hospital 55874,HC Tprnl Plmt Biodegrdabl Matrl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,28189.68,N/A,16913.81,N/A,3947.59,N/A,4209.58,N/A,15932.62,N/A,9584.48,N/A,10285.68,N/A,3947.59,N/A,4246.26,N/A,4246.26,N/A,6403.03,N/A,10285.68,N/A,10285.68,N/A,10285.68,N/A,15932.62,N/A,4246.26,N/A,3947.59,N/A,7897.00,N/A,7897.00,N/A,3947.59,N/A,4246.26,N/A,4209.58,N/A,176.71,N/A,N/A,176.71,16913.81,,Hospital 56440,Marsupialization Bartholins Gland Cyst,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15782.25,N/A,9469.35,N/A,2192.93,N/A,208.70,N/A,9067.54,N/A,5365.97,N/A,6264.74,N/A,2192.93,N/A,2553.29,N/A,2553.29,N/A,3899.92,N/A,6264.74,N/A,6264.74,N/A,6264.74,N/A,9067.55,N/A,2553.29,N/A,2192.93,N/A,3397.00,N/A,3397.00,N/A,2192.93,N/A,2553.29,N/A,208.70,N/A,229.57,N/A,N/A,208.70,9469.35,,Hospital 56515,HC Destruction Lesions Vulva Extensive,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,23520.80,N/A,14112.48,N/A,3293.19,N/A,2606.39,N/A,13540.38,N/A,7997.07,N/A,6188.26,N/A,3293.19,N/A,2553.29,N/A,2553.29,N/A,3852.31,N/A,6188.26,N/A,6188.26,N/A,6188.26,N/A,13540.38,N/A,2553.29,N/A,3293.19,N/A,4332.50,N/A,4332.50,N/A,3293.19,N/A,2553.29,N/A,2606.39,N/A,773.19,N/A,N/A,773.19,14112.48,,Hospital 56606,Biopsy Vulva/Perineum Each Addl Lesion,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13371.90,N/A,8023.14,N/A,1866.31,N/A,635.26,N/A,7694.59,N/A,4546.45,N/A,1635.54,N/A,1866.31,N/A,635.26,N/A,635.26,N/A,1018.15,N/A,1635.54,N/A,1635.54,N/A,1635.54,N/A,7694.59,N/A,635.26,N/A,1866.31,N/A,1694.50,N/A,1694.50,N/A,1866.31,N/A,635.26,N/A,635.26,N/A,698.79,N/A,N/A,635.26,8023.14,,Hospital 56620,Vulvectomy Simple Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21598.80,N/A,12959.28,N/A,3023.83,N/A,2670.86,N/A,12433.11,N/A,7269.81,N/A,6276.22,N/A,3023.83,N/A,2553.29,N/A,2553.29,N/A,3907.07,N/A,6276.22,N/A,6276.22,N/A,6276.22,N/A,12433.11,N/A,2553.29,N/A,3023.83,N/A,5095.50,N/A,5095.50,N/A,3023.83,N/A,2553.29,N/A,2670.86,N/A,1190.43,N/A,N/A,1190.43,12959.28,,Hospital 56630,Vulvectomy Radical Partial,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24754.83,N/A,14852.90,N/A,3333.01,N/A,1225.23,N/A,14241.85,N/A,8416.64,N/A,11871.79,N/A,3333.01,N/A,1624.61,N/A,1624.61,N/A,7390.41,N/A,11871.79,N/A,11871.79,N/A,11871.79,N/A,14241.87,N/A,1624.61,N/A,3333.01,N/A,4562.00,N/A,4562.00,N/A,3333.01,N/A,1624.61,N/A,1225.23,N/A,1347.77,N/A,N/A,1225.23,14852.90,,Hospital 56740,Exc Bartholins Gland/Cyst,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24925.00,N/A,14955.00,N/A,3473.17,N/A,2670.86,N/A,14351.06,N/A,8474.50,N/A,6194.58,N/A,3473.17,N/A,2553.29,N/A,2553.29,N/A,3856.25,N/A,6194.58,N/A,6194.58,N/A,6194.58,N/A,14351.07,N/A,2553.29,N/A,3473.17,N/A,4112.50,N/A,4112.50,N/A,3473.17,N/A,2553.29,N/A,2670.86,N/A,474.10,N/A,N/A,474.10,14955.00,,Hospital 56821,Colposcopy Vulva W/Biopsy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10426.00,N/A,6255.60,N/A,1459.64,N/A,280.47,N/A,6001.78,N/A,3544.84,N/A,645.82,N/A,1459.64,N/A,263.65,N/A,263.65,N/A,402.04,N/A,645.82,N/A,645.82,N/A,645.82,N/A,6001.78,N/A,263.65,N/A,1459.64,N/A,527.00,N/A,527.00,N/A,1459.64,N/A,263.65,N/A,280.47,N/A,252.75,N/A,N/A,252.75,6255.60,,Hospital 57000,Colpotomy W/Exploration,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,125325.88,N/A,75195.53,N/A,17545.64,N/A,9801.35,N/A,72019.92,N/A,42610.82,N/A,19917.14,N/A,17545.64,N/A,9735.92,N/A,9735.92,N/A,12398.80,N/A,19917.14,N/A,19917.14,N/A,19917.14,N/A,72019.92,N/A,9735.92,N/A,17545.64,N/A,12694.75,N/A,12694.75,N/A,17545.64,N/A,9734.60,N/A,9801.35,N/A,2320.17,N/A,N/A,2320.17,75195.53,,Hospital 57010,Colpotomy W/Drainage Pelvic Abscess,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33538.00,N/A,20122.80,N/A,4659.02,N/A,2670.86,N/A,19308.51,N/A,11402.92,N/A,6220.79,N/A,4659.02,N/A,2553.29,N/A,2553.29,N/A,3872.57,N/A,6220.79,N/A,6220.79,N/A,6220.79,N/A,19308.52,N/A,2553.29,N/A,4659.02,N/A,3397.00,N/A,3397.00,N/A,4659.02,N/A,2553.29,N/A,2670.86,N/A,535.64,N/A,N/A,535.64,20122.80,,Hospital 57023,I&D Vaginal Hematoma Non-Obstetrical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21002.20,N/A,12601.32,N/A,2935.34,N/A,2606.39,N/A,12089.72,N/A,7140.75,N/A,6191.58,N/A,2935.34,N/A,2553.29,N/A,2553.29,N/A,3854.38,N/A,6191.58,N/A,6191.58,N/A,6191.58,N/A,12089.71,N/A,2553.29,N/A,2935.34,N/A,5095.50,N/A,5095.50,N/A,2935.34,N/A,2553.29,N/A,2606.39,N/A,627.58,N/A,N/A,627.58,12601.32,,Hospital 57061,Destruction Vaginal Lesions Simple,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18529.90,N/A,11117.94,N/A,2551.37,N/A,2670.86,N/A,10668.38,N/A,6300.17,N/A,6200.13,N/A,2551.37,N/A,2553.29,N/A,2553.29,N/A,3859.69,N/A,6200.13,N/A,6200.13,N/A,6200.13,N/A,10668.40,N/A,2553.29,N/A,2551.37,N/A,3397.00,N/A,3397.00,N/A,2551.37,N/A,2553.29,N/A,2670.86,N/A,155.68,N/A,N/A,155.68,11117.94,,Hospital 57065,Destruction Vaginal Lesions Extensive,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35565.30,N/A,21339.18,N/A,4925.27,N/A,2670.86,N/A,20477.17,N/A,12092.21,N/A,6190.12,N/A,4925.27,N/A,2553.29,N/A,2553.29,N/A,3853.47,N/A,6190.12,N/A,6190.12,N/A,6190.12,N/A,20477.19,N/A,2553.29,N/A,4925.27,N/A,3397.00,N/A,3397.00,N/A,4925.27,N/A,2553.29,N/A,2670.86,N/A,243.81,N/A,N/A,243.81,21339.18,,Hospital 57120,Colpocleisis Le Fort Type,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32591.32,N/A,19554.79,N/A,4562.79,N/A,4617.31,N/A,18632.85,N/A,11081.03,N/A,10185.10,N/A,4562.79,N/A,4185.69,N/A,4185.69,N/A,6340.41,N/A,10185.10,N/A,10185.10,N/A,10185.10,N/A,18632.87,N/A,4185.69,N/A,4562.79,N/A,9384.50,N/A,9384.50,N/A,4562.79,N/A,4185.69,N/A,1824.24,N/A,2006.66,N/A,N/A,1824.24,19554.79,,Hospital 57155,HC Insertion Uterine Tandem&/Vaginal Ovoids,N/A,0342 - NUCLEAR MEDICINE - THERAPEUTIC PROCEDURES,N/A,55312.20,N/A,33187.32,N/A,7743.72,N/A,7324.39,N/A,31812.02,N/A,18806.16,N/A,16617.39,N/A,7743.72,N/A,6925.48,N/A,6925.48,N/A,10344.63,N/A,16617.39,N/A,16617.39,N/A,16617.39,N/A,31812.02,N/A,6925.48,N/A,7743.72,N/A,28150.73,N/A,28150.73,N/A,7743.72,N/A,6925.48,N/A,7324.39,N/A,2468.56,N/A,N/A,2468.56,33187.32,,Hospital 57160,HC Insertion of Pessary,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,403.00,N/A,241.80,N/A,56.42,N/A,286.13,N/A,232.05,N/A,137.02,N/A,N/A,N/A,56.42,N/A,270.00,N/A,270.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,232.05,N/A,270.00,N/A,56.42,N/A,216.01,N/A,216.01,N/A,56.42,N/A,270.00,N/A,286.13,N/A,48.58,N/A,N/A,48.58,286.13,,Hospital CPT 57240,Anterior Colporraphy Rpr Cystocele W/Cysto,N/A,N/A,1335.00,1335.00,801.00,801.00,N/A,186.90,N/A,592.33,N/A,1335.00,N/A,453.90,N/A,1335.00,N/A,186.90,N/A,592.33,N/A,592.33,N/A,1097.83,N/A,1335.00,N/A,1335.00,N/A,1335.00,N/A,1335.00,N/A,592.33,N/A,186.90,N/A,1335.00,N/A,1335.00,N/A,186.90,N/A,592.33,N/A,592.33,N/A,651.56,801.00,801.00,186.90,1335.00,,Hospital CPT 57250,Post Colporrhaphy Rectocele W/WO Perineorrhaphy,N/A,N/A,1343.00,1343.00,805.80,805.80,N/A,188.02,N/A,595.82,N/A,1343.00,N/A,456.62,N/A,1343.00,N/A,188.02,N/A,595.82,N/A,595.82,N/A,1102.78,N/A,1343.00,N/A,1343.00,N/A,1343.00,N/A,1343.00,N/A,595.82,N/A,188.02,N/A,1343.00,N/A,1343.00,N/A,188.02,N/A,595.82,N/A,595.82,N/A,655.40,805.80,805.80,188.02,1343.00,,Hospital 57260,Cmbnd Anterpost Colporraphy W/Cysto,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48771.05,44267.73,29262.63,26560.64,6244.71,6151.07,7682.45,6542.02,14249.03,25432.90,16582.16,15051.01,14207.57,15184.59,6437.12,6151.07,145558.00,6254.06,145558.00,6254.06,8843.88,9452.70,14207.57,15184.59,14207.57,15184.59,14207.57,15184.59,14249.03,25180.71,7652.80,6254.06,6437.12,6151.07,16903.46,9384.50,6843.00,9384.50,N/A,6151.07,7652.80,6254.06,7682.45,6542.02,6887.72,2579.25,6244.71,145558.00,2579.25,26560.64,,Hospital 57267,Insj Mesh/Prosth Pelvic Floor Defect Each Site,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42022.40,N/A,25213.44,N/A,5883.13,N/A,1507.07,N/A,24004.56,N/A,14287.62,N/A,15142.80,N/A,5883.13,N/A,6254.06,N/A,6254.06,N/A,9426.67,N/A,15142.80,N/A,15142.80,N/A,15142.80,N/A,24004.57,N/A,6254.06,N/A,5883.13,N/A,8375.75,N/A,8375.75,N/A,5883.13,N/A,6254.06,N/A,1507.07,N/A,1657.77,N/A,N/A,1507.07,25213.44,,Hospital 57270,Repair Enterocele Abdominal Approach Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,58294.12,44080.18,34976.47,26448.11,9613.52,6115.52,11667.58,8164.21,21664.85,25375.10,19820.00,14985.23,21872.09,30085.96,9909.73,6115.52,11637.93,8206.20,11637.93,8206.20,13614.87,18729.10,21872.09,30085.96,21872.09,30085.96,21872.09,30085.96,21664.85,23880.31,11637.93,8206.20,9909.73,6115.52,26022.32,9595.50,26022.32,9595.50,604.47,6115.52,11637.93,8206.20,11667.58,8164.21,10603.41,2377.73,604.47,34976.47,2377.73,30085.96,,Hospital 57280,Colpopexy Abdominal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,53051.08,27346.30,31830.65,16407.78,6244.71,3828.48,8135.31,4378.42,17234.57,15743.85,18037.36,9297.74,14207.57,20286.47,6437.12,3828.48,65192.00,4185.69,65192.00,4185.69,8843.88,12628.72,14207.57,20286.47,14207.57,20286.47,14207.57,20286.47,17234.57,15743.87,7652.80,4185.69,6437.12,3828.48,16903.46,6260.50,16903.46,6260.50,N/A,3828.48,7652.80,4185.69,7682.45,4378.42,6887.72,1685.08,6244.71,65192.00,1685.08,20286.47,,Hospital 57285,Paravaginal Defect Repair Vaginal Approach,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25847.25,N/A,15508.35,N/A,3618.62,N/A,1342.17,N/A,14875.54,N/A,8788.07,N/A,15152.17,N/A,3618.62,N/A,6254.06,N/A,6254.06,N/A,9432.52,N/A,15152.17,N/A,15152.17,N/A,15152.17,N/A,14875.53,N/A,6254.06,N/A,3618.62,N/A,8944.50,N/A,8944.50,N/A,3618.62,N/A,6254.06,N/A,1342.17,N/A,1476.38,N/A,N/A,1342.17,15508.35,,Hospital 57300,Clsr Rectovaginal Fistula Vaginal/Transanal Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23895.80,N/A,14337.48,N/A,3345.42,N/A,589.11,N/A,13747.47,N/A,8124.58,N/A,6220.75,N/A,3345.42,N/A,2553.29,N/A,2553.29,N/A,3872.53,N/A,6220.75,N/A,6220.75,N/A,6220.75,N/A,13747.47,N/A,2553.29,N/A,3345.42,N/A,3397.00,N/A,3397.00,N/A,3345.42,N/A,2553.29,N/A,589.11,N/A,648.02,N/A,N/A,589.11,14337.48,,Hospital 57410,Pelvic Examination W/Anesthesia Other Than Local,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16395.30,N/A,9837.18,N/A,2292.23,N/A,2670.86,N/A,9193.26,N/A,5574.40,N/A,6183.91,N/A,2292.23,N/A,2553.29,N/A,2553.29,N/A,3849.60,N/A,6183.91,N/A,6183.91,N/A,6183.91,N/A,9439.70,N/A,2553.29,N/A,2292.23,N/A,3397.00,N/A,3397.00,N/A,2292.23,N/A,2553.29,N/A,2670.86,N/A,308.81,N/A,N/A,308.81,9837.18,,Hospital 57420,HC Colposcopy Entire Vagina,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,12440.92,N/A,7464.55,N/A,1741.73,N/A,600.73,N/A,7152.78,N/A,4109.21,N/A,1404.15,N/A,1741.73,N/A,564.71,N/A,564.71,N/A,874.11,N/A,1404.15,N/A,1404.15,N/A,1404.15,N/A,7152.78,N/A,564.71,N/A,1741.73,N/A,1694.50,N/A,1694.50,N/A,1741.73,N/A,564.71,N/A,600.73,N/A,185.58,N/A,N/A,185.58,7464.55,,Hospital 57426,Revision Prosthetic Vaginal Graft Laparoscopic,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,62974.52,N/A,37784.71,N/A,8754.74,N/A,6542.02,N/A,36258.10,N/A,21411.33,N/A,15209.87,N/A,8754.74,N/A,6254.06,N/A,6254.06,N/A,9468.44,N/A,15209.87,N/A,15209.87,N/A,15209.87,N/A,36258.09,N/A,6254.06,N/A,8754.74,N/A,4562.00,N/A,4562.00,N/A,8754.74,N/A,6254.06,N/A,6542.02,N/A,1027.80,N/A,N/A,1027.80,37784.71,,Hospital 57456,HC Colposcopy of Cervix W/Biopsy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1331.00,N/A,798.60,N/A,178.87,N/A,47.98,N/A,766.39,N/A,452.54,N/A,109.52,N/A,178.87,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,766.40,N/A,263.65,N/A,178.87,N/A,181.25,N/A,181.25,N/A,178.87,N/A,263.65,N/A,279.40,N/A,261.21,N/A,N/A,45.28,798.60,,Hospital 57461,Colposcopy Cervix Vag Eltrd Conization Cervix,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14535.10,N/A,8721.06,N/A,2034.92,N/A,2670.86,N/A,8367.75,N/A,4941.93,N/A,6190.68,N/A,2034.92,N/A,2553.29,N/A,2553.29,N/A,3853.81,N/A,6190.68,N/A,6190.68,N/A,6190.68,N/A,8367.75,N/A,2553.29,N/A,2034.92,N/A,3397.00,N/A,3397.00,N/A,2034.92,N/A,2553.29,N/A,2670.86,N/A,691.88,N/A,N/A,691.88,8721.06,,Hospital 57510,Cautery Cervix Electro/Thermal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 57513,Cautery Cervix Laser Ablation,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12544.68,N/A,7526.81,N/A,1740.65,N/A,2816.58,N/A,7214.25,N/A,4265.19,N/A,6225.04,N/A,1740.65,N/A,2553.29,N/A,2553.29,N/A,3875.22,N/A,6225.04,N/A,6225.04,N/A,6225.04,N/A,7214.27,N/A,2553.29,N/A,1740.65,N/A,5095.50,N/A,5095.50,N/A,1740.65,N/A,2553.29,N/A,257.74,N/A,283.51,N/A,N/A,257.74,7526.81,,Hospital CPT 57522,Conization Cervix W/WO D&C Rpr Eltrd Exc,N/A,N/A,502.00,502.00,301.20,301.20,N/A,70.28,N/A,244.32,N/A,502.00,N/A,170.68,N/A,502.00,N/A,70.28,N/A,244.32,N/A,244.32,N/A,502.00,N/A,502.00,N/A,502.00,N/A,502.00,N/A,502.00,N/A,244.32,N/A,70.28,N/A,502.00,N/A,502.00,N/A,70.28,N/A,244.32,N/A,244.32,N/A,268.75,301.20,301.20,70.28,502.00,,Hospital 57558,Dilation & Curettage Cervical Stump,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38673.10,N/A,23203.86,N/A,5414.24,N/A,4272.74,N/A,22169.14,N/A,13146.50,N/A,10135.98,N/A,5414.24,N/A,4185.69,N/A,4185.69,N/A,6309.84,N/A,10135.98,N/A,10135.98,N/A,10135.98,N/A,22169.14,N/A,4185.69,N/A,5414.24,N/A,6260.50,N/A,6260.50,N/A,5414.24,N/A,4185.69,N/A,4272.74,N/A,429.53,N/A,N/A,429.53,23203.86,,Hospital CPT 57720,HC Revision of Cervix,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,6840.00,6840.00,4104.00,4104.00,N/A,957.60,N/A,321.42,N/A,3938.47,N/A,2325.60,N/A,954.78,N/A,957.60,N/A,321.42,N/A,321.42,N/A,594.35,N/A,954.78,N/A,954.78,N/A,954.78,N/A,3938.47,N/A,321.42,N/A,957.60,N/A,6840.00,N/A,6840.00,N/A,957.60,N/A,321.42,N/A,321.42,N/A,353.56,4104.00,4104.00,321.42,6840.00,,Hospital 58100,HC Endometrial Biopsy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1115.00,N/A,669.00,N/A,153.23,N/A,45.77,N/A,642.02,N/A,248.88,N/A,110.54,N/A,153.23,N/A,45.28,N/A,45.28,N/A,69.20,N/A,110.54,N/A,110.54,N/A,110.54,N/A,642.02,N/A,270.00,N/A,153.23,N/A,59.36,N/A,59.36,N/A,153.23,N/A,270.00,N/A,272.92,N/A,110.44,N/A,N/A,45.28,669.00,,Hospital 58110,HC Endomet Biopsy Done W/Colposcopy,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,12312.00,N/A,7387.20,N/A,1723.67,N/A,2540.23,N/A,7087.17,N/A,4186.07,N/A,6210.83,N/A,1723.67,N/A,2553.29,N/A,2553.29,N/A,3866.35,N/A,6210.83,N/A,6210.83,N/A,6210.83,N/A,7087.16,N/A,2553.29,N/A,1723.67,N/A,3660.50,N/A,3660.50,N/A,1723.67,N/A,2553.29,N/A,2540.23,N/A,841.54,N/A,N/A,841.54,7387.20,,Hospital 58120,Dilation & Curettage Dx&/Ther Nonobstetric,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15158.70,N/A,9095.22,N/A,2122.22,N/A,2553.29,N/A,8719.07,N/A,5153.96,N/A,6281.76,N/A,2122.22,N/A,2553.29,N/A,2553.29,N/A,3910.44,N/A,6281.76,N/A,6281.76,N/A,6281.76,N/A,8719.08,N/A,2553.29,N/A,2122.22,N/A,3397.00,N/A,3397.00,N/A,2122.22,N/A,2553.29,N/A,2553.29,N/A,2808.62,N/A,N/A,2122.22,9095.22,,Hospital 58150,Total Abdominal Hysterect W/WO Rmvl Tube Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,66214.67,49804.92,39728.80,29882.95,6244.71,6915.15,7682.45,1392.09,15146.86,28662.48,22512.99,16933.68,14207.57,816.00,6437.12,6915.15,170848.00,1271.00,170848.00,1271.00,8843.88,816.00,14207.57,816.00,14207.57,816.00,14207.57,816.00,15146.86,28662.48,7652.80,1271.00,6437.12,6915.15,16903.46,4957.25,4562.00,4957.25,6437.12,6915.15,7652.80,1271.00,7682.45,1392.09,6887.72,1531.31,4562.00,170848.00,816.00,29882.95,,Hospital 58263,Vag Hyst 250 Gm/< W/Rmvl Tube Ovary W/Rpr Ntrcl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,42298.73,44354.92,25379.24,26612.95,9613.52,6200.86,11637.93,6542.02,24794.64,25476.54,14381.57,15080.67,21872.09,15194.48,9909.73,6200.86,11637.93,6254.06,11637.93,6254.06,13614.87,9458.86,21872.09,15194.48,21872.09,15194.48,21872.09,15194.48,24794.64,25476.56,11637.93,6254.06,9909.73,6200.86,26022.32,9384.50,26022.32,9384.50,N/A,6200.86,11637.93,6254.06,11637.93,6542.02,10603.41,2719.57,9613.52,26022.32,2719.57,26612.95,,Hospital 58267,Vag Hyst 250 Gm/< W/Colpo-Urtcstopexy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44111.23,N/A,26466.74,N/A,6180.52,N/A,2250.29,N/A,25311.55,N/A,14997.84,N/A,20788.05,N/A,6180.52,N/A,2239.26,N/A,2239.26,N/A,12940.98,N/A,20788.05,N/A,20788.05,N/A,20788.05,N/A,25311.53,N/A,2239.26,N/A,6180.52,N/A,6843.00,N/A,6843.00,N/A,6180.52,N/A,2239.26,N/A,2250.29,N/A,2429.66,N/A,N/A,2239.26,26466.74,,Hospital 58280,Vag Hyster W/Tot/Prtl Vaginect W/Rpr Enterocele,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,44111.23,N/A,26466.74,N/A,6180.52,N/A,2250.29,N/A,25311.55,N/A,14997.84,N/A,20788.05,N/A,6180.52,N/A,2239.26,N/A,2239.26,N/A,12940.98,N/A,20788.05,N/A,20788.05,N/A,20788.05,N/A,25311.53,N/A,2239.26,N/A,6180.52,N/A,6843.00,N/A,6843.00,N/A,6180.52,N/A,2239.26,N/A,2250.29,N/A,2429.66,N/A,N/A,2239.26,26466.74,,Hospital CPT 58301,Removal Intrauterine Device Iud,N/A,0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC,183.00,183.00,109.80,109.80,N/A,25.62,N/A,280.47,N/A,105.37,N/A,62.22,N/A,183.00,N/A,25.62,N/A,263.65,N/A,263.65,N/A,183.00,N/A,183.00,N/A,183.00,N/A,183.00,N/A,105.37,N/A,263.65,N/A,25.62,N/A,183.00,N/A,183.00,N/A,25.62,N/A,263.65,N/A,280.47,N/A,70.85,109.80,109.80,25.62,280.47,,Hospital CPT 58301,HC Removal Iud,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,922.00,922.00,553.20,553.20,N/A,129.08,N/A,280.47,N/A,530.89,N/A,313.48,N/A,637.74,N/A,129.08,N/A,263.65,N/A,263.65,N/A,397.01,N/A,637.74,N/A,637.74,N/A,637.74,N/A,530.89,N/A,263.65,N/A,129.08,N/A,922.00,N/A,922.00,N/A,129.08,N/A,263.65,N/A,280.47,N/A,70.85,553.20,553.20,70.85,922.00,,Hospital CPT 58340,HC Cath/Intro Sal Cont Hyst,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,355.00,355.00,213.00,213.00,N/A,49.70,N/A,355.00,N/A,204.41,N/A,120.70,N/A,355.00,N/A,49.70,N/A,355.00,N/A,355.00,N/A,355.00,N/A,355.00,N/A,355.00,N/A,355.00,N/A,204.41,N/A,355.00,N/A,49.70,N/A,527.00,N/A,527.00,N/A,49.70,N/A,355.00,N/A,355.00,N/A,59.11,213.00,213.00,49.70,527.00,,Hospital 58356,Endometrial Cryoablation W/US & Endometrial Cr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43862.10,N/A,26317.26,N/A,6136.84,N/A,4452.67,N/A,25253.95,N/A,14913.11,N/A,10142.59,N/A,6136.84,N/A,4185.69,N/A,4185.69,N/A,6313.95,N/A,10142.59,N/A,10142.59,N/A,10142.59,N/A,25253.95,N/A,4185.69,N/A,6136.84,N/A,5963.00,N/A,5963.00,N/A,6136.84,N/A,4185.69,N/A,4452.67,N/A,422.50,N/A,N/A,422.50,26317.26,,Hospital 58544,Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58539.52,N/A,35123.71,N/A,8143.52,N/A,1092.00,N/A,33672.25,N/A,19903.44,N/A,19896.19,N/A,8143.52,N/A,8206.20,N/A,8206.20,N/A,12385.75,N/A,19896.19,N/A,19896.19,N/A,19896.19,N/A,33672.25,N/A,8206.20,N/A,8143.52,N/A,7897.00,N/A,7897.00,N/A,8143.52,N/A,8206.20,N/A,1092.00,N/A,1195.08,N/A,N/A,1092.00,35123.71,,Hospital 58553,Laps W/Vaginal Hysterectomy > 250 Grams,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,98378.72,N/A,59027.23,N/A,13765.18,N/A,8892.10,N/A,56640.18,N/A,33448.77,N/A,19929.83,N/A,13765.18,N/A,8206.20,N/A,8206.20,N/A,12406.71,N/A,19929.83,N/A,19929.83,N/A,19929.83,N/A,56640.20,N/A,8206.20,N/A,13765.18,N/A,7897.00,N/A,7897.00,N/A,13765.18,N/A,8206.20,N/A,8892.10,N/A,1537.14,N/A,N/A,1537.14,59027.23,,Hospital 58554,Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,94415.02,N/A,56649.01,N/A,13161.38,N/A,8376.85,N/A,54259.43,N/A,32101.11,N/A,19909.37,N/A,13161.38,N/A,8206.20,N/A,8206.20,N/A,12393.97,N/A,19909.37,N/A,19909.37,N/A,19909.37,N/A,54115.47,N/A,8206.20,N/A,13161.38,N/A,10878.50,N/A,10878.50,N/A,13161.38,N/A,8206.20,N/A,8376.85,N/A,2611.30,N/A,N/A,2611.30,56649.01,,Hospital CPT 58558,Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,N/A,N/A,2476.00,2476.00,1485.60,1485.60,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,N/A,2476.00,1485.60,1485.60,1485.60,2476.00,,Hospital CPT 58561,Hysteroscopy Removal Leiomyomata,N/A,N/A,898.00,898.00,538.80,538.80,N/A,125.72,N/A,345.63,N/A,898.00,N/A,305.32,N/A,898.00,N/A,125.72,N/A,345.63,N/A,345.63,N/A,641.22,N/A,898.00,N/A,898.00,N/A,898.00,N/A,898.00,N/A,345.63,N/A,125.72,N/A,898.00,N/A,898.00,N/A,125.72,N/A,345.63,N/A,345.63,N/A,380.19,538.80,538.80,125.72,898.00,,Hospital 58573,Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,52011.22,N/A,31206.73,N/A,7208.06,N/A,8666.06,N/A,29946.10,N/A,17683.80,N/A,20180.46,N/A,7208.06,N/A,8288.21,N/A,8288.21,N/A,12674.05,N/A,20180.46,N/A,20180.46,N/A,20180.46,N/A,29946.13,N/A,8303.71,N/A,7208.06,N/A,7897.00,N/A,7897.00,N/A,7208.06,N/A,8288.21,N/A,8666.06,N/A,1694.92,N/A,N/A,1694.92,31206.73,,Hospital 58575,Laps Tot Hysterectomy Resj Malignancy W/Omntc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67410.32,N/A,40446.19,N/A,9355.06,N/A,2171.48,N/A,38811.91,N/A,22919.50,N/A,6311.77,N/A,9355.06,N/A,2158.00,N/A,2158.00,N/A,3929.11,N/A,6311.77,N/A,6311.77,N/A,6311.77,N/A,38716.91,N/A,2158.00,N/A,9355.06,N/A,4562.00,N/A,4562.00,N/A,9355.06,N/A,2158.00,N/A,2171.48,N/A,3760.23,N/A,N/A,2158.00,40446.19,,Hospital 58615,Occlusion Flp Tube Dev Vag/Suprapubic Appr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43008.82,N/A,25805.29,N/A,6015.42,N/A,4329.19,N/A,24761.03,N/A,14574.85,N/A,10139.77,N/A,6015.42,N/A,4185.69,N/A,4185.69,N/A,6312.20,N/A,10139.77,N/A,10139.77,N/A,10139.77,N/A,24761.04,N/A,4185.69,N/A,6015.42,N/A,6260.50,N/A,6260.50,N/A,6015.42,N/A,4185.69,N/A,4329.19,N/A,540.11,N/A,N/A,540.11,25805.29,,Hospital CPT 58660,Laparoscopy W/Lysis of Adhesions,N/A,N/A,1342.00,1342.00,805.20,805.20,N/A,187.88,N/A,659.91,N/A,1342.00,N/A,456.28,N/A,1342.00,N/A,187.88,N/A,659.91,N/A,659.91,N/A,1222.54,N/A,1342.00,N/A,1342.00,N/A,1342.00,N/A,1342.00,N/A,659.91,N/A,187.88,N/A,1342.00,N/A,1342.00,N/A,187.88,N/A,659.91,N/A,659.91,N/A,725.90,805.20,805.20,187.88,1342.00,,Hospital CPT 58661,Laparoscopy W/Rmvl Adnexal Structures,N/A,N/A,1297.00,1297.00,778.20,778.20,N/A,181.58,N/A,631.56,N/A,1297.00,N/A,440.98,N/A,1297.00,N/A,181.58,N/A,631.56,N/A,631.56,N/A,1171.50,N/A,1297.00,N/A,1297.00,N/A,1297.00,N/A,1297.00,N/A,631.56,N/A,181.58,N/A,1297.00,N/A,1297.00,N/A,181.58,N/A,631.56,N/A,631.56,N/A,694.72,778.20,778.20,181.58,1297.00,,Hospital CPT 58670,Laparoscopy Fulguration Oviducts,N/A,N/A,721.00,721.00,432.60,432.60,N/A,100.94,N/A,358.90,N/A,721.00,N/A,245.14,N/A,721.00,N/A,100.94,N/A,358.90,N/A,358.90,N/A,664.98,N/A,721.00,N/A,721.00,N/A,721.00,N/A,721.00,N/A,358.90,N/A,100.94,N/A,721.00,N/A,721.00,N/A,100.94,N/A,358.90,N/A,358.90,N/A,394.79,432.60,432.60,100.94,721.00,,Hospital 58673,Laparoscopy Salpingostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20116.18,N/A,12069.71,N/A,2809.54,N/A,5100.19,N/A,11578.26,N/A,6833.88,N/A,11420.23,N/A,2809.54,N/A,4706.78,N/A,4706.78,N/A,7109.30,N/A,11420.23,N/A,11420.23,N/A,11420.23,N/A,11578.27,N/A,4706.78,N/A,2809.54,N/A,12694.75,N/A,12694.75,N/A,2809.54,N/A,4706.78,N/A,5100.19,N/A,2056.54,N/A,N/A,2056.54,12694.75,,Hospital 58674,Laps Abltj Uterine Fibroids W/Intraop US Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30189.88,N/A,18113.93,N/A,4188.91,N/A,9052.40,N/A,17368.42,N/A,10264.56,N/A,19904.53,N/A,4188.91,N/A,8206.20,N/A,8206.20,N/A,12390.95,N/A,19904.53,N/A,19904.53,N/A,19904.53,N/A,17368.43,N/A,8206.20,N/A,4188.91,N/A,7897.00,N/A,7897.00,N/A,4188.91,N/A,8206.20,N/A,822.10,N/A,898.18,N/A,N/A,822.10,19904.53,,Hospital 58700,Salpingectomy Complete/Partial Uni/Bi Spx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23820.20,N/A,14292.12,N/A,3323.29,N/A,4297.49,N/A,13712.86,N/A,8098.87,N/A,20294.76,N/A,3323.29,N/A,4185.69,N/A,4185.69,N/A,12633.89,N/A,20294.76,N/A,20294.76,N/A,20294.76,N/A,13712.86,N/A,4185.69,N/A,3323.29,N/A,6974.75,N/A,6974.75,N/A,3323.29,N/A,4185.69,N/A,4297.49,N/A,1255.34,N/A,N/A,1255.34,20294.76,,Hospital 58740,Lysis of Adhesions Salpinx/Ovary,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72309.08,N/A,43385.45,N/A,10064.76,N/A,2469.95,N/A,41625.70,N/A,24585.08,N/A,22864.26,N/A,10064.76,N/A,2453.34,N/A,2453.34,N/A,14232.76,N/A,22864.26,N/A,22864.26,N/A,22864.26,N/A,38232.51,N/A,2453.34,N/A,10064.76,N/A,6260.50,N/A,6260.50,N/A,10064.76,N/A,2453.34,N/A,2469.95,N/A,2135.00,N/A,N/A,2135.00,43385.45,,Hospital 58950,Rescj Ovarian/Tubal/Peritoneal Malignancy W/Bso,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,57784.88,N/A,34670.93,N/A,8028.71,N/A,2210.36,N/A,33267.95,N/A,19646.86,N/A,13631.54,N/A,8028.71,N/A,2193.27,N/A,2193.27,N/A,8483.14,N/A,13631.54,N/A,13631.54,N/A,13631.54,N/A,33267.96,N/A,2193.27,N/A,8028.71,N/A,4562.00,N/A,4562.00,N/A,8028.71,N/A,2193.27,N/A,2210.36,N/A,2503.41,N/A,N/A,2193.27,34670.93,,Hospital CPT 59000,HC Amniocentesis Any Method,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,940.00,940.00,564.00,564.00,N/A,131.60,N/A,666.03,N/A,541.25,N/A,319.60,N/A,940.00,N/A,131.60,N/A,635.26,N/A,635.26,N/A,940.00,N/A,940.00,N/A,940.00,N/A,940.00,N/A,541.25,N/A,635.26,N/A,131.60,N/A,1431.00,N/A,1431.00,N/A,131.60,N/A,635.26,N/A,76.33,N/A,83.96,564.00,564.00,76.33,1431.00,,Hospital CPT 59020,HC Monitoring Cst Fetal,N/A,0721 - LABOR ROOM/DELIVERY - LABOR,490.00,490.00,294.00,294.00,N/A,68.60,N/A,168.27,N/A,282.14,N/A,166.60,N/A,389.10,N/A,68.60,N/A,160.86,N/A,160.86,N/A,242.22,N/A,389.10,N/A,389.10,N/A,389.10,N/A,282.14,N/A,160.86,N/A,68.60,N/A,262.64,N/A,262.64,N/A,68.60,N/A,160.86,N/A,168.27,N/A,32.74,294.00,294.00,32.74,389.10,,Hospital CPT 59025,HC Non Stress Test,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,1290.00,1290.00,774.00,774.00,N/A,180.60,N/A,160.86,N/A,742.78,N/A,438.60,N/A,389.10,N/A,180.60,N/A,160.86,N/A,160.86,N/A,242.22,N/A,389.10,N/A,389.10,N/A,389.10,N/A,742.78,N/A,160.86,N/A,180.60,N/A,691.44,N/A,691.44,N/A,180.60,N/A,160.86,N/A,160.86,N/A,176.94,774.00,774.00,160.86,774.00,,Hospital CPT 59050,HC Internal Fetal Monitor,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,214.00,214.00,128.40,128.40,N/A,29.96,N/A,48.18,N/A,123.22,N/A,72.76,N/A,144.54,N/A,29.96,N/A,48.18,N/A,48.18,N/A,89.98,N/A,144.54,N/A,144.54,N/A,144.54,N/A,123.22,N/A,48.18,N/A,29.96,N/A,114.70,N/A,114.70,N/A,29.96,N/A,48.18,N/A,48.18,N/A,53.00,128.40,128.40,29.96,144.54,,Hospital 59121,Tx Ectopic Pregnancy W/O Salping&/Oophorectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25803.42,N/A,15482.05,N/A,3580.27,N/A,893.62,N/A,14855.49,N/A,8773.16,N/A,10435.71,N/A,3580.27,N/A,889.54,N/A,889.54,N/A,6496.42,N/A,10435.71,N/A,10435.71,N/A,10435.71,N/A,14855.49,N/A,889.54,N/A,3580.27,N/A,4825.50,N/A,4825.50,N/A,3580.27,N/A,889.54,N/A,893.62,N/A,991.14,N/A,N/A,889.54,15482.05,,Hospital 59151,Laps Tx Ectopic Preg W/Salping&/Oophorectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,41099.42,29046.90,24659.65,17428.14,16696.30,4066.56,20046.15,804.67,37626.46,16715.09,13973.79,9875.94,37986.38,11425.72,17210.74,4066.56,20016.50,4706.78,20016.50,4706.78,23645.64,7112.74,37986.38,11425.72,37986.38,11425.72,37986.38,11425.72,37626.46,16715.09,20016.50,4706.78,17210.74,4066.56,41099.41,7897.00,41099.41,7897.00,4061.00,4066.56,20016.50,4706.78,20046.15,804.67,18415.49,885.15,4061.00,41099.41,804.67,17428.14,,Hospital 59200,HC Cytotec/Cervidil Insertion,N/A,0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION,18097.13,N/A,10858.28,N/A,6117.74,N/A,7502.61,N/A,14044.71,N/A,6153.03,N/A,13918.71,N/A,6306.24,N/A,1686.00,N/A,1686.00,N/A,8664.07,N/A,13918.71,N/A,13918.71,N/A,13918.71,N/A,14044.71,N/A,7502.61,N/A,6306.24,N/A,16559.79,N/A,16559.79,N/A,6306.24,N/A,7502.61,N/A,7502.61,N/A,6747.68,N/A,1686.00,16559.79,N/A,N/A,,Hospital 59300,Episiotomy/Vag Rpr Oth/Thn Attending,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,13944.73,N/A,8366.84,N/A,1936.66,N/A,2816.58,N/A,8019.23,N/A,4741.21,N/A,6199.92,N/A,1936.66,N/A,2553.29,N/A,2553.29,N/A,3859.57,N/A,6199.92,N/A,6199.92,N/A,6199.92,N/A,8019.24,N/A,2553.29,N/A,1936.66,N/A,3397.00,N/A,3397.00,N/A,1936.66,N/A,2553.29,N/A,148.76,N/A,163.64,N/A,N/A,148.76,8366.84,,Hospital 59510,OB Antepartum Care Cesarean Dlvr & Postpartum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46301.60,N/A,27780.96,N/A,6305.45,N/A,2903.02,N/A,26435.89,N/A,15742.54,N/A,10759.85,N/A,6305.45,N/A,2884.35,N/A,2884.35,N/A,7488.73,N/A,10759.85,N/A,10759.85,N/A,10759.85,N/A,26435.90,N/A,2884.35,N/A,6305.45,N/A,527.00,N/A,527.00,N/A,6305.45,N/A,2884.35,N/A,2903.02,N/A,3175.94,N/A,N/A,527.00,27780.96,,Hospital CPT 59820,Tx Missed Abortion First Trimester Surgical,N/A,N/A,725.00,725.00,435.00,435.00,N/A,101.50,N/A,365.77,N/A,725.00,N/A,246.50,N/A,725.00,N/A,101.50,N/A,365.77,N/A,365.77,N/A,725.00,N/A,725.00,N/A,725.00,N/A,725.00,N/A,725.00,N/A,365.77,N/A,101.50,N/A,725.00,N/A,725.00,N/A,101.50,N/A,365.77,N/A,365.77,N/A,402.35,435.00,435.00,101.50,725.00,,Hospital 59871,Removal Cerclage Suture Under Anesthesia,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,15277.20,N/A,9166.32,N/A,2110.91,N/A,2716.15,N/A,8794.21,N/A,5194.25,N/A,6219.20,N/A,2110.91,N/A,2553.29,N/A,2553.29,N/A,3871.56,N/A,6219.20,N/A,6219.20,N/A,6219.20,N/A,7978.31,N/A,2553.29,N/A,2110.91,N/A,4562.00,N/A,4562.00,N/A,2110.91,N/A,2553.29,N/A,2716.15,N/A,218.40,N/A,N/A,218.40,9166.32,,Hospital 59899,HC Maternity Care Procedure,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,12868.02,1267.00,7720.81,760.20,3368.28,155.48,4250.13,165.16,7590.69,729.53,4375.12,430.78,4696.00,389.10,3472.06,155.48,1124.00,160.86,1124.00,160.86,2923.00,242.22,4696.00,389.10,4696.00,389.10,4696.00,389.10,7590.69,729.53,4250.13,160.86,3472.06,155.48,9117.42,484.16,9117.42,484.16,3472.06,155.48,4250.13,160.86,4250.13,165.16,3715.11,43.20,1124.00,9117.42,43.20,760.20,,Hospital 60200,Exc Cyst/Adenoma Thyroid/Transection Isthmus,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25300.50,N/A,15180.30,N/A,3533.21,N/A,4923.50,N/A,14566.09,N/A,8602.16,N/A,11440.84,N/A,3533.21,N/A,4706.78,N/A,4706.78,N/A,7122.14,N/A,11440.84,N/A,11440.84,N/A,11440.84,N/A,14566.09,N/A,4706.78,N/A,3533.21,N/A,7897.00,N/A,7897.00,N/A,3533.21,N/A,4706.78,N/A,4923.50,N/A,745.16,N/A,N/A,745.16,15180.30,,Hospital 60220,Total Thyroid Lobectomy Uni W/WO Isthmusectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60188.37,40242.23,36113.02,24145.34,6806.44,5557.70,8346.96,4903.52,15338.87,23159.82,19635.47,13682.36,11456.45,11457.41,7016.16,5557.70,135442.00,4742.15,135442.00,4742.15,7131.86,7132.45,11456.45,11457.41,11456.45,11457.41,11456.45,11457.41,15338.87,23159.81,8317.31,4742.15,7016.16,5557.70,18424.00,7897.00,18424.00,7897.00,N/A,5557.70,8317.31,4742.15,8346.96,4903.52,7507.29,1009.13,6806.44,135442.00,1009.13,24145.34,,Hospital 60225,Total Thyroid Lobec Uni W/Contralat Stot Lobec,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,103730.47,48521.27,62238.28,29112.76,N/A,6792.97,17285.53,4757.75,N/A,27933.76,N/A,16497.24,N/A,11441.90,15821.69,6792.97,23129.22,4706.78,23129.22,4706.78,N/A,7122.80,N/A,11441.90,N/A,11441.90,N/A,11441.90,N/A,27903.53,23200.11,4706.78,15821.69,6792.97,41026.93,7897.00,41026.93,7897.00,N/A,6792.97,23200.11,4706.78,17285.53,4757.75,N/A,1189.76,15821.69,62238.28,1189.76,29112.76,,Hospital 60252,Thyroidectomy Total/Subtotal Lmtd Neck Dissect,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41274.33,N/A,24764.60,N/A,5734.31,N/A,4780.29,N/A,23763.71,N/A,14033.28,N/A,11703.51,N/A,5734.31,N/A,4821.94,N/A,4821.94,N/A,7286.15,N/A,11703.51,N/A,11703.51,N/A,11703.51,N/A,23763.73,N/A,4821.94,N/A,5734.31,N/A,5963.00,N/A,5963.00,N/A,5734.31,N/A,4821.94,N/A,4780.29,N/A,1779.08,N/A,N/A,1779.08,24764.60,,Hospital 60254,Thyroidectomy Total/Subtotal Rad Neck Dissect,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87417.72,N/A,52450.63,N/A,12108.75,N/A,2859.36,N/A,50314.93,N/A,29643.73,N/A,12507.58,N/A,12108.75,N/A,1901.33,N/A,1901.33,N/A,7786.22,N/A,12507.58,N/A,12507.58,N/A,12507.58,N/A,50184.25,N/A,1901.33,N/A,12108.75,N/A,3660.50,N/A,3660.50,N/A,12108.75,N/A,1901.33,N/A,2859.36,N/A,3139.20,N/A,N/A,1901.33,52450.63,,Hospital 60500,Parathyroidectomy/Exploration Parathyroids,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43456.87,N/A,26074.12,N/A,6042.25,N/A,4987.25,N/A,25010.94,N/A,14775.34,N/A,11703.62,N/A,6042.25,N/A,4821.94,N/A,4821.94,N/A,7285.72,N/A,11703.62,N/A,11703.62,N/A,11703.62,N/A,25010.93,N/A,4821.94,N/A,6042.25,N/A,5963.00,N/A,5963.00,N/A,6042.25,N/A,4821.94,N/A,4987.25,N/A,1147.30,N/A,N/A,1147.30,26074.12,,Hospital 60512,Parathyroid Autotransplantation Add-On,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,87417.72,N/A,52450.63,N/A,12108.75,N/A,2859.36,N/A,50314.93,N/A,29643.73,N/A,12507.58,N/A,12108.75,N/A,1901.33,N/A,1901.33,N/A,7786.22,N/A,12507.58,N/A,12507.58,N/A,12507.58,N/A,50184.25,N/A,1901.33,N/A,12108.75,N/A,3660.50,N/A,3660.50,N/A,12108.75,N/A,1901.33,N/A,2859.36,N/A,3139.20,N/A,N/A,1901.33,52450.63,,Hospital 60650,Laparoscopy Adrenalectomy Prtl/Compl Tabdl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,90444.37,N/A,54266.62,N/A,12650.93,N/A,1462.17,N/A,52058.24,N/A,30751.10,N/A,12895.54,N/A,12650.93,N/A,1443.50,N/A,1443.50,N/A,8026.98,N/A,12895.54,N/A,12895.54,N/A,12895.54,N/A,51885.49,N/A,1443.50,N/A,12650.93,N/A,5963.00,N/A,5963.00,N/A,12650.93,N/A,1443.50,N/A,1462.17,N/A,1803.56,N/A,N/A,1443.50,54266.62,,Hospital 60699,Unlisted Procedure Endocrine System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28305.20,N/A,16983.12,N/A,3953.87,N/A,4923.50,N/A,16296.83,N/A,9623.77,N/A,11411.86,N/A,3953.87,N/A,4706.78,N/A,4706.78,N/A,7104.10,N/A,11411.86,N/A,11411.86,N/A,11411.86,N/A,16296.84,N/A,4706.78,N/A,3953.87,N/A,7897.00,N/A,7897.00,N/A,3953.87,N/A,4706.78,N/A,4923.50,N/A,8.27,N/A,N/A,8.27,16983.12,,Hospital CPT 61070,"HC Puncture of Shunt,Asp or Inj",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1465.00,1465.00,879.00,879.00,N/A,205.10,N/A,608.66,N/A,843.55,N/A,498.10,N/A,1407.47,N/A,205.10,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,843.55,N/A,581.86,N/A,205.10,N/A,785.24,N/A,785.24,N/A,205.10,N/A,581.86,N/A,608.66,N/A,59.41,879.00,879.00,59.41,1407.47,,Hospital 61154,Burr Hole W/Evac&/Drg Hematoma Xdrl/Sdrl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,254178.18,N/A,152506.91,N/A,N/A,N/A,13688.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13688.10,N/A,13688.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13688.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13688.10,N/A,13688.10,N/A,N/A,N/A,13688.10,152506.91,N/A,N/A,,Hospital 61316,Incision & Subcutaneous Plmt Cranial Bone Graf,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36692.37,N/A,22015.42,N/A,5136.93,N/A,2052.96,N/A,20914.49,N/A,12475.39,N/A,29428.51,N/A,5136.93,N/A,2052.96,N/A,2052.96,N/A,18319.27,N/A,29428.51,N/A,29428.51,N/A,29428.51,N/A,20914.49,N/A,2052.96,N/A,5136.93,N/A,2464.50,N/A,2464.50,N/A,5136.93,N/A,2052.96,N/A,2052.96,N/A,2258.26,N/A,N/A,2052.96,29428.51,,Hospital 61500,Craniectomy W/Excision Tumor/Lesion Skull,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,30509.77,N/A,18305.86,N/A,4218.51,N/A,1358.75,N/A,17562.69,N/A,10373.33,N/A,14811.02,N/A,4218.51,N/A,1347.91,N/A,1347.91,N/A,9220.13,N/A,14811.02,N/A,14811.02,N/A,14811.02,N/A,17562.71,N/A,1347.91,N/A,4218.51,N/A,7897.00,N/A,7897.00,N/A,4218.51,N/A,1353.92,N/A,1358.75,N/A,1391.31,N/A,N/A,1347.91,18305.86,,Hospital 61510,Craniec Trephine Bone Flp Brain Tumor Suprtentor,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,92148.88,N/A,55289.33,N/A,24221.84,N/A,28918.84,N/A,58904.55,N/A,31330.62,N/A,56751.71,N/A,24968.16,N/A,28918.84,N/A,28918.84,N/A,35329.63,N/A,56751.71,N/A,56751.71,N/A,56751.71,N/A,58904.55,N/A,3633.43,N/A,24968.16,N/A,65564.82,N/A,65564.82,N/A,N/A,N/A,28918.84,N/A,3633.43,N/A,26715.93,N/A,3633.43,65564.82,N/A,N/A,,Hospital 61598,Transpetrosal Approach/Skull,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,66791.73,N/A,40075.04,N/A,9306.51,N/A,6294.29,N/A,38481.40,N/A,22709.18,N/A,30057.98,N/A,9306.51,N/A,6287.92,N/A,6287.92,N/A,18907.67,N/A,30057.98,N/A,30057.98,N/A,30057.98,N/A,38481.44,N/A,6311.17,N/A,9306.51,N/A,2464.50,N/A,2464.50,N/A,9306.51,N/A,6287.92,N/A,6294.29,N/A,7061.16,N/A,N/A,2464.50,40075.04,,Hospital 61623,HC Endovasc Tempory Vessel Occl,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,254229.97,N/A,152537.98,N/A,32306.99,N/A,36434.11,N/A,140131.55,N/A,86438.19,N/A,88522.87,N/A,31516.91,N/A,36434.11,N/A,36434.11,N/A,55117.06,N/A,88522.87,N/A,88522.87,N/A,88522.87,N/A,140131.55,N/A,36434.11,N/A,31516.91,N/A,120505.00,N/A,120505.00,N/A,22360.64,N/A,36434.11,N/A,37275.72,N/A,33723.09,N/A,22360.64,152537.98,N/A,N/A,,Hospital 61624,HC Embo Intracranial/Spinal,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,234168.08,128761.35,140500.85,77256.81,26936.71,17974.47,23779.89,9308.89,129073.45,73269.80,79617.15,43778.86,48548.34,44144.92,23393.49,17974.47,23661.29,9287.44,23661.29,9287.44,50767.64,27481.06,48548.34,44144.92,81537.33,44144.92,81537.33,44144.92,129073.45,73269.81,23661.29,9287.44,23393.49,17974.47,110995.67,15608.50,110995.67,15608.50,18853.82,17974.47,23661.29,9287.44,24188.15,9308.89,25031.03,1776.65,18853.82,140500.85,1776.65,77256.81,,Hospital 61626,HC Embol Ex/Cranial Head/Neck,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,108686.20,67299.67,65211.72,40379.80,9651.93,9424.11,11683.38,15680.06,59907.83,38513.59,36953.31,22881.89,21959.47,37553.71,9949.32,9424.11,3372.00,15512.06,3372.00,15512.06,13669.26,23377.91,21959.47,37553.71,21959.47,37553.71,21959.47,37553.71,59907.83,38513.59,11683.38,15512.06,9949.32,9424.11,26126.29,14072.75,26126.29,14072.75,11936.48,9424.11,11683.38,15512.06,16566.56,15680.06,10645.77,1372.72,3372.00,65211.72,1372.72,40379.80,,Hospital 61641,HC Dilate Ic Vasospasm Ea Add Vessel Same Family,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1287473.73,N/A,772484.24,N/A,164982.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,164982.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,164982.95,N/A,N/A,N/A,N/A,N/A,164982.95,N/A,N/A,N/A,N/A,N/A,164982.95,N/A,164982.95,772484.24,N/A,N/A,,Hospital 61642,HC Dilate Ic Vasospasm Add-On,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,713853.62,N/A,428312.17,N/A,62365.92,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62365.92,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62365.92,N/A,N/A,N/A,N/A,N/A,62365.92,N/A,N/A,N/A,N/A,N/A,62365.92,N/A,62365.92,428312.17,N/A,N/A,,Hospital CPT 61650,HC Evasc Prlng Admn Rx Agnt 1st,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,771.00,771.00,462.60,462.60,N/A,107.94,N/A,549.51,N/A,443.94,N/A,262.14,N/A,771.00,N/A,107.94,N/A,549.51,N/A,549.51,N/A,771.00,N/A,771.00,N/A,771.00,N/A,771.00,N/A,443.94,N/A,549.51,N/A,107.94,N/A,771.00,N/A,771.00,N/A,107.94,N/A,549.51,N/A,549.51,N/A,604.46,462.60,462.60,107.94,771.00,,Hospital CPT 61782,Strtctc Cptr Asstd Px Extradural Cranial,N/A,N/A,356.00,356.00,213.60,213.60,N/A,49.84,N/A,166.53,N/A,356.00,N/A,121.04,N/A,356.00,N/A,49.84,N/A,166.53,N/A,166.53,N/A,309.44,N/A,356.00,N/A,356.00,N/A,356.00,N/A,356.00,N/A,166.53,N/A,49.84,N/A,356.00,N/A,356.00,N/A,49.84,N/A,166.53,N/A,166.53,N/A,183.18,213.60,213.60,49.84,356.00,,Hospital 61783,"Stereotactic Comp Assist Proc,Spinal",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,166812.53,111577.15,100087.52,66946.29,25542.16,15571.28,29105.10,20865.79,91947.07,63750.57,56716.26,37936.26,58030.64,49228.83,26329.16,15571.28,273694.00,20865.79,273694.00,19924.58,36122.72,30841.88,58030.64,49228.83,58030.64,49228.83,58030.64,49228.83,91947.07,63554.85,29045.80,19947.52,26329.16,15571.28,69041.97,19049.75,69041.97,19049.75,7080.07,15571.28,29045.80,19924.58,29105.10,20835.08,28172.20,4452.85,7080.07,273694.00,4452.85,66946.29,,Hospital 61791,Stereo Treat Trigeminal Tract,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10592.80,N/A,6355.68,N/A,1508.43,N/A,1640.81,N/A,6096.21,N/A,3601.55,N/A,3945.97,N/A,1508.43,N/A,1623.23,N/A,1623.23,N/A,2456.44,N/A,3945.97,N/A,3945.97,N/A,3945.97,N/A,6096.21,N/A,1623.23,N/A,1508.43,N/A,3397.00,N/A,3397.00,N/A,1508.43,N/A,1623.23,N/A,1640.81,N/A,1243.38,N/A,N/A,1243.38,6355.68,,Hospital 61863,Implant Neuroelectrode,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,92377.82,85605.13,55426.69,51363.08,13312.01,11961.70,1700.92,1631.53,46467.13,48890.09,31408.46,29105.74,31426.24,15179.19,13722.18,11961.70,15373.50,1622.65,15373.50,1622.65,19563.77,9450.00,31426.24,15179.19,31426.24,15179.19,31426.24,15179.19,46467.13,48890.14,15373.50,1622.65,13722.18,11961.70,36306.49,1643.00,36306.49,1643.00,N/A,11961.70,15373.50,1622.65,15403.15,1631.53,14682.73,1777.42,1700.92,55426.69,1622.65,51363.08,,Hospital 61886,"Imp Stim,Cranial,Subq,>1 Array",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,160823.32,N/A,96493.99,N/A,22497.85,N/A,27732.61,N/A,90854.73,N/A,54679.92,N/A,64154.71,N/A,22497.85,N/A,26511.88,N/A,26511.88,N/A,39937.54,N/A,64154.71,N/A,64154.71,N/A,64154.71,N/A,90854.75,N/A,26511.88,N/A,22497.85,N/A,29766.00,N/A,29766.00,N/A,22497.85,N/A,26511.88,N/A,27732.61,N/A,923.86,N/A,N/A,923.86,96493.99,,Hospital 61888,Revis/Remov Cranial Neurorcvr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,48240.03,N/A,28944.02,N/A,13312.01,N/A,16042.72,N/A,33449.16,N/A,16401.62,N/A,31190.00,N/A,13722.18,N/A,10793.67,N/A,10793.67,N/A,19416.71,N/A,31190.00,N/A,31190.00,N/A,31190.00,N/A,33449.16,N/A,16013.07,N/A,13722.18,N/A,36033.58,N/A,36033.58,N/A,N/A,N/A,16013.07,N/A,16042.72,N/A,14682.73,N/A,10793.67,36033.58,N/A,N/A,,Hospital 62141,"Repair Skull Defect,>5cm",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,91225.33,N/A,54735.20,N/A,12633.71,N/A,6281.32,N/A,51699.62,N/A,31014.58,N/A,7972.82,N/A,12633.71,N/A,6281.19,N/A,6281.19,N/A,5216.41,N/A,7972.82,N/A,7972.82,N/A,7972.82,N/A,51699.66,N/A,6301.31,N/A,12633.71,N/A,1643.00,N/A,1643.00,N/A,12633.71,N/A,6281.19,N/A,6281.32,N/A,1594.47,N/A,N/A,1594.47,54735.20,,Hospital 62223,Create Shunt:Ventric-Peritoneal,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,88521.60,N/A,53112.96,N/A,9060.85,N/A,10651.65,N/A,20951.43,N/A,30097.34,N/A,21525.78,N/A,9340.03,N/A,366986.00,N/A,366986.00,N/A,13400.44,N/A,21525.78,N/A,21525.78,N/A,21525.78,N/A,20951.43,N/A,10622.00,N/A,9340.03,N/A,24868.57,N/A,1906.50,N/A,N/A,N/A,10622.00,N/A,10651.65,N/A,9993.84,N/A,1906.50,366986.00,N/A,N/A,,Hospital 62269,Percut Needle Biopsy Spinal Cord,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,59025.82,N/A,35415.49,N/A,8263.62,N/A,12186.91,N/A,33972.59,N/A,20068.77,N/A,28539.87,N/A,8263.62,N/A,11782.94,N/A,11782.94,N/A,17766.62,N/A,28539.87,N/A,28539.87,N/A,28539.87,N/A,33972.58,N/A,11782.94,N/A,8263.62,N/A,8964.25,N/A,8964.25,N/A,8263.62,N/A,11782.94,N/A,12186.91,N/A,1396.78,N/A,N/A,1396.78,35415.49,,Hospital CPT 62270,HC Diagnostic Lumbar Puncture,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1802.00,1802.00,1081.20,1081.20,N/A,252.28,N/A,618.98,N/A,1037.59,N/A,612.68,N/A,1407.47,N/A,252.28,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1037.59,N/A,581.86,N/A,252.28,N/A,965.87,N/A,965.87,N/A,252.28,N/A,581.86,N/A,618.98,N/A,65.97,1081.20,1081.20,65.97,1407.47,,Hospital CPT 62270,HC Spinal Puncture Lumbar Diagnos,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1802.00,1802.00,1081.20,1081.20,N/A,252.28,N/A,618.98,N/A,1037.59,N/A,612.68,N/A,1407.47,N/A,252.28,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1037.59,N/A,581.86,N/A,252.28,N/A,1802.00,N/A,1802.00,N/A,252.28,N/A,581.86,N/A,618.98,N/A,65.97,1081.20,1081.20,65.97,1802.00,,Hospital CPT 62270,"HC Spinal Puncture, Lumbar, Diagnostic",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1802.00,1802.00,1081.20,1081.20,N/A,252.28,N/A,618.98,N/A,1037.59,N/A,612.68,N/A,1407.47,N/A,252.28,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1037.59,N/A,581.86,N/A,252.28,N/A,1431.00,N/A,1431.00,N/A,252.28,N/A,581.86,N/A,618.98,N/A,65.97,1081.20,1081.20,65.97,1431.00,,Hospital CPT 62272,"HC Spinal Puncture,Therapeutic",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1256.00,1256.00,753.60,753.60,N/A,175.84,N/A,608.66,N/A,723.20,N/A,427.04,N/A,1256.00,N/A,175.84,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1256.00,N/A,1256.00,N/A,1256.00,N/A,723.20,N/A,581.86,N/A,175.84,N/A,1431.00,N/A,1431.00,N/A,175.84,N/A,581.86,N/A,608.66,N/A,94.26,753.60,753.60,94.26,1431.00,,Hospital CPT 62272,HC Drain Cerebro Spinal Flui,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1256.00,1256.00,753.60,753.60,N/A,175.84,N/A,608.66,N/A,723.20,N/A,427.04,N/A,1256.00,N/A,175.84,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1256.00,N/A,1256.00,N/A,1256.00,N/A,723.20,N/A,581.86,N/A,175.84,N/A,1256.00,N/A,1256.00,N/A,175.84,N/A,581.86,N/A,608.66,N/A,94.26,753.60,753.60,94.26,1256.00,,Hospital 62282,HC Inj Neurolytic Epi Lumbar,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,394939.93,N/A,236963.96,N/A,N/A,N/A,10687.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10687.67,N/A,10687.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10687.67,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10687.67,N/A,10687.67,N/A,N/A,N/A,10687.67,236963.96,N/A,N/A,,Hospital 62287,Dcmprn Perq Nucleus Pulposus 1/> Levels Lumbar,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,42255.90,N/A,25353.54,N/A,5910.09,N/A,1682.81,N/A,24154.20,N/A,14367.01,N/A,3951.95,N/A,5910.09,N/A,1627.16,N/A,1627.16,N/A,2460.17,N/A,3951.95,N/A,3951.95,N/A,3951.95,N/A,24154.21,N/A,1627.16,N/A,5910.09,N/A,4562.00,N/A,4562.00,N/A,5910.09,N/A,1627.16,N/A,1682.81,N/A,608.87,N/A,N/A,608.87,25353.54,,Hospital 62290,HC Lum Discogram/Inj Each Level,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,10005.60,N/A,6003.36,N/A,1400.78,N/A,1656.99,N/A,5183.50,N/A,3401.90,N/A,3938.72,N/A,1400.78,N/A,1623.23,N/A,1623.23,N/A,2451.93,N/A,3938.72,N/A,3938.72,N/A,3938.72,N/A,5183.50,N/A,1623.23,N/A,1400.78,N/A,790.50,N/A,790.50,N/A,1400.78,N/A,1623.23,N/A,1656.99,N/A,614.52,N/A,N/A,614.52,6003.36,,Hospital CPT 62304,HC Myelogram Lumbar,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1495.00,1495.00,897.00,897.00,N/A,209.30,N/A,113.36,N/A,860.82,N/A,508.30,N/A,1495.00,N/A,209.30,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1495.00,N/A,1495.00,N/A,1495.00,N/A,860.82,N/A,668.93,N/A,209.30,N/A,1431.00,N/A,1431.00,N/A,209.30,N/A,668.93,N/A,113.36,N/A,124.70,897.00,897.00,113.36,1495.00,,Hospital CPT 62305,HC Myelogram 2 or More Regions,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1767.00,1767.00,1060.20,1060.20,N/A,247.38,N/A,682.84,N/A,1017.44,N/A,600.78,N/A,1618.07,N/A,247.38,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1017.44,N/A,668.93,N/A,247.38,N/A,1431.00,N/A,1431.00,N/A,247.38,N/A,668.93,N/A,682.84,N/A,130.14,1060.20,1060.20,130.14,1618.07,,Hospital 62322,Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5851.30,N/A,3510.78,N/A,819.18,N/A,815.52,N/A,3368.27,N/A,1989.44,N/A,1872.75,N/A,819.18,N/A,769.55,N/A,769.55,N/A,1165.82,N/A,1872.75,N/A,1872.75,N/A,1872.75,N/A,3368.28,N/A,769.55,N/A,819.18,N/A,1431.00,N/A,1431.00,N/A,819.18,N/A,769.55,N/A,815.52,N/A,86.15,N/A,N/A,86.15,3510.78,,Hospital CPT 62325,HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Crv/Thrc W/Img Gdn,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,804.99,N/A,2054.45,N/A,1213.12,N/A,1861.48,N/A,499.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2054.45,N/A,769.55,N/A,499.52,N/A,1912.45,N/A,1912.45,N/A,499.52,N/A,769.55,N/A,799.52,N/A,118.48,2140.80,2140.80,118.48,2140.80,,Hospital CPT 62325,HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Crv/Thrc W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,804.99,N/A,2054.45,N/A,1213.12,N/A,1861.48,N/A,499.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2054.45,N/A,769.55,N/A,499.52,N/A,1431.00,N/A,1431.00,N/A,499.52,N/A,769.55,N/A,799.52,N/A,118.48,2140.80,2140.80,118.48,2140.80,,Hospital CPT 62327,HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Lmbr/Sac W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,804.99,N/A,1402.65,N/A,828.24,N/A,1861.48,N/A,341.04,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1402.65,N/A,769.55,N/A,341.04,N/A,1431.00,N/A,1431.00,N/A,341.04,N/A,769.55,N/A,100.65,N/A,110.72,1461.60,1461.60,100.65,1861.48,,Hospital CPT 62327,HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Lmbr/Sac W/Img Gdn,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2436.00,2436.00,1461.60,1461.60,N/A,341.04,N/A,804.99,N/A,1402.65,N/A,828.24,N/A,1861.48,N/A,341.04,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1402.65,N/A,769.55,N/A,341.04,N/A,1305.70,N/A,1305.70,N/A,341.04,N/A,769.55,N/A,100.65,N/A,110.72,1461.60,1461.60,100.65,1861.48,,Hospital 62351,Implant Spinal Cath W Laminect,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,98268.40,N/A,58961.04,N/A,13741.70,N/A,6258.61,N/A,56010.02,N/A,33411.26,N/A,14526.26,N/A,13741.70,N/A,5973.28,N/A,5973.28,N/A,9042.88,N/A,14526.26,N/A,14526.26,N/A,14526.26,N/A,56010.04,N/A,5973.28,N/A,13741.70,N/A,10178.00,N/A,10178.00,N/A,13741.70,N/A,5983.58,N/A,6258.61,N/A,1883.25,N/A,N/A,1883.25,58961.04,,Hospital 62355,Remove Spinal Canal Catheter,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16797.00,N/A,10078.20,N/A,2352.03,N/A,1666.59,N/A,9621.23,N/A,5710.99,N/A,3951.64,N/A,2352.03,N/A,1623.23,N/A,1623.23,N/A,2459.98,N/A,3951.64,N/A,3951.64,N/A,3951.64,N/A,9621.23,N/A,1623.23,N/A,2352.03,N/A,3397.00,N/A,3397.00,N/A,2352.03,N/A,1623.23,N/A,1666.59,N/A,290.55,N/A,N/A,290.55,10078.20,,Hospital CPT 62367,HC Analysis Pump W/O Rep or Refil,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1160.00,1160.00,696.00,696.00,N/A,162.40,N/A,24.33,N/A,667.93,N/A,394.40,N/A,90.48,N/A,162.40,N/A,24.33,N/A,24.33,N/A,56.32,N/A,90.48,N/A,90.48,N/A,90.48,N/A,667.93,N/A,24.33,N/A,162.40,N/A,621.76,N/A,621.76,N/A,162.40,N/A,24.33,N/A,24.33,N/A,26.76,696.00,696.00,24.33,696.00,,Hospital 63012,"Laminectomy,Facetectomy,Lumbar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35239.53,N/A,21143.72,N/A,4930.70,N/A,6248.31,N/A,20289.01,N/A,11981.44,N/A,14479.17,N/A,4930.70,N/A,5973.28,N/A,5973.28,N/A,9013.55,N/A,14479.17,N/A,14479.17,N/A,14479.17,N/A,20289.01,N/A,5973.28,N/A,4930.70,N/A,7897.00,N/A,7897.00,N/A,4930.70,N/A,5973.28,N/A,6248.31,N/A,1271.94,N/A,N/A,1271.94,21143.72,,Hospital 63016,"Laminectomy,>2 Sgmt,Thoracic",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,135785.60,N/A,81471.36,N/A,19000.67,N/A,27732.61,N/A,77077.04,N/A,46167.09,N/A,65171.81,N/A,19000.67,N/A,26511.88,N/A,26511.88,N/A,40579.33,N/A,65171.81,N/A,65171.81,N/A,65171.81,N/A,77077.04,N/A,26511.88,N/A,19000.67,N/A,41048.50,N/A,41048.50,N/A,19000.67,N/A,26511.88,N/A,27732.61,N/A,2003.36,N/A,N/A,2003.36,81471.36,,Hospital 63030,Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,77739.07,28163.92,46643.44,16898.35,7894.17,3942.94,6421.39,5973.28,17790.16,16212.87,26431.28,9575.72,17960.33,14506.96,8137.40,3942.94,6421.39,5973.28,3372.00,5973.28,11179.89,9030.86,17960.33,14506.96,17960.33,14506.96,17960.33,14506.96,N/A,16212.88,9604.05,5973.28,8137.40,3942.94,21368.31,8160.50,21368.31,8160.50,3562.37,3942.94,6123.11,5973.28,9604.05,5973.28,8707.02,6570.60,3372.00,46643.44,3942.94,16898.35,,Hospital 63035,Lamnotmy W/Dcmprsn Nrv Each Addl Crvcl/Lmbr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31711.42,N/A,19026.85,N/A,4439.61,N/A,5973.28,N/A,18255.70,N/A,10781.89,N/A,14492.43,N/A,4439.61,N/A,5973.28,N/A,5973.28,N/A,9021.80,N/A,14492.43,N/A,14492.43,N/A,14492.43,N/A,18255.70,N/A,5973.28,N/A,4439.61,N/A,8160.50,N/A,8160.50,N/A,4439.61,N/A,5973.28,N/A,5973.28,N/A,6570.60,N/A,N/A,4439.61,19026.85,,Hospital 63040,Laminotomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52203.93,N/A,31322.36,N/A,7894.17,N/A,9633.70,N/A,17790.16,N/A,16813.31,N/A,15162.10,N/A,8137.40,N/A,100036.00,N/A,100036.00,N/A,9634.68,N/A,15162.10,N/A,15162.10,N/A,15162.10,N/A,17790.16,N/A,9604.05,N/A,8137.40,N/A,21368.31,N/A,21368.31,N/A,N/A,N/A,9604.05,N/A,9633.70,N/A,8707.02,N/A,7894.17,100036.00,N/A,N/A,,Hospital 63043,"Redo Excis Cerv Disk, Addn Cerv Interspc",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,52203.93,N/A,31322.36,N/A,7894.17,N/A,9633.70,N/A,17790.16,N/A,16813.31,N/A,15162.10,N/A,8137.40,N/A,100036.00,N/A,100036.00,N/A,9634.68,N/A,15162.10,N/A,15162.10,N/A,15162.10,N/A,17790.16,N/A,9604.05,N/A,8137.40,N/A,21368.31,N/A,21368.31,N/A,N/A,N/A,9604.05,N/A,9633.70,N/A,8707.02,N/A,7894.17,100036.00,N/A,N/A,,Hospital 63046,"Laminec/Facetect/Foramin,Thoracic",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81897.78,N/A,49138.67,N/A,11446.29,N/A,11761.23,N/A,46861.28,N/A,27779.67,N/A,16089.37,N/A,11446.29,N/A,5973.28,N/A,5973.28,N/A,10015.92,N/A,16089.37,N/A,16089.37,N/A,16089.37,N/A,46861.32,N/A,5973.28,N/A,N/A,N/A,11845.50,N/A,11845.50,N/A,11446.29,N/A,5973.28,N/A,2434.71,N/A,2665.95,N/A,N/A,2434.71,49138.67,,Hospital 63050,"C- Laminoplasty, 2 or More",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,204809.67,N/A,122885.80,N/A,28645.60,N/A,28210.79,N/A,116384.97,N/A,69635.27,N/A,78645.11,N/A,28645.60,N/A,26519.74,N/A,26519.74,N/A,48958.10,N/A,78645.11,N/A,78645.11,N/A,78645.11,N/A,116384.99,N/A,26519.74,N/A,28645.60,N/A,43340.75,N/A,43340.75,N/A,28645.60,N/A,26519.74,N/A,28210.79,N/A,2838.23,N/A,N/A,2838.23,122885.80,,Hospital 63056,"Decompress Spinal Cord,1 Seg",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35262.77,N/A,21157.66,N/A,4936.78,N/A,1702.18,N/A,20274.04,N/A,11909.37,N/A,15135.14,N/A,4936.78,N/A,6123.42,N/A,6123.42,N/A,9617.92,N/A,15135.14,N/A,15135.14,N/A,15135.14,N/A,20274.06,N/A,6146.36,N/A,4936.78,N/A,7897.00,N/A,7897.00,N/A,4936.78,N/A,6123.42,N/A,1702.18,N/A,1872.39,N/A,N/A,1702.18,21157.66,,Hospital 63075,"Disk Surg,Anter,Cervical,Single Lvl",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,85036.03,54134.88,51021.62,32480.93,N/A,7485.26,18670.77,6132.82,42498.31,30923.77,28912.25,18405.87,37062.76,14471.27,16887.40,7485.26,11932.77,5973.28,11932.77,5973.28,N/A,9008.64,37062.76,14471.27,N/A,14471.27,37062.76,14471.27,42498.31,30923.78,18641.12,5973.28,16887.40,7485.26,44095.43,8160.50,N/A,8160.50,N/A,7485.26,12083.63,5973.28,18670.77,6132.82,18069.51,1709.81,11932.77,51021.62,1709.81,32480.93,,Hospital 63082,"Remv Vert Body,Cerv,Each Addnl Sgmt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61453.83,N/A,36872.30,N/A,8537.51,N/A,12060.69,N/A,35082.02,N/A,20894.34,N/A,46699.04,N/A,8537.51,N/A,11933.08,N/A,N/A,N/A,29267.08,N/A,46699.04,N/A,46699.04,N/A,46699.04,N/A,35082.10,N/A,11956.02,N/A,8537.51,N/A,13819.75,N/A,13819.75,N/A,8537.51,N/A,11933.08,N/A,12060.69,N/A,4674.16,N/A,N/A,4674.16,46699.04,,Hospital 63268,"Excis Intrasp Lesn,Xdural,Sacral",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,39482.20,N/A,23689.32,N/A,5520.71,N/A,6248.31,N/A,22731.25,N/A,13423.94,N/A,14515.82,N/A,5520.71,N/A,5973.28,N/A,5973.28,N/A,9039.99,N/A,14515.82,N/A,14515.82,N/A,14515.82,N/A,22731.25,N/A,5973.28,N/A,5520.71,N/A,9595.50,N/A,9595.50,N/A,5520.71,N/A,5973.28,N/A,6248.31,N/A,2960.68,N/A,N/A,2960.68,23689.32,,Hospital 63282,"Bx/Excis Spin Tum,Indur,Xmed,Lumb",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,60372.52,N/A,36223.51,N/A,12489.41,N/A,15069.64,N/A,28145.91,N/A,19590.66,N/A,29586.67,N/A,12874.23,N/A,159608.00,N/A,159608.00,N/A,18626.82,N/A,29586.67,N/A,29586.67,N/A,29586.67,N/A,28145.91,N/A,15039.99,N/A,12874.23,N/A,33806.93,N/A,33806.93,N/A,N/A,N/A,15039.99,N/A,15069.64,N/A,13775.43,N/A,12489.41,159608.00,N/A,N/A,,Hospital CPT 63650,"HC Perc Implnt Neuro Stim,Epidurl",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,16515.00,16515.00,9909.00,9909.00,N/A,2312.10,N/A,5963.54,N/A,9509.34,N/A,5615.10,N/A,14425.31,N/A,2312.10,N/A,5963.54,N/A,5963.54,N/A,8980.03,N/A,14425.31,N/A,14425.31,N/A,14425.31,N/A,9509.34,N/A,5963.54,N/A,2312.10,N/A,8852.04,N/A,8852.04,N/A,2312.10,N/A,5963.54,N/A,5963.54,N/A,6559.89,9909.00,9909.00,2312.10,14425.31,,Hospital 63661,"Remove Spinal Neurostim Electrode Perc Array, Incl Fluoro",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29389.20,N/A,17633.52,N/A,4102.19,N/A,3041.19,N/A,16873.95,N/A,9992.32,N/A,7556.59,N/A,4102.19,N/A,2940.64,N/A,2940.64,N/A,4703.68,N/A,7556.59,N/A,7556.59,N/A,7556.59,N/A,16873.94,N/A,2940.64,N/A,4102.19,N/A,6260.50,N/A,6260.50,N/A,4102.19,N/A,2940.64,N/A,3041.19,N/A,742.44,N/A,N/A,742.44,17633.52,,Hospital 63662,"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35169.43,N/A,21101.66,N/A,4907.54,N/A,1165.38,N/A,20237.00,N/A,11957.61,N/A,7192.96,N/A,4907.54,N/A,2932.78,N/A,2932.78,N/A,4477.74,N/A,7192.96,N/A,7192.96,N/A,7192.96,N/A,20237.04,N/A,2932.78,N/A,4907.54,N/A,6843.00,N/A,6843.00,N/A,4907.54,N/A,2932.78,N/A,1165.38,N/A,1281.92,N/A,N/A,1165.38,21101.66,,Hospital CPT 63663,"Revision Spinal Neurostim Electrode Perc Array, Incl Fluoro",N/A,N/A,1511.00,1511.00,906.60,906.60,N/A,211.54,N/A,432.36,N/A,1511.00,N/A,513.74,N/A,1511.00,N/A,211.54,N/A,432.36,N/A,432.36,N/A,1511.00,N/A,1511.00,N/A,1511.00,N/A,1511.00,N/A,1511.00,N/A,432.36,N/A,211.54,N/A,1511.00,N/A,1511.00,N/A,211.54,N/A,432.36,N/A,432.36,N/A,475.60,906.60,906.60,211.54,1511.00,,Hospital 63688,Revise/Remove Neurostim/Receiver,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35814.73,N/A,21488.84,N/A,4966.74,N/A,2993.78,N/A,20590.90,N/A,12177.02,N/A,7382.36,N/A,4966.74,N/A,2932.78,N/A,2932.78,N/A,4595.39,N/A,7382.36,N/A,7382.36,N/A,7382.36,N/A,20590.90,N/A,2932.78,N/A,4966.74,N/A,6843.00,N/A,6843.00,N/A,4966.74,N/A,2932.78,N/A,2993.78,N/A,1310.22,N/A,N/A,1310.22,21488.84,,Hospital HCPCS 6370000000,MILNACIPRAN HCL 25 MG PO TABS,00456-1525-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.60,16.60,9.96,9.96,N/A,2.32,N/A,16.60,N/A,9.33,N/A,5.64,N/A,2.32,N/A,2.32,N/A,16.60,N/A,16.60,N/A,1.44,N/A,2.32,N/A,2.32,N/A,2.32,N/A,9.33,N/A,16.60,N/A,2.32,N/A,8.90,N/A,8.90,N/A,2.32,N/A,16.60,N/A,16.60,N/A,16.60,9.96,9.96,1.44,16.60,,Hospital HCPCS 6370000000,RACEPINEPHRINE HCL 2.25 % IN NEBU,00487-5901-99,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,DEXMETHYLPHENIDATE HCL ER 15 MG PO CP24,00781-2684-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.00,17.00,10.20,10.20,N/A,2.38,N/A,17.00,N/A,9.56,N/A,5.78,N/A,2.38,N/A,2.38,N/A,17.00,N/A,17.00,N/A,1.48,N/A,2.38,N/A,2.38,N/A,2.38,N/A,9.56,N/A,17.00,N/A,2.38,N/A,9.11,N/A,9.11,N/A,2.38,N/A,17.00,N/A,17.00,N/A,17.00,10.20,10.20,1.48,17.00,,Hospital HCPCS 6370000000,ZOLPIDEM TARTRATE 5 MG PO TABS,00904-6082-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CEFDINIR 300 MG PO CAPS,65862-0177-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXCARBAZEPINE ER 300 MG PO TB24,17772-0122-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),25.20,25.20,15.12,15.12,N/A,3.53,N/A,25.20,N/A,14.17,N/A,8.57,N/A,3.53,N/A,3.53,N/A,25.20,N/A,25.20,N/A,2.19,N/A,3.53,N/A,3.53,N/A,3.53,N/A,14.17,N/A,25.20,N/A,3.53,N/A,13.51,N/A,13.51,N/A,3.53,N/A,25.20,N/A,25.20,N/A,25.20,15.12,15.12,2.19,25.20,,Hospital HCPCS 6370000000,OXYCODONE HCL 10 MG PO TABS,10702-0056-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MELATONIN 1 MG PO TABS,74312-0028-32,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,64980-0301-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),44.80,44.80,26.88,26.88,N/A,6.27,N/A,44.80,N/A,25.19,N/A,15.23,N/A,6.27,N/A,6.27,N/A,44.80,N/A,44.80,N/A,3.90,N/A,6.27,N/A,6.27,N/A,6.27,N/A,25.19,N/A,44.80,N/A,6.27,N/A,24.01,N/A,24.01,N/A,6.27,N/A,44.80,N/A,44.80,N/A,44.80,26.88,26.88,3.90,44.80,,Hospital HCPCS 6370000000,NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24,50742-0261-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT,64980-0322-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 6370000000,LANSOPRAZOLE 30 MG PO CPDR,51079-0121-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.30,5.30,3.18,3.18,N/A,N/A,N/A,5.30,N/A,2.98,N/A,1.80,N/A,N/A,N/A,N/A,N/A,5.30,N/A,5.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.98,N/A,5.30,N/A,N/A,N/A,2.84,N/A,2.84,N/A,N/A,N/A,5.30,N/A,5.30,N/A,5.30,3.18,3.18,1.80,5.30,,Hospital HCPCS 6370000000,DIALYVITE/ZINC PO TABS,10542-0012-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DORZOLAMIDE HCL-TIMOLOL MAL 22.3-6.8 MG/ML OP SOLN,24208-0486-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),112.50,112.50,67.50,67.50,N/A,15.75,N/A,112.50,N/A,63.25,N/A,38.25,N/A,15.75,N/A,15.75,N/A,112.50,N/A,112.50,N/A,9.79,N/A,15.75,N/A,15.75,N/A,15.75,N/A,63.25,N/A,112.50,N/A,15.75,N/A,60.30,N/A,60.30,N/A,15.75,N/A,112.50,N/A,112.50,N/A,112.50,67.50,67.50,9.79,112.50,,Hospital HCPCS 6370000000,FLUTICASONE-SALMETEROL 45-21 MCG/ACT IN AERO,00173-0715-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),734.80,734.80,440.88,440.88,N/A,102.87,N/A,734.80,N/A,413.10,N/A,249.83,N/A,102.87,N/A,102.87,N/A,734.80,N/A,734.80,N/A,63.93,N/A,102.87,N/A,102.87,N/A,102.87,N/A,413.10,N/A,734.80,N/A,102.87,N/A,393.85,N/A,393.85,N/A,102.87,N/A,734.80,N/A,734.80,N/A,734.80,440.88,440.88,63.93,734.80,,Hospital HCPCS 6370000000,CINACALCET HCL 30 MG PO TABS,70436-0007-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.80,12.80,7.68,7.68,N/A,1.79,N/A,12.80,N/A,7.20,N/A,4.35,N/A,1.79,N/A,1.79,N/A,12.80,N/A,12.80,N/A,1.11,N/A,1.79,N/A,1.79,N/A,1.79,N/A,7.20,N/A,12.80,N/A,1.79,N/A,6.86,N/A,6.86,N/A,1.79,N/A,12.80,N/A,12.80,N/A,12.80,7.68,7.68,1.11,12.80,,Hospital HCPCS 6370000000,DOXEPIN HCL 50 MG PO CAPS,51079-0438-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PROPAFENONE HCL ER 225 MG PO CP12,49884-0113-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.20,13.20,7.92,7.92,N/A,1.85,N/A,13.20,N/A,7.42,N/A,4.49,N/A,1.85,N/A,1.85,N/A,13.20,N/A,13.20,N/A,1.15,N/A,1.85,N/A,1.85,N/A,1.85,N/A,7.42,N/A,13.20,N/A,1.85,N/A,7.08,N/A,7.08,N/A,1.85,N/A,13.20,N/A,13.20,N/A,13.20,7.92,7.92,1.15,13.20,,Hospital HCPCS 6370000000,BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,99999-9914-47,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.30,9.30,5.58,5.58,N/A,1.30,N/A,9.30,N/A,5.23,N/A,3.16,N/A,1.30,N/A,1.30,N/A,9.30,N/A,9.30,N/A,N/A,N/A,1.30,N/A,1.30,N/A,1.30,N/A,5.23,N/A,9.30,N/A,1.30,N/A,4.98,N/A,4.98,N/A,1.30,N/A,9.30,N/A,9.30,N/A,9.30,5.58,5.58,1.30,9.30,,Hospital HCPCS 6370000000,ETRAVIRINE 100 MG PO TABS,59676-0570-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.00,27.00,16.20,16.20,N/A,3.78,N/A,27.00,N/A,15.18,N/A,9.18,N/A,3.78,N/A,3.78,N/A,27.00,N/A,27.00,N/A,2.35,N/A,3.78,N/A,3.78,N/A,3.78,N/A,15.18,N/A,27.00,N/A,3.78,N/A,14.47,N/A,14.47,N/A,3.78,N/A,27.00,N/A,27.00,N/A,27.00,16.20,16.20,2.35,27.00,,Hospital HCPCS 6370000000,TIMOLOL HEMIHYDRATE 0.5 % OP SOLN,76478-0002-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),342.90,342.90,205.74,205.74,N/A,48.01,N/A,342.90,N/A,192.78,N/A,116.59,N/A,48.01,N/A,48.01,N/A,342.90,N/A,342.90,N/A,29.83,N/A,48.01,N/A,48.01,N/A,48.01,N/A,192.78,N/A,342.90,N/A,48.01,N/A,183.79,N/A,183.79,N/A,48.01,N/A,342.90,N/A,342.90,N/A,342.90,205.74,205.74,29.83,342.90,,Hospital HCPCS 6370000000,DOXEPIN HCL 10 MG PO CAPS,00378-1049-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,XEROFORM PETROLAT GAUZE 5"X9" EX MISC,08080-4336-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 6370000000,BUDESONIDE 180 MCG/ACT IN AEPB,00186-0916-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),578.10,578.10,346.86,346.86,N/A,80.93,N/A,578.10,N/A,325.01,N/A,196.55,N/A,80.93,N/A,80.93,N/A,578.10,N/A,578.10,N/A,50.29,N/A,80.93,N/A,80.93,N/A,80.93,N/A,325.01,N/A,578.10,N/A,80.93,N/A,309.86,N/A,309.86,N/A,80.93,N/A,578.10,N/A,578.10,N/A,578.10,346.86,346.86,50.29,578.10,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL 5 MG PO TABS,00406-1142-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GALANTAMINE HYDROBROMIDE 4 MG PO TABS,68084-0729-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 6370000000,AMPHETAMINE-DEXTROAMPHETAMINE 15 MG PO TABS,00555-0777-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MISOPROSTOL 200 MCG PO TABS,59762-5008-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PROPAFENONE HCL 225 MG PO TABS,00591-0583-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ISOSORBIDE DINITRATE 40 MG PO TABS,00187-0192-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),45.50,45.50,27.30,27.30,N/A,6.37,N/A,45.50,N/A,25.58,N/A,15.47,N/A,6.37,N/A,6.37,N/A,45.50,N/A,45.50,N/A,3.96,N/A,6.37,N/A,6.37,N/A,6.37,N/A,25.58,N/A,45.50,N/A,6.37,N/A,24.39,N/A,24.39,N/A,6.37,N/A,45.50,N/A,45.50,N/A,45.50,27.30,27.30,3.96,45.50,,Hospital HCPCS 6370000000,CLOBETASOL PROPIONATE 0.05 % EX CREA,51672-1258-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),140.10,140.10,84.06,84.06,N/A,19.61,N/A,140.10,N/A,78.76,N/A,47.63,N/A,19.61,N/A,19.61,N/A,140.10,N/A,140.10,N/A,12.19,N/A,19.61,N/A,19.61,N/A,19.61,N/A,78.76,N/A,140.10,N/A,19.61,N/A,75.09,N/A,75.09,N/A,19.61,N/A,140.10,N/A,140.10,N/A,140.10,84.06,84.06,12.19,140.10,,Hospital HCPCS 6370000000,ACETAMINOPHEN 325 MG PO TABS,50580-0458-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,FLORANEX PO TABS,77333-0441-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PAROXETINE HCL 10 MG PO TABS,68084-0044-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXAZEPAM 15 MG PO CAPS,62584-0813-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.30,7.30,4.38,4.38,N/A,1.02,N/A,7.30,N/A,4.10,N/A,2.48,N/A,1.02,N/A,1.02,N/A,7.30,N/A,7.30,N/A,N/A,N/A,1.02,N/A,1.02,N/A,1.02,N/A,4.10,N/A,7.30,N/A,1.02,N/A,3.91,N/A,3.91,N/A,1.02,N/A,7.30,N/A,7.30,N/A,7.30,4.38,4.38,1.02,7.30,,Hospital HCPCS 6370000000,VALSARTAN 160 MG PO TABS,51660-0142-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA-ENTACAPONE 12.5-50-200 MG PO TABS,47335-0001-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 6370000000,BUPROPION HCL 100 MG PO TABS,60505-0157-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUCONAZOLE 100 MG PO TABS,68001-0252-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MERCAPTOPURINE 50 MG PO TABS,00054-4581-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.20,7.20,4.32,4.32,N/A,1.01,N/A,7.20,N/A,4.05,N/A,2.45,N/A,1.01,N/A,1.01,N/A,7.20,N/A,7.20,N/A,N/A,N/A,1.01,N/A,1.01,N/A,1.01,N/A,4.05,N/A,7.20,N/A,1.01,N/A,3.86,N/A,3.86,N/A,1.01,N/A,7.20,N/A,7.20,N/A,7.20,4.32,4.32,1.01,7.20,,Hospital HCPCS 6370000000,DOCUSATE SODIUM 100 MG PO CAPS,00904-7183-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,BENZOCAINE 20 % MT SOLN,00283-0610-26,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),22.80,22.80,13.68,13.68,N/A,3.19,N/A,22.80,N/A,12.82,N/A,7.75,N/A,3.19,N/A,3.19,N/A,22.80,N/A,22.80,N/A,1.98,N/A,3.19,N/A,3.19,N/A,3.19,N/A,12.82,N/A,22.80,N/A,3.19,N/A,12.22,N/A,12.22,N/A,3.19,N/A,22.80,N/A,22.80,N/A,22.80,13.68,13.68,1.98,22.80,,Hospital HCPCS 6370000000,DULOXETINE HCL 30 MG PO CPEP,68084-0683-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,EMTRICITABINE 200 MG PO CAPS,61958-0601-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),40.30,40.30,24.18,24.18,N/A,5.64,N/A,40.30,N/A,22.66,N/A,13.70,N/A,5.64,N/A,5.64,N/A,40.30,N/A,40.30,N/A,3.51,N/A,5.64,N/A,5.64,N/A,5.64,N/A,22.66,N/A,40.30,N/A,5.64,N/A,21.60,N/A,21.60,N/A,5.64,N/A,40.30,N/A,40.30,N/A,40.30,24.18,24.18,3.51,40.30,,Hospital HCPCS 6370000000,VITAMIN E 45 MG (100 UNIT) PO CAPS,80681-0134-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDOCAINE 4 % EX PTCH,00536-1202-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR,43386-0090-19,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),54.00,54.00,32.40,32.40,N/A,7.56,N/A,54.00,N/A,30.36,N/A,18.36,N/A,7.56,N/A,7.56,N/A,54.00,N/A,54.00,N/A,4.70,N/A,7.56,N/A,7.56,N/A,7.56,N/A,30.36,N/A,54.00,N/A,7.56,N/A,28.94,N/A,28.94,N/A,7.56,N/A,54.00,N/A,54.00,N/A,54.00,32.40,32.40,4.70,54.00,,Hospital HCPCS 6370000000,VIRT-CAPS 1 MG PO CAPS,69543-0260-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PSYLLIUM 0.52 G PO CAPS,37000-0405-14,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NIFEDIPINE ER OSMOTIC RELEASE 90 MG PO TB24,68084-0603-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.10,7.10,4.26,4.26,N/A,N/A,N/A,7.10,N/A,3.99,N/A,2.41,N/A,N/A,N/A,N/A,N/A,7.10,N/A,7.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.99,N/A,7.10,N/A,N/A,N/A,3.81,N/A,3.81,N/A,N/A,N/A,7.10,N/A,7.10,N/A,7.10,4.26,4.26,2.41,7.10,,Hospital HCPCS 6370000000,DINOPROSTONE 10 MG VA INST,55566-2800-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1079.70,1079.70,647.82,647.82,N/A,151.16,N/A,1079.70,N/A,607.01,N/A,367.10,N/A,151.16,N/A,151.16,N/A,1079.70,N/A,1079.70,N/A,93.93,N/A,151.16,N/A,151.16,N/A,151.16,N/A,607.01,N/A,1079.70,N/A,151.16,N/A,578.72,N/A,578.72,N/A,151.16,N/A,1079.70,N/A,1079.70,N/A,1079.70,647.82,647.82,93.93,1079.70,,Hospital HCPCS 6370000000,CHLORDIAZEPOXIDE HCL 25 MG PO CAPS,00555-0159-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL 20 MG PO TABS,00406-1146-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 6370000000,IMIPRAMINE HCL 50 MG PO TABS,49884-0056-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BENZOCAINE 20 % RE OINT,63736-0037-51,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.80,8.80,5.28,5.28,N/A,1.23,N/A,8.80,N/A,4.95,N/A,2.99,N/A,1.23,N/A,1.23,N/A,8.80,N/A,8.80,N/A,N/A,N/A,1.23,N/A,1.23,N/A,1.23,N/A,4.95,N/A,8.80,N/A,1.23,N/A,4.72,N/A,4.72,N/A,1.23,N/A,8.80,N/A,8.80,N/A,8.80,5.28,5.28,1.23,8.80,,Hospital HCPCS 6370000000,ATENOLOL 50 MG PO TABS,00093-0752-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CANAGLIFLOZIN 100 MG PO TABS,50458-0140-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),42.80,42.80,25.68,25.68,N/A,5.99,N/A,42.80,N/A,24.06,N/A,14.55,N/A,5.99,N/A,5.99,N/A,42.80,N/A,42.80,N/A,3.72,N/A,5.99,N/A,5.99,N/A,5.99,N/A,24.06,N/A,42.80,N/A,5.99,N/A,22.94,N/A,22.94,N/A,5.99,N/A,42.80,N/A,42.80,N/A,42.80,25.68,25.68,3.72,42.80,,Hospital HCPCS 6370000000,ESZOPICLONE 3 MG PO TABS,63402-0193-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.30,35.30,21.18,21.18,N/A,4.94,N/A,35.30,N/A,19.85,N/A,12.00,N/A,4.94,N/A,4.94,N/A,35.30,N/A,35.30,N/A,3.07,N/A,4.94,N/A,4.94,N/A,4.94,N/A,19.85,N/A,35.30,N/A,4.94,N/A,18.92,N/A,18.92,N/A,4.94,N/A,35.30,N/A,35.30,N/A,35.30,21.18,21.18,3.07,35.30,,Hospital HCPCS 6370000000,MOMETASONE FUROATE 0.1 % EX OINT,45802-0119-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.70,35.70,21.42,21.42,N/A,5.00,N/A,35.70,N/A,20.07,N/A,12.14,N/A,5.00,N/A,5.00,N/A,35.70,N/A,35.70,N/A,3.11,N/A,5.00,N/A,5.00,N/A,5.00,N/A,20.07,N/A,35.70,N/A,5.00,N/A,19.14,N/A,19.14,N/A,5.00,N/A,35.70,N/A,35.70,N/A,35.70,21.42,21.42,3.11,35.70,,Hospital HCPCS 6370000000,PHENYLEPHRINE-MINERAL OIL-PET 0.25-14-74.9 % RE OINT,00573-2871-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.60,12.60,7.56,7.56,N/A,1.76,N/A,12.60,N/A,7.08,N/A,4.28,N/A,1.76,N/A,1.76,N/A,12.60,N/A,12.60,N/A,1.10,N/A,1.76,N/A,1.76,N/A,1.76,N/A,7.08,N/A,12.60,N/A,1.76,N/A,6.75,N/A,6.75,N/A,1.76,N/A,12.60,N/A,12.60,N/A,12.60,7.56,7.56,1.10,12.60,,Hospital HCPCS 6370000000,WARFARIN SODIUM 5 MG PO TABS,00093-1721-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POSACONAZOLE 100 MG PO TBEC,00254-2045-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),36.40,36.40,21.84,21.84,N/A,5.10,N/A,36.40,N/A,20.46,N/A,12.38,N/A,5.10,N/A,5.10,N/A,36.40,N/A,36.40,N/A,3.17,N/A,5.10,N/A,5.10,N/A,5.10,N/A,20.46,N/A,36.40,N/A,5.10,N/A,19.51,N/A,19.51,N/A,5.10,N/A,36.40,N/A,36.40,N/A,36.40,21.84,21.84,3.17,36.40,,Hospital HCPCS 6370000000,METHOCARBAMOL 750 MG PO TABS,31722-0534-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BUPROPION HCL ER (SR) 100 MG PO TB12,00591-3540-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MELATONIN 3 MG PO TABS,31604-0027-41,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PROPAFENONE HCL ER 325 MG PO CP12,49884-0210-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.70,16.70,10.02,10.02,N/A,2.34,N/A,16.70,N/A,9.39,N/A,5.68,N/A,2.34,N/A,2.34,N/A,16.70,N/A,16.70,N/A,1.45,N/A,2.34,N/A,2.34,N/A,2.34,N/A,9.39,N/A,16.70,N/A,2.34,N/A,8.95,N/A,8.95,N/A,2.34,N/A,16.70,N/A,16.70,N/A,16.70,10.02,10.02,1.45,16.70,,Hospital HCPCS 6370000000,HYDROCORTISONE 1 % EX CREA,00472-0321-26,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.30,24.30,14.58,14.58,N/A,3.40,N/A,24.30,N/A,13.66,N/A,8.26,N/A,3.40,N/A,3.40,N/A,24.30,N/A,24.30,N/A,2.11,N/A,3.40,N/A,3.40,N/A,3.40,N/A,13.66,N/A,24.30,N/A,3.40,N/A,13.02,N/A,13.02,N/A,3.40,N/A,24.30,N/A,24.30,N/A,24.30,14.58,14.58,2.11,24.30,,Hospital HCPCS 6370000000,TROSPIUM CHLORIDE ER 60 MG PO CP24,00591-3636-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.20,12.20,7.32,7.32,N/A,1.71,N/A,12.20,N/A,6.86,N/A,4.15,N/A,1.71,N/A,1.71,N/A,12.20,N/A,12.20,N/A,1.06,N/A,1.71,N/A,1.71,N/A,1.71,N/A,6.86,N/A,12.20,N/A,1.71,N/A,6.54,N/A,6.54,N/A,1.71,N/A,12.20,N/A,12.20,N/A,12.20,7.32,7.32,1.06,12.20,,Hospital HCPCS 6370000000,ACARBOSE 25 MG PO TABS,23155-0147-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VALPROIC ACID 250 MG/5ML PO SOLN,00121-0675-85,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.10,7.10,4.26,4.26,N/A,N/A,N/A,7.10,N/A,3.99,N/A,2.41,N/A,N/A,N/A,N/A,N/A,7.10,N/A,7.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.99,N/A,7.10,N/A,N/A,N/A,3.81,N/A,3.81,N/A,N/A,N/A,7.10,N/A,7.10,N/A,7.10,4.26,4.26,2.41,7.10,,Hospital HCPCS 6370000000,NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,24208-0635-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),188.80,188.80,113.28,113.28,N/A,26.43,N/A,188.80,N/A,106.14,N/A,64.19,N/A,26.43,N/A,26.43,N/A,188.80,N/A,188.80,N/A,16.43,N/A,26.43,N/A,26.43,N/A,26.43,N/A,106.14,N/A,188.80,N/A,26.43,N/A,101.20,N/A,101.20,N/A,26.43,N/A,188.80,N/A,188.80,N/A,188.80,113.28,113.28,16.43,188.80,,Hospital HCPCS 6370000000,DORZOLAMIDE HCL 2 % OP SOLN,24208-0485-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),76.50,76.50,45.90,45.90,N/A,10.71,N/A,76.50,N/A,43.01,N/A,26.01,N/A,10.71,N/A,10.71,N/A,76.50,N/A,76.50,N/A,6.66,N/A,10.71,N/A,10.71,N/A,10.71,N/A,43.01,N/A,76.50,N/A,10.71,N/A,41.00,N/A,41.00,N/A,10.71,N/A,76.50,N/A,76.50,N/A,76.50,45.90,45.90,6.66,76.50,,Hospital HCPCS 6370000000,DESIPRAMINE HCL 25 MG PO TABS,45963-0342-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,QUETIAPINE FUMARATE ER 300 MG PO TB24,00310-0283-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),47.90,47.90,28.74,28.74,N/A,6.71,N/A,47.90,N/A,26.93,N/A,16.29,N/A,6.71,N/A,6.71,N/A,47.90,N/A,47.90,N/A,4.17,N/A,6.71,N/A,6.71,N/A,6.71,N/A,26.93,N/A,47.90,N/A,6.71,N/A,25.67,N/A,25.67,N/A,6.71,N/A,47.90,N/A,47.90,N/A,47.90,28.74,28.74,4.17,47.90,,Hospital HCPCS 6370000000,CLONIDINE 0.2 MG/24HR TD PTWK,00378-0872-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),100.40,100.40,60.24,60.24,N/A,14.06,N/A,100.40,N/A,56.44,N/A,34.14,N/A,14.06,N/A,14.06,N/A,100.40,N/A,100.40,N/A,8.73,N/A,14.06,N/A,14.06,N/A,14.06,N/A,56.44,N/A,100.40,N/A,14.06,N/A,53.81,N/A,53.81,N/A,14.06,N/A,100.40,N/A,100.40,N/A,100.40,60.24,60.24,8.73,100.40,,Hospital HCPCS 6370000000,MEDERMA EX GEL,00259-0303-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),52.40,52.40,31.44,31.44,N/A,7.34,N/A,52.40,N/A,29.46,N/A,17.82,N/A,7.34,N/A,7.34,N/A,52.40,N/A,52.40,N/A,4.56,N/A,7.34,N/A,7.34,N/A,7.34,N/A,29.46,N/A,52.40,N/A,7.34,N/A,28.09,N/A,28.09,N/A,7.34,N/A,52.40,N/A,52.40,N/A,52.40,31.44,31.44,4.56,52.40,,Hospital HCPCS 6370000000,VALGANCICLOVIR HCL 450 MG PO TABS,00004-0038-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),397.90,397.90,238.74,238.74,N/A,55.71,N/A,397.90,N/A,223.70,N/A,135.29,N/A,55.71,N/A,55.71,N/A,397.90,N/A,397.90,N/A,34.62,N/A,55.71,N/A,55.71,N/A,55.71,N/A,223.70,N/A,397.90,N/A,55.71,N/A,213.27,N/A,213.27,N/A,55.71,N/A,397.90,N/A,397.90,N/A,397.90,238.74,238.74,34.62,397.90,,Hospital HCPCS 6370000000,VALSARTAN 80 MG PO TABS,00378-5813-77,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NITROGLYCERIN 2 % TD OINT,00281-0326-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,LOSARTAN POTASSIUM 100 MG PO TABS,68084-0348-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCORTISONE VALERATE 0.2 % EX CREA,51672-1290-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),133.30,133.30,79.98,79.98,N/A,18.66,N/A,133.30,N/A,74.94,N/A,45.32,N/A,18.66,N/A,18.66,N/A,133.30,N/A,133.30,N/A,11.60,N/A,18.66,N/A,18.66,N/A,18.66,N/A,74.94,N/A,133.30,N/A,18.66,N/A,71.45,N/A,71.45,N/A,18.66,N/A,133.30,N/A,133.30,N/A,133.30,79.98,79.98,11.60,133.30,,Hospital HCPCS 6370000000,PIOGLITAZONE HCL 30 MG PO TABS,00093-7272-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ERYTHROMYCIN ETHYLSUCCINATE 400 MG PO TABS,24338-0110-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.40,27.40,16.44,16.44,N/A,3.84,N/A,27.40,N/A,15.40,N/A,9.32,N/A,3.84,N/A,3.84,N/A,27.40,N/A,27.40,N/A,2.38,N/A,3.84,N/A,3.84,N/A,3.84,N/A,15.40,N/A,27.40,N/A,3.84,N/A,14.69,N/A,14.69,N/A,3.84,N/A,27.40,N/A,27.40,N/A,27.40,16.44,16.44,2.38,27.40,,Hospital HCPCS 6370000000,RIVAROXABAN 15 MG PO TABS,50458-0578-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),38.80,38.80,23.28,23.28,N/A,5.43,N/A,38.80,N/A,21.81,N/A,13.19,N/A,5.43,N/A,5.43,N/A,38.80,N/A,38.80,N/A,3.38,N/A,5.43,N/A,5.43,N/A,5.43,N/A,21.81,N/A,38.80,N/A,5.43,N/A,20.80,N/A,20.80,N/A,5.43,N/A,38.80,N/A,38.80,N/A,38.80,23.28,23.28,3.38,38.80,,Hospital HCPCS 6370000000,REPAGLINIDE 0.5 MG PO TABS,00574-0240-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,THIOTHIXENE 1 MG PO CAPS,00378-1001-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ARIPIPRAZOLE 2 MG PO TABS,59148-0006-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),43.80,43.80,26.28,26.28,N/A,6.13,N/A,43.80,N/A,24.62,N/A,14.89,N/A,6.13,N/A,6.13,N/A,43.80,N/A,43.80,N/A,3.81,N/A,6.13,N/A,6.13,N/A,6.13,N/A,24.62,N/A,43.80,N/A,6.13,N/A,23.48,N/A,23.48,N/A,6.13,N/A,43.80,N/A,43.80,N/A,43.80,26.28,26.28,3.81,43.80,,Hospital HCPCS 6370000000,CETAPHIL GENTLE CLEANSER EX LIQD,20555-0011-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.40,6.40,3.84,3.84,N/A,N/A,N/A,6.40,N/A,3.60,N/A,2.18,N/A,N/A,N/A,N/A,N/A,6.40,N/A,6.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.60,N/A,6.40,N/A,N/A,N/A,3.43,N/A,3.43,N/A,N/A,N/A,6.40,N/A,6.40,N/A,6.40,3.84,3.84,2.18,6.40,,Hospital HCPCS 6370000000,DOLUTEGRAVIR SODIUM 50 MG PO TABS,49702-0228-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),150.90,150.90,90.54,90.54,N/A,21.13,N/A,150.90,N/A,84.84,N/A,51.31,N/A,21.13,N/A,21.13,N/A,150.90,N/A,150.90,N/A,13.13,N/A,21.13,N/A,21.13,N/A,21.13,N/A,84.84,N/A,150.90,N/A,21.13,N/A,80.88,N/A,80.88,N/A,21.13,N/A,150.90,N/A,150.90,N/A,150.90,90.54,90.54,13.13,150.90,,Hospital HCPCS 6370000000,LANOLIN EX CREAM,20451-8712-19,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,62756-0161-91,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),399.00,399.00,239.40,239.40,N/A,55.86,N/A,399.00,N/A,224.32,N/A,135.66,N/A,55.86,N/A,55.86,N/A,399.00,N/A,399.00,N/A,34.71,N/A,55.86,N/A,55.86,N/A,55.86,N/A,224.32,N/A,399.00,N/A,55.86,N/A,213.86,N/A,213.86,N/A,55.86,N/A,399.00,N/A,399.00,N/A,399.00,239.40,239.40,34.71,399.00,,Hospital HCPCS 6370000000,PROPRANOLOL HCL ER 80 MG PO CP24,51991-0818-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NYSTATIN 100000 UNIT/GM EX OINT,00168-0007-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),47.30,47.30,28.38,28.38,N/A,6.62,N/A,47.30,N/A,26.59,N/A,16.08,N/A,6.62,N/A,6.62,N/A,47.30,N/A,47.30,N/A,4.12,N/A,6.62,N/A,6.62,N/A,6.62,N/A,26.59,N/A,47.30,N/A,6.62,N/A,25.35,N/A,25.35,N/A,6.62,N/A,47.30,N/A,47.30,N/A,47.30,28.38,28.38,4.12,47.30,,Hospital HCPCS 6370000000,FOLTANX 3-35-2 MG PO TABS,51991-0813-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,CLINDAMYCIN HCL 300 MG PO CAPS,63304-0693-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,COBICISTAT 150 MG PO TABS,61958-1401-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.10,20.10,12.06,12.06,N/A,2.81,N/A,20.10,N/A,11.30,N/A,6.83,N/A,2.81,N/A,2.81,N/A,20.10,N/A,20.10,N/A,1.75,N/A,2.81,N/A,2.81,N/A,2.81,N/A,11.30,N/A,20.10,N/A,2.81,N/A,10.77,N/A,10.77,N/A,2.81,N/A,20.10,N/A,20.10,N/A,20.10,12.06,12.06,1.75,20.10,,Hospital HCPCS 6370000000,METOPROLOL TARTRATE 50 MG PO TABS,62584-0266-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MINOXIDIL 10 MG PO TABS,53489-0387-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DIPHENHYDRAMINE-ZINC ACETATE 1-0.1 % EX CREA,12547-0171-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.80,7.80,4.68,4.68,N/A,1.09,N/A,7.80,N/A,4.39,N/A,2.65,N/A,1.09,N/A,1.09,N/A,7.80,N/A,7.80,N/A,N/A,N/A,1.09,N/A,1.09,N/A,1.09,N/A,4.39,N/A,7.80,N/A,1.09,N/A,4.18,N/A,4.18,N/A,1.09,N/A,7.80,N/A,7.80,N/A,7.80,4.68,4.68,1.09,7.80,,Hospital HCPCS 6370000000,ETHYL CHLORIDE EX AERO,00386-0001-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),56.90,56.90,34.14,34.14,N/A,7.97,N/A,56.90,N/A,31.99,N/A,19.35,N/A,7.97,N/A,7.97,N/A,56.90,N/A,56.90,N/A,4.95,N/A,7.97,N/A,7.97,N/A,7.97,N/A,31.99,N/A,56.90,N/A,7.97,N/A,30.50,N/A,30.50,N/A,7.97,N/A,56.90,N/A,56.90,N/A,56.90,34.14,34.14,4.95,56.90,,Hospital HCPCS 6370000000,CEFUROXIME AXETIL 250 MG PO TABS,68180-0302-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DANTROLENE SODIUM 25 MG PO CAPS,68084-0300-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BACITRACIN 500 UNIT/GM EX OINT,45802-0060-70,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LETS KIT,09999-9913-29,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 50 MCG PO TABS,00074-4552-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.50,6.50,3.90,3.90,N/A,N/A,N/A,6.50,N/A,3.65,N/A,2.21,N/A,N/A,N/A,N/A,N/A,6.50,N/A,6.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.65,N/A,6.50,N/A,N/A,N/A,3.48,N/A,3.48,N/A,N/A,N/A,6.50,N/A,6.50,N/A,6.50,3.90,3.90,2.21,6.50,,Hospital HCPCS 6370000000,FLUOCINOLONE ACETONIDE BODY 0.01 % EX OIL,65162-0704-86,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),69.50,69.50,41.70,41.70,N/A,9.73,N/A,69.50,N/A,39.07,N/A,23.63,N/A,9.73,N/A,9.73,N/A,69.50,N/A,69.50,N/A,6.05,N/A,9.73,N/A,9.73,N/A,9.73,N/A,39.07,N/A,69.50,N/A,9.73,N/A,37.25,N/A,37.25,N/A,9.73,N/A,69.50,N/A,69.50,N/A,69.50,41.70,41.70,6.05,69.50,,Hospital HCPCS 6370000000,ERYTHROMYCIN 5 MG/GM OP OINT,00574-4024-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.40,16.40,9.84,9.84,N/A,2.30,N/A,16.40,N/A,9.22,N/A,5.58,N/A,2.30,N/A,2.30,N/A,16.40,N/A,16.40,N/A,1.43,N/A,2.30,N/A,2.30,N/A,2.30,N/A,9.22,N/A,16.40,N/A,2.30,N/A,8.79,N/A,8.79,N/A,2.30,N/A,16.40,N/A,16.40,N/A,16.40,9.84,9.84,1.43,16.40,,Hospital HCPCS 6370000000,LURASIDONE HCL 40 MG PO TABS,67877-0639-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AMIODARONE HCL 100 MG PO TABS,51672-4055-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.30,6.30,3.78,3.78,N/A,N/A,N/A,6.30,N/A,3.54,N/A,2.14,N/A,N/A,N/A,N/A,N/A,6.30,N/A,6.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.54,N/A,6.30,N/A,N/A,N/A,3.38,N/A,3.38,N/A,N/A,N/A,6.30,N/A,6.30,N/A,6.30,3.78,3.78,2.14,6.30,,Hospital HCPCS 6370000000,NORTRIPTYLINE HCL 25 MG PO CAPS,51672-4002-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CETAPHIL GENTLE CLEANSER EX LIQD,00299-3921-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 6370000000,SUCROSE 24 % (PRESERVATIVE FREE) ORAL SOLN,09999-9908-65,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TORSEMIDE 100 MG PO TABS,31722-0532-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,24208-0720-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),121.30,121.30,72.78,72.78,N/A,16.98,N/A,121.30,N/A,68.19,N/A,41.24,N/A,16.98,N/A,16.98,N/A,121.30,N/A,121.30,N/A,10.55,N/A,16.98,N/A,16.98,N/A,16.98,N/A,68.19,N/A,121.30,N/A,16.98,N/A,65.02,N/A,65.02,N/A,16.98,N/A,121.30,N/A,121.30,N/A,121.30,72.78,72.78,10.55,121.30,,Hospital HCPCS 6370000000,BACLOFEN 10 MG PO TABS,00904-6475-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,IVABRADINE HCL 5 MG PO TABS,55513-0800-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.20,20.20,12.12,12.12,N/A,2.83,N/A,20.20,N/A,11.36,N/A,6.87,N/A,2.83,N/A,2.83,N/A,20.20,N/A,20.20,N/A,1.76,N/A,2.83,N/A,2.83,N/A,2.83,N/A,11.36,N/A,20.20,N/A,2.83,N/A,10.83,N/A,10.83,N/A,2.83,N/A,20.20,N/A,20.20,N/A,20.20,12.12,12.12,1.76,20.20,,Hospital HCPCS 6370000000,MORPHINE SULFATE ER 100 MG PO TBCR,42858-0804-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CALCITRIOL 0.25 MCG PO CAPS,23155-0662-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CHOLECALCIFEROL 125 MCG (5000 UT) PO CAPS,50268-0868-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MOMETASONE FUROATE 0.1 % EX CREA,45802-0257-42,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),67.60,67.60,40.56,40.56,N/A,9.46,N/A,67.60,N/A,38.00,N/A,22.98,N/A,9.46,N/A,9.46,N/A,67.60,N/A,67.60,N/A,5.88,N/A,9.46,N/A,9.46,N/A,9.46,N/A,38.00,N/A,67.60,N/A,9.46,N/A,36.23,N/A,36.23,N/A,9.46,N/A,67.60,N/A,67.60,N/A,67.60,40.56,40.56,5.88,67.60,,Hospital HCPCS 6370000000,HYDROCORTISONE 10 MG PO TABS,00115-1697-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,IVERMECTIN 3 MG PO TABS,00006-0032-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.50,10.50,6.30,6.30,N/A,1.47,N/A,10.50,N/A,5.90,N/A,3.57,N/A,1.47,N/A,1.47,N/A,10.50,N/A,10.50,N/A,N/A,N/A,1.47,N/A,1.47,N/A,1.47,N/A,5.90,N/A,10.50,N/A,1.47,N/A,5.63,N/A,5.63,N/A,1.47,N/A,10.50,N/A,10.50,N/A,10.50,6.30,6.30,1.47,10.50,,Hospital HCPCS 6370000000,EMPAGLIFLOZIN 10 MG PO TABS,00597-0152-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),42.80,42.80,25.68,25.68,N/A,5.99,N/A,42.80,N/A,24.06,N/A,14.55,N/A,5.99,N/A,5.99,N/A,42.80,N/A,42.80,N/A,3.72,N/A,5.99,N/A,5.99,N/A,5.99,N/A,24.06,N/A,42.80,N/A,5.99,N/A,22.94,N/A,22.94,N/A,5.99,N/A,42.80,N/A,42.80,N/A,42.80,25.68,25.68,3.72,42.80,,Hospital HCPCS 6370000000,PREDNISOLONE ACETATE 1 % OP SUSP,61314-0637-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),99.60,99.60,59.76,59.76,N/A,13.94,N/A,99.60,N/A,56.00,N/A,33.86,N/A,13.94,N/A,13.94,N/A,99.60,N/A,99.60,N/A,8.67,N/A,13.94,N/A,13.94,N/A,13.94,N/A,56.00,N/A,99.60,N/A,13.94,N/A,53.39,N/A,53.39,N/A,13.94,N/A,99.60,N/A,99.60,N/A,99.60,59.76,59.76,8.67,99.60,,Hospital HCPCS 6370000000,SOLIFENACIN SUCCINATE 5 MG PO TABS,51248-0150-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),29.00,29.00,17.40,17.40,N/A,4.06,N/A,29.00,N/A,16.30,N/A,9.86,N/A,4.06,N/A,4.06,N/A,29.00,N/A,29.00,N/A,2.52,N/A,4.06,N/A,4.06,N/A,4.06,N/A,16.30,N/A,29.00,N/A,4.06,N/A,15.54,N/A,15.54,N/A,4.06,N/A,29.00,N/A,29.00,N/A,29.00,17.40,17.40,2.52,29.00,,Hospital HCPCS 6370000000,LORAZEPAM 1 MG PO TABS,00904-6008-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MEPROBAMATE 400 MG PO TABS,55111-0641-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.90,14.90,8.94,8.94,N/A,2.09,N/A,14.90,N/A,8.38,N/A,5.07,N/A,2.09,N/A,2.09,N/A,14.90,N/A,14.90,N/A,1.30,N/A,2.09,N/A,2.09,N/A,2.09,N/A,8.38,N/A,14.90,N/A,2.09,N/A,7.99,N/A,7.99,N/A,2.09,N/A,14.90,N/A,14.90,N/A,14.90,8.94,8.94,1.30,14.90,,Hospital HCPCS 6370000000,METOCLOPRAMIDE HCL 5 MG PO TABS,51079-0886-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CYCLOBENZAPRINE HCL 5 MG PO TABS,10702-0006-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DESOXIMETASONE 0.25 % EX CREA,51672-1270-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),124.90,124.90,74.94,74.94,N/A,17.49,N/A,124.90,N/A,70.22,N/A,42.47,N/A,17.49,N/A,17.49,N/A,124.90,N/A,124.90,N/A,10.87,N/A,17.49,N/A,17.49,N/A,17.49,N/A,70.22,N/A,124.90,N/A,17.49,N/A,66.95,N/A,66.95,N/A,17.49,N/A,124.90,N/A,124.90,N/A,124.90,74.94,74.94,10.87,124.90,,Hospital HCPCS 6370000000,ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN,09999-9910-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 6370000000,VITAMIN D3 125 MCG (5000 UT) PO CAPS,31604-0026-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SILDENAFIL CITRATE 20 MG PO TABS,00904-6671-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GLYCOPYRROLATE 1 MG PO TABS,55111-0648-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LEVETIRACETAM 250 MG PO TABS,68084-0859-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PREGABALIN 25 MG PO CAPS,60687-0473-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHADONE HCL 10 MG PO TABS,00406-5771-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DOCUSATE CALCIUM 240 MG PO CAPS,46122-0260-78,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,DOFETILIDE 125 MCG PO CAPS,00069-5800-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.60,23.60,14.16,14.16,N/A,3.30,N/A,23.60,N/A,13.27,N/A,8.02,N/A,3.30,N/A,3.30,N/A,23.60,N/A,23.60,N/A,2.05,N/A,3.30,N/A,3.30,N/A,3.30,N/A,13.27,N/A,23.60,N/A,3.30,N/A,12.65,N/A,12.65,N/A,3.30,N/A,23.60,N/A,23.60,N/A,23.60,14.16,14.16,2.05,23.60,,Hospital HCPCS 6370000000,MESALAMINE ER 0.375 G PO CP24,65649-0103-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),38.30,38.30,22.98,22.98,N/A,5.36,N/A,38.30,N/A,21.53,N/A,13.02,N/A,5.36,N/A,5.36,N/A,38.30,N/A,38.30,N/A,3.33,N/A,5.36,N/A,5.36,N/A,5.36,N/A,21.53,N/A,38.30,N/A,5.36,N/A,20.53,N/A,20.53,N/A,5.36,N/A,38.30,N/A,38.30,N/A,38.30,22.98,22.98,3.33,38.30,,Hospital HCPCS 6370000000,VENLAFAXINE HCL 75 MG PO TABS,68001-0160-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LEVOBUNOLOL HCL 0.5 % OP SOLN,24208-0505-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),40.30,40.30,24.18,24.18,N/A,5.64,N/A,40.30,N/A,22.66,N/A,13.70,N/A,5.64,N/A,5.64,N/A,40.30,N/A,40.30,N/A,3.51,N/A,5.64,N/A,5.64,N/A,5.64,N/A,22.66,N/A,40.30,N/A,5.64,N/A,21.60,N/A,21.60,N/A,5.64,N/A,40.30,N/A,40.30,N/A,40.30,24.18,24.18,3.51,40.30,,Hospital HCPCS 6370000000,LINEZOLID 600 MG PO TABS,67877-0419-33,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 6370000000,HALOPERIDOL 2 MG PO TABS,51079-0735-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP,00121-0431-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DICLOFENAC SODIUM 1 % EX GEL,45802-0953-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.70,27.70,16.62,16.62,N/A,3.88,N/A,27.70,N/A,15.57,N/A,9.42,N/A,3.88,N/A,3.88,N/A,27.70,N/A,27.70,N/A,2.41,N/A,3.88,N/A,3.88,N/A,3.88,N/A,15.57,N/A,27.70,N/A,3.88,N/A,14.85,N/A,14.85,N/A,3.88,N/A,27.70,N/A,27.70,N/A,27.70,16.62,16.62,2.41,27.70,,Hospital HCPCS 6370000000,GLYBURIDE 2.5 MG PO TABS,23155-0057-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SACUBITRIL-VALSARTAN 24-26 MG PO TABS,00078-0659-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.90,23.90,14.34,14.34,N/A,3.35,N/A,23.90,N/A,13.44,N/A,8.13,N/A,3.35,N/A,3.35,N/A,23.90,N/A,23.90,N/A,2.08,N/A,3.35,N/A,3.35,N/A,3.35,N/A,13.44,N/A,23.90,N/A,3.35,N/A,12.81,N/A,12.81,N/A,3.35,N/A,23.90,N/A,23.90,N/A,23.90,14.34,14.34,2.08,23.90,,Hospital HCPCS 6370000000,SACUBITRIL-VALSARTAN 49-51 MG PO TABS,00078-0777-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.90,23.90,14.34,14.34,N/A,3.35,N/A,23.90,N/A,13.44,N/A,8.13,N/A,3.35,N/A,3.35,N/A,23.90,N/A,23.90,N/A,2.08,N/A,3.35,N/A,3.35,N/A,3.35,N/A,13.44,N/A,23.90,N/A,3.35,N/A,12.81,N/A,12.81,N/A,3.35,N/A,23.90,N/A,23.90,N/A,23.90,14.34,14.34,2.08,23.90,,Hospital HCPCS 6370000000,PENICILLAMINE 250 MG PO CAPS,25010-0705-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),589.30,589.30,353.58,353.58,N/A,82.50,N/A,589.30,N/A,331.30,N/A,200.36,N/A,82.50,N/A,82.50,N/A,589.30,N/A,589.30,N/A,51.27,N/A,82.50,N/A,82.50,N/A,82.50,N/A,331.30,N/A,589.30,N/A,82.50,N/A,315.86,N/A,315.86,N/A,82.50,N/A,589.30,N/A,589.30,N/A,589.30,353.58,353.58,51.27,589.30,,Hospital HCPCS 6370000000,MIDODRINE HCL 2.5 MG PO TABS,00245-0211-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROMORPHONE HCL 1 MG/ML PO LIQD,00054-0386-63,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DESIPRAMINE HCL 10 MG PO TABS,45963-0341-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.30,6.30,3.78,3.78,N/A,N/A,N/A,6.30,N/A,3.54,N/A,2.14,N/A,N/A,N/A,N/A,N/A,6.30,N/A,6.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.54,N/A,6.30,N/A,N/A,N/A,3.38,N/A,3.38,N/A,N/A,N/A,6.30,N/A,6.30,N/A,6.30,3.78,3.78,2.14,6.30,,Hospital HCPCS 6370000000,METOCLOPRAMIDE HCL 10 MG/10ML PO SOLN,00121-1576-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CELECOXIB 200 MG PO CAPS,00093-7166-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GLIMEPIRIDE 1 MG PO TABS,55111-0320-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PERPHENAZINE-AMITRIPTYLINE 2-10 MG PO TABS,00378-0330-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AMPHETAMINE-DEXTROAMPHET ER 15 MG PO CP24,00228-3063-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRENATAL 27-0.8 MG PO TABS,00904-5313-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PERMETHRIN 1 % EX LIQD,63736-0120-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.10,20.10,12.06,12.06,N/A,2.81,N/A,20.10,N/A,11.30,N/A,6.83,N/A,2.81,N/A,2.81,N/A,20.10,N/A,20.10,N/A,1.75,N/A,2.81,N/A,2.81,N/A,2.81,N/A,11.30,N/A,20.10,N/A,2.81,N/A,10.77,N/A,10.77,N/A,2.81,N/A,20.10,N/A,20.10,N/A,20.10,12.06,12.06,1.75,20.10,,Hospital HCPCS 6370000000,ATORVASTATIN CALCIUM 40 MG PO TABS,60505-2580-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,WARFARIN SODIUM 2.5 MG PO TABS,68084-0027-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUOCINONIDE 0.05 % EX OINT,51672-1264-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),58.40,58.40,35.04,35.04,N/A,8.18,N/A,58.40,N/A,32.83,N/A,19.86,N/A,8.18,N/A,8.18,N/A,58.40,N/A,58.40,N/A,5.08,N/A,8.18,N/A,8.18,N/A,8.18,N/A,32.83,N/A,58.40,N/A,8.18,N/A,31.30,N/A,31.30,N/A,8.18,N/A,58.40,N/A,58.40,N/A,58.40,35.04,35.04,5.08,58.40,,Hospital HCPCS 6370000000,NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,24208-0830-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.80,35.80,21.48,21.48,N/A,5.01,N/A,35.80,N/A,20.13,N/A,12.17,N/A,5.01,N/A,5.01,N/A,35.80,N/A,35.80,N/A,3.11,N/A,5.01,N/A,5.01,N/A,5.01,N/A,20.13,N/A,35.80,N/A,5.01,N/A,19.19,N/A,19.19,N/A,5.01,N/A,35.80,N/A,35.80,N/A,35.80,21.48,21.48,3.11,35.80,,Hospital HCPCS 6370000000,MIRTAZAPINE 7.5 MG PO TABS,13107-0001-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LEVONORGESTREL 1.5 MG PO TABS,62756-0718-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),45.00,45.00,27.00,27.00,N/A,6.30,N/A,45.00,N/A,25.30,N/A,15.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,3.92,N/A,6.30,N/A,6.30,N/A,6.30,N/A,25.30,N/A,45.00,N/A,6.30,N/A,24.12,N/A,24.12,N/A,6.30,N/A,45.00,N/A,45.00,N/A,45.00,27.00,27.00,3.92,45.00,,Hospital HCPCS 6370000000,PRAZOSIN HCL 2 MG PO CAPS,51079-0631-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DISOPYRAMIDE PHOSPHATE 100 MG PO CAPS,00093-3127-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRAMOXINE-HC 1-1 % EX FOAM,00037-6824-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),191.00,191.00,114.60,114.60,N/A,26.74,N/A,191.00,N/A,107.38,N/A,64.94,N/A,26.74,N/A,26.74,N/A,191.00,N/A,191.00,N/A,16.62,N/A,26.74,N/A,26.74,N/A,26.74,N/A,107.38,N/A,191.00,N/A,26.74,N/A,102.38,N/A,102.38,N/A,26.74,N/A,191.00,N/A,191.00,N/A,191.00,114.60,114.60,16.62,191.00,,Hospital HCPCS 6370000000,DIVALPROEX SODIUM ER 250 MG PO TB24,51079-0766-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXYBUTYNIN CHLORIDE ER 5 MG PO TB24,68084-0480-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.80,5.80,3.48,3.48,N/A,N/A,N/A,5.80,N/A,3.26,N/A,1.97,N/A,N/A,N/A,N/A,N/A,5.80,N/A,5.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.26,N/A,5.80,N/A,N/A,N/A,3.11,N/A,3.11,N/A,N/A,N/A,5.80,N/A,5.80,N/A,5.80,3.48,3.48,1.97,5.80,,Hospital HCPCS 6370000000,EPINEPHRINE 0.125 MG/ACT IN AERO,17270-0553-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MAGIC MOUTHWASH WITHOUT NYSTATIN SIMPLE,09999-9902-85,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.40,12.40,7.44,7.44,N/A,1.74,N/A,12.40,N/A,6.97,N/A,4.22,N/A,1.74,N/A,1.74,N/A,12.40,N/A,12.40,N/A,1.08,N/A,1.74,N/A,1.74,N/A,1.74,N/A,6.97,N/A,12.40,N/A,1.74,N/A,6.65,N/A,6.65,N/A,1.74,N/A,12.40,N/A,12.40,N/A,12.40,7.44,7.44,1.08,12.40,,Hospital HCPCS 6370000000,BETAMETHASONE DIPROPIONATE 0.05 % EX CREA,00168-0055-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),95.10,95.10,57.06,57.06,N/A,13.31,N/A,95.10,N/A,53.47,N/A,32.33,N/A,13.31,N/A,13.31,N/A,95.10,N/A,95.10,N/A,8.27,N/A,13.31,N/A,13.31,N/A,13.31,N/A,53.47,N/A,95.10,N/A,13.31,N/A,50.97,N/A,50.97,N/A,13.31,N/A,95.10,N/A,95.10,N/A,95.10,57.06,57.06,8.27,95.10,,Hospital HCPCS 6370000000,SAXAGLIPTIN HCL 5 MG PO TABS,00310-6105-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.40,35.40,21.24,21.24,N/A,4.96,N/A,35.40,N/A,19.90,N/A,12.04,N/A,4.96,N/A,4.96,N/A,35.40,N/A,35.40,N/A,3.08,N/A,4.96,N/A,4.96,N/A,4.96,N/A,19.90,N/A,35.40,N/A,4.96,N/A,18.97,N/A,18.97,N/A,4.96,N/A,35.40,N/A,35.40,N/A,35.40,21.24,21.24,3.08,35.40,,Hospital HCPCS 6370000000,FAMCICLOVIR 500 MG PO TABS,00093-8119-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.30,7.30,4.38,4.38,N/A,1.02,N/A,7.30,N/A,4.10,N/A,2.48,N/A,1.02,N/A,1.02,N/A,7.30,N/A,7.30,N/A,N/A,N/A,1.02,N/A,1.02,N/A,1.02,N/A,4.10,N/A,7.30,N/A,1.02,N/A,3.91,N/A,3.91,N/A,1.02,N/A,7.30,N/A,7.30,N/A,7.30,4.38,4.38,1.02,7.30,,Hospital HCPCS 6370000000,CARIPRAZINE HCL 1.5 MG PO CAPS,61874-0115-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),98.50,98.50,59.10,59.10,N/A,13.79,N/A,98.50,N/A,55.38,N/A,33.49,N/A,13.79,N/A,13.79,N/A,98.50,N/A,98.50,N/A,8.57,N/A,13.79,N/A,13.79,N/A,13.79,N/A,55.38,N/A,98.50,N/A,13.79,N/A,52.80,N/A,52.80,N/A,13.79,N/A,98.50,N/A,98.50,N/A,98.50,59.10,59.10,8.57,98.50,,Hospital HCPCS 6370000000,TRIFLURIDINE 1 % OP SOLN,61314-0044-75,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),401.30,401.30,240.78,240.78,N/A,56.18,N/A,401.30,N/A,225.61,N/A,136.44,N/A,56.18,N/A,56.18,N/A,401.30,N/A,401.30,N/A,34.91,N/A,56.18,N/A,56.18,N/A,56.18,N/A,225.61,N/A,401.30,N/A,56.18,N/A,215.10,N/A,215.10,N/A,56.18,N/A,401.30,N/A,401.30,N/A,401.30,240.78,240.78,34.91,401.30,,Hospital HCPCS 6370000000,CETIRIZINE HCL 5 MG PO TABS,00378-3635-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CENTRUM PO LIQD,54629-0800-98,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FENOFIBRATE 54 MG PO TABS,00378-7100-77,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SULINDAC 200 MG PO TABS,00591-5660-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NICOTINE POLACRILEX 2 MG MT LOZG,45802-0344-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),21.30,21.30,12.78,12.78,N/A,2.98,N/A,21.30,N/A,11.97,N/A,7.24,N/A,2.98,N/A,2.98,N/A,21.30,N/A,21.30,N/A,1.85,N/A,2.98,N/A,2.98,N/A,2.98,N/A,11.97,N/A,21.30,N/A,2.98,N/A,11.42,N/A,11.42,N/A,2.98,N/A,21.30,N/A,21.30,N/A,21.30,12.78,12.78,1.85,21.30,,Hospital HCPCS 6370000000,CLONIDINE 0.1 MG/24HR TD PTWK,00378-0871-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),59.70,59.70,35.82,35.82,N/A,8.36,N/A,59.70,N/A,33.56,N/A,20.30,N/A,8.36,N/A,8.36,N/A,59.70,N/A,59.70,N/A,5.19,N/A,8.36,N/A,8.36,N/A,8.36,N/A,33.56,N/A,59.70,N/A,8.36,N/A,32.00,N/A,32.00,N/A,8.36,N/A,59.70,N/A,59.70,N/A,59.70,35.82,35.82,5.19,59.70,,Hospital HCPCS 6370000000,OLODATEROL HCL 2.5 MCG/ACT IN AERS,09999-9915-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.90,5.90,3.54,3.54,N/A,N/A,N/A,5.90,N/A,3.32,N/A,2.01,N/A,N/A,N/A,N/A,N/A,5.90,N/A,5.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.32,N/A,5.90,N/A,N/A,N/A,3.16,N/A,3.16,N/A,N/A,N/A,5.90,N/A,5.90,N/A,5.90,3.54,3.54,2.01,5.90,,Hospital HCPCS 6370000000,COLLAGENASE 250 UNIT/GM EX OINT,50484-0010-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),617.10,617.10,370.26,370.26,N/A,86.39,N/A,617.10,N/A,346.93,N/A,209.81,N/A,86.39,N/A,86.39,N/A,617.10,N/A,617.10,N/A,53.69,N/A,86.39,N/A,86.39,N/A,86.39,N/A,346.93,N/A,617.10,N/A,86.39,N/A,330.77,N/A,330.77,N/A,86.39,N/A,617.10,N/A,617.10,N/A,617.10,370.26,370.26,53.69,617.10,,Hospital HCPCS 6370000000,SOTALOL HCL 80 MG PO TABS,00093-1061-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MELATONIN 5 MG PO TBDP,47469-0058-65,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ROSUVASTATIN CALCIUM 20 MG PO TABS,68462-0263-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLOTRIMAZOLE 10 MG MT TROC,00574-0107-70,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NORTRIPTYLINE HCL 75 MG PO CAPS,00093-0813-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DESONIDE 0.05 % EX CREA,51672-1280-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),578.10,578.10,346.86,346.86,N/A,80.93,N/A,578.10,N/A,325.01,N/A,196.55,N/A,80.93,N/A,80.93,N/A,578.10,N/A,578.10,N/A,50.29,N/A,80.93,N/A,80.93,N/A,80.93,N/A,325.01,N/A,578.10,N/A,80.93,N/A,309.86,N/A,309.86,N/A,80.93,N/A,578.10,N/A,578.10,N/A,578.10,346.86,346.86,50.29,578.10,,Hospital HCPCS 6370000000,SODIUM HYPOCHLORITE 0.25 % EX SOLN,39328-0063-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.50,24.50,14.70,14.70,N/A,3.43,N/A,24.50,N/A,13.77,N/A,8.33,N/A,3.43,N/A,3.43,N/A,24.50,N/A,24.50,N/A,2.13,N/A,3.43,N/A,3.43,N/A,3.43,N/A,13.77,N/A,24.50,N/A,3.43,N/A,13.13,N/A,13.13,N/A,3.43,N/A,24.50,N/A,24.50,N/A,24.50,14.70,14.70,2.13,24.50,,Hospital HCPCS 6370000000,CLONIDINE HCL 0.3 MG PO TABS,52817-0182-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MAGNESIUM CITRATE PO SOLN,N/A,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OMEPRAZOLE 10 MG PO CPDR,62175-0114-32,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,LOTEPREDNOL ETABONATE 0.5 % OP SUSP,24208-0299-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),637.10,637.10,382.26,382.26,N/A,89.19,N/A,637.10,N/A,358.18,N/A,216.61,N/A,89.19,N/A,89.19,N/A,637.10,N/A,637.10,N/A,55.43,N/A,89.19,N/A,89.19,N/A,89.19,N/A,358.18,N/A,637.10,N/A,89.19,N/A,341.49,N/A,341.49,N/A,89.19,N/A,637.10,N/A,637.10,N/A,637.10,382.26,382.26,55.43,637.10,,Hospital HCPCS 6370000000,DEMECLOCYCLINE HCL 150 MG PO TABS,65162-0554-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.30,14.30,8.58,8.58,N/A,2.00,N/A,14.30,N/A,8.04,N/A,4.86,N/A,2.00,N/A,2.00,N/A,14.30,N/A,14.30,N/A,1.24,N/A,2.00,N/A,2.00,N/A,2.00,N/A,8.04,N/A,14.30,N/A,2.00,N/A,7.66,N/A,7.66,N/A,2.00,N/A,14.30,N/A,14.30,N/A,14.30,8.58,8.58,1.24,14.30,,Hospital HCPCS 6370000000,FLUDROCORTISONE ACETATE 0.1 MG PO TABS,68084-0288-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SORBITOL 70 % SOLN,46287-0500-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,SITAGLIPTIN PHOSPHATE 25 MG PO TABS,00006-0221-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),39.20,39.20,23.52,23.52,N/A,5.49,N/A,39.20,N/A,22.04,N/A,13.33,N/A,5.49,N/A,5.49,N/A,39.20,N/A,39.20,N/A,3.41,N/A,5.49,N/A,5.49,N/A,5.49,N/A,22.04,N/A,39.20,N/A,5.49,N/A,21.01,N/A,21.01,N/A,5.49,N/A,39.20,N/A,39.20,N/A,39.20,23.52,23.52,3.41,39.20,,Hospital HCPCS 6370000000,SODIUM CHLORIDE 1 G PO TABS,00223-1760-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,SERTRALINE HCL 25 MG PO TABS,60687-0231-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXYCODONE HCL 5 MG/5ML PO SOLN,00121-4839-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.30,13.30,7.98,7.98,N/A,1.86,N/A,13.30,N/A,7.48,N/A,4.52,N/A,1.86,N/A,1.86,N/A,13.30,N/A,13.30,N/A,1.16,N/A,1.86,N/A,1.86,N/A,1.86,N/A,7.48,N/A,13.30,N/A,1.86,N/A,7.13,N/A,7.13,N/A,1.86,N/A,13.30,N/A,13.30,N/A,13.30,7.98,7.98,1.16,13.30,,Hospital HCPCS 6370000000,NITROGLYCERIN 0.4 MG SL SUBL,00071-0418-24,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ROTIGOTINE 1 MG/24HR TD PT24,50474-0801-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),57.20,57.20,34.32,34.32,N/A,8.01,N/A,57.20,N/A,32.16,N/A,19.45,N/A,8.01,N/A,8.01,N/A,57.20,N/A,57.20,N/A,4.98,N/A,8.01,N/A,8.01,N/A,8.01,N/A,32.16,N/A,57.20,N/A,8.01,N/A,30.66,N/A,30.66,N/A,8.01,N/A,57.20,N/A,57.20,N/A,57.20,34.32,34.32,4.98,57.20,,Hospital HCPCS 6370000000,AZITHROMYCIN 500 MG PO TABS,50111-0788-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.90,10.90,6.54,6.54,N/A,1.53,N/A,10.90,N/A,6.13,N/A,3.71,N/A,1.53,N/A,1.53,N/A,10.90,N/A,10.90,N/A,N/A,N/A,1.53,N/A,1.53,N/A,1.53,N/A,6.13,N/A,10.90,N/A,1.53,N/A,5.84,N/A,5.84,N/A,1.53,N/A,10.90,N/A,10.90,N/A,10.90,6.54,6.54,1.53,10.90,,Hospital HCPCS 6370000000,PREDNISOLONE ACETATE 0.12 % OP SUSP,11980-0174-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),360.90,360.90,216.54,216.54,N/A,50.53,N/A,360.90,N/A,202.90,N/A,122.71,N/A,50.53,N/A,50.53,N/A,360.90,N/A,360.90,N/A,31.40,N/A,50.53,N/A,50.53,N/A,50.53,N/A,202.90,N/A,360.90,N/A,50.53,N/A,193.44,N/A,193.44,N/A,50.53,N/A,360.90,N/A,360.90,N/A,360.90,216.54,216.54,31.40,360.90,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 25 MCG PO TABS,00074-4341-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.50,6.50,3.90,3.90,N/A,N/A,N/A,6.50,N/A,3.65,N/A,2.21,N/A,N/A,N/A,N/A,N/A,6.50,N/A,6.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.65,N/A,6.50,N/A,N/A,N/A,3.48,N/A,3.48,N/A,N/A,N/A,6.50,N/A,6.50,N/A,6.50,3.90,3.90,2.21,6.50,,Hospital HCPCS 6370000000,MAGNESIUM GLUCONATE 500 (27 MG) MG PO TABS,60258-0172-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RISPERIDONE 0.5 MG PO TBDP,49884-0311-55,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 6370000000,PHENTERMINE HCL 30 MG PO CAPS,00185-5000-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.70,3.70,2.22,2.22,N/A,N/A,N/A,3.70,N/A,2.08,N/A,1.26,N/A,N/A,N/A,N/A,N/A,3.70,N/A,3.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.08,N/A,3.70,N/A,N/A,N/A,1.98,N/A,1.98,N/A,N/A,N/A,3.70,N/A,3.70,N/A,3.70,2.22,2.22,1.26,3.70,,Hospital HCPCS 6370000000,LIDOCAINE HCL 4 % EX SOLN,00054-3505-47,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),90.00,90.00,54.00,54.00,N/A,12.60,N/A,90.00,N/A,50.60,N/A,30.60,N/A,12.60,N/A,12.60,N/A,90.00,N/A,90.00,N/A,7.83,N/A,12.60,N/A,12.60,N/A,12.60,N/A,50.60,N/A,90.00,N/A,12.60,N/A,48.24,N/A,48.24,N/A,12.60,N/A,90.00,N/A,90.00,N/A,90.00,54.00,54.00,7.83,90.00,,Hospital HCPCS 6370000000,LORAZEPAM 2 MG PO TABS,00904-6009-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LAMIVUDINE 10 MG/ML PO SOLN,09999-9910-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.30,11.30,6.78,6.78,N/A,1.58,N/A,11.30,N/A,6.35,N/A,3.84,N/A,1.58,N/A,1.58,N/A,11.30,N/A,11.30,N/A,N/A,N/A,1.58,N/A,1.58,N/A,1.58,N/A,6.35,N/A,11.30,N/A,1.58,N/A,6.06,N/A,6.06,N/A,1.58,N/A,11.30,N/A,11.30,N/A,11.30,6.78,6.78,1.58,11.30,,Hospital HCPCS 6370000000,ADAPALENE 0.1 % EX CREA,00168-0424-46,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),530.80,530.80,318.48,318.48,N/A,74.31,N/A,530.80,N/A,298.42,N/A,180.47,N/A,74.31,N/A,74.31,N/A,530.80,N/A,530.80,N/A,46.18,N/A,74.31,N/A,74.31,N/A,74.31,N/A,298.42,N/A,530.80,N/A,74.31,N/A,284.51,N/A,284.51,N/A,74.31,N/A,530.80,N/A,530.80,N/A,530.80,318.48,318.48,46.18,530.80,,Hospital HCPCS 6370000000,PROPYLENE GLYCOL LIQD,00574-0072-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.20,19.20,11.52,11.52,N/A,2.69,N/A,19.20,N/A,10.79,N/A,6.53,N/A,2.69,N/A,2.69,N/A,19.20,N/A,19.20,N/A,1.67,N/A,2.69,N/A,2.69,N/A,2.69,N/A,10.79,N/A,19.20,N/A,2.69,N/A,10.29,N/A,10.29,N/A,2.69,N/A,19.20,N/A,19.20,N/A,19.20,11.52,11.52,1.67,19.20,,Hospital HCPCS 6370000000,PREGABALIN 150 MG PO CAPS,72205-0015-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,UREA 15 G PO PACK,62530-0000-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.90,7.90,4.74,4.74,N/A,1.11,N/A,7.90,N/A,4.44,N/A,2.69,N/A,1.11,N/A,1.11,N/A,7.90,N/A,7.90,N/A,N/A,N/A,1.11,N/A,1.11,N/A,1.11,N/A,4.44,N/A,7.90,N/A,1.11,N/A,4.23,N/A,4.23,N/A,1.11,N/A,7.90,N/A,7.90,N/A,7.90,4.74,4.74,1.11,7.90,,Hospital HCPCS 6370000000,NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,24208-0780-55,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),102.60,102.60,61.56,61.56,N/A,14.36,N/A,102.60,N/A,57.68,N/A,34.88,N/A,14.36,N/A,14.36,N/A,102.60,N/A,102.60,N/A,8.93,N/A,14.36,N/A,14.36,N/A,14.36,N/A,57.68,N/A,102.60,N/A,14.36,N/A,54.99,N/A,54.99,N/A,14.36,N/A,102.60,N/A,102.60,N/A,102.60,61.56,61.56,8.93,102.60,,Hospital HCPCS 6370000000,MORPHINE SULFATE ER BEADS 30 MG PO CP24,00228-3090-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),31.00,31.00,18.60,18.60,N/A,4.34,N/A,31.00,N/A,17.43,N/A,10.54,N/A,4.34,N/A,4.34,N/A,31.00,N/A,31.00,N/A,2.70,N/A,4.34,N/A,4.34,N/A,4.34,N/A,17.43,N/A,31.00,N/A,4.34,N/A,16.62,N/A,16.62,N/A,4.34,N/A,31.00,N/A,31.00,N/A,31.00,18.60,18.60,2.70,31.00,,Hospital HCPCS 6370000000,MEXILETINE HCL 250 MG PO CAPS,00093-8741-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MAGNESIUM CARBONATE 54 (MAG EQUIV) MG/5ML PO LIQD,00187-5267-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TERBUTALINE SULFATE 2.5 MG PO TABS,00527-1318-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.80,9.80,5.88,5.88,N/A,1.37,N/A,9.80,N/A,5.51,N/A,3.33,N/A,1.37,N/A,1.37,N/A,9.80,N/A,9.80,N/A,N/A,N/A,1.37,N/A,1.37,N/A,1.37,N/A,5.51,N/A,9.80,N/A,1.37,N/A,5.25,N/A,5.25,N/A,1.37,N/A,9.80,N/A,9.80,N/A,9.80,5.88,5.88,1.37,9.80,,Hospital HCPCS 6370000000,LISDEXAMFETAMINE DIMESYLATE 70 MG PO CAPS,59417-0107-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.40,26.40,15.84,15.84,N/A,3.70,N/A,26.40,N/A,14.84,N/A,8.98,N/A,3.70,N/A,3.70,N/A,26.40,N/A,26.40,N/A,2.30,N/A,3.70,N/A,3.70,N/A,3.70,N/A,14.84,N/A,26.40,N/A,3.70,N/A,14.15,N/A,14.15,N/A,3.70,N/A,26.40,N/A,26.40,N/A,26.40,15.84,15.84,2.30,26.40,,Hospital HCPCS 6370000000,VERAPAMIL HCL 120 MG PO TABS,00591-0345-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 100 MCG PO TABS,00074-6624-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NALOXEGOL OXALATE 12.5 MG PO TABS,57841-1300-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),28.90,28.90,17.34,17.34,N/A,4.05,N/A,28.90,N/A,16.25,N/A,9.83,N/A,4.05,N/A,4.05,N/A,28.90,N/A,28.90,N/A,2.51,N/A,4.05,N/A,4.05,N/A,4.05,N/A,16.25,N/A,28.90,N/A,4.05,N/A,15.49,N/A,15.49,N/A,4.05,N/A,28.90,N/A,28.90,N/A,28.90,17.34,17.34,2.51,28.90,,Hospital HCPCS 6370000000,CHLORTHALIDONE 25 MG PO TABS,51079-0058-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ALLOPURINOL 100 MG PO TABS,62584-0988-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CELECOXIB 100 MG PO CAPS,00025-1520-34,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.10,20.10,12.06,12.06,N/A,2.81,N/A,20.10,N/A,11.30,N/A,6.83,N/A,2.81,N/A,2.81,N/A,20.10,N/A,20.10,N/A,1.75,N/A,2.81,N/A,2.81,N/A,2.81,N/A,11.30,N/A,20.10,N/A,2.81,N/A,10.77,N/A,10.77,N/A,2.81,N/A,20.10,N/A,20.10,N/A,20.10,12.06,12.06,1.75,20.10,,Hospital HCPCS 6370000000,RIVAROXABAN 20 MG PO TABS,50458-0579-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),38.80,38.80,23.28,23.28,N/A,5.43,N/A,38.80,N/A,21.81,N/A,13.19,N/A,5.43,N/A,5.43,N/A,38.80,N/A,38.80,N/A,3.38,N/A,5.43,N/A,5.43,N/A,5.43,N/A,21.81,N/A,38.80,N/A,5.43,N/A,20.80,N/A,20.80,N/A,5.43,N/A,38.80,N/A,38.80,N/A,38.80,23.28,23.28,3.38,38.80,,Hospital HCPCS 6370000000,HYDROCORTISONE 2.5 % EX CREA,00168-0080-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.50,7.50,4.50,4.50,N/A,1.05,N/A,7.50,N/A,4.22,N/A,2.55,N/A,1.05,N/A,1.05,N/A,7.50,N/A,7.50,N/A,N/A,N/A,1.05,N/A,1.05,N/A,1.05,N/A,4.22,N/A,7.50,N/A,1.05,N/A,4.02,N/A,4.02,N/A,1.05,N/A,7.50,N/A,7.50,N/A,7.50,4.50,4.50,1.05,7.50,,Hospital HCPCS 6370000000,ISOSORBIDE MONONITRATE 20 MG PO TABS,00228-2620-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FERROUS SULFATE 220 (44 FE) MG/5ML PO ELIX,09999-9903-63,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL 60 MG PO TABS,00093-0319-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHYLCELLULOSE (LAXATIVE) 500 MG PO TABS,00135-0199-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DOXYCYCLINE HYCLATE 100 MG PO CAPS,00143-3142-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,COLLODION FLEXIBLE EX LIQD,49452-2230-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),54.50,54.50,32.70,32.70,N/A,7.63,N/A,54.50,N/A,30.64,N/A,18.53,N/A,7.63,N/A,7.63,N/A,54.50,N/A,54.50,N/A,4.74,N/A,7.63,N/A,7.63,N/A,7.63,N/A,30.64,N/A,54.50,N/A,7.63,N/A,29.21,N/A,29.21,N/A,7.63,N/A,54.50,N/A,54.50,N/A,54.50,32.70,32.70,4.74,54.50,,Hospital HCPCS 6370000000,PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS PO CPEP,00032-1224-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.90,16.90,10.14,10.14,N/A,2.37,N/A,16.90,N/A,9.50,N/A,5.75,N/A,2.37,N/A,2.37,N/A,16.90,N/A,16.90,N/A,1.47,N/A,2.37,N/A,2.37,N/A,2.37,N/A,9.50,N/A,16.90,N/A,2.37,N/A,9.06,N/A,9.06,N/A,2.37,N/A,16.90,N/A,16.90,N/A,16.90,10.14,10.14,1.47,16.90,,Hospital HCPCS 6370000000,PSYLLIUM 58.12 % PO PACK,37000-0024-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LATANOPROST 0.005 % OP SOLN,61314-0547-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.10,24.10,14.46,14.46,N/A,3.37,N/A,24.10,N/A,13.55,N/A,8.19,N/A,3.37,N/A,3.37,N/A,24.10,N/A,24.10,N/A,2.10,N/A,3.37,N/A,3.37,N/A,3.37,N/A,13.55,N/A,24.10,N/A,3.37,N/A,12.92,N/A,12.92,N/A,3.37,N/A,24.10,N/A,24.10,N/A,24.10,14.46,14.46,2.10,24.10,,Hospital HCPCS 6370000000,LIOTHYRONINE SODIUM 25 MCG PO TABS,51862-0321-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LISDEXAMFETAMINE DIMESYLATE 50 MG PO CAPS,59417-0105-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.40,26.40,15.84,15.84,N/A,3.70,N/A,26.40,N/A,14.84,N/A,8.98,N/A,3.70,N/A,3.70,N/A,26.40,N/A,26.40,N/A,2.30,N/A,3.70,N/A,3.70,N/A,3.70,N/A,14.84,N/A,26.40,N/A,3.70,N/A,14.15,N/A,14.15,N/A,3.70,N/A,26.40,N/A,26.40,N/A,26.40,15.84,15.84,2.30,26.40,,Hospital HCPCS 6370000000,TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS,61958-0401-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),94.10,94.10,56.46,56.46,N/A,13.17,N/A,94.10,N/A,52.90,N/A,31.99,N/A,13.17,N/A,13.17,N/A,94.10,N/A,94.10,N/A,8.19,N/A,13.17,N/A,13.17,N/A,13.17,N/A,52.90,N/A,94.10,N/A,13.17,N/A,50.44,N/A,50.44,N/A,13.17,N/A,94.10,N/A,94.10,N/A,94.10,56.46,56.46,8.19,94.10,,Hospital HCPCS 6370000000,MEXILETINE HCL 200 MG PO CAPS,00093-8740-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VITAMINS A & D EX OINT,00168-0035-45,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,59310-0304-80,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),601.70,601.70,361.02,361.02,N/A,84.24,N/A,601.70,N/A,338.28,N/A,204.58,N/A,84.24,N/A,84.24,N/A,601.70,N/A,601.70,N/A,52.35,N/A,84.24,N/A,84.24,N/A,84.24,N/A,338.28,N/A,601.70,N/A,84.24,N/A,322.51,N/A,322.51,N/A,84.24,N/A,601.70,N/A,601.70,N/A,601.70,361.02,361.02,52.35,601.70,,Hospital HCPCS 6370000000,THEOPHYLLINE ER 300 MG PO TB12,62332-0025-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.80,7.80,4.68,4.68,N/A,1.09,N/A,7.80,N/A,4.39,N/A,2.65,N/A,1.09,N/A,1.09,N/A,7.80,N/A,7.80,N/A,N/A,N/A,1.09,N/A,1.09,N/A,1.09,N/A,4.39,N/A,7.80,N/A,1.09,N/A,4.18,N/A,4.18,N/A,1.09,N/A,7.80,N/A,7.80,N/A,7.80,4.68,4.68,1.09,7.80,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL ER 54 MG PO TB24,00406-0154-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.40,12.40,7.44,7.44,N/A,1.74,N/A,12.40,N/A,6.97,N/A,4.22,N/A,1.74,N/A,1.74,N/A,12.40,N/A,12.40,N/A,1.08,N/A,1.74,N/A,1.74,N/A,1.74,N/A,6.97,N/A,12.40,N/A,1.74,N/A,6.65,N/A,6.65,N/A,1.74,N/A,12.40,N/A,12.40,N/A,12.40,7.44,7.44,1.08,12.40,,Hospital HCPCS 6370000000,ALBENDAZOLE 200 MG PO TABS,72205-0051-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),67.30,67.30,40.38,40.38,N/A,9.42,N/A,67.30,N/A,37.84,N/A,22.88,N/A,9.42,N/A,9.42,N/A,67.30,N/A,67.30,N/A,5.86,N/A,9.42,N/A,9.42,N/A,9.42,N/A,37.84,N/A,67.30,N/A,9.42,N/A,36.07,N/A,36.07,N/A,9.42,N/A,67.30,N/A,67.30,N/A,67.30,40.38,40.38,5.86,67.30,,Hospital HCPCS 6370000000,DIPHENHYDRAMINE HCL 25 MG PO TABS,00904-5551-59,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,RISPERIDONE 0.5 MG PO TABS,68084-0271-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MENTHOL-ZINC OXIDE 0.44-20.6 % EX OINT,00799-0001-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.00,11.00,6.60,6.60,N/A,1.54,N/A,11.00,N/A,6.18,N/A,3.74,N/A,1.54,N/A,1.54,N/A,11.00,N/A,11.00,N/A,N/A,N/A,1.54,N/A,1.54,N/A,1.54,N/A,6.18,N/A,11.00,N/A,1.54,N/A,5.90,N/A,5.90,N/A,1.54,N/A,11.00,N/A,11.00,N/A,11.00,6.60,6.60,1.54,11.00,,Hospital HCPCS 6370000000,TALC 3 G PL POWD,62327-0333-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),319.50,319.50,191.70,191.70,N/A,44.73,N/A,319.50,N/A,179.62,N/A,108.63,N/A,44.73,N/A,44.73,N/A,319.50,N/A,319.50,N/A,27.80,N/A,44.73,N/A,44.73,N/A,44.73,N/A,179.62,N/A,319.50,N/A,44.73,N/A,171.25,N/A,171.25,N/A,44.73,N/A,319.50,N/A,319.50,N/A,319.50,191.70,191.70,27.80,319.50,,Hospital HCPCS 6370000000,CHOLESTYRAMINE 4 G PO PACK,49884-0465-65,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXYCODONE HCL ER 40 MG PO T12A,59011-0440-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.50,33.50,20.10,20.10,N/A,4.69,N/A,33.50,N/A,18.83,N/A,11.39,N/A,4.69,N/A,4.69,N/A,33.50,N/A,33.50,N/A,2.91,N/A,4.69,N/A,4.69,N/A,4.69,N/A,18.83,N/A,33.50,N/A,4.69,N/A,17.96,N/A,17.96,N/A,4.69,N/A,33.50,N/A,33.50,N/A,33.50,20.10,20.10,2.91,33.50,,Hospital HCPCS 6370000000,HYDRALAZINE HCL 50 MG PO TABS,00904-6442-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POTASSIUM BICARB-CITRIC ACID 10 MEQ PO TBEF,51801-0013-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,QUETIAPINE FUMARATE 400 MG PO TABS,68001-0181-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RAMELTEON 8 MG PO TABS,64764-0805-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),29.20,29.20,17.52,17.52,N/A,4.09,N/A,29.20,N/A,16.42,N/A,9.93,N/A,4.09,N/A,4.09,N/A,29.20,N/A,29.20,N/A,2.54,N/A,4.09,N/A,4.09,N/A,4.09,N/A,16.42,N/A,29.20,N/A,4.09,N/A,15.65,N/A,15.65,N/A,4.09,N/A,29.20,N/A,29.20,N/A,29.20,17.52,17.52,2.54,29.20,,Hospital HCPCS 6370000000,PINDOLOL 10 MG PO TABS,00378-0127-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDRALAZINE HCL 10 MG PO TABS,00904-6440-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ROPINIROLE HCL 0.25 MG PO TABS,68462-0253-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLOTRIMAZOLE 1 % VA CREA,51672-2003-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.20,9.20,5.52,5.52,N/A,1.29,N/A,9.20,N/A,5.17,N/A,3.13,N/A,1.29,N/A,1.29,N/A,9.20,N/A,9.20,N/A,N/A,N/A,1.29,N/A,1.29,N/A,1.29,N/A,5.17,N/A,9.20,N/A,1.29,N/A,4.93,N/A,4.93,N/A,1.29,N/A,9.20,N/A,9.20,N/A,9.20,5.52,5.52,1.29,9.20,,Hospital HCPCS 6370000000,TOPIRAMATE 25 MG PO TABS,68084-0342-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR,68084-0281-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ALPRAZOLAM 2 MG PO TBDP,00228-4025-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.60,20.60,12.36,12.36,N/A,2.88,N/A,20.60,N/A,11.58,N/A,7.00,N/A,2.88,N/A,2.88,N/A,20.60,N/A,20.60,N/A,1.79,N/A,2.88,N/A,2.88,N/A,2.88,N/A,11.58,N/A,20.60,N/A,2.88,N/A,11.04,N/A,11.04,N/A,2.88,N/A,20.60,N/A,20.60,N/A,20.60,12.36,12.36,1.79,20.60,,Hospital HCPCS 6370000000,MEMANTINE HCL 5 MG PO TABS,00456-3205-63,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.70,16.70,10.02,10.02,N/A,2.34,N/A,16.70,N/A,9.39,N/A,5.68,N/A,2.34,N/A,2.34,N/A,16.70,N/A,16.70,N/A,1.45,N/A,2.34,N/A,2.34,N/A,2.34,N/A,9.39,N/A,16.70,N/A,2.34,N/A,8.95,N/A,8.95,N/A,2.34,N/A,16.70,N/A,16.70,N/A,16.70,10.02,10.02,1.45,16.70,,Hospital HCPCS 6370000000,OPIUM 10 MG/ML (1%) PO TINC,62559-0153-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.20,5.20,3.12,3.12,N/A,N/A,N/A,5.20,N/A,2.92,N/A,1.77,N/A,N/A,N/A,N/A,N/A,5.20,N/A,5.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.92,N/A,5.20,N/A,N/A,N/A,2.79,N/A,2.79,N/A,N/A,N/A,5.20,N/A,5.20,N/A,5.20,3.12,3.12,1.77,5.20,,Hospital HCPCS 6370000000,MISOPROSTOL 100 MCG PO TABS,59762-5007-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BARICITINIB 2 MG PO TABS,00002-4182-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),187.30,187.30,112.38,112.38,N/A,26.22,N/A,187.30,N/A,105.30,N/A,63.68,N/A,26.22,N/A,26.22,N/A,187.30,N/A,187.30,N/A,16.30,N/A,26.22,N/A,26.22,N/A,26.22,N/A,105.30,N/A,187.30,N/A,26.22,N/A,100.39,N/A,100.39,N/A,26.22,N/A,187.30,N/A,187.30,N/A,187.30,112.38,112.38,16.30,187.30,,Hospital HCPCS 6370000000,MONTELUKAST SODIUM 4 MG PO PACK,27241-0015-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 6370000000,HYDROXYCHLOROQUINE 25 MG/ML PO SUSP,09999-9914-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUTICASONE PROPIONATE HFA 110 MCG/ACT IN AERO,09999-9907-93,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,IBUPROFEN 200 MG PO TABS,00904-7914-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,ZIDOVUDINE 100 MG PO CAPS,65862-0107-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TOPIRAMATE 100 MG PO TABS,68462-0109-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CEFPODOXIME PROXETIL 100 MG PO TABS,00781-5438-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.20,12.20,7.32,7.32,N/A,1.71,N/A,12.20,N/A,6.86,N/A,4.15,N/A,1.71,N/A,1.71,N/A,12.20,N/A,12.20,N/A,1.06,N/A,1.71,N/A,1.71,N/A,1.71,N/A,6.86,N/A,12.20,N/A,1.71,N/A,6.54,N/A,6.54,N/A,1.71,N/A,12.20,N/A,12.20,N/A,12.20,7.32,7.32,1.06,12.20,,Hospital HCPCS 6370000000,DIVALPROEX SODIUM 500 MG PO TBEC,62756-0798-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BENZTROPINE MESYLATE 0.5 MG PO TABS,00603-2433-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PAROXETINE HCL 20 MG PO TABS,68084-0045-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER BEADS 180 MG PO CP24,62037-0697-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AMMONIA AROMATIC IN INHA,09999-9910-47,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MIRTAZAPINE 15 MG PO TABS,68084-0119-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MINOCYCLINE HCL 50 MG PO CAPS,00591-5694-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SPIRONOLACTONE 25 MG PO TABS,53746-0511-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PSEUDOEPHEDRINE HCL 30 MG PO TABS,00904-5053-59,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,THIORIDAZINE HCL 25 MG PO TABS,51079-0566-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PERPHENAZINE 4 MG PO TABS,00603-5061-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ASCORBIC ACID 500 MG PO TABS,00904-0523-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR,00187-3013-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),79.00,79.00,47.40,47.40,N/A,11.06,N/A,79.00,N/A,44.41,N/A,26.86,N/A,11.06,N/A,11.06,N/A,79.00,N/A,79.00,N/A,6.87,N/A,11.06,N/A,11.06,N/A,11.06,N/A,44.41,N/A,79.00,N/A,11.06,N/A,42.34,N/A,42.34,N/A,11.06,N/A,79.00,N/A,79.00,N/A,79.00,47.40,47.40,6.87,79.00,,Hospital HCPCS 6370000000,MOEXIPRIL HCL 15 MG PO TABS,00093-5150-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,09999-9915-38,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),173.90,173.90,104.34,104.34,N/A,24.35,N/A,173.90,N/A,97.77,N/A,59.13,N/A,24.35,N/A,24.35,N/A,173.90,N/A,173.90,N/A,15.13,N/A,24.35,N/A,24.35,N/A,24.35,N/A,97.77,N/A,173.90,N/A,24.35,N/A,93.21,N/A,93.21,N/A,24.35,N/A,173.90,N/A,173.90,N/A,173.90,104.34,104.34,15.13,173.90,,Hospital HCPCS 6370000000,LOXAPINE SUCCINATE 5 MG PO CAPS,00591-0369-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RISPERIDONE 3 MG PO TABS,68084-0274-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OSELTAMIVIR PHOSPHATE 30 MG PO CAPS,47781-0468-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),21.10,21.10,12.66,12.66,N/A,2.95,N/A,21.10,N/A,11.86,N/A,7.17,N/A,2.95,N/A,2.95,N/A,21.10,N/A,21.10,N/A,1.84,N/A,2.95,N/A,2.95,N/A,2.95,N/A,11.86,N/A,21.10,N/A,2.95,N/A,11.31,N/A,11.31,N/A,2.95,N/A,21.10,N/A,21.10,N/A,21.10,12.66,12.66,1.84,21.10,,Hospital HCPCS 6370000000,QUETIAPINE FUMARATE 200 MG PO TABS,67877-0246-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,COLCHICINE 0.6 MG PO CAPS,60687-0358-95,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.30,15.30,9.18,9.18,N/A,2.14,N/A,15.30,N/A,8.60,N/A,5.20,N/A,2.14,N/A,2.14,N/A,15.30,N/A,15.30,N/A,1.33,N/A,2.14,N/A,2.14,N/A,2.14,N/A,8.60,N/A,15.30,N/A,2.14,N/A,8.20,N/A,8.20,N/A,2.14,N/A,15.30,N/A,15.30,N/A,15.30,9.18,9.18,1.33,15.30,,Hospital HCPCS 6370000000,DEXMETHYLPHENIDATE HCL ER 5 MG PO CP24,00078-0430-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,16.87,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,16.87,N/A,30.00,N/A,4.20,N/A,16.08,N/A,16.08,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital HCPCS 6370000000,TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,45802-0064-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.30,7.30,4.38,4.38,N/A,1.02,N/A,7.30,N/A,4.10,N/A,2.48,N/A,1.02,N/A,1.02,N/A,7.30,N/A,7.30,N/A,N/A,N/A,1.02,N/A,1.02,N/A,1.02,N/A,4.10,N/A,7.30,N/A,1.02,N/A,3.91,N/A,3.91,N/A,1.02,N/A,7.30,N/A,7.30,N/A,7.30,4.38,4.38,1.02,7.30,,Hospital HCPCS 6370000000,POLYSPORIN 500-10000 UNIT/GM EX OINT,00081-0798-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.20,10.20,6.12,6.12,N/A,1.43,N/A,10.20,N/A,5.73,N/A,3.47,N/A,1.43,N/A,1.43,N/A,10.20,N/A,10.20,N/A,N/A,N/A,1.43,N/A,1.43,N/A,1.43,N/A,5.73,N/A,10.20,N/A,1.43,N/A,5.47,N/A,5.47,N/A,1.43,N/A,10.20,N/A,10.20,N/A,10.20,6.12,6.12,1.43,10.20,,Hospital HCPCS 6370000000,BRIMONIDINE TARTRATE 0.15 % OP SOLN,61314-0144-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),345.10,345.10,207.06,207.06,N/A,48.31,N/A,345.10,N/A,194.02,N/A,117.33,N/A,48.31,N/A,48.31,N/A,345.10,N/A,345.10,N/A,30.02,N/A,48.31,N/A,48.31,N/A,48.31,N/A,194.02,N/A,345.10,N/A,48.31,N/A,184.97,N/A,184.97,N/A,48.31,N/A,345.10,N/A,345.10,N/A,345.10,207.06,207.06,30.02,345.10,,Hospital HCPCS 6370000000,NALTREXONE HCL 50 MG PO TABS,00406-1170-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PILOCARPINE HCL 1 % OP SOLN,61314-0203-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),177.50,177.50,106.50,106.50,N/A,24.85,N/A,177.50,N/A,99.79,N/A,60.35,N/A,24.85,N/A,24.85,N/A,177.50,N/A,177.50,N/A,15.44,N/A,24.85,N/A,24.85,N/A,24.85,N/A,99.79,N/A,177.50,N/A,24.85,N/A,95.14,N/A,95.14,N/A,24.85,N/A,177.50,N/A,177.50,N/A,177.50,106.50,106.50,15.44,177.50,,Hospital HCPCS 6370000000,TRIFLUOPERAZINE HCL 5 MG PO TABS,51079-0574-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS,00555-0972-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LISDEXAMFETAMINE DIMESYLATE 20 MG PO CAPS,59417-0102-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.40,26.40,15.84,15.84,N/A,3.70,N/A,26.40,N/A,14.84,N/A,8.98,N/A,3.70,N/A,3.70,N/A,26.40,N/A,26.40,N/A,2.30,N/A,3.70,N/A,3.70,N/A,3.70,N/A,14.84,N/A,26.40,N/A,3.70,N/A,14.15,N/A,14.15,N/A,3.70,N/A,26.40,N/A,26.40,N/A,26.40,15.84,15.84,2.30,26.40,,Hospital HCPCS 6370000000,ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,00046-0872-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),936.30,936.30,561.78,561.78,N/A,131.08,N/A,936.30,N/A,526.39,N/A,318.34,N/A,131.08,N/A,131.08,N/A,936.30,N/A,936.30,N/A,81.46,N/A,131.08,N/A,131.08,N/A,131.08,N/A,526.39,N/A,936.30,N/A,131.08,N/A,501.86,N/A,501.86,N/A,131.08,N/A,936.30,N/A,936.30,N/A,936.30,561.78,561.78,81.46,936.30,,Hospital HCPCS 6370000000,FA-PYRIDOXINE-CYANOCOBALAMIN 2.5-25-2 MG PO TABS,51991-0384-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUPHENAZINE HCL 1 MG PO TABS,00527-1788-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DORAVIRINE 100 MG PO TABS,00006-3069-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),119.80,119.80,71.88,71.88,N/A,16.77,N/A,119.80,N/A,67.35,N/A,40.73,N/A,16.77,N/A,16.77,N/A,119.80,N/A,119.80,N/A,10.42,N/A,16.77,N/A,16.77,N/A,16.77,N/A,67.35,N/A,119.80,N/A,16.77,N/A,64.21,N/A,64.21,N/A,16.77,N/A,119.80,N/A,119.80,N/A,119.80,71.88,71.88,10.42,119.80,,Hospital HCPCS 6370000000,BIOTENE DRY MOUTH MOISTURIZING MT SOLN,55299-0601-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.20,19.20,11.52,11.52,N/A,2.69,N/A,19.20,N/A,10.79,N/A,6.53,N/A,2.69,N/A,2.69,N/A,19.20,N/A,19.20,N/A,1.67,N/A,2.69,N/A,2.69,N/A,2.69,N/A,10.79,N/A,19.20,N/A,2.69,N/A,10.29,N/A,10.29,N/A,2.69,N/A,19.20,N/A,19.20,N/A,19.20,11.52,11.52,1.67,19.20,,Hospital HCPCS 6370000000,BETAMETHASONE VALERATE 0.1 % EX CREA,00168-0040-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),50.40,50.40,30.24,30.24,N/A,7.06,N/A,50.40,N/A,28.33,N/A,17.14,N/A,7.06,N/A,7.06,N/A,50.40,N/A,50.40,N/A,4.38,N/A,7.06,N/A,7.06,N/A,7.06,N/A,28.33,N/A,50.40,N/A,7.06,N/A,27.01,N/A,27.01,N/A,7.06,N/A,50.40,N/A,50.40,N/A,50.40,30.24,30.24,4.38,50.40,,Hospital HCPCS 6370000000,METRONIDAZOLE 0.75 % VA GEL,00781-7077-87,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),275.20,275.20,165.12,165.12,N/A,38.53,N/A,275.20,N/A,154.72,N/A,93.57,N/A,38.53,N/A,38.53,N/A,275.20,N/A,275.20,N/A,23.94,N/A,38.53,N/A,38.53,N/A,38.53,N/A,154.72,N/A,275.20,N/A,38.53,N/A,147.51,N/A,147.51,N/A,38.53,N/A,275.20,N/A,275.20,N/A,275.20,165.12,165.12,23.94,275.20,,Hospital HCPCS 6370000000,IBUPROFEN 600 MG PO TABS,00904-5854-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,MORPHINE SULFATE ER 30 MG PO TBCR,00406-8330-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FOSAMPRENAVIR CALCIUM 700 MG PO TABS,49702-0207-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),43.50,43.50,26.10,26.10,N/A,6.09,N/A,43.50,N/A,24.46,N/A,14.79,N/A,6.09,N/A,6.09,N/A,43.50,N/A,43.50,N/A,3.78,N/A,6.09,N/A,6.09,N/A,6.09,N/A,24.46,N/A,43.50,N/A,6.09,N/A,23.32,N/A,23.32,N/A,6.09,N/A,43.50,N/A,43.50,N/A,43.50,26.10,26.10,3.78,43.50,,Hospital HCPCS 6370000000,TORSEMIDE 20 MG PO TABS,50111-0917-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MULTIPLE VITAMINS PO TABS,00904-0539-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PHENTERMINE HCL 37.5 MG PO TABS,51224-0101-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 6370000000,SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK,00310-1110-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),54.80,54.80,32.88,32.88,N/A,7.67,N/A,54.80,N/A,30.81,N/A,18.63,N/A,7.67,N/A,7.67,N/A,54.80,N/A,54.80,N/A,4.77,N/A,7.67,N/A,7.67,N/A,7.67,N/A,30.81,N/A,54.80,N/A,7.67,N/A,29.37,N/A,29.37,N/A,7.67,N/A,54.80,N/A,54.80,N/A,54.80,32.88,32.88,4.77,54.80,,Hospital HCPCS 6370000000,ASPIRIN 300 MG RE SUPP,00574-7034-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),2.70,2.70,1.62,1.62,N/A,N/A,N/A,2.70,N/A,1.52,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.70,N/A,2.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.52,N/A,2.70,N/A,N/A,N/A,1.45,N/A,1.45,N/A,N/A,N/A,2.70,N/A,2.70,N/A,2.70,1.62,1.62,1.45,2.70,,Hospital HCPCS 6370000000,ZOLPIDEM TARTRATE ER 12.5 MG PO TBCR,00955-1703-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRIMIDONE 50 MG PO TABS,00527-1301-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BUPROPION HCL 75 MG PO TABS,60505-0158-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TETRACAINE HCL 0.5 % OP SOLN,00065-0741-14,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.30,26.30,15.78,15.78,N/A,3.68,N/A,26.30,N/A,14.79,N/A,8.94,N/A,3.68,N/A,3.68,N/A,26.30,N/A,26.30,N/A,2.29,N/A,3.68,N/A,3.68,N/A,3.68,N/A,14.79,N/A,26.30,N/A,3.68,N/A,14.10,N/A,14.10,N/A,3.68,N/A,26.30,N/A,26.30,N/A,26.30,15.78,15.78,2.29,26.30,,Hospital HCPCS 6370000000,VERAPAMIL HCL 80 MG PO TABS,00591-0343-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VITAMIN E 180 MG (400 UNIT) PO CAPS,77333-0951-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LANSOPRAZOLE 30 MG PO TBDD,00378-6982-32,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.40,20.40,12.24,12.24,N/A,2.86,N/A,20.40,N/A,11.47,N/A,6.94,N/A,2.86,N/A,2.86,N/A,20.40,N/A,20.40,N/A,1.77,N/A,2.86,N/A,2.86,N/A,2.86,N/A,11.47,N/A,20.40,N/A,2.86,N/A,10.93,N/A,10.93,N/A,2.86,N/A,20.40,N/A,20.40,N/A,20.40,12.24,12.24,1.77,20.40,,Hospital HCPCS 6370000000,DIPYRIDAMOLE 50 MG PO TABS,64980-0134-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ELVITEG-COBIC-EMTRICIT-TENOFDF 150-150-200-300 MG PO TABS,61958-1201-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),282.00,282.00,169.20,169.20,N/A,39.48,N/A,282.00,N/A,158.54,N/A,95.88,N/A,39.48,N/A,39.48,N/A,282.00,N/A,282.00,N/A,24.53,N/A,39.48,N/A,39.48,N/A,39.48,N/A,158.54,N/A,282.00,N/A,39.48,N/A,151.15,N/A,151.15,N/A,39.48,N/A,282.00,N/A,282.00,N/A,282.00,169.20,169.20,24.53,282.00,,Hospital HCPCS 6370000000,GLIPIZIDE ER 5 MG PO TB24,68084-0111-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SELENIUM SULFIDE 1 % EX LOTN,00536-1995-53,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.60,6.60,3.96,3.96,N/A,N/A,N/A,6.60,N/A,3.71,N/A,2.24,N/A,N/A,N/A,N/A,N/A,6.60,N/A,6.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.71,N/A,6.60,N/A,N/A,N/A,3.54,N/A,3.54,N/A,N/A,N/A,6.60,N/A,6.60,N/A,6.60,3.96,3.96,2.24,6.60,,Hospital HCPCS 6370000000,PROPRANOLOL HCL ER 60 MG PO CP24,51991-0817-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LAMOTRIGINE 150 MG PO TABS,29300-0113-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRIHEXYPHENIDYL HCL 5 MG PO TABS,00591-5337-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DEXLANSOPRAZOLE 30 MG PO CPDR,64764-0171-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.20,23.20,13.92,13.92,N/A,3.25,N/A,23.20,N/A,13.04,N/A,7.89,N/A,3.25,N/A,3.25,N/A,23.20,N/A,23.20,N/A,2.02,N/A,3.25,N/A,3.25,N/A,3.25,N/A,13.04,N/A,23.20,N/A,3.25,N/A,12.44,N/A,12.44,N/A,3.25,N/A,23.20,N/A,23.20,N/A,23.20,13.92,13.92,2.02,23.20,,Hospital HCPCS 6370000000,VALACYCLOVIR HCL 500 MG PO TABS,00378-4275-93,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS,43598-0221-14,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MORPHINE SULFATE ER 60 MG PO TBCR,00406-8380-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 6370000000,DOXYCYCLINE MONOHYDRATE 50 MG PO CAPS,49884-0726-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HALOPERIDOL 1 MG PO TABS,00378-0257-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,QUINIDINE GLUCONATE ER 324 MG PO TBCR,53489-0141-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.40,16.40,9.84,9.84,N/A,2.30,N/A,16.40,N/A,9.22,N/A,5.58,N/A,2.30,N/A,2.30,N/A,16.40,N/A,16.40,N/A,1.43,N/A,2.30,N/A,2.30,N/A,2.30,N/A,9.22,N/A,16.40,N/A,2.30,N/A,8.79,N/A,8.79,N/A,2.30,N/A,16.40,N/A,16.40,N/A,16.40,9.84,9.84,1.43,16.40,,Hospital HCPCS 6370000000,MALATHION 0.5 % EX LOTN,51672-5294-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),498.90,498.90,299.34,299.34,N/A,69.85,N/A,498.90,N/A,280.48,N/A,169.63,N/A,69.85,N/A,69.85,N/A,498.90,N/A,498.90,N/A,43.40,N/A,69.85,N/A,69.85,N/A,69.85,N/A,280.48,N/A,498.90,N/A,69.85,N/A,267.41,N/A,267.41,N/A,69.85,N/A,498.90,N/A,498.90,N/A,498.90,299.34,299.34,43.40,498.90,,Hospital HCPCS 6370000000,OYSTER SHELL CALCIUM W/D 500-5 MG-MCG PO TABS,00536-7817-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VILAZODONE HCL 10 MG PO TABS,00456-1110-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.70,23.70,14.22,14.22,N/A,3.32,N/A,23.70,N/A,13.32,N/A,8.06,N/A,3.32,N/A,3.32,N/A,23.70,N/A,23.70,N/A,2.06,N/A,3.32,N/A,3.32,N/A,3.32,N/A,13.32,N/A,23.70,N/A,3.32,N/A,12.70,N/A,12.70,N/A,3.32,N/A,23.70,N/A,23.70,N/A,23.70,14.22,14.22,2.06,23.70,,Hospital HCPCS 6370000000,ESTROGENS CONJUGATED 0.625 MG PO TABS,00046-1102-81,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.40,14.40,8.64,8.64,N/A,2.02,N/A,14.40,N/A,8.10,N/A,4.90,N/A,2.02,N/A,2.02,N/A,14.40,N/A,14.40,N/A,1.25,N/A,2.02,N/A,2.02,N/A,2.02,N/A,8.10,N/A,14.40,N/A,2.02,N/A,7.72,N/A,7.72,N/A,2.02,N/A,14.40,N/A,14.40,N/A,14.40,8.64,8.64,1.25,14.40,,Hospital HCPCS 6370000000,MILNACIPRAN HCL 50 MG PO TABS,00456-1550-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.60,16.60,9.96,9.96,N/A,2.32,N/A,16.60,N/A,9.33,N/A,5.64,N/A,2.32,N/A,2.32,N/A,16.60,N/A,16.60,N/A,1.44,N/A,2.32,N/A,2.32,N/A,2.32,N/A,9.33,N/A,16.60,N/A,2.32,N/A,8.90,N/A,8.90,N/A,2.32,N/A,16.60,N/A,16.60,N/A,16.60,9.96,9.96,1.44,16.60,,Hospital HCPCS 6370000000,PROCHLORPERAZINE 25 MG RE SUPP,00713-0135-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.70,19.70,11.82,11.82,N/A,2.76,N/A,19.70,N/A,11.08,N/A,6.70,N/A,2.76,N/A,2.76,N/A,19.70,N/A,19.70,N/A,1.71,N/A,2.76,N/A,2.76,N/A,2.76,N/A,11.08,N/A,19.70,N/A,2.76,N/A,10.56,N/A,10.56,N/A,2.76,N/A,19.70,N/A,19.70,N/A,19.70,11.82,11.82,1.71,19.70,,Hospital HCPCS 6370000000,PANCRELIPASE (LIP-PROT-AMYL) 20000-63000 UNITS PO CPEP,73562-0112-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.90,16.90,10.14,10.14,N/A,2.37,N/A,16.90,N/A,9.50,N/A,5.75,N/A,2.37,N/A,2.37,N/A,16.90,N/A,16.90,N/A,1.47,N/A,2.37,N/A,2.37,N/A,2.37,N/A,9.50,N/A,16.90,N/A,2.37,N/A,9.06,N/A,9.06,N/A,2.37,N/A,16.90,N/A,16.90,N/A,16.90,10.14,10.14,1.47,16.90,,Hospital HCPCS 6370000000,TOLVAPTAN 15 MG PO TABS,59148-0020-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1170.50,1170.50,702.30,702.30,N/A,163.87,N/A,1170.50,N/A,658.06,N/A,397.97,N/A,163.87,N/A,163.87,N/A,1170.50,N/A,1170.50,N/A,101.83,N/A,163.87,N/A,163.87,N/A,163.87,N/A,658.06,N/A,1170.50,N/A,163.87,N/A,627.39,N/A,627.39,N/A,163.87,N/A,1170.50,N/A,1170.50,N/A,1170.50,702.30,702.30,101.83,1170.50,,Hospital HCPCS 6370000000,FLEET ENEMA 7-19 GM/118ML RE ENEM,00536-7415-51,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DESONIDE 0.05 % EX OINT,45802-0423-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),43.60,43.60,26.16,26.16,N/A,6.10,N/A,43.60,N/A,24.51,N/A,14.82,N/A,6.10,N/A,6.10,N/A,43.60,N/A,43.60,N/A,3.79,N/A,6.10,N/A,6.10,N/A,6.10,N/A,24.51,N/A,43.60,N/A,6.10,N/A,23.37,N/A,23.37,N/A,6.10,N/A,43.60,N/A,43.60,N/A,43.60,26.16,26.16,3.79,43.60,,Hospital HCPCS 6370000000,FLUVASTATIN SODIUM 20 MG PO CAPS,00378-8020-93,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.10,9.10,5.46,5.46,N/A,1.27,N/A,9.10,N/A,5.12,N/A,3.09,N/A,1.27,N/A,1.27,N/A,9.10,N/A,9.10,N/A,N/A,N/A,1.27,N/A,1.27,N/A,1.27,N/A,5.12,N/A,9.10,N/A,1.27,N/A,4.88,N/A,4.88,N/A,1.27,N/A,9.10,N/A,9.10,N/A,9.10,5.46,5.46,1.27,9.10,,Hospital HCPCS 6370000000,PREGABALIN 75 MG PO CAPS,00071-1014-68,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.30,20.30,12.18,12.18,N/A,2.84,N/A,20.30,N/A,11.41,N/A,6.90,N/A,2.84,N/A,2.84,N/A,20.30,N/A,20.30,N/A,1.77,N/A,2.84,N/A,2.84,N/A,2.84,N/A,11.41,N/A,20.30,N/A,2.84,N/A,10.88,N/A,10.88,N/A,2.84,N/A,20.30,N/A,20.30,N/A,20.30,12.18,12.18,1.77,20.30,,Hospital HCPCS 6370000000,MELOXICAM 7.5 MG PO TABS,50268-0525-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUTICASONE-SALMETEROL 100-50 MCG/ACT IN AEPB,00173-0695-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),713.40,713.40,428.04,428.04,N/A,99.88,N/A,713.40,N/A,401.07,N/A,242.56,N/A,99.88,N/A,99.88,N/A,713.40,N/A,713.40,N/A,62.07,N/A,99.88,N/A,99.88,N/A,99.88,N/A,401.07,N/A,713.40,N/A,99.88,N/A,382.38,N/A,382.38,N/A,99.88,N/A,713.40,N/A,713.40,N/A,713.40,428.04,428.04,62.07,713.40,,Hospital HCPCS 6370000000,AMITRIPTYLINE HCL 50 MG PO TABS,00781-1488-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RIFAXIMIN 200 MG PO TABS,65649-0301-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),21.70,21.70,13.02,13.02,N/A,3.04,N/A,21.70,N/A,12.20,N/A,7.38,N/A,3.04,N/A,3.04,N/A,21.70,N/A,21.70,N/A,1.89,N/A,3.04,N/A,3.04,N/A,3.04,N/A,12.20,N/A,21.70,N/A,3.04,N/A,11.63,N/A,11.63,N/A,3.04,N/A,21.70,N/A,21.70,N/A,21.70,13.02,13.02,1.89,21.70,,Hospital HCPCS 6370000000,HALOPERIDOL 0.5 MG PO TABS,51079-0733-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DOXEPIN HCL 25 MG PO CAPS,51079-0437-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NEFAZODONE HCL 50 MG PO TABS,00093-7178-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MESALAMINE 1.2 G PO TBEC,54092-0100-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.00,19.00,11.40,11.40,N/A,2.66,N/A,19.00,N/A,10.68,N/A,6.46,N/A,2.66,N/A,2.66,N/A,19.00,N/A,19.00,N/A,1.65,N/A,2.66,N/A,2.66,N/A,2.66,N/A,10.68,N/A,19.00,N/A,2.66,N/A,10.18,N/A,10.18,N/A,2.66,N/A,19.00,N/A,19.00,N/A,19.00,11.40,11.40,1.65,19.00,,Hospital HCPCS 6370000000,CONJ ESTROG-MEDROXYPROGEST ACE 0.45-1.5 MG PO TABS,35356-0279-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.30,13.30,7.98,7.98,N/A,1.86,N/A,13.30,N/A,7.48,N/A,4.52,N/A,1.86,N/A,1.86,N/A,13.30,N/A,13.30,N/A,1.16,N/A,1.86,N/A,1.86,N/A,1.86,N/A,7.48,N/A,13.30,N/A,1.86,N/A,7.13,N/A,7.13,N/A,1.86,N/A,13.30,N/A,13.30,N/A,13.30,7.98,7.98,1.16,13.30,,Hospital HCPCS 6370000000,ZIPRASIDONE HCL 80 MG PO CAPS,00781-2168-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUTICASONE-SALMETEROL 250-50 MCG/ACT IN AEPB,00173-0696-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),341.40,341.40,204.84,204.84,N/A,47.80,N/A,341.40,N/A,191.94,N/A,116.08,N/A,47.80,N/A,47.80,N/A,341.40,N/A,341.40,N/A,29.70,N/A,47.80,N/A,47.80,N/A,47.80,N/A,191.94,N/A,341.40,N/A,47.80,N/A,182.99,N/A,182.99,N/A,47.80,N/A,341.40,N/A,341.40,N/A,341.40,204.84,204.84,29.70,341.40,,Hospital HCPCS 6370000000,VITAMIN D 25 MCG (1000 UT) PO TABS,20555-0033-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MESALAMINE 1000 MG RE SUPP,58914-0501-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),87.20,87.20,52.32,52.32,N/A,12.21,N/A,87.20,N/A,49.02,N/A,29.65,N/A,12.21,N/A,12.21,N/A,87.20,N/A,87.20,N/A,7.59,N/A,12.21,N/A,12.21,N/A,12.21,N/A,49.02,N/A,87.20,N/A,12.21,N/A,46.74,N/A,46.74,N/A,12.21,N/A,87.20,N/A,87.20,N/A,87.20,52.32,52.32,7.59,87.20,,Hospital HCPCS 6370000000,GUAIFENESIN 200 MG PO TABS,00904-5154-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,DEXMETHYLPHENIDATE HCL ER 20 MG PO CP24,00078-0432-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),38.30,38.30,22.98,22.98,N/A,5.36,N/A,38.30,N/A,21.53,N/A,13.02,N/A,5.36,N/A,5.36,N/A,38.30,N/A,38.30,N/A,3.33,N/A,5.36,N/A,5.36,N/A,5.36,N/A,21.53,N/A,38.30,N/A,5.36,N/A,20.53,N/A,20.53,N/A,5.36,N/A,38.30,N/A,38.30,N/A,38.30,22.98,22.98,3.33,38.30,,Hospital HCPCS 6370000000,LISDEXAMFETAMINE DIMESYLATE 60 MG PO CAPS,59417-0106-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.30,32.30,19.38,19.38,N/A,4.52,N/A,32.30,N/A,18.16,N/A,10.98,N/A,4.52,N/A,4.52,N/A,32.30,N/A,32.30,N/A,2.81,N/A,4.52,N/A,4.52,N/A,4.52,N/A,18.16,N/A,32.30,N/A,4.52,N/A,17.31,N/A,17.31,N/A,4.52,N/A,32.30,N/A,32.30,N/A,32.30,19.38,19.38,2.81,32.30,,Hospital HCPCS 6370000000,DARUNAVIR 800 MG PO TABS,59676-0566-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),146.20,146.20,87.72,87.72,N/A,20.47,N/A,146.20,N/A,82.19,N/A,49.71,N/A,20.47,N/A,20.47,N/A,146.20,N/A,146.20,N/A,12.72,N/A,20.47,N/A,20.47,N/A,20.47,N/A,82.19,N/A,146.20,N/A,20.47,N/A,78.36,N/A,78.36,N/A,20.47,N/A,146.20,N/A,146.20,N/A,146.20,87.72,87.72,12.72,146.20,,Hospital HCPCS 6370000000,RASAGILINE MESYLATE 0.5 MG PO TABS,68546-0142-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),74.80,74.80,44.88,44.88,N/A,10.47,N/A,74.80,N/A,42.05,N/A,25.43,N/A,10.47,N/A,10.47,N/A,74.80,N/A,74.80,N/A,6.51,N/A,10.47,N/A,10.47,N/A,10.47,N/A,42.05,N/A,74.80,N/A,10.47,N/A,40.09,N/A,40.09,N/A,10.47,N/A,74.80,N/A,74.80,N/A,74.80,44.88,44.88,6.51,74.80,,Hospital HCPCS 6370000000,ESTRADIOL-NORETHINDRONE ACET 1-0.5 MG PO TABS,51991-0474-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.20,9.20,5.52,5.52,N/A,1.29,N/A,9.20,N/A,5.17,N/A,3.13,N/A,1.29,N/A,1.29,N/A,9.20,N/A,9.20,N/A,N/A,N/A,1.29,N/A,1.29,N/A,1.29,N/A,5.17,N/A,9.20,N/A,1.29,N/A,4.93,N/A,4.93,N/A,1.29,N/A,9.20,N/A,9.20,N/A,9.20,5.52,5.52,1.29,9.20,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 75 MCG PO TABS,00074-5182-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.50,6.50,3.90,3.90,N/A,N/A,N/A,6.50,N/A,3.65,N/A,2.21,N/A,N/A,N/A,N/A,N/A,6.50,N/A,6.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.65,N/A,6.50,N/A,N/A,N/A,3.48,N/A,3.48,N/A,N/A,N/A,6.50,N/A,6.50,N/A,6.50,3.90,3.90,2.21,6.50,,Hospital HCPCS 6370000000,PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS,76385-0102-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCODONE-IBUPROFEN 7.5-200 MG PO TABS,53746-0145-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DICLOFENAC SODIUM 50 MG PO TBEC,00228-2550-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SELEGILINE 6 MG/24HR TD PT24,49502-0900-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),143.20,143.20,85.92,85.92,N/A,20.05,N/A,143.20,N/A,80.51,N/A,48.69,N/A,20.05,N/A,20.05,N/A,143.20,N/A,143.20,N/A,12.46,N/A,20.05,N/A,20.05,N/A,20.05,N/A,80.51,N/A,143.20,N/A,20.05,N/A,76.76,N/A,76.76,N/A,20.05,N/A,143.20,N/A,143.20,N/A,143.20,85.92,85.92,12.46,143.20,,Hospital HCPCS 6370000000,ARIPIPRAZOLE 5 MG PO TABS,59148-0007-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),43.80,43.80,26.28,26.28,N/A,6.13,N/A,43.80,N/A,24.62,N/A,14.89,N/A,6.13,N/A,6.13,N/A,43.80,N/A,43.80,N/A,3.81,N/A,6.13,N/A,6.13,N/A,6.13,N/A,24.62,N/A,43.80,N/A,6.13,N/A,23.48,N/A,23.48,N/A,6.13,N/A,43.80,N/A,43.80,N/A,43.80,26.28,26.28,3.81,43.80,,Hospital HCPCS 6370000000,IMATINIB MESYLATE 100 MG PO TABS,00078-0401-34,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),842.80,842.80,505.68,505.68,N/A,117.99,N/A,842.80,N/A,473.82,N/A,286.55,N/A,117.99,N/A,117.99,N/A,842.80,N/A,842.80,N/A,73.32,N/A,117.99,N/A,117.99,N/A,117.99,N/A,473.82,N/A,842.80,N/A,117.99,N/A,451.74,N/A,451.74,N/A,117.99,N/A,842.80,N/A,842.80,N/A,842.80,505.68,505.68,73.32,842.80,,Hospital HCPCS 6370000000,FLUOXETINE HCL 10 MG PO CAPS,00904-5784-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBAMAZEPINE ER 100 MG PO TB12,00078-0510-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS,00406-0523-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VORTIOXETINE HBR 5 MG PO TABS,64764-0720-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.40,33.40,20.04,20.04,N/A,4.68,N/A,33.40,N/A,18.78,N/A,11.36,N/A,4.68,N/A,4.68,N/A,33.40,N/A,33.40,N/A,2.91,N/A,4.68,N/A,4.68,N/A,4.68,N/A,18.78,N/A,33.40,N/A,4.68,N/A,17.90,N/A,17.90,N/A,4.68,N/A,33.40,N/A,33.40,N/A,33.40,20.04,20.04,2.91,33.40,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24,60687-0195-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MESALAMINE 4 G RE ENEM,45802-0098-46,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),30.20,30.20,18.12,18.12,N/A,4.23,N/A,30.20,N/A,16.98,N/A,10.27,N/A,4.23,N/A,4.23,N/A,30.20,N/A,30.20,N/A,2.63,N/A,4.23,N/A,4.23,N/A,4.23,N/A,16.98,N/A,30.20,N/A,4.23,N/A,16.19,N/A,16.19,N/A,4.23,N/A,30.20,N/A,30.20,N/A,30.20,18.12,18.12,2.63,30.20,,Hospital HCPCS 6370000000,VORTIOXETINE HBR 20 MG PO TABS,64764-0750-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.40,33.40,20.04,20.04,N/A,4.68,N/A,33.40,N/A,18.78,N/A,11.36,N/A,4.68,N/A,4.68,N/A,33.40,N/A,33.40,N/A,2.91,N/A,4.68,N/A,4.68,N/A,4.68,N/A,18.78,N/A,33.40,N/A,4.68,N/A,17.90,N/A,17.90,N/A,4.68,N/A,33.40,N/A,33.40,N/A,33.40,20.04,20.04,2.91,33.40,,Hospital HCPCS 6370000000,RIVASTIGMINE 4.6 MG/24HR TD PT24,00078-0501-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),51.50,51.50,30.90,30.90,N/A,7.21,N/A,51.50,N/A,28.95,N/A,17.51,N/A,7.21,N/A,7.21,N/A,51.50,N/A,51.50,N/A,4.48,N/A,7.21,N/A,7.21,N/A,7.21,N/A,28.95,N/A,51.50,N/A,7.21,N/A,27.60,N/A,27.60,N/A,7.21,N/A,51.50,N/A,51.50,N/A,51.50,30.90,30.90,4.48,51.50,,Hospital HCPCS 6370000000,NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS,47781-0307-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CENTRUM PO LIQD,09999-9907-24,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PEG 3350 17 G PO PACK,00904-6931-86,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROXYUREA 500 MG PO CAPS,49884-0724-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LURASIDONE HCL 20 MG PO TABS,47335-0578-83,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LANSINOH LANOLIN EX CREA,44677-0102-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER 60 MG PO CP12,51079-0924-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.50,7.50,4.50,4.50,N/A,1.05,N/A,7.50,N/A,4.22,N/A,2.55,N/A,1.05,N/A,1.05,N/A,7.50,N/A,7.50,N/A,N/A,N/A,1.05,N/A,1.05,N/A,1.05,N/A,4.22,N/A,7.50,N/A,1.05,N/A,4.02,N/A,4.02,N/A,1.05,N/A,7.50,N/A,7.50,N/A,7.50,4.50,4.50,1.05,7.50,,Hospital HCPCS 6370000000,SITAGLIPTIN PHOSPHATE 50 MG PO TABS,00006-0112-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),39.20,39.20,23.52,23.52,N/A,5.49,N/A,39.20,N/A,22.04,N/A,13.33,N/A,5.49,N/A,5.49,N/A,39.20,N/A,39.20,N/A,3.41,N/A,5.49,N/A,5.49,N/A,5.49,N/A,22.04,N/A,39.20,N/A,5.49,N/A,21.01,N/A,21.01,N/A,5.49,N/A,39.20,N/A,39.20,N/A,39.20,23.52,23.52,3.41,39.20,,Hospital HCPCS 6370000000,THYROID 60 MG PO TABS,42192-0330-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,INDOMETHACIN ER 75 MG PO CPCR,10702-0016-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OSELTAMIVIR PHOSPHATE 75 MG PO CAPS,00004-0800-85,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),34.20,34.20,20.52,20.52,N/A,4.79,N/A,34.20,N/A,19.23,N/A,11.63,N/A,4.79,N/A,4.79,N/A,34.20,N/A,34.20,N/A,2.98,N/A,4.79,N/A,4.79,N/A,4.79,N/A,19.23,N/A,34.20,N/A,4.79,N/A,18.33,N/A,18.33,N/A,4.79,N/A,34.20,N/A,34.20,N/A,34.20,20.52,20.52,2.98,34.20,,Hospital HCPCS 6370000000,FLEET PEDIATRIC 3.5-9.5 GM/59ML RE ENEM,00132-0202-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRANDOLAPRIL 2 MG PO TABS,68180-0567-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MINERAL OIL RE ENEM,00132-0301-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ASENAPINE MALEATE 10 MG SL SUBL,00456-2410-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),45.10,45.10,27.06,27.06,N/A,6.31,N/A,45.10,N/A,25.36,N/A,15.33,N/A,6.31,N/A,6.31,N/A,45.10,N/A,45.10,N/A,3.92,N/A,6.31,N/A,6.31,N/A,6.31,N/A,25.36,N/A,45.10,N/A,6.31,N/A,24.17,N/A,24.17,N/A,6.31,N/A,45.10,N/A,45.10,N/A,45.10,27.06,27.06,3.92,45.10,,Hospital HCPCS 6370000000,FESOTERODINE FUMARATE ER 4 MG PO TB24,00069-0242-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),28.30,28.30,16.98,16.98,N/A,3.96,N/A,28.30,N/A,15.91,N/A,9.62,N/A,3.96,N/A,3.96,N/A,28.30,N/A,28.30,N/A,2.46,N/A,3.96,N/A,3.96,N/A,3.96,N/A,15.91,N/A,28.30,N/A,3.96,N/A,15.17,N/A,15.17,N/A,3.96,N/A,28.30,N/A,28.30,N/A,28.30,16.98,16.98,2.46,28.30,,Hospital HCPCS 6370000000,TIZANIDINE HCL 2 MG PO TABS,60505-0251-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TROLAMINE SALICYLATE 10 % EX CREA,41167-0057-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.90,9.90,5.94,5.94,N/A,1.39,N/A,9.90,N/A,5.57,N/A,3.37,N/A,1.39,N/A,1.39,N/A,9.90,N/A,9.90,N/A,N/A,N/A,1.39,N/A,1.39,N/A,1.39,N/A,5.57,N/A,9.90,N/A,1.39,N/A,5.31,N/A,5.31,N/A,1.39,N/A,9.90,N/A,9.90,N/A,9.90,5.94,5.94,1.39,9.90,,Hospital HCPCS 6370000000,DIAZEPAM 2.5 MG RE GEL,66490-0650-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),665.30,665.30,399.18,399.18,N/A,93.14,N/A,665.30,N/A,374.03,N/A,226.20,N/A,93.14,N/A,93.14,N/A,665.30,N/A,665.30,N/A,57.88,N/A,93.14,N/A,93.14,N/A,93.14,N/A,374.03,N/A,665.30,N/A,93.14,N/A,356.60,N/A,356.60,N/A,93.14,N/A,665.30,N/A,665.30,N/A,665.30,399.18,399.18,57.88,665.30,,Hospital HCPCS 6370000000,RISPERIDONE 1 MG PO TABS,68084-0272-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCORTISONE ACETATE 25 MG RE SUPP,00574-7090-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.00,26.00,15.60,15.60,N/A,3.64,N/A,26.00,N/A,14.62,N/A,8.84,N/A,3.64,N/A,3.64,N/A,26.00,N/A,26.00,N/A,2.26,N/A,3.64,N/A,3.64,N/A,3.64,N/A,14.62,N/A,26.00,N/A,3.64,N/A,13.94,N/A,13.94,N/A,3.64,N/A,26.00,N/A,26.00,N/A,26.00,15.60,15.60,2.26,26.00,,Hospital HCPCS 6370000000,DICLOFENAC SODIUM 75 MG PO TBEC,16571-0201-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SODIUM BICARBONATE 325 MG PO TABS,00223-1720-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,TRIHEXYPHENIDYL HCL 2 MG PO TABS,00591-5335-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OLANZAPINE-FLUOXETINE HCL 6-25 MG PO CAPS,00002-3231-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),30.20,30.20,18.12,18.12,N/A,4.23,N/A,30.20,N/A,16.98,N/A,10.27,N/A,4.23,N/A,4.23,N/A,30.20,N/A,30.20,N/A,2.63,N/A,4.23,N/A,4.23,N/A,4.23,N/A,16.98,N/A,30.20,N/A,4.23,N/A,16.19,N/A,16.19,N/A,4.23,N/A,30.20,N/A,30.20,N/A,30.20,18.12,18.12,2.63,30.20,,Hospital HCPCS 6370000000,DIVALPROEX SODIUM 125 MG PO CSDR,68084-0313-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RIVAROXABAN 10 MG PO TABS,50458-0580-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),38.80,38.80,23.28,23.28,N/A,5.43,N/A,38.80,N/A,21.81,N/A,13.19,N/A,5.43,N/A,5.43,N/A,38.80,N/A,38.80,N/A,3.38,N/A,5.43,N/A,5.43,N/A,5.43,N/A,21.81,N/A,38.80,N/A,5.43,N/A,20.80,N/A,20.80,N/A,5.43,N/A,38.80,N/A,38.80,N/A,38.80,23.28,23.28,3.38,38.80,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 137 MCG PO TABS,00074-3727-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ACTIDOSE WITH SORBITOL 25 GM/120ML PO SUSP,66689-0203-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.80,33.80,20.28,20.28,N/A,4.73,N/A,33.80,N/A,19.00,N/A,11.49,N/A,4.73,N/A,4.73,N/A,33.80,N/A,33.80,N/A,2.94,N/A,4.73,N/A,4.73,N/A,4.73,N/A,19.00,N/A,33.80,N/A,4.73,N/A,18.12,N/A,18.12,N/A,4.73,N/A,33.80,N/A,33.80,N/A,33.80,20.28,20.28,2.94,33.80,,Hospital HCPCS 6370000000,BREXPIPRAZOLE 1 MG PO TABS,59148-0037-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),100.00,100.00,60.00,60.00,N/A,14.00,N/A,100.00,N/A,56.22,N/A,34.00,N/A,14.00,N/A,14.00,N/A,100.00,N/A,100.00,N/A,8.70,N/A,14.00,N/A,14.00,N/A,14.00,N/A,56.22,N/A,100.00,N/A,14.00,N/A,53.60,N/A,53.60,N/A,14.00,N/A,100.00,N/A,100.00,N/A,100.00,60.00,60.00,8.70,100.00,,Hospital HCPCS 6370000000,LACOSAMIDE 50 MG PO TABS,00131-2477-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.00,24.00,14.40,14.40,N/A,3.36,N/A,24.00,N/A,13.49,N/A,8.16,N/A,3.36,N/A,3.36,N/A,24.00,N/A,24.00,N/A,2.09,N/A,3.36,N/A,3.36,N/A,3.36,N/A,13.49,N/A,24.00,N/A,3.36,N/A,12.86,N/A,12.86,N/A,3.36,N/A,24.00,N/A,24.00,N/A,24.00,14.40,14.40,2.09,24.00,,Hospital HCPCS 6370000000,RIVAROXABAN 2.5 MG PO TABS,50458-0577-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.40,19.40,11.64,11.64,N/A,2.72,N/A,19.40,N/A,10.91,N/A,6.60,N/A,2.72,N/A,2.72,N/A,19.40,N/A,19.40,N/A,1.69,N/A,2.72,N/A,2.72,N/A,2.72,N/A,10.91,N/A,19.40,N/A,2.72,N/A,10.40,N/A,10.40,N/A,2.72,N/A,19.40,N/A,19.40,N/A,19.40,11.64,11.64,1.69,19.40,,Hospital HCPCS 6370000000,THERAPEUTIC MULTIVIT/MINERAL PO TABS,00536-4661-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PSEUDOEPHEDRINE-DEXBROMPHEN-DM 20-0.667-10 MG/5ML PO LIQD,12830-0816-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),67.10,67.10,40.26,40.26,N/A,9.39,N/A,67.10,N/A,37.72,N/A,22.81,N/A,9.39,N/A,9.39,N/A,67.10,N/A,67.10,N/A,5.84,N/A,9.39,N/A,9.39,N/A,9.39,N/A,37.72,N/A,67.10,N/A,9.39,N/A,35.97,N/A,35.97,N/A,9.39,N/A,67.10,N/A,67.10,N/A,67.10,40.26,40.26,5.84,67.10,,Hospital HCPCS 6370000000,FLURBIPROFEN 100 MG PO TABS,00093-0711-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AZELASTINE HCL 0.05 % OP SOLN,61314-0308-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),78.80,78.80,47.28,47.28,N/A,11.03,N/A,78.80,N/A,44.30,N/A,26.79,N/A,11.03,N/A,11.03,N/A,78.80,N/A,78.80,N/A,6.86,N/A,11.03,N/A,11.03,N/A,11.03,N/A,44.30,N/A,78.80,N/A,11.03,N/A,42.24,N/A,42.24,N/A,11.03,N/A,78.80,N/A,78.80,N/A,78.80,47.28,47.28,6.86,78.80,,Hospital HCPCS 6370000000,BROMFENAC SODIUM (ONCE-DAILY) 0.09 % OP SOLN,62332-0508-17,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),801.30,801.30,480.78,480.78,N/A,112.18,N/A,801.30,N/A,450.49,N/A,272.44,N/A,112.18,N/A,112.18,N/A,801.30,N/A,801.30,N/A,69.71,N/A,112.18,N/A,112.18,N/A,112.18,N/A,450.49,N/A,801.30,N/A,112.18,N/A,429.50,N/A,429.50,N/A,112.18,N/A,801.30,N/A,801.30,N/A,801.30,480.78,480.78,69.71,801.30,,Hospital HCPCS 6370000000,TORSEMIDE 10 MG PO TABS,31722-0530-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,76329-3015-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.90,20.90,12.54,12.54,N/A,2.93,N/A,20.90,N/A,11.75,N/A,7.11,N/A,2.93,N/A,2.93,N/A,20.90,N/A,20.90,N/A,1.82,N/A,2.93,N/A,2.93,N/A,2.93,N/A,11.75,N/A,20.90,N/A,2.93,N/A,11.20,N/A,11.20,N/A,2.93,N/A,20.90,N/A,20.90,N/A,20.90,12.54,12.54,1.82,20.90,,Hospital HCPCS 6370000000,TIZANIDINE HCL 4 MG PO TABS,68084-0645-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ATORVASTATIN CALCIUM 20 MG PO TABS,68084-0098-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,59310-0302-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),449.40,449.40,269.64,269.64,N/A,62.92,N/A,449.40,N/A,252.65,N/A,152.80,N/A,62.92,N/A,62.92,N/A,449.40,N/A,449.40,N/A,39.10,N/A,62.92,N/A,62.92,N/A,62.92,N/A,252.65,N/A,449.40,N/A,62.92,N/A,240.88,N/A,240.88,N/A,62.92,N/A,449.40,N/A,449.40,N/A,449.40,269.64,269.64,39.10,449.40,,Hospital HCPCS 6370000000,METFORMIN HCL 850 MG PO TABS,60687-0143-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PEPPERMINT SPIRIT SPRT,00395-2243-91,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.50,17.50,10.50,10.50,N/A,2.45,N/A,17.50,N/A,9.84,N/A,5.95,N/A,2.45,N/A,2.45,N/A,17.50,N/A,17.50,N/A,1.52,N/A,2.45,N/A,2.45,N/A,2.45,N/A,9.84,N/A,17.50,N/A,2.45,N/A,9.38,N/A,9.38,N/A,2.45,N/A,17.50,N/A,17.50,N/A,17.50,10.50,10.50,1.52,17.50,,Hospital HCPCS 6370000000,TOLTERODINE TARTRATE 1 MG PO TABS,00009-4541-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.90,16.90,10.14,10.14,N/A,2.37,N/A,16.90,N/A,9.50,N/A,5.75,N/A,2.37,N/A,2.37,N/A,16.90,N/A,16.90,N/A,1.47,N/A,2.37,N/A,2.37,N/A,2.37,N/A,9.50,N/A,16.90,N/A,2.37,N/A,9.06,N/A,9.06,N/A,2.37,N/A,16.90,N/A,16.90,N/A,16.90,10.14,10.14,1.47,16.90,,Hospital HCPCS 6370000000,HYDROXYZINE PAMOATE 25 MG PO CAPS,68084-0847-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,APIXABAN 5 MG PO TABS,00003-0894-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.90,19.90,11.94,11.94,N/A,2.79,N/A,19.90,N/A,11.19,N/A,6.77,N/A,2.79,N/A,2.79,N/A,19.90,N/A,19.90,N/A,1.73,N/A,2.79,N/A,2.79,N/A,2.79,N/A,11.19,N/A,19.90,N/A,2.79,N/A,10.67,N/A,10.67,N/A,2.79,N/A,19.90,N/A,19.90,N/A,19.90,11.94,11.94,1.73,19.90,,Hospital HCPCS 6370000000,TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,24208-0295-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),113.80,113.80,68.28,68.28,N/A,15.93,N/A,113.80,N/A,63.98,N/A,38.69,N/A,15.93,N/A,15.93,N/A,113.80,N/A,113.80,N/A,9.90,N/A,15.93,N/A,15.93,N/A,15.93,N/A,63.98,N/A,113.80,N/A,15.93,N/A,61.00,N/A,61.00,N/A,15.93,N/A,113.80,N/A,113.80,N/A,113.80,68.28,68.28,9.90,113.80,,Hospital HCPCS 6370000000,ALPRAZOLAM ER 0.5 MG PO TB24,59762-0057-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 6370000000,BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG PO TABS,29300-0187-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLOBETASOL PROPIONATE 0.05 % EX SOLN,68462-0532-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),67.50,67.50,40.50,40.50,N/A,9.45,N/A,67.50,N/A,37.95,N/A,22.95,N/A,9.45,N/A,9.45,N/A,67.50,N/A,67.50,N/A,5.87,N/A,9.45,N/A,9.45,N/A,9.45,N/A,37.95,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,9.45,N/A,67.50,N/A,67.50,N/A,67.50,40.50,40.50,5.87,67.50,,Hospital HCPCS 6370000000,GLYCERIN (LAXATIVE) 2 G RE SUPP,00132-0079-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RIVASTIGMINE TARTRATE 3 MG PO CAPS,62756-0146-86,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RIVASTIGMINE 9.5 MG/24HR TD PT24,00078-0502-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),51.50,51.50,30.90,30.90,N/A,7.21,N/A,51.50,N/A,28.95,N/A,17.51,N/A,7.21,N/A,7.21,N/A,51.50,N/A,51.50,N/A,4.48,N/A,7.21,N/A,7.21,N/A,7.21,N/A,28.95,N/A,51.50,N/A,7.21,N/A,27.60,N/A,27.60,N/A,7.21,N/A,51.50,N/A,51.50,N/A,51.50,30.90,30.90,4.48,51.50,,Hospital HCPCS 6370000000,FELODIPINE ER 5 MG PO TB24,00603-3582-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BIMATOPROST 0.01 % OP SOLN,00023-3205-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1026.10,1026.10,615.66,615.66,N/A,143.65,N/A,1026.10,N/A,576.87,N/A,348.87,N/A,143.65,N/A,143.65,N/A,1026.10,N/A,1026.10,N/A,89.27,N/A,143.65,N/A,143.65,N/A,143.65,N/A,576.87,N/A,1026.10,N/A,143.65,N/A,549.99,N/A,549.99,N/A,143.65,N/A,1026.10,N/A,1026.10,N/A,1026.10,615.66,615.66,89.27,1026.10,,Hospital HCPCS 6370000000,SEVELAMER CARBONATE 0.8 G PO PACK,65862-0930-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUOCINONIDE 0.05 % EX CREA,00093-0262-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),82.00,82.00,49.20,49.20,N/A,11.48,N/A,82.00,N/A,46.10,N/A,27.88,N/A,11.48,N/A,11.48,N/A,82.00,N/A,82.00,N/A,7.13,N/A,11.48,N/A,11.48,N/A,11.48,N/A,46.10,N/A,82.00,N/A,11.48,N/A,43.95,N/A,43.95,N/A,11.48,N/A,82.00,N/A,82.00,N/A,82.00,49.20,49.20,7.13,82.00,,Hospital HCPCS 6370000000,PROMETHAZINE HCL 50 MG RE SUPP,00713-0132-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),60.40,60.40,36.24,36.24,N/A,8.46,N/A,60.40,N/A,33.96,N/A,20.54,N/A,8.46,N/A,8.46,N/A,60.40,N/A,60.40,N/A,5.25,N/A,8.46,N/A,8.46,N/A,8.46,N/A,33.96,N/A,60.40,N/A,8.46,N/A,32.37,N/A,32.37,N/A,8.46,N/A,60.40,N/A,60.40,N/A,60.40,36.24,36.24,5.25,60.40,,Hospital HCPCS 6370000000,GABAPENTIN 300 MG PO CAPS,00904-6666-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TICAGRELOR 60 MG PO TABS,00186-0776-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.00,16.00,9.60,9.60,N/A,2.24,N/A,16.00,N/A,9.00,N/A,5.44,N/A,2.24,N/A,2.24,N/A,16.00,N/A,16.00,N/A,1.39,N/A,2.24,N/A,2.24,N/A,2.24,N/A,9.00,N/A,16.00,N/A,2.24,N/A,8.58,N/A,8.58,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,9.60,9.60,1.39,16.00,,Hospital HCPCS 6370000000,ACETAMINOPHEN ER 650 MG PO TBCR,00904-5769-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,ISRADIPINE 2.5 MG PO CAPS,16252-0539-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDOCAINE 4 % EX CREA,00496-0882-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.80,15.80,9.48,9.48,N/A,2.21,N/A,15.80,N/A,8.88,N/A,5.37,N/A,2.21,N/A,2.21,N/A,15.80,N/A,15.80,N/A,1.37,N/A,2.21,N/A,2.21,N/A,2.21,N/A,8.88,N/A,15.80,N/A,2.21,N/A,8.47,N/A,8.47,N/A,2.21,N/A,15.80,N/A,15.80,N/A,15.80,9.48,9.48,1.37,15.80,,Hospital HCPCS 6370000000,GLUCOSE 40 % PO GEL,00574-0069-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.20,14.20,8.52,8.52,N/A,1.99,N/A,14.20,N/A,7.98,N/A,4.83,N/A,1.99,N/A,1.99,N/A,14.20,N/A,14.20,N/A,1.24,N/A,1.99,N/A,1.99,N/A,1.99,N/A,7.98,N/A,14.20,N/A,1.99,N/A,7.61,N/A,7.61,N/A,1.99,N/A,14.20,N/A,14.20,N/A,14.20,8.52,8.52,1.24,14.20,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 125 MCG PO TABS,00074-7068-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA 25-250 MG PO TABS,68084-0094-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LUBIPROSTONE 8 MCG PO CAPS,64764-0080-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.00,14.00,8.40,8.40,N/A,1.96,N/A,14.00,N/A,7.87,N/A,4.76,N/A,1.96,N/A,1.96,N/A,14.00,N/A,14.00,N/A,1.22,N/A,1.96,N/A,1.96,N/A,1.96,N/A,7.87,N/A,14.00,N/A,1.96,N/A,7.50,N/A,7.50,N/A,1.96,N/A,14.00,N/A,14.00,N/A,14.00,8.40,8.40,1.22,14.00,,Hospital HCPCS 6370000000,POTASSIUM GLUCONATE 550 (90 K) MG PO TABS,31604-0013-58,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NITROGLYCERIN 0.6 MG/HR TD PT24,00378-9116-93,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NADOLOL 20 MG PO TABS,51079-0812-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.70,11.70,7.02,7.02,N/A,1.64,N/A,11.70,N/A,6.58,N/A,3.98,N/A,1.64,N/A,1.64,N/A,11.70,N/A,11.70,N/A,1.02,N/A,1.64,N/A,1.64,N/A,1.64,N/A,6.58,N/A,11.70,N/A,1.64,N/A,6.27,N/A,6.27,N/A,1.64,N/A,11.70,N/A,11.70,N/A,11.70,7.02,7.02,1.02,11.70,,Hospital HCPCS 6370000000,LOTEPREDNOL ETABONATE 0.5 % OP GEL,24208-0503-07,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),511.20,511.20,306.72,306.72,N/A,71.57,N/A,511.20,N/A,287.40,N/A,173.81,N/A,71.57,N/A,71.57,N/A,511.20,N/A,511.20,N/A,44.47,N/A,71.57,N/A,71.57,N/A,71.57,N/A,287.40,N/A,511.20,N/A,71.57,N/A,274.00,N/A,274.00,N/A,71.57,N/A,511.20,N/A,511.20,N/A,511.20,306.72,306.72,44.47,511.20,,Hospital HCPCS 6370000000,MORPHINE NEONATAL ORAL SOLUTION 0.4 MG/ML,09999-9904-78,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RIBAVIRIN 200 MG PO CAPS,65862-0290-84,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MICONAZOLE NITRATE 200 MG VA SUPP,00472-1738-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),98.60,98.60,59.16,59.16,N/A,13.80,N/A,98.60,N/A,55.43,N/A,33.52,N/A,13.80,N/A,13.80,N/A,98.60,N/A,98.60,N/A,8.58,N/A,13.80,N/A,13.80,N/A,13.80,N/A,55.43,N/A,98.60,N/A,13.80,N/A,52.85,N/A,52.85,N/A,13.80,N/A,98.60,N/A,98.60,N/A,98.60,59.16,59.16,8.58,98.60,,Hospital HCPCS 6370000000,TELMISARTAN 40 MG PO TABS,00597-0040-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.60,10.60,6.36,6.36,N/A,1.48,N/A,10.60,N/A,5.96,N/A,3.60,N/A,1.48,N/A,1.48,N/A,10.60,N/A,10.60,N/A,N/A,N/A,1.48,N/A,1.48,N/A,1.48,N/A,5.96,N/A,10.60,N/A,1.48,N/A,5.68,N/A,5.68,N/A,1.48,N/A,10.60,N/A,10.60,N/A,10.60,6.36,6.36,1.48,10.60,,Hospital HCPCS 6370000000,PANCRELIPASE (LIP-PROT-AMYL) 12000-38000 UNITS PO CPEP,00032-1212-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.50,8.50,5.10,5.10,N/A,1.19,N/A,8.50,N/A,4.78,N/A,2.89,N/A,1.19,N/A,1.19,N/A,8.50,N/A,8.50,N/A,N/A,N/A,1.19,N/A,1.19,N/A,1.19,N/A,4.78,N/A,8.50,N/A,1.19,N/A,4.56,N/A,4.56,N/A,1.19,N/A,8.50,N/A,8.50,N/A,8.50,5.10,5.10,1.19,8.50,,Hospital HCPCS 6370000000,BENZTROPINE MESYLATE 1 MG PO TABS,68084-0388-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POLYSACCHARIDE IRON COMPLEX 150 MG PO CAPS,00904-5395-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PROPRANOLOL HCL 10 MG PO TABS,00591-5554-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRAZOSIN HCL 5 MG PO CAPS,51079-0632-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.10,8.10,4.86,4.86,N/A,1.13,N/A,8.10,N/A,4.55,N/A,2.75,N/A,1.13,N/A,1.13,N/A,8.10,N/A,8.10,N/A,N/A,N/A,1.13,N/A,1.13,N/A,1.13,N/A,4.55,N/A,8.10,N/A,1.13,N/A,4.34,N/A,4.34,N/A,1.13,N/A,8.10,N/A,8.10,N/A,8.10,4.86,4.86,1.13,8.10,,Hospital HCPCS 6370000000,VERAPAMIL HCL ER 120 MG PO CP24,00378-6320-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FERRALET 90 90-1 MG PO TABS,00178-0089-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.40,5.40,3.24,3.24,N/A,N/A,N/A,5.40,N/A,3.04,N/A,1.84,N/A,N/A,N/A,N/A,N/A,5.40,N/A,5.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.04,N/A,5.40,N/A,N/A,N/A,2.89,N/A,2.89,N/A,N/A,N/A,5.40,N/A,5.40,N/A,5.40,3.24,3.24,1.84,5.40,,Hospital HCPCS 6370000000,DOFETILIDE 250 MCG PO CAPS,00069-5810-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.50,24.50,14.70,14.70,N/A,3.43,N/A,24.50,N/A,13.77,N/A,8.33,N/A,3.43,N/A,3.43,N/A,24.50,N/A,24.50,N/A,2.13,N/A,3.43,N/A,3.43,N/A,3.43,N/A,13.77,N/A,24.50,N/A,3.43,N/A,13.13,N/A,13.13,N/A,3.43,N/A,24.50,N/A,24.50,N/A,24.50,14.70,14.70,2.13,24.50,,Hospital HCPCS 6370000000,LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,76329-3012-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.00,13.00,7.80,7.80,N/A,1.82,N/A,13.00,N/A,7.31,N/A,4.42,N/A,1.82,N/A,1.82,N/A,13.00,N/A,13.00,N/A,1.13,N/A,1.82,N/A,1.82,N/A,1.82,N/A,7.31,N/A,13.00,N/A,1.82,N/A,6.97,N/A,6.97,N/A,1.82,N/A,13.00,N/A,13.00,N/A,13.00,7.80,7.80,1.13,13.00,,Hospital HCPCS 6370000000,CHLORPROMAZINE HCL 10 MG PO TABS,00832-0300-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.00,6.00,3.60,3.60,N/A,N/A,N/A,6.00,N/A,3.37,N/A,2.04,N/A,N/A,N/A,N/A,N/A,6.00,N/A,6.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.37,N/A,6.00,N/A,N/A,N/A,3.22,N/A,3.22,N/A,N/A,N/A,6.00,N/A,6.00,N/A,6.00,3.60,3.60,2.04,6.00,,Hospital HCPCS 6370000000,HYDROMORPHONE HCL 8 MG PO TABS,42858-0303-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ESTRADIOL 0.1 MG/24HR TD PTWK,00378-3352-99,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),41.80,41.80,25.08,25.08,N/A,5.85,N/A,41.80,N/A,23.50,N/A,14.21,N/A,5.85,N/A,5.85,N/A,41.80,N/A,41.80,N/A,3.64,N/A,5.85,N/A,5.85,N/A,5.85,N/A,23.50,N/A,41.80,N/A,5.85,N/A,22.40,N/A,22.40,N/A,5.85,N/A,41.80,N/A,41.80,N/A,41.80,25.08,25.08,3.64,41.80,,Hospital HCPCS 6370000000,AMPICILLIN 500 MG PO CAPS,00781-2145-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHADONE HCL 5 MG PO TABS,00406-5755-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PERINDOPRIL ERBUMINE 4 MG PO TABS,00054-0111-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ALPRAZOLAM 0.25 MG PO TABS,65862-0676-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HALOPERIDOL 5 MG PO TABS,51079-0736-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRANYLCYPROMINE SULFATE 10 MG PO TABS,64980-0183-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.10,6.10,3.66,3.66,N/A,N/A,N/A,6.10,N/A,3.43,N/A,2.07,N/A,N/A,N/A,N/A,N/A,6.10,N/A,6.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.43,N/A,6.10,N/A,N/A,N/A,3.27,N/A,3.27,N/A,N/A,N/A,6.10,N/A,6.10,N/A,6.10,3.66,3.66,2.07,6.10,,Hospital HCPCS 6370000000,BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,00023-9211-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),459.30,459.30,275.58,275.58,N/A,64.30,N/A,459.30,N/A,258.22,N/A,156.16,N/A,64.30,N/A,64.30,N/A,459.30,N/A,459.30,N/A,39.96,N/A,64.30,N/A,64.30,N/A,64.30,N/A,258.22,N/A,459.30,N/A,64.30,N/A,246.18,N/A,246.18,N/A,64.30,N/A,459.30,N/A,459.30,N/A,459.30,275.58,275.58,39.96,459.30,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL ER (CD) 40 MG PO CPCR,00093-5298-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.40,10.40,6.24,6.24,N/A,1.46,N/A,10.40,N/A,5.85,N/A,3.54,N/A,1.46,N/A,1.46,N/A,10.40,N/A,10.40,N/A,N/A,N/A,1.46,N/A,1.46,N/A,1.46,N/A,5.85,N/A,10.40,N/A,1.46,N/A,5.57,N/A,5.57,N/A,1.46,N/A,10.40,N/A,10.40,N/A,10.40,6.24,6.24,1.46,10.40,,Hospital HCPCS 6370000000,DIVALPROEX SODIUM 250 MG PO TBEC,62756-0797-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ASENAPINE MALEATE 2.5 MG SL SUBL,00456-2402-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),45.10,45.10,27.06,27.06,N/A,6.31,N/A,45.10,N/A,25.36,N/A,15.33,N/A,6.31,N/A,6.31,N/A,45.10,N/A,45.10,N/A,3.92,N/A,6.31,N/A,6.31,N/A,6.31,N/A,25.36,N/A,45.10,N/A,6.31,N/A,24.17,N/A,24.17,N/A,6.31,N/A,45.10,N/A,45.10,N/A,45.10,27.06,27.06,3.92,45.10,,Hospital HCPCS 6370000000,METHIMAZOLE 5 MG PO TABS,49884-0640-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MISOPROSTOL 25 MCG PRE-SPLIT TABLET,09999-9900-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TOPIRAMATE 50 MG PO TABS,68382-0139-14,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDRALAZINE HCL 25 MG PO TABS,62584-0733-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLOBETASOL PROPIONATE 0.05 % EX OINT,00168-0162-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),147.90,147.90,88.74,88.74,N/A,20.71,N/A,147.90,N/A,83.15,N/A,50.29,N/A,20.71,N/A,20.71,N/A,147.90,N/A,147.90,N/A,12.87,N/A,20.71,N/A,20.71,N/A,20.71,N/A,83.15,N/A,147.90,N/A,20.71,N/A,79.27,N/A,79.27,N/A,20.71,N/A,147.90,N/A,147.90,N/A,147.90,88.74,88.74,12.87,147.90,,Hospital HCPCS 6370000000,FUROSEMIDE 80 MG PO TABS,51079-0527-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CULTURELLE DIGESTIVE HEALTH PO CAPS,49100-0400-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PREDNISOLONE ACETATE 1 % OP SUSP,61314-0637-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),199.20,199.20,119.52,119.52,N/A,27.89,N/A,199.20,N/A,111.99,N/A,67.73,N/A,27.89,N/A,27.89,N/A,199.20,N/A,199.20,N/A,17.33,N/A,27.89,N/A,27.89,N/A,27.89,N/A,111.99,N/A,199.20,N/A,27.89,N/A,106.77,N/A,106.77,N/A,27.89,N/A,199.20,N/A,199.20,N/A,199.20,119.52,119.52,17.33,199.20,,Hospital HCPCS 6370000000,CARBOXYMETHYLCELLULOSE SODIUM 0.5 % OP SOLN,00023-0798-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.60,35.60,21.36,21.36,N/A,4.98,N/A,35.60,N/A,20.01,N/A,12.10,N/A,4.98,N/A,4.98,N/A,35.60,N/A,35.60,N/A,3.10,N/A,4.98,N/A,4.98,N/A,4.98,N/A,20.01,N/A,35.60,N/A,4.98,N/A,19.08,N/A,19.08,N/A,4.98,N/A,35.60,N/A,35.60,N/A,35.60,21.36,21.36,3.10,35.60,,Hospital HCPCS 6370000000,COLCHICINE 0.6 MG PO TABS,64764-0119-07,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.20,16.20,9.72,9.72,N/A,2.27,N/A,16.20,N/A,9.11,N/A,5.51,N/A,2.27,N/A,2.27,N/A,16.20,N/A,16.20,N/A,1.41,N/A,2.27,N/A,2.27,N/A,2.27,N/A,9.11,N/A,16.20,N/A,2.27,N/A,8.68,N/A,8.68,N/A,2.27,N/A,16.20,N/A,16.20,N/A,16.20,9.72,9.72,1.41,16.20,,Hospital HCPCS 6370000000,CARBAMAZEPINE ER 200 MG PO TB12,51672-4124-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBOXYMETHYLCELLULOSE SODIUM 1 % OP GEL,00023-9205-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.80,17.80,10.68,10.68,N/A,2.49,N/A,17.80,N/A,10.01,N/A,6.05,N/A,2.49,N/A,2.49,N/A,17.80,N/A,17.80,N/A,1.55,N/A,2.49,N/A,2.49,N/A,2.49,N/A,10.01,N/A,17.80,N/A,2.49,N/A,9.54,N/A,9.54,N/A,2.49,N/A,17.80,N/A,17.80,N/A,17.80,10.68,10.68,1.55,17.80,,Hospital HCPCS 6370000000,AYR SALINE NASAL NA GEL,00225-0525-47,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.90,17.90,10.74,10.74,N/A,2.51,N/A,17.90,N/A,10.06,N/A,6.09,N/A,2.51,N/A,2.51,N/A,17.90,N/A,17.90,N/A,1.56,N/A,2.51,N/A,2.51,N/A,2.51,N/A,10.06,N/A,17.90,N/A,2.51,N/A,9.59,N/A,9.59,N/A,2.51,N/A,17.90,N/A,17.90,N/A,17.90,10.74,10.74,1.56,17.90,,Hospital HCPCS 6370000000,TRANEXAMIC ACID 650 MG PO TABS,00591-3720-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.40,9.40,5.64,5.64,N/A,1.32,N/A,9.40,N/A,5.28,N/A,3.20,N/A,1.32,N/A,1.32,N/A,9.40,N/A,9.40,N/A,N/A,N/A,1.32,N/A,1.32,N/A,1.32,N/A,5.28,N/A,9.40,N/A,1.32,N/A,5.04,N/A,5.04,N/A,1.32,N/A,9.40,N/A,9.40,N/A,9.40,5.64,5.64,1.32,9.40,,Hospital HCPCS 6370000000,SIMETHICONE 40 MG/0.6ML PO LIQD,62372-0650-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.70,17.70,10.62,10.62,N/A,2.48,N/A,17.70,N/A,9.95,N/A,6.02,N/A,2.48,N/A,2.48,N/A,17.70,N/A,17.70,N/A,1.54,N/A,2.48,N/A,2.48,N/A,2.48,N/A,9.95,N/A,17.70,N/A,2.48,N/A,9.49,N/A,9.49,N/A,2.48,N/A,17.70,N/A,17.70,N/A,17.70,10.62,10.62,1.54,17.70,,Hospital HCPCS 6370000000,TENOFOVIR ALAFENAMIDE FUMARATE 25 MG PO TABS,61958-2301-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),97.40,97.40,58.44,58.44,N/A,13.64,N/A,97.40,N/A,54.76,N/A,33.12,N/A,13.64,N/A,13.64,N/A,97.40,N/A,97.40,N/A,8.47,N/A,13.64,N/A,13.64,N/A,13.64,N/A,54.76,N/A,97.40,N/A,13.64,N/A,52.21,N/A,52.21,N/A,13.64,N/A,97.40,N/A,97.40,N/A,97.40,58.44,58.44,8.47,97.40,,Hospital HCPCS 6370000000,ROFLUMILAST 500 MCG PO TABS,00310-0095-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),31.40,31.40,18.84,18.84,N/A,4.40,N/A,31.40,N/A,17.65,N/A,10.68,N/A,4.40,N/A,4.40,N/A,31.40,N/A,31.40,N/A,2.73,N/A,4.40,N/A,4.40,N/A,4.40,N/A,17.65,N/A,31.40,N/A,4.40,N/A,16.83,N/A,16.83,N/A,4.40,N/A,31.40,N/A,31.40,N/A,31.40,18.84,18.84,2.73,31.40,,Hospital HCPCS 6370000000,DESOXIMETASONE 0.05 % EX GEL,51672-1261-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),165.40,165.40,99.24,99.24,N/A,23.16,N/A,165.40,N/A,92.99,N/A,56.24,N/A,23.16,N/A,23.16,N/A,165.40,N/A,165.40,N/A,14.39,N/A,23.16,N/A,23.16,N/A,23.16,N/A,92.99,N/A,165.40,N/A,23.16,N/A,88.65,N/A,88.65,N/A,23.16,N/A,165.40,N/A,165.40,N/A,165.40,99.24,99.24,14.39,165.40,,Hospital HCPCS 6370000000,CLARITHROMYCIN 500 MG PO TABS,00781-1962-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MINERAL OIL LIGHT OIL,63323-0254-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),34.30,34.30,20.58,20.58,N/A,4.80,N/A,34.30,N/A,19.28,N/A,11.66,N/A,4.80,N/A,4.80,N/A,34.30,N/A,34.30,N/A,2.98,N/A,4.80,N/A,4.80,N/A,4.80,N/A,19.28,N/A,34.30,N/A,4.80,N/A,18.38,N/A,18.38,N/A,4.80,N/A,34.30,N/A,34.30,N/A,34.30,20.58,20.58,2.98,34.30,,Hospital HCPCS 6370000000,FEXOFENADINE HCL 180 MG PO TABS,41167-4120-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.10,1.10,N/A,N/A,N/A,N/A,N/A,1.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.10,N/A,1.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.10,N/A,1.10,N/A,1.10,N/A,N/A,1.10,1.10,,Hospital HCPCS 6370000000,NATEGLINIDE 60 MG PO TABS,00591-3354-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS,00406-0123-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PALIPERIDONE ER 1.5 MG PO TB24,50458-0554-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.60,27.60,16.56,16.56,N/A,3.86,N/A,27.60,N/A,15.52,N/A,9.38,N/A,3.86,N/A,3.86,N/A,27.60,N/A,27.60,N/A,2.40,N/A,3.86,N/A,3.86,N/A,3.86,N/A,15.52,N/A,27.60,N/A,3.86,N/A,14.79,N/A,14.79,N/A,3.86,N/A,27.60,N/A,27.60,N/A,27.60,16.56,16.56,2.40,27.60,,Hospital HCPCS 6370000000,ATENOLOL 100 MG PO TABS,51079-0685-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER 90 MG PO CP12,51079-0925-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.80,8.80,5.28,5.28,N/A,1.23,N/A,8.80,N/A,4.95,N/A,2.99,N/A,1.23,N/A,1.23,N/A,8.80,N/A,8.80,N/A,N/A,N/A,1.23,N/A,1.23,N/A,1.23,N/A,4.95,N/A,8.80,N/A,1.23,N/A,4.72,N/A,4.72,N/A,1.23,N/A,8.80,N/A,8.80,N/A,8.80,5.28,5.28,1.23,8.80,,Hospital HCPCS 6370000000,MONSELS FERRIC SUBSULFATE EX SOLN,48783-0112-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),31.00,31.00,18.60,18.60,N/A,4.34,N/A,31.00,N/A,17.43,N/A,10.54,N/A,4.34,N/A,4.34,N/A,31.00,N/A,31.00,N/A,2.70,N/A,4.34,N/A,4.34,N/A,4.34,N/A,17.43,N/A,31.00,N/A,4.34,N/A,16.62,N/A,16.62,N/A,4.34,N/A,31.00,N/A,31.00,N/A,31.00,18.60,18.60,2.70,31.00,,Hospital HCPCS 6370000000,CLONIDINE 0.3 MG/24HR TD PTWK,00378-0873-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),139.30,139.30,83.58,83.58,N/A,19.50,N/A,139.30,N/A,78.31,N/A,47.36,N/A,19.50,N/A,19.50,N/A,139.30,N/A,139.30,N/A,12.12,N/A,19.50,N/A,19.50,N/A,19.50,N/A,78.31,N/A,139.30,N/A,19.50,N/A,74.66,N/A,74.66,N/A,19.50,N/A,139.30,N/A,139.30,N/A,139.30,83.58,83.58,12.12,139.30,,Hospital HCPCS 6370000000,VITAMIN A 3 MG (10000 UT) PO CAPS,00904-2085-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,APIXABAN 2.5 MG PO TABS,00003-0893-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.90,19.90,11.94,11.94,N/A,2.79,N/A,19.90,N/A,11.19,N/A,6.77,N/A,2.79,N/A,2.79,N/A,19.90,N/A,19.90,N/A,1.73,N/A,2.79,N/A,2.79,N/A,2.79,N/A,11.19,N/A,19.90,N/A,2.79,N/A,10.67,N/A,10.67,N/A,2.79,N/A,19.90,N/A,19.90,N/A,19.90,11.94,11.94,1.73,19.90,,Hospital HCPCS 6370000000,NICOTINE 7 MG/24HR TD PT24,00067-5124-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.20,3.20,1.92,1.92,N/A,N/A,N/A,3.20,N/A,1.80,N/A,1.09,N/A,N/A,N/A,N/A,N/A,3.20,N/A,3.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.80,N/A,3.20,N/A,N/A,N/A,1.72,N/A,1.72,N/A,N/A,N/A,3.20,N/A,3.20,N/A,3.20,1.92,1.92,1.09,3.20,,Hospital HCPCS 6370000000,LISDEXAMFETAMINE DIMESYLATE 30 MG PO CAPS,59417-0103-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.40,26.40,15.84,15.84,N/A,3.70,N/A,26.40,N/A,14.84,N/A,8.98,N/A,3.70,N/A,3.70,N/A,26.40,N/A,26.40,N/A,2.30,N/A,3.70,N/A,3.70,N/A,3.70,N/A,14.84,N/A,26.40,N/A,3.70,N/A,14.15,N/A,14.15,N/A,3.70,N/A,26.40,N/A,26.40,N/A,26.40,15.84,15.84,2.30,26.40,,Hospital HCPCS 6370000000,IPRATROPIUM BROMIDE 0.06 % NA SOLN,00054-0046-41,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),162.00,162.00,97.20,97.20,N/A,22.68,N/A,162.00,N/A,91.08,N/A,55.08,N/A,22.68,N/A,22.68,N/A,162.00,N/A,162.00,N/A,14.09,N/A,22.68,N/A,22.68,N/A,22.68,N/A,91.08,N/A,162.00,N/A,22.68,N/A,86.83,N/A,86.83,N/A,22.68,N/A,162.00,N/A,162.00,N/A,162.00,97.20,97.20,14.09,162.00,,Hospital HCPCS 6370000000,INDOMETHACIN 50 MG RE SUPP,69344-0102-33,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),776.30,776.30,465.78,465.78,N/A,108.68,N/A,776.30,N/A,436.44,N/A,263.94,N/A,108.68,N/A,108.68,N/A,776.30,N/A,776.30,N/A,67.54,N/A,108.68,N/A,108.68,N/A,108.68,N/A,436.44,N/A,776.30,N/A,108.68,N/A,416.10,N/A,416.10,N/A,108.68,N/A,776.30,N/A,776.30,N/A,776.30,465.78,465.78,67.54,776.30,,Hospital HCPCS 6370000000,CALCIUM CARBONATE ANTACID 500 MG PO CHEW,66553-0004-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,SALMETEROL XINAFOATE 50 MCG/ACT IN AEPB,00173-0521-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),952.90,952.90,571.74,571.74,N/A,133.41,N/A,952.90,N/A,535.72,N/A,323.99,N/A,133.41,N/A,133.41,N/A,952.90,N/A,952.90,N/A,82.90,N/A,133.41,N/A,133.41,N/A,133.41,N/A,535.72,N/A,952.90,N/A,133.41,N/A,510.75,N/A,510.75,N/A,133.41,N/A,952.90,N/A,952.90,N/A,952.90,571.74,571.74,82.90,952.90,,Hospital HCPCS 6370000000,CODEINE SULFATE 30 MG PO TABS,00054-0244-24,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ANASTROZOLE 1 MG PO TABS,68001-0155-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POLYETHYLENE GLYCOL 3350 17 GM/SCOOP PO POWD,45802-0868-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,EST ESTROGENS-METHYLTEST 0.625-1.25 MG PO TABS,62559-0150-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 6370000000,CLOTRIMAZOLE 1 % EX CREA,45802-0434-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.10,7.10,4.26,4.26,N/A,N/A,N/A,7.10,N/A,3.99,N/A,2.41,N/A,N/A,N/A,N/A,N/A,7.10,N/A,7.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.99,N/A,7.10,N/A,N/A,N/A,3.81,N/A,3.81,N/A,N/A,N/A,7.10,N/A,7.10,N/A,7.10,4.26,4.26,2.41,7.10,,Hospital HCPCS 6370000000,BUTALBITAL-APAP-CAFFEINE 50-325-40 MG PO TABS,00591-3369-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DICLOFENAC-MISOPROSTOL 75-0.2 MG PO TBEC,00025-1421-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.30,19.30,11.58,11.58,N/A,2.70,N/A,19.30,N/A,10.85,N/A,6.56,N/A,2.70,N/A,2.70,N/A,19.30,N/A,19.30,N/A,1.68,N/A,2.70,N/A,2.70,N/A,2.70,N/A,10.85,N/A,19.30,N/A,2.70,N/A,10.34,N/A,10.34,N/A,2.70,N/A,19.30,N/A,19.30,N/A,19.30,11.58,11.58,1.68,19.30,,Hospital HCPCS 6370000000,RIZATRIPTAN BENZOATE 10 MG PO TABS,51991-0355-78,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.60,12.60,7.56,7.56,N/A,1.76,N/A,12.60,N/A,7.08,N/A,4.28,N/A,1.76,N/A,1.76,N/A,12.60,N/A,12.60,N/A,1.10,N/A,1.76,N/A,1.76,N/A,1.76,N/A,7.08,N/A,12.60,N/A,1.76,N/A,6.75,N/A,6.75,N/A,1.76,N/A,12.60,N/A,12.60,N/A,12.60,7.56,7.56,1.10,12.60,,Hospital HCPCS 6370000000,BACITRACIN-POLYMYXIN B OP OINT,00574-4021-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),49.00,49.00,29.40,29.40,N/A,6.86,N/A,49.00,N/A,27.55,N/A,16.66,N/A,6.86,N/A,6.86,N/A,49.00,N/A,49.00,N/A,4.26,N/A,6.86,N/A,6.86,N/A,6.86,N/A,27.55,N/A,49.00,N/A,6.86,N/A,26.26,N/A,26.26,N/A,6.86,N/A,49.00,N/A,49.00,N/A,49.00,29.40,29.40,4.26,49.00,,Hospital HCPCS 6370000000,TIMOLOL MALEATE 0.5 % OP SOLN,61314-0227-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),21.80,21.80,13.08,13.08,N/A,3.05,N/A,21.80,N/A,12.26,N/A,7.41,N/A,3.05,N/A,3.05,N/A,21.80,N/A,21.80,N/A,1.90,N/A,3.05,N/A,3.05,N/A,3.05,N/A,12.26,N/A,21.80,N/A,3.05,N/A,11.68,N/A,11.68,N/A,3.05,N/A,21.80,N/A,21.80,N/A,21.80,13.08,13.08,1.90,21.80,,Hospital HCPCS 6370000000,PERPHENAZINE-AMITRIPTYLINE 2-25 MG PO TABS,00378-0442-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,TAMSULOSIN HCL 0.4 MG PO CAPS,68084-0299-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ISOSORBIDE DINITRATE 20 MG PO TABS,00781-1695-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DONEPEZIL HCL 5 MG PO TABS,13668-0102-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDOCAINE HCL 4 % MT SOLN,76329-6300-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),185.50,185.50,111.30,111.30,N/A,25.97,N/A,185.50,N/A,104.29,N/A,63.07,N/A,25.97,N/A,25.97,N/A,185.50,N/A,185.50,N/A,16.14,N/A,25.97,N/A,25.97,N/A,25.97,N/A,104.29,N/A,185.50,N/A,25.97,N/A,99.43,N/A,99.43,N/A,25.97,N/A,185.50,N/A,185.50,N/A,185.50,111.30,111.30,16.14,185.50,,Hospital HCPCS 6370000000,TEMAZEPAM 7.5 MG PO CAPS,68084-0549-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 6370000000,HYDROCORTISONE 5 MG PO TABS,59762-0073-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARVEDILOL 6.25 MG PO TABS,68001-0154-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TELMISARTAN 20 MG PO TABS,00597-0039-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.60,10.60,6.36,6.36,N/A,1.48,N/A,10.60,N/A,5.96,N/A,3.60,N/A,1.48,N/A,1.48,N/A,10.60,N/A,10.60,N/A,N/A,N/A,1.48,N/A,1.48,N/A,1.48,N/A,5.96,N/A,10.60,N/A,1.48,N/A,5.68,N/A,5.68,N/A,1.48,N/A,10.60,N/A,10.60,N/A,10.60,6.36,6.36,1.48,10.60,,Hospital HCPCS 6370000000,CLOPIDOGREL BISULFATE 300 MG PO TABS,68084-0752-95,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.20,32.20,19.32,19.32,N/A,4.51,N/A,32.20,N/A,18.10,N/A,10.95,N/A,4.51,N/A,4.51,N/A,32.20,N/A,32.20,N/A,2.80,N/A,4.51,N/A,4.51,N/A,4.51,N/A,18.10,N/A,32.20,N/A,4.51,N/A,17.26,N/A,17.26,N/A,4.51,N/A,32.20,N/A,32.20,N/A,32.20,19.32,19.32,2.80,32.20,,Hospital HCPCS 6370000000,ROPINIROLE HCL 1 MG PO TABS,68462-0255-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS,13668-0094-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA-ENTACAPONE 50-200-200 MG PO TABS,47335-0006-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 6370000000,SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS,53746-0271-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ETHOSUXIMIDE 250 MG PO CAPS,23155-0532-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TIMOLOL MALEATE 0.5 % OP SOLG,61314-0225-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),391.10,391.10,234.66,234.66,N/A,54.75,N/A,391.10,N/A,219.88,N/A,132.97,N/A,54.75,N/A,54.75,N/A,391.10,N/A,391.10,N/A,34.03,N/A,54.75,N/A,54.75,N/A,54.75,N/A,219.88,N/A,391.10,N/A,54.75,N/A,209.63,N/A,209.63,N/A,54.75,N/A,391.10,N/A,391.10,N/A,391.10,234.66,234.66,34.03,391.10,,Hospital HCPCS 6370000000,NALOXONE HCL 4 MG/0.1ML NA LIQD,69547-0353-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital HCPCS 6370000000,RIFAXIMIN 550 MG PO TABS,65649-0303-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),111.60,111.60,66.96,66.96,N/A,15.62,N/A,111.60,N/A,62.74,N/A,37.94,N/A,15.62,N/A,15.62,N/A,111.60,N/A,111.60,N/A,9.71,N/A,15.62,N/A,15.62,N/A,15.62,N/A,62.74,N/A,111.60,N/A,15.62,N/A,59.82,N/A,59.82,N/A,15.62,N/A,111.60,N/A,111.60,N/A,111.60,66.96,66.96,9.71,111.60,,Hospital HCPCS 6370000000,OLANZAPINE 5 MG PO TBDP,59746-0306-32,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TOLVAPTAN 30 MG PO TABS,59148-0021-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1214.20,1214.20,728.52,728.52,N/A,169.99,N/A,1214.20,N/A,682.62,N/A,412.83,N/A,169.99,N/A,169.99,N/A,1214.20,N/A,1214.20,N/A,105.64,N/A,169.99,N/A,169.99,N/A,169.99,N/A,682.62,N/A,1214.20,N/A,169.99,N/A,650.81,N/A,650.81,N/A,169.99,N/A,1214.20,N/A,1214.20,N/A,1214.20,728.52,728.52,105.64,1214.20,,Hospital HCPCS 6370000000,LOXAPINE SUCCINATE 50 MG PO CAPS,00591-0372-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TALC 5 G PL SUSR,63256-0200-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),175.50,175.50,105.30,105.30,N/A,24.57,N/A,175.50,N/A,98.67,N/A,59.67,N/A,24.57,N/A,24.57,N/A,175.50,N/A,175.50,N/A,15.27,N/A,24.57,N/A,24.57,N/A,24.57,N/A,98.67,N/A,175.50,N/A,24.57,N/A,94.07,N/A,94.07,N/A,24.57,N/A,175.50,N/A,175.50,N/A,175.50,105.30,105.30,15.27,175.50,,Hospital HCPCS 6370000000,RILPIVIRINE HCL 25 MG PO TABS,59676-0278-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),96.50,96.50,57.90,57.90,N/A,13.51,N/A,96.50,N/A,54.25,N/A,32.81,N/A,13.51,N/A,13.51,N/A,96.50,N/A,96.50,N/A,8.40,N/A,13.51,N/A,13.51,N/A,13.51,N/A,54.25,N/A,96.50,N/A,13.51,N/A,51.72,N/A,51.72,N/A,13.51,N/A,96.50,N/A,96.50,N/A,96.50,57.90,57.90,8.40,96.50,,Hospital HCPCS 6370000000,NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,24208-0790-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),114.90,114.90,68.94,68.94,N/A,16.09,N/A,114.90,N/A,64.60,N/A,39.07,N/A,16.09,N/A,16.09,N/A,114.90,N/A,114.90,N/A,10.00,N/A,16.09,N/A,16.09,N/A,16.09,N/A,64.60,N/A,114.90,N/A,16.09,N/A,61.59,N/A,61.59,N/A,16.09,N/A,114.90,N/A,114.90,N/A,114.90,68.94,68.94,10.00,114.90,,Hospital HCPCS 6370000000,ISOSORBIDE MONONITRATE ER 30 MG PO TB24,62175-0128-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SILVER NITRATE-POT NITRATE 75-25 % EX MISC,99990-9906-64,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDOCAINE 5 % EX PTCH,00591-3525-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 6370000000,ARMODAFINIL 250 MG PO TABS,63459-0225-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),76.10,76.10,45.66,45.66,N/A,10.65,N/A,76.10,N/A,42.78,N/A,25.87,N/A,10.65,N/A,10.65,N/A,76.10,N/A,76.10,N/A,6.62,N/A,10.65,N/A,10.65,N/A,10.65,N/A,42.78,N/A,76.10,N/A,10.65,N/A,40.79,N/A,40.79,N/A,10.65,N/A,76.10,N/A,76.10,N/A,76.10,45.66,45.66,6.62,76.10,,Hospital HCPCS 6370000000,SALINE SPRAY 0.65 % NA SOLN,00904-3865-75,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ISONIAZID 300 MG PO TABS,51079-0083-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LUBIPROSTONE 24 MCG PO CAPS,64764-0240-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.00,14.00,8.40,8.40,N/A,1.96,N/A,14.00,N/A,7.87,N/A,4.76,N/A,1.96,N/A,1.96,N/A,14.00,N/A,14.00,N/A,1.22,N/A,1.96,N/A,1.96,N/A,1.96,N/A,7.87,N/A,14.00,N/A,1.96,N/A,7.50,N/A,7.50,N/A,1.96,N/A,14.00,N/A,14.00,N/A,14.00,8.40,8.40,1.22,14.00,,Hospital HCPCS 6370000000,DIAZEPAM 2 MG PO TABS,51079-0284-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NITROFURANTOIN MACROCRYSTAL 25 MG PO CAPS,47781-0306-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.20,13.20,7.92,7.92,N/A,1.85,N/A,13.20,N/A,7.42,N/A,4.49,N/A,1.85,N/A,1.85,N/A,13.20,N/A,13.20,N/A,1.15,N/A,1.85,N/A,1.85,N/A,1.85,N/A,7.42,N/A,13.20,N/A,1.85,N/A,7.08,N/A,7.08,N/A,1.85,N/A,13.20,N/A,13.20,N/A,13.20,7.92,7.92,1.15,13.20,,Hospital HCPCS 6370000000,CHOLESTYRAMINE LIGHT 4 G PO PACK,49884-0466-63,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LOPERAMIDE HCL 2 MG PO CAPS,51079-0690-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.70,1.70,1.02,1.02,N/A,N/A,N/A,1.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.70,N/A,1.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.70,N/A,1.70,N/A,1.70,1.02,1.02,1.02,1.70,,Hospital HCPCS 6370000000,ALOGLIPTIN BENZOATE 6.25 MG PO TABS,45802-0087-65,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.70,14.70,8.82,8.82,N/A,2.06,N/A,14.70,N/A,8.26,N/A,5.00,N/A,2.06,N/A,2.06,N/A,14.70,N/A,14.70,N/A,1.28,N/A,2.06,N/A,2.06,N/A,2.06,N/A,8.26,N/A,14.70,N/A,2.06,N/A,7.88,N/A,7.88,N/A,2.06,N/A,14.70,N/A,14.70,N/A,14.70,8.82,8.82,1.28,14.70,,Hospital HCPCS 6370000000,PHENOBARBITAL 32.4 MG PO TABS,00603-5166-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CEREFOLIN NAC 6-90.314-2-600 MG PO TABS,00525-0555-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.40,13.40,8.04,8.04,N/A,1.88,N/A,13.40,N/A,7.53,N/A,4.56,N/A,1.88,N/A,1.88,N/A,13.40,N/A,13.40,N/A,1.17,N/A,1.88,N/A,1.88,N/A,1.88,N/A,7.53,N/A,13.40,N/A,1.88,N/A,7.18,N/A,7.18,N/A,1.88,N/A,13.40,N/A,13.40,N/A,13.40,8.04,8.04,1.17,13.40,,Hospital HCPCS 6370000000,PROPAFENONE HCL ER 425 MG PO CP12,49884-0211-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.70,16.70,10.02,10.02,N/A,2.34,N/A,16.70,N/A,9.39,N/A,5.68,N/A,2.34,N/A,2.34,N/A,16.70,N/A,16.70,N/A,1.45,N/A,2.34,N/A,2.34,N/A,2.34,N/A,9.39,N/A,16.70,N/A,2.34,N/A,8.95,N/A,8.95,N/A,2.34,N/A,16.70,N/A,16.70,N/A,16.70,10.02,10.02,1.45,16.70,,Hospital HCPCS 6370000000,FELBAMATE 600 MG PO TABS,00037-0431-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.50,35.50,21.30,21.30,N/A,4.97,N/A,35.50,N/A,19.96,N/A,12.07,N/A,4.97,N/A,4.97,N/A,35.50,N/A,35.50,N/A,3.09,N/A,4.97,N/A,4.97,N/A,4.97,N/A,19.96,N/A,35.50,N/A,4.97,N/A,19.03,N/A,19.03,N/A,4.97,N/A,35.50,N/A,35.50,N/A,35.50,21.30,21.30,3.09,35.50,,Hospital HCPCS 6370000000,POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF,51801-0011-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,24208-0795-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.80,35.80,21.48,21.48,N/A,5.01,N/A,35.80,N/A,20.13,N/A,12.17,N/A,5.01,N/A,5.01,N/A,35.80,N/A,35.80,N/A,3.11,N/A,5.01,N/A,5.01,N/A,5.01,N/A,20.13,N/A,35.80,N/A,5.01,N/A,19.19,N/A,19.19,N/A,5.01,N/A,35.80,N/A,35.80,N/A,35.80,21.48,21.48,3.11,35.80,,Hospital HCPCS 6370000000,BALSAM PERU-CASTOR OIL TOPICAL OINTMENT,71351-0014-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),60.30,60.30,36.18,36.18,N/A,8.44,N/A,60.30,N/A,33.90,N/A,20.50,N/A,8.44,N/A,8.44,N/A,60.30,N/A,60.30,N/A,5.25,N/A,8.44,N/A,8.44,N/A,8.44,N/A,33.90,N/A,60.30,N/A,8.44,N/A,32.32,N/A,32.32,N/A,8.44,N/A,60.30,N/A,60.30,N/A,60.30,36.18,36.18,5.25,60.30,,Hospital HCPCS 6370000000,AMOXICILLIN 500 MG PO CAPS,00781-2613-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS,13668-0091-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,39328-0064-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.50,24.50,14.70,14.70,N/A,3.43,N/A,24.50,N/A,13.77,N/A,8.33,N/A,3.43,N/A,3.43,N/A,24.50,N/A,24.50,N/A,2.13,N/A,3.43,N/A,3.43,N/A,3.43,N/A,13.77,N/A,24.50,N/A,3.43,N/A,13.13,N/A,13.13,N/A,3.43,N/A,24.50,N/A,24.50,N/A,24.50,14.70,14.70,2.13,24.50,,Hospital HCPCS 6370000000,BRIMONIDINE TARTRATE 0.2 % OP SOLN,24208-0411-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.70,32.70,19.62,19.62,N/A,4.58,N/A,32.70,N/A,18.38,N/A,11.12,N/A,4.58,N/A,4.58,N/A,32.70,N/A,32.70,N/A,2.84,N/A,4.58,N/A,4.58,N/A,4.58,N/A,18.38,N/A,32.70,N/A,4.58,N/A,17.53,N/A,17.53,N/A,4.58,N/A,32.70,N/A,32.70,N/A,32.70,19.62,19.62,2.84,32.70,,Hospital HCPCS 6370000000,VENLAFAXINE HCL ER 75 MG PO CP24,68382-0035-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LINAGLIPTIN 5 MG PO TABS,00597-0140-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),37.90,37.90,22.74,22.74,N/A,5.31,N/A,37.90,N/A,21.31,N/A,12.89,N/A,5.31,N/A,5.31,N/A,37.90,N/A,37.90,N/A,3.30,N/A,5.31,N/A,5.31,N/A,5.31,N/A,21.31,N/A,37.90,N/A,5.31,N/A,20.31,N/A,20.31,N/A,5.31,N/A,37.90,N/A,37.90,N/A,37.90,22.74,22.74,3.30,37.90,,Hospital HCPCS 6370000000,BENZOCAINE-MENTHOL 6-10 MG MT LOZG,78112-0011-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.40,5.40,3.24,3.24,N/A,N/A,N/A,5.40,N/A,3.04,N/A,1.84,N/A,N/A,N/A,N/A,N/A,5.40,N/A,5.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.04,N/A,5.40,N/A,N/A,N/A,2.89,N/A,2.89,N/A,N/A,N/A,5.40,N/A,5.40,N/A,5.40,3.24,3.24,1.84,5.40,,Hospital HCPCS 6370000000,ESTRADIOL 0.1 MG/GM VA CREA,00430-3754-14,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),775.80,775.80,465.48,465.48,N/A,108.61,N/A,775.80,N/A,436.15,N/A,263.77,N/A,108.61,N/A,108.61,N/A,775.80,N/A,775.80,N/A,67.49,N/A,108.61,N/A,108.61,N/A,108.61,N/A,436.15,N/A,775.80,N/A,108.61,N/A,415.83,N/A,415.83,N/A,108.61,N/A,775.80,N/A,775.80,N/A,775.80,465.48,465.48,67.49,775.80,,Hospital HCPCS 6370000000,ESTRADIOL 0.075 MG/24HR TD PTWK,00781-7136-54,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),41.80,41.80,25.08,25.08,N/A,5.85,N/A,41.80,N/A,23.50,N/A,14.21,N/A,5.85,N/A,5.85,N/A,41.80,N/A,41.80,N/A,3.64,N/A,5.85,N/A,5.85,N/A,5.85,N/A,23.50,N/A,41.80,N/A,5.85,N/A,22.40,N/A,22.40,N/A,5.85,N/A,41.80,N/A,41.80,N/A,41.80,25.08,25.08,3.64,41.80,,Hospital HCPCS 6370000000,CLOZAPINE 100 MG PO TABS,51079-0922-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ESZOPICLONE 1 MG PO TABS,63402-0190-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),35.30,35.30,21.18,21.18,N/A,4.94,N/A,35.30,N/A,19.85,N/A,12.00,N/A,4.94,N/A,4.94,N/A,35.30,N/A,35.30,N/A,3.07,N/A,4.94,N/A,4.94,N/A,4.94,N/A,19.85,N/A,35.30,N/A,4.94,N/A,18.92,N/A,18.92,N/A,4.94,N/A,35.30,N/A,35.30,N/A,35.30,21.18,21.18,3.07,35.30,,Hospital HCPCS 6370000000,SERTACONAZOLE NITRATE 2 % EX CREA,00187-5115-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),2024.00,2024.00,1214.40,1214.40,N/A,283.36,N/A,2024.00,N/A,1137.89,N/A,688.16,N/A,283.36,N/A,283.36,N/A,2024.00,N/A,2024.00,N/A,176.09,N/A,283.36,N/A,283.36,N/A,283.36,N/A,1137.89,N/A,2024.00,N/A,283.36,N/A,1084.86,N/A,1084.86,N/A,283.36,N/A,2024.00,N/A,2024.00,N/A,2024.00,1214.40,1214.40,176.09,2024.00,,Hospital HCPCS 6370000000,BENZOYL PEROXIDE 5 % EX GEL,00536-1055-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.00,26.00,15.60,15.60,N/A,3.64,N/A,26.00,N/A,14.62,N/A,8.84,N/A,3.64,N/A,3.64,N/A,26.00,N/A,26.00,N/A,2.26,N/A,3.64,N/A,3.64,N/A,3.64,N/A,14.62,N/A,26.00,N/A,3.64,N/A,13.94,N/A,13.94,N/A,3.64,N/A,26.00,N/A,26.00,N/A,26.00,15.60,15.60,2.26,26.00,,Hospital HCPCS 6370000000,TIMOLOL MALEATE 0.25 % OP SOLN,61314-0226-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.70,11.70,7.02,7.02,N/A,1.64,N/A,11.70,N/A,6.58,N/A,3.98,N/A,1.64,N/A,1.64,N/A,11.70,N/A,11.70,N/A,1.02,N/A,1.64,N/A,1.64,N/A,1.64,N/A,6.58,N/A,11.70,N/A,1.64,N/A,6.27,N/A,6.27,N/A,1.64,N/A,11.70,N/A,11.70,N/A,11.70,7.02,7.02,1.02,11.70,,Hospital HCPCS 6370000000,GLUCOSE 40 % PO GEL,09999-9912-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.10,7.10,4.26,4.26,N/A,N/A,N/A,7.10,N/A,3.99,N/A,2.41,N/A,N/A,N/A,N/A,N/A,7.10,N/A,7.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.99,N/A,7.10,N/A,N/A,N/A,3.81,N/A,3.81,N/A,N/A,N/A,7.10,N/A,7.10,N/A,7.10,4.26,4.26,2.41,7.10,,Hospital HCPCS 6370000000,SODIUM CHLORIDE 0.9 % IN NEBU,00487-9301-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OLANZAPINE 10 MG PO TABS,68084-0740-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GLIPIZIDE ER 10 MG PO TB24,59762-0542-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL ER 36 MG PO TB24,00406-0136-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.50,11.50,6.90,6.90,N/A,1.61,N/A,11.50,N/A,6.47,N/A,3.91,N/A,1.61,N/A,1.61,N/A,11.50,N/A,11.50,N/A,1.00,N/A,1.61,N/A,1.61,N/A,1.61,N/A,6.47,N/A,11.50,N/A,1.61,N/A,6.16,N/A,6.16,N/A,1.61,N/A,11.50,N/A,11.50,N/A,11.50,6.90,6.90,1.00,11.50,,Hospital HCPCS 6370000000,METOPROLOL SUCCINATE ER 25 MG PO TB24,00904-6322-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRAZOSIN HCL 1 MG PO CAPS,51079-0630-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,25021-0673-76,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.40,13.40,8.04,8.04,N/A,1.88,N/A,13.40,N/A,7.53,N/A,4.56,N/A,1.88,N/A,1.88,N/A,13.40,N/A,13.40,N/A,1.17,N/A,1.88,N/A,1.88,N/A,1.88,N/A,7.53,N/A,13.40,N/A,1.88,N/A,7.18,N/A,7.18,N/A,1.88,N/A,13.40,N/A,13.40,N/A,13.40,8.04,8.04,1.17,13.40,,Hospital HCPCS 6370000000,CARBAMIDE PEROXIDE 6.5 % OT SOLN,00904-6627-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OFLOXACIN 0.3 % OT SOLN,60505-0363-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),146.30,146.30,87.78,87.78,N/A,20.48,N/A,146.30,N/A,82.25,N/A,49.74,N/A,20.48,N/A,20.48,N/A,146.30,N/A,146.30,N/A,12.73,N/A,20.48,N/A,20.48,N/A,20.48,N/A,82.25,N/A,146.30,N/A,20.48,N/A,78.42,N/A,78.42,N/A,20.48,N/A,146.30,N/A,146.30,N/A,146.30,87.78,87.78,12.73,146.30,,Hospital HCPCS 6370000000,AMPHETAMINE-DEXTROAMPHETAMINE 20 MG PO TABS,00185-0853-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VITAMIN D3 10 MCG (400 UNIT) PO TABS,00904-5823-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PETROLATUM GEL,53329-0068-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.80,7.80,4.68,4.68,N/A,1.09,N/A,7.80,N/A,4.39,N/A,2.65,N/A,1.09,N/A,1.09,N/A,7.80,N/A,7.80,N/A,N/A,N/A,1.09,N/A,1.09,N/A,1.09,N/A,4.39,N/A,7.80,N/A,1.09,N/A,4.18,N/A,4.18,N/A,1.09,N/A,7.80,N/A,7.80,N/A,7.80,4.68,4.68,1.09,7.80,,Hospital HCPCS 6370000000,AMPHETAMINE-DEXTROAMPHET ER 25 MG PO CP24,00228-3064-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 88 MCG PO TABS,00074-6594-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VENLAFAXINE HCL ER 37.5 MG PO CP24,68084-0698-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CILOSTAZOL 50 MG PO TABS,00054-0028-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUTICASONE-SALMETEROL 115-21 MCG/ACT IN AERO,00173-0716-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),913.00,913.00,547.80,547.80,N/A,127.82,N/A,913.00,N/A,513.29,N/A,310.42,N/A,127.82,N/A,127.82,N/A,913.00,N/A,913.00,N/A,79.43,N/A,127.82,N/A,127.82,N/A,127.82,N/A,513.29,N/A,913.00,N/A,127.82,N/A,489.37,N/A,489.37,N/A,127.82,N/A,913.00,N/A,913.00,N/A,913.00,547.80,547.80,79.43,913.00,,Hospital HCPCS 6370000000,NITAZOXANIDE 500 MG PO TABS,67546-0111-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),303.00,303.00,181.80,181.80,N/A,42.42,N/A,303.00,N/A,170.35,N/A,103.02,N/A,42.42,N/A,42.42,N/A,303.00,N/A,303.00,N/A,26.36,N/A,42.42,N/A,42.42,N/A,42.42,N/A,170.35,N/A,303.00,N/A,42.42,N/A,162.41,N/A,162.41,N/A,42.42,N/A,303.00,N/A,303.00,N/A,303.00,181.80,181.80,26.36,303.00,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL ER 27 MG PO TB24,00406-0127-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.00,9.00,5.40,5.40,N/A,1.26,N/A,9.00,N/A,5.06,N/A,3.06,N/A,1.26,N/A,1.26,N/A,9.00,N/A,9.00,N/A,N/A,N/A,1.26,N/A,1.26,N/A,1.26,N/A,5.06,N/A,9.00,N/A,1.26,N/A,4.82,N/A,4.82,N/A,1.26,N/A,9.00,N/A,9.00,N/A,9.00,5.40,5.40,1.26,9.00,,Hospital HCPCS 6370000000,TICAGRELOR 90 MG PO TABS,00186-0777-39,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.00,16.00,9.60,9.60,N/A,2.24,N/A,16.00,N/A,9.00,N/A,5.44,N/A,2.24,N/A,2.24,N/A,16.00,N/A,16.00,N/A,1.39,N/A,2.24,N/A,2.24,N/A,2.24,N/A,9.00,N/A,16.00,N/A,2.24,N/A,8.58,N/A,8.58,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,9.60,9.60,1.39,16.00,,Hospital HCPCS 6370000000,MARAVIROC 150 MG PO TABS,49702-0223-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),61.30,61.30,36.78,36.78,N/A,8.58,N/A,61.30,N/A,34.46,N/A,20.84,N/A,8.58,N/A,8.58,N/A,61.30,N/A,61.30,N/A,5.33,N/A,8.58,N/A,8.58,N/A,8.58,N/A,34.46,N/A,61.30,N/A,8.58,N/A,32.86,N/A,32.86,N/A,8.58,N/A,61.30,N/A,61.30,N/A,61.30,36.78,36.78,5.33,61.30,,Hospital HCPCS 6370000000,PEG-3350/ELECTROLYTES 236 G PO SOLR,10572-0100-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),45.00,45.00,27.00,27.00,N/A,6.30,N/A,45.00,N/A,25.30,N/A,15.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,3.92,N/A,6.30,N/A,6.30,N/A,6.30,N/A,25.30,N/A,45.00,N/A,6.30,N/A,24.12,N/A,24.12,N/A,6.30,N/A,45.00,N/A,45.00,N/A,45.00,27.00,27.00,3.92,45.00,,Hospital HCPCS 6370000000,LOSARTAN POTASSIUM 25 MG PO TABS,68084-0346-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CHLORHEXIDINE GLUCONATE 4 % EX SOLN,00116-2994-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),9.10,9.10,5.46,5.46,N/A,1.27,N/A,9.10,N/A,5.12,N/A,3.09,N/A,1.27,N/A,1.27,N/A,9.10,N/A,9.10,N/A,N/A,N/A,1.27,N/A,1.27,N/A,1.27,N/A,5.12,N/A,9.10,N/A,1.27,N/A,4.88,N/A,4.88,N/A,1.27,N/A,9.10,N/A,9.10,N/A,9.10,5.46,5.46,1.27,9.10,,Hospital HCPCS 6370000000,TRAZODONE HCL 150 MG PO TABS,60687-0432-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ABACAVIR SULFATE 300 MG PO TABS,00378-4105-91,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),18.10,18.10,10.86,10.86,N/A,2.53,N/A,18.10,N/A,10.18,N/A,6.15,N/A,2.53,N/A,2.53,N/A,18.10,N/A,18.10,N/A,1.57,N/A,2.53,N/A,2.53,N/A,2.53,N/A,10.18,N/A,18.10,N/A,2.53,N/A,9.70,N/A,9.70,N/A,2.53,N/A,18.10,N/A,18.10,N/A,18.10,10.86,10.86,1.57,18.10,,Hospital HCPCS 6370000000,TOPIRAMATE 15 MG PO CPSP,00093-7335-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ALOGLIPTIN BENZOATE 25 MG PO TABS,45802-0150-65,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.70,14.70,8.82,8.82,N/A,2.06,N/A,14.70,N/A,8.26,N/A,5.00,N/A,2.06,N/A,2.06,N/A,14.70,N/A,14.70,N/A,1.28,N/A,2.06,N/A,2.06,N/A,2.06,N/A,8.26,N/A,14.70,N/A,2.06,N/A,7.88,N/A,7.88,N/A,2.06,N/A,14.70,N/A,14.70,N/A,14.70,8.82,8.82,1.28,14.70,,Hospital HCPCS 6370000000,FLUTICASONE PROPIONATE HFA 44 MCG/ACT IN AERO,09999-9908-29,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,IPRATROPIUM BROMIDE 0.03 % NA SOLN,24208-0398-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),82.20,82.20,49.32,49.32,N/A,11.51,N/A,82.20,N/A,46.21,N/A,27.95,N/A,11.51,N/A,11.51,N/A,82.20,N/A,82.20,N/A,7.15,N/A,11.51,N/A,11.51,N/A,11.51,N/A,46.21,N/A,82.20,N/A,11.51,N/A,44.06,N/A,44.06,N/A,11.51,N/A,82.20,N/A,82.20,N/A,82.20,49.32,49.32,7.15,82.20,,Hospital HCPCS 6370000000,TRIPLE ANTIBIOTIC 5-400-5000 EX OINT,00904-0734-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,KETOCONAZOLE 2 % EX CREA,00168-0099-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.80,33.80,20.28,20.28,N/A,4.73,N/A,33.80,N/A,19.00,N/A,11.49,N/A,4.73,N/A,4.73,N/A,33.80,N/A,33.80,N/A,2.94,N/A,4.73,N/A,4.73,N/A,4.73,N/A,19.00,N/A,33.80,N/A,4.73,N/A,18.12,N/A,18.12,N/A,4.73,N/A,33.80,N/A,33.80,N/A,33.80,20.28,20.28,2.94,33.80,,Hospital HCPCS 6370000000,DEPLIN 7.5 7.5-90.314 MG PO CAPS,00525-1139-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.40,13.40,8.04,8.04,N/A,1.88,N/A,13.40,N/A,7.53,N/A,4.56,N/A,1.88,N/A,1.88,N/A,13.40,N/A,13.40,N/A,1.17,N/A,1.88,N/A,1.88,N/A,1.88,N/A,7.53,N/A,13.40,N/A,1.88,N/A,7.18,N/A,7.18,N/A,1.88,N/A,13.40,N/A,13.40,N/A,13.40,8.04,8.04,1.17,13.40,,Hospital HCPCS 6370000000,CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,00168-0258-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),38.00,38.00,22.80,22.80,N/A,5.32,N/A,38.00,N/A,21.36,N/A,12.92,N/A,5.32,N/A,5.32,N/A,38.00,N/A,38.00,N/A,3.31,N/A,5.32,N/A,5.32,N/A,5.32,N/A,21.36,N/A,38.00,N/A,5.32,N/A,20.37,N/A,20.37,N/A,5.32,N/A,38.00,N/A,38.00,N/A,38.00,22.80,22.80,3.31,38.00,,Hospital HCPCS 6370000000,LOPERAMIDE HCL 1 MG/7.5ML PO LIQD,00904-6836-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24,60687-0228-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LEVOTHYROXINE SODIUM 112 MCG PO TABS,00074-9296-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CILOSTAZOL 100 MG PO TABS,00093-2064-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHIMAZOLE 10 MG PO TABS,49884-0641-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS,00310-6210-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),41.20,41.20,24.72,24.72,N/A,5.77,N/A,41.20,N/A,23.16,N/A,14.01,N/A,5.77,N/A,5.77,N/A,41.20,N/A,41.20,N/A,3.58,N/A,5.77,N/A,5.77,N/A,5.77,N/A,23.16,N/A,41.20,N/A,5.77,N/A,22.08,N/A,22.08,N/A,5.77,N/A,41.20,N/A,41.20,N/A,41.20,24.72,24.72,3.58,41.20,,Hospital HCPCS 6370000000,CEPHALEXIN 500 MG PO CAPS,68180-0122-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GLUCOSE 40% PO GEL NEONATAL SYRINGE,09999-9912-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.70,6.70,4.02,4.02,N/A,N/A,N/A,6.70,N/A,3.77,N/A,2.28,N/A,N/A,N/A,N/A,N/A,6.70,N/A,6.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.77,N/A,6.70,N/A,N/A,N/A,3.59,N/A,3.59,N/A,N/A,N/A,6.70,N/A,6.70,N/A,6.70,4.02,4.02,2.28,6.70,,Hospital HCPCS 6370000000,OLANZAPINE-FLUOXETINE HCL 12-25 MG PO CAPS,00093-5506-56,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),39.30,39.30,23.58,23.58,N/A,5.50,N/A,39.30,N/A,22.09,N/A,13.36,N/A,5.50,N/A,5.50,N/A,39.30,N/A,39.30,N/A,3.42,N/A,5.50,N/A,5.50,N/A,5.50,N/A,22.09,N/A,39.30,N/A,5.50,N/A,21.06,N/A,21.06,N/A,5.50,N/A,39.30,N/A,39.30,N/A,39.30,23.58,23.58,3.42,39.30,,Hospital HCPCS 6370000000,METHYLCELLULOSE (LAXATIVE) PO POWD,00904-5675-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.30,13.30,7.98,7.98,N/A,1.86,N/A,13.30,N/A,7.48,N/A,4.52,N/A,1.86,N/A,1.86,N/A,13.30,N/A,13.30,N/A,1.16,N/A,1.86,N/A,1.86,N/A,1.86,N/A,7.48,N/A,13.30,N/A,1.86,N/A,7.13,N/A,7.13,N/A,1.86,N/A,13.30,N/A,13.30,N/A,13.30,7.98,7.98,1.16,13.30,,Hospital HCPCS 6370000000,MEXILETINE HCL 150 MG PO CAPS,00093-8739-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TALC POWD,38779-0519-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),57.20,57.20,34.32,34.32,N/A,8.01,N/A,57.20,N/A,32.16,N/A,19.45,N/A,8.01,N/A,8.01,N/A,57.20,N/A,57.20,N/A,4.98,N/A,8.01,N/A,8.01,N/A,8.01,N/A,32.16,N/A,57.20,N/A,8.01,N/A,30.66,N/A,30.66,N/A,8.01,N/A,57.20,N/A,57.20,N/A,57.20,34.32,34.32,4.98,57.20,,Hospital HCPCS 6370000000,BIOTENE DRY MOUTH MOISTURIZING MT SOLN,48582-0001-55,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.10,10.10,6.06,6.06,N/A,1.41,N/A,10.10,N/A,5.68,N/A,3.43,N/A,1.41,N/A,1.41,N/A,10.10,N/A,10.10,N/A,N/A,N/A,1.41,N/A,1.41,N/A,1.41,N/A,5.68,N/A,10.10,N/A,1.41,N/A,5.41,N/A,5.41,N/A,1.41,N/A,10.10,N/A,10.10,N/A,10.10,6.06,6.06,1.41,10.10,,Hospital HCPCS 6370000000,PHENAZOPYRIDINE HCL 100 MG PO TABS,51293-0801-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR,68084-0282-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ROPINIROLE HCL 0.5 MG PO TABS,16729-0233-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GUAIFENESIN ER 600 MG PO TB12,63824-0008-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ZOLPIDEM TARTRATE ER 6.25 MG PO TBCR,00955-1702-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.70,3.70,2.22,2.22,N/A,N/A,N/A,3.70,N/A,2.08,N/A,1.26,N/A,N/A,N/A,N/A,N/A,3.70,N/A,3.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.08,N/A,3.70,N/A,N/A,N/A,1.98,N/A,1.98,N/A,N/A,N/A,3.70,N/A,3.70,N/A,3.70,2.22,2.22,1.26,3.70,,Hospital HCPCS 6370000000,MODAFINIL 200 MG PO TABS,55253-0802-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.70,15.70,9.42,9.42,N/A,2.20,N/A,15.70,N/A,8.83,N/A,5.34,N/A,2.20,N/A,2.20,N/A,15.70,N/A,15.70,N/A,1.37,N/A,2.20,N/A,2.20,N/A,2.20,N/A,8.83,N/A,15.70,N/A,2.20,N/A,8.42,N/A,8.42,N/A,2.20,N/A,15.70,N/A,15.70,N/A,15.70,9.42,9.42,1.37,15.70,,Hospital HCPCS 6370000000,ACETAMINOPHEN 325 MG RE SUPP,51672-2116-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.60,1.60,N/A,N/A,N/A,N/A,N/A,1.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.60,N/A,1.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.60,N/A,1.60,N/A,1.60,N/A,N/A,1.60,1.60,,Hospital HCPCS 6370000000,BISMUTH SUBSALICYLATE 262 MG PO CHEW,01490-0326-42,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MAGIC BUTT CREAM,09999-9904-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),22.50,22.50,13.50,13.50,N/A,3.15,N/A,22.50,N/A,12.65,N/A,7.65,N/A,3.15,N/A,3.15,N/A,22.50,N/A,22.50,N/A,1.96,N/A,3.15,N/A,3.15,N/A,3.15,N/A,12.65,N/A,22.50,N/A,3.15,N/A,12.06,N/A,12.06,N/A,3.15,N/A,22.50,N/A,22.50,N/A,22.50,13.50,13.50,1.96,22.50,,Hospital HCPCS 6370000000,LITHIUM CARBONATE 300 MG PO CAPS,00054-8527-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BUPROPION HCL ER (SR) 150 MG PO TB12,00591-3541-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DANTROLENE SODIUM 50 MG PO CAPS,00115-4422-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA-ENTACAPONE 25-100-200 MG PO TABS,47335-0003-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 6370000000,PANCRELIPASE (LIP-PROT-AMYL) 5000-24000 UNITS PO CPEP,73562-0115-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LIDO-EPINEPHRINE-TETRACAINE 4-0.18-0.5 % EX GEL,71266-6290-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),28.10,28.10,16.86,16.86,N/A,3.93,N/A,28.10,N/A,15.80,N/A,9.55,N/A,3.93,N/A,3.93,N/A,28.10,N/A,28.10,N/A,2.44,N/A,3.93,N/A,3.93,N/A,3.93,N/A,15.80,N/A,28.10,N/A,3.93,N/A,15.06,N/A,15.06,N/A,3.93,N/A,28.10,N/A,28.10,N/A,28.10,16.86,16.86,2.44,28.10,,Hospital HCPCS 6370000000,CHLORDIAZEPOXIDE HCL 10 MG PO CAPS,00555-0033-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NYSTATIN 500000 UNITS PO TABS,53489-0400-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FERRIC SUBSULFATE 259 MG/GM EX SOLN,59365-6065-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.70,33.70,20.22,20.22,N/A,4.72,N/A,33.70,N/A,18.95,N/A,11.46,N/A,4.72,N/A,4.72,N/A,33.70,N/A,33.70,N/A,2.93,N/A,4.72,N/A,4.72,N/A,4.72,N/A,18.95,N/A,33.70,N/A,4.72,N/A,18.06,N/A,18.06,N/A,4.72,N/A,33.70,N/A,33.70,N/A,33.70,20.22,20.22,2.93,33.70,,Hospital HCPCS 6370000000,IODINE 2 % EX TINC,00395-1213-91,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.70,6.70,4.02,4.02,N/A,N/A,N/A,6.70,N/A,3.77,N/A,2.28,N/A,N/A,N/A,N/A,N/A,6.70,N/A,6.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.77,N/A,6.70,N/A,N/A,N/A,3.59,N/A,3.59,N/A,N/A,N/A,6.70,N/A,6.70,N/A,6.70,4.02,4.02,2.28,6.70,,Hospital HCPCS 6370000000,TRIAMTERENE-HCTZ 37.5-25 MG PO TABS,00591-0424-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PHENYLEPHRINE HCL 1 % NA SOLN,46122-0149-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),18.30,18.30,10.98,10.98,N/A,2.56,N/A,18.30,N/A,10.29,N/A,6.22,N/A,2.56,N/A,2.56,N/A,18.30,N/A,18.30,N/A,1.59,N/A,2.56,N/A,2.56,N/A,2.56,N/A,10.29,N/A,18.30,N/A,2.56,N/A,9.81,N/A,9.81,N/A,2.56,N/A,18.30,N/A,18.30,N/A,18.30,10.98,10.98,1.59,18.30,,Hospital HCPCS 6370000000,RISPERIDONE 0.25 MG PO TABS,68084-0270-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ATORVASTATIN CALCIUM 80 MG PO TABS,60505-2671-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,55150-0173-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),168.80,168.80,101.28,101.28,N/A,23.63,N/A,168.80,N/A,94.90,N/A,57.39,N/A,23.63,N/A,23.63,N/A,168.80,N/A,168.80,N/A,14.69,N/A,23.63,N/A,23.63,N/A,23.63,N/A,94.90,N/A,168.80,N/A,23.63,N/A,90.48,N/A,90.48,N/A,23.63,N/A,168.80,N/A,168.80,N/A,168.80,101.28,101.28,14.69,168.80,,Hospital HCPCS 6370000000,QUININE SULFATE 324 MG PO CAPS,53489-0700-07,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.20,13.20,7.92,7.92,N/A,1.85,N/A,13.20,N/A,7.42,N/A,4.49,N/A,1.85,N/A,1.85,N/A,13.20,N/A,13.20,N/A,1.15,N/A,1.85,N/A,1.85,N/A,1.85,N/A,7.42,N/A,13.20,N/A,1.85,N/A,7.08,N/A,7.08,N/A,1.85,N/A,13.20,N/A,13.20,N/A,13.20,7.92,7.92,1.15,13.20,,Hospital HCPCS 6370000000,FLECAINIDE ACETATE 50 MG PO TABS,00054-0010-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SWEET OIL OIL,00395-2063-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),36.90,36.90,22.14,22.14,N/A,5.17,N/A,36.90,N/A,20.75,N/A,12.55,N/A,5.17,N/A,5.17,N/A,36.90,N/A,36.90,N/A,3.21,N/A,5.17,N/A,5.17,N/A,5.17,N/A,20.75,N/A,36.90,N/A,5.17,N/A,19.78,N/A,19.78,N/A,5.17,N/A,36.90,N/A,36.90,N/A,36.90,22.14,22.14,3.21,36.90,,Hospital HCPCS 6370000000,FENTANYL 100 MCG/HR TD PT72,60505-7009-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),43.70,43.70,26.22,26.22,N/A,6.12,N/A,43.70,N/A,24.57,N/A,14.86,N/A,6.12,N/A,6.12,N/A,43.70,N/A,43.70,N/A,3.80,N/A,6.12,N/A,6.12,N/A,6.12,N/A,24.57,N/A,43.70,N/A,6.12,N/A,23.42,N/A,23.42,N/A,6.12,N/A,43.70,N/A,43.70,N/A,43.70,26.22,26.22,3.80,43.70,,Hospital HCPCS 6370000000,SUCRALFATE 1 G PO TABS,51079-0753-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ARMODAFINIL 50 MG PO TABS,63459-0205-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),25.30,25.30,15.18,15.18,N/A,3.54,N/A,25.30,N/A,14.22,N/A,8.60,N/A,3.54,N/A,3.54,N/A,25.30,N/A,25.30,N/A,2.20,N/A,3.54,N/A,3.54,N/A,3.54,N/A,14.22,N/A,25.30,N/A,3.54,N/A,13.56,N/A,13.56,N/A,3.54,N/A,25.30,N/A,25.30,N/A,25.30,15.18,15.18,2.20,25.30,,Hospital HCPCS 6370000000,FLUTICASONE PROPIONATE HFA 220 MCG/ACT IN AERO,09999-9907-94,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TERBINAFINE HCL 250 MG PO TABS,69097-0859-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VITAMIN B-12 100 MCG PO TABS,80681-0071-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,SOTALOL HCL 120 MG PO TABS,00093-1060-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ARMODAFINIL 150 MG PO TABS,63459-0215-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),76.10,76.10,45.66,45.66,N/A,10.65,N/A,76.10,N/A,42.78,N/A,25.87,N/A,10.65,N/A,10.65,N/A,76.10,N/A,76.10,N/A,6.62,N/A,10.65,N/A,10.65,N/A,10.65,N/A,42.78,N/A,76.10,N/A,10.65,N/A,40.79,N/A,40.79,N/A,10.65,N/A,76.10,N/A,76.10,N/A,76.10,45.66,45.66,6.62,76.10,,Hospital HCPCS 6370000000,ACETAMINOPHEN 120 MG RE SUPP,00713-0118-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,OFLOXACIN 0.3 % OP SOLN,24208-0434-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),46.00,46.00,27.60,27.60,N/A,6.44,N/A,46.00,N/A,25.86,N/A,15.64,N/A,6.44,N/A,6.44,N/A,46.00,N/A,46.00,N/A,4.00,N/A,6.44,N/A,6.44,N/A,6.44,N/A,25.86,N/A,46.00,N/A,6.44,N/A,24.66,N/A,24.66,N/A,6.44,N/A,46.00,N/A,46.00,N/A,46.00,27.60,27.60,4.00,46.00,,Hospital HCPCS 6370000000,NICOTINE 21 MG/24HR TD PT24,00067-5126-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.20,3.20,1.92,1.92,N/A,N/A,N/A,3.20,N/A,1.80,N/A,1.09,N/A,N/A,N/A,N/A,N/A,3.20,N/A,3.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.80,N/A,3.20,N/A,N/A,N/A,1.72,N/A,1.72,N/A,N/A,N/A,3.20,N/A,3.20,N/A,3.20,1.92,1.92,1.09,3.20,,Hospital HCPCS 6370000000,PENTOSAN POLYSULFATE SODIUM 100 MG PO CAPS,50458-0098-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),22.70,22.70,13.62,13.62,N/A,3.18,N/A,22.70,N/A,12.76,N/A,7.72,N/A,3.18,N/A,3.18,N/A,22.70,N/A,22.70,N/A,1.97,N/A,3.18,N/A,3.18,N/A,3.18,N/A,12.76,N/A,22.70,N/A,3.18,N/A,12.17,N/A,12.17,N/A,3.18,N/A,22.70,N/A,22.70,N/A,22.70,13.62,13.62,1.97,22.70,,Hospital HCPCS 6370000000,EMPAGLIFLOZIN 25 MG PO TABS,00597-0153-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),42.80,42.80,25.68,25.68,N/A,5.99,N/A,42.80,N/A,24.06,N/A,14.55,N/A,5.99,N/A,5.99,N/A,42.80,N/A,42.80,N/A,3.72,N/A,5.99,N/A,5.99,N/A,5.99,N/A,24.06,N/A,42.80,N/A,5.99,N/A,22.94,N/A,22.94,N/A,5.99,N/A,42.80,N/A,42.80,N/A,42.80,25.68,25.68,3.72,42.80,,Hospital HCPCS 6370000000,VENLAFAXINE HCL 25 MG PO TABS,57664-0392-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CHLORZOXAZONE 500 MG PO TABS,00591-2520-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PALIPERIDONE ER 6 MG PO TB24,00904-6936-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),30.80,30.80,18.48,18.48,N/A,4.31,N/A,30.80,N/A,17.32,N/A,10.47,N/A,4.31,N/A,4.31,N/A,30.80,N/A,30.80,N/A,2.68,N/A,4.31,N/A,4.31,N/A,4.31,N/A,17.32,N/A,30.80,N/A,4.31,N/A,16.51,N/A,16.51,N/A,4.31,N/A,30.80,N/A,30.80,N/A,30.80,18.48,18.48,2.68,30.80,,Hospital HCPCS 6370000000,CAFFEINE CITRATE 20 MG/ML PO SOLN,63323-0406-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),87.20,87.20,52.32,52.32,N/A,12.21,N/A,87.20,N/A,49.02,N/A,29.65,N/A,12.21,N/A,12.21,N/A,87.20,N/A,87.20,N/A,7.59,N/A,12.21,N/A,12.21,N/A,12.21,N/A,49.02,N/A,87.20,N/A,12.21,N/A,46.74,N/A,46.74,N/A,12.21,N/A,87.20,N/A,87.20,N/A,87.20,52.32,52.32,7.59,87.20,,Hospital HCPCS 6370000000,OCUVITE-LUTEIN PO TABS,00536-5090-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,KETOROLAC TROMETHAMINE 0.4 % OP SOLN,00023-9277-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),637.10,637.10,382.26,382.26,N/A,89.19,N/A,637.10,N/A,358.18,N/A,216.61,N/A,89.19,N/A,89.19,N/A,637.10,N/A,637.10,N/A,55.43,N/A,89.19,N/A,89.19,N/A,89.19,N/A,358.18,N/A,637.10,N/A,89.19,N/A,341.49,N/A,341.49,N/A,89.19,N/A,637.10,N/A,637.10,N/A,637.10,382.26,382.26,55.43,637.10,,Hospital HCPCS 6370000000,DESOXIMETASONE 0.25 % EX OINT,51672-1262-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),88.60,88.60,53.16,53.16,N/A,12.40,N/A,88.60,N/A,49.81,N/A,30.12,N/A,12.40,N/A,12.40,N/A,88.60,N/A,88.60,N/A,7.71,N/A,12.40,N/A,12.40,N/A,12.40,N/A,49.81,N/A,88.60,N/A,12.40,N/A,47.49,N/A,47.49,N/A,12.40,N/A,88.60,N/A,88.60,N/A,88.60,53.16,53.16,7.71,88.60,,Hospital HCPCS 6370000000,ACETIC ACID 3 % SOLN,51552-0051-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),114.80,114.80,68.88,68.88,N/A,16.07,N/A,114.80,N/A,64.54,N/A,39.03,N/A,16.07,N/A,16.07,N/A,114.80,N/A,114.80,N/A,9.99,N/A,16.07,N/A,16.07,N/A,16.07,N/A,64.54,N/A,114.80,N/A,16.07,N/A,61.53,N/A,61.53,N/A,16.07,N/A,114.80,N/A,114.80,N/A,114.80,68.88,68.88,9.99,114.80,,Hospital HCPCS 6370000000,BETAMETHASONE VALERATE 0.12 % EX FOAM,45802-0053-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),588.50,588.50,353.10,353.10,N/A,82.39,N/A,588.50,N/A,330.85,N/A,200.09,N/A,82.39,N/A,82.39,N/A,588.50,N/A,588.50,N/A,51.20,N/A,82.39,N/A,82.39,N/A,82.39,N/A,330.85,N/A,588.50,N/A,82.39,N/A,315.44,N/A,315.44,N/A,82.39,N/A,588.50,N/A,588.50,N/A,588.50,353.10,353.10,51.20,588.50,,Hospital HCPCS 6370000000,LINACLOTIDE 145 MCG PO CAPS,00456-1201-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),36.80,36.80,22.08,22.08,N/A,5.15,N/A,36.80,N/A,20.69,N/A,12.51,N/A,5.15,N/A,5.15,N/A,36.80,N/A,36.80,N/A,3.20,N/A,5.15,N/A,5.15,N/A,5.15,N/A,20.69,N/A,36.80,N/A,5.15,N/A,19.72,N/A,19.72,N/A,5.15,N/A,36.80,N/A,36.80,N/A,36.80,22.08,22.08,3.20,36.80,,Hospital HCPCS 6370000000,BETAXOLOL HCL 10 MG PO TABS,10702-0013-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PAROXETINE HCL 30 MG PO TABS,68084-0046-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METOPROLOL TARTRATE 25 MG PO TABS,62584-0265-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BETAMETHASONE VALERATE 0.1 % EX OINT,00472-0371-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),36.70,36.70,22.02,22.02,N/A,5.14,N/A,36.70,N/A,20.63,N/A,12.48,N/A,5.14,N/A,5.14,N/A,36.70,N/A,36.70,N/A,3.19,N/A,5.14,N/A,5.14,N/A,5.14,N/A,20.63,N/A,36.70,N/A,5.14,N/A,19.67,N/A,19.67,N/A,5.14,N/A,36.70,N/A,36.70,N/A,36.70,22.02,22.02,3.19,36.70,,Hospital HCPCS 6370000000,ZONISAMIDE 100 MG PO CAPS,62756-0260-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AZITHROMYCIN 250 MG PO TABS,50111-0787-66,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRAMADOL-ACETAMINOPHEN 37.5-325 MG PO TABS,57664-0537-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXYCODONE HCL 5 MG PO TABS,00406-0552-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,09999-9908-52,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXCARBAZEPINE 150 MG PO TABS,68462-0137-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TETRACYCLINE HCL 250 MG PO CAPS,69238-1522-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DOXYLAMINE SUCCINATE (SLEEP) 25 MG PO TABS,41167-0006-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS,00406-0124-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHYLPHENIDATE HCL 10 MG PO TABS,00406-1144-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ROPINIROLE HCL 2 MG PO TABS,68462-0256-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MELATONIN 10 MG PO CAPS,30768-0194-84,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,THEOPHYLLINE ER 100 MG PO CP24,52244-0100-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.60,6.60,3.96,3.96,N/A,N/A,N/A,6.60,N/A,3.71,N/A,2.24,N/A,N/A,N/A,N/A,N/A,6.60,N/A,6.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.71,N/A,6.60,N/A,N/A,N/A,3.54,N/A,3.54,N/A,N/A,N/A,6.60,N/A,6.60,N/A,6.60,3.96,3.96,2.24,6.60,,Hospital HCPCS 6370000000,OXYMETAZOLINE HCL 0.05 % NA SOLN,45802-0410-59,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCORTISONE 2.5 % EX OINT,45802-0014-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.90,5.90,3.54,3.54,N/A,N/A,N/A,5.90,N/A,3.32,N/A,2.01,N/A,N/A,N/A,N/A,N/A,5.90,N/A,5.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.32,N/A,5.90,N/A,N/A,N/A,3.16,N/A,3.16,N/A,N/A,N/A,5.90,N/A,5.90,N/A,5.90,3.54,3.54,2.01,5.90,,Hospital HCPCS 6370000000,OXYCODONE HCL ER 20 MG PO T12A,59011-0420-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.10,20.10,12.06,12.06,N/A,2.81,N/A,20.10,N/A,11.30,N/A,6.83,N/A,2.81,N/A,2.81,N/A,20.10,N/A,20.10,N/A,1.75,N/A,2.81,N/A,2.81,N/A,2.81,N/A,11.30,N/A,20.10,N/A,2.81,N/A,10.77,N/A,10.77,N/A,2.81,N/A,20.10,N/A,20.10,N/A,20.10,12.06,12.06,1.75,20.10,,Hospital HCPCS 6370000000,ZALEPLON 10 MG PO CAPS,00054-0085-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.00,3.00,1.80,1.80,N/A,N/A,N/A,3.00,N/A,1.69,N/A,1.02,N/A,N/A,N/A,N/A,N/A,3.00,N/A,3.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.69,N/A,3.00,N/A,N/A,N/A,1.61,N/A,1.61,N/A,N/A,N/A,3.00,N/A,3.00,N/A,3.00,1.80,1.80,1.02,3.00,,Hospital HCPCS 6370000000,SERTRALINE HCL 50 MG PO TABS,00904-6925-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TIMOLOL MALEATE 5 MG PO TABS,00378-0055-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DM-GUAIFENESIN ER 30-600 MG PO TB12,63824-0056-34,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,URSODIOL 300 MG PO CAPS,00527-1326-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,THIAMINE MONONITRATE 100 MG PO TABS,50268-0851-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BISACODYL 5 MG PO TBEC,00904-6407-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PROPYLENE GLYCOL LIQD,38779-0510-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),182.30,182.30,109.38,109.38,N/A,25.52,N/A,182.30,N/A,102.49,N/A,61.98,N/A,25.52,N/A,25.52,N/A,182.30,N/A,182.30,N/A,15.86,N/A,25.52,N/A,25.52,N/A,25.52,N/A,102.49,N/A,182.30,N/A,25.52,N/A,97.71,N/A,97.71,N/A,25.52,N/A,182.30,N/A,182.30,N/A,182.30,109.38,109.38,15.86,182.30,,Hospital HCPCS 6370000000,BISACODYL 10 MG RE SUPP,00574-7050-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PANTOPRAZOLE SODIUM 40 MG PO PACK,00008-0844-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),37.20,37.20,22.32,22.32,N/A,5.21,N/A,37.20,N/A,20.91,N/A,12.65,N/A,5.21,N/A,5.21,N/A,37.20,N/A,37.20,N/A,3.24,N/A,5.21,N/A,5.21,N/A,5.21,N/A,20.91,N/A,37.20,N/A,5.21,N/A,19.94,N/A,19.94,N/A,5.21,N/A,37.20,N/A,37.20,N/A,37.20,22.32,22.32,3.24,37.20,,Hospital HCPCS 6370000000,OPTICHAMBER DIAMOND MISC,08373-7478-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),109.10,109.10,65.46,65.46,N/A,15.27,N/A,109.10,N/A,61.34,N/A,37.09,N/A,15.27,N/A,15.27,N/A,109.10,N/A,109.10,N/A,9.49,N/A,15.27,N/A,15.27,N/A,15.27,N/A,61.34,N/A,109.10,N/A,15.27,N/A,58.48,N/A,58.48,N/A,15.27,N/A,109.10,N/A,109.10,N/A,109.10,65.46,65.46,9.49,109.10,,Hospital HCPCS 6370000000,ABACAVIR-LAMIVUDINE-ZIDOVUDINE 300-150-300 MG PO TABS,49702-0217-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),181.10,181.10,108.66,108.66,N/A,25.35,N/A,181.10,N/A,101.81,N/A,61.57,N/A,25.35,N/A,25.35,N/A,181.10,N/A,181.10,N/A,15.76,N/A,25.35,N/A,25.35,N/A,25.35,N/A,101.81,N/A,181.10,N/A,25.35,N/A,97.07,N/A,97.07,N/A,25.35,N/A,181.10,N/A,181.10,N/A,181.10,108.66,108.66,15.76,181.10,,Hospital HCPCS 6370000000,SUMATRIPTAN SUCCINATE 25 MG PO TABS,63304-0097-19,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,HYDROCERIN EX CREA,72140-0000-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.30,12.30,7.38,7.38,N/A,1.72,N/A,12.30,N/A,6.92,N/A,4.18,N/A,1.72,N/A,1.72,N/A,12.30,N/A,12.30,N/A,1.07,N/A,1.72,N/A,1.72,N/A,1.72,N/A,6.92,N/A,12.30,N/A,1.72,N/A,6.59,N/A,6.59,N/A,1.72,N/A,12.30,N/A,12.30,N/A,12.30,7.38,7.38,1.07,12.30,,Hospital HCPCS 6370000000,TRIPLE ANTIBIOTIC EX OINT,00904-8805-67,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,APRACLONIDINE HCL 0.5 % OP SOLN,61314-0665-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),144.60,144.60,86.76,86.76,N/A,20.24,N/A,144.60,N/A,81.29,N/A,49.16,N/A,20.24,N/A,20.24,N/A,144.60,N/A,144.60,N/A,12.58,N/A,20.24,N/A,20.24,N/A,20.24,N/A,81.29,N/A,144.60,N/A,20.24,N/A,77.51,N/A,77.51,N/A,20.24,N/A,144.60,N/A,144.60,N/A,144.60,86.76,86.76,12.58,144.60,,Hospital HCPCS 6370000000,OXYCODONE HCL ER 15 MG PO T12A,59011-0415-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.50,15.50,9.30,9.30,N/A,2.17,N/A,15.50,N/A,8.71,N/A,5.27,N/A,2.17,N/A,2.17,N/A,15.50,N/A,15.50,N/A,1.35,N/A,2.17,N/A,2.17,N/A,2.17,N/A,8.71,N/A,15.50,N/A,2.17,N/A,8.31,N/A,8.31,N/A,2.17,N/A,15.50,N/A,15.50,N/A,15.50,9.30,9.30,1.35,15.50,,Hospital HCPCS 6370000000,OXYCODONE HCL ER 30 MG PO T12A,59011-0430-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.30,33.30,19.98,19.98,N/A,4.66,N/A,33.30,N/A,18.72,N/A,11.32,N/A,4.66,N/A,4.66,N/A,33.30,N/A,33.30,N/A,2.90,N/A,4.66,N/A,4.66,N/A,4.66,N/A,18.72,N/A,33.30,N/A,4.66,N/A,17.85,N/A,17.85,N/A,4.66,N/A,33.30,N/A,33.30,N/A,33.30,19.98,19.98,2.90,33.30,,Hospital HCPCS 6370000000,BACITRACIN 500 UNIT/GM OP OINT,00574-4022-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),222.10,222.10,133.26,133.26,N/A,31.09,N/A,222.10,N/A,124.86,N/A,75.51,N/A,31.09,N/A,31.09,N/A,222.10,N/A,222.10,N/A,19.32,N/A,31.09,N/A,31.09,N/A,31.09,N/A,124.86,N/A,222.10,N/A,31.09,N/A,119.05,N/A,119.05,N/A,31.09,N/A,222.10,N/A,222.10,N/A,222.10,133.26,133.26,19.32,222.10,,Hospital HCPCS 6370000000,SENNOSIDES 8.6 MG PO TABS,67618-0300-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,LAMIVUDINE 150 MG PO TABS,49702-0203-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.60,15.60,9.36,9.36,N/A,2.18,N/A,15.60,N/A,8.77,N/A,5.30,N/A,2.18,N/A,2.18,N/A,15.60,N/A,15.60,N/A,1.36,N/A,2.18,N/A,2.18,N/A,2.18,N/A,8.77,N/A,15.60,N/A,2.18,N/A,8.36,N/A,8.36,N/A,2.18,N/A,15.60,N/A,15.60,N/A,15.60,9.36,9.36,1.36,15.60,,Hospital HCPCS 6370000000,PROPYLTHIOURACIL 50 MG PO TABS,00228-2348-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FERROUS SULFATE 325 (65 FE) MG PO TABS,00904-7591-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,FENTANYL 12 MCG/HR TD PT72,00378-9119-98,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),36.60,36.60,21.96,21.96,N/A,5.12,N/A,36.60,N/A,20.58,N/A,12.44,N/A,5.12,N/A,5.12,N/A,36.60,N/A,36.60,N/A,3.18,N/A,5.12,N/A,5.12,N/A,5.12,N/A,20.58,N/A,36.60,N/A,5.12,N/A,19.62,N/A,19.62,N/A,5.12,N/A,36.60,N/A,36.60,N/A,36.60,21.96,21.96,3.18,36.60,,Hospital HCPCS 6370000000,SEVELAMER CARBONATE 2.4 G PO PACK,58468-0131-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),40.20,40.20,24.12,24.12,N/A,5.63,N/A,40.20,N/A,22.60,N/A,13.67,N/A,5.63,N/A,5.63,N/A,40.20,N/A,40.20,N/A,3.50,N/A,5.63,N/A,5.63,N/A,5.63,N/A,22.60,N/A,40.20,N/A,5.63,N/A,21.55,N/A,21.55,N/A,5.63,N/A,40.20,N/A,40.20,N/A,40.20,24.12,24.12,3.50,40.20,,Hospital HCPCS 6370000000,IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,09999-9908-32,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),47.10,47.10,28.26,28.26,N/A,6.59,N/A,47.10,N/A,26.48,N/A,16.01,N/A,6.59,N/A,6.59,N/A,47.10,N/A,47.10,N/A,4.10,N/A,6.59,N/A,6.59,N/A,6.59,N/A,26.48,N/A,47.10,N/A,6.59,N/A,25.25,N/A,25.25,N/A,6.59,N/A,47.10,N/A,47.10,N/A,47.10,28.26,28.26,4.10,47.10,,Hospital HCPCS 6370000000,HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS,00406-0125-23,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NITROGLYCERIN ER 2.5 MG PO CPCR,49483-0221-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DIPHENHYDRAMINE-ACETAMINOPHEN 12.5-325 MG PO TABS,75137-0004-95,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METOPROLOL SUCCINATE ER 50 MG PO TB24,51079-0170-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DEXMETHYLPHENIDATE HCL ER 10 MG PO CP24,00078-0431-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),30.50,30.50,18.30,18.30,N/A,4.27,N/A,30.50,N/A,17.15,N/A,10.37,N/A,4.27,N/A,4.27,N/A,30.50,N/A,30.50,N/A,2.65,N/A,4.27,N/A,4.27,N/A,4.27,N/A,17.15,N/A,30.50,N/A,4.27,N/A,16.35,N/A,16.35,N/A,4.27,N/A,30.50,N/A,30.50,N/A,30.50,18.30,18.30,2.65,30.50,,Hospital HCPCS 6370000000,DONEPEZIL HCL 10 MG PO TBDP,00781-5277-64,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DRONEDARONE HCL 400 MG PO TABS,00024-4142-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.20,27.20,16.32,16.32,N/A,3.81,N/A,27.20,N/A,15.29,N/A,9.25,N/A,3.81,N/A,3.81,N/A,27.20,N/A,27.20,N/A,2.37,N/A,3.81,N/A,3.81,N/A,3.81,N/A,15.29,N/A,27.20,N/A,3.81,N/A,14.58,N/A,14.58,N/A,3.81,N/A,27.20,N/A,27.20,N/A,27.20,16.32,16.32,2.37,27.20,,Hospital HCPCS 6370000000,RISEDRONATE SODIUM 35 MG PO TABS,00430-0472-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),191.90,191.90,115.14,115.14,N/A,26.87,N/A,191.90,N/A,107.89,N/A,65.25,N/A,26.87,N/A,26.87,N/A,191.90,N/A,191.90,N/A,16.70,N/A,26.87,N/A,26.87,N/A,26.87,N/A,107.89,N/A,191.90,N/A,26.87,N/A,102.86,N/A,102.86,N/A,26.87,N/A,191.90,N/A,191.90,N/A,191.90,115.14,115.14,16.70,191.90,,Hospital HCPCS 6370000000,TIMOLOL MALEATE 0.5 % OP SOLN,64980-0514-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.00,32.00,19.20,19.20,N/A,4.48,N/A,32.00,N/A,17.99,N/A,10.88,N/A,4.48,N/A,4.48,N/A,32.00,N/A,32.00,N/A,2.78,N/A,4.48,N/A,4.48,N/A,4.48,N/A,17.99,N/A,32.00,N/A,4.48,N/A,17.15,N/A,17.15,N/A,4.48,N/A,32.00,N/A,32.00,N/A,32.00,19.20,19.20,2.78,32.00,,Hospital HCPCS 6370000000,FUROSEMIDE 20 MG PO TABS,51079-0072-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXICONAZOLE NITRATE 1 % EX LOTN,10337-0359-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1599.80,1599.80,959.88,959.88,N/A,223.97,N/A,1599.80,N/A,899.41,N/A,543.93,N/A,223.97,N/A,223.97,N/A,1599.80,N/A,1599.80,N/A,139.18,N/A,223.97,N/A,223.97,N/A,223.97,N/A,899.41,N/A,1599.80,N/A,223.97,N/A,857.49,N/A,857.49,N/A,223.97,N/A,1599.80,N/A,1599.80,N/A,1599.80,959.88,959.88,139.18,1599.80,,Hospital HCPCS 6370000000,GALANTAMINE HYDROBROMIDE ER 8 MG PO CP24,47335-0835-83,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.40,10.40,6.24,6.24,N/A,1.46,N/A,10.40,N/A,5.85,N/A,3.54,N/A,1.46,N/A,1.46,N/A,10.40,N/A,10.40,N/A,N/A,N/A,1.46,N/A,1.46,N/A,1.46,N/A,5.85,N/A,10.40,N/A,1.46,N/A,5.57,N/A,5.57,N/A,1.46,N/A,10.40,N/A,10.40,N/A,10.40,6.24,6.24,1.46,10.40,,Hospital HCPCS 6370000000,SENNA 8.8 MG/5ML PO SYRP,09999-9901-13,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LISDEXAMFETAMINE DIMESYLATE 40 MG PO CAPS,59417-0104-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.40,26.40,15.84,15.84,N/A,3.70,N/A,26.40,N/A,14.84,N/A,8.98,N/A,3.70,N/A,3.70,N/A,26.40,N/A,26.40,N/A,2.30,N/A,3.70,N/A,3.70,N/A,3.70,N/A,14.84,N/A,26.40,N/A,3.70,N/A,14.15,N/A,14.15,N/A,3.70,N/A,26.40,N/A,26.40,N/A,26.40,15.84,15.84,2.30,26.40,,Hospital HCPCS 6370000000,GLIMEPIRIDE 4 MG PO TABS,68084-0327-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ESZOPICLONE 2 MG PO TABS,47335-0587-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METHYLERGONOVINE MALEATE 0.2 MG PO TABS,27437-0050-57,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),140.10,140.10,84.06,84.06,N/A,19.61,N/A,140.10,N/A,78.76,N/A,47.63,N/A,19.61,N/A,19.61,N/A,140.10,N/A,140.10,N/A,12.19,N/A,19.61,N/A,19.61,N/A,19.61,N/A,78.76,N/A,140.10,N/A,19.61,N/A,75.09,N/A,75.09,N/A,19.61,N/A,140.10,N/A,140.10,N/A,140.10,84.06,84.06,12.19,140.10,,Hospital HCPCS 6370000000,ALPRAZOLAM 1 MG PO TABS,59762-3721-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24,10370-0830-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SCOPOLAMINE 1 MG/3DAYS TD PT72,10019-0553-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),48.00,48.00,28.80,28.80,N/A,6.72,N/A,48.00,N/A,26.99,N/A,16.32,N/A,6.72,N/A,6.72,N/A,48.00,N/A,48.00,N/A,4.18,N/A,6.72,N/A,6.72,N/A,6.72,N/A,26.99,N/A,48.00,N/A,6.72,N/A,25.73,N/A,25.73,N/A,6.72,N/A,48.00,N/A,48.00,N/A,48.00,28.80,28.80,4.18,48.00,,Hospital HCPCS 6370000000,LAMOTRIGINE 200 MG PO TABS,51672-4133-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DONEPEZIL HCL 10 MG PO TABS,00904-6478-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TERBINAFINE HCL 1 % EX CREA,51672-2080-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.50,14.50,8.70,8.70,N/A,2.03,N/A,14.50,N/A,8.15,N/A,4.93,N/A,2.03,N/A,2.03,N/A,14.50,N/A,14.50,N/A,1.26,N/A,2.03,N/A,2.03,N/A,2.03,N/A,8.15,N/A,14.50,N/A,2.03,N/A,7.77,N/A,7.77,N/A,2.03,N/A,14.50,N/A,14.50,N/A,14.50,8.70,8.70,1.26,14.50,,Hospital HCPCS 6370000000,COLESTIPOL HCL 1 G PO TABS,59762-0450-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRIFLUOPERAZINE HCL 2 MG PO TABS,00378-2402-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CEPHALEXIN 250 MG PO CAPS,62756-0293-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PHENOBARBITAL 97.2 MG PO TABS,00603-5168-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LITHIUM CARBONATE ER 450 MG PO TBCR,00054-0020-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BETHANECHOL CHLORIDE 10 MG PO TABS,00832-0511-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBAMAZEPINE 200 MG PO TABS,00904-6172-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DAPSONE 100 MG PO TABS,49938-0101-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.30,6.30,3.78,3.78,N/A,N/A,N/A,6.30,N/A,3.54,N/A,2.14,N/A,N/A,N/A,N/A,N/A,6.30,N/A,6.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.54,N/A,6.30,N/A,N/A,N/A,3.38,N/A,3.38,N/A,N/A,N/A,6.30,N/A,6.30,N/A,6.30,3.78,3.78,2.14,6.30,,Hospital HCPCS 6370000000,AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG PO TB12,00781-1943-39,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.90,13.90,8.34,8.34,N/A,1.95,N/A,13.90,N/A,7.81,N/A,4.73,N/A,1.95,N/A,1.95,N/A,13.90,N/A,13.90,N/A,1.21,N/A,1.95,N/A,1.95,N/A,1.95,N/A,7.81,N/A,13.90,N/A,1.95,N/A,7.45,N/A,7.45,N/A,1.95,N/A,13.90,N/A,13.90,N/A,13.90,8.34,8.34,1.21,13.90,,Hospital HCPCS 6370000000,TRIFLUOPERAZINE HCL 1 MG PO TABS,51079-0572-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12,43598-0339-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CETIRIZINE HCL 10 MG PO TABS,45802-0919-87,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,SORBITOL 70 % SOLN,00121-0659-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,NISOLDIPINE ER 20 MG PO TB24,00378-2222-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),29.70,29.70,17.82,17.82,N/A,4.16,N/A,29.70,N/A,16.70,N/A,10.10,N/A,4.16,N/A,4.16,N/A,29.70,N/A,29.70,N/A,2.58,N/A,4.16,N/A,4.16,N/A,4.16,N/A,16.70,N/A,29.70,N/A,4.16,N/A,15.92,N/A,15.92,N/A,4.16,N/A,29.70,N/A,29.70,N/A,29.70,17.82,17.82,2.58,29.70,,Hospital HCPCS 6370000000,PRAVASTATIN SODIUM 10 MG PO TABS,00904-5891-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BENZOCAINE-MENTHOL 20-0.5 % EX AERO,16864-0680-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.50,12.50,7.50,7.50,N/A,1.75,N/A,12.50,N/A,7.03,N/A,4.25,N/A,1.75,N/A,1.75,N/A,12.50,N/A,12.50,N/A,1.09,N/A,1.75,N/A,1.75,N/A,1.75,N/A,7.03,N/A,12.50,N/A,1.75,N/A,6.70,N/A,6.70,N/A,1.75,N/A,12.50,N/A,12.50,N/A,12.50,7.50,7.50,1.09,12.50,,Hospital HCPCS 6370000000,CIMETIDINE 300 MG PO TABS,00093-8192-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PROPRANOLOL HCL 80 MG PO TABS,00115-1662-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VORTIOXETINE HBR 10 MG PO TABS,64764-0730-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.40,33.40,20.04,20.04,N/A,4.68,N/A,33.40,N/A,18.78,N/A,11.36,N/A,4.68,N/A,4.68,N/A,33.40,N/A,33.40,N/A,2.91,N/A,4.68,N/A,4.68,N/A,4.68,N/A,18.78,N/A,33.40,N/A,4.68,N/A,17.90,N/A,17.90,N/A,4.68,N/A,33.40,N/A,33.40,N/A,33.40,20.04,20.04,2.91,33.40,,Hospital HCPCS 6370000000,DICLOFENAC-MISOPROSTOL 50-0.2 MG PO TBEC,59762-0028-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.10,6.10,3.66,3.66,N/A,N/A,N/A,6.10,N/A,3.43,N/A,2.07,N/A,N/A,N/A,N/A,N/A,6.10,N/A,6.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.43,N/A,6.10,N/A,N/A,N/A,3.27,N/A,3.27,N/A,N/A,N/A,6.10,N/A,6.10,N/A,6.10,3.66,3.66,2.07,6.10,,Hospital HCPCS 6370000000,METOLAZONE 2.5 MG PO TABS,51079-0023-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.20,6.20,3.72,3.72,N/A,N/A,N/A,6.20,N/A,3.49,N/A,2.11,N/A,N/A,N/A,N/A,N/A,6.20,N/A,6.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.49,N/A,6.20,N/A,N/A,N/A,3.32,N/A,3.32,N/A,N/A,N/A,6.20,N/A,6.20,N/A,6.20,3.72,3.72,2.11,6.20,,Hospital HCPCS 6370000000,CHLORPROMAZINE HCL 100 MG PO TABS,00832-0303-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.40,17.40,10.44,10.44,N/A,2.44,N/A,17.40,N/A,9.78,N/A,5.92,N/A,2.44,N/A,2.44,N/A,17.40,N/A,17.40,N/A,1.51,N/A,2.44,N/A,2.44,N/A,2.44,N/A,9.78,N/A,17.40,N/A,2.44,N/A,9.33,N/A,9.33,N/A,2.44,N/A,17.40,N/A,17.40,N/A,17.40,10.44,10.44,1.51,17.40,,Hospital HCPCS 6370000000,HYDROCORTISONE 20 MG PO TABS,00115-1700-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER 120 MG PO CP12,51079-0926-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.30,12.30,7.38,7.38,N/A,1.72,N/A,12.30,N/A,6.92,N/A,4.18,N/A,1.72,N/A,1.72,N/A,12.30,N/A,12.30,N/A,1.07,N/A,1.72,N/A,1.72,N/A,1.72,N/A,6.92,N/A,12.30,N/A,1.72,N/A,6.59,N/A,6.59,N/A,1.72,N/A,12.30,N/A,12.30,N/A,12.30,7.38,7.38,1.07,12.30,,Hospital HCPCS 6370000000,CLINDAMYCIN HCL 150 MG PO CAPS,68084-0243-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,49884-0161-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),505.40,505.40,303.24,303.24,N/A,70.76,N/A,505.40,N/A,284.14,N/A,171.84,N/A,70.76,N/A,70.76,N/A,505.40,N/A,505.40,N/A,43.97,N/A,70.76,N/A,70.76,N/A,70.76,N/A,284.14,N/A,505.40,N/A,70.76,N/A,270.89,N/A,270.89,N/A,70.76,N/A,505.40,N/A,505.40,N/A,505.40,303.24,303.24,43.97,505.40,,Hospital HCPCS 6370000000,LANTHANUM CARBONATE 500 MG PO CHEW,54092-0252-45,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.10,27.10,16.26,16.26,N/A,3.79,N/A,27.10,N/A,15.24,N/A,9.21,N/A,3.79,N/A,3.79,N/A,27.10,N/A,27.10,N/A,2.36,N/A,3.79,N/A,3.79,N/A,3.79,N/A,15.24,N/A,27.10,N/A,3.79,N/A,14.53,N/A,14.53,N/A,3.79,N/A,27.10,N/A,27.10,N/A,27.10,16.26,16.26,2.36,27.10,,Hospital HCPCS 6370000000,CENTRUM PO LIQD,00005-4344-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PYRIDOSTIGMINE BROMIDE 60 MG PO TABS,00115-3511-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PHENYLEPHRINE HCL 1 % NA SOLN,00067-2086-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),18.30,18.30,10.98,10.98,N/A,2.56,N/A,18.30,N/A,10.29,N/A,6.22,N/A,2.56,N/A,2.56,N/A,18.30,N/A,18.30,N/A,1.59,N/A,2.56,N/A,2.56,N/A,2.56,N/A,10.29,N/A,18.30,N/A,2.56,N/A,9.81,N/A,9.81,N/A,2.56,N/A,18.30,N/A,18.30,N/A,18.30,10.98,10.98,1.59,18.30,,Hospital HCPCS 6370000000,MAGNESIUM GLUCONATE 500 MG PO TABS,35046-0003-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,00574-7040-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),60.30,60.30,36.18,36.18,N/A,8.44,N/A,60.30,N/A,33.90,N/A,20.50,N/A,8.44,N/A,8.44,N/A,60.30,N/A,60.30,N/A,5.25,N/A,8.44,N/A,8.44,N/A,8.44,N/A,33.90,N/A,60.30,N/A,8.44,N/A,32.32,N/A,32.32,N/A,8.44,N/A,60.30,N/A,60.30,N/A,60.30,36.18,36.18,5.25,60.30,,Hospital HCPCS 6370000000,LOPINAVIR-RITONAVIR 200-50 MG PO TABS,00074-6799-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),19.30,19.30,11.58,11.58,N/A,2.70,N/A,19.30,N/A,10.85,N/A,6.56,N/A,2.70,N/A,2.70,N/A,19.30,N/A,19.30,N/A,1.68,N/A,2.70,N/A,2.70,N/A,2.70,N/A,10.85,N/A,19.30,N/A,2.70,N/A,10.34,N/A,10.34,N/A,2.70,N/A,19.30,N/A,19.30,N/A,19.30,11.58,11.58,1.68,19.30,,Hospital HCPCS 6370000000,AMOXICILLIN 250 MG PO CAPS,00781-2020-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SOOTHE NIGHTTIME OP OINT,10119-0022-39,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.40,15.40,9.24,9.24,N/A,2.16,N/A,15.40,N/A,8.66,N/A,5.24,N/A,2.16,N/A,2.16,N/A,15.40,N/A,15.40,N/A,1.34,N/A,2.16,N/A,2.16,N/A,2.16,N/A,8.66,N/A,15.40,N/A,2.16,N/A,8.25,N/A,8.25,N/A,2.16,N/A,15.40,N/A,15.40,N/A,15.40,9.24,9.24,1.34,15.40,,Hospital HCPCS 6370000000,BENZOCAINE-BENZETHONIUM 20-0.2 % EX AERO,51409-0007-24,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.20,12.20,7.32,7.32,N/A,1.71,N/A,12.20,N/A,6.86,N/A,4.15,N/A,1.71,N/A,1.71,N/A,12.20,N/A,12.20,N/A,1.06,N/A,1.71,N/A,1.71,N/A,1.71,N/A,6.86,N/A,12.20,N/A,1.71,N/A,6.54,N/A,6.54,N/A,1.71,N/A,12.20,N/A,12.20,N/A,12.20,7.32,7.32,1.06,12.20,,Hospital HCPCS 6370000000,MUPIROCIN 2 % EX OINT,45802-0112-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),20.30,20.30,12.18,12.18,N/A,2.84,N/A,20.30,N/A,11.41,N/A,6.90,N/A,2.84,N/A,2.84,N/A,20.30,N/A,20.30,N/A,1.77,N/A,2.84,N/A,2.84,N/A,2.84,N/A,11.41,N/A,20.30,N/A,2.84,N/A,10.88,N/A,10.88,N/A,2.84,N/A,20.30,N/A,20.30,N/A,20.30,12.18,12.18,1.77,20.30,,Hospital HCPCS 6370000000,BRIMONIDINE TARTRATE 0.2 % OP SOLN,61314-0143-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),33.80,33.80,20.28,20.28,N/A,4.73,N/A,33.80,N/A,19.00,N/A,11.49,N/A,4.73,N/A,4.73,N/A,33.80,N/A,33.80,N/A,2.94,N/A,4.73,N/A,4.73,N/A,4.73,N/A,19.00,N/A,33.80,N/A,4.73,N/A,18.12,N/A,18.12,N/A,4.73,N/A,33.80,N/A,33.80,N/A,33.80,20.28,20.28,2.94,33.80,,Hospital HCPCS 6370000000,OXYMORPHONE HCL 10 MG PO TABS,00054-0284-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.00,13.00,7.80,7.80,N/A,1.82,N/A,13.00,N/A,7.31,N/A,4.42,N/A,1.82,N/A,1.82,N/A,13.00,N/A,13.00,N/A,1.13,N/A,1.82,N/A,1.82,N/A,1.82,N/A,7.31,N/A,13.00,N/A,1.82,N/A,6.97,N/A,6.97,N/A,1.82,N/A,13.00,N/A,13.00,N/A,13.00,7.80,7.80,1.13,13.00,,Hospital HCPCS 6370000000,ESLICARBAZEPINE ACETATE 200 MG PO TABS,63402-0202-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),84.10,84.10,50.46,50.46,N/A,11.77,N/A,84.10,N/A,47.28,N/A,28.59,N/A,11.77,N/A,11.77,N/A,84.10,N/A,84.10,N/A,7.32,N/A,11.77,N/A,11.77,N/A,11.77,N/A,47.28,N/A,84.10,N/A,11.77,N/A,45.08,N/A,45.08,N/A,11.77,N/A,84.10,N/A,84.10,N/A,84.10,50.46,50.46,7.32,84.10,,Hospital HCPCS 6370000000,DOFETILIDE 500 MCG PO CAPS,00069-5820-43,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),24.50,24.50,14.70,14.70,N/A,3.43,N/A,24.50,N/A,13.77,N/A,8.33,N/A,3.43,N/A,3.43,N/A,24.50,N/A,24.50,N/A,2.13,N/A,3.43,N/A,3.43,N/A,3.43,N/A,13.77,N/A,24.50,N/A,3.43,N/A,13.13,N/A,13.13,N/A,3.43,N/A,24.50,N/A,24.50,N/A,24.50,14.70,14.70,2.13,24.50,,Hospital HCPCS 6370000000,BENZOCAINE-MENTHOL 15-10 MG MT LOZG,78112-0017-46,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.40,5.40,3.24,3.24,N/A,N/A,N/A,5.40,N/A,3.04,N/A,1.84,N/A,N/A,N/A,N/A,N/A,5.40,N/A,5.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.04,N/A,5.40,N/A,N/A,N/A,2.89,N/A,2.89,N/A,N/A,N/A,5.40,N/A,5.40,N/A,5.40,3.24,3.24,1.84,5.40,,Hospital HCPCS 6370000000,MINOXIDIL 2.5 MG PO TABS,53489-0386-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METOLAZONE 5 MG PO TABS,51079-0024-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,N/A,N/A,N/A,N/A,7.00,N/A,7.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,2.38,7.00,,Hospital HCPCS 6370000000,VILAZODONE HCL 40 MG PO TABS,00456-1140-30,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.70,23.70,14.22,14.22,N/A,3.32,N/A,23.70,N/A,13.32,N/A,8.06,N/A,3.32,N/A,3.32,N/A,23.70,N/A,23.70,N/A,2.06,N/A,3.32,N/A,3.32,N/A,3.32,N/A,13.32,N/A,23.70,N/A,3.32,N/A,12.70,N/A,12.70,N/A,3.32,N/A,23.70,N/A,23.70,N/A,23.70,14.22,14.22,2.06,23.70,,Hospital HCPCS 6370000000,HALOBETASOL PROPIONATE 0.05 % EX OINT,45802-0131-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),143.30,143.30,85.98,85.98,N/A,20.06,N/A,143.30,N/A,80.56,N/A,48.72,N/A,20.06,N/A,20.06,N/A,143.30,N/A,143.30,N/A,12.47,N/A,20.06,N/A,20.06,N/A,20.06,N/A,80.56,N/A,143.30,N/A,20.06,N/A,76.81,N/A,76.81,N/A,20.06,N/A,143.30,N/A,143.30,N/A,143.30,85.98,85.98,12.47,143.30,,Hospital HCPCS 6370000000,"PANCRELIPASE (LIP-PROT-AMYL) 15000-47000-63,000 UNITS PO CPEP",73562-0111-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.40,12.40,7.44,7.44,N/A,1.74,N/A,12.40,N/A,6.97,N/A,4.22,N/A,1.74,N/A,1.74,N/A,12.40,N/A,12.40,N/A,1.08,N/A,1.74,N/A,1.74,N/A,1.74,N/A,6.97,N/A,12.40,N/A,1.74,N/A,6.65,N/A,6.65,N/A,1.74,N/A,12.40,N/A,12.40,N/A,12.40,7.44,7.44,1.08,12.40,,Hospital HCPCS 6370000000,HYDROMORPHONE HCL 2 MG PO TABS,42858-0301-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METOCLOPRAMIDE HCL 10 MG PO TABS,00093-2203-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NYSTATIN 100000 UNIT/GM EX CREA,51672-1289-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),29.50,29.50,17.70,17.70,N/A,4.13,N/A,29.50,N/A,16.58,N/A,10.03,N/A,4.13,N/A,4.13,N/A,29.50,N/A,29.50,N/A,2.57,N/A,4.13,N/A,4.13,N/A,4.13,N/A,16.58,N/A,29.50,N/A,4.13,N/A,15.81,N/A,15.81,N/A,4.13,N/A,29.50,N/A,29.50,N/A,29.50,17.70,17.70,2.57,29.50,,Hospital HCPCS 6370000000,ETHAMBUTOL HCL 400 MG PO TABS,68084-0280-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ASPIRIN 325 MG PO TABS,66553-0001-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,FLUOROMETHOLONE 0.1 % OP SUSP,60758-0880-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),159.90,159.90,95.94,95.94,N/A,22.39,N/A,159.90,N/A,89.90,N/A,54.37,N/A,22.39,N/A,22.39,N/A,159.90,N/A,159.90,N/A,13.91,N/A,22.39,N/A,22.39,N/A,22.39,N/A,89.90,N/A,159.90,N/A,22.39,N/A,85.71,N/A,85.71,N/A,22.39,N/A,159.90,N/A,159.90,N/A,159.90,95.94,95.94,13.91,159.90,,Hospital HCPCS 6370000000,LETS KIT,51552-1345-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,MESALAMINE 400 MG PO CPDR,00023-5853-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.80,8.80,5.28,5.28,N/A,1.23,N/A,8.80,N/A,4.95,N/A,2.99,N/A,1.23,N/A,1.23,N/A,8.80,N/A,8.80,N/A,N/A,N/A,1.23,N/A,1.23,N/A,1.23,N/A,4.95,N/A,8.80,N/A,1.23,N/A,4.72,N/A,4.72,N/A,1.23,N/A,8.80,N/A,8.80,N/A,8.80,5.28,5.28,1.23,8.80,,Hospital HCPCS 6370000000,FLUTICASONE-SALMETEROL 500-50 MCG/ACT IN AEPB,00173-0697-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),556.50,556.50,333.90,333.90,N/A,77.91,N/A,556.50,N/A,312.86,N/A,189.21,N/A,77.91,N/A,77.91,N/A,556.50,N/A,556.50,N/A,48.42,N/A,77.91,N/A,77.91,N/A,77.91,N/A,312.86,N/A,556.50,N/A,77.91,N/A,298.28,N/A,298.28,N/A,77.91,N/A,556.50,N/A,556.50,N/A,556.50,333.90,333.90,48.42,556.50,,Hospital HCPCS 6370000000,NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR,65162-0321-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PREGABALIN 50 MG PO CAPS,72205-0012-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DESONIDE 0.05 % EX LOTN,00168-0310-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),533.00,533.00,319.80,319.80,N/A,74.62,N/A,533.00,N/A,299.65,N/A,181.22,N/A,74.62,N/A,74.62,N/A,533.00,N/A,533.00,N/A,46.37,N/A,74.62,N/A,74.62,N/A,74.62,N/A,299.65,N/A,533.00,N/A,74.62,N/A,285.69,N/A,285.69,N/A,74.62,N/A,533.00,N/A,533.00,N/A,533.00,319.80,319.80,46.37,533.00,,Hospital HCPCS 6370000000,CALAMINE 8-8 % EX LOTN,00904-2533-21,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MORPHINE SULFATE ER 15 MG PO TBCR,00406-8315-62,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LAMOTRIGINE 100 MG PO TABS,68084-0319-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ESTRADIOL 0.05 MG/24HR TD PTWK,00378-3350-99,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),41.80,41.80,25.08,25.08,N/A,5.85,N/A,41.80,N/A,23.50,N/A,14.21,N/A,5.85,N/A,5.85,N/A,41.80,N/A,41.80,N/A,3.64,N/A,5.85,N/A,5.85,N/A,5.85,N/A,23.50,N/A,41.80,N/A,5.85,N/A,22.40,N/A,22.40,N/A,5.85,N/A,41.80,N/A,41.80,N/A,41.80,25.08,25.08,3.64,41.80,,Hospital HCPCS 6370000000,POTASSIUM PHOSPHATE MONOBASIC 500 MG PO TABS,00486-1111-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,VALPROIC ACID 250 MG PO CAPS,69452-0150-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS,00406-0522-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SUMATRIPTAN SUCCINATE 100 MG PO TABS,65862-0148-36,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,AQUAPHOR EX OINT,72140-0452-31,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.40,8.40,5.04,5.04,N/A,1.18,N/A,8.40,N/A,4.72,N/A,2.86,N/A,1.18,N/A,1.18,N/A,8.40,N/A,8.40,N/A,N/A,N/A,1.18,N/A,1.18,N/A,1.18,N/A,4.72,N/A,8.40,N/A,1.18,N/A,4.50,N/A,4.50,N/A,1.18,N/A,8.40,N/A,8.40,N/A,8.40,5.04,5.04,1.18,8.40,,Hospital HCPCS 6370000000,DEUTETRABENAZINE 6 MG PO TABS,68546-0170-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),165.80,165.80,99.48,99.48,N/A,23.21,N/A,165.80,N/A,93.21,N/A,56.37,N/A,23.21,N/A,23.21,N/A,165.80,N/A,165.80,N/A,14.42,N/A,23.21,N/A,23.21,N/A,23.21,N/A,93.21,N/A,165.80,N/A,23.21,N/A,88.87,N/A,88.87,N/A,23.21,N/A,165.80,N/A,165.80,N/A,165.80,99.48,99.48,14.42,165.80,,Hospital HCPCS 6370000000,TETRAHYDROZOLINE-ZN SULFATE 0.05-0.25 % OP SOLN,74300-0004-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PHENYTOIN 50 MG PO CHEW,00071-0007-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CARBIDOPA-LEVODOPA 25-100 MG PO TBDP,47335-0187-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS,59762-1061-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GUAIFENESIN-DM 100-10 MG/5ML PO SYRP,00121-0638-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),4.70,4.70,2.82,2.82,N/A,N/A,N/A,4.70,N/A,2.64,N/A,1.60,N/A,N/A,N/A,N/A,N/A,4.70,N/A,4.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.64,N/A,4.70,N/A,N/A,N/A,2.52,N/A,2.52,N/A,N/A,N/A,4.70,N/A,4.70,N/A,4.70,2.82,2.82,1.60,4.70,,Hospital HCPCS 6370000000,CIPROFLOXACIN 250 MG/5ML (5%) PO SUSR,50419-0777-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),293.40,293.40,176.04,176.04,N/A,41.08,N/A,293.40,N/A,164.95,N/A,99.76,N/A,41.08,N/A,41.08,N/A,293.40,N/A,293.40,N/A,25.53,N/A,41.08,N/A,41.08,N/A,41.08,N/A,164.95,N/A,293.40,N/A,41.08,N/A,157.26,N/A,157.26,N/A,41.08,N/A,293.40,N/A,293.40,N/A,293.40,176.04,176.04,25.53,293.40,,Hospital HCPCS 6370000000,TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,09999-9914-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ITRACONAZOLE 100 MG PO CAPS,10147-1700-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),16.70,16.70,10.02,10.02,N/A,2.34,N/A,16.70,N/A,9.39,N/A,5.68,N/A,2.34,N/A,2.34,N/A,16.70,N/A,16.70,N/A,1.45,N/A,2.34,N/A,2.34,N/A,2.34,N/A,9.39,N/A,16.70,N/A,2.34,N/A,8.95,N/A,8.95,N/A,2.34,N/A,16.70,N/A,16.70,N/A,16.70,10.02,10.02,1.45,16.70,,Hospital HCPCS 6370000000,NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,00168-0081-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),306.90,306.90,184.14,184.14,N/A,42.97,N/A,306.90,N/A,172.54,N/A,104.35,N/A,42.97,N/A,42.97,N/A,306.90,N/A,306.90,N/A,26.70,N/A,42.97,N/A,42.97,N/A,42.97,N/A,172.54,N/A,306.90,N/A,42.97,N/A,164.50,N/A,164.50,N/A,42.97,N/A,306.90,N/A,306.90,N/A,306.90,184.14,184.14,26.70,306.90,,Hospital HCPCS 6370000000,LEUCOVORIN CALCIUM 5 MG PO TABS,00555-0484-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLUORESCEIN SODIUM 1 MG OP STRP,17238-0900-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FIDAXOMICIN 200 MG PO TABS,52015-0080-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),503.50,503.50,302.10,302.10,N/A,70.49,N/A,503.50,N/A,283.07,N/A,171.19,N/A,70.49,N/A,70.49,N/A,503.50,N/A,503.50,N/A,43.80,N/A,70.49,N/A,70.49,N/A,70.49,N/A,283.07,N/A,503.50,N/A,70.49,N/A,269.88,N/A,269.88,N/A,70.49,N/A,503.50,N/A,503.50,N/A,503.50,302.10,302.10,43.80,503.50,,Hospital HCPCS 6370000000,LISINOPRIL 2.5 MG PO TABS,68180-0512-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CALCIUM POLYCARBOPHIL 625 MG PO TABS,00536-4306-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BETHANECHOL CHLORIDE 25 MG PO TABS,00832-0512-89,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,COCAINE HCL POWD,09999-9911-29,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),236.30,236.30,141.78,141.78,N/A,33.08,N/A,236.30,N/A,132.85,N/A,80.34,N/A,33.08,N/A,33.08,N/A,236.30,N/A,236.30,N/A,20.56,N/A,33.08,N/A,33.08,N/A,33.08,N/A,132.85,N/A,236.30,N/A,33.08,N/A,126.66,N/A,126.66,N/A,33.08,N/A,236.30,N/A,236.30,N/A,236.30,141.78,141.78,20.56,236.30,,Hospital HCPCS 6370000000,PINDOLOL 5 MG PO TABS,00378-0052-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LANSOPRAZOLE 15 MG PO TBDD,64764-0543-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),31.20,31.20,18.72,18.72,N/A,4.37,N/A,31.20,N/A,17.54,N/A,10.61,N/A,4.37,N/A,4.37,N/A,31.20,N/A,31.20,N/A,2.71,N/A,4.37,N/A,4.37,N/A,4.37,N/A,17.54,N/A,31.20,N/A,4.37,N/A,16.72,N/A,16.72,N/A,4.37,N/A,31.20,N/A,31.20,N/A,31.20,18.72,18.72,2.71,31.20,,Hospital HCPCS 6370000000,IODINE STRONG 5 % PO SOLN,09999-9908-50,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),7.60,7.60,4.56,4.56,N/A,1.06,N/A,7.60,N/A,4.27,N/A,2.58,N/A,1.06,N/A,1.06,N/A,7.60,N/A,7.60,N/A,N/A,N/A,1.06,N/A,1.06,N/A,1.06,N/A,4.27,N/A,7.60,N/A,1.06,N/A,4.07,N/A,4.07,N/A,1.06,N/A,7.60,N/A,7.60,N/A,7.60,4.56,4.56,1.06,7.60,,Hospital HCPCS 6370000000,NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,00168-0089-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),112.30,112.30,67.38,67.38,N/A,15.72,N/A,112.30,N/A,63.14,N/A,38.18,N/A,15.72,N/A,15.72,N/A,112.30,N/A,112.30,N/A,9.77,N/A,15.72,N/A,15.72,N/A,15.72,N/A,63.14,N/A,112.30,N/A,15.72,N/A,60.19,N/A,60.19,N/A,15.72,N/A,112.30,N/A,112.30,N/A,112.30,67.38,67.38,9.77,112.30,,Hospital HCPCS 6370000000,THIORIDAZINE HCL 10 MG PO TABS,51079-0565-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DICLOXACILLIN SODIUM 250 MG PO CAPS,00093-3123-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SEVELAMER CARBONATE 800 MG PO TABS,58468-0130-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.40,13.40,8.04,8.04,N/A,1.88,N/A,13.40,N/A,7.53,N/A,4.56,N/A,1.88,N/A,1.88,N/A,13.40,N/A,13.40,N/A,1.17,N/A,1.88,N/A,1.88,N/A,1.88,N/A,7.53,N/A,13.40,N/A,1.88,N/A,7.18,N/A,7.18,N/A,1.88,N/A,13.40,N/A,13.40,N/A,13.40,8.04,8.04,1.17,13.40,,Hospital HCPCS 6370000000,HYDROCORTISONE (PERIANAL) 1 % EX CREA,62559-0430-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),112.60,112.60,67.56,67.56,N/A,15.76,N/A,112.60,N/A,63.30,N/A,38.28,N/A,15.76,N/A,15.76,N/A,112.60,N/A,112.60,N/A,9.80,N/A,15.76,N/A,15.76,N/A,15.76,N/A,63.30,N/A,112.60,N/A,15.76,N/A,60.35,N/A,60.35,N/A,15.76,N/A,112.60,N/A,112.60,N/A,112.60,67.56,67.56,9.80,112.60,,Hospital HCPCS 6370000000,SODIUM POLYSTYRENE SULFONATE PO POWD,10702-0036-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),28.20,28.20,16.92,16.92,N/A,3.95,N/A,28.20,N/A,15.85,N/A,9.59,N/A,3.95,N/A,3.95,N/A,28.20,N/A,28.20,N/A,2.45,N/A,3.95,N/A,3.95,N/A,3.95,N/A,15.85,N/A,28.20,N/A,3.95,N/A,15.12,N/A,15.12,N/A,3.95,N/A,28.20,N/A,28.20,N/A,28.20,16.92,16.92,2.45,28.20,,Hospital HCPCS 6370000000,OLANZAPINE 5 MG PO TABS,68084-0723-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,RALTEGRAVIR POTASSIUM 400 MG PO TABS,00006-0227-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),68.40,68.40,41.04,41.04,N/A,9.58,N/A,68.40,N/A,38.45,N/A,23.26,N/A,9.58,N/A,9.58,N/A,68.40,N/A,68.40,N/A,5.95,N/A,9.58,N/A,9.58,N/A,9.58,N/A,38.45,N/A,68.40,N/A,9.58,N/A,36.66,N/A,36.66,N/A,9.58,N/A,68.40,N/A,68.40,N/A,68.40,41.04,41.04,5.95,68.40,,Hospital HCPCS 6370000000,PENICILLIN V POTASSIUM 250 MG PO TABS,00093-1172-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,00168-0006-80,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),26.10,26.10,15.66,15.66,N/A,3.65,N/A,26.10,N/A,14.67,N/A,8.87,N/A,3.65,N/A,3.65,N/A,26.10,N/A,26.10,N/A,2.27,N/A,3.65,N/A,3.65,N/A,3.65,N/A,14.67,N/A,26.10,N/A,3.65,N/A,13.99,N/A,13.99,N/A,3.65,N/A,26.10,N/A,26.10,N/A,26.10,15.66,15.66,2.27,26.10,,Hospital HCPCS 6370000000,ACETIC ACID 3 % SOLN,09999-9910-41,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital HCPCS 6370000000,AMMONIUM LACTATE 12 % EX CREA,45802-0513-77,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),23.70,23.70,14.22,14.22,N/A,3.32,N/A,23.70,N/A,13.32,N/A,8.06,N/A,3.32,N/A,3.32,N/A,23.70,N/A,23.70,N/A,2.06,N/A,3.32,N/A,3.32,N/A,3.32,N/A,13.32,N/A,23.70,N/A,3.32,N/A,12.70,N/A,12.70,N/A,3.32,N/A,23.70,N/A,23.70,N/A,23.70,14.22,14.22,2.06,23.70,,Hospital HCPCS 6370000000,LITHIUM CARBONATE ER 300 MG PO TBCR,00054-0021-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PYRIDOXINE HCL 25 MG PO TABS,00536-4406-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,COCAINE HCL 4 % EX SOLN,09999-9910-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),148.80,148.80,89.28,89.28,N/A,20.83,N/A,148.80,N/A,83.66,N/A,50.59,N/A,20.83,N/A,20.83,N/A,148.80,N/A,148.80,N/A,12.95,N/A,20.83,N/A,20.83,N/A,20.83,N/A,83.66,N/A,148.80,N/A,20.83,N/A,79.76,N/A,79.76,N/A,20.83,N/A,148.80,N/A,148.80,N/A,148.80,89.28,89.28,12.95,148.80,,Hospital HCPCS 6370000000,TIMOLOL MALEATE 0.25 % OP SOLG,61314-0224-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),356.90,356.90,214.14,214.14,N/A,49.97,N/A,356.90,N/A,200.65,N/A,121.35,N/A,49.97,N/A,49.97,N/A,356.90,N/A,356.90,N/A,31.05,N/A,49.97,N/A,49.97,N/A,49.97,N/A,200.65,N/A,356.90,N/A,49.97,N/A,191.30,N/A,191.30,N/A,49.97,N/A,356.90,N/A,356.90,N/A,356.90,214.14,214.14,31.05,356.90,,Hospital HCPCS 6370000000,POTASSIUM BICARBONATE 25 MEQ PO TBEF,51801-0001-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FINASTERIDE 5 MG PO TABS,31722-0525-90,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,URSODIOL 250 MG PO TABS,58914-0785-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),12.40,12.40,7.44,7.44,N/A,1.74,N/A,12.40,N/A,6.97,N/A,4.22,N/A,1.74,N/A,1.74,N/A,12.40,N/A,12.40,N/A,1.08,N/A,1.74,N/A,1.74,N/A,1.74,N/A,6.97,N/A,12.40,N/A,1.74,N/A,6.65,N/A,6.65,N/A,1.74,N/A,12.40,N/A,12.40,N/A,12.40,7.44,7.44,1.08,12.40,,Hospital HCPCS 6370000000,SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK,00310-1105-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),54.80,54.80,32.88,32.88,N/A,7.67,N/A,54.80,N/A,30.81,N/A,18.63,N/A,7.67,N/A,7.67,N/A,54.80,N/A,54.80,N/A,4.77,N/A,7.67,N/A,7.67,N/A,7.67,N/A,30.81,N/A,54.80,N/A,7.67,N/A,29.37,N/A,29.37,N/A,7.67,N/A,54.80,N/A,54.80,N/A,54.80,32.88,32.88,4.77,54.80,,Hospital HCPCS 6370000000,THYROID 30 MG PO TABS,00456-0458-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PHENYLEPHRINE HCL 0.125 % NA SOLN,56184-0121-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),43.20,43.20,25.92,25.92,N/A,6.05,N/A,43.20,N/A,24.29,N/A,14.69,N/A,6.05,N/A,6.05,N/A,43.20,N/A,43.20,N/A,3.76,N/A,6.05,N/A,6.05,N/A,6.05,N/A,24.29,N/A,43.20,N/A,6.05,N/A,23.16,N/A,23.16,N/A,6.05,N/A,43.20,N/A,43.20,N/A,43.20,25.92,25.92,3.76,43.20,,Hospital HCPCS 6370000000,BETAMETHASONE DIPROPIONATE AUG 0.05 % EX OINT,00168-0268-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),89.90,89.90,53.94,53.94,N/A,12.59,N/A,89.90,N/A,50.54,N/A,30.57,N/A,12.59,N/A,12.59,N/A,89.90,N/A,89.90,N/A,7.82,N/A,12.59,N/A,12.59,N/A,12.59,N/A,50.54,N/A,89.90,N/A,12.59,N/A,48.19,N/A,48.19,N/A,12.59,N/A,89.90,N/A,89.90,N/A,89.90,53.94,53.94,7.82,89.90,,Hospital HCPCS 6370000000,BUPROPION HCL ER (XL) 150 MG PO TB24,10370-0101-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TRAZODONE HCL 100 MG PO TABS,00904-6869-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLOBAZAM 10 MG PO TABS,00832-0580-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BALSALAZIDE DISODIUM 750 MG PO CAPS,00054-0079-28,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.10,5.10,3.06,3.06,N/A,N/A,N/A,5.10,N/A,2.87,N/A,1.73,N/A,N/A,N/A,N/A,N/A,5.10,N/A,5.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.87,N/A,5.10,N/A,N/A,N/A,2.73,N/A,2.73,N/A,N/A,N/A,5.10,N/A,5.10,N/A,5.10,3.06,3.06,1.73,5.10,,Hospital HCPCS 6370000000,DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN,47335-0788-91,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),277.10,277.10,166.26,166.26,N/A,38.79,N/A,277.10,N/A,155.79,N/A,94.21,N/A,38.79,N/A,38.79,N/A,277.10,N/A,277.10,N/A,24.11,N/A,38.79,N/A,38.79,N/A,38.79,N/A,155.79,N/A,277.10,N/A,38.79,N/A,148.53,N/A,148.53,N/A,38.79,N/A,277.10,N/A,277.10,N/A,277.10,166.26,166.26,24.11,277.10,,Hospital HCPCS 6370000000,OXYCODONE HCL ER 10 MG PO T12A,59011-0410-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),10.80,10.80,6.48,6.48,N/A,1.51,N/A,10.80,N/A,6.07,N/A,3.67,N/A,1.51,N/A,1.51,N/A,10.80,N/A,10.80,N/A,N/A,N/A,1.51,N/A,1.51,N/A,1.51,N/A,6.07,N/A,10.80,N/A,1.51,N/A,5.79,N/A,5.79,N/A,1.51,N/A,10.80,N/A,10.80,N/A,10.80,6.48,6.48,1.51,10.80,,Hospital HCPCS 6370000000,ESCITALOPRAM OXALATE 10 MG PO TABS,68084-0617-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DAPSONE 7.5 % EX GEL,51672-5307-03,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1214.20,1214.20,728.52,728.52,N/A,169.99,N/A,1214.20,N/A,682.62,N/A,412.83,N/A,169.99,N/A,169.99,N/A,1214.20,N/A,1214.20,N/A,105.64,N/A,169.99,N/A,169.99,N/A,169.99,N/A,682.62,N/A,1214.20,N/A,169.99,N/A,650.81,N/A,650.81,N/A,169.99,N/A,1214.20,N/A,1214.20,N/A,1214.20,728.52,728.52,105.64,1214.20,,Hospital HCPCS 6370000000,MESALAMINE ER 500 MG PO CPCR,54092-0191-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.70,13.70,8.22,8.22,N/A,1.92,N/A,13.70,N/A,7.70,N/A,4.66,N/A,1.92,N/A,1.92,N/A,13.70,N/A,13.70,N/A,1.19,N/A,1.92,N/A,1.92,N/A,1.92,N/A,7.70,N/A,13.70,N/A,1.92,N/A,7.34,N/A,7.34,N/A,1.92,N/A,13.70,N/A,13.70,N/A,13.70,8.22,8.22,1.19,13.70,,Hospital HCPCS 6370000000,DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24,63739-0016-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MOEXIPRIL HCL 7.5 MG PO TABS,00093-0017-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,KETOROLAC TROMETHAMINE 0.5 % OP SOLN,60505-1003-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),72.10,72.10,43.26,43.26,N/A,10.09,N/A,72.10,N/A,40.53,N/A,24.51,N/A,10.09,N/A,10.09,N/A,72.10,N/A,72.10,N/A,6.27,N/A,10.09,N/A,10.09,N/A,10.09,N/A,40.53,N/A,72.10,N/A,10.09,N/A,38.65,N/A,38.65,N/A,10.09,N/A,72.10,N/A,72.10,N/A,72.10,43.26,43.26,6.27,72.10,,Hospital HCPCS 6370000000,FLUTICASONE PROPIONATE 0.05 % EX CREA,45802-0222-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),32.60,32.60,19.56,19.56,N/A,4.56,N/A,32.60,N/A,18.33,N/A,11.08,N/A,4.56,N/A,4.56,N/A,32.60,N/A,32.60,N/A,2.84,N/A,4.56,N/A,4.56,N/A,4.56,N/A,18.33,N/A,32.60,N/A,4.56,N/A,17.47,N/A,17.47,N/A,4.56,N/A,32.60,N/A,32.60,N/A,32.60,19.56,19.56,2.84,32.60,,Hospital HCPCS 6370000000,HALOBETASOL PROPIONATE 0.05 % EX CREA,45802-0129-35,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),74.30,74.30,44.58,44.58,N/A,10.40,N/A,74.30,N/A,41.77,N/A,25.26,N/A,10.40,N/A,10.40,N/A,74.30,N/A,74.30,N/A,6.46,N/A,10.40,N/A,10.40,N/A,10.40,N/A,41.77,N/A,74.30,N/A,10.40,N/A,39.82,N/A,39.82,N/A,10.40,N/A,74.30,N/A,74.30,N/A,74.30,44.58,44.58,6.46,74.30,,Hospital HCPCS 6370000000,LITHIUM CARBONATE 150 MG PO CAPS,00054-8526-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,METRONIDAZOLE 500 MG PO TABS,50111-0334-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CAPSAICIN 0.025 % EX CREA,00536-2525-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.70,15.70,9.42,9.42,N/A,2.20,N/A,15.70,N/A,8.83,N/A,5.34,N/A,2.20,N/A,2.20,N/A,15.70,N/A,15.70,N/A,1.37,N/A,2.20,N/A,2.20,N/A,2.20,N/A,8.83,N/A,15.70,N/A,2.20,N/A,8.42,N/A,8.42,N/A,2.20,N/A,15.70,N/A,15.70,N/A,15.70,9.42,9.42,1.37,15.70,,Hospital HCPCS 6370000000,BRIMONIDINE TARTRATE 0.2 % OP SOLN,61314-0143-10,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.00,27.00,16.20,16.20,N/A,3.78,N/A,27.00,N/A,15.18,N/A,9.18,N/A,3.78,N/A,3.78,N/A,27.00,N/A,27.00,N/A,2.35,N/A,3.78,N/A,3.78,N/A,3.78,N/A,15.18,N/A,27.00,N/A,3.78,N/A,14.47,N/A,14.47,N/A,3.78,N/A,27.00,N/A,27.00,N/A,27.00,16.20,16.20,2.35,27.00,,Hospital HCPCS 6370000000,CHARCOAL ACTIVATED PO LIQD,66689-0201-08,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),21.40,21.40,12.84,12.84,N/A,3.00,N/A,21.40,N/A,12.03,N/A,7.28,N/A,3.00,N/A,3.00,N/A,21.40,N/A,21.40,N/A,1.86,N/A,3.00,N/A,3.00,N/A,3.00,N/A,12.03,N/A,21.40,N/A,3.00,N/A,11.47,N/A,11.47,N/A,3.00,N/A,21.40,N/A,21.40,N/A,21.40,12.84,12.84,1.86,21.40,,Hospital HCPCS 6370000000,MORPHINE SULFATE 15 MG PO TABS,00054-0235-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CULTURELLE PO CAPS,49100-0400-07,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ALOGLIPTIN BENZOATE 12.5 MG PO TABS,45802-0103-65,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.70,14.70,8.82,8.82,N/A,2.06,N/A,14.70,N/A,8.26,N/A,5.00,N/A,2.06,N/A,2.06,N/A,14.70,N/A,14.70,N/A,1.28,N/A,2.06,N/A,2.06,N/A,2.06,N/A,8.26,N/A,14.70,N/A,2.06,N/A,7.88,N/A,7.88,N/A,2.06,N/A,14.70,N/A,14.70,N/A,14.70,8.82,8.82,1.28,14.70,,Hospital HCPCS 6370000000,MEGESTROL ACETATE 40 MG/ML PO SUSP,09999-9908-83,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLOMIPRAMINE HCL 25 MG PO CAPS,51672-4011-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),15.20,15.20,9.12,9.12,N/A,2.13,N/A,15.20,N/A,8.55,N/A,5.17,N/A,2.13,N/A,2.13,N/A,15.20,N/A,15.20,N/A,1.32,N/A,2.13,N/A,2.13,N/A,2.13,N/A,8.55,N/A,15.20,N/A,2.13,N/A,8.15,N/A,8.15,N/A,2.13,N/A,15.20,N/A,15.20,N/A,15.20,9.12,9.12,1.32,15.20,,Hospital HCPCS 6370000000,VERAPAMIL HCL ER 100 MG PO CP24,62175-0485-37,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),11.00,11.00,6.60,6.60,N/A,1.54,N/A,11.00,N/A,6.18,N/A,3.74,N/A,1.54,N/A,1.54,N/A,11.00,N/A,11.00,N/A,N/A,N/A,1.54,N/A,1.54,N/A,1.54,N/A,6.18,N/A,11.00,N/A,1.54,N/A,5.90,N/A,5.90,N/A,1.54,N/A,11.00,N/A,11.00,N/A,11.00,6.60,6.60,1.54,11.00,,Hospital HCPCS 6370000000,OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS,53746-0203-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,00597-0024-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1037.90,1037.90,622.74,622.74,N/A,145.31,N/A,1037.90,N/A,583.51,N/A,352.89,N/A,145.31,N/A,145.31,N/A,1037.90,N/A,1037.90,N/A,90.30,N/A,145.31,N/A,145.31,N/A,145.31,N/A,583.51,N/A,1037.90,N/A,145.31,N/A,556.31,N/A,556.31,N/A,145.31,N/A,1037.90,N/A,1037.90,N/A,1037.90,622.74,622.74,90.30,1037.90,,Hospital HCPCS 6370000000,ZIPRASIDONE HCL 20 MG PO CAPS,68084-0103-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.30,6.30,3.78,3.78,N/A,N/A,N/A,6.30,N/A,3.54,N/A,2.14,N/A,N/A,N/A,N/A,N/A,6.30,N/A,6.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.54,N/A,6.30,N/A,N/A,N/A,3.38,N/A,3.38,N/A,N/A,N/A,6.30,N/A,6.30,N/A,6.30,3.78,3.78,2.14,6.30,,Hospital HCPCS 6370000000,AMOXICILLIN 875 MG PO TABS,00781-5061-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,SULFACETAMIDE SODIUM 10 % OP SOLN,24208-0670-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),109.70,109.70,65.82,65.82,N/A,15.36,N/A,109.70,N/A,61.67,N/A,37.30,N/A,15.36,N/A,15.36,N/A,109.70,N/A,109.70,N/A,9.54,N/A,15.36,N/A,15.36,N/A,15.36,N/A,61.67,N/A,109.70,N/A,15.36,N/A,58.80,N/A,58.80,N/A,15.36,N/A,109.70,N/A,109.70,N/A,109.70,65.82,65.82,9.54,109.70,,Hospital HCPCS 6370000000,ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN,54838-0551-70,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.80,6.80,4.08,4.08,N/A,N/A,N/A,6.80,N/A,3.82,N/A,2.31,N/A,N/A,N/A,N/A,N/A,6.80,N/A,6.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.82,N/A,6.80,N/A,N/A,N/A,3.64,N/A,3.64,N/A,N/A,N/A,6.80,N/A,6.80,N/A,6.80,4.08,4.08,2.31,6.80,,Hospital HCPCS 6370000000,NICARDIPINE HCL 20 MG PO CAPS,42806-0501-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),27.90,27.90,16.74,16.74,N/A,3.91,N/A,27.90,N/A,15.69,N/A,9.49,N/A,3.91,N/A,3.91,N/A,27.90,N/A,27.90,N/A,2.43,N/A,3.91,N/A,3.91,N/A,3.91,N/A,15.69,N/A,27.90,N/A,3.91,N/A,14.95,N/A,14.95,N/A,3.91,N/A,27.90,N/A,27.90,N/A,27.90,16.74,16.74,2.43,27.90,,Hospital HCPCS 6370000000,BISOPROLOL FUMARATE 5 MG PO TABS,29300-0126-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,LOSARTAN POTASSIUM 50 MG PO TABS,68084-0347-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ACETIC ACID 5 % SOLN,51552-0055-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),55.70,55.70,33.42,33.42,N/A,7.80,N/A,55.70,N/A,31.31,N/A,18.94,N/A,7.80,N/A,7.80,N/A,55.70,N/A,55.70,N/A,4.85,N/A,7.80,N/A,7.80,N/A,7.80,N/A,31.31,N/A,55.70,N/A,7.80,N/A,29.86,N/A,29.86,N/A,7.80,N/A,55.70,N/A,55.70,N/A,55.70,33.42,33.42,4.85,55.70,,Hospital HCPCS 6370000000,CETIRIZINE HCL 5 MG/5ML PO SOLN,09999-9902-59,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DEUTETRABENAZINE 9 MG PO TABS,68546-0171-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),186.50,186.50,111.90,111.90,N/A,26.11,N/A,186.50,N/A,104.85,N/A,63.41,N/A,26.11,N/A,26.11,N/A,186.50,N/A,186.50,N/A,16.23,N/A,26.11,N/A,26.11,N/A,26.11,N/A,104.85,N/A,186.50,N/A,26.11,N/A,99.96,N/A,99.96,N/A,26.11,N/A,186.50,N/A,186.50,N/A,186.50,111.90,111.90,16.23,186.50,,Hospital HCPCS 6370000000,LACTASE 3000 UNITS PO TABS,00904-5224-52,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NAPROXEN 250 MG PO TABS,68462-0188-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,BUDESONIDE 90 MCG/ACT IN AEPB,00186-0917-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),431.70,431.70,259.02,259.02,N/A,60.44,N/A,431.70,N/A,242.70,N/A,146.78,N/A,60.44,N/A,60.44,N/A,431.70,N/A,431.70,N/A,37.56,N/A,60.44,N/A,60.44,N/A,60.44,N/A,242.70,N/A,431.70,N/A,60.44,N/A,231.39,N/A,231.39,N/A,60.44,N/A,431.70,N/A,431.70,N/A,431.70,259.02,259.02,37.56,431.70,,Hospital HCPCS 6370000000,FLUTICASONE-SALMETEROL 230-21 MCG/ACT IN AERO,00173-0717-22,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),730.30,730.30,438.18,438.18,N/A,102.24,N/A,730.30,N/A,410.57,N/A,248.30,N/A,102.24,N/A,102.24,N/A,730.30,N/A,730.30,N/A,63.54,N/A,102.24,N/A,102.24,N/A,102.24,N/A,410.57,N/A,730.30,N/A,102.24,N/A,391.44,N/A,391.44,N/A,102.24,N/A,730.30,N/A,730.30,N/A,730.30,438.18,438.18,63.54,730.30,,Hospital HCPCS 6370000000,ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,09999-9907-92,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,OYSTER SHELL CALCIUM 500 MG PO TABS,00904-1883-61,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.00,1.00,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital HCPCS 6370000000,PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS,00071-0369-40,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NORTRIPTYLINE HCL 10 MG PO CAPS,51672-4001-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,DIAZEPAM 10 MG RE GEL,00187-0658-20,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),789.20,789.20,473.52,473.52,N/A,110.49,N/A,789.20,N/A,443.69,N/A,268.33,N/A,110.49,N/A,110.49,N/A,789.20,N/A,789.20,N/A,68.66,N/A,110.49,N/A,110.49,N/A,110.49,N/A,443.69,N/A,789.20,N/A,110.49,N/A,423.01,N/A,423.01,N/A,110.49,N/A,789.20,N/A,789.20,N/A,789.20,473.52,473.52,68.66,789.20,,Hospital HCPCS 6370000000,MORPHINE SULFATE 30 MG PO TABS,00054-0236-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PRIMIDONE 250 MG PO TABS,68084-0203-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,FLECAINIDE ACETATE 100 MG PO TABS,00054-0011-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,CLONAZEPAM 0.25 MG PO TBDP,49884-0307-02,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,TOBRAMYCIN 0.3 % OP SOLN,61314-0643-05,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),34.90,34.90,20.94,20.94,N/A,4.89,N/A,34.90,N/A,19.62,N/A,11.87,N/A,4.89,N/A,4.89,N/A,34.90,N/A,34.90,N/A,3.04,N/A,4.89,N/A,4.89,N/A,4.89,N/A,19.62,N/A,34.90,N/A,4.89,N/A,18.71,N/A,18.71,N/A,4.89,N/A,34.90,N/A,34.90,N/A,34.90,20.94,20.94,3.04,34.90,,Hospital HCPCS 6370000000,CHLORPROMAZINE HCL 25 MG PO TABS,00832-0301-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),8.60,8.60,5.16,5.16,N/A,1.20,N/A,8.60,N/A,4.83,N/A,2.92,N/A,1.20,N/A,1.20,N/A,8.60,N/A,8.60,N/A,N/A,N/A,1.20,N/A,1.20,N/A,1.20,N/A,4.83,N/A,8.60,N/A,1.20,N/A,4.61,N/A,4.61,N/A,1.20,N/A,8.60,N/A,8.60,N/A,8.60,5.16,5.16,1.20,8.60,,Hospital HCPCS 6370000000,BUSPIRONE HCL 5 MG PO TABS,51079-0985-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,NEOMYCIN SULFATE 500 MG PO TABS,39822-0310-07,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PERMETHRIN 5 % EX CREA,00472-0242-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),222.80,222.80,133.68,133.68,N/A,31.19,N/A,222.80,N/A,125.26,N/A,75.75,N/A,31.19,N/A,31.19,N/A,222.80,N/A,222.80,N/A,19.38,N/A,31.19,N/A,31.19,N/A,31.19,N/A,125.26,N/A,222.80,N/A,31.19,N/A,119.42,N/A,119.42,N/A,31.19,N/A,222.80,N/A,222.80,N/A,222.80,133.68,133.68,19.38,222.80,,Hospital HCPCS 6370000000,PROMETHAZINE HCL 12.5 MG RE SUPP,45802-0758-00,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),22.00,22.00,13.20,13.20,N/A,3.08,N/A,22.00,N/A,12.37,N/A,7.48,N/A,3.08,N/A,3.08,N/A,22.00,N/A,22.00,N/A,1.91,N/A,3.08,N/A,3.08,N/A,3.08,N/A,12.37,N/A,22.00,N/A,3.08,N/A,11.79,N/A,11.79,N/A,3.08,N/A,22.00,N/A,22.00,N/A,22.00,13.20,13.20,1.91,22.00,,Hospital HCPCS 6370000000,RIVASTIGMINE TARTRATE 1.5 MG PO CAPS,N/A,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.80,5.80,3.48,3.48,N/A,N/A,N/A,5.80,N/A,3.26,N/A,1.97,N/A,N/A,N/A,N/A,N/A,5.80,N/A,5.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.26,N/A,5.80,N/A,N/A,N/A,3.11,N/A,3.11,N/A,N/A,N/A,5.80,N/A,5.80,N/A,5.80,3.48,3.48,1.97,5.80,,Hospital HCPCS 6370000000,DIVALPROEX SODIUM ER 500 MG PO TB24,51079-0767-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.70,5.70,3.42,3.42,N/A,N/A,N/A,5.70,N/A,3.20,N/A,1.94,N/A,N/A,N/A,N/A,N/A,5.70,N/A,5.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.20,N/A,5.70,N/A,N/A,N/A,3.06,N/A,3.06,N/A,N/A,N/A,5.70,N/A,5.70,N/A,5.70,3.42,3.42,1.94,5.70,,Hospital HCPCS 6370000000,NICOTINE 14 MG/24HR TD PT24,00536-5895-88,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),3.90,3.90,2.34,2.34,N/A,N/A,N/A,3.90,N/A,2.19,N/A,1.33,N/A,N/A,N/A,N/A,N/A,3.90,N/A,3.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.19,N/A,3.90,N/A,N/A,N/A,2.09,N/A,2.09,N/A,N/A,N/A,3.90,N/A,3.90,N/A,3.90,2.34,2.34,1.33,3.90,,Hospital HCPCS 6370000000,ESTROGENS CONJUGATED 0.3 MG PO TABS,00046-1100-81,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),14.40,14.40,8.64,8.64,N/A,2.02,N/A,14.40,N/A,8.10,N/A,4.90,N/A,2.02,N/A,2.02,N/A,14.40,N/A,14.40,N/A,1.25,N/A,2.02,N/A,2.02,N/A,2.02,N/A,8.10,N/A,14.40,N/A,2.02,N/A,7.72,N/A,7.72,N/A,2.02,N/A,14.40,N/A,14.40,N/A,14.40,8.64,8.64,1.25,14.40,,Hospital HCPCS 6370000000,FEBUXOSTAT 40 MG PO TABS,00378-3925-93,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.70,5.70,3.42,3.42,N/A,N/A,N/A,5.70,N/A,3.20,N/A,1.94,N/A,N/A,N/A,N/A,N/A,5.70,N/A,5.70,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.20,N/A,5.70,N/A,N/A,N/A,3.06,N/A,3.06,N/A,N/A,N/A,5.70,N/A,5.70,N/A,5.70,3.42,3.42,1.94,5.70,,Hospital HCPCS 6370000000,ASENAPINE MALEATE 5 MG SL SUBL,59762-2012-06,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),13.60,13.60,8.16,8.16,N/A,1.90,N/A,13.60,N/A,7.65,N/A,4.62,N/A,1.90,N/A,1.90,N/A,13.60,N/A,13.60,N/A,1.18,N/A,1.90,N/A,1.90,N/A,1.90,N/A,7.65,N/A,13.60,N/A,1.90,N/A,7.29,N/A,7.29,N/A,1.90,N/A,13.60,N/A,13.60,N/A,13.60,8.16,8.16,1.18,13.60,,Hospital HCPCS 6370000000,MELATONIN 5 MG PO TABS,31604-0027-43,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ATORVASTATIN CALCIUM 10 MG PO TABS,60505-2578-09,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POTASSIUM CITRATE ER 10 MEQ (1080 MG) PO TBCR,00245-0071-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,ZINC SULFATE 220 (50 ZN) MG PO CAPS,68585-0008-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK,60258-0006-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,GLIMEPIRIDE 2 MG PO TABS,68084-0326-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,BUSPIRONE HCL 15 MG PO TABS,51079-0960-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,MECLIZINE HCL 12.5 MG PO TABS,50268-0522-15,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),1.40,1.40,N/A,N/A,N/A,N/A,N/A,1.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.40,N/A,1.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.40,N/A,1.40,N/A,1.40,N/A,N/A,1.40,1.40,,Hospital HCPCS 6370000000,ATENOLOL 25 MG PO TABS,51079-0759-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,POTASSIUM CHLORIDE 20 MEQ PO PACK,69238-1617-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),6.40,6.40,3.84,3.84,N/A,N/A,N/A,6.40,N/A,3.60,N/A,2.18,N/A,N/A,N/A,N/A,N/A,6.40,N/A,6.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.60,N/A,6.40,N/A,N/A,N/A,3.43,N/A,3.43,N/A,N/A,N/A,6.40,N/A,6.40,N/A,6.40,3.84,3.84,2.18,6.40,,Hospital HCPCS 6370000000,TROSPIUM CHLORIDE 20 MG PO TABS,00574-0145-60,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS 6370000000,PROMETHAZINE-CODEINE 6.25-10 MG/5ML PO SOLN,09999-9999-18,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital 64413,HC Peripheral Block - Cervical,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25914.52,N/A,15548.71,N/A,3628.03,N/A,4832.50,N/A,14916.79,N/A,8810.93,N/A,11435.30,N/A,3628.03,N/A,4706.78,N/A,4706.78,N/A,7118.70,N/A,11435.30,N/A,11435.30,N/A,11435.30,N/A,14916.80,N/A,4706.78,N/A,3628.03,N/A,7897.00,N/A,7897.00,N/A,3628.03,N/A,4706.78,N/A,4832.50,N/A,1012.99,N/A,N/A,1012.99,15548.71,,Hospital CPT 64415,HC Inj Aa&/Strd Brachial Plexus W/Img Gdn,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,2342.00,2342.00,1405.20,1405.20,N/A,327.88,N/A,769.55,N/A,1348.52,N/A,796.28,N/A,1861.48,N/A,327.88,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1348.52,N/A,769.55,N/A,327.88,N/A,2342.00,N/A,2342.00,N/A,327.88,N/A,769.55,N/A,769.55,N/A,846.51,1405.20,1405.20,327.88,2342.00,,Hospital CPT 64415,HC Peripheral Block - Brachial Plexus Single W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2342.00,2342.00,1405.20,1405.20,N/A,327.88,N/A,769.55,N/A,1348.52,N/A,796.28,N/A,1861.48,N/A,327.88,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1348.52,N/A,769.55,N/A,327.88,N/A,1431.00,N/A,1431.00,N/A,327.88,N/A,769.55,N/A,769.55,N/A,846.51,1405.20,1405.20,327.88,1861.48,,Hospital CPT 64417,HC Axillary Nerve Block W/Img Gdn,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2404.00,2404.00,1442.40,1442.40,N/A,336.56,N/A,769.55,N/A,1384.22,N/A,817.36,N/A,1861.48,N/A,336.56,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1384.22,N/A,769.55,N/A,336.56,N/A,1288.54,N/A,1288.54,N/A,336.56,N/A,769.55,N/A,769.55,N/A,846.51,1442.40,1442.40,336.56,1861.48,,Hospital CPT 64417,HC Peripheral Block - Axillary W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2404.00,2404.00,1442.40,1442.40,N/A,336.56,N/A,769.55,N/A,1384.22,N/A,817.36,N/A,1861.48,N/A,336.56,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1384.22,N/A,769.55,N/A,336.56,N/A,1431.00,N/A,1431.00,N/A,336.56,N/A,769.55,N/A,769.55,N/A,846.51,1442.40,1442.40,336.56,1861.48,,Hospital CPT 64420,HC Intercostal Nerve Block Single,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1136.00,1136.00,681.60,681.60,N/A,159.04,N/A,581.86,N/A,654.11,N/A,386.24,N/A,1136.00,N/A,159.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1136.00,N/A,1136.00,N/A,1136.00,N/A,654.11,N/A,581.86,N/A,159.04,N/A,608.90,N/A,608.90,N/A,159.04,N/A,581.86,N/A,581.86,N/A,640.05,681.60,681.60,159.04,1136.00,,Hospital CPT 64420,HC Injection Aa&/Strd Intercostal Nrv Single Lvl,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1136.00,1136.00,681.60,681.60,N/A,159.04,N/A,581.86,N/A,654.11,N/A,386.24,N/A,1136.00,N/A,159.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1136.00,N/A,1136.00,N/A,1136.00,N/A,654.11,N/A,581.86,N/A,159.04,N/A,1136.00,N/A,1136.00,N/A,159.04,N/A,581.86,N/A,581.86,N/A,640.05,681.60,681.60,159.04,1136.00,,Hospital CPT 64420,HC N Block Inj Intercost Sng,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1136.00,1136.00,681.60,681.60,N/A,159.04,N/A,581.86,N/A,654.11,N/A,386.24,N/A,1136.00,N/A,159.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1136.00,N/A,1136.00,N/A,1136.00,N/A,654.11,N/A,581.86,N/A,159.04,N/A,1431.00,N/A,1431.00,N/A,159.04,N/A,581.86,N/A,581.86,N/A,640.05,681.60,681.60,159.04,1431.00,,Hospital CPT 64430,HC Pudendal Nerve Block,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2323.00,2323.00,1393.80,1393.80,N/A,325.22,N/A,804.99,N/A,1337.58,N/A,789.82,N/A,1861.48,N/A,325.22,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1337.58,N/A,769.55,N/A,325.22,N/A,1245.13,N/A,1245.13,N/A,325.22,N/A,769.55,N/A,769.55,N/A,846.51,1393.80,1393.80,325.22,1861.48,,Hospital CPT 64445,HC Peripheral Block - Sciatic Single W/Img,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2863.00,2863.00,1717.80,1717.80,N/A,400.82,N/A,581.86,N/A,1648.52,N/A,973.42,N/A,1407.47,N/A,400.82,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1648.52,N/A,581.86,N/A,400.82,N/A,1431.00,N/A,1431.00,N/A,400.82,N/A,581.86,N/A,581.86,N/A,640.05,1717.80,1717.80,400.82,1717.80,,Hospital CPT 64445,HC Sciatic/Piriformis Nerve Block,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2863.00,2863.00,1717.80,1717.80,N/A,400.82,N/A,581.86,N/A,1648.52,N/A,973.42,N/A,1407.47,N/A,400.82,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1648.52,N/A,581.86,N/A,400.82,N/A,1534.57,N/A,1534.57,N/A,400.82,N/A,581.86,N/A,581.86,N/A,640.05,1717.80,1717.80,400.82,1717.80,,Hospital CPT 64447,HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,2404.00,2404.00,1442.40,1442.40,N/A,336.56,N/A,581.86,N/A,1384.22,N/A,817.36,N/A,1407.47,N/A,336.56,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,1384.22,N/A,581.86,N/A,336.56,N/A,1431.00,N/A,1431.00,N/A,336.56,N/A,581.86,N/A,581.86,N/A,640.05,1442.40,1442.40,336.56,1442.40,,Hospital CPT 64450,HC Peripheral Block - Peripheral Nerve or Branch,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,581.86,N/A,884.43,N/A,522.24,N/A,1407.47,N/A,215.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,884.43,N/A,581.86,N/A,215.04,N/A,1431.00,N/A,1431.00,N/A,215.04,N/A,581.86,N/A,581.86,N/A,640.05,921.60,921.60,215.04,1431.00,,Hospital CPT 64450,HC Inj Aa&/Strd Other Peripheral Nerve/Branch,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,581.86,N/A,884.43,N/A,522.24,N/A,1407.47,N/A,215.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,884.43,N/A,581.86,N/A,215.04,N/A,1536.00,N/A,1536.00,N/A,215.04,N/A,581.86,N/A,581.86,N/A,640.05,921.60,921.60,215.04,1536.00,,Hospital CPT 64450,HC Periph Nerve Injection,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,581.86,N/A,884.43,N/A,522.24,N/A,1407.47,N/A,215.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,884.43,N/A,581.86,N/A,215.04,N/A,823.30,N/A,823.30,N/A,215.04,N/A,581.86,N/A,581.86,N/A,640.05,921.60,921.60,215.04,1407.47,,Hospital 64479,HC Inj Anes/Ster Transforamin C/O,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,9515.50,5164.60,5709.30,3098.76,5123.90,723.04,6326.96,815.52,9515.50,2973.46,3235.27,1755.96,9515.50,1869.09,5281.78,723.04,1686.00,769.55,1686.00,769.55,7256.58,1163.55,9515.50,1869.09,9515.50,1869.09,9515.50,1869.09,9515.50,2973.47,6326.96,769.55,5281.78,723.04,9515.50,1694.50,9515.50,1694.50,5071.13,723.04,6326.96,769.55,6326.96,815.52,5651.50,203.11,1686.00,9515.50,203.11,3098.76,,Hospital CPT 64483,"HC Trans, Esb, L/S, Single",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2688.00,2688.00,1612.80,1612.80,N/A,376.32,N/A,818.64,N/A,1547.75,N/A,913.92,N/A,1861.48,N/A,376.32,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1547.75,N/A,769.55,N/A,376.32,N/A,1440.77,N/A,1440.77,N/A,376.32,N/A,769.55,N/A,106.37,N/A,117.01,1612.80,1612.80,106.37,1861.48,,Hospital CPT 64488,HC Peripheral Block - Tap Bilateral Injection,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,1937.00,1937.00,1162.20,1162.20,N/A,271.18,N/A,67.53,N/A,1115.32,N/A,658.58,N/A,1937.00,N/A,271.18,N/A,1937.00,N/A,1937.00,N/A,1937.00,N/A,1937.00,N/A,1937.00,N/A,1937.00,N/A,1115.32,N/A,1937.00,N/A,271.18,N/A,527.00,N/A,527.00,N/A,271.18,N/A,1937.00,N/A,1937.00,N/A,74.28,1162.20,1162.20,67.53,1937.00,,Hospital CPT 64490,HC N Block Paravert Thoracic 1st,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,769.55,N/A,2054.45,N/A,1213.12,N/A,1861.48,N/A,499.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2054.45,N/A,769.55,N/A,499.52,N/A,1431.00,N/A,1431.00,N/A,499.52,N/A,769.55,N/A,769.55,N/A,846.51,2140.80,2140.80,499.52,2140.80,,Hospital CPT 64490,"HC Facet Jnt, C/T, Single",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,769.55,N/A,2054.45,N/A,1213.12,N/A,1861.48,N/A,499.52,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,2054.45,N/A,769.55,N/A,499.52,N/A,1912.45,N/A,1912.45,N/A,499.52,N/A,769.55,N/A,769.55,N/A,846.51,2140.80,2140.80,499.52,2140.80,,Hospital CPT 64494,HC N Block Paravert Lumbar 2nd,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,3568.00,N/A,2054.45,N/A,1213.12,N/A,3568.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,2054.45,N/A,3568.00,N/A,499.52,N/A,527.00,N/A,527.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,2140.80,2140.80,499.52,3568.00,,Hospital CPT 64494,"HC Facet Inj, L/S 2nd Level",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3568.00,3568.00,2140.80,2140.80,N/A,499.52,N/A,3568.00,N/A,2054.45,N/A,1213.12,N/A,3568.00,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,3568.00,N/A,2054.45,N/A,3568.00,N/A,499.52,N/A,1912.45,N/A,1912.45,N/A,499.52,N/A,3568.00,N/A,3568.00,N/A,3568.00,2140.80,2140.80,499.52,3568.00,,Hospital 64553,Prq Impltj Neurostimulator Eltrd Cranial Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,55655.40,N/A,33393.24,N/A,7791.76,N/A,27732.61,N/A,31570.88,N/A,18922.83,N/A,55655.40,N/A,7791.76,N/A,26511.88,N/A,26511.88,N/A,40037.21,N/A,55655.40,N/A,55655.40,N/A,55655.40,N/A,31570.88,N/A,26511.88,N/A,7791.76,N/A,33714.50,N/A,33714.50,N/A,7791.76,N/A,26511.88,N/A,27732.61,N/A,1304.82,N/A,N/A,1304.82,55655.40,,Hospital 64568,Open Implantation Cranial Nerve Nea & Pulse Gen,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,243173.93,N/A,145904.36,N/A,34044.36,N/A,28202.93,N/A,137201.32,N/A,82679.13,N/A,64150.79,N/A,34044.36,N/A,26511.88,N/A,26511.88,N/A,39935.11,N/A,64150.79,N/A,64150.79,N/A,64150.79,N/A,137201.33,N/A,26511.88,N/A,34044.36,N/A,29766.00,N/A,29766.00,N/A,34044.36,N/A,26511.88,N/A,28202.93,N/A,641.63,N/A,N/A,641.63,145904.36,,Hospital 64569,Revise/Replace Cranial Nerve Stim Electrode/Connect Pulse Gen,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,193471.42,N/A,116082.85,N/A,27085.99,N/A,14881.53,N/A,109138.89,N/A,65780.27,N/A,26114.46,N/A,27085.99,N/A,14795.47,N/A,14795.47,N/A,16256.76,N/A,26114.46,N/A,26114.46,N/A,26114.46,N/A,109017.97,N/A,14795.47,N/A,27085.99,N/A,7897.00,N/A,7897.00,N/A,27085.99,N/A,14795.47,N/A,14881.53,N/A,805.62,N/A,N/A,805.62,116082.85,,Hospital 64570,Remove Implant Cranial Nerve Stim Electrode/Pulse Gen,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29228.10,N/A,17536.86,N/A,4047.82,N/A,5695.60,N/A,16824.41,N/A,9937.55,N/A,13524.68,N/A,4047.82,N/A,5579.57,N/A,5579.57,N/A,8419.38,N/A,13524.68,N/A,13524.68,N/A,13524.68,N/A,16824.41,N/A,5579.57,N/A,4047.82,N/A,7897.00,N/A,7897.00,N/A,4047.82,N/A,5579.57,N/A,5695.60,N/A,785.22,N/A,N/A,785.22,17536.86,,Hospital 64581,Open Implantation Nea Sacral Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,79105.20,N/A,47463.12,N/A,11074.73,N/A,633.94,N/A,44760.56,N/A,26895.77,N/A,14448.67,N/A,11074.73,N/A,5963.54,N/A,5963.54,N/A,8994.57,N/A,14448.67,N/A,14448.67,N/A,14448.67,N/A,44760.59,N/A,5963.54,N/A,11074.73,N/A,11660.00,N/A,11660.00,N/A,11074.73,N/A,5963.54,N/A,633.94,N/A,697.33,N/A,N/A,633.94,47463.12,,Hospital 64585,Revj/Rmvl Peripheral Neurostimulator Electrode,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,24439.12,N/A,14663.47,N/A,3410.98,N/A,260.71,N/A,14055.94,N/A,8309.30,N/A,7211.43,N/A,3410.98,N/A,2932.78,N/A,2932.78,N/A,4489.25,N/A,7211.43,N/A,7211.43,N/A,7211.43,N/A,14055.96,N/A,2932.78,N/A,3410.98,N/A,6843.00,N/A,6843.00,N/A,3410.98,N/A,2932.78,N/A,260.71,N/A,286.79,N/A,N/A,260.71,14663.47,,Hospital 64610,"Inject 5th N.-2,3 Div,F.Ovale,Xray",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,78385.97,N/A,47031.58,N/A,10961.52,N/A,5670.87,N/A,45039.37,N/A,26651.22,N/A,4042.64,N/A,10961.52,N/A,5657.93,N/A,5657.93,N/A,2516.63,N/A,4042.64,N/A,4042.64,N/A,4042.64,N/A,45039.36,N/A,5657.93,N/A,10961.52,N/A,9727.25,N/A,9727.25,N/A,10961.52,N/A,5657.93,N/A,5670.87,N/A,1262.15,N/A,N/A,1262.15,47031.58,,Hospital 64620,"Dest,Intercostal,Neurolytic",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,5282.50,N/A,3169.50,N/A,739.55,N/A,804.99,N/A,3041.39,N/A,1796.05,N/A,1864.10,N/A,739.55,N/A,769.55,N/A,769.55,N/A,1160.43,N/A,1864.10,N/A,1864.10,N/A,1864.10,N/A,3041.39,N/A,769.55,N/A,739.55,N/A,1431.00,N/A,1431.00,N/A,739.55,N/A,769.55,N/A,804.99,N/A,209.87,N/A,N/A,209.87,3169.50,,Hospital 64624,Destruction Neurolytic Agt Genicular Nerve W/Img,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10711.80,N/A,6427.08,N/A,1499.65,N/A,1656.99,N/A,6167.52,N/A,3642.01,N/A,3929.53,N/A,1499.65,N/A,1623.23,N/A,1623.23,N/A,2446.21,N/A,3929.53,N/A,3929.53,N/A,3929.53,N/A,6167.53,N/A,1623.23,N/A,1499.65,N/A,3397.00,N/A,3397.00,N/A,1499.65,N/A,1623.23,N/A,1656.99,N/A,167.42,N/A,N/A,167.42,6427.08,,Hospital 64628,Thermal Dstrj Intraosseous Bvn 1st 2 Lmbr/Sac,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,75222.90,N/A,45133.74,N/A,10531.20,N/A,12186.91,N/A,43016.27,N/A,25575.79,N/A,28555.15,N/A,10531.20,N/A,11782.94,N/A,11782.94,N/A,17776.14,N/A,28555.15,N/A,28555.15,N/A,28555.15,N/A,43016.27,N/A,11782.94,N/A,10531.20,N/A,8292.25,N/A,8292.25,N/A,10531.20,N/A,11782.94,N/A,12186.91,N/A,937.79,N/A,N/A,937.79,45133.74,,Hospital 64629,Thermal Dstrj Intraosseous Bvn Ea Addl Lmbr/Sac,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,76298.60,N/A,45779.16,N/A,10681.80,N/A,12186.91,N/A,43638.82,N/A,25941.53,N/A,28512.00,N/A,10681.80,N/A,11782.94,N/A,11782.94,N/A,17749.27,N/A,28512.00,N/A,28512.00,N/A,28512.00,N/A,43638.82,N/A,11782.94,N/A,10681.80,N/A,8160.50,N/A,8160.50,N/A,10681.80,N/A,11782.94,N/A,12186.91,N/A,727.51,N/A,N/A,727.51,45779.16,,Hospital 64632,Destruct by Neuro Agent; Plantar Digital Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14273.97,N/A,8564.38,N/A,1998.36,N/A,252.09,N/A,8181.86,N/A,4853.15,N/A,603.25,N/A,1998.36,N/A,245.53,N/A,245.53,N/A,375.53,N/A,603.25,N/A,603.25,N/A,603.25,N/A,8181.86,N/A,245.53,N/A,1998.36,N/A,527.00,N/A,527.00,N/A,1998.36,N/A,245.53,N/A,252.09,N/A,176.62,N/A,N/A,176.62,8564.38,,Hospital CPT 64633,"HC Rfl,Facet,C/T,Single W/Img",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,5736.00,5736.00,3441.60,3441.60,N/A,803.04,N/A,1726.77,N/A,3302.79,N/A,1950.24,N/A,3926.47,N/A,803.04,N/A,1623.23,N/A,1623.23,N/A,2444.31,N/A,3926.47,N/A,3926.47,N/A,3926.47,N/A,3302.79,N/A,1623.23,N/A,803.04,N/A,3074.50,N/A,3074.50,N/A,803.04,N/A,1623.23,N/A,1726.77,N/A,201.94,3441.60,3441.60,201.94,3926.47,,Hospital CPT 64640,HC Destr Neurolytic Periph Nerve,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,3270.00,3270.00,1962.00,1962.00,N/A,457.80,N/A,818.64,N/A,1882.87,N/A,1111.80,N/A,1861.48,N/A,457.80,N/A,769.55,N/A,769.55,N/A,1158.81,N/A,1861.48,N/A,1861.48,N/A,1861.48,N/A,1882.87,N/A,769.55,N/A,457.80,N/A,1752.72,N/A,1752.72,N/A,457.80,N/A,769.55,N/A,818.64,N/A,124.67,1962.00,1962.00,124.67,1962.00,,Hospital CPT 64642,"HC Dest Botox-1 Extrem, 1-4 Muscl",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,581.86,N/A,884.43,N/A,522.24,N/A,1407.47,N/A,215.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,884.43,N/A,581.86,N/A,215.04,N/A,823.30,N/A,823.30,N/A,215.04,N/A,581.86,N/A,581.86,N/A,640.05,921.60,921.60,215.04,1407.47,,Hospital CPT 64645,"HC Dest Botx-Ea Add Ext,5 or >Mus",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1749.00,1749.00,1049.40,1049.40,N/A,244.86,N/A,1749.00,N/A,1007.07,N/A,594.66,N/A,1749.00,N/A,244.86,N/A,1749.00,N/A,1749.00,N/A,1749.00,N/A,1749.00,N/A,1749.00,N/A,1749.00,N/A,1007.07,N/A,1749.00,N/A,244.86,N/A,937.46,N/A,937.46,N/A,244.86,N/A,1749.00,N/A,1749.00,N/A,1749.00,1049.40,1049.40,244.86,1749.00,,Hospital CPT 64646,HC Dest Botox -Trunk 1-5 Muscle,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1536.00,1536.00,921.60,921.60,N/A,215.04,N/A,581.86,N/A,884.43,N/A,522.24,N/A,1407.47,N/A,215.04,N/A,581.86,N/A,581.86,N/A,876.18,N/A,1407.47,N/A,1407.47,N/A,1407.47,N/A,884.43,N/A,581.86,N/A,215.04,N/A,823.30,N/A,823.30,N/A,215.04,N/A,581.86,N/A,581.86,N/A,640.05,921.60,921.60,215.04,1407.47,,Hospital 64680,HC Injection Treatment of Nerve,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,29893.93,16343.70,17936.36,9806.22,3234.91,2279.26,3960.67,1645.14,7357.66,9409.70,10163.94,5556.86,7358.66,3817.75,3334.59,2279.26,286058.00,1572.73,286058.00,1572.73,4580.60,2376.62,7358.66,3817.75,7358.66,3817.75,7358.66,3817.75,7357.66,9409.70,3901.37,1572.73,3334.59,2279.26,8754.97,2586.50,8754.97,2586.50,2869.94,2279.26,3901.37,1572.73,3960.67,1645.14,3568.01,454.47,2869.94,286058.00,454.47,9806.22,,Hospital CPT 64721,Neuroplasty &/Transpos Median Nrv Carpal Tunne,N/A,N/A,727.00,727.00,436.20,436.20,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,436.20,436.20,436.20,727.00,,Hospital 64722,Relieve Pressure on Nerve(S),N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28028.40,N/A,16817.04,N/A,3923.98,N/A,3027.62,N/A,16137.60,N/A,9529.65,N/A,7020.93,N/A,3923.98,N/A,2894.35,N/A,2894.35,N/A,4370.66,N/A,7020.93,N/A,7020.93,N/A,7020.93,N/A,16137.61,N/A,2894.35,N/A,3923.98,N/A,5227.25,N/A,5227.25,N/A,3923.98,N/A,2894.35,N/A,3027.62,N/A,943.15,N/A,N/A,943.15,16817.04,,Hospital 64727,"Intern Nerve Revis,Oper Microscope",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,28028.40,N/A,16817.04,N/A,3923.98,N/A,3027.62,N/A,16137.60,N/A,9529.65,N/A,7020.93,N/A,3923.98,N/A,2894.35,N/A,2894.35,N/A,4370.66,N/A,7020.93,N/A,7020.93,N/A,7020.93,N/A,16137.61,N/A,2894.35,N/A,3923.98,N/A,5227.25,N/A,5227.25,N/A,3923.98,N/A,2894.35,N/A,3027.62,N/A,943.15,N/A,N/A,943.15,16817.04,,Hospital 64772,Transection/Avulsion Oth Spinal Nrv Xdrl,N/A,0370 - ANESTHESIA - GENERAL CLASSIFICATION,N/A,46959.70,N/A,28175.82,N/A,6574.35,N/A,2811.81,N/A,27035.50,N/A,15966.29,N/A,6564.62,N/A,6574.35,N/A,2688.04,N/A,2688.04,N/A,4086.61,N/A,6564.62,N/A,6564.62,N/A,6564.62,N/A,27035.51,N/A,2688.04,N/A,6574.35,N/A,5277.50,N/A,5277.50,N/A,6574.35,N/A,2688.04,N/A,2811.81,N/A,6463.04,N/A,N/A,2688.04,28175.82,,Hospital 64774,Excise Cutaneous Neuroma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51242.45,N/A,30745.47,N/A,7174.23,N/A,5695.60,N/A,29231.09,N/A,17422.45,N/A,13516.44,N/A,7174.23,N/A,5579.57,N/A,5579.57,N/A,8414.24,N/A,13516.44,N/A,13516.44,N/A,13516.44,N/A,29231.10,N/A,5579.57,N/A,7174.23,N/A,5227.25,N/A,5227.25,N/A,7174.23,N/A,5579.57,N/A,5695.60,N/A,1710.51,N/A,N/A,1710.51,30745.47,,Hospital 64782,Excise Hand/Foot Neuroma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35400.00,N/A,21240.00,N/A,4924.70,N/A,1730.70,N/A,20379.12,N/A,11970.38,N/A,3959.97,N/A,4924.70,N/A,1627.16,N/A,1627.16,N/A,2465.17,N/A,3959.97,N/A,3959.97,N/A,3959.97,N/A,20379.13,N/A,1627.16,N/A,4924.70,N/A,3397.00,N/A,3397.00,N/A,4924.70,N/A,1627.16,N/A,1730.70,N/A,570.58,N/A,N/A,570.58,21240.00,,Hospital 64787,Implant Nerve End to Bone/Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33233.52,N/A,19940.11,N/A,4652.71,N/A,1466.89,N/A,19041.40,N/A,11299.40,N/A,11435.46,N/A,4652.71,N/A,4706.78,N/A,4706.78,N/A,7118.79,N/A,11435.46,N/A,11435.46,N/A,11435.46,N/A,19041.39,N/A,4706.78,N/A,4652.71,N/A,9727.25,N/A,9727.25,N/A,4652.71,N/A,4706.78,N/A,1466.89,N/A,1613.58,N/A,N/A,1466.89,19940.11,,Hospital 64788,Exc Neurofibroma/Neurolemmoma Cutan Nrv,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8172.30,N/A,4903.38,N/A,1144.12,N/A,1609.21,N/A,4703.79,N/A,2778.59,N/A,3946.72,N/A,1144.12,N/A,1623.23,N/A,1623.23,N/A,2456.91,N/A,3946.72,N/A,3946.72,N/A,3946.72,N/A,4703.79,N/A,1623.23,N/A,1144.12,N/A,3397.00,N/A,3397.00,N/A,1144.12,N/A,1623.23,N/A,1609.21,N/A,455.75,N/A,N/A,455.75,4903.38,,Hospital 64790,Excise Major Periph Neurofibroma,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18611.38,N/A,11166.83,N/A,2605.60,N/A,1790.62,N/A,10707.32,N/A,6327.87,N/A,3948.07,N/A,2605.60,N/A,1623.23,N/A,1623.23,N/A,2457.75,N/A,3948.07,N/A,3948.07,N/A,3948.07,N/A,10707.33,N/A,1623.23,N/A,2605.60,N/A,4332.50,N/A,4332.50,N/A,2605.60,N/A,1623.23,N/A,1270.99,N/A,1398.09,N/A,N/A,1270.99,11166.83,,Hospital 64818,"Sympathectomy,Lumbar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25098.12,N/A,15058.87,N/A,3490.01,N/A,847.02,N/A,14443.63,N/A,8487.79,N/A,14301.17,N/A,3490.01,N/A,847.55,N/A,847.55,N/A,8902.20,N/A,14301.17,N/A,14301.17,N/A,14301.17,N/A,14443.62,N/A,847.55,N/A,3490.01,N/A,1643.00,N/A,1643.00,N/A,3490.01,N/A,847.55,N/A,847.02,N/A,876.50,N/A,N/A,847.02,15058.87,,Hospital 64832,Repair Each Addnl Digit Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,38526.55,N/A,23115.93,N/A,5393.73,N/A,2861.72,N/A,22179.27,N/A,13099.05,N/A,6529.94,N/A,5393.73,N/A,2690.13,N/A,2690.13,N/A,4065.02,N/A,6529.94,N/A,6529.94,N/A,6529.94,N/A,22179.27,N/A,2690.13,N/A,5393.73,N/A,7983.50,N/A,7983.50,N/A,5393.73,N/A,2690.13,N/A,2861.72,N/A,3474.59,N/A,N/A,2690.13,23115.93,,Hospital 64857,Repair Major Peripheral Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23005.70,N/A,13803.42,N/A,3220.80,N/A,5836.48,N/A,13244.91,N/A,7821.94,N/A,13551.35,N/A,3220.80,N/A,5579.57,N/A,5579.57,N/A,8435.98,N/A,13551.35,N/A,13551.35,N/A,13551.35,N/A,13244.92,N/A,5579.57,N/A,3220.80,N/A,8244.00,N/A,8244.00,N/A,3220.80,N/A,5579.57,N/A,5836.48,N/A,1487.95,N/A,N/A,1487.95,13803.42,,Hospital 64891,"Nerve Graft,Hand/Foot,One,>4cm",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,122631.57,N/A,73578.94,N/A,17168.41,N/A,9234.84,N/A,69411.99,N/A,41694.72,N/A,13521.88,N/A,17168.41,N/A,9220.34,N/A,9220.34,N/A,8417.63,N/A,13521.88,N/A,13521.88,N/A,13521.88,N/A,69411.99,N/A,9220.34,N/A,17168.41,N/A,7661.50,N/A,7661.50,N/A,17168.41,N/A,9220.34,N/A,9234.84,N/A,1969.13,N/A,N/A,1969.13,73578.94,,Hospital 64892,"Nerve Graft,Arm/Leg,One,Up to 4cm",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,123625.45,N/A,74175.27,N/A,17308.40,N/A,9303.92,N/A,70189.59,N/A,42032.65,N/A,13512.25,N/A,17308.40,N/A,9289.41,N/A,9289.41,N/A,8411.64,N/A,13512.25,N/A,13512.25,N/A,13512.25,N/A,70189.59,N/A,9289.41,N/A,17308.40,N/A,10878.50,N/A,10878.50,N/A,17308.40,N/A,9289.41,N/A,9303.92,N/A,1790.15,N/A,N/A,1790.15,74175.27,,Hospital 64910,Nerve Repair W/Conduit Each Nerve,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,107859.17,N/A,64715.50,N/A,15095.89,N/A,8238.14,N/A,61697.49,N/A,36672.12,N/A,13536.31,N/A,15095.89,N/A,8193.66,N/A,8193.66,N/A,8426.61,N/A,13536.31,N/A,13536.31,N/A,13536.31,N/A,61697.50,N/A,8193.66,N/A,15095.89,N/A,6898.50,N/A,6898.50,N/A,15095.89,N/A,8193.66,N/A,8238.14,N/A,913.38,N/A,N/A,913.38,64715.50,,Hospital 64912,Nerve Repair W/Nerve Allograft First Strand,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,99767.72,N/A,59860.63,N/A,13967.49,N/A,842.46,N/A,56347.63,N/A,33921.03,N/A,13629.00,N/A,13967.49,N/A,5579.57,N/A,5579.57,N/A,8484.32,N/A,13629.00,N/A,13629.00,N/A,13629.00,N/A,56347.65,N/A,5579.57,N/A,13967.49,N/A,5963.00,N/A,5963.00,N/A,13967.49,N/A,5579.57,N/A,842.46,N/A,926.71,N/A,N/A,842.46,59860.63,,Hospital CPT 64999,"HC Unlisted Procedure, Nervous System",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,968.00,968.00,580.80,580.80,N/A,135.52,N/A,252.09,N/A,557.37,N/A,329.12,N/A,593.92,N/A,135.52,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,557.37,N/A,245.53,N/A,135.52,N/A,527.00,N/A,527.00,N/A,135.52,N/A,245.53,N/A,250.63,N/A,968.00,580.80,580.80,135.52,968.00,,Hospital CPT 64999,"HC Unlisted Procedure, Nervous System",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,968.00,968.00,580.80,580.80,N/A,135.52,N/A,252.09,N/A,557.37,N/A,329.12,N/A,593.92,N/A,135.52,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,557.37,N/A,245.53,N/A,135.52,N/A,518.85,N/A,518.85,N/A,135.52,N/A,245.53,N/A,250.63,N/A,968.00,580.80,580.80,135.52,968.00,,Hospital CPT 64999,HC Unlisted Procedure Nervous System,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,968.00,968.00,580.80,580.80,N/A,135.52,N/A,252.09,N/A,557.37,N/A,329.12,N/A,593.92,N/A,135.52,N/A,245.53,N/A,245.53,N/A,369.73,N/A,593.92,N/A,593.92,N/A,593.92,N/A,557.37,N/A,245.53,N/A,135.52,N/A,968.00,N/A,968.00,N/A,135.52,N/A,245.53,N/A,250.63,N/A,968.00,580.80,580.80,135.52,968.00,,Hospital 65105,Remove Eye W Musc to Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50542.30,N/A,30325.38,N/A,7065.41,N/A,1794.71,N/A,29033.26,N/A,17184.39,N/A,7783.91,N/A,7065.41,N/A,3156.58,N/A,3156.58,N/A,4845.63,N/A,7783.91,N/A,7783.91,N/A,7783.91,N/A,29033.26,N/A,3156.58,N/A,7065.41,N/A,4562.00,N/A,4562.00,N/A,7065.41,N/A,3156.58,N/A,1794.71,N/A,1233.68,N/A,N/A,1233.68,30325.38,,Hospital 65150,Reinsert Ocular Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7226.60,N/A,4335.96,N/A,1011.72,N/A,3140.43,N/A,4147.83,N/A,2457.04,N/A,7226.60,N/A,1011.72,N/A,3156.58,N/A,3156.58,N/A,5414.83,N/A,7226.60,N/A,7226.60,N/A,7226.60,N/A,4147.83,N/A,3156.58,N/A,1011.72,N/A,4562.00,N/A,4562.00,N/A,1011.72,N/A,3156.58,N/A,3140.43,N/A,723.97,N/A,N/A,723.97,7226.60,,Hospital 65155,"Reinsert Ocular Implant,Reinforcemt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17401.62,N/A,10440.97,N/A,2436.23,N/A,3129.31,N/A,10018.83,N/A,5916.55,N/A,7645.85,N/A,2436.23,N/A,3156.58,N/A,3156.58,N/A,4759.70,N/A,7645.85,N/A,7645.85,N/A,7645.85,N/A,10018.83,N/A,3156.58,N/A,2436.23,N/A,4562.00,N/A,4562.00,N/A,2436.23,N/A,3156.58,N/A,3129.31,N/A,994.90,N/A,N/A,994.90,10440.97,,Hospital CPT 65205,HC Rmvl FB Conjunctival Sprfcl,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,490.00,490.00,294.00,294.00,N/A,68.60,N/A,27.73,N/A,282.14,N/A,166.60,N/A,82.65,N/A,68.60,N/A,27.73,N/A,27.73,N/A,51.45,N/A,82.65,N/A,82.65,N/A,82.65,N/A,282.14,N/A,27.73,N/A,68.60,N/A,490.00,N/A,490.00,N/A,68.60,N/A,27.73,N/A,27.73,N/A,30.50,294.00,294.00,27.73,490.00,,Hospital CPT 65210,HC Rmvl FB Conjunctiv Embedded,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,490.00,490.00,294.00,294.00,N/A,68.60,N/A,34.28,N/A,282.14,N/A,166.60,N/A,109.05,N/A,68.60,N/A,34.28,N/A,34.28,N/A,67.88,N/A,109.05,N/A,109.05,N/A,109.05,N/A,282.14,N/A,34.28,N/A,68.60,N/A,490.00,N/A,490.00,N/A,68.60,N/A,34.28,N/A,34.28,N/A,37.71,294.00,294.00,34.28,490.00,,Hospital CPT 65222,HC Rmvl FB Corneal W Slit Lamp,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,697.00,697.00,418.20,418.20,N/A,97.58,N/A,47.64,N/A,401.33,N/A,236.98,N/A,188.34,N/A,97.58,N/A,47.64,N/A,47.64,N/A,117.24,N/A,188.34,N/A,188.34,N/A,188.34,N/A,401.33,N/A,47.64,N/A,97.58,N/A,697.00,N/A,697.00,N/A,97.58,N/A,47.64,N/A,47.64,N/A,52.40,418.20,418.20,47.64,697.00,,Hospital CPT 65235,"Removal,FB,Intraocular,Ant Chamber/Lens",N/A,N/A,1382.00,1382.00,829.20,829.20,N/A,193.48,N/A,678.88,N/A,1382.00,N/A,469.88,N/A,1382.00,N/A,193.48,N/A,678.88,N/A,678.88,N/A,1263.96,N/A,1382.00,N/A,1382.00,N/A,1382.00,N/A,1382.00,N/A,678.88,N/A,193.48,N/A,1382.00,N/A,1382.00,N/A,193.48,N/A,678.88,N/A,678.88,N/A,746.77,829.20,829.20,193.48,1382.00,,Hospital CPT 65235,"HC Removal,FB,Intraocular,Ant Chamber/Lens",N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5731.00,5731.00,3438.60,3438.60,N/A,802.34,N/A,678.88,N/A,3299.91,N/A,1948.54,N/A,2030.46,N/A,802.34,N/A,678.88,N/A,678.88,N/A,1263.96,N/A,2030.46,N/A,2030.46,N/A,2030.46,N/A,3299.91,N/A,678.88,N/A,802.34,N/A,5731.00,N/A,5731.00,N/A,802.34,N/A,678.88,N/A,678.88,N/A,746.77,3438.60,3438.60,678.88,5731.00,,Hospital 65265,"Remv F.B.,Eye,Post Sgmt,Nonmagnetic",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,51294.35,N/A,30776.61,N/A,7181.20,N/A,2703.20,N/A,29508.90,N/A,16560.05,N/A,8763.67,N/A,7181.20,N/A,3608.17,N/A,3608.17,N/A,5455.56,N/A,8763.67,N/A,8763.67,N/A,8763.67,N/A,29508.94,N/A,3608.17,N/A,7181.20,N/A,8510.75,N/A,8510.75,N/A,7181.20,N/A,3608.17,N/A,2703.20,N/A,2835.92,N/A,N/A,2703.20,30776.61,,Hospital 65710,"Corneal Transplant,Lamellar",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37753.03,N/A,22651.82,N/A,5282.13,N/A,3577.00,N/A,21728.63,N/A,12836.03,N/A,11100.13,N/A,5282.13,N/A,3608.17,N/A,3608.17,N/A,6907.48,N/A,11100.13,N/A,11100.13,N/A,11100.13,N/A,21728.61,N/A,3608.17,N/A,5282.13,N/A,7661.50,N/A,7661.50,N/A,5282.13,N/A,3608.17,N/A,3577.00,N/A,1979.53,N/A,N/A,1979.53,22651.82,,Hospital 65730,"Corneal Transplant,Penetrating",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,50939.93,N/A,30563.96,N/A,7125.94,N/A,2344.42,N/A,29324.40,N/A,17319.60,N/A,9326.40,N/A,7125.94,N/A,3608.17,N/A,3608.17,N/A,5805.26,N/A,9326.40,N/A,9326.40,N/A,9326.40,N/A,29324.41,N/A,3608.17,N/A,7125.94,N/A,8510.75,N/A,8510.75,N/A,7125.94,N/A,3608.17,N/A,2344.42,N/A,2578.86,N/A,N/A,2344.42,30563.96,,Hospital 65750,"Corneal Transplant,Penetrat,Aphakia",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,66442.90,N/A,39865.74,N/A,9296.26,N/A,1180.78,N/A,37919.19,N/A,22590.59,N/A,9306.97,N/A,9296.26,N/A,3608.17,N/A,3608.17,N/A,5793.17,N/A,9306.97,N/A,9306.97,N/A,9306.97,N/A,37919.19,N/A,3608.17,N/A,9296.26,N/A,5963.00,N/A,5963.00,N/A,9296.26,N/A,3608.17,N/A,1180.78,N/A,1298.86,N/A,N/A,1180.78,39865.74,,Hospital CPT 65782,"Ocular Reconst, Transplant",N/A,N/A,2247.00,2247.00,1348.20,1348.20,N/A,314.58,N/A,1064.85,N/A,2247.00,N/A,763.98,N/A,2247.00,N/A,314.58,N/A,1064.85,N/A,1064.85,N/A,1982.31,N/A,2247.00,N/A,2247.00,N/A,2247.00,N/A,2247.00,N/A,1064.85,N/A,314.58,N/A,2247.00,N/A,2247.00,N/A,314.58,N/A,1064.85,N/A,1064.85,N/A,1171.34,1348.20,1348.20,314.58,2247.00,,Hospital CPT 65820,Goniotomy,N/A,N/A,1453.00,1453.00,871.80,871.80,N/A,203.42,N/A,767.77,N/A,1453.00,N/A,494.02,N/A,1453.00,N/A,203.42,N/A,767.77,N/A,767.77,N/A,1420.07,N/A,1453.00,N/A,1453.00,N/A,1453.00,N/A,1453.00,N/A,767.77,N/A,203.42,N/A,1453.00,N/A,1453.00,N/A,203.42,N/A,767.77,N/A,767.77,N/A,844.55,871.80,871.80,203.42,1453.00,,Hospital 65850,Incision of Eye,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,26198.98,N/A,15719.39,N/A,3667.87,N/A,2039.85,N/A,14967.04,N/A,8907.67,N/A,4787.84,N/A,3667.87,N/A,1950.06,N/A,1950.06,N/A,2980.52,N/A,4787.84,N/A,4787.84,N/A,4787.84,N/A,14967.05,N/A,1950.06,N/A,3667.87,N/A,5095.50,N/A,5095.50,N/A,3667.87,N/A,1950.06,N/A,2039.85,N/A,1422.28,N/A,N/A,1422.28,15719.39,,Hospital 65855,Trabeculoplasty by Laser Surgery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,4886.73,N/A,2932.04,N/A,684.15,N/A,528.73,N/A,2813.78,N/A,1661.49,N/A,1159.41,N/A,684.15,N/A,479.31,N/A,479.31,N/A,721.75,N/A,1159.41,N/A,1159.41,N/A,1159.41,N/A,2813.78,N/A,479.31,N/A,684.15,N/A,1431.00,N/A,1431.00,N/A,684.15,N/A,479.31,N/A,191.90,N/A,211.09,N/A,N/A,191.90,2932.04,,Hospital 65865,"Incise Inner Eye Adhesns,Incisn",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7550.80,N/A,4530.48,N/A,1057.11,N/A,1940.08,N/A,4347.38,N/A,2567.27,N/A,4720.09,N/A,1057.11,N/A,1950.06,N/A,1950.06,N/A,2938.34,N/A,4720.09,N/A,4720.09,N/A,4720.09,N/A,4347.38,N/A,1950.06,N/A,1057.11,N/A,3397.00,N/A,3397.00,N/A,1057.11,N/A,1950.06,N/A,1940.08,N/A,487.56,N/A,N/A,487.56,4720.09,,Hospital 65870,"Incise Ant Synechiae,Eye",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18872.77,N/A,11323.66,N/A,2642.18,N/A,2039.85,N/A,10857.99,N/A,6416.74,N/A,4733.17,N/A,2642.18,N/A,1950.06,N/A,1950.06,N/A,2946.49,N/A,4733.17,N/A,4733.17,N/A,4733.17,N/A,10857.99,N/A,1950.06,N/A,2642.18,N/A,5095.50,N/A,5095.50,N/A,2642.18,N/A,1950.06,N/A,2039.85,N/A,1164.00,N/A,N/A,1164.00,11323.66,,Hospital 65875,Severing Ads Ant Seg Incal Spx Post Synechiae,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17169.30,N/A,10301.58,N/A,2403.72,N/A,3589.71,N/A,9884.02,N/A,5837.56,N/A,8745.60,N/A,2403.72,N/A,3608.17,N/A,3608.17,N/A,5444.30,N/A,8745.60,N/A,8745.60,N/A,8745.60,N/A,9884.05,N/A,3608.17,N/A,2403.72,N/A,7793.25,N/A,7793.25,N/A,2403.72,N/A,3608.17,N/A,3589.71,N/A,2045.02,N/A,N/A,2045.02,10301.58,,Hospital 66160,"Glaucoma Surg,Sclerect,Punch/Sciss",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,96746.55,N/A,58047.93,N/A,13529.46,N/A,2021.36,N/A,55694.36,N/A,32893.82,N/A,17201.00,N/A,13529.46,N/A,3608.17,N/A,3608.17,N/A,10698.79,N/A,17201.00,N/A,17201.00,N/A,17201.00,N/A,55694.36,N/A,3608.17,N/A,13529.46,N/A,7661.50,N/A,7661.50,N/A,13529.46,N/A,3608.17,N/A,2021.36,N/A,2223.51,N/A,N/A,2021.36,58047.93,,Hospital 66179,Aqueous Shunt Extraocular Reservoir W/O Graft,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22424.98,N/A,13454.99,N/A,3139.49,N/A,3774.30,N/A,12788.73,N/A,7624.49,N/A,8731.84,N/A,3139.49,N/A,3608.17,N/A,3608.17,N/A,5435.74,N/A,8731.84,N/A,8731.84,N/A,8731.84,N/A,12788.73,N/A,3608.17,N/A,3139.49,N/A,5963.00,N/A,5963.00,N/A,3139.49,N/A,3608.17,N/A,3774.30,N/A,1103.51,N/A,N/A,1103.51,13454.99,,Hospital 66250,Revis/Repair OP Wound Anter Sgmt,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10078.40,N/A,6047.04,N/A,1410.98,N/A,1997.13,N/A,5800.31,N/A,3426.66,N/A,4695.83,N/A,1410.98,N/A,1909.23,N/A,1909.23,N/A,2923.25,N/A,4695.83,N/A,4695.83,N/A,4695.83,N/A,5800.32,N/A,1909.23,N/A,1410.98,N/A,3397.00,N/A,3397.00,N/A,1410.98,N/A,1909.23,N/A,1997.13,N/A,567.11,N/A,N/A,567.11,6047.04,,Hospital 66500,Incision of Iris,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22413.25,N/A,13447.95,N/A,3137.85,N/A,3577.00,N/A,12903.96,N/A,7620.50,N/A,8746.66,N/A,3137.85,N/A,3608.17,N/A,3608.17,N/A,5444.97,N/A,8746.66,N/A,8746.66,N/A,8746.66,N/A,12903.96,N/A,3608.17,N/A,3137.85,N/A,3660.50,N/A,3660.50,N/A,3137.85,N/A,3608.17,N/A,3577.00,N/A,1280.20,N/A,N/A,1280.20,13447.95,,Hospital 66682,Suture Iris/Ciliary Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45040.37,N/A,27024.22,N/A,6305.65,N/A,2354.77,N/A,25914.83,N/A,15313.71,N/A,8750.04,N/A,6305.65,N/A,3608.17,N/A,3608.17,N/A,5447.08,N/A,8750.04,N/A,8750.04,N/A,8750.04,N/A,25914.85,N/A,3608.17,N/A,6305.65,N/A,8510.75,N/A,8510.75,N/A,6305.65,N/A,3608.17,N/A,2354.77,N/A,2452.63,N/A,N/A,2354.77,27024.22,,Hospital 66710,"Destruc,Ciliary Body,Cyclophotocoag",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,6194.98,N/A,3716.99,N/A,867.30,N/A,1997.13,N/A,3564.27,N/A,2106.30,N/A,4693.92,N/A,867.30,N/A,1909.23,N/A,1909.23,N/A,2922.04,N/A,4693.92,N/A,4693.92,N/A,4693.92,N/A,3564.28,N/A,1909.23,N/A,867.30,N/A,3397.00,N/A,3397.00,N/A,867.30,N/A,1909.23,N/A,1997.13,N/A,399.80,N/A,N/A,399.80,4693.92,,Hospital 66711,Ecp Ciliary Body Dstrj W/O Rmvl Crystalline Lens,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,16527.00,N/A,9916.20,N/A,2313.79,N/A,2039.85,N/A,9513.24,N/A,5619.18,N/A,5008.37,N/A,2313.79,N/A,1950.06,N/A,1950.06,N/A,3117.58,N/A,5008.37,N/A,5008.37,N/A,5008.37,N/A,9513.25,N/A,1950.06,N/A,2313.79,N/A,5095.50,N/A,5095.50,N/A,2313.79,N/A,1950.06,N/A,2039.85,N/A,1378.50,N/A,N/A,1378.50,9916.20,,Hospital CPT 66761,Iridotomy/Irridectomy Laser Surg per Session,N/A,N/A,499.00,499.00,299.40,299.40,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,299.40,299.40,299.40,499.00,,Hospital 66770,Resec Cyst/Lesn Iris/Ciliary Body,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,35732.52,N/A,21439.51,N/A,4987.22,N/A,453.46,N/A,20565.37,N/A,10919.67,N/A,1210.70,N/A,4987.22,N/A,479.31,N/A,479.31,N/A,753.67,N/A,1210.70,N/A,1210.70,N/A,1210.70,N/A,20565.36,N/A,479.31,N/A,4987.22,N/A,1431.00,N/A,1431.00,N/A,4987.22,N/A,479.31,N/A,453.46,N/A,498.81,N/A,N/A,453.46,21439.51,,Hospital 66850,Rmvl Lens Material Phacofragmentation Aspir,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,45040.37,N/A,27024.22,N/A,6305.65,N/A,2354.77,N/A,25914.83,N/A,15313.71,N/A,8750.04,N/A,6305.65,N/A,3608.17,N/A,3608.17,N/A,5447.08,N/A,8750.04,N/A,8750.04,N/A,8750.04,N/A,25914.85,N/A,3608.17,N/A,6305.65,N/A,8510.75,N/A,8510.75,N/A,6305.65,N/A,3608.17,N/A,2354.77,N/A,2452.63,N/A,N/A,2354.77,27024.22,,Hospital 66940,"Extract Lens,Extracapsular",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,2768.07,N/A,1660.84,N/A,387.53,N/A,2151.15,N/A,1593.85,N/A,941.14,N/A,2768.07,N/A,387.53,N/A,1950.06,N/A,1950.06,N/A,2768.07,N/A,2768.07,N/A,2768.07,N/A,2768.07,N/A,1593.85,N/A,1950.06,N/A,387.53,N/A,1871.00,N/A,1871.00,N/A,387.53,N/A,1950.06,N/A,728.82,N/A,801.70,N/A,N/A,387.53,2768.07,,Hospital 66983,"Remv Cataract Intracap,Insert Lens",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,53921.35,N/A,32352.81,N/A,7549.00,N/A,958.50,N/A,30921.13,N/A,18333.27,N/A,8790.55,N/A,7549.00,N/A,3608.17,N/A,3608.17,N/A,5472.30,N/A,8790.55,N/A,8790.55,N/A,8790.55,N/A,30921.14,N/A,3608.17,N/A,7549.00,N/A,7661.50,N/A,7661.50,N/A,7549.00,N/A,3608.17,N/A,958.50,N/A,916.74,N/A,N/A,916.74,32352.81,,Hospital CPT 66984,Xcapsl Ctrc Rmvl Insj Io Lens Prosth W/O Ecp,N/A,N/A,1249.00,1249.00,749.40,749.40,N/A,174.86,N/A,505.85,N/A,1249.00,N/A,424.66,N/A,1249.00,N/A,174.86,N/A,505.85,N/A,505.85,N/A,942.38,N/A,1249.00,N/A,1249.00,N/A,1249.00,N/A,1249.00,N/A,505.85,N/A,174.86,N/A,1249.00,N/A,1249.00,N/A,174.86,N/A,505.85,N/A,505.85,N/A,556.44,749.40,749.40,174.86,1249.00,,Hospital CPT 66985,Insert Lens Prosthesis Only,N/A,N/A,1501.00,1501.00,900.60,900.60,N/A,210.14,N/A,713.85,N/A,1501.00,N/A,510.34,N/A,1501.00,N/A,210.14,N/A,713.85,N/A,713.85,N/A,1329.21,N/A,1501.00,N/A,1501.00,N/A,1501.00,N/A,1501.00,N/A,713.85,N/A,210.14,N/A,1501.00,N/A,1501.00,N/A,210.14,N/A,713.85,N/A,713.85,N/A,785.24,900.60,900.60,210.14,1501.00,,Hospital 66991,Xcapsl Ctrc Rmvl Insj Io Lens Prosth Insj 1+,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22578.02,N/A,13546.81,N/A,3160.92,N/A,3818.73,N/A,12795.90,N/A,7676.53,N/A,4253.56,N/A,3160.92,N/A,3838.37,N/A,3838.37,N/A,4252.40,N/A,4253.56,N/A,4253.56,N/A,4253.56,N/A,12795.90,N/A,3838.37,N/A,3160.92,N/A,5963.00,N/A,5963.00,N/A,3160.92,N/A,3838.37,N/A,3818.73,N/A,698.27,N/A,N/A,698.27,13546.81,,Hospital 66999,Eye Surg Ant Sgmt Proc Unlisted,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18371.83,N/A,11023.10,N/A,2571.15,N/A,487.12,N/A,10576.45,N/A,6246.42,N/A,4726.30,N/A,2571.15,N/A,1950.06,N/A,1950.06,N/A,2942.21,N/A,4726.30,N/A,4726.30,N/A,4726.30,N/A,10576.44,N/A,1950.06,N/A,2571.15,N/A,4332.50,N/A,4332.50,N/A,2571.15,N/A,1950.06,N/A,487.12,N/A,535.83,N/A,N/A,487.12,11023.10,,Hospital 67010,"Subtot Remv Vitreous,Mech Virectomy",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,22342.02,N/A,13405.21,N/A,3126.98,N/A,507.23,N/A,12862.64,N/A,7596.28,N/A,4727.46,N/A,3126.98,N/A,1950.06,N/A,1950.06,N/A,2942.94,N/A,4727.46,N/A,4727.46,N/A,4727.46,N/A,12862.64,N/A,1950.06,N/A,3126.98,N/A,3397.00,N/A,3397.00,N/A,3126.98,N/A,1950.06,N/A,507.23,N/A,557.96,N/A,N/A,507.23,13405.21,,Hospital 67015,"Releas Vitreous,Subret/Choroid Fluid",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32242.20,N/A,19345.32,N/A,4508.17,N/A,1397.81,N/A,18468.78,N/A,10962.35,N/A,8752.99,N/A,4508.17,N/A,3608.17,N/A,3608.17,N/A,5448.92,N/A,8752.99,N/A,8752.99,N/A,8752.99,N/A,18468.78,N/A,3608.17,N/A,4508.17,N/A,7661.50,N/A,7661.50,N/A,4508.17,N/A,3608.17,N/A,1397.81,N/A,1537.59,N/A,N/A,1397.81,19345.32,,Hospital CPT 67036,Vitrectomy Mechanical Pars Plana,N/A,N/A,1760.00,1760.00,1056.00,1056.00,N/A,246.40,N/A,833.40,N/A,1760.00,N/A,598.40,N/A,1760.00,N/A,246.40,N/A,833.40,N/A,833.40,N/A,1550.32,N/A,1760.00,N/A,1760.00,N/A,1760.00,N/A,1760.00,N/A,833.40,N/A,246.40,N/A,1760.00,N/A,1760.00,N/A,246.40,N/A,833.40,N/A,833.40,N/A,916.74,1056.00,1056.00,246.40,1760.00,,Hospital CPT 67042,Vitrectomy Pars Plana Remove Int Memb Retina,N/A,N/A,2517.00,2517.00,1510.20,1510.20,N/A,352.38,N/A,1065.50,N/A,2517.00,N/A,855.78,N/A,2517.00,N/A,352.38,N/A,1065.50,N/A,1065.50,N/A,1982.89,N/A,2517.00,N/A,2517.00,N/A,2517.00,N/A,2517.00,N/A,1065.50,N/A,352.38,N/A,2517.00,N/A,2517.00,N/A,352.38,N/A,1065.50,N/A,1065.50,N/A,1172.05,1510.20,1510.20,352.38,2517.00,,Hospital CPT 67043,Vitrectomy Pars Plana Remove Subretinal Membrane,N/A,N/A,2698.00,2698.00,1618.80,1618.80,N/A,377.72,N/A,1124.38,N/A,2698.00,N/A,917.32,N/A,2698.00,N/A,377.72,N/A,1124.38,N/A,1124.38,N/A,2091.49,N/A,2698.00,N/A,2698.00,N/A,2698.00,N/A,2698.00,N/A,1124.38,N/A,377.72,N/A,2698.00,N/A,2698.00,N/A,377.72,N/A,1124.38,N/A,1124.38,N/A,1236.82,1618.80,1618.80,377.72,2698.00,,Hospital 67101,Rpr Retinal Dtchmnt Drg Subretinal Fluid Crtx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,61092.77,N/A,36655.66,N/A,8552.97,N/A,3838.31,N/A,35167.08,N/A,20771.53,N/A,8800.59,N/A,8552.97,N/A,3608.17,N/A,3608.17,N/A,5478.53,N/A,8800.59,N/A,8800.59,N/A,8800.59,N/A,35167.09,N/A,3608.17,N/A,8552.97,N/A,7661.50,N/A,7661.50,N/A,8552.97,N/A,3608.17,N/A,3838.31,N/A,1275.44,N/A,N/A,1275.44,36655.66,,Hospital 67110,"Repair Detacd Retina,Inject Air/Gas",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32015.25,N/A,19209.15,N/A,4476.46,N/A,1887.49,N/A,18423.84,N/A,10885.18,N/A,8768.86,N/A,4476.46,N/A,3608.17,N/A,3608.17,N/A,5458.79,N/A,8768.86,N/A,8768.86,N/A,8768.86,N/A,18423.85,N/A,3608.17,N/A,4476.46,N/A,7793.25,N/A,7793.25,N/A,4476.46,N/A,3608.17,N/A,1887.49,N/A,2076.25,N/A,N/A,1887.49,19209.15,,Hospital 67120,Rmvl Implnt Matl Posterior Segment Extraocular,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21400.10,N/A,12840.06,N/A,2951.02,N/A,2082.30,N/A,12319.15,N/A,7276.04,N/A,4746.76,N/A,2951.02,N/A,1957.92,N/A,1957.92,N/A,2954.94,N/A,4746.76,N/A,4746.76,N/A,4746.76,N/A,12319.15,N/A,1957.92,N/A,2951.02,N/A,3397.00,N/A,3397.00,N/A,2951.02,N/A,1957.92,N/A,2082.30,N/A,608.99,N/A,N/A,608.99,12840.06,,Hospital 67121,Rmvl Implt Matrl Posterior Segment Intraocular,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,11213.10,N/A,6727.86,N/A,1569.84,N/A,3589.71,N/A,6455.39,N/A,3812.46,N/A,8750.72,N/A,1569.84,N/A,3608.17,N/A,3608.17,N/A,5447.49,N/A,8750.72,N/A,8750.72,N/A,8750.72,N/A,6455.41,N/A,3608.17,N/A,1569.84,N/A,9093.25,N/A,9093.25,N/A,1569.84,N/A,3608.17,N/A,3589.71,N/A,2649.12,N/A,N/A,1569.84,9093.25,,Hospital 67210,Dstrj Loclzd Lesion Retina 1/> Sess Pc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,3527.33,N/A,2116.40,N/A,493.83,N/A,528.73,N/A,2031.04,N/A,1199.30,N/A,1159.41,N/A,493.83,N/A,479.31,N/A,479.31,N/A,721.75,N/A,1159.41,N/A,1159.41,N/A,1159.41,N/A,2031.05,N/A,479.31,N/A,493.83,N/A,1431.00,N/A,1431.00,N/A,493.83,N/A,479.31,N/A,461.45,N/A,507.60,N/A,N/A,461.45,2116.40,,Hospital 67220,"Dest,Choroid Lesion,Photocoag",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,72389.20,N/A,43433.52,N/A,10102.87,N/A,3842.24,N/A,41678.59,N/A,24612.33,N/A,8755.18,N/A,10102.87,N/A,3612.10,N/A,3612.10,N/A,5450.27,N/A,8755.18,N/A,8755.18,N/A,8755.18,N/A,41678.59,N/A,3612.10,N/A,10102.87,N/A,6678.50,N/A,6678.50,N/A,10102.87,N/A,3612.10,N/A,3842.24,N/A,1780.60,N/A,N/A,1780.60,43433.52,,Hospital 67227,Destruction Retinopathy Cryotherapy Diathermy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27745.52,N/A,16647.31,N/A,3849.30,N/A,1317.05,N/A,15973.83,N/A,9433.47,N/A,8730.91,N/A,3849.30,N/A,3608.17,N/A,3608.17,N/A,5435.16,N/A,8730.91,N/A,8730.91,N/A,8730.91,N/A,15973.84,N/A,3608.17,N/A,3849.30,N/A,8244.00,N/A,8244.00,N/A,3849.30,N/A,3608.17,N/A,1317.05,N/A,1448.76,N/A,N/A,1317.05,16647.31,,Hospital 67318,"Strabismus Surg,Super-Obliq Musc",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36468.60,N/A,21881.16,N/A,5105.61,N/A,3301.92,N/A,20996.63,N/A,12399.35,N/A,7681.31,N/A,5105.61,N/A,3156.58,N/A,3156.58,N/A,4781.76,N/A,7681.31,N/A,7681.31,N/A,7681.31,N/A,20996.63,N/A,3156.58,N/A,5105.61,N/A,7109.75,N/A,7109.75,N/A,5105.61,N/A,3156.58,N/A,3301.92,N/A,1982.25,N/A,N/A,1982.25,21881.16,,Hospital 67320,Transposition Procedure Extraocular Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,32197.35,N/A,19318.41,N/A,4501.95,N/A,1192.85,N/A,18526.84,N/A,10947.08,N/A,4692.20,N/A,4501.95,N/A,1909.23,N/A,1909.23,N/A,2920.98,N/A,4692.20,N/A,4692.20,N/A,4692.20,N/A,17570.76,N/A,1909.23,N/A,4501.95,N/A,5227.25,N/A,5227.25,N/A,4501.95,N/A,1909.23,N/A,1192.85,N/A,1312.14,N/A,N/A,1192.85,19318.41,,Hospital 67331,Strabismus Previous Eye X Involve Eo Musc,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18267.48,N/A,10960.49,N/A,2541.84,N/A,2106.10,N/A,10512.34,N/A,6210.95,N/A,4636.03,N/A,2541.84,N/A,1909.23,N/A,1909.23,N/A,2886.02,N/A,4636.03,N/A,4636.03,N/A,4636.03,N/A,10512.35,N/A,1909.23,N/A,2541.84,N/A,3660.50,N/A,3660.50,N/A,2541.84,N/A,1909.23,N/A,675.20,N/A,742.72,N/A,N/A,675.20,10960.49,,Hospital CPT 67332,Strabismus Scarring Eo Musc/Rstcv Myopathy,N/A,N/A,658.00,658.00,394.80,394.80,N/A,92.12,N/A,244.36,N/A,658.00,N/A,223.72,N/A,591.81,N/A,92.12,N/A,244.36,N/A,244.36,N/A,368.40,N/A,591.81,N/A,591.81,N/A,591.81,N/A,658.00,N/A,244.36,N/A,92.12,N/A,658.00,N/A,658.00,N/A,92.12,N/A,244.36,N/A,244.36,N/A,268.80,394.80,394.80,92.12,658.00,,Hospital 67399,Unlisted Procedure Extraocular Muscle,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8210.30,N/A,4926.18,N/A,1151.52,N/A,1899.46,N/A,4726.58,N/A,2791.50,N/A,4626.24,N/A,1151.52,N/A,1909.23,N/A,1909.23,N/A,2879.92,N/A,4626.24,N/A,4626.24,N/A,4626.24,N/A,4726.58,N/A,1909.23,N/A,1151.52,N/A,3660.50,N/A,3660.50,N/A,1151.52,N/A,1909.23,N/A,1899.46,N/A,472.04,N/A,N/A,472.04,4926.18,,Hospital 67413,"Explore Eye Socket,Remv F.B.",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7309.20,N/A,4385.52,N/A,1023.28,N/A,1997.13,N/A,4208.23,N/A,2485.12,N/A,4625.23,N/A,1023.28,N/A,1909.23,N/A,1909.23,N/A,2879.29,N/A,4625.23,N/A,4625.23,N/A,4625.23,N/A,4208.24,N/A,1909.23,N/A,1023.28,N/A,3397.00,N/A,3397.00,N/A,1023.28,N/A,1909.23,N/A,1997.13,N/A,996.39,N/A,N/A,996.39,4625.23,,Hospital 67550,Insert Eye Socket Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14481.10,N/A,8688.66,N/A,2027.36,N/A,3301.92,N/A,8337.42,N/A,4923.57,N/A,7648.75,N/A,2027.36,N/A,3156.58,N/A,3156.58,N/A,4761.49,N/A,7648.75,N/A,7648.75,N/A,7648.75,N/A,8337.42,N/A,3156.58,N/A,2027.36,N/A,7109.75,N/A,7109.75,N/A,2027.36,N/A,3156.58,N/A,3301.92,N/A,2162.25,N/A,N/A,2027.36,8688.66,,Hospital 67560,Revise Eye Socket Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17937.10,N/A,10762.26,N/A,2511.19,N/A,3301.92,N/A,10324.62,N/A,6098.61,N/A,7651.44,N/A,2511.19,N/A,3156.58,N/A,3156.58,N/A,4763.17,N/A,7651.44,N/A,7651.44,N/A,7651.44,N/A,10324.61,N/A,3156.58,N/A,2511.19,N/A,6843.00,N/A,6843.00,N/A,2511.19,N/A,3156.58,N/A,3301.92,N/A,1642.92,N/A,N/A,1642.92,10762.26,,Hospital 67599,Orbit Surgery Proc Unlisted,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18106.10,N/A,10863.66,N/A,2534.85,N/A,2039.85,N/A,10398.95,N/A,6156.07,N/A,4723.74,N/A,2534.85,N/A,1950.06,N/A,1950.06,N/A,2940.62,N/A,4723.74,N/A,4723.74,N/A,4723.74,N/A,10398.94,N/A,1950.06,N/A,2534.85,N/A,3660.50,N/A,3660.50,N/A,2534.85,N/A,1950.06,N/A,2039.85,N/A,556.44,N/A,N/A,556.44,10863.66,,Hospital CPT 67715,HC Canthotomy Separate Procedure,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5520.00,5520.00,3312.00,3312.00,N/A,772.80,N/A,99.94,N/A,3178.42,N/A,1876.80,N/A,721.92,N/A,772.80,N/A,99.94,N/A,99.94,N/A,449.40,N/A,721.92,N/A,721.92,N/A,721.92,N/A,3178.42,N/A,99.94,N/A,772.80,N/A,5520.00,N/A,5520.00,N/A,772.80,N/A,99.94,N/A,99.94,N/A,109.93,3312.00,3312.00,99.94,5520.00,,Hospital CPT 67800,Excision Chalazion Single,N/A,N/A,215.00,215.00,129.00,129.00,N/A,30.10,N/A,95.25,N/A,215.00,N/A,73.10,N/A,215.00,N/A,30.10,N/A,95.25,N/A,95.25,N/A,215.00,N/A,215.00,N/A,215.00,N/A,215.00,N/A,215.00,N/A,95.25,N/A,30.10,N/A,215.00,N/A,215.00,N/A,30.10,N/A,95.25,N/A,95.25,N/A,104.78,129.00,129.00,30.10,215.00,,Hospital 67805,"Excis Chalazion,Mult,Both Lids",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21208.10,N/A,12724.86,N/A,2969.13,N/A,244.01,N/A,12211.19,N/A,7210.76,N/A,581.30,N/A,2969.13,N/A,239.04,N/A,239.04,N/A,361.86,N/A,581.30,N/A,581.30,N/A,581.30,N/A,12139.21,N/A,239.04,N/A,2969.13,N/A,790.50,N/A,790.50,N/A,2969.13,N/A,239.04,N/A,244.01,N/A,167.82,N/A,N/A,167.82,12724.86,,Hospital 67820,HC Correction Trichiasis Epilation Forceps Only,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,317.00,N/A,190.20,N/A,44.38,N/A,111.11,N/A,182.53,N/A,107.78,N/A,N/A,N/A,44.38,N/A,104.85,N/A,104.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,182.53,N/A,104.85,N/A,44.38,N/A,169.91,N/A,169.91,N/A,44.38,N/A,104.85,N/A,111.11,N/A,22.74,N/A,N/A,22.74,190.20,,Hospital CPT 67840,Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure,N/A,N/A,470.00,470.00,282.00,282.00,N/A,65.80,N/A,146.35,N/A,470.00,N/A,159.80,N/A,470.00,N/A,65.80,N/A,146.35,N/A,146.35,N/A,470.00,N/A,470.00,N/A,470.00,N/A,470.00,N/A,470.00,N/A,146.35,N/A,65.80,N/A,470.00,N/A,470.00,N/A,65.80,N/A,146.35,N/A,146.35,N/A,160.99,282.00,282.00,65.80,470.00,,Hospital 67908,Rpr Blpos Conjunctivo-Tarso-Musc-Levator Rescj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7757.00,N/A,4654.20,N/A,1085.98,N/A,1997.13,N/A,4466.20,N/A,2637.38,N/A,4622.87,N/A,1085.98,N/A,1909.23,N/A,1909.23,N/A,2877.83,N/A,4622.87,N/A,4622.87,N/A,4622.87,N/A,4466.21,N/A,1909.23,N/A,1085.98,N/A,3397.00,N/A,3397.00,N/A,1085.98,N/A,1909.23,N/A,1997.13,N/A,439.63,N/A,N/A,439.63,4654.20,,Hospital 67912,Correction Eyelid W/ Implant,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,21291.27,N/A,12774.76,N/A,2968.40,N/A,456.49,N/A,12253.29,N/A,7239.03,N/A,4651.05,N/A,2968.40,N/A,1909.23,N/A,1909.23,N/A,2895.37,N/A,4651.05,N/A,4651.05,N/A,4651.05,N/A,12253.30,N/A,1909.23,N/A,2968.40,N/A,3397.00,N/A,3397.00,N/A,2968.40,N/A,1909.23,N/A,456.49,N/A,502.14,N/A,N/A,456.49,12774.76,,Hospital 67914,Repair Ectropion Suture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,12209.20,N/A,7325.52,N/A,1709.28,N/A,1997.13,N/A,7029.32,N/A,4151.15,N/A,4631.13,N/A,1709.28,N/A,1909.23,N/A,1909.23,N/A,2882.97,N/A,4631.13,N/A,4631.13,N/A,4631.13,N/A,7029.32,N/A,1909.23,N/A,1709.28,N/A,5944.75,N/A,5944.75,N/A,1709.28,N/A,1909.23,N/A,1997.13,N/A,1702.43,N/A,N/A,1702.43,7325.52,,Hospital 67921,Repair Entropion Suture,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10132.50,N/A,6079.50,N/A,1411.47,N/A,289.00,N/A,5833.89,N/A,3445.05,N/A,4622.92,N/A,1411.47,N/A,1909.23,N/A,1909.23,N/A,2877.86,N/A,4622.92,N/A,4622.92,N/A,4622.92,N/A,5833.89,N/A,1909.23,N/A,1411.47,N/A,3397.00,N/A,3397.00,N/A,1411.47,N/A,1909.23,N/A,289.00,N/A,317.90,N/A,N/A,289.00,6079.50,,Hospital CPT 67935,HC Repair Eyelid Wound,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,5506.00,5506.00,3303.60,3303.60,N/A,770.84,N/A,411.43,N/A,3170.35,N/A,1872.04,N/A,1662.60,N/A,770.84,N/A,411.43,N/A,411.43,N/A,1034.97,N/A,1662.60,N/A,1662.60,N/A,1662.60,N/A,3170.35,N/A,411.43,N/A,770.84,N/A,5506.00,N/A,5506.00,N/A,770.84,N/A,411.43,N/A,411.43,N/A,452.57,3303.60,3303.60,411.43,5506.00,,Hospital CPT 67938,HC Remove Eyelid FB,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,862.00,862.00,517.20,517.20,N/A,120.68,N/A,108.37,N/A,496.34,N/A,293.08,N/A,743.76,N/A,120.68,N/A,108.37,N/A,108.37,N/A,462.99,N/A,743.76,N/A,743.76,N/A,743.76,N/A,496.34,N/A,108.37,N/A,120.68,N/A,862.00,N/A,862.00,N/A,120.68,N/A,108.37,N/A,108.37,N/A,119.21,517.20,517.20,108.37,862.00,,Hospital 67966,"Revision of Eyelid,> 1/4 Lid Margin",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,25964.20,N/A,15578.52,N/A,3634.98,N/A,1948.93,N/A,14946.49,N/A,8827.82,N/A,4638.83,N/A,3634.98,N/A,1909.23,N/A,1909.23,N/A,2887.76,N/A,4638.83,N/A,4638.83,N/A,4638.83,N/A,14946.50,N/A,1909.23,N/A,3634.98,N/A,3397.00,N/A,3397.00,N/A,3634.98,N/A,1909.23,N/A,1948.93,N/A,838.07,N/A,N/A,838.07,15578.52,,Hospital 67975,"Reconstruc Eyelid,Second Stage",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7225.00,N/A,4335.00,N/A,1011.50,N/A,1997.13,N/A,4159.74,N/A,2456.50,N/A,4622.56,N/A,1011.50,N/A,1909.23,N/A,1909.23,N/A,2877.63,N/A,4622.56,N/A,4622.56,N/A,4622.56,N/A,4159.75,N/A,1909.23,N/A,1011.50,N/A,3397.00,N/A,3397.00,N/A,1011.50,N/A,1909.23,N/A,1997.13,N/A,697.39,N/A,N/A,697.39,4622.56,,Hospital 67999,Unlisted Procedure Eyelids,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37312.00,N/A,22387.20,N/A,5223.68,N/A,2710.70,N/A,21474.22,N/A,12686.08,N/A,6004.27,N/A,5223.68,N/A,2457.30,N/A,2457.30,N/A,3737.77,N/A,6004.27,N/A,6004.27,N/A,6004.27,N/A,21474.23,N/A,2457.30,N/A,5223.68,N/A,2938.25,N/A,2938.25,N/A,5223.68,N/A,2457.30,N/A,514.77,N/A,566.25,N/A,N/A,514.77,22387.20,,Hospital CPT 68110,Excision Lesion Conjunctiva 1 Cm,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,33248.20,N/A,19948.92,N/A,4654.75,N/A,397.86,N/A,19048.59,N/A,11304.39,N/A,4629.71,N/A,4654.75,N/A,1909.23,N/A,1909.23,N/A,2882.09,N/A,4629.71,N/A,4629.71,N/A,4629.71,N/A,19048.60,N/A,1909.23,N/A,4654.75,N/A,6260.50,N/A,6260.50,N/A,4654.75,N/A,1909.23,N/A,397.86,N/A,437.65,N/A,N/A,397.86,19948.92,,Hospital 68320,Conjunctivoplasty W/Grf/Xtnsv Rearrangement,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,10328.70,N/A,6197.22,N/A,1446.02,N/A,1997.13,N/A,5946.40,N/A,3511.76,N/A,4639.09,N/A,1446.02,N/A,1909.23,N/A,1909.23,N/A,2887.92,N/A,4639.09,N/A,4639.09,N/A,4639.09,N/A,5946.41,N/A,1909.23,N/A,1446.02,N/A,3397.00,N/A,3397.00,N/A,1446.02,N/A,1909.23,N/A,1997.13,N/A,548.63,N/A,N/A,548.63,6197.22,,Hospital 68399,Conjunctival Surgery Unlisted,N/A,0516 - CLINIC - URGENT CARE CLINIC,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 68510,Biopsy of Tear Gland,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20924.32,N/A,12554.59,N/A,2924.16,N/A,667.17,N/A,12044.91,N/A,7114.26,N/A,4650.69,N/A,2924.16,N/A,1909.23,N/A,1909.23,N/A,2895.15,N/A,4650.69,N/A,4650.69,N/A,4650.69,N/A,12044.92,N/A,1909.23,N/A,2924.16,N/A,3397.00,N/A,3397.00,N/A,2924.16,N/A,1909.23,N/A,667.17,N/A,733.89,N/A,N/A,667.17,12554.59,,Hospital 68700,Repair Tear Ducts,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5577.92,N/A,3346.75,N/A,780.91,N/A,1997.13,N/A,3207.61,N/A,1896.49,N/A,4621.99,N/A,780.91,N/A,1909.23,N/A,1909.23,N/A,2877.28,N/A,4621.99,N/A,4621.99,N/A,4621.99,N/A,3207.62,N/A,1909.23,N/A,780.91,N/A,3397.00,N/A,3397.00,N/A,780.91,N/A,1909.23,N/A,1997.13,N/A,614.53,N/A,N/A,614.53,4621.99,,Hospital 68720,Dacryocstorhinostomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,34942.97,N/A,20965.78,N/A,4881.52,N/A,762.39,N/A,20101.43,N/A,11880.61,N/A,7660.46,N/A,4881.52,N/A,3156.58,N/A,3156.58,N/A,4768.78,N/A,7660.46,N/A,7660.46,N/A,7660.46,N/A,20101.45,N/A,3156.58,N/A,4881.52,N/A,4562.00,N/A,4562.00,N/A,4881.52,N/A,3156.58,N/A,762.39,N/A,838.63,N/A,N/A,762.39,20965.78,,Hospital 68750,Create Conjunc-Nasal Fistula+Stent,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27808.08,N/A,16684.85,N/A,3893.15,N/A,3774.30,N/A,15849.66,N/A,9454.74,N/A,9863.98,N/A,3893.15,N/A,3608.17,N/A,3608.17,N/A,6140.50,N/A,9863.98,N/A,9863.98,N/A,9863.98,N/A,15849.66,N/A,3608.17,N/A,3893.15,N/A,8375.75,N/A,8375.75,N/A,3893.15,N/A,3608.17,N/A,3774.30,N/A,919.08,N/A,N/A,919.08,16684.85,,Hospital 68761,"Close Tear Duct Opening by Plug,Ea",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14386.37,N/A,8631.82,N/A,2014.09,N/A,2151.15,N/A,8262.34,N/A,4596.14,N/A,4735.08,N/A,2014.09,N/A,1950.06,N/A,1950.06,N/A,2947.68,N/A,4735.08,N/A,4735.08,N/A,4735.08,N/A,8262.36,N/A,1950.06,N/A,2014.09,N/A,3660.50,N/A,3660.50,N/A,2014.09,N/A,1950.06,N/A,739.76,N/A,676.13,N/A,N/A,676.13,8631.82,,Hospital 68810,Probe Nasolacrimal Duct,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8633.60,N/A,5180.16,N/A,1177.78,N/A,1997.13,N/A,4970.96,N/A,2935.42,N/A,4622.62,N/A,1177.78,N/A,1909.23,N/A,1909.23,N/A,2877.66,N/A,4622.62,N/A,4622.62,N/A,4622.62,N/A,4970.97,N/A,1909.23,N/A,1177.78,N/A,3660.50,N/A,3660.50,N/A,1177.78,N/A,1909.23,N/A,1997.13,N/A,786.15,N/A,N/A,786.15,5180.16,,Hospital CPT 69000,HC Drainage Ext Ear Abscess,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,979.00,979.00,587.40,587.40,N/A,137.06,N/A,116.83,N/A,563.71,N/A,332.86,N/A,518.97,N/A,137.06,N/A,116.83,N/A,116.83,N/A,323.06,N/A,518.97,N/A,518.97,N/A,518.97,N/A,563.71,N/A,116.83,N/A,137.06,N/A,979.00,N/A,979.00,N/A,137.06,N/A,116.83,N/A,116.83,N/A,128.51,587.40,587.40,116.83,979.00,,Hospital CPT 69020,HC Drain Outer Ear Canal Lesion,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,721.00,721.00,432.60,432.60,N/A,100.94,N/A,135.03,N/A,415.15,N/A,245.14,N/A,649.83,N/A,100.94,N/A,135.03,N/A,135.03,N/A,404.52,N/A,649.83,N/A,649.83,N/A,649.83,N/A,415.15,N/A,135.03,N/A,100.94,N/A,721.00,N/A,721.00,N/A,100.94,N/A,135.03,N/A,135.03,N/A,148.53,432.60,432.60,100.94,721.00,,Hospital 69110,Excision External Ear Partial Simple Repair,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17493.75,N/A,10496.25,N/A,2449.13,N/A,339.43,N/A,10064.77,N/A,5947.88,N/A,5672.64,N/A,2449.13,N/A,2332.78,N/A,2332.78,N/A,3531.33,N/A,5672.64,N/A,5672.64,N/A,5672.64,N/A,10064.79,N/A,2332.78,N/A,2449.13,N/A,1871.00,N/A,1871.00,N/A,2449.13,N/A,2332.78,N/A,339.43,N/A,373.38,N/A,N/A,339.43,10496.25,,Hospital 69150,Rad Excis Ext Canal Lesn,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37044.52,N/A,22226.71,N/A,5186.23,N/A,5043.96,N/A,21283.77,N/A,12595.14,N/A,11692.02,N/A,5186.23,N/A,4821.94,N/A,4821.94,N/A,7278.52,N/A,11692.02,N/A,11692.02,N/A,11692.02,N/A,21283.77,N/A,4821.94,N/A,5186.23,N/A,3397.00,N/A,3397.00,N/A,5186.23,N/A,4821.94,N/A,5043.96,N/A,1094.38,N/A,N/A,1094.38,22226.71,,Hospital CPT 69200,HC FB Removal From Ear,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,660.00,660.00,396.00,396.00,N/A,92.40,N/A,111.11,N/A,380.03,N/A,224.40,N/A,253.64,N/A,92.40,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,380.03,N/A,104.85,N/A,92.40,N/A,660.00,N/A,660.00,N/A,92.40,N/A,104.85,N/A,111.11,N/A,49.64,396.00,396.00,49.64,660.00,,Hospital CPT 69209,HC Rem Impact Cerumen Irrigat Uni,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,523.00,523.00,313.80,313.80,N/A,73.22,N/A,55.01,N/A,301.14,N/A,177.82,N/A,125.56,N/A,73.22,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,301.14,N/A,51.91,N/A,73.22,N/A,523.00,N/A,523.00,N/A,73.22,N/A,51.91,N/A,55.01,N/A,14.87,313.80,313.80,14.87,523.00,,Hospital CPT 69210,"HC Cerumen Removal,Unilat",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,525.00,525.00,315.00,315.00,N/A,73.50,N/A,55.01,N/A,302.30,N/A,178.50,N/A,125.56,N/A,73.50,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,302.30,N/A,51.91,N/A,73.50,N/A,281.40,N/A,281.40,N/A,73.50,N/A,51.91,N/A,55.22,N/A,34.99,315.00,315.00,34.99,315.00,,Hospital CPT 69210,HC Remove Impacted Cerumen,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,575.00,575.00,345.00,345.00,N/A,80.50,N/A,55.01,N/A,331.09,N/A,195.50,N/A,125.56,N/A,80.50,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,331.09,N/A,51.91,N/A,80.50,N/A,575.00,N/A,575.00,N/A,80.50,N/A,51.91,N/A,55.22,N/A,34.99,345.00,345.00,34.99,575.00,,Hospital 69220,"Debride Mastoid Cavity,Simple",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17398.20,N/A,10438.92,N/A,2435.75,N/A,168.66,N/A,10017.89,N/A,5915.39,N/A,394.46,N/A,2435.75,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,10017.89,N/A,163.07,N/A,2435.75,N/A,790.50,N/A,790.50,N/A,2435.75,N/A,163.07,N/A,168.66,N/A,53.25,N/A,N/A,53.25,10438.92,,Hospital 69222,Debridement Mastoidectomy Cavity Cmplx,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,31012.10,N/A,18607.26,N/A,4330.23,N/A,434.53,N/A,17852.52,N/A,10544.12,N/A,1023.21,N/A,4330.23,N/A,420.39,N/A,420.39,N/A,636.97,N/A,1023.21,N/A,1023.21,N/A,1023.21,N/A,17852.52,N/A,420.39,N/A,4330.23,N/A,527.00,N/A,527.00,N/A,4330.23,N/A,420.39,N/A,434.53,N/A,149.51,N/A,N/A,149.51,18607.26,,Hospital 69300,Otoplasty Protruding Ear W/WO Size Rdctj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,27739.00,N/A,16643.40,N/A,3883.47,N/A,2733.05,N/A,15968.23,N/A,9431.27,N/A,6244.06,N/A,3883.47,N/A,2569.18,N/A,2569.18,N/A,3887.04,N/A,6244.06,N/A,6244.06,N/A,6244.06,N/A,15968.23,N/A,2569.18,N/A,3883.47,N/A,5095.50,N/A,5095.50,N/A,3883.47,N/A,2569.18,N/A,2733.05,N/A,487.80,N/A,N/A,487.80,16643.40,,Hospital 69320,"Rebuild Ext Aud Canal,Cong Anomaly",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,86231.43,N/A,51738.86,N/A,12072.40,N/A,5043.96,N/A,49636.73,N/A,29318.68,N/A,11753.54,N/A,12072.40,N/A,4821.94,N/A,4821.94,N/A,7320.10,N/A,11753.54,N/A,11753.54,N/A,11753.54,N/A,49636.76,N/A,4821.94,N/A,12072.40,N/A,8944.50,N/A,8944.50,N/A,12072.40,N/A,4821.94,N/A,5043.96,N/A,2242.11,N/A,N/A,2242.11,51738.86,,Hospital 69399,Outer Ear Surgery Proc Unlisted,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,8221.00,N/A,4932.60,N/A,1150.95,N/A,186.06,N/A,4732.29,N/A,2795.16,N/A,472.67,N/A,1150.95,N/A,187.68,N/A,187.68,N/A,294.25,N/A,472.67,N/A,472.67,N/A,472.67,N/A,4732.30,N/A,187.68,N/A,1150.95,N/A,527.00,N/A,527.00,N/A,1150.95,N/A,187.68,N/A,186.06,N/A,N/A,N/A,N/A,186.06,4932.60,,Hospital 69424,Ventilating Tube Rmvl Requiring General Anes,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,14982.67,N/A,8989.60,N/A,2097.57,N/A,1296.52,N/A,8622.49,N/A,5094.10,N/A,3032.22,N/A,2097.57,N/A,1253.55,N/A,1253.55,N/A,1887.61,N/A,3032.22,N/A,3032.22,N/A,3032.22,N/A,8622.49,N/A,1253.55,N/A,2097.57,N/A,5965.25,N/A,5965.25,N/A,2097.57,N/A,1253.55,N/A,1296.52,N/A,228.35,N/A,N/A,228.35,8989.60,,Hospital 69440,Exploration of Middle Ear,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,20767.30,N/A,12460.38,N/A,2899.40,N/A,2687.47,N/A,11957.03,N/A,7060.88,N/A,6228.19,N/A,2899.40,N/A,2569.18,N/A,2569.18,N/A,3877.17,N/A,6228.19,N/A,6228.19,N/A,6228.19,N/A,11925.36,N/A,2569.18,N/A,2899.40,N/A,4332.50,N/A,4332.50,N/A,2899.40,N/A,2569.18,N/A,2687.47,N/A,830.10,N/A,N/A,830.10,12460.38,,Hospital 69501,"Mastoidectomy,Simple",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,60868.52,N/A,36521.11,N/A,8521.59,N/A,4922.21,N/A,35035.74,N/A,20695.29,N/A,11705.54,N/A,8521.59,N/A,4821.94,N/A,4821.94,N/A,7286.92,N/A,11705.54,N/A,11705.54,N/A,11705.54,N/A,35035.73,N/A,4821.94,N/A,8521.59,N/A,5963.00,N/A,5963.00,N/A,8521.59,N/A,4821.94,N/A,4922.21,N/A,747.79,N/A,N/A,747.79,36521.11,,Hospital 69502,"Mastoidectomy,Complete",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43617.08,N/A,26170.25,N/A,6106.40,N/A,5319.17,N/A,24909.54,N/A,14829.81,N/A,11724.63,N/A,6106.40,N/A,4821.94,N/A,4821.94,N/A,7298.80,N/A,11724.63,N/A,11724.63,N/A,11724.63,N/A,24909.55,N/A,4821.94,N/A,6106.40,N/A,4332.50,N/A,4332.50,N/A,6106.40,N/A,4821.94,N/A,1438.98,N/A,1582.88,N/A,N/A,1438.98,26170.25,,Hospital 69602,Mastoid Revisn ->Mod Rad Mastoidect,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,46206.32,N/A,27723.79,N/A,6468.89,N/A,5043.96,N/A,26604.03,N/A,15710.15,N/A,11691.96,N/A,6468.89,N/A,4821.94,N/A,4821.94,N/A,7278.47,N/A,11691.96,N/A,11691.96,N/A,11691.96,N/A,26604.03,N/A,4821.94,N/A,6468.89,N/A,5963.00,N/A,5963.00,N/A,6468.89,N/A,4821.94,N/A,5043.96,N/A,1188.87,N/A,N/A,1188.87,27723.79,,Hospital 69610,Tympanic Memb Rpr W/WO Prepj Perfor Patch,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,9296.20,N/A,5577.72,N/A,1301.47,N/A,1242.72,N/A,5332.01,N/A,3160.71,N/A,3032.22,N/A,1301.47,N/A,1253.55,N/A,1253.55,N/A,1887.61,N/A,3032.22,N/A,3032.22,N/A,3032.22,N/A,5332.01,N/A,1253.55,N/A,1301.47,N/A,3397.00,N/A,3397.00,N/A,1301.47,N/A,1253.55,N/A,1242.72,N/A,302.12,N/A,N/A,302.12,5577.72,,Hospital 69631,Tympanoplasty W/O Mastoidect W/O Ossicle Recnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29881.83,N/A,17929.10,N/A,4172.96,N/A,1705.64,N/A,17126.71,N/A,10159.82,N/A,11822.36,N/A,4172.96,N/A,4821.94,N/A,4821.94,N/A,7359.63,N/A,11822.36,N/A,11822.36,N/A,11822.36,N/A,17126.73,N/A,4821.94,N/A,4172.96,N/A,6898.50,N/A,6898.50,N/A,4172.96,N/A,4821.94,N/A,1705.64,N/A,1526.55,N/A,N/A,1526.55,17929.10,,Hospital CPT 69633,Tympanoplasty W/O Mastoidec 1st/Revj Prosth Torp,N/A,N/A,2051.00,2051.00,1230.60,1230.60,N/A,287.14,N/A,1002.29,N/A,2051.00,N/A,697.34,N/A,2051.00,N/A,287.14,N/A,1002.29,N/A,1002.29,N/A,1855.45,N/A,2051.00,N/A,2051.00,N/A,2051.00,N/A,2051.00,N/A,1002.29,N/A,287.14,N/A,2051.00,N/A,2051.00,N/A,287.14,N/A,1002.29,N/A,1002.29,N/A,1102.52,1230.60,1230.60,287.14,2051.00,,Hospital 69637,"Tympanoplas/Antrot,Rebld Ossic+Prost",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58643.97,N/A,35186.38,N/A,8210.16,N/A,5043.96,N/A,33740.50,N/A,19938.96,N/A,11718.67,N/A,8210.16,N/A,4821.94,N/A,4821.94,N/A,7295.09,N/A,11718.67,N/A,11718.67,N/A,11718.67,N/A,33740.51,N/A,4821.94,N/A,8210.16,N/A,6898.50,N/A,6898.50,N/A,8210.16,N/A,4821.94,N/A,5043.96,N/A,2291.90,N/A,N/A,2291.90,35186.38,,Hospital 69641,Tmpp Mastoidectomy W/O Ossicular Chain Recnstj,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,36316.98,N/A,21790.19,N/A,5084.38,N/A,5319.17,N/A,20886.10,N/A,12052.73,N/A,11699.04,N/A,5084.38,N/A,4821.94,N/A,4821.94,N/A,7282.87,N/A,11699.04,N/A,11699.04,N/A,11699.04,N/A,20886.10,N/A,4821.94,N/A,5084.38,N/A,6898.50,N/A,6898.50,N/A,5084.38,N/A,4821.94,N/A,1559.46,N/A,1715.41,N/A,N/A,1559.46,21790.19,,Hospital 69645,Tympanoplasty Mastoidectomy Rad/Compl W/O Ocr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,49494.70,N/A,29696.82,N/A,6957.07,N/A,1491.23,N/A,28496.30,N/A,16828.20,N/A,11705.63,N/A,6957.07,N/A,4821.94,N/A,4821.94,N/A,7286.97,N/A,11705.63,N/A,11705.63,N/A,11705.63,N/A,28496.30,N/A,4821.94,N/A,6957.07,N/A,5963.00,N/A,5963.00,N/A,6957.07,N/A,4821.94,N/A,1491.23,N/A,1640.38,N/A,N/A,1491.23,29696.82,,Hospital 69660,Stapedectomy,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41661.00,N/A,24996.60,N/A,5832.54,N/A,5043.96,N/A,23974.37,N/A,14164.74,N/A,11705.32,N/A,5832.54,N/A,4821.94,N/A,4821.94,N/A,7286.76,N/A,11705.32,N/A,11705.32,N/A,11705.32,N/A,23974.40,N/A,4821.94,N/A,5832.54,N/A,7661.50,N/A,7661.50,N/A,5832.54,N/A,4821.94,N/A,5043.96,N/A,1822.50,N/A,N/A,1822.50,24996.60,,Hospital 69666,Repair Oval Window Fistula,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,41661.00,N/A,24996.60,N/A,5832.54,N/A,5043.96,N/A,23974.37,N/A,14164.74,N/A,11705.32,N/A,5832.54,N/A,4821.94,N/A,4821.94,N/A,7286.76,N/A,11705.32,N/A,11705.32,N/A,11705.32,N/A,23974.40,N/A,4821.94,N/A,5832.54,N/A,7661.50,N/A,7661.50,N/A,5832.54,N/A,4821.94,N/A,5043.96,N/A,1822.50,N/A,N/A,1822.50,24996.60,,Hospital 69710,"Implant/Replace Hear Aid,Temp Bone",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,29767.90,N/A,17860.74,N/A,4167.50,N/A,N/A,N/A,17011.93,N/A,10121.09,N/A,1979.26,N/A,4167.50,N/A,N/A,N/A,N/A,N/A,1229.99,N/A,1979.26,N/A,1979.26,N/A,1979.26,N/A,17011.94,N/A,N/A,N/A,4167.50,N/A,5963.00,N/A,5963.00,N/A,4167.50,N/A,N/A,N/A,N/A,N/A,22132.67,N/A,N/A,1229.99,22132.67,,Hospital 69799,Middle Ear Surgery Proc Unlisted,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17822.97,N/A,10693.78,N/A,2495.21,N/A,187.68,N/A,10257.69,N/A,6059.80,N/A,478.47,N/A,2495.21,N/A,187.68,N/A,187.68,N/A,297.87,N/A,478.47,N/A,478.47,N/A,478.47,N/A,10257.69,N/A,187.68,N/A,2495.21,N/A,527.00,N/A,527.00,N/A,2495.21,N/A,187.68,N/A,187.68,N/A,206.45,N/A,N/A,187.68,10693.78,,Hospital 69805,"Endolymph Sac Operatn,No Shunt",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,43660.47,N/A,26196.28,N/A,6112.48,N/A,5319.17,N/A,24997.94,N/A,14844.30,N/A,11705.54,N/A,6112.48,N/A,4821.94,N/A,4821.94,N/A,7286.92,N/A,11705.54,N/A,11705.54,N/A,11705.54,N/A,24997.97,N/A,4821.94,N/A,6112.48,N/A,5963.00,N/A,5963.00,N/A,6112.48,N/A,4821.94,N/A,985.69,N/A,1084.26,N/A,N/A,985.69,26196.28,,Hospital 70015,HC Cisternography Positive Contrast Rs&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,8337.60,N/A,5002.56,N/A,1167.27,N/A,1154.54,N/A,4558.87,N/A,2834.79,N/A,5948.78,N/A,1167.27,N/A,1124.51,N/A,1124.51,N/A,3703.20,N/A,5948.78,N/A,5948.78,N/A,5948.78,N/A,4558.87,N/A,1124.51,N/A,1167.27,N/A,1780.59,N/A,1780.59,N/A,1167.27,N/A,1124.51,N/A,1154.54,N/A,398.52,N/A,N/A,398.52,5948.78,,Hospital 70130,HC Mastoids or Petrous Ridges,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,465.00,N/A,279.00,N/A,65.10,N/A,100.96,N/A,267.75,N/A,158.10,N/A,233.46,N/A,65.10,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,267.75,N/A,96.52,N/A,65.10,N/A,249.24,N/A,249.24,N/A,65.10,N/A,96.52,N/A,100.96,N/A,45.97,N/A,N/A,45.97,279.00,,Hospital CPT 70140,HC Facial Bones Less Than 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1038.00,1038.00,622.80,622.80,N/A,145.32,N/A,20.13,N/A,597.68,N/A,352.92,N/A,189.77,N/A,145.32,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,597.68,N/A,78.46,N/A,145.32,N/A,556.37,N/A,556.37,N/A,145.32,N/A,78.46,N/A,20.13,N/A,22.14,622.80,622.80,20.13,622.80,,Hospital CPT 70200,HC Orbits Min 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1038.00,1038.00,622.80,622.80,N/A,145.32,N/A,100.96,N/A,597.68,N/A,352.92,N/A,233.46,N/A,145.32,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,597.68,N/A,96.52,N/A,145.32,N/A,556.37,N/A,556.37,N/A,145.32,N/A,96.52,N/A,100.96,N/A,34.72,622.80,622.80,34.72,622.80,,Hospital CPT 70210,HC Sinuses Less Than 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,425.00,425.00,255.00,255.00,N/A,59.50,N/A,78.46,N/A,244.72,N/A,144.50,N/A,189.77,N/A,59.50,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,244.72,N/A,78.46,N/A,59.50,N/A,227.80,N/A,227.80,N/A,59.50,N/A,78.46,N/A,78.46,N/A,86.30,255.00,255.00,59.50,255.00,,Hospital CPT 70250,HC Skull Less Than 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1052.00,1052.00,631.20,631.20,N/A,147.28,N/A,96.52,N/A,605.74,N/A,357.68,N/A,233.46,N/A,147.28,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,605.74,N/A,96.52,N/A,147.28,N/A,563.87,N/A,563.87,N/A,147.28,N/A,96.52,N/A,96.52,N/A,106.17,631.20,631.20,96.52,631.20,,Hospital CPT 70260,HC Skull Complete Min 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1345.00,1345.00,807.00,807.00,N/A,188.30,N/A,98.52,N/A,774.45,N/A,457.30,N/A,233.46,N/A,188.30,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,774.45,N/A,96.52,N/A,188.30,N/A,720.92,N/A,720.92,N/A,188.30,N/A,96.52,N/A,98.52,N/A,106.17,807.00,807.00,96.52,807.00,,Hospital 70328,HC Tmj Open/Closed Mouth Unilateral,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,261.00,N/A,156.60,N/A,36.54,N/A,82.88,N/A,150.28,N/A,88.74,N/A,189.77,N/A,36.54,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,150.28,N/A,78.46,N/A,36.54,N/A,139.90,N/A,139.90,N/A,36.54,N/A,78.46,N/A,23.44,N/A,25.78,N/A,N/A,23.44,189.77,,Hospital CPT 70336,HC MRI - Tmj Unilat or Bilat,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,1555.00,1218.00,933.00,730.80,N/A,170.52,N/A,220.59,N/A,1110.00,N/A,414.12,N/A,510.09,N/A,170.52,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,170.52,N/A,1060.00,N/A,1060.00,N/A,170.52,N/A,210.88,N/A,220.59,N/A,209.69,933.00,933.00,170.52,1110.00,,Hospital CPT 70360,HC Soft Tissue Lat Neck,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,657.00,657.00,394.20,394.20,N/A,91.98,N/A,78.46,N/A,378.30,N/A,223.38,N/A,189.77,N/A,91.98,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,378.30,N/A,78.46,N/A,91.98,N/A,352.15,N/A,352.15,N/A,91.98,N/A,78.46,N/A,78.46,N/A,86.30,394.20,394.20,78.46,394.20,,Hospital CPT 70486,HC CT Facial Bones W/O Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2583.00,1834.00,1549.80,1100.40,N/A,256.76,N/A,96.52,N/A,914.00,N/A,623.56,N/A,233.46,N/A,256.76,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,256.76,N/A,689.00,N/A,689.00,N/A,256.76,N/A,96.52,N/A,96.52,N/A,106.17,1549.80,1549.80,96.52,1100.40,,Hospital CPT 70487,HC CT Facial Bones W/ Contrast,N/A,0351 - CT SCAN - HEAD SCAN,2949.00,2108.00,1769.40,1264.80,N/A,295.12,N/A,170.35,N/A,914.00,N/A,716.72,N/A,393.92,N/A,295.12,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,295.12,N/A,689.00,N/A,689.00,N/A,295.12,N/A,162.85,N/A,170.35,N/A,179.14,1769.40,1769.40,162.85,1264.80,,Hospital CPT 70488,HC CT Facial Bones W/WO Contrast,N/A,0351 - CT SCAN - HEAD SCAN,3318.00,2428.00,1990.80,1456.80,N/A,339.92,N/A,170.35,N/A,914.00,N/A,825.52,N/A,393.92,N/A,339.92,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,339.92,N/A,689.00,N/A,689.00,N/A,339.92,N/A,162.85,N/A,170.35,N/A,131.65,1990.80,1990.80,131.65,1456.80,,Hospital CPT 70540,HC MRI Face Neck Eye WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2372.00,2013.00,1423.20,1207.80,N/A,281.82,N/A,222.76,N/A,1110.00,N/A,684.42,N/A,510.09,N/A,281.82,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,281.82,N/A,1060.00,N/A,1060.00,N/A,281.82,N/A,210.88,N/A,157.55,N/A,173.31,1423.20,1423.20,157.55,1207.80,,Hospital CPT 70544,HC MRI-Angio Head WO Contrast,N/A,0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK,2372.00,2013.00,1423.20,1207.80,N/A,281.82,N/A,210.88,N/A,1110.00,N/A,684.42,N/A,510.09,N/A,281.82,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,281.82,N/A,1060.00,N/A,1060.00,N/A,281.82,N/A,210.88,N/A,210.88,N/A,231.97,1423.20,1423.20,210.88,1207.80,,Hospital CPT 70545,HC MRI-Angio Head W Contrast,N/A,0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK,2965.00,2313.00,1779.00,1387.80,N/A,323.82,N/A,163.27,N/A,1110.00,N/A,786.42,N/A,804.78,N/A,323.82,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,323.82,N/A,1060.00,N/A,1060.00,N/A,323.82,N/A,332.71,N/A,163.27,N/A,179.60,1779.00,1779.00,163.27,1387.80,,Hospital CPT 70546,HC MRI-Angio Head WO& W Contras,N/A,0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK,3447.00,2660.00,2068.20,1596.00,N/A,372.40,N/A,344.11,N/A,1110.00,N/A,904.40,N/A,804.78,N/A,372.40,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,372.40,N/A,1060.00,N/A,1060.00,N/A,372.40,N/A,332.71,N/A,344.11,N/A,272.51,2068.20,2068.20,272.51,1596.00,,Hospital CPT 70547,HC MRI-Angio Neck WO Contrast,N/A,0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK,2372.00,2013.00,1423.20,1207.80,N/A,281.82,N/A,210.88,N/A,1110.00,N/A,684.42,N/A,510.09,N/A,281.82,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,281.82,N/A,1060.00,N/A,1060.00,N/A,281.82,N/A,210.88,N/A,210.88,N/A,231.97,1423.20,1423.20,210.88,1207.80,,Hospital CPT 70548,HC MRI-Angio Neck W Contrast,N/A,0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK,2965.00,2313.00,1779.00,1387.80,N/A,323.82,N/A,351.45,N/A,1110.00,N/A,786.42,N/A,804.78,N/A,323.82,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,323.82,N/A,1060.00,N/A,1060.00,N/A,323.82,N/A,332.71,N/A,168.08,N/A,184.89,1779.00,1779.00,168.08,1387.80,,Hospital CPT 70552,HC MRI-Brain W Contrast,N/A,0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN/BRAINSTEM,2965.00,2313.00,1779.00,1387.80,N/A,323.82,N/A,331.00,N/A,1110.00,N/A,786.42,N/A,804.78,N/A,323.82,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,323.82,N/A,1060.00,N/A,1060.00,N/A,323.82,N/A,332.71,N/A,348.03,N/A,197.46,1779.00,1779.00,197.46,1387.80,,Hospital CPT 70553,HC MRI-Brain WO & W Contrast,N/A,0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN/BRAINSTEM,3447.00,2995.00,2068.20,1797.00,N/A,419.30,N/A,332.71,N/A,1110.00,N/A,1018.30,N/A,804.78,N/A,419.30,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,419.30,N/A,1060.00,N/A,1060.00,N/A,419.30,N/A,332.71,N/A,332.71,N/A,365.98,2068.20,2068.20,332.71,1797.00,,Hospital 70555,HC MRI Brain Functional W Phys Admin,N/A,0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN/BRAINSTEM,N/A,3747.00,N/A,2248.20,N/A,524.58,N/A,220.59,N/A,1561.43,N/A,1273.98,N/A,510.09,N/A,524.58,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1561.43,N/A,210.88,N/A,524.58,N/A,1480.22,N/A,1480.22,N/A,524.58,N/A,210.88,N/A,220.59,N/A,N/A,N/A,N/A,210.88,2248.20,,Hospital CPT 71046,HC X-Ray Exam Chest 2 Views,N/A,0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY,792.00,792.00,475.20,475.20,N/A,110.88,N/A,78.46,N/A,456.03,N/A,269.28,N/A,189.77,N/A,110.88,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,456.03,N/A,78.46,N/A,110.88,N/A,424.51,N/A,424.51,N/A,110.88,N/A,78.46,N/A,78.46,N/A,86.30,475.20,475.20,78.46,475.20,,Hospital CPT 71100,HC Ribs Unilateral 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,762.00,762.00,457.20,457.20,N/A,106.68,N/A,78.46,N/A,438.76,N/A,259.08,N/A,189.77,N/A,106.68,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,438.76,N/A,78.46,N/A,106.68,N/A,408.43,N/A,408.43,N/A,106.68,N/A,78.46,N/A,78.46,N/A,86.30,457.20,457.20,78.46,457.20,,Hospital CPT 71110,HC Ribs Bilat 3 Vw W/O Chest,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,319.00,319.00,191.40,191.40,N/A,44.66,N/A,96.52,N/A,183.68,N/A,108.46,N/A,233.46,N/A,44.66,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,183.68,N/A,96.52,N/A,44.66,N/A,170.98,N/A,170.98,N/A,44.66,N/A,96.52,N/A,96.52,N/A,29.76,191.40,191.40,29.76,233.46,,Hospital CPT 71111,HC Ribs Bilateral 1 View Cvr Min 4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1439.00,1439.00,863.40,863.40,N/A,201.46,N/A,100.96,N/A,828.58,N/A,489.26,N/A,233.46,N/A,201.46,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,828.58,N/A,96.52,N/A,201.46,N/A,771.30,N/A,771.30,N/A,201.46,N/A,96.52,N/A,96.52,N/A,37.04,863.40,863.40,37.04,863.40,,Hospital CPT 71120,HC Sternum Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,890.00,890.00,534.00,534.00,N/A,124.60,N/A,21.94,N/A,512.46,N/A,302.60,N/A,189.77,N/A,124.60,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,512.46,N/A,78.46,N/A,124.60,N/A,477.04,N/A,477.04,N/A,124.60,N/A,78.46,N/A,78.46,N/A,86.30,534.00,534.00,21.94,534.00,,Hospital CPT 71130,HC Sterno-Clavicular Jt Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,343.00,272.00,205.80,163.20,N/A,38.08,N/A,77.78,N/A,156.62,N/A,92.48,N/A,189.77,N/A,38.08,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,156.62,N/A,78.46,N/A,38.08,N/A,145.79,N/A,145.79,N/A,38.08,N/A,78.46,N/A,81.15,N/A,30.75,205.80,205.80,30.75,189.77,,Hospital CPT 71250,HC CT Chest W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 71270,HC CT Chest W/WO Contrast,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,162.85,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1369.80,,Hospital CPT 71552,HC MRI-Chest W & WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,348.03,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,348.03,N/A,392.93,2851.80,2851.80,332.71,1930.80,,Hospital 71555,MR Angio Chest (Mra),N/A,N/A,142057.80,2672.00,85234.68,1603.20,10166.90,374.08,N/A,240.82,N/A,1110.00,N/A,908.48,N/A,949.89,10166.90,374.08,N/A,240.82,N/A,240.82,N/A,591.31,N/A,949.89,N/A,949.89,N/A,949.89,N/A,1110.00,N/A,240.82,10166.90,374.08,N/A,1060.00,N/A,1060.00,10166.90,374.08,N/A,240.82,N/A,240.82,10166.90,264.90,10166.90,85234.68,240.82,1603.20,,Hospital CPT 72040,HC C-Spine 2-3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1031.00,1031.00,618.60,618.60,N/A,144.34,N/A,78.46,N/A,593.65,N/A,350.54,N/A,189.77,N/A,144.34,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,593.65,N/A,78.46,N/A,144.34,N/A,552.62,N/A,552.62,N/A,144.34,N/A,78.46,N/A,78.46,N/A,86.30,618.60,618.60,78.46,618.60,,Hospital CPT 72052,HC C-Spine Complete W/ Flex/Ext,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1283.00,1283.00,769.80,769.80,N/A,179.62,N/A,101.95,N/A,738.75,N/A,436.22,N/A,233.46,N/A,179.62,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,738.75,N/A,96.52,N/A,179.62,N/A,687.69,N/A,687.69,N/A,179.62,N/A,96.52,N/A,42.99,N/A,47.29,769.80,769.80,42.99,769.80,,Hospital CPT 72083,HC X-Ray Exam Entire Spine 4/5 Vw,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1361.00,1361.00,816.60,816.60,N/A,190.54,N/A,106.47,N/A,783.66,N/A,462.74,N/A,233.46,N/A,190.54,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,783.66,N/A,96.52,N/A,190.54,N/A,729.50,N/A,729.50,N/A,190.54,N/A,96.52,N/A,55.32,N/A,60.85,816.60,816.60,55.32,816.60,,Hospital CPT 72084,HC X-Ray Exam Entire Spine 6/> Vw,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1642.00,1642.00,985.20,985.20,N/A,229.88,N/A,70.66,N/A,945.46,N/A,558.28,N/A,269.76,N/A,229.88,N/A,70.66,N/A,70.66,N/A,167.93,N/A,269.76,N/A,269.76,N/A,269.76,N/A,945.46,N/A,70.66,N/A,229.88,N/A,880.11,N/A,880.11,N/A,229.88,N/A,70.66,N/A,70.66,N/A,77.73,985.20,985.20,70.66,985.20,,Hospital CPT 72100,HC L-Spine 2-3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,990.00,990.00,594.00,594.00,N/A,138.60,N/A,96.52,N/A,570.04,N/A,336.60,N/A,233.46,N/A,138.60,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,570.04,N/A,96.52,N/A,138.60,N/A,530.64,N/A,530.64,N/A,138.60,N/A,96.52,N/A,96.52,N/A,106.17,594.00,594.00,96.52,594.00,,Hospital CPT 72120,HC L-Spine Bend Only 2-3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,393.00,393.00,235.80,235.80,N/A,55.02,N/A,96.52,N/A,226.29,N/A,133.62,N/A,233.46,N/A,55.02,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,226.29,N/A,96.52,N/A,55.02,N/A,210.65,N/A,210.65,N/A,55.02,N/A,96.52,N/A,96.52,N/A,106.17,235.80,235.80,55.02,235.80,,Hospital CPT 72126,HC CT C-Spine W/ Contrast,N/A,0352 - CT SCAN - BODY SCAN,2949.00,2108.00,1769.40,1264.80,N/A,295.12,N/A,332.71,N/A,914.00,N/A,716.72,N/A,804.78,N/A,295.12,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,295.12,N/A,689.00,N/A,689.00,N/A,295.12,N/A,332.71,N/A,332.71,N/A,365.98,1769.40,1769.40,295.12,1264.80,,Hospital CPT 72129,HC CT T-Spine W/ Contrast,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1982.00,1664.40,1189.20,N/A,277.48,N/A,162.85,N/A,914.00,N/A,673.88,N/A,393.92,N/A,277.48,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,277.48,N/A,689.00,N/A,689.00,N/A,277.48,N/A,162.85,N/A,162.85,N/A,179.14,1664.40,1664.40,162.85,1189.20,,Hospital CPT 72131,HC CT L-Spine W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 72132,HC CT L-Spine W/ Contrast,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1982.00,1664.40,1189.20,N/A,277.48,N/A,332.71,N/A,914.00,N/A,673.88,N/A,804.78,N/A,277.48,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,277.48,N/A,689.00,N/A,689.00,N/A,277.48,N/A,332.71,N/A,332.71,N/A,365.98,1664.40,1664.40,277.48,1189.20,,Hospital CPT 72133,HC CT L-Spine W/WO Contrast,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,162.85,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1369.80,,Hospital CPT 72146,HC MRI-Spine Thoracic WO Contrast,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1461.00,,Hospital CPT 72147,HC MRI-Spine Thoracic W Contrast,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,348.03,N/A,1110.00,N/A,951.32,N/A,804.78,N/A,391.72,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,332.71,N/A,348.03,N/A,201.09,2454.00,2454.00,201.09,1678.80,,Hospital CPT 72149,HC MRI-Spine Lumbar W Contrast,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),4090.00,2798.00,2454.00,1678.80,N/A,391.72,N/A,348.03,N/A,1110.00,N/A,951.32,N/A,804.78,N/A,391.72,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,391.72,N/A,1060.00,N/A,1060.00,N/A,391.72,N/A,332.71,N/A,332.71,N/A,198.78,2454.00,2454.00,198.78,1678.80,,Hospital CPT 72156,HC MRI-Spine Cervical W & WO Cont,N/A,0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD/SPINE),4322.00,2925.00,2593.20,1755.00,N/A,409.50,N/A,332.71,N/A,1110.00,N/A,994.50,N/A,804.78,N/A,409.50,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,409.50,N/A,1060.00,N/A,1060.00,N/A,409.50,N/A,332.71,N/A,332.71,N/A,365.98,2593.20,2593.20,332.71,1755.00,,Hospital CPT 72159,HC Mra Spinal Canal W/O Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,1785.00,1785.00,1071.00,1071.00,N/A,249.90,N/A,251.05,N/A,1110.00,N/A,606.90,N/A,984.36,N/A,249.90,N/A,251.05,N/A,251.05,N/A,612.76,N/A,984.36,N/A,984.36,N/A,984.36,N/A,1110.00,N/A,251.05,N/A,249.90,N/A,1060.00,N/A,1060.00,N/A,249.90,N/A,251.05,N/A,251.05,N/A,1785.00,1071.00,1071.00,249.90,1785.00,,Hospital CPT 72190,HC Pelvis Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,823.00,823.00,493.80,493.80,N/A,115.22,N/A,97.56,N/A,473.88,N/A,279.82,N/A,233.46,N/A,115.22,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,473.88,N/A,96.52,N/A,115.22,N/A,441.13,N/A,441.13,N/A,115.22,N/A,96.52,N/A,27.05,N/A,29.76,493.80,493.80,27.05,493.80,,Hospital CPT 72191,HC Cta Pelvis W & W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,170.74,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,211.98,N/A,233.18,1872.00,1872.00,162.85,1034.40,,Hospital CPT 72192,HC CT Pelvis W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 72197,HC MRI-Pelvis WO & W Contrast,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,332.71,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1930.80,,Hospital CPT 72202,HC Sacroiliac Jnts Min 3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1038.00,1038.00,622.80,622.80,N/A,145.32,N/A,96.52,N/A,597.68,N/A,352.92,N/A,233.46,N/A,145.32,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,597.68,N/A,96.52,N/A,145.32,N/A,556.37,N/A,556.37,N/A,145.32,N/A,96.52,N/A,96.52,N/A,106.17,622.80,622.80,96.52,622.80,,Hospital CPT 72220,HC Sacrum and Coccyx Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,856.00,856.00,513.60,513.60,N/A,119.84,N/A,78.46,N/A,492.88,N/A,291.04,N/A,189.77,N/A,119.84,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,492.88,N/A,78.46,N/A,119.84,N/A,458.82,N/A,458.82,N/A,119.84,N/A,78.46,N/A,78.46,N/A,86.30,513.60,513.60,78.46,513.60,,Hospital CPT 72265,HC Lumbar Myelogram S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4422.00,3103.00,2653.20,1861.80,N/A,434.42,N/A,668.93,N/A,1786.71,N/A,1055.02,N/A,1618.07,N/A,434.42,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1786.71,N/A,668.93,N/A,434.42,N/A,1663.21,N/A,1663.21,N/A,434.42,N/A,668.93,N/A,668.93,N/A,735.82,2653.20,2653.20,434.42,1861.80,,Hospital CPT 72270,HC Myelography 2+ Regions S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,2456.00,2456.00,1473.60,1473.60,N/A,343.84,N/A,699.73,N/A,1414.16,N/A,835.04,N/A,1618.07,N/A,343.84,N/A,668.93,N/A,668.93,N/A,1007.28,N/A,1618.07,N/A,1618.07,N/A,1618.07,N/A,1414.16,N/A,668.93,N/A,343.84,N/A,1316.42,N/A,1316.42,N/A,343.84,N/A,668.93,N/A,699.73,N/A,100.55,1473.60,1473.60,100.55,1618.07,,Hospital CPT 73010,HC X-Ray Scapula,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1034.00,1034.00,620.40,620.40,N/A,144.76,N/A,96.52,N/A,595.38,N/A,351.56,N/A,233.46,N/A,144.76,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,595.38,N/A,96.52,N/A,144.76,N/A,554.22,N/A,554.22,N/A,144.76,N/A,96.52,N/A,96.52,N/A,106.17,620.40,620.40,96.52,620.40,,Hospital CPT 73020,HC Shoulder 1 View,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,977.00,977.00,586.20,586.20,N/A,136.78,N/A,78.46,N/A,562.56,N/A,332.18,N/A,189.77,N/A,136.78,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,562.56,N/A,78.46,N/A,136.78,N/A,523.67,N/A,523.67,N/A,136.78,N/A,78.46,N/A,78.46,N/A,86.30,586.20,586.20,78.46,586.20,,Hospital CPT 73050,HC X-Ray Ac Joints,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,635.00,635.00,381.00,381.00,N/A,88.90,N/A,79.31,N/A,365.63,N/A,215.90,N/A,189.77,N/A,88.90,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,365.63,N/A,78.46,N/A,88.90,N/A,340.36,N/A,340.36,N/A,88.90,N/A,78.46,N/A,79.31,N/A,19.17,381.00,381.00,19.17,381.00,,Hospital CPT 73060,HC Humerus Min 2 View,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,869.00,869.00,521.40,521.40,N/A,121.66,N/A,78.46,N/A,500.37,N/A,295.46,N/A,189.77,N/A,121.66,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,500.37,N/A,78.46,N/A,121.66,N/A,465.78,N/A,465.78,N/A,121.66,N/A,78.46,N/A,78.46,N/A,86.30,521.40,521.40,78.46,521.40,,Hospital CPT 73070,HC Elbow 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,848.00,733.00,508.80,439.80,N/A,102.62,N/A,78.46,N/A,422.06,N/A,249.22,N/A,189.77,N/A,102.62,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,422.06,N/A,78.46,N/A,102.62,N/A,392.89,N/A,392.89,N/A,102.62,N/A,78.46,N/A,78.46,N/A,86.30,508.80,508.80,78.46,439.80,,Hospital CPT 73100,HC Xr Wrist 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,747.00,747.00,448.20,448.20,N/A,104.58,N/A,78.46,N/A,430.12,N/A,253.98,N/A,189.77,N/A,104.58,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,430.12,N/A,78.46,N/A,104.58,N/A,400.39,N/A,400.39,N/A,104.58,N/A,78.46,N/A,78.46,N/A,86.30,448.20,448.20,78.46,448.20,,Hospital CPT 73120,HC Hand 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,671.00,671.00,402.60,402.60,N/A,93.94,N/A,96.52,N/A,386.36,N/A,228.14,N/A,233.46,N/A,93.94,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,386.36,N/A,96.52,N/A,93.94,N/A,359.66,N/A,359.66,N/A,93.94,N/A,96.52,N/A,96.52,N/A,106.17,402.60,402.60,93.94,402.60,,Hospital CPT 73140,HC Fingers Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,814.00,814.00,488.40,488.40,N/A,113.96,N/A,78.46,N/A,468.70,N/A,276.76,N/A,189.77,N/A,113.96,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,468.70,N/A,78.46,N/A,113.96,N/A,436.30,N/A,436.30,N/A,113.96,N/A,78.46,N/A,78.46,N/A,86.30,488.40,488.40,78.46,488.40,,Hospital CPT 73200,HC CT Upper Extremity W/O Contrast,N/A,0352 - CT SCAN - BODY SCAN,2429.00,1724.00,1457.40,1034.40,N/A,241.36,N/A,96.52,N/A,914.00,N/A,586.16,N/A,233.46,N/A,241.36,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,914.00,N/A,96.52,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,96.52,N/A,96.52,N/A,106.17,1457.40,1457.40,96.52,1034.40,,Hospital CPT 73201,HC CT Upper Extremity W/ Contrast,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1982.00,1664.40,1189.20,N/A,277.48,N/A,360.52,N/A,914.00,N/A,673.88,N/A,804.78,N/A,277.48,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,277.48,N/A,689.00,N/A,689.00,N/A,277.48,N/A,332.71,N/A,348.03,N/A,154.47,1664.40,1664.40,154.47,1189.20,,Hospital CPT 73202,HC CT Upper Extremity W/WO Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,2283.00,1872.00,1369.80,N/A,319.62,N/A,185.52,N/A,914.00,N/A,776.22,N/A,393.92,N/A,319.62,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,319.62,N/A,689.00,N/A,689.00,N/A,319.62,N/A,162.85,N/A,185.52,N/A,204.07,1872.00,1872.00,162.85,1369.80,,Hospital CPT 73206,HC Cta Upper Extremity W & W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,170.35,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,170.35,N/A,225.21,1872.00,1872.00,162.85,1034.40,,Hospital CPT 73218,HC MRI-Upper Ext WO Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,210.88,N/A,1110.00,N/A,827.90,N/A,510.09,N/A,340.90,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1461.00,,Hospital CPT 73220,HC MRI-Upper Ext W & WO Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,348.03,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,301.57,N/A,331.73,2851.80,2851.80,301.57,1930.80,,Hospital CPT 73223,HC MRI-Upper Ext Jnt W & WO Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,4753.00,3218.00,2851.80,1930.80,N/A,450.52,N/A,332.71,N/A,1110.00,N/A,1094.12,N/A,804.78,N/A,450.52,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,1110.00,N/A,332.71,N/A,450.52,N/A,1060.00,N/A,1060.00,N/A,450.52,N/A,332.71,N/A,332.71,N/A,365.98,2851.80,2851.80,332.71,1930.80,,Hospital CPT 73502,HC X-Ray Exam Hip Uni 2-3 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,557.00,557.00,334.20,334.20,N/A,77.98,N/A,78.46,N/A,320.72,N/A,189.38,N/A,189.77,N/A,77.98,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,320.72,N/A,78.46,N/A,77.98,N/A,298.55,N/A,298.55,N/A,77.98,N/A,78.46,N/A,78.46,N/A,86.30,334.20,334.20,77.98,334.20,,Hospital CPT 73503,HC X-Ray Exam Uni Hip W/Pelvis 4/> Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,701.00,701.00,420.60,420.60,N/A,98.14,N/A,101.95,N/A,403.64,N/A,238.34,N/A,233.46,N/A,98.14,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,403.64,N/A,96.52,N/A,98.14,N/A,375.74,N/A,375.74,N/A,98.14,N/A,96.52,N/A,41.19,N/A,45.31,420.60,420.60,41.19,420.60,,Hospital CPT 73522,HC X-Ray Exam Bil Hips W/Pelvis 3-4 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1446.00,1446.00,867.60,867.60,N/A,202.44,N/A,35.47,N/A,832.61,N/A,491.64,N/A,233.46,N/A,202.44,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,832.61,N/A,96.52,N/A,202.44,N/A,775.06,N/A,775.06,N/A,202.44,N/A,96.52,N/A,35.47,N/A,39.02,867.60,867.60,35.47,867.60,,Hospital CPT 73551,HC X-Ray Femur 1 View,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,434.00,434.00,260.40,260.40,N/A,60.76,N/A,82.07,N/A,249.90,N/A,147.56,N/A,189.77,N/A,60.76,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,249.90,N/A,78.46,N/A,60.76,N/A,232.62,N/A,232.62,N/A,60.76,N/A,78.46,N/A,82.07,N/A,20.82,260.40,260.40,20.82,260.40,,Hospital CPT 73552,HC X-Ray Exam of Femur Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,869.00,869.00,521.40,521.40,N/A,121.66,N/A,78.46,N/A,500.37,N/A,295.46,N/A,189.77,N/A,121.66,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,500.37,N/A,78.46,N/A,121.66,N/A,465.78,N/A,465.78,N/A,121.66,N/A,78.46,N/A,78.46,N/A,86.30,521.40,521.40,78.46,521.40,,Hospital CPT 73560,HC X-Ray Knee 1-2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,502.00,502.00,301.20,301.20,N/A,70.28,N/A,78.46,N/A,289.05,N/A,170.68,N/A,189.77,N/A,70.28,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,289.05,N/A,78.46,N/A,70.28,N/A,269.07,N/A,269.07,N/A,70.28,N/A,78.46,N/A,78.46,N/A,86.30,301.20,301.20,70.28,301.20,,Hospital CPT 73564,HC X-Ray Knee Rout Inc Tun Pat Min 4 View,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,916.00,916.00,549.60,549.60,N/A,128.24,N/A,96.52,N/A,527.43,N/A,311.44,N/A,233.46,N/A,128.24,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,527.43,N/A,96.52,N/A,128.24,N/A,490.98,N/A,490.98,N/A,128.24,N/A,96.52,N/A,96.52,N/A,106.17,549.60,549.60,96.52,549.60,,Hospital CPT 73565,HC X-Ray Knee Standing Ap,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,299.00,299.00,179.40,179.40,N/A,41.86,N/A,82.07,N/A,172.16,N/A,101.66,N/A,189.77,N/A,41.86,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,172.16,N/A,78.46,N/A,41.86,N/A,160.26,N/A,160.26,N/A,41.86,N/A,78.46,N/A,28.86,N/A,31.75,179.40,179.40,28.86,189.77,,Hospital CPT 73592,HC X-Ray Low Ext Infant Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,565.00,565.00,339.00,339.00,N/A,79.10,N/A,81.15,N/A,325.33,N/A,192.10,N/A,189.77,N/A,79.10,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,325.33,N/A,78.46,N/A,79.10,N/A,302.84,N/A,302.84,N/A,79.10,N/A,78.46,N/A,81.15,N/A,23.80,339.00,339.00,23.80,339.00,,Hospital CPT 73650,HC X-Ray Os Calcis Min 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,769.00,769.00,461.40,461.40,N/A,107.66,N/A,78.46,N/A,442.79,N/A,261.46,N/A,189.77,N/A,107.66,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,442.79,N/A,78.46,N/A,107.66,N/A,412.18,N/A,412.18,N/A,107.66,N/A,78.46,N/A,78.46,N/A,86.30,461.40,461.40,78.46,461.40,,Hospital CPT 73721,HC MRI Lower Ext Jnt W/O Cont,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,3273.00,1599.00,1963.80,959.40,N/A,223.86,N/A,210.88,N/A,1110.00,N/A,543.66,N/A,510.09,N/A,223.86,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,223.86,N/A,1060.00,N/A,1060.00,N/A,223.86,N/A,210.88,N/A,210.88,N/A,231.97,1963.80,1963.80,210.88,1110.00,,Hospital CPT 74019,HC X-Ray Exam Abdomen 2 Views,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1054.00,1054.00,632.40,632.40,N/A,147.56,N/A,96.52,N/A,606.89,N/A,358.36,N/A,233.46,N/A,147.56,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,606.89,N/A,96.52,N/A,147.56,N/A,564.94,N/A,564.94,N/A,147.56,N/A,96.52,N/A,96.52,N/A,106.17,632.40,632.40,96.52,632.40,,Hospital CPT 74022,HC X-Ray Abdominal Series Complete,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1411.00,1411.00,846.60,846.60,N/A,197.54,N/A,96.52,N/A,812.45,N/A,479.74,N/A,233.46,N/A,197.54,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,812.45,N/A,96.52,N/A,197.54,N/A,756.30,N/A,756.30,N/A,197.54,N/A,96.52,N/A,96.52,N/A,106.17,846.60,846.60,96.52,846.60,,Hospital CPT 74160,HC CT Abdomen W/ Cont,N/A,0352 - CT SCAN - BODY SCAN,2774.00,1128.00,1664.40,676.80,N/A,157.92,N/A,162.85,N/A,914.00,N/A,383.52,N/A,393.92,N/A,157.92,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,157.92,N/A,689.00,N/A,689.00,N/A,157.92,N/A,162.85,N/A,162.85,N/A,179.14,1664.40,1664.40,157.92,914.00,,Hospital CPT 74174,HC Cta Abd & Pelvis W & W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,332.71,N/A,914.00,N/A,586.16,N/A,804.78,N/A,241.36,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,914.00,N/A,332.71,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,332.71,N/A,332.71,N/A,365.98,1872.00,1872.00,241.36,1034.40,,Hospital CPT 74175,HC CT Angio Abdomen W & W/O Cont,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,162.85,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1034.40,,Hospital 74221,HC X-Ray Xm Esophagus Double Cntrst,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,71473.42,914.78,42884.05,548.87,5869.15,128.07,13184.76,72.16,13226.60,526.74,24300.96,311.03,13872.42,393.92,6049.99,128.07,13184.76,162.85,7208.54,162.85,N/A,245.22,13872.42,393.92,N/A,393.92,13872.42,393.92,13226.60,526.75,13184.76,162.85,6049.99,128.07,15886.89,410.04,15886.89,410.04,6049.99,128.07,7208.54,162.85,7208.54,165.05,6473.49,79.38,5869.15,42884.05,72.16,548.87,,Hospital CPT 74230,HC Dysphagia/Swallowing Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1593.00,1593.00,955.80,955.80,N/A,223.02,N/A,162.85,N/A,917.25,N/A,541.62,N/A,393.92,N/A,223.02,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,917.25,N/A,162.85,N/A,223.02,N/A,853.85,N/A,853.85,N/A,223.02,N/A,162.85,N/A,162.85,N/A,179.14,955.80,955.80,162.85,955.80,,Hospital CPT 74246,HC Radiologic Exam Upr GI Trc Double Contrast Study,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1268.00,1001.00,760.80,600.60,N/A,140.14,N/A,162.85,N/A,576.38,N/A,340.34,N/A,393.92,N/A,140.14,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,576.38,N/A,162.85,N/A,140.14,N/A,536.54,N/A,536.54,N/A,140.14,N/A,162.85,N/A,162.85,N/A,179.14,760.80,760.80,140.14,600.60,,Hospital 74251,HC Enteroclysis Small Bowel,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,917.00,N/A,550.20,N/A,128.38,N/A,170.35,N/A,528.01,N/A,311.78,N/A,393.92,N/A,128.38,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,528.01,N/A,162.85,N/A,128.38,N/A,491.51,N/A,491.51,N/A,128.38,N/A,162.85,N/A,170.35,N/A,326.48,N/A,N/A,128.38,550.20,,Hospital 74262,HC CT Cologrph Dx WO/W Cont,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,N/A,1560.00,N/A,936.00,N/A,218.40,N/A,344.28,N/A,914.00,N/A,530.40,N/A,393.92,N/A,218.40,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,218.40,N/A,689.00,N/A,689.00,N/A,218.40,N/A,162.85,N/A,344.28,N/A,378.71,N/A,N/A,162.85,936.00,,Hospital CPT 74270,HC Flouro X-Ray Barium Enema,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,937.00,739.00,562.20,443.40,N/A,103.46,N/A,162.85,N/A,425.52,N/A,251.26,N/A,393.92,N/A,103.46,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,425.52,N/A,162.85,N/A,103.46,N/A,396.10,N/A,396.10,N/A,103.46,N/A,162.85,N/A,162.85,N/A,179.14,562.20,562.20,103.46,443.40,,Hospital 74301,HC X-Ray Oper Cholangio Addnl Set,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,44265.15,N/A,26559.09,N/A,6961.68,N/A,8500.95,N/A,15688.71,N/A,15050.15,N/A,15838.79,N/A,7176.18,N/A,1686.00,N/A,1686.00,N/A,9859.28,N/A,15838.79,N/A,15838.79,N/A,15838.79,N/A,15688.71,N/A,8500.95,N/A,7176.18,N/A,18844.20,N/A,18844.20,N/A,8434.62,N/A,8500.95,N/A,8500.95,N/A,7678.51,N/A,1686.00,26559.09,N/A,N/A,,Hospital CPT 74328,HC X-Ray Bile Duct Endoscopy,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1465.00,1465.00,879.00,879.00,N/A,205.10,N/A,1465.00,N/A,843.55,N/A,498.10,N/A,1465.00,N/A,205.10,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,1465.00,N/A,843.55,N/A,1465.00,N/A,205.10,N/A,785.24,N/A,785.24,N/A,205.10,N/A,1465.00,N/A,1465.00,N/A,1465.00,879.00,879.00,205.10,1465.00,,Hospital CPT 74330,HC Ercp Biliary and Pancreatic,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,3356.00,2650.00,2013.60,1590.00,N/A,371.00,N/A,2650.00,N/A,1525.87,N/A,901.00,N/A,2650.00,N/A,371.00,N/A,2650.00,N/A,2650.00,N/A,2650.00,N/A,2650.00,N/A,2650.00,N/A,2650.00,N/A,1525.87,N/A,2650.00,N/A,371.00,N/A,1420.40,N/A,1420.40,N/A,371.00,N/A,2650.00,N/A,2650.00,N/A,2650.00,2013.60,2013.60,371.00,2650.00,,Hospital CPT 74340,HC Feeding Tube Placement,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,466.00,366.00,279.60,219.60,N/A,51.24,N/A,366.00,N/A,210.74,N/A,124.44,N/A,366.00,N/A,51.24,N/A,366.00,N/A,366.00,N/A,366.00,N/A,366.00,N/A,366.00,N/A,366.00,N/A,210.74,N/A,366.00,N/A,51.24,N/A,196.18,N/A,196.18,N/A,51.24,N/A,366.00,N/A,366.00,N/A,366.00,279.60,279.60,51.24,366.00,,Hospital CPT 74355,HC Perc Placement Entero Tube,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,643.00,643.00,385.80,385.80,N/A,90.02,N/A,643.00,N/A,370.24,N/A,218.62,N/A,90.02,N/A,90.02,N/A,643.00,N/A,643.00,N/A,55.94,N/A,90.02,N/A,90.02,N/A,90.02,N/A,370.24,N/A,643.00,N/A,90.02,N/A,344.65,N/A,344.65,N/A,90.02,N/A,643.00,N/A,643.00,N/A,643.00,385.80,385.80,55.94,643.00,,Hospital 74400,"HC Uro/Pyelo, IV W/WO Kub, W/WO Tomography",N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,43654.58,1754.00,26192.75,1052.40,7528.22,245.56,9171.14,170.35,17407.26,1009.56,14842.56,596.36,17127.73,422.92,7760.17,245.56,1686.00,162.85,1686.00,162.85,10661.62,264.57,17127.73,422.92,18506.48,422.92,17127.73,422.92,17407.26,1009.56,9171.14,162.85,7760.17,245.56,20377.73,924.60,20377.73,924.60,4434.42,245.56,9171.14,162.85,9171.14,170.35,8303.39,114.11,1686.00,26192.75,114.11,1052.40,,Hospital CPT 74420,HC Retrograde,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1710.00,1350.00,1026.00,810.00,N/A,189.00,N/A,332.71,N/A,777.33,N/A,459.00,N/A,804.78,N/A,189.00,N/A,332.71,N/A,332.71,N/A,500.99,N/A,804.78,N/A,804.78,N/A,804.78,N/A,777.33,N/A,332.71,N/A,189.00,N/A,723.60,N/A,723.60,N/A,189.00,N/A,332.71,N/A,332.71,N/A,365.98,1026.00,1026.00,189.00,810.00,,Hospital CPT 74450,HC Retro Urethrocystography S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,670.00,670.00,402.00,402.00,N/A,93.80,N/A,213.16,N/A,385.79,N/A,227.80,N/A,510.09,N/A,93.80,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,385.79,N/A,210.88,N/A,93.80,N/A,359.12,N/A,359.12,N/A,93.80,N/A,210.88,N/A,213.16,N/A,670.00,402.00,402.00,93.80,670.00,,Hospital CPT 74485,HC Dilate Nephrost Ureter Urethra,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,2589.00,2043.00,1553.40,1225.80,N/A,286.02,N/A,1693.17,N/A,1176.36,N/A,694.62,N/A,2043.00,N/A,286.02,N/A,1675.03,N/A,1675.03,N/A,2043.00,N/A,2043.00,N/A,2043.00,N/A,2043.00,N/A,1176.36,N/A,1675.03,N/A,286.02,N/A,1095.05,N/A,1095.05,N/A,286.02,N/A,1675.03,N/A,1693.17,N/A,81.03,1553.40,1553.40,81.03,2043.00,,Hospital CPT 74740,HC Hysterosalpingogram,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1804.00,1425.00,1082.40,855.00,N/A,199.50,N/A,210.88,N/A,820.52,N/A,484.50,N/A,510.09,N/A,199.50,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,820.52,N/A,210.88,N/A,199.50,N/A,763.80,N/A,763.80,N/A,199.50,N/A,210.88,N/A,210.88,N/A,231.97,1082.40,1082.40,199.50,855.00,,Hospital CPT 75557,HC MRI-Myocardium WO Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,1241.00,973.00,744.60,583.80,N/A,136.22,N/A,232.62,N/A,973.00,N/A,330.82,N/A,510.09,N/A,136.22,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,973.00,N/A,210.88,N/A,136.22,N/A,973.00,N/A,973.00,N/A,136.22,N/A,210.88,N/A,167.19,N/A,183.91,744.60,744.60,136.22,973.00,,Hospital 75559,HC Cardiac MRI WO Cont With Stress Imaging,N/A,0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER,N/A,6628.20,N/A,3976.92,N/A,927.95,N/A,798.88,N/A,2705.29,N/A,2253.59,N/A,1958.48,N/A,927.95,N/A,763.72,N/A,763.72,N/A,1219.19,N/A,1958.48,N/A,1958.48,N/A,1958.48,N/A,2705.29,N/A,763.72,N/A,927.95,N/A,1060.00,N/A,1060.00,N/A,927.95,N/A,763.72,N/A,798.88,N/A,522.93,N/A,N/A,522.93,3976.92,,Hospital CPT 75573,HC Cta Heart Ejection Fract,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,2774.00,1724.00,1664.40,1034.40,N/A,241.36,N/A,176.77,N/A,914.00,N/A,586.16,N/A,862.68,N/A,241.36,N/A,176.77,N/A,176.77,N/A,537.02,N/A,862.68,N/A,862.68,N/A,862.68,N/A,914.00,N/A,176.77,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,176.77,N/A,176.77,N/A,194.45,1664.40,1664.40,176.77,1034.40,,Hospital CPT 75574,HC Cta Heart W/WO Calcium,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,2774.00,1724.00,1664.40,1034.40,N/A,241.36,N/A,170.35,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,170.35,N/A,221.90,1664.40,1664.40,162.85,1034.40,,Hospital CPT 75605,"HC Aortography, Thoracic, by Serialography, Radiological S&I",N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,8877.00,8877.00,5326.20,5326.20,N/A,1242.78,N/A,4765.38,N/A,5111.38,N/A,3018.18,N/A,8877.00,N/A,1242.78,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,8877.00,N/A,8877.00,N/A,8877.00,N/A,5111.38,N/A,4641.41,N/A,1242.78,N/A,4758.07,N/A,4758.07,N/A,1242.78,N/A,4641.41,N/A,4765.38,N/A,67.45,5326.20,5326.20,67.45,8877.00,,Hospital CPT 75625,HC Abdominal Aortogram,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,6437.00,6437.00,3862.20,3862.20,N/A,901.18,N/A,2690.13,N/A,3706.42,N/A,2188.58,N/A,6437.00,N/A,901.18,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6437.00,N/A,6437.00,N/A,6437.00,N/A,3706.42,N/A,2690.13,N/A,901.18,N/A,3450.23,N/A,3450.23,N/A,901.18,N/A,2690.13,N/A,2690.13,N/A,2959.14,3862.20,3862.20,901.18,6437.00,,Hospital CPT 75630,HC Abd Aortogram With Runoffs,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,6786.00,6786.00,4071.60,4071.60,N/A,950.04,N/A,58.63,N/A,3907.38,N/A,2307.24,N/A,6507.21,N/A,950.04,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,3907.38,N/A,2690.13,N/A,950.04,N/A,3637.30,N/A,3637.30,N/A,950.04,N/A,2690.13,N/A,2813.99,N/A,2959.14,4071.60,4071.60,58.63,6507.21,,Hospital CPT 75635,HC Cta Abdominal Aorta W Runoffs,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,162.85,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1034.40,,Hospital CPT 75635,HC Cta Aorta W/Contrast,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,162.85,N/A,914.00,N/A,586.16,N/A,393.92,N/A,241.36,N/A,162.85,N/A,162.85,N/A,245.22,N/A,393.92,N/A,393.92,N/A,393.92,N/A,914.00,N/A,162.85,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,162.85,N/A,162.85,N/A,179.14,1872.00,1872.00,162.85,1034.40,,Hospital 75705,HC Spinal Angiography/Selective,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,374888.23,75719.18,224932.94,45431.51,43036.91,10593.22,11375.91,10027.43,160728.52,43338.37,N/A,25744.52,N/A,23310.60,43036.91,10593.22,11375.91,9586.05,11375.91,9586.05,N/A,14511.28,N/A,23310.60,N/A,23310.60,N/A,23310.60,160728.52,43338.38,11375.91,9586.05,43036.91,10593.22,160728.52,12055.25,183792.41,12055.25,43036.91,10593.22,11375.91,9586.05,11375.91,10027.43,43036.91,1441.83,11375.91,224932.94,1441.83,45431.51,,Hospital CPT 75710,HC Extremity Arteriogram Unilateral,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,5331.00,5331.00,3198.60,3198.60,N/A,746.34,N/A,2690.13,N/A,3069.59,N/A,1812.54,N/A,5331.00,N/A,746.34,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,5331.00,N/A,5331.00,N/A,5331.00,N/A,3069.59,N/A,2690.13,N/A,746.34,N/A,2857.42,N/A,2857.42,N/A,746.34,N/A,2690.13,N/A,2690.13,N/A,2959.14,3198.60,3198.60,746.34,5331.00,,Hospital CPT 75716,HC Extremity Arteriogram Bilateral,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,8762.00,8762.00,5257.20,5257.20,N/A,1226.68,N/A,2690.13,N/A,5045.16,N/A,2979.08,N/A,6507.21,N/A,1226.68,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5045.16,N/A,2690.13,N/A,1226.68,N/A,4696.43,N/A,4696.43,N/A,1226.68,N/A,2690.13,N/A,2690.13,N/A,2959.14,5257.20,5257.20,1226.68,6507.21,,Hospital CPT 75716,HC Artery X-Rays Arms/Legs (Cath),N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,8762.00,8762.00,5257.20,5257.20,N/A,1226.68,N/A,2690.13,N/A,5045.16,N/A,2979.08,N/A,6507.21,N/A,1226.68,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,5045.16,N/A,2690.13,N/A,1226.68,N/A,4696.43,N/A,4696.43,N/A,1226.68,N/A,2690.13,N/A,2690.13,N/A,2959.14,5257.20,5257.20,1226.68,6507.21,,Hospital CPT 75731,HC Adrenal Arteriogram Unilateral,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,4343.00,4343.00,2605.80,2605.80,N/A,608.02,N/A,2813.99,N/A,2500.70,N/A,1476.62,N/A,4343.00,N/A,608.02,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,4343.00,N/A,4343.00,N/A,4343.00,N/A,2500.70,N/A,2690.13,N/A,608.02,N/A,2327.85,N/A,2327.85,N/A,608.02,N/A,2690.13,N/A,2813.99,N/A,95.90,2605.80,2605.80,95.90,4343.00,,Hospital CPT 75736,HC Pelvis Arteriogram,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,7539.00,7539.00,4523.40,4523.40,N/A,1055.46,N/A,4855.12,N/A,4340.96,N/A,2563.26,N/A,7539.00,N/A,1055.46,N/A,4641.41,N/A,4641.41,N/A,6989.13,N/A,7539.00,N/A,7539.00,N/A,7539.00,N/A,4340.96,N/A,4641.41,N/A,1055.46,N/A,4040.90,N/A,4040.90,N/A,1055.46,N/A,4641.41,N/A,4855.12,N/A,87.96,4523.40,4523.40,87.96,7539.00,,Hospital CPT 75741,HC Pulmonary Arteriogram Uni,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,11157.00,11157.00,6694.20,6694.20,N/A,1561.98,N/A,63.74,N/A,6424.20,N/A,3793.38,N/A,364.77,N/A,1561.98,N/A,63.74,N/A,63.74,N/A,227.07,N/A,364.77,N/A,364.77,N/A,364.77,N/A,6424.20,N/A,63.74,N/A,1561.98,N/A,5980.15,N/A,5980.15,N/A,1561.98,N/A,63.74,N/A,63.74,N/A,70.11,6694.20,6694.20,63.74,6694.20,,Hospital CPT 75756,HC Angio Int Mammary S&I,N/A,0321 - RADIOLOGY - DIAGNOSTIC - ANGIOCARDIOGRAPHY,8023.00,8023.00,4813.80,4813.80,N/A,1123.22,N/A,93.20,N/A,4619.64,N/A,2727.82,N/A,444.21,N/A,1123.22,N/A,93.20,N/A,93.20,N/A,276.52,N/A,444.21,N/A,444.21,N/A,444.21,N/A,4619.64,N/A,93.20,N/A,1123.22,N/A,4300.33,N/A,4300.33,N/A,1123.22,N/A,93.20,N/A,93.20,N/A,102.52,4813.80,4813.80,93.20,4813.80,,Hospital CPT 75820,HC Fluoro Xray Venogram Ext Unil,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,2333.00,1842.00,1399.80,1105.20,N/A,257.88,N/A,1343.59,N/A,1060.62,N/A,626.28,N/A,1842.00,N/A,257.88,N/A,1343.59,N/A,1343.59,N/A,1842.00,N/A,1842.00,N/A,1842.00,N/A,1842.00,N/A,1060.62,N/A,1343.59,N/A,257.88,N/A,987.31,N/A,987.31,N/A,257.88,N/A,1343.59,N/A,1343.59,N/A,1477.95,1399.80,1399.80,257.88,1842.00,,Hospital CPT 75822,HC Venography Extremity Bilateral,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4894.00,3865.00,2936.40,2319.00,N/A,541.10,N/A,1371.53,N/A,2225.47,N/A,1314.10,N/A,3250.03,N/A,541.10,N/A,1343.59,N/A,1343.59,N/A,2023.21,N/A,3250.03,N/A,3250.03,N/A,3250.03,N/A,2225.47,N/A,1343.59,N/A,541.10,N/A,2071.64,N/A,2071.64,N/A,541.10,N/A,1343.59,N/A,1379.48,N/A,65.15,2936.40,2936.40,65.15,3250.03,,Hospital CPT 75825,HC Venography Canal Inferior,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,4343.00,3731.00,2605.80,2238.60,N/A,522.34,N/A,2813.99,N/A,2148.31,N/A,1268.54,N/A,3731.00,N/A,522.34,N/A,2690.13,N/A,2690.13,N/A,3731.00,N/A,3731.00,N/A,3731.00,N/A,3731.00,N/A,2148.31,N/A,2690.13,N/A,522.34,N/A,1999.82,N/A,1999.82,N/A,522.34,N/A,2690.13,N/A,55.62,N/A,2959.14,2605.80,2605.80,55.62,3731.00,,Hospital 75840,HC Veno Adrenal Unilat Sel S&I Rt,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,239039.13,N/A,143423.48,N/A,28308.16,N/A,29170.64,N/A,131758.37,N/A,81273.31,N/A,N/A,N/A,25187.57,N/A,2810.00,N/A,32008.96,N/A,51823.69,N/A,N/A,N/A,N/A,N/A,83233.43,N/A,131758.37,N/A,29170.64,N/A,25187.57,N/A,125386.47,N/A,N/A,N/A,19705.28,N/A,29170.64,N/A,32008.96,N/A,26950.70,N/A,2810.00,143423.48,N/A,N/A,,Hospital 75894,HC Transcath Therapy Emboliz S&,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,208571.75,65499.33,125143.05,39299.60,20634.13,9169.92,16650.44,4800.54,114964.75,37710.02,70914.39,20498.05,72624.68,11261.04,17235.10,9169.92,16650.44,4641.41,16650.44,4641.41,45218.36,7010.22,72624.68,11261.04,72624.68,11261.04,72624.68,11261.04,114964.75,37710.03,16650.44,4641.41,17235.10,9169.92,122789.28,7983.50,122789.28,7983.50,14379.58,9169.92,16650.44,4641.41,16650.44,4800.54,18441.55,836.53,14379.58,125143.05,836.53,39299.60,,Hospital CPT 75898,HC Angiogram F/U Study,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,7447.00,7447.00,4468.20,4468.20,N/A,1042.58,N/A,2967.53,N/A,4287.98,N/A,2531.98,N/A,6507.21,N/A,1042.58,N/A,2690.13,N/A,2690.13,N/A,4050.86,N/A,6507.21,N/A,6507.21,N/A,6507.21,N/A,4287.98,N/A,2690.13,N/A,1042.58,N/A,3991.59,N/A,3991.59,N/A,1042.58,N/A,2690.13,N/A,2861.72,N/A,7447.00,4468.20,4468.20,1042.58,7447.00,,Hospital CPT 75901,HC Catheter Stripping Procedure,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,670.00,528.00,402.00,316.80,N/A,73.92,N/A,195.44,N/A,304.02,N/A,179.52,N/A,528.00,N/A,73.92,N/A,195.44,N/A,195.44,N/A,387.34,N/A,528.00,N/A,528.00,N/A,528.00,N/A,304.02,N/A,195.44,N/A,73.92,N/A,283.01,N/A,283.01,N/A,73.92,N/A,195.44,N/A,195.44,N/A,214.98,402.00,402.00,73.92,528.00,,Hospital 75902,HC Mech Removal Intracath S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,N/A,28650.88,N/A,17190.53,N/A,4011.11,N/A,2861.72,N/A,16474.58,N/A,9741.29,N/A,6523.72,N/A,4011.11,N/A,2690.13,N/A,2690.13,N/A,4061.12,N/A,6523.72,N/A,6523.72,N/A,6523.72,N/A,16474.58,N/A,2690.13,N/A,4011.11,N/A,5277.50,N/A,5277.50,N/A,4011.11,N/A,2690.13,N/A,2861.72,N/A,548.56,N/A,N/A,548.56,17190.53,,Hospital 75957,HC Xray Endovasc Thor Ao Repr,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,1345756.58,N/A,807453.95,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,N/A,N/A,N/A,N/A,173728.29,N/A,173728.29,807453.95,N/A,N/A,,Hospital 75970,HC Transcatheter Biopsy S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,80287.75,29813.85,48172.65,17888.31,5046.55,4176.10,6235.45,4691.68,11372.81,17166.39,27297.84,10136.71,60576.47,11233.34,5202.04,4176.10,6235.45,4641.41,6996.64,4641.41,60576.47,6992.96,60576.47,11233.34,60576.47,11233.34,11481.60,11233.34,17604.50,17166.39,6996.64,4641.41,N/A,4176.10,17604.50,8160.50,13660.24,8160.50,N/A,4176.10,6235.45,4641.41,6996.64,4691.68,N/A,730.43,5046.55,60576.47,730.43,17888.31,,Hospital CPT 75989,HC Rad Guide for Perc Drain Tube,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,3698.00,3698.00,2218.80,2218.80,N/A,517.72,N/A,53.52,N/A,2129.31,N/A,1257.32,N/A,3698.00,N/A,517.72,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,2129.31,N/A,3698.00,N/A,517.72,N/A,1982.13,N/A,1982.13,N/A,517.72,N/A,3698.00,N/A,53.52,N/A,58.87,2218.80,2218.80,53.52,3698.00,,Hospital CPT 75989,HC CT-Guided Aspiration,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,3698.00,3698.00,2218.80,2218.80,N/A,517.72,N/A,53.52,N/A,914.00,N/A,1257.32,N/A,3698.00,N/A,517.72,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,3698.00,N/A,914.00,N/A,3698.00,N/A,517.72,N/A,689.00,N/A,689.00,N/A,517.72,N/A,3698.00,N/A,53.52,N/A,58.87,2218.80,2218.80,53.52,3698.00,,Hospital CPT 76000,Fluoroscopy Up to 1 Hour Physician/Qhp Time,N/A,N/A,86.00,86.00,51.60,51.60,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,N/A,86.00,51.60,51.60,51.60,86.00,,Hospital CPT 76000,HC Repositioning Vad Under Fluoro,N/A,0323 - RADIOLOGY - DIAGNOSTIC - ARTERIOGRAPHY,679.00,679.00,407.40,407.40,N/A,95.06,N/A,210.88,N/A,390.97,N/A,230.86,N/A,510.09,N/A,95.06,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,390.97,N/A,210.88,N/A,95.06,N/A,363.94,N/A,363.94,N/A,95.06,N/A,210.88,N/A,210.88,N/A,231.97,407.40,407.40,95.06,510.09,,Hospital CPT 76000,HC Fluoroscopy Up to 1 Hour,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,679.00,679.00,407.40,407.40,N/A,95.06,N/A,210.88,N/A,390.97,N/A,230.86,N/A,510.09,N/A,95.06,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,390.97,N/A,210.88,N/A,95.06,N/A,363.94,N/A,363.94,N/A,95.06,N/A,210.88,N/A,210.88,N/A,231.97,407.40,407.40,95.06,510.09,,Hospital CPT 76010,HC Nose to Rectum Child,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,264.00,264.00,158.40,158.40,N/A,36.96,N/A,81.15,N/A,152.01,N/A,89.76,N/A,189.77,N/A,36.96,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,152.01,N/A,78.46,N/A,36.96,N/A,141.50,N/A,141.50,N/A,36.96,N/A,78.46,N/A,81.15,N/A,86.30,158.40,158.40,36.96,189.77,,Hospital CPT 76080,HC Sinogram,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,739.00,585.00,443.40,351.00,N/A,81.90,N/A,32.16,N/A,336.84,N/A,198.90,N/A,585.00,N/A,81.90,N/A,454.35,N/A,454.35,N/A,585.00,N/A,585.00,N/A,585.00,N/A,585.00,N/A,336.84,N/A,454.35,N/A,81.90,N/A,313.56,N/A,313.56,N/A,81.90,N/A,454.35,N/A,450.42,N/A,35.38,443.40,443.40,32.16,585.00,,Hospital CPT 76497,HC Cta/Cardiac Unlisted CT,N/A,0352 - CT SCAN - BODY SCAN,3120.00,1724.00,1872.00,1034.40,N/A,241.36,N/A,82.07,N/A,914.00,N/A,586.16,N/A,189.77,N/A,241.36,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,914.00,N/A,78.46,N/A,241.36,N/A,689.00,N/A,689.00,N/A,241.36,N/A,78.46,N/A,82.07,N/A,1724.00,1872.00,1872.00,78.46,1724.00,,Hospital CPT 76499,HC Radiographic Procedure Unlisted,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,204.00,204.00,122.40,122.40,N/A,28.56,N/A,80.09,N/A,117.46,N/A,69.36,N/A,189.77,N/A,28.56,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,117.46,N/A,78.46,N/A,28.56,N/A,109.34,N/A,109.34,N/A,28.56,N/A,78.46,N/A,85.01,N/A,204.00,122.40,122.40,28.56,204.00,,Hospital CPT 76506,HC Neonatal Head,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,400.00,400.00,240.00,240.00,N/A,56.00,N/A,95.68,N/A,230.32,N/A,136.00,N/A,233.46,N/A,56.00,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,230.32,N/A,96.52,N/A,56.00,N/A,214.40,N/A,214.40,N/A,56.00,N/A,96.52,N/A,95.68,N/A,106.17,240.00,240.00,56.00,240.00,,Hospital 76512,HC Ophthalmic US Dx B-Scan,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital 76514,HC Echo Exam of Eye Thickness,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,494.00,N/A,296.40,N/A,69.16,N/A,111.11,N/A,284.44,N/A,167.96,N/A,N/A,N/A,69.16,N/A,104.85,N/A,104.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,284.44,N/A,104.85,N/A,69.16,N/A,25.19,N/A,25.19,N/A,69.16,N/A,104.85,N/A,111.11,N/A,53.54,N/A,N/A,25.19,296.40,,Hospital CPT 76641,HC US Breast Comp,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1215.00,911.00,729.00,546.60,N/A,127.54,N/A,96.52,N/A,524.55,N/A,309.74,N/A,233.46,N/A,127.54,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,524.55,N/A,96.52,N/A,127.54,N/A,488.30,N/A,488.30,N/A,127.54,N/A,96.52,N/A,96.52,N/A,106.17,729.00,729.00,96.52,546.60,,Hospital CPT 76705,HC US Abdominal Limited,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,851.00,851.00,510.60,510.60,N/A,119.14,N/A,96.52,N/A,490.01,N/A,289.34,N/A,233.46,N/A,119.14,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,490.01,N/A,96.52,N/A,119.14,N/A,456.14,N/A,456.14,N/A,119.14,N/A,96.52,N/A,96.52,N/A,106.17,510.60,510.60,96.52,510.60,,Hospital CPT 76800,HC US Spinal Canal and Contents,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,606.00,606.00,363.60,363.60,N/A,84.84,N/A,98.52,N/A,348.93,N/A,206.04,N/A,233.46,N/A,84.84,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,348.93,N/A,96.52,N/A,84.84,N/A,324.82,N/A,324.82,N/A,84.84,N/A,96.52,N/A,98.52,N/A,86.99,363.60,363.60,84.84,363.60,,Hospital CPT 76802,HC Fetal Eval 1st Trim @ Addl Ges,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,532.00,532.00,319.20,319.20,N/A,74.48,N/A,532.00,N/A,306.33,N/A,180.88,N/A,532.00,N/A,74.48,N/A,532.00,N/A,532.00,N/A,532.00,N/A,532.00,N/A,532.00,N/A,532.00,N/A,306.33,N/A,532.00,N/A,74.48,N/A,285.15,N/A,285.15,N/A,74.48,N/A,532.00,N/A,532.00,N/A,21.18,319.20,319.20,21.18,532.00,,Hospital CPT 76810,HC Fetal Eval 2-3 Trim @ Addl Gest,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,532.00,532.00,319.20,319.20,N/A,74.48,N/A,532.00,N/A,306.33,N/A,180.88,N/A,532.00,N/A,74.48,N/A,532.00,N/A,532.00,N/A,532.00,N/A,532.00,N/A,532.00,N/A,532.00,N/A,306.33,N/A,532.00,N/A,74.48,N/A,285.15,N/A,285.15,N/A,74.48,N/A,532.00,N/A,532.00,N/A,41.34,319.20,319.20,41.34,532.00,,Hospital CPT 76812,HC Detail Fetal Anat Exam +Gest,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,189.00,189.00,113.40,113.40,N/A,26.46,N/A,189.00,N/A,108.83,N/A,64.26,N/A,189.00,N/A,26.46,N/A,189.00,N/A,189.00,N/A,189.00,N/A,189.00,N/A,189.00,N/A,189.00,N/A,108.83,N/A,189.00,N/A,26.46,N/A,101.30,N/A,101.30,N/A,26.46,N/A,189.00,N/A,189.00,N/A,107.48,113.40,113.40,26.46,189.00,,Hospital 76813,HC US OB 1st Tr Fetal Translu Sgl,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,3098.00,N/A,1858.80,N/A,433.72,N/A,102.67,N/A,1783.83,N/A,1053.32,N/A,233.46,N/A,433.72,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1783.83,N/A,96.52,N/A,433.72,N/A,165.62,N/A,165.62,N/A,433.72,N/A,96.52,N/A,102.67,N/A,131.95,N/A,N/A,96.52,1858.80,,Hospital CPT 76816,HC Fetal Eval Follow-Up/Repeat,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,792.00,792.00,475.20,475.20,N/A,110.88,N/A,106.47,N/A,456.03,N/A,269.28,N/A,233.46,N/A,110.88,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,456.03,N/A,96.52,N/A,110.88,N/A,424.51,N/A,424.51,N/A,110.88,N/A,96.52,N/A,62.54,N/A,68.79,475.20,475.20,62.54,475.20,,Hospital CPT 76818,"HC Ultrasound, Fetal Biophys",N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1762.00,1762.00,1057.20,1057.20,N/A,246.68,N/A,96.52,N/A,1014.56,N/A,599.08,N/A,233.46,N/A,246.68,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1014.56,N/A,96.52,N/A,246.68,N/A,944.43,N/A,944.43,N/A,246.68,N/A,96.52,N/A,96.52,N/A,106.17,1057.20,1057.20,96.52,1057.20,,Hospital CPT 76819,HC Fetal Bio W/O Nonstress Test,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,1147.00,1147.00,688.20,688.20,N/A,160.58,N/A,96.52,N/A,660.44,N/A,389.98,N/A,233.46,N/A,160.58,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,660.44,N/A,96.52,N/A,160.58,N/A,614.79,N/A,614.79,N/A,160.58,N/A,96.52,N/A,96.52,N/A,106.17,688.20,688.20,96.52,688.20,,Hospital 76820,HC Doppler Velocimetry Fetal Umb,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,28774.10,3206.00,17264.46,1923.60,5682.97,449.08,6988.30,96.02,12807.04,1846.01,9783.18,1090.04,7322.00,233.46,5858.07,449.08,6988.30,96.52,6988.30,96.52,4558.00,145.34,7322.00,233.46,7322.00,233.46,7322.00,233.46,12807.04,1846.02,6988.30,205.66,5858.07,449.08,15382.93,423.97,15382.93,423.97,5096.25,449.08,6988.30,205.66,6988.30,204.60,6268.14,180.28,4558.00,17264.46,96.02,1923.60,,Hospital 76826,HC Fetal Echo 2d W/WO M-Mode F/U or Repeat,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,77133.70,2499.00,46280.22,1499.40,8615.41,349.86,10457.23,810.33,19415.53,1438.92,26225.46,849.66,8524.00,1842.57,8880.87,349.86,N/A,761.75,N/A,761.75,4558.00,1147.04,7322.00,1842.57,7322.00,1842.57,7322.00,1842.57,19415.53,1438.92,N/A,761.75,8880.87,349.86,23320.60,111.48,N/A,111.48,N/A,349.86,N/A,761.75,N/A,810.33,9502.53,438.86,4558.00,46280.22,111.48,1842.57,,Hospital 76828,HC Echo Exam of Fetal Heart Fu/Repeat,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,29462.90,5340.00,17677.74,3204.00,5682.97,747.84,6988.30,95.68,13042.09,3074.77,10017.39,1815.60,7322.00,233.46,5858.07,747.84,6988.30,96.52,6988.30,96.52,4558.00,145.34,7322.00,233.46,7322.00,233.46,7322.00,233.46,13042.09,3074.78,6988.30,205.66,5858.07,747.84,15382.93,423.97,15382.93,423.97,N/A,747.84,6988.30,205.66,6988.30,203.88,6268.14,222.58,4558.00,17677.74,95.68,3204.00,,Hospital CPT 76830,"HC US Transvaginal, Non OB",N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,973.00,973.00,583.80,583.80,N/A,136.22,N/A,96.52,N/A,560.25,N/A,330.82,N/A,233.46,N/A,136.22,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,560.25,N/A,96.52,N/A,136.22,N/A,521.53,N/A,521.53,N/A,136.22,N/A,96.52,N/A,96.52,N/A,106.17,583.80,583.80,96.52,583.80,,Hospital CPT 76831,HC Echo Exam Uterus,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,973.00,973.00,583.80,583.80,N/A,136.22,N/A,74.57,N/A,560.25,N/A,330.82,N/A,319.92,N/A,136.22,N/A,74.57,N/A,74.57,N/A,199.15,N/A,319.92,N/A,319.92,N/A,319.92,N/A,560.25,N/A,74.57,N/A,136.22,N/A,521.53,N/A,521.53,N/A,136.22,N/A,74.57,N/A,74.57,N/A,82.03,583.80,583.80,74.57,583.80,,Hospital 76873,HC Endorectal Volume W/Contrast,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,10153.00,N/A,6091.80,N/A,1421.42,N/A,1074.51,N/A,5846.10,N/A,3452.02,N/A,2267.53,N/A,1421.42,N/A,1046.56,N/A,1046.56,N/A,1411.59,N/A,2267.53,N/A,2267.53,N/A,2267.53,N/A,5846.10,N/A,1046.56,N/A,1421.42,N/A,5249.05,N/A,5249.05,N/A,1421.42,N/A,1046.56,N/A,1074.51,N/A,419.62,N/A,N/A,419.62,6091.80,,Hospital CPT 76881,HC US Extrem Complete Nonvasc,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,559.00,559.00,335.40,335.40,N/A,78.26,N/A,96.52,N/A,321.87,N/A,190.06,N/A,233.46,N/A,78.26,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,321.87,N/A,96.52,N/A,78.26,N/A,299.62,N/A,299.62,N/A,78.26,N/A,96.52,N/A,96.52,N/A,106.17,335.40,335.40,78.26,335.40,,Hospital CPT 76882,HC US Extrem Limited Nonvasc,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,363.00,363.00,217.80,217.80,N/A,50.82,N/A,96.52,N/A,209.02,N/A,123.42,N/A,233.46,N/A,50.82,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,209.02,N/A,96.52,N/A,50.82,N/A,194.57,N/A,194.57,N/A,50.82,N/A,96.52,N/A,96.52,N/A,106.17,217.80,217.80,50.82,233.46,,Hospital 76975,HC GI Endoscopic US S&I,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,179334.10,25733.20,107600.46,15439.92,14299.34,3599.27,12587.85,1676.97,98848.96,14816.33,60973.59,8749.29,20115.86,3813.81,11091.65,3599.27,3372.00,1576.66,3372.00,1576.66,12521.66,2374.17,20115.86,3813.81,20115.86,3813.81,20115.86,3813.81,98848.96,14816.33,12587.85,1576.66,11091.65,3599.27,23932.86,2806.50,23932.86,2806.50,9268.84,3599.27,12587.85,1576.66,10724.80,1676.97,11868.06,474.21,3372.00,107600.46,474.21,15439.92,,Hospital CPT 76982,HC Ultrasound Elastography First Target Lesion,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,343.00,343.00,205.80,205.80,N/A,48.02,N/A,100.96,N/A,197.50,N/A,116.62,N/A,233.46,N/A,48.02,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,197.50,N/A,96.52,N/A,48.02,N/A,183.85,N/A,183.85,N/A,48.02,N/A,96.52,N/A,100.96,N/A,65.15,205.80,205.80,48.02,233.46,,Hospital 76999,HC Ultrasound Procedure Unlisted,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,49266.90,568.00,29560.14,340.80,10440.92,79.52,12616.71,77.78,23529.46,327.05,16750.74,193.12,23754.54,189.77,10762.62,79.52,8692.40,78.46,12616.71,78.46,14786.65,118.14,23754.54,189.77,23754.54,189.77,23754.54,189.77,23529.46,327.05,9933.60,78.46,10762.62,79.52,20434.47,304.45,28261.97,304.45,5161.87,79.52,9189.70,78.46,12616.71,77.78,11516.01,167.08,5161.87,29560.14,77.78,340.80,,Hospital 77011,HC CT Guide for Stereotactic Loca,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,174397.58,24711.02,104638.55,14826.61,25542.16,3442.40,31989.76,1400.58,96127.95,14607.77,59295.18,8401.74,58111.96,3298.90,26329.16,3442.40,31989.76,1354.15,562.00,1354.15,36173.34,2053.63,58111.96,3298.90,58111.96,3298.90,58111.96,3298.90,96127.95,14607.77,30480.71,1354.15,26329.16,3442.40,69138.72,1871.00,69138.72,1871.00,8405.94,3442.40,30480.71,1354.15,30480.71,1400.58,28172.20,564.52,562.00,104638.55,564.52,14826.61,,Hospital CPT 77012,HC CT Guidance Needle Placement,N/A,0350 - CT SCAN - GENERAL CLASSIFICATION,6130.00,6130.00,3678.00,3678.00,N/A,858.20,N/A,6130.00,N/A,914.00,N/A,2084.20,N/A,6130.00,N/A,858.20,N/A,6130.00,N/A,6130.00,N/A,6130.00,N/A,6130.00,N/A,6130.00,N/A,6130.00,N/A,914.00,N/A,6130.00,N/A,858.20,N/A,689.00,N/A,689.00,N/A,858.20,N/A,6130.00,N/A,6130.00,N/A,6130.00,3678.00,3678.00,689.00,6130.00,,Hospital CPT 77021,HC MRI-Guidance Needle Placement,N/A,0619 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - OTHER MRT,1491.00,1172.00,894.60,703.20,N/A,164.08,N/A,1172.00,N/A,1110.00,N/A,398.48,N/A,1172.00,N/A,164.08,N/A,1172.00,N/A,1172.00,N/A,1172.00,N/A,1172.00,N/A,1172.00,N/A,1172.00,N/A,1110.00,N/A,1172.00,N/A,164.08,N/A,1060.00,N/A,1060.00,N/A,164.08,N/A,1172.00,N/A,1172.00,N/A,356.24,894.60,894.60,164.08,1172.00,,Hospital CPT 77053,HC Galactogram S&I,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,743.00,743.00,445.80,445.80,N/A,104.02,N/A,215.26,N/A,427.82,N/A,252.62,N/A,510.09,N/A,104.02,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,427.82,N/A,210.88,N/A,104.02,N/A,398.25,N/A,398.25,N/A,104.02,N/A,210.88,N/A,215.26,N/A,35.71,445.80,445.80,35.71,510.09,,Hospital CPT 77063,HC Screening Breast Tomo,N/A,0403 - OTHER IMAGING SERVICES - SCREENING MAMMOGRAPHY,68.00,68.00,40.80,40.80,N/A,9.52,N/A,21.05,N/A,68.00,N/A,23.12,N/A,63.90,N/A,9.52,N/A,21.05,N/A,21.05,N/A,39.78,N/A,63.90,N/A,63.90,N/A,63.90,N/A,68.00,N/A,21.05,N/A,9.52,N/A,68.00,N/A,68.00,N/A,9.52,N/A,21.05,N/A,21.05,N/A,23.16,40.80,40.80,9.52,68.00,,Hospital CPT 77066,HC Mammo Dgx Bilateral Incl Cad if Perf,N/A,0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY,487.00,487.00,292.20,292.20,N/A,68.18,N/A,100.43,N/A,203.00,N/A,165.58,N/A,296.43,N/A,68.18,N/A,100.43,N/A,100.43,N/A,184.53,N/A,296.43,N/A,296.43,N/A,296.43,N/A,203.00,N/A,100.43,N/A,68.18,N/A,318.00,N/A,318.00,N/A,68.18,N/A,100.43,N/A,100.43,N/A,110.47,292.20,292.20,68.18,318.00,,Hospital CPT 77067,HC Mammo Screening Incl Cad if Perf,N/A,0403 - OTHER IMAGING SERVICES - SCREENING MAMMOGRAPHY,625.00,625.00,375.00,375.00,N/A,87.50,N/A,82.99,N/A,203.00,N/A,212.50,N/A,245.85,N/A,87.50,N/A,82.99,N/A,82.99,N/A,153.04,N/A,245.85,N/A,245.85,N/A,245.85,N/A,203.00,N/A,82.99,N/A,87.50,N/A,318.00,N/A,318.00,N/A,87.50,N/A,82.99,N/A,82.99,N/A,91.29,375.00,375.00,82.99,375.00,,Hospital 77074,HC Skeletal Survey Large Bone,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,102740.10,576.00,61644.06,345.60,16574.67,80.64,19872.62,100.96,37352.35,331.66,34931.63,195.84,37709.66,233.46,N/A,80.64,7691.07,96.52,5058.00,96.52,23473.39,145.34,37709.66,233.46,37709.66,233.46,37709.66,233.46,37352.35,331.66,19872.62,96.52,N/A,80.64,44865.08,308.74,44865.08,308.74,N/A,80.64,19872.62,96.52,19872.62,100.96,18281.34,43.98,5058.00,61644.06,43.98,345.60,,Hospital CPT 77080,HC Dexa Axial Skeleton,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,639.00,209.00,383.40,125.40,N/A,29.26,N/A,96.52,N/A,120.34,N/A,71.06,N/A,209.00,N/A,29.26,N/A,96.52,N/A,96.52,N/A,145.34,N/A,209.00,N/A,209.00,N/A,209.00,N/A,120.34,N/A,96.52,N/A,29.26,N/A,112.02,N/A,112.02,N/A,29.26,N/A,96.52,N/A,96.52,N/A,106.17,383.40,383.40,29.26,209.00,,Hospital CPT 77081,HC Dexa Appendicular Skeleton,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,719.00,569.00,431.40,341.40,N/A,79.66,N/A,81.51,N/A,327.63,N/A,193.46,N/A,189.77,N/A,79.66,N/A,78.46,N/A,78.46,N/A,118.14,N/A,189.77,N/A,189.77,N/A,189.77,N/A,327.63,N/A,78.46,N/A,79.66,N/A,304.98,N/A,304.98,N/A,79.66,N/A,78.46,N/A,85.01,N/A,20.82,431.40,431.40,20.82,341.40,,Hospital 77085,HC DXA; Axial Incl Vfa,N/A,0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION,19669.00,874.02,11801.40,524.41,4145.53,122.36,5169.60,39.73,9342.30,503.26,6687.46,297.16,9431.66,90.69,4273.26,122.36,1124.00,37.49,1124.00,37.49,5870.99,56.46,9431.66,90.69,9431.66,90.69,9431.66,90.69,9342.30,503.26,5169.60,37.49,4273.26,122.36,11221.32,468.46,11221.32,468.46,N/A,122.36,5169.60,37.49,5169.60,39.73,4572.39,35.71,1124.00,11801.40,35.71,524.41,,Hospital CPT 77280,HC Simulation Simple,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,384.00,384.00,230.40,230.40,N/A,53.76,N/A,205.98,N/A,221.11,N/A,130.56,N/A,291.34,N/A,53.76,N/A,120.45,N/A,120.45,N/A,181.37,N/A,291.34,N/A,291.34,N/A,291.34,N/A,221.11,N/A,120.45,N/A,53.76,N/A,205.82,N/A,205.82,N/A,53.76,N/A,120.45,N/A,205.98,N/A,226.58,230.40,230.40,53.76,291.34,,Hospital 77306,HC Isodose Plan-Simple,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,171539.23,7043.00,102923.54,4225.80,N/A,986.02,N/A,1183.54,5900.78,4055.36,58323.33,2394.62,44491.81,2642.08,N/A,986.02,N/A,1092.27,N/A,1092.27,27695.12,1644.77,44491.81,2642.08,44491.81,2642.08,44491.81,2642.08,5900.78,4055.36,N/A,1092.27,N/A,986.02,5900.78,3775.05,5900.78,3775.05,N/A,986.02,N/A,1092.27,N/A,1183.54,N/A,515.95,5900.78,102923.54,515.95,4225.80,,Hospital 77307,HC Telethx Isodose Plan Cplx,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,86137.90,37498.00,51682.74,22498.80,8766.47,5249.72,10142.03,1052.59,N/A,21591.41,47431.33,12749.32,47431.33,17127.63,8766.47,5249.72,12477.57,7080.72,12477.57,7080.72,47431.33,10662.25,47431.33,17127.63,47431.33,17127.63,47431.33,17127.63,N/A,21591.41,10142.03,7080.72,8766.47,5249.72,N/A,20098.96,N/A,20098.96,8766.47,5249.72,10142.03,7080.72,10142.03,1052.59,8766.47,1157.85,8766.47,51682.74,1052.59,22498.80,,Hospital 77331,HC Special Doses Verification,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,78231.30,37158.00,46938.78,22294.80,5202.56,5202.12,20216.22,4222.71,78231.30,21395.59,26598.64,12633.72,39514.64,9426.51,4276.01,5202.12,20216.22,3897.03,20216.22,3897.03,4934.82,5868.20,39514.64,9426.51,39514.64,9426.51,39514.64,9426.51,11816.00,21395.59,20212.06,3897.03,4276.01,5202.12,16416.00,19916.70,16416.00,19916.70,N/A,5202.12,20216.22,3897.03,20216.22,4222.71,4575.34,908.59,4276.01,78231.30,908.59,22294.80,,Hospital 77336,HC Continuing Medical Physics,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,92384.90,36564.00,55430.94,21938.40,7393.97,5118.96,10559.90,8794.08,22311.28,21053.55,31410.87,12431.76,20558.86,19631.37,7393.97,5118.96,11865.21,8115.75,11865.21,8115.75,12797.41,12220.86,20558.86,19631.37,27479.88,19631.37,20558.86,19631.37,22311.28,21053.55,10955.14,8115.75,7393.97,5118.96,24459.92,19598.34,22311.28,19598.34,7393.97,5118.96,10955.14,8115.75,10955.14,8794.08,7393.97,240.78,7393.97,55430.94,240.78,21938.40,,Hospital 77338,HC Mlc Device(S) for Imrt,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,92191.12,42352.80,55314.67,25411.68,9036.31,5929.39,11430.01,7183.52,20364.07,24376.52,31344.98,14399.95,20558.86,17228.93,9314.74,5929.39,3934.00,7106.57,3934.00,7106.57,12797.41,10725.36,20558.86,17228.93,20558.86,17228.93,20558.86,17228.93,29183.79,24376.52,10955.14,7106.57,7743.30,5929.39,29183.79,22701.11,29183.79,22701.11,7743.30,5929.39,10955.14,7106.57,10955.14,7183.52,7743.30,4174.77,3934.00,55314.67,4174.77,25411.68,,Hospital CPT 77370,HC Special Med Physics Consult,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,384.00,384.00,230.40,230.40,N/A,53.76,N/A,128.13,N/A,221.11,N/A,130.56,N/A,291.34,N/A,53.76,N/A,120.45,N/A,120.45,N/A,181.37,N/A,291.34,N/A,291.34,N/A,291.34,N/A,221.11,N/A,120.45,N/A,53.76,N/A,205.82,N/A,205.82,N/A,53.76,N/A,120.45,N/A,125.99,N/A,127.83,230.40,230.40,53.76,291.34,,Hospital 77372,HC Srs Linear Based,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,94316.10,40645.00,56589.66,24387.00,N/A,5690.30,9080.25,7141.86,16792.33,23403.39,32067.47,13819.30,16952.96,17090.46,N/A,5690.30,4496.00,7065.34,N/A,7065.34,10552.82,10639.15,16952.96,17090.46,16952.96,17090.46,16952.96,17090.46,N/A,23403.39,9080.25,7065.34,N/A,5690.30,20169.79,21785.72,N/A,21785.72,N/A,5690.30,N/A,7065.34,9080.25,7141.86,8218.66,2741.93,4496.00,56589.66,2741.93,24387.00,,Hospital 77373,HC Sbrt Delivery,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,114272.60,32149.00,68563.56,19289.40,N/A,4500.86,12196.24,5885.38,N/A,18511.38,N/A,10930.66,N/A,13382.62,N/A,4500.86,6744.00,5532.51,6744.00,5532.51,N/A,8330.96,N/A,13382.62,N/A,13382.62,N/A,13382.62,N/A,18511.38,12196.24,5532.51,N/A,4500.86,N/A,17231.86,N/A,17231.86,N/A,4500.86,12196.24,5532.51,12196.24,5885.38,N/A,4119.23,6744.00,68563.56,4119.23,19289.40,,Hospital 77385,HC Ntsty Modul Rad Tx Dlvr Smpl,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,53422.10,30997.00,32053.26,18598.20,6606.16,4339.58,8992.15,9914.42,N/A,17848.04,18163.51,10538.98,18042.86,22132.35,8174.80,4339.58,8155.08,9149.67,8155.08,9149.67,11231.26,13777.76,18042.86,22132.35,18042.86,22132.35,18042.86,22132.35,17871.91,17848.04,8992.15,9149.67,6606.16,4339.58,21466.50,16614.33,N/A,16614.33,6606.16,4339.58,8155.08,9149.67,8992.15,9914.42,6606.16,240.78,6606.16,32053.26,240.78,22132.35,,Hospital 77387,HC Guidance for Radiaj Tx Dlvr,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,94704.08,27189.00,56822.45,16313.40,9031.71,3806.46,12268.24,4250.73,74355.64,15655.50,38039.11,9244.26,38039.11,9489.27,9031.71,3806.46,12727.02,3922.95,12928.17,3922.95,38039.11,5907.21,38039.11,9489.27,38039.11,9489.27,38039.11,9489.27,74355.64,15655.50,12268.24,3922.95,9031.71,3806.46,74355.64,14573.34,74355.64,14573.34,9031.71,3806.46,12268.24,3922.95,12268.24,4250.73,9031.71,240.78,9031.71,74355.64,240.78,16313.40,,Hospital 77402,"HC Rad Tx Delivery,>= 1 Mev; Smpl",N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,107682.80,12815.00,64609.68,7689.00,N/A,1794.10,N/A,1224.05,59354.76,7378.87,36612.15,4357.10,12662.53,2900.53,N/A,1794.10,N/A,1199.10,420376.00,1199.10,7882.13,1805.63,12662.53,2900.53,12662.53,2900.53,12662.53,2900.53,5900.78,7378.87,6640.72,1199.10,5988.40,1794.10,5900.78,6706.96,15065.25,6706.96,N/A,1794.10,N/A,1199.10,6848.27,1224.05,N/A,482.78,5900.78,420376.00,482.78,7689.00,,Hospital 77417,HC Portal Film,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,88560.30,33796.00,53136.18,20277.60,7238.91,4727.42,9570.52,2782.06,79795.70,19459.77,N/A,11490.64,N/A,6326.18,7238.91,4727.42,5620.00,2615.30,9570.52,2615.30,N/A,3938.14,N/A,6326.18,N/A,6326.18,N/A,6326.18,79795.70,19459.77,9362.81,2615.30,7238.91,4727.42,26396.32,18076.16,79795.70,18076.16,7238.91,4727.42,9570.52,2615.30,11801.39,2782.06,7238.91,328.04,5620.00,79795.70,328.04,20277.60,,Hospital 77770,HC Remote Afterld Brachy 1 Channe,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,43705.00,N/A,26223.00,N/A,6118.70,N/A,5622.86,N/A,25103.21,N/A,14859.70,N/A,13137.47,N/A,6118.70,N/A,5528.82,N/A,5528.82,N/A,8178.37,N/A,13137.47,N/A,13137.47,N/A,13137.47,N/A,25103.21,N/A,5528.82,N/A,6118.70,N/A,20977.44,N/A,20977.44,N/A,6118.70,N/A,5528.82,N/A,5622.86,N/A,1894.21,N/A,N/A,1894.21,26223.00,,Hospital 77790,HC Supervis/Handle/Load Rad Sourc,N/A,0333 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - RADIATION THERAPY,N/A,170168.13,N/A,102100.88,N/A,23804.77,N/A,1827.81,N/A,93803.24,N/A,57857.17,N/A,61732.35,N/A,23804.77,N/A,27195.81,N/A,27195.81,N/A,38429.58,N/A,61732.35,N/A,61732.35,N/A,61732.35,N/A,93803.25,N/A,27195.81,N/A,23804.77,N/A,12055.25,N/A,12055.25,N/A,23804.77,N/A,27195.81,N/A,1827.81,N/A,2010.60,N/A,N/A,1827.81,102100.88,,Hospital CPT 78012,HC NM Thyroid Uptake Measurement,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,890.00,890.00,534.00,534.00,N/A,124.60,N/A,350.99,N/A,512.46,N/A,302.60,N/A,849.03,N/A,124.60,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,512.46,N/A,350.99,N/A,124.60,N/A,477.04,N/A,477.04,N/A,124.60,N/A,350.99,N/A,350.99,N/A,386.09,534.00,534.00,124.60,849.03,,Hospital CPT 78013,HC NM Thyroid Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1463.00,1463.00,877.80,877.80,N/A,204.82,N/A,347.96,N/A,842.40,N/A,497.42,N/A,849.03,N/A,204.82,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,842.40,N/A,350.99,N/A,204.82,N/A,784.17,N/A,784.17,N/A,204.82,N/A,350.99,N/A,347.96,N/A,165.01,877.80,877.80,165.01,877.80,,Hospital 78072,HC NM Parathyrd Planar W/Spect&CT,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,35145.10,3031.50,21087.06,1818.90,5436.51,424.41,6696.75,460.52,12251.62,1660.03,11949.33,1030.71,12368.82,1102.01,5604.02,424.41,3372.00,455.58,3372.00,455.58,7699.30,686.03,12368.82,1102.01,12368.82,1102.01,12368.82,1102.01,N/A,1660.03,6696.75,455.58,3499.12,424.41,14715.80,702.70,14715.80,702.70,3499.12,424.41,6696.75,455.58,6696.75,460.52,5996.30,340.32,3372.00,21087.06,340.32,1818.90,,Hospital 78102,HC NM Bone Marrow Imaging-Ltd,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,46907.65,7204.90,28144.59,4322.94,10053.63,1008.69,12158.56,358.29,23248.80,3855.30,15948.61,2449.67,22873.39,6749.93,10363.40,1008.69,3372.00,350.99,3372.00,350.99,14238.15,6294.54,22873.39,6749.93,22873.39,6749.93,22873.39,6749.93,23248.80,3855.30,12158.56,350.99,10363.40,1008.69,27213.62,698.94,27213.62,698.94,12910.08,1008.69,12158.56,350.99,12158.56,358.29,11088.83,137.21,3372.00,28144.59,137.21,6749.93,,Hospital 78104,HC NM Bn Marrow Wb,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,138960.33,N/A,83376.20,N/A,34961.71,N/A,14103.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,34961.71,N/A,14103.93,N/A,14103.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14103.93,N/A,34961.71,N/A,N/A,N/A,N/A,N/A,34961.71,N/A,14103.93,N/A,14103.93,N/A,34961.71,N/A,14103.93,83376.20,N/A,N/A,,Hospital CPT 78140,HC NM Hepatic Hemangioma,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1605.00,1605.00,963.00,963.00,N/A,224.70,N/A,76.93,N/A,924.16,N/A,545.70,N/A,297.18,N/A,224.70,N/A,76.93,N/A,76.93,N/A,184.99,N/A,297.18,N/A,297.18,N/A,297.18,N/A,924.16,N/A,76.93,N/A,224.70,N/A,860.28,N/A,860.28,N/A,224.70,N/A,76.93,N/A,76.93,N/A,84.62,963.00,963.00,76.93,963.00,,Hospital 78205,HC NM Spect Liver Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,N/A,67796.12,N/A,40677.67,N/A,9491.11,N/A,10027.43,N/A,38990.75,N/A,23050.68,N/A,25769.55,N/A,9491.11,N/A,9586.05,N/A,9586.05,N/A,16933.75,N/A,25769.55,N/A,25769.55,N/A,25769.55,N/A,38990.75,N/A,9586.05,N/A,9491.11,N/A,12055.25,N/A,12055.25,N/A,9491.11,N/A,9586.05,N/A,10027.43,N/A,1455.99,N/A,N/A,1455.99,40677.67,,Hospital CPT 78264,HC NM Gastric Emptying Study,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2293.00,2293.00,1375.80,1375.80,N/A,321.02,N/A,350.99,N/A,1320.31,N/A,779.62,N/A,849.03,N/A,321.02,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1320.31,N/A,350.99,N/A,321.02,N/A,1229.05,N/A,1229.05,N/A,321.02,N/A,350.99,N/A,350.99,N/A,386.09,1375.80,1375.80,321.02,1375.80,,Hospital CPT 78278,HC NM Acute GI Bleed Study,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1394.00,1394.00,836.40,836.40,N/A,195.16,N/A,255.25,N/A,802.67,N/A,473.96,N/A,849.03,N/A,195.16,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,802.67,N/A,350.99,N/A,195.16,N/A,747.18,N/A,747.18,N/A,195.16,N/A,350.99,N/A,255.25,N/A,280.78,836.40,836.40,195.16,849.03,,Hospital CPT 78300,HC NM Bone Limited,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1149.00,1149.00,689.40,689.40,N/A,160.86,N/A,367.99,N/A,661.59,N/A,390.66,N/A,849.03,N/A,160.86,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,661.59,N/A,350.99,N/A,160.86,N/A,615.86,N/A,615.86,N/A,160.86,N/A,350.99,N/A,360.37,N/A,184.86,689.40,689.40,160.86,849.03,,Hospital CPT 78305,HC NM Bone Multiple,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1336.00,1336.00,801.60,801.60,N/A,187.04,N/A,199.93,N/A,769.27,N/A,454.24,N/A,849.03,N/A,187.04,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,769.27,N/A,350.99,N/A,187.04,N/A,716.10,N/A,716.10,N/A,187.04,N/A,350.99,N/A,199.93,N/A,219.92,801.60,801.60,187.04,849.03,,Hospital CPT 78306,HC NM Bone Scan Whole Body,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1568.00,1568.00,940.80,940.80,N/A,219.52,N/A,350.99,N/A,902.85,N/A,533.12,N/A,849.03,N/A,219.52,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,902.85,N/A,350.99,N/A,219.52,N/A,840.45,N/A,840.45,N/A,219.52,N/A,350.99,N/A,350.99,N/A,386.09,940.80,940.80,219.52,940.80,,Hospital CPT 78315,HC NM 3 Phase Bone Scan,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2942.00,2942.00,1765.20,1765.20,N/A,411.88,N/A,350.99,N/A,1694.00,N/A,1000.28,N/A,849.03,N/A,411.88,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1694.00,N/A,350.99,N/A,411.88,N/A,1576.91,N/A,1576.91,N/A,411.88,N/A,350.99,N/A,350.99,N/A,386.09,1765.20,1765.20,350.99,1765.20,,Hospital 78428,HC NM Cardiac Shunt Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,32533.20,N/A,19519.92,N/A,6438.89,N/A,7882.51,N/A,14510.55,N/A,10948.95,N/A,14649.36,N/A,6637.28,N/A,2810.00,N/A,2810.00,N/A,9118.89,N/A,14649.36,N/A,14649.36,N/A,14649.36,N/A,N/A,N/A,7882.51,N/A,6637.28,N/A,17429.08,N/A,17429.08,N/A,N/A,N/A,7882.51,N/A,7882.51,N/A,N/A,N/A,2810.00,19519.92,N/A,N/A,,Hospital CPT 78451,HC NM Sest. Rest Stress Single,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,6553.00,6553.00,3931.80,3931.80,N/A,917.42,N/A,1211.56,N/A,3773.22,N/A,2228.02,N/A,2899.26,N/A,917.42,N/A,1198.58,N/A,1198.58,N/A,1804.84,N/A,2899.26,N/A,2899.26,N/A,2899.26,N/A,3773.22,N/A,1198.58,N/A,917.42,N/A,3512.41,N/A,3512.41,N/A,917.42,N/A,1198.58,N/A,1253.77,N/A,255.63,3931.80,3931.80,255.63,3931.80,,Hospital CPT 78454,HC NM Planar Mult Studies Rest Stres,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3504.00,3504.00,2102.40,2102.40,N/A,490.56,N/A,312.96,N/A,2017.60,N/A,1191.36,N/A,1097.34,N/A,490.56,N/A,312.96,N/A,312.96,N/A,683.09,N/A,1097.34,N/A,1097.34,N/A,1097.34,N/A,2017.60,N/A,312.96,N/A,490.56,N/A,1878.14,N/A,1878.14,N/A,490.56,N/A,312.96,N/A,312.96,N/A,344.26,2102.40,2102.40,312.96,2102.40,,Hospital 78459,HC Pet Myocardial Imaging,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,133938.93,30703.70,80363.36,18422.22,15979.32,4311.07,19346.27,1400.12,73827.14,6480.18,45539.24,10439.26,37769.00,3350.48,16471.67,4311.07,19168.37,1385.12,19168.37,1385.12,23510.89,2085.73,37769.00,3350.48,37769.00,3350.48,37769.00,3350.48,N/A,6480.18,19168.37,1385.12,16471.67,4311.07,43253.58,13508.17,43253.58,13508.17,1333.77,4311.07,19168.37,1385.12,19168.37,1400.12,N/A,78.62,1333.77,80363.36,78.62,18422.22,,Hospital 78469,HC NM Myocard Infarct Spect Scan,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,149896.98,N/A,89938.19,N/A,18915.40,N/A,56899.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18915.40,N/A,56899.06,N/A,56899.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,56899.06,N/A,18915.40,N/A,N/A,N/A,N/A,N/A,18915.40,N/A,56899.06,N/A,56899.06,N/A,18915.40,N/A,18915.40,89938.19,N/A,N/A,,Hospital CPT 78472,HC NM Cardiac Muga Scan Gated Restin,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2701.00,2701.00,1620.60,1620.60,N/A,378.14,N/A,350.99,N/A,1555.24,N/A,918.34,N/A,849.03,N/A,378.14,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,1555.24,N/A,350.99,N/A,378.14,N/A,1447.74,N/A,1447.74,N/A,378.14,N/A,350.99,N/A,350.99,N/A,386.09,1620.60,1620.60,350.99,1620.60,,Hospital 78579,HC NM Lung Ventilation Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,77768.40,N/A,46661.04,N/A,N/A,N/A,5126.05,N/A,N/A,N/A,26441.26,N/A,N/A,N/A,N/A,N/A,5126.05,N/A,5126.05,N/A,N/A,N/A,9347.92,N/A,9347.92,N/A,9347.92,N/A,N/A,N/A,5126.05,N/A,N/A,N/A,N/A,N/A,11121.69,N/A,N/A,N/A,5126.05,N/A,5126.05,N/A,4531.79,N/A,4531.79,46661.04,N/A,N/A,,Hospital CPT 78580,HC NM Lung Scan Perfusion Only,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1705.00,1705.00,1023.00,1023.00,N/A,238.70,N/A,350.99,N/A,981.74,N/A,579.70,N/A,849.03,N/A,238.70,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,981.74,N/A,350.99,N/A,238.70,N/A,913.88,N/A,913.88,N/A,238.70,N/A,350.99,N/A,350.99,N/A,386.09,1023.00,1023.00,238.70,1023.00,,Hospital CPT 78598,HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,2539.00,2539.00,1523.40,1523.40,N/A,355.46,N/A,465.06,N/A,1461.96,N/A,863.26,N/A,1102.01,N/A,355.46,N/A,455.58,N/A,455.58,N/A,686.03,N/A,1102.01,N/A,1102.01,N/A,1102.01,N/A,1461.96,N/A,455.58,N/A,355.46,N/A,1360.90,N/A,1360.90,N/A,355.46,N/A,455.58,N/A,465.06,N/A,246.05,1523.40,1523.40,246.05,1523.40,,Hospital CPT 78605,HC NM Brain Complete,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,749.00,749.00,449.40,449.40,N/A,104.86,N/A,148.50,N/A,431.27,N/A,254.66,N/A,509.16,N/A,104.86,N/A,148.50,N/A,148.50,N/A,316.95,N/A,509.16,N/A,509.16,N/A,509.16,N/A,431.27,N/A,148.50,N/A,104.86,N/A,401.46,N/A,401.46,N/A,104.86,N/A,148.50,N/A,148.50,N/A,163.35,449.40,449.40,104.86,509.16,,Hospital 78608,HC Brain Imaging Pet,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,N/A,8003.68,N/A,4802.21,N/A,1114.84,N/A,3.28,N/A,3935.76,N/A,2721.25,N/A,3253.30,N/A,1114.84,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,3253.30,N/A,3253.30,N/A,3253.30,N/A,3935.76,N/A,1344.94,N/A,1114.84,N/A,3161.39,N/A,3161.39,N/A,1114.84,N/A,1344.94,N/A,3.28,N/A,3.61,N/A,N/A,3.28,4802.21,,Hospital 78610,HC Brain Flow Imaging Only,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,54474.50,N/A,32684.70,N/A,12321.15,N/A,11166.54,N/A,N/A,N/A,N/A,N/A,21590.77,N/A,9498.95,N/A,11166.54,N/A,11166.54,N/A,13440.90,N/A,21590.77,N/A,21590.77,N/A,21590.77,N/A,20766.80,N/A,11166.54,N/A,9498.95,N/A,24943.66,N/A,24943.66,N/A,12321.15,N/A,11166.54,N/A,11166.54,N/A,10163.88,N/A,9498.95,32684.70,N/A,N/A,,Hospital 78700,HC NM Renal Scan,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,N/A,1171.02,N/A,702.61,N/A,163.94,N/A,127.15,N/A,674.27,N/A,398.14,N/A,849.03,N/A,163.94,N/A,350.99,N/A,350.99,N/A,528.54,N/A,849.03,N/A,849.03,N/A,849.03,N/A,674.27,N/A,350.99,N/A,163.94,N/A,627.66,N/A,627.66,N/A,163.94,N/A,360.99,N/A,127.15,N/A,139.87,N/A,N/A,127.15,849.03,,Hospital CPT 78701,HC NM Renal W/Vascular Flow,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,1422.00,1422.00,853.20,853.20,N/A,199.08,N/A,168.05,N/A,818.79,N/A,483.48,N/A,567.21,N/A,199.08,N/A,168.05,N/A,168.05,N/A,353.09,N/A,567.21,N/A,567.21,N/A,567.21,N/A,818.79,N/A,168.05,N/A,199.08,N/A,762.19,N/A,762.19,N/A,199.08,N/A,168.05,N/A,168.05,N/A,184.86,853.20,853.20,168.05,853.20,,Hospital CPT 78804,"HC NM Tumor Localization,Whole Body",N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,3771.00,3771.00,2262.60,2262.60,N/A,527.94,N/A,1253.77,N/A,2171.34,N/A,1282.14,N/A,2899.26,N/A,527.94,N/A,1198.58,N/A,1198.58,N/A,1804.84,N/A,2899.26,N/A,2899.26,N/A,2899.26,N/A,2171.34,N/A,1198.58,N/A,527.94,N/A,2021.26,N/A,2021.26,N/A,527.94,N/A,1198.58,N/A,1253.77,N/A,565.85,2262.60,2262.60,527.94,2899.26,,Hospital 78808,HC NM Inject for Neoprobe Study,N/A,0340 - NUCLEAR MEDICINE - GENERAL CLASSIFICATION,N/A,33168.98,N/A,19901.39,N/A,4656.13,N/A,4780.29,N/A,19011.14,N/A,11277.46,N/A,11687.41,N/A,4656.13,N/A,4821.94,N/A,4821.94,N/A,7275.63,N/A,11687.41,N/A,11687.41,N/A,11687.41,N/A,19011.16,N/A,4821.94,N/A,4656.13,N/A,5963.00,N/A,5963.00,N/A,4656.13,N/A,4821.94,N/A,4780.29,N/A,1319.89,N/A,N/A,1319.89,19901.39,,Hospital 78812,HC Pet Imaging Skull Base to Mid-Thigh,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,N/A,7249.00,N/A,4349.40,N/A,1014.86,N/A,1397.31,N/A,2821.00,N/A,2464.66,N/A,3253.30,N/A,1014.86,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,3253.30,N/A,3253.30,N/A,3253.30,N/A,2821.00,N/A,1344.94,N/A,1014.86,N/A,3885.46,N/A,3885.46,N/A,1014.86,N/A,1344.94,N/A,1397.31,N/A,N/A,N/A,N/A,1014.86,4349.40,,Hospital CPT 78814,HC Pet/CT Limited Area,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,6199.00,2435.00,3719.40,1461.00,N/A,340.90,N/A,1338.06,N/A,2435.00,N/A,827.90,N/A,2435.00,N/A,340.90,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,2435.00,N/A,2435.00,N/A,2435.00,N/A,2435.00,N/A,1344.94,N/A,340.90,N/A,1305.16,N/A,1305.16,N/A,340.90,N/A,1344.94,N/A,1338.06,N/A,2435.00,3719.40,3719.40,340.90,2435.00,,Hospital CPT 78815,HC Pet/CT Skull Base to Mid Thigh,N/A,0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY,8637.00,2435.00,5182.20,1461.00,N/A,340.90,N/A,1344.94,N/A,2435.00,N/A,827.90,N/A,2435.00,N/A,340.90,N/A,1344.94,N/A,1344.94,N/A,2025.24,N/A,2435.00,N/A,2435.00,N/A,2435.00,N/A,2435.00,N/A,1344.94,N/A,340.90,N/A,1305.16,N/A,1305.16,N/A,340.90,N/A,1344.94,N/A,1344.94,N/A,1479.44,5182.20,5182.20,340.90,2435.00,,Hospital 78832,HC Rp Loclzj Tum Spect W/CT 2 Area 1d/1 AR Img>2+D,N/A,0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES,44820.77,N/A,26892.46,N/A,N/A,N/A,7906.74,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4496.00,N/A,4496.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7906.74,N/A,5281.78,N/A,N/A,N/A,13869.62,N/A,5281.78,N/A,7906.74,N/A,7906.74,N/A,N/A,N/A,4496.00,26892.46,N/A,N/A,,Hospital CPT 79005,HC NM I 131 Thyroid Treatment,N/A,0342 - NUCLEAR MEDICINE - THERAPEUTIC PROCEDURES,7230.00,7230.00,4338.00,4338.00,N/A,1012.20,N/A,223.57,N/A,4163.03,N/A,2458.20,N/A,545.50,N/A,1012.20,N/A,225.52,N/A,225.52,N/A,339.59,N/A,545.50,N/A,545.50,N/A,545.50,N/A,4163.03,N/A,225.52,N/A,1012.20,N/A,3875.28,N/A,3875.28,N/A,1012.20,N/A,225.52,N/A,45.38,N/A,49.92,4338.00,4338.00,45.38,4338.00,,Hospital 79101,HC NM Rx IV Admin,N/A,0342 - NUCLEAR MEDICINE - THERAPEUTIC PROCEDURES,195709.18,66290.60,117425.51,39774.36,N/A,9243.96,13596.12,17863.59,N/A,35016.99,66541.13,22538.80,68145.94,43245.28,14454.42,9243.96,8430.00,17861.15,8430.00,17861.15,42429.75,26920.61,68145.94,43245.28,68145.94,43245.28,68145.94,43245.28,107874.91,35016.99,13596.12,17861.15,14454.42,9243.96,30503.06,1273.06,30503.06,1273.06,12131.21,9243.96,13596.12,17861.15,13596.12,17863.59,15466.23,95.61,8430.00,117425.51,95.61,43245.28,,Hospital 79445,HC Intra Art Admin Radpharm,N/A,0340 - NUCLEAR MEDICINE - GENERAL CLASSIFICATION,122516.87,109716.38,73510.12,65829.83,5450.92,15363.93,6713.79,27637.19,67531.29,59980.93,41655.74,37303.58,12401.59,61668.78,5618.87,15363.93,2810.00,27195.81,2810.00,27195.81,7719.70,38390.01,12401.59,61668.78,12401.59,61668.78,12401.59,61668.78,67531.29,59980.93,6713.79,27195.81,5618.87,15363.93,14754.79,11923.50,14754.79,11923.50,N/A,15363.93,6713.79,27195.81,6713.79,27637.19,6012.19,1233.26,2810.00,73510.12,1233.26,65829.83,,Hospital CPT 80048,HC Basic Metabolic Panel,N/A,0301 - LABORATORY - CHEMISTRY,154.00,131.00,92.40,78.60,N/A,8.46,N/A,8.46,N/A,75.43,N/A,44.54,N/A,8.46,N/A,8.46,N/A,8.46,N/A,8.46,N/A,5.69,N/A,5.69,N/A,5.69,N/A,5.69,N/A,75.43,N/A,8.46,N/A,8.46,N/A,8.46,N/A,8.46,N/A,8.46,N/A,8.46,N/A,8.46,N/A,9.31,92.40,92.40,5.69,78.60,,Hospital CPT 80053,HC Comprehensive Metabolic Panel,N/A,0301 - LABORATORY - CHEMISTRY,257.00,57.00,154.20,34.20,N/A,10.56,N/A,10.56,N/A,32.82,N/A,19.38,N/A,10.56,N/A,10.56,N/A,10.56,N/A,10.56,N/A,7.15,N/A,7.15,N/A,7.15,N/A,7.15,N/A,32.82,N/A,10.56,N/A,10.56,N/A,10.56,N/A,10.56,N/A,10.56,N/A,10.56,N/A,10.56,N/A,11.62,154.20,154.20,7.15,34.20,,Hospital CPT 80074,HC Hepatitis Panel Acute,N/A,0301 - LABORATORY - CHEMISTRY,453.00,385.00,271.80,231.00,N/A,47.63,N/A,47.63,N/A,221.68,N/A,130.90,N/A,47.63,N/A,47.63,N/A,47.63,N/A,47.63,N/A,29.65,N/A,47.63,N/A,47.63,N/A,47.63,N/A,221.68,N/A,47.63,N/A,47.63,N/A,47.63,N/A,47.63,N/A,47.63,N/A,47.63,N/A,47.63,N/A,52.39,271.80,271.80,29.65,231.00,,Hospital Custom 8010000000,HC Hemodialysis Acute Inpt,N/A,0801 - INPATIENT RENAL DIALYSIS - INPATIENT HEMODIALYSIS,2248.00,2248.00,1348.80,1348.80,N/A,314.72,N/A,2248.00,N/A,1294.40,N/A,764.32,N/A,314.72,N/A,314.72,N/A,2248.00,N/A,2248.00,N/A,195.58,N/A,314.72,N/A,314.72,N/A,314.72,N/A,1294.40,N/A,2248.00,N/A,314.72,N/A,1204.93,N/A,1204.93,N/A,314.72,N/A,2248.00,N/A,2248.00,N/A,2248.00,1348.80,1348.80,195.58,2248.00,,Hospital CPT 80143,HC Drug Assay Acetaminophen,N/A,0301 - LABORATORY - CHEMISTRY,198.00,198.00,118.80,118.80,N/A,18.64,N/A,18.64,N/A,114.01,N/A,67.32,N/A,7.46,N/A,18.64,N/A,18.64,N/A,18.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,7.46,N/A,114.01,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,118.80,118.80,7.46,118.80,,Hospital CPT 80145,HC So Adalimumab Level,N/A,0301 - LABORATORY - CHEMISTRY,448.00,448.00,268.80,268.80,N/A,38.57,N/A,38.57,N/A,257.96,N/A,152.32,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,24.01,N/A,15.43,N/A,15.43,N/A,15.43,N/A,257.96,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,42.43,268.80,268.80,15.43,268.80,,Hospital CPT 80150,HC Amikacin,N/A,0301 - LABORATORY - CHEMISTRY,120.00,90.00,72.00,54.00,N/A,15.08,N/A,15.08,N/A,51.82,N/A,30.60,N/A,12.81,N/A,15.08,N/A,15.08,N/A,15.08,N/A,12.81,N/A,12.81,N/A,12.81,N/A,12.81,N/A,51.82,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,16.59,72.00,72.00,12.81,54.00,,Hospital CPT 80156,HC So Carbamazepine (Tegretol),N/A,0301 - LABORATORY - CHEMISTRY,296.00,296.00,177.60,177.60,N/A,14.57,N/A,14.57,N/A,170.44,N/A,100.64,N/A,12.37,N/A,14.57,N/A,14.57,N/A,14.57,N/A,12.37,N/A,12.37,N/A,12.37,N/A,12.37,N/A,170.44,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,16.03,177.60,177.60,12.37,177.60,,Hospital CPT 80156,HC Carbamazepine (Tegretol),N/A,0301 - LABORATORY - CHEMISTRY,327.00,247.00,196.20,148.20,N/A,14.57,N/A,14.57,N/A,142.22,N/A,83.98,N/A,12.37,N/A,14.57,N/A,14.57,N/A,14.57,N/A,12.37,N/A,12.37,N/A,12.37,N/A,12.37,N/A,142.22,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,16.03,196.20,196.20,12.37,148.20,,Hospital CPT 80159,HC Drug Assay Clozapine,N/A,0301 - LABORATORY - CHEMISTRY,102.00,102.00,61.20,61.20,N/A,20.15,N/A,20.15,N/A,58.73,N/A,34.68,N/A,25.23,N/A,20.15,N/A,20.15,N/A,20.15,N/A,25.23,N/A,25.23,N/A,25.23,N/A,25.23,N/A,58.73,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,22.17,61.20,61.20,20.15,61.20,,Hospital CPT 80159,HC So Drug Assay Clozapine,N/A,0301 - LABORATORY - CHEMISTRY,92.00,92.00,55.20,55.20,N/A,20.15,N/A,20.15,N/A,52.97,N/A,31.28,N/A,25.23,N/A,20.15,N/A,20.15,N/A,20.15,N/A,25.23,N/A,25.23,N/A,25.23,N/A,25.23,N/A,52.97,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,20.15,N/A,22.17,55.20,55.20,20.15,55.20,,Hospital CPT 80162,HC Digoxin,N/A,0301 - LABORATORY - CHEMISTRY,156.00,118.00,93.60,70.80,N/A,13.28,N/A,13.28,N/A,67.94,N/A,40.12,N/A,11.28,N/A,13.28,N/A,13.28,N/A,13.28,N/A,8.27,N/A,11.28,N/A,11.28,N/A,13.28,N/A,67.94,N/A,13.28,N/A,13.28,N/A,13.28,N/A,13.28,N/A,13.28,N/A,13.28,N/A,13.28,N/A,14.61,93.60,93.60,8.27,70.80,,Hospital CPT 80164,HC Depakene (Valproic Acid),N/A,0301 - LABORATORY - CHEMISTRY,236.00,175.00,141.60,105.00,N/A,13.54,N/A,13.54,N/A,100.77,N/A,59.50,N/A,11.51,N/A,13.54,N/A,13.54,N/A,13.54,N/A,11.51,N/A,11.51,N/A,11.51,N/A,11.51,N/A,100.77,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,14.89,141.60,141.60,11.51,105.00,,Hospital CPT 80164,HC So Depakene (Valproic Acid),N/A,0301 - LABORATORY - CHEMISTRY,214.00,214.00,128.40,128.40,N/A,13.54,N/A,13.54,N/A,123.22,N/A,72.76,N/A,11.51,N/A,13.54,N/A,13.54,N/A,13.54,N/A,11.51,N/A,11.51,N/A,11.51,N/A,11.51,N/A,123.22,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,14.89,128.40,128.40,11.51,128.40,,Hospital CPT 80167,HC So Drug Assay Felbamate,N/A,0301 - LABORATORY - CHEMISTRY,72.00,72.00,43.20,43.20,N/A,18.64,N/A,18.64,N/A,41.46,N/A,24.48,N/A,7.46,N/A,18.64,N/A,18.64,N/A,18.64,N/A,7.46,N/A,7.46,N/A,7.46,N/A,7.46,N/A,41.46,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,18.64,N/A,20.50,43.20,43.20,7.46,43.20,,Hospital CPT 80168,HC So Ethosuximide (Zarontin),N/A,0301 - LABORATORY - CHEMISTRY,128.00,128.00,76.80,76.80,N/A,16.34,N/A,16.34,N/A,73.70,N/A,43.52,N/A,13.89,N/A,16.34,N/A,16.34,N/A,16.34,N/A,13.89,N/A,13.89,N/A,13.89,N/A,13.89,N/A,73.70,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,17.97,76.80,76.80,13.89,76.80,,Hospital CPT 80168,HC Ethosuximide (Zarontin),N/A,0301 - LABORATORY - CHEMISTRY,142.00,106.00,85.20,63.60,N/A,16.34,N/A,16.34,N/A,61.03,N/A,36.04,N/A,13.89,N/A,16.34,N/A,16.34,N/A,16.34,N/A,13.89,N/A,13.89,N/A,13.89,N/A,13.89,N/A,61.03,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,16.34,N/A,17.97,85.20,85.20,13.89,63.60,,Hospital CPT 80170,HC Gentamicin,N/A,0301 - LABORATORY - CHEMISTRY,128.00,96.00,76.80,57.60,N/A,16.38,N/A,16.38,N/A,55.28,N/A,32.64,N/A,13.93,N/A,16.38,N/A,16.38,N/A,16.38,N/A,13.93,N/A,13.93,N/A,13.93,N/A,13.93,N/A,55.28,N/A,16.38,N/A,16.38,N/A,16.38,N/A,16.38,N/A,16.38,N/A,16.38,N/A,16.38,N/A,18.02,76.80,76.80,13.93,57.60,,Hospital CPT 80176,HC So Lidocaine,N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,14.69,N/A,14.69,N/A,38.58,N/A,22.78,N/A,14.69,N/A,14.69,N/A,14.69,N/A,14.69,N/A,9.14,N/A,14.69,N/A,14.69,N/A,14.69,N/A,38.58,N/A,14.69,N/A,14.69,N/A,14.69,N/A,14.69,N/A,14.69,N/A,14.69,N/A,14.69,N/A,16.16,40.20,40.20,9.14,40.20,,Hospital CPT 80177,HC Drug Scrn Quan Levetiracetam,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,13.25,N/A,13.25,N/A,43.19,N/A,25.50,N/A,18.09,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,43.19,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,45.00,45.00,13.25,45.00,,Hospital CPT 80177,HC So Drug Scrn Quan Levetiracetam,N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,13.25,N/A,13.25,N/A,38.58,N/A,22.78,N/A,18.09,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,38.58,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,40.20,40.20,13.25,40.20,,Hospital CPT 80178,HC Lithium,N/A,0301 - LABORATORY - CHEMISTRY,197.00,148.00,118.20,88.80,N/A,6.61,N/A,6.61,N/A,85.22,N/A,50.32,N/A,5.62,N/A,6.61,N/A,6.61,N/A,6.61,N/A,5.62,N/A,5.62,N/A,5.62,N/A,5.62,N/A,85.22,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,7.27,118.20,118.20,5.62,88.80,,Hospital CPT 80183,HC Oxcarbazepine Metabolite,N/A,0301 - LABORATORY - CHEMISTRY,83.00,83.00,49.80,49.80,N/A,13.25,N/A,13.25,N/A,47.79,N/A,28.22,N/A,18.09,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,47.79,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,49.80,49.80,13.25,49.80,,Hospital CPT 80183,HC So Oxcarbazepine Metabolite,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,13.25,N/A,13.25,N/A,43.19,N/A,25.50,N/A,18.09,N/A,13.25,N/A,13.25,N/A,13.25,N/A,18.09,N/A,18.09,N/A,18.09,N/A,18.09,N/A,43.19,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,45.00,45.00,13.25,45.00,,Hospital CPT 80184,HC Phenobarbital,N/A,0301 - LABORATORY - CHEMISTRY,183.00,138.00,109.80,82.80,N/A,15.30,N/A,15.30,N/A,138.00,N/A,46.92,N/A,9.73,N/A,15.30,N/A,15.30,N/A,15.30,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,79.46,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,16.83,109.80,109.80,9.73,138.00,,Hospital CPT 80184,HC So Phenobarbital,N/A,0301 - LABORATORY - CHEMISTRY,165.00,165.00,99.00,99.00,N/A,15.30,N/A,15.30,N/A,165.00,N/A,56.10,N/A,9.73,N/A,15.30,N/A,15.30,N/A,15.30,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,95.01,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,15.30,N/A,16.83,99.00,99.00,9.73,165.00,,Hospital CPT 80188,HC Primidone,N/A,0301 - LABORATORY - CHEMISTRY,117.00,84.00,70.20,50.40,N/A,16.59,N/A,16.59,N/A,84.00,N/A,28.56,N/A,14.11,N/A,16.59,N/A,16.59,N/A,16.59,N/A,14.11,N/A,14.11,N/A,14.11,N/A,14.11,N/A,48.37,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,18.25,70.20,70.20,14.11,84.00,,Hospital CPT 80188,HC So Primidone,N/A,0301 - LABORATORY - CHEMISTRY,102.00,102.00,61.20,61.20,N/A,16.59,N/A,16.59,N/A,102.00,N/A,34.68,N/A,14.11,N/A,16.59,N/A,16.59,N/A,16.59,N/A,14.11,N/A,14.11,N/A,14.11,N/A,14.11,N/A,58.73,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,16.59,N/A,18.25,61.20,61.20,14.11,102.00,,Hospital CPT 80189,HC So Drug Assay Itraconazole,N/A,0301 - LABORATORY - CHEMISTRY,100.00,100.00,60.00,60.00,N/A,14.00,N/A,27.11,N/A,57.58,N/A,34.00,N/A,10.84,N/A,14.00,N/A,27.11,N/A,27.11,N/A,10.84,N/A,10.84,N/A,27.11,N/A,10.84,N/A,57.58,N/A,27.11,N/A,14.00,N/A,27.11,N/A,27.11,N/A,14.00,N/A,27.11,N/A,27.11,N/A,100.00,60.00,60.00,10.84,100.00,,Hospital CPT 80195,HC Sirolimus,N/A,0301 - LABORATORY - CHEMISTRY,311.00,230.00,186.60,138.00,N/A,13.73,N/A,13.73,N/A,132.43,N/A,78.20,N/A,11.67,N/A,13.73,N/A,13.73,N/A,13.73,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,132.43,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,186.60,186.60,11.67,138.00,,Hospital CPT 80195,HC So Sirolimus,N/A,0301 - LABORATORY - CHEMISTRY,281.00,281.00,168.60,168.60,N/A,13.73,N/A,13.73,N/A,161.80,N/A,95.54,N/A,11.67,N/A,13.73,N/A,13.73,N/A,13.73,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,161.80,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,13.73,N/A,15.10,168.60,168.60,11.67,168.60,,Hospital CPT 80198,HC Theophylline,N/A,0301 - LABORATORY - CHEMISTRY,164.00,122.00,98.40,73.20,N/A,14.14,N/A,14.14,N/A,70.25,N/A,41.48,N/A,12.02,N/A,14.14,N/A,14.14,N/A,14.14,N/A,12.02,N/A,12.02,N/A,12.02,N/A,14.14,N/A,70.25,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,14.14,N/A,15.55,98.40,98.40,12.02,73.20,,Hospital CPT 80200,HC Tobramycin,N/A,0301 - LABORATORY - CHEMISTRY,175.00,131.00,105.00,78.60,N/A,16.13,N/A,16.13,N/A,75.43,N/A,44.54,N/A,13.70,N/A,16.13,N/A,16.13,N/A,16.13,N/A,13.70,N/A,13.70,N/A,13.70,N/A,13.70,N/A,75.43,N/A,16.13,N/A,16.13,N/A,16.13,N/A,16.13,N/A,16.13,N/A,16.13,N/A,16.13,N/A,17.74,105.00,105.00,13.70,78.60,,Hospital CPT 80202,HC Vancomycin,N/A,0301 - LABORATORY - CHEMISTRY,160.00,119.00,96.00,71.40,N/A,13.54,N/A,13.54,N/A,68.52,N/A,40.46,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,8.43,N/A,13.54,N/A,13.54,N/A,13.54,N/A,68.52,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,13.54,N/A,14.89,96.00,96.00,8.43,71.40,,Hospital CPT 80204,HC Drug Assay Methotrexate,N/A,0301 - LABORATORY - CHEMISTRY,60.00,60.00,36.00,36.00,N/A,8.40,N/A,38.57,N/A,34.55,N/A,20.40,N/A,15.43,N/A,8.40,N/A,38.57,N/A,38.57,N/A,15.43,N/A,15.43,N/A,15.43,N/A,15.43,N/A,34.55,N/A,38.57,N/A,8.40,N/A,38.57,N/A,38.57,N/A,8.40,N/A,38.57,N/A,38.57,N/A,60.00,36.00,36.00,8.40,60.00,,Hospital CPT 80204,HC So Drug Assay Methotrexate,N/A,0301 - LABORATORY - CHEMISTRY,60.00,60.00,36.00,36.00,N/A,8.40,N/A,38.57,N/A,34.55,N/A,20.40,N/A,15.43,N/A,8.40,N/A,38.57,N/A,38.57,N/A,15.43,N/A,15.43,N/A,15.43,N/A,15.43,N/A,34.55,N/A,38.57,N/A,8.40,N/A,38.57,N/A,38.57,N/A,8.40,N/A,38.57,N/A,38.57,N/A,60.00,36.00,36.00,8.40,60.00,,Hospital CPT 80230,HC So Infliximab Level,N/A,0301 - LABORATORY - CHEMISTRY,225.00,225.00,135.00,135.00,N/A,38.57,N/A,38.57,N/A,129.56,N/A,76.50,N/A,15.43,N/A,38.57,N/A,38.57,N/A,38.57,N/A,15.43,N/A,15.43,N/A,15.43,N/A,15.43,N/A,129.56,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,38.57,N/A,42.43,135.00,135.00,15.43,135.00,,Hospital CPT 80306,HC Drug Test Prsmv Instrument,N/A,0301 - LABORATORY - CHEMISTRY,46.00,46.00,27.60,27.60,N/A,17.14,N/A,17.14,N/A,26.49,N/A,15.64,N/A,17.14,N/A,17.14,N/A,17.14,N/A,17.14,N/A,10.67,N/A,17.14,N/A,17.14,N/A,17.14,N/A,26.49,N/A,17.14,N/A,17.14,N/A,17.14,N/A,17.14,N/A,17.14,N/A,17.14,N/A,17.14,N/A,18.85,27.60,27.60,10.67,27.60,,Hospital 80321,HC Alcohol Biomarkers; 1 or 2,N/A,0301 - LABORATORY - CHEMISTRY,87120.30,1217.00,52272.18,730.20,7416.72,81.28,9039.24,65.29,16714.19,700.76,29620.90,413.78,16874.07,51.08,6691.71,81.28,5479.47,65.29,9039.24,65.29,10503.72,51.08,16874.07,51.08,16874.07,51.08,16874.07,51.08,N/A,700.76,9039.24,65.29,7645.25,81.28,N/A,59.72,20075.93,59.72,6691.71,81.28,9039.24,65.29,5479.47,65.29,8180.41,65.70,5479.47,52272.18,51.08,730.20,,Hospital 80346,HC So Benzodiazepines1-12,N/A,0309 - LABORATORY - OTHER LABORATORY,31838.33,540.00,19103.00,324.00,4809.16,103.16,5954.63,62.14,10837.83,N/A,10825.04,183.60,11267.85,34.29,4957.34,103.16,1124.00,62.14,1124.00,62.14,7014.57,34.29,11267.85,34.29,11267.85,34.29,11267.85,34.29,N/A,310.93,5954.63,62.14,4957.34,103.16,13017.66,62.14,13017.66,62.14,4340.04,103.16,5954.63,62.14,5954.63,62.14,5304.35,68.35,1124.00,19103.00,34.29,324.00,,Hospital 80347,HC Benzodiazepines 13+,N/A,0301 - LABORATORY - CHEMISTRY,10682.70,757.00,6409.62,454.20,1079.73,58.71,1542.91,164.43,2433.25,435.88,3632.12,257.38,1589.00,36.70,1113.00,58.71,1542.91,164.43,1542.91,164.43,989.00,36.70,1589.00,36.70,1589.00,36.70,1589.00,36.70,2433.25,435.88,1542.91,164.43,1113.00,58.71,2704.00,44.43,2704.00,44.43,4103.46,58.71,1542.91,164.43,1542.91,164.43,1190.91,48.88,989.00,6409.62,36.70,454.20,,Hospital 80349,HC So Cannabinoids Natural,N/A,0309 - LABORATORY - OTHER LABORATORY,31838.33,N/A,19103.00,N/A,4809.16,N/A,5954.63,N/A,10837.83,N/A,10825.04,N/A,11267.85,N/A,4957.34,N/A,1124.00,N/A,1124.00,N/A,7014.57,N/A,11267.85,N/A,11267.85,N/A,11267.85,N/A,10837.83,N/A,5954.63,N/A,4957.34,N/A,13017.66,N/A,13017.66,N/A,4340.04,N/A,5954.63,N/A,5954.63,N/A,4340.04,N/A,1124.00,19103.00,N/A,N/A,,Hospital 80361,HC So Opiates 1 or More,N/A,0309 - LABORATORY - OTHER LABORATORY,N/A,1082.00,N/A,649.20,N/A,128.54,N/A,113.39,N/A,623.02,N/A,367.88,N/A,72.03,N/A,128.54,N/A,113.39,N/A,113.39,N/A,72.03,N/A,72.03,N/A,72.03,N/A,72.03,N/A,623.02,N/A,113.39,N/A,128.54,N/A,107.82,N/A,107.82,N/A,128.54,N/A,113.39,N/A,113.39,N/A,118.61,N/A,N/A,72.03,649.20,,Hospital 80365,HC So Drug Screening Oxycodone,N/A,0309 - LABORATORY - OTHER LABORATORY,29298.47,10194.22,17579.08,6116.53,6928.07,1416.15,8461.19,277.89,15612.97,5867.10,9961.48,3466.04,15762.32,688.70,7141.54,1416.15,2248.00,263.06,2248.00,263.06,9811.68,428.67,15762.32,688.70,15762.32,688.70,15762.32,688.70,15612.97,5867.11,8461.19,263.06,7610.73,1416.15,N/A,798.73,18753.23,798.73,7610.73,1416.15,8461.19,263.06,8461.19,170.93,7641.45,181.90,2248.00,18753.23,170.93,6116.53,,Hospital CPT 80371,HC So Stimulants Synthetic,N/A,0301 - LABORATORY - CHEMISTRY,255.00,255.00,153.00,153.00,N/A,35.70,N/A,255.00,N/A,146.83,N/A,86.70,N/A,35.70,N/A,35.70,N/A,255.00,N/A,255.00,N/A,22.19,N/A,35.70,N/A,35.70,N/A,35.70,N/A,146.83,N/A,255.00,N/A,35.70,N/A,255.00,N/A,255.00,N/A,35.70,N/A,255.00,N/A,255.00,N/A,255.00,153.00,153.00,22.19,255.00,,Hospital 80400,HC Acth Stimulation,N/A,0301 - LABORATORY - CHEMISTRY,102993.60,2523.30,61796.16,1513.98,9711.84,310.34,13006.17,301.83,52743.83,1435.20,42198.98,857.92,42198.98,785.03,9711.84,310.34,44112.34,295.68,9223.46,295.68,42198.98,488.69,42198.98,785.03,42198.98,785.03,42198.98,785.03,52743.83,1273.98,6679.73,295.68,9711.84,310.34,52743.83,199.00,52743.83,199.00,9711.84,310.34,7222.48,295.68,10723.57,301.83,9711.84,163.88,6679.73,61796.16,163.88,1513.98,,Hospital Custom 8040000000,HC Ccpd Inpatient,N/A,0804 - INPATIENT RENAL DIALYSIS - INPATIENT CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD),524.00,524.00,314.40,314.40,N/A,73.36,N/A,524.00,N/A,301.72,N/A,178.16,N/A,73.36,N/A,73.36,N/A,524.00,N/A,524.00,N/A,45.59,N/A,73.36,N/A,73.36,N/A,73.36,N/A,301.72,N/A,524.00,N/A,73.36,N/A,280.86,N/A,280.86,N/A,73.36,N/A,524.00,N/A,524.00,N/A,524.00,314.40,314.40,45.59,524.00,,Hospital Custom 8090000000,HC Continuous Venovenous Hemofil,N/A,0809 - INPATIENT RENAL DIALYSIS - OTHER INPATIENT DIALYSIS,3632.00,3632.00,2179.20,2179.20,N/A,508.48,N/A,3632.00,N/A,2091.31,N/A,1234.88,N/A,508.48,N/A,508.48,N/A,3632.00,N/A,3632.00,N/A,315.98,N/A,508.48,N/A,508.48,N/A,508.48,N/A,2091.31,N/A,3632.00,N/A,508.48,N/A,1946.75,N/A,1946.75,N/A,508.48,N/A,3632.00,N/A,3632.00,N/A,3632.00,2179.20,2179.20,315.98,3632.00,,Hospital CPT 81003,"HC Urinalysis, Auto, W/O Scope",N/A,0307 - LABORATORY - UROLOGY,78.00,68.00,46.80,40.80,N/A,2.25,N/A,2.25,N/A,39.15,N/A,23.12,N/A,2.25,N/A,2.25,N/A,2.25,N/A,2.25,N/A,1.91,N/A,2.25,N/A,2.25,N/A,2.25,N/A,39.15,N/A,2.25,N/A,2.25,N/A,2.25,N/A,2.25,N/A,2.25,N/A,2.25,N/A,2.25,N/A,2.48,46.80,46.80,1.91,40.80,,Hospital CPT 81025,HC Hcg (Urine) Pregnancy Test,N/A,0307 - LABORATORY - UROLOGY,43.00,39.00,25.80,23.40,N/A,8.61,N/A,8.61,N/A,22.46,N/A,13.26,N/A,1.02,N/A,8.61,N/A,8.61,N/A,8.61,N/A,5.36,N/A,1.02,N/A,1.02,N/A,1.02,N/A,22.46,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,9.47,25.80,25.80,1.02,23.40,,Hospital CPT 81050,HC Urine Volume Measurement,N/A,0307 - LABORATORY - UROLOGY,40.00,40.00,24.00,24.00,N/A,3.64,N/A,3.64,N/A,40.00,N/A,13.60,N/A,2.41,N/A,3.64,N/A,3.64,N/A,3.64,N/A,2.41,N/A,2.41,N/A,2.41,N/A,2.41,N/A,23.03,N/A,3.64,N/A,3.64,N/A,3.64,N/A,3.64,N/A,3.64,N/A,3.64,N/A,3.64,N/A,4.00,24.00,24.00,2.41,40.00,,Hospital CPT 81109,HC So Hpa-5 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,60.36,N/A,122.22,N/A,122.22,N/A,122.22,N/A,60.36,N/A,60.36,N/A,60.36,N/A,60.36,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,60.36,183.60,,Hospital CPT 81111,HC So Hpa-9 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,76.08,N/A,122.22,N/A,122.22,N/A,122.22,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,76.08,183.60,,Hospital CPT 81112,HC So Hpa-15 Genotyping,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,306.00,306.00,183.60,183.60,N/A,122.22,N/A,122.22,N/A,176.19,N/A,104.04,N/A,60.36,N/A,122.22,N/A,122.22,N/A,122.22,N/A,60.36,N/A,60.36,N/A,60.36,N/A,60.36,N/A,176.19,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,122.22,N/A,134.44,183.60,183.60,60.36,183.60,,Hospital CPT 81120,HC So Idh1 Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,483.00,483.00,289.80,289.80,N/A,193.25,N/A,193.25,N/A,278.11,N/A,164.22,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,120.30,N/A,193.25,N/A,193.25,N/A,193.25,N/A,278.11,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,212.58,289.80,289.80,120.30,289.80,,Hospital CPT 81161,HC So Dmd Dup/Delete Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,700.00,700.00,420.00,420.00,N/A,279.00,N/A,279.00,N/A,403.06,N/A,238.00,N/A,107.98,N/A,279.00,N/A,279.00,N/A,279.00,N/A,107.98,N/A,107.98,N/A,107.98,N/A,107.98,N/A,403.06,N/A,279.00,N/A,279.00,N/A,279.00,N/A,279.00,N/A,279.00,N/A,279.00,N/A,279.00,N/A,306.90,420.00,420.00,107.98,420.00,,Hospital CPT 81162,HC So Brca1&2 Seq & Full Dup/Del,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4662.00,4662.00,2797.20,2797.20,N/A,1824.88,N/A,1824.88,N/A,2684.38,N/A,1585.08,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,1135.99,N/A,1103.72,N/A,1824.88,N/A,1824.88,N/A,2684.38,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,1824.88,N/A,2007.37,2797.20,2797.20,1103.72,2797.20,,Hospital CPT 81179,HC So Atxn2 Gene Detc Abnor Allele,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,186.00,186.00,111.60,111.60,N/A,137.00,N/A,137.00,N/A,107.10,N/A,63.24,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,107.10,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,111.60,111.60,63.24,150.70,,Hospital CPT 81180,HC So Atxn3 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,200.00,200.00,120.00,120.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,68.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,120.00,120.00,68.00,150.70,,Hospital CPT 81181,HC So Atxn7 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,200.00,200.00,120.00,120.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,68.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,120.00,120.00,68.00,150.70,,Hospital CPT 81184,HC So Cacna1a Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,200.00,200.00,120.00,120.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,68.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,115.16,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,120.00,120.00,68.00,150.70,,Hospital CPT 81189,HC So Cstb Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1050.00,1050.00,630.00,630.00,N/A,274.83,N/A,274.83,N/A,604.59,N/A,357.00,N/A,109.93,N/A,274.83,N/A,274.83,N/A,274.83,N/A,109.93,N/A,109.93,N/A,109.93,N/A,109.93,N/A,604.59,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,302.31,630.00,630.00,109.93,630.00,,Hospital CPT 81200,HC So Aspa Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,118.00,118.00,70.80,70.80,N/A,47.25,N/A,47.25,N/A,67.94,N/A,40.12,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,29.41,N/A,47.25,N/A,47.25,N/A,47.25,N/A,67.94,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,47.25,N/A,51.98,70.80,70.80,29.41,70.80,,Hospital CPT 81203,HC So Apc Gene Dup.Delet Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,700.00,700.00,420.00,420.00,N/A,200.00,N/A,200.00,N/A,403.06,N/A,238.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,124.50,N/A,200.00,N/A,200.00,N/A,200.00,N/A,403.06,N/A,200.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,200.00,N/A,220.00,420.00,420.00,124.50,420.00,,Hospital CPT 81207,HC So Bcr/Abl1 Gene Minor Bp,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,603.00,603.00,361.80,361.80,N/A,144.84,N/A,144.84,N/A,347.21,N/A,205.02,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,90.16,N/A,144.84,N/A,144.84,N/A,36.53,N/A,347.21,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,159.32,361.80,361.80,36.53,361.80,,Hospital CPT 81207,HC Bcr/Abl1 Gene Minor Bp,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,666.00,666.00,399.60,399.60,N/A,144.84,N/A,144.84,N/A,383.48,N/A,226.44,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,90.16,N/A,144.84,N/A,144.84,N/A,36.53,N/A,383.48,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,144.84,N/A,159.32,399.60,399.60,36.53,399.60,,Hospital CPT 81209,HC So Blm Gene Analysis 2281del6ins7 Variant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,98.00,98.00,58.80,58.80,N/A,39.31,N/A,39.31,N/A,56.43,N/A,33.32,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,24.47,N/A,39.31,N/A,39.31,N/A,39.31,N/A,56.43,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,39.31,N/A,43.24,58.80,58.80,24.47,58.80,,Hospital CPT 81219,HC So Calr Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,500.00,500.00,300.00,300.00,N/A,121.63,N/A,121.63,N/A,287.90,N/A,170.00,N/A,66.59,N/A,121.63,N/A,121.63,N/A,121.63,N/A,66.59,N/A,66.59,N/A,121.63,N/A,121.63,N/A,287.90,N/A,121.63,N/A,121.63,N/A,121.63,N/A,121.63,N/A,121.63,N/A,121.63,N/A,121.63,N/A,133.79,300.00,300.00,66.59,300.00,,Hospital CPT 81222,HC So Duplication/Deletion Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,869.00,869.00,521.40,521.40,N/A,435.07,N/A,435.07,N/A,500.37,N/A,295.46,N/A,435.07,N/A,435.07,N/A,435.07,N/A,435.07,N/A,270.83,N/A,435.07,N/A,435.07,N/A,435.07,N/A,500.37,N/A,435.07,N/A,435.07,N/A,435.07,N/A,435.07,N/A,435.07,N/A,435.07,N/A,435.07,N/A,478.58,521.40,521.40,270.83,521.40,,Hospital CPT 81223,HC So Cftr Gene Seq,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4312.00,4312.00,2587.20,2587.20,N/A,499.00,N/A,499.00,N/A,2482.85,N/A,1466.08,N/A,769.77,N/A,499.00,N/A,499.00,N/A,499.00,N/A,769.77,N/A,769.77,N/A,769.77,N/A,769.77,N/A,2482.85,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,499.00,N/A,548.90,2587.20,2587.20,499.00,2587.20,,Hospital CPT 81226,HC So Cyp2d6 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,765.00,765.00,459.00,459.00,N/A,450.91,N/A,450.91,N/A,440.49,N/A,260.10,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,280.69,N/A,450.91,N/A,450.91,N/A,450.91,N/A,440.49,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,496.00,459.00,459.00,260.10,496.00,,Hospital CPT 81226,HC Cyp2d6 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1518.00,1518.00,910.80,910.80,N/A,450.91,N/A,450.91,N/A,874.06,N/A,516.12,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,280.69,N/A,450.91,N/A,450.91,N/A,450.91,N/A,874.06,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,450.91,N/A,496.00,910.80,910.80,280.69,910.80,,Hospital 81230,HC So Cyp3a4 Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,N/A,4526.00,N/A,2715.60,N/A,1524.92,N/A,1292.49,N/A,2606.07,N/A,1538.84,N/A,347.13,N/A,1524.92,N/A,1292.49,N/A,1292.49,N/A,347.13,N/A,347.13,N/A,347.13,N/A,347.13,N/A,2606.07,N/A,1292.49,N/A,1524.92,N/A,1286.92,N/A,1286.92,N/A,1524.92,N/A,1292.49,N/A,1292.49,N/A,1415.62,N/A,N/A,347.13,2715.60,,Hospital CPT 81231,HC So Cytochrome P450 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,438.00,438.00,262.80,262.80,N/A,174.81,N/A,174.81,N/A,252.20,N/A,148.92,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,108.82,N/A,174.81,N/A,174.81,N/A,174.81,N/A,252.20,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,262.80,262.80,108.82,262.80,,Hospital CPT 81235,HC So Egfr Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1710.00,1710.00,1026.00,1026.00,N/A,324.58,N/A,324.58,N/A,984.62,N/A,581.40,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,202.05,N/A,324.58,N/A,324.58,N/A,324.58,N/A,984.62,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,357.04,1026.00,1026.00,202.05,1026.00,,Hospital CPT 81235,HC Egfr by Pcr&Frag Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1886.00,1602.00,1131.60,961.20,N/A,324.58,N/A,324.58,N/A,922.43,N/A,544.68,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,202.05,N/A,324.58,N/A,324.58,N/A,324.58,N/A,922.43,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,324.58,N/A,357.04,1131.60,1131.60,202.05,961.20,,Hospital CPT 81240,HC F2 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,191.00,163.00,114.60,97.80,N/A,65.69,N/A,65.69,N/A,93.86,N/A,55.42,N/A,26.02,N/A,65.69,N/A,65.69,N/A,65.69,N/A,26.02,N/A,26.02,N/A,26.02,N/A,26.02,N/A,93.86,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,72.26,114.60,114.60,26.02,97.80,,Hospital CPT 81240,HC So1 F2 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,173.00,173.00,103.80,103.80,N/A,65.69,N/A,65.69,N/A,99.61,N/A,58.82,N/A,26.02,N/A,65.69,N/A,65.69,N/A,65.69,N/A,26.02,N/A,26.02,N/A,26.02,N/A,26.02,N/A,99.61,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,72.26,103.80,103.80,26.02,103.80,,Hospital CPT 81240,HC So F2 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,173.00,173.00,103.80,103.80,N/A,65.69,N/A,65.69,N/A,99.61,N/A,58.82,N/A,26.02,N/A,65.69,N/A,65.69,N/A,65.69,N/A,26.02,N/A,26.02,N/A,26.02,N/A,26.02,N/A,99.61,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,65.69,N/A,72.26,103.80,103.80,26.02,103.80,,Hospital CPT 81241,HC So F5 Factor V Leiden Mutation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,232.00,232.00,139.20,139.20,N/A,73.37,N/A,73.37,N/A,133.59,N/A,78.88,N/A,26.74,N/A,73.37,N/A,73.37,N/A,73.37,N/A,26.74,N/A,26.74,N/A,26.74,N/A,26.74,N/A,133.59,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,80.71,139.20,139.20,26.74,139.20,,Hospital CPT 81241,"HC F5, Factor V Leiden Mutation",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,256.00,217.00,153.60,130.20,N/A,73.37,N/A,73.37,N/A,124.95,N/A,73.78,N/A,26.74,N/A,73.37,N/A,73.37,N/A,73.37,N/A,26.74,N/A,26.74,N/A,26.74,N/A,26.74,N/A,124.95,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,73.37,N/A,80.71,153.60,153.60,26.74,130.20,,Hospital CPT 81247,HC G6pd Gene Alys Cmn Variant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,571.00,571.00,342.60,342.60,N/A,174.81,N/A,174.81,N/A,328.78,N/A,194.14,N/A,69.92,N/A,174.81,N/A,174.81,N/A,174.81,N/A,69.92,N/A,69.92,N/A,69.92,N/A,69.92,N/A,328.78,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,342.60,342.60,69.92,342.60,,Hospital CPT 81247,HC So G6pd Gene Alys Cmn Variant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,518.00,518.00,310.80,310.80,N/A,174.81,N/A,174.81,N/A,298.26,N/A,176.12,N/A,69.92,N/A,174.81,N/A,174.81,N/A,174.81,N/A,69.92,N/A,69.92,N/A,69.92,N/A,69.92,N/A,298.26,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,174.81,N/A,192.29,310.80,310.80,69.92,310.80,,Hospital 81249,HC So G6pd Full Gene Sequence,N/A,0301 - LABORATORY - CHEMISTRY,N/A,1707.00,N/A,1024.20,N/A,228.08,N/A,621.55,N/A,982.89,N/A,580.38,N/A,14.54,N/A,228.08,N/A,621.55,N/A,621.55,N/A,14.54,N/A,14.54,N/A,14.54,N/A,14.54,N/A,982.89,N/A,621.55,N/A,228.08,N/A,15.98,N/A,15.98,N/A,228.08,N/A,621.55,N/A,621.55,N/A,17.58,N/A,N/A,14.54,1024.20,,Hospital CPT 81255,HC So Hexa Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,129.00,129.00,77.40,77.40,N/A,51.45,N/A,51.45,N/A,74.28,N/A,43.86,N/A,51.45,N/A,51.45,N/A,51.45,N/A,51.45,N/A,32.03,N/A,51.45,N/A,51.45,N/A,51.45,N/A,74.28,N/A,51.45,N/A,51.45,N/A,51.45,N/A,51.45,N/A,51.45,N/A,51.45,N/A,51.45,N/A,56.60,77.40,77.40,32.03,77.40,,Hospital CPT 81257,HC So Hba1/Ahb2 Alpha Globulin,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1325.00,1325.00,795.00,795.00,N/A,102.26,N/A,102.26,N/A,762.94,N/A,450.50,N/A,102.26,N/A,102.26,N/A,102.26,N/A,102.26,N/A,63.66,N/A,102.26,N/A,102.26,N/A,102.26,N/A,762.94,N/A,102.26,N/A,102.26,N/A,102.26,N/A,102.26,N/A,102.26,N/A,102.26,N/A,102.26,N/A,112.49,795.00,795.00,63.66,795.00,,Hospital CPT 81265,HC So Comparative Analysis Using Str,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,580.00,580.00,348.00,348.00,N/A,233.07,N/A,233.07,N/A,333.96,N/A,197.20,N/A,233.07,N/A,233.07,N/A,233.07,N/A,233.07,N/A,145.09,N/A,233.07,N/A,233.07,N/A,233.07,N/A,333.96,N/A,233.07,N/A,233.07,N/A,233.07,N/A,233.07,N/A,233.07,N/A,233.07,N/A,233.07,N/A,256.38,348.00,348.00,145.09,348.00,,Hospital 81267,HC So1 Chimerism Anal No Cell Selec,N/A,0301 - LABORATORY - CHEMISTRY,241435.00,N/A,144861.00,N/A,N/A,N/A,N/A,N/A,27021.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,27021.07,N/A,N/A,N/A,N/A,N/A,27021.07,N/A,27021.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,27021.07,144861.00,N/A,N/A,,Hospital CPT 81273,HC So Kit Gene Analysis D816 Variant,N/A,0301 - LABORATORY - CHEMISTRY,500.00,500.00,300.00,300.00,N/A,124.87,N/A,124.87,N/A,287.90,N/A,170.00,N/A,43.29,N/A,124.87,N/A,124.87,N/A,124.87,N/A,43.29,N/A,43.29,N/A,43.29,N/A,43.29,N/A,287.90,N/A,124.87,N/A,124.87,N/A,124.87,N/A,124.87,N/A,124.87,N/A,124.87,N/A,124.87,N/A,137.36,300.00,300.00,43.29,300.00,,Hospital CPT 81275,HC Kras Gene Variants Exon 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,665.00,665.00,399.00,399.00,N/A,193.25,N/A,193.25,N/A,382.91,N/A,226.10,N/A,90.56,N/A,193.25,N/A,193.25,N/A,193.25,N/A,90.56,N/A,90.56,N/A,90.56,N/A,90.56,N/A,382.91,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,212.58,399.00,399.00,90.56,399.00,,Hospital CPT 81275,HC So Kras Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,602.00,602.00,361.20,361.20,N/A,193.25,N/A,193.25,N/A,346.63,N/A,204.68,N/A,90.56,N/A,193.25,N/A,193.25,N/A,193.25,N/A,90.56,N/A,90.56,N/A,90.56,N/A,90.56,N/A,346.63,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,193.25,N/A,212.58,361.20,361.20,90.56,361.20,,Hospital 81277,HC So Plcg2 Gene Analysis Comm Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,229605.57,N/A,137763.34,N/A,N/A,N/A,N/A,N/A,64905.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,64905.07,N/A,N/A,N/A,N/A,N/A,64905.07,N/A,108833.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,64905.07,137763.34,N/A,N/A,,Hospital CPT 81287,HC Mgmt Methylation Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,417.00,417.00,250.20,250.20,N/A,124.64,N/A,124.64,N/A,240.11,N/A,141.78,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,77.59,N/A,124.64,N/A,124.64,N/A,124.64,N/A,240.11,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,137.10,250.20,250.20,77.59,250.20,,Hospital CPT 81287,HC So Mgmt Methylation Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,800.00,800.00,480.00,480.00,N/A,124.64,N/A,124.64,N/A,460.64,N/A,272.00,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,77.59,N/A,124.64,N/A,124.64,N/A,124.64,N/A,460.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,124.64,N/A,137.10,480.00,480.00,77.59,480.00,,Hospital CPT 81302,HC So Mecp2 Gene Analysis Full,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,897.00,897.00,538.20,538.20,N/A,527.87,N/A,527.87,N/A,516.49,N/A,304.98,N/A,198.44,N/A,527.87,N/A,527.87,N/A,527.87,N/A,198.44,N/A,198.44,N/A,198.44,N/A,198.44,N/A,516.49,N/A,527.87,N/A,527.87,N/A,527.87,N/A,527.87,N/A,527.87,N/A,527.87,N/A,527.87,N/A,580.66,538.20,538.20,198.44,580.66,,Hospital CPT 81306,HC Nudt 15 Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,802.00,802.00,481.20,481.20,N/A,291.36,N/A,291.36,N/A,461.79,N/A,272.68,N/A,116.54,N/A,291.36,N/A,291.36,N/A,291.36,N/A,116.54,N/A,116.54,N/A,116.54,N/A,116.54,N/A,461.79,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,291.36,N/A,320.50,481.20,481.20,116.54,481.20,,Hospital CPT 81309,HC So Pik2ca Gene Analysisi Targeted Seq Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,700.00,700.00,420.00,420.00,N/A,274.83,N/A,274.83,N/A,700.00,N/A,238.00,N/A,109.93,N/A,274.83,N/A,274.83,N/A,274.83,N/A,109.93,N/A,109.93,N/A,109.93,N/A,109.93,N/A,403.06,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,274.83,N/A,302.31,420.00,420.00,109.93,700.00,,Hospital CPT 81314,HC So Car Ion Chnnipath Inc 2 Gns,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1320.00,1320.00,792.00,792.00,N/A,329.51,N/A,329.51,N/A,1320.00,N/A,448.80,N/A,69.13,N/A,329.51,N/A,329.51,N/A,329.51,N/A,69.13,N/A,69.13,N/A,69.13,N/A,69.13,N/A,760.06,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,329.51,N/A,362.46,792.00,792.00,69.13,1320.00,,Hospital CPT 81323,HC So Pten Gene Dup/Delet Variant,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,700.00,700.00,420.00,420.00,N/A,300.00,N/A,300.00,N/A,403.06,N/A,238.00,N/A,700.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,700.00,N/A,700.00,N/A,700.00,N/A,700.00,N/A,403.06,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,300.00,N/A,330.00,420.00,420.00,238.00,700.00,,Hospital CPT 81325,HC So Full Sequence Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1895.00,1895.00,1137.00,1137.00,N/A,769.58,N/A,769.58,N/A,1091.14,N/A,644.30,N/A,769.58,N/A,769.58,N/A,769.58,N/A,769.58,N/A,479.06,N/A,769.58,N/A,769.58,N/A,769.58,N/A,1091.14,N/A,769.58,N/A,769.58,N/A,769.58,N/A,769.58,N/A,769.58,N/A,769.58,N/A,769.58,N/A,846.54,1137.00,1137.00,479.06,1137.00,,Hospital CPT 81329,HC So Smn1 + Smn2 Gene Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,275.00,275.00,165.00,165.00,N/A,137.00,N/A,137.00,N/A,158.35,N/A,93.50,N/A,54.80,N/A,137.00,N/A,137.00,N/A,137.00,N/A,54.80,N/A,54.80,N/A,54.80,N/A,54.80,N/A,158.35,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,165.00,165.00,54.80,165.00,,Hospital CPT 81330,HC So Smpd1� Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,500.00,500.00,300.00,300.00,N/A,70.00,N/A,47.00,N/A,287.90,N/A,170.00,N/A,70.00,N/A,70.00,N/A,47.00,N/A,47.00,N/A,43.50,N/A,70.00,N/A,70.00,N/A,70.00,N/A,287.90,N/A,47.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,70.00,N/A,47.00,N/A,47.00,N/A,500.00,300.00,300.00,43.50,500.00,,Hospital CPT 81331,HC So Prader-Willi Methylation Analy,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,382.00,382.00,229.20,229.20,N/A,51.07,N/A,51.07,N/A,219.96,N/A,129.88,N/A,24.61,N/A,51.07,N/A,51.07,N/A,51.07,N/A,24.61,N/A,24.61,N/A,24.61,N/A,24.61,N/A,219.96,N/A,51.07,N/A,51.07,N/A,51.07,N/A,51.07,N/A,51.07,N/A,51.07,N/A,51.07,N/A,56.18,229.20,229.20,24.61,229.20,,Hospital CPT 81332,HC So Serpina 1 Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,175.00,175.00,105.00,105.00,N/A,43.65,N/A,43.65,N/A,100.77,N/A,59.50,N/A,31.01,N/A,43.65,N/A,43.65,N/A,43.65,N/A,31.01,N/A,31.01,N/A,31.01,N/A,31.01,N/A,100.77,N/A,43.65,N/A,43.65,N/A,43.65,N/A,43.65,N/A,43.65,N/A,43.65,N/A,43.65,N/A,48.02,105.00,105.00,31.01,105.00,,Hospital CPT 81338,HC So Mpl Gene Analysis Common Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,843.00,843.00,505.80,505.80,N/A,150.33,N/A,150.33,N/A,485.40,N/A,286.62,N/A,60.13,N/A,150.33,N/A,150.33,N/A,150.33,N/A,60.13,N/A,60.13,N/A,150.33,N/A,150.33,N/A,485.40,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,165.36,505.80,505.80,60.13,505.80,,Hospital CPT 81339,HC So Mpl Gene Seq Alys Exon 10,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,514.00,514.00,308.40,308.40,N/A,185.20,N/A,185.20,N/A,295.96,N/A,174.76,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,115.29,N/A,185.20,N/A,185.20,N/A,185.20,N/A,295.96,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,185.20,N/A,203.72,308.40,308.40,115.29,308.40,,Hospital CPT 81351,HC So Tp53 Gene Full Gene Sequence,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1600.00,1600.00,960.00,960.00,N/A,641.85,N/A,641.85,N/A,921.28,N/A,544.00,N/A,641.85,N/A,641.85,N/A,641.85,N/A,641.85,N/A,399.55,N/A,641.85,N/A,641.85,N/A,641.85,N/A,921.28,N/A,641.85,N/A,641.85,N/A,641.85,N/A,641.85,N/A,641.85,N/A,641.85,N/A,641.85,N/A,706.04,960.00,960.00,399.55,960.00,,Hospital CPT 81363,HC So Hbb Gene Dup/Del Variants,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,510.00,510.00,306.00,306.00,N/A,202.40,N/A,202.40,N/A,293.66,N/A,173.40,N/A,80.96,N/A,202.40,N/A,202.40,N/A,202.40,N/A,80.96,N/A,80.96,N/A,80.96,N/A,80.96,N/A,293.66,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,202.40,N/A,222.64,306.00,306.00,80.96,306.00,,Hospital 81371,HC Recp Lr Hla I & II Type Verify - Bmt,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,225269.03,3027.00,135161.42,1816.20,N/A,700.55,36881.00,514.20,N/A,1742.95,N/A,1029.18,N/A,383.45,N/A,700.55,35163.16,509.37,35163.16,509.37,N/A,287.70,N/A,383.45,N/A,383.45,N/A,383.45,N/A,1742.95,36881.00,509.37,N/A,700.55,N/A,668.07,N/A,668.07,N/A,700.55,36881.00,509.37,36881.00,514.20,N/A,734.89,35163.16,135161.42,287.70,1816.20,,Hospital CPT 81378,HC So Hla I & II Typing Hr,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1382.00,1382.00,829.20,829.20,N/A,345.57,N/A,345.57,N/A,795.76,N/A,469.88,N/A,345.57,N/A,345.57,N/A,345.57,N/A,345.57,N/A,215.12,N/A,345.57,N/A,345.57,N/A,345.57,N/A,795.76,N/A,345.57,N/A,345.57,N/A,345.57,N/A,345.57,N/A,345.57,N/A,345.57,N/A,345.57,N/A,380.13,829.20,829.20,215.12,829.20,,Hospital CPT 81380,HC So Hla I Tping High Resol One Locus Ea,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,709.00,709.00,425.40,425.40,N/A,177.25,N/A,177.25,N/A,408.24,N/A,241.06,N/A,177.25,N/A,177.25,N/A,177.25,N/A,177.25,N/A,110.34,N/A,177.25,N/A,177.25,N/A,177.25,N/A,408.24,N/A,177.25,N/A,177.25,N/A,177.25,N/A,177.25,N/A,177.25,N/A,177.25,N/A,177.25,N/A,194.98,425.40,425.40,110.34,425.40,,Hospital CPT 81401,HC Mopath Procedure Level 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1905.00,1620.00,1143.00,972.00,N/A,137.00,N/A,137.00,N/A,932.80,N/A,550.80,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,932.80,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,1143.00,1143.00,85.28,972.00,,Hospital CPT 81401,HC So1 Molecular Path Level 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,294.00,294.00,176.40,176.40,N/A,137.00,N/A,137.00,N/A,169.29,N/A,99.96,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,169.29,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,176.40,176.40,85.28,176.40,,Hospital CPT 81401,HC So Molecular Path Level 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,197.00,197.00,118.20,118.20,N/A,137.00,N/A,137.00,N/A,113.43,N/A,66.98,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,113.43,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,118.20,118.20,66.98,150.70,,Hospital CPT 81401,HC So2 Molecular Path Level 2,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,475.00,475.00,285.00,285.00,N/A,137.00,N/A,137.00,N/A,273.51,N/A,161.50,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,85.28,N/A,137.00,N/A,137.00,N/A,137.00,N/A,273.51,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,137.00,N/A,150.70,285.00,285.00,85.28,285.00,,Hospital CPT 81402,"HC So Molecular Pathology Procedure, Level 3",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,350.00,350.00,210.00,210.00,N/A,150.33,N/A,150.33,N/A,201.53,N/A,119.00,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,93.58,N/A,150.33,N/A,150.33,N/A,150.33,N/A,201.53,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,150.33,N/A,165.36,210.00,210.00,93.58,210.00,,Hospital CPT 81405,HC So1 Mopath Procedure Level 6,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2424.00,2424.00,1454.40,1454.40,N/A,301.35,N/A,301.35,N/A,1395.74,N/A,824.16,N/A,159.69,N/A,301.35,N/A,301.35,N/A,301.35,N/A,159.69,N/A,159.69,N/A,159.69,N/A,159.69,N/A,1395.74,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,331.49,1454.40,1454.40,159.69,1454.40,,Hospital CPT 81405,HC Tgfbr1/Tgfbr2 Loeys-Dietz Syn,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2673.00,2673.00,1603.80,1603.80,N/A,301.35,N/A,301.35,N/A,1539.11,N/A,908.82,N/A,159.69,N/A,301.35,N/A,301.35,N/A,301.35,N/A,159.69,N/A,159.69,N/A,159.69,N/A,159.69,N/A,1539.11,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,331.49,1603.80,1603.80,159.69,1603.80,,Hospital CPT 81405,HC Molecular Pathology Procedure Level 6,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1427.00,1427.00,856.20,856.20,N/A,301.35,N/A,301.35,N/A,821.67,N/A,485.18,N/A,159.69,N/A,301.35,N/A,301.35,N/A,301.35,N/A,159.69,N/A,159.69,N/A,159.69,N/A,159.69,N/A,821.67,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,331.49,856.20,856.20,159.69,856.20,,Hospital CPT 81405,HC So Mopath Procedure Level 6,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1294.00,1294.00,776.40,776.40,N/A,301.35,N/A,301.35,N/A,745.09,N/A,439.96,N/A,159.69,N/A,301.35,N/A,301.35,N/A,301.35,N/A,159.69,N/A,159.69,N/A,159.69,N/A,159.69,N/A,745.09,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,301.35,N/A,331.49,776.40,776.40,159.69,776.40,,Hospital CPT 81407,HC So Molecular Pathology Level 8,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2115.00,2115.00,1269.00,1269.00,N/A,846.27,N/A,846.27,N/A,1217.82,N/A,719.10,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,526.80,N/A,846.27,N/A,846.27,N/A,846.27,N/A,1217.82,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,846.27,N/A,930.90,1269.00,1269.00,526.80,1269.00,,Hospital CPT 81411,HC So Aortic Dysfunction/Dilation,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4000.00,4000.00,2400.00,2400.00,N/A,1350.19,N/A,1350.19,N/A,2303.20,N/A,1360.00,N/A,1883.31,N/A,1350.19,N/A,1350.19,N/A,1350.19,N/A,1883.31,N/A,1883.31,N/A,1883.31,N/A,1883.31,N/A,2303.20,N/A,1350.19,N/A,1350.19,N/A,1350.19,N/A,1350.19,N/A,1350.19,N/A,1350.19,N/A,1350.19,N/A,1485.21,2400.00,2400.00,1350.19,2400.00,,Hospital CPT 81413,HC So Car Ion Chnnlpath Geno Seq Inc 10 Gns,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2330.00,2330.00,1398.00,1398.00,N/A,584.90,N/A,584.90,N/A,1341.61,N/A,792.20,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,364.10,N/A,584.90,N/A,584.90,N/A,584.90,N/A,1341.61,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,643.39,1398.00,1398.00,364.10,1398.00,,Hospital CPT 81414,HC So Car Ion Chnnlpath Dup/Del Panel 2 Gns,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2330.00,2330.00,1398.00,1398.00,N/A,584.90,N/A,584.90,N/A,1341.61,N/A,792.20,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,364.10,N/A,584.90,N/A,584.90,N/A,584.90,N/A,1341.61,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,643.39,1398.00,1398.00,364.10,1398.00,,Hospital CPT 81420,HC So Fetal Chrmoml Aneuploidy,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1438.00,1438.00,862.80,862.80,N/A,759.05,N/A,759.05,N/A,828.00,N/A,488.92,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,472.51,N/A,759.05,N/A,759.05,N/A,759.05,N/A,828.00,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,834.96,862.80,862.80,472.51,862.80,,Hospital CPT 81420,HC So1 Fetal Chrmoml Aneuploidy,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1438.00,1438.00,862.80,862.80,N/A,759.05,N/A,759.05,N/A,828.00,N/A,488.92,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,472.51,N/A,759.05,N/A,759.05,N/A,759.05,N/A,828.00,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,759.05,N/A,834.96,862.80,862.80,472.51,862.80,,Hospital CPT 81432,HC So Hereditary Breast Cancer Related Disorders,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1800.00,1800.00,1080.00,1080.00,N/A,679.05,N/A,679.05,N/A,1036.44,N/A,612.00,N/A,679.05,N/A,679.05,N/A,679.05,N/A,679.05,N/A,422.71,N/A,679.05,N/A,679.05,N/A,679.05,N/A,1036.44,N/A,679.05,N/A,679.05,N/A,679.05,N/A,679.05,N/A,679.05,N/A,679.05,N/A,679.05,N/A,746.96,1080.00,1080.00,422.71,1080.00,,Hospital CPT 81435,HC So Hereditary Colon Cancer Disorders,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1755.00,1755.00,1053.00,1053.00,N/A,584.90,N/A,584.90,N/A,1010.53,N/A,596.70,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,364.10,N/A,584.90,N/A,584.90,N/A,584.90,N/A,1010.53,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,584.90,N/A,643.39,1053.00,1053.00,364.10,1053.00,,Hospital 81439,HC So Inherited Cardmypthy 5 Gns,N/A,0301 - LABORATORY - CHEMISTRY,142197.20,N/A,85318.32,N/A,7486.07,N/A,9121.28,N/A,N/A,N/A,N/A,N/A,17031.85,N/A,11427.36,N/A,9121.28,N/A,9121.28,N/A,N/A,N/A,N/A,N/A,17031.85,N/A,N/A,N/A,78379.10,N/A,9121.28,N/A,7716.73,N/A,N/A,N/A,20263.65,N/A,11427.36,N/A,9121.28,N/A,9121.28,N/A,11427.36,N/A,7486.07,85318.32,N/A,N/A,,Hospital CPT 81445,HC So Targ Geonomic Seq Analy,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4062.00,4062.00,2437.20,2437.20,N/A,597.91,N/A,597.91,N/A,2338.90,N/A,1381.08,N/A,597.91,N/A,597.91,N/A,597.91,N/A,597.91,N/A,372.20,N/A,597.91,N/A,597.91,N/A,597.91,N/A,2338.90,N/A,597.91,N/A,597.91,N/A,597.91,N/A,597.91,N/A,597.91,N/A,597.91,N/A,597.91,N/A,657.70,2437.20,2437.20,372.20,2437.20,,Hospital CPT 81450,HC So Genomic Seq Dna&Rna Analys Neo 5-50 Gene,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1899.00,1899.00,1139.40,1139.40,N/A,759.53,N/A,759.53,N/A,1093.44,N/A,645.66,N/A,759.53,N/A,759.53,N/A,759.53,N/A,759.53,N/A,472.81,N/A,759.53,N/A,759.53,N/A,759.53,N/A,1093.44,N/A,759.53,N/A,759.53,N/A,759.53,N/A,759.53,N/A,759.53,N/A,759.53,N/A,759.53,N/A,835.48,1139.40,1139.40,472.81,1139.40,,Hospital CPT 81460,HC So Whole Mitochondrial Genome,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2553.00,2553.00,1531.80,1531.80,N/A,1287.00,N/A,1287.00,N/A,1470.02,N/A,868.02,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,801.16,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1470.02,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1287.00,N/A,1415.70,1531.80,1531.80,801.16,1531.80,,Hospital CPT 81465,HC So Whole Mitochondrial Genome Deletion Analysis,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,1850.00,1850.00,1110.00,1110.00,N/A,936.00,N/A,936.00,N/A,1065.23,N/A,629.00,N/A,936.00,N/A,936.00,N/A,936.00,N/A,936.00,N/A,582.66,N/A,936.00,N/A,936.00,N/A,936.00,N/A,1065.23,N/A,936.00,N/A,936.00,N/A,936.00,N/A,936.00,N/A,936.00,N/A,936.00,N/A,936.00,N/A,1029.60,1110.00,1110.00,582.66,1110.00,,Hospital CPT 81479,"HC Molecular Pathology, Unlisted",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,663.00,191.00,397.80,114.60,N/A,26.74,N/A,191.00,N/A,109.98,N/A,64.94,N/A,26.74,N/A,26.74,N/A,191.00,N/A,191.00,N/A,N/A,N/A,N/A,N/A,26.74,N/A,N/A,N/A,109.98,N/A,191.00,N/A,26.74,N/A,191.00,N/A,191.00,N/A,26.74,N/A,191.00,N/A,191.00,N/A,191.00,397.80,397.80,26.74,191.00,,Hospital CPT 81479,"HC So Molecular Pathology, Unlisted",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,663.00,663.00,397.80,397.80,N/A,92.82,N/A,663.00,N/A,381.76,N/A,225.42,N/A,92.82,N/A,92.82,N/A,663.00,N/A,663.00,N/A,N/A,N/A,N/A,N/A,92.82,N/A,N/A,N/A,381.76,N/A,663.00,N/A,92.82,N/A,663.00,N/A,663.00,N/A,92.82,N/A,663.00,N/A,663.00,N/A,663.00,397.80,397.80,92.82,663.00,,Hospital CPT 81479,HC So2 Unlisted Molecular Path Proc,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4000.00,4000.00,2400.00,2400.00,N/A,560.00,N/A,4000.00,N/A,2303.20,N/A,1360.00,N/A,560.00,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,N/A,N/A,N/A,N/A,560.00,N/A,N/A,N/A,2303.20,N/A,4000.00,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,4000.00,2400.00,2400.00,560.00,4000.00,,Hospital CPT 81479,"HC So1 Molecular Pathology, Unlisted",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,4000.00,4000.00,2400.00,2400.00,N/A,560.00,N/A,4000.00,N/A,2303.20,N/A,1360.00,N/A,560.00,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,N/A,N/A,N/A,N/A,560.00,N/A,N/A,N/A,2303.20,N/A,4000.00,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,560.00,N/A,4000.00,N/A,4000.00,N/A,4000.00,2400.00,2400.00,560.00,4000.00,,Hospital CPT 81503,"HC So Oncology Score, Biolchemical Assay",N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,2691.00,2691.00,1614.60,1614.60,N/A,897.00,N/A,897.00,N/A,1549.48,N/A,914.94,N/A,49.15,N/A,897.00,N/A,897.00,N/A,897.00,N/A,49.15,N/A,49.15,N/A,49.15,N/A,49.15,N/A,1549.48,N/A,897.00,N/A,897.00,N/A,897.00,N/A,897.00,N/A,897.00,N/A,897.00,N/A,897.00,N/A,986.70,1614.60,1614.60,49.15,1614.60,,Hospital CPT 81508,HC So Maternal Screen 1st Trim,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,217.00,217.00,130.20,130.20,N/A,54.30,N/A,54.30,N/A,124.95,N/A,73.78,N/A,14.24,N/A,54.30,N/A,54.30,N/A,54.30,N/A,14.24,N/A,14.24,N/A,14.24,N/A,14.24,N/A,124.95,N/A,54.30,N/A,54.30,N/A,54.30,N/A,54.30,N/A,54.30,N/A,54.30,N/A,54.30,N/A,59.73,130.20,130.20,14.24,130.20,,Hospital CPT 81514,HC Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,726.00,726.00,435.60,435.60,N/A,262.99,N/A,262.99,N/A,418.03,N/A,246.84,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,163.71,N/A,262.99,N/A,262.99,N/A,262.99,N/A,418.03,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,262.99,N/A,289.29,435.60,435.60,163.71,435.60,,Hospital 81519,HC So Oncology Breast Mrna,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,76051.72,N/A,45631.03,N/A,9049.65,N/A,10970.91,N/A,N/A,N/A,25857.58,N/A,20589.21,N/A,9328.49,N/A,2810.00,N/A,2810.00,N/A,12816.30,N/A,20589.21,N/A,20589.21,N/A,20589.21,N/A,N/A,N/A,10970.91,N/A,9328.49,N/A,24496.02,N/A,24496.02,N/A,9328.49,N/A,10970.91,N/A,10970.91,N/A,N/A,N/A,2810.00,45631.03,N/A,N/A,,Hospital 81539,HC So Oncology Prostate Prob Score,N/A,0301 - LABORATORY - CHEMISTRY,N/A,2746.00,N/A,1647.60,N/A,1532.07,N/A,1537.64,N/A,1581.14,N/A,933.64,N/A,412.71,N/A,1532.07,N/A,1537.64,N/A,1537.64,N/A,412.71,N/A,412.71,N/A,412.71,N/A,412.71,N/A,1581.14,N/A,1537.64,N/A,1532.07,N/A,1532.07,N/A,1532.07,N/A,1532.07,N/A,1537.64,N/A,1537.64,N/A,1685.28,N/A,N/A,412.71,1685.28,,Hospital CPT 82013,HC So Acetylcholinesterase,N/A,0307 - LABORATORY - UROLOGY,139.00,139.00,83.40,83.40,N/A,12.29,N/A,12.29,N/A,80.04,N/A,47.26,N/A,12.29,N/A,12.29,N/A,12.29,N/A,12.29,N/A,7.65,N/A,12.29,N/A,12.29,N/A,12.29,N/A,80.04,N/A,12.29,N/A,12.29,N/A,12.29,N/A,12.29,N/A,12.29,N/A,12.29,N/A,12.29,N/A,13.52,83.40,83.40,7.65,83.40,,Hospital CPT 82040,HC So Albumin,N/A,0307 - LABORATORY - UROLOGY,117.00,117.00,70.20,70.20,N/A,4.95,N/A,4.95,N/A,67.37,N/A,39.78,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,3.08,N/A,4.95,N/A,4.95,N/A,4.95,N/A,67.37,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,5.45,70.20,70.20,3.08,70.20,,Hospital CPT 82040,HC Albumin,N/A,0307 - LABORATORY - UROLOGY,129.00,113.00,77.40,67.80,N/A,4.95,N/A,4.95,N/A,65.07,N/A,38.42,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,3.08,N/A,4.95,N/A,4.95,N/A,4.95,N/A,65.07,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,4.95,N/A,5.45,77.40,77.40,3.08,67.80,,Hospital 82044,"HC Chg Microalbumin, Semiquant",N/A,0307 - LABORATORY - UROLOGY,53521.60,1059.00,32112.96,635.40,6498.75,100.23,12616.71,105.80,23529.46,609.78,18197.34,360.06,17110.65,80.77,10762.62,100.23,12616.71,105.80,12616.71,105.80,14786.65,80.77,23754.54,80.77,23754.54,80.77,23754.54,80.77,23529.46,609.78,12616.71,105.80,6498.75,100.23,28261.97,100.23,28261.97,100.23,6656.64,100.23,12616.71,105.80,12616.71,105.80,6498.75,110.26,6498.75,32112.96,80.77,635.40,,Hospital CPT 82075,HC Breath Alcohol Test,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,101.00,76.00,60.60,45.60,N/A,30.00,N/A,30.00,N/A,43.76,N/A,25.84,N/A,9.88,N/A,30.00,N/A,30.00,N/A,30.00,N/A,9.88,N/A,9.88,N/A,9.88,N/A,9.88,N/A,43.76,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,33.00,60.60,60.60,9.88,45.60,,Hospital CPT 82075,HC Breath Alcohol Test,N/A,0307 - LABORATORY - UROLOGY,101.00,76.00,60.60,45.60,N/A,30.00,N/A,30.00,N/A,43.76,N/A,25.84,N/A,9.88,N/A,30.00,N/A,30.00,N/A,30.00,N/A,9.88,N/A,9.88,N/A,9.88,N/A,9.88,N/A,43.76,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,33.00,60.60,60.60,9.88,45.60,,Hospital CPT 82077,HC Drug Assay of Alcohol Spec Xcp UR&Breath Ia,N/A,0301 - LABORATORY - CHEMISTRY,210.00,210.00,126.00,126.00,N/A,17.27,N/A,17.27,N/A,120.92,N/A,71.40,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,10.75,N/A,17.27,N/A,6.91,N/A,17.27,N/A,120.92,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,17.27,N/A,19.00,126.00,126.00,6.91,126.00,,Hospital CPT 82088,"HC Aldosterone, Serum",N/A,0307 - LABORATORY - UROLOGY,253.00,189.00,151.80,113.40,N/A,40.75,N/A,40.75,N/A,108.83,N/A,64.26,N/A,34.63,N/A,40.75,N/A,40.75,N/A,40.75,N/A,34.63,N/A,40.75,N/A,34.63,N/A,34.63,N/A,108.83,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,44.83,151.80,151.80,34.63,113.40,,Hospital CPT 82088,"HC So Aldosterone, Serum",N/A,0307 - LABORATORY - UROLOGY,229.00,229.00,137.40,137.40,N/A,40.75,N/A,40.75,N/A,131.86,N/A,77.86,N/A,34.63,N/A,40.75,N/A,40.75,N/A,40.75,N/A,34.63,N/A,40.75,N/A,34.63,N/A,34.63,N/A,131.86,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,40.75,N/A,44.83,137.40,137.40,34.63,137.40,,Hospital CPT 82103,HC So Alpha 1 Antitrypsin,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,13.44,N/A,13.44,N/A,93.28,N/A,55.08,N/A,11.42,N/A,13.44,N/A,13.44,N/A,13.44,N/A,11.42,N/A,13.44,N/A,11.42,N/A,11.42,N/A,93.28,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,14.78,97.20,97.20,11.42,97.20,,Hospital CPT 82103,HC Alpha 1 Antitrypsin,N/A,0301 - LABORATORY - CHEMISTRY,180.00,134.00,108.00,80.40,N/A,13.44,N/A,13.44,N/A,77.16,N/A,45.56,N/A,11.42,N/A,13.44,N/A,13.44,N/A,13.44,N/A,11.42,N/A,13.44,N/A,11.42,N/A,11.42,N/A,77.16,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,14.78,108.00,108.00,11.42,80.40,,Hospital CPT 82104,"HC Alpha-1,Antitrypsin,Phenotype",N/A,0301 - LABORATORY - CHEMISTRY,105.00,78.00,63.00,46.80,N/A,14.46,N/A,14.46,N/A,44.91,N/A,26.52,N/A,12.29,N/A,14.46,N/A,14.46,N/A,14.46,N/A,12.29,N/A,14.46,N/A,12.29,N/A,12.29,N/A,44.91,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,15.91,63.00,63.00,12.29,46.80,,Hospital CPT 82104,"HC So Alpha-1,Antitrypsin,Phenotype",N/A,0301 - LABORATORY - CHEMISTRY,95.00,95.00,57.00,57.00,N/A,14.46,N/A,14.46,N/A,54.70,N/A,32.30,N/A,12.29,N/A,14.46,N/A,14.46,N/A,14.46,N/A,12.29,N/A,14.46,N/A,12.29,N/A,12.29,N/A,54.70,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,15.91,57.00,57.00,12.29,57.00,,Hospital CPT 82105,HC Alpha Fetoprotein,N/A,0301 - LABORATORY - CHEMISTRY,323.00,240.00,193.80,144.00,N/A,16.77,N/A,16.77,N/A,138.19,N/A,81.60,N/A,14.26,N/A,16.77,N/A,16.77,N/A,16.77,N/A,14.26,N/A,16.77,N/A,14.26,N/A,14.26,N/A,138.19,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,18.45,193.80,193.80,14.26,144.00,,Hospital CPT 82105,HC So Alpha Fetoprotein,N/A,0301 - LABORATORY - CHEMISTRY,293.00,293.00,175.80,175.80,N/A,16.77,N/A,16.77,N/A,168.71,N/A,99.62,N/A,14.26,N/A,16.77,N/A,16.77,N/A,16.77,N/A,14.26,N/A,16.77,N/A,14.26,N/A,14.26,N/A,168.71,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,16.77,N/A,18.45,175.80,175.80,14.26,175.80,,Hospital CPT 82106,HC So Alpha-Fetoprot Amniotic Fluid,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,17.00,N/A,17.00,N/A,39.15,N/A,23.12,N/A,17.00,N/A,17.00,N/A,17.00,N/A,17.00,N/A,10.58,N/A,17.00,N/A,17.00,N/A,17.00,N/A,39.15,N/A,17.00,N/A,17.00,N/A,17.00,N/A,17.00,N/A,17.00,N/A,17.00,N/A,17.00,N/A,18.70,40.80,40.80,10.58,40.80,,Hospital 82107,HC So Alpha-Fetoprotein (Afp),N/A,0301 - LABORATORY - CHEMISTRY,49907.45,980.00,29944.47,588.00,9484.96,102.54,11485.86,108.11,22135.51,564.29,16968.53,333.20,21579.59,87.78,9777.20,102.54,4496.00,108.11,4496.00,108.11,13432.79,87.78,21579.59,87.78,21579.59,87.78,21579.59,87.78,22135.51,564.29,11485.86,108.11,9777.20,102.54,25674.32,102.54,25674.32,102.54,9777.20,102.54,11485.86,108.11,11485.86,108.11,10461.61,112.80,4496.00,29944.47,87.78,588.00,,Hospital CPT 82131,HC Amino Acids Quantitation Each,N/A,0301 - LABORATORY - CHEMISTRY,131.00,98.00,78.60,58.80,N/A,22.98,N/A,22.98,N/A,56.43,N/A,33.32,N/A,14.33,N/A,22.98,N/A,22.98,N/A,22.98,N/A,14.33,N/A,14.33,N/A,14.33,N/A,14.33,N/A,56.43,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,25.28,78.60,78.60,14.33,58.80,,Hospital CPT 82131,HC So Amino Acids Quantitation Each,N/A,0301 - LABORATORY - CHEMISTRY,119.00,119.00,71.40,71.40,N/A,22.98,N/A,22.98,N/A,68.52,N/A,40.46,N/A,14.33,N/A,22.98,N/A,22.98,N/A,22.98,N/A,14.33,N/A,14.33,N/A,14.33,N/A,14.33,N/A,68.52,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,22.98,N/A,25.28,71.40,71.40,14.33,71.40,,Hospital CPT 82135,HC So Delta Aminolevulinic Acid,N/A,0301 - LABORATORY - CHEMISTRY,118.00,118.00,70.80,70.80,N/A,16.45,N/A,16.45,N/A,67.94,N/A,40.12,N/A,13.99,N/A,16.45,N/A,16.45,N/A,16.45,N/A,13.99,N/A,13.99,N/A,13.99,N/A,13.99,N/A,67.94,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,18.10,70.80,70.80,13.99,70.80,,Hospital CPT 82135,HC Delta Aminolevulinic Acid,N/A,0301 - LABORATORY - CHEMISTRY,130.00,97.00,78.00,58.20,N/A,16.45,N/A,16.45,N/A,55.85,N/A,32.98,N/A,13.99,N/A,16.45,N/A,16.45,N/A,16.45,N/A,13.99,N/A,13.99,N/A,13.99,N/A,13.99,N/A,55.85,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,16.45,N/A,18.10,78.00,78.00,13.99,58.20,,Hospital CPT 82139,"HC Amino Acids, 6 or < Ea Spec",N/A,0301 - LABORATORY - CHEMISTRY,419.00,314.00,251.40,188.40,N/A,16.87,N/A,16.87,N/A,180.80,N/A,106.76,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,180.80,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,251.40,251.40,1.73,188.40,,Hospital CPT 82139,"HC So Amino Acids, 6 or < Ea Spec",N/A,0301 - LABORATORY - CHEMISTRY,380.00,380.00,228.00,228.00,N/A,16.87,N/A,16.87,N/A,218.80,N/A,129.20,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,218.80,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,228.00,228.00,1.73,228.00,,Hospital CPT 82140,HC Ammonia,N/A,0301 - LABORATORY - CHEMISTRY,180.00,134.00,108.00,80.40,N/A,14.57,N/A,14.57,N/A,77.16,N/A,45.56,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,9.07,N/A,14.57,N/A,14.57,N/A,14.57,N/A,77.16,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,16.03,108.00,108.00,9.07,80.40,,Hospital CPT 82140,HC So Ammonia,N/A,0301 - LABORATORY - CHEMISTRY,162.00,162.00,97.20,97.20,N/A,14.57,N/A,14.57,N/A,93.28,N/A,55.08,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,9.07,N/A,14.57,N/A,14.57,N/A,14.57,N/A,93.28,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,14.57,N/A,16.03,97.20,97.20,9.07,97.20,,Hospital CPT 82143,HC So Amniotic Fluid Scan,N/A,0301 - LABORATORY - CHEMISTRY,175.00,175.00,105.00,105.00,N/A,9.35,N/A,9.35,N/A,100.77,N/A,59.50,N/A,9.35,N/A,9.35,N/A,9.35,N/A,9.35,N/A,5.82,N/A,9.35,N/A,9.35,N/A,9.35,N/A,100.77,N/A,9.35,N/A,9.35,N/A,9.35,N/A,9.35,N/A,9.35,N/A,9.35,N/A,9.35,N/A,10.29,105.00,105.00,5.82,105.00,,Hospital CPT 82172,HC So Lipoprotein A,N/A,0301 - LABORATORY - CHEMISTRY,84.00,84.00,50.40,50.40,N/A,21.09,N/A,21.09,N/A,48.37,N/A,28.56,N/A,12.04,N/A,21.09,N/A,21.09,N/A,21.09,N/A,12.04,N/A,21.09,N/A,12.04,N/A,12.04,N/A,48.37,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,23.20,50.40,50.40,12.04,50.40,,Hospital CPT 82172,HC Lipoprotein A,N/A,0301 - LABORATORY - CHEMISTRY,93.00,70.00,55.80,42.00,N/A,21.09,N/A,21.09,N/A,40.31,N/A,23.80,N/A,12.04,N/A,21.09,N/A,21.09,N/A,21.09,N/A,12.04,N/A,21.09,N/A,12.04,N/A,12.04,N/A,40.31,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,21.09,N/A,23.20,55.80,55.80,12.04,42.00,,Hospital CPT 82180,HC So Vitamin C,N/A,0301 - LABORATORY - CHEMISTRY,88.00,88.00,52.80,52.80,N/A,9.89,N/A,9.89,N/A,50.67,N/A,29.92,N/A,4.94,N/A,9.89,N/A,9.89,N/A,9.89,N/A,4.94,N/A,4.94,N/A,4.94,N/A,4.94,N/A,50.67,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,10.88,52.80,52.80,4.94,52.80,,Hospital CPT 82180,HC Vitamin C,N/A,0301 - LABORATORY - CHEMISTRY,98.00,72.00,58.80,43.20,N/A,9.89,N/A,9.89,N/A,41.46,N/A,24.48,N/A,4.94,N/A,9.89,N/A,9.89,N/A,9.89,N/A,4.94,N/A,4.94,N/A,4.94,N/A,4.94,N/A,41.46,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,9.89,N/A,10.88,58.80,58.80,4.94,43.20,,Hospital CPT 82232,HC Beta-2-Microglobulin,N/A,0301 - LABORATORY - CHEMISTRY,170.00,128.00,102.00,76.80,N/A,16.18,N/A,16.18,N/A,73.70,N/A,43.52,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,10.07,N/A,16.18,N/A,16.18,N/A,16.18,N/A,73.70,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,17.80,102.00,102.00,10.07,76.80,,Hospital CPT 82232,HC So Beta-2-Microglobulin,N/A,0301 - LABORATORY - CHEMISTRY,154.00,154.00,92.40,92.40,N/A,16.18,N/A,16.18,N/A,88.67,N/A,52.36,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,10.07,N/A,16.18,N/A,16.18,N/A,16.18,N/A,88.67,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,16.18,N/A,17.80,92.40,92.40,10.07,92.40,,Hospital CPT 82248,HC Bilirubin Direct,N/A,0301 - LABORATORY - CHEMISTRY,158.00,118.00,94.80,70.80,N/A,5.02,N/A,5.02,N/A,67.94,N/A,40.12,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,3.12,N/A,4.26,N/A,5.02,N/A,4.26,N/A,67.94,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.02,N/A,5.52,94.80,94.80,3.12,70.80,,Hospital CPT 82261,"HC Biotinidase,Each Specimen",N/A,0301 - LABORATORY - CHEMISTRY,721.00,539.00,432.60,323.40,N/A,16.87,N/A,16.87,N/A,310.36,N/A,183.26,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,310.36,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,432.60,432.60,1.73,323.40,,Hospital CPT 82261,"HC So Biotinidase,Each Specimen",N/A,0301 - LABORATORY - CHEMISTRY,654.00,654.00,392.40,392.40,N/A,16.87,N/A,16.87,N/A,376.57,N/A,222.36,N/A,1.73,N/A,16.87,N/A,16.87,N/A,16.87,N/A,1.73,N/A,1.73,N/A,1.73,N/A,1.73,N/A,376.57,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,16.87,N/A,18.56,392.40,392.40,1.73,392.40,,Hospital CPT 82270,HC Occult Blood Feces,N/A,0301 - LABORATORY - CHEMISTRY,64.00,48.00,38.40,28.80,N/A,4.38,N/A,4.38,N/A,27.64,N/A,16.32,N/A,2.77,N/A,4.38,N/A,4.38,N/A,4.38,N/A,2.77,N/A,4.38,N/A,2.77,N/A,2.77,N/A,27.64,N/A,4.38,N/A,4.38,N/A,4.38,N/A,4.38,N/A,4.38,N/A,4.38,N/A,4.38,N/A,4.82,38.40,38.40,2.77,28.80,,Hospital CPT 82271,"HC Occult Blood, Body Fluids",N/A,0301 - LABORATORY - CHEMISTRY,34.00,26.00,20.40,15.60,N/A,5.32,N/A,5.32,N/A,14.97,N/A,8.84,N/A,5.32,N/A,5.32,N/A,5.32,N/A,5.32,N/A,3.31,N/A,5.32,N/A,5.32,N/A,5.32,N/A,14.97,N/A,5.32,N/A,5.32,N/A,5.32,N/A,5.32,N/A,5.32,N/A,5.32,N/A,5.32,N/A,5.85,20.40,20.40,3.31,15.60,,Hospital CPT 82274,HC Occult Blood Fecal,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,15.92,N/A,15.92,N/A,68.00,N/A,23.12,N/A,13.52,N/A,15.92,N/A,15.92,N/A,15.92,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,39.15,N/A,15.92,N/A,15.92,N/A,15.92,N/A,15.92,N/A,15.92,N/A,15.92,N/A,15.92,N/A,17.51,40.80,40.80,13.52,68.00,,Hospital CPT 82306,HC So Vitamin D Hydroxyvitamin D,N/A,0301 - LABORATORY - CHEMISTRY,194.00,194.00,116.40,116.40,N/A,29.60,N/A,29.60,N/A,111.71,N/A,65.96,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,18.43,N/A,29.60,N/A,29.60,N/A,29.60,N/A,111.71,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,32.56,116.40,116.40,18.43,116.40,,Hospital CPT 82306,HC Vitamin D Hydroxyvitamin D,N/A,0301 - LABORATORY - CHEMISTRY,214.00,160.00,128.40,96.00,N/A,29.60,N/A,29.60,N/A,92.13,N/A,54.40,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,18.43,N/A,29.60,N/A,29.60,N/A,29.60,N/A,92.13,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,29.60,N/A,32.56,128.40,128.40,18.43,96.00,,Hospital CPT 82340,"HC Calcium,Urine 24 Hr",N/A,0301 - LABORATORY - CHEMISTRY,107.00,79.00,64.20,47.40,N/A,6.03,N/A,6.03,N/A,79.00,N/A,26.86,N/A,3.34,N/A,6.03,N/A,6.03,N/A,6.03,N/A,3.34,N/A,3.34,N/A,3.34,N/A,3.34,N/A,45.49,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.63,64.20,64.20,3.34,79.00,,Hospital CPT 82340,"HC So Calcium,Urine 24 Hr",N/A,0301 - LABORATORY - CHEMISTRY,97.00,97.00,58.20,58.20,N/A,6.03,N/A,6.03,N/A,97.00,N/A,32.98,N/A,3.34,N/A,6.03,N/A,6.03,N/A,6.03,N/A,3.34,N/A,3.34,N/A,3.34,N/A,3.34,N/A,55.85,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.03,N/A,6.63,58.20,58.20,3.34,97.00,,Hospital 82355,HC Calculus Analysis Qual,N/A,0301 - LABORATORY - CHEMISTRY,65096.23,40277.80,39057.74,24166.68,5750.19,5572.40,7067.82,426.61,13591.43,23159.85,22132.72,13694.45,13082.47,12523.54,5927.36,5572.40,1124.00,7600.71,1124.00,7600.71,8143.53,7793.75,13082.47,12523.54,13082.47,12523.54,13082.47,12523.54,13591.43,23159.86,7067.82,7600.71,5927.36,5572.40,15564.88,5963.00,15564.88,5963.00,5927.36,5572.40,7067.82,7600.71,7067.82,426.61,6342.28,469.28,1124.00,39057.74,426.61,24166.68,,Hospital CPT 82365,HC Urinary Stone Analysis,N/A,0301 - LABORATORY - CHEMISTRY,46.00,46.00,27.60,27.60,N/A,12.90,N/A,12.90,N/A,26.49,N/A,15.64,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,8.03,N/A,10.96,N/A,10.96,N/A,10.96,N/A,26.49,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,14.19,27.60,27.60,8.03,27.60,,Hospital CPT 82365,HC So Urinary Stone Analysis,N/A,0301 - LABORATORY - CHEMISTRY,46.00,46.00,27.60,27.60,N/A,12.90,N/A,12.90,N/A,26.49,N/A,15.64,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,8.03,N/A,10.96,N/A,10.96,N/A,10.96,N/A,26.49,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,14.19,27.60,27.60,8.03,27.60,,Hospital CPT 82373,"HC So Transferrin, Carbohydrate Dfct",N/A,0301 - LABORATORY - CHEMISTRY,175.00,175.00,105.00,105.00,N/A,18.06,N/A,18.06,N/A,100.77,N/A,59.50,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,11.24,N/A,18.06,N/A,18.06,N/A,18.06,N/A,100.77,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,19.87,105.00,105.00,11.24,105.00,,Hospital CPT 82373,"HC Transferrin, Carbohydrate Dfct",N/A,0301 - LABORATORY - CHEMISTRY,175.00,175.00,105.00,105.00,N/A,18.06,N/A,18.06,N/A,100.77,N/A,59.50,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,11.24,N/A,18.06,N/A,18.06,N/A,18.06,N/A,100.77,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,18.06,N/A,19.87,105.00,105.00,11.24,105.00,,Hospital CPT 82374,HC Co-2,N/A,0301 - LABORATORY - CHEMISTRY,84.00,84.00,50.40,50.40,N/A,4.88,N/A,4.88,N/A,48.37,N/A,28.56,N/A,4.16,N/A,4.88,N/A,4.88,N/A,4.88,N/A,4.16,N/A,4.16,N/A,4.16,N/A,4.16,N/A,48.37,N/A,4.88,N/A,4.88,N/A,4.88,N/A,4.88,N/A,4.88,N/A,4.88,N/A,4.88,N/A,5.37,50.40,50.40,4.16,50.40,,Hospital CPT 82375,HC Carboxyhemoglobin,N/A,0301 - LABORATORY - CHEMISTRY,121.00,91.00,72.60,54.60,N/A,12.32,N/A,12.32,N/A,52.40,N/A,30.94,N/A,10.48,N/A,12.32,N/A,12.32,N/A,12.32,N/A,10.48,N/A,10.48,N/A,10.48,N/A,12.32,N/A,52.40,N/A,12.32,N/A,12.32,N/A,12.32,N/A,12.32,N/A,12.32,N/A,12.32,N/A,12.32,N/A,13.55,72.60,72.60,10.48,54.60,,Hospital CPT 82384,HC So Catecholamines Fractionated,N/A,0301 - LABORATORY - CHEMISTRY,368.00,368.00,220.80,220.80,N/A,25.25,N/A,25.25,N/A,368.00,N/A,125.12,N/A,21.46,N/A,25.25,N/A,25.25,N/A,25.25,N/A,21.46,N/A,21.46,N/A,21.46,N/A,25.25,N/A,211.89,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,27.78,220.80,220.80,21.46,368.00,,Hospital CPT 82384,HC Catecholamines Fractionated,N/A,0301 - LABORATORY - CHEMISTRY,406.00,303.00,243.60,181.80,N/A,25.25,N/A,25.25,N/A,303.00,N/A,103.02,N/A,21.46,N/A,25.25,N/A,25.25,N/A,25.25,N/A,21.46,N/A,21.46,N/A,21.46,N/A,25.25,N/A,174.47,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,25.25,N/A,27.78,243.60,243.60,21.46,303.00,,Hospital CPT 82390,HC Ceruloplasmin,N/A,0301 - LABORATORY - CHEMISTRY,223.00,165.00,133.80,99.00,N/A,10.74,N/A,10.74,N/A,95.01,N/A,56.10,N/A,9.13,N/A,10.74,N/A,10.74,N/A,10.74,N/A,9.13,N/A,9.13,N/A,9.13,N/A,9.13,N/A,95.01,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,11.81,133.80,133.80,9.13,99.00,,Hospital CPT 82390,HC So Ceruloplasmin,N/A,0301 - LABORATORY - CHEMISTRY,201.00,201.00,120.60,120.60,N/A,10.74,N/A,10.74,N/A,115.74,N/A,68.34,N/A,9.13,N/A,10.74,N/A,10.74,N/A,10.74,N/A,9.13,N/A,9.13,N/A,9.13,N/A,9.13,N/A,115.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,10.74,N/A,11.81,120.60,120.60,9.13,120.60,,Hospital CPT 82435,"HC Chloride,Serum",N/A,0301 - LABORATORY - CHEMISTRY,69.00,69.00,41.40,41.40,N/A,4.60,N/A,4.60,N/A,39.73,N/A,23.46,N/A,3.91,N/A,4.60,N/A,4.60,N/A,4.60,N/A,3.91,N/A,3.91,N/A,4.60,N/A,3.91,N/A,39.73,N/A,4.60,N/A,4.60,N/A,4.60,N/A,4.60,N/A,4.60,N/A,4.60,N/A,4.60,N/A,5.06,41.40,41.40,3.91,41.40,,Hospital CPT 82482,"HC Cholinesterase, RBC",N/A,0301 - LABORATORY - CHEMISTRY,93.00,70.00,55.80,42.00,N/A,9.81,N/A,9.81,N/A,40.31,N/A,23.80,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,6.11,N/A,9.81,N/A,9.81,N/A,9.81,N/A,40.31,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,10.79,55.80,55.80,6.11,42.00,,Hospital CPT 82482,"HC So Cholinesterase, RBC",N/A,0301 - LABORATORY - CHEMISTRY,84.00,84.00,50.40,50.40,N/A,9.81,N/A,9.81,N/A,48.37,N/A,28.56,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,6.11,N/A,9.81,N/A,9.81,N/A,9.81,N/A,48.37,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,10.79,50.40,50.40,6.11,50.40,,Hospital CPT 82507,HC So Citric Acid 24hr Urine,N/A,0301 - LABORATORY - CHEMISTRY,87.00,87.00,52.20,52.20,N/A,27.80,N/A,27.80,N/A,87.00,N/A,29.58,N/A,23.63,N/A,27.80,N/A,27.80,N/A,27.80,N/A,23.63,N/A,23.63,N/A,23.63,N/A,23.63,N/A,50.09,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,30.58,52.20,52.20,23.63,87.00,,Hospital CPT 82507,HC Citric Acid 24hr Urine,N/A,0301 - LABORATORY - CHEMISTRY,97.00,71.00,58.20,42.60,N/A,27.80,N/A,27.80,N/A,71.00,N/A,24.14,N/A,23.63,N/A,27.80,N/A,27.80,N/A,27.80,N/A,23.63,N/A,23.63,N/A,23.63,N/A,23.63,N/A,40.88,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,27.80,N/A,30.58,58.20,58.20,23.63,71.00,,Hospital CPT 82525,"HC Copper,Serum",N/A,0301 - LABORATORY - CHEMISTRY,201.00,147.00,120.60,88.20,N/A,12.41,N/A,12.41,N/A,84.64,N/A,49.98,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,7.73,N/A,10.55,N/A,10.55,N/A,10.55,N/A,84.64,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,13.65,120.60,120.60,7.73,88.20,,Hospital CPT 82525,"HC So1 Copper,Serum",N/A,0301 - LABORATORY - CHEMISTRY,181.00,181.00,108.60,108.60,N/A,12.41,N/A,12.41,N/A,104.22,N/A,61.54,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,7.73,N/A,10.55,N/A,10.55,N/A,10.55,N/A,104.22,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,13.65,108.60,108.60,7.73,108.60,,Hospital CPT 82525,HC So Copper,N/A,0301 - LABORATORY - CHEMISTRY,181.00,181.00,108.60,108.60,N/A,12.41,N/A,12.41,N/A,104.22,N/A,61.54,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,7.73,N/A,10.55,N/A,10.55,N/A,10.55,N/A,104.22,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,12.41,N/A,13.65,108.60,108.60,7.73,108.60,,Hospital CPT 82530,"HC So Cortisol,Free",N/A,0301 - LABORATORY - CHEMISTRY,91.00,91.00,54.60,54.60,N/A,16.71,N/A,16.71,N/A,91.00,N/A,30.94,N/A,14.20,N/A,16.71,N/A,16.71,N/A,16.71,N/A,14.20,N/A,14.20,N/A,14.20,N/A,14.20,N/A,52.40,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,18.38,54.60,54.60,14.20,91.00,,Hospital CPT 82530,"HC Cortisol,Free",N/A,0301 - LABORATORY - CHEMISTRY,101.00,76.00,60.60,45.60,N/A,16.71,N/A,16.71,N/A,76.00,N/A,25.84,N/A,14.20,N/A,16.71,N/A,16.71,N/A,16.71,N/A,14.20,N/A,14.20,N/A,14.20,N/A,14.20,N/A,43.76,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,16.71,N/A,18.38,60.60,60.60,14.20,76.00,,Hospital CPT 82550,HC Cpk (CK),N/A,0301 - LABORATORY - CHEMISTRY,132.00,99.00,79.20,59.40,N/A,6.51,N/A,6.51,N/A,57.00,N/A,33.66,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,4.05,N/A,6.51,N/A,6.51,N/A,6.51,N/A,57.00,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,7.16,79.20,79.20,4.05,59.40,,Hospital CPT 82550,HC So Cpk (CK),N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,6.51,N/A,6.51,N/A,69.10,N/A,40.80,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,4.05,N/A,6.51,N/A,6.51,N/A,6.51,N/A,69.10,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,6.51,N/A,7.16,72.00,72.00,4.05,72.00,,Hospital CPT 82552,HC Creatine Kinase Isoenzyme,N/A,0301 - LABORATORY - CHEMISTRY,55.00,55.00,33.00,33.00,N/A,13.39,N/A,13.39,N/A,31.67,N/A,18.70,N/A,11.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,31.67,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,14.73,33.00,33.00,11.39,33.00,,Hospital CPT 82552,HC So Creatine Kinase Isoenzyme,N/A,0301 - LABORATORY - CHEMISTRY,49.00,49.00,29.40,29.40,N/A,13.39,N/A,13.39,N/A,28.21,N/A,16.66,N/A,11.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,11.39,N/A,28.21,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,13.39,N/A,14.73,29.40,29.40,11.39,29.40,,Hospital CPT 82553,HC So CKMB,N/A,0301 - LABORATORY - CHEMISTRY,59.00,59.00,35.40,35.40,N/A,11.55,N/A,11.55,N/A,33.97,N/A,20.06,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,7.19,N/A,5.59,N/A,11.55,N/A,11.55,N/A,33.97,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,12.71,35.40,35.40,5.59,35.40,,Hospital CPT 82553,HC CK Mb Fraction,N/A,0301 - LABORATORY - CHEMISTRY,65.00,49.00,39.00,29.40,N/A,11.55,N/A,11.55,N/A,28.21,N/A,16.66,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,7.19,N/A,5.59,N/A,11.55,N/A,11.55,N/A,28.21,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,11.55,N/A,12.71,39.00,39.00,5.59,29.40,,Hospital CPT 82600,HC So Assay of Cyanide,N/A,0301 - LABORATORY - CHEMISTRY,189.00,189.00,113.40,113.40,N/A,19.40,N/A,19.40,N/A,108.83,N/A,64.26,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,12.08,N/A,19.40,N/A,19.40,N/A,19.40,N/A,108.83,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,21.34,113.40,113.40,12.08,113.40,,Hospital CPT 82600,HC Assay of Cyanide,N/A,0301 - LABORATORY - CHEMISTRY,209.00,186.00,125.40,111.60,N/A,19.40,N/A,19.40,N/A,107.10,N/A,63.24,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,12.08,N/A,19.40,N/A,19.40,N/A,19.40,N/A,107.10,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,19.40,N/A,21.34,125.40,125.40,12.08,111.60,,Hospital CPT 82607,HC Vitamin B-12,N/A,0301 - LABORATORY - CHEMISTRY,312.00,232.00,187.20,139.20,N/A,15.08,N/A,15.08,N/A,133.59,N/A,78.88,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,9.39,N/A,15.08,N/A,15.08,N/A,12.81,N/A,133.59,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,16.59,187.20,187.20,9.39,139.20,,Hospital CPT 82633,HC So Deoxycorticosterone,N/A,0301 - LABORATORY - CHEMISTRY,125.00,125.00,75.00,75.00,N/A,30.98,N/A,30.98,N/A,71.98,N/A,42.50,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,19.29,N/A,30.98,N/A,30.98,N/A,30.98,N/A,71.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,30.98,N/A,34.08,75.00,75.00,19.29,75.00,,Hospital CPT 82634,HC 11-Deoxycortisol,N/A,0301 - LABORATORY - CHEMISTRY,95.00,95.00,57.00,57.00,N/A,29.28,N/A,29.28,N/A,54.70,N/A,32.30,N/A,24.88,N/A,29.28,N/A,29.28,N/A,29.28,N/A,24.88,N/A,24.88,N/A,24.88,N/A,24.88,N/A,54.70,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,29.28,N/A,32.21,57.00,57.00,24.88,57.00,,Hospital CPT 82638,HC So Dibucaine Number,N/A,0301 - LABORATORY - CHEMISTRY,48.00,48.00,28.80,28.80,N/A,12.25,N/A,12.25,N/A,27.64,N/A,16.32,N/A,10.41,N/A,12.25,N/A,12.25,N/A,12.25,N/A,10.41,N/A,10.41,N/A,10.41,N/A,10.41,N/A,27.64,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,12.25,N/A,13.48,28.80,28.80,10.41,28.80,,Hospital CPT 82652,"HC So Dihydroxyvitamin D, 1 25",N/A,0301 - LABORATORY - CHEMISTRY,453.00,453.00,271.80,271.80,N/A,38.50,N/A,38.50,N/A,260.84,N/A,154.02,N/A,32.72,N/A,38.50,N/A,38.50,N/A,38.50,N/A,32.72,N/A,32.72,N/A,32.72,N/A,32.72,N/A,260.84,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,42.35,271.80,271.80,32.72,271.80,,Hospital CPT 82652,"HC Dihydroxyvitamin D, 1 25",N/A,0301 - LABORATORY - CHEMISTRY,500.00,372.00,300.00,223.20,N/A,38.50,N/A,38.50,N/A,214.20,N/A,126.48,N/A,32.72,N/A,38.50,N/A,38.50,N/A,38.50,N/A,32.72,N/A,32.72,N/A,32.72,N/A,32.72,N/A,214.20,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,38.50,N/A,42.35,300.00,300.00,32.72,223.20,,Hospital CPT 82664,HC So Electrophoretic Test,N/A,0301 - LABORATORY - CHEMISTRY,154.00,154.00,92.40,92.40,N/A,61.50,N/A,61.50,N/A,88.67,N/A,52.36,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,38.28,N/A,61.50,N/A,61.50,N/A,61.50,N/A,88.67,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,67.65,92.40,92.40,38.28,92.40,,Hospital CPT 82664,HC Electrophoretic Test,N/A,0301 - LABORATORY - CHEMISTRY,154.00,154.00,92.40,92.40,N/A,61.50,N/A,61.50,N/A,88.67,N/A,52.36,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,38.28,N/A,61.50,N/A,61.50,N/A,61.50,N/A,88.67,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,61.50,N/A,67.65,92.40,92.40,38.28,92.40,,Hospital CPT 82668,HC Erythropoietin,N/A,0301 - LABORATORY - CHEMISTRY,255.00,191.00,153.00,114.60,N/A,18.79,N/A,18.79,N/A,109.98,N/A,64.94,N/A,15.98,N/A,18.79,N/A,18.79,N/A,18.79,N/A,15.98,N/A,15.98,N/A,18.79,N/A,15.98,N/A,109.98,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,20.67,153.00,153.00,15.98,114.60,,Hospital CPT 82668,HC So Erythropoietin,N/A,0301 - LABORATORY - CHEMISTRY,231.00,231.00,138.60,138.60,N/A,18.79,N/A,18.79,N/A,133.01,N/A,78.54,N/A,15.98,N/A,18.79,N/A,18.79,N/A,18.79,N/A,15.98,N/A,15.98,N/A,18.79,N/A,15.98,N/A,133.01,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,18.79,N/A,20.67,138.60,138.60,15.98,138.60,,Hospital CPT 82726,HC So Very Long Chain Fatty Acids,N/A,0301 - LABORATORY - CHEMISTRY,190.00,190.00,114.00,114.00,N/A,19.75,N/A,19.75,N/A,109.40,N/A,64.60,N/A,15.34,N/A,19.75,N/A,19.75,N/A,19.75,N/A,15.34,N/A,15.34,N/A,15.34,N/A,15.34,N/A,109.40,N/A,19.75,N/A,19.75,N/A,19.75,N/A,19.75,N/A,19.75,N/A,19.75,N/A,19.75,N/A,21.73,114.00,114.00,15.34,114.00,,Hospital CPT 82728,HC Ferritin,N/A,0301 - LABORATORY - CHEMISTRY,223.00,165.00,133.80,99.00,N/A,13.63,N/A,13.63,N/A,95.01,N/A,56.10,N/A,11.58,N/A,13.63,N/A,13.63,N/A,13.63,N/A,11.58,N/A,13.63,N/A,13.63,N/A,13.63,N/A,95.01,N/A,13.63,N/A,13.63,N/A,13.63,N/A,13.63,N/A,13.63,N/A,13.63,N/A,13.63,N/A,14.99,133.80,133.80,11.58,99.00,,Hospital CPT 82735,HC So Fluoride,N/A,0301 - LABORATORY - CHEMISTRY,184.00,184.00,110.40,110.40,N/A,18.54,N/A,18.54,N/A,105.95,N/A,62.56,N/A,18.54,N/A,18.54,N/A,18.54,N/A,18.54,N/A,11.54,N/A,18.54,N/A,18.54,N/A,18.54,N/A,105.95,N/A,18.54,N/A,18.54,N/A,18.54,N/A,18.54,N/A,18.54,N/A,18.54,N/A,18.54,N/A,20.39,110.40,110.40,11.54,110.40,,Hospital CPT 82746,"HC Folic Acid, Serum",N/A,0301 - LABORATORY - CHEMISTRY,303.00,227.00,181.80,136.20,N/A,14.70,N/A,14.70,N/A,130.71,N/A,77.18,N/A,14.70,N/A,14.70,N/A,14.70,N/A,14.70,N/A,9.15,N/A,14.70,N/A,14.70,N/A,14.70,N/A,130.71,N/A,14.70,N/A,14.70,N/A,14.70,N/A,14.70,N/A,14.70,N/A,14.70,N/A,14.70,N/A,16.17,181.80,181.80,9.15,136.20,,Hospital CPT 82747,"HC So Folic Acid, RBC",N/A,0301 - LABORATORY - CHEMISTRY,117.00,117.00,70.20,70.20,N/A,17.65,N/A,17.65,N/A,67.37,N/A,39.78,N/A,14.72,N/A,17.65,N/A,17.65,N/A,17.65,N/A,14.72,N/A,14.72,N/A,14.72,N/A,14.72,N/A,67.37,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,19.42,70.20,70.20,14.72,70.20,,Hospital CPT 82747,"HC Folic Acid, RBC",N/A,0301 - LABORATORY - CHEMISTRY,129.00,97.00,77.40,58.20,N/A,17.65,N/A,17.65,N/A,55.85,N/A,32.98,N/A,14.72,N/A,17.65,N/A,17.65,N/A,17.65,N/A,14.72,N/A,14.72,N/A,14.72,N/A,14.72,N/A,55.85,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,17.65,N/A,19.42,77.40,77.40,14.72,58.20,,Hospital 82777,HC So Galectin-3,N/A,0301 - LABORATORY - CHEMISTRY,51603.30,4255.00,30961.98,2553.00,5767.26,449.71,7088.02,455.28,12996.98,2450.00,17545.12,1446.70,13121.31,352.33,5944.96,449.71,7088.02,455.28,7088.02,455.28,8167.71,352.33,13121.31,352.33,13121.31,352.33,13121.31,352.33,12996.98,2450.00,7088.02,455.28,5944.96,449.71,15611.08,449.71,15611.08,449.71,N/A,449.71,7088.02,455.28,7088.02,455.28,6361.10,494.70,5767.26,30961.98,352.33,2553.00,,Hospital CPT 82784,HC So Immunoglobulin,N/A,0301 - LABORATORY - CHEMISTRY,142.00,142.00,85.20,85.20,N/A,9.30,N/A,9.30,N/A,81.76,N/A,48.28,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,5.79,N/A,9.30,N/A,9.30,N/A,9.30,N/A,81.76,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,10.23,85.20,85.20,5.79,85.20,,Hospital CPT 82784,HC Immunoglobulin,N/A,0301 - LABORATORY - CHEMISTRY,158.00,118.00,94.80,70.80,N/A,9.30,N/A,9.30,N/A,67.94,N/A,40.12,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,5.79,N/A,9.30,N/A,9.30,N/A,9.30,N/A,67.94,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,9.30,N/A,10.23,94.80,94.80,5.79,70.80,,Hospital CPT 82785,HC Immunoglobulin Ige,N/A,0301 - LABORATORY - CHEMISTRY,171.00,129.00,102.60,77.40,N/A,16.46,N/A,16.46,N/A,74.28,N/A,43.86,N/A,13.99,N/A,16.46,N/A,16.46,N/A,16.46,N/A,10.25,N/A,13.99,N/A,13.99,N/A,13.99,N/A,74.28,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,18.11,102.60,102.60,10.25,77.40,,Hospital CPT 82785,"HC So Immunoglobulin,Ige",N/A,0301 - LABORATORY - CHEMISTRY,155.00,155.00,93.00,93.00,N/A,16.46,N/A,16.46,N/A,89.25,N/A,52.70,N/A,13.99,N/A,16.46,N/A,16.46,N/A,16.46,N/A,10.25,N/A,13.99,N/A,13.99,N/A,13.99,N/A,89.25,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,16.46,N/A,18.11,93.00,93.00,10.25,93.00,,Hospital CPT 82800,HC Ph-Blood,N/A,0301 - LABORATORY - CHEMISTRY,270.00,202.00,162.00,121.20,N/A,11.00,N/A,11.00,N/A,116.31,N/A,68.68,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,6.85,N/A,11.00,N/A,11.00,N/A,11.00,N/A,116.31,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,12.10,162.00,162.00,6.85,121.20,,Hospital CPT 82805,HC Arterial Gases,N/A,0301 - LABORATORY - CHEMISTRY,197.00,197.00,118.20,118.20,N/A,78.77,N/A,78.77,N/A,113.43,N/A,66.98,N/A,19.15,N/A,78.77,N/A,78.77,N/A,78.77,N/A,49.03,N/A,78.77,N/A,19.15,N/A,19.15,N/A,113.43,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,86.65,118.20,118.20,19.15,118.20,,Hospital CPT 82805,HC Blood Gas Saturation,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,217.00,164.00,130.20,98.40,N/A,78.77,N/A,78.77,N/A,94.43,N/A,55.76,N/A,19.15,N/A,78.77,N/A,78.77,N/A,78.77,N/A,49.03,N/A,78.77,N/A,19.15,N/A,19.15,N/A,94.43,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,78.77,N/A,86.65,130.20,130.20,19.15,98.40,,Hospital CPT 82820,HC Hemoglobin-Oxygen Affinity,N/A,0301 - LABORATORY - CHEMISTRY,193.00,193.00,115.80,115.80,N/A,13.34,N/A,13.34,N/A,111.13,N/A,65.62,N/A,13.34,N/A,13.34,N/A,13.34,N/A,13.34,N/A,8.30,N/A,13.34,N/A,13.34,N/A,13.34,N/A,111.13,N/A,13.34,N/A,13.34,N/A,13.34,N/A,13.34,N/A,13.34,N/A,13.34,N/A,13.34,N/A,14.67,115.80,115.80,8.30,115.80,,Hospital CPT 82943,HC Glucagon,N/A,0301 - LABORATORY - CHEMISTRY,50.00,40.00,30.00,24.00,N/A,14.29,N/A,14.29,N/A,23.03,N/A,13.60,N/A,4.94,N/A,14.29,N/A,14.29,N/A,14.29,N/A,4.94,N/A,4.94,N/A,4.94,N/A,4.94,N/A,23.03,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,15.72,30.00,30.00,4.94,24.00,,Hospital CPT 82943,HC So Glucagon,N/A,0301 - LABORATORY - CHEMISTRY,45.00,45.00,27.00,27.00,N/A,14.29,N/A,14.29,N/A,25.91,N/A,15.30,N/A,4.94,N/A,14.29,N/A,14.29,N/A,14.29,N/A,4.94,N/A,4.94,N/A,4.94,N/A,4.94,N/A,25.91,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,14.29,N/A,15.72,27.00,27.00,4.94,27.00,,Hospital CPT 82947,"HC Glucose, Fasting",N/A,0301 - LABORATORY - CHEMISTRY,131.00,131.00,78.60,78.60,N/A,3.93,N/A,3.93,N/A,75.43,N/A,44.54,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,2.45,N/A,3.93,N/A,3.93,N/A,3.93,N/A,75.43,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,4.32,78.60,78.60,2.45,78.60,,Hospital CPT 82947,"HC Glucose Quant, for Cmpk/Bmpk",N/A,0301 - LABORATORY - CHEMISTRY,119.00,119.00,71.40,71.40,N/A,3.93,N/A,3.93,N/A,68.52,N/A,40.46,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,2.45,N/A,3.93,N/A,3.93,N/A,3.93,N/A,68.52,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,3.93,N/A,4.32,71.40,71.40,2.45,71.40,,Hospital CPT 82951,HC Glucose Tolerance Test,N/A,0301 - LABORATORY - CHEMISTRY,103.00,77.00,61.80,46.20,N/A,12.87,N/A,12.87,N/A,44.34,N/A,26.18,N/A,10.94,N/A,12.87,N/A,12.87,N/A,12.87,N/A,10.94,N/A,12.87,N/A,10.94,N/A,10.94,N/A,44.34,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,61.80,61.80,10.94,46.20,,Hospital 82963,HC So Assay of Glucosidase,N/A,0301 - LABORATORY - CHEMISTRY,N/A,1039.00,N/A,623.40,N/A,292.80,N/A,325.63,N/A,598.26,N/A,353.26,N/A,325.63,N/A,292.80,N/A,325.63,N/A,325.63,N/A,202.70,N/A,325.63,N/A,325.63,N/A,325.63,N/A,598.26,N/A,325.63,N/A,292.80,N/A,320.06,N/A,320.06,N/A,292.80,N/A,325.63,N/A,325.63,N/A,314.07,N/A,N/A,202.70,623.40,,Hospital CPT 82977,HC Ggtp,N/A,0301 - LABORATORY - CHEMISTRY,101.00,76.00,60.60,45.60,N/A,7.20,N/A,7.20,N/A,43.76,N/A,25.84,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,6.12,N/A,6.12,N/A,6.12,N/A,6.12,N/A,43.76,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.92,60.60,60.60,6.12,45.60,,Hospital CPT 82977,HC So Ggtp,N/A,0301 - LABORATORY - CHEMISTRY,91.00,91.00,54.60,54.60,N/A,7.20,N/A,7.20,N/A,52.40,N/A,30.94,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,6.12,N/A,6.12,N/A,6.12,N/A,6.12,N/A,52.40,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.92,54.60,54.60,6.12,54.60,,Hospital CPT 82985,HC Fructosamine,N/A,0301 - LABORATORY - CHEMISTRY,54.00,41.00,32.40,24.60,N/A,16.76,N/A,16.76,N/A,23.61,N/A,13.94,N/A,12.81,N/A,16.76,N/A,16.76,N/A,16.76,N/A,12.81,N/A,12.81,N/A,12.81,N/A,12.81,N/A,23.61,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,18.44,32.40,32.40,12.81,24.60,,Hospital CPT 82985,HC So Fructosamine,N/A,0301 - LABORATORY - CHEMISTRY,48.00,48.00,28.80,28.80,N/A,16.76,N/A,16.76,N/A,27.64,N/A,16.32,N/A,12.81,N/A,16.76,N/A,16.76,N/A,16.76,N/A,12.81,N/A,12.81,N/A,12.81,N/A,12.81,N/A,27.64,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,18.44,28.80,28.80,12.81,28.80,,Hospital CPT 83001,HC Gonadotropin Follicle Stimulating Hormone,N/A,0301 - LABORATORY - CHEMISTRY,146.00,108.00,87.60,64.80,N/A,18.58,N/A,18.58,N/A,62.19,N/A,36.72,N/A,15.79,N/A,18.58,N/A,18.58,N/A,18.58,N/A,15.79,N/A,15.79,N/A,15.79,N/A,15.79,N/A,62.19,N/A,18.58,N/A,18.58,N/A,18.58,N/A,18.58,N/A,18.58,N/A,18.58,N/A,18.58,N/A,20.44,87.60,87.60,15.79,64.80,,Hospital CPT 83003,HC Growth Hormone,N/A,0301 - LABORATORY - CHEMISTRY,203.00,149.00,121.80,89.40,N/A,16.67,N/A,16.67,N/A,85.79,N/A,50.66,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,14.17,N/A,14.17,N/A,14.17,N/A,14.17,N/A,85.79,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,18.34,121.80,121.80,14.17,89.40,,Hospital CPT 83003,HC So Growth Hormone,N/A,0301 - LABORATORY - CHEMISTRY,183.00,183.00,109.80,109.80,N/A,16.67,N/A,16.67,N/A,105.37,N/A,62.22,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,14.17,N/A,14.17,N/A,14.17,N/A,14.17,N/A,105.37,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,16.67,N/A,18.34,109.80,109.80,14.17,109.80,,Hospital CPT 83013,HC So H Pylori Breath Test,N/A,0301 - LABORATORY - CHEMISTRY,188.00,188.00,112.80,112.80,N/A,67.36,N/A,67.36,N/A,108.25,N/A,63.92,N/A,57.24,N/A,67.36,N/A,67.36,N/A,67.36,N/A,57.24,N/A,57.24,N/A,57.24,N/A,57.24,N/A,108.25,N/A,67.36,N/A,67.36,N/A,67.36,N/A,67.36,N/A,67.36,N/A,67.36,N/A,67.36,N/A,74.10,112.80,112.80,57.24,112.80,,Hospital CPT 83015,"HC Mercury, Qualitative",N/A,0301 - LABORATORY - CHEMISTRY,179.00,132.00,107.40,79.20,N/A,20.94,N/A,20.94,N/A,76.01,N/A,44.88,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,13.04,N/A,20.94,N/A,20.94,N/A,20.94,N/A,76.01,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,23.03,107.40,107.40,13.04,79.20,,Hospital CPT 83015,"HC Lead, Urine",N/A,0301 - LABORATORY - CHEMISTRY,134.00,101.00,80.40,60.60,N/A,20.94,N/A,20.94,N/A,58.16,N/A,34.34,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,13.04,N/A,20.94,N/A,20.94,N/A,20.94,N/A,58.16,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,23.03,80.40,80.40,13.04,60.60,,Hospital CPT 83015,"HC So Lead, Urine",N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,20.94,N/A,20.94,N/A,69.67,N/A,41.14,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,13.04,N/A,20.94,N/A,20.94,N/A,20.94,N/A,69.67,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,20.94,N/A,23.03,72.60,72.60,13.04,72.60,,Hospital CPT 83020,HC So Hemoglobin Electrophoresis,N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,12.87,N/A,12.87,N/A,69.67,N/A,41.14,N/A,10.94,N/A,12.87,N/A,12.87,N/A,12.87,N/A,10.94,N/A,10.94,N/A,10.94,N/A,10.94,N/A,69.67,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,72.60,72.60,10.94,72.60,,Hospital CPT 83020,HC Hemoglobin Electrophoresis,N/A,0301 - LABORATORY - CHEMISTRY,134.00,101.00,80.40,60.60,N/A,12.87,N/A,12.87,N/A,58.16,N/A,34.34,N/A,10.94,N/A,12.87,N/A,12.87,N/A,12.87,N/A,10.94,N/A,10.94,N/A,10.94,N/A,10.94,N/A,58.16,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,12.87,N/A,14.16,80.40,80.40,10.94,60.60,,Hospital CPT 83050,HC Methemoglobin,N/A,0301 - LABORATORY - CHEMISTRY,59.00,44.00,35.40,26.40,N/A,8.20,N/A,8.20,N/A,25.34,N/A,14.96,N/A,8.20,N/A,8.20,N/A,8.20,N/A,8.20,N/A,5.10,N/A,8.20,N/A,8.20,N/A,8.20,N/A,25.34,N/A,8.20,N/A,8.20,N/A,8.20,N/A,8.20,N/A,8.20,N/A,8.20,N/A,8.20,N/A,9.02,35.40,35.40,5.10,26.40,,Hospital CPT 83051,HC So Serum Hgb Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,62.00,62.00,37.20,37.20,N/A,7.31,N/A,7.31,N/A,35.70,N/A,21.08,N/A,6.21,N/A,7.31,N/A,7.31,N/A,7.31,N/A,6.21,N/A,6.21,N/A,6.21,N/A,6.21,N/A,35.70,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,8.04,37.20,37.20,6.21,37.20,,Hospital CPT 83051,HC Serum Hgb Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,69.00,51.00,41.40,30.60,N/A,7.31,N/A,7.31,N/A,29.37,N/A,17.34,N/A,6.21,N/A,7.31,N/A,7.31,N/A,7.31,N/A,6.21,N/A,6.21,N/A,6.21,N/A,6.21,N/A,29.37,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,8.04,41.40,41.40,6.21,30.60,,Hospital CPT 83090,HC So Homocystine,N/A,0301 - LABORATORY - CHEMISTRY,89.00,89.00,53.40,53.40,N/A,17.92,N/A,17.92,N/A,51.25,N/A,30.26,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,14.33,N/A,14.33,N/A,14.33,N/A,14.33,N/A,51.25,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,19.71,53.40,53.40,14.33,53.40,,Hospital CPT 83090,HC Homocystine,N/A,0301 - LABORATORY - CHEMISTRY,99.00,75.00,59.40,45.00,N/A,17.92,N/A,17.92,N/A,43.19,N/A,25.50,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,14.33,N/A,14.33,N/A,14.33,N/A,14.33,N/A,43.19,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,17.92,N/A,19.71,59.40,59.40,14.33,45.00,,Hospital CPT 83497,HC Serotonin Metabloite,N/A,0301 - LABORATORY - CHEMISTRY,134.00,101.00,80.40,60.60,N/A,12.90,N/A,12.90,N/A,101.00,N/A,34.34,N/A,10.37,N/A,12.90,N/A,12.90,N/A,12.90,N/A,10.37,N/A,10.37,N/A,10.37,N/A,10.37,N/A,58.16,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,14.19,80.40,80.40,10.37,101.00,,Hospital CPT 83497,HC So Serotonin Metabloite,N/A,0301 - LABORATORY - CHEMISTRY,121.00,121.00,72.60,72.60,N/A,12.90,N/A,12.90,N/A,121.00,N/A,41.14,N/A,10.37,N/A,12.90,N/A,12.90,N/A,12.90,N/A,10.37,N/A,10.37,N/A,10.37,N/A,10.37,N/A,69.67,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,12.90,N/A,14.19,72.60,72.60,10.37,121.00,,Hospital CPT 83516,HC So2 Immunoassay,N/A,0301 - LABORATORY - CHEMISTRY,555.00,555.00,333.00,333.00,N/A,11.53,N/A,11.53,N/A,319.57,N/A,188.70,N/A,9.26,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.26,N/A,9.26,N/A,9.26,N/A,9.26,N/A,319.57,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,333.00,333.00,9.26,333.00,,Hospital CPT 83516,"HC Immunoassay Quant,Rp,Ea Addit",N/A,0301 - LABORATORY - CHEMISTRY,273.00,204.00,163.80,122.40,N/A,11.53,N/A,11.53,N/A,117.46,N/A,69.36,N/A,9.26,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.26,N/A,9.26,N/A,9.26,N/A,9.26,N/A,117.46,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,163.80,163.80,9.26,122.40,,Hospital CPT 83516,HC Immunoassay for Analyte,N/A,0301 - LABORATORY - CHEMISTRY,612.00,457.00,367.20,274.20,N/A,11.53,N/A,11.53,N/A,263.14,N/A,155.38,N/A,9.26,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.26,N/A,9.26,N/A,9.26,N/A,9.26,N/A,263.14,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,367.20,367.20,9.26,274.20,,Hospital CPT 83516,HC So Immunoassay,N/A,0301 - LABORATORY - CHEMISTRY,141.00,141.00,84.60,84.60,N/A,11.53,N/A,11.53,N/A,81.19,N/A,47.94,N/A,9.26,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.26,N/A,9.26,N/A,9.26,N/A,9.26,N/A,81.19,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,84.60,84.60,9.26,84.60,,Hospital CPT 83516,HC Immunoassay,N/A,0301 - LABORATORY - CHEMISTRY,156.00,117.00,93.60,70.20,N/A,11.53,N/A,11.53,N/A,67.37,N/A,39.78,N/A,9.26,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.26,N/A,9.26,N/A,9.26,N/A,9.26,N/A,67.37,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,93.60,93.60,9.26,70.20,,Hospital CPT 83516,HC So1 Immunoassay,N/A,0301 - LABORATORY - CHEMISTRY,247.00,247.00,148.20,148.20,N/A,11.53,N/A,11.53,N/A,142.22,N/A,83.98,N/A,9.26,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.26,N/A,9.26,N/A,9.26,N/A,9.26,N/A,142.22,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,148.20,148.20,9.26,148.20,,Hospital CPT 83525,HC So Insulin,N/A,0301 - LABORATORY - CHEMISTRY,128.00,128.00,76.80,76.80,N/A,11.43,N/A,11.43,N/A,73.70,N/A,43.52,N/A,9.71,N/A,11.43,N/A,11.43,N/A,11.43,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,73.70,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,12.57,76.80,76.80,9.71,76.80,,Hospital CPT 83525,HC Insulin,N/A,0301 - LABORATORY - CHEMISTRY,142.00,105.00,85.20,63.00,N/A,11.43,N/A,11.43,N/A,60.46,N/A,35.70,N/A,9.71,N/A,11.43,N/A,11.43,N/A,11.43,N/A,9.71,N/A,9.71,N/A,9.71,N/A,9.71,N/A,60.46,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,11.43,N/A,12.57,85.20,85.20,9.71,63.00,,Hospital CPT 83527,HC Assay of Insulin,N/A,0301 - LABORATORY - CHEMISTRY,83.00,63.00,49.80,37.80,N/A,12.95,N/A,12.95,N/A,36.28,N/A,21.42,N/A,11.00,N/A,12.95,N/A,12.95,N/A,12.95,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,36.28,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,14.25,49.80,49.80,11.00,37.80,,Hospital CPT 83527,HC So Assay of Insulin,N/A,0301 - LABORATORY - CHEMISTRY,75.00,75.00,45.00,45.00,N/A,12.95,N/A,12.95,N/A,43.19,N/A,25.50,N/A,11.00,N/A,12.95,N/A,12.95,N/A,12.95,N/A,11.00,N/A,11.00,N/A,11.00,N/A,11.00,N/A,43.19,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,14.25,45.00,45.00,11.00,45.00,,Hospital CPT 83529,HC So Immunoassay Ria,N/A,0301 - LABORATORY - CHEMISTRY,126.00,126.00,75.60,75.60,N/A,17.64,N/A,17.27,N/A,72.55,N/A,42.84,N/A,6.91,N/A,17.64,N/A,17.27,N/A,17.27,N/A,6.91,N/A,6.91,N/A,6.91,N/A,6.91,N/A,72.55,N/A,17.27,N/A,17.64,N/A,17.27,N/A,17.27,N/A,17.64,N/A,17.27,N/A,17.27,N/A,126.00,75.60,75.60,6.91,126.00,,Hospital CPT 83540,HC So Iron,N/A,0301 - LABORATORY - CHEMISTRY,83.00,83.00,49.80,49.80,N/A,6.47,N/A,6.47,N/A,47.79,N/A,28.22,N/A,5.51,N/A,6.47,N/A,6.47,N/A,6.47,N/A,4.03,N/A,5.51,N/A,6.47,N/A,6.47,N/A,47.79,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,49.80,49.80,4.03,49.80,,Hospital CPT 83540,HC Iron,N/A,0301 - LABORATORY - CHEMISTRY,92.00,69.00,55.20,41.40,N/A,6.47,N/A,6.47,N/A,39.73,N/A,23.46,N/A,5.51,N/A,6.47,N/A,6.47,N/A,6.47,N/A,4.03,N/A,5.51,N/A,6.47,N/A,6.47,N/A,39.73,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,55.20,55.20,4.03,41.40,,Hospital CPT 83550,HC Iron Binding Capacity,N/A,0301 - LABORATORY - CHEMISTRY,229.00,171.00,137.40,102.60,N/A,8.74,N/A,8.74,N/A,98.46,N/A,58.14,N/A,7.43,N/A,8.74,N/A,8.74,N/A,8.74,N/A,5.44,N/A,7.43,N/A,8.74,N/A,8.74,N/A,98.46,N/A,8.74,N/A,8.74,N/A,8.74,N/A,8.74,N/A,8.74,N/A,8.74,N/A,8.74,N/A,9.61,137.40,137.40,5.44,102.60,,Hospital CPT 83586,HC So Urine 17-Ketosteroids,N/A,0301 - LABORATORY - CHEMISTRY,45.00,45.00,27.00,27.00,N/A,12.80,N/A,12.80,N/A,45.00,N/A,15.30,N/A,10.88,N/A,12.80,N/A,12.80,N/A,12.80,N/A,10.88,N/A,10.88,N/A,10.88,N/A,10.88,N/A,25.91,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,14.08,27.00,27.00,10.88,45.00,,Hospital CPT 83593,HC Ketosteroids Fractionated,N/A,0301 - LABORATORY - CHEMISTRY,187.00,187.00,112.20,112.20,N/A,28.50,N/A,28.50,N/A,107.67,N/A,63.58,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,17.74,N/A,28.50,N/A,28.50,N/A,28.50,N/A,107.67,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,31.35,112.20,112.20,17.74,112.20,,Hospital CPT 83625,HC Ld Isoenzyme Referred,N/A,0301 - LABORATORY - CHEMISTRY,81.00,81.00,48.60,48.60,N/A,12.79,N/A,12.79,N/A,46.64,N/A,27.54,N/A,10.88,N/A,12.79,N/A,12.79,N/A,12.79,N/A,10.88,N/A,10.88,N/A,10.88,N/A,10.88,N/A,46.64,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,14.07,48.60,48.60,10.88,48.60,,Hospital CPT 83625,HC So Ld Isoenzyme Referred,N/A,0301 - LABORATORY - CHEMISTRY,81.00,81.00,48.60,48.60,N/A,12.79,N/A,12.79,N/A,46.64,N/A,27.54,N/A,10.88,N/A,12.79,N/A,12.79,N/A,12.79,N/A,10.88,N/A,10.88,N/A,10.88,N/A,10.88,N/A,46.64,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,12.79,N/A,14.07,48.60,48.60,10.88,48.60,,Hospital CPT 83664,HC So Lamellar Bdy Fetal Lung,N/A,0301 - LABORATORY - CHEMISTRY,48.00,48.00,28.80,28.80,N/A,19.32,N/A,19.32,N/A,27.64,N/A,16.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,12.03,N/A,19.32,N/A,19.32,N/A,19.32,N/A,27.64,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,21.25,28.80,28.80,12.03,28.80,,Hospital CPT 83664,HC Lamellar Body Density,N/A,0301 - LABORATORY - CHEMISTRY,77.00,77.00,46.20,46.20,N/A,19.32,N/A,19.32,N/A,44.34,N/A,26.18,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,12.03,N/A,19.32,N/A,19.32,N/A,19.32,N/A,44.34,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,19.32,N/A,21.25,46.20,46.20,12.03,46.20,,Hospital CPT 83670,HC So Leucine Aminopeptidase,N/A,0301 - LABORATORY - CHEMISTRY,77.00,77.00,46.20,46.20,N/A,9.81,N/A,9.81,N/A,44.34,N/A,26.18,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,6.11,N/A,9.81,N/A,9.81,N/A,9.81,N/A,44.34,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,9.81,N/A,10.79,46.20,46.20,6.11,46.20,,Hospital CPT 83701,HC So Lipoprotein Bld Hr Fraction,N/A,0301 - LABORATORY - CHEMISTRY,111.00,111.00,66.60,66.60,N/A,33.86,N/A,33.86,N/A,63.91,N/A,37.74,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,21.08,N/A,33.86,N/A,33.86,N/A,33.86,N/A,63.91,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,37.25,66.60,66.60,21.08,66.60,,Hospital CPT 83701,HC Lipoprotein Bld Hr Fraction,N/A,0301 - LABORATORY - CHEMISTRY,123.00,93.00,73.80,55.80,N/A,33.86,N/A,33.86,N/A,53.55,N/A,31.62,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,21.08,N/A,33.86,N/A,33.86,N/A,33.86,N/A,53.55,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,37.25,73.80,73.80,21.08,55.80,,Hospital CPT 83704,"HC So Lipoprotein,Bld,by Nmr",N/A,0301 - LABORATORY - CHEMISTRY,218.00,218.00,130.80,130.80,N/A,34.19,N/A,34.19,N/A,125.52,N/A,74.12,N/A,26.81,N/A,34.19,N/A,34.19,N/A,34.19,N/A,26.81,N/A,26.81,N/A,26.81,N/A,26.81,N/A,125.52,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,37.61,130.80,130.80,26.81,130.80,,Hospital CPT 83704,"HC Lipoprotein,Bld,by Nmr",N/A,0301 - LABORATORY - CHEMISTRY,240.00,180.00,144.00,108.00,N/A,34.19,N/A,34.19,N/A,103.64,N/A,61.20,N/A,26.81,N/A,34.19,N/A,34.19,N/A,34.19,N/A,26.81,N/A,26.81,N/A,26.81,N/A,26.81,N/A,103.64,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,34.19,N/A,37.61,144.00,144.00,26.81,108.00,,Hospital CPT 83718,HC Assay of Lipoprotein,N/A,0301 - LABORATORY - CHEMISTRY,34.00,34.00,20.40,20.40,N/A,8.19,N/A,8.19,N/A,19.58,N/A,11.56,N/A,6.96,N/A,8.19,N/A,8.19,N/A,8.19,N/A,6.96,N/A,6.96,N/A,6.96,N/A,6.96,N/A,19.58,N/A,8.19,N/A,8.19,N/A,8.19,N/A,8.19,N/A,8.19,N/A,8.19,N/A,8.19,N/A,9.01,20.40,20.40,6.96,20.40,,Hospital CPT 83735,HC So Magnesium,N/A,0301 - LABORATORY - CHEMISTRY,130.00,130.00,78.00,78.00,N/A,6.70,N/A,6.70,N/A,74.85,N/A,44.20,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,4.17,N/A,5.69,N/A,6.70,N/A,5.69,N/A,74.85,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,7.37,78.00,78.00,4.17,78.00,,Hospital CPT 83735,HC Magnesium,N/A,0301 - LABORATORY - CHEMISTRY,144.00,106.00,86.40,63.60,N/A,6.70,N/A,6.70,N/A,61.03,N/A,36.04,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,4.17,N/A,5.69,N/A,6.70,N/A,5.69,N/A,61.03,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,6.70,N/A,7.37,86.40,86.40,4.17,63.60,,Hospital CPT 83825,HC So Assay of Mercury Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,16.26,N/A,16.26,N/A,96.73,N/A,57.12,N/A,13.82,N/A,16.26,N/A,16.26,N/A,16.26,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,96.73,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,17.89,100.80,100.80,13.82,100.80,,Hospital CPT 83825,HC Assay of Mercury Quantitative,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,16.26,N/A,16.26,N/A,96.73,N/A,57.12,N/A,13.82,N/A,16.26,N/A,16.26,N/A,16.26,N/A,13.82,N/A,13.82,N/A,13.82,N/A,13.82,N/A,96.73,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,16.26,N/A,17.89,100.80,100.80,13.82,100.80,,Hospital CPT 83864,HC So Mucopolysaccharides Quant,N/A,0301 - LABORATORY - CHEMISTRY,71.00,71.00,42.60,42.60,N/A,28.50,N/A,28.50,N/A,40.88,N/A,24.14,N/A,16.92,N/A,28.50,N/A,28.50,N/A,28.50,N/A,16.92,N/A,16.92,N/A,16.92,N/A,16.92,N/A,40.88,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,31.35,42.60,42.60,16.92,42.60,,Hospital CPT 83864,HC Mucopolysaccharides Quant,N/A,0301 - LABORATORY - CHEMISTRY,71.00,71.00,42.60,42.60,N/A,28.50,N/A,28.50,N/A,40.88,N/A,24.14,N/A,16.92,N/A,28.50,N/A,28.50,N/A,28.50,N/A,16.92,N/A,16.92,N/A,16.92,N/A,16.92,N/A,40.88,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,28.50,N/A,31.35,42.60,42.60,16.92,42.60,,Hospital CPT 83874,HC So Myoglobin,N/A,0301 - LABORATORY - CHEMISTRY,144.00,144.00,86.40,86.40,N/A,12.92,N/A,12.92,N/A,82.92,N/A,48.96,N/A,10.97,N/A,12.92,N/A,12.92,N/A,12.92,N/A,8.04,N/A,12.92,N/A,10.97,N/A,10.97,N/A,82.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,14.21,86.40,86.40,8.04,86.40,,Hospital CPT 83874,HC Myoglobin,N/A,0301 - LABORATORY - CHEMISTRY,160.00,120.00,96.00,72.00,N/A,12.92,N/A,12.92,N/A,69.10,N/A,40.80,N/A,10.97,N/A,12.92,N/A,12.92,N/A,12.92,N/A,8.04,N/A,12.92,N/A,10.97,N/A,10.97,N/A,69.10,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,12.92,N/A,14.21,96.00,96.00,8.04,72.00,,Hospital CPT 83876,HC Assay Myeloperoxidase,N/A,0301 - LABORATORY - CHEMISTRY,156.00,135.00,93.60,81.00,N/A,50.86,N/A,50.86,N/A,77.73,N/A,45.90,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,31.66,N/A,50.86,N/A,50.86,N/A,50.86,N/A,77.73,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,55.95,93.60,93.60,31.66,81.00,,Hospital CPT 83880,HC So Natriuretic Peptide,N/A,0301 - LABORATORY - CHEMISTRY,322.00,322.00,193.20,193.20,N/A,39.26,N/A,39.26,N/A,185.41,N/A,109.48,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,24.44,N/A,39.26,N/A,39.26,N/A,39.26,N/A,185.41,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,43.19,193.20,193.20,24.44,193.20,,Hospital CPT 83880,HC Natriuretic Peptide,N/A,0301 - LABORATORY - CHEMISTRY,356.00,265.00,213.60,159.00,N/A,39.26,N/A,39.26,N/A,152.59,N/A,90.10,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,24.44,N/A,39.26,N/A,39.26,N/A,39.26,N/A,152.59,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,39.26,N/A,43.19,213.60,213.60,24.44,159.00,,Hospital CPT 83883,HC Nephelometry Ea Analyte Nes,N/A,0301 - LABORATORY - CHEMISTRY,103.00,77.00,61.80,46.20,N/A,13.60,N/A,13.60,N/A,44.34,N/A,26.18,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,8.47,N/A,13.60,N/A,13.60,N/A,13.60,N/A,44.34,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,14.96,61.80,61.80,8.47,46.20,,Hospital CPT 83883,HC So Nephelometry Ea Analyte Nes,N/A,0301 - LABORATORY - CHEMISTRY,93.00,93.00,55.80,55.80,N/A,13.60,N/A,13.60,N/A,53.55,N/A,31.62,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,8.47,N/A,13.60,N/A,13.60,N/A,13.60,N/A,53.55,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,13.60,N/A,14.96,55.80,55.80,8.47,55.80,,Hospital CPT 83885,HC So Nickel,N/A,0301 - LABORATORY - CHEMISTRY,85.00,85.00,51.00,51.00,N/A,24.51,N/A,24.51,N/A,48.94,N/A,28.90,N/A,20.82,N/A,24.51,N/A,24.51,N/A,24.51,N/A,20.82,N/A,20.82,N/A,20.82,N/A,20.82,N/A,48.94,N/A,24.51,N/A,24.51,N/A,24.51,N/A,24.51,N/A,24.51,N/A,24.51,N/A,24.51,N/A,26.96,51.00,51.00,20.82,51.00,,Hospital CPT 83915,HC Assay of Nucleotidase,N/A,0301 - LABORATORY - CHEMISTRY,56.00,56.00,33.60,33.60,N/A,11.15,N/A,11.15,N/A,32.24,N/A,19.04,N/A,7.66,N/A,11.15,N/A,11.15,N/A,11.15,N/A,7.66,N/A,7.66,N/A,7.66,N/A,7.66,N/A,32.24,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,12.27,33.60,33.60,7.66,33.60,,Hospital CPT 83915,HC So Assay of Nucleotidase,N/A,0301 - LABORATORY - CHEMISTRY,50.00,50.00,30.00,30.00,N/A,11.15,N/A,11.15,N/A,28.79,N/A,17.00,N/A,7.66,N/A,11.15,N/A,11.15,N/A,11.15,N/A,7.66,N/A,7.66,N/A,7.66,N/A,7.66,N/A,28.79,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,11.15,N/A,12.27,30.00,30.00,7.66,30.00,,Hospital CPT 83916,"HC Oligoclonal Bands,CSF",N/A,0301 - LABORATORY - CHEMISTRY,289.00,214.00,173.40,128.40,N/A,27.39,N/A,27.39,N/A,123.22,N/A,72.76,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,17.05,N/A,27.39,N/A,27.39,N/A,27.39,N/A,123.22,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,30.13,173.40,173.40,17.05,128.40,,Hospital CPT 83916,"HC So Oligoclonal Bands,CSF",N/A,0301 - LABORATORY - CHEMISTRY,261.00,261.00,156.60,156.60,N/A,27.39,N/A,27.39,N/A,150.28,N/A,88.74,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,17.05,N/A,27.39,N/A,27.39,N/A,27.39,N/A,150.28,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,27.39,N/A,30.13,156.60,156.60,17.05,156.60,,Hospital CPT 83918,HC So Organic Acid,N/A,0301 - LABORATORY - CHEMISTRY,280.00,280.00,168.00,168.00,N/A,23.60,N/A,23.60,N/A,161.22,N/A,95.20,N/A,13.99,N/A,23.60,N/A,23.60,N/A,23.60,N/A,13.99,N/A,13.99,N/A,13.99,N/A,13.99,N/A,161.22,N/A,23.60,N/A,23.60,N/A,23.60,N/A,23.60,N/A,23.60,N/A,23.60,N/A,23.60,N/A,25.96,168.00,168.00,13.99,168.00,,Hospital CPT 83921,"HC So Organic Acid, Single,Quant",N/A,0301 - LABORATORY - CHEMISTRY,148.00,148.00,88.80,88.80,N/A,21.21,N/A,21.21,N/A,85.22,N/A,50.32,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,13.20,N/A,13.99,N/A,13.99,N/A,13.99,N/A,85.22,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,23.33,88.80,88.80,13.20,88.80,,Hospital CPT 83921,"HC Organic Acid, Single,Quant",N/A,0301 - LABORATORY - CHEMISTRY,164.00,121.00,98.40,72.60,N/A,21.21,N/A,21.21,N/A,69.67,N/A,41.14,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,13.20,N/A,13.99,N/A,13.99,N/A,13.99,N/A,69.67,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,21.21,N/A,23.33,98.40,98.40,13.20,72.60,,Hospital CPT 83930,HC Osmolality,N/A,0301 - LABORATORY - CHEMISTRY,120.00,90.00,72.00,54.00,N/A,6.61,N/A,6.61,N/A,51.82,N/A,30.60,N/A,5.62,N/A,6.61,N/A,6.61,N/A,6.61,N/A,5.62,N/A,5.62,N/A,5.62,N/A,5.62,N/A,51.82,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,7.27,72.00,72.00,5.62,54.00,,Hospital CPT 83930,HC So Osmolality Serum,N/A,0301 - LABORATORY - CHEMISTRY,108.00,108.00,64.80,64.80,N/A,6.61,N/A,6.61,N/A,62.19,N/A,36.72,N/A,5.62,N/A,6.61,N/A,6.61,N/A,6.61,N/A,5.62,N/A,5.62,N/A,5.62,N/A,5.62,N/A,62.19,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,7.27,64.80,64.80,5.62,64.80,,Hospital CPT 83945,"HC Oxalate Urine, 24hr",N/A,0301 - LABORATORY - CHEMISTRY,108.00,82.00,64.80,49.20,N/A,14.45,N/A,14.45,N/A,82.00,N/A,27.88,N/A,10.94,N/A,14.45,N/A,14.45,N/A,14.45,N/A,10.94,N/A,10.94,N/A,10.94,N/A,10.94,N/A,47.22,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,15.90,64.80,64.80,10.94,82.00,,Hospital CPT 83945,"HC So Oxalate Urine, 24hr",N/A,0301 - LABORATORY - CHEMISTRY,98.00,98.00,58.80,58.80,N/A,14.45,N/A,14.45,N/A,98.00,N/A,33.32,N/A,10.94,N/A,14.45,N/A,14.45,N/A,14.45,N/A,10.94,N/A,10.94,N/A,10.94,N/A,10.94,N/A,56.43,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,14.45,N/A,15.90,58.80,58.80,10.94,98.00,,Hospital CPT 83986,HC So Ph Body Fluids,N/A,0301 - LABORATORY - CHEMISTRY,41.00,41.00,24.60,24.60,N/A,3.58,N/A,3.58,N/A,23.61,N/A,13.94,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.04,N/A,3.04,N/A,3.04,N/A,3.04,N/A,23.61,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.94,24.60,24.60,3.04,24.60,,Hospital CPT 83986,HC Ph Body Fluids,N/A,0301 - LABORATORY - CHEMISTRY,46.00,34.00,27.60,20.40,N/A,3.58,N/A,3.58,N/A,19.58,N/A,11.56,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.04,N/A,3.04,N/A,3.04,N/A,3.04,N/A,19.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.94,27.60,27.60,3.04,20.40,,Hospital CPT 83986,HC POC Ph Body Fluids,N/A,0301 - LABORATORY - CHEMISTRY,41.00,41.00,24.60,24.60,N/A,3.58,N/A,3.58,N/A,23.61,N/A,13.94,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.04,N/A,3.04,N/A,3.04,N/A,3.04,N/A,23.61,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.58,N/A,3.94,24.60,24.60,3.04,24.60,,Hospital CPT 83992,HC Phencyclidine,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,20.17,N/A,120.00,N/A,69.10,N/A,40.80,N/A,12.49,N/A,20.17,N/A,120.00,N/A,120.00,N/A,12.49,N/A,12.49,N/A,12.49,N/A,12.49,N/A,69.10,N/A,120.00,N/A,20.17,N/A,37.37,N/A,37.37,N/A,20.17,N/A,120.00,N/A,120.00,N/A,22.19,72.00,72.00,12.49,120.00,,Hospital CPT 83992,HC So Phencyclidine,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,20.17,N/A,120.00,N/A,69.10,N/A,40.80,N/A,12.49,N/A,20.17,N/A,120.00,N/A,120.00,N/A,12.49,N/A,12.49,N/A,12.49,N/A,12.49,N/A,69.10,N/A,120.00,N/A,20.17,N/A,37.37,N/A,37.37,N/A,20.17,N/A,120.00,N/A,120.00,N/A,22.19,72.00,72.00,12.49,120.00,,Hospital CPT 83992,HC So1 Phencyclidine,N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,20.17,N/A,67.00,N/A,38.58,N/A,22.78,N/A,12.49,N/A,20.17,N/A,67.00,N/A,67.00,N/A,12.49,N/A,12.49,N/A,12.49,N/A,12.49,N/A,38.58,N/A,67.00,N/A,20.17,N/A,37.37,N/A,37.37,N/A,20.17,N/A,67.00,N/A,67.00,N/A,22.19,40.20,40.20,12.49,67.00,,Hospital CPT 83993,"HC Calprotectin, Fecal",N/A,0301 - LABORATORY - CHEMISTRY,142.00,105.00,85.20,63.00,N/A,19.63,N/A,19.63,N/A,105.00,N/A,35.70,N/A,16.68,N/A,19.63,N/A,19.63,N/A,19.63,N/A,16.68,N/A,16.68,N/A,16.68,N/A,16.68,N/A,60.46,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,21.59,85.20,85.20,16.68,105.00,,Hospital CPT 83993,HC So Calprotectin Fecal,N/A,0301 - LABORATORY - CHEMISTRY,128.00,128.00,76.80,76.80,N/A,19.63,N/A,19.63,N/A,128.00,N/A,43.52,N/A,16.68,N/A,19.63,N/A,19.63,N/A,19.63,N/A,16.68,N/A,16.68,N/A,16.68,N/A,16.68,N/A,73.70,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,19.63,N/A,21.59,76.80,76.80,16.68,128.00,,Hospital CPT 84030,HC Newborn Screen (Pku),N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,5.50,N/A,5.50,N/A,38.58,N/A,22.78,N/A,4.67,N/A,5.50,N/A,5.50,N/A,5.50,N/A,4.67,N/A,4.67,N/A,4.67,N/A,4.67,N/A,38.58,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.05,40.20,40.20,4.67,40.20,,Hospital CPT 84030,HC So Newborn Screen (Pku),N/A,0301 - LABORATORY - CHEMISTRY,150.00,150.00,90.00,90.00,N/A,5.50,N/A,5.50,N/A,86.37,N/A,51.00,N/A,4.67,N/A,5.50,N/A,5.50,N/A,5.50,N/A,4.67,N/A,4.67,N/A,4.67,N/A,4.67,N/A,86.37,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.05,90.00,90.00,4.67,90.00,,Hospital CPT 84060,HC So Phosphatase Acid Total,N/A,0301 - LABORATORY - CHEMISTRY,31.00,31.00,18.60,18.60,N/A,7.64,N/A,7.64,N/A,17.85,N/A,10.54,N/A,7.64,N/A,7.64,N/A,7.64,N/A,7.64,N/A,4.76,N/A,7.64,N/A,7.64,N/A,7.64,N/A,17.85,N/A,7.64,N/A,7.64,N/A,7.64,N/A,7.64,N/A,7.64,N/A,7.64,N/A,7.64,N/A,8.40,18.60,18.60,4.76,18.60,,Hospital CPT 84075,HC Alkaline Phosphatase,N/A,0301 - LABORATORY - CHEMISTRY,40.00,40.00,24.00,24.00,N/A,5.18,N/A,5.18,N/A,23.03,N/A,13.60,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,23.03,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,24.00,24.00,4.40,24.00,,Hospital CPT 84075,HC So Alkaline Phosphatase,N/A,0301 - LABORATORY - CHEMISTRY,36.00,36.00,21.60,21.60,N/A,5.18,N/A,5.18,N/A,20.73,N/A,12.24,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,4.40,N/A,4.40,N/A,4.40,N/A,4.40,N/A,20.73,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,21.60,21.60,4.40,21.60,,Hospital CPT 84078,HC Assay Alkaline Phosphatase,N/A,0301 - LABORATORY - CHEMISTRY,49.00,49.00,29.40,29.40,N/A,8.26,N/A,8.26,N/A,28.21,N/A,16.66,N/A,8.26,N/A,8.26,N/A,8.26,N/A,8.26,N/A,5.14,N/A,8.26,N/A,8.26,N/A,8.26,N/A,28.21,N/A,8.26,N/A,8.26,N/A,8.26,N/A,8.26,N/A,8.26,N/A,8.26,N/A,8.26,N/A,9.09,29.40,29.40,5.14,29.40,,Hospital CPT 84087,HC So Phosphohexose Isomerase,N/A,0301 - LABORATORY - CHEMISTRY,254.00,254.00,152.40,152.40,N/A,10.73,N/A,10.73,N/A,146.25,N/A,86.36,N/A,10.73,N/A,10.73,N/A,10.73,N/A,10.73,N/A,6.68,N/A,10.73,N/A,10.73,N/A,10.73,N/A,146.25,N/A,10.73,N/A,10.73,N/A,10.73,N/A,10.73,N/A,10.73,N/A,10.73,N/A,10.73,N/A,11.80,152.40,152.40,6.68,152.40,,Hospital CPT 84110,"HC Porphobilinogen,Urine Quant",N/A,0301 - LABORATORY - CHEMISTRY,75.00,55.00,45.00,33.00,N/A,8.44,N/A,8.44,N/A,31.67,N/A,18.70,N/A,7.18,N/A,8.44,N/A,8.44,N/A,8.44,N/A,7.18,N/A,7.18,N/A,7.18,N/A,7.18,N/A,31.67,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,9.28,45.00,45.00,7.18,33.00,,Hospital CPT 84110,"HC So Porphobilinogen,Urine Quant",N/A,0301 - LABORATORY - CHEMISTRY,67.00,67.00,40.20,40.20,N/A,8.44,N/A,8.44,N/A,38.58,N/A,22.78,N/A,7.18,N/A,8.44,N/A,8.44,N/A,8.44,N/A,7.18,N/A,7.18,N/A,7.18,N/A,7.18,N/A,38.58,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,8.44,N/A,9.28,40.20,40.20,7.18,40.20,,Hospital CPT 84112,HC Eval Amniotic Fluid Protein/Amnisure,N/A,0301 - LABORATORY - CHEMISTRY,296.00,296.00,177.60,177.60,N/A,98.11,N/A,98.11,N/A,170.44,N/A,100.64,N/A,98.11,N/A,98.11,N/A,98.11,N/A,98.11,N/A,61.07,N/A,98.11,N/A,98.11,N/A,98.11,N/A,170.44,N/A,98.11,N/A,98.11,N/A,98.11,N/A,98.11,N/A,98.11,N/A,98.11,N/A,98.11,N/A,107.92,177.60,177.60,61.07,177.60,,Hospital CPT 84126,HC So Porphyrins Feces Quant,N/A,0301 - LABORATORY - CHEMISTRY,195.00,195.00,117.00,117.00,N/A,39.11,N/A,39.11,N/A,112.28,N/A,66.30,N/A,39.11,N/A,39.11,N/A,39.11,N/A,39.11,N/A,24.35,N/A,39.11,N/A,39.11,N/A,39.11,N/A,112.28,N/A,39.11,N/A,39.11,N/A,39.11,N/A,39.11,N/A,39.11,N/A,39.11,N/A,39.11,N/A,43.02,117.00,117.00,24.35,117.00,,Hospital CPT 84132,HC Potassium,N/A,0301 - LABORATORY - CHEMISTRY,48.00,36.00,28.80,21.60,N/A,4.76,N/A,4.76,N/A,20.73,N/A,12.24,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,2.96,N/A,4.76,N/A,4.76,N/A,4.76,N/A,20.73,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,5.24,28.80,28.80,2.96,21.60,,Hospital CPT 84132,HC So Potassium,N/A,0301 - LABORATORY - CHEMISTRY,43.00,43.00,25.80,25.80,N/A,4.76,N/A,4.76,N/A,24.76,N/A,14.62,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,2.96,N/A,4.76,N/A,4.76,N/A,4.76,N/A,24.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,4.76,N/A,5.24,25.80,25.80,2.96,25.80,,Hospital CPT 84133,HC So Potassium 24hr Urine,N/A,0301 - LABORATORY - CHEMISTRY,40.00,40.00,24.00,24.00,N/A,4.73,N/A,4.73,N/A,23.03,N/A,13.60,N/A,3.65,N/A,4.73,N/A,4.73,N/A,4.73,N/A,3.65,N/A,3.65,N/A,3.65,N/A,3.65,N/A,23.03,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,5.20,24.00,24.00,3.65,24.00,,Hospital CPT 84133,HC Potassium 24hr Urine,N/A,0301 - LABORATORY - CHEMISTRY,44.00,32.00,26.40,19.20,N/A,4.73,N/A,4.73,N/A,18.43,N/A,10.88,N/A,3.65,N/A,4.73,N/A,4.73,N/A,4.73,N/A,3.65,N/A,3.65,N/A,3.65,N/A,3.65,N/A,18.43,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,4.73,N/A,5.20,26.40,26.40,3.65,19.20,,Hospital CPT 84145,HC So Procalcitonin,N/A,0301 - LABORATORY - CHEMISTRY,684.00,684.00,410.40,410.40,N/A,27.22,N/A,27.22,N/A,393.85,N/A,232.56,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,16.94,N/A,27.22,N/A,27.22,N/A,27.22,N/A,393.85,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,29.94,410.40,410.40,16.94,410.40,,Hospital CPT 84145,HC Procalcitonin,N/A,0301 - LABORATORY - CHEMISTRY,755.00,563.00,453.00,337.80,N/A,27.22,N/A,27.22,N/A,324.18,N/A,191.42,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,16.94,N/A,27.22,N/A,27.22,N/A,27.22,N/A,324.18,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,27.22,N/A,29.94,453.00,453.00,16.94,337.80,,Hospital CPT 84153,HC So Assay of Psa Total,N/A,0301 - LABORATORY - CHEMISTRY,221.00,221.00,132.60,132.60,N/A,18.39,N/A,18.39,N/A,127.25,N/A,75.14,N/A,15.64,N/A,18.39,N/A,18.39,N/A,18.39,N/A,15.64,N/A,18.39,N/A,15.64,N/A,15.64,N/A,127.25,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,20.23,132.60,132.60,15.64,132.60,,Hospital CPT 84153,HC Assay of Psa Total,N/A,0301 - LABORATORY - CHEMISTRY,245.00,183.00,147.00,109.80,N/A,18.39,N/A,18.39,N/A,105.37,N/A,62.22,N/A,15.64,N/A,18.39,N/A,18.39,N/A,18.39,N/A,15.64,N/A,18.39,N/A,15.64,N/A,15.64,N/A,105.37,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,20.23,147.00,147.00,15.64,109.80,,Hospital CPT 84154,HC So Prostate Specific Antigen/Free,N/A,0301 - LABORATORY - CHEMISTRY,102.00,102.00,61.20,61.20,N/A,18.39,N/A,18.39,N/A,58.73,N/A,34.68,N/A,15.64,N/A,18.39,N/A,18.39,N/A,18.39,N/A,15.64,N/A,15.64,N/A,15.64,N/A,15.64,N/A,58.73,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,20.23,61.20,61.20,15.64,61.20,,Hospital CPT 84154,HC Prostate Specific Antigen/Free,N/A,0301 - LABORATORY - CHEMISTRY,113.00,84.00,67.80,50.40,N/A,18.39,N/A,18.39,N/A,48.37,N/A,28.56,N/A,15.64,N/A,18.39,N/A,18.39,N/A,18.39,N/A,15.64,N/A,15.64,N/A,15.64,N/A,15.64,N/A,48.37,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,18.39,N/A,20.23,67.80,67.80,15.64,50.40,,Hospital CPT 84157,HC So Assay of Protein Other,N/A,0301 - LABORATORY - CHEMISTRY,64.00,64.00,38.40,38.40,N/A,4.00,N/A,4.00,N/A,36.85,N/A,21.76,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,2.49,N/A,4.00,N/A,4.00,N/A,4.00,N/A,36.85,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.40,38.40,38.40,2.49,38.40,,Hospital CPT 84157,"HC Total Protein, Other Source",N/A,0301 - LABORATORY - CHEMISTRY,71.00,54.00,42.60,32.40,N/A,4.00,N/A,4.00,N/A,31.09,N/A,18.36,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,2.49,N/A,4.00,N/A,4.00,N/A,4.00,N/A,31.09,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.00,N/A,4.40,42.60,42.60,2.49,32.40,,Hospital CPT 84181,HC Protein Western Blot,N/A,0301 - LABORATORY - CHEMISTRY,350.00,350.00,210.00,210.00,N/A,17.03,N/A,17.03,N/A,201.53,N/A,119.00,N/A,14.47,N/A,17.03,N/A,17.03,N/A,17.03,N/A,14.47,N/A,14.47,N/A,14.47,N/A,14.47,N/A,201.53,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,17.03,N/A,18.73,210.00,210.00,14.47,210.00,,Hospital CPT 84182,HC So Protein Western Blot Test,N/A,0301 - LABORATORY - CHEMISTRY,106.00,106.00,63.60,63.60,N/A,29.21,N/A,29.21,N/A,61.03,N/A,36.04,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,61.03,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,32.13,63.60,63.60,15.29,63.60,,Hospital CPT 84182,"HC Western Blot,Immuneprb,Band ID",N/A,0301 - LABORATORY - CHEMISTRY,118.00,88.00,70.80,52.80,N/A,29.21,N/A,29.21,N/A,50.67,N/A,29.92,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,15.29,N/A,15.29,N/A,15.29,N/A,15.29,N/A,50.67,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,29.21,N/A,32.13,70.80,70.80,15.29,52.80,,Hospital CPT 84202,HC Protoporphyrin RBC Quant,N/A,0301 - LABORATORY - CHEMISTRY,66.00,66.00,39.60,39.60,N/A,14.35,N/A,14.35,N/A,38.00,N/A,22.44,N/A,12.19,N/A,14.35,N/A,14.35,N/A,14.35,N/A,12.19,N/A,12.19,N/A,12.19,N/A,12.19,N/A,38.00,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,15.79,39.60,39.60,12.19,39.60,,Hospital CPT 84202,HC So Protoporphyrin RBC Quant,N/A,0301 - LABORATORY - CHEMISTRY,60.00,60.00,36.00,36.00,N/A,14.35,N/A,14.35,N/A,34.55,N/A,20.40,N/A,12.19,N/A,14.35,N/A,14.35,N/A,14.35,N/A,12.19,N/A,12.19,N/A,12.19,N/A,12.19,N/A,34.55,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,14.35,N/A,15.79,36.00,36.00,12.19,36.00,,Hospital CPT 84206,HC So Proinsulin Level,N/A,0301 - LABORATORY - CHEMISTRY,106.00,106.00,63.60,63.60,N/A,26.69,N/A,26.69,N/A,61.03,N/A,36.04,N/A,15.14,N/A,26.69,N/A,26.69,N/A,26.69,N/A,15.14,N/A,15.14,N/A,26.69,N/A,15.14,N/A,61.03,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,29.36,63.60,63.60,15.14,63.60,,Hospital CPT 84206,HC Proinsulin Level,N/A,0301 - LABORATORY - CHEMISTRY,118.00,88.00,70.80,52.80,N/A,26.69,N/A,26.69,N/A,50.67,N/A,29.92,N/A,15.14,N/A,26.69,N/A,26.69,N/A,26.69,N/A,15.14,N/A,15.14,N/A,26.69,N/A,15.14,N/A,50.67,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,26.69,N/A,29.36,70.80,70.80,15.14,52.80,,Hospital CPT 84220,HC So Pyruvate Kinase,N/A,0301 - LABORATORY - CHEMISTRY,68.00,68.00,40.80,40.80,N/A,9.44,N/A,9.44,N/A,39.15,N/A,23.12,N/A,8.02,N/A,9.44,N/A,9.44,N/A,9.44,N/A,8.02,N/A,8.02,N/A,8.02,N/A,8.02,N/A,39.15,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,9.44,N/A,10.38,40.80,40.80,8.02,40.80,,Hospital CPT 84238,HC So Receptor Assay Nonendocrine,N/A,0301 - LABORATORY - CHEMISTRY,152.00,152.00,91.20,91.20,N/A,36.57,N/A,36.57,N/A,87.52,N/A,51.68,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,22.76,N/A,36.57,N/A,31.07,N/A,31.07,N/A,87.52,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,40.23,91.20,91.20,22.76,91.20,,Hospital CPT 84238,HC Receptor Assay Nonendocrine,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,36.57,N/A,36.57,N/A,96.73,N/A,57.12,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,22.76,N/A,36.57,N/A,31.07,N/A,31.07,N/A,96.73,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,36.57,N/A,40.23,100.80,100.80,22.76,100.80,,Hospital CPT 84255,"HC Selenium, Serum",N/A,0301 - LABORATORY - CHEMISTRY,192.00,145.00,115.20,87.00,N/A,25.53,N/A,25.53,N/A,83.49,N/A,49.30,N/A,21.70,N/A,25.53,N/A,25.53,N/A,25.53,N/A,15.89,N/A,25.53,N/A,25.53,N/A,21.70,N/A,83.49,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,28.08,115.20,115.20,15.89,87.00,,Hospital CPT 84255,"HC So Selenium, Serum",N/A,0301 - LABORATORY - CHEMISTRY,174.00,174.00,104.40,104.40,N/A,25.53,N/A,25.53,N/A,100.19,N/A,59.16,N/A,21.70,N/A,25.53,N/A,25.53,N/A,25.53,N/A,15.89,N/A,25.53,N/A,25.53,N/A,21.70,N/A,100.19,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,25.53,N/A,28.08,104.40,104.40,15.89,104.40,,Hospital CPT 84275,HC So Lipid Associated Sialic Acid,N/A,0301 - LABORATORY - CHEMISTRY,216.00,216.00,129.60,129.60,N/A,13.44,N/A,13.44,N/A,216.00,N/A,73.44,N/A,11.42,N/A,13.44,N/A,13.44,N/A,13.44,N/A,11.42,N/A,11.42,N/A,11.42,N/A,11.42,N/A,124.37,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,13.44,N/A,14.78,129.60,129.60,11.42,216.00,,Hospital CPT 84302,"HC Sodium, Other Source",N/A,0301 - LABORATORY - CHEMISTRY,24.00,24.00,14.40,14.40,N/A,4.86,N/A,4.86,N/A,13.82,N/A,8.16,N/A,4.13,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.13,N/A,4.13,N/A,4.13,N/A,4.13,N/A,13.82,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,5.35,14.40,14.40,4.13,14.40,,Hospital CPT 84302,"HC So Sodium, Other Source",N/A,0301 - LABORATORY - CHEMISTRY,22.00,22.00,13.20,13.20,N/A,4.86,N/A,4.86,N/A,12.67,N/A,7.48,N/A,4.13,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.13,N/A,4.13,N/A,4.13,N/A,4.13,N/A,12.67,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,4.86,N/A,5.35,13.20,13.20,4.13,13.20,,Hospital CPT 84315,HC So Specific Gravity Body Fluids,N/A,0301 - LABORATORY - CHEMISTRY,22.00,22.00,13.20,13.20,N/A,3.28,N/A,3.28,N/A,12.67,N/A,7.48,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,2.04,N/A,3.28,N/A,3.28,N/A,3.28,N/A,12.67,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.61,13.20,13.20,2.04,13.20,,Hospital CPT 84315,HC Specific Gravity Body Fluids,N/A,0301 - LABORATORY - CHEMISTRY,25.00,18.00,15.00,10.80,N/A,3.28,N/A,3.28,N/A,10.36,N/A,6.12,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,2.04,N/A,3.28,N/A,3.28,N/A,3.28,N/A,10.36,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.28,N/A,3.61,15.00,15.00,2.04,10.80,,Hospital CPT 84378,"HC So Sugars, Single, Quant",N/A,0301 - LABORATORY - CHEMISTRY,1359.00,1359.00,815.40,815.40,N/A,11.53,N/A,11.53,N/A,782.51,N/A,462.06,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,7.18,N/A,11.53,N/A,11.53,N/A,11.53,N/A,782.51,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,815.40,815.40,7.18,815.40,,Hospital CPT 84378,"HC Sugars, Single, Quant",N/A,0301 - LABORATORY - CHEMISTRY,1498.00,1117.00,898.80,670.20,N/A,11.53,N/A,11.53,N/A,643.17,N/A,379.78,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,7.18,N/A,11.53,N/A,11.53,N/A,11.53,N/A,643.17,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,898.80,898.80,7.18,670.20,,Hospital 84410,HC So Testosterone Bioavailable,N/A,0301 - LABORATORY - CHEMISTRY,21271.68,1561.00,12763.01,936.60,4799.56,130.34,5943.28,135.91,10816.19,898.83,7232.37,530.74,10919.66,97.57,4947.44,130.34,2248.00,135.91,2248.00,135.91,6797.23,97.57,10919.66,97.57,10919.66,97.57,10919.66,97.57,10816.19,898.83,5943.28,135.91,4947.44,130.34,12991.67,130.34,12991.67,130.34,4947.44,130.34,5943.28,135.91,5943.28,135.91,5293.76,143.38,2248.00,12991.67,97.57,936.60,,Hospital CPT 84430,HC So Thiocyanate,N/A,0301 - LABORATORY - CHEMISTRY,153.00,153.00,91.80,91.80,N/A,11.63,N/A,11.63,N/A,88.10,N/A,52.02,N/A,11.63,N/A,11.63,N/A,11.63,N/A,11.63,N/A,7.24,N/A,11.63,N/A,11.63,N/A,11.63,N/A,88.10,N/A,11.63,N/A,11.63,N/A,11.63,N/A,11.63,N/A,11.63,N/A,11.63,N/A,11.63,N/A,12.79,91.80,91.80,7.24,91.80,,Hospital CPT 84439,HC So T4 Free,N/A,0301 - LABORATORY - CHEMISTRY,170.00,170.00,102.00,102.00,N/A,9.02,N/A,9.02,N/A,97.89,N/A,57.80,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,5.61,N/A,7.66,N/A,9.02,N/A,7.66,N/A,97.89,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.92,102.00,102.00,5.61,102.00,,Hospital CPT 84439,"HC T-4,Free",N/A,0301 - LABORATORY - CHEMISTRY,188.00,139.00,112.80,83.40,N/A,9.02,N/A,9.02,N/A,80.04,N/A,47.26,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,5.61,N/A,7.66,N/A,9.02,N/A,7.66,N/A,80.04,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.02,N/A,9.92,112.80,112.80,5.61,83.40,,Hospital CPT 84443,HC So Tsh 3rd Generation,N/A,0301 - LABORATORY - CHEMISTRY,315.00,315.00,189.00,189.00,N/A,16.80,N/A,16.80,N/A,181.38,N/A,107.10,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,10.46,N/A,16.80,N/A,14.28,N/A,14.28,N/A,181.38,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,18.48,189.00,189.00,10.46,189.00,,Hospital CPT 84443,HC Thyroid Stimulating Hormone,N/A,0301 - LABORATORY - CHEMISTRY,348.00,83.00,208.80,49.80,N/A,16.80,N/A,16.80,N/A,47.79,N/A,28.22,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,10.46,N/A,16.80,N/A,14.28,N/A,14.28,N/A,47.79,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,16.80,N/A,18.48,208.80,208.80,10.46,49.80,,Hospital CPT 84445,HC Thyroid Stim Immunoglobulin,N/A,0301 - LABORATORY - CHEMISTRY,217.00,164.00,130.20,98.40,N/A,50.86,N/A,50.86,N/A,94.43,N/A,55.76,N/A,43.21,N/A,50.86,N/A,50.86,N/A,50.86,N/A,43.21,N/A,50.86,N/A,43.21,N/A,50.86,N/A,94.43,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,55.95,130.20,130.20,43.21,98.40,,Hospital CPT 84445,HC So Thyroid Stim Immunoglobulin,N/A,0301 - LABORATORY - CHEMISTRY,197.00,197.00,118.20,118.20,N/A,50.86,N/A,50.86,N/A,113.43,N/A,66.98,N/A,43.21,N/A,50.86,N/A,50.86,N/A,50.86,N/A,43.21,N/A,50.86,N/A,43.21,N/A,50.86,N/A,113.43,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,50.86,N/A,55.95,118.20,118.20,43.21,118.20,,Hospital 84449,HC So Assay of Transcortin Cortisol Binding Globulin,N/A,0301 - LABORATORY - CHEMISTRY,N/A,1949.00,N/A,1169.40,N/A,210.88,N/A,216.45,N/A,1122.24,N/A,599.42,N/A,161.59,N/A,210.88,N/A,216.45,N/A,216.45,N/A,161.59,N/A,161.59,N/A,161.59,N/A,161.59,N/A,1122.24,N/A,216.45,N/A,210.88,N/A,210.88,N/A,210.88,N/A,210.88,N/A,216.45,N/A,216.45,N/A,231.97,N/A,N/A,161.59,1169.40,,Hospital CPT 84479,HC T-3 Uptake,N/A,0301 - LABORATORY - CHEMISTRY,186.00,139.00,111.60,83.40,N/A,6.47,N/A,6.47,N/A,80.04,N/A,47.26,N/A,5.50,N/A,6.47,N/A,6.47,N/A,6.47,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.47,N/A,80.04,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,111.60,111.60,5.50,83.40,,Hospital CPT 84479,HC So T-3 Uptake,N/A,0301 - LABORATORY - CHEMISTRY,168.00,168.00,100.80,100.80,N/A,6.47,N/A,6.47,N/A,96.73,N/A,57.12,N/A,5.50,N/A,6.47,N/A,6.47,N/A,6.47,N/A,5.50,N/A,5.50,N/A,5.50,N/A,6.47,N/A,96.73,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,100.80,100.80,5.50,100.80,,Hospital CPT 84482,HC T3 Reverse,N/A,0301 - LABORATORY - CHEMISTRY,194.00,146.00,116.40,87.60,N/A,15.76,N/A,15.76,N/A,84.07,N/A,49.64,N/A,13.40,N/A,15.76,N/A,15.76,N/A,15.76,N/A,13.40,N/A,13.40,N/A,13.40,N/A,13.40,N/A,84.07,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,17.34,116.40,116.40,13.40,87.60,,Hospital CPT 84482,HC So T3 Reverse,N/A,0301 - LABORATORY - CHEMISTRY,176.00,176.00,105.60,105.60,N/A,15.76,N/A,15.76,N/A,101.34,N/A,59.84,N/A,13.40,N/A,15.76,N/A,15.76,N/A,15.76,N/A,13.40,N/A,13.40,N/A,13.40,N/A,13.40,N/A,101.34,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,15.76,N/A,17.34,105.60,105.60,13.40,105.60,,Hospital CPT 84520,HC So Bun,N/A,0301 - LABORATORY - CHEMISTRY,120.00,120.00,72.00,72.00,N/A,3.95,N/A,3.95,N/A,69.10,N/A,40.80,N/A,3.35,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.35,N/A,3.35,N/A,3.35,N/A,3.35,N/A,69.10,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,4.35,72.00,72.00,3.35,72.00,,Hospital CPT 84520,HC Bun,N/A,0301 - LABORATORY - CHEMISTRY,132.00,132.00,79.20,79.20,N/A,3.95,N/A,3.95,N/A,76.01,N/A,44.88,N/A,3.35,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.35,N/A,3.35,N/A,3.35,N/A,3.35,N/A,76.01,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,3.95,N/A,4.35,79.20,79.20,3.35,79.20,,Hospital CPT 84545,HC Urea Nitrogen Clearance,N/A,0301 - LABORATORY - CHEMISTRY,31.00,31.00,18.60,18.60,N/A,7.20,N/A,7.20,N/A,17.85,N/A,10.54,N/A,4.94,N/A,7.20,N/A,7.20,N/A,7.20,N/A,4.94,N/A,4.94,N/A,4.94,N/A,4.94,N/A,17.85,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.92,18.60,18.60,4.94,18.60,,Hospital CPT 84545,HC So Urea Nitrogen Clearance,N/A,0301 - LABORATORY - CHEMISTRY,31.00,31.00,18.60,18.60,N/A,7.20,N/A,7.20,N/A,17.85,N/A,10.54,N/A,4.94,N/A,7.20,N/A,7.20,N/A,7.20,N/A,4.94,N/A,4.94,N/A,4.94,N/A,4.94,N/A,17.85,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.20,N/A,7.92,18.60,18.60,4.94,18.60,,Hospital CPT 84560,"HC So Uric Acid,Urine, 24hr",N/A,0301 - LABORATORY - CHEMISTRY,35.00,35.00,21.00,21.00,N/A,5.08,N/A,5.08,N/A,20.15,N/A,11.90,N/A,4.04,N/A,5.08,N/A,5.08,N/A,5.08,N/A,4.04,N/A,4.04,N/A,4.04,N/A,4.04,N/A,20.15,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.59,21.00,21.00,4.04,21.00,,Hospital CPT 84560,"HC Uric Acid,Urine, 24hr",N/A,0301 - LABORATORY - CHEMISTRY,39.00,28.00,23.40,16.80,N/A,5.08,N/A,5.08,N/A,16.12,N/A,9.52,N/A,4.04,N/A,5.08,N/A,5.08,N/A,5.08,N/A,4.04,N/A,4.04,N/A,4.04,N/A,4.04,N/A,16.12,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.08,N/A,5.59,23.40,23.40,4.04,16.80,,Hospital CPT 84588,"HC So Antidiuretic Hormone, Plasma",N/A,0301 - LABORATORY - CHEMISTRY,257.00,257.00,154.20,154.20,N/A,33.94,N/A,33.94,N/A,147.98,N/A,87.38,N/A,28.85,N/A,33.94,N/A,33.94,N/A,33.94,N/A,28.85,N/A,28.85,N/A,28.85,N/A,28.85,N/A,147.98,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,37.33,154.20,154.20,28.85,154.20,,Hospital CPT 84588,"HC Antidiuretic Hormone, Plasma",N/A,0301 - LABORATORY - CHEMISTRY,284.00,212.00,170.40,127.20,N/A,33.94,N/A,33.94,N/A,122.07,N/A,72.08,N/A,28.85,N/A,33.94,N/A,33.94,N/A,33.94,N/A,28.85,N/A,28.85,N/A,28.85,N/A,28.85,N/A,122.07,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,33.94,N/A,37.33,170.40,170.40,28.85,127.20,,Hospital CPT 84600,HC Assay of Volatiles,N/A,0301 - LABORATORY - CHEMISTRY,146.00,108.00,87.60,64.80,N/A,17.11,N/A,17.11,N/A,62.19,N/A,36.72,N/A,9.97,N/A,17.11,N/A,17.11,N/A,17.11,N/A,9.97,N/A,9.97,N/A,9.97,N/A,9.97,N/A,62.19,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,18.82,87.60,87.60,9.97,64.80,,Hospital CPT 84600,HC So Assay of Volatiles,N/A,0301 - LABORATORY - CHEMISTRY,132.00,132.00,79.20,79.20,N/A,17.11,N/A,17.11,N/A,76.01,N/A,44.88,N/A,9.97,N/A,17.11,N/A,17.11,N/A,17.11,N/A,9.97,N/A,9.97,N/A,9.97,N/A,9.97,N/A,76.01,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,17.11,N/A,18.82,79.20,79.20,9.97,79.20,,Hospital CPT 84620,HC So Dxylose Absorption,N/A,0301 - LABORATORY - CHEMISTRY,165.00,165.00,99.00,99.00,N/A,12.91,N/A,12.91,N/A,95.01,N/A,56.10,N/A,12.91,N/A,12.91,N/A,12.91,N/A,12.91,N/A,8.04,N/A,12.91,N/A,12.91,N/A,12.91,N/A,95.01,N/A,12.91,N/A,12.91,N/A,12.91,N/A,12.91,N/A,12.91,N/A,12.91,N/A,12.91,N/A,14.20,99.00,99.00,8.04,99.00,,Hospital CPT 85002,HC Mielke Bleeding Time,N/A,0305 - LABORATORY - HEMATOLOGY,126.00,126.00,75.60,75.60,N/A,4.82,N/A,4.82,N/A,72.55,N/A,42.84,N/A,4.82,N/A,4.82,N/A,4.82,N/A,4.82,N/A,3.00,N/A,4.82,N/A,4.82,N/A,4.82,N/A,72.55,N/A,4.82,N/A,4.82,N/A,4.82,N/A,4.82,N/A,4.82,N/A,4.82,N/A,4.82,N/A,5.30,75.60,75.60,3.00,75.60,,Hospital CPT 85013,HC Spun Microhematocrit,N/A,0305 - LABORATORY - HEMATOLOGY,25.00,25.00,15.00,15.00,N/A,7.00,N/A,7.00,N/A,14.40,N/A,8.50,N/A,7.00,N/A,7.00,N/A,7.00,N/A,7.00,N/A,4.36,N/A,7.00,N/A,7.00,N/A,7.00,N/A,14.40,N/A,7.00,N/A,7.00,N/A,7.00,N/A,7.00,N/A,7.00,N/A,7.00,N/A,7.00,N/A,7.70,15.00,15.00,4.36,15.00,,Hospital CPT 85014,HC 16081 Hematocrit,N/A,0305 - LABORATORY - HEMATOLOGY,39.00,30.00,23.40,18.00,N/A,2.37,N/A,2.37,N/A,17.27,N/A,10.20,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,1.48,N/A,2.37,N/A,2.37,N/A,2.37,N/A,17.27,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.61,23.40,23.40,1.48,18.00,,Hospital CPT 85018,HC Hemoglobin,N/A,0305 - LABORATORY - HEMATOLOGY,39.00,30.00,23.40,18.00,N/A,2.37,N/A,2.37,N/A,17.27,N/A,10.20,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,1.48,N/A,2.37,N/A,2.37,N/A,2.37,N/A,17.27,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.37,N/A,2.61,23.40,23.40,1.48,18.00,,Hospital CPT 85025,HC Cbc,N/A,0305 - LABORATORY - HEMATOLOGY,205.00,34.00,123.00,20.40,N/A,7.77,N/A,7.77,N/A,19.58,N/A,11.56,N/A,6.61,N/A,7.77,N/A,7.77,N/A,7.77,N/A,6.61,N/A,6.61,N/A,6.61,N/A,6.61,N/A,19.58,N/A,7.77,N/A,7.77,N/A,7.77,N/A,7.77,N/A,7.77,N/A,7.77,N/A,7.77,N/A,8.55,123.00,123.00,6.61,20.40,,Hospital CPT 85027,HC Cbc (Hemogram),N/A,0305 - LABORATORY - HEMATOLOGY,95.00,79.00,57.00,47.40,N/A,6.47,N/A,6.47,N/A,45.49,N/A,26.86,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,4.03,N/A,6.47,N/A,6.47,N/A,5.50,N/A,45.49,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,57.00,57.00,4.03,47.40,,Hospital CPT 85041,"HC RBC, Automated",N/A,0305 - LABORATORY - HEMATOLOGY,23.00,23.00,13.80,13.80,N/A,3.02,N/A,3.02,N/A,13.24,N/A,7.82,N/A,2.47,N/A,3.02,N/A,3.02,N/A,3.02,N/A,2.47,N/A,2.47,N/A,2.47,N/A,2.47,N/A,13.24,N/A,3.02,N/A,3.02,N/A,3.02,N/A,3.02,N/A,3.02,N/A,3.02,N/A,3.02,N/A,3.32,13.80,13.80,2.47,13.80,,Hospital CPT 85048,HC Automated Leukocyte Count,N/A,0305 - LABORATORY - HEMATOLOGY,32.00,25.00,19.20,15.00,N/A,2.54,N/A,2.54,N/A,14.40,N/A,8.50,N/A,2.03,N/A,2.54,N/A,2.54,N/A,2.54,N/A,2.03,N/A,2.03,N/A,2.03,N/A,2.03,N/A,14.40,N/A,2.54,N/A,2.54,N/A,2.54,N/A,2.54,N/A,2.54,N/A,2.54,N/A,2.54,N/A,2.79,19.20,19.20,2.03,15.00,,Hospital CPT 85245,HC Von Wille Brand Factor,N/A,0305 - LABORATORY - HEMATOLOGY,114.00,97.00,68.40,58.20,N/A,22.94,N/A,22.94,N/A,55.85,N/A,32.98,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,55.85,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,68.40,68.40,14.28,58.20,,Hospital CPT 85245,HC So Von Wille Brand Factor,N/A,0305 - LABORATORY - HEMATOLOGY,103.00,103.00,61.80,61.80,N/A,22.94,N/A,22.94,N/A,59.31,N/A,35.02,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,59.31,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,61.80,61.80,14.28,61.80,,Hospital CPT 85246,"HC F8,Vw Factor Antigen",N/A,0305 - LABORATORY - HEMATOLOGY,163.00,139.00,97.80,83.40,N/A,22.94,N/A,22.94,N/A,80.04,N/A,47.26,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,80.04,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,97.80,97.80,14.28,83.40,,Hospital CPT 85246,"HC So F8,Vw Factor Antigen",N/A,0305 - LABORATORY - HEMATOLOGY,147.00,147.00,88.20,88.20,N/A,22.94,N/A,22.94,N/A,84.64,N/A,49.98,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,84.64,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,88.20,88.20,14.28,88.20,,Hospital CPT 85246,"HC So1 Factor VIII, Vw Factor Ag",N/A,0305 - LABORATORY - HEMATOLOGY,147.00,147.00,88.20,88.20,N/A,22.94,N/A,22.94,N/A,84.64,N/A,49.98,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,84.64,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,88.20,88.20,14.28,88.20,,Hospital CPT 85247,HC Factor VIII Vonwillebrands Fac,N/A,0305 - LABORATORY - HEMATOLOGY,108.00,108.00,64.80,64.80,N/A,22.94,N/A,22.94,N/A,62.19,N/A,36.72,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,62.19,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,64.80,64.80,14.28,64.80,,Hospital CPT 85247,HC So Factor VIII Vonwillebrands Fac,N/A,0305 - LABORATORY - HEMATOLOGY,98.00,98.00,58.80,58.80,N/A,22.94,N/A,22.94,N/A,56.43,N/A,33.32,N/A,19.50,N/A,22.94,N/A,22.94,N/A,22.94,N/A,14.28,N/A,22.94,N/A,19.50,N/A,19.50,N/A,56.43,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,22.94,N/A,25.23,58.80,58.80,14.28,58.80,,Hospital CPT 85260,HC So Factor X,N/A,0305 - LABORATORY - HEMATOLOGY,95.00,95.00,57.00,57.00,N/A,17.90,N/A,17.90,N/A,54.70,N/A,32.30,N/A,15.22,N/A,17.90,N/A,17.90,N/A,17.90,N/A,15.22,N/A,15.22,N/A,17.90,N/A,15.22,N/A,54.70,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,57.00,57.00,15.22,57.00,,Hospital CPT 85260,HC Factor X,N/A,0305 - LABORATORY - HEMATOLOGY,105.00,91.00,63.00,54.60,N/A,17.90,N/A,17.90,N/A,52.40,N/A,30.94,N/A,15.22,N/A,17.90,N/A,17.90,N/A,17.90,N/A,15.22,N/A,15.22,N/A,17.90,N/A,15.22,N/A,52.40,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,63.00,63.00,15.22,54.60,,Hospital CPT 85270,HC So Factor XI,N/A,0305 - LABORATORY - HEMATOLOGY,109.00,109.00,65.40,65.40,N/A,17.90,N/A,17.90,N/A,62.76,N/A,37.06,N/A,15.22,N/A,17.90,N/A,17.90,N/A,17.90,N/A,15.22,N/A,15.22,N/A,15.22,N/A,15.22,N/A,62.76,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,65.40,65.40,15.22,65.40,,Hospital CPT 85270,HC Factor XI,N/A,0305 - LABORATORY - HEMATOLOGY,121.00,103.00,72.60,61.80,N/A,17.90,N/A,17.90,N/A,59.31,N/A,35.02,N/A,15.22,N/A,17.90,N/A,17.90,N/A,17.90,N/A,15.22,N/A,15.22,N/A,15.22,N/A,15.22,N/A,59.31,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,17.90,N/A,19.69,72.60,72.60,15.22,61.80,,Hospital CPT 85280,HC So Factor XII,N/A,0305 - LABORATORY - HEMATOLOGY,95.00,95.00,57.00,57.00,N/A,19.35,N/A,19.35,N/A,54.70,N/A,32.30,N/A,16.44,N/A,19.35,N/A,19.35,N/A,19.35,N/A,16.44,N/A,16.44,N/A,16.44,N/A,16.44,N/A,54.70,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,57.00,57.00,16.44,57.00,,Hospital CPT 85280,HC Factor XII,N/A,0305 - LABORATORY - HEMATOLOGY,105.00,91.00,63.00,54.60,N/A,19.35,N/A,19.35,N/A,52.40,N/A,30.94,N/A,16.44,N/A,19.35,N/A,19.35,N/A,19.35,N/A,16.44,N/A,16.44,N/A,16.44,N/A,16.44,N/A,52.40,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,19.35,N/A,21.29,63.00,63.00,16.44,54.60,,Hospital 85291,HC So Clot Factor XIII Fibrin Scrn,N/A,0305 - LABORATORY - HEMATOLOGY,N/A,389.00,N/A,233.40,N/A,179.21,N/A,184.78,N/A,223.99,N/A,132.26,N/A,184.78,N/A,179.21,N/A,184.78,N/A,184.78,N/A,115.02,N/A,184.78,N/A,184.78,N/A,184.78,N/A,223.99,N/A,184.78,N/A,179.21,N/A,179.21,N/A,179.21,N/A,179.21,N/A,184.78,N/A,184.78,N/A,197.13,N/A,N/A,115.02,233.40,,Hospital CPT 85301,HC So Antithrombin III,N/A,0305 - LABORATORY - HEMATOLOGY,131.00,131.00,78.60,78.60,N/A,10.81,N/A,10.81,N/A,75.43,N/A,44.54,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,6.73,N/A,10.81,N/A,9.19,N/A,9.19,N/A,75.43,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,11.89,78.60,78.60,6.73,78.60,,Hospital CPT 85301,HC Antithrombin III,N/A,0305 - LABORATORY - HEMATOLOGY,145.00,122.00,87.00,73.20,N/A,10.81,N/A,10.81,N/A,70.25,N/A,41.48,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,6.73,N/A,10.81,N/A,9.19,N/A,9.19,N/A,70.25,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,10.81,N/A,11.89,87.00,87.00,6.73,73.20,,Hospital CPT 85303,"HC So Protein C, Activity",N/A,0305 - LABORATORY - HEMATOLOGY,152.00,152.00,91.20,91.20,N/A,13.84,N/A,13.84,N/A,87.52,N/A,51.68,N/A,11.75,N/A,13.84,N/A,13.84,N/A,13.84,N/A,8.62,N/A,13.84,N/A,11.75,N/A,11.75,N/A,87.52,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,15.22,91.20,91.20,8.62,91.20,,Hospital CPT 85303,"HC Protein C, Activity",N/A,0305 - LABORATORY - HEMATOLOGY,168.00,145.00,100.80,87.00,N/A,13.84,N/A,13.84,N/A,83.49,N/A,49.30,N/A,11.75,N/A,13.84,N/A,13.84,N/A,13.84,N/A,8.62,N/A,13.84,N/A,11.75,N/A,11.75,N/A,83.49,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,13.84,N/A,15.22,100.80,100.80,8.62,87.00,,Hospital CPT 85362,HC So Fibrin Degradation Prod,N/A,0305 - LABORATORY - HEMATOLOGY,73.00,73.00,43.80,43.80,N/A,6.89,N/A,6.89,N/A,42.03,N/A,24.82,N/A,5.86,N/A,6.89,N/A,6.89,N/A,6.89,N/A,5.86,N/A,5.86,N/A,5.86,N/A,5.86,N/A,42.03,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,7.58,43.80,43.80,5.86,43.80,,Hospital CPT 85362,HC Fibrin Degradation Products,N/A,0305 - LABORATORY - HEMATOLOGY,73.00,73.00,43.80,43.80,N/A,6.89,N/A,6.89,N/A,42.03,N/A,24.82,N/A,5.86,N/A,6.89,N/A,6.89,N/A,6.89,N/A,5.86,N/A,5.86,N/A,5.86,N/A,5.86,N/A,42.03,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,6.89,N/A,7.58,43.80,43.80,5.86,43.80,,Hospital CPT 85378,HC D-Dimer Qual,N/A,0305 - LABORATORY - HEMATOLOGY,91.00,91.00,54.60,54.60,N/A,9.72,N/A,9.72,N/A,52.40,N/A,30.94,N/A,6.06,N/A,9.72,N/A,9.72,N/A,9.72,N/A,6.06,N/A,6.06,N/A,6.06,N/A,6.06,N/A,52.40,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,10.69,54.60,54.60,6.06,54.60,,Hospital CPT 85379,"HC So D-Dimer, Quantitative",N/A,0305 - LABORATORY - HEMATOLOGY,90.00,90.00,54.00,54.00,N/A,10.18,N/A,10.18,N/A,51.82,N/A,30.60,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,6.34,N/A,10.18,N/A,10.18,N/A,10.18,N/A,51.82,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,11.20,54.00,54.00,6.34,54.00,,Hospital CPT 85379,"HC D-Dimer, Quantitative",N/A,0305 - LABORATORY - HEMATOLOGY,100.00,87.00,60.00,52.20,N/A,10.18,N/A,10.18,N/A,50.09,N/A,29.58,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,6.34,N/A,10.18,N/A,10.18,N/A,10.18,N/A,50.09,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,11.20,60.00,60.00,6.34,52.20,,Hospital CPT 85384,HC Fibrinogen,N/A,0305 - LABORATORY - HEMATOLOGY,54.00,46.00,32.40,27.60,N/A,9.72,N/A,9.72,N/A,26.49,N/A,15.64,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,6.05,N/A,9.72,N/A,9.72,N/A,9.72,N/A,26.49,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,10.69,32.40,32.40,6.05,27.60,,Hospital CPT 85384,HC So Fibrinogen,N/A,0305 - LABORATORY - HEMATOLOGY,48.00,48.00,28.80,28.80,N/A,9.72,N/A,9.72,N/A,27.64,N/A,16.32,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,6.05,N/A,9.72,N/A,9.72,N/A,9.72,N/A,27.64,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,9.72,N/A,10.69,28.80,28.80,6.05,28.80,,Hospital CPT 85385,HC So Fibrinogen Antigen,N/A,0305 - LABORATORY - HEMATOLOGY,121.00,121.00,72.60,72.60,N/A,14.46,N/A,14.46,N/A,69.67,N/A,41.14,N/A,7.22,N/A,14.46,N/A,14.46,N/A,14.46,N/A,7.22,N/A,7.22,N/A,7.22,N/A,7.22,N/A,69.67,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,14.46,N/A,15.91,72.60,72.60,7.22,72.60,,Hospital CPT 85390,HC So Lupus Anticoagulant,N/A,0305 - LABORATORY - HEMATOLOGY,150.00,150.00,90.00,90.00,N/A,15.48,N/A,15.48,N/A,86.37,N/A,51.00,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,9.64,N/A,15.48,N/A,4.39,N/A,15.48,N/A,86.37,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,17.03,90.00,90.00,4.39,90.00,,Hospital CPT 85390,HC Lupus Anticoagulant,N/A,0305 - LABORATORY - HEMATOLOGY,150.00,150.00,90.00,90.00,N/A,15.48,N/A,15.48,N/A,86.37,N/A,51.00,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,9.64,N/A,15.48,N/A,4.39,N/A,15.48,N/A,86.37,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,15.48,N/A,17.03,90.00,90.00,4.39,90.00,,Hospital CPT 85397,HC Adamts-13 Activity,N/A,0305 - LABORATORY - HEMATOLOGY,128.00,109.00,76.80,65.40,N/A,30.86,N/A,30.86,N/A,62.76,N/A,37.06,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,19.21,N/A,30.86,N/A,30.86,N/A,30.86,N/A,62.76,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,33.95,76.80,76.80,19.21,65.40,,Hospital CPT 85397,HC So Adamts-13 Activity,N/A,0305 - LABORATORY - HEMATOLOGY,116.00,116.00,69.60,69.60,N/A,30.86,N/A,30.86,N/A,66.79,N/A,39.44,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,19.21,N/A,30.86,N/A,30.86,N/A,30.86,N/A,66.79,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,30.86,N/A,33.95,69.60,69.60,19.21,69.60,,Hospital CPT 85410,HC Alpha-2 Antiplasmin,N/A,0305 - LABORATORY - HEMATOLOGY,85.00,85.00,51.00,51.00,N/A,7.71,N/A,7.71,N/A,48.94,N/A,28.90,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,4.80,N/A,7.71,N/A,7.71,N/A,7.71,N/A,48.94,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,8.48,51.00,51.00,4.80,51.00,,Hospital CPT 85410,HC So Alpha-2 Antiplasmin,N/A,0305 - LABORATORY - HEMATOLOGY,85.00,85.00,51.00,51.00,N/A,7.71,N/A,7.71,N/A,48.94,N/A,28.90,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,4.80,N/A,7.71,N/A,7.71,N/A,7.71,N/A,48.94,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,7.71,N/A,8.48,51.00,51.00,4.80,51.00,,Hospital CPT 85415,HC So Plasminogen Activator,N/A,0305 - LABORATORY - HEMATOLOGY,88.00,88.00,52.80,52.80,N/A,17.19,N/A,17.19,N/A,50.67,N/A,29.92,N/A,14.61,N/A,17.19,N/A,17.19,N/A,17.19,N/A,14.61,N/A,14.61,N/A,14.61,N/A,14.61,N/A,50.67,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,18.91,52.80,52.80,14.61,52.80,,Hospital CPT 85415,HC Plasminogen Activator,N/A,0305 - LABORATORY - HEMATOLOGY,98.00,83.00,58.80,49.80,N/A,17.19,N/A,17.19,N/A,47.79,N/A,28.22,N/A,14.61,N/A,17.19,N/A,17.19,N/A,17.19,N/A,14.61,N/A,14.61,N/A,14.61,N/A,14.61,N/A,47.79,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,17.19,N/A,18.91,58.80,58.80,14.61,49.80,,Hospital CPT 85445,HC So Induced Acetyl Phenylhydrazine,N/A,0305 - LABORATORY - HEMATOLOGY,90.00,90.00,54.00,54.00,N/A,6.82,N/A,6.82,N/A,51.82,N/A,30.60,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,4.25,N/A,6.82,N/A,6.82,N/A,6.82,N/A,51.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,6.82,N/A,7.50,54.00,54.00,4.25,54.00,,Hospital CPT 85460,HC So Hemoglobin Fetal,N/A,0305 - LABORATORY - HEMATOLOGY,132.00,132.00,79.20,79.20,N/A,7.73,N/A,7.73,N/A,76.01,N/A,44.88,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,4.81,N/A,7.73,N/A,7.73,N/A,7.73,N/A,76.01,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,8.50,79.20,79.20,4.81,79.20,,Hospital CPT 85460,HC Hemoglobin Fetal,N/A,0305 - LABORATORY - HEMATOLOGY,146.00,146.00,87.60,87.60,N/A,7.73,N/A,7.73,N/A,84.07,N/A,49.64,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,4.81,N/A,7.73,N/A,7.73,N/A,7.73,N/A,84.07,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,7.73,N/A,8.50,87.60,87.60,4.81,87.60,,Hospital CPT 85461,HC Fetal Screen,N/A,0305 - LABORATORY - HEMATOLOGY,88.00,74.00,52.80,44.40,N/A,9.36,N/A,9.36,N/A,42.61,N/A,25.16,N/A,9.36,N/A,9.36,N/A,9.36,N/A,9.36,N/A,5.83,N/A,9.36,N/A,9.36,N/A,9.36,N/A,42.61,N/A,9.36,N/A,9.36,N/A,9.36,N/A,9.36,N/A,9.36,N/A,9.36,N/A,9.36,N/A,10.30,52.80,52.80,5.83,44.40,,Hospital CPT 85525,HC So Heparin Neutralizatin,N/A,0305 - LABORATORY - HEMATOLOGY,60.00,60.00,36.00,36.00,N/A,11.84,N/A,11.84,N/A,34.55,N/A,20.40,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,7.37,N/A,11.84,N/A,11.84,N/A,11.84,N/A,34.55,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,13.02,36.00,36.00,7.37,36.00,,Hospital CPT 85525,HC Heparin Neutralization,N/A,0305 - LABORATORY - HEMATOLOGY,66.00,55.00,39.60,33.00,N/A,11.84,N/A,11.84,N/A,31.67,N/A,18.70,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,7.37,N/A,11.84,N/A,11.84,N/A,11.84,N/A,31.67,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,11.84,N/A,13.02,39.60,39.60,7.37,33.00,,Hospital CPT 85540,HC Leukocyte Alka Phosphat Stain,N/A,0305 - LABORATORY - HEMATOLOGY,29.00,29.00,17.40,17.40,N/A,8.60,N/A,8.60,N/A,16.70,N/A,9.86,N/A,7.31,N/A,8.60,N/A,8.60,N/A,8.60,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,16.70,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,9.46,17.40,17.40,7.31,17.40,,Hospital CPT 85540,HC So Leukocyte Alka Phosphat Stain,N/A,0305 - LABORATORY - HEMATOLOGY,26.00,26.00,15.60,15.60,N/A,8.60,N/A,8.60,N/A,14.97,N/A,8.84,N/A,7.31,N/A,8.60,N/A,8.60,N/A,8.60,N/A,7.31,N/A,7.31,N/A,7.31,N/A,7.31,N/A,14.97,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,8.60,N/A,9.46,15.60,15.60,7.31,15.60,,Hospital CPT 85557,HC So Osmotic Fragility,N/A,0305 - LABORATORY - HEMATOLOGY,245.00,245.00,147.00,147.00,N/A,13.36,N/A,13.36,N/A,141.07,N/A,83.30,N/A,13.36,N/A,13.36,N/A,13.36,N/A,13.36,N/A,8.32,N/A,13.36,N/A,13.36,N/A,13.36,N/A,141.07,N/A,13.36,N/A,13.36,N/A,13.36,N/A,13.36,N/A,13.36,N/A,13.36,N/A,13.36,N/A,14.70,147.00,147.00,8.32,147.00,,Hospital CPT 85613,"HC Viper Venom Time,Diluted",N/A,0305 - LABORATORY - HEMATOLOGY,105.00,91.00,63.00,54.60,N/A,9.58,N/A,9.58,N/A,52.40,N/A,30.94,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,8.14,N/A,8.14,N/A,8.14,N/A,8.14,N/A,52.40,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,10.54,63.00,63.00,8.14,54.60,,Hospital CPT 85613,HC So Drvvt,N/A,0305 - LABORATORY - HEMATOLOGY,95.00,95.00,57.00,57.00,N/A,9.58,N/A,9.58,N/A,54.70,N/A,32.30,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,8.14,N/A,8.14,N/A,8.14,N/A,8.14,N/A,54.70,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,9.58,N/A,10.54,57.00,57.00,8.14,57.00,,Hospital CPT 85705,HC Tissue Thromboplastin Inhib,N/A,0305 - LABORATORY - HEMATOLOGY,210.00,210.00,126.00,126.00,N/A,9.63,N/A,9.63,N/A,120.92,N/A,71.40,N/A,9.63,N/A,9.63,N/A,9.63,N/A,9.63,N/A,5.99,N/A,9.63,N/A,9.63,N/A,9.63,N/A,120.92,N/A,9.63,N/A,9.63,N/A,9.63,N/A,9.63,N/A,9.63,N/A,9.63,N/A,9.63,N/A,10.59,126.00,126.00,5.99,126.00,,Hospital CPT 85732,HC So Ptt / Thromboplastin Subs,N/A,0305 - LABORATORY - HEMATOLOGY,60.00,60.00,36.00,36.00,N/A,6.47,N/A,6.47,N/A,34.55,N/A,20.40,N/A,5.50,N/A,6.47,N/A,6.47,N/A,6.47,N/A,5.50,N/A,5.50,N/A,6.47,N/A,5.50,N/A,34.55,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,36.00,36.00,5.50,36.00,,Hospital CPT 85732,HC Ptt / Thromboplastin Subs,N/A,0305 - LABORATORY - HEMATOLOGY,66.00,55.00,39.60,33.00,N/A,6.47,N/A,6.47,N/A,31.67,N/A,18.70,N/A,5.50,N/A,6.47,N/A,6.47,N/A,6.47,N/A,5.50,N/A,5.50,N/A,6.47,N/A,5.50,N/A,31.67,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,6.47,N/A,7.12,39.60,39.60,5.50,33.00,,Hospital CPT 85810,HC Viscosity,N/A,0305 - LABORATORY - HEMATOLOGY,44.00,40.00,26.40,24.00,N/A,11.67,N/A,11.67,N/A,23.03,N/A,13.60,N/A,9.92,N/A,11.67,N/A,11.67,N/A,11.67,N/A,9.92,N/A,9.92,N/A,11.67,N/A,9.92,N/A,23.03,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,12.84,26.40,26.40,9.92,24.00,,Hospital CPT 85810,HC So Viscosity,N/A,0305 - LABORATORY - HEMATOLOGY,40.00,40.00,24.00,24.00,N/A,11.67,N/A,11.67,N/A,23.03,N/A,13.60,N/A,9.92,N/A,11.67,N/A,11.67,N/A,11.67,N/A,9.92,N/A,9.92,N/A,11.67,N/A,9.92,N/A,23.03,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,11.67,N/A,12.84,24.00,24.00,9.92,24.00,,Hospital 85999,HC So Hematology Procedure,N/A,0305 - LABORATORY - HEMATOLOGY,62656.17,N/A,37593.70,N/A,10440.92,N/A,12616.71,N/A,25405.97,N/A,21303.09,N/A,23754.54,N/A,10762.62,N/A,1686.00,N/A,1686.00,N/A,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,25405.97,N/A,12616.71,N/A,10762.62,N/A,28261.97,N/A,28261.97,N/A,10762.62,N/A,N/A,N/A,12616.71,N/A,11516.01,N/A,1686.00,37593.70,N/A,N/A,,Hospital CPT 86000,HC Agglutinins Febrile,N/A,0305 - LABORATORY - HEMATOLOGY,75.00,75.00,45.00,45.00,N/A,6.98,N/A,6.98,N/A,43.19,N/A,25.50,N/A,6.98,N/A,6.98,N/A,6.98,N/A,6.98,N/A,4.35,N/A,6.98,N/A,6.98,N/A,6.98,N/A,43.19,N/A,6.98,N/A,6.98,N/A,6.98,N/A,6.98,N/A,6.98,N/A,6.98,N/A,6.98,N/A,7.68,45.00,45.00,4.35,45.00,,Hospital CPT 86008,HC Allergen Spec Ige Recombinant/Purified Compnt Ea,N/A,0305 - LABORATORY - HEMATOLOGY,53.00,53.00,31.80,31.80,N/A,17.93,N/A,17.93,N/A,30.52,N/A,18.02,N/A,8.86,N/A,17.93,N/A,17.93,N/A,17.93,N/A,8.86,N/A,8.86,N/A,8.86,N/A,8.86,N/A,30.52,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,19.72,31.80,31.80,8.86,31.80,,Hospital CPT 86008,HC Allergen Spec Ige Recombinant/Purified Compnt Ea,N/A,0302 - LABORATORY - IMMUNOLOGY,69.00,69.00,41.40,41.40,N/A,17.93,N/A,17.93,N/A,39.73,N/A,23.46,N/A,8.86,N/A,17.93,N/A,17.93,N/A,17.93,N/A,8.86,N/A,8.86,N/A,8.86,N/A,8.86,N/A,39.73,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,19.72,41.40,41.40,8.86,41.40,,Hospital CPT 86008,HC So Allergen Spec Ige Recombinant/Purified Compnt Ea,N/A,0305 - LABORATORY - HEMATOLOGY,53.00,53.00,31.80,31.80,N/A,17.93,N/A,17.93,N/A,30.52,N/A,18.02,N/A,8.86,N/A,17.93,N/A,17.93,N/A,17.93,N/A,8.86,N/A,8.86,N/A,8.86,N/A,8.86,N/A,30.52,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,17.93,N/A,19.72,31.80,31.80,8.86,31.80,,Hospital 86015,HC So Actin Smooth Muscle Antibody Each,N/A,0301 - LABORATORY - CHEMISTRY,59791.90,1978.00,35875.14,1186.80,10072.83,167.50,12181.28,183.27,22699.94,1138.93,20329.24,672.52,22917.08,133.66,10383.19,167.50,10740.65,183.27,10740.65,183.27,14265.35,133.66,18408.59,133.66,22917.08,133.66,18835.42,133.66,22699.94,1138.93,12084.04,183.27,10383.19,167.50,27265.61,177.18,27265.61,177.18,7894.77,167.50,12181.28,183.27,12181.28,183.27,11110.02,154.22,7894.77,35875.14,133.66,1186.80,,Hospital CPT 86021,HC Antibody ID; Leukocyte Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,121.00,121.00,72.60,72.60,N/A,15.05,N/A,15.05,N/A,69.67,N/A,41.14,N/A,12.80,N/A,15.05,N/A,15.05,N/A,15.05,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,69.67,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,72.60,72.60,12.80,72.60,,Hospital CPT 86021,HC So Antibody ID; Leukocyte Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,121.00,121.00,72.60,72.60,N/A,15.05,N/A,15.05,N/A,69.67,N/A,41.14,N/A,12.80,N/A,15.05,N/A,15.05,N/A,15.05,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,69.67,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,72.60,72.60,12.80,72.60,,Hospital CPT 86036,HC So Antineutrophil Cytoplasmic Antb Screen Ea Antb,N/A,0302 - LABORATORY - IMMUNOLOGY,30.00,30.00,18.00,18.00,N/A,4.20,N/A,12.05,N/A,17.27,N/A,10.20,N/A,12.05,N/A,4.20,N/A,12.05,N/A,12.05,N/A,7.50,N/A,12.05,N/A,4.82,N/A,4.82,N/A,17.27,N/A,12.05,N/A,4.20,N/A,12.05,N/A,12.05,N/A,4.20,N/A,12.05,N/A,12.05,N/A,30.00,18.00,18.00,4.20,30.00,,Hospital CPT 86038,HC So Anti Nuclear Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,280.00,280.00,168.00,168.00,N/A,12.09,N/A,12.09,N/A,161.22,N/A,95.20,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,7.53,N/A,12.09,N/A,12.09,N/A,12.09,N/A,161.22,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,13.30,168.00,168.00,7.53,168.00,,Hospital CPT 86038,HC Anti Nuclear Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,309.00,237.00,185.40,142.20,N/A,12.09,N/A,12.09,N/A,136.46,N/A,80.58,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,7.53,N/A,12.09,N/A,12.09,N/A,12.09,N/A,136.46,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,13.30,185.40,185.40,7.53,142.20,,Hospital CPT 86039,HC So Antinuclear Ab Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,97.00,97.00,58.20,58.20,N/A,11.16,N/A,11.16,N/A,55.85,N/A,32.98,N/A,9.49,N/A,11.16,N/A,11.16,N/A,11.16,N/A,9.49,N/A,9.49,N/A,9.49,N/A,9.49,N/A,55.85,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,12.28,58.20,58.20,9.49,58.20,,Hospital CPT 86039,HC Antinuclear Ab Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,107.00,83.00,64.20,49.80,N/A,11.16,N/A,11.16,N/A,47.79,N/A,28.22,N/A,9.49,N/A,11.16,N/A,11.16,N/A,11.16,N/A,9.49,N/A,9.49,N/A,9.49,N/A,9.49,N/A,47.79,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,11.16,N/A,12.28,64.20,64.20,9.49,49.80,,Hospital CPT 86052,HC So Aquaporin-4 Antibody Cell-Based Imfluor Assay Ea,N/A,0302 - LABORATORY - IMMUNOLOGY,475.00,475.00,285.00,285.00,N/A,66.50,N/A,12.05,N/A,273.51,N/A,161.50,N/A,12.05,N/A,66.50,N/A,12.05,N/A,12.05,N/A,7.50,N/A,12.05,N/A,12.05,N/A,12.05,N/A,273.51,N/A,12.05,N/A,66.50,N/A,12.05,N/A,12.05,N/A,66.50,N/A,12.05,N/A,12.05,N/A,475.00,285.00,285.00,7.50,475.00,,Hospital 86053,HC So Aquaporin-4 Antibody Flow Cytometry Each,N/A,0302 - LABORATORY - IMMUNOLOGY,150606.90,5829.00,90364.14,3497.40,8375.60,739.86,6679.73,189.98,83014.52,3356.33,51206.35,1981.86,12703.98,1407.47,5589.17,739.86,11448.65,581.86,6679.73,581.86,7908.61,876.18,12703.98,1407.47,12703.98,1407.47,12703.98,1407.47,83014.52,3356.33,6679.73,581.86,5589.17,739.86,14676.82,1431.00,14676.82,1431.00,4247.33,739.86,6679.73,581.86,6679.73,189.98,5980.42,167.48,4247.33,90364.14,167.48,3497.40,,Hospital CPT 86063,HC Aso Screen,N/A,0302 - LABORATORY - IMMUNOLOGY,80.00,80.00,48.00,48.00,N/A,5.77,N/A,5.77,N/A,46.06,N/A,27.20,N/A,4.36,N/A,5.77,N/A,5.77,N/A,5.77,N/A,4.36,N/A,4.36,N/A,4.36,N/A,4.36,N/A,46.06,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,5.77,N/A,6.35,48.00,48.00,4.36,48.00,,Hospital 86077,"Phys Bld Bank Serv,Diff Xmtch",N/A,N/A,N/A,52121.52,N/A,31272.91,N/A,7221.43,N/A,8164.21,N/A,30004.14,N/A,17721.30,N/A,19974.46,N/A,7221.43,N/A,8206.20,N/A,8206.20,N/A,12435.81,N/A,19974.46,N/A,19974.46,N/A,19974.46,N/A,29283.24,N/A,8206.20,N/A,7221.43,N/A,10878.50,N/A,10878.50,N/A,7221.43,N/A,8206.20,N/A,8164.21,N/A,2497.95,N/A,N/A,2497.95,31272.91,,Hospital CPT 86078,HC Transfusion Reaction Report,N/A,0302 - LABORATORY - IMMUNOLOGY,195.00,195.00,117.00,117.00,N/A,27.30,N/A,47.49,N/A,112.28,N/A,66.30,N/A,195.00,N/A,27.30,N/A,142.00,N/A,142.00,N/A,195.00,N/A,195.00,N/A,195.00,N/A,195.00,N/A,112.28,N/A,142.00,N/A,27.30,N/A,152.32,N/A,152.32,N/A,27.30,N/A,142.00,N/A,47.49,N/A,52.24,117.00,117.00,27.30,195.00,,Hospital CPT 86152,HC So Cell Enumeration & ID,N/A,0302 - LABORATORY - IMMUNOLOGY,763.00,763.00,457.80,457.80,N/A,250.78,N/A,250.78,N/A,439.34,N/A,259.42,N/A,250.78,N/A,250.78,N/A,250.78,N/A,250.78,N/A,156.11,N/A,250.78,N/A,250.78,N/A,250.78,N/A,439.34,N/A,250.78,N/A,250.78,N/A,250.78,N/A,250.78,N/A,250.78,N/A,250.78,N/A,250.78,N/A,275.86,457.80,457.80,156.11,457.80,,Hospital CPT 86160,HC Complement C-3/C-4,N/A,0302 - LABORATORY - IMMUNOLOGY,352.00,271.00,211.20,162.60,N/A,12.00,N/A,12.00,N/A,156.04,N/A,92.14,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,10.21,N/A,10.21,N/A,10.21,N/A,10.21,N/A,156.04,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,13.20,211.20,211.20,10.21,162.60,,Hospital CPT 86160,HC So Complement C-3/C-4,N/A,0302 - LABORATORY - IMMUNOLOGY,319.00,319.00,191.40,191.40,N/A,12.00,N/A,12.00,N/A,183.68,N/A,108.46,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,10.21,N/A,10.21,N/A,10.21,N/A,10.21,N/A,183.68,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,13.20,191.40,191.40,10.21,191.40,,Hospital CPT 86161,HC So Esterase Inhibitor,N/A,0302 - LABORATORY - IMMUNOLOGY,113.00,113.00,67.80,67.80,N/A,12.00,N/A,12.00,N/A,65.07,N/A,38.42,N/A,10.21,N/A,12.00,N/A,12.00,N/A,12.00,N/A,10.21,N/A,10.21,N/A,10.21,N/A,10.21,N/A,65.07,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,13.20,67.80,67.80,10.21,67.80,,Hospital CPT 86161,HC Esterase Inhibitor,N/A,0302 - LABORATORY - IMMUNOLOGY,125.00,97.00,75.00,58.20,N/A,12.00,N/A,12.00,N/A,55.85,N/A,32.98,N/A,10.21,N/A,12.00,N/A,12.00,N/A,12.00,N/A,10.21,N/A,10.21,N/A,10.21,N/A,10.21,N/A,55.85,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,12.00,N/A,13.20,75.00,75.00,10.21,58.20,,Hospital CPT 86225,HC Dna Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,164.00,124.00,98.40,74.40,N/A,13.74,N/A,13.74,N/A,71.40,N/A,42.16,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,10.07,N/A,13.74,N/A,10.07,N/A,10.07,N/A,71.40,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,15.11,98.40,98.40,10.07,74.40,,Hospital CPT 86225,HC So Dna Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,148.00,148.00,88.80,88.80,N/A,13.74,N/A,13.74,N/A,85.22,N/A,50.32,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,10.07,N/A,13.74,N/A,10.07,N/A,10.07,N/A,85.22,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,13.74,N/A,15.11,88.80,88.80,10.07,88.80,,Hospital 86231,HC So Endomysial Antibody Each Immunoglobulin Class,N/A,0302 - LABORATORY - IMMUNOLOGY,33885.62,1702.00,20331.37,1021.20,4244.22,172.22,5286.34,185.68,9564.70,980.00,11521.11,578.68,9656.20,148.61,4375.00,172.22,3372.00,185.68,3372.00,185.68,14828.96,148.61,9656.20,148.61,9656.20,148.61,9656.20,148.61,9564.70,980.00,5286.34,185.68,4375.00,172.22,14564.12,180.11,14564.12,180.11,4375.00,172.22,5286.34,185.68,5286.34,185.68,4681.25,184.82,3372.00,20331.37,148.61,1021.20,,Hospital CPT 86255,HC So Anti Striated Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,209.00,209.00,125.40,125.40,N/A,12.05,N/A,12.05,N/A,120.34,N/A,71.06,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,7.50,N/A,4.45,N/A,12.05,N/A,4.45,N/A,120.34,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,13.26,125.40,125.40,4.45,125.40,,Hospital CPT 86255,HC Anti Striated Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,231.00,176.00,138.60,105.60,N/A,12.05,N/A,12.05,N/A,101.34,N/A,59.84,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,7.50,N/A,4.45,N/A,12.05,N/A,4.45,N/A,101.34,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,13.26,138.60,138.60,4.45,105.60,,Hospital CPT 86256,HC Fluor Anti Titer,N/A,0302 - LABORATORY - IMMUNOLOGY,231.00,176.00,138.60,105.60,N/A,12.05,N/A,12.05,N/A,101.34,N/A,59.84,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,9.14,N/A,9.14,N/A,9.14,N/A,9.14,N/A,101.34,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,12.05,N/A,13.26,138.60,138.60,9.14,105.60,,Hospital 86258,HC So Dgp Antibody Each Ig Class,N/A,0302 - LABORATORY - IMMUNOLOGY,28778.82,1362.00,17267.29,817.20,4201.55,112.87,5235.86,131.44,9468.53,784.23,9784.80,463.08,9559.10,131.44,4371.05,112.87,2248.00,131.44,2248.00,131.44,5950.32,81.82,9559.10,131.44,9559.10,131.44,9559.10,131.44,9468.53,784.23,5235.86,131.44,4331.00,112.87,11372.94,124.83,11372.94,124.83,4331.00,112.87,5235.86,131.44,5235.86,131.44,4634.17,86.59,2248.00,17267.29,81.82,817.20,,Hospital CPT 86300,"HC So Ca 15-3, (27.29)",N/A,0302 - LABORATORY - IMMUNOLOGY,231.00,231.00,138.60,138.60,N/A,20.81,N/A,20.81,N/A,133.01,N/A,78.54,N/A,17.69,N/A,20.81,N/A,20.81,N/A,20.81,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,133.01,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,138.60,138.60,17.69,138.60,,Hospital CPT 86300,"HC Ca 15-3, (27.29)",N/A,0302 - LABORATORY - IMMUNOLOGY,255.00,195.00,153.00,117.00,N/A,20.81,N/A,20.81,N/A,112.28,N/A,66.30,N/A,17.69,N/A,20.81,N/A,20.81,N/A,20.81,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,112.28,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,153.00,153.00,17.69,117.00,,Hospital CPT 86305,HC So Human Epididymis Prot 4 (He4),N/A,0302 - LABORATORY - IMMUNOLOGY,313.00,313.00,187.80,187.80,N/A,20.81,N/A,20.81,N/A,180.23,N/A,106.42,N/A,17.69,N/A,20.81,N/A,20.81,N/A,20.81,N/A,17.69,N/A,17.69,N/A,17.69,N/A,17.69,N/A,180.23,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,187.80,187.80,17.69,187.80,,Hospital CPT 86316,HC So Quantitative Enzyme Immunoassy,N/A,0302 - LABORATORY - IMMUNOLOGY,103.00,103.00,61.80,61.80,N/A,20.81,N/A,20.81,N/A,59.31,N/A,35.02,N/A,17.69,N/A,20.81,N/A,20.81,N/A,20.81,N/A,12.95,N/A,20.81,N/A,17.69,N/A,17.69,N/A,59.31,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,61.80,61.80,12.95,61.80,,Hospital CPT 86316,HC Quantitative Enzyme Immunoassy,N/A,0302 - LABORATORY - IMMUNOLOGY,352.00,271.00,211.20,162.60,N/A,20.81,N/A,20.81,N/A,156.04,N/A,92.14,N/A,17.69,N/A,20.81,N/A,20.81,N/A,20.81,N/A,12.95,N/A,20.81,N/A,17.69,N/A,17.69,N/A,156.04,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,20.81,N/A,22.89,211.20,211.20,12.95,162.60,,Hospital 86325,HC So Immunoelectrophoresis; Other Fluids W Concentration,N/A,0302 - LABORATORY - IMMUNOLOGY,78859.40,2572.00,47315.64,1543.20,9193.91,226.62,9399.35,228.52,52925.16,1480.96,66786.64,874.48,66786.64,177.65,9193.91,226.62,9399.35,240.76,9399.35,240.76,66786.64,177.65,66786.64,177.65,66786.64,177.65,66786.64,177.65,52925.16,1480.96,9399.35,232.19,9193.91,226.62,52925.16,226.62,52925.16,226.62,9193.91,226.62,9399.35,232.19,9073.32,232.19,8212.19,249.27,8212.19,66786.64,177.65,1543.20,,Hospital CPT 86331,"HC So Gel Diffusion, Qualitative",N/A,0302 - LABORATORY - IMMUNOLOGY,81.00,81.00,48.60,48.60,N/A,11.98,N/A,11.98,N/A,46.64,N/A,27.54,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.88,N/A,9.88,N/A,9.88,N/A,9.88,N/A,46.64,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,48.60,48.60,9.88,48.60,,Hospital CPT 86331,"HC Gel Diffusion, Qualitative",N/A,0302 - LABORATORY - IMMUNOLOGY,90.00,68.00,54.00,40.80,N/A,11.98,N/A,11.98,N/A,39.15,N/A,23.12,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.88,N/A,9.88,N/A,9.88,N/A,9.88,N/A,39.15,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,54.00,54.00,9.88,40.80,,Hospital CPT 86332,HC Immune Complex,N/A,0302 - LABORATORY - IMMUNOLOGY,236.00,182.00,141.60,109.20,N/A,24.37,N/A,24.37,N/A,104.80,N/A,61.88,N/A,20.71,N/A,24.37,N/A,24.37,N/A,24.37,N/A,20.71,N/A,20.71,N/A,24.37,N/A,20.71,N/A,104.80,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,26.81,141.60,141.60,20.71,109.20,,Hospital CPT 86332,HC So Immune Complex,N/A,0302 - LABORATORY - IMMUNOLOGY,214.00,214.00,128.40,128.40,N/A,24.37,N/A,24.37,N/A,123.22,N/A,72.76,N/A,20.71,N/A,24.37,N/A,24.37,N/A,24.37,N/A,20.71,N/A,20.71,N/A,24.37,N/A,20.71,N/A,123.22,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,24.37,N/A,26.81,128.40,128.40,20.71,128.40,,Hospital CPT 86340,HC Intrinsic Factor Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,146.00,110.00,87.60,66.00,N/A,15.08,N/A,15.08,N/A,63.34,N/A,37.40,N/A,12.81,N/A,15.08,N/A,15.08,N/A,15.08,N/A,12.81,N/A,12.81,N/A,12.81,N/A,12.81,N/A,63.34,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,16.59,87.60,87.60,12.81,66.00,,Hospital CPT 86340,HC So Intrinsic Factor Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,132.00,132.00,79.20,79.20,N/A,15.08,N/A,15.08,N/A,76.01,N/A,44.88,N/A,12.81,N/A,15.08,N/A,15.08,N/A,15.08,N/A,12.81,N/A,12.81,N/A,12.81,N/A,12.81,N/A,76.01,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,15.08,N/A,16.59,79.20,79.20,12.81,79.20,,Hospital CPT 86341,HC So Islet Cell Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,133.00,133.00,79.80,79.80,N/A,23.57,N/A,23.57,N/A,76.58,N/A,45.22,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,14.67,N/A,23.57,N/A,16.81,N/A,16.81,N/A,76.58,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,25.93,79.80,79.80,14.67,79.80,,Hospital CPT 86341,HC Islet Cell Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,147.00,113.00,88.20,67.80,N/A,23.57,N/A,23.57,N/A,65.07,N/A,38.42,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,14.67,N/A,23.57,N/A,16.81,N/A,16.81,N/A,65.07,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,23.57,N/A,25.93,88.20,88.20,14.67,67.80,,Hospital 86343,HC So Leukocyte Histamine Release,N/A,0302 - LABORATORY - IMMUNOLOGY,N/A,2397.00,N/A,1438.20,N/A,261.90,N/A,267.47,N/A,1380.22,N/A,813.27,N/A,212.85,N/A,261.90,N/A,267.47,N/A,267.47,N/A,212.85,N/A,212.85,N/A,212.85,N/A,212.85,N/A,1380.22,N/A,267.47,N/A,261.90,N/A,261.90,N/A,261.90,N/A,261.90,N/A,267.47,N/A,267.47,N/A,288.08,N/A,N/A,212.85,1438.20,,Hospital CPT 86352,HC So1 Cellular Stim for Biomarker,N/A,0302 - LABORATORY - IMMUNOLOGY,981.00,981.00,588.60,588.60,N/A,135.86,N/A,135.86,N/A,564.86,N/A,333.54,N/A,115.46,N/A,135.86,N/A,135.86,N/A,135.86,N/A,115.46,N/A,115.46,N/A,115.46,N/A,115.46,N/A,564.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,149.45,588.60,588.60,115.46,588.60,,Hospital CPT 86352,HC So Cellular Stim for Biomarker,N/A,0302 - LABORATORY - IMMUNOLOGY,981.00,981.00,588.60,588.60,N/A,135.86,N/A,135.86,N/A,564.86,N/A,333.54,N/A,115.46,N/A,135.86,N/A,135.86,N/A,135.86,N/A,115.46,N/A,115.46,N/A,115.46,N/A,115.46,N/A,564.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,149.45,588.60,588.60,115.46,588.60,,Hospital CPT 86352,HC Cell Function Assay W/ Stimul,N/A,0302 - LABORATORY - IMMUNOLOGY,1083.00,826.00,649.80,495.60,N/A,135.86,N/A,135.86,N/A,475.61,N/A,280.84,N/A,115.46,N/A,135.86,N/A,135.86,N/A,135.86,N/A,115.46,N/A,115.46,N/A,115.46,N/A,115.46,N/A,475.61,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,135.86,N/A,149.45,649.80,649.80,115.46,495.60,,Hospital CPT 86359,HC So T Cell Total,N/A,0302 - LABORATORY - IMMUNOLOGY,120.00,120.00,72.00,72.00,N/A,37.73,N/A,37.73,N/A,69.10,N/A,40.80,N/A,32.06,N/A,37.73,N/A,37.73,N/A,37.73,N/A,32.06,N/A,32.06,N/A,32.06,N/A,32.06,N/A,69.10,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,41.50,72.00,72.00,32.06,72.00,,Hospital CPT 86359,HC T-Cells Total Count,N/A,0302 - LABORATORY - IMMUNOLOGY,342.00,261.00,205.20,156.60,N/A,37.73,N/A,37.73,N/A,150.28,N/A,88.74,N/A,32.06,N/A,37.73,N/A,37.73,N/A,37.73,N/A,32.06,N/A,32.06,N/A,32.06,N/A,32.06,N/A,150.28,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,37.73,N/A,41.50,205.20,205.20,32.06,156.60,,Hospital CPT 86361,"HC T Cells, Absolute Cd4 Count",N/A,0302 - LABORATORY - IMMUNOLOGY,245.00,187.00,147.00,112.20,N/A,26.78,N/A,26.78,N/A,107.67,N/A,63.58,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,22.75,N/A,26.78,N/A,22.75,N/A,22.75,N/A,107.67,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,29.46,147.00,147.00,22.75,112.20,,Hospital CPT 86361,HC So T Helper Cell Cd4,N/A,0302 - LABORATORY - IMMUNOLOGY,221.00,221.00,132.60,132.60,N/A,26.78,N/A,26.78,N/A,127.25,N/A,75.14,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,22.75,N/A,26.78,N/A,22.75,N/A,22.75,N/A,127.25,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,26.78,N/A,29.46,132.60,132.60,22.75,132.60,,Hospital 86364,HC So Tiss Trnsgltmnase Ea Ig Clas,N/A,0302 - LABORATORY - IMMUNOLOGY,35143.52,1762.00,21086.11,1057.20,4201.55,231.34,5235.86,150.92,9468.53,1014.54,11948.79,599.08,9559.10,233.46,4331.00,231.34,2248.00,96.52,2248.00,96.52,5950.32,145.34,9559.10,233.46,9559.10,233.46,9559.10,233.46,9468.53,1014.54,5235.86,96.52,4331.00,231.34,11372.94,688.37,11372.94,688.37,4331.00,231.34,5235.86,96.52,5235.86,150.92,4634.17,94.71,2248.00,21086.11,94.71,1057.20,,Hospital 86367,HC So Stem Cells Total Count,N/A,0302 - LABORATORY - IMMUNOLOGY,N/A,24621.83,N/A,14773.10,N/A,3308.23,N/A,485.69,N/A,14025.57,N/A,8371.43,N/A,7200.56,N/A,3308.23,N/A,2690.13,N/A,2690.13,N/A,4482.47,N/A,7200.56,N/A,7200.56,N/A,7200.56,N/A,13894.86,N/A,2690.13,N/A,3308.23,N/A,4562.00,N/A,4562.00,N/A,3308.23,N/A,2690.13,N/A,485.69,N/A,534.28,N/A,N/A,485.69,14773.10,,Hospital CPT 86376,HC So Microsomal Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,183.00,183.00,109.80,109.80,N/A,14.55,N/A,14.55,N/A,105.37,N/A,62.22,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,12.37,N/A,12.37,N/A,12.37,N/A,12.37,N/A,105.37,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,16.01,109.80,109.80,12.37,109.80,,Hospital CPT 86376,HC Microsomal Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,203.00,152.00,121.80,91.20,N/A,14.55,N/A,14.55,N/A,87.52,N/A,51.68,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,12.37,N/A,12.37,N/A,12.37,N/A,12.37,N/A,87.52,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,14.55,N/A,16.01,121.80,121.80,12.37,91.20,,Hospital 86381,HC So Mitochondrial Ab Each,N/A,0302 - LABORATORY - IMMUNOLOGY,64326.67,2249.00,38596.00,1349.40,5950.35,230.08,6827.38,251.61,14571.79,1294.97,21871.07,764.66,18408.59,180.80,5717.85,230.08,6827.38,251.61,12748.14,251.61,7855.69,180.80,12620.05,180.80,12620.05,180.80,18408.59,180.80,12500.48,1294.97,6827.38,251.61,5717.85,230.08,15014.71,246.04,15014.71,246.04,5950.35,230.08,6827.38,251.61,6827.38,251.61,6118.10,202.89,5717.85,38596.00,180.80,1349.40,,Hospital CPT 86382,HC So Neutralization Test,N/A,0302 - LABORATORY - IMMUNOLOGY,163.00,163.00,97.80,97.80,N/A,16.91,N/A,16.91,N/A,93.86,N/A,55.42,N/A,16.91,N/A,16.91,N/A,16.91,N/A,16.91,N/A,10.53,N/A,16.91,N/A,14.37,N/A,16.91,N/A,93.86,N/A,16.91,N/A,16.91,N/A,16.91,N/A,16.91,N/A,16.91,N/A,16.91,N/A,16.91,N/A,18.60,97.80,97.80,10.53,97.80,,Hospital CPT 86431,HC Ra Titer Quantitative,N/A,0302 - LABORATORY - IMMUNOLOGY,54.00,42.00,32.40,25.20,N/A,5.67,N/A,5.67,N/A,24.18,N/A,14.28,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,3.53,N/A,4.82,N/A,4.82,N/A,4.82,N/A,24.18,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,6.24,32.40,32.40,3.53,25.20,,Hospital CPT 86431,"HC So Ra Titer, Quantitative",N/A,0302 - LABORATORY - IMMUNOLOGY,48.00,48.00,28.80,28.80,N/A,5.67,N/A,5.67,N/A,27.64,N/A,16.32,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,3.53,N/A,4.82,N/A,4.82,N/A,4.82,N/A,27.64,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,5.67,N/A,6.24,28.80,28.80,3.53,28.80,,Hospital CPT 86480,"HC TB Test, Cell Immun Measure",N/A,0302 - LABORATORY - IMMUNOLOGY,502.00,384.00,301.20,230.40,N/A,61.98,N/A,61.98,N/A,221.11,N/A,130.56,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,38.58,N/A,61.98,N/A,61.98,N/A,61.98,N/A,221.11,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,68.18,301.20,301.20,38.58,230.40,,Hospital CPT 86480,"HC So TB Test, Cell Immun Measure",N/A,0302 - LABORATORY - IMMUNOLOGY,455.00,455.00,273.00,273.00,N/A,61.98,N/A,61.98,N/A,261.99,N/A,154.70,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,38.58,N/A,61.98,N/A,61.98,N/A,61.98,N/A,261.99,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,61.98,N/A,68.18,273.00,273.00,38.58,273.00,,Hospital CPT 86481,HC So TB Test Tcell Enumeration,N/A,0302 - LABORATORY - IMMUNOLOGY,257.00,257.00,154.20,154.20,N/A,100.00,N/A,100.00,N/A,147.98,N/A,87.38,N/A,52.67,N/A,100.00,N/A,100.00,N/A,100.00,N/A,52.67,N/A,100.00,N/A,52.67,N/A,52.67,N/A,147.98,N/A,100.00,N/A,100.00,N/A,100.00,N/A,100.00,N/A,100.00,N/A,100.00,N/A,100.00,N/A,110.00,154.20,154.20,52.67,154.20,,Hospital CPT 86580,HC TB Intradermal Test,N/A,0302 - LABORATORY - IMMUNOLOGY,41.00,30.00,24.60,18.00,N/A,7.41,N/A,9.31,N/A,17.27,N/A,10.20,N/A,30.00,N/A,7.41,N/A,22.54,N/A,22.54,N/A,30.00,N/A,30.00,N/A,30.00,N/A,30.00,N/A,17.27,N/A,22.54,N/A,7.41,N/A,25.23,N/A,25.23,N/A,7.41,N/A,22.54,N/A,9.31,N/A,8.15,24.60,24.60,7.41,30.00,,Hospital 86602,HC So Antinomyces Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,50244.83,3608.00,30146.90,2164.80,5247.13,356.62,6532.04,371.46,11824.84,2077.47,17083.24,1226.72,11937.95,371.46,5408.81,356.62,147244.00,371.46,147244.00,371.46,7431.10,231.23,11937.95,371.46,11937.95,371.46,11937.95,371.46,11824.84,2077.47,6472.74,371.46,5408.81,356.62,14203.18,365.89,14203.18,365.89,5408.81,356.62,6472.74,371.46,6532.04,371.46,5787.42,362.74,5247.13,147244.00,231.23,2164.80,,Hospital CPT 86606,HC So Aspergillus Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,89.00,89.00,53.40,53.40,N/A,15.05,N/A,15.05,N/A,51.25,N/A,30.26,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,51.25,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,53.40,53.40,12.80,53.40,,Hospital CPT 86606,HC Aspergillus Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,99.00,76.00,59.40,45.60,N/A,15.05,N/A,15.05,N/A,43.76,N/A,25.84,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,12.80,N/A,12.80,N/A,12.80,N/A,12.80,N/A,43.76,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,15.05,N/A,16.56,59.40,59.40,12.80,45.60,,Hospital CPT 86609,HC So Bacterium Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,137.00,137.00,82.20,82.20,N/A,12.88,N/A,12.88,N/A,78.88,N/A,46.58,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,8.02,N/A,12.88,N/A,12.88,N/A,12.88,N/A,78.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,82.20,82.20,8.02,82.20,,Hospital CPT 86609,HC Pnemococcal Antibody Each,N/A,0302 - LABORATORY - IMMUNOLOGY,137.00,137.00,82.20,82.20,N/A,12.88,N/A,12.88,N/A,78.88,N/A,46.58,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,8.02,N/A,12.88,N/A,12.88,N/A,12.88,N/A,78.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,12.88,N/A,14.17,82.20,82.20,8.02,82.20,,Hospital CPT 86611,HC So Bartonella Henselae,N/A,0302 - LABORATORY - IMMUNOLOGY,133.00,133.00,79.80,79.80,N/A,10.18,N/A,10.18,N/A,76.58,N/A,45.22,N/A,8.65,N/A,10.18,N/A,10.18,N/A,10.18,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,76.58,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,11.20,79.80,79.80,8.65,79.80,,Hospital CPT 86611,HC Bartonella Henselae,N/A,0302 - LABORATORY - IMMUNOLOGY,147.00,113.00,88.20,67.80,N/A,10.18,N/A,10.18,N/A,65.07,N/A,38.42,N/A,8.65,N/A,10.18,N/A,10.18,N/A,10.18,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,65.07,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,11.20,88.20,88.20,8.65,67.80,,Hospital CPT 86615,HC Bordetella,N/A,0302 - LABORATORY - IMMUNOLOGY,159.00,121.00,95.40,72.60,N/A,13.19,N/A,13.19,N/A,69.67,N/A,41.14,N/A,11.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,11.21,N/A,11.21,N/A,11.21,N/A,11.21,N/A,69.67,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,95.40,95.40,11.21,72.60,,Hospital CPT 86615,HC So Bordetella,N/A,0302 - LABORATORY - IMMUNOLOGY,143.00,143.00,85.80,85.80,N/A,13.19,N/A,13.19,N/A,82.34,N/A,48.62,N/A,11.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,11.21,N/A,11.21,N/A,11.21,N/A,11.21,N/A,82.34,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,85.80,85.80,11.21,85.80,,Hospital CPT 86622,HC Brucella Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,140.00,107.00,84.00,64.20,N/A,8.93,N/A,8.93,N/A,61.61,N/A,36.38,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,5.56,N/A,8.93,N/A,8.93,N/A,8.93,N/A,61.61,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,9.82,84.00,84.00,5.56,64.20,,Hospital CPT 86622,HC So Brucella Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,126.00,126.00,75.60,75.60,N/A,8.93,N/A,8.93,N/A,72.55,N/A,42.84,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,5.56,N/A,8.93,N/A,8.93,N/A,8.93,N/A,72.55,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,8.93,N/A,9.82,75.60,75.60,5.56,75.60,,Hospital CPT 86631,HC So Chlamydia Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,48.00,48.00,28.80,28.80,N/A,11.82,N/A,11.82,N/A,27.64,N/A,16.32,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,7.36,N/A,11.82,N/A,10.05,N/A,11.82,N/A,27.64,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,13.00,28.80,28.80,7.36,28.80,,Hospital CPT 86631,HC Chlamydia Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,54.00,54.00,32.40,32.40,N/A,11.82,N/A,11.82,N/A,31.09,N/A,18.36,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,7.36,N/A,11.82,N/A,10.05,N/A,11.82,N/A,31.09,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,11.82,N/A,13.00,32.40,32.40,7.36,32.40,,Hospital CPT 86632,"HC Chlamydia, Ab, Igm",N/A,0302 - LABORATORY - IMMUNOLOGY,121.00,92.00,72.60,55.20,N/A,12.68,N/A,12.68,N/A,52.97,N/A,31.28,N/A,10.78,N/A,12.68,N/A,12.68,N/A,12.68,N/A,10.78,N/A,10.78,N/A,10.78,N/A,10.78,N/A,52.97,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,13.95,72.60,72.60,10.78,55.20,,Hospital CPT 86632,"HC So Chlamydia, Ab, Igm",N/A,0302 - LABORATORY - IMMUNOLOGY,109.00,109.00,65.40,65.40,N/A,12.68,N/A,12.68,N/A,62.76,N/A,37.06,N/A,10.78,N/A,12.68,N/A,12.68,N/A,12.68,N/A,10.78,N/A,10.78,N/A,10.78,N/A,10.78,N/A,62.76,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,12.68,N/A,13.95,65.40,65.40,10.78,65.40,,Hospital CPT 86635,HC So Coccidioides,N/A,0302 - LABORATORY - IMMUNOLOGY,89.00,89.00,53.40,53.40,N/A,11.47,N/A,11.47,N/A,51.25,N/A,30.26,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,9.75,N/A,9.75,N/A,9.75,N/A,9.75,N/A,51.25,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,12.62,53.40,53.40,9.75,53.40,,Hospital CPT 86635,HC Coccidioides,N/A,0302 - LABORATORY - IMMUNOLOGY,99.00,76.00,59.40,45.60,N/A,11.47,N/A,11.47,N/A,43.76,N/A,25.84,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,9.75,N/A,9.75,N/A,9.75,N/A,9.75,N/A,43.76,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,11.47,N/A,12.62,59.40,59.40,9.75,45.60,,Hospital 86641,HC Cryptococcus Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,67580.20,2494.00,40548.12,1496.40,10141.65,249.51,12262.69,255.08,22855.02,1436.06,22977.27,847.96,23073.65,210.09,10454.13,249.51,3934.00,255.08,3934.00,255.08,N/A,210.09,23073.65,210.09,N/A,210.09,23073.65,210.09,22855.02,1436.06,12262.69,255.08,10454.13,249.51,27451.88,249.51,27451.88,249.51,6800.44,249.51,12262.69,255.08,12262.69,255.08,11185.92,274.49,3934.00,40548.12,210.09,1496.40,,Hospital CPT 86644,"HC Cytomegalovirus, Igg Antibody",N/A,0302 - LABORATORY - IMMUNOLOGY,317.00,240.00,190.20,144.00,N/A,14.39,N/A,14.39,N/A,138.19,N/A,81.60,N/A,12.23,N/A,14.39,N/A,14.39,N/A,14.39,N/A,12.23,N/A,12.23,N/A,14.39,N/A,12.23,N/A,138.19,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,190.20,190.20,12.23,144.00,,Hospital CPT 86644,"HC So Cytomegalovirus, Igg Antibody",N/A,0302 - LABORATORY - IMMUNOLOGY,287.00,287.00,172.20,172.20,N/A,14.39,N/A,14.39,N/A,165.25,N/A,97.58,N/A,12.23,N/A,14.39,N/A,14.39,N/A,14.39,N/A,12.23,N/A,12.23,N/A,14.39,N/A,12.23,N/A,165.25,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,172.20,172.20,12.23,172.20,,Hospital 86648,HC So Diphtheria Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,N/A,729.00,N/A,437.40,N/A,94.99,N/A,100.56,N/A,419.76,N/A,247.86,N/A,83.17,N/A,94.99,N/A,100.56,N/A,100.56,N/A,83.17,N/A,83.17,N/A,83.17,N/A,83.17,N/A,419.76,N/A,100.56,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,100.56,N/A,100.56,N/A,104.49,N/A,N/A,83.17,437.40,,Hospital CPT 86653,"HC So Encephalitis, St.Louis",N/A,0302 - LABORATORY - IMMUNOLOGY,183.00,183.00,109.80,109.80,N/A,13.19,N/A,13.19,N/A,105.37,N/A,62.22,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,105.37,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,109.80,109.80,8.21,109.80,,Hospital CPT 86653,"HC Encephalitis, St.Louis",N/A,0302 - LABORATORY - IMMUNOLOGY,203.00,152.00,121.80,91.20,N/A,13.19,N/A,13.19,N/A,87.52,N/A,51.68,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,87.52,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,121.80,121.80,8.21,91.20,,Hospital CPT 86654,"HC So Encephalitis, Western Equine",N/A,0302 - LABORATORY - IMMUNOLOGY,183.00,183.00,109.80,109.80,N/A,13.19,N/A,13.19,N/A,105.37,N/A,62.22,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,105.37,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,109.80,109.80,8.21,109.80,,Hospital CPT 86654,"HC Encephalitis, Western Equine",N/A,0302 - LABORATORY - IMMUNOLOGY,203.00,152.00,121.80,91.20,N/A,13.19,N/A,13.19,N/A,87.52,N/A,51.68,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,87.52,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,121.80,121.80,8.21,91.20,,Hospital CPT 86658,HC So Enterovirus,N/A,0302 - LABORATORY - IMMUNOLOGY,95.00,95.00,57.00,57.00,N/A,13.03,N/A,13.03,N/A,54.70,N/A,32.30,N/A,11.08,N/A,13.03,N/A,13.03,N/A,13.03,N/A,8.11,N/A,13.03,N/A,11.08,N/A,11.08,N/A,54.70,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,14.33,57.00,57.00,8.11,57.00,,Hospital CPT 86658,HC Enterovirus,N/A,0302 - LABORATORY - IMMUNOLOGY,105.00,79.00,63.00,47.40,N/A,13.03,N/A,13.03,N/A,45.49,N/A,26.86,N/A,11.08,N/A,13.03,N/A,13.03,N/A,13.03,N/A,8.11,N/A,13.03,N/A,11.08,N/A,11.08,N/A,45.49,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,13.03,N/A,14.33,63.00,63.00,8.11,47.40,,Hospital CPT 86665,HC So Epstein-Barr Virus Vca,N/A,0302 - LABORATORY - IMMUNOLOGY,389.00,389.00,233.40,233.40,N/A,18.14,N/A,18.14,N/A,223.99,N/A,132.26,N/A,15.41,N/A,18.14,N/A,18.14,N/A,18.14,N/A,15.41,N/A,15.41,N/A,15.41,N/A,15.41,N/A,223.99,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,19.95,233.40,233.40,15.41,233.40,,Hospital CPT 86665,HC Epstein-Barr Virus Vca,N/A,0302 - LABORATORY - IMMUNOLOGY,429.00,429.00,257.40,257.40,N/A,18.14,N/A,18.14,N/A,247.02,N/A,145.86,N/A,15.41,N/A,18.14,N/A,18.14,N/A,18.14,N/A,15.41,N/A,15.41,N/A,15.41,N/A,15.41,N/A,247.02,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,18.14,N/A,19.95,257.40,257.40,15.41,257.40,,Hospital CPT 86666,HC Ehrlichia Chaffeensis Igg /Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,88.00,66.00,52.80,39.60,N/A,10.18,N/A,10.18,N/A,38.00,N/A,22.44,N/A,8.65,N/A,10.18,N/A,10.18,N/A,10.18,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,38.00,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,11.20,52.80,52.80,8.65,39.60,,Hospital CPT 86666,HC So Ehrlichia Chaffeensis Igg /Igm,N/A,0302 - LABORATORY - IMMUNOLOGY,80.00,80.00,48.00,48.00,N/A,10.18,N/A,10.18,N/A,46.06,N/A,27.20,N/A,8.65,N/A,10.18,N/A,10.18,N/A,10.18,N/A,8.65,N/A,8.65,N/A,8.65,N/A,8.65,N/A,46.06,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,10.18,N/A,11.20,48.00,48.00,8.65,48.00,,Hospital CPT 86668,HC So Francisella Tularensis Ab Det,N/A,0302 - LABORATORY - IMMUNOLOGY,146.00,146.00,87.60,87.60,N/A,14.16,N/A,14.16,N/A,84.07,N/A,49.64,N/A,14.16,N/A,14.16,N/A,14.16,N/A,14.16,N/A,8.81,N/A,14.16,N/A,14.16,N/A,14.16,N/A,84.07,N/A,14.16,N/A,14.16,N/A,14.16,N/A,14.16,N/A,14.16,N/A,14.16,N/A,14.16,N/A,15.58,87.60,87.60,8.81,87.60,,Hospital CPT 86674,HC So Giardia Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,107.00,107.00,64.20,64.20,N/A,14.72,N/A,14.72,N/A,61.61,N/A,36.38,N/A,12.51,N/A,14.72,N/A,14.72,N/A,14.72,N/A,12.51,N/A,12.51,N/A,12.51,N/A,12.51,N/A,61.61,N/A,14.72,N/A,14.72,N/A,14.72,N/A,14.72,N/A,14.72,N/A,14.72,N/A,14.72,N/A,16.19,64.20,64.20,12.51,64.20,,Hospital CPT 86677,HC H.Pylori. Serum,N/A,0302 - LABORATORY - IMMUNOLOGY,373.00,284.00,223.80,170.40,N/A,16.85,N/A,16.85,N/A,163.53,N/A,96.56,N/A,12.34,N/A,16.85,N/A,16.85,N/A,16.85,N/A,12.34,N/A,12.34,N/A,12.34,N/A,12.34,N/A,163.53,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,18.54,223.80,223.80,12.34,170.40,,Hospital CPT 86677,HC So H.Pylori. Serum,N/A,0302 - LABORATORY - IMMUNOLOGY,338.00,338.00,202.80,202.80,N/A,16.85,N/A,16.85,N/A,194.62,N/A,114.92,N/A,12.34,N/A,16.85,N/A,16.85,N/A,16.85,N/A,12.34,N/A,12.34,N/A,12.34,N/A,12.34,N/A,194.62,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,18.54,202.80,202.80,12.34,202.80,,Hospital CPT 86687,HC Htlv1,N/A,0302 - LABORATORY - IMMUNOLOGY,58.00,58.00,34.80,34.80,N/A,9.09,N/A,9.09,N/A,33.40,N/A,19.72,N/A,7.13,N/A,9.09,N/A,9.09,N/A,9.09,N/A,7.13,N/A,7.13,N/A,7.13,N/A,7.13,N/A,33.40,N/A,9.09,N/A,9.09,N/A,9.09,N/A,9.09,N/A,9.09,N/A,9.09,N/A,9.09,N/A,10.00,34.80,34.80,7.13,34.80,,Hospital CPT 86692,HC So Hepatitis Delta Agent Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,23.00,23.00,13.80,13.80,N/A,17.16,N/A,17.16,N/A,13.24,N/A,7.82,N/A,14.59,N/A,17.16,N/A,17.16,N/A,17.16,N/A,14.59,N/A,14.59,N/A,14.59,N/A,14.59,N/A,13.24,N/A,17.16,N/A,17.16,N/A,17.16,N/A,17.16,N/A,17.16,N/A,17.16,N/A,17.16,N/A,18.88,13.80,13.80,7.82,18.88,,Hospital CPT 86703,HC Antibody Hiv 1 & Hiv 2 Assay,N/A,0302 - LABORATORY - IMMUNOLOGY,306.00,232.00,183.60,139.20,N/A,13.71,N/A,13.71,N/A,133.59,N/A,78.88,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,11.66,N/A,11.66,N/A,11.66,N/A,11.66,N/A,133.59,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,15.08,183.60,183.60,11.66,139.20,,Hospital CPT 86703,"HC So Antibody,Hiv 1 & Hiv 2, Assay",N/A,0302 - LABORATORY - IMMUNOLOGY,277.00,277.00,166.20,166.20,N/A,13.71,N/A,13.71,N/A,159.50,N/A,94.18,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,11.66,N/A,11.66,N/A,11.66,N/A,11.66,N/A,159.50,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,13.71,N/A,15.08,166.20,166.20,11.66,166.20,,Hospital CPT 86708,HC So Hepatitis a Antibody (Total),N/A,0302 - LABORATORY - IMMUNOLOGY,155.00,155.00,93.00,93.00,N/A,12.39,N/A,12.39,N/A,89.25,N/A,52.70,N/A,10.53,N/A,12.39,N/A,12.39,N/A,12.39,N/A,10.53,N/A,10.53,N/A,10.53,N/A,12.39,N/A,89.25,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,13.63,93.00,93.00,10.53,93.00,,Hospital CPT 86708,HC Hepatitis a Antibody (Total),N/A,0302 - LABORATORY - IMMUNOLOGY,171.00,131.00,102.60,78.60,N/A,12.39,N/A,12.39,N/A,75.43,N/A,44.54,N/A,10.53,N/A,12.39,N/A,12.39,N/A,12.39,N/A,10.53,N/A,10.53,N/A,10.53,N/A,12.39,N/A,75.43,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,13.63,102.60,102.60,10.53,78.60,,Hospital CPT 86709,"HC So Hepatitis, a Igm Anitbody",N/A,0302 - LABORATORY - IMMUNOLOGY,106.00,106.00,63.60,63.60,N/A,11.26,N/A,11.26,N/A,61.03,N/A,36.04,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,9.57,N/A,11.26,N/A,9.57,N/A,11.26,N/A,61.03,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,12.39,63.60,63.60,9.57,63.60,,Hospital CPT 86709,"HC Hepatitis, a Igm Anitbody",N/A,0302 - LABORATORY - IMMUNOLOGY,118.00,90.00,70.80,54.00,N/A,11.26,N/A,11.26,N/A,51.82,N/A,30.60,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,9.57,N/A,11.26,N/A,9.57,N/A,11.26,N/A,51.82,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,11.26,N/A,12.39,70.80,70.80,9.57,54.00,,Hospital CPT 86711,HC So John Cunningham Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,200.00,200.00,120.00,120.00,N/A,16.89,N/A,16.89,N/A,115.16,N/A,68.00,N/A,19.79,N/A,16.89,N/A,16.89,N/A,16.89,N/A,19.79,N/A,19.79,N/A,19.79,N/A,19.79,N/A,115.16,N/A,16.89,N/A,16.89,N/A,16.89,N/A,16.89,N/A,16.89,N/A,16.89,N/A,16.89,N/A,18.58,120.00,120.00,16.89,120.00,,Hospital CPT 86720,HC Leptospira Ab's,N/A,0302 - LABORATORY - IMMUNOLOGY,166.00,124.00,99.60,74.40,N/A,16.20,N/A,16.20,N/A,71.40,N/A,42.16,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,10.08,N/A,16.20,N/A,16.20,N/A,16.20,N/A,71.40,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,17.82,99.60,99.60,10.08,74.40,,Hospital CPT 86720,HC So Leptospira Ab's,N/A,0302 - LABORATORY - IMMUNOLOGY,150.00,150.00,90.00,90.00,N/A,16.20,N/A,16.20,N/A,86.37,N/A,51.00,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,10.08,N/A,16.20,N/A,16.20,N/A,16.20,N/A,86.37,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,17.82,90.00,90.00,10.08,90.00,,Hospital CPT 86723,HC Listeria Monocytogenes Ab,N/A,0302 - LABORATORY - IMMUNOLOGY,191.00,191.00,114.60,114.60,N/A,13.19,N/A,13.19,N/A,109.98,N/A,64.94,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,8.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,109.98,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,114.60,114.60,8.21,114.60,,Hospital CPT 86738,HC Mycoplasma Igg,N/A,0302 - LABORATORY - IMMUNOLOGY,296.00,227.00,177.60,136.20,N/A,13.24,N/A,13.24,N/A,130.71,N/A,77.18,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,8.24,N/A,13.24,N/A,11.26,N/A,11.26,N/A,130.71,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,14.56,177.60,177.60,8.24,136.20,,Hospital CPT 86738,HC So Mycoplasma Igg,N/A,0302 - LABORATORY - IMMUNOLOGY,268.00,268.00,160.80,160.80,N/A,13.24,N/A,13.24,N/A,154.31,N/A,91.12,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,8.24,N/A,13.24,N/A,11.26,N/A,11.26,N/A,154.31,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,13.24,N/A,14.56,160.80,160.80,8.24,160.80,,Hospital CPT 86741,HC So Neisseria Meningitidis,N/A,0302 - LABORATORY - IMMUNOLOGY,85.00,85.00,51.00,51.00,N/A,13.19,N/A,13.19,N/A,48.94,N/A,28.90,N/A,11.21,N/A,13.19,N/A,13.19,N/A,13.19,N/A,11.21,N/A,11.21,N/A,11.21,N/A,11.21,N/A,48.94,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,13.19,N/A,14.51,51.00,51.00,11.21,51.00,,Hospital CPT 86747,HC So Parvo,N/A,0302 - LABORATORY - IMMUNOLOGY,100.00,100.00,60.00,60.00,N/A,15.03,N/A,15.03,N/A,57.58,N/A,34.00,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,9.36,N/A,15.03,N/A,12.78,N/A,15.03,N/A,57.58,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,16.53,60.00,60.00,9.36,60.00,,Hospital CPT 86747,HC Parvo,N/A,0302 - LABORATORY - IMMUNOLOGY,110.00,84.00,66.00,50.40,N/A,15.03,N/A,15.03,N/A,48.37,N/A,28.56,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,9.36,N/A,15.03,N/A,12.78,N/A,15.03,N/A,48.37,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,15.03,N/A,16.53,66.00,66.00,9.36,50.40,,Hospital CPT 86753,HC So Amoebic Antibodies by Iha,N/A,0302 - LABORATORY - IMMUNOLOGY,140.00,140.00,84.00,84.00,N/A,12.39,N/A,12.39,N/A,80.61,N/A,47.60,N/A,10.53,N/A,12.39,N/A,12.39,N/A,12.39,N/A,10.53,N/A,10.53,N/A,10.53,N/A,10.53,N/A,80.61,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,13.63,84.00,84.00,10.53,84.00,,Hospital CPT 86753,HC Amoebic Antibodies by Iha,N/A,0302 - LABORATORY - IMMUNOLOGY,154.00,119.00,92.40,71.40,N/A,12.39,N/A,12.39,N/A,68.52,N/A,40.46,N/A,10.53,N/A,12.39,N/A,12.39,N/A,12.39,N/A,10.53,N/A,10.53,N/A,10.53,N/A,10.53,N/A,68.52,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,12.39,N/A,13.63,92.40,92.40,10.53,71.40,,Hospital CPT 86756,HC So Ab Respiratory Syncytial Virus,N/A,0302 - LABORATORY - IMMUNOLOGY,120.00,120.00,72.00,72.00,N/A,15.89,N/A,15.89,N/A,69.10,N/A,40.80,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,9.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,69.10,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,15.89,N/A,17.48,72.00,72.00,9.89,72.00,,Hospital CPT 86762,HC So Rubella Latex Test,N/A,0302 - LABORATORY - IMMUNOLOGY,238.00,238.00,142.80,142.80,N/A,14.39,N/A,14.39,N/A,137.04,N/A,80.92,N/A,12.23,N/A,14.39,N/A,14.39,N/A,14.39,N/A,12.23,N/A,12.23,N/A,12.23,N/A,12.23,N/A,137.04,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,142.80,142.80,12.23,142.80,,Hospital CPT 86762,HC Rubella Latex Test,N/A,0302 - LABORATORY - IMMUNOLOGY,263.00,201.00,157.80,120.60,N/A,14.39,N/A,14.39,N/A,115.74,N/A,68.34,N/A,12.23,N/A,14.39,N/A,14.39,N/A,14.39,N/A,12.23,N/A,12.23,N/A,12.23,N/A,12.23,N/A,115.74,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,14.39,N/A,15.83,157.80,157.80,12.23,120.60,,Hospital 86774,HC So Tetanus Antibodies,N/A,0302 - LABORATORY - IMMUNOLOGY,N/A,729.00,N/A,437.40,N/A,94.99,N/A,100.56,N/A,419.76,N/A,247.86,N/A,83.17,N/A,94.99,N/A,100.56,N/A,100.56,N/A,83.17,N/A,83.17,N/A,83.17,N/A,83.17,N/A,419.76,N/A,100.56,N/A,94.99,N/A,94.99,N/A,94.99,N/A,94.99,N/A,100.56,N/A,100.56,N/A,104.49,N/A,N/A,83.17,437.40,,Hospital CPT 86784,HC So Trichinosis Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,235.00,235.00,141.00,141.00,N/A,12.56,N/A,12.56,N/A,135.31,N/A,79.90,N/A,12.56,N/A,12.56,N/A,12.56,N/A,12.56,N/A,7.82,N/A,12.56,N/A,12.56,N/A,12.56,N/A,135.31,N/A,12.56,N/A,12.56,N/A,12.56,N/A,12.56,N/A,12.56,N/A,12.56,N/A,12.56,N/A,13.82,141.00,141.00,7.82,141.00,,Hospital CPT 86788,"HC West Nile Ab, Igm",N/A,0302 - LABORATORY - IMMUNOLOGY,149.00,117.00,89.40,70.20,N/A,16.85,N/A,16.85,N/A,67.37,N/A,39.78,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,10.49,N/A,16.85,N/A,14.32,N/A,16.85,N/A,67.37,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,18.54,89.40,89.40,10.49,70.20,,Hospital CPT 86788,"HC So West Nile Ab, Igm",N/A,0302 - LABORATORY - IMMUNOLOGY,135.00,135.00,81.00,81.00,N/A,16.85,N/A,16.85,N/A,77.73,N/A,45.90,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,10.49,N/A,16.85,N/A,14.32,N/A,16.85,N/A,77.73,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,16.85,N/A,18.54,81.00,81.00,10.49,81.00,,Hospital CPT 86800,HC Antithyroglobulin Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,162.00,123.00,97.20,73.80,N/A,15.91,N/A,15.91,N/A,70.82,N/A,41.82,N/A,13.52,N/A,15.91,N/A,15.91,N/A,15.91,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,70.82,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,17.50,97.20,97.20,13.52,73.80,,Hospital CPT 86800,HC So Antithyroglobulin Antibody,N/A,0302 - LABORATORY - IMMUNOLOGY,146.00,146.00,87.60,87.60,N/A,15.91,N/A,15.91,N/A,84.07,N/A,49.64,N/A,13.52,N/A,15.91,N/A,15.91,N/A,15.91,N/A,13.52,N/A,13.52,N/A,13.52,N/A,13.52,N/A,84.07,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,15.91,N/A,17.50,87.60,87.60,13.52,87.60,,Hospital CPT 86817,"HC Hla Typing Dr/Dq, Multiple Ag",N/A,0302 - LABORATORY - IMMUNOLOGY,375.00,375.00,225.00,225.00,N/A,106.14,N/A,106.14,N/A,215.93,N/A,127.50,N/A,106.14,N/A,106.14,N/A,106.14,N/A,106.14,N/A,66.07,N/A,106.14,N/A,106.14,N/A,106.14,N/A,215.93,N/A,106.14,N/A,106.14,N/A,106.14,N/A,106.14,N/A,106.14,N/A,106.14,N/A,106.14,N/A,116.75,225.00,225.00,66.07,225.00,,Hospital CPT 86821,HC So Lymphocyte Culture Mixed,N/A,0302 - LABORATORY - IMMUNOLOGY,90.00,90.00,54.00,54.00,N/A,36.56,N/A,36.56,N/A,51.82,N/A,30.60,N/A,36.56,N/A,36.56,N/A,36.56,N/A,36.56,N/A,22.76,N/A,36.56,N/A,36.56,N/A,36.56,N/A,51.82,N/A,36.56,N/A,36.56,N/A,36.56,N/A,36.56,N/A,36.56,N/A,36.56,N/A,36.56,N/A,40.22,54.00,54.00,22.76,54.00,,Hospital CPT 86830,HC So Hla Class I Phenotype Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,600.00,600.00,360.00,360.00,N/A,95.52,N/A,95.52,N/A,345.48,N/A,204.00,N/A,95.52,N/A,95.52,N/A,95.52,N/A,95.52,N/A,59.46,N/A,95.52,N/A,95.52,N/A,95.52,N/A,345.48,N/A,95.52,N/A,95.52,N/A,95.52,N/A,95.52,N/A,95.52,N/A,95.52,N/A,95.52,N/A,105.07,360.00,360.00,59.46,360.00,,Hospital 86831,HC So Hla Class II Phenotype Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,64781.70,N/A,38869.02,N/A,5869.15,N/A,7208.54,N/A,13295.99,N/A,22025.78,N/A,13872.42,N/A,6049.99,N/A,4496.00,N/A,4496.00,N/A,8635.47,N/A,13872.42,N/A,13872.42,N/A,N/A,N/A,13295.99,N/A,7208.54,N/A,6049.99,N/A,15886.89,N/A,15886.89,N/A,N/A,N/A,7208.54,N/A,7208.54,N/A,6473.49,N/A,4496.00,38869.02,N/A,N/A,,Hospital CPT 86833,HC So Hla Class II High Defin Qual,N/A,0302 - LABORATORY - IMMUNOLOGY,475.00,475.00,285.00,285.00,N/A,325.80,N/A,325.80,N/A,273.51,N/A,161.50,N/A,325.80,N/A,325.80,N/A,325.80,N/A,325.80,N/A,149.70,N/A,325.80,N/A,325.80,N/A,325.80,N/A,273.51,N/A,325.80,N/A,325.80,N/A,325.80,N/A,325.80,N/A,325.80,N/A,325.80,N/A,325.80,N/A,358.38,285.00,285.00,149.70,358.38,,Hospital CPT 86849,HC Unlisted Immunology Procedure,N/A,0302 - LABORATORY - IMMUNOLOGY,242.00,242.00,145.20,145.20,N/A,110.00,N/A,242.00,N/A,139.34,N/A,82.28,N/A,242.00,N/A,110.00,N/A,242.00,N/A,242.00,N/A,242.00,N/A,242.00,N/A,242.00,N/A,242.00,N/A,139.34,N/A,242.00,N/A,110.00,N/A,242.00,N/A,242.00,N/A,110.00,N/A,242.00,N/A,242.00,N/A,121.00,145.20,145.20,82.28,242.00,,Hospital CPT 86880,"HC Coombs,Direct",N/A,0302 - LABORATORY - IMMUNOLOGY,78.00,78.00,46.80,46.80,N/A,5.39,N/A,55.01,N/A,44.91,N/A,26.52,N/A,78.00,N/A,5.39,N/A,51.91,N/A,51.91,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,44.91,N/A,51.91,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,51.91,N/A,54.30,N/A,5.93,46.80,46.80,5.39,78.00,,Hospital CPT 86880,"HC So Coombs,Direct",N/A,0302 - LABORATORY - IMMUNOLOGY,70.00,70.00,42.00,42.00,N/A,5.39,N/A,55.01,N/A,40.31,N/A,23.80,N/A,70.00,N/A,5.39,N/A,51.91,N/A,51.91,N/A,70.00,N/A,70.00,N/A,70.00,N/A,70.00,N/A,40.31,N/A,51.91,N/A,5.39,N/A,5.39,N/A,5.39,N/A,5.39,N/A,51.91,N/A,54.30,N/A,5.93,42.00,42.00,5.39,70.00,,Hospital CPT 86901,"HC Blood Typing, Rh(D)",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,122.00,91.00,73.20,54.60,N/A,2.99,N/A,30.67,N/A,52.40,N/A,30.94,N/A,74.18,N/A,2.99,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,52.40,N/A,30.67,N/A,2.99,N/A,2.99,N/A,2.99,N/A,2.99,N/A,30.67,N/A,30.67,N/A,33.73,73.20,73.20,2.99,74.18,,Hospital CPT 86901,"HC So Blood Typing, Rh(D)",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,110.00,110.00,66.00,66.00,N/A,2.99,N/A,30.67,N/A,63.34,N/A,37.40,N/A,74.18,N/A,2.99,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,63.34,N/A,30.67,N/A,2.99,N/A,2.99,N/A,2.99,N/A,2.99,N/A,30.67,N/A,30.67,N/A,33.73,66.00,66.00,2.99,74.18,,Hospital CPT 86902,HC So Blood Type Antigen Donor Ea,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,235.00,235.00,141.00,141.00,N/A,6.35,N/A,6.35,N/A,135.31,N/A,79.90,N/A,235.00,N/A,6.35,N/A,292.68,N/A,292.68,N/A,235.00,N/A,235.00,N/A,235.00,N/A,235.00,N/A,135.31,N/A,292.68,N/A,6.35,N/A,6.35,N/A,6.35,N/A,6.35,N/A,292.68,N/A,6.35,N/A,6.99,141.00,141.00,6.35,292.68,,Hospital CPT 86902,HC Blood Type Antigen Donor Ea,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,810.00,810.00,486.00,486.00,N/A,6.35,N/A,6.35,N/A,466.40,N/A,275.40,N/A,707.98,N/A,6.35,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,466.40,N/A,292.68,N/A,6.35,N/A,6.35,N/A,6.35,N/A,6.35,N/A,292.68,N/A,6.35,N/A,6.99,486.00,486.00,6.35,707.98,,Hospital CPT 86923,HC Compatibility Test Electric,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,315.00,315.00,189.00,189.00,N/A,44.10,N/A,142.00,N/A,181.38,N/A,107.10,N/A,315.00,N/A,44.10,N/A,142.00,N/A,142.00,N/A,213.84,N/A,315.00,N/A,315.00,N/A,315.00,N/A,181.38,N/A,142.00,N/A,44.10,N/A,152.32,N/A,152.32,N/A,44.10,N/A,142.00,N/A,142.00,N/A,156.20,189.00,189.00,44.10,315.00,,Hospital CPT 86941,HC So Hemolysin Incubated,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,68.00,68.00,40.80,40.80,N/A,12.11,N/A,12.11,N/A,39.15,N/A,23.12,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,7.54,N/A,12.11,N/A,12.11,N/A,12.11,N/A,39.15,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,12.11,N/A,13.32,40.80,40.80,7.54,40.80,,Hospital CPT 86970,HC So1 RBC Pretx Incubatj W/Chemicl,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,290.00,290.00,174.00,174.00,N/A,40.60,N/A,32.50,N/A,166.98,N/A,98.60,N/A,74.18,N/A,40.60,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,166.98,N/A,30.67,N/A,40.60,N/A,34.57,N/A,34.57,N/A,40.60,N/A,30.67,N/A,32.50,N/A,290.00,174.00,174.00,30.67,290.00,,Hospital CPT 86970,HC So2 RBC Pretx Incubatj W/Chemicl,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,435.00,435.00,261.00,261.00,N/A,60.90,N/A,32.50,N/A,250.47,N/A,147.90,N/A,74.18,N/A,60.90,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,250.47,N/A,30.67,N/A,60.90,N/A,34.57,N/A,34.57,N/A,60.90,N/A,30.67,N/A,32.50,N/A,435.00,261.00,261.00,30.67,435.00,,Hospital CPT 86970,HC So RBC Pretx Incubatj W/Chemicl,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,140.00,140.00,84.00,84.00,N/A,19.60,N/A,32.50,N/A,80.61,N/A,47.60,N/A,74.18,N/A,19.60,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,80.61,N/A,30.67,N/A,19.60,N/A,34.57,N/A,34.57,N/A,19.60,N/A,30.67,N/A,32.50,N/A,140.00,84.00,84.00,19.60,140.00,,Hospital 86971,HC Antibody Screen With Enzymes,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,46564.18,N/A,27938.51,N/A,5254.60,N/A,6481.56,N/A,11841.67,N/A,15831.82,N/A,11954.95,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,N/A,N/A,11954.95,N/A,N/A,N/A,11954.95,N/A,11841.67,N/A,6481.56,N/A,5416.50,N/A,14223.40,N/A,14223.40,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,5795.66,N/A,5254.60,27938.51,N/A,N/A,,Hospital CPT 86972,HC So RBC Pretx Incubatj W/Chemicl,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.49,N/A,86.37,N/A,51.00,N/A,150.00,N/A,21.00,N/A,142.00,N/A,142.00,N/A,150.00,N/A,150.00,N/A,150.00,N/A,150.00,N/A,86.37,N/A,142.00,N/A,21.00,N/A,150.00,N/A,150.00,N/A,21.00,N/A,142.00,N/A,150.49,N/A,150.00,90.00,90.00,21.00,150.49,,Hospital CPT 86978,HC So RBC Pretreatment Serum,N/A,0302 - LABORATORY - IMMUNOLOGY,195.00,195.00,117.00,117.00,N/A,27.30,N/A,32.15,N/A,112.28,N/A,66.30,N/A,74.18,N/A,27.30,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,112.28,N/A,30.67,N/A,27.30,N/A,34.57,N/A,34.57,N/A,27.30,N/A,30.67,N/A,195.00,N/A,195.00,117.00,117.00,27.30,195.00,,Hospital 86985,HC Split Blood or Products,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,35535.40,N/A,21321.24,N/A,22533.44,N/A,26921.54,N/A,35359.45,N/A,12082.04,N/A,17948.93,N/A,23227.73,N/A,26921.54,N/A,26921.54,N/A,11172.33,N/A,17948.93,N/A,17948.93,N/A,17948.93,N/A,35359.45,N/A,26921.54,N/A,23227.73,N/A,13000.00,N/A,13000.00,N/A,N/A,N/A,26921.54,N/A,26921.54,N/A,24853.67,N/A,11172.33,35359.45,N/A,N/A,,Hospital CPT 87070,"HC Culture, Aerobic",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,240.00,191.00,144.00,114.60,N/A,8.62,N/A,8.62,N/A,109.98,N/A,64.94,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,5.37,N/A,8.62,N/A,8.62,N/A,8.62,N/A,109.98,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,9.48,144.00,144.00,5.37,114.60,,Hospital CPT 87070,HC So Body Fluid Culture,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,218.00,218.00,130.80,130.80,N/A,8.62,N/A,8.62,N/A,125.52,N/A,74.12,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,5.37,N/A,8.62,N/A,8.62,N/A,8.62,N/A,125.52,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,8.62,N/A,9.48,130.80,130.80,5.37,130.80,,Hospital 87071,HC Culture Aerobic Quant Other,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,187736.60,6354.60,112641.96,3812.76,18929.30,881.33,14092.38,1336.71,154186.81,3657.38,75656.74,2160.57,75656.74,3268.11,18929.30,881.33,14021.02,1343.59,14092.38,1343.59,75656.74,2034.46,75656.74,3268.11,75656.74,3268.11,75656.74,3268.11,154186.81,3657.37,14092.38,1343.59,18929.30,881.33,154186.81,1871.00,154186.81,1871.00,18929.30,881.33,14092.38,1343.59,14092.38,1336.71,18929.30,211.04,14021.02,154186.81,211.04,3812.76,,Hospital CPT 87075,"HC Culture,Anaerobic",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,147.00,118.00,88.20,70.80,N/A,9.47,N/A,9.47,N/A,67.94,N/A,40.12,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,5.90,N/A,9.47,N/A,9.47,N/A,9.47,N/A,67.94,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,9.47,N/A,10.42,88.20,88.20,5.90,70.80,,Hospital CPT 87077,HC Aerobic ID,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,154.00,122.00,92.40,73.20,N/A,8.08,N/A,8.08,N/A,70.25,N/A,41.48,N/A,6.87,N/A,8.08,N/A,8.08,N/A,8.08,N/A,6.87,N/A,6.87,N/A,6.87,N/A,8.08,N/A,70.25,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.89,92.40,92.40,6.87,73.20,,Hospital CPT 87077,HC So Culture Aerobic Identify,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,140.00,140.00,84.00,84.00,N/A,8.08,N/A,8.08,N/A,80.61,N/A,47.60,N/A,6.87,N/A,8.08,N/A,8.08,N/A,8.08,N/A,6.87,N/A,6.87,N/A,6.87,N/A,8.08,N/A,80.61,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.08,N/A,8.89,84.00,84.00,6.87,84.00,,Hospital CPT 87081,"HC So Cult,Pathognic Orgnsms,Screen",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,97.00,97.00,58.20,58.20,N/A,6.63,N/A,6.63,N/A,55.85,N/A,32.98,N/A,5.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,5.63,N/A,6.63,N/A,5.63,N/A,5.63,N/A,55.85,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,7.29,58.20,58.20,5.63,58.20,,Hospital CPT 87081,"HC Cult,Pathognic Orgnsms,Screen",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,107.00,85.00,64.20,51.00,N/A,6.63,N/A,6.63,N/A,48.94,N/A,28.90,N/A,5.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,5.63,N/A,6.63,N/A,5.63,N/A,5.63,N/A,48.94,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,6.63,N/A,7.29,64.20,64.20,5.63,51.00,,Hospital CPT 87088,HC Cult Urine W ID Isolates,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,276.00,276.00,165.60,165.60,N/A,8.09,N/A,8.09,N/A,158.92,N/A,93.84,N/A,6.88,N/A,8.09,N/A,8.09,N/A,8.09,N/A,5.04,N/A,6.88,N/A,6.88,N/A,6.88,N/A,158.92,N/A,8.09,N/A,8.09,N/A,8.09,N/A,8.09,N/A,8.09,N/A,8.09,N/A,8.09,N/A,8.90,165.60,165.60,5.04,165.60,,Hospital CPT 87106,HC Fungus ID Yeast,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,82.00,66.00,49.20,39.60,N/A,10.32,N/A,10.32,N/A,38.00,N/A,22.44,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,6.42,N/A,7.62,N/A,7.62,N/A,7.62,N/A,38.00,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,11.35,49.20,49.20,6.42,39.60,,Hospital CPT 87106,HC So Fungus ID Yeast,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,74.00,74.00,44.40,44.40,N/A,10.32,N/A,10.32,N/A,42.61,N/A,25.16,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,6.42,N/A,7.62,N/A,7.62,N/A,7.62,N/A,42.61,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,10.32,N/A,11.35,44.40,44.40,6.42,44.40,,Hospital CPT 87109,HC So Culture Mycoplasma Any Source,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,59.00,59.00,35.40,35.40,N/A,15.39,N/A,15.39,N/A,33.97,N/A,20.06,N/A,13.07,N/A,15.39,N/A,15.39,N/A,15.39,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,33.97,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,16.93,35.40,35.40,13.07,35.40,,Hospital CPT 87109,HC Culture Mycoplasma Any Source,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,65.00,59.00,39.00,35.40,N/A,15.39,N/A,15.39,N/A,33.97,N/A,20.06,N/A,13.07,N/A,15.39,N/A,15.39,N/A,15.39,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,33.97,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,15.39,N/A,16.93,39.00,39.00,13.07,35.40,,Hospital CPT 87140,HC Cult Typ Ift Ea Antiserum,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,49.00,34.00,29.40,20.40,N/A,5.57,N/A,5.57,N/A,19.58,N/A,11.56,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,3.47,N/A,5.57,N/A,3.03,N/A,5.57,N/A,19.58,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,6.13,29.40,29.40,3.03,20.40,,Hospital CPT 87140,HC So Cult Typ Ift Ea Antiserum,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,44.00,44.00,26.40,26.40,N/A,5.57,N/A,5.57,N/A,25.34,N/A,14.96,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,3.47,N/A,5.57,N/A,3.03,N/A,5.57,N/A,25.34,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,5.57,N/A,6.13,26.40,26.40,3.03,26.40,,Hospital CPT 87147,HC So Slide Coagulase,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,24.00,24.00,14.40,14.40,N/A,5.18,N/A,5.18,N/A,13.82,N/A,8.16,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,5.18,N/A,4.40,N/A,4.40,N/A,13.82,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,14.40,14.40,3.22,14.40,,Hospital CPT 87147,HC Culture Type Immunolog,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,27.00,21.00,16.20,12.60,N/A,5.18,N/A,5.18,N/A,12.09,N/A,7.14,N/A,4.40,N/A,5.18,N/A,5.18,N/A,5.18,N/A,3.22,N/A,5.18,N/A,4.40,N/A,4.40,N/A,12.09,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.18,N/A,5.70,16.20,16.20,3.22,12.60,,Hospital CPT 87149,HC Microbial Identification Each,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,100.00,100.00,60.00,60.00,N/A,20.05,N/A,20.05,N/A,57.58,N/A,34.00,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,12.48,N/A,20.05,N/A,20.05,N/A,20.05,N/A,57.58,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,22.06,60.00,60.00,12.48,60.00,,Hospital CPT 87153,HC So Dna/Rna Sequencing,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,437.00,437.00,262.20,262.20,N/A,115.36,N/A,115.36,N/A,251.62,N/A,148.58,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,71.81,N/A,115.36,N/A,115.36,N/A,115.36,N/A,251.62,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,126.90,262.20,262.20,71.81,262.20,,Hospital CPT 87153,"HC Culture Typing,Dna/Rna Sequencing",N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,482.00,482.00,289.20,289.20,N/A,115.36,N/A,115.36,N/A,277.54,N/A,163.88,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,71.81,N/A,115.36,N/A,115.36,N/A,115.36,N/A,277.54,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,115.36,N/A,126.90,289.20,289.20,71.81,289.20,,Hospital 87154,HC Blood Culture Multiplex Pcr 2,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,93733.30,2130.00,56239.98,1278.00,10440.92,176.13,12735.31,321.22,23529.46,1226.45,31869.32,724.20,23754.54,179.64,10762.62,176.13,180964.00,321.22,180964.00,321.22,14786.65,179.64,23754.54,179.64,23754.54,179.64,23754.54,179.64,23529.46,1226.45,12616.71,321.22,8881.57,176.13,28261.97,315.65,28261.97,315.65,9050.74,176.13,12616.71,321.22,14021.02,321.22,11516.01,107.37,8881.57,180964.00,107.37,1278.00,,Hospital CPT 87158,HC So Culture Typing Add,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,167.00,167.00,100.20,100.20,N/A,7.74,N/A,7.74,N/A,96.16,N/A,56.78,N/A,4.44,N/A,7.74,N/A,7.74,N/A,7.74,N/A,4.44,N/A,4.44,N/A,7.74,N/A,4.44,N/A,96.16,N/A,7.74,N/A,7.74,N/A,7.74,N/A,7.74,N/A,7.74,N/A,7.74,N/A,7.74,N/A,8.51,100.20,100.20,4.44,100.20,,Hospital CPT 87172,HC Pinworm Test,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,16.00,16.00,9.60,9.60,N/A,4.27,N/A,4.27,N/A,16.00,N/A,5.44,N/A,3.05,N/A,4.27,N/A,4.27,N/A,4.27,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,9.21,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,9.60,9.60,3.05,16.00,,Hospital CPT 87172,HC Pinworm Test,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,14.00,14.00,8.40,8.40,N/A,4.27,N/A,4.27,N/A,14.00,N/A,4.76,N/A,3.05,N/A,4.27,N/A,4.27,N/A,4.27,N/A,3.05,N/A,3.05,N/A,3.05,N/A,3.05,N/A,8.06,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.27,N/A,4.70,8.40,8.40,3.05,14.00,,Hospital CPT 87185,HC So Microbe Susceptible Enzyme,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,35.00,35.00,21.00,21.00,N/A,4.75,N/A,4.75,N/A,35.00,N/A,11.90,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20.15,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,21.00,21.00,4.75,35.00,,Hospital CPT 87185,HC Microbe Suscept Enzyme per Enz,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,39.00,29.00,23.40,17.40,N/A,4.75,N/A,4.75,N/A,29.00,N/A,9.86,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16.70,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,4.75,N/A,5.23,23.40,23.40,4.75,29.00,,Hospital CPT 87188,HC Suscept Macrobroth Dilution Ea,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,96.00,96.00,57.60,57.60,N/A,6.64,N/A,6.64,N/A,55.28,N/A,32.64,N/A,6.64,N/A,6.64,N/A,6.64,N/A,6.64,N/A,4.13,N/A,6.64,N/A,6.64,N/A,6.64,N/A,55.28,N/A,6.64,N/A,6.64,N/A,6.64,N/A,6.64,N/A,6.64,N/A,6.64,N/A,6.64,N/A,7.30,57.60,57.60,4.13,57.60,,Hospital CPT 87207,HC Malaria Prep,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,326.00,259.00,195.60,155.40,N/A,5.99,N/A,5.99,N/A,149.13,N/A,88.06,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,3.73,N/A,5.99,N/A,5.99,N/A,5.99,N/A,149.13,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,6.59,195.60,195.60,3.73,155.40,,Hospital CPT 87207,HC So Malaria Prep,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,295.00,295.00,177.00,177.00,N/A,5.99,N/A,5.99,N/A,169.86,N/A,100.30,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,3.73,N/A,5.99,N/A,5.99,N/A,5.99,N/A,169.86,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,5.99,N/A,6.59,177.00,177.00,3.73,177.00,,Hospital CPT 87209,HC Complex Special Stain,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,106.00,83.00,63.60,49.80,N/A,17.98,N/A,17.98,N/A,47.79,N/A,28.22,N/A,15.28,N/A,17.98,N/A,17.98,N/A,17.98,N/A,15.28,N/A,15.28,N/A,15.28,N/A,15.28,N/A,47.79,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,19.78,63.60,63.60,15.28,49.80,,Hospital CPT 87209,HC So Smear Complex Stain,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,96.00,96.00,57.60,57.60,N/A,17.98,N/A,17.98,N/A,55.28,N/A,32.64,N/A,15.28,N/A,17.98,N/A,17.98,N/A,17.98,N/A,15.28,N/A,15.28,N/A,15.28,N/A,15.28,N/A,55.28,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,17.98,N/A,19.78,57.60,57.60,15.28,57.60,,Hospital CPT 87255,HC Genet Virus Isolate Hsv,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,223.00,223.00,133.80,133.80,N/A,33.86,N/A,33.86,N/A,128.40,N/A,75.82,N/A,28.78,N/A,33.86,N/A,33.86,N/A,33.86,N/A,28.78,N/A,28.78,N/A,33.86,N/A,28.78,N/A,128.40,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,33.86,N/A,37.25,133.80,133.80,28.78,133.80,,Hospital CPT 87270,HC Chlamydia Trachomatis Ag Dfa,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,154.00,154.00,92.40,92.40,N/A,11.98,N/A,11.98,N/A,88.67,N/A,52.36,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,88.67,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,92.40,92.40,7.46,92.40,,Hospital CPT 87274,HC Herpes Simplex Virus 1 Ag If,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,46.00,46.00,27.60,27.60,N/A,11.98,N/A,11.98,N/A,26.49,N/A,15.64,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,26.49,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,27.60,27.60,7.46,27.60,,Hospital CPT 87274,HC So Herpes Simplex Virus 1 Ag If,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,41.00,41.00,24.60,24.60,N/A,11.98,N/A,11.98,N/A,23.61,N/A,13.94,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,11.98,N/A,11.98,N/A,11.98,N/A,23.61,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,24.60,24.60,7.46,24.60,,Hospital 87279,HC So Parainfluenza 1,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,66008.00,8291.80,39604.80,4975.08,5790.73,1247.75,11171.90,1431.09,17372.34,4773.66,N/A,2819.21,N/A,3498.95,5026.72,1247.75,11171.90,1443.56,11171.90,1443.56,N/A,2178.17,N/A,3498.95,N/A,3498.95,N/A,3498.95,13049.88,4773.66,11171.90,1443.56,5026.72,1247.75,17372.34,1871.00,15674.62,1871.00,5026.72,1247.75,7115.77,1443.56,7115.77,1431.09,5026.72,531.78,5026.72,39604.80,531.78,4975.08,,Hospital CPT 87299,HC Infect Org Nos Ag Ift Ea Org,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,48.00,48.00,28.80,28.80,N/A,16.10,N/A,16.10,N/A,27.64,N/A,16.32,N/A,16.10,N/A,16.10,N/A,16.10,N/A,16.10,N/A,10.02,N/A,16.10,N/A,16.10,N/A,16.10,N/A,27.64,N/A,16.10,N/A,16.10,N/A,16.10,N/A,16.10,N/A,16.10,N/A,16.10,N/A,16.10,N/A,17.71,28.80,28.80,10.02,28.80,,Hospital CPT 87324,"HC Clost Diff,Infect Agent Antign",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,60.00,48.00,36.00,28.80,N/A,11.98,N/A,11.98,N/A,27.64,N/A,16.32,N/A,9.73,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,9.73,N/A,9.73,N/A,9.73,N/A,27.64,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,36.00,36.00,7.46,28.80,,Hospital CPT 87327,HC So Cryptococcus Ag CSF,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,75.00,75.00,45.00,45.00,N/A,13.42,N/A,13.42,N/A,43.19,N/A,25.50,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,9.73,N/A,9.73,N/A,13.42,N/A,9.73,N/A,43.19,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,14.76,45.00,45.00,9.73,45.00,,Hospital CPT 87327,HC Cryptospondium Ag,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,83.00,66.00,49.80,39.60,N/A,13.42,N/A,13.42,N/A,38.00,N/A,22.44,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,9.73,N/A,9.73,N/A,13.42,N/A,9.73,N/A,38.00,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,13.42,N/A,14.76,49.80,49.80,9.73,39.60,,Hospital CPT 87329,HC Giardia Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,107.00,85.00,64.20,51.00,N/A,11.98,N/A,11.98,N/A,85.00,N/A,28.90,N/A,9.73,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,48.94,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,64.20,64.20,9.73,85.00,,Hospital CPT 87329,HC So Giardia Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,97.00,97.00,58.20,58.20,N/A,11.98,N/A,11.98,N/A,97.00,N/A,32.98,N/A,9.73,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,55.85,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,58.20,58.20,9.73,97.00,,Hospital CPT 87337,HC E.Histolytica Antigen Detect,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,50.00,50.00,30.00,30.00,N/A,11.98,N/A,11.98,N/A,28.79,N/A,17.00,N/A,9.73,N/A,11.98,N/A,11.98,N/A,11.98,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,28.79,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,30.00,30.00,9.73,30.00,,Hospital CPT 87340,HC Hepatitis B Surface Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,148.00,119.00,88.80,71.40,N/A,10.33,N/A,10.33,N/A,68.52,N/A,40.46,N/A,8.78,N/A,10.33,N/A,10.33,N/A,10.33,N/A,8.78,N/A,8.78,N/A,8.78,N/A,8.78,N/A,68.52,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,10.33,N/A,11.36,88.80,88.80,8.78,71.40,,Hospital CPT 87350,HC Hepatitis Be Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,182.00,145.00,109.20,87.00,N/A,11.53,N/A,11.53,N/A,83.49,N/A,49.30,N/A,9.79,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.79,N/A,9.79,N/A,9.79,N/A,9.79,N/A,83.49,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,109.20,109.20,9.79,87.00,,Hospital CPT 87350,HC So Hepatitis Be Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,164.00,164.00,98.40,98.40,N/A,11.53,N/A,11.53,N/A,94.43,N/A,55.76,N/A,9.79,N/A,11.53,N/A,11.53,N/A,11.53,N/A,9.79,N/A,9.79,N/A,9.79,N/A,9.79,N/A,94.43,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,11.53,N/A,12.68,98.40,98.40,9.79,98.40,,Hospital CPT 87385,HC Histoplasma Capsulatum,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,389.00,307.00,233.40,184.20,N/A,13.25,N/A,13.25,N/A,176.77,N/A,104.38,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,176.77,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,233.40,233.40,9.73,184.20,,Hospital CPT 87385,HC So Histoplasma Capsulatum,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,352.00,352.00,211.20,211.20,N/A,13.25,N/A,13.25,N/A,202.68,N/A,119.68,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,9.73,N/A,9.73,N/A,9.73,N/A,9.73,N/A,202.68,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,13.25,N/A,14.58,211.20,211.20,9.73,211.20,,Hospital CPT 87389,HC So Hiv-1 & Hiv-2 Ab,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,90.00,90.00,54.00,54.00,N/A,24.08,N/A,24.08,N/A,90.00,N/A,30.60,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,20.47,N/A,24.08,N/A,20.47,N/A,20.47,N/A,51.82,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,26.49,54.00,54.00,20.47,90.00,,Hospital CPT 87389,HC Hiv Combo Testing W/Reflx,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,100.00,100.00,60.00,60.00,N/A,24.08,N/A,24.08,N/A,100.00,N/A,34.00,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,20.47,N/A,24.08,N/A,20.47,N/A,20.47,N/A,57.58,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,24.08,N/A,26.49,60.00,60.00,20.47,100.00,,Hospital CPT 87390,HC Hiv 1 Antigen,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,86.00,86.00,51.60,51.60,N/A,24.06,N/A,24.06,N/A,49.52,N/A,29.24,N/A,14.99,N/A,24.06,N/A,24.06,N/A,24.06,N/A,14.99,N/A,14.99,N/A,14.99,N/A,14.99,N/A,49.52,N/A,24.06,N/A,24.06,N/A,24.06,N/A,24.06,N/A,24.06,N/A,24.06,N/A,24.06,N/A,26.47,51.60,51.60,14.99,51.60,,Hospital CPT 87426,HC Iaad Ia Severe Aqt Respir Synd Coronavirus,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,70.00,70.00,42.00,42.00,N/A,26.37,N/A,35.33,N/A,40.31,N/A,23.80,N/A,25.30,N/A,26.37,N/A,35.33,N/A,35.33,N/A,25.30,N/A,25.30,N/A,25.30,N/A,35.33,N/A,40.31,N/A,35.33,N/A,26.37,N/A,35.64,N/A,35.64,N/A,26.37,N/A,35.33,N/A,35.33,N/A,29.01,42.00,42.00,23.80,42.00,,Hospital 87430,HC Strep a Ag Eia,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,44553.40,1153.50,26732.04,692.10,9495.09,157.25,8955.27,118.26,21397.96,664.01,15148.16,392.19,21602.65,271.21,9787.65,157.25,11497.84,109.14,11497.84,109.14,13447.14,168.83,21602.65,271.21,21602.65,271.21,21602.65,271.21,21397.96,434.27,11497.84,109.14,9787.65,157.25,25701.76,233.84,25701.76,233.84,4418.80,157.25,11497.84,109.14,11497.84,118.26,10472.79,88.51,4418.80,26732.04,88.51,692.10,,Hospital CPT 87449,"HC Ag Detect Nos, Eia Multi Step",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,184.00,92.00,110.40,55.20,N/A,11.98,N/A,11.98,N/A,52.97,N/A,31.28,N/A,9.73,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,9.73,N/A,9.73,N/A,9.73,N/A,52.97,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,110.40,110.40,7.46,55.20,,Hospital CPT 87449,"HC So Ag Detect Nos, Eia Multi Step",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,166.00,166.00,99.60,99.60,N/A,11.98,N/A,11.98,N/A,95.58,N/A,56.44,N/A,9.73,N/A,11.98,N/A,11.98,N/A,11.98,N/A,7.46,N/A,9.73,N/A,9.73,N/A,9.73,N/A,95.58,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,11.98,N/A,13.18,99.60,99.60,7.46,99.60,,Hospital CPT 87471,HC Bartonella Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,146.00,146.00,87.60,87.60,N/A,35.09,N/A,35.09,N/A,84.07,N/A,49.64,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,84.07,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,87.60,87.60,21.84,87.60,,Hospital CPT 87471,HC So Bartonella Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,475.00,475.00,285.00,285.00,N/A,35.09,N/A,35.09,N/A,273.51,N/A,161.50,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,273.51,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,285.00,285.00,21.84,285.00,,Hospital CPT 87476,HC So B Burgdorferi Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,138.00,138.00,82.80,82.80,N/A,35.09,N/A,35.09,N/A,79.46,N/A,46.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,79.46,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,82.80,82.80,21.84,82.80,,Hospital CPT 87480,HC Candida Dna Dir Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,182.00,182.00,109.20,109.20,N/A,20.05,N/A,20.05,N/A,182.00,N/A,61.88,N/A,16.76,N/A,20.05,N/A,20.05,N/A,20.05,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,104.80,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,22.06,109.20,109.20,16.76,182.00,,Hospital CPT 87480,HC So Candida Dna Dir Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,164.00,164.00,98.40,98.40,N/A,20.05,N/A,20.05,N/A,164.00,N/A,55.76,N/A,16.76,N/A,20.05,N/A,20.05,N/A,20.05,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,94.43,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,22.06,98.40,98.40,16.76,164.00,,Hospital CPT 87483,HC Cns Dna Amp Probe Type 12-25,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1151.00,1151.00,690.60,690.60,N/A,416.78,N/A,416.78,N/A,662.75,N/A,391.34,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,259.45,N/A,416.78,N/A,416.78,N/A,416.78,N/A,662.75,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,690.60,690.60,259.45,690.60,,Hospital CPT 87483,HC So Cns Dna Amp Probe Type 12-25,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1143.00,1143.00,685.80,685.80,N/A,416.78,N/A,416.78,N/A,658.14,N/A,388.62,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,259.45,N/A,416.78,N/A,416.78,N/A,416.78,N/A,658.14,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,685.80,685.80,259.45,685.80,,Hospital 87484,HC So Iadna Ehrlichia Chaffeensis Amplified Probe Tq,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,33995.30,N/A,20397.18,N/A,10440.92,N/A,12616.71,N/A,23529.46,N/A,11558.40,N/A,23754.54,N/A,10762.62,N/A,12616.71,N/A,12616.71,N/A,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,23529.46,N/A,12616.71,N/A,10762.62,N/A,28261.97,N/A,28261.97,N/A,N/A,N/A,12616.71,N/A,12616.71,N/A,11516.01,N/A,10440.92,28261.97,N/A,N/A,,Hospital CPT 87486,HC Chlamydia Pneumoniae Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,88.00,88.00,52.80,52.80,N/A,35.09,N/A,35.09,N/A,50.67,N/A,29.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,50.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,52.80,52.80,21.84,52.80,,Hospital CPT 87486,HC So Chlamydia Pneumoniae Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,88.00,88.00,52.80,52.80,N/A,35.09,N/A,35.09,N/A,50.67,N/A,29.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,50.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,52.80,52.80,21.84,52.80,,Hospital CPT 87490,HC Chlamydia Dna Probe Direct,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,374.00,374.00,224.40,224.40,N/A,22.75,N/A,22.75,N/A,215.35,N/A,127.16,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,14.16,N/A,22.75,N/A,22.75,N/A,22.75,N/A,215.35,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,22.75,N/A,25.03,224.40,224.40,14.16,224.40,,Hospital CPT 87493,"HC Clost Diff,Toxin Gene,Amp Prbe",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,183.00,146.00,109.80,87.60,N/A,37.27,N/A,37.27,N/A,84.07,N/A,49.64,N/A,29.83,N/A,37.27,N/A,37.27,N/A,37.27,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,84.07,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,41.00,109.80,109.80,29.83,87.60,,Hospital CPT 87493,"HC So Clost Diff,Toxin Gene,Amp Prbe",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,165.00,165.00,99.00,99.00,N/A,37.27,N/A,37.27,N/A,95.01,N/A,56.10,N/A,29.83,N/A,37.27,N/A,37.27,N/A,37.27,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,95.01,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,37.27,N/A,41.00,99.00,99.00,29.83,99.00,,Hospital CPT 87496,HC So Cytomegalovirus Pcr,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,287.00,287.00,172.20,172.20,N/A,35.09,N/A,35.09,N/A,165.25,N/A,97.58,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,29.83,N/A,35.09,N/A,165.25,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,172.20,172.20,21.84,172.20,,Hospital CPT 87496,HC Cytomeg Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,317.00,251.00,190.20,150.60,N/A,35.09,N/A,35.09,N/A,144.53,N/A,85.34,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,29.83,N/A,35.09,N/A,144.53,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,190.20,190.20,21.84,150.60,,Hospital 87500,HC Vanomycin Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,92672.15,54736.78,55603.29,32842.07,7451.40,7656.68,9287.80,4922.21,16792.33,31413.90,31508.53,18610.49,39161.61,11805.28,6734.46,7656.68,127574.00,4821.94,127574.00,4821.94,39161.61,7349.00,39161.61,11805.28,16952.96,11805.28,39161.61,11805.28,16792.33,31413.89,12123.89,4821.94,7680.99,7656.68,20169.79,8944.50,20169.79,8944.50,7422.24,7656.68,9080.25,4821.94,13006.17,4922.21,8218.66,1268.25,6734.46,127574.00,1268.25,32842.07,,Hospital CPT 87505,HC Infect Agent Detection GI,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,625.00,625.00,375.00,375.00,N/A,128.29,N/A,128.29,N/A,359.88,N/A,212.50,N/A,176.34,N/A,128.29,N/A,128.29,N/A,128.29,N/A,176.34,N/A,176.34,N/A,176.34,N/A,128.29,N/A,359.88,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,141.12,375.00,375.00,128.29,375.00,,Hospital CPT 87505,HC So Infect Agent Detection GI,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,625.00,625.00,375.00,375.00,N/A,128.29,N/A,128.29,N/A,359.88,N/A,212.50,N/A,176.34,N/A,128.29,N/A,128.29,N/A,128.29,N/A,176.34,N/A,176.34,N/A,176.34,N/A,128.29,N/A,359.88,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,128.29,N/A,141.12,375.00,375.00,128.29,375.00,,Hospital CPT 87507,HC Iadna-Dna/Rna Probe Tq,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,869.00,869.00,521.40,521.40,N/A,416.78,N/A,416.78,N/A,500.37,N/A,295.46,N/A,572.91,N/A,416.78,N/A,416.78,N/A,416.78,N/A,572.91,N/A,416.78,N/A,572.91,N/A,416.78,N/A,500.37,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,521.40,521.40,295.46,572.91,,Hospital CPT 87507,HC So Dna/Rna Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1143.00,1143.00,685.80,685.80,N/A,416.78,N/A,416.78,N/A,658.14,N/A,388.62,N/A,572.91,N/A,416.78,N/A,416.78,N/A,416.78,N/A,572.91,N/A,416.78,N/A,572.91,N/A,416.78,N/A,658.14,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,416.78,N/A,458.46,685.80,685.80,388.62,685.80,,Hospital CPT 87510,HC Gardner Vag Dna Dir Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,70.00,70.00,42.00,42.00,N/A,20.05,N/A,20.05,N/A,70.00,N/A,23.80,N/A,16.76,N/A,20.05,N/A,20.05,N/A,20.05,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,40.31,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,20.05,N/A,22.06,42.00,42.00,16.76,70.00,,Hospital CPT 87522,HC So1 Hcv Ultraquant,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,348.00,348.00,208.80,208.80,N/A,42.84,N/A,42.84,N/A,200.38,N/A,118.32,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,200.38,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,208.80,208.80,36.40,208.80,,Hospital CPT 87522,HC So Hcv Ultraquant,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,348.00,348.00,208.80,208.80,N/A,42.84,N/A,42.84,N/A,200.38,N/A,118.32,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,200.38,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,208.80,208.80,36.40,208.80,,Hospital CPT 87522,HC Hepatitis C Virus Quantitative,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,384.00,305.00,230.40,183.00,N/A,42.84,N/A,42.84,N/A,175.62,N/A,103.70,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,175.62,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,230.40,230.40,36.40,183.00,,Hospital CPT 87533,HC So Hhv-6 Dna Quant,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,395.00,395.00,237.00,237.00,N/A,41.76,N/A,41.76,N/A,227.44,N/A,134.30,N/A,35.48,N/A,41.76,N/A,41.76,N/A,41.76,N/A,35.48,N/A,35.48,N/A,35.48,N/A,35.48,N/A,227.44,N/A,41.76,N/A,41.76,N/A,41.76,N/A,41.76,N/A,41.76,N/A,41.76,N/A,41.76,N/A,45.94,237.00,237.00,35.48,237.00,,Hospital CPT 87536,"HC So Hiv-1, Quantification",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,387.00,387.00,232.20,232.20,N/A,85.10,N/A,85.10,N/A,222.83,N/A,131.58,N/A,72.31,N/A,85.10,N/A,85.10,N/A,85.10,N/A,72.31,N/A,72.31,N/A,72.31,N/A,72.31,N/A,222.83,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,93.61,232.20,232.20,72.31,232.20,,Hospital CPT 87536,"HC Hiv-1, Quantification",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,427.00,341.00,256.20,204.60,N/A,85.10,N/A,85.10,N/A,196.35,N/A,115.94,N/A,72.31,N/A,85.10,N/A,85.10,N/A,85.10,N/A,72.31,N/A,72.31,N/A,72.31,N/A,72.31,N/A,196.35,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,85.10,N/A,93.61,256.20,256.20,72.31,204.60,,Hospital CPT 87551,HC Mycobacteria Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,372.00,372.00,223.20,223.20,N/A,48.24,N/A,48.24,N/A,214.20,N/A,126.48,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,30.03,N/A,48.24,N/A,48.24,N/A,48.24,N/A,214.20,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,53.06,223.20,223.20,30.03,223.20,,Hospital CPT 87551,HC So Mycobacteria Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,337.00,337.00,202.20,202.20,N/A,48.24,N/A,48.24,N/A,194.04,N/A,114.58,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,30.03,N/A,48.24,N/A,48.24,N/A,48.24,N/A,194.04,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,48.24,N/A,53.06,202.20,202.20,30.03,202.20,,Hospital CPT 87556,HC Mituberculosis Dna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,270.00,215.00,162.00,129.00,N/A,41.68,N/A,41.68,N/A,123.80,N/A,73.10,N/A,29.83,N/A,41.68,N/A,41.68,N/A,41.68,N/A,29.83,N/A,29.83,N/A,29.83,N/A,41.68,N/A,123.80,N/A,41.68,N/A,41.68,N/A,41.68,N/A,41.68,N/A,41.68,N/A,41.68,N/A,41.68,N/A,45.85,162.00,162.00,29.83,129.00,,Hospital CPT 87561,HC So M.Avium-Intra Dna Amp Prob,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,157.00,157.00,94.20,94.20,N/A,35.09,N/A,35.09,N/A,90.40,N/A,53.38,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,90.40,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,94.20,94.20,21.84,94.20,,Hospital CPT 87563,HC So Iadna Mycoplasma Genitalium Amplified Probe Tech,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,144.00,144.00,86.40,86.40,N/A,35.09,N/A,35.09,N/A,82.92,N/A,48.96,N/A,14.04,N/A,35.09,N/A,35.09,N/A,35.09,N/A,14.04,N/A,14.04,N/A,14.04,N/A,35.09,N/A,82.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,86.40,86.40,14.04,86.40,,Hospital CPT 87581,HC Mycoplasma Pneumonia Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,146.00,146.00,87.60,87.60,N/A,35.09,N/A,35.09,N/A,84.07,N/A,49.64,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,84.07,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,87.60,87.60,21.84,87.60,,Hospital CPT 87581,HC So Mycoplasma Pneumonia Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,88.00,88.00,52.80,52.80,N/A,35.09,N/A,35.09,N/A,50.67,N/A,29.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,35.09,N/A,35.09,N/A,35.09,N/A,50.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,52.80,52.80,21.84,52.80,,Hospital CPT 87625,HC So Hpv Genotype,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,57.00,57.00,34.20,34.20,N/A,40.55,N/A,40.55,N/A,57.00,N/A,19.38,N/A,16.76,N/A,40.55,N/A,40.55,N/A,40.55,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,32.82,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,44.61,34.20,34.20,16.76,57.00,,Hospital CPT 87625,HC Hpv Genotype,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,63.00,47.00,37.80,28.20,N/A,40.55,N/A,40.55,N/A,47.00,N/A,15.98,N/A,16.76,N/A,40.55,N/A,40.55,N/A,40.55,N/A,16.76,N/A,16.76,N/A,16.76,N/A,16.76,N/A,27.06,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,40.55,N/A,44.61,37.80,37.80,15.98,47.00,,Hospital CPT 87640,HC So Staph Aureus Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,88.00,88.00,52.80,52.80,N/A,35.09,N/A,35.09,N/A,50.67,N/A,29.92,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,50.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,52.80,52.80,29.83,52.80,,Hospital CPT 87640,HC Staph Aureus Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,88.00,88.00,52.80,52.80,N/A,35.09,N/A,35.09,N/A,50.67,N/A,29.92,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,29.83,N/A,29.83,N/A,50.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,52.80,52.80,29.83,52.80,,Hospital CPT 87641,HC So Mrsa Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,88.00,88.00,52.80,52.80,N/A,35.09,N/A,35.09,N/A,50.67,N/A,29.92,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,29.83,N/A,35.09,N/A,29.83,N/A,50.67,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,52.80,52.80,21.84,52.80,,Hospital CPT 87641,HC Mrsa Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,349.00,349.00,209.40,209.40,N/A,35.09,N/A,35.09,N/A,200.95,N/A,118.66,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,21.84,N/A,29.83,N/A,35.09,N/A,29.83,N/A,200.95,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,209.40,209.40,21.84,209.40,,Hospital CPT 87653,HC Strep Group B Amplified Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,146.00,146.00,87.60,87.60,N/A,35.09,N/A,35.09,N/A,84.07,N/A,49.64,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,35.09,N/A,29.83,N/A,84.07,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,87.60,87.60,29.83,87.60,,Hospital CPT 87653,HC So Iadna Streptococcus Group B Amp Probe Tq,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,143.00,143.00,85.80,85.80,N/A,35.09,N/A,35.09,N/A,82.34,N/A,48.62,N/A,29.83,N/A,35.09,N/A,35.09,N/A,35.09,N/A,29.83,N/A,29.83,N/A,35.09,N/A,29.83,N/A,82.34,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,85.80,85.80,29.83,85.80,,Hospital CPT 87661,HC So Trichomonas Vaginalis Amplif,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,131.00,131.00,78.60,78.60,N/A,35.09,N/A,35.09,N/A,131.00,N/A,44.54,N/A,47.87,N/A,35.09,N/A,35.09,N/A,35.09,N/A,47.87,N/A,47.87,N/A,47.87,N/A,47.87,N/A,75.43,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,78.60,78.60,35.09,131.00,,Hospital CPT 87661,HC Trichomonas Vaginalis Amplif,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,145.00,145.00,87.00,87.00,N/A,35.09,N/A,35.09,N/A,145.00,N/A,49.30,N/A,47.87,N/A,35.09,N/A,35.09,N/A,35.09,N/A,47.87,N/A,47.87,N/A,47.87,N/A,47.87,N/A,83.49,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,35.09,N/A,38.60,87.00,87.00,35.09,145.00,,Hospital 87662,HC So Zika Virus Dna/Rna Amp Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,42279.50,N/A,25367.70,N/A,5483.99,N/A,6752.92,N/A,12358.62,N/A,12936.83,N/A,12744.84,N/A,5652.96,N/A,6752.92,N/A,6752.92,N/A,8034.54,N/A,12744.84,N/A,12744.84,N/A,12744.84,N/A,12358.62,N/A,6752.92,N/A,5652.96,N/A,14844.32,N/A,14844.32,N/A,N/A,N/A,6752.92,N/A,6752.92,N/A,6048.67,N/A,5483.99,25367.70,N/A,N/A,,Hospital CPT 87799,"HC Bk Virus,Quant,Pcr, Urine",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,732.00,582.00,439.20,349.20,N/A,42.84,N/A,42.84,N/A,335.12,N/A,197.88,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,335.12,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,439.20,439.20,36.40,349.20,,Hospital CPT 87799,"HC Dna Quantification, Each",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1026.00,815.00,615.60,489.00,N/A,42.84,N/A,42.84,N/A,469.28,N/A,277.10,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,469.28,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,615.60,615.60,36.40,489.00,,Hospital CPT 87799,"HC So Dna Quantification, Each",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,663.00,663.00,397.80,397.80,N/A,42.84,N/A,42.84,N/A,381.76,N/A,225.42,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,381.76,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,397.80,397.80,36.40,397.80,,Hospital CPT 87799,"HC So1 Dna Quantification, Each",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,930.00,930.00,558.00,558.00,N/A,42.84,N/A,42.84,N/A,535.49,N/A,316.20,N/A,36.40,N/A,42.84,N/A,42.84,N/A,42.84,N/A,36.40,N/A,36.40,N/A,36.40,N/A,36.40,N/A,535.49,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,42.84,N/A,47.12,558.00,558.00,36.40,558.00,,Hospital CPT 87899,"HC Infectious Agent,Nos",N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,127.00,113.00,76.20,67.80,N/A,16.07,N/A,16.07,N/A,65.07,N/A,38.42,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,10.00,N/A,16.07,N/A,16.07,N/A,16.07,N/A,65.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,16.07,N/A,17.68,76.20,76.20,10.00,67.80,,Hospital CPT 87903,HC So Hiv Phenotype to 10 Drugs,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1258.00,1258.00,754.80,754.80,N/A,488.66,N/A,488.66,N/A,724.36,N/A,427.72,N/A,415.26,N/A,488.66,N/A,488.66,N/A,488.66,N/A,415.26,N/A,415.26,N/A,415.26,N/A,415.26,N/A,724.36,N/A,488.66,N/A,488.66,N/A,488.66,N/A,488.66,N/A,488.66,N/A,488.66,N/A,488.66,N/A,537.53,754.80,754.80,415.26,754.80,,Hospital CPT 87906,HC So Genotype Dna/Rna Hiv,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,438.00,438.00,262.80,262.80,N/A,128.73,N/A,128.73,N/A,252.20,N/A,148.92,N/A,109.39,N/A,128.73,N/A,128.73,N/A,128.73,N/A,109.39,N/A,109.39,N/A,109.39,N/A,109.39,N/A,252.20,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,141.60,262.80,262.80,109.39,262.80,,Hospital CPT 87906,HC Genotype Dna/Rna Hiv,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,483.00,483.00,289.80,289.80,N/A,128.73,N/A,128.73,N/A,278.11,N/A,164.22,N/A,109.39,N/A,128.73,N/A,128.73,N/A,128.73,N/A,109.39,N/A,109.39,N/A,109.39,N/A,109.39,N/A,278.11,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,128.73,N/A,141.60,289.80,289.80,109.39,289.80,,Hospital CPT 87910,HC So Genotype Cytomegalovirus,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,1000.00,1000.00,600.00,600.00,N/A,257.45,N/A,257.45,N/A,575.80,N/A,340.00,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,160.26,N/A,257.45,N/A,257.45,N/A,257.45,N/A,575.80,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,257.45,N/A,283.20,600.00,600.00,160.26,600.00,,Hospital CPT 88112,HC Cytology,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,102.00,88.00,61.20,52.80,N/A,12.32,N/A,45.28,N/A,50.67,N/A,29.92,N/A,88.00,N/A,12.32,N/A,45.28,N/A,45.28,N/A,68.18,N/A,88.00,N/A,88.00,N/A,88.00,N/A,50.67,N/A,45.28,N/A,12.32,N/A,50.75,N/A,50.75,N/A,12.32,N/A,45.28,N/A,45.28,N/A,49.81,61.20,61.20,12.32,88.00,,Hospital CPT 88112,HC So Cyto Urine,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,92.00,92.00,55.20,55.20,N/A,12.88,N/A,45.28,N/A,52.97,N/A,31.28,N/A,92.00,N/A,12.88,N/A,45.28,N/A,45.28,N/A,68.18,N/A,92.00,N/A,92.00,N/A,92.00,N/A,52.97,N/A,45.28,N/A,12.88,N/A,50.75,N/A,50.75,N/A,12.88,N/A,45.28,N/A,45.28,N/A,49.81,55.20,55.20,12.88,92.00,,Hospital CPT 88121,HC Cytp Urine 3-5 Probes Comptr,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,602.00,602.00,361.20,361.20,N/A,84.28,N/A,148.54,N/A,346.63,N/A,204.68,N/A,343.50,N/A,84.28,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,346.63,N/A,142.00,N/A,84.28,N/A,297.45,N/A,297.45,N/A,84.28,N/A,142.00,N/A,148.54,N/A,378.42,361.20,361.20,84.28,378.42,,Hospital CPT 88121,HC So Cytp Urine 3-5 Probes Comptr,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,545.00,545.00,327.00,327.00,N/A,76.30,N/A,148.54,N/A,313.81,N/A,185.30,N/A,343.50,N/A,76.30,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,313.81,N/A,142.00,N/A,76.30,N/A,297.45,N/A,297.45,N/A,76.30,N/A,142.00,N/A,148.54,N/A,378.42,327.00,327.00,76.30,378.42,,Hospital CPT 88142,HC Cytopath C/V Thin Layer,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,69.00,57.00,41.40,34.20,N/A,20.26,N/A,20.26,N/A,32.82,N/A,19.38,N/A,17.22,N/A,20.26,N/A,20.26,N/A,20.26,N/A,17.22,N/A,17.22,N/A,17.22,N/A,20.26,N/A,32.82,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,20.26,N/A,22.29,41.40,41.40,17.22,34.20,,Hospital CPT 88143,HC Pap Thin Prep Man Screen,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,93.00,93.00,55.80,55.80,N/A,23.04,N/A,23.04,N/A,53.55,N/A,31.62,N/A,23.04,N/A,23.04,N/A,23.04,N/A,23.04,N/A,14.34,N/A,23.04,N/A,23.04,N/A,23.04,N/A,53.55,N/A,23.04,N/A,23.04,N/A,23.04,N/A,23.04,N/A,23.04,N/A,23.04,N/A,23.04,N/A,25.34,55.80,55.80,14.34,55.80,,Hospital CPT 88160,"HC Cytology,Misc Fixed Slides",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,122.00,105.00,73.20,63.00,N/A,14.70,N/A,23.42,N/A,105.00,N/A,35.70,N/A,54.51,N/A,14.70,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,60.46,N/A,22.54,N/A,14.70,N/A,25.23,N/A,25.23,N/A,14.70,N/A,22.54,N/A,23.42,N/A,44.97,73.20,73.20,14.70,105.00,,Hospital CPT 88161,HC Cytology Other Source,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,182.00,182.00,109.20,109.20,N/A,25.48,N/A,23.01,N/A,104.80,N/A,61.88,N/A,54.51,N/A,25.48,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,104.80,N/A,22.54,N/A,25.48,N/A,25.23,N/A,25.23,N/A,25.48,N/A,22.54,N/A,23.01,N/A,47.29,109.20,109.20,22.54,109.20,,Hospital CPT 88164,HC Cytopath Tbs C/V Manual,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,174.00,148.00,104.40,88.80,N/A,15.15,N/A,17.31,N/A,148.00,N/A,50.32,N/A,8.98,N/A,15.15,N/A,17.31,N/A,17.31,N/A,8.98,N/A,8.98,N/A,8.98,N/A,8.98,N/A,85.22,N/A,17.31,N/A,15.15,N/A,15.92,N/A,15.92,N/A,15.15,N/A,17.31,N/A,17.31,N/A,16.67,104.40,104.40,8.98,148.00,,Hospital CPT 88172,HC Fna Immed.Eval.& Slide Prep,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,302.00,256.00,181.20,153.60,N/A,35.84,N/A,142.00,N/A,147.40,N/A,87.04,N/A,256.00,N/A,35.84,N/A,142.00,N/A,142.00,N/A,213.84,N/A,256.00,N/A,256.00,N/A,256.00,N/A,147.40,N/A,142.00,N/A,35.84,N/A,152.32,N/A,152.32,N/A,35.84,N/A,142.00,N/A,142.00,N/A,156.20,181.20,181.20,35.84,256.00,,Hospital CPT 88173,HC Fna Interp. & Report,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,455.00,386.00,273.00,231.60,N/A,54.04,N/A,45.28,N/A,222.26,N/A,131.24,N/A,109.52,N/A,54.04,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,222.26,N/A,45.28,N/A,54.04,N/A,50.75,N/A,50.75,N/A,54.04,N/A,45.28,N/A,45.28,N/A,49.81,273.00,273.00,45.28,231.60,,Hospital CPT 88175,HC Cytopath C/V Auto Fluid Redo,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,306.00,306.00,183.60,183.60,N/A,26.61,N/A,26.61,N/A,176.19,N/A,104.04,N/A,21.82,N/A,26.61,N/A,26.61,N/A,26.61,N/A,21.82,N/A,21.82,N/A,26.61,N/A,21.82,N/A,176.19,N/A,26.61,N/A,26.61,N/A,26.61,N/A,26.61,N/A,26.61,N/A,26.61,N/A,26.61,N/A,29.27,183.60,183.60,21.82,183.60,,Hospital CPT 88182,"HC Flow Ctyo,Dna Analysis, Path",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,149.00,149.00,89.40,89.40,N/A,20.86,N/A,47.47,N/A,85.79,N/A,50.66,N/A,109.52,N/A,20.86,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,85.79,N/A,45.28,N/A,20.86,N/A,50.75,N/A,50.75,N/A,20.86,N/A,45.28,N/A,96.17,N/A,105.79,89.40,89.40,20.86,109.52,,Hospital CPT 88182,HC So Cell Marker Study,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,135.00,135.00,81.00,81.00,N/A,18.90,N/A,47.47,N/A,77.73,N/A,45.90,N/A,109.52,N/A,18.90,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,77.73,N/A,45.28,N/A,18.90,N/A,50.75,N/A,50.75,N/A,18.90,N/A,45.28,N/A,96.17,N/A,105.79,81.00,81.00,18.90,109.52,,Hospital CPT 88185,"HC Flow Cytometry, Ea Add Mrkr (Path)",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,152.00,130.00,91.20,78.00,N/A,18.20,N/A,130.00,N/A,74.85,N/A,44.20,N/A,130.00,N/A,18.20,N/A,130.00,N/A,130.00,N/A,130.00,N/A,130.00,N/A,130.00,N/A,130.00,N/A,74.85,N/A,130.00,N/A,18.20,N/A,22.15,N/A,22.15,N/A,18.20,N/A,130.00,N/A,130.00,N/A,130.00,91.20,91.20,18.20,130.00,,Hospital CPT 88185,HC Flow Cytometry Ea Add Mrkr,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,152.00,130.00,91.20,78.00,N/A,18.20,N/A,130.00,N/A,74.85,N/A,44.20,N/A,130.00,N/A,18.20,N/A,130.00,N/A,130.00,N/A,130.00,N/A,130.00,N/A,130.00,N/A,130.00,N/A,74.85,N/A,130.00,N/A,18.20,N/A,22.15,N/A,22.15,N/A,18.20,N/A,130.00,N/A,130.00,N/A,130.00,91.20,91.20,18.20,130.00,,Hospital CPT 88185,HC So Cytoplasmic Tech Comp,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,138.00,138.00,82.80,82.80,N/A,19.32,N/A,138.00,N/A,79.46,N/A,46.92,N/A,138.00,N/A,19.32,N/A,138.00,N/A,138.00,N/A,138.00,N/A,138.00,N/A,138.00,N/A,138.00,N/A,79.46,N/A,138.00,N/A,19.32,N/A,22.15,N/A,22.15,N/A,19.32,N/A,138.00,N/A,138.00,N/A,138.00,82.80,82.80,19.32,138.00,,Hospital CPT 88230,HC So Tissue Culture Lymphocyte,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,433.00,433.00,259.80,259.80,N/A,116.49,N/A,116.49,N/A,249.32,N/A,147.22,N/A,99.01,N/A,116.49,N/A,116.49,N/A,116.49,N/A,99.01,N/A,99.01,N/A,99.01,N/A,99.01,N/A,249.32,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,128.14,259.80,259.80,99.01,259.80,,Hospital CPT 88230,HC Tissue Culture Lymphocyte,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,478.00,478.00,286.80,286.80,N/A,116.49,N/A,116.49,N/A,275.23,N/A,162.52,N/A,99.01,N/A,116.49,N/A,116.49,N/A,116.49,N/A,99.01,N/A,99.01,N/A,99.01,N/A,99.01,N/A,275.23,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,116.49,N/A,128.14,286.80,286.80,99.01,286.80,,Hospital CPT 88233,HC So Tissue Culture Skin/Biopsy,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,938.00,938.00,562.80,562.80,N/A,140.73,N/A,140.73,N/A,540.10,N/A,318.92,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,87.60,N/A,140.73,N/A,140.73,N/A,140.73,N/A,540.10,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,154.80,562.80,562.80,87.60,562.80,,Hospital CPT 88233,HC Tissue Culture Skin/Biopsy,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,1034.00,1034.00,620.40,620.40,N/A,140.73,N/A,140.73,N/A,595.38,N/A,351.56,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,87.60,N/A,140.73,N/A,140.73,N/A,140.73,N/A,595.38,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,140.73,N/A,154.80,620.40,620.40,87.60,620.40,,Hospital CPT 88239,HC Tissue Culture Tumor,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,550.00,550.00,330.00,330.00,N/A,147.52,N/A,147.52,N/A,316.69,N/A,187.00,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,91.83,N/A,147.52,N/A,147.52,N/A,147.52,N/A,316.69,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,162.27,330.00,330.00,91.83,330.00,,Hospital CPT 88239,HC So Tissue Culture Tumor,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,499.00,499.00,299.40,299.40,N/A,147.52,N/A,147.52,N/A,287.32,N/A,169.66,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,91.83,N/A,147.52,N/A,147.52,N/A,147.52,N/A,287.32,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,147.52,N/A,162.27,299.40,299.40,91.83,299.40,,Hospital CPT 88240,HC So Cryopreserve/Storage of Cells,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,39.00,39.00,23.40,23.40,N/A,13.07,N/A,13.07,N/A,22.46,N/A,13.26,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,8.14,N/A,13.07,N/A,13.07,N/A,13.07,N/A,22.46,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,13.07,N/A,14.38,23.40,23.40,8.14,23.40,,Hospital CPT 88241,HC So Thawing of Cells,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,36.00,36.00,21.60,21.60,N/A,12.09,N/A,12.09,N/A,20.73,N/A,12.24,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,7.53,N/A,12.09,N/A,12.09,N/A,12.09,N/A,20.73,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,12.09,N/A,13.30,21.60,21.60,7.53,21.60,,Hospital CPT 88249,HC Chrom Anal Clastogen Stress,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,861.00,861.00,516.60,516.60,N/A,173.17,N/A,173.17,N/A,495.76,N/A,292.74,N/A,147.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,147.17,N/A,147.17,N/A,147.17,N/A,147.17,N/A,495.76,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,173.17,N/A,190.49,516.60,516.60,147.17,516.60,,Hospital CPT 88262,HC Chromosome Anal 15-20 (Path),N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,620.00,462.00,372.00,277.20,N/A,125.49,N/A,125.49,N/A,266.02,N/A,157.08,N/A,105.92,N/A,125.49,N/A,125.49,N/A,125.49,N/A,105.92,N/A,125.49,N/A,105.92,N/A,105.92,N/A,266.02,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,138.04,372.00,372.00,105.92,277.20,,Hospital CPT 88262,HC Chromosome Anal 15-20,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,620.00,462.00,372.00,277.20,N/A,125.49,N/A,125.49,N/A,266.02,N/A,157.08,N/A,105.92,N/A,125.49,N/A,125.49,N/A,125.49,N/A,105.92,N/A,125.49,N/A,105.92,N/A,105.92,N/A,266.02,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,138.04,372.00,372.00,105.92,277.20,,Hospital CPT 88262,HC So Chromosome Anal 15-20,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,561.00,561.00,336.60,336.60,N/A,125.49,N/A,125.49,N/A,323.02,N/A,190.74,N/A,105.92,N/A,125.49,N/A,125.49,N/A,125.49,N/A,105.92,N/A,125.49,N/A,105.92,N/A,105.92,N/A,323.02,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,125.49,N/A,138.04,336.60,336.60,105.92,336.60,,Hospital CPT 88263,HC Chromosome Analysis 45,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,436.00,436.00,261.60,261.60,N/A,150.29,N/A,150.29,N/A,251.05,N/A,148.24,N/A,150.29,N/A,150.29,N/A,150.29,N/A,150.29,N/A,93.56,N/A,150.29,N/A,150.29,N/A,150.29,N/A,251.05,N/A,150.29,N/A,150.29,N/A,150.29,N/A,150.29,N/A,150.29,N/A,150.29,N/A,150.29,N/A,165.32,261.60,261.60,93.56,261.60,,Hospital CPT 88264,HC So Chromosome Analysis 20-25,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,421.00,421.00,252.60,252.60,N/A,144.61,N/A,144.61,N/A,242.41,N/A,143.14,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,105.92,N/A,105.92,N/A,144.61,N/A,144.61,N/A,242.41,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,159.07,252.60,252.60,105.92,252.60,,Hospital CPT 88264,HC Chromosome Analysis 20-25,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,421.00,421.00,252.60,252.60,N/A,144.61,N/A,144.61,N/A,242.41,N/A,143.14,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,105.92,N/A,105.92,N/A,144.61,N/A,144.61,N/A,242.41,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,159.07,252.60,252.60,105.92,252.60,,Hospital CPT 88264,HC Chromosome Analysis 20-25 (Path),N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,465.00,465.00,279.00,279.00,N/A,144.61,N/A,144.61,N/A,267.75,N/A,158.10,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,105.92,N/A,105.92,N/A,144.61,N/A,144.61,N/A,267.75,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,144.61,N/A,159.07,279.00,279.00,105.92,279.00,,Hospital CPT 88267,HC So Chromosome Analysis 15,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,407.00,407.00,244.20,244.20,N/A,188.57,N/A,188.57,N/A,234.35,N/A,138.38,N/A,188.57,N/A,188.57,N/A,188.57,N/A,188.57,N/A,117.38,N/A,188.57,N/A,188.57,N/A,188.57,N/A,234.35,N/A,188.57,N/A,188.57,N/A,188.57,N/A,188.57,N/A,188.57,N/A,188.57,N/A,188.57,N/A,207.43,244.20,244.20,117.38,244.20,,Hospital CPT 88269,HC So Chromosome Analysis Am Fl,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,1188.00,1188.00,712.80,712.80,N/A,173.66,N/A,173.66,N/A,684.05,N/A,403.92,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,108.10,N/A,173.66,N/A,173.66,N/A,173.66,N/A,684.05,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,191.03,712.80,712.80,108.10,712.80,,Hospital CPT 88269,HC Chromosome Analysis Am Fl,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,1188.00,1188.00,712.80,712.80,N/A,173.66,N/A,173.66,N/A,684.05,N/A,403.92,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,108.10,N/A,173.66,N/A,173.66,N/A,173.66,N/A,684.05,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,173.66,N/A,191.03,712.80,712.80,108.10,712.80,,Hospital CPT 88274,"HC So Mol Cytogen,Insitu 25-99 Cells",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,720.00,720.00,432.00,432.00,N/A,42.38,N/A,42.38,N/A,414.58,N/A,244.80,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,26.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,414.58,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,46.62,432.00,432.00,26.38,432.00,,Hospital CPT 88274,"HC Mol Cytogen,Insitu 25-99 Cells",N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,794.00,594.00,476.40,356.40,N/A,42.38,N/A,42.38,N/A,342.03,N/A,201.96,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,26.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,342.03,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,42.38,N/A,46.62,476.40,476.40,26.38,356.40,,Hospital CPT 88300,HC Gross Exam,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,78.00,66.00,46.80,39.60,N/A,9.24,N/A,22.54,N/A,38.00,N/A,22.44,N/A,54.51,N/A,9.24,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,38.00,N/A,22.54,N/A,9.24,N/A,25.23,N/A,25.23,N/A,9.24,N/A,22.54,N/A,22.54,N/A,24.79,46.80,46.80,9.24,54.51,,Hospital CPT 88307,HC Tissue Level V,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,830.00,705.00,498.00,423.00,N/A,98.70,N/A,292.68,N/A,405.94,N/A,239.70,N/A,705.00,N/A,98.70,N/A,292.68,N/A,292.68,N/A,440.73,N/A,705.00,N/A,705.00,N/A,705.00,N/A,405.94,N/A,292.68,N/A,98.70,N/A,297.45,N/A,297.45,N/A,98.70,N/A,292.68,N/A,292.68,N/A,321.95,498.00,498.00,98.70,705.00,,Hospital CPT 88307,HC So Surgical Path V,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,752.00,752.00,451.20,451.20,N/A,105.28,N/A,292.68,N/A,433.00,N/A,255.68,N/A,707.98,N/A,105.28,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,433.00,N/A,292.68,N/A,105.28,N/A,297.45,N/A,297.45,N/A,105.28,N/A,292.68,N/A,292.68,N/A,321.95,451.20,451.20,105.28,707.98,,Hospital CPT 88312,HC Special Stain Grp 1 Microorgan,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,305.00,259.00,183.00,155.40,N/A,36.26,N/A,45.28,N/A,149.13,N/A,88.06,N/A,109.52,N/A,36.26,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,149.13,N/A,45.28,N/A,36.26,N/A,50.75,N/A,50.75,N/A,36.26,N/A,45.28,N/A,45.28,N/A,49.81,183.00,183.00,36.26,155.40,,Hospital CPT 88312,HC So Special Stain Grp 1 Microorgan,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,276.00,276.00,165.60,165.60,N/A,38.64,N/A,45.28,N/A,158.92,N/A,93.84,N/A,109.52,N/A,38.64,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,158.92,N/A,45.28,N/A,38.64,N/A,50.75,N/A,50.75,N/A,38.64,N/A,45.28,N/A,45.28,N/A,49.81,165.60,165.60,38.64,165.60,,Hospital CPT 88319,HC So Histochemical Identification,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1638.00,1638.00,982.80,982.80,N/A,229.32,N/A,100.11,N/A,943.16,N/A,556.92,N/A,365.40,N/A,229.32,N/A,100.11,N/A,100.11,N/A,227.46,N/A,365.40,N/A,365.40,N/A,365.40,N/A,943.16,N/A,100.11,N/A,229.32,N/A,669.29,N/A,669.29,N/A,229.32,N/A,100.11,N/A,100.11,N/A,110.12,982.80,982.80,100.11,982.80,,Hospital CPT 88319,HC Histochemical Identification,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1806.00,1806.00,1083.60,1083.60,N/A,252.84,N/A,100.11,N/A,1039.89,N/A,614.04,N/A,365.40,N/A,252.84,N/A,100.11,N/A,100.11,N/A,227.46,N/A,365.40,N/A,365.40,N/A,365.40,N/A,1039.89,N/A,100.11,N/A,252.84,N/A,669.29,N/A,669.29,N/A,252.84,N/A,100.11,N/A,100.11,N/A,110.12,1083.60,1083.60,100.11,1083.60,,Hospital CPT 88323,HC Pathology Consult - Referred,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1257.00,1068.00,754.20,640.80,N/A,149.52,N/A,46.22,N/A,614.95,N/A,363.12,N/A,109.52,N/A,149.52,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,614.95,N/A,45.28,N/A,149.52,N/A,50.75,N/A,50.75,N/A,149.52,N/A,45.28,N/A,46.22,N/A,49.81,754.20,754.20,45.28,640.80,,Hospital CPT 88323,HC So Pathology Consult - Referred,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1140.00,1140.00,684.00,684.00,N/A,159.60,N/A,46.22,N/A,656.41,N/A,387.60,N/A,109.52,N/A,159.60,N/A,45.28,N/A,45.28,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,656.41,N/A,45.28,N/A,159.60,N/A,50.75,N/A,50.75,N/A,159.60,N/A,45.28,N/A,46.22,N/A,49.81,684.00,684.00,45.28,684.00,,Hospital CPT 88325,"HC Surg Path, Consult, Slides",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1503.00,1277.00,901.80,766.20,N/A,178.78,N/A,130.63,N/A,735.30,N/A,434.18,N/A,445.89,N/A,178.78,N/A,130.63,N/A,130.63,N/A,277.57,N/A,445.89,N/A,445.89,N/A,445.89,N/A,735.30,N/A,130.63,N/A,178.78,N/A,152.32,N/A,152.32,N/A,178.78,N/A,130.63,N/A,130.63,N/A,143.69,901.80,901.80,130.63,766.20,,Hospital CPT 88325,"HC So Surg Path, Consult, Slides",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1362.00,1362.00,817.20,817.20,N/A,190.68,N/A,130.63,N/A,784.24,N/A,463.08,N/A,445.89,N/A,190.68,N/A,130.63,N/A,130.63,N/A,277.57,N/A,445.89,N/A,445.89,N/A,445.89,N/A,784.24,N/A,130.63,N/A,190.68,N/A,152.32,N/A,152.32,N/A,190.68,N/A,130.63,N/A,130.63,N/A,143.69,817.20,817.20,130.63,817.20,,Hospital CPT 88329,HC Path Consult During Surgery,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,83.00,83.00,49.80,49.80,N/A,11.62,N/A,30.67,N/A,47.79,N/A,28.22,N/A,74.18,N/A,11.62,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,47.79,N/A,30.67,N/A,11.62,N/A,34.57,N/A,34.57,N/A,11.62,N/A,30.67,N/A,30.67,N/A,33.73,49.80,49.80,11.62,74.18,,Hospital CPT 88331,HC Frozen Section,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,366.00,312.00,219.60,187.20,N/A,43.68,N/A,142.00,N/A,179.65,N/A,106.08,N/A,312.00,N/A,43.68,N/A,142.00,N/A,142.00,N/A,213.84,N/A,312.00,N/A,312.00,N/A,312.00,N/A,179.65,N/A,142.00,N/A,43.68,N/A,152.32,N/A,152.32,N/A,43.68,N/A,142.00,N/A,142.00,N/A,156.20,219.60,219.60,43.68,312.00,,Hospital CPT 88333,HC Touch Prep W/O Frozen,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,1941.00,1941.00,1164.60,1164.60,N/A,271.74,N/A,701.22,N/A,1117.63,N/A,659.94,N/A,1696.20,N/A,271.74,N/A,701.22,N/A,701.22,N/A,1055.92,N/A,1696.20,N/A,1696.20,N/A,1696.20,N/A,1117.63,N/A,701.22,N/A,271.74,N/A,669.29,N/A,669.29,N/A,271.74,N/A,701.22,N/A,701.22,N/A,771.34,1164.60,1164.60,271.74,1696.20,,Hospital CPT 88334,HC Touch Prep W/ Frozen,N/A,0311 - LABORATORY PATHOLOGICAL - CYTOLOGY,70.00,59.00,42.00,35.40,N/A,8.26,N/A,59.00,N/A,33.97,N/A,20.06,N/A,59.00,N/A,8.26,N/A,59.00,N/A,59.00,N/A,59.00,N/A,59.00,N/A,59.00,N/A,59.00,N/A,33.97,N/A,59.00,N/A,8.26,N/A,19.38,N/A,19.38,N/A,8.26,N/A,59.00,N/A,59.00,N/A,59.00,42.00,42.00,8.26,59.00,,Hospital CPT 88341,"HC So1 Ihc, Ea Addl Antibody",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,497.00,497.00,298.20,298.20,N/A,69.58,N/A,497.00,N/A,286.17,N/A,168.98,N/A,497.00,N/A,69.58,N/A,497.00,N/A,497.00,N/A,497.00,N/A,497.00,N/A,497.00,N/A,497.00,N/A,286.17,N/A,497.00,N/A,69.58,N/A,61.60,N/A,61.60,N/A,69.58,N/A,497.00,N/A,497.00,N/A,497.00,298.20,298.20,61.60,497.00,,Hospital CPT 88341,HC So Ihc Ea Addl Single Ab Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,497.00,497.00,298.20,298.20,N/A,69.58,N/A,497.00,N/A,286.17,N/A,168.98,N/A,497.00,N/A,69.58,N/A,497.00,N/A,497.00,N/A,497.00,N/A,497.00,N/A,497.00,N/A,497.00,N/A,286.17,N/A,497.00,N/A,69.58,N/A,61.60,N/A,61.60,N/A,69.58,N/A,497.00,N/A,497.00,N/A,497.00,298.20,298.20,61.60,497.00,,Hospital CPT 88341,HC Ihc Ea Addl Single Ab Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,548.00,548.00,328.80,328.80,N/A,76.72,N/A,548.00,N/A,315.54,N/A,186.32,N/A,548.00,N/A,76.72,N/A,548.00,N/A,548.00,N/A,548.00,N/A,548.00,N/A,548.00,N/A,548.00,N/A,315.54,N/A,548.00,N/A,76.72,N/A,61.60,N/A,61.60,N/A,76.72,N/A,548.00,N/A,548.00,N/A,548.00,328.80,328.80,61.60,548.00,,Hospital CPT 88342,HC Immunoperoxidase Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,548.00,467.00,328.80,280.20,N/A,65.38,N/A,142.00,N/A,268.90,N/A,158.78,N/A,343.50,N/A,65.38,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,268.90,N/A,142.00,N/A,65.38,N/A,152.32,N/A,152.32,N/A,65.38,N/A,142.00,N/A,142.00,N/A,156.20,328.80,328.80,65.38,343.50,,Hospital CPT 88342,"HC So1 Ihc, per Specimen, Inital Ab",N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,5138.00,5138.00,3082.80,3082.80,N/A,719.32,N/A,142.00,N/A,2958.46,N/A,1746.92,N/A,343.50,N/A,719.32,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,2958.46,N/A,142.00,N/A,719.32,N/A,152.32,N/A,152.32,N/A,719.32,N/A,142.00,N/A,142.00,N/A,156.20,3082.80,3082.80,142.00,3082.80,,Hospital CPT 88342,HC So Immunoperoxidase Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,1025.00,1025.00,615.00,615.00,N/A,143.50,N/A,142.00,N/A,590.20,N/A,348.50,N/A,343.50,N/A,143.50,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,590.20,N/A,142.00,N/A,143.50,N/A,152.32,N/A,152.32,N/A,143.50,N/A,142.00,N/A,142.00,N/A,156.20,615.00,615.00,142.00,615.00,,Hospital CPT 88344,HC So Ihc Ea Multiplex Ab Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,574.00,574.00,344.40,344.40,N/A,80.36,N/A,117.27,N/A,330.51,N/A,195.16,N/A,574.00,N/A,80.36,N/A,292.68,N/A,292.68,N/A,440.73,N/A,574.00,N/A,574.00,N/A,574.00,N/A,330.51,N/A,292.68,N/A,80.36,N/A,297.45,N/A,297.45,N/A,80.36,N/A,292.68,N/A,311.35,N/A,129.00,344.40,344.40,80.36,574.00,,Hospital CPT 88344,HC Ihc Ea Multiplex Ab Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,574.00,574.00,344.40,344.40,N/A,80.36,N/A,117.27,N/A,330.51,N/A,195.16,N/A,574.00,N/A,80.36,N/A,292.68,N/A,292.68,N/A,440.73,N/A,574.00,N/A,574.00,N/A,574.00,N/A,330.51,N/A,292.68,N/A,80.36,N/A,297.45,N/A,297.45,N/A,80.36,N/A,292.68,N/A,311.35,N/A,129.00,344.40,344.40,80.36,574.00,,Hospital CPT 88346,HC Immunofluoresc per Spec 1st Ab,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,810.00,810.00,486.00,486.00,N/A,113.40,N/A,302.72,N/A,466.40,N/A,275.40,N/A,707.98,N/A,113.40,N/A,292.68,N/A,292.68,N/A,440.73,N/A,707.98,N/A,707.98,N/A,707.98,N/A,466.40,N/A,292.68,N/A,113.40,N/A,297.45,N/A,297.45,N/A,113.40,N/A,292.68,N/A,298.77,N/A,114.44,486.00,486.00,113.40,707.98,,Hospital CPT 88346,HC So Immunofluoresc per Spec 1st Ab,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,215.00,215.00,129.00,129.00,N/A,30.10,N/A,302.72,N/A,123.80,N/A,73.10,N/A,215.00,N/A,30.10,N/A,292.68,N/A,292.68,N/A,215.00,N/A,215.00,N/A,215.00,N/A,215.00,N/A,123.80,N/A,292.68,N/A,30.10,N/A,215.00,N/A,215.00,N/A,30.10,N/A,292.68,N/A,298.77,N/A,114.44,129.00,129.00,30.10,302.72,,Hospital CPT 88364,HC So Insitu Hybridization,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,226.00,226.00,135.60,135.60,N/A,31.64,N/A,92.01,N/A,130.13,N/A,76.84,N/A,226.00,N/A,31.64,N/A,226.00,N/A,226.00,N/A,226.00,N/A,226.00,N/A,226.00,N/A,226.00,N/A,130.13,N/A,226.00,N/A,31.64,N/A,105.89,N/A,105.89,N/A,31.64,N/A,226.00,N/A,92.01,N/A,101.21,135.60,135.60,31.64,226.00,,Hospital CPT 88366,HC So Multiplex Probe Stain Procedure,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,564.00,564.00,338.40,338.40,N/A,78.96,N/A,298.77,N/A,324.75,N/A,191.76,N/A,564.00,N/A,78.96,N/A,292.68,N/A,292.68,N/A,440.73,N/A,564.00,N/A,564.00,N/A,564.00,N/A,324.75,N/A,292.68,N/A,78.96,N/A,297.45,N/A,297.45,N/A,78.96,N/A,292.68,N/A,298.77,N/A,217.64,338.40,338.40,78.96,564.00,,Hospital CPT 88366,HC Ewsr1 Insitu Hybridization (Fish),N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,623.00,623.00,373.80,373.80,N/A,87.22,N/A,298.77,N/A,358.72,N/A,211.82,N/A,623.00,N/A,87.22,N/A,292.68,N/A,292.68,N/A,440.73,N/A,623.00,N/A,623.00,N/A,623.00,N/A,358.72,N/A,292.68,N/A,87.22,N/A,297.45,N/A,297.45,N/A,87.22,N/A,292.68,N/A,298.77,N/A,217.64,373.80,373.80,87.22,623.00,,Hospital CPT 88368,HC in Situ Hybrid per Specimen,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,315.00,315.00,189.00,189.00,N/A,44.10,N/A,298.77,N/A,181.38,N/A,107.10,N/A,315.00,N/A,44.10,N/A,292.68,N/A,292.68,N/A,315.00,N/A,315.00,N/A,315.00,N/A,315.00,N/A,181.38,N/A,292.68,N/A,44.10,N/A,297.45,N/A,297.45,N/A,44.10,N/A,292.68,N/A,298.77,N/A,92.59,189.00,189.00,44.10,315.00,,Hospital CPT 88368,HC So in Situ Hybrid per Specimen,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,315.00,315.00,189.00,189.00,N/A,44.10,N/A,298.77,N/A,181.38,N/A,107.10,N/A,315.00,N/A,44.10,N/A,292.68,N/A,292.68,N/A,315.00,N/A,315.00,N/A,315.00,N/A,315.00,N/A,181.38,N/A,292.68,N/A,44.10,N/A,297.45,N/A,297.45,N/A,44.10,N/A,292.68,N/A,298.77,N/A,92.59,189.00,189.00,44.10,315.00,,Hospital CPT 88369,HC So Ish Ea Addl Single Probe Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,276.00,276.00,165.60,165.60,N/A,38.64,N/A,276.00,N/A,158.92,N/A,93.84,N/A,276.00,N/A,38.64,N/A,276.00,N/A,276.00,N/A,276.00,N/A,276.00,N/A,276.00,N/A,276.00,N/A,158.92,N/A,276.00,N/A,38.64,N/A,84.79,N/A,84.79,N/A,38.64,N/A,276.00,N/A,276.00,N/A,81.03,165.60,165.60,38.64,276.00,,Hospital CPT 88369,HC Ish Ea Addl Single Probe Stain,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,358.00,358.00,214.80,214.80,N/A,50.12,N/A,358.00,N/A,206.14,N/A,121.72,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,206.14,N/A,358.00,N/A,50.12,N/A,84.79,N/A,84.79,N/A,50.12,N/A,358.00,N/A,358.00,N/A,81.03,214.80,214.80,50.12,358.00,,Hospital CPT 88381,HC Microdissection,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,684.00,581.00,410.40,348.60,N/A,81.34,N/A,581.00,N/A,581.00,N/A,197.54,N/A,581.00,N/A,81.34,N/A,581.00,N/A,581.00,N/A,581.00,N/A,581.00,N/A,581.00,N/A,581.00,N/A,334.54,N/A,581.00,N/A,81.34,N/A,189.99,N/A,189.99,N/A,81.34,N/A,581.00,N/A,581.00,N/A,181.54,410.40,410.40,81.34,581.00,,Hospital CPT 88381,HC So Microdissection Manual,N/A,0312 - LABORATORY PATHOLOGICAL - HISTOLOGY,620.00,620.00,372.00,372.00,N/A,86.80,N/A,620.00,N/A,620.00,N/A,210.80,N/A,620.00,N/A,86.80,N/A,620.00,N/A,620.00,N/A,620.00,N/A,620.00,N/A,620.00,N/A,620.00,N/A,357.00,N/A,620.00,N/A,86.80,N/A,189.99,N/A,189.99,N/A,86.80,N/A,620.00,N/A,620.00,N/A,181.54,372.00,372.00,86.80,620.00,,Hospital 88738,HC Noninvasive Hemoglobin,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,45597.90,N/A,27358.74,N/A,9495.09,N/A,11497.84,N/A,21397.96,N/A,15503.29,N/A,N/A,N/A,N/A,N/A,2810.00,N/A,2810.00,N/A,13447.14,N/A,21602.65,N/A,21602.65,N/A,21602.65,N/A,21397.96,N/A,11497.84,N/A,9787.65,N/A,25701.76,N/A,25701.76,N/A,N/A,N/A,11497.84,N/A,11497.84,N/A,10472.79,N/A,2810.00,27358.74,N/A,N/A,,Hospital CPT 89060,HC Crystals-Joint Fluid,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,273.00,204.00,163.80,122.40,N/A,7.33,N/A,7.33,N/A,117.46,N/A,69.36,N/A,6.08,N/A,7.33,N/A,7.33,N/A,7.33,N/A,6.08,N/A,6.08,N/A,6.08,N/A,6.08,N/A,117.46,N/A,7.33,N/A,7.33,N/A,7.33,N/A,7.33,N/A,7.33,N/A,7.33,N/A,7.33,N/A,8.06,163.80,163.80,6.08,122.40,,Hospital CPT 89220,HC Obtain Sputum Spec-Induced,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,393.00,393.00,235.80,235.80,N/A,55.02,N/A,153.87,N/A,226.29,N/A,133.62,N/A,343.50,N/A,55.02,N/A,142.00,N/A,142.00,N/A,213.84,N/A,343.50,N/A,343.50,N/A,343.50,N/A,226.29,N/A,142.00,N/A,55.02,N/A,210.65,N/A,210.65,N/A,55.02,N/A,142.00,N/A,153.87,N/A,18.16,235.80,235.80,18.16,343.50,,Hospital CPT 89240,HC So Unlisted Misc Path Procedure,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,58.00,58.00,34.80,34.80,N/A,8.12,N/A,46.22,N/A,33.40,N/A,19.72,N/A,58.00,N/A,8.12,N/A,45.28,N/A,45.28,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,33.40,N/A,45.28,N/A,8.12,N/A,50.75,N/A,50.75,N/A,8.12,N/A,45.28,N/A,46.22,N/A,58.00,34.80,34.80,8.12,58.00,,Hospital CPT 89240,HC Unlisted Misc Path Procedure,N/A,0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION,58.00,58.00,34.80,34.80,N/A,8.12,N/A,46.22,N/A,33.40,N/A,19.72,N/A,58.00,N/A,8.12,N/A,45.28,N/A,45.28,N/A,58.00,N/A,58.00,N/A,58.00,N/A,58.00,N/A,33.40,N/A,45.28,N/A,8.12,N/A,50.75,N/A,50.75,N/A,8.12,N/A,45.28,N/A,46.22,N/A,58.00,34.80,34.80,8.12,58.00,,Hospital CPT 89310,HC Semen Analysis W Count,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,29.00,29.00,17.40,17.40,N/A,8.61,N/A,8.61,N/A,16.70,N/A,9.86,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,5.36,N/A,8.61,N/A,8.61,N/A,8.61,N/A,16.70,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,8.61,N/A,9.47,17.40,17.40,5.36,17.40,,Hospital CPT 89325,HC So Sperm Antibodies,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,164.00,164.00,98.40,98.40,N/A,10.67,N/A,10.67,N/A,94.43,N/A,55.76,N/A,9.07,N/A,10.67,N/A,10.67,N/A,10.67,N/A,9.07,N/A,9.07,N/A,9.07,N/A,9.07,N/A,94.43,N/A,10.67,N/A,10.67,N/A,10.67,N/A,10.67,N/A,10.67,N/A,10.67,N/A,10.67,N/A,11.74,98.40,98.40,9.07,98.40,,Hospital 89398,HC So Sperm Morphology,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,N/A,589.00,N/A,353.40,N/A,44.23,N/A,60.48,N/A,22.35,N/A,200.26,N/A,109.52,N/A,44.23,N/A,57.59,N/A,57.59,N/A,68.18,N/A,109.52,N/A,109.52,N/A,109.52,N/A,339.14,N/A,57.59,N/A,44.23,N/A,63.06,N/A,63.06,N/A,44.23,N/A,57.59,N/A,60.48,N/A,13.54,N/A,N/A,13.54,353.40,,Hospital HCPCS 90375,RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,13533-0318-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3017.00,3017.00,1810.20,1810.20,N/A,422.38,N/A,569.36,N/A,1696.16,N/A,1025.78,N/A,1481.58,N/A,422.38,N/A,569.36,N/A,569.36,N/A,922.30,N/A,1481.58,N/A,1481.58,N/A,1481.58,N/A,1696.16,N/A,569.36,N/A,422.38,N/A,1617.11,N/A,1617.11,N/A,422.38,N/A,569.36,N/A,569.36,N/A,626.29,1810.20,1810.20,422.38,1810.20,,Hospital HCPCS 90375,RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,13533-0318-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15084.90,15084.90,9050.94,9050.94,N/A,2111.89,N/A,2846.78,N/A,8480.73,N/A,5128.87,N/A,7407.92,N/A,2111.89,N/A,2846.78,N/A,2846.78,N/A,4611.50,N/A,7407.92,N/A,7407.92,N/A,7407.92,N/A,8480.73,N/A,2846.78,N/A,2111.89,N/A,8085.51,N/A,8085.51,N/A,2111.89,N/A,2846.78,N/A,2846.78,N/A,3131.46,9050.94,9050.94,2111.89,9050.94,,Hospital HCPCS 90375,RABIES IMMUNE GLOBULIN 300 UNIT/2ML IJ SOLN,49281-0190-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3879.20,3879.20,2327.52,2327.52,N/A,543.09,N/A,3879.20,N/A,2180.89,N/A,1318.93,N/A,1831.08,N/A,543.09,N/A,3879.20,N/A,3879.20,N/A,1139.86,N/A,1831.08,N/A,1831.08,N/A,1831.08,N/A,2180.89,N/A,3879.20,N/A,543.09,N/A,2079.25,N/A,2079.25,N/A,543.09,N/A,3879.20,N/A,3879.20,N/A,3879.20,2327.52,2327.52,543.09,3879.20,,Hospital 90376,"Rabies Ig, Heat Treated",N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT 90472,HC Subsequent Immun Admin,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,11.79,N/A,61.03,N/A,36.04,N/A,106.00,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,N/A,106.00,N/A,106.00,N/A,106.00,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,11.79,N/A,12.97,63.60,63.60,11.79,106.00,,Hospital 90474,HC Immune Admin Oral/Nasal Addl,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,N/A,718.02,N/A,430.81,N/A,100.52,N/A,40.12,N/A,411.19,N/A,244.12,N/A,312.37,N/A,100.52,N/A,38.26,N/A,38.26,N/A,302.66,N/A,312.37,N/A,312.37,N/A,312.37,N/A,411.19,N/A,38.26,N/A,100.52,N/A,384.87,N/A,384.87,N/A,100.52,N/A,38.26,N/A,39.07,N/A,42.98,N/A,N/A,38.26,430.81,,Hospital 90586,"Bcg Vaccine, Intravesical",N/A,N/A,N/A,5809.80,N/A,3485.88,N/A,813.38,N/A,600.73,N/A,3297.74,N/A,1975.34,N/A,1732.84,N/A,813.38,N/A,564.71,N/A,564.71,N/A,1078.72,N/A,1732.84,N/A,1732.84,N/A,1732.84,N/A,3297.74,N/A,564.71,N/A,813.38,N/A,527.00,N/A,527.00,N/A,813.38,N/A,564.71,N/A,600.73,N/A,46.19,N/A,N/A,46.19,3485.88,,Hospital HCPCS 90632,HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,58160-0826-43,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),172.60,172.60,103.56,103.56,N/A,24.16,N/A,172.60,N/A,97.04,N/A,58.68,N/A,172.60,N/A,24.16,N/A,172.60,N/A,172.60,N/A,110.85,N/A,172.60,N/A,172.60,N/A,172.60,N/A,97.04,N/A,172.60,N/A,24.16,N/A,92.51,N/A,92.51,N/A,24.16,N/A,172.60,N/A,172.60,N/A,172.60,103.56,103.56,24.16,172.60,,Hospital 90649,HC 4vhpv Vaccine 3 Dose Schedule for Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,974.00,N/A,584.40,N/A,136.36,N/A,64.81,N/A,552.69,N/A,331.16,N/A,465.40,N/A,136.36,N/A,60.93,N/A,60.93,N/A,435.68,N/A,465.40,N/A,465.40,N/A,465.40,N/A,552.69,N/A,60.93,N/A,136.36,N/A,522.06,N/A,522.06,N/A,136.36,N/A,60.93,N/A,64.81,N/A,55.95,N/A,N/A,55.95,584.40,,Hospital HCPCS 90677,PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,00005-2000-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),560.30,560.30,336.18,336.18,N/A,78.44,N/A,560.30,N/A,315.00,N/A,190.50,N/A,560.30,N/A,78.44,N/A,560.30,N/A,560.30,N/A,457.44,N/A,560.30,N/A,560.30,N/A,560.30,N/A,315.00,N/A,560.30,N/A,78.44,N/A,300.32,N/A,300.32,N/A,78.44,N/A,560.30,N/A,560.30,N/A,560.30,336.18,336.18,78.44,560.30,,Hospital 90681,HC Rh1 Vacc 2 Does Live Oral,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,903.00,N/A,541.80,N/A,126.42,N/A,187.68,N/A,514.08,N/A,307.02,N/A,432.00,N/A,126.42,N/A,185.66,N/A,185.66,N/A,852.31,N/A,432.00,N/A,432.00,N/A,432.00,N/A,514.08,N/A,185.66,N/A,126.42,N/A,484.01,N/A,484.01,N/A,126.42,N/A,185.66,N/A,187.68,N/A,17.04,N/A,N/A,17.04,852.31,,Hospital 90686,HC Iiv4 Vacc Presrv Free 0.5 Ml Dos for Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),24818.00,364.00,14890.80,218.40,6576.20,50.96,5664.34,149.00,10425.00,208.99,8438.12,123.76,6352.00,44.00,6576.20,50.96,5664.34,147.40,5664.34,147.40,3956.00,33.10,6352.00,44.00,6352.00,44.00,6352.00,44.00,5872.36,208.99,3710.34,147.40,6707.76,50.96,24818.00,195.10,24818.00,195.10,4461.28,50.96,6196.00,147.40,5664.34,149.00,6707.72,169.11,3710.34,24818.00,33.10,218.40,,Hospital 90688,HC Flu Vacc 4 Val 3yrs Plus Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,68.02,N/A,40.81,N/A,9.52,N/A,38.68,N/A,39.16,N/A,23.12,N/A,68.01,N/A,9.52,N/A,38.26,N/A,38.26,N/A,68.01,N/A,68.01,N/A,68.01,N/A,68.01,N/A,39.16,N/A,38.26,N/A,9.52,N/A,36.46,N/A,36.46,N/A,9.52,N/A,38.26,N/A,38.68,N/A,N/A,N/A,N/A,9.52,68.01,,Hospital 90691,"HC Typhoid Vaccine, Im",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,42.50,N/A,25.50,N/A,5.96,N/A,67.21,N/A,24.19,N/A,14.46,N/A,42.50,N/A,5.96,N/A,60.93,N/A,60.93,N/A,42.50,N/A,42.50,N/A,42.50,N/A,42.50,N/A,24.19,N/A,60.93,N/A,5.96,N/A,22.78,N/A,22.78,N/A,5.96,N/A,60.93,N/A,15.49,N/A,17.04,N/A,N/A,5.96,67.21,,Hospital 90694,HC Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),20901.90,532.00,12541.14,319.20,8700.77,72.71,10557.80,40.55,20901.90,304.44,7106.65,180.88,20901.90,285.37,8968.85,72.71,1781.62,38.26,1781.62,38.26,14786.65,198.85,20901.90,285.37,20901.90,285.37,20901.90,285.37,20901.90,304.44,10557.80,147.40,8968.85,72.71,20901.90,86.90,20901.90,86.90,N/A,72.71,10557.80,147.40,10557.80,156.21,9596.67,27.72,1781.62,20901.90,27.72,319.20,,Hospital 90696,HC Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,546.00,N/A,327.60,N/A,76.44,N/A,224.81,N/A,309.07,N/A,185.64,N/A,538.37,N/A,76.44,N/A,220.93,N/A,220.93,N/A,546.00,N/A,538.37,N/A,538.37,N/A,538.37,N/A,309.07,N/A,220.93,N/A,76.44,N/A,292.66,N/A,292.66,N/A,76.44,N/A,220.93,N/A,224.81,N/A,42.98,N/A,N/A,42.98,546.00,,Hospital 90713,"HC Poliomyelitis Immunizatn,Inactv,Sub-Q",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1945644.77,3164.87,1167386.86,1898.92,442322.58,443.08,N/A,50.86,378392.87,1788.50,N/A,1076.04,N/A,1299.61,442322.58,443.08,N/A,76.52,N/A,76.52,N/A,809.02,N/A,1299.61,N/A,1299.61,N/A,1299.61,378392.87,1788.50,N/A,76.52,442322.58,443.08,378392.87,1696.36,378392.87,1696.36,442322.58,443.08,N/A,76.52,N/A,50.86,442322.58,55.95,378392.87,1167386.86,50.86,1898.92,,Hospital HCPCS 90714,TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ,49281-0215-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),85.40,85.40,51.24,51.24,N/A,11.96,N/A,85.40,N/A,48.01,N/A,29.04,N/A,75.08,N/A,11.96,N/A,85.40,N/A,85.40,N/A,46.74,N/A,75.08,N/A,75.08,N/A,75.08,N/A,48.01,N/A,85.40,N/A,11.96,N/A,45.77,N/A,45.77,N/A,11.96,N/A,85.40,N/A,85.40,N/A,85.40,51.24,51.24,11.96,85.40,,Hospital HCPCS 90714,TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5ML IM SUSP,13533-0131-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),61.20,61.20,36.72,36.72,N/A,8.57,N/A,61.20,N/A,34.41,N/A,20.81,N/A,61.20,N/A,8.57,N/A,61.20,N/A,61.20,N/A,46.74,N/A,61.20,N/A,61.20,N/A,61.20,N/A,34.41,N/A,61.20,N/A,8.57,N/A,32.80,N/A,32.80,N/A,8.57,N/A,61.20,N/A,61.20,N/A,61.20,36.72,36.72,8.57,61.20,,Hospital HCPCS 90715,TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP,49281-0400-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),113.60,113.60,68.16,68.16,N/A,15.90,N/A,113.60,N/A,63.87,N/A,38.62,N/A,95.21,N/A,15.90,N/A,113.60,N/A,113.60,N/A,59.27,N/A,95.21,N/A,95.21,N/A,95.21,N/A,63.87,N/A,113.60,N/A,15.90,N/A,60.89,N/A,60.89,N/A,15.90,N/A,113.60,N/A,113.60,N/A,113.60,68.16,68.16,15.90,113.60,,Hospital HCPCS 90715,TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,58160-0842-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),100.80,100.80,60.48,60.48,N/A,14.11,N/A,100.80,N/A,56.67,N/A,34.27,N/A,95.21,N/A,14.11,N/A,100.80,N/A,100.80,N/A,59.27,N/A,95.21,N/A,95.21,N/A,95.21,N/A,56.67,N/A,100.80,N/A,14.11,N/A,54.03,N/A,54.03,N/A,14.11,N/A,100.80,N/A,100.80,N/A,100.80,60.48,60.48,14.11,100.80,,Hospital 90750,HC Hzv Vacc Recombinant Im,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,688.00,N/A,412.80,N/A,96.32,N/A,64.57,N/A,391.59,N/A,233.92,N/A,482.30,N/A,96.32,N/A,60.93,N/A,60.93,N/A,389.48,N/A,482.30,N/A,482.30,N/A,482.30,N/A,391.59,N/A,60.93,N/A,96.32,N/A,368.77,N/A,368.77,N/A,96.32,N/A,60.93,N/A,64.57,N/A,31.77,N/A,N/A,31.77,482.30,,Hospital 90756,HC Cciiv4 Vacc Abx Free Im 0.5ml Dose Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,3036.00,N/A,1821.60,N/A,425.04,N/A,40.70,N/A,1712.02,N/A,1032.24,N/A,491.78,N/A,425.04,N/A,38.26,N/A,38.26,N/A,306.14,N/A,491.78,N/A,491.78,N/A,491.78,N/A,1712.02,N/A,38.26,N/A,425.04,N/A,1627.29,N/A,1627.29,N/A,425.04,N/A,38.26,N/A,40.70,N/A,33.56,N/A,N/A,33.56,1821.60,,Hospital 90785,HC Psychotherapy Complex Interactive,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,N/A,4151.00,N/A,2490.60,N/A,581.14,N/A,526.16,N/A,2390.14,N/A,1411.34,N/A,1728.39,N/A,581.14,N/A,503.90,N/A,503.90,N/A,1194.75,N/A,1728.39,N/A,1728.39,N/A,1728.39,N/A,3062.74,N/A,499.63,N/A,581.14,N/A,616.94,N/A,616.94,N/A,581.14,N/A,503.90,N/A,538.91,N/A,592.79,N/A,N/A,499.63,3062.74,,Hospital CPT 90791,HC Php Psych Evaluation,N/A,0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - GENERAL CLASSIFICATION,502.00,502.00,301.20,301.20,N/A,70.28,N/A,151.06,N/A,289.05,N/A,170.68,N/A,318.26,N/A,70.28,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,401.60,N/A,131.57,N/A,70.28,N/A,269.07,N/A,269.07,N/A,70.28,N/A,131.57,N/A,139.97,N/A,166.17,301.20,301.20,70.28,401.60,,Hospital CPT 90792,HC Php Psy Eval W/Med Srvc,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,572.00,571.00,343.20,342.60,N/A,79.94,N/A,137.63,N/A,328.78,N/A,194.14,N/A,318.26,N/A,79.94,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,456.80,N/A,131.57,N/A,79.94,N/A,571.00,N/A,571.00,N/A,79.94,N/A,131.57,N/A,137.63,N/A,188.52,343.20,343.20,79.94,571.00,,Hospital 90804,"Psychotherapy, Office (20-30)",N/A,N/A,N/A,2095.00,N/A,1257.00,N/A,296.10,N/A,12.60,N/A,1206.32,N/A,712.30,N/A,296.10,N/A,296.10,N/A,12.60,N/A,12.60,N/A,184.05,N/A,296.10,N/A,296.10,N/A,296.10,N/A,1882.35,N/A,12.60,N/A,296.10,N/A,12.60,N/A,12.60,N/A,296.10,N/A,742.60,N/A,12.60,N/A,13.86,N/A,N/A,12.60,1882.35,,Hospital 90806,"Psychotherapy, Office (45-50)",N/A,N/A,N/A,2095.00,N/A,1257.00,N/A,296.10,N/A,12.60,N/A,1206.32,N/A,712.30,N/A,296.10,N/A,296.10,N/A,12.60,N/A,12.60,N/A,184.05,N/A,296.10,N/A,296.10,N/A,296.10,N/A,1882.35,N/A,12.60,N/A,296.10,N/A,12.60,N/A,12.60,N/A,296.10,N/A,742.60,N/A,12.60,N/A,13.86,N/A,N/A,12.60,1882.35,,Hospital CPT 90837,HC OP Psych Tx 60 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,928.00,928.00,556.80,556.80,N/A,129.92,N/A,139.97,N/A,534.34,N/A,315.52,N/A,318.26,N/A,129.92,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,742.40,N/A,131.57,N/A,129.92,N/A,928.00,N/A,928.00,N/A,129.92,N/A,131.57,N/A,139.97,N/A,144.73,556.80,556.80,129.92,928.00,,Hospital CPT 90837,HC Php Psych Tx 60 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,928.00,928.00,556.80,556.80,N/A,129.92,N/A,139.97,N/A,534.34,N/A,315.52,N/A,318.26,N/A,129.92,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,742.40,N/A,131.57,N/A,129.92,N/A,928.00,N/A,928.00,N/A,129.92,N/A,131.57,N/A,139.97,N/A,144.73,556.80,556.80,129.92,928.00,,Hospital CPT 90837,HC Iop Tx 60 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,928.00,928.00,556.80,556.80,N/A,129.92,N/A,139.97,N/A,534.34,N/A,315.52,N/A,318.26,N/A,129.92,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,742.40,N/A,131.57,N/A,129.92,N/A,928.00,N/A,928.00,N/A,129.92,N/A,131.57,N/A,139.97,N/A,144.73,556.80,556.80,129.92,928.00,,Hospital CPT 90840,HC Php Crisis Tx First Addl 30,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,358.00,358.00,214.80,214.80,N/A,50.12,N/A,358.00,N/A,206.14,N/A,121.72,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,286.40,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,68.84,214.80,214.80,50.12,358.00,,Hospital CPT 90840,HC Iop Crisis Tx First Addl 30,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,358.00,358.00,214.80,214.80,N/A,50.12,N/A,358.00,N/A,206.14,N/A,121.72,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,358.00,N/A,286.40,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,50.12,N/A,358.00,N/A,358.00,N/A,68.84,214.80,214.80,50.12,358.00,,Hospital CPT 90846,HC Php Family Tx WO Pt,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,930.00,930.00,558.00,558.00,N/A,130.20,N/A,138.99,N/A,535.49,N/A,316.20,N/A,318.26,N/A,130.20,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,535.49,N/A,131.57,N/A,130.20,N/A,930.00,N/A,930.00,N/A,130.20,N/A,131.57,N/A,95.55,N/A,105.11,558.00,558.00,95.55,930.00,,Hospital CPT 90846,HC Iop Family Tx WO Pt,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,930.00,930.00,558.00,558.00,N/A,130.20,N/A,138.99,N/A,535.49,N/A,316.20,N/A,318.26,N/A,130.20,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,535.49,N/A,131.57,N/A,130.20,N/A,930.00,N/A,930.00,N/A,130.20,N/A,131.57,N/A,95.55,N/A,105.11,558.00,558.00,95.55,930.00,,Hospital CPT 90849,HC Iop Multi Fam Group Tx,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,538.00,538.00,322.80,322.80,N/A,75.32,N/A,139.97,N/A,309.78,N/A,182.92,N/A,318.26,N/A,75.32,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,309.78,N/A,131.57,N/A,75.32,N/A,538.00,N/A,538.00,N/A,75.32,N/A,131.57,N/A,139.97,N/A,30.04,322.80,322.80,30.04,538.00,,Hospital CPT 90849,HC Php Multi Fam Group Tx,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,538.00,538.00,322.80,322.80,N/A,75.32,N/A,139.97,N/A,309.78,N/A,182.92,N/A,318.26,N/A,75.32,N/A,131.57,N/A,131.57,N/A,198.13,N/A,318.26,N/A,318.26,N/A,318.26,N/A,309.78,N/A,131.57,N/A,75.32,N/A,538.00,N/A,538.00,N/A,75.32,N/A,131.57,N/A,139.97,N/A,30.04,322.80,322.80,30.04,538.00,,Hospital CPT 90853,HC Iop Group,N/A,0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - GROUP THERAPY,479.00,479.00,287.40,287.40,N/A,67.06,N/A,72.35,N/A,275.81,N/A,162.86,N/A,165.69,N/A,67.06,N/A,68.50,N/A,68.50,N/A,103.15,N/A,165.69,N/A,165.69,N/A,165.69,N/A,383.20,N/A,68.50,N/A,67.06,N/A,479.00,N/A,479.00,N/A,67.06,N/A,68.50,N/A,23.40,N/A,25.74,287.40,287.40,23.40,479.00,,Hospital 90857,Interactive Group Psychotherapy,N/A,N/A,N/A,2095.00,N/A,1257.00,N/A,296.10,N/A,12.60,N/A,1206.32,N/A,712.30,N/A,296.10,N/A,296.10,N/A,12.60,N/A,12.60,N/A,184.05,N/A,296.10,N/A,296.10,N/A,296.10,N/A,1882.35,N/A,12.60,N/A,296.10,N/A,12.60,N/A,12.60,N/A,296.10,N/A,742.60,N/A,12.60,N/A,13.86,N/A,N/A,12.60,1882.35,,Hospital 90867,HC Tcranial Magn Stim Tx Plan,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,2540.00,N/A,1524.00,N/A,355.60,N/A,1307.90,N/A,1462.54,N/A,863.60,N/A,2540.00,N/A,355.60,N/A,1264.55,N/A,1264.55,N/A,1904.15,N/A,2540.00,N/A,2540.00,N/A,2540.00,N/A,1462.54,N/A,1264.55,N/A,355.60,N/A,1361.42,N/A,1361.42,N/A,355.60,N/A,1264.55,N/A,1307.90,N/A,N/A,N/A,N/A,355.60,2540.00,,Hospital 90868,HC Tcranial Magn Stim Tx Deli,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,5840.00,N/A,3504.00,N/A,817.60,N/A,2045.12,N/A,3362.64,N/A,1985.60,N/A,4894.08,N/A,817.60,N/A,2023.28,N/A,2023.28,N/A,3046.64,N/A,4894.08,N/A,4894.08,N/A,4894.08,N/A,3362.64,N/A,2023.28,N/A,817.60,N/A,3130.24,N/A,3130.24,N/A,817.60,N/A,2023.28,N/A,2045.12,N/A,2230.02,N/A,N/A,817.60,4894.08,,Hospital 90899,HC Php Psycho ED Group,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,N/A,66.00,N/A,39.60,N/A,9.24,N/A,N/A,N/A,38.00,N/A,22.44,N/A,64.83,N/A,9.24,N/A,N/A,N/A,N/A,N/A,40.36,N/A,64.83,N/A,64.83,N/A,64.83,N/A,38.00,N/A,N/A,N/A,9.24,N/A,27.72,N/A,27.72,N/A,9.24,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9.24,64.83,,Hospital 90901,HC Biofeedback (Any Modality),N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,N/A,2913.00,N/A,1747.80,N/A,407.82,N/A,281.05,N/A,1677.33,N/A,990.42,N/A,986.07,N/A,407.82,N/A,281.05,N/A,281.05,N/A,900.31,N/A,986.07,N/A,986.07,N/A,986.07,N/A,1677.33,N/A,290.31,N/A,407.82,N/A,1561.38,N/A,1561.38,N/A,407.82,N/A,281.05,N/A,281.05,N/A,309.15,N/A,N/A,281.05,1747.80,,Hospital CPT 90912,HC Bfb Traing W/Emg &/Manometry 1st 15 Min Cntct,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,227.00,227.00,136.20,136.20,N/A,31.78,N/A,41.90,N/A,130.71,N/A,77.18,N/A,224.61,N/A,31.78,N/A,41.90,N/A,41.90,N/A,139.82,N/A,224.61,N/A,224.61,N/A,224.61,N/A,130.71,N/A,41.90,N/A,31.78,N/A,121.67,N/A,121.67,N/A,31.78,N/A,41.90,N/A,41.90,N/A,46.09,136.20,136.20,31.78,224.61,,Hospital CPT 90913,HC Bfb Traing W/Emg&/Manometry Ea Addl 15 Min Cntct,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,227.00,227.00,136.20,136.20,N/A,31.78,N/A,23.56,N/A,130.71,N/A,77.18,N/A,91.65,N/A,31.78,N/A,23.56,N/A,23.56,N/A,57.05,N/A,91.65,N/A,91.65,N/A,91.65,N/A,130.71,N/A,23.56,N/A,31.78,N/A,121.67,N/A,121.67,N/A,31.78,N/A,23.56,N/A,23.56,N/A,25.92,136.20,136.20,23.56,136.20,,Hospital 91010,Esophageal Motility Study W/Interp&Rpt,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,3582.00,N/A,2149.20,N/A,501.48,N/A,456.66,N/A,2062.52,N/A,1217.88,N/A,1055.99,N/A,501.48,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,2062.52,N/A,436.56,N/A,501.48,N/A,527.00,N/A,527.00,N/A,501.48,N/A,436.56,N/A,456.66,N/A,160.73,N/A,N/A,160.73,2149.20,,Hospital 91020,Gastric Motility Study,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,3582.00,N/A,2149.20,N/A,501.48,N/A,456.66,N/A,2062.52,N/A,1217.88,N/A,2111.98,N/A,501.48,N/A,436.56,N/A,436.56,N/A,1314.74,N/A,2111.98,N/A,2111.98,N/A,2111.98,N/A,2062.52,N/A,436.56,N/A,501.48,N/A,527.00,N/A,527.00,N/A,501.48,N/A,436.56,N/A,456.66,N/A,208.70,N/A,N/A,208.70,2149.20,,Hospital 91030,Acid Perfusion of Esophagus,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,41763.20,N/A,25057.92,N/A,5846.85,N/A,1901.20,N/A,2552.00,N/A,14199.48,N/A,4357.21,N/A,5846.85,N/A,1787.20,N/A,1787.20,N/A,2712.45,N/A,4357.21,N/A,4357.21,N/A,4357.21,N/A,2552.00,N/A,1787.20,N/A,5846.85,N/A,2938.25,N/A,2938.25,N/A,5846.85,N/A,1787.20,N/A,1901.20,N/A,786.28,N/A,N/A,786.28,25057.92,,Hospital CPT 91035,Gastroesophag Reflx Test W/Tel Ph Eltrd,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,1224.00,1224.00,734.40,734.40,N/A,171.36,N/A,360.26,N/A,704.78,N/A,416.16,N/A,1055.99,N/A,171.36,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,704.78,N/A,436.56,N/A,171.36,N/A,527.00,N/A,527.00,N/A,171.36,N/A,436.56,N/A,360.26,N/A,396.29,734.40,734.40,171.36,1055.99,,Hospital 91112,GI Transit & Pres Meas Wireless Capsule W/Interp,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,7620.38,N/A,4572.23,N/A,1066.85,N/A,779.79,N/A,4387.82,N/A,2590.93,N/A,1803.23,N/A,1066.85,N/A,745.47,N/A,745.47,N/A,1122.54,N/A,1803.23,N/A,1803.23,N/A,1803.23,N/A,4387.82,N/A,745.47,N/A,1066.85,N/A,1871.00,N/A,1871.00,N/A,1066.85,N/A,745.47,N/A,779.79,N/A,1612.30,N/A,N/A,745.47,4572.23,,Hospital 91122,HC Anorectal Manometry,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,1141.00,N/A,684.60,N/A,159.74,N/A,399.19,N/A,656.99,N/A,387.94,N/A,611.76,N/A,159.74,N/A,384.24,N/A,384.24,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,656.99,N/A,384.24,N/A,159.74,N/A,611.57,N/A,611.57,N/A,159.74,N/A,384.24,N/A,399.19,N/A,214.30,N/A,N/A,159.74,684.60,,Hospital 91200,HC Liver Elastography W/O Imag W/I&R,N/A,0402 - OTHER IMAGING SERVICES - ULTRASOUND,N/A,414.00,N/A,248.40,N/A,57.96,N/A,134.84,N/A,238.38,N/A,140.76,N/A,317.67,N/A,57.96,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,238.38,N/A,131.33,N/A,57.96,N/A,221.90,N/A,221.90,N/A,57.96,N/A,131.33,N/A,134.84,N/A,19.83,N/A,N/A,19.83,317.67,,Hospital 91300,Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,N/A,N/A,34802.00,218749.97,20881.20,131249.98,5366.09,30609.30,6613.46,16810.92,12092.93,124490.27,11832.68,74375.01,12208.61,29278.17,5531.43,30609.30,2810.00,16739.64,2810.00,16739.64,7599.57,18422.24,12208.61,29278.17,12208.61,29278.17,12208.61,N/A,12092.93,123481.53,6613.46,16762.58,5531.43,30609.30,14525.20,13819.75,14525.20,13819.75,3791.84,30609.30,6613.46,16739.64,2595.88,16810.92,5918.63,4502.30,2595.88,20881.20,4502.30,131249.98,,Hospital 91305,Pfizer-BioNTech Covid-19 Vaccine (Ready to Use),N/A,N/A,39801.62,N/A,23880.97,N/A,9357.99,N/A,11335.66,N/A,21088.99,N/A,13532.56,N/A,21290.73,N/A,9646.33,N/A,2810.00,N/A,2810.00,N/A,13252.98,N/A,21290.73,N/A,21290.73,N/A,21290.73,N/A,21088.99,N/A,11335.66,N/A,9646.33,N/A,25330.65,N/A,25330.65,N/A,3266.67,N/A,11335.66,N/A,11335.66,N/A,10321.57,N/A,2810.00,25330.65,N/A,N/A,,Hospital 91306,HC Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,317.02,N/A,190.21,N/A,43.87,N/A,39.73,N/A,182.54,N/A,107.78,N/A,90.69,N/A,43.87,N/A,37.49,N/A,37.49,N/A,56.46,N/A,90.69,N/A,90.69,N/A,90.69,N/A,182.54,N/A,37.49,N/A,43.87,N/A,113.57,N/A,113.57,N/A,43.87,N/A,37.49,N/A,39.73,N/A,38.20,N/A,N/A,37.49,190.21,,Hospital 91313,HC Sarscov2 Vaccine Bivalent 50 Mcg/0.5 Ml Im Use,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),18938.72,105.02,11363.23,63.01,4244.22,14.70,5286.34,39.73,9564.70,60.47,6439.14,35.70,9656.20,90.69,4375.00,14.70,5286.34,37.49,5286.34,37.49,6010.76,56.46,9656.20,90.69,9656.20,90.69,9656.20,90.69,9564.70,60.47,5286.34,37.49,4375.00,14.70,11488.46,56.29,11488.46,56.29,N/A,14.70,5286.34,37.49,5286.34,39.73,4681.25,N/A,4244.22,11488.46,14.70,90.69,,Hospital 92012,HC Ophth Medical Xm&Eval Intermediate Estab Pt,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,491.00,N/A,294.60,N/A,68.74,N/A,115.66,N/A,282.71,N/A,166.94,N/A,N/A,N/A,68.74,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,282.71,N/A,109.14,N/A,68.74,N/A,263.17,N/A,263.17,N/A,68.74,N/A,109.14,N/A,115.66,N/A,68.35,N/A,N/A,68.35,294.60,,Hospital 92018,Ophth Xm&Eval Anes W/WO Manj Globe Compl,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,5585.00,N/A,3351.00,N/A,781.90,N/A,1899.46,N/A,3214.85,N/A,1898.90,N/A,4627.53,N/A,781.90,N/A,1909.23,N/A,1909.23,N/A,2880.73,N/A,4627.53,N/A,4627.53,N/A,4627.53,N/A,3214.85,N/A,1909.23,N/A,781.90,N/A,3397.00,N/A,3397.00,N/A,781.90,N/A,1909.23,N/A,1899.46,N/A,145.29,N/A,N/A,145.29,4627.53,,Hospital 92019,Eye Exam & Treatment,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7483.00,N/A,4489.80,N/A,1047.62,N/A,1899.46,N/A,4308.70,N/A,2544.22,N/A,4618.26,N/A,1047.62,N/A,1909.23,N/A,1909.23,N/A,2874.96,N/A,4618.26,N/A,4618.26,N/A,4618.26,N/A,4308.70,N/A,1909.23,N/A,1047.62,N/A,3397.00,N/A,3397.00,N/A,1047.62,N/A,1909.23,N/A,1899.46,N/A,75.26,N/A,N/A,75.26,4618.26,,Hospital 92133,HC Cmptr Ophth Img Optic Nerve,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,154.00,N/A,92.40,N/A,21.56,N/A,55.01,N/A,88.67,N/A,52.36,N/A,N/A,N/A,21.56,N/A,51.91,N/A,51.91,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,88.67,N/A,51.91,N/A,21.56,N/A,82.54,N/A,82.54,N/A,21.56,N/A,51.91,N/A,55.01,N/A,14.87,N/A,N/A,14.87,92.40,,Hospital 92136,HC Ophthalmic Biometry,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,317.00,N/A,190.20,N/A,44.38,N/A,111.11,N/A,182.53,N/A,107.78,N/A,N/A,N/A,44.38,N/A,104.85,N/A,104.85,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,182.53,N/A,104.85,N/A,44.38,N/A,169.91,N/A,169.91,N/A,44.38,N/A,104.85,N/A,111.11,N/A,19.17,N/A,N/A,19.17,190.20,,Hospital 92145,HC Cornea Hysteresis Determin Impulse Stimj Uni/Bi,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,256.00,N/A,153.60,N/A,35.84,N/A,115.66,N/A,147.41,N/A,87.04,N/A,N/A,N/A,35.84,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,147.41,N/A,109.14,N/A,35.84,N/A,137.22,N/A,137.22,N/A,35.84,N/A,109.14,N/A,115.66,N/A,6.93,N/A,N/A,6.93,153.60,,Hospital 92242,Fluorescein Icg Angrph W/Multiframe I&R Uni/Bi,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,23083.50,N/A,13850.10,N/A,3231.68,N/A,3838.31,N/A,13290.45,N/A,7848.39,N/A,8735.25,N/A,3231.68,N/A,3608.17,N/A,3608.17,N/A,5437.87,N/A,8735.25,N/A,8735.25,N/A,8735.25,N/A,13290.45,N/A,3608.17,N/A,3231.68,N/A,5963.00,N/A,5963.00,N/A,3231.68,N/A,3608.17,N/A,3838.31,N/A,1369.84,N/A,N/A,1369.84,13850.10,,Hospital 92502,Ear and Throat Examination,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,7923.50,N/A,4754.10,N/A,1109.29,N/A,408.96,N/A,4561.03,N/A,2693.99,N/A,1010.76,N/A,1109.29,N/A,412.53,N/A,412.53,N/A,629.22,N/A,1010.76,N/A,1010.76,N/A,1010.76,N/A,4535.12,N/A,412.53,N/A,1109.29,N/A,527.00,N/A,527.00,N/A,1109.29,N/A,412.53,N/A,408.96,N/A,99.33,N/A,N/A,99.33,4754.10,,Hospital CPT 92511,HC Nasopharyngoscopy Endoscope,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,586.00,586.00,351.60,351.60,N/A,82.04,N/A,163.17,N/A,337.42,N/A,199.24,N/A,390.46,N/A,82.04,N/A,161.42,N/A,161.42,N/A,243.07,N/A,390.46,N/A,390.46,N/A,390.46,N/A,337.42,N/A,161.42,N/A,82.04,N/A,586.00,N/A,586.00,N/A,82.04,N/A,161.42,N/A,163.17,N/A,39.37,351.60,351.60,39.37,586.00,,Hospital 92538,HC Cal Vstblr Test W/Rec 2 Irriga,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,6383.00,N/A,3829.80,N/A,893.62,N/A,366.64,N/A,3396.85,N/A,2170.22,N/A,868.80,N/A,893.62,N/A,359.18,N/A,359.18,N/A,540.84,N/A,868.80,N/A,868.80,N/A,868.80,N/A,3396.85,N/A,359.18,N/A,893.62,N/A,3000.23,N/A,3000.23,N/A,893.62,N/A,359.18,N/A,366.64,N/A,176.21,N/A,N/A,176.21,3829.80,,Hospital 92550,HC Tympanometry and Reflex Threshold Measurements,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,439.00,N/A,263.40,N/A,61.46,N/A,134.06,N/A,252.77,N/A,149.26,N/A,317.67,N/A,61.46,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,252.77,N/A,131.33,N/A,61.46,N/A,235.30,N/A,235.30,N/A,61.46,N/A,131.33,N/A,134.06,N/A,63.70,N/A,N/A,61.46,317.67,,Hospital 92552,HC Audiometry Pure Tone Air,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,24145.10,981.00,14487.06,588.60,8017.40,137.34,9749.82,103.95,18067.86,564.86,8209.33,333.54,18240.70,253.64,8264.43,137.34,1686.00,104.85,1686.00,104.85,11354.41,157.89,18240.70,253.64,18240.70,253.64,18240.70,253.64,18067.86,564.86,9749.82,104.85,8264.43,137.34,21701.88,525.82,21701.88,525.82,N/A,137.34,9749.82,104.85,9749.82,103.95,8842.94,82.99,1686.00,21701.88,82.99,588.60,,Hospital 92553,HC Audiometry Pure Tone Air Bone,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,21337.40,561.00,12802.44,336.60,7930.45,78.54,9646.96,134.06,17871.91,323.02,7254.72,190.74,18042.86,357.43,8174.80,78.54,9646.96,131.33,9646.96,131.33,11231.26,222.46,18042.86,357.43,18042.86,357.43,18042.86,357.43,17871.91,323.02,9646.96,131.33,8174.80,78.54,21337.40,300.69,21337.40,300.69,4392.68,78.54,9646.96,131.33,9646.96,134.06,8747.03,50.91,4392.68,21337.40,50.91,357.43,,Hospital 92555,HC Speech Reception Threshold 925,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,21337.40,845.00,12802.44,507.00,7930.45,118.30,9646.96,105.99,17871.91,486.55,7254.72,287.30,18042.86,253.64,8174.80,118.30,9646.96,104.85,9646.96,104.85,11231.26,157.89,18042.86,253.64,18042.86,253.64,18042.86,253.64,17871.91,486.55,9646.96,104.85,8174.80,118.30,21337.40,452.92,21337.40,452.92,4392.68,118.30,9646.96,104.85,9646.96,105.99,8747.03,68.76,4392.68,21337.40,68.76,507.00,,Hospital 92557,HC Comprehensive Hearing Eval,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,79421.30,237.00,47652.78,142.20,9484.96,33.18,9249.53,134.06,21375.12,136.46,N/A,80.58,N/A,237.00,9777.20,33.18,9249.53,131.33,9249.53,131.33,N/A,197.75,N/A,237.00,N/A,237.00,N/A,237.00,21375.12,136.46,9249.53,131.33,9777.20,33.18,N/A,127.03,25674.32,127.03,14309.38,33.18,9249.53,131.33,11485.86,134.06,10461.61,45.58,9249.53,47652.78,33.18,237.00,,Hospital 92567,HC Tympanometry,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,55365.00,521.00,33219.00,312.60,7192.14,72.94,10050.72,134.06,16208.06,299.99,18824.10,177.14,16851.15,357.43,7413.74,72.94,8773.57,131.33,8773.57,131.33,10490.34,222.46,16851.15,357.43,16851.15,357.43,16851.15,357.43,16208.06,299.99,8773.57,131.33,7413.74,72.94,19468.01,279.25,19468.01,279.25,4392.68,72.94,8773.57,131.33,8773.57,134.06,7932.70,45.58,4392.68,33219.00,45.58,357.43,,Hospital 92582,HC Play Audiometry 92582,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,563.00,N/A,337.80,N/A,78.82,N/A,134.06,N/A,324.17,N/A,191.42,N/A,317.67,N/A,78.82,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,324.17,N/A,131.33,N/A,78.82,N/A,301.77,N/A,301.77,N/A,78.82,N/A,131.33,N/A,134.06,N/A,111.41,N/A,N/A,78.82,337.80,,Hospital 92585,HC Brain Stem Aud Evoked Resp,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,11973.40,3098.00,7184.04,1858.80,11973.40,433.72,26921.54,N/A,11973.40,1783.83,4070.96,1053.32,6047.76,408.24,11973.40,433.72,26921.54,N/A,26921.54,N/A,3764.44,253.69,6047.76,408.24,6047.76,408.24,6047.76,408.24,11973.40,1783.83,26921.54,N/A,11973.40,433.72,7800.00,1660.53,7800.00,1660.53,1800.46,433.72,26921.54,N/A,26921.54,N/A,11973.40,N/A,1800.46,26921.54,253.69,1858.80,,Hospital 92586,HC Evoked Response Abr P/F Neonate,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,5256.50,745.00,3153.90,447.00,1079.73,104.30,1542.91,109.14,2433.25,428.97,1787.21,253.30,1589.00,108.79,1113.00,104.30,1542.91,109.14,1542.91,109.14,989.00,67.67,1589.00,108.79,1589.00,108.79,1589.00,108.79,2433.25,428.97,1542.91,109.14,1113.00,104.30,1352.00,399.32,1352.00,399.32,1844.56,104.30,1542.91,109.14,1542.91,109.14,1190.91,120.06,989.00,3153.90,67.67,447.00,,Hospital 92591,"Hearing Aid Exam, Both Ears",N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,500.00,N/A,300.00,N/A,70.00,N/A,N/A,N/A,287.90,N/A,170.00,N/A,70.00,N/A,70.00,N/A,N/A,N/A,N/A,N/A,43.50,N/A,70.00,N/A,70.00,N/A,70.00,N/A,287.90,N/A,N/A,N/A,70.00,N/A,268.00,N/A,268.00,N/A,70.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,43.50,300.00,,Hospital CPT 92609,HC Ther Speech Genrating Device Prgrmg&Modification,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,279.00,279.00,167.40,167.40,N/A,39.06,N/A,103.86,N/A,160.65,N/A,94.86,N/A,279.00,N/A,39.06,N/A,103.86,N/A,103.86,N/A,279.00,N/A,279.00,N/A,279.00,N/A,279.00,N/A,160.65,N/A,99.87,N/A,39.06,N/A,149.54,N/A,149.54,N/A,39.06,N/A,103.86,N/A,103.86,N/A,114.25,167.40,167.40,39.06,279.00,,Hospital CPT 92610,HC Swallowing Evaluation,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,974.00,974.00,584.40,584.40,N/A,136.36,N/A,67.74,N/A,560.83,N/A,331.16,N/A,241.32,N/A,136.36,N/A,67.74,N/A,67.74,N/A,150.22,N/A,241.32,N/A,241.32,N/A,241.32,N/A,560.83,N/A,67.74,N/A,136.36,N/A,522.06,N/A,522.06,N/A,136.36,N/A,67.74,N/A,67.74,N/A,74.51,584.40,584.40,67.74,584.40,,Hospital CPT 92610,HC Bedside Swallowing Eval,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,974.00,974.00,584.40,584.40,N/A,136.36,N/A,67.74,N/A,560.83,N/A,331.16,N/A,241.32,N/A,136.36,N/A,67.74,N/A,67.74,N/A,150.22,N/A,241.32,N/A,241.32,N/A,241.32,N/A,560.83,N/A,67.74,N/A,136.36,N/A,522.06,N/A,522.06,N/A,136.36,N/A,67.74,N/A,67.74,N/A,74.51,584.40,584.40,67.74,584.40,,Hospital CPT 92611,HC Motion Fluor Eval Swlng Funcj C/V Rec,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,856.00,856.00,513.60,513.60,N/A,119.84,N/A,87.44,N/A,492.88,N/A,291.04,N/A,259.56,N/A,119.84,N/A,87.44,N/A,87.44,N/A,161.58,N/A,259.56,N/A,259.56,N/A,259.56,N/A,492.88,N/A,87.44,N/A,119.84,N/A,458.82,N/A,458.82,N/A,119.84,N/A,87.44,N/A,87.44,N/A,96.18,513.60,513.60,87.44,513.60,,Hospital 92626,"HC Eval Auditory Rehab Status, 1st Hour",N/A,0471 - AUDIOLOGY - DIAGNOSTIC,N/A,374.00,N/A,224.40,N/A,52.36,N/A,134.06,N/A,215.35,N/A,127.16,N/A,317.67,N/A,52.36,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,215.35,N/A,131.33,N/A,52.36,N/A,200.46,N/A,200.46,N/A,52.36,N/A,131.33,N/A,134.06,N/A,79.34,N/A,N/A,52.36,317.67,,Hospital CPT 92650,HC Aep Scr Auditory Potential W/Stimuli Auto Alys,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,339.00,339.00,203.40,203.40,N/A,47.46,N/A,339.00,N/A,195.20,N/A,115.26,N/A,47.46,N/A,47.46,N/A,339.00,N/A,339.00,N/A,29.49,N/A,47.46,N/A,47.46,N/A,47.46,N/A,195.20,N/A,339.00,N/A,47.46,N/A,181.70,N/A,181.70,N/A,47.46,N/A,339.00,N/A,339.00,N/A,339.00,203.40,203.40,29.49,339.00,,Hospital CPT 92653,HC Aep Neurodiagnostic Interpretation and Report,N/A,0471 - AUDIOLOGY - DIAGNOSTIC,651.00,651.00,390.60,390.60,N/A,91.14,N/A,250.72,N/A,374.85,N/A,221.34,N/A,611.76,N/A,91.14,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,374.85,N/A,252.91,N/A,91.14,N/A,348.94,N/A,348.94,N/A,91.14,N/A,252.91,N/A,250.72,N/A,89.14,390.60,390.60,89.14,611.76,,Hospital CPT 92933,HC Prq Card Stent/Ath/Angio Single,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,17245.00,17245.00,10347.00,10347.00,N/A,2414.30,N/A,15512.06,N/A,9929.67,N/A,5863.30,N/A,17245.00,N/A,2414.30,N/A,15512.06,N/A,15512.06,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,9929.67,N/A,15512.06,N/A,2414.30,N/A,7897.00,N/A,7897.00,N/A,2414.30,N/A,15512.06,N/A,15512.06,N/A,17063.27,10347.00,10347.00,2414.30,17245.00,,Hospital CPT 92943,HC Prq Card Revasc Chronic 1vsl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,17245.00,17245.00,10347.00,10347.00,N/A,2414.30,N/A,9586.05,N/A,9929.67,N/A,5863.30,N/A,17245.00,N/A,2414.30,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,9929.67,N/A,9586.05,N/A,2414.30,N/A,7897.00,N/A,7897.00,N/A,2414.30,N/A,9586.05,N/A,9586.05,N/A,10544.65,10347.00,10347.00,2414.30,17245.00,,Hospital CPT 92944,HC Prq Card Revasc Chronic Addl,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,17245.00,17245.00,10347.00,10347.00,N/A,2414.30,N/A,17245.00,N/A,9929.67,N/A,5863.30,N/A,17245.00,N/A,2414.30,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,17245.00,N/A,9929.67,N/A,17245.00,N/A,2414.30,N/A,7897.00,N/A,7897.00,N/A,2414.30,N/A,17245.00,N/A,17245.00,N/A,17245.00,10347.00,10347.00,2414.30,17245.00,,Hospital CPT 92950,HC Resuscitation,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,1000.00,1000.00,600.00,600.00,N/A,140.00,N/A,264.55,N/A,575.80,N/A,340.00,N/A,611.76,N/A,140.00,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,575.80,N/A,252.91,N/A,140.00,N/A,536.00,N/A,536.00,N/A,140.00,N/A,252.91,N/A,264.55,N/A,197.60,600.00,600.00,140.00,611.76,,Hospital CPT 92950,HC Cardiopulm Resuscitation,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,702.00,702.00,421.20,421.20,N/A,98.28,N/A,264.55,N/A,404.21,N/A,238.68,N/A,611.76,N/A,98.28,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,404.21,N/A,252.91,N/A,98.28,N/A,702.00,N/A,702.00,N/A,98.28,N/A,252.91,N/A,264.55,N/A,197.60,421.20,421.20,98.28,702.00,,Hospital CPT 92953,HC Transcutaneous Pacing,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1241.00,1241.00,744.60,744.60,N/A,173.74,N/A,N/A,N/A,714.57,N/A,421.94,N/A,2.79,N/A,173.74,N/A,N/A,N/A,N/A,N/A,1.74,N/A,2.79,N/A,2.79,N/A,2.79,N/A,714.57,N/A,N/A,N/A,173.74,N/A,1241.00,N/A,1241.00,N/A,173.74,N/A,N/A,N/A,N/A,N/A,1.02,744.60,744.60,1.02,1241.00,,Hospital CPT 92953,HC Temporary External Pacing,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,1241.00,1241.00,744.60,744.60,N/A,173.74,N/A,N/A,N/A,714.57,N/A,421.94,N/A,2.79,N/A,173.74,N/A,N/A,N/A,N/A,N/A,1.74,N/A,2.79,N/A,2.79,N/A,2.79,N/A,714.57,N/A,N/A,N/A,173.74,N/A,665.18,N/A,665.18,N/A,173.74,N/A,N/A,N/A,N/A,N/A,1.02,744.60,744.60,1.02,744.60,,Hospital CPT 92953,HC Temp External Pacing,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1241.00,1241.00,744.60,744.60,N/A,173.74,N/A,N/A,N/A,714.57,N/A,421.94,N/A,2.79,N/A,173.74,N/A,N/A,N/A,N/A,N/A,1.74,N/A,2.79,N/A,2.79,N/A,2.79,N/A,714.57,N/A,N/A,N/A,173.74,N/A,1241.00,N/A,1241.00,N/A,173.74,N/A,N/A,N/A,N/A,N/A,1.02,744.60,744.60,1.02,1241.00,,Hospital CPT 92977,HC Thrombolysis/Coronary,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,459.00,459.00,275.40,275.40,N/A,64.26,N/A,45.85,N/A,264.29,N/A,156.06,N/A,140.19,N/A,64.26,N/A,45.85,N/A,45.85,N/A,87.27,N/A,140.19,N/A,140.19,N/A,140.19,N/A,264.29,N/A,45.85,N/A,64.26,N/A,459.00,N/A,459.00,N/A,64.26,N/A,45.85,N/A,45.85,N/A,50.44,275.40,275.40,45.85,459.00,,Hospital CPT 92977,HC IV Thrombolysis,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,459.00,459.00,275.40,275.40,N/A,64.26,N/A,45.85,N/A,264.29,N/A,156.06,N/A,140.19,N/A,64.26,N/A,45.85,N/A,45.85,N/A,87.27,N/A,140.19,N/A,140.19,N/A,140.19,N/A,264.29,N/A,45.85,N/A,64.26,N/A,459.00,N/A,459.00,N/A,64.26,N/A,45.85,N/A,45.85,N/A,50.44,275.40,275.40,45.85,459.00,,Hospital CPT 92978,HC Ivus Initial Vessel,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,6880.00,6880.00,4128.00,4128.00,N/A,963.20,N/A,6880.00,N/A,3961.50,N/A,2339.20,N/A,6880.00,N/A,963.20,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,6880.00,N/A,3961.50,N/A,6880.00,N/A,963.20,N/A,527.00,N/A,527.00,N/A,963.20,N/A,6880.00,N/A,6880.00,N/A,6880.00,4128.00,4128.00,527.00,6880.00,,Hospital CPT 92987,HC Perc Balloon Valvuloplasty; Mitral Valve,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,24630.00,24630.00,14778.00,14778.00,N/A,3448.20,N/A,1306.20,N/A,14181.95,N/A,8374.20,N/A,23187.86,N/A,3448.20,N/A,9586.05,N/A,9586.05,N/A,14434.89,N/A,23187.86,N/A,23187.86,N/A,23187.86,N/A,14181.95,N/A,9586.05,N/A,3448.20,N/A,7897.00,N/A,7897.00,N/A,3448.20,N/A,9586.05,N/A,1306.20,N/A,1436.82,14778.00,14778.00,1306.20,23187.86,,Hospital CPT 92990,HC Perc Balloon Valvuloplasty; Pulm Valve,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,24630.00,24630.00,14778.00,14778.00,N/A,3448.20,N/A,1038.96,N/A,14181.95,N/A,8374.20,N/A,3068.43,N/A,3448.20,N/A,1038.96,N/A,1038.96,N/A,1910.10,N/A,3068.43,N/A,3068.43,N/A,3068.43,N/A,14181.95,N/A,1038.96,N/A,3448.20,N/A,24630.00,N/A,24630.00,N/A,3448.20,N/A,1038.96,N/A,1038.96,N/A,1142.86,14778.00,14778.00,1038.96,24630.00,,Hospital 92997,HC Pulm Art Balloon Angioplasty; Single Vessel,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,N/A,57829.28,N/A,34697.57,N/A,8099.01,N/A,10201.42,N/A,33273.91,N/A,19661.95,N/A,23284.82,N/A,8099.01,N/A,9589.98,N/A,9589.98,N/A,14495.25,N/A,23284.82,N/A,23284.82,N/A,23284.82,N/A,33273.91,N/A,9589.98,N/A,8099.01,N/A,8292.25,N/A,8292.25,N/A,8099.01,N/A,9589.98,N/A,10201.42,N/A,1101.49,N/A,N/A,1101.49,34697.57,,Hospital 93000,HC Electrocardiogram Complete,N/A,0517 - CLINIC - FAMILY PRACTICE CLINIC,N/A,363.00,N/A,217.80,N/A,50.82,N/A,54.30,N/A,209.02,N/A,123.42,N/A,140.56,N/A,50.82,N/A,65.28,N/A,65.28,N/A,93.16,N/A,140.56,N/A,140.56,N/A,140.56,N/A,209.02,N/A,65.28,N/A,50.82,N/A,194.57,N/A,194.57,N/A,50.82,N/A,65.28,N/A,67.67,N/A,20.65,N/A,N/A,20.65,217.80,,Hospital CPT 93005,HC >= 12 Lead Ekg,N/A,0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION,453.00,453.00,271.80,271.80,N/A,63.42,N/A,51.91,N/A,260.84,N/A,154.02,N/A,125.56,N/A,63.42,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,260.84,N/A,51.91,N/A,63.42,N/A,242.81,N/A,242.81,N/A,63.42,N/A,51.91,N/A,51.91,N/A,57.10,271.80,271.80,51.91,271.80,,Hospital CPT 93242,HC External Ecg Rec>48hr<7d Recording,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,269.00,269.00,161.40,161.40,N/A,37.66,N/A,30.67,N/A,154.89,N/A,91.46,N/A,74.18,N/A,37.66,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,154.89,N/A,30.67,N/A,37.66,N/A,144.18,N/A,144.18,N/A,37.66,N/A,30.67,N/A,30.67,N/A,33.73,161.40,161.40,30.67,161.40,,Hospital CPT 93246,HC External Ecg Rec>7d<15d Recording,N/A,0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR,269.00,269.00,161.40,161.40,N/A,37.66,N/A,51.91,N/A,154.89,N/A,91.46,N/A,125.56,N/A,37.66,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,154.89,N/A,51.91,N/A,37.66,N/A,144.18,N/A,144.18,N/A,37.66,N/A,51.91,N/A,51.91,N/A,57.10,161.40,161.40,37.66,161.40,,Hospital 93283,HC Prog Eval Dual Lead Icd,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,59871.30,389.00,35922.78,233.40,13870.55,54.46,16673.79,32.45,31258.40,223.99,20356.24,132.26,31557.41,76.46,14297.92,54.46,16673.79,31.61,16673.79,31.61,19643.76,47.60,31557.41,76.46,31557.41,76.46,31557.41,76.46,31258.40,223.99,16673.79,31.61,14297.92,54.46,37545.44,208.50,37545.44,208.50,5813.90,54.46,16673.79,31.61,16673.79,32.45,15298.78,43.98,5813.90,37545.44,31.61,233.40,,Hospital 93285,HC Prog Eval Impl Loop Recorder,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,211.00,N/A,126.60,N/A,29.54,N/A,113.39,N/A,121.50,N/A,71.74,N/A,N/A,N/A,29.54,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,121.50,N/A,109.14,N/A,29.54,N/A,113.10,N/A,113.10,N/A,29.54,N/A,109.14,N/A,113.39,N/A,36.38,N/A,N/A,29.54,126.60,,Hospital CPT 93289,HC Icd Interrogate,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,164.00,164.00,98.40,98.40,N/A,22.96,N/A,33.49,N/A,94.43,N/A,55.76,N/A,76.46,N/A,22.96,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,94.43,N/A,31.61,N/A,22.96,N/A,87.90,N/A,87.90,N/A,22.96,N/A,31.61,N/A,32.84,N/A,37.37,98.40,98.40,22.96,98.40,,Hospital 93293,HC Teletrace Sng Dual or Mult Lds,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,N/A,255.00,N/A,153.00,N/A,35.70,N/A,29.46,N/A,146.83,N/A,86.70,N/A,76.46,N/A,35.70,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,146.83,N/A,31.61,N/A,35.70,N/A,136.68,N/A,136.68,N/A,35.70,N/A,31.61,N/A,29.46,N/A,32.41,N/A,N/A,29.46,153.00,,Hospital 93299,Rem Interrog Icpms/Scrms <30 D Tech Review,N/A,N/A,N/A,195.00,N/A,117.00,N/A,27.30,N/A,N/A,N/A,112.28,N/A,66.30,N/A,27.30,N/A,27.30,N/A,N/A,N/A,N/A,N/A,16.97,N/A,27.30,N/A,27.30,N/A,27.30,N/A,112.28,N/A,N/A,N/A,27.30,N/A,104.52,N/A,104.52,N/A,27.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16.97,117.00,,Hospital CPT 93307,HC 2d Echo Without Contrast - Without Dop/Color Flow,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,2443.00,2443.00,1465.80,1465.80,N/A,342.02,N/A,215.26,N/A,1406.68,N/A,830.62,N/A,510.09,N/A,342.02,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1406.68,N/A,210.88,N/A,342.02,N/A,1309.45,N/A,1309.45,N/A,342.02,N/A,210.88,N/A,215.26,N/A,94.58,1465.80,1465.80,94.58,1465.80,,Hospital CPT 93312,HC Transesophageal Echo,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,2965.00,2965.00,1779.00,1779.00,N/A,415.10,N/A,454.35,N/A,1707.25,N/A,1008.10,N/A,1099.02,N/A,415.10,N/A,454.35,N/A,454.35,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,1707.25,N/A,454.35,N/A,415.10,N/A,1589.24,N/A,1589.24,N/A,415.10,N/A,454.35,N/A,454.35,N/A,499.78,1779.00,1779.00,415.10,1779.00,,Hospital 93318,HC Tee Monitoring WO Contrast,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,112254.93,N/A,67352.96,N/A,N/A,N/A,49837.51,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49837.51,N/A,49837.51,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49837.51,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,49837.51,N/A,49837.51,N/A,N/A,N/A,49837.51,67352.96,N/A,N/A,,Hospital CPT 93320,HC Doppler Echo,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,727.00,727.00,436.20,436.20,N/A,101.78,N/A,727.00,N/A,418.61,N/A,247.18,N/A,727.00,N/A,101.78,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,418.61,N/A,727.00,N/A,101.78,N/A,389.67,N/A,389.67,N/A,101.78,N/A,727.00,N/A,30.36,N/A,33.40,436.20,436.20,30.36,727.00,,Hospital CPT 93325,HC Doppler Color Flow Mapping,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,727.00,727.00,436.20,436.20,N/A,101.78,N/A,727.00,N/A,418.61,N/A,247.18,N/A,727.00,N/A,101.78,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,727.00,N/A,418.61,N/A,727.00,N/A,101.78,N/A,389.67,N/A,389.67,N/A,101.78,N/A,727.00,N/A,727.00,N/A,727.00,436.20,436.20,101.78,727.00,,Hospital CPT 93451,HC Right Heart Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,6376.00,6376.00,3825.60,3825.60,N/A,892.64,N/A,2894.91,N/A,3671.30,N/A,2167.84,N/A,6376.00,N/A,892.64,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6376.00,N/A,6376.00,N/A,6376.00,N/A,3671.30,N/A,2671.61,N/A,892.64,N/A,5963.00,N/A,5963.00,N/A,892.64,N/A,2671.61,N/A,2794.62,N/A,766.73,3825.60,3825.60,766.73,6376.00,,Hospital CPT 93453,HC R&L Heart Cath WO Graft,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11430.00,11430.00,6858.00,6858.00,N/A,1600.20,N/A,2842.02,N/A,11012.00,N/A,3886.20,N/A,6462.39,N/A,1600.20,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,11012.00,N/A,2671.61,N/A,1600.20,N/A,5963.00,N/A,5963.00,N/A,1600.20,N/A,2671.61,N/A,2842.02,N/A,867.28,6858.00,6858.00,867.28,11012.00,,Hospital CPT 93455,HC Coronaries With Graft,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,10955.00,10955.00,6573.00,6573.00,N/A,1533.70,N/A,691.92,N/A,6307.89,N/A,3724.70,N/A,6462.39,N/A,1533.70,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,6307.89,N/A,2671.61,N/A,1533.70,N/A,5963.00,N/A,5963.00,N/A,1533.70,N/A,2671.61,N/A,691.92,N/A,761.11,6573.00,6573.00,691.92,6573.00,,Hospital CPT 93456,HC Rh W Coro No Lvgram,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13028.00,13028.00,7816.80,7816.80,N/A,1823.92,N/A,2794.62,N/A,7501.52,N/A,4429.52,N/A,6462.39,N/A,1823.92,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,7501.52,N/A,2671.61,N/A,1823.92,N/A,5963.00,N/A,5963.00,N/A,1823.92,N/A,2671.61,N/A,2894.91,N/A,851.08,7816.80,7816.80,851.08,7816.80,,Hospital CPT 93458,HC L Heart W Lv & Coronary,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13028.00,13028.00,7816.80,7816.80,N/A,1823.92,N/A,2671.61,N/A,11012.00,N/A,4429.52,N/A,6462.39,N/A,1823.92,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,11012.00,N/A,2671.61,N/A,1823.92,N/A,5963.00,N/A,5963.00,N/A,1823.92,N/A,2671.61,N/A,2671.61,N/A,2938.77,7816.80,7816.80,1823.92,11012.00,,Hospital CPT 93460,HC Rh Lh W Coron & Lvgram,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11701.00,11701.00,7020.60,7020.60,N/A,1638.14,N/A,2671.61,N/A,11012.00,N/A,3978.34,N/A,6462.39,N/A,1638.14,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,11012.00,N/A,2671.61,N/A,1638.14,N/A,5963.00,N/A,5963.00,N/A,1638.14,N/A,2671.61,N/A,2671.61,N/A,2938.77,7020.60,7020.60,1638.14,11012.00,,Hospital CPT 93461,HC R&L Heart Cath W Graft,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,15244.00,15244.00,9146.40,9146.40,N/A,2134.16,N/A,2671.61,N/A,11012.00,N/A,5182.96,N/A,6462.39,N/A,2134.16,N/A,2671.61,N/A,2671.61,N/A,4022.97,N/A,6462.39,N/A,6462.39,N/A,6462.39,N/A,11012.00,N/A,2671.61,N/A,2134.16,N/A,5963.00,N/A,5963.00,N/A,2134.16,N/A,2671.61,N/A,2671.61,N/A,2938.77,9146.40,9146.40,2134.16,11012.00,,Hospital 93505,HC Biopsy Endomyocardial,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,71509.88,10061.18,42905.93,6036.71,5869.15,1395.19,7208.54,2813.99,13501.35,5788.67,24313.37,3420.80,13872.42,6512.39,N/A,1395.19,7208.54,2690.13,N/A,2690.13,8635.47,4054.08,13872.42,6512.39,13872.42,6512.39,13872.42,6512.39,13501.35,5788.67,7208.54,2690.13,6049.99,1395.19,15886.89,4562.00,15886.89,4562.00,N/A,1395.19,7208.54,2690.13,7208.54,2813.99,6473.49,615.42,5869.15,42905.93,615.42,6512.39,,Hospital 93533,HC Rt Ht With Lt Ht Thru Se,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,N/A,130563.55,N/A,78338.13,N/A,17840.10,N/A,10205.35,N/A,75112.88,N/A,44391.60,N/A,23339.32,N/A,17840.10,N/A,9593.91,N/A,9593.91,N/A,14529.18,N/A,23339.32,N/A,23339.32,N/A,23339.32,N/A,75112.88,N/A,9593.91,N/A,17840.10,N/A,20405.00,N/A,17621.75,N/A,17840.10,N/A,9593.91,N/A,10205.35,N/A,2317.23,N/A,N/A,2317.23,78338.13,,Hospital CPT 93563,HC Inject Congenital Card Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,1701.00,1701.00,1020.60,1020.60,N/A,238.14,N/A,1701.00,N/A,979.44,N/A,578.34,N/A,1701.00,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,1701.00,N/A,979.44,N/A,1701.00,N/A,238.14,N/A,527.00,N/A,527.00,N/A,238.14,N/A,1701.00,N/A,1701.00,N/A,61.47,1020.60,1020.60,61.47,1701.00,,Hospital 93565,HC Selective Lv La Angiocard Cath,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,94598.37,N/A,56759.02,N/A,17835.24,N/A,23140.38,N/A,40193.15,N/A,32163.45,N/A,42155.67,N/A,N/A,N/A,23140.38,N/A,5058.00,N/A,N/A,N/A,N/A,N/A,42155.67,N/A,42155.67,N/A,40193.15,N/A,21363.81,N/A,18384.77,N/A,48277.25,N/A,N/A,N/A,N/A,N/A,21363.81,N/A,21363.81,N/A,19671.71,N/A,5058.00,56759.02,N/A,N/A,,Hospital CPT 93581,HC Transcath Closure of Vsd,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,42150.00,42150.00,25290.00,25290.00,N/A,5901.00,N/A,1271.19,N/A,24269.97,N/A,14331.00,N/A,3735.45,N/A,5901.00,N/A,1271.19,N/A,1271.19,N/A,2325.32,N/A,3735.45,N/A,3735.45,N/A,3735.45,N/A,24269.97,N/A,1271.19,N/A,5901.00,N/A,42150.00,N/A,42150.00,N/A,5901.00,N/A,1271.19,N/A,1271.19,N/A,1398.31,25290.00,25290.00,1271.19,42150.00,,Hospital 93591,HC Perq Transcath Cls Paravalvr Leak 1 Aortic Valve,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,207050.18,N/A,124230.11,N/A,20782.30,N/A,19168.37,N/A,114126.06,N/A,70397.06,N/A,72094.88,N/A,17407.95,N/A,3934.00,N/A,3934.00,N/A,44888.48,N/A,72094.88,N/A,72094.88,N/A,72094.88,N/A,114126.06,N/A,19168.37,N/A,17407.95,N/A,98141.79,N/A,N/A,N/A,N/A,N/A,19168.37,N/A,19168.37,N/A,18626.50,N/A,3934.00,124230.11,N/A,N/A,,Hospital CPT 93593,HC R Hrt Cath Chd W/Img Cath Trgt Zone Nml Nt Connj,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13028.00,13028.00,7816.80,7816.80,N/A,1823.92,N/A,13028.00,N/A,7501.52,N/A,4429.52,N/A,1823.92,N/A,1823.92,N/A,13028.00,N/A,13028.00,N/A,1133.44,N/A,1823.92,N/A,1823.92,N/A,1823.92,N/A,7501.52,N/A,13028.00,N/A,1823.92,N/A,13028.00,N/A,13028.00,N/A,1823.92,N/A,13028.00,N/A,13028.00,N/A,13028.00,7816.80,7816.80,1133.44,13028.00,,Hospital CPT 93600,HC Bundle of His Recording,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,6359.89,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,6079.94,N/A,1842.26,N/A,1871.00,N/A,1871.00,N/A,1842.26,N/A,6079.94,N/A,6359.89,N/A,13159.00,7895.40,7895.40,1842.26,13159.00,,Hospital CPT 93602,HC Intra-Atrial Recording,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,6079.94,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,6079.94,N/A,1842.26,N/A,1871.00,N/A,1871.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,6687.94,7895.40,7895.40,1842.26,13159.00,,Hospital CPT 93603,HC Right Ventricle Recording,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,2085.00,2085.00,1251.00,1251.00,N/A,291.90,N/A,1055.20,N/A,1200.54,N/A,708.90,N/A,2085.00,N/A,291.90,N/A,1008.75,N/A,1008.75,N/A,1519.00,N/A,2085.00,N/A,2085.00,N/A,2085.00,N/A,1200.54,N/A,1008.75,N/A,291.90,N/A,1117.56,N/A,1117.56,N/A,291.90,N/A,1008.75,N/A,1055.20,N/A,2085.00,1251.00,1251.00,291.90,2085.00,,Hospital CPT 93609,HC Map Tachycardia Add-On,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,13159.00,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,13159.00,N/A,1842.26,N/A,7053.22,N/A,7053.22,N/A,1842.26,N/A,13159.00,N/A,13159.00,N/A,13159.00,7895.40,7895.40,1842.26,13159.00,,Hospital CPT 93610,HC Intra-Atrial Pacing,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,6359.89,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,6079.94,N/A,1842.26,N/A,1871.00,N/A,1871.00,N/A,1842.26,N/A,6079.94,N/A,6359.89,N/A,13159.00,7895.40,7895.40,1842.26,13159.00,,Hospital CPT 93612,HC Intrventricular Pacing,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,12042.00,12042.00,7225.20,7225.20,N/A,1685.88,N/A,6359.89,N/A,6933.78,N/A,4094.28,N/A,12042.00,N/A,1685.88,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,12042.00,N/A,12042.00,N/A,12042.00,N/A,6933.78,N/A,6079.94,N/A,1685.88,N/A,6454.51,N/A,6454.51,N/A,1685.88,N/A,6079.94,N/A,6359.89,N/A,12042.00,7225.20,7225.20,1685.88,12042.00,,Hospital CPT 93613,HC Electrophys Map 3d Add-On,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,11735.00,11735.00,7041.00,7041.00,N/A,1642.90,N/A,283.00,N/A,6757.01,N/A,3989.90,N/A,11735.00,N/A,1642.90,N/A,11735.00,N/A,11735.00,N/A,11735.00,N/A,11735.00,N/A,11735.00,N/A,11735.00,N/A,6757.01,N/A,11735.00,N/A,1642.90,N/A,527.00,N/A,527.00,N/A,1642.90,N/A,11735.00,N/A,283.00,N/A,311.30,7041.00,7041.00,283.00,11735.00,,Hospital 93615,HC Esoph Rec a/V Ekg,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,81276.48,N/A,48765.89,N/A,17921.66,N/A,21466.05,N/A,48320.18,N/A,27634.01,N/A,42359.94,N/A,18473.86,N/A,N/A,N/A,2248.00,N/A,26368.72,N/A,42359.94,N/A,42359.94,N/A,42359.94,N/A,48320.18,N/A,21466.05,N/A,18473.86,N/A,N/A,N/A,N/A,N/A,N/A,N/A,21466.05,N/A,21466.05,N/A,19767.03,N/A,2248.00,48765.89,N/A,N/A,,Hospital CPT 93618,HC Nips Eps,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,2844.00,2844.00,1706.40,1706.40,N/A,398.16,N/A,1008.75,N/A,1637.58,N/A,966.96,N/A,2440.09,N/A,398.16,N/A,1008.75,N/A,1008.75,N/A,1519.00,N/A,2440.09,N/A,2440.09,N/A,2440.09,N/A,1637.58,N/A,1008.75,N/A,398.16,N/A,1871.00,N/A,1871.00,N/A,398.16,N/A,1008.75,N/A,1008.75,N/A,1109.62,1706.40,1706.40,398.16,2440.09,,Hospital CPT 93620,HC Ep Study,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13159.00,13159.00,7895.40,7895.40,N/A,1842.26,N/A,6079.94,N/A,7576.95,N/A,4474.06,N/A,13159.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,9155.31,N/A,13159.00,N/A,13159.00,N/A,13159.00,N/A,7576.95,N/A,6079.94,N/A,1842.26,N/A,7897.00,N/A,7897.00,N/A,1842.26,N/A,6079.94,N/A,6079.94,N/A,6687.94,7895.40,7895.40,1842.26,13159.00,,Hospital CPT 93621,HC Electrophysiology Evaluation,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,7563.00,7563.00,4537.80,4537.80,N/A,1058.82,N/A,7563.00,N/A,4354.78,N/A,2571.42,N/A,7563.00,N/A,1058.82,N/A,7563.00,N/A,7563.00,N/A,7563.00,N/A,7563.00,N/A,7563.00,N/A,7563.00,N/A,4354.78,N/A,7563.00,N/A,1058.82,N/A,527.00,N/A,527.00,N/A,1058.82,N/A,7563.00,N/A,7563.00,N/A,7563.00,4537.80,4537.80,527.00,7563.00,,Hospital CPT 93623,HC Prog Stim/Pac Aft IV Drug Addon,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,8107.00,8107.00,4864.20,4864.20,N/A,1134.98,N/A,8107.00,N/A,4668.01,N/A,2756.38,N/A,8107.00,N/A,1134.98,N/A,8107.00,N/A,8107.00,N/A,8107.00,N/A,8107.00,N/A,8107.00,N/A,8107.00,N/A,4668.01,N/A,8107.00,N/A,1134.98,N/A,527.00,N/A,527.00,N/A,1134.98,N/A,8107.00,N/A,8107.00,N/A,8107.00,4864.20,4864.20,527.00,8107.00,,Hospital CPT 93640,HC Ep Eval Leads Initial,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,3073.00,3073.00,1843.80,1843.80,N/A,430.22,N/A,3073.00,N/A,1769.43,N/A,1044.82,N/A,3073.00,N/A,430.22,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,3073.00,N/A,1769.43,N/A,3073.00,N/A,430.22,N/A,1647.13,N/A,1647.13,N/A,430.22,N/A,3073.00,N/A,3073.00,N/A,3073.00,1843.80,1843.80,430.22,3073.00,,Hospital CPT 93662,HC Intracardiac Ecg (Ice),N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,7506.00,7506.00,4503.60,4503.60,N/A,1050.84,N/A,7506.00,N/A,4321.95,N/A,2552.04,N/A,7506.00,N/A,1050.84,N/A,7506.00,N/A,7506.00,N/A,7506.00,N/A,7506.00,N/A,7506.00,N/A,7506.00,N/A,4321.95,N/A,7506.00,N/A,1050.84,N/A,527.00,N/A,527.00,N/A,1050.84,N/A,7506.00,N/A,7506.00,N/A,7506.00,4503.60,4503.60,527.00,7506.00,,Hospital 93668,"HC Peripheral Art Disease Rehab, Ea",N/A,0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION,13156.30,1584.00,7893.78,950.40,4773.95,221.76,5912.98,485.37,10758.49,912.06,4473.14,538.56,10861.40,1130.04,4921.05,221.76,562.00,467.19,562.00,467.19,6760.97,703.44,10861.40,1130.04,10861.40,1130.04,10861.40,1130.04,10758.49,912.06,5912.98,467.19,4921.05,221.76,12922.36,849.06,12922.36,849.06,N/A,221.76,5912.98,467.19,5912.98,485.37,5265.52,121.95,562.00,12922.36,121.95,1130.04,,Hospital CPT 93724,HC Analyze Pacer Sys,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,853.00,853.00,511.80,511.80,N/A,119.42,N/A,41.49,N/A,491.16,N/A,290.02,N/A,806.67,N/A,119.42,N/A,41.49,N/A,41.49,N/A,502.15,N/A,806.67,N/A,806.67,N/A,806.67,N/A,491.16,N/A,41.49,N/A,119.42,N/A,853.00,N/A,853.00,N/A,119.42,N/A,41.49,N/A,41.49,N/A,45.64,511.80,511.80,41.49,853.00,,Hospital 93797,HC Cardiac Nonmonitored Exer Sess,N/A,0943 - OTHER THERAPEUTIC SERVICES - CARDIAC REHABILITATION,N/A,2025.00,N/A,1215.00,N/A,283.50,N/A,35.45,N/A,1166.01,N/A,688.50,N/A,786.81,N/A,283.50,N/A,325.29,N/A,325.29,N/A,489.81,N/A,786.81,N/A,786.81,N/A,786.81,N/A,1166.01,N/A,325.29,N/A,283.50,N/A,1085.40,N/A,1085.40,N/A,283.50,N/A,325.29,N/A,35.45,N/A,9.80,N/A,N/A,9.80,1215.00,,Hospital CPT 93798,HC Cardiac Rehab Outpatient,N/A,0943 - OTHER THERAPEUTIC SERVICES - CARDIAC REHABILITATION,449.00,449.00,269.40,269.40,N/A,62.86,N/A,108.43,N/A,258.53,N/A,152.66,N/A,262.27,N/A,62.86,N/A,108.43,N/A,108.43,N/A,163.27,N/A,262.27,N/A,262.27,N/A,262.27,N/A,258.53,N/A,108.43,N/A,62.86,N/A,240.66,N/A,240.66,N/A,62.86,N/A,108.43,N/A,108.43,N/A,449.00,269.40,269.40,62.86,449.00,,Hospital CPT 93799,HC Unlisted Cardiovascular Service or Procedure,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,13670.00,13670.00,8202.00,8202.00,N/A,1913.80,N/A,132.75,N/A,7871.19,N/A,4647.80,N/A,317.67,N/A,1913.80,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,7871.19,N/A,131.33,N/A,1913.80,N/A,527.00,N/A,527.00,N/A,1913.80,N/A,131.33,N/A,134.06,N/A,13670.00,8202.00,8202.00,131.33,13670.00,,Hospital 93886,HC Tcd Complete (Bil),N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,383879.88,1522.00,230327.93,913.20,60832.90,213.23,65284.84,504.87,211594.60,876.37,130519.15,517.48,133666.98,1135.24,56657.19,213.23,65284.84,477.18,65284.84,477.18,83225.16,706.71,133666.98,1135.24,133666.98,1135.24,133666.98,1135.24,211594.60,876.37,65284.84,477.18,56657.19,213.23,181959.07,770.01,181959.07,770.01,45023.44,213.23,65284.84,477.18,65284.84,504.87,41860.55,832.59,41860.55,230327.93,213.23,1135.24,,Hospital CPT 93923,HC Tcp02/Abi 3+ Levels,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,1247.00,1247.00,748.20,748.20,N/A,174.58,N/A,131.33,N/A,718.02,N/A,423.98,N/A,317.67,N/A,174.58,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,718.02,N/A,131.33,N/A,174.58,N/A,668.39,N/A,668.39,N/A,174.58,N/A,131.33,N/A,131.33,N/A,144.46,748.20,748.20,131.33,748.20,,Hospital CPT 93925,HC Bil Niv Arterial Low Ext Duplex,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,3614.00,3614.00,2168.40,2168.40,N/A,505.96,N/A,210.88,N/A,2080.94,N/A,1228.76,N/A,510.09,N/A,505.96,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,2080.94,N/A,210.88,N/A,505.96,N/A,1937.10,N/A,1937.10,N/A,505.96,N/A,210.88,N/A,210.88,N/A,231.97,2168.40,2168.40,210.88,2168.40,,Hospital CPT 93926,HC Uni Niv Arterial Low Ext Duplex,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,2378.00,2378.00,1426.80,1426.80,N/A,332.92,N/A,96.52,N/A,1369.25,N/A,808.52,N/A,233.46,N/A,332.92,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1369.25,N/A,96.52,N/A,332.92,N/A,1274.61,N/A,1274.61,N/A,332.92,N/A,96.52,N/A,96.52,N/A,106.17,1426.80,1426.80,96.52,1426.80,,Hospital CPT 93930,HC Bil Niv Arterial Upp Ext Duplex,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,3749.00,3749.00,2249.40,2249.40,N/A,524.86,N/A,143.69,N/A,2158.67,N/A,1274.66,N/A,510.09,N/A,524.86,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,2158.67,N/A,210.88,N/A,524.86,N/A,2009.46,N/A,2009.46,N/A,524.86,N/A,210.88,N/A,143.69,N/A,158.06,2249.40,2249.40,143.69,2249.40,,Hospital CPT 93975,HC US Duplex Abd/Pelvis/Scrotum Comp,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,2965.00,2965.00,1779.00,1779.00,N/A,415.10,N/A,210.88,N/A,1707.25,N/A,1008.10,N/A,510.09,N/A,415.10,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1707.25,N/A,210.88,N/A,415.10,N/A,1589.24,N/A,1589.24,N/A,415.10,N/A,210.88,N/A,210.88,N/A,231.97,1779.00,1779.00,210.88,1779.00,,Hospital CPT 93976,HC US Duplex Abd/Pelvis/Scrotum Ltd,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,1206.00,1206.00,723.60,723.60,N/A,168.84,N/A,100.27,N/A,694.41,N/A,410.04,N/A,233.46,N/A,168.84,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,694.41,N/A,96.52,N/A,168.84,N/A,646.42,N/A,646.42,N/A,168.84,N/A,96.52,N/A,102.28,N/A,120.05,723.60,723.60,96.52,723.60,,Hospital CPT 93980,HC Duplex Scan Penile Comp,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,301.00,301.00,180.60,180.60,N/A,42.14,N/A,102.67,N/A,173.32,N/A,102.34,N/A,233.46,N/A,42.14,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,173.32,N/A,96.52,N/A,42.14,N/A,161.34,N/A,161.34,N/A,42.14,N/A,96.52,N/A,102.67,N/A,56.22,180.60,180.60,42.14,233.46,,Hospital CPT 93985,HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,1361.00,1361.00,816.60,816.60,N/A,190.54,N/A,210.88,N/A,783.66,N/A,462.74,N/A,510.09,N/A,190.54,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,783.66,N/A,210.88,N/A,190.54,N/A,729.50,N/A,729.50,N/A,190.54,N/A,210.88,N/A,210.88,N/A,231.97,816.60,816.60,190.54,816.60,,Hospital CPT 94003,HC Ventilator Subsequent Day,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,1914.00,1914.00,1148.40,1148.40,N/A,267.96,N/A,534.81,N/A,1102.08,N/A,650.76,N/A,1216.09,N/A,267.96,N/A,502.74,N/A,502.74,N/A,757.04,N/A,1216.09,N/A,1216.09,N/A,1216.09,N/A,1102.08,N/A,502.74,N/A,267.96,N/A,1025.90,N/A,1025.90,N/A,267.96,N/A,502.74,N/A,534.81,N/A,69.51,1148.40,1148.40,69.51,1216.09,,Hospital CPT 94010,HC Spirometry / Tvc / Mvv,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,516.00,516.00,309.60,309.60,N/A,72.24,N/A,131.33,N/A,297.11,N/A,175.44,N/A,317.67,N/A,72.24,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,297.11,N/A,131.33,N/A,72.24,N/A,276.58,N/A,276.58,N/A,72.24,N/A,131.33,N/A,131.33,N/A,144.46,309.60,309.60,72.24,317.67,,Hospital CPT 94010,HC Pif (Copd Assessment),N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,516.00,516.00,309.60,309.60,N/A,72.24,N/A,131.33,N/A,297.11,N/A,175.44,N/A,317.67,N/A,72.24,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,297.11,N/A,131.33,N/A,72.24,N/A,276.58,N/A,276.58,N/A,72.24,N/A,131.33,N/A,131.33,N/A,144.46,309.60,309.60,72.24,317.67,,Hospital CPT 94150,HC Manual Spirometry 1 Time,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,292.00,292.00,175.20,175.20,N/A,40.88,N/A,131.33,N/A,168.13,N/A,99.28,N/A,292.00,N/A,40.88,N/A,131.33,N/A,131.33,N/A,197.75,N/A,292.00,N/A,292.00,N/A,292.00,N/A,168.13,N/A,131.33,N/A,40.88,N/A,156.51,N/A,156.51,N/A,40.88,N/A,131.33,N/A,131.33,N/A,144.46,175.20,175.20,40.88,292.00,,Hospital 94617,HC Exercise Test for Bronchospasm,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,N/A,1826.00,N/A,1095.60,N/A,255.64,N/A,269.04,N/A,1051.41,N/A,620.84,N/A,611.76,N/A,255.64,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,1051.41,N/A,252.91,N/A,255.64,N/A,978.73,N/A,854.38,N/A,255.64,N/A,252.91,N/A,269.04,N/A,110.41,N/A,N/A,110.41,1095.60,,Hospital 94619,HC Exercise Test for Bronchospasm WO Electrocard,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,N/A,1428.60,N/A,857.16,N/A,200.00,N/A,262.75,N/A,822.58,N/A,485.72,N/A,611.76,N/A,200.00,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,822.58,N/A,252.91,N/A,200.00,N/A,765.74,N/A,765.74,N/A,200.00,N/A,252.91,N/A,262.75,N/A,103.46,N/A,N/A,103.46,857.16,,Hospital CPT 94625,HC OP Pulm Rehab WO Cont Oximtry Mntr,N/A,0948 - OTHER THERAPEUTIC SERVICES - PULMONARY REHABILITATION,343.00,343.00,205.80,205.80,N/A,48.02,N/A,51.91,N/A,197.50,N/A,116.62,N/A,125.56,N/A,48.02,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,197.50,N/A,51.91,N/A,48.02,N/A,183.85,N/A,183.85,N/A,48.02,N/A,51.91,N/A,51.91,N/A,57.10,205.80,205.80,48.02,205.80,,Hospital CPT 94626,HC OP Pulm Rehab W/Cont Oximtry Mntr,N/A,0948 - OTHER THERAPEUTIC SERVICES - PULMONARY REHABILITATION,343.00,343.00,205.80,205.80,N/A,48.02,N/A,56.25,N/A,197.50,N/A,116.62,N/A,125.56,N/A,48.02,N/A,51.91,N/A,51.91,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,197.50,N/A,51.91,N/A,48.02,N/A,183.85,N/A,183.85,N/A,48.02,N/A,51.91,N/A,53.29,N/A,28.86,205.80,205.80,28.86,205.80,,Hospital CPT 94640,"HC Aerosol, Hhn, Mdi, Ippb",N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,289.00,289.00,173.40,173.40,N/A,40.46,N/A,172.93,N/A,166.41,N/A,98.26,N/A,289.00,N/A,40.46,N/A,172.93,N/A,172.93,N/A,260.40,N/A,289.00,N/A,289.00,N/A,289.00,N/A,166.41,N/A,172.93,N/A,40.46,N/A,154.90,N/A,154.90,N/A,40.46,N/A,172.93,N/A,172.93,N/A,190.23,173.40,173.40,40.46,289.00,,Hospital CPT 94640,HC Sputum Induction,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,289.00,289.00,173.40,173.40,N/A,40.46,N/A,172.93,N/A,166.41,N/A,98.26,N/A,289.00,N/A,40.46,N/A,172.93,N/A,172.93,N/A,260.40,N/A,289.00,N/A,289.00,N/A,289.00,N/A,166.41,N/A,172.93,N/A,40.46,N/A,154.90,N/A,154.90,N/A,40.46,N/A,172.93,N/A,172.93,N/A,190.23,173.40,173.40,40.46,289.00,,Hospital CPT 94660,HC Cpap/Bipap Daily,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,471.00,471.00,282.60,282.60,N/A,65.94,N/A,180.89,N/A,271.20,N/A,160.14,N/A,418.30,N/A,65.94,N/A,172.93,N/A,172.93,N/A,260.40,N/A,418.30,N/A,418.30,N/A,418.30,N/A,271.20,N/A,172.93,N/A,65.94,N/A,252.46,N/A,252.46,N/A,65.94,N/A,172.93,N/A,36.72,N/A,40.39,282.60,282.60,36.72,418.30,,Hospital CPT 94667,"HC Post.Drain/Percussion,Initial",N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,240.00,240.00,144.00,144.00,N/A,33.60,N/A,107.03,N/A,138.19,N/A,81.60,N/A,240.00,N/A,33.60,N/A,104.85,N/A,104.85,N/A,157.89,N/A,240.00,N/A,240.00,N/A,240.00,N/A,138.19,N/A,104.85,N/A,33.60,N/A,128.64,N/A,128.64,N/A,33.60,N/A,104.85,N/A,107.03,N/A,22.13,144.00,144.00,22.13,240.00,,Hospital CPT 94669,HC Oscill Chest Wall Mechani,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,479.00,479.00,287.40,287.40,N/A,67.06,N/A,177.55,N/A,275.81,N/A,162.86,N/A,418.30,N/A,67.06,N/A,172.93,N/A,172.93,N/A,260.40,N/A,418.30,N/A,418.30,N/A,418.30,N/A,275.81,N/A,172.93,N/A,67.06,N/A,256.74,N/A,256.74,N/A,67.06,N/A,172.93,N/A,180.89,N/A,18.16,287.40,287.40,18.16,418.30,,Hospital 94680,HC Oxygen Uptake Output Expired,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,44719.30,59493.30,26831.58,35695.98,8791.75,8269.55,10665.54,5043.96,21397.96,34252.14,15204.57,20227.72,21602.65,11748.69,9062.64,8269.55,2248.00,4821.94,2248.00,4821.94,13447.14,7313.78,21602.65,11748.69,21602.65,11748.69,21602.65,11748.69,21397.96,33747.78,10665.54,4821.94,9062.64,8269.55,25701.76,5963.00,25701.76,5963.00,7595.51,8269.55,10665.54,4821.94,10665.54,5043.96,9697.03,1511.44,2248.00,26831.58,1511.44,35695.98,,Hospital 94681,HC Co2 Output Expired Ga,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,364597.57,N/A,218758.54,N/A,18207.91,N/A,47166.91,N/A,68484.09,N/A,322269.97,N/A,322269.97,N/A,18207.91,N/A,47166.91,N/A,47166.91,N/A,322269.97,N/A,322269.97,N/A,322269.97,N/A,322269.97,N/A,68484.09,N/A,47166.91,N/A,18207.91,N/A,68484.09,N/A,68484.09,N/A,18207.91,N/A,39592.36,N/A,47166.91,N/A,18207.91,N/A,18207.91,322269.97,N/A,N/A,,Hospital 94690,HC Metabolic Assessment Indiv,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,706918.25,N/A,424150.95,N/A,N/A,N/A,130475.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130475.30,N/A,130475.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130475.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130475.30,N/A,130475.30,N/A,N/A,N/A,130475.30,424150.95,N/A,N/A,,Hospital CPT 94762,HC Pulse Oximetry Continuous,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,616.00,616.00,369.60,369.60,N/A,86.24,N/A,134.06,N/A,354.69,N/A,209.44,N/A,317.67,N/A,86.24,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,354.69,N/A,131.33,N/A,86.24,N/A,330.18,N/A,330.18,N/A,86.24,N/A,131.33,N/A,131.33,N/A,144.46,369.60,369.60,86.24,369.60,,Hospital 94775,HC Peds - Home Apnea Rec Hk-Up,N/A,0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION,N/A,251.00,N/A,150.60,N/A,35.14,N/A,139.71,N/A,144.53,N/A,85.34,N/A,251.00,N/A,35.14,N/A,131.33,N/A,131.33,N/A,197.75,N/A,251.00,N/A,251.00,N/A,251.00,N/A,144.53,N/A,131.33,N/A,35.14,N/A,134.54,N/A,134.54,N/A,35.14,N/A,131.33,N/A,139.71,N/A,239.00,N/A,N/A,35.14,251.00,,Hospital CPT 94780,HC Car Seat Study Minimum 60 Min W Report Code,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,125.00,125.00,75.00,75.00,N/A,17.50,N/A,30.67,N/A,71.98,N/A,42.50,N/A,74.18,N/A,17.50,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,71.98,N/A,30.67,N/A,17.50,N/A,67.00,N/A,67.00,N/A,17.50,N/A,30.67,N/A,30.67,N/A,33.73,75.00,75.00,17.50,75.00,,Hospital 94781,HC Car Seat Study Add 30 Min,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,7124.95,159.00,4274.97,95.40,7124.95,22.26,26921.54,31.86,7124.95,91.55,2422.48,54.06,3598.81,74.18,7124.95,22.26,26921.54,30.67,26921.54,30.67,2240.08,46.18,3598.81,74.18,3598.81,74.18,3598.81,74.18,7124.95,91.55,26921.54,30.67,7124.95,22.26,7124.95,85.22,7124.95,85.22,2426.83,22.26,26921.54,30.67,26921.54,31.86,7124.95,34.26,2240.08,26921.54,22.26,95.40,,Hospital CPT 94799,HC Mech-Mv-Vc-Tv-Rr-Neg If,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,415.00,415.00,249.00,249.00,N/A,58.10,N/A,134.06,N/A,238.96,N/A,141.10,N/A,317.67,N/A,58.10,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,238.96,N/A,131.33,N/A,58.10,N/A,222.44,N/A,222.44,N/A,58.10,N/A,131.33,N/A,134.06,N/A,415.00,249.00,249.00,58.10,415.00,,Hospital 95012,HC Exhaled Nitric Oxide Meas,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,340406.88,1330.00,204244.13,798.00,N/A,186.20,N/A,110.32,N/A,765.82,115738.34,452.20,118529.68,N/A,N/A,186.20,N/A,109.14,N/A,109.14,73800.21,N/A,118529.68,N/A,118529.68,422.08,118529.68,N/A,N/A,765.82,N/A,109.14,N/A,186.20,N/A,712.87,N/A,712.87,N/A,186.20,N/A,109.14,N/A,110.32,N/A,36.69,73800.21,204244.13,36.69,798.00,,Hospital 95018,HC Allg Test Perq & Ic Drug/Biol Immed React,N/A,0924 - OTHER DIAGNOSTIC SERVICES - ALLERGY TEST,N/A,4560.50,N/A,2736.30,N/A,638.47,N/A,385.17,N/A,2625.62,N/A,1550.57,N/A,894.27,N/A,638.47,N/A,368.21,N/A,368.21,N/A,556.69,N/A,894.27,N/A,894.27,N/A,894.27,N/A,2625.63,N/A,368.21,N/A,638.47,N/A,319.73,N/A,319.74,N/A,638.47,N/A,368.21,N/A,385.17,N/A,7.63,N/A,N/A,7.63,2736.30,,Hospital 95070,Inhlj Brncl Challenge Tstg W/Histam/Methachol,N/A,N/A,N/A,7784.60,N/A,4670.76,N/A,1089.84,N/A,3004.50,N/A,4418.92,N/A,2646.76,N/A,6947.68,N/A,1089.84,N/A,2872.25,N/A,2872.25,N/A,4325.06,N/A,6947.68,N/A,6947.68,N/A,6947.68,N/A,4418.92,N/A,2872.25,N/A,1089.84,N/A,4172.55,N/A,4172.55,N/A,1089.84,N/A,2872.25,N/A,3004.50,N/A,354.02,N/A,N/A,354.02,6947.68,,Hospital 95249,HC Cont Gluc Mntr Pt Provided Equip,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,335.00,N/A,201.00,N/A,46.90,N/A,170.67,N/A,192.89,N/A,113.90,N/A,125.56,N/A,46.90,N/A,161.05,N/A,161.05,N/A,78.16,N/A,125.56,N/A,125.56,N/A,125.56,N/A,192.89,N/A,161.05,N/A,46.90,N/A,179.56,N/A,179.56,N/A,46.90,N/A,161.05,N/A,170.67,N/A,57.17,N/A,N/A,46.90,201.00,,Hospital 95250,"HC Glucose Monitoring,72 Hrs,Sub-Q Sensor",N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,N/A,740.00,N/A,444.00,N/A,103.60,N/A,237.12,N/A,426.10,N/A,251.60,N/A,546.01,N/A,103.60,N/A,214.60,N/A,214.60,N/A,357.79,N/A,546.01,N/A,546.01,N/A,546.01,N/A,426.10,N/A,214.60,N/A,103.60,N/A,396.64,N/A,396.64,N/A,103.60,N/A,214.60,N/A,237.12,N/A,260.84,N/A,N/A,103.60,546.01,,Hospital 95706,HC Eeg WO Vid 2-12 Hr Intmt Monitoring,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,65085.32,N/A,39051.19,N/A,7887.39,N/A,18743.28,N/A,53228.41,N/A,17474.51,N/A,17474.51,N/A,7887.39,N/A,13941.79,N/A,13941.79,N/A,17474.51,N/A,17474.51,N/A,17474.51,N/A,17474.51,N/A,23094.26,N/A,18743.28,N/A,7887.39,N/A,53228.41,N/A,53228.41,N/A,7887.39,N/A,18743.28,N/A,18743.28,N/A,7887.39,N/A,7887.39,53228.41,N/A,N/A,,Hospital 95711,HC Veeg by Tech 2-12 Hours Unmonitored,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,150440.12,24283.40,90264.07,14570.04,7081.37,3403.50,41700.30,2244.87,82922.59,13979.00,51149.63,8256.35,25559.07,5182.46,36105.82,3403.50,41700.30,2103.42,41700.30,2103.42,25559.07,3225.43,25559.07,5182.46,87039.42,5182.46,25055.00,5182.46,82922.59,13979.00,11436.86,2103.42,7081.37,3403.50,57349.97,12393.32,94811.60,12393.32,7258.53,3403.50,16616.49,2103.42,14122.50,2244.87,7081.37,381.95,7081.37,94811.60,381.95,14570.04,,Hospital 95713,HC Veeg by Tech 2-12 Hr Cont R-T Monitoring,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,65445.50,N/A,39267.30,N/A,10247.81,N/A,12388.26,N/A,23094.26,N/A,22251.47,N/A,24010.58,N/A,10563.56,N/A,2248.00,N/A,2248.00,N/A,14947.30,N/A,24010.58,N/A,24010.58,N/A,24010.58,N/A,23094.26,N/A,12388.26,N/A,10563.56,N/A,27739.24,N/A,27739.24,N/A,5543.32,N/A,12388.26,N/A,12388.26,N/A,11303.01,N/A,2248.00,39267.30,N/A,N/A,,Hospital CPT 95714,HC Veeg by Tech Ea Incr 12-26 Hr Unmonitored,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,4468.00,4468.00,2680.80,2680.80,N/A,625.52,N/A,457.70,N/A,2572.67,N/A,1519.12,N/A,1055.99,N/A,625.52,N/A,436.56,N/A,436.56,N/A,657.37,N/A,1055.99,N/A,1055.99,N/A,1055.99,N/A,2572.67,N/A,436.56,N/A,625.52,N/A,2394.85,N/A,2394.85,N/A,625.52,N/A,436.56,N/A,4468.00,N/A,4468.00,2680.80,2680.80,436.56,4468.00,,Hospital 95716,HC Veeg by Tech Ea Incr 12-26 Hr Cont R-T Mntr,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,97452.10,N/A,58471.26,N/A,4834.23,N/A,23943.87,N/A,18765.00,N/A,33133.71,N/A,816.00,N/A,4983.18,N/A,5058.00,N/A,5058.00,N/A,816.00,N/A,816.00,N/A,816.00,N/A,816.00,N/A,10894.34,N/A,23943.87,N/A,4983.18,N/A,13085.53,N/A,13085.53,N/A,6919.60,N/A,5984.30,N/A,23943.87,N/A,15092.37,N/A,816.00,58471.26,N/A,N/A,,Hospital CPT 95800,HC Sleep Study Unattended,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,855.00,855.00,513.00,513.00,N/A,119.70,N/A,130.19,N/A,492.31,N/A,290.70,N/A,317.67,N/A,119.70,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,492.31,N/A,131.33,N/A,119.70,N/A,458.28,N/A,458.28,N/A,119.70,N/A,131.33,N/A,130.19,N/A,117.08,513.00,513.00,117.08,513.00,,Hospital CPT 95806,HC Sleep Study Unatt & Resp Efft,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,608.00,608.00,364.80,364.80,N/A,85.12,N/A,42.07,N/A,350.09,N/A,206.72,N/A,317.67,N/A,85.12,N/A,131.33,N/A,131.33,N/A,197.75,N/A,317.67,N/A,317.67,N/A,317.67,N/A,350.09,N/A,131.33,N/A,85.12,N/A,325.89,N/A,325.89,N/A,85.12,N/A,131.33,N/A,42.07,N/A,46.28,364.80,364.80,42.07,364.80,,Hospital CPT 95810,HC Adult Sleep Study (Polysomnogram),N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,10265.00,10265.00,6159.00,6159.00,N/A,1437.10,N/A,843.78,N/A,5910.59,N/A,3490.10,N/A,2041.05,N/A,1437.10,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,5910.59,N/A,843.78,N/A,1437.10,N/A,5502.04,N/A,5502.04,N/A,1437.10,N/A,843.78,N/A,843.78,N/A,928.16,6159.00,6159.00,843.78,6159.00,,Hospital CPT 95810,HC Sleep Study Reduced Services,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,10265.00,10265.00,6159.00,6159.00,N/A,1437.10,N/A,843.78,N/A,5910.59,N/A,3490.10,N/A,2041.05,N/A,1437.10,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,5910.59,N/A,843.78,N/A,1437.10,N/A,5502.04,N/A,5502.04,N/A,1437.10,N/A,843.78,N/A,843.78,N/A,928.16,6159.00,6159.00,843.78,6159.00,,Hospital CPT 95811,HC Adult Cpap Titration Study,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,10675.00,10675.00,6405.00,6405.00,N/A,1494.50,N/A,843.78,N/A,6146.67,N/A,3629.50,N/A,2041.05,N/A,1494.50,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,6146.67,N/A,843.78,N/A,1494.50,N/A,5721.80,N/A,5721.80,N/A,1494.50,N/A,843.78,N/A,843.78,N/A,928.16,6405.00,6405.00,843.78,6405.00,,Hospital CPT 95811,HC Aborted Cpap,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,10675.00,10675.00,6405.00,6405.00,N/A,1494.50,N/A,843.78,N/A,6146.67,N/A,3629.50,N/A,2041.05,N/A,1494.50,N/A,843.78,N/A,843.78,N/A,1270.59,N/A,2041.05,N/A,2041.05,N/A,2041.05,N/A,6146.67,N/A,843.78,N/A,1494.50,N/A,5721.80,N/A,5721.80,N/A,1494.50,N/A,843.78,N/A,843.78,N/A,928.16,6405.00,6405.00,843.78,6405.00,,Hospital CPT 95816,HC Eeg Awake & Drowsy,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,1347.00,1347.00,808.20,808.20,N/A,188.58,N/A,252.91,N/A,775.60,N/A,457.98,N/A,611.76,N/A,188.58,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,775.60,N/A,252.91,N/A,188.58,N/A,721.99,N/A,721.99,N/A,188.58,N/A,252.91,N/A,252.91,N/A,278.20,808.20,808.20,188.58,808.20,,Hospital CPT 95819,HC Eeg Awake and Asleep,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,1347.00,1347.00,808.20,808.20,N/A,188.58,N/A,252.91,N/A,775.60,N/A,457.98,N/A,611.76,N/A,188.58,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,775.60,N/A,252.91,N/A,188.58,N/A,721.99,N/A,721.99,N/A,188.58,N/A,252.91,N/A,252.91,N/A,278.20,808.20,808.20,188.58,808.20,,Hospital CPT 95822,HC Eeg Coma or Sleep Only,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,820.00,820.00,492.00,492.00,N/A,114.80,N/A,321.42,N/A,472.16,N/A,278.80,N/A,820.00,N/A,114.80,N/A,321.42,N/A,321.42,N/A,695.38,N/A,820.00,N/A,820.00,N/A,820.00,N/A,472.16,N/A,321.42,N/A,114.80,N/A,439.52,N/A,439.52,N/A,114.80,N/A,321.42,N/A,321.42,N/A,353.56,492.00,492.00,114.80,820.00,,Hospital 95851,HC Pt Rom Meas. & Rep. Ea Ext. No H,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,84015.00,N/A,50409.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28473.13,N/A,42299.33,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9869.64,N/A,42299.33,N/A,42299.33,N/A,42299.33,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9869.64,50409.00,N/A,N/A,,Hospital CPT 95860,HC Emg 1 Ext & Paraspinal,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,351.00,351.00,210.60,210.60,N/A,49.14,N/A,109.68,N/A,202.11,N/A,119.34,N/A,253.64,N/A,49.14,N/A,104.85,N/A,104.85,N/A,157.89,N/A,253.64,N/A,253.64,N/A,253.64,N/A,202.11,N/A,104.85,N/A,49.14,N/A,188.14,N/A,188.14,N/A,49.14,N/A,104.85,N/A,109.68,N/A,62.83,210.60,210.60,49.14,253.64,,Hospital CPT 95886,HC Emg Comp Ea Ext W Nrv Conduct,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,483.00,483.00,289.80,289.80,N/A,67.62,N/A,483.00,N/A,278.11,N/A,164.22,N/A,483.00,N/A,67.62,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,483.00,N/A,278.11,N/A,483.00,N/A,67.62,N/A,258.89,N/A,258.89,N/A,67.62,N/A,483.00,N/A,483.00,N/A,483.00,289.80,289.80,67.62,483.00,,Hospital CPT 95926,HC Somatosensory Testing Lwr Limbs,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,752.00,752.00,451.20,451.20,N/A,105.28,N/A,118.43,N/A,433.00,N/A,255.68,N/A,418.77,N/A,105.28,N/A,118.43,N/A,118.43,N/A,260.68,N/A,418.77,N/A,418.77,N/A,418.77,N/A,433.00,N/A,118.43,N/A,105.28,N/A,403.07,N/A,403.07,N/A,105.28,N/A,118.43,N/A,118.43,N/A,130.27,451.20,451.20,105.28,451.20,,Hospital 95938,HC Short-Latency Somatosens Ep Std Upr & Low Limbs,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,150650.33,N/A,90390.20,N/A,20090.18,N/A,24090.60,N/A,83038.46,N/A,51221.11,N/A,31660.05,N/A,20709.19,N/A,121954.00,N/A,121954.00,N/A,28452.13,N/A,45707.94,N/A,45707.94,N/A,45707.94,N/A,83038.46,N/A,22409.48,N/A,20709.19,N/A,54381.04,N/A,54381.04,N/A,4254.92,N/A,24031.30,N/A,24090.60,N/A,22158.84,N/A,4254.92,121954.00,N/A,N/A,,Hospital 95939,HC Ctr Motr Ep Std Transcrnl Motr Stim Upr&Low Limb,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,225821.53,N/A,135492.92,N/A,25028.36,N/A,24149.90,N/A,124472.83,N/A,76779.32,N/A,78631.06,N/A,21536.68,N/A,2248.00,N/A,2248.00,N/A,N/A,N/A,78631.06,N/A,78631.06,N/A,78631.06,N/A,124472.83,N/A,24647.95,N/A,21536.68,N/A,120330.22,N/A,120330.22,N/A,17394.84,N/A,24031.30,N/A,24031.30,N/A,23044.25,N/A,2248.00,135492.92,N/A,N/A,,Hospital 95940,HC Evok Ionm in or per 15min,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,150650.33,160993.23,90390.20,96595.94,20090.18,5719.03,24090.60,20161.67,83038.46,91715.72,51221.11,54737.75,45707.94,64265.28,20709.19,22467.96,121954.00,19943.19,121954.00,19943.19,65087.55,64265.28,45707.94,64265.28,65087.55,64265.28,45707.94,64265.28,83038.46,20531.21,31214.35,20161.67,20709.19,22467.96,54381.04,20531.21,54381.04,19049.75,4254.92,22467.96,24031.30,20161.67,24090.60,20161.67,22158.84,4158.00,4254.92,121954.00,4158.00,96595.94,,Hospital 95941,HC Evok Ionm Remote per Hr,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,217336.80,N/A,130402.08,N/A,N/A,N/A,N/A,N/A,119796.04,N/A,73719.34,N/A,75497.28,N/A,33493.80,N/A,N/A,N/A,N/A,N/A,47006.92,N/A,75497.28,N/A,75497.28,N/A,75497.28,N/A,119796.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,132671.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33493.80,132671.44,N/A,N/A,,Hospital 95953,HC Eeg Cont Ea 24hr 16ch Unattended,N/A,0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION,260656.20,N/A,156393.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,156393.72,156393.72,N/A,N/A,,Hospital 95972,HC Scs Analysis W/Program Complx,N/A,0922 - OTHER DIAGNOSTIC SERVICES - ELECTROMYELGRAM,N/A,23192.95,N/A,13915.77,N/A,3247.01,N/A,5912.03,N/A,13150.82,N/A,7885.61,N/A,14433.18,N/A,3247.01,N/A,5963.54,N/A,5963.54,N/A,8984.93,N/A,14433.18,N/A,14433.18,N/A,14433.18,N/A,13150.83,N/A,5963.54,N/A,3247.01,N/A,11845.50,N/A,11845.50,N/A,3247.01,N/A,5963.54,N/A,5912.03,N/A,917.16,N/A,N/A,917.16,14433.18,,Hospital CPT 95976,HC Elec Alys Implt Smpl Cn Npgt Prgrmg,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,88.00,88.00,52.80,52.80,N/A,12.32,N/A,31.44,N/A,50.67,N/A,29.92,N/A,76.46,N/A,12.32,N/A,31.61,N/A,31.61,N/A,47.60,N/A,76.46,N/A,76.46,N/A,76.46,N/A,50.67,N/A,31.61,N/A,12.32,N/A,47.17,N/A,47.17,N/A,12.32,N/A,31.61,N/A,31.44,N/A,42.22,52.80,52.80,12.32,76.46,,Hospital 95980,Elec Alys Nstim Pls Gen Gastric Intraop W/ Prog,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,93485.93,N/A,56091.56,N/A,5460.52,N/A,6408.84,N/A,46488.40,N/A,31785.21,N/A,12736.48,N/A,5628.77,N/A,214122.00,N/A,214122.00,N/A,7928.84,N/A,12736.48,N/A,12736.48,N/A,12736.48,N/A,46488.40,N/A,6379.19,N/A,5628.77,N/A,14714.36,N/A,14714.36,N/A,14400.21,N/A,6379.19,N/A,6408.84,N/A,6022.78,N/A,5460.52,214122.00,N/A,N/A,,Hospital CPT 95990,"HC Codman Pump, Refill & Analysis",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,810.00,810.00,486.00,486.00,N/A,113.40,N/A,80.84,N/A,466.40,N/A,275.40,N/A,237.84,N/A,113.40,N/A,80.84,N/A,80.84,N/A,148.06,N/A,237.84,N/A,237.84,N/A,237.84,N/A,466.40,N/A,80.84,N/A,113.40,N/A,434.16,N/A,434.16,N/A,113.40,N/A,80.84,N/A,80.84,N/A,88.92,486.00,486.00,80.84,486.00,,Hospital 96040,HC Genetic Counseling,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,232.00,N/A,139.20,N/A,32.48,N/A,N/A,N/A,133.59,N/A,78.88,N/A,32.48,N/A,32.48,N/A,N/A,N/A,N/A,N/A,20.18,N/A,32.48,N/A,32.48,N/A,32.48,N/A,133.59,N/A,N/A,N/A,32.48,N/A,124.35,N/A,124.35,N/A,32.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20.18,139.20,,Hospital CPT 96105,"HC Assess of Aphasia,per Hour",N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,339.00,339.00,203.40,203.40,N/A,47.46,N/A,94.70,N/A,195.20,N/A,115.26,N/A,279.93,N/A,47.46,N/A,94.70,N/A,94.70,N/A,174.26,N/A,279.93,N/A,279.93,N/A,279.93,N/A,195.20,N/A,94.70,N/A,47.46,N/A,181.70,N/A,181.70,N/A,47.46,N/A,94.70,N/A,94.70,N/A,104.17,203.40,203.40,47.46,279.93,,Hospital 96112,HC Developmental Tst Admin Phys/Qhp 1st Hour,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,1593.00,N/A,955.80,N/A,223.02,N/A,503.43,N/A,917.25,N/A,541.62,N/A,1490.43,N/A,223.02,N/A,513.68,N/A,513.68,N/A,1269.26,N/A,1490.43,N/A,1490.43,N/A,1490.43,N/A,917.25,N/A,543.72,N/A,223.02,N/A,853.86,N/A,853.86,N/A,223.02,N/A,513.68,N/A,503.43,N/A,553.78,N/A,N/A,223.02,1490.43,,Hospital 96131,HC Psychological Tst Eval Svc Phys/Qhp Ea Addl Hour,N/A,0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - TESTING,N/A,1355.00,N/A,813.00,N/A,189.70,N/A,397.63,N/A,780.22,N/A,460.70,N/A,904.16,N/A,189.70,N/A,373.78,N/A,373.78,N/A,562.86,N/A,904.16,N/A,904.16,N/A,904.16,N/A,780.22,N/A,373.78,N/A,189.70,N/A,527.96,N/A,527.96,N/A,189.70,N/A,373.78,N/A,397.63,N/A,481.36,N/A,N/A,189.70,904.16,,Hospital CPT 96360,HC Inf 1st Hour Hyd,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,1083.00,1083.00,649.80,649.80,N/A,151.62,N/A,186.54,N/A,623.59,N/A,368.22,N/A,451.22,N/A,151.62,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,623.59,N/A,186.54,N/A,151.62,N/A,580.49,N/A,580.49,N/A,151.62,N/A,186.54,N/A,186.54,N/A,205.20,649.80,649.80,151.62,649.80,,Hospital CPT 96361,HC Inf Ea Add'l Hour Hyd,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,645.00,645.00,387.00,387.00,N/A,90.30,N/A,38.26,N/A,371.39,N/A,219.30,N/A,92.56,N/A,90.30,N/A,38.26,N/A,38.26,N/A,57.62,N/A,92.56,N/A,92.56,N/A,92.56,N/A,371.39,N/A,38.26,N/A,90.30,N/A,345.72,N/A,345.72,N/A,90.30,N/A,38.26,N/A,38.26,N/A,42.09,387.00,387.00,38.26,387.00,,Hospital CPT 96365,HC IV 1st Hour Init Drug,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,1198.00,1198.00,718.80,718.80,N/A,167.72,N/A,186.54,N/A,689.81,N/A,407.32,N/A,451.22,N/A,167.72,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,689.81,N/A,186.54,N/A,167.72,N/A,642.13,N/A,642.13,N/A,167.72,N/A,186.54,N/A,186.54,N/A,205.20,718.80,718.80,167.72,718.80,,Hospital CPT 96365,"HC Infusion Thrpy, 1st Hr, Other",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1198.00,1198.00,718.80,718.80,N/A,167.72,N/A,186.54,N/A,689.81,N/A,407.32,N/A,451.22,N/A,167.72,N/A,186.54,N/A,186.54,N/A,280.89,N/A,451.22,N/A,451.22,N/A,451.22,N/A,689.81,N/A,186.54,N/A,167.72,N/A,642.13,N/A,642.13,N/A,167.72,N/A,186.54,N/A,186.54,N/A,205.20,718.80,718.80,167.72,718.80,,Hospital CPT 96367,HC IV Inf 1st Hour Ea New Drug,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,1068.00,1068.00,640.80,640.80,N/A,149.52,N/A,60.93,N/A,614.95,N/A,363.12,N/A,147.37,N/A,149.52,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,614.95,N/A,60.93,N/A,149.52,N/A,572.45,N/A,572.45,N/A,149.52,N/A,60.93,N/A,60.93,N/A,67.02,640.80,640.80,60.93,640.80,,Hospital CPT 96368,HC IV Inf Thera Concurrent,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,602.00,602.00,361.20,361.20,N/A,84.28,N/A,602.00,N/A,346.63,N/A,204.68,N/A,602.00,N/A,84.28,N/A,602.00,N/A,602.00,N/A,602.00,N/A,602.00,N/A,602.00,N/A,602.00,N/A,346.63,N/A,602.00,N/A,84.28,N/A,322.67,N/A,322.67,N/A,84.28,N/A,602.00,N/A,602.00,N/A,602.00,361.20,361.20,84.28,602.00,,Hospital CPT 96374,HC IV Push Initial Drug,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,445.00,445.00,267.00,267.00,N/A,62.30,N/A,186.54,N/A,256.23,N/A,151.30,N/A,445.00,N/A,62.30,N/A,186.54,N/A,186.54,N/A,280.89,N/A,445.00,N/A,445.00,N/A,445.00,N/A,256.23,N/A,186.54,N/A,62.30,N/A,238.52,N/A,238.52,N/A,62.30,N/A,186.54,N/A,186.54,N/A,205.20,267.00,267.00,62.30,445.00,,Hospital CPT 96376,HC IV Push Same Drug,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,397.00,397.00,238.20,238.20,N/A,55.58,N/A,397.00,N/A,228.59,N/A,134.98,N/A,397.00,N/A,55.58,N/A,397.00,N/A,397.00,N/A,397.00,N/A,397.00,N/A,397.00,N/A,397.00,N/A,228.59,N/A,397.00,N/A,55.58,N/A,212.79,N/A,212.79,N/A,55.58,N/A,397.00,N/A,397.00,N/A,397.00,238.20,238.20,55.58,397.00,,Hospital CPT 96379,HC Unlisted Therapeutic Proph/Dx IV/Ia Njx/Nfs,N/A,0260 - IV THERAPY - GENERAL CLASSIFICATION,106.00,106.00,63.60,63.60,N/A,14.84,N/A,106.00,N/A,61.03,N/A,36.04,N/A,14.84,N/A,14.84,N/A,106.00,N/A,106.00,N/A,9.22,N/A,14.84,N/A,14.84,N/A,14.84,N/A,61.03,N/A,106.00,N/A,14.84,N/A,56.82,N/A,56.82,N/A,14.84,N/A,106.00,N/A,106.00,N/A,106.00,63.60,63.60,9.22,106.00,,Hospital CPT 96416,HC Initiate Prolonged Chemo Pump,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,906.00,906.00,543.60,543.60,N/A,126.84,N/A,300.37,N/A,521.67,N/A,308.04,N/A,726.56,N/A,126.84,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,521.67,N/A,300.37,N/A,126.84,N/A,485.62,N/A,485.62,N/A,126.84,N/A,300.37,N/A,300.37,N/A,330.41,543.60,543.60,126.84,726.56,,Hospital CPT 96417,HC Chemo Infuse New Drug 1st Hour,N/A,0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV,557.00,557.00,334.20,334.20,N/A,77.98,N/A,60.93,N/A,320.72,N/A,189.38,N/A,147.37,N/A,77.98,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,320.72,N/A,60.93,N/A,77.98,N/A,298.55,N/A,298.55,N/A,77.98,N/A,60.93,N/A,60.93,N/A,67.02,334.20,334.20,60.93,334.20,,Hospital CPT 96450,HC Chemo It Inj Incl Spinal Punct,N/A,0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED,762.00,762.00,457.20,457.20,N/A,106.68,N/A,314.20,N/A,438.76,N/A,259.08,N/A,726.56,N/A,106.68,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,438.76,N/A,300.37,N/A,106.68,N/A,408.43,N/A,408.43,N/A,106.68,N/A,300.37,N/A,314.20,N/A,81.53,457.20,457.20,81.53,726.56,,Hospital CPT 96542,HC Chemo-Intrathecal Reservoir Tx,N/A,0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED,583.00,583.00,349.80,349.80,N/A,81.62,N/A,40.59,N/A,335.69,N/A,198.22,N/A,353.13,N/A,81.62,N/A,40.59,N/A,40.59,N/A,219.82,N/A,353.13,N/A,353.13,N/A,353.13,N/A,335.69,N/A,40.59,N/A,81.62,N/A,312.49,N/A,312.49,N/A,81.62,N/A,40.59,N/A,40.59,N/A,44.65,349.80,349.80,40.59,353.13,,Hospital 97010,HC Cold/Hot Trtmt,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,N/A,2847.00,N/A,1708.20,N/A,398.58,N/A,378.65,N/A,1639.30,N/A,967.98,N/A,1095.63,N/A,398.58,N/A,378.65,N/A,378.65,N/A,1094.20,N/A,1095.63,N/A,1095.63,N/A,1095.63,N/A,1639.30,N/A,363.95,N/A,398.58,N/A,1525.97,N/A,1525.97,N/A,398.58,N/A,378.65,N/A,378.65,N/A,416.50,N/A,N/A,363.95,1708.20,,Hospital CPT 97014,HC Ot Elec Stim Unattended,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,289.00,289.00,173.40,173.40,N/A,40.46,N/A,13.10,N/A,166.41,N/A,98.26,N/A,40.46,N/A,40.46,N/A,13.10,N/A,13.10,N/A,25.14,N/A,40.46,N/A,40.46,N/A,40.46,N/A,166.41,N/A,11.71,N/A,40.46,N/A,154.90,N/A,154.90,N/A,40.46,N/A,13.10,N/A,13.10,N/A,289.00,173.40,173.40,11.71,289.00,,Hospital CPT 97018,HC Pt Parrafin Bath,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,92.00,77.00,55.20,46.20,N/A,10.78,N/A,5.62,N/A,44.34,N/A,26.18,N/A,16.44,N/A,10.78,N/A,5.62,N/A,5.62,N/A,16.44,N/A,16.44,N/A,16.44,N/A,16.44,N/A,44.34,N/A,5.48,N/A,10.78,N/A,41.27,N/A,41.27,N/A,10.78,N/A,5.62,N/A,5.62,N/A,6.18,55.20,55.20,5.48,46.20,,Hospital 97026,HC Ot Infrared Modality,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,N/A,3572.00,N/A,2143.20,N/A,500.08,N/A,503.97,N/A,2056.75,N/A,1214.48,N/A,1444.47,N/A,500.08,N/A,503.97,N/A,503.97,N/A,1444.47,N/A,1444.47,N/A,1444.47,N/A,1444.47,N/A,2056.75,N/A,481.49,N/A,500.08,N/A,1914.59,N/A,1914.59,N/A,500.08,N/A,503.97,N/A,503.97,N/A,554.39,N/A,N/A,481.49,2143.20,,Hospital CPT 97032,HC Ot Electricl Stim Attended 15,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,188.00,159.00,112.80,95.40,N/A,22.26,N/A,14.37,N/A,91.55,N/A,54.06,N/A,42.27,N/A,22.26,N/A,14.37,N/A,14.37,N/A,42.27,N/A,42.27,N/A,42.27,N/A,42.27,N/A,91.55,N/A,14.09,N/A,22.26,N/A,85.22,N/A,85.22,N/A,22.26,N/A,14.37,N/A,14.37,N/A,15.81,112.80,112.80,14.09,95.40,,Hospital CPT 97032,HC Pt Estim-Manual Each 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,188.00,159.00,112.80,95.40,N/A,22.26,N/A,14.37,N/A,91.55,N/A,54.06,N/A,42.27,N/A,22.26,N/A,14.37,N/A,14.37,N/A,42.27,N/A,42.27,N/A,42.27,N/A,42.27,N/A,91.55,N/A,14.09,N/A,22.26,N/A,85.22,N/A,85.22,N/A,22.26,N/A,14.37,N/A,14.37,N/A,15.81,112.80,112.80,14.09,95.40,,Hospital CPT 97033,HC Iontophoresis,N/A,0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION,166.00,140.00,99.60,84.00,N/A,19.60,N/A,19.77,N/A,80.61,N/A,47.60,N/A,57.18,N/A,19.60,N/A,19.77,N/A,19.77,N/A,57.18,N/A,57.18,N/A,57.18,N/A,57.18,N/A,80.61,N/A,19.06,N/A,19.60,N/A,75.04,N/A,75.04,N/A,19.60,N/A,19.77,N/A,19.77,N/A,21.75,99.60,99.60,19.06,84.00,,Hospital CPT 97035,HC Ot Ultrasound 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,105.00,90.00,63.00,54.00,N/A,12.60,N/A,13.87,N/A,51.82,N/A,30.60,N/A,41.91,N/A,12.60,N/A,13.87,N/A,13.87,N/A,41.91,N/A,41.91,N/A,41.91,N/A,41.91,N/A,51.82,N/A,13.97,N/A,12.60,N/A,48.24,N/A,48.24,N/A,12.60,N/A,13.87,N/A,13.87,N/A,15.26,63.00,63.00,12.60,54.00,,Hospital CPT 97035,HC Pt Ultrasound Each 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,105.00,90.00,63.00,54.00,N/A,12.60,N/A,13.87,N/A,51.82,N/A,30.60,N/A,41.91,N/A,12.60,N/A,13.87,N/A,13.87,N/A,41.91,N/A,41.91,N/A,41.91,N/A,41.91,N/A,51.82,N/A,13.97,N/A,12.60,N/A,48.24,N/A,48.24,N/A,12.60,N/A,13.87,N/A,13.87,N/A,15.26,63.00,63.00,12.60,54.00,,Hospital 97113,HC Pt Aquatic Therapeutic Exer 15 Mn,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,47499.50,2378.00,28499.70,1426.80,6973.26,332.92,13469.64,319.97,25317.23,1369.24,N/A,808.52,N/A,974.31,6973.26,332.92,9824.57,319.97,9824.57,319.97,N/A,974.31,N/A,974.31,N/A,974.31,N/A,974.31,25317.23,1369.24,13469.64,324.77,6973.26,332.92,25317.23,1274.62,20520.00,1274.62,6973.26,332.92,13469.64,319.97,13469.64,319.97,6973.26,351.97,6973.26,28499.70,319.97,1426.80,,Hospital CPT 97116,HC Pt Gait Training Ea 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,179.00,151.00,107.40,90.60,N/A,21.14,N/A,29.14,N/A,86.95,N/A,51.34,N/A,85.77,N/A,21.14,N/A,29.14,N/A,29.14,N/A,85.77,N/A,85.77,N/A,85.77,N/A,85.77,N/A,86.95,N/A,28.59,N/A,21.14,N/A,80.94,N/A,80.94,N/A,21.14,N/A,29.14,N/A,29.14,N/A,32.05,107.40,107.40,21.14,90.60,,Hospital CPT 97124,HC Pt Massage Ea 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,50.00,44.00,30.00,26.40,N/A,6.16,N/A,27.75,N/A,25.34,N/A,14.96,N/A,44.00,N/A,6.16,N/A,27.75,N/A,27.75,N/A,44.00,N/A,44.00,N/A,44.00,N/A,44.00,N/A,25.34,N/A,28.91,N/A,6.16,N/A,23.58,N/A,23.58,N/A,6.16,N/A,27.75,N/A,27.75,N/A,30.53,30.00,30.00,6.16,44.00,,Hospital CPT 97124,HC Ot Massage 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,50.00,44.00,30.00,26.40,N/A,6.16,N/A,27.75,N/A,25.34,N/A,14.96,N/A,44.00,N/A,6.16,N/A,27.75,N/A,27.75,N/A,44.00,N/A,44.00,N/A,44.00,N/A,44.00,N/A,25.34,N/A,28.91,N/A,6.16,N/A,23.58,N/A,23.58,N/A,6.16,N/A,27.75,N/A,27.75,N/A,30.53,30.00,30.00,6.16,44.00,,Hospital 97127,HC Sp Ther Ivntj W/Focus Cog Funcj,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,157760.80,N/A,94656.48,N/A,7631.03,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7631.03,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,7631.03,N/A,N/A,N/A,N/A,N/A,7631.03,N/A,N/A,N/A,N/A,N/A,7631.03,N/A,7631.03,94656.48,N/A,N/A,,Hospital CPT 97140,HC Ot Manual Therapy per 15 Min.,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,93.00,79.00,55.80,47.40,N/A,11.06,N/A,27.15,N/A,45.49,N/A,26.86,N/A,79.00,N/A,11.06,N/A,27.15,N/A,27.15,N/A,79.00,N/A,79.00,N/A,79.00,N/A,79.00,N/A,45.49,N/A,26.37,N/A,11.06,N/A,42.34,N/A,42.34,N/A,11.06,N/A,27.15,N/A,27.15,N/A,29.87,55.80,55.80,11.06,79.00,,Hospital CPT 97140,HC Pt Manual Therapy Ea 15,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,93.00,79.00,55.80,47.40,N/A,11.06,N/A,27.15,N/A,45.49,N/A,26.86,N/A,79.00,N/A,11.06,N/A,27.15,N/A,27.15,N/A,79.00,N/A,79.00,N/A,79.00,N/A,79.00,N/A,45.49,N/A,26.37,N/A,11.06,N/A,42.34,N/A,42.34,N/A,11.06,N/A,27.15,N/A,27.15,N/A,29.87,55.80,55.80,11.06,79.00,,Hospital 97154,HC Group Adaptive Bhv Tx by Protocol Tech Ea 15 Min,N/A,0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - GROUP THERAPY,N/A,108613.00,N/A,65167.80,N/A,15205.82,N/A,4122.56,N/A,62539.38,N/A,36928.42,N/A,9374.40,N/A,15205.82,N/A,3875.36,N/A,3875.36,N/A,5835.68,N/A,9374.40,N/A,9374.40,N/A,9374.40,N/A,86890.40,N/A,3875.36,N/A,15205.82,N/A,N/A,N/A,N/A,N/A,15205.82,N/A,3875.36,N/A,4122.56,N/A,3347.04,N/A,N/A,3347.04,86890.40,,Hospital 97155,HC Adapt Bhv Tx Prtcl Modificaj Phys/Qhp Ea 15 Min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,N/A,96478.00,N/A,57886.80,N/A,13506.92,N/A,4637.88,N/A,55552.03,N/A,32802.52,N/A,10546.20,N/A,13506.92,N/A,4359.78,N/A,4359.78,N/A,6565.14,N/A,10546.20,N/A,10546.20,N/A,10546.20,N/A,77182.40,N/A,4359.78,N/A,13506.92,N/A,N/A,N/A,N/A,N/A,13506.92,N/A,4359.78,N/A,4637.88,N/A,N/A,N/A,N/A,4359.78,77182.40,,Hospital 97156,HC Family Adapt Bhv Tx Gdn Phys/Qhp Ea 15 Min,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,N/A,110594.00,N/A,66356.40,N/A,N/A,N/A,N/A,N/A,100097.00,N/A,37601.96,N/A,9960.30,N/A,15483.16,N/A,4117.57,N/A,4117.57,N/A,6200.41,N/A,9960.30,N/A,9960.30,N/A,9960.30,N/A,100097.00,N/A,4117.57,N/A,N/A,N/A,100097.00,N/A,100097.00,N/A,N/A,N/A,4117.57,N/A,N/A,N/A,N/A,N/A,N/A,4117.57,100097.00,,Hospital 97157,HC Multiple Fam Group Bhv Tx Gdn Phys/Qhp Ea 15 Min,N/A,0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - FAMILY THERAPY,N/A,1148.00,N/A,688.80,N/A,160.72,N/A,308.45,N/A,661.02,N/A,390.32,N/A,701.35,N/A,160.72,N/A,289.94,N/A,289.94,N/A,436.62,N/A,701.35,N/A,701.35,N/A,701.35,N/A,826.48,N/A,289.94,N/A,160.72,N/A,N/A,N/A,N/A,N/A,160.72,N/A,289.94,N/A,308.45,N/A,60.08,N/A,N/A,60.08,826.48,,Hospital CPT 97161,HC Pt Eval Low Complex,N/A,0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION,444.00,444.00,266.40,266.40,N/A,62.16,N/A,82.01,N/A,255.66,N/A,150.96,N/A,292.53,N/A,62.16,N/A,82.01,N/A,82.01,N/A,292.53,N/A,292.53,N/A,292.53,N/A,292.53,N/A,255.66,N/A,97.51,N/A,62.16,N/A,237.98,N/A,237.98,N/A,62.16,N/A,82.01,N/A,82.01,N/A,90.21,266.40,266.40,62.16,292.53,,Hospital CPT 97162,HC Pt Eval Mod Complex,N/A,0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION,445.00,445.00,267.00,267.00,N/A,62.30,N/A,82.01,N/A,256.23,N/A,151.30,N/A,292.53,N/A,62.30,N/A,82.01,N/A,82.01,N/A,292.53,N/A,292.53,N/A,292.53,N/A,292.53,N/A,256.23,N/A,97.51,N/A,62.30,N/A,238.52,N/A,238.52,N/A,62.30,N/A,82.01,N/A,82.01,N/A,90.21,267.00,267.00,62.30,292.53,,Hospital CPT 97165,HC Ot Eval Low Complex,N/A,0434 - OCCUPATIONAL THERAPY - EVALUATION OR REEVALUATION,433.00,433.00,259.80,259.80,N/A,60.62,N/A,86.74,N/A,249.32,N/A,147.22,N/A,292.53,N/A,60.62,N/A,86.74,N/A,86.74,N/A,292.53,N/A,292.53,N/A,292.53,N/A,292.53,N/A,249.32,N/A,97.51,N/A,60.62,N/A,232.09,N/A,232.09,N/A,60.62,N/A,86.74,N/A,86.74,N/A,95.41,259.80,259.80,60.62,292.53,,Hospital CPT 97166,HC Ot Eval Mod Complex,N/A,0434 - OCCUPATIONAL THERAPY - EVALUATION OR REEVALUATION,509.00,509.00,305.40,305.40,N/A,71.26,N/A,86.43,N/A,293.08,N/A,173.06,N/A,292.53,N/A,71.26,N/A,86.43,N/A,86.43,N/A,292.53,N/A,292.53,N/A,292.53,N/A,292.53,N/A,293.08,N/A,97.51,N/A,71.26,N/A,272.82,N/A,272.82,N/A,71.26,N/A,86.43,N/A,86.43,N/A,95.07,305.40,305.40,71.26,305.40,,Hospital 97533,HC Ot Sensory Integrate 15 Min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,66322.00,1830.00,39793.20,1098.00,7803.84,256.20,17125.49,432.99,66322.00,1053.72,N/A,622.20,33499.25,1427.67,7156.93,256.20,17125.49,432.99,17125.49,432.99,6255.30,1427.67,N/A,1427.67,33499.25,1427.67,33499.25,1427.67,17724.00,1053.72,17123.87,475.89,7156.93,256.20,24624.00,980.88,24624.00,980.88,12745.31,256.20,24556.21,432.99,17125.49,432.99,12745.31,476.28,6255.30,66322.00,256.20,1427.67,,Hospital CPT 97542,HC Ot Wheelchair Mngment Training,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,83.00,83.00,49.80,49.80,N/A,11.62,N/A,31.80,N/A,47.79,N/A,28.22,N/A,83.00,N/A,11.62,N/A,31.80,N/A,31.80,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,47.79,N/A,30.84,N/A,11.62,N/A,44.49,N/A,44.49,N/A,11.62,N/A,31.80,N/A,31.80,N/A,34.98,49.80,49.80,11.62,83.00,,Hospital CPT 97542,HC Wheelchair Training per 15 Min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,83.00,83.00,49.80,49.80,N/A,11.62,N/A,31.80,N/A,47.79,N/A,28.22,N/A,83.00,N/A,11.62,N/A,31.80,N/A,31.80,N/A,83.00,N/A,83.00,N/A,83.00,N/A,83.00,N/A,47.79,N/A,30.84,N/A,11.62,N/A,44.49,N/A,44.49,N/A,11.62,N/A,31.80,N/A,31.80,N/A,34.98,49.80,49.80,11.62,83.00,,Hospital CPT 97597,"HC Debrid,Open Wnd 1st 20sqcm or Less",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,3398.00,3398.00,2038.80,2038.80,N/A,475.72,N/A,163.07,N/A,1956.57,N/A,1155.32,N/A,394.46,N/A,475.72,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,1956.57,N/A,163.07,N/A,475.72,N/A,527.00,N/A,527.00,N/A,475.72,N/A,163.07,N/A,163.07,N/A,179.38,2038.80,2038.80,163.07,2038.80,,Hospital CPT 97597,HC Wound Debridement Tis 20 Cm/<,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,163.07,N/A,723.78,N/A,427.38,N/A,394.46,N/A,175.98,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,723.78,N/A,163.07,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,175.98,N/A,163.07,N/A,163.07,N/A,179.38,754.20,754.20,163.07,1257.00,,Hospital CPT 97605,HC Wound Vac <=50 Sq Cm Dme,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,763.00,763.00,457.80,457.80,N/A,106.82,N/A,163.07,N/A,439.34,N/A,259.42,N/A,394.46,N/A,106.82,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,439.34,N/A,163.07,N/A,106.82,N/A,408.97,N/A,408.97,N/A,106.82,N/A,163.07,N/A,163.07,N/A,179.38,457.80,457.80,106.82,457.80,,Hospital CPT 97605,HC Neg Press Wound Tx Appl<= 50,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,763.00,763.00,457.80,457.80,N/A,106.82,N/A,163.07,N/A,439.34,N/A,259.42,N/A,394.46,N/A,106.82,N/A,163.07,N/A,163.07,N/A,245.56,N/A,394.46,N/A,394.46,N/A,394.46,N/A,439.34,N/A,163.07,N/A,106.82,N/A,763.00,N/A,763.00,N/A,106.82,N/A,163.07,N/A,163.07,N/A,179.38,457.80,457.80,106.82,763.00,,Hospital CPT 97606,HC Wound Vac >50 Sq Cm Dme,N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,336.90,N/A,723.78,N/A,427.38,N/A,814.92,N/A,175.98,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,723.78,N/A,336.90,N/A,175.98,N/A,673.75,N/A,673.75,N/A,175.98,N/A,336.90,N/A,336.90,N/A,370.59,754.20,754.20,175.98,814.92,,Hospital CPT 97606,HC Neg Press Wound Tx >= 50 Sqcm,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1257.00,1257.00,754.20,754.20,N/A,175.98,N/A,336.90,N/A,723.78,N/A,427.38,N/A,814.92,N/A,175.98,N/A,336.90,N/A,336.90,N/A,507.30,N/A,814.92,N/A,814.92,N/A,814.92,N/A,723.78,N/A,336.90,N/A,175.98,N/A,1257.00,N/A,1257.00,N/A,175.98,N/A,336.90,N/A,336.90,N/A,370.59,754.20,754.20,175.98,1257.00,,Hospital 97802,HC Med Nut Therapy Ind Init 15 Min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,22051.90,360.00,13231.14,216.00,6928.07,50.40,8461.19,123.76,15612.97,207.29,7497.65,122.40,11953.64,360.00,7141.54,50.40,1686.00,123.76,1686.00,123.76,9811.68,257.94,15762.32,360.00,15762.32,360.00,15762.32,360.00,15612.97,207.29,8461.19,123.76,6643.85,50.40,18753.23,192.96,18753.23,192.96,6643.85,50.40,8461.19,123.76,8461.19,123.76,7641.45,136.14,1686.00,18753.23,50.40,360.00,,Hospital 97803,HC Med Nut Therapy Ind Fu 15 Min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,28373.60,232.00,17024.16,139.20,11073.25,32.48,17263.87,52.74,N/A,133.59,14950.18,78.88,14950.18,180.24,11073.25,32.48,24192.22,52.74,24192.22,52.74,14950.18,112.20,14950.18,180.24,14950.18,180.24,14950.18,180.24,N/A,133.59,18591.86,52.74,11073.25,32.48,N/A,124.35,N/A,124.35,11073.25,32.48,11951.91,52.74,17263.87,52.74,11073.25,58.01,11073.25,24192.22,32.48,180.24,,Hospital 98927,HC Omt 5-6 Reg,N/A,0530 - OSTEOPATHIC SERVICES - GENERAL CLASSIFICATION,N/A,71.00,N/A,42.60,N/A,9.94,N/A,24.00,N/A,40.88,N/A,24.14,N/A,54.57,N/A,9.94,N/A,22.56,N/A,22.56,N/A,33.97,N/A,54.57,N/A,54.57,N/A,54.57,N/A,40.88,N/A,22.56,N/A,9.94,N/A,38.06,N/A,38.06,N/A,9.94,N/A,22.56,N/A,24.00,N/A,49.70,N/A,N/A,9.94,54.57,,Hospital 98928,HC Omt 7-8 Body Regions,N/A,0530 - OSTEOPATHIC SERVICES - GENERAL CLASSIFICATION,N/A,71.00,N/A,42.60,N/A,9.94,N/A,24.00,N/A,40.88,N/A,24.14,N/A,54.57,N/A,9.94,N/A,22.56,N/A,22.56,N/A,33.97,N/A,54.57,N/A,54.57,N/A,54.57,N/A,40.88,N/A,22.56,N/A,9.94,N/A,38.06,N/A,38.06,N/A,9.94,N/A,22.56,N/A,24.00,N/A,62.82,N/A,N/A,9.94,62.82,,Hospital CPT 98966,HC Pt Nonphysician Telephone Assessment 5-10min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,41.00,41.00,24.60,24.60,N/A,5.74,N/A,11.04,N/A,23.61,N/A,13.94,N/A,37.83,N/A,5.74,N/A,11.04,N/A,11.04,N/A,23.55,N/A,37.83,N/A,37.83,N/A,37.83,N/A,23.61,N/A,11.04,N/A,5.74,N/A,21.98,N/A,21.98,N/A,5.74,N/A,11.04,N/A,11.04,N/A,12.14,24.60,24.60,5.74,37.83,,Hospital CPT 98966,HC Sp Nonphysician Telephone Assessment 5-10min,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,41.00,41.00,24.60,24.60,N/A,5.74,N/A,11.04,N/A,23.61,N/A,13.94,N/A,37.83,N/A,5.74,N/A,11.04,N/A,11.04,N/A,23.55,N/A,37.83,N/A,37.83,N/A,37.83,N/A,23.61,N/A,11.04,N/A,5.74,N/A,21.98,N/A,21.98,N/A,5.74,N/A,11.04,N/A,11.04,N/A,12.14,24.60,24.60,5.74,37.83,,Hospital CPT 98966,HC Ot Nonphysician Telephone Assessment 5-10min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,41.00,41.00,24.60,24.60,N/A,5.74,N/A,11.04,N/A,23.61,N/A,13.94,N/A,37.83,N/A,5.74,N/A,11.04,N/A,11.04,N/A,23.55,N/A,37.83,N/A,37.83,N/A,37.83,N/A,23.61,N/A,11.04,N/A,5.74,N/A,21.98,N/A,21.98,N/A,5.74,N/A,11.04,N/A,11.04,N/A,12.14,24.60,24.60,5.74,37.83,,Hospital CPT 98967,HC Sp Nonphysician Telephone Assessment 11-20min,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,80.00,80.00,48.00,48.00,N/A,11.20,N/A,21.48,N/A,46.06,N/A,27.20,N/A,69.45,N/A,11.20,N/A,21.48,N/A,21.48,N/A,43.23,N/A,69.45,N/A,69.45,N/A,69.45,N/A,46.06,N/A,21.48,N/A,11.20,N/A,42.88,N/A,42.88,N/A,11.20,N/A,21.48,N/A,21.48,N/A,23.63,48.00,48.00,11.20,69.45,,Hospital CPT 98967,HC Pt Nonphysician Telephone Assessment 11-20min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,80.00,80.00,48.00,48.00,N/A,11.20,N/A,21.48,N/A,46.06,N/A,27.20,N/A,69.45,N/A,11.20,N/A,21.48,N/A,21.48,N/A,43.23,N/A,69.45,N/A,69.45,N/A,69.45,N/A,46.06,N/A,21.48,N/A,11.20,N/A,42.88,N/A,42.88,N/A,11.20,N/A,21.48,N/A,21.48,N/A,23.63,48.00,48.00,11.20,69.45,,Hospital CPT 98967,HC Ot Nonphysician Telephone Assessment 11-20min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,80.00,80.00,48.00,48.00,N/A,11.20,N/A,21.48,N/A,46.06,N/A,27.20,N/A,69.45,N/A,11.20,N/A,21.48,N/A,21.48,N/A,43.23,N/A,69.45,N/A,69.45,N/A,69.45,N/A,46.06,N/A,21.48,N/A,11.20,N/A,42.88,N/A,42.88,N/A,11.20,N/A,21.48,N/A,21.48,N/A,23.63,48.00,48.00,11.20,69.45,,Hospital CPT 98968,HC Sp Nonphysician Telephone Assessment 21-30min,N/A,0440 - SPEECH THERAPY - LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION,118.00,118.00,70.80,70.80,N/A,16.52,N/A,31.31,N/A,67.94,N/A,40.12,N/A,97.53,N/A,16.52,N/A,31.31,N/A,31.31,N/A,60.71,N/A,97.53,N/A,97.53,N/A,97.53,N/A,67.94,N/A,31.31,N/A,16.52,N/A,63.25,N/A,63.25,N/A,16.52,N/A,31.31,N/A,31.31,N/A,34.44,70.80,70.80,16.52,97.53,,Hospital CPT 98968,HC Ot Nonphysician Telephone Assessment 21-30min,N/A,0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION,118.00,118.00,70.80,70.80,N/A,16.52,N/A,31.31,N/A,67.94,N/A,40.12,N/A,97.53,N/A,16.52,N/A,31.31,N/A,31.31,N/A,60.71,N/A,97.53,N/A,97.53,N/A,97.53,N/A,67.94,N/A,31.31,N/A,16.52,N/A,63.25,N/A,63.25,N/A,16.52,N/A,31.31,N/A,31.31,N/A,34.44,70.80,70.80,16.52,97.53,,Hospital CPT 98968,HC Pt Nonphysician Telephone Assessment 21-30min,N/A,0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION,118.00,118.00,70.80,70.80,N/A,16.52,N/A,31.31,N/A,67.94,N/A,40.12,N/A,97.53,N/A,16.52,N/A,31.31,N/A,31.31,N/A,60.71,N/A,97.53,N/A,97.53,N/A,97.53,N/A,67.94,N/A,31.31,N/A,16.52,N/A,63.25,N/A,63.25,N/A,16.52,N/A,31.31,N/A,31.31,N/A,34.44,70.80,70.80,16.52,97.53,,Hospital 99072,Addl Supl Matrl&Staf Tm Drg Phe Res-Tr Nfct Ds,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,18644.10,N/A,11186.46,N/A,2610.18,N/A,1590.93,N/A,10729.38,N/A,6339.00,N/A,4961.07,N/A,2610.18,N/A,1558.52,N/A,1558.52,N/A,3087.07,N/A,4961.07,N/A,4961.07,N/A,4961.07,N/A,10729.38,N/A,1558.52,N/A,2610.18,N/A,1871.00,N/A,1871.00,N/A,2610.18,N/A,1558.52,N/A,1590.93,N/A,871.35,N/A,N/A,871.35,11186.46,,Hospital 99078,Phys/Qhp Education Svcs Rendered Pts Grp Setting,N/A,N/A,N/A,69.00,N/A,41.40,N/A,9.66,N/A,N/A,N/A,39.73,N/A,23.46,N/A,N/A,N/A,9.66,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,39.73,N/A,N/A,N/A,9.66,N/A,36.98,N/A,36.98,N/A,9.66,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9.66,41.40,,Hospital CPT 99151,HC Mod Sed Same Phys/Qhp <5 Yrs,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,1057.00,1057.00,634.20,634.20,N/A,147.98,N/A,1057.00,N/A,608.62,N/A,359.38,N/A,1057.00,N/A,147.98,N/A,1057.00,N/A,1057.00,N/A,1057.00,N/A,1057.00,N/A,1057.00,N/A,1057.00,N/A,608.62,N/A,1057.00,N/A,147.98,N/A,566.55,N/A,566.55,N/A,147.98,N/A,1057.00,N/A,1057.00,N/A,26.58,634.20,634.20,26.58,1057.00,,Hospital CPT 99153,HC Mod Sed Same Phys/Qhp Ea,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,423.00,423.00,253.80,253.80,N/A,59.22,N/A,423.00,N/A,243.56,N/A,143.82,N/A,423.00,N/A,59.22,N/A,423.00,N/A,423.00,N/A,423.00,N/A,423.00,N/A,423.00,N/A,423.00,N/A,243.56,N/A,423.00,N/A,59.22,N/A,226.73,N/A,226.73,N/A,59.22,N/A,423.00,N/A,423.00,N/A,423.00,253.80,253.80,59.22,423.00,,Hospital CPT 99155,HC Mod Sed Oth Phys/Qhp <5 Yrs Initial 15 Min,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,1162.00,1162.00,697.20,697.20,N/A,162.68,N/A,1162.00,N/A,669.08,N/A,395.08,N/A,1162.00,N/A,162.68,N/A,1162.00,N/A,1162.00,N/A,1162.00,N/A,1162.00,N/A,1162.00,N/A,1162.00,N/A,669.08,N/A,1162.00,N/A,162.68,N/A,622.83,N/A,622.83,N/A,162.68,N/A,1162.00,N/A,81.39,N/A,89.53,697.20,697.20,81.39,1162.00,,Hospital CPT 99156,HC Mod Sed Oth Phys/Qhp 5/>Yrs Initial 15 Min,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,1019.00,1019.00,611.40,611.40,N/A,142.66,N/A,1019.00,N/A,586.74,N/A,346.46,N/A,1019.00,N/A,142.66,N/A,1019.00,N/A,1019.00,N/A,1019.00,N/A,1019.00,N/A,1019.00,N/A,1019.00,N/A,586.74,N/A,1019.00,N/A,142.66,N/A,546.18,N/A,546.18,N/A,142.66,N/A,1019.00,N/A,74.28,N/A,81.71,611.40,611.40,74.28,1019.00,,Hospital 99201,"HC New Pt, E/M Level 1",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,204.00,N/A,122.40,N/A,28.56,N/A,108.58,N/A,117.46,N/A,69.36,N/A,N/A,N/A,28.56,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,117.46,N/A,109.14,N/A,28.56,N/A,109.34,N/A,109.34,N/A,28.56,N/A,109.14,N/A,108.58,N/A,N/A,N/A,N/A,28.56,122.40,,Hospital CPT 99203,"HC New Pt, E/M Level 3",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,801.00,801.00,480.60,480.60,N/A,112.14,N/A,109.14,N/A,461.22,N/A,272.34,N/A,801.00,N/A,112.14,N/A,109.14,N/A,109.14,N/A,801.00,N/A,801.00,N/A,801.00,N/A,801.00,N/A,461.22,N/A,109.14,N/A,112.14,N/A,429.34,N/A,429.34,N/A,112.14,N/A,109.14,N/A,109.14,N/A,88.42,480.60,480.60,88.42,801.00,,Hospital CPT 99211,"HC Est Pt, E/M Level 1",N/A,0510 - CLINIC - GENERAL CLASSIFICATION,422.00,422.00,253.20,253.20,N/A,59.08,N/A,109.14,N/A,242.99,N/A,143.48,N/A,422.00,N/A,59.08,N/A,109.14,N/A,109.14,N/A,422.00,N/A,422.00,N/A,422.00,N/A,422.00,N/A,242.99,N/A,109.14,N/A,59.08,N/A,226.19,N/A,226.19,N/A,59.08,N/A,109.14,N/A,109.14,N/A,120.06,253.20,253.20,59.08,422.00,,Hospital CPT 99211,"HC Est Pt, Outpt Visit Level 1",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,422.00,422.00,253.20,253.20,N/A,59.08,N/A,109.14,N/A,242.99,N/A,143.48,N/A,264.01,N/A,59.08,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,242.99,N/A,109.14,N/A,59.08,N/A,226.19,N/A,226.19,N/A,59.08,N/A,109.14,N/A,109.14,N/A,120.06,253.20,253.20,59.08,264.01,,Hospital CPT 99221,Initial Hospital Care/Day 30 Minutes,N/A,N/A,146.00,146.00,87.60,87.60,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,N/A,146.00,87.60,87.60,87.60,146.00,,Hospital CPT 99223,Initial Hospital Care/Day 70 Minutes,N/A,N/A,291.00,291.00,174.60,174.60,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,N/A,291.00,174.60,174.60,174.60,291.00,,Hospital CPT 99231,Sbsq Hospital Care/Day 15 Minutes,N/A,N/A,78.00,78.00,46.80,46.80,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,N/A,78.00,46.80,46.80,46.80,78.00,,Hospital 99234,Observation/Inpatient Hospital Care 40 Minutes,N/A,N/A,N/A,3777.00,N/A,2266.20,N/A,561.48,N/A,403.91,N/A,2174.80,N/A,1284.18,N/A,938.02,N/A,561.48,N/A,394.66,N/A,394.66,N/A,583.93,N/A,938.02,N/A,938.02,N/A,938.02,N/A,2174.80,N/A,394.66,N/A,561.48,N/A,1365.76,N/A,1365.76,N/A,561.48,N/A,394.66,N/A,403.91,N/A,303.17,N/A,N/A,303.17,2266.20,,Hospital CPT 99292,HC E/M Crit Care Each Addit 30min,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,431.00,431.00,258.60,258.60,N/A,60.34,N/A,105.53,N/A,248.17,N/A,146.54,N/A,344.04,N/A,60.34,N/A,105.53,N/A,105.53,N/A,214.16,N/A,344.04,N/A,344.04,N/A,344.04,N/A,248.17,N/A,105.53,N/A,60.34,N/A,431.00,N/A,431.00,N/A,60.34,N/A,105.53,N/A,105.53,N/A,116.08,258.60,258.60,60.34,431.00,,Hospital 99381,HC Prev Visit New Infant,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,N/A,N/A,185.98,N/A,109.82,N/A,N/A,N/A,45.22,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,185.98,N/A,N/A,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,N/A,N/A,N/A,N/A,128.07,N/A,N/A,45.22,193.80,,Hospital 99385,HC Prev Visit New Age18-39,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,67.21,N/A,185.98,N/A,109.82,N/A,N/A,N/A,45.22,N/A,67.21,N/A,67.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,185.98,N/A,67.21,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,67.21,N/A,67.21,N/A,139.02,N/A,N/A,45.22,193.80,,Hospital 99387,HC Prev Visit New 65 & Over,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,186.00,N/A,111.60,N/A,26.04,N/A,186.00,N/A,107.10,N/A,63.24,N/A,N/A,N/A,26.04,N/A,186.00,N/A,186.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,107.10,N/A,186.00,N/A,26.04,N/A,99.70,N/A,99.70,N/A,26.04,N/A,186.00,N/A,186.00,N/A,N/A,N/A,N/A,26.04,186.00,,Hospital 99391,HC Prev Visit Est Infant,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,104.73,N/A,185.98,N/A,109.82,N/A,N/A,N/A,45.22,N/A,104.73,N/A,104.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,185.98,N/A,104.73,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,104.73,N/A,104.73,N/A,134.28,N/A,N/A,45.22,193.80,,Hospital 99392,HC Prev Visit Est Age 1-4,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,466.02,N/A,279.61,N/A,65.24,N/A,274.43,N/A,268.33,N/A,158.44,N/A,147.37,N/A,65.24,N/A,109.14,N/A,109.14,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,268.33,N/A,109.14,N/A,65.24,N/A,249.80,N/A,249.80,N/A,65.24,N/A,269.14,N/A,27.28,N/A,30.01,N/A,N/A,27.28,279.61,,Hospital 99394,HC Uc Periodic Preventive Med Est Patient Age 12-17yrs,N/A,0516 - CLINIC - URGENT CARE CLINIC,N/A,168.00,N/A,100.80,N/A,23.52,N/A,N/A,N/A,96.73,N/A,57.12,N/A,70.72,N/A,23.52,N/A,N/A,N/A,N/A,N/A,70.72,N/A,70.72,N/A,70.72,N/A,70.72,N/A,96.73,N/A,N/A,N/A,23.52,N/A,90.05,N/A,90.05,N/A,23.52,N/A,N/A,N/A,N/A,N/A,128.07,N/A,N/A,23.52,128.07,,Hospital 99396,HC Prev Visit Est Age 40-64,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,323.00,N/A,193.80,N/A,45.22,N/A,41.63,N/A,185.98,N/A,109.82,N/A,429.65,N/A,45.22,N/A,41.63,N/A,41.63,N/A,429.65,N/A,429.65,N/A,429.65,N/A,429.65,N/A,185.98,N/A,41.63,N/A,45.22,N/A,173.13,N/A,173.13,N/A,45.22,N/A,41.63,N/A,41.63,N/A,133.13,N/A,N/A,41.63,429.65,,Hospital 99397,HC Prev Visit Est Age 65+,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,186.00,N/A,111.60,N/A,26.04,N/A,40.92,N/A,107.10,N/A,63.24,N/A,N/A,N/A,26.04,N/A,42.78,N/A,42.78,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,107.10,N/A,115.66,N/A,26.04,N/A,99.70,N/A,99.70,N/A,26.04,N/A,186.00,N/A,42.78,N/A,288.89,N/A,N/A,26.04,288.89,,Hospital 99403,HC Prevent Counseling Indiv 45 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,335.00,N/A,201.00,N/A,46.90,N/A,N/A,N/A,192.89,N/A,113.90,N/A,153.43,N/A,46.90,N/A,N/A,N/A,N/A,N/A,153.43,N/A,153.43,N/A,153.43,N/A,153.43,N/A,192.89,N/A,N/A,N/A,46.90,N/A,179.56,N/A,179.56,N/A,46.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,46.90,201.00,,Hospital 99404,HC Prevent Counseling Indiv 60 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,417.00,N/A,250.20,N/A,58.38,N/A,N/A,N/A,240.11,N/A,141.78,N/A,N/A,N/A,58.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,240.11,N/A,N/A,N/A,58.38,N/A,223.51,N/A,223.51,N/A,58.38,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,58.38,250.20,,Hospital 99406,HC Smoke/Tobac Counsel 3-10,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,339.00,N/A,203.40,N/A,47.46,N/A,137.41,N/A,195.20,N/A,115.26,N/A,64.83,N/A,47.46,N/A,109.14,N/A,109.14,N/A,40.36,N/A,64.83,N/A,64.83,N/A,64.83,N/A,195.20,N/A,135.94,N/A,47.46,N/A,181.70,N/A,181.70,N/A,47.46,N/A,135.94,N/A,137.41,N/A,101.16,N/A,N/A,40.36,203.40,,Hospital CPT 99460,"Initial Normal Newborn Care, Hospital or Birth Center",N/A,N/A,201.00,201.00,120.60,120.60,N/A,28.14,N/A,91.23,N/A,201.00,N/A,68.34,N/A,201.00,N/A,28.14,N/A,91.23,N/A,91.23,N/A,166.79,N/A,201.00,N/A,201.00,N/A,201.00,N/A,201.00,N/A,91.23,N/A,28.14,N/A,201.00,N/A,201.00,N/A,28.14,N/A,91.23,N/A,91.23,N/A,100.35,120.60,120.60,28.14,201.00,,Hospital CPT 99464,HC Attendace at Delivery,N/A,0722 - LABOR ROOM/DELIVERY - DELIVERY ROOM,256.00,256.00,153.60,153.60,N/A,35.84,N/A,71.61,N/A,147.40,N/A,87.04,N/A,210.15,N/A,35.84,N/A,71.61,N/A,71.61,N/A,130.82,N/A,210.15,N/A,210.15,N/A,210.15,N/A,147.40,N/A,71.61,N/A,35.84,N/A,137.22,N/A,137.22,N/A,35.84,N/A,71.61,N/A,71.61,N/A,78.77,153.60,153.60,35.84,210.15,,Hospital 99496,HC Trans Care Mgmt 7 Day Disch,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,363.00,N/A,217.80,N/A,50.82,N/A,114.43,N/A,209.02,N/A,123.42,N/A,N/A,N/A,50.82,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,209.02,N/A,109.14,N/A,50.82,N/A,194.57,N/A,194.57,N/A,50.82,N/A,109.14,N/A,187.04,N/A,205.74,N/A,N/A,50.82,217.80,,Hospital 99498,HC Advncd Care Plan Addl 30 Min,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,683.00,N/A,409.80,N/A,95.62,N/A,120.40,N/A,393.27,N/A,232.22,N/A,N/A,N/A,95.62,N/A,109.14,N/A,109.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,393.27,N/A,109.14,N/A,95.62,N/A,366.09,N/A,366.09,N/A,95.62,N/A,109.14,N/A,144.29,N/A,158.72,N/A,N/A,95.62,409.80,,Hospital A0390,Advanced Life Support Mileag,N/A,N/A,N/A,3031.00,N/A,1818.60,N/A,424.34,N/A,444.60,N/A,1745.25,N/A,1030.54,N/A,104.72,N/A,424.34,N/A,444.60,N/A,444.60,N/A,65.08,N/A,104.72,N/A,104.72,N/A,104.72,N/A,1745.25,N/A,444.60,N/A,424.34,N/A,1624.62,N/A,1624.62,N/A,424.34,N/A,444.60,N/A,444.60,N/A,412.50,N/A,N/A,65.08,1818.60,,Hospital A2007,"HC Restrata, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,20423.12,N/A,12253.87,N/A,2859.50,N/A,1858.70,N/A,11757.07,N/A,6943.85,N/A,4424.08,N/A,2859.50,N/A,1820.83,N/A,1820.83,N/A,2754.07,N/A,4424.08,N/A,4424.08,N/A,4424.08,N/A,11757.07,N/A,1820.83,N/A,2859.50,N/A,2134.50,N/A,2134.50,N/A,2859.50,N/A,1820.83,N/A,1858.70,N/A,380.51,N/A,N/A,380.51,12253.87,,Hospital A2020,HC Ac5 Advanced Wound System (Ac5),N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,8677.02,N/A,5206.21,N/A,1200.88,N/A,1575.40,N/A,4995.46,N/A,2950.18,N/A,3779.67,N/A,1200.88,N/A,1558.52,N/A,1558.52,N/A,2352.92,N/A,3779.67,N/A,3779.67,N/A,3779.67,N/A,4995.46,N/A,1558.52,N/A,1200.88,N/A,1871.00,N/A,1871.00,N/A,1200.88,N/A,1558.52,N/A,1575.40,N/A,118.19,N/A,N/A,118.19,5206.21,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-10,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,15.00,N/A,N/A,2.10,15.00,,Hospital HCPCS A4216,SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,00409-4888-20,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS A4216,NORMAL SALINE FLUSH 0.9 % IV SOLN,08290-3065-46,0258 - PHARMACY - IV SOLUTIONS,12.50,12.50,7.50,7.50,N/A,N/A,N/A,12.50,N/A,7.20,N/A,4.25,N/A,12.50,N/A,1.75,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,7.20,N/A,12.50,N/A,1.75,N/A,6.70,N/A,6.70,N/A,N/A,N/A,12.50,N/A,12.50,N/A,N/A,7.50,7.50,1.75,12.50,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-50,0258 - PHARMACY - IV SOLUTIONS,16.20,16.20,9.72,9.72,N/A,N/A,N/A,16.20,N/A,9.33,N/A,5.51,N/A,16.20,N/A,2.27,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,16.20,N/A,9.33,N/A,16.20,N/A,2.27,N/A,8.68,N/A,8.68,N/A,N/A,N/A,16.20,N/A,16.20,N/A,N/A,9.72,9.72,2.27,16.20,,Hospital HCPCS A4216,SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,00409-4888-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-10,0258 - PHARMACY - IV SOLUTIONS,15.00,15.00,9.00,9.00,N/A,N/A,N/A,15.00,N/A,8.64,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,N/A,N/A,15.00,N/A,15.00,N/A,N/A,9.00,9.00,2.10,15.00,,Hospital HCPCS A4216,NORMAL SALINE FLUSH 0.9 % IV SOLN,08290-3065-45,0258 - PHARMACY - IV SOLUTIONS,12.50,12.50,7.50,7.50,N/A,N/A,N/A,12.50,N/A,7.20,N/A,4.25,N/A,12.50,N/A,1.75,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,12.50,N/A,7.20,N/A,12.50,N/A,1.75,N/A,6.70,N/A,6.70,N/A,N/A,N/A,12.50,N/A,12.50,N/A,N/A,7.50,7.50,1.75,12.50,,Hospital HCPCS A4216,SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,00409-4888-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-99,0250 - PHARMACY - GENERAL CLASSIFICATION,29.10,29.10,N/A,N/A,N/A,4.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.07,N/A,N/A,N/A,N/A,N/A,29.10,N/A,N/A,4.07,29.10,,Hospital HCPCS A4216,NORMAL SALINE FLUSH 0.9 % IV SOLN,08290-3065-46,0250 - PHARMACY - GENERAL CLASSIFICATION,12.50,12.50,N/A,N/A,N/A,1.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.75,N/A,N/A,N/A,N/A,N/A,12.50,N/A,N/A,1.75,12.50,,Hospital HCPCS A4216,NORMAL SALINE FLUSH 0.9 % IV SOLN,08290-3065-45,0250 - PHARMACY - GENERAL CLASSIFICATION,12.50,12.50,N/A,N/A,N/A,1.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1.75,N/A,N/A,N/A,N/A,N/A,12.50,N/A,N/A,1.75,12.50,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-20,0258 - PHARMACY - IV SOLUTIONS,15.00,15.00,9.00,9.00,N/A,N/A,N/A,15.00,N/A,8.64,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,N/A,N/A,15.00,N/A,15.00,N/A,N/A,9.00,9.00,2.10,15.00,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-50,0250 - PHARMACY - GENERAL CLASSIFICATION,16.20,16.20,N/A,N/A,N/A,2.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.27,N/A,N/A,N/A,N/A,N/A,16.20,N/A,N/A,2.27,16.20,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-20,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.10,N/A,N/A,N/A,N/A,N/A,15.00,N/A,N/A,2.10,15.00,,Hospital HCPCS A4216,STERILE WATER FOR INJECTION IJ SOLN,00409-4887-99,0258 - PHARMACY - IV SOLUTIONS,29.10,29.10,17.46,17.46,N/A,N/A,N/A,29.10,N/A,16.76,N/A,9.89,N/A,29.10,N/A,4.07,N/A,29.10,N/A,29.10,N/A,29.10,N/A,29.10,N/A,29.10,N/A,29.10,N/A,16.76,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,N/A,N/A,29.10,N/A,29.10,N/A,N/A,17.46,17.46,4.07,29.10,,Hospital HCPCS A4216,SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,00409-4888-20,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS A4216,SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,00409-4888-06,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS A4216,SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,00409-4888-06,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS A4217,SODIUM CHLORIDE 0.9 % IR SOLN,00338-0048-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS A4217,SODIUM CHLORIDE 0.9 % IR SOLN,00338-0048-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS A4217,SODIUM CHLORIDE 0.9 % IR SOLN,00338-0048-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,6.52,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS A4217,SODIUM CHLORIDE 0.9 % IR SOLN,00338-0048-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,6.52,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital A4218,Sterile saline or water,N/A,N/A,46371.50,1985.70,27822.90,1191.42,4856.64,278.00,6010.79,492.49,10944.83,1125.88,15766.31,675.14,11049.52,444.55,5006.28,278.00,562.00,478.66,562.00,478.66,6878.07,276.74,11049.52,444.55,11049.52,444.55,11049.52,444.55,10944.83,1125.87,6010.79,478.66,5006.28,278.00,13146.18,1064.34,13146.18,1064.35,3007.58,278.00,6010.79,478.66,6010.79,492.49,5356.72,58.35,562.00,27822.90,58.35,1191.42,,Hospital A4245,"Pad,Prep,Alcohol,Large,2-Ply, Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2642.27,N/A,1585.36,N/A,669.84,N/A,1512.00,N/A,701.40,N/A,674.88,N/A,674.88,N/A,669.84,N/A,1512.00,N/A,1512.00,N/A,674.88,N/A,674.88,N/A,674.88,N/A,674.88,N/A,701.40,N/A,1512.00,N/A,669.84,N/A,701.40,N/A,701.40,N/A,669.84,N/A,1512.00,N/A,1512.00,N/A,669.84,N/A,N/A,669.84,1585.36,,Hospital A4247,"Swabstick, Pvp-I, 3/Pk",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3225.13,N/A,1935.08,N/A,963.04,N/A,1188.00,N/A,N/A,N/A,1096.55,N/A,723.00,N/A,451.52,N/A,1188.00,N/A,1188.00,N/A,906.00,N/A,723.00,N/A,723.00,N/A,723.00,N/A,1857.04,N/A,1188.00,N/A,963.04,N/A,643.20,N/A,643.20,N/A,963.04,N/A,1188.00,N/A,1188.00,N/A,963.04,N/A,N/A,451.52,1935.08,,Hospital A4248,"Cloth,2% Chlorhexidine Gluconate",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3487.17,N/A,2092.30,N/A,N/A,N/A,325.76,N/A,N/A,N/A,1185.63,N/A,722.31,N/A,488.20,N/A,N/A,N/A,N/A,N/A,700.99,N/A,722.31,N/A,722.31,N/A,722.31,N/A,2007.90,N/A,N/A,N/A,N/A,N/A,153.90,N/A,153.90,N/A,N/A,N/A,N/A,N/A,325.76,N/A,358.34,N/A,N/A,153.90,2092.30,,Hospital A4300,Cath Impl Vasc Access Portal,N/A,N/A,13547.25,N/A,8128.35,N/A,3368.28,N/A,4250.13,N/A,7641.29,N/A,4606.07,N/A,4696.00,N/A,3472.06,N/A,4250.13,N/A,4250.13,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,7641.29,N/A,4250.13,N/A,3472.06,N/A,9117.42,N/A,9117.42,N/A,3472.06,N/A,4250.13,N/A,4250.13,N/A,3715.11,N/A,2923.00,9117.42,N/A,N/A,,Hospital A4310,"Tray,Foley Insertion,W/10ml Syringe",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1587.22,N/A,952.33,N/A,963.00,N/A,945.00,N/A,760.00,N/A,1029.46,N/A,1029.46,N/A,963.00,N/A,1350.00,N/A,1350.00,N/A,1029.46,N/A,1029.46,N/A,1029.46,N/A,1029.46,N/A,760.00,N/A,1712.52,N/A,963.00,N/A,760.00,N/A,760.00,N/A,963.00,N/A,1350.00,N/A,147.06,N/A,963.00,N/A,N/A,147.06,1712.52,,Hospital A4320,"Tray,Irr Piston Syr, 0.9% Strl Saline",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1308.88,N/A,785.33,N/A,N/A,N/A,675.00,N/A,N/A,N/A,674.88,N/A,674.88,N/A,N/A,N/A,675.00,N/A,675.00,N/A,674.88,N/A,674.88,N/A,674.88,N/A,674.88,N/A,N/A,N/A,675.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,675.00,N/A,675.00,N/A,N/A,N/A,N/A,674.88,785.33,,Hospital A4332,"Jelly, Lube, Sterile, Foil Pack, 2.7g",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2414.15,N/A,1448.49,N/A,N/A,N/A,375.00,N/A,N/A,N/A,820.81,N/A,555.00,N/A,337.99,N/A,375.00,N/A,375.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1390.07,N/A,375.00,N/A,N/A,N/A,221.98,N/A,221.98,N/A,N/A,N/A,375.00,N/A,375.00,N/A,94.46,N/A,N/A,94.46,1448.49,,Hospital A4333,Foley Securement Device Silicone,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1509.17,N/A,905.50,N/A,573.64,N/A,945.00,N/A,N/A,N/A,449.92,N/A,449.92,N/A,573.64,N/A,945.00,N/A,945.00,N/A,449.92,N/A,449.92,N/A,449.92,N/A,449.92,N/A,N/A,N/A,1186.47,N/A,573.64,N/A,N/A,N/A,N/A,N/A,573.64,N/A,945.00,N/A,945.00,N/A,573.64,N/A,N/A,449.92,1186.47,,Hospital A4334,"Strap,Catheter,Adjbl Foam,Hook&Loop",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2436.95,N/A,1462.17,N/A,1674.19,N/A,475.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1674.19,N/A,475.00,N/A,475.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,475.00,N/A,1674.19,N/A,N/A,N/A,N/A,N/A,1674.19,N/A,475.00,N/A,475.00,N/A,1674.19,N/A,N/A,475.00,1674.19,,Hospital A4338,"Catheter,Foley,Sili-Elast,Ltx,16fr,10ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1509.17,N/A,905.50,N/A,N/A,N/A,1281.96,N/A,N/A,N/A,1029.46,N/A,1029.46,N/A,N/A,N/A,1281.96,N/A,1281.96,N/A,1029.46,N/A,1029.46,N/A,1029.46,N/A,1029.46,N/A,N/A,N/A,1603.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1281.96,N/A,147.06,N/A,N/A,N/A,N/A,147.06,1603.87,,Hospital A4344,"Catheter,Foley,100%Silicone,18fr,10ml,Lf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2414.15,N/A,1448.49,N/A,N/A,N/A,945.00,N/A,N/A,N/A,820.81,N/A,555.00,N/A,337.99,N/A,945.00,N/A,945.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1390.07,N/A,2443.02,N/A,N/A,N/A,221.98,N/A,221.98,N/A,N/A,N/A,945.00,N/A,945.00,N/A,94.46,N/A,N/A,94.46,2443.02,,Hospital A4351,"Catheter,Soft,Male,14fr,13in,Lf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2185.17,N/A,1311.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1311.10,1311.10,,Hospital A4353,"Tray,Urethral,Pre-Conn,Vinyl,14fr",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2488.50,N/A,1493.10,N/A,N/A,N/A,1045.00,N/A,N/A,N/A,846.09,N/A,555.00,N/A,348.39,N/A,1045.00,N/A,1045.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1432.88,N/A,1045.00,N/A,N/A,N/A,47.44,N/A,47.44,N/A,N/A,N/A,1045.00,N/A,1045.00,N/A,94.27,N/A,N/A,47.44,1493.10,,Hospital A4354,"Tray,Add a Cath,Foley,Drain Bg,10ml Syr",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1281.97,N/A,769.18,N/A,N/A,N/A,1509.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1509.17,N/A,1509.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1509.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1509.17,N/A,1509.17,N/A,N/A,N/A,N/A,769.18,1509.17,,Hospital A4357,"Bag,Drainage,a/R Tower,2000ml,Metal Clm",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2436.95,N/A,1462.17,N/A,963.00,N/A,1615.00,N/A,638.60,N/A,N/A,N/A,N/A,N/A,963.00,N/A,1615.00,N/A,1615.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,638.60,N/A,2443.02,N/A,963.00,N/A,638.60,N/A,638.60,N/A,963.00,N/A,1615.00,N/A,1615.00,N/A,963.00,N/A,N/A,638.60,2443.02,,Hospital A4358,"Bag,Leg,Twist-Valve,Straps,Large,32oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1922.03,N/A,1153.22,N/A,N/A,N/A,945.00,N/A,700.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,810.00,N/A,810.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,700.00,N/A,810.00,N/A,N/A,N/A,700.00,N/A,700.00,N/A,N/A,N/A,810.00,N/A,810.00,N/A,N/A,N/A,N/A,700.00,1153.22,,Hospital A4365,"Dbf-See Htp7760bx,Remover,Adhesive, Wipe",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1952.50,N/A,1171.50,N/A,N/A,N/A,26.43,N/A,510.88,N/A,663.85,N/A,446.67,N/A,273.35,N/A,N/A,N/A,N/A,N/A,445.66,N/A,446.67,N/A,446.67,N/A,446.67,N/A,1124.25,N/A,N/A,N/A,N/A,N/A,188.94,N/A,188.94,N/A,N/A,N/A,N/A,N/A,26.43,N/A,29.07,N/A,N/A,26.43,1171.50,,Hospital A4369,"Spray,Skin Barrier,1.7 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2088.83,N/A,1253.30,N/A,N/A,N/A,1766.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1766.95,N/A,1766.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1766.95,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1766.95,N/A,1766.95,N/A,N/A,N/A,N/A,1253.30,1766.95,,Hospital A4371,Powder Non-Sterile Protective Ostomy,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2523.97,N/A,1514.38,N/A,N/A,N/A,3538.49,N/A,431.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3538.49,N/A,3538.49,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,431.00,N/A,3538.49,N/A,N/A,N/A,431.00,N/A,431.00,N/A,N/A,N/A,3538.49,N/A,3538.49,N/A,N/A,N/A,N/A,431.00,3538.49,,Hospital A4373,"Barrier,2pc,Flex,Convlt,Yellow,Cuttofit",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,992.33,N/A,595.40,N/A,N/A,N/A,61.30,N/A,N/A,N/A,337.40,N/A,222.00,N/A,138.93,N/A,N/A,N/A,N/A,N/A,222.00,N/A,222.00,N/A,222.00,N/A,222.00,N/A,571.38,N/A,N/A,N/A,N/A,N/A,103.08,N/A,103.08,N/A,N/A,N/A,N/A,N/A,61.30,N/A,67.44,N/A,N/A,61.30,595.40,,Hospital A4385,"Ring,Protective,Brava,2.5mm,Thick,18mm,D",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2091.32,N/A,1254.79,N/A,656.88,N/A,1092.89,N/A,510.88,N/A,449.92,N/A,449.92,N/A,656.88,N/A,1092.89,N/A,1092.89,N/A,449.92,N/A,449.92,N/A,449.92,N/A,449.92,N/A,510.88,N/A,1092.89,N/A,656.88,N/A,510.88,N/A,510.88,N/A,656.88,N/A,1092.89,N/A,1092.89,N/A,656.88,N/A,N/A,449.92,1254.79,,Hospital A4388,"Pouch,Premier 1pc,Ft,Clr,2.5""Bar Opn'ing",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1071.47,N/A,642.88,N/A,N/A,N/A,1092.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1092.89,N/A,1092.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1092.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1092.89,N/A,1092.89,N/A,N/A,N/A,N/A,642.88,1092.89,,Hospital A4389,"1pc,Easiclose,Convex,Maxi,Cutofit,Tr",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1791.13,N/A,1074.68,N/A,281.52,N/A,1045.00,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,281.52,N/A,1045.00,N/A,1045.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,1045.00,N/A,281.52,N/A,1080.00,N/A,1080.00,N/A,281.52,N/A,1045.00,N/A,1045.00,N/A,281.52,N/A,N/A,281.52,1080.00,,Hospital A4392,"Pouch,1pc,Urostomy,Softconv,Cutofit,Opq",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4295.62,N/A,2577.37,N/A,N/A,N/A,25.81,N/A,1233.95,N/A,1460.50,N/A,1110.00,N/A,601.39,N/A,N/A,N/A,N/A,N/A,1110.00,N/A,1110.00,N/A,1110.00,N/A,1110.00,N/A,2473.42,N/A,N/A,N/A,N/A,N/A,158.45,N/A,158.45,N/A,N/A,N/A,N/A,N/A,25.81,N/A,28.40,N/A,N/A,25.81,2577.37,,Hospital A4394,"Deodorant,Brava,Lubri,0.25 Oz,Sachet,Nds",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2092.52,N/A,1255.51,N/A,656.88,N/A,60.09,N/A,1100.00,N/A,711.45,N/A,457.95,N/A,292.95,N/A,N/A,N/A,N/A,N/A,492.85,N/A,457.95,N/A,457.95,N/A,457.95,N/A,1204.85,N/A,N/A,N/A,656.88,N/A,214.40,N/A,214.40,N/A,656.88,N/A,N/A,N/A,60.09,N/A,66.11,N/A,N/A,60.09,1255.51,,Hospital A4406,"Paste,Brava,Pectin,Sting-Free,2 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2027.97,N/A,1216.78,N/A,N/A,N/A,19.29,N/A,1054.00,N/A,689.51,N/A,392.92,N/A,283.92,N/A,1215.00,N/A,1215.00,N/A,452.43,N/A,392.92,N/A,392.92,N/A,392.92,N/A,1167.70,N/A,1215.00,N/A,N/A,N/A,214.40,N/A,214.40,N/A,N/A,N/A,1215.00,N/A,19.29,N/A,21.23,N/A,N/A,19.29,1216.78,,Hospital A4409,"Barrier,Skn,70mm,2.75flg,57mm,2.25 Ctf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2088.83,N/A,1253.30,N/A,656.88,N/A,1993.11,N/A,1679.00,N/A,449.92,N/A,449.92,N/A,656.88,N/A,1993.11,N/A,1993.11,N/A,449.92,N/A,449.92,N/A,449.92,N/A,449.92,N/A,1679.00,N/A,1993.11,N/A,656.88,N/A,1679.00,N/A,1679.00,N/A,656.88,N/A,1993.11,N/A,1993.11,N/A,656.88,N/A,N/A,449.92,1993.11,,Hospital A4410,"Barrier,Snsra,2pc,Flx,3/8-2 3/4,Ylw,Nds",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3306.75,N/A,1984.05,N/A,1611.87,N/A,70.10,N/A,431.00,N/A,1124.29,N/A,555.00,N/A,462.93,N/A,N/A,N/A,N/A,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1904.01,N/A,N/A,N/A,1611.87,N/A,486.02,N/A,486.02,N/A,1611.87,N/A,N/A,N/A,70.10,N/A,77.11,N/A,N/A,70.10,1984.05,,Hospital A4425,"Pouch,Mio,Flx Easi,Maxi,Trnsp,70mm",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2179.37,N/A,1307.62,N/A,N/A,N/A,1993.11,N/A,431.00,N/A,453.13,N/A,453.13,N/A,N/A,N/A,1993.11,N/A,1993.11,N/A,453.13,N/A,453.13,N/A,453.13,N/A,453.13,N/A,431.00,N/A,1993.11,N/A,N/A,N/A,431.00,N/A,431.00,N/A,N/A,N/A,1993.11,N/A,1993.11,N/A,N/A,N/A,N/A,431.00,1993.11,,Hospital A4452,"Tape,Cloth,Surgical,Medipore-H,2x10yd",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2912.58,N/A,1747.55,N/A,958.61,N/A,1755.00,N/A,700.00,N/A,1237.28,N/A,1237.28,N/A,958.61,N/A,1301.00,N/A,1301.00,N/A,1237.28,N/A,1237.28,N/A,1237.28,N/A,1237.28,N/A,700.00,N/A,2304.31,N/A,958.61,N/A,700.00,N/A,700.00,N/A,958.61,N/A,1140.00,N/A,1773.91,N/A,958.61,N/A,N/A,700.00,2304.31,,Hospital A4456,"Wipes,Adhesive Remover,6""X4.5""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2686.62,N/A,1611.97,N/A,481.52,N/A,1993.11,N/A,1080.00,N/A,1574.72,N/A,1574.72,N/A,481.52,N/A,1993.11,N/A,1993.11,N/A,1574.72,N/A,1574.72,N/A,1574.72,N/A,1574.72,N/A,1080.00,N/A,1993.11,N/A,481.52,N/A,1080.00,N/A,1080.00,N/A,481.52,N/A,1993.11,N/A,1993.11,N/A,481.52,N/A,N/A,481.52,1993.11,,Hospital A4461,"Strap,Montgomery,Medfix,7-1/4x11-1/8",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2730.27,N/A,1638.16,N/A,N/A,N/A,2871.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,52.64,N/A,2871.58,N/A,2871.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,653.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2871.58,N/A,2871.58,N/A,N/A,N/A,N/A,52.64,2871.58,,Hospital A4467,"Binder,Abdominal,Unisize,72-84,12",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5660.10,N/A,3396.06,N/A,N/A,N/A,1620.00,N/A,N/A,N/A,1924.44,N/A,1344.56,N/A,792.42,N/A,1620.00,N/A,1620.00,N/A,1339.80,N/A,1344.56,N/A,1344.56,N/A,1344.56,N/A,3259.09,N/A,1620.00,N/A,N/A,N/A,461.01,N/A,461.01,N/A,N/A,N/A,1620.00,N/A,1620.00,N/A,29.21,N/A,N/A,29.21,3396.06,,Hospital A4612,Battery Cables,N/A,N/A,N/A,53881.90,N/A,32329.14,N/A,7547.04,N/A,9008.62,N/A,30320.17,N/A,18319.84,N/A,25852.48,N/A,7547.04,N/A,9008.62,N/A,9008.62,N/A,16093.41,N/A,25852.48,N/A,25852.48,N/A,25852.48,N/A,30320.17,N/A,9056.83,N/A,7547.04,N/A,753.88,N/A,753.88,N/A,7547.04,N/A,9056.83,N/A,9056.83,N/A,9962.51,N/A,N/A,753.88,32329.14,,Hospital HCPCS A4649,Surgical Supplies,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital A4670,"Monitor,Bp,Auto,Digital,Adult",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5443.63,N/A,3266.18,N/A,1284.00,N/A,55.63,N/A,N/A,N/A,1850.84,N/A,1344.86,N/A,762.11,N/A,N/A,N/A,N/A,N/A,1339.99,N/A,1344.86,N/A,1344.86,N/A,1344.86,N/A,3134.44,N/A,N/A,N/A,1284.00,N/A,130.60,N/A,130.60,N/A,1284.00,N/A,N/A,N/A,55.63,N/A,61.21,N/A,N/A,55.63,3266.18,,Hospital A4927,"Glove,Exam,Stretch Vinyl,Pf,X-Large",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1509.17,N/A,905.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,905.50,905.50,,Hospital A5056,"Pouch,Mio,1pc,Easi,Maxi,Transp,Pc,1 3/8""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3824.12,N/A,2294.47,N/A,625.59,N/A,735.00,N/A,N/A,N/A,1300.21,N/A,777.00,N/A,535.37,N/A,735.00,N/A,735.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,2201.92,N/A,735.00,N/A,625.59,N/A,334.52,N/A,334.52,N/A,625.59,N/A,735.00,N/A,735.00,N/A,63.59,N/A,N/A,63.59,2294.47,,Hospital A5071,"Pouch,Mio,1pc,Maxi,Trns,Ctf,3/8-1 3/4",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5348.48,N/A,3209.09,N/A,N/A,N/A,675.44,N/A,1080.00,N/A,1818.49,N/A,1111.39,N/A,748.80,N/A,N/A,N/A,N/A,N/A,1110.86,N/A,1111.39,N/A,1111.39,N/A,1111.39,N/A,3079.65,N/A,N/A,N/A,N/A,N/A,508.39,N/A,508.39,N/A,N/A,N/A,N/A,N/A,675.44,N/A,742.99,N/A,N/A,508.39,3209.09,,Hospital A5200,"Tube Securement Device,Sterile Med",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1515.32,N/A,909.19,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,909.19,909.19,,Hospital A6021,"Dressing,Prisma,Collagen W/Orc,4.34 Sqin",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2202.90,N/A,1321.74,N/A,867.93,N/A,2004.25,N/A,600.00,N/A,449.92,N/A,449.92,N/A,867.93,N/A,2004.25,N/A,2004.25,N/A,449.92,N/A,449.92,N/A,449.92,N/A,449.92,N/A,600.00,N/A,2004.25,N/A,867.93,N/A,600.00,N/A,600.00,N/A,867.93,N/A,2004.25,N/A,2004.25,N/A,867.93,N/A,N/A,449.92,2004.25,,Hospital A6023,"Dressing,Collagen,Puracol,8x8",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3558.08,N/A,2134.85,N/A,N/A,N/A,950.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,91.11,N/A,950.00,N/A,950.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,950.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,950.00,N/A,950.00,N/A,N/A,N/A,N/A,91.11,2134.85,,Hospital A6027,"Dressing,Afm Ag,4"" X 5""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2004.25,N/A,1202.55,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3.12,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,3.12,2004.25,,Hospital A6198,"Dressing,Optilock,Non-Adhesive,8x12",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5006.27,N/A,3003.76,N/A,986.68,N/A,107.05,N/A,1490.00,N/A,1702.14,N/A,1056.44,N/A,700.85,N/A,1536.00,N/A,1536.00,N/A,1116.90,N/A,1056.44,N/A,1056.44,N/A,1056.44,N/A,2882.61,N/A,1536.00,N/A,986.68,N/A,214.40,N/A,214.40,N/A,986.68,N/A,1140.00,N/A,107.05,N/A,117.77,N/A,N/A,107.05,3003.76,,Hospital A6206,"Dressing, Contact Layer, Versatel, 3x4",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3082.02,N/A,1849.21,N/A,1218.80,N/A,2484.13,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1218.80,N/A,2484.13,N/A,2484.13,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2484.13,N/A,1218.80,N/A,N/A,N/A,N/A,N/A,1218.80,N/A,2484.13,N/A,2484.13,N/A,1218.80,N/A,N/A,1218.80,2484.13,,Hospital A6207,"Dressing, Acticoat, Flex 3, 4""X8""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2711.17,N/A,1626.70,N/A,N/A,N/A,2430.00,N/A,N/A,N/A,642.00,N/A,642.00,N/A,N/A,N/A,2430.00,N/A,2430.00,N/A,642.00,N/A,642.00,N/A,642.00,N/A,642.00,N/A,N/A,N/A,252.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2430.00,N/A,2430.00,N/A,N/A,N/A,N/A,252.64,2430.00,,Hospital A6210,"Dressing,Hydrofera,Blue,No Border,4x5",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2825.00,N/A,1695.00,N/A,1239.90,N/A,2202.90,N/A,785.00,N/A,1124.80,N/A,1124.80,N/A,132.25,N/A,2202.90,N/A,2202.90,N/A,1124.80,N/A,1124.80,N/A,1124.80,N/A,1124.80,N/A,785.00,N/A,2506.20,N/A,1239.90,N/A,785.00,N/A,785.00,N/A,1239.90,N/A,2202.90,N/A,2202.90,N/A,1239.90,N/A,N/A,132.25,2506.20,,Hospital A6211,"Dressing,Hydrofera,Blue,No Border,8""X8""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3127.33,N/A,1876.40,N/A,625.59,N/A,57.64,N/A,N/A,N/A,1063.29,N/A,778.39,N/A,437.84,N/A,N/A,N/A,N/A,N/A,777.86,N/A,778.39,N/A,778.39,N/A,778.39,N/A,1800.73,N/A,N/A,N/A,625.59,N/A,175.44,N/A,175.44,N/A,625.59,N/A,N/A,N/A,57.64,N/A,63.40,N/A,N/A,57.64,1876.40,,Hospital A6216,"Gauze,Sponge,4x4,8ply,Ns,Lf,200/Pk",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2853.68,N/A,1712.21,N/A,995.61,N/A,1755.00,N/A,1404.92,N/A,1028.37,N/A,1028.37,N/A,995.61,N/A,1260.00,N/A,1260.00,N/A,1028.37,N/A,1028.37,N/A,1028.37,N/A,1028.37,N/A,1054.00,N/A,2329.66,N/A,995.61,N/A,848.19,N/A,800.00,N/A,1203.80,N/A,1080.00,N/A,2204.45,N/A,995.61,N/A,N/A,800.00,2329.66,,Hospital A6219,"Gauze,Bordered,2 X 2(1 X 1pad)Strl",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2673.82,N/A,1604.29,N/A,669.84,N/A,1620.00,N/A,N/A,N/A,674.88,N/A,674.88,N/A,669.84,N/A,1620.00,N/A,1620.00,N/A,674.88,N/A,674.88,N/A,674.88,N/A,674.88,N/A,N/A,N/A,1620.00,N/A,669.84,N/A,N/A,N/A,N/A,N/A,669.84,N/A,648.00,N/A,1620.00,N/A,669.84,N/A,N/A,648.00,1620.00,,Hospital A6220,"Gauze,Border,6x6,4x4pad,Sterile",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4020.93,N/A,2412.56,N/A,1324.18,N/A,3.17,N/A,675.00,N/A,1367.12,N/A,999.00,N/A,562.93,N/A,1404.00,N/A,1404.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2315.26,N/A,1404.00,N/A,1324.18,N/A,11.22,N/A,11.22,N/A,1324.18,N/A,1404.00,N/A,3.17,N/A,3.49,N/A,N/A,3.17,2412.56,,Hospital A6223,"Dressing,Gauze,Xeroform,Curad,5x9,St",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3053.02,N/A,1831.81,N/A,1176.63,N/A,1755.00,N/A,957.00,N/A,1038.02,N/A,666.00,N/A,427.43,N/A,1347.00,N/A,1347.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1757.92,N/A,2303.35,N/A,1176.63,N/A,135.63,N/A,135.63,N/A,1176.63,N/A,1188.00,N/A,1805.00,N/A,159.98,N/A,N/A,135.63,2303.35,,Hospital A6224,"Dressing,Gauze,Petrolatm,Curad,3x18,St",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2673.82,N/A,1604.29,N/A,N/A,N/A,3253.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3253.10,N/A,3253.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3253.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3253.10,N/A,3253.10,N/A,N/A,N/A,N/A,1604.29,3253.10,,Hospital A6228,"Dressing,Mesalt,Hypertonic 8x8(4x4 F",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2172.98,N/A,1303.79,N/A,N/A,N/A,N/A,N/A,1054.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1054.00,N/A,N/A,N/A,N/A,N/A,1054.00,N/A,1054.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1054.00,1303.79,,Hospital A6231,"Dressing,Opsite,Post-OP,11 3/4 X 4",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4864.80,N/A,2918.88,N/A,1824.98,N/A,41.38,N/A,N/A,N/A,1654.03,N/A,846.07,N/A,681.07,N/A,1404.00,N/A,1404.00,N/A,1274.64,N/A,846.07,N/A,846.07,N/A,846.07,N/A,2801.16,N/A,1404.00,N/A,1824.98,N/A,1929.60,N/A,1929.60,N/A,1824.98,N/A,1404.00,N/A,41.38,N/A,45.51,N/A,N/A,41.38,2918.88,,Hospital A6234,"Dressing,Exuderm,Lp/Thin,Hdrocold,4x4",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3924.78,N/A,2354.87,N/A,820.44,N/A,213.95,N/A,3300.00,N/A,1334.44,N/A,1001.78,N/A,549.49,N/A,1620.00,N/A,1620.00,N/A,1000.72,N/A,1001.78,N/A,1001.78,N/A,1001.78,N/A,2259.88,N/A,1620.00,N/A,820.44,N/A,174.09,N/A,174.09,N/A,820.44,N/A,1620.00,N/A,213.95,N/A,235.37,N/A,N/A,174.09,3300.00,,Hospital A6235,"Dressing,Duoderm,Xtra Thin,Cgf,6 X 6",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1689.10,N/A,1013.46,N/A,N/A,N/A,1566.24,N/A,N/A,N/A,574.29,N/A,278.00,N/A,236.48,N/A,1566.24,N/A,1566.24,N/A,256.80,N/A,278.00,N/A,278.00,N/A,278.00,N/A,972.59,N/A,1566.24,N/A,N/A,N/A,47.76,N/A,47.76,N/A,N/A,N/A,1566.24,N/A,1566.24,N/A,35.71,N/A,N/A,35.71,1566.24,,Hospital A6240,"Paste,Woud Dressing,Hydrofil,Triad,6oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2004.25,N/A,1202.55,N/A,N/A,N/A,1518.40,N/A,N/A,N/A,1028.37,N/A,1028.37,N/A,N/A,N/A,1518.40,N/A,1518.40,N/A,1028.37,N/A,1028.37,N/A,1028.37,N/A,1028.37,N/A,N/A,N/A,1518.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1518.40,N/A,1518.40,N/A,N/A,N/A,N/A,1028.37,1518.40,,Hospital A6254,"Mbo-Dressing,Primapore,4""X3.125""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3610.72,N/A,2166.43,N/A,819.00,N/A,10.22,N/A,1335.00,N/A,1227.64,N/A,559.00,N/A,505.50,N/A,2070.65,N/A,2070.65,N/A,930.00,N/A,559.00,N/A,559.00,N/A,559.00,N/A,2079.05,N/A,2070.65,N/A,819.00,N/A,1715.20,N/A,1715.20,N/A,819.00,N/A,2070.65,N/A,10.22,N/A,11.24,N/A,N/A,10.22,2166.43,,Hospital A6257,"Dressing,Trnsprnt,Suresite123,4x4.8",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2489.25,N/A,1493.55,N/A,743.94,N/A,1826.07,N/A,804.00,N/A,846.35,N/A,555.00,N/A,348.50,N/A,1826.07,N/A,1826.07,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1433.31,N/A,2175.38,N/A,743.94,N/A,47.83,N/A,47.83,N/A,743.94,N/A,1826.07,N/A,1826.07,N/A,96.25,N/A,N/A,47.83,2175.38,,Hospital A6258,"Dressing,Trnsprnt,Suresite123,6x8",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2436.22,N/A,1461.73,N/A,481.52,N/A,2224.30,N/A,700.00,N/A,925.52,N/A,925.52,N/A,481.52,N/A,2224.30,N/A,2224.30,N/A,925.52,N/A,925.52,N/A,925.52,N/A,925.52,N/A,700.00,N/A,2244.37,N/A,481.52,N/A,700.00,N/A,700.00,N/A,481.52,N/A,2224.30,N/A,2224.30,N/A,481.52,N/A,N/A,481.52,2244.37,,Hospital A6259,"Dressing,Trnsprnt,Suresite123,8x12",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3720.07,N/A,2232.04,N/A,N/A,N/A,154.00,N/A,900.00,N/A,1264.82,N/A,999.00,N/A,520.81,N/A,2123.15,N/A,2123.15,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2142.02,N/A,2123.15,N/A,N/A,N/A,64.36,N/A,64.36,N/A,N/A,N/A,2123.15,N/A,154.00,N/A,169.40,N/A,N/A,64.36,2232.04,,Hospital A6260,"Cleanser,Wound,Dermal,Bottle,8 Oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2853.68,N/A,1712.21,N/A,958.61,N/A,1993.11,N/A,689.64,N/A,1391.00,N/A,1391.00,N/A,958.61,N/A,945.00,N/A,945.00,N/A,1391.00,N/A,1391.00,N/A,1391.00,N/A,1391.00,N/A,689.64,N/A,2359.28,N/A,958.61,N/A,689.64,N/A,689.64,N/A,958.61,N/A,1993.11,N/A,1993.11,N/A,958.61,N/A,N/A,689.64,2359.28,,Hospital A6261,"Tube, Gel, Iodosorb, 10 Gram",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2054.55,N/A,1232.73,N/A,625.59,N/A,2409.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,625.59,N/A,2409.88,N/A,2409.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2409.88,N/A,625.59,N/A,N/A,N/A,N/A,N/A,625.59,N/A,2409.88,N/A,2409.88,N/A,625.59,N/A,N/A,625.59,2409.88,,Hospital A6413,"Bandage,Adhesive,Plastic,1x3,Strl,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2202.90,N/A,1321.74,N/A,N/A,N/A,945.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.00,N/A,945.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.00,N/A,945.00,N/A,N/A,N/A,N/A,945.00,1321.74,,Hospital A6442,"Bandage,Conforming,Peha-Haft,1.5x4.5yds",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2864.73,N/A,1718.84,N/A,N/A,N/A,354.85,N/A,N/A,N/A,974.01,N/A,731.07,N/A,401.07,N/A,N/A,N/A,N/A,N/A,706.43,N/A,731.07,N/A,731.07,N/A,731.07,N/A,1649.52,N/A,N/A,N/A,N/A,N/A,249.10,N/A,249.10,N/A,N/A,N/A,N/A,N/A,354.85,N/A,390.34,N/A,N/A,249.10,1718.84,,Hospital A6446,"Bandage,Gauze,Bulkee II,4.5x4.1yd,Strl",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2905.68,N/A,1743.41,N/A,1083.17,N/A,7.40,N/A,1080.00,N/A,987.94,N/A,778.39,N/A,406.80,N/A,1313.00,N/A,1313.00,N/A,777.86,N/A,778.39,N/A,778.39,N/A,778.39,N/A,1673.09,N/A,2303.35,N/A,1083.17,N/A,56.66,N/A,56.66,N/A,1203.80,N/A,1010.00,N/A,7.40,N/A,8.14,N/A,N/A,7.40,2303.35,,Hospital A6448,"Bandage,Elastic,Matrix,Sterile,2x5yd,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5269.38,N/A,3161.63,N/A,867.93,N/A,41.03,N/A,N/A,N/A,1791.60,N/A,1277.00,N/A,737.71,N/A,2765.00,N/A,2765.00,N/A,1338.00,N/A,1277.00,N/A,1277.00,N/A,1277.00,N/A,3034.11,N/A,2765.00,N/A,867.93,N/A,214.40,N/A,214.40,N/A,867.93,N/A,2765.00,N/A,41.03,N/A,45.14,N/A,N/A,41.03,3161.63,,Hospital A6449,"Bandage,Elastic,Matrix,Sterile,4x5yd,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3347.08,N/A,2008.25,N/A,991.92,N/A,1718.00,N/A,1300.00,N/A,1250.12,N/A,1250.12,N/A,991.92,N/A,1050.00,N/A,1050.00,N/A,1250.12,N/A,1250.12,N/A,1250.12,N/A,1250.12,N/A,1300.00,N/A,2329.66,N/A,991.92,N/A,1300.00,N/A,1300.00,N/A,991.92,N/A,1080.00,N/A,1718.00,N/A,991.92,N/A,N/A,991.92,2329.66,,Hospital A6450,"Bandage,Elastic,Matrix,6x5yd,Hook&Lp",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2866.93,N/A,1720.16,N/A,1324.18,N/A,1045.00,N/A,N/A,N/A,749.00,N/A,749.00,N/A,1324.18,N/A,1045.00,N/A,1045.00,N/A,749.00,N/A,749.00,N/A,749.00,N/A,749.00,N/A,N/A,N/A,1045.00,N/A,1324.18,N/A,N/A,N/A,N/A,N/A,1324.18,N/A,1045.00,N/A,1045.00,N/A,1324.18,N/A,N/A,749.00,1720.16,,Hospital A6452,"Bandage,Elstc,Swift-Wrap,4x5yd,Slf Clsr",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3060.33,N/A,1836.20,N/A,N/A,N/A,953.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,203.91,N/A,953.00,N/A,953.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,953.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,953.00,N/A,953.00,N/A,N/A,N/A,N/A,203.91,1836.20,,Hospital A6453,"Bandage,Coflex Lf2,2x5yd,Tan,Ns,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2304.32,N/A,1382.59,N/A,214.00,N/A,1235.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,214.00,N/A,1235.00,N/A,1235.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1235.00,N/A,214.00,N/A,N/A,N/A,N/A,N/A,214.00,N/A,1235.00,N/A,1235.00,N/A,214.00,N/A,N/A,214.00,1382.59,,Hospital A6456,"Coflex,Unna Boot,4,Latex Free,Tan",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2403.17,N/A,1441.90,N/A,843.99,N/A,1620.00,N/A,N/A,N/A,963.00,N/A,963.00,N/A,843.99,N/A,1755.00,N/A,1755.00,N/A,963.00,N/A,963.00,N/A,963.00,N/A,963.00,N/A,N/A,N/A,2303.35,N/A,843.99,N/A,N/A,N/A,N/A,N/A,843.99,N/A,665.00,N/A,1755.00,N/A,843.99,N/A,N/A,665.00,2303.35,,Hospital A6457,"Bandage,Tubular,Elst,Medigrip,Size F 1yd",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2783.83,N/A,1670.30,N/A,1324.18,N/A,1620.00,N/A,N/A,N/A,1124.80,N/A,1124.80,N/A,1324.18,N/A,1620.00,N/A,1620.00,N/A,1124.80,N/A,1124.80,N/A,1124.80,N/A,1124.80,N/A,N/A,N/A,2004.25,N/A,1324.18,N/A,N/A,N/A,N/A,N/A,1324.18,N/A,990.00,N/A,1620.00,N/A,1324.18,N/A,N/A,990.00,2004.25,,Hospital A6530,"Stocking,Anti-Embolism,K-L,Xl Reg,Lf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2078.38,N/A,1247.03,N/A,N/A,N/A,440.00,N/A,N/A,N/A,706.66,N/A,445.21,N/A,290.97,N/A,440.00,N/A,440.00,N/A,444.75,N/A,445.21,N/A,445.21,N/A,445.21,N/A,1196.73,N/A,440.00,N/A,N/A,N/A,42.02,N/A,42.02,N/A,N/A,N/A,440.00,N/A,440.00,N/A,8.66,N/A,N/A,8.66,1247.03,,Hospital A7048,"Kit,Drain,Pleural,W/Dressing Pack,1000ml",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2322.97,N/A,1393.78,N/A,N/A,N/A,675.00,N/A,N/A,N/A,1349.76,N/A,1349.76,N/A,N/A,N/A,675.00,N/A,675.00,N/A,1349.76,N/A,1349.76,N/A,1349.76,N/A,1349.76,N/A,N/A,N/A,675.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,675.00,N/A,675.00,N/A,N/A,N/A,N/A,675.00,1393.78,,Hospital A8001,HC Hard Protect Helmet Prefab,N/A,0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY,107423.85,N/A,64454.31,N/A,N/A,N/A,25184.88,N/A,59212.03,N/A,36407.62,N/A,49356.05,N/A,21714.41,N/A,N/A,N/A,25184.88,N/A,30725.61,N/A,49356.05,N/A,49356.05,N/A,49356.05,N/A,59212.03,N/A,N/A,N/A,21714.41,N/A,57020.67,N/A,57020.67,N/A,N/A,N/A,N/A,N/A,25184.88,N/A,N/A,N/A,21714.41,64454.31,N/A,N/A,,Hospital A9500,HC Tc99m Sestamibi,N/A,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,53265.23,6237.00,31959.14,3742.20,5869.15,873.18,7326.47,805.34,13825.30,3535.85,16649.53,2120.58,7194.29,1948.05,6049.99,873.18,7267.17,805.34,7267.17,805.34,4478.59,1212.70,7194.29,1948.05,7194.29,1948.05,7194.29,1948.05,13825.30,3535.85,7267.17,805.34,6049.99,873.18,16606.00,2745.39,16606.00,2745.39,N/A,873.18,7267.17,805.34,7326.47,805.34,6473.49,885.87,4478.59,31959.14,805.34,3742.20,,Hospital A9502,HC Tc99m Tetrofosmin,N/A,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,57413.70,18219.40,34448.22,10931.64,4541.36,2550.72,8507.03,1198.58,10234.33,10241.71,19520.66,6194.60,1588.00,4041.03,4681.29,2550.72,8507.03,1198.58,8507.03,1198.58,989.00,2515.61,1588.00,4041.03,1588.00,4041.03,1588.00,4041.03,10234.33,10241.71,8507.03,1198.58,4681.29,2550.72,12292.77,6422.35,12292.77,6422.35,5869.15,2550.72,5637.84,1198.58,8507.03,1198.58,1676.93,1318.44,989.00,34448.22,1198.58,10931.64,,Hospital HCPCS A9516,SODIUM IODIDE I-123 3.7 MBQ PO CAPS,48815-1001-01,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,648.00,648.00,388.80,388.80,N/A,90.72,N/A,648.00,N/A,340.91,N/A,220.32,N/A,433.77,N/A,90.72,N/A,648.00,N/A,648.00,N/A,270.03,N/A,433.77,N/A,433.77,N/A,433.77,N/A,340.91,N/A,648.00,N/A,90.72,N/A,347.33,N/A,347.33,N/A,90.72,N/A,648.00,N/A,648.00,N/A,648.00,388.80,388.80,90.72,648.00,,Hospital A9517,"I131 iodide cap, rx",N/A,N/A,28085.40,5688.00,16851.24,3412.80,3934.82,796.32,4979.62,699.64,8867.43,3058.90,9549.04,1933.92,9300.40,996.37,4056.05,796.32,4920.32,676.39,4920.32,676.39,5789.42,790.46,9300.40,996.37,9300.40,996.37,9300.40,996.37,8867.43,3058.90,4920.32,676.39,4056.05,796.32,10650.94,716.63,10650.94,716.63,N/A,796.32,4920.32,676.39,4920.32,45.38,4339.98,49.92,3934.82,16851.24,45.38,3412.80,,Hospital A9520,Tc99 tilmanocept diag 0.5mci,N/A,N/A,77689.82,54198.63,46613.89,32519.18,9261.97,7574.23,11251.72,5370.83,20872.60,30901.91,26414.53,18427.54,21072.26,14337.59,9547.35,7574.23,103970.00,5370.83,103970.00,5370.83,13116.99,8925.41,21072.26,14337.59,21072.26,14337.59,21072.26,14337.59,20872.60,30901.92,11222.07,5370.83,9547.35,7574.23,25070.73,6358.25,25070.73,6358.25,3087.75,7574.23,5366.90,5370.83,11251.72,5370.83,10215.66,5907.91,3087.75,103970.00,5370.83,32519.18,,Hospital A9528,"Iodine I-131 iodide cap, dx",N/A,N/A,52770.80,3500.60,31662.48,2100.36,6438.89,490.08,7882.51,354.79,14510.55,2006.96,N/A,1190.20,N/A,907.05,6637.28,490.08,7882.51,350.99,7882.51,350.99,9118.89,564.66,N/A,907.05,14649.36,907.05,14649.36,907.05,14510.55,2006.96,7882.51,350.99,6637.28,490.08,17429.08,1782.74,17429.08,1782.74,N/A,490.08,7882.51,350.99,7882.51,354.79,7101.89,200.40,6438.89,31662.48,200.40,2100.36,,Hospital A9538,HC Tc99m Pyrophosphate,N/A,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,82378.92,2430.00,49427.35,1458.00,5902.44,340.20,8674.05,1253.77,32699.86,1395.41,14367.51,826.20,14367.51,2430.00,5902.44,340.20,9640.41,1198.58,9640.41,1198.58,14367.51,1908.11,14367.51,2430.00,14367.51,2430.00,14367.51,2430.00,32699.86,1395.41,9640.41,1198.58,5902.44,340.20,32699.86,1261.74,32699.86,1261.74,5902.44,340.20,9375.90,1198.58,9640.41,1253.77,5902.44,310.54,5902.44,49427.35,310.54,2430.00,,Hospital HCPCS A9541,TECHNETIUM TC 99M FILTERED SULFUR COLLOID,00040-8400-72,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,448.00,448.00,268.80,268.80,N/A,62.72,N/A,448.00,N/A,235.69,N/A,152.32,N/A,448.00,N/A,62.72,N/A,448.00,N/A,448.00,N/A,431.08,N/A,448.00,N/A,448.00,N/A,448.00,N/A,235.69,N/A,448.00,N/A,62.72,N/A,240.13,N/A,240.13,N/A,62.72,N/A,448.00,N/A,448.00,N/A,448.00,268.80,268.80,62.72,448.00,,Hospital HCPCS A9541,TECHNET TC 99M SULFUR COLLOID CO KIT,00040-8400-72,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,448.00,448.00,268.80,268.80,N/A,62.72,N/A,448.00,N/A,235.69,N/A,152.32,N/A,448.00,N/A,62.72,N/A,448.00,N/A,448.00,N/A,431.08,N/A,448.00,N/A,448.00,N/A,448.00,N/A,235.69,N/A,448.00,N/A,62.72,N/A,240.13,N/A,240.13,N/A,62.72,N/A,448.00,N/A,448.00,N/A,448.00,268.80,268.80,62.72,448.00,,Hospital HCPCS A9541,TECHNETIUM TC 99M SULFUR COLLOID EGG,00040-8400-72,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,448.00,448.00,268.80,268.80,N/A,62.72,N/A,448.00,N/A,235.69,N/A,152.32,N/A,448.00,N/A,62.72,N/A,448.00,N/A,448.00,N/A,431.08,N/A,448.00,N/A,448.00,N/A,448.00,N/A,235.69,N/A,448.00,N/A,62.72,N/A,240.13,N/A,240.13,N/A,62.72,N/A,448.00,N/A,448.00,N/A,448.00,268.80,268.80,62.72,448.00,,Hospital A9547,In111 oxyquinoline,N/A,N/A,152998.98,7841.38,91799.39,4704.83,17835.24,1097.79,21363.81,1223.50,84333.04,4248.46,N/A,2666.07,42155.67,7530.52,18384.77,1097.79,14530.51,1198.58,21363.81,1198.58,N/A,4687.84,N/A,7530.52,N/A,7530.52,N/A,7530.52,84333.04,4248.46,21363.81,1198.58,18384.77,1097.79,48277.25,1327.67,48277.25,1327.67,4665.46,1097.79,21363.81,1198.58,21363.81,1223.50,19671.71,254.32,4665.46,91799.39,254.32,7530.52,,Hospital A9551,Tc99m succimer,N/A,N/A,N/A,46012.20,N/A,27607.32,N/A,6441.71,N/A,3187.39,N/A,24942.75,N/A,15644.15,N/A,9082.62,N/A,6441.71,N/A,3104.47,N/A,3104.47,N/A,5654.08,N/A,9082.62,N/A,9082.62,N/A,9082.62,N/A,24942.75,N/A,3104.47,N/A,6441.71,N/A,3792.25,N/A,3792.25,N/A,6441.71,N/A,3104.47,N/A,3187.39,N/A,845.28,N/A,N/A,845.28,27607.32,,Hospital A9558,Xe133 xenon 10mci,N/A,N/A,47672.30,3014.00,28603.38,1808.40,3977.49,421.96,4970.81,558.63,8963.60,1721.80,16208.58,1024.76,9401.27,1485.48,6391.48,421.96,4970.81,534.04,4970.81,534.04,5852.21,1569.95,9401.27,1485.48,9401.27,1485.48,9401.27,1485.48,8963.60,1721.80,4970.81,534.04,4100.05,421.96,10766.46,1468.10,10766.46,1468.10,6391.48,421.96,4970.81,534.04,4970.81,558.63,4387.05,285.39,3977.49,28603.38,285.39,1808.40,,Hospital A9561,Tc99m oxidronate,N/A,N/A,80019.53,3502.00,48011.72,2101.20,10018.42,490.28,12116.91,513.84,23192.60,2324.34,27206.65,1190.68,22793.29,1261.60,10327.10,490.28,12116.91,513.84,12116.91,513.84,14188.29,785.37,22793.29,1261.60,22793.29,1261.60,22793.29,1261.60,23192.60,2324.34,12116.91,513.84,10327.10,490.28,27118.32,1937.88,27118.32,1937.88,N/A,490.28,12116.91,513.84,12116.91,513.84,11050.00,565.23,10018.42,48011.72,490.28,2324.34,,Hospital A9567,Technetium TC-99m aerosol,N/A,N/A,76039.50,6966.42,45623.70,4179.85,6928.07,884.04,8461.19,625.11,15612.97,4887.95,25853.43,2368.58,15762.32,1602.94,7141.54,884.04,8461.19,630.56,8461.19,630.56,9811.68,997.88,N/A,1602.94,15762.32,1602.94,15762.32,1602.94,15612.97,4887.95,8461.19,630.56,7141.54,884.04,18753.23,3540.97,N/A,3540.97,13564.01,884.04,8461.19,630.56,8461.19,625.11,7641.45,394.07,6928.07,45623.70,394.07,4887.95,,Hospital A9569,Technetium TC-99m auto WBC,N/A,N/A,149601.33,9945.60,89760.80,5967.36,16699.14,1392.38,13026.36,354.79,16186.89,5311.30,N/A,3381.50,N/A,8768.06,16699.14,1392.38,13026.36,350.99,13026.36,350.99,N/A,5458.21,N/A,8768.06,N/A,8768.06,N/A,8768.06,16186.89,5311.30,13026.36,350.99,16699.14,1392.38,16186.89,851.17,16186.89,851.17,16699.14,1392.38,13026.36,350.99,13026.36,354.79,16699.14,207.68,13026.36,89760.80,207.68,8768.06,,Hospital A9572,Indium in-111 Pentetreotide,N/A,N/A,N/A,12627.50,N/A,7576.50,N/A,1767.85,N/A,2507.54,N/A,7055.42,N/A,4293.35,N/A,5798.52,N/A,1767.85,N/A,2397.16,N/A,2397.16,N/A,3609.68,N/A,5798.52,N/A,5798.52,N/A,5798.52,N/A,7055.42,N/A,2397.16,N/A,1767.85,N/A,4437.54,N/A,4437.54,N/A,1767.85,N/A,2397.16,N/A,2507.54,N/A,876.39,N/A,N/A,876.39,7576.50,,Hospital A9576,Inj Prohance Multipack,N/A,N/A,93448.60,3175.60,56069.16,1905.36,4441.07,444.58,5519.19,353.93,10008.32,1205.91,31772.52,1079.70,10405.42,830.89,4577.91,444.58,5519.19,332.71,5519.19,332.71,25866.35,517.24,25866.35,830.89,10405.42,830.89,16707.37,830.89,10008.32,1205.91,5519.19,332.71,4577.91,444.58,12021.30,1060.00,12021.30,1060.00,5959.85,444.58,5519.19,332.71,5519.19,353.93,4898.36,224.55,4441.07,56069.16,224.55,1905.36,,Hospital A9577,Inj Multihance,N/A,N/A,47075.30,3220.60,28245.18,1932.36,6759.09,453.89,8261.21,332.71,15612.97,1560.36,16005.60,1095.00,15762.32,1088.20,6967.35,453.89,8261.21,332.71,8261.21,332.71,9811.68,677.41,15762.32,1088.20,15762.32,1088.20,15762.32,1088.20,15612.97,1560.36,8261.21,441.85,6967.35,453.89,18753.23,1067.77,18753.23,1067.77,6684.57,453.89,8261.21,441.85,8261.21,441.85,7455.07,486.04,6684.57,28245.18,332.71,1932.36,,Hospital HCPCS A9578,GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN,00270-5164-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),73.30,73.30,43.98,43.98,N/A,10.26,N/A,73.30,N/A,41.21,N/A,24.92,N/A,47.92,N/A,10.26,N/A,73.30,N/A,73.30,N/A,29.83,N/A,47.92,N/A,47.92,N/A,47.92,N/A,41.21,N/A,73.30,N/A,10.26,N/A,39.29,N/A,39.29,N/A,10.26,N/A,73.30,N/A,73.30,N/A,73.30,43.98,43.98,10.26,73.30,,Hospital HCPCS A9578,GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN,00270-5164-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),146.60,146.60,87.96,87.96,N/A,20.52,N/A,146.60,N/A,82.42,N/A,49.84,N/A,95.83,N/A,20.52,N/A,146.60,N/A,146.60,N/A,59.66,N/A,95.83,N/A,95.83,N/A,95.83,N/A,82.42,N/A,146.60,N/A,20.52,N/A,78.58,N/A,78.58,N/A,20.52,N/A,146.60,N/A,146.60,N/A,146.60,87.96,87.96,20.52,146.60,,Hospital A9581,Gadoxetate disodium inj,N/A,N/A,72595.38,4006.00,43557.23,2403.60,10072.83,560.84,11666.14,331.00,22610.98,1424.83,24682.43,1362.04,22827.27,1186.55,10383.19,560.84,349564.00,332.71,349564.00,332.71,14209.44,738.64,22827.27,1186.55,22827.27,1186.55,22827.27,1186.55,22610.98,1424.83,11577.19,332.71,10383.19,560.84,27158.75,1060.00,27158.75,1060.00,8819.23,560.84,11577.19,332.71,11666.14,331.00,11110.02,252.01,8819.23,349564.00,252.01,2403.60,,Hospital A9582,Iodine I-123 iobenguane,N/A,N/A,N/A,17274.00,N/A,10364.40,N/A,2418.36,N/A,1298.76,N/A,9216.57,N/A,5873.16,N/A,17274.00,N/A,2418.36,N/A,1198.58,N/A,1198.58,N/A,11324.15,N/A,17274.00,N/A,17274.00,N/A,17274.00,N/A,9216.57,N/A,1198.58,N/A,2418.36,N/A,1388.24,N/A,1388.24,N/A,2418.36,N/A,1198.58,N/A,1298.76,N/A,579.41,N/A,N/A,579.41,17274.00,,Hospital A9584,Iodine I-123 ioflupane,N/A,N/A,N/A,8549.70,N/A,5129.82,N/A,1145.30,N/A,1340.39,N/A,4751.19,N/A,2903.67,N/A,6419.82,N/A,1145.30,N/A,1263.94,N/A,1263.94,N/A,5824.69,N/A,6419.82,N/A,6419.82,N/A,6419.82,N/A,4751.19,N/A,1263.94,N/A,1145.30,N/A,2237.51,N/A,2237.51,N/A,1145.30,N/A,1263.94,N/A,1340.39,N/A,423.43,N/A,N/A,423.43,6419.82,,Hospital A9586,Florbetapir F18,N/A,N/A,N/A,23185.00,N/A,13911.00,N/A,3245.90,N/A,1483.63,N/A,8735.91,N/A,7882.90,N/A,10653.97,N/A,3245.90,N/A,1344.94,N/A,1344.94,N/A,6632.23,N/A,10653.97,N/A,10653.97,N/A,10653.97,N/A,8735.91,N/A,1344.94,N/A,3245.90,N/A,6787.90,N/A,6787.90,N/A,3245.90,N/A,1344.94,N/A,1513.30,N/A,N/A,N/A,N/A,1344.94,13911.00,,Hospital A9596,Gallium illuccix 1 millicure,N/A,N/A,N/A,4080.00,N/A,2448.00,N/A,571.20,N/A,6071.90,N/A,3686.43,N/A,1387.20,N/A,4080.00,N/A,571.20,N/A,6071.90,N/A,6071.90,N/A,4080.00,N/A,4080.00,N/A,4080.00,N/A,4080.00,N/A,3686.43,N/A,6071.90,N/A,571.20,N/A,1305.16,N/A,1305.16,N/A,571.20,N/A,6071.90,N/A,6071.90,N/A,6679.10,N/A,N/A,571.20,6679.10,,Hospital A9698,Non-rad contrast materialNOC,N/A,N/A,N/A,518.10,N/A,310.86,N/A,72.53,N/A,172.58,N/A,298.32,N/A,176.15,N/A,273.68,N/A,72.53,N/A,162.85,N/A,162.85,N/A,170.37,N/A,273.68,N/A,273.68,N/A,273.68,N/A,298.32,N/A,162.85,N/A,72.53,N/A,261.57,N/A,261.57,N/A,72.53,N/A,162.85,N/A,172.58,N/A,103.85,N/A,N/A,72.53,310.86,,Hospital A9900,"Bag Set,Kangaroo Joey,1000ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2432.97,N/A,1459.78,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1459.78,1459.78,,Hospital C1721,HC Misc Cardioverter-Defib Dual,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,173615.00,146746.13,104169.00,88047.68,26980.91,20523.86,32212.32,28966.21,95696.59,83063.88,59029.11,49893.69,63772.54,70138.51,27812.24,20523.86,32182.67,28966.21,32182.67,28966.21,39697.89,43662.58,63772.54,70138.51,63772.54,70138.51,63772.54,70138.51,95696.59,83063.93,32182.67,28966.21,27812.24,20523.86,73033.19,29766.00,73033.19,29766.00,8269.14,20523.86,32182.67,28966.21,32212.32,28966.21,29759.10,31862.83,8269.14,104169.00,20523.86,88047.68,,Hospital C1725,HC Misc Cath Translum Angio,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,136834.25,38196.87,82100.55,22918.12,19157.38,5347.55,17140.14,9586.05,75423.04,11012.00,46523.65,12986.94,33716.47,23440.55,14704.30,5347.55,17140.14,9586.05,17140.14,9586.05,20988.23,14592.17,33716.47,23440.55,33716.47,23440.55,33716.47,23440.55,75423.04,11012.00,17140.14,9586.05,14704.30,5347.55,38612.56,14641.50,38612.56,14641.50,1839.87,5347.55,17140.14,9586.05,17140.14,9586.05,15733.60,10544.65,1839.87,82100.55,5347.55,23440.55,,Hospital C1733,HC Cath Ep Othr Than Cool-Tip,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,130167.67,112423.23,78100.60,67453.94,12504.35,15628.50,15057.65,21434.19,71748.42,64205.86,55703.87,38223.90,29555.50,51430.12,12889.63,15628.50,2248.00,21204.54,2248.00,21204.54,18398.06,32016.24,29555.50,51430.12,29555.50,51430.12,29555.50,51430.12,72320.51,18818.38,15057.65,21204.54,12889.63,15628.50,33847.36,16637.00,33847.36,16637.00,674.55,15628.50,15057.65,21204.54,15057.65,21434.19,13791.91,1478.12,674.55,78100.60,1478.12,67453.94,,Hospital C1734,HC Implant Ortho/Device/Drug Bone/Bone or Tissue to Bone,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,139034.48,103799.88,83420.69,62279.93,9425.21,14526.26,11533.78,14890.62,76635.81,59095.71,44007.55,35287.07,21443.65,29724.97,9715.61,14526.26,2810.00,13581.13,2810.00,13581.13,44007.55,18503.09,44007.55,29724.97,44007.55,29724.97,44007.55,29724.97,45152.24,59095.71,11415.18,13581.13,14518.14,14526.26,45152.24,10535.75,25512.59,10535.75,2224.47,14526.26,11415.18,13581.13,11415.18,14890.62,10395.71,1639.18,2224.47,83420.69,1639.18,62279.93,,Hospital C1747,"HC Endoscope, Single, Urinary Tract",N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,62559.53,32242.33,37535.72,19345.40,8726.28,4501.02,7147.75,5168.91,30718.81,18546.97,21270.24,10962.40,30442.02,10915.05,8995.15,4501.02,7147.75,5168.91,7147.75,5168.91,18949.45,6794.18,30442.02,10915.05,30442.02,10915.05,30442.02,10915.05,30718.81,18546.97,7147.75,5168.91,8995.15,4501.02,36218.41,5963.00,36218.41,5963.00,4615.14,4501.02,7147.75,5168.91,7147.75,5168.91,9624.81,5685.80,4615.14,37535.72,4501.02,19345.40,,Hospital C1748,HC Endoscope Single Ugi,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,91775.92,37793.58,55065.55,22676.15,10440.92,5291.10,12616.71,3080.11,30540.62,21588.33,21882.01,12849.82,21882.01,7167.91,10762.62,5291.10,6182.00,2944.53,6182.00,2944.53,21882.01,4462.17,21882.01,7167.91,21882.01,7167.91,21882.01,7167.91,30540.62,21588.33,12616.71,2944.53,6588.89,5291.10,24086.75,5095.50,28261.97,5095.50,6588.89,5291.10,11523.40,2944.53,12616.71,3080.11,11516.01,786.71,6182.00,55065.55,786.71,22676.15,,Hospital C1750,HC Misc Cath Hemodialysis,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,109951.78,16989.28,65971.07,10193.57,12198.69,2351.15,15224.87,2690.13,70770.44,9759.93,42406.68,5776.36,42406.68,6645.86,12198.69,2351.15,19318.54,2690.13,19318.54,2690.13,42406.68,4137.18,42406.68,6645.86,42406.68,6645.86,42406.68,6645.86,70770.44,9759.93,15224.87,2690.13,12198.69,2344.85,70770.44,4562.00,70770.44,4562.00,12198.69,2351.15,15224.87,2690.13,15224.87,2690.13,13947.83,2959.14,12198.69,70770.44,2344.85,10193.57,,Hospital C1751,HC Misc Central Infusion Catheter,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,140442.42,8354.43,84265.45,5012.66,14264.78,1161.17,20976.41,1343.59,43253.58,4802.58,51424.55,2840.50,51424.55,3267.49,10762.62,1161.17,26002.72,1343.59,26002.72,1343.59,51424.55,2034.08,51424.55,3267.49,51424.55,3267.49,51424.55,3267.49,43253.58,4431.19,26002.72,1343.59,7559.46,1161.17,43253.58,1431.00,43253.58,1431.00,11384.62,1161.17,22343.84,1343.59,20976.41,1343.59,12253.85,1477.95,7559.46,84265.45,1161.17,5012.66,,Hospital C1752,HC Misc Cath Hemo/Peri Short-Term,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,146484.72,14698.92,87890.83,8819.35,29563.93,2057.85,35238.26,1517.16,80742.38,2552.00,49804.80,4997.63,67262.04,3560.65,30474.85,2057.85,2248.00,1466.87,2248.00,1466.87,41869.05,2216.58,67262.04,3560.65,67262.04,3560.65,67262.04,3560.65,80742.38,2552.00,35238.26,1466.87,30474.85,2057.85,80025.04,2806.50,80025.04,2806.50,3526.77,2057.85,35238.26,1466.87,35238.26,1517.16,32608.09,578.53,2248.00,87890.83,578.53,8819.35,,Hospital C1757,HC Misc Cath Thrombectomy,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,139353.10,57763.33,83611.86,34658.00,27273.78,8075.39,32529.13,10387.29,76811.43,33245.66,47380.06,19639.53,64464.77,23228.53,28114.13,8075.39,32529.13,9586.05,32529.13,9586.05,40128.80,14460.21,43927.23,23228.53,64464.77,23228.53,64464.77,23228.53,76811.43,33245.66,32529.13,9586.05,28114.13,8075.39,73825.94,8160.50,73825.94,8160.50,2280.16,8075.39,32529.13,9586.05,32529.13,10387.29,30082.12,534.32,2280.16,83611.86,534.32,34658.00,,Hospital C1760,HC Misc Closure Device Vasc Implantable/Insertable,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,139105.67,27836.52,83463.40,16701.91,15979.32,3881.71,19168.37,2671.61,167079.20,11012.00,47295.92,9464.42,37769.00,6555.48,16471.67,3881.71,19168.37,2671.61,19168.37,2671.61,23510.89,4080.91,28770.76,6555.48,28770.76,6555.48,28770.76,6555.48,76675.04,11012.00,19168.37,2671.61,16471.67,3881.71,167079.20,5963.00,43253.58,5963.00,2236.91,3881.71,19168.37,2671.61,19168.37,2671.61,17624.69,2938.77,2236.91,167079.20,2671.61,16701.91,,Hospital C1764,HC Misc Implantable Loop Recorder,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,103851.43,51498.95,62310.86,30899.37,18663.70,7209.85,22343.84,7371.31,59619.14,29231.19,35309.49,17509.65,44113.85,17831.46,19238.76,7209.85,22343.84,7371.31,22343.84,7371.31,27460.51,11100.43,44113.85,17831.46,44113.85,17831.46,44113.85,17831.46,59619.14,29231.19,22343.84,7371.31,19238.76,7209.85,50519.78,11660.00,50519.78,11660.00,12857.19,7209.85,22343.84,7371.31,22343.84,7371.31,20585.48,8108.44,12857.19,62310.86,7209.85,30899.37,,Hospital C1766,HC Ep Intro/Sheath Strble Non-Peel,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,171190.37,152612.63,102714.22,91567.58,21407.83,21282.67,25590.01,22180.90,94360.13,87364.64,58204.72,51888.32,50599.92,51528.41,22067.44,21282.67,2810.00,21204.54,2810.00,21204.54,31498.04,32081.04,55703.87,51528.41,50599.92,51528.41,50599.92,51528.41,94360.13,87364.65,25590.01,21204.54,22067.44,21282.67,57947.72,17032.25,57947.72,17032.25,7845.31,21282.67,25590.01,21204.54,25590.01,22180.90,23612.17,2214.88,2810.00,102714.22,2214.88,91567.58,,Hospital C1771,HC Misc Urinary Sling,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,87481.92,39903.32,52489.15,23941.99,8135.30,5619.30,9889.28,8425.38,50017.37,22891.05,29743.85,13567.13,18508.93,19870.37,8385.96,5619.30,562.00,8206.20,562.00,8206.20,11521.38,12369.69,18508.93,19870.37,18508.93,19870.37,18508.93,19870.37,50017.37,22891.06,9889.28,8206.20,8385.96,5619.30,22021.00,11010.25,22021.00,11010.25,8385.96,5619.30,9889.28,8206.20,9889.28,8425.38,8972.98,2181.57,562.00,52489.15,2181.57,23941.99,,Hospital C1773,"HC Retrieval Device, Insertable",N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,179413.22,43550.68,107647.93,26130.41,18584.75,6024.43,21363.81,1343.59,98892.56,25065.06,61000.49,14807.24,53919.87,3384.11,19157.38,6024.43,21363.81,1343.59,22250.45,1343.59,53919.87,2106.58,53919.87,3384.11,53919.87,3384.11,53919.87,3384.11,98892.56,25065.07,22250.45,1343.59,19157.38,6024.43,50306.07,790.50,50306.07,790.50,19157.38,6024.43,21363.81,1343.59,21363.81,1343.59,20498.40,1477.95,18584.75,107647.93,790.50,26130.41,,Hospital C1776,HC Implant Joint,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,76999.28,65681.32,46199.57,39408.79,10199.26,9168.33,12360.50,11864.95,37072.40,37480.38,26179.76,22331.64,23204.73,29826.15,10513.52,9168.33,12330.85,11864.95,12330.85,11864.95,14444.40,18677.77,23204.73,29826.15,23204.73,29826.15,23204.73,29826.15,37072.40,37480.43,12330.85,11880.45,10513.52,9144.81,27607.84,12375.50,27607.84,12375.50,15338.33,9168.33,12330.85,11864.95,12360.50,11864.95,11249.46,13051.44,10199.26,46199.57,9144.81,39408.79,,Hospital C1777,HC Misc Icd Lead Single Endocardial,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,222832.68,146701.53,133699.61,88020.92,37818.19,20530.43,45002.63,28966.21,122825.37,82963.41,75763.11,49878.53,77590.34,70119.14,38983.44,20530.43,45002.63,28966.21,45002.63,28966.21,48310.13,43650.52,77590.34,70119.14,77590.34,70119.14,77590.34,70119.14,122825.37,82963.44,45002.63,28966.21,38983.44,20530.43,148659.36,29766.00,148659.36,29766.00,16872.39,20530.43,45002.63,28966.21,45002.63,28966.21,41712.28,31862.83,16872.39,148659.36,20530.43,88020.92,,Hospital C1778,HC Misc Stim Lead,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,227877.53,142427.28,136726.52,85456.37,25031.66,19939.82,21832.68,26511.88,125606.09,80596.68,77478.36,48425.28,79346.96,64261.88,21512.90,19939.82,21832.68,26511.88,21832.68,26511.88,49403.85,40004.26,79346.96,64261.88,79346.96,64261.88,79346.96,64261.88,125606.09,80596.68,21832.68,26511.88,21512.90,19939.82,142831.40,42930.00,142831.40,42930.00,17754.23,19939.82,21832.68,26511.88,21832.68,26511.88,23018.80,29163.07,17754.23,142831.40,19939.82,85456.37,,Hospital C1783,HC Ocular Imp Aqueous Drain De,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,23826.10,N/A,14295.66,N/A,3335.66,N/A,3774.30,N/A,13677.32,N/A,8100.88,N/A,9041.54,N/A,3335.66,N/A,3608.17,N/A,3608.17,N/A,5628.28,N/A,9041.54,N/A,9041.54,N/A,9041.54,N/A,13677.32,N/A,3608.17,N/A,3335.66,N/A,5963.00,N/A,5963.00,N/A,3335.66,N/A,3608.17,N/A,3774.30,N/A,1164.26,N/A,N/A,1164.26,14295.66,,Hospital C1784,HC Ocular Dev Intraop Det Retina,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,110653.83,43348.90,66392.30,26009.34,9049.65,6068.85,10970.91,1109.64,60992.40,24948.80,37622.30,14738.63,20589.21,8772.62,9328.49,6068.85,1124.00,3608.17,1124.00,3608.17,12816.30,5461.14,20589.21,8772.62,20589.21,8772.62,20589.21,8772.62,60992.40,24948.82,10970.91,3608.17,9328.49,6068.85,24496.02,5963.00,24496.02,5963.00,N/A,6068.85,10970.91,3608.17,10970.91,1109.64,9981.48,1220.60,1124.00,66392.30,1109.64,26009.34,,Hospital C1786,HC Misc Pacemaker Sgl Rate,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,146414.53,110838.53,87848.72,66503.12,17609.05,15499.46,21096.24,15512.06,80703.69,62992.93,49780.93,37685.11,41621.05,37669.15,18151.61,15499.46,21096.24,15512.06,21096.24,15512.06,25908.76,23449.77,41621.05,37669.15,41621.05,37669.15,41621.05,37669.15,80703.69,62992.94,21096.24,15512.06,18151.61,15499.46,47665.00,37100.00,47665.00,37100.00,3514.50,15499.46,21096.24,15512.06,21096.24,15512.06,19422.23,17063.27,3514.50,87848.72,15499.46,66503.12,,Hospital C1788,HC Misc Port-a-Cath,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,49020.73,15540.93,29412.44,9324.56,4673.13,2164.93,5793.71,2690.13,11303.64,8927.31,16667.06,5283.92,10632.01,6533.83,4817.11,2164.93,5793.71,2690.13,5793.71,2690.13,6618.18,4067.44,10632.01,6533.83,10632.01,6533.83,10632.01,6533.83,11303.64,8927.30,5793.71,2690.13,4817.11,2164.93,12649.44,4562.00,12649.44,4562.00,N/A,2164.93,5793.71,2690.13,5793.71,2690.13,5154.31,2959.14,4673.13,29412.44,2164.93,9324.56,,Hospital C1789,HC Misc Breast Implant,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,160018.82,45037.93,96011.29,27022.76,10815.12,6272.21,8875.29,5973.28,88202.37,25766.13,54406.39,15312.88,N/A,14533.44,9314.48,6272.21,1686.00,5973.28,1686.00,5973.28,13116.99,9047.33,N/A,14533.44,21072.26,14533.44,21072.26,14533.44,88202.37,25766.13,8875.29,5973.28,9314.48,6272.21,25070.73,10085.00,25070.73,10085.00,5892.53,6272.21,8875.29,5973.28,8875.29,5973.28,9966.50,6570.60,1686.00,96011.29,5973.28,27022.76,,Hospital C1813,HC Misc Penile Implant Inflatable,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,163336.72,107581.98,98002.03,64549.19,N/A,15061.47,16016.30,18213.89,N/A,61192.41,N/A,36577.87,N/A,42235.52,N/A,15061.47,4496.00,17412.16,4496.00,17412.16,N/A,26292.42,N/A,42235.52,N/A,42235.52,N/A,42235.52,N/A,61192.41,16016.30,17412.16,N/A,15061.47,N/A,16637.00,N/A,16637.00,N/A,15061.47,16016.30,17412.16,16016.30,18213.89,N/A,857.95,4496.00,98002.03,857.95,64549.19,,Hospital C1819,HC Misc Surg Tiss Localiz/Excise Dev,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,143319.83,45689.88,85991.90,27413.93,24221.84,6396.57,28918.84,5366.90,78997.90,26058.68,48728.74,15534.56,56751.71,14277.78,24968.16,6396.57,28918.84,5366.90,28918.84,5366.90,35329.63,8888.18,N/A,14277.78,56751.71,14277.78,N/A,14277.78,78997.90,26058.68,28918.84,5366.90,24968.16,6396.57,65564.82,11850.25,65564.82,11850.25,2973.55,6396.57,28918.84,5366.90,28918.84,5366.90,26715.93,5903.59,2973.55,85991.90,5366.90,27413.93,,Hospital C1820,HC Misc Neurostim Generator Rechgbl,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,239202.32,142427.28,143521.39,85456.37,25778.10,19939.82,30815.76,26511.88,131848.31,80596.68,81328.78,48425.28,83290.24,64261.88,22132.62,19939.82,30815.76,26511.88,30815.76,26511.88,51859.06,40004.26,83290.24,64261.88,83290.24,64261.88,N/A,64261.88,131848.31,80596.68,30815.76,26511.88,22132.62,19939.82,165535.92,42930.00,165535.92,42930.00,19733.80,19939.82,30815.76,26511.88,30815.76,26511.88,23681.90,29163.07,19733.80,165535.92,19939.82,85456.37,,Hospital C1821,HC Misc Spinous Process Decomp Sys,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,181967.73,94108.08,109180.64,56464.85,18568.74,13106.65,40453.52,2176.24,102648.52,53742.90,61869.03,31996.75,61134.07,29145.72,18568.74,13106.65,38789.97,11933.08,35139.99,11933.08,38054.54,18339.77,61134.07,29145.72,61134.07,29145.72,61134.07,29145.72,102648.52,53742.91,32825.52,11956.02,18568.74,13106.65,102648.52,8160.50,109186.62,8160.50,18568.74,13106.65,40578.42,11933.08,40453.52,2176.24,18568.74,2393.89,18568.74,109186.62,2176.24,56464.85,,Hospital C1822,HC Gen Neurostim Hf Rechg Bat,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,128529.60,N/A,77117.76,N/A,17976.72,N/A,27732.61,N/A,72918.25,N/A,43700.06,N/A,64277.80,N/A,17976.72,N/A,26511.88,N/A,26511.88,N/A,40023.85,N/A,64277.80,N/A,64277.80,N/A,64277.80,N/A,72918.26,N/A,26511.88,N/A,17976.72,N/A,42930.00,N/A,42930.00,N/A,17976.72,N/A,26511.88,N/A,27732.61,N/A,1285.02,N/A,N/A,1285.02,77117.76,,Hospital C1849,"Skin substitute, synthetic",N/A,N/A,N/A,9896.33,N/A,5937.80,N/A,1385.49,N/A,1630.28,N/A,5685.07,N/A,3364.76,N/A,4707.80,N/A,1385.49,N/A,1558.52,N/A,1558.52,N/A,2929.67,N/A,4707.80,N/A,4707.80,N/A,4707.80,N/A,5685.07,N/A,1558.52,N/A,1385.49,N/A,1871.00,N/A,1871.00,N/A,1385.49,N/A,1558.52,N/A,1630.28,N/A,88.51,N/A,N/A,88.51,5937.80,,Hospital C1877,HC Misc Stent Nonctd/Cvd WO Del Sys,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,211261.93,N/A,126757.16,N/A,21921.71,N/A,21363.81,N/A,116447.58,N/A,71829.05,N/A,N/A,N/A,18526.78,N/A,21363.81,N/A,21363.81,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,116447.58,N/A,21363.81,N/A,18526.78,N/A,119699.13,N/A,119699.13,N/A,14849.83,N/A,21363.81,N/A,21363.81,N/A,19823.66,N/A,14849.83,126757.16,N/A,N/A,,Hospital C1878,HC Matrl for Vocal Cord Synth,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,21895.35,N/A,13137.21,N/A,3059.68,N/A,240.65,N/A,12500.93,N/A,7444.42,N/A,7347.79,N/A,3059.68,N/A,3010.42,N/A,3010.42,N/A,4574.14,N/A,7347.79,N/A,7347.79,N/A,7347.79,N/A,12500.93,N/A,3010.42,N/A,3059.68,N/A,3397.00,N/A,3397.00,N/A,3059.68,N/A,3010.42,N/A,240.65,N/A,264.72,N/A,N/A,240.65,13137.21,,Hospital C1880,HC Misc Vena Cava Filter,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,109896.08,24001.43,65937.65,14400.86,11705.76,3350.41,28589.33,4855.12,60574.72,13717.35,20255.10,8160.49,55508.52,11236.80,7156.93,3350.41,12616.71,4641.41,28589.33,4641.41,20255.10,6995.26,20255.10,11236.80,20255.10,11236.80,20255.10,11236.80,60574.72,13717.35,12616.71,4641.41,7156.93,3350.41,43126.21,7897.00,43126.21,7897.00,13496.62,3350.41,28589.33,4641.41,28589.33,4855.12,10264.14,267.12,7156.93,65937.65,267.12,14400.86,,Hospital C1881,HC Misc Chronic Hemodialysis Cath,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,102693.43,12250.43,61616.06,7350.26,6532.22,1706.73,16645.16,2676.37,38532.48,7018.52,54848.63,4165.16,54848.63,6526.64,6532.22,1706.73,13869.73,2690.13,22427.19,2690.13,54848.63,4062.95,54848.63,6526.64,54848.63,6526.64,54848.63,6526.64,38532.48,6995.81,22900.35,2690.13,6532.22,1706.73,38532.48,4562.00,38532.48,4562.00,6532.22,1706.73,12710.11,2690.13,15681.83,2676.37,6532.22,386.96,6532.22,61616.06,386.96,7350.26,,Hospital C1882,HC Misc Cardio-Defib Generator Bi-V,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,274294.18,222334.17,164576.51,133400.50,N/A,31110.96,31949.18,28966.21,N/A,126385.52,N/A,75593.61,N/A,70127.98,N/A,31110.96,31949.18,28966.21,31949.18,28966.21,N/A,43656.03,N/A,70127.98,N/A,70127.98,N/A,70127.98,N/A,126385.54,31949.18,28966.21,N/A,31110.96,N/A,38084.50,N/A,38084.50,N/A,31110.96,40659.05,28966.21,31949.18,28966.21,N/A,31862.83,31949.18,164576.51,28966.21,133400.50,,Hospital C1884,HC Embolic Protection Device C1884,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,147349.12,78852.53,88409.47,47311.52,30574.84,11002.64,36434.11,10027.43,81218.83,45101.29,50098.70,26809.86,71636.77,23271.24,31516.91,11002.64,36434.11,9586.05,36434.11,9586.05,44596.02,14486.79,71636.77,23271.24,71636.77,23271.24,71636.77,23271.24,81218.83,45101.30,36434.11,9586.05,31516.91,11002.64,82761.42,11845.50,82761.42,11845.50,3677.86,11002.64,36434.11,9586.05,36434.11,10027.43,33723.09,1102.16,3677.86,88409.47,1102.16,47311.52,,Hospital C1885,HC Cath Translumin Angio Laser,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,169365.78,95557.68,101619.47,57334.61,15979.32,13349.65,19168.37,9586.05,93354.42,54289.17,57584.36,32489.62,37769.00,23316.99,16471.67,13349.65,19168.37,9586.05,19168.37,9586.05,23510.89,14515.27,37769.00,23316.99,37769.00,23316.99,37769.00,23316.99,93354.42,54289.18,19168.37,9586.05,16471.67,13349.65,43253.58,11660.00,43253.58,11660.00,7526.38,13349.65,22818.61,9586.05,19168.37,9586.05,17624.69,10544.65,7526.38,101619.47,9586.05,57334.61,,Hospital C1887,HC Catheter Guiding,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,115219.27,42838.18,69131.56,25702.91,22812.44,5997.34,27251.59,9586.05,63508.86,11012.00,39174.55,14564.97,53919.87,23474.11,23515.33,5997.34,27251.59,9586.05,27251.59,9586.05,33564.68,14613.08,53919.87,23474.11,53919.87,23474.11,53919.87,23474.11,63508.86,11012.00,27251.59,9586.05,23515.33,5997.34,61749.77,10878.50,61749.77,10878.50,14704.30,5997.34,27251.59,9586.05,27251.59,9586.05,25161.40,10544.65,14704.30,69131.56,5997.34,25702.91,,Hospital C1892,HC Misc Introducer Peel-Away,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,184861.30,96583.12,110916.78,57949.87,N/A,13472.53,26002.72,17044.18,N/A,54927.69,44061.60,32691.04,44061.60,40922.75,N/A,13472.53,26002.72,16861.57,26002.72,16861.57,44061.60,25475.20,44061.60,40922.75,44061.60,40922.75,44061.60,40922.75,N/A,54927.69,26002.72,16861.57,N/A,13472.53,N/A,22467.00,N/A,22467.00,N/A,13472.53,26002.72,16861.57,26002.72,17044.18,N/A,940.20,26002.72,110916.78,940.20,57949.87,,Hospital C1895,HC Misc Defib Endocardial Dual Lead,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,252984.30,152657.12,151790.58,91594.27,N/A,21363.14,22185.45,28966.21,139444.95,86367.56,105105.86,51903.42,105105.86,70146.07,N/A,21363.14,31949.18,28966.21,31949.18,28966.21,105105.86,43667.29,105105.86,70146.07,105105.86,70146.07,105105.86,70146.07,N/A,86367.57,31949.18,28966.21,N/A,21363.14,N/A,29766.00,N/A,29766.00,N/A,21363.14,31949.18,28966.21,31949.18,28966.21,N/A,31862.83,22185.45,151790.58,21363.14,91594.27,,Hospital C1897,HC Misc Stim Lead Test/Trial,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,68216.62,53224.57,40929.97,31934.74,7894.17,7386.37,9604.05,6347.85,26767.21,30384.97,23193.65,18096.35,17960.33,14491.10,8137.40,7386.37,1686.00,5967.47,1686.00,5967.47,11179.89,9020.98,17960.33,14491.10,17960.33,14491.10,17960.33,14491.10,26767.21,30384.97,9604.05,5967.47,8137.40,7386.37,21368.31,7897.00,21368.31,7897.00,2990.80,7386.37,9604.05,5967.47,9604.05,6347.85,8707.02,392.53,1686.00,40929.97,392.53,31934.74,,Hospital C1899,"Lead, pmkr/AICD combination",N/A,N/A,N/A,68920.42,N/A,41352.25,N/A,9637.40,N/A,12194.77,N/A,39678.50,N/A,23432.95,N/A,28551.25,N/A,9637.40,N/A,11790.80,N/A,11790.80,N/A,17773.71,N/A,28551.25,N/A,28551.25,N/A,28551.25,N/A,39678.50,N/A,11790.80,N/A,9637.40,N/A,8160.50,N/A,8160.50,N/A,9637.40,N/A,11790.80,N/A,12194.77,N/A,718.67,N/A,N/A,718.67,41352.25,,Hospital C1900,HC Misc Lead Left Ventricular,N/A,0275 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PACEMAKER,274294.18,222334.17,164576.51,133400.50,N/A,31110.96,31563.92,28966.21,N/A,126385.52,N/A,75593.61,N/A,70127.98,N/A,31110.96,31563.92,28966.21,31563.92,28966.21,N/A,43656.03,N/A,70127.98,N/A,70127.98,N/A,70127.98,N/A,126385.54,31563.92,28966.21,N/A,31110.96,N/A,38084.50,N/A,38084.50,N/A,31110.96,40659.05,28966.21,31563.92,28966.21,N/A,31862.83,31563.92,164576.51,28966.21,133400.50,,Hospital C1982,HC Cath Pressure Gener One Way Valve,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,200212.77,N/A,120127.66,N/A,28015.46,N/A,39604.93,N/A,109296.05,N/A,68072.34,N/A,66962.49,N/A,28015.46,N/A,35224.44,N/A,35224.44,N/A,41679.73,N/A,66962.49,N/A,66962.49,N/A,66962.49,N/A,109253.04,N/A,35224.44,N/A,28015.46,N/A,12055.25,N/A,12055.25,N/A,28015.46,N/A,35224.44,N/A,39604.93,N/A,1349.29,N/A,N/A,1349.29,120127.66,,Hospital C2615,"HC Sealant, Pulmonary, Liquid",N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,322361.90,49267.38,193417.14,29560.43,29420.75,6867.64,64301.36,1448.39,83426.82,28210.50,101225.53,16750.92,101225.53,3308.11,29420.75,6867.64,64301.36,1362.01,64301.36,1362.01,101225.53,2059.36,101225.53,3308.11,101225.53,3308.11,101225.53,3308.11,83426.82,28210.50,64301.36,1362.01,29420.75,6867.64,83426.82,1871.00,83426.82,1871.00,29420.75,6867.64,53231.62,1362.01,64301.36,1448.39,29420.75,182.27,29420.75,193417.14,182.27,29560.43,,Hospital C2616,"HC Brachytx, Non-Str Yttrium-90",N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,122516.87,126943.57,73510.12,76166.14,5450.92,17725.56,6713.79,27299.63,67531.29,73027.39,41655.74,43160.81,12401.59,61721.45,5618.87,17725.56,2810.00,27195.81,2810.00,27195.81,7719.70,38422.80,12401.59,61721.45,12401.59,61721.45,12401.59,61721.45,67531.29,72380.19,6713.79,27195.81,5618.87,17725.56,14754.79,12055.25,14754.79,12055.25,N/A,17725.56,6713.79,27195.81,6713.79,27299.63,6012.19,1413.58,2810.00,73510.12,1413.58,76166.14,,Hospital C2618,HC Misc Probe Cryoablation,N/A,0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY,208338.07,58802.77,125002.84,35281.66,12677.99,8232.39,17836.76,429.08,97314.55,33848.92,51424.55,19992.94,51424.55,11467.15,12677.99,8232.39,19331.03,4706.78,17836.76,4706.78,51424.55,7138.53,51424.55,11467.15,64183.50,11467.15,51424.55,11467.15,97314.55,33848.94,31812.13,4706.78,12677.99,8232.39,97314.55,7897.00,97314.55,7897.00,12677.99,8232.39,31449.56,4706.78,31449.56,429.08,12677.99,471.99,12677.99,125002.84,429.08,35281.66,,Hospital C2622,HC Misc Penile Implant Non-Inflatabl,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,91650.57,77799.27,54990.34,46679.56,12867.10,10891.89,15486.76,18213.89,54971.75,44164.56,31161.19,26451.75,29274.44,42184.58,13263.56,10891.89,1686.00,17412.16,1686.00,17412.16,18222.66,26260.70,29274.44,42184.58,29274.44,42184.58,29274.44,42184.58,54971.75,44164.57,15486.76,17412.16,13263.56,10891.89,34829.28,16637.00,34829.28,16637.00,5847.62,10891.89,15486.76,17412.16,15486.76,18213.89,14192.01,852.01,1686.00,54990.34,852.01,46679.56,,Hospital C2623,HC Cath Translumin Drug-Coat,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,122141.93,37935.12,73285.16,22761.07,17835.24,5234.53,21363.81,9586.05,67324.63,21793.39,N/A,12897.93,42155.67,23223.24,18384.77,5234.53,21363.81,9586.05,21363.81,9586.05,26241.56,14456.91,N/A,23223.24,N/A,23223.24,42155.67,23223.24,67324.63,21793.40,21363.81,9586.05,18384.77,5234.53,48277.25,15608.50,48277.25,15608.50,14277.58,5234.53,21363.81,9586.05,21363.81,9586.05,19671.71,10544.65,14277.58,73285.16,5234.53,23223.24,,Hospital C2624,HC Wireless Pressure Sensor (Implantable),N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,163671.88,N/A,98203.13,N/A,22899.74,N/A,25793.01,N/A,93176.20,N/A,55648.44,N/A,59652.94,N/A,22899.74,N/A,24657.66,N/A,24657.66,N/A,37135.24,N/A,59652.94,N/A,59652.94,N/A,59652.94,N/A,93176.20,N/A,24657.66,N/A,22899.74,N/A,44644.01,N/A,44644.01,N/A,22899.74,N/A,24657.66,N/A,25793.01,N/A,451.72,N/A,N/A,451.72,98203.13,,Hospital C2625,HC Misc Stent Noncor Temp W Del Sys,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,64167.83,20999.53,38500.70,12599.72,4330.11,2939.93,5387.94,4732.58,10135.74,12081.45,21817.06,7139.85,9851.60,11462.84,4463.53,2939.93,5387.94,4732.58,5387.94,4732.58,6132.39,7135.83,9851.60,11462.84,9851.60,11462.84,9851.60,11462.84,10135.74,12081.46,5387.94,4732.58,4463.53,2939.93,11720.95,5095.50,11720.95,5095.50,5185.55,2939.93,5387.94,4732.58,5387.94,4732.58,4775.98,5205.84,4330.11,38500.70,2939.93,12599.72,,Hospital C2626,HC Infusion Pump Non-Prog Temp,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,92738.27,62318.17,55642.96,37390.90,10199.26,8724.56,12330.85,1327.02,32380.52,35701.01,31531.01,21188.18,23204.73,14588.31,10513.52,8724.56,562.00,5973.28,562.00,5973.28,14444.40,9081.48,23204.73,14588.31,23204.73,14588.31,23204.73,14588.31,32380.52,35701.02,12330.85,5973.28,10513.52,8724.56,27607.84,8944.50,27607.84,8944.50,13992.83,8724.56,12330.85,5973.28,12330.85,1327.02,11249.46,1459.73,562.00,55642.96,1327.02,37390.90,,Hospital C2631,HC Rep Dev Urinary W/O Sling,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,89411.67,42022.40,53647.00,25213.44,23540.08,5883.13,18575.51,1507.07,55681.79,24004.56,N/A,14287.62,53556.94,15142.80,24265.39,5883.13,84300.00,6254.06,84300.00,6254.06,N/A,9426.67,N/A,15142.80,53556.94,15142.80,N/A,15142.80,55681.79,24004.57,N/A,6254.06,24265.39,5883.13,63719.39,8375.75,63719.39,8375.75,N/A,5883.13,N/A,6254.06,N/A,1507.07,25963.97,1657.77,18575.51,84300.00,1507.07,25213.44,,Hospital C2698,"Brachytx, Stranded, Nos",N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,18443.10,N/A,11065.86,N/A,2582.04,N/A,4247.73,N/A,10452.04,N/A,6270.66,N/A,10369.04,N/A,2582.04,N/A,4246.26,N/A,4246.26,N/A,6454.94,N/A,10369.04,N/A,10369.04,N/A,10369.04,N/A,10452.04,N/A,4246.26,N/A,2582.04,N/A,7897.00,N/A,7897.00,N/A,2582.04,N/A,4284.41,N/A,4247.73,N/A,173.10,N/A,N/A,173.10,11065.86,,Hospital CPT C5271,"HC App Lc,T,a,L ,1st 25cm or <",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,2264.00,2264.00,1358.40,1358.40,N/A,316.96,N/A,548.78,N/A,1303.61,N/A,769.76,N/A,1269.02,N/A,316.96,N/A,524.62,N/A,524.62,N/A,789.99,N/A,1269.02,N/A,1269.02,N/A,1269.02,N/A,1303.61,N/A,524.62,N/A,316.96,N/A,527.00,N/A,527.00,N/A,316.96,N/A,524.62,N/A,548.78,N/A,2264.00,1358.40,1358.40,316.96,2264.00,,Hospital CPT C5272,"HC App Lc,Trnk,Arm,Leg,Add 25",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,818.00,818.00,490.80,490.80,N/A,114.52,N/A,818.00,N/A,471.00,N/A,278.12,N/A,818.00,N/A,114.52,N/A,818.00,N/A,818.00,N/A,818.00,N/A,818.00,N/A,818.00,N/A,818.00,N/A,471.00,N/A,818.00,N/A,114.52,N/A,527.00,N/A,527.00,N/A,114.52,N/A,818.00,N/A,818.00,N/A,818.00,490.80,490.80,114.52,818.00,,Hospital CPT C5273,"HC App Lc,Trnk,Arm,Leg,>=100 Sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,7584.00,7584.00,4550.40,4550.40,N/A,1061.76,N/A,7584.00,N/A,4366.87,N/A,2578.56,N/A,1061.76,N/A,1061.76,N/A,7584.00,N/A,7584.00,N/A,659.81,N/A,1061.76,N/A,1061.76,N/A,1061.76,N/A,4366.87,N/A,7584.00,N/A,1061.76,N/A,7584.00,N/A,7584.00,N/A,1061.76,N/A,7584.00,N/A,7584.00,N/A,7584.00,4550.40,4550.40,659.81,7584.00,,Hospital CPT C5274,"HC App Lc,Trnk,Arm,Lg,Add 100sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,5129.00,5129.00,3077.40,3077.40,N/A,718.06,N/A,5129.00,N/A,2953.28,N/A,1743.86,N/A,718.06,N/A,718.06,N/A,5129.00,N/A,5129.00,N/A,446.22,N/A,718.06,N/A,718.06,N/A,718.06,N/A,2953.28,N/A,5129.00,N/A,718.06,N/A,5129.00,N/A,5129.00,N/A,718.06,N/A,5129.00,N/A,5129.00,N/A,5129.00,3077.40,3077.40,446.22,5129.00,,Hospital CPT C5278,"HC App Lc,H,H,F,Add 100 Sqcm",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,1532.00,1532.00,919.20,919.20,N/A,214.48,N/A,1532.00,N/A,882.13,N/A,520.88,N/A,214.48,N/A,214.48,N/A,1532.00,N/A,1532.00,N/A,133.28,N/A,214.48,N/A,214.48,N/A,214.48,N/A,882.13,N/A,1532.00,N/A,214.48,N/A,1532.00,N/A,1532.00,N/A,214.48,N/A,1532.00,N/A,1532.00,N/A,1532.00,919.20,919.20,133.28,1532.00,,Hospital C7508,Perq lumb&thor vert aug,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,37771.87,N/A,22663.12,N/A,5288.91,N/A,319.21,N/A,21734.29,N/A,12842.43,N/A,2636.95,N/A,5288.91,N/A,300.54,N/A,300.54,N/A,1639.65,N/A,2636.95,N/A,2636.95,N/A,2636.95,N/A,21734.28,N/A,300.54,N/A,5288.91,N/A,1643.00,N/A,1643.00,N/A,5288.91,N/A,300.54,N/A,319.21,N/A,457.44,N/A,N/A,300.54,22663.12,,Hospital CPT C8902,HC Mra Abdomen W&W/O Contrast,N/A,0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER,3273.00,2435.00,1963.80,1461.00,N/A,340.90,N/A,2435.00,N/A,1110.00,N/A,827.90,N/A,959.52,N/A,340.90,N/A,332.71,N/A,332.71,N/A,597.30,N/A,959.52,N/A,959.52,N/A,959.52,N/A,1110.00,N/A,332.71,N/A,340.90,N/A,1060.00,N/A,1060.00,N/A,340.90,N/A,332.71,N/A,2435.00,N/A,267.88,1963.80,1963.80,267.88,2435.00,,Hospital CPT C8906,HC MRI-Breast Bilat W Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,2003.00,2003.00,1201.80,1201.80,N/A,280.42,N/A,339.63,N/A,1110.00,N/A,681.02,N/A,280.42,N/A,280.42,N/A,332.71,N/A,332.71,N/A,174.26,N/A,280.42,N/A,280.42,N/A,280.42,N/A,1110.00,N/A,332.71,N/A,280.42,N/A,1060.00,N/A,1060.00,N/A,280.42,N/A,332.71,N/A,339.63,N/A,2003.00,1201.80,1201.80,174.26,2003.00,,Hospital C8910,HC Mra Chest W/O Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,81906.70,N/A,49144.02,N/A,4256.49,N/A,5300.87,N/A,9592.35,N/A,27848.28,N/A,9972.95,N/A,4387.64,N/A,2248.00,N/A,2248.00,N/A,6208.46,N/A,9972.95,N/A,9972.95,N/A,9972.95,N/A,9592.35,N/A,5300.87,N/A,4387.64,N/A,11521.68,N/A,11521.68,N/A,N/A,N/A,5300.87,N/A,5300.87,N/A,4694.78,N/A,2248.00,49144.02,N/A,N/A,,Hospital C8912,HC Mra Lower Extremities W/Contr,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,N/A,3096.02,N/A,1857.61,N/A,433.44,N/A,341.59,N/A,2350.08,N/A,1052.64,N/A,900.61,N/A,433.44,N/A,332.71,N/A,332.71,N/A,560.65,N/A,900.61,N/A,900.61,N/A,900.61,N/A,2350.08,N/A,332.71,N/A,433.44,N/A,1749.00,N/A,1749.00,N/A,433.44,N/A,332.71,N/A,341.59,N/A,N/A,N/A,N/A,332.71,2350.08,,Hospital C8913,HC Mra Lower Ext W/O Contrast,N/A,0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION,N/A,2795.00,N/A,1677.00,N/A,391.30,N/A,209.06,N/A,1110.00,N/A,950.30,N/A,510.09,N/A,391.30,N/A,210.88,N/A,210.88,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1110.00,N/A,210.88,N/A,391.30,N/A,1060.00,N/A,1060.00,N/A,391.30,N/A,210.88,N/A,209.06,N/A,N/A,N/A,N/A,209.06,1677.00,,Hospital CPT C8923,HC 2d Echo W Contrast - WO Dop/Color Flow,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,2443.00,2443.00,1465.80,1465.80,N/A,342.02,N/A,668.93,N/A,1406.68,N/A,830.62,N/A,510.09,N/A,342.02,N/A,668.93,N/A,668.93,N/A,317.54,N/A,510.09,N/A,510.09,N/A,510.09,N/A,1406.68,N/A,668.93,N/A,342.02,N/A,1309.45,N/A,1309.45,N/A,342.02,N/A,668.93,N/A,668.93,N/A,231.97,1465.80,1465.80,231.97,1465.80,,Hospital C8925,HC Transesophageal Echo W/Ctrst,N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,66622.77,7173.63,39973.66,4304.18,5280.53,1004.31,7146.52,737.91,16967.09,4129.48,22651.74,2439.03,23754.54,1625.84,5280.53,1004.31,3372.00,668.93,7146.52,668.93,14786.65,1012.12,23754.54,1625.84,23754.54,1625.84,23754.54,1625.84,23529.46,4129.49,12616.71,668.93,5280.53,1004.31,28261.97,3845.07,16967.09,3845.07,5280.53,1004.31,7146.52,668.93,7146.52,49.01,5280.53,53.92,3372.00,39973.66,49.01,4304.18,,Hospital CPT C8928,HC Stress Echo W Contrast,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,2856.00,2856.00,1713.60,1713.60,N/A,399.84,N/A,668.93,N/A,1644.48,N/A,971.04,N/A,1099.02,N/A,399.84,N/A,668.93,N/A,668.93,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,1644.48,N/A,668.93,N/A,399.84,N/A,1530.82,N/A,1530.82,N/A,399.84,N/A,668.93,N/A,668.93,N/A,499.78,1713.60,1713.60,399.84,1713.60,,Hospital CPT C8929,HC 2d Echo W Contrast - W Dop/Color Flow,N/A,0483 - CARDIOLOGY - ECHOCARDIOLOGY,3344.00,3344.00,2006.40,2006.40,N/A,468.16,N/A,668.93,N/A,1925.48,N/A,1136.96,N/A,1099.02,N/A,468.16,N/A,668.93,N/A,668.93,N/A,684.16,N/A,1099.02,N/A,1099.02,N/A,1099.02,N/A,1925.48,N/A,668.93,N/A,468.16,N/A,1792.38,N/A,1792.38,N/A,468.16,N/A,668.93,N/A,668.93,N/A,499.78,2006.40,2006.40,468.16,2006.40,,Hospital HCPCS C9046,COCAINE HCL 40 MG/ML NA SOLN,64950-0362-04,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),137.90,137.90,82.74,82.74,N/A,19.31,N/A,137.90,N/A,77.53,N/A,46.89,N/A,137.90,N/A,19.31,N/A,137.90,N/A,137.90,N/A,89.00,N/A,137.90,N/A,137.90,N/A,137.90,N/A,77.53,N/A,137.90,N/A,19.31,N/A,73.91,N/A,73.91,N/A,19.31,N/A,137.90,N/A,137.90,N/A,137.90,82.74,82.74,19.31,137.90,,Hospital C9053,"Inj, crizanlizumab-tmca",N/A,N/A,N/A,134715.10,N/A,80829.06,N/A,18854.12,N/A,360.23,N/A,75788.22,N/A,45803.15,N/A,19140.68,N/A,18854.12,N/A,338.63,N/A,338.63,N/A,11895.47,N/A,19140.68,N/A,19140.68,N/A,19140.68,N/A,75379.09,N/A,338.63,N/A,18854.12,N/A,1659.27,N/A,1659.27,N/A,18854.12,N/A,338.63,N/A,360.23,N/A,223.65,N/A,N/A,223.65,80829.06,,Hospital C9066,Sacituzumab govitecan-hziy,N/A,N/A,N/A,110691.10,N/A,66414.66,N/A,15463.70,N/A,519.91,N/A,62300.24,N/A,37634.97,N/A,15966.03,N/A,15463.70,N/A,514.35,N/A,514.35,N/A,9923.14,N/A,15966.03,N/A,15966.03,N/A,15966.03,N/A,60840.73,N/A,514.35,N/A,15463.70,N/A,2382.62,N/A,2382.62,N/A,15463.70,N/A,514.35,N/A,519.91,N/A,268.22,N/A,N/A,268.22,66414.66,,Hospital C9070,"Injection, tafasitamab-cxix",N/A,N/A,69593.70,N/A,41756.22,N/A,6485.30,N/A,7937.41,N/A,14615.15,N/A,23661.86,N/A,14754.95,N/A,6685.12,N/A,7937.41,N/A,7937.41,N/A,9184.61,N/A,14754.95,N/A,14754.95,N/A,14754.95,N/A,14615.15,N/A,7937.41,N/A,6685.12,N/A,17554.71,N/A,17554.71,N/A,N/A,N/A,7937.41,N/A,7937.41,N/A,7153.08,N/A,6485.30,41756.22,N/A,N/A,,Hospital C9086,"Inj, anifrolumab-fnia",N/A,N/A,N/A,30688.60,N/A,18413.16,N/A,4296.40,N/A,309.30,N/A,17260.88,N/A,10434.12,N/A,4667.82,N/A,4296.40,N/A,295.68,N/A,295.68,N/A,2901.21,N/A,4667.82,N/A,4667.82,N/A,4667.82,N/A,17260.88,N/A,295.68,N/A,4296.40,N/A,16449.09,N/A,16449.09,N/A,4296.40,N/A,295.68,N/A,309.30,N/A,67.14,N/A,N/A,67.14,18413.16,,Hospital HCPCS C9113,PANTOPRAZOLE SODIUM 40 MG IV SOLR,00008-4001-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),34.30,34.30,20.58,20.58,N/A,4.80,N/A,34.30,N/A,19.28,N/A,11.66,N/A,12.69,N/A,4.80,N/A,34.30,N/A,34.30,N/A,7.90,N/A,12.69,N/A,12.69,N/A,12.69,N/A,19.28,N/A,34.30,N/A,4.80,N/A,18.38,N/A,18.38,N/A,4.80,N/A,34.30,N/A,34.30,N/A,34.30,20.58,20.58,4.80,34.30,,Hospital C9122,Mometasone furoate (sinuva),N/A,N/A,N/A,77030.02,N/A,46218.01,N/A,10784.19,N/A,5538.92,N/A,44038.27,N/A,26190.18,N/A,13577.85,N/A,10784.19,N/A,5587.18,N/A,5587.18,N/A,8452.48,N/A,13577.85,N/A,13577.85,N/A,13577.85,N/A,44038.27,N/A,5587.18,N/A,10784.19,N/A,7983.50,N/A,7983.50,N/A,10784.19,N/A,5587.18,N/A,5538.92,N/A,1511.07,N/A,N/A,1511.07,46218.01,,Hospital C9148,"Injection, teclistamab-cqyv, 0.5 mg",N/A,N/A,221570.45,N/A,132942.27,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,132942.27,132942.27,N/A,N/A,,Hospital C9248,"Inj, clevidipine butyrate",N/A,N/A,146098.62,N/A,87659.17,N/A,N/A,N/A,N/A,N/A,80529.56,N/A,49673.53,N/A,N/A,N/A,N/A,N/A,26638.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,80529.56,N/A,N/A,N/A,22980.66,N/A,98657.07,N/A,98657.07,N/A,N/A,N/A,N/A,N/A,N/A,N/A,24589.31,N/A,22980.66,98657.07,N/A,N/A,,Hospital C9250,HC Artiss Fibrin Sealant 2ml,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),164341.80,N/A,98605.08,N/A,11305.70,N/A,9192.59,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8203.96,N/A,3372.00,N/A,3372.00,N/A,N/A,N/A,17169.00,N/A,17169.00,N/A,N/A,N/A,90585.20,N/A,9192.59,N/A,8203.96,N/A,20426.82,N/A,20426.82,N/A,6648.19,N/A,9192.59,N/A,9514.39,N/A,8778.24,N/A,3372.00,98605.08,N/A,N/A,,Hospital HCPCS C9254,LACOSAMIDE 200 MG/20ML IV SOLN,00131-1810-67,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),147.40,147.40,88.44,88.44,N/A,20.64,N/A,147.40,N/A,82.87,N/A,50.12,N/A,42.74,N/A,20.64,N/A,147.40,N/A,147.40,N/A,26.60,N/A,42.74,N/A,42.74,N/A,42.74,N/A,82.87,N/A,147.40,N/A,20.64,N/A,79.01,N/A,79.01,N/A,20.64,N/A,147.40,N/A,147.40,N/A,147.40,88.44,88.44,20.64,147.40,,Hospital C9257,Bevacizumab injection,N/A,N/A,N/A,28027.38,N/A,16816.43,N/A,3923.85,N/A,3090.83,N/A,15958.74,N/A,9529.32,N/A,15540.95,N/A,3923.85,N/A,3010.42,N/A,3010.42,N/A,9674.44,N/A,15540.95,N/A,15540.95,N/A,15540.95,N/A,15958.74,N/A,3010.42,N/A,3923.85,N/A,2806.50,N/A,2806.50,N/A,3923.85,N/A,3010.42,N/A,3090.83,N/A,175.13,N/A,N/A,175.13,16816.43,,Hospital HCPCS C9290,BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,65250-0133-09,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),671.10,671.10,402.66,402.66,N/A,93.95,N/A,671.10,N/A,377.29,N/A,228.17,N/A,230.79,N/A,93.95,N/A,671.10,N/A,671.10,N/A,143.67,N/A,230.79,N/A,230.79,N/A,230.79,N/A,377.29,N/A,671.10,N/A,93.95,N/A,359.71,N/A,359.71,N/A,93.95,N/A,671.10,N/A,671.10,N/A,671.10,402.66,402.66,93.95,671.10,,Hospital C9352,HC Neuragen Nerve Guide per Cm Length,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,45510.55,N/A,27306.33,N/A,6371.49,N/A,1726.77,N/A,26084.20,N/A,15473.59,N/A,3960.16,N/A,6371.49,N/A,1623.23,N/A,1623.23,N/A,2465.29,N/A,3960.16,N/A,3960.16,N/A,3960.16,N/A,26084.20,N/A,1623.23,N/A,6371.49,N/A,3397.00,N/A,3397.00,N/A,6371.49,N/A,1623.23,N/A,1726.77,N/A,549.85,N/A,N/A,549.85,27306.33,,Hospital C9359,"HC Implnt,Bon Void Filler-Putty",N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,171407.62,63310.13,102844.57,37986.08,13255.14,8821.27,13100.10,1644.89,94479.88,35984.53,58278.59,21525.45,24684.23,28624.50,11183.84,8821.27,2248.00,11782.94,2248.00,11782.94,15365.36,17819.31,24684.23,28624.50,24684.23,28624.50,24684.23,28624.50,94479.88,35984.55,13100.10,11782.94,11183.84,8821.27,29368.07,7897.00,29368.07,7897.00,7883.29,8821.27,13100.10,11782.94,13100.10,1644.89,11966.71,1803.26,2248.00,102844.57,1644.89,37986.08,,Hospital C9360,HC�Surgimend Neonatal per 0.5 Sq Cm,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,142663.05,N/A,85597.83,N/A,19964.81,N/A,15066.11,N/A,80992.33,N/A,48161.71,N/A,37919.58,N/A,19964.81,N/A,15066.11,N/A,15066.11,N/A,23605.62,N/A,37919.58,N/A,37919.58,N/A,37919.58,N/A,79882.77,N/A,15066.11,N/A,19964.81,N/A,12986.00,N/A,12986.00,N/A,19964.81,N/A,15066.11,N/A,15066.11,N/A,16572.72,N/A,N/A,12986.00,85597.83,,Hospital C9361,HC Collagen Matrix Nerve Wrap (Neuromend) per 0.5cm Length,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,93070.42,N/A,55842.25,N/A,13024.74,N/A,5770.86,N/A,53336.02,N/A,31643.93,N/A,13528.14,N/A,13024.74,N/A,5579.57,N/A,5579.57,N/A,8421.54,N/A,13528.14,N/A,13528.14,N/A,13528.14,N/A,53336.02,N/A,5579.57,N/A,13024.74,N/A,8601.75,N/A,8601.75,N/A,13024.74,N/A,5579.57,N/A,5770.86,N/A,1705.36,N/A,N/A,1705.36,55842.25,,Hospital C9362,HC Implnt Bone Void Filler-Strip,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,360970.47,138713.97,216582.28,83228.38,11695.17,19362.32,40586.31,3128.01,283321.61,78715.52,78604.60,47162.75,78604.60,49374.61,11695.17,19362.32,40586.31,19924.58,40586.31,19924.58,78604.60,30932.64,78604.60,49374.61,78604.60,49374.61,78604.60,49374.61,283321.61,78715.54,40586.31,19947.52,11695.17,19362.32,283321.61,19049.75,283321.61,19049.75,11695.17,19362.32,39169.70,19924.58,40586.31,3128.01,11695.17,3428.56,11695.17,283321.61,3128.01,83228.38,,Hospital C9363,Integra Meshed Bil Wound Mat,N/A,N/A,N/A,56987.23,N/A,34192.34,N/A,7965.91,N/A,3852.18,N/A,32334.36,N/A,19375.65,N/A,9019.53,N/A,7965.91,N/A,3724.75,N/A,3724.75,N/A,5614.84,N/A,9019.53,N/A,9019.53,N/A,9019.53,N/A,32334.36,N/A,3724.75,N/A,7965.91,N/A,5629.25,N/A,5629.25,N/A,7965.91,N/A,3724.75,N/A,3852.18,N/A,640.22,N/A,N/A,640.22,34192.34,,Hospital C9460,"Injection, cangrelor",N/A,N/A,308310.92,78260.22,184986.55,46956.13,40362.71,10902.21,37093.53,10027.43,169940.97,11012.00,104825.71,26608.48,107353.86,29756.18,36252.99,10902.21,37093.53,9586.05,37093.53,9586.05,66841.81,18526.45,107353.86,29756.18,107353.86,29756.18,107353.86,29756.18,169940.97,11012.00,37093.53,9586.05,36252.99,10902.21,162714.76,14641.50,162714.76,14641.50,31813.99,10902.21,37093.53,9586.05,37093.53,10027.43,38790.70,1104.33,31813.99,184986.55,1104.33,46956.13,,Hospital C9604,HC Perc D-E Cor Revasc T Cabg S,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,108047.77,72931.78,64828.66,43759.07,15979.32,10059.52,19168.37,832.50,59555.93,11012.00,36736.24,24796.81,37769.00,23489.63,16471.67,10059.52,19168.37,9586.05,19168.37,9586.05,23510.89,14622.74,37769.00,23489.63,37769.00,23489.63,37769.00,23489.63,59555.93,11012.00,19168.37,9586.05,16471.67,10059.52,43253.58,14641.50,43253.58,14641.50,5958.52,10059.52,21531.75,9586.05,19168.37,832.50,17624.69,909.64,5958.52,64828.66,832.50,43759.07,,Hospital C9607,HC Perc D-E Cor Revasc Chro Sin,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,158788.70,88790.95,95273.22,53274.57,10820.83,12346.20,12315.69,103.01,87524.33,50727.57,53988.15,30188.92,24076.89,37597.55,10500.32,12346.20,12315.69,15512.06,12315.69,15512.06,14987.67,23405.19,24076.89,37597.55,24076.89,37597.55,24076.89,37597.55,87524.33,50727.57,12315.69,15512.06,10500.32,12346.20,27573.18,11923.50,27573.18,11923.50,5677.50,12346.20,12315.69,15512.06,12315.69,103.01,11235.34,107.20,5677.50,95273.22,103.01,53274.57,,Hospital C9740,Cysto impl 4 or more,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,54121.30,49112.57,32472.78,29467.54,8397.76,6875.77,7811.48,7661.04,27862.78,27720.55,18401.24,16698.28,19106.07,18702.74,8656.51,6875.77,10199.76,7727.79,10199.76,7727.79,11893.08,11642.80,19106.07,18702.74,19106.07,18702.74,19106.07,18702.74,27862.78,27720.55,10199.76,7727.79,8656.51,6875.77,22731.45,7897.00,22731.45,7897.00,N/A,6875.77,10199.76,7727.79,10229.41,7661.04,9262.46,2332.60,7811.48,32472.78,2332.60,29467.54,,Hospital C9752,Intraosseous des lumb/sacrum,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,81448.58,N/A,48869.15,N/A,11402.80,N/A,N/A,N/A,46494.21,N/A,27692.51,N/A,5184.73,N/A,11402.80,N/A,N/A,N/A,N/A,N/A,3221.98,N/A,5184.73,N/A,5184.73,N/A,5184.73,N/A,46494.20,N/A,N/A,N/A,11402.80,N/A,26834.39,N/A,26834.39,N/A,11402.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3221.98,48869.15,,Hospital C9755,Rf magnetic-guide av fistula,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,85063.30,N/A,51037.98,N/A,11911.02,N/A,6257.15,N/A,48971.05,N/A,28921.52,N/A,6578.74,N/A,11911.02,N/A,N/A,N/A,N/A,N/A,4095.39,N/A,6578.74,N/A,6578.74,N/A,6578.74,N/A,48971.05,N/A,N/A,N/A,11911.02,N/A,5629.25,N/A,5629.25,N/A,11911.02,N/A,6248.17,N/A,6257.15,N/A,1010.29,N/A,N/A,1010.29,51037.98,,Hospital C9757,Spine/lumbar disk surgery,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,130202.40,N/A,78121.44,N/A,10665.51,N/A,12083.83,N/A,71767.56,N/A,44268.82,N/A,23788.52,N/A,10994.13,N/A,381598.00,N/A,381598.00,N/A,N/A,N/A,23788.52,N/A,23788.52,N/A,23788.52,N/A,71767.56,N/A,12054.18,N/A,10994.13,N/A,28302.40,N/A,28302.40,N/A,680.62,N/A,12054.18,N/A,12083.83,N/A,11763.72,N/A,680.62,381598.00,N/A,N/A,,Hospital C9766,HC Revasc Intra Lithotrip-Ather,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,195901.98,107601.03,117541.19,64560.62,N/A,15032.33,32812.38,16226.30,N/A,61638.50,N/A,36584.36,N/A,37591.55,N/A,15032.33,32812.38,15512.06,32812.38,15512.06,N/A,23402.25,N/A,37591.55,N/A,37591.55,N/A,37591.55,N/A,61638.50,32812.38,15512.06,N/A,15032.33,N/A,11660.00,N/A,11660.00,N/A,15032.33,31193.81,15512.06,32812.38,16226.30,N/A,312.07,31193.81,117541.19,312.07,64560.62,,Hospital C9772,HC Revasc Lithotrip Tibi/Perone,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,161879.22,89778.07,97127.53,53866.84,N/A,12561.58,31940.37,10027.43,N/A,51678.30,N/A,30524.53,N/A,23231.76,N/A,12561.58,31940.37,9586.05,31940.37,9586.05,N/A,14462.73,N/A,23231.76,N/A,23231.76,N/A,23231.76,N/A,51678.30,31940.37,9586.05,N/A,12561.58,N/A,15608.50,N/A,15608.50,N/A,12561.58,21363.81,9586.05,31940.37,10027.43,N/A,905.34,21363.81,97127.53,905.34,53866.84,,Hospital C9774,HC Revasc Lithotr-Ather Tib/Per,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,121424.60,103638.47,72854.76,62183.08,27273.78,14509.38,32558.78,16226.30,66929.24,59467.35,41284.36,35237.09,64464.77,37581.11,28114.13,14509.38,15512.06,15512.06,15512.06,15512.06,40128.80,23397.05,64464.77,37581.11,64464.77,37581.11,64464.77,37581.11,66929.24,59467.35,32529.13,15512.06,28114.13,14509.38,73825.94,11660.00,73825.94,11660.00,N/A,14509.38,32529.13,15512.06,32558.78,16226.30,30082.12,283.45,15512.06,73825.94,283.45,62183.08,,Hospital C9785,"Endoscopic Outlet Reduction, Gastric Pouch Application, With Endoscopy and Intraluminal Tube Insertion",N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,67105.28,N/A,40263.17,N/A,9385.97,N/A,8.61,N/A,38570.08,N/A,22815.80,N/A,20050.72,N/A,9385.97,N/A,8206.20,N/A,8206.20,N/A,12481.81,N/A,20050.72,N/A,20050.72,N/A,20050.72,N/A,38570.09,N/A,8206.20,N/A,9385.97,N/A,N/A,N/A,N/A,N/A,9385.97,N/A,8206.20,N/A,8.61,N/A,9.47,N/A,N/A,8.61,40263.17,,Hospital CPT C9803,HC Hopd Sars-Cov-2 Spec Collection Covid-19,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,66.00,66.00,39.60,39.60,N/A,9.24,N/A,66.00,N/A,38.00,N/A,22.44,N/A,54.51,N/A,9.24,N/A,22.54,N/A,22.54,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,38.00,N/A,22.54,N/A,9.24,N/A,25.23,N/A,25.23,N/A,9.24,N/A,22.54,N/A,66.00,N/A,66.00,39.60,39.60,9.24,66.00,,Hospital C9899,"Inpt implant pros dev,no cov",N/A,N/A,163765.47,N/A,98259.28,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,98259.28,98259.28,N/A,N/A,,Hospital ADA D1208,PR Topical Application of Fluoride,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital D2740,Crown Porcelain/Ceramic Subs,N/A,N/A,N/A,11619.32,N/A,6971.59,N/A,1626.70,N/A,192.69,N/A,6685.99,N/A,3943.39,N/A,495.19,N/A,1626.70,N/A,187.68,N/A,187.68,N/A,308.23,N/A,495.19,N/A,495.19,N/A,495.19,N/A,6686.00,N/A,187.68,N/A,1626.70,N/A,527.00,N/A,527.00,N/A,1626.70,N/A,187.68,N/A,192.69,N/A,N/A,N/A,N/A,187.68,6971.59,,Hospital D6783,HC Dental Crown,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,14894.37,N/A,8936.62,N/A,2085.20,N/A,192.69,N/A,8573.30,N/A,5064.08,N/A,482.47,N/A,2085.20,N/A,187.68,N/A,187.68,N/A,300.32,N/A,482.47,N/A,482.47,N/A,482.47,N/A,8573.31,N/A,187.68,N/A,2085.20,N/A,527.00,N/A,527.00,N/A,2085.20,N/A,187.68,N/A,192.69,N/A,1263.91,N/A,N/A,187.68,8936.62,,Hospital D7140,Extraction Erupted Tooth/Exr,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,17948.00,N/A,10768.80,N/A,2512.71,N/A,2597.00,N/A,10332.15,N/A,6102.32,N/A,6255.33,N/A,2512.71,N/A,2569.18,N/A,2569.18,N/A,3894.07,N/A,6255.33,N/A,6255.33,N/A,6255.33,N/A,10271.69,N/A,2569.18,N/A,2512.71,N/A,1871.00,N/A,1871.00,N/A,2512.71,N/A,2569.18,N/A,2597.00,N/A,252.91,N/A,N/A,252.91,10768.80,,Hospital E0191,"Protector, Heel, Conv Foam, 1pr",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5221.43,N/A,3132.86,N/A,N/A,N/A,105.98,N/A,N/A,N/A,1775.29,N/A,1222.83,N/A,730.99,N/A,3290.00,N/A,3290.00,N/A,1222.14,N/A,1222.83,N/A,1222.83,N/A,1222.83,N/A,3006.51,N/A,3290.00,N/A,N/A,N/A,225.88,N/A,225.88,N/A,N/A,N/A,3290.00,N/A,105.98,N/A,116.58,N/A,N/A,105.98,3290.00,,Hospital E0746,Electromyograph Biofeedback,N/A,N/A,N/A,1712.00,N/A,1027.20,N/A,239.68,N/A,78.80,N/A,985.78,N/A,582.08,N/A,263.66,N/A,239.68,N/A,78.80,N/A,78.80,N/A,228.78,N/A,263.66,N/A,263.66,N/A,263.66,N/A,985.78,N/A,75.36,N/A,239.68,N/A,917.62,N/A,917.62,N/A,239.68,N/A,78.80,N/A,78.80,N/A,64.80,N/A,N/A,64.80,1027.20,,Hospital E0783,HC Programmable Infusion Pump,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,161715.93,N/A,97029.56,N/A,22632.23,N/A,12279.02,N/A,91815.44,N/A,54983.42,N/A,20374.20,N/A,22632.23,N/A,12233.25,N/A,12233.25,N/A,12683.31,N/A,20374.20,N/A,20374.20,N/A,20374.20,N/A,91815.46,N/A,12233.25,N/A,22632.23,N/A,10085.00,N/A,10085.00,N/A,22632.23,N/A,12233.25,N/A,12279.02,N/A,2439.80,N/A,N/A,2439.80,97029.56,,Hospital CPT G0008,HC Admin Influenza Vaccine,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,122.00,122.00,73.20,73.20,N/A,17.08,N/A,40.55,N/A,70.25,N/A,41.48,N/A,122.00,N/A,17.08,N/A,38.26,N/A,38.26,N/A,91.74,N/A,122.00,N/A,122.00,N/A,122.00,N/A,70.25,N/A,38.26,N/A,17.08,N/A,65.39,N/A,65.39,N/A,17.08,N/A,38.26,N/A,40.70,N/A,122.00,73.20,73.20,17.08,122.00,,Hospital CPT G0010,HC Admin Hepatitis B Vaccine,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,110.00,110.00,66.00,66.00,N/A,15.40,N/A,110.00,N/A,63.34,N/A,37.40,N/A,110.00,N/A,15.40,N/A,38.26,N/A,38.26,N/A,91.74,N/A,110.00,N/A,110.00,N/A,110.00,N/A,63.34,N/A,38.26,N/A,15.40,N/A,58.96,N/A,58.96,N/A,15.40,N/A,38.26,N/A,40.70,N/A,110.00,66.00,66.00,15.40,110.00,,Hospital G0101,HC Screening Pelvic & Breast Exam,N/A,0770 - PREVENTIVE CARE SERVICES - GENERAL CLASSIFICATION,N/A,277.00,N/A,166.20,N/A,38.78,N/A,188.25,N/A,159.50,N/A,94.18,N/A,165.69,N/A,38.78,N/A,177.64,N/A,177.64,N/A,103.15,N/A,165.69,N/A,165.69,N/A,165.69,N/A,159.50,N/A,177.64,N/A,38.78,N/A,148.47,N/A,148.47,N/A,38.78,N/A,177.64,N/A,188.25,N/A,29.24,N/A,N/A,29.24,188.25,,Hospital G0105,Colorectal Scrn; Hi Risk Ind,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,5396.60,N/A,3237.96,N/A,755.30,N/A,750.46,N/A,3106.20,N/A,1834.84,N/A,1825.56,N/A,755.30,N/A,750.46,N/A,750.46,N/A,1136.44,N/A,1825.56,N/A,1825.56,N/A,1825.56,N/A,3106.20,N/A,750.46,N/A,755.30,N/A,1431.00,N/A,1431.00,N/A,755.30,N/A,750.46,N/A,750.46,N/A,825.51,N/A,N/A,750.46,3237.96,,Hospital G0109,HC Diabetes Group/30min,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,38113.20,888.00,22867.92,532.80,10088.39,124.32,10170.68,119.60,19925.26,511.32,7227.62,301.92,7227.62,352.32,10088.39,124.32,10170.68,119.60,10170.68,119.60,7227.62,219.32,7227.62,352.32,7227.62,352.32,7227.62,352.32,120018.84,511.32,10170.68,119.60,10088.39,124.32,120018.84,475.96,120018.84,475.96,10088.39,124.32,10170.68,119.60,10170.68,119.60,9752.01,163.14,7227.62,120018.84,119.60,532.80,,Hospital G0153,St Admit Visit,N/A,0444 - SPEECH THERAPY - LANGUAGE PATHOLOGY - EVALUATION OR REEVALUATION,N/A,2752.62,N/A,1651.57,N/A,1963.39,N/A,2025.00,N/A,897.79,N/A,1597.19,N/A,1597.19,N/A,1963.39,N/A,2293.00,N/A,2293.00,N/A,1597.19,N/A,1597.19,N/A,1597.19,N/A,1597.19,N/A,897.79,N/A,2458.15,N/A,1963.39,N/A,897.79,N/A,897.79,N/A,1963.39,N/A,1235.00,N/A,2064.67,N/A,1963.39,N/A,N/A,897.79,2458.15,,Hospital G0156,HH/Hspc Aide Routine,N/A,0571 - HOME HEALTH (HH) AIDE - VISIT CHARGE,N/A,7625.00,N/A,4575.00,N/A,3121.60,N/A,1996.88,N/A,4203.00,N/A,2592.50,N/A,1067.50,N/A,1067.50,N/A,1989.00,N/A,1989.00,N/A,663.50,N/A,1067.50,N/A,1067.50,N/A,1067.50,N/A,4390.50,N/A,2041.31,N/A,3121.60,N/A,1082.70,N/A,1082.70,N/A,3121.60,N/A,1527.00,N/A,2329.66,N/A,3121.60,N/A,N/A,663.50,4575.00,,Hospital G0159,Pt Maintenance Visit,N/A,0421 - PHYSICAL THERAPY - VISIT,N/A,1350.08,N/A,810.05,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,810.05,810.05,,Hospital G0161,Pt Maintenance Visit,N/A,0441 - SPEECH THERAPY - LANGUAGE PATHOLOGY - VISIT,N/A,2603.00,N/A,1561.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1561.80,1561.80,,Hospital G0162,HH/Hspc Sn Management and Evaluation,N/A,0551 - HOME HEALTH (HH) - SKILLED NURSING - VISIT CHARGE,N/A,2516.18,N/A,1509.71,N/A,601.90,N/A,1739.87,N/A,912.00,N/A,428.00,N/A,428.00,N/A,75.23,N/A,1739.87,N/A,1739.87,N/A,428.00,N/A,428.00,N/A,428.00,N/A,428.00,N/A,912.00,N/A,2090.00,N/A,601.90,N/A,912.00,N/A,912.00,N/A,601.90,N/A,864.00,N/A,1739.87,N/A,601.90,N/A,N/A,75.23,2090.00,,Hospital G0166,"HC Extrnl Counterpulse, per Treatment",N/A,0480 - CARDIOLOGY - GENERAL CLASSIFICATION,41901.42,983.00,25140.85,589.80,5869.15,137.62,7208.54,113.62,13226.60,566.01,14246.49,334.22,13872.42,253.64,6049.99,137.62,7208.54,104.85,7208.54,104.85,8635.47,157.89,13872.42,253.64,13872.42,253.64,13872.42,253.64,13226.60,566.01,7208.54,104.85,6049.99,137.62,15886.89,526.89,15886.89,526.89,N/A,137.62,7208.54,104.85,7208.54,113.62,6473.49,106.13,5869.15,25140.85,104.85,589.80,,Hospital CPT G0239,HC Group Exercise,N/A,0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION,85.00,85.00,51.00,51.00,N/A,11.90,N/A,30.67,N/A,48.94,N/A,28.90,N/A,74.18,N/A,11.90,N/A,30.67,N/A,30.67,N/A,46.18,N/A,74.18,N/A,74.18,N/A,74.18,N/A,48.94,N/A,30.67,N/A,11.90,N/A,45.56,N/A,45.56,N/A,11.90,N/A,30.67,N/A,30.67,N/A,33.73,51.00,51.00,11.90,74.18,,Hospital G0248,HC Demonstrate Home Inr Device,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,672.00,N/A,403.20,N/A,90.34,N/A,112.06,N/A,386.93,N/A,228.48,N/A,264.01,N/A,90.34,N/A,109.14,N/A,109.14,N/A,164.35,N/A,264.01,N/A,264.01,N/A,264.01,N/A,386.93,N/A,218.28,N/A,90.34,N/A,8.58,N/A,8.58,N/A,90.34,N/A,218.28,N/A,224.12,N/A,72.56,N/A,N/A,8.58,403.20,,Hospital G0259,Inject for Sacroiliac Joint,N/A,N/A,N/A,3164.90,N/A,1898.94,N/A,443.52,N/A,3.93,N/A,1821.23,N/A,1076.07,N/A,6.05,N/A,443.52,N/A,3.93,N/A,3.93,N/A,3.77,N/A,6.05,N/A,6.05,N/A,6.05,N/A,1821.23,N/A,3.93,N/A,443.52,N/A,3.93,N/A,3.93,N/A,443.52,N/A,3.93,N/A,3.93,N/A,4.32,N/A,N/A,3.77,1898.94,,Hospital CPT G0260,"HC Sacroiliac Joint Inj, W/ Img",N/A,0761 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM,2822.00,2822.00,1693.20,1693.20,N/A,395.08,N/A,581.86,N/A,1624.91,N/A,959.48,N/A,451.29,N/A,395.08,N/A,581.86,N/A,581.86,N/A,280.93,N/A,451.29,N/A,451.29,N/A,451.29,N/A,1624.91,N/A,581.86,N/A,395.08,N/A,1512.59,N/A,1512.59,N/A,395.08,N/A,581.86,N/A,581.86,N/A,86.91,1693.20,1693.20,86.91,1693.20,,Hospital CPT G0278,HC Iliac Angiogram Nonselective,N/A,0481 - CARDIOLOGY - CARDIAC CATH LAB,3744.00,3744.00,2246.40,2246.40,N/A,524.16,N/A,3744.00,N/A,2155.80,N/A,1272.96,N/A,3744.00,N/A,524.16,N/A,3744.00,N/A,3744.00,N/A,3744.00,N/A,3744.00,N/A,3744.00,N/A,3744.00,N/A,2155.80,N/A,3744.00,N/A,524.16,N/A,3744.00,N/A,3744.00,N/A,524.16,N/A,3744.00,N/A,3744.00,N/A,3744.00,2246.40,2246.40,524.16,3744.00,,Hospital CPT G0279,HC Dx Breast Tomo Bil,N/A,0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY,75.00,75.00,45.00,45.00,N/A,10.50,N/A,21.05,N/A,75.00,N/A,25.50,N/A,75.00,N/A,10.50,N/A,21.05,N/A,21.05,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,21.05,N/A,10.50,N/A,75.00,N/A,75.00,N/A,10.50,N/A,21.05,N/A,21.05,N/A,23.16,45.00,45.00,10.50,75.00,,Hospital CPT G0279,HC Dx Breast Tomo Uni,N/A,0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY,75.00,75.00,45.00,45.00,N/A,10.50,N/A,21.05,N/A,75.00,N/A,25.50,N/A,75.00,N/A,10.50,N/A,21.05,N/A,21.05,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,21.05,N/A,10.50,N/A,75.00,N/A,75.00,N/A,10.50,N/A,21.05,N/A,21.05,N/A,23.16,45.00,45.00,10.50,75.00,,Hospital G0300,HH/Hspc Lpn Routine Visit,N/A,0551 - HOME HEALTH (HH) - SKILLED NURSING - VISIT CHARGE,N/A,3200.00,N/A,1920.00,N/A,1098.42,N/A,1430.00,N/A,1660.36,N/A,1088.00,N/A,722.00,N/A,448.00,N/A,1050.00,N/A,1050.00,N/A,783.00,N/A,722.00,N/A,722.00,N/A,722.00,N/A,1842.56,N/A,2385.46,N/A,1098.42,N/A,1132.00,N/A,1080.00,N/A,1201.62,N/A,1080.00,N/A,1430.00,N/A,1098.42,N/A,N/A,448.00,2385.46,,Hospital G0328,HC Fecal Blood Scrn Immuniassay,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,N/A,535.00,N/A,321.00,N/A,80.35,N/A,18.05,N/A,308.05,N/A,181.90,N/A,18.05,N/A,80.35,N/A,18.05,N/A,18.05,N/A,11.24,N/A,18.05,N/A,18.05,N/A,18.05,N/A,308.05,N/A,109.14,N/A,80.35,N/A,18.05,N/A,18.05,N/A,80.35,N/A,127.19,N/A,18.05,N/A,19.86,N/A,N/A,11.24,321.00,,Hospital G0365,HC Vessel Mapping Hemo Access,N/A,0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB,N/A,1875.00,N/A,1125.00,N/A,259.33,N/A,78.46,N/A,1079.63,N/A,637.50,N/A,268.17,N/A,259.33,N/A,78.46,N/A,78.46,N/A,166.86,N/A,268.17,N/A,268.17,N/A,268.17,N/A,1079.63,N/A,78.46,N/A,259.33,N/A,974.11,N/A,974.11,N/A,259.33,N/A,78.46,N/A,78.46,N/A,86.30,N/A,N/A,78.46,1125.00,,Hospital CPT G0379,HC Direct Referral Observation Surcharge,N/A,0762 - SPECIALTY ROOM - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM (A),632.00,632.00,379.20,379.20,N/A,88.48,N/A,494.97,N/A,363.91,N/A,214.88,N/A,632.00,N/A,88.48,N/A,494.97,N/A,494.97,N/A,632.00,N/A,632.00,N/A,632.00,N/A,632.00,N/A,363.91,N/A,494.97,N/A,88.48,N/A,338.75,N/A,338.75,N/A,88.48,N/A,494.97,N/A,494.97,N/A,544.46,379.20,379.20,88.48,632.00,,Hospital G0382,HC B-Level 3 Em,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital G0383,HC B-Level 4 Em,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT G0400,HC Home Sleep Study Type IV,N/A,0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION,855.00,855.00,513.00,513.00,N/A,119.70,N/A,262.75,N/A,492.31,N/A,290.70,N/A,611.76,N/A,119.70,N/A,252.91,N/A,252.91,N/A,380.83,N/A,611.76,N/A,611.76,N/A,611.76,N/A,492.31,N/A,252.91,N/A,119.70,N/A,458.28,N/A,458.28,N/A,119.70,N/A,252.91,N/A,262.75,N/A,855.00,513.00,513.00,119.70,855.00,,Hospital G0412,Open tx iliac spine uni/bil,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,58884.83,N/A,35330.90,N/A,8243.89,N/A,774.36,N/A,33788.22,N/A,20020.85,N/A,14662.84,N/A,8243.89,N/A,770.75,N/A,770.75,N/A,9127.90,N/A,14662.84,N/A,14662.84,N/A,14662.84,N/A,33788.21,N/A,770.75,N/A,8243.89,N/A,7897.00,N/A,7897.00,N/A,8243.89,N/A,770.75,N/A,774.36,N/A,797.23,N/A,N/A,770.75,35330.90,,Hospital G0423,HC Icr Cardiac Rehab WO/Exer,N/A,0943 - OTHER THERAPEUTIC SERVICES - CARDIAC REHABILITATION,51259.40,5640.00,30755.64,3384.00,10440.92,789.60,12616.71,1328.16,23529.46,3247.56,17428.20,1917.60,23754.54,3147.24,10762.62,789.60,12616.71,1301.16,12616.71,1301.16,14786.65,1959.24,23754.54,3147.24,23754.54,3147.24,23754.54,3147.24,23529.46,3247.56,12616.71,1301.16,10762.62,789.60,28261.97,3023.04,28261.97,3023.04,N/A,789.60,12616.71,1301.16,12616.71,1328.16,11516.01,1459.92,10440.92,30755.64,789.60,3384.00,,Hospital G0455,Fecal microbiota prep instil,N/A,0750 - GASTRO-INTESTINAL (GI) - GENERAL CLASSIFICATION,N/A,20361.13,N/A,12216.68,N/A,2850.57,N/A,1415.45,N/A,2552.00,N/A,6922.79,N/A,3279.35,N/A,2850.57,N/A,1353.14,N/A,1353.14,N/A,2041.46,N/A,3279.35,N/A,3279.35,N/A,3279.35,N/A,2552.00,N/A,1353.14,N/A,2850.57,N/A,1871.00,N/A,1871.00,N/A,2850.57,N/A,1353.14,N/A,1415.45,N/A,418.19,N/A,N/A,418.19,12216.68,,Hospital G0460,HC Autolog Prp Not Diab Ulcer,N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,N/A,4315.00,N/A,2589.00,N/A,604.10,N/A,1688.79,N/A,2484.58,N/A,1467.10,N/A,3769.94,N/A,604.10,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,2484.58,N/A,1558.52,N/A,604.10,N/A,N/A,N/A,N/A,N/A,604.10,N/A,1558.52,N/A,1688.79,N/A,N/A,N/A,N/A,604.10,3769.94,,Hospital G0469,"Fqhc visit, mh new pt",N/A,N/A,N/A,186.00,N/A,111.60,N/A,26.04,N/A,110.15,N/A,107.10,N/A,63.24,N/A,N/A,N/A,26.04,N/A,110.15,N/A,110.15,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,107.10,N/A,110.15,N/A,26.04,N/A,99.70,N/A,99.70,N/A,26.04,N/A,110.15,N/A,110.15,N/A,N/A,N/A,N/A,26.04,111.60,,Hospital G0471,Ven blood coll snf/hha,N/A,N/A,N/A,81.00,N/A,48.60,N/A,14.02,N/A,19.03,N/A,13.46,N/A,27.54,N/A,16.86,N/A,14.02,N/A,19.03,N/A,19.03,N/A,12.87,N/A,16.86,N/A,16.86,N/A,16.86,N/A,46.64,N/A,19.03,N/A,14.02,N/A,8.46,N/A,8.46,N/A,14.02,N/A,19.03,N/A,19.03,N/A,14.81,N/A,N/A,8.46,48.60,,Hospital G0472,HC Hep C Screen High Risk/Other,N/A,0301 - LABORATORY - CHEMISTRY,N/A,309.00,N/A,185.40,N/A,73.37,N/A,46.35,N/A,177.92,N/A,105.06,N/A,46.35,N/A,73.37,N/A,46.35,N/A,46.35,N/A,28.85,N/A,46.35,N/A,46.35,N/A,46.35,N/A,177.92,N/A,155.49,N/A,73.37,N/A,46.35,N/A,46.35,N/A,73.37,N/A,155.49,N/A,162.45,N/A,50.99,N/A,N/A,28.85,185.40,,Hospital G0476,Hpv combo assay ca screen,N/A,N/A,N/A,526.00,N/A,315.60,N/A,61.70,N/A,61.70,N/A,N/A,N/A,178.84,N/A,38.22,N/A,61.70,N/A,61.70,N/A,61.70,N/A,38.22,N/A,38.22,N/A,38.22,N/A,38.22,N/A,302.87,N/A,61.70,N/A,61.70,N/A,61.70,N/A,61.70,N/A,61.70,N/A,61.70,N/A,61.70,N/A,67.87,N/A,N/A,38.22,315.60,,Hospital G0481,HC So Benzodiazepines 13+ G0481,N/A,0301 - LABORATORY - CHEMISTRY,7601.00,1968.00,4560.60,1180.80,7601.00,305.46,11787.50,688.50,7601.00,1133.19,2584.34,669.11,3839.27,300.58,7601.00,305.46,11787.50,688.50,11787.50,688.50,2389.75,186.84,3839.27,300.58,3839.27,300.58,3839.27,300.58,7601.00,1133.18,11787.50,109.14,7601.00,305.46,2080.00,62.14,2080.00,62.14,1826.01,305.46,11787.50,109.14,11787.50,115.66,7601.00,68.35,1826.01,11787.50,62.14,1180.80,,Hospital G0483,"PR Drug Test(S), Definitive, 1-7 Drug Classes",N/A,N/A,N/A,2656.00,N/A,1593.60,N/A,514.57,N/A,100.96,N/A,1529.33,N/A,903.04,N/A,233.46,N/A,514.57,N/A,96.52,N/A,96.52,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,1529.33,N/A,96.52,N/A,514.57,N/A,1247.32,N/A,1247.32,N/A,514.57,N/A,96.52,N/A,100.96,N/A,447.50,N/A,N/A,96.52,1593.60,,Hospital HCPCS G0491,HC Dialysis Ctr Injury Non-Esrd,N/A,0821 - HEMODIALYSIS - OUTPATIENT OR HOME - HEMODIALYSIS COMPOSITE OR OTHER RATE,2044.00,2044.00,1226.40,1226.40,N/A,286.16,N/A,2044.00,N/A,1176.94,N/A,694.96,N/A,286.16,N/A,286.16,N/A,2044.00,N/A,2044.00,N/A,177.83,N/A,286.16,N/A,286.16,N/A,286.16,N/A,1176.94,N/A,2044.00,N/A,286.16,N/A,1095.58,N/A,1095.58,N/A,286.16,N/A,2044.00,N/A,2044.00,N/A,2044.00,1226.40,1226.40,177.83,2044.00,,Hospital CPT G0492,HC Dialysis Injury Related,N/A,0801 - INPATIENT RENAL DIALYSIS - INPATIENT HEMODIALYSIS,2044.00,2044.00,1226.40,1226.40,N/A,286.16,N/A,2044.00,N/A,1176.94,N/A,694.96,N/A,286.16,N/A,286.16,N/A,2044.00,N/A,2044.00,N/A,177.83,N/A,286.16,N/A,286.16,N/A,286.16,N/A,1176.94,N/A,2044.00,N/A,286.16,N/A,1095.58,N/A,1095.58,N/A,286.16,N/A,2044.00,N/A,2044.00,N/A,2044.00,1226.40,1226.40,177.83,2044.00,,Hospital G0493,Rn Change in Pt Condition,N/A,0551 - HOME HEALTH (HH) - SKILLED NURSING - VISIT CHARGE,N/A,2430.03,N/A,1458.02,N/A,N/A,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1080.00,N/A,1080.00,N/A,N/A,N/A,N/A,1080.00,1458.02,,Hospital G0494,HH/Hspc Lpn Change in Pt Condition,N/A,0551 - HOME HEALTH (HH) - SKILLED NURSING - VISIT CHARGE,N/A,2819.97,N/A,1691.98,N/A,1787.63,N/A,432.00,N/A,1197.68,N/A,N/A,N/A,N/A,N/A,27.37,N/A,432.00,N/A,432.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1197.68,N/A,432.00,N/A,1787.63,N/A,1197.68,N/A,1197.68,N/A,1787.63,N/A,432.00,N/A,432.00,N/A,1787.63,N/A,N/A,27.37,1787.63,,Hospital HCPCS G0498,HC Chemo Extend IV Infus W/Pump Cost,N/A,0280 - ONCOLOGY - GENERAL CLASSIFICATION,846.00,846.00,507.60,507.60,N/A,118.44,N/A,300.37,N/A,487.13,N/A,287.64,N/A,726.56,N/A,118.44,N/A,300.37,N/A,300.37,N/A,452.30,N/A,726.56,N/A,726.56,N/A,726.56,N/A,487.13,N/A,300.37,N/A,118.44,N/A,453.46,N/A,453.46,N/A,118.44,N/A,300.37,N/A,300.37,N/A,330.41,507.60,507.60,118.44,726.56,,Hospital HCPCS G0498,PR Chemo Admin IV Infusion Technique Initiation of Infusion in Office,N/A,N/A,316.00,316.00,189.60,189.60,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,44.24,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,N/A,316.00,189.60,189.60,44.24,316.00,,Hospital G0499,Hepb screen high risk indiv,N/A,N/A,N/A,3271.80,N/A,1963.08,N/A,416.66,N/A,153.91,N/A,1879.94,N/A,1112.41,N/A,393.36,N/A,416.66,N/A,153.91,N/A,153.91,N/A,244.62,N/A,393.36,N/A,393.36,N/A,393.36,N/A,1879.94,N/A,153.91,N/A,416.66,N/A,998.65,N/A,998.65,N/A,416.66,N/A,153.91,N/A,153.91,N/A,169.32,N/A,N/A,153.91,1963.08,,Hospital G0500,HC Mod Sedat Endo Service >5yrs,N/A,0372 - ANESTHESIA - ANESTHESIA INCIDENT TO OTHER DX SERVICES,N/A,6414.00,N/A,3848.40,N/A,897.96,N/A,268.40,N/A,2552.00,N/A,2180.76,N/A,2376.44,N/A,897.96,N/A,977.91,N/A,977.91,N/A,1479.38,N/A,2376.44,N/A,2376.44,N/A,2376.44,N/A,2552.00,N/A,977.91,N/A,897.96,N/A,1871.00,N/A,1871.00,N/A,897.96,N/A,977.91,N/A,268.40,N/A,295.24,N/A,N/A,268.40,3848.40,,Hospital G1010,HC Radiology Clinical Decision Support Mechanism - Stanson,N/A,0359 - CT SCAN - OTHER CT SCAN,41549.03,2307.02,24929.42,1384.21,6432.49,322.98,7904.59,162.85,14496.13,1841.49,14126.67,784.38,15203.93,412.57,6630.68,322.98,7874.94,162.85,7874.94,162.85,9464.32,256.83,15203.93,412.57,15203.93,412.57,15203.93,412.57,14496.13,1841.49,7874.94,162.85,6630.68,322.98,17411.75,1378.00,17411.75,1378.00,N/A,322.98,7874.94,162.85,7904.59,162.85,7094.83,179.14,6432.49,24929.42,162.85,1841.49,,Hospital G1016,HC Radiology Clinical Decision Support Mechanism - Speed of Care,N/A,0359 - CT SCAN - OTHER CT SCAN,N/A,1434.52,N/A,860.71,N/A,201.67,N/A,168.44,N/A,1434.51,N/A,487.73,N/A,417.23,N/A,201.67,N/A,162.85,N/A,162.85,N/A,259.73,N/A,417.23,N/A,417.23,N/A,417.23,N/A,1434.51,N/A,162.85,N/A,201.67,N/A,1386.12,N/A,1386.12,N/A,201.67,N/A,162.85,N/A,168.44,N/A,210.99,N/A,N/A,162.85,1434.51,,Hospital G2168,Pt Pta Maintenance Visit,N/A,0421 - PHYSICAL THERAPY - VISIT,N/A,2195.55,N/A,1317.33,N/A,N/A,N/A,1805.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1805.00,N/A,1805.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1805.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1805.00,N/A,1805.00,N/A,N/A,N/A,N/A,1317.33,1805.00,,Hospital G2171,"HC Avf Any Site, Magnetic/Art/Ven",N/A,0361 - OPERATING ROOM SERVICES - MINOR SURGERY,250707.50,80865.48,150424.50,48519.29,N/A,11321.16,22759.57,790.11,N/A,46528.66,N/A,27494.27,N/A,7792.79,N/A,11321.16,24934.04,769.55,24934.04,769.55,N/A,4844.72,N/A,7792.79,N/A,7792.79,N/A,7792.79,N/A,46528.67,24934.04,769.55,N/A,11321.16,N/A,1431.00,N/A,1431.00,N/A,11321.16,24934.04,769.55,24934.04,790.11,N/A,94.54,22759.57,150424.50,94.54,48519.29,,Hospital H0004,HC Php Bh Counsel/Thrpy per 15min,N/A,0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INDIVIDUAL THERAPY,N/A,3967.00,N/A,2380.20,N/A,555.38,N/A,214.95,N/A,2284.21,N/A,1348.78,N/A,718.56,N/A,555.38,N/A,205.49,N/A,205.49,N/A,447.07,N/A,718.56,N/A,718.56,N/A,718.56,N/A,2239.54,N/A,205.49,N/A,555.38,N/A,N/A,N/A,N/A,N/A,555.38,N/A,3285.00,N/A,214.95,N/A,77.22,N/A,N/A,77.22,3285.00,,Hospital H0005,HC Group Counseling per 15 Minutes,N/A,0905 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INTENSIVE OUTPATIENT SERVICES - PSYCHIATRIC,N/A,879.00,N/A,527.40,N/A,117.74,N/A,130.90,N/A,506.12,N/A,298.86,N/A,332.82,N/A,117.74,N/A,131.57,N/A,131.57,N/A,207.17,N/A,332.82,N/A,332.82,N/A,332.82,N/A,879.00,N/A,131.57,N/A,117.74,N/A,25.20,N/A,25.20,N/A,117.74,N/A,879.00,N/A,130.90,N/A,101.92,N/A,N/A,25.20,879.00,,Hospital H0015,HC Iop Sud Counseling per Day,N/A,0906 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - INTENSIVE OUTPATIENT SERVICES - CHEMICAL DEPENDENCY,N/A,1819.00,N/A,1091.40,N/A,246.68,N/A,37.80,N/A,1047.36,N/A,618.46,N/A,246.68,N/A,246.68,N/A,37.80,N/A,37.80,N/A,153.32,N/A,246.68,N/A,246.68,N/A,246.68,N/A,1819.00,N/A,37.80,N/A,246.68,N/A,37.80,N/A,37.80,N/A,246.68,N/A,1856.80,N/A,37.80,N/A,41.58,N/A,N/A,37.80,1856.80,,Hospital H1000,HC Prenatal Risk Assessment Form,N/A,0510 - CLINIC - GENERAL CLASSIFICATION,N/A,1110.00,N/A,666.00,N/A,155.40,N/A,217.94,N/A,639.14,N/A,377.40,N/A,233.46,N/A,155.40,N/A,205.66,N/A,205.66,N/A,145.34,N/A,233.46,N/A,233.46,N/A,233.46,N/A,639.14,N/A,205.66,N/A,155.40,N/A,482.94,N/A,482.94,N/A,155.40,N/A,205.66,N/A,217.94,N/A,70.44,N/A,N/A,70.44,666.00,,Hospital J0130,Abciximab Injection,N/A,N/A,199778.30,N/A,119866.98,N/A,26053.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,26053.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,26053.10,N/A,N/A,N/A,N/A,N/A,26053.10,N/A,N/A,N/A,N/A,N/A,26053.10,N/A,26053.10,119866.98,N/A,N/A,,Hospital J0131,"Inj, acetaminophen (nos)",N/A,N/A,541764.17,N/A,325058.50,N/A,N/A,N/A,N/A,N/A,378392.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,378392.87,N/A,N/A,N/A,N/A,N/A,378392.87,N/A,378392.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,325058.50,378392.87,N/A,N/A,,Hospital HCPCS J0153,ADENOSINE 6 MG/2ML IV SOLN,63323-0651-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),53.70,53.70,32.22,32.22,N/A,7.52,N/A,53.70,N/A,30.19,N/A,18.26,N/A,3.65,N/A,7.52,N/A,53.70,N/A,53.70,N/A,2.27,N/A,3.65,N/A,3.65,N/A,3.65,N/A,30.19,N/A,53.70,N/A,7.52,N/A,28.78,N/A,28.78,N/A,7.52,N/A,53.70,N/A,53.70,N/A,53.70,32.22,32.22,2.27,53.70,,Hospital HCPCS J0153,ADENOSINE 12 MG/4ML IV SOLN,25021-0301-68,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),43.90,43.90,26.34,26.34,N/A,6.15,N/A,43.90,N/A,24.68,N/A,14.93,N/A,3.65,N/A,6.15,N/A,43.90,N/A,43.90,N/A,2.27,N/A,3.65,N/A,3.65,N/A,3.65,N/A,24.68,N/A,43.90,N/A,6.15,N/A,23.53,N/A,23.53,N/A,6.15,N/A,43.90,N/A,43.90,N/A,43.90,26.34,26.34,2.27,43.90,,Hospital HCPCS J0153,ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,67457-0857-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1323.00,1323.00,793.80,793.80,N/A,185.22,N/A,1323.00,N/A,743.79,N/A,449.82,N/A,109.56,N/A,185.22,N/A,1323.00,N/A,1323.00,N/A,68.20,N/A,109.56,N/A,109.56,N/A,109.56,N/A,743.79,N/A,1323.00,N/A,185.22,N/A,709.13,N/A,709.13,N/A,185.22,N/A,1323.00,N/A,1323.00,N/A,1323.00,793.80,793.80,68.20,1323.00,,Hospital J0185,"Inj., aprepitant, 1 mg",N/A,N/A,N/A,12472.32,N/A,7483.39,N/A,1736.80,N/A,849.19,N/A,7107.22,N/A,4240.59,N/A,2142.23,N/A,1736.80,N/A,815.90,N/A,815.90,N/A,1333.57,N/A,2142.23,N/A,2142.23,N/A,2142.23,N/A,7065.06,N/A,925.04,N/A,1736.80,N/A,2719.02,N/A,2719.02,N/A,1736.80,N/A,925.04,N/A,297.39,N/A,321.00,N/A,N/A,297.39,7483.39,,Hospital HCPCS J0206,ALLOPURINOL SODIUM 500 MG IV SOLR,67457-0187-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),26912.70,26912.70,16147.62,16147.62,N/A,3767.78,N/A,26912.70,N/A,15130.32,N/A,9150.32,N/A,3767.78,N/A,3767.78,N/A,26912.70,N/A,26912.70,N/A,2341.40,N/A,3767.78,N/A,3767.78,N/A,3767.78,N/A,15130.32,N/A,26912.70,N/A,3767.78,N/A,14425.21,N/A,14425.21,N/A,3767.78,N/A,26912.70,N/A,26912.70,N/A,26912.70,16147.62,16147.62,2341.40,26912.70,,Hospital HCPCS J0208,SODIUM THIOSULFATE 250 MG/ML IV SOLN,60267-0705-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,288.85,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,288.85,N/A,288.85,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,288.85,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,288.85,N/A,15.00,N/A,15.00,9.00,9.00,2.10,288.85,,Hospital HCPCS J0222,PATISIRAN SODIUM 10 MG/5ML IV SOLN,71336-1000-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),44032.50,44032.50,26419.50,26419.50,N/A,6164.55,N/A,10047.20,N/A,24755.07,N/A,14971.05,N/A,25633.23,N/A,6164.55,N/A,10047.20,N/A,10047.20,N/A,15956.93,N/A,25633.23,N/A,25633.23,N/A,25633.23,N/A,24755.07,N/A,10047.20,N/A,6164.55,N/A,23601.42,N/A,23601.42,N/A,6164.55,N/A,10047.20,N/A,10047.20,N/A,11051.92,26419.50,26419.50,6164.55,26419.50,,Hospital HCPCS J0225,VUTRISIRAN SODIUM 25 MG/0.5ML SC SOSY,71336-1003-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),537079.50,537079.50,322247.70,322247.70,N/A,75191.13,N/A,123523.75,N/A,301946.09,N/A,182607.03,N/A,121896.35,N/A,75191.13,N/A,123523.75,N/A,123523.75,N/A,121896.35,N/A,121896.35,N/A,121896.35,N/A,121896.35,N/A,301946.09,N/A,123523.75,N/A,75191.13,N/A,287874.61,N/A,287874.61,N/A,75191.13,N/A,123523.75,N/A,123523.75,N/A,135876.13,322247.70,322247.70,75191.13,322247.70,,Hospital HCPCS J0270,ALPROSTADIL 500 MCG/ML IJ SOLN,00009-3169-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),888.80,888.80,533.28,533.28,N/A,124.43,N/A,888.80,N/A,499.68,N/A,302.19,N/A,888.80,N/A,124.43,N/A,888.80,N/A,888.80,N/A,888.80,N/A,888.80,N/A,888.80,N/A,888.80,N/A,499.68,N/A,888.80,N/A,124.43,N/A,476.40,N/A,476.40,N/A,124.43,N/A,888.80,N/A,888.80,N/A,888.80,533.28,533.28,124.43,888.80,,Hospital HCPCS J0278,AMIKACIN SULFATE 1 GM/4ML IJ SOLN (MIXTURES ONLY),25021-0173-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),52.40,52.40,31.44,31.44,N/A,7.34,N/A,52.40,N/A,29.46,N/A,17.82,N/A,10.36,N/A,7.34,N/A,52.40,N/A,52.40,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,29.46,N/A,52.40,N/A,7.34,N/A,28.09,N/A,28.09,N/A,7.34,N/A,52.40,N/A,52.40,N/A,52.40,31.44,31.44,6.45,52.40,,Hospital HCPCS J0278,AMIKACIN SULFATE 500 MG/2ML IJ SOLN,25021-0173-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),52.40,52.40,31.44,31.44,N/A,7.34,N/A,52.40,N/A,29.46,N/A,17.82,N/A,10.36,N/A,7.34,N/A,52.40,N/A,52.40,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,29.46,N/A,52.40,N/A,7.34,N/A,28.09,N/A,28.09,N/A,7.34,N/A,52.40,N/A,52.40,N/A,52.40,31.44,31.44,6.45,52.40,,Hospital J0283,"Inj, amiodarone (nexterone)",N/A,N/A,442087.88,N/A,265252.73,N/A,N/A,N/A,27654.06,N/A,N/A,N/A,451453.97,N/A,451453.97,N/A,N/A,N/A,14612.00,N/A,14612.00,N/A,451453.97,N/A,451453.97,N/A,451453.97,N/A,451453.97,N/A,N/A,N/A,27654.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,27654.06,N/A,27654.06,N/A,N/A,N/A,14612.00,451453.97,N/A,N/A,,Hospital HCPCS J0285,AMPHOTERICIN B 50 MG IV SOLR,39822-1055-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),295.00,295.00,177.00,177.00,N/A,41.30,N/A,295.00,N/A,165.85,N/A,100.30,N/A,119.97,N/A,41.30,N/A,295.00,N/A,295.00,N/A,74.68,N/A,119.97,N/A,119.97,N/A,119.97,N/A,165.85,N/A,295.00,N/A,41.30,N/A,158.12,N/A,158.12,N/A,41.30,N/A,295.00,N/A,295.00,N/A,295.00,177.00,177.00,41.30,295.00,,Hospital HCPCS J0289,AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,00469-3051-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1910.60,1910.60,1146.36,1146.36,N/A,267.48,N/A,139.36,N/A,1074.14,N/A,649.60,N/A,341.36,N/A,267.48,N/A,139.36,N/A,139.36,N/A,212.50,N/A,341.36,N/A,341.36,N/A,341.36,N/A,1074.14,N/A,139.36,N/A,267.48,N/A,1024.08,N/A,1024.08,N/A,267.48,N/A,139.36,N/A,139.36,N/A,1910.60,1146.36,1146.36,139.36,1910.60,,Hospital HCPCS J0330,SUCCINYLCHOLINE CHLORIDE 100 MG/5ML IV SOSY,69374-0920-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.49,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.55,N/A,2.49,N/A,2.49,N/A,2.49,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.55,15.00,,Hospital HCPCS J0330,SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,66794-0232-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.49,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.55,N/A,2.49,N/A,2.49,N/A,2.49,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.55,15.00,,Hospital HCPCS J0330,SUCCINYLCHOLINE CHLORIDE 200 MG/10ML IV SOSY,69374-0919-10,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J0400,Aripiprazole Injection,N/A,N/A,67411.90,N/A,40447.14,N/A,26304.80,N/A,5637.84,N/A,10234.33,N/A,22920.07,N/A,N/A,N/A,26304.80,N/A,5637.84,N/A,5637.84,N/A,15824.00,N/A,25408.00,N/A,25408.00,N/A,25408.00,N/A,23489.44,N/A,14252.12,N/A,26831.04,N/A,67411.90,N/A,67411.90,N/A,4070.16,N/A,24784.00,N/A,5637.84,N/A,26830.88,N/A,4070.16,67411.90,N/A,N/A,,Hospital HCPCS J0491,ANIFROLUMAB-FNIA 300 MG/2ML IV SOLN,00310-3040-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21013.00,21013.00,12607.80,12607.80,N/A,2941.82,N/A,4996.80,N/A,11813.51,N/A,7144.42,N/A,12571.86,N/A,2941.82,N/A,4996.80,N/A,4996.80,N/A,7826.10,N/A,12571.86,N/A,12571.86,N/A,12571.86,N/A,11813.51,N/A,4996.80,N/A,2941.82,N/A,11262.97,N/A,11262.97,N/A,2941.82,N/A,4996.80,N/A,4996.80,N/A,5496.48,12607.80,12607.80,2941.82,12607.80,,Hospital J0515,Inj Benztropine Mesylate,N/A,N/A,15245.50,N/A,9147.30,N/A,6576.20,N/A,8441.00,N/A,8340.00,N/A,5183.48,N/A,6352.00,N/A,6576.20,N/A,8441.00,N/A,8441.00,N/A,3956.00,N/A,6352.00,N/A,6352.00,N/A,6352.00,N/A,5872.36,N/A,3747.81,N/A,6707.76,N/A,15245.50,N/A,15245.50,N/A,5030.79,N/A,6196.00,N/A,8441.00,N/A,6707.72,N/A,3747.81,15245.50,N/A,N/A,,Hospital J0517,"Inj., benralizumab, 1 mg",N/A,N/A,62090.80,32504.30,37254.48,19502.58,5254.60,4550.60,6481.56,5193.77,11841.67,18279.34,21110.89,11051.46,11954.95,13267.79,5416.50,4550.60,1686.00,5188.68,1686.00,5188.68,7441.68,8259.33,11954.95,13267.79,11954.95,13267.79,11954.95,13267.79,11841.67,18279.34,6481.56,5188.68,5416.50,4550.60,14223.40,17422.30,14223.40,17422.30,7558.23,4550.60,6481.56,5188.68,6481.56,5193.77,5795.66,14.73,1686.00,37254.48,14.73,19502.58,,Hospital J0558,PenG benzathine/procaine inj,N/A,N/A,33885.80,2588.30,20331.48,1552.98,3683.56,362.36,4652.75,436.77,8301.19,1459.63,11521.17,880.02,8380.60,946.75,3797.05,362.36,59010.00,437.08,59010.00,437.08,5216.73,589.36,8380.60,946.75,8380.60,946.75,8380.60,946.75,8301.19,1459.63,4623.10,437.08,3797.05,362.36,9970.82,1387.33,9970.82,1387.33,6844.62,362.36,4623.10,437.08,4652.75,436.77,4062.85,29.46,3683.56,59010.00,29.46,1552.98,,Hospital HCPCS J0571,BUPRENORPHINE HCL 8 MG SL SUBL,00054-0177-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,4.90,N/A,5.00,N/A,5.00,N/A,5.00,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital J0573,Bupren/nal 3.1 to 6mg bupren,N/A,N/A,31910.50,3922.20,19146.30,2353.32,6204.24,485.34,8441.00,368.48,14595.00,2258.41,7568.00,1333.55,11116.00,821.03,6204.24,485.34,8441.00,347.18,8441.00,347.18,7568.00,511.10,11116.00,821.03,11116.00,821.03,11116.00,821.03,10276.63,1346.33,6271.01,347.18,6328.35,485.34,31910.50,1215.81,31910.50,1215.81,5185.36,485.34,10843.00,347.18,8441.00,368.48,5488.70,187.15,5185.36,31910.50,187.15,2353.32,,Hospital HCPCS J0583,BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,63323-0562-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3429.00,3429.00,2057.40,2057.40,N/A,480.06,N/A,3429.00,N/A,1927.78,N/A,1165.86,N/A,187.78,N/A,480.06,N/A,3429.00,N/A,3429.00,N/A,116.89,N/A,187.78,N/A,187.78,N/A,187.78,N/A,1927.78,N/A,3429.00,N/A,480.06,N/A,1837.94,N/A,1837.94,N/A,480.06,N/A,3429.00,N/A,3429.00,N/A,3429.00,2057.40,2057.40,116.89,3429.00,,Hospital HCPCS J0587,RIMABOTULINUMTOXINB 5000 UNIT/ML IM SOLN,10454-0711-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2679.90,2679.90,1607.94,1607.94,N/A,375.19,N/A,636.05,N/A,1506.64,N/A,911.17,N/A,1576.02,N/A,375.19,N/A,636.05,N/A,636.05,N/A,981.08,N/A,1576.02,N/A,1576.02,N/A,1576.02,N/A,1506.64,N/A,636.05,N/A,375.19,N/A,1436.43,N/A,1436.43,N/A,375.19,N/A,636.05,N/A,636.05,N/A,699.66,1607.94,1607.94,375.19,1607.94,,Hospital HCPCS J0587,RIMABOTULINUMTOXINB 10000 UNIT/2ML IM SOLN,10454-0712-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5359.80,5359.80,3215.88,3215.88,N/A,750.37,N/A,1272.10,N/A,3013.28,N/A,1822.33,N/A,3152.03,N/A,750.37,N/A,1272.10,N/A,1272.10,N/A,1962.17,N/A,3152.03,N/A,3152.03,N/A,3152.03,N/A,3013.28,N/A,1272.10,N/A,750.37,N/A,2872.85,N/A,2872.85,N/A,750.37,N/A,1272.10,N/A,1272.10,N/A,1399.31,3215.88,3215.88,750.37,3215.88,,Hospital HCPCS J0587,RIMABOTULINUMTOXINB 2500 UNIT/0.5ML IM SOLN,10454-0710-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1340.00,1340.00,804.00,804.00,N/A,187.60,N/A,318.03,N/A,753.35,N/A,455.60,N/A,788.01,N/A,187.60,N/A,318.03,N/A,318.03,N/A,490.54,N/A,788.01,N/A,788.01,N/A,788.01,N/A,753.35,N/A,318.03,N/A,187.60,N/A,718.24,N/A,718.24,N/A,187.60,N/A,318.03,N/A,318.03,N/A,349.83,804.00,804.00,187.60,804.00,,Hospital HCPCS J0588,INCOBOTULINUMTOXINA 100 UNITS IM SOLR,00259-1610-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1116.00,1116.00,669.60,669.60,N/A,156.24,N/A,1116.00,N/A,627.42,N/A,379.44,N/A,655.27,N/A,156.24,N/A,1116.00,N/A,1116.00,N/A,407.91,N/A,655.27,N/A,655.27,N/A,655.27,N/A,627.42,N/A,1116.00,N/A,156.24,N/A,598.18,N/A,598.18,N/A,156.24,N/A,1116.00,N/A,1116.00,N/A,1116.00,669.60,669.60,156.24,1116.00,,Hospital J0594,Busulfan injection,N/A,N/A,560838.27,N/A,336502.96,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145771.72,336502.96,N/A,N/A,,Hospital J0597,"C-1 esterase, berinert",N/A,N/A,85260.08,N/A,51156.05,N/A,2688.65,N/A,3446.18,N/A,6059.09,N/A,28988.43,N/A,6117.05,N/A,2771.49,N/A,3446.18,N/A,3446.18,N/A,3807.72,N/A,6117.05,N/A,6117.05,N/A,6117.05,N/A,6059.09,N/A,3446.18,N/A,2771.49,N/A,7277.76,N/A,7277.76,N/A,2771.49,N/A,3446.18,N/A,3446.18,N/A,2965.50,N/A,2688.65,51156.05,N/A,N/A,,Hospital J0598,"C-1 esterase, cinryze",N/A,N/A,N/A,130848.60,N/A,78509.16,N/A,18318.80,N/A,6271.14,N/A,73571.32,N/A,44488.52,N/A,16164.75,N/A,18318.80,N/A,6259.24,N/A,6259.24,N/A,10062.71,N/A,16164.75,N/A,16164.75,N/A,16164.75,N/A,73571.32,N/A,6259.24,N/A,18318.80,N/A,70134.85,N/A,70134.85,N/A,18318.80,N/A,6259.24,N/A,6271.14,N/A,39.24,N/A,N/A,39.24,78509.16,,Hospital J0606,"Inj, etelcalcetide, 0.1 mg",N/A,N/A,305955.30,9396.40,183573.18,5637.84,N/A,1315.50,34891.54,249.48,N/A,5304.09,N/A,3194.78,N/A,1606.06,N/A,1315.50,34891.54,249.48,34891.54,249.48,N/A,999.54,N/A,1606.06,N/A,1606.06,N/A,1606.06,N/A,5304.09,34891.54,249.48,N/A,1315.50,N/A,5036.48,N/A,5036.48,N/A,1315.50,34891.54,249.48,34891.54,249.48,N/A,752.58,34891.54,183573.18,249.48,5637.84,,Hospital J0611,Calcium glucon (wg critical),N/A,N/A,172791.20,N/A,103674.72,N/A,7587.52,N/A,12913.21,N/A,94625.33,N/A,N/A,N/A,N/A,N/A,7587.52,N/A,14021.02,N/A,14021.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,94625.33,N/A,14793.57,N/A,7587.52,N/A,94625.33,N/A,94625.33,N/A,7587.52,N/A,14021.02,N/A,14021.02,N/A,7587.52,N/A,7587.52,103674.72,N/A,N/A,,Hospital HCPCS J0665,BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,55150-0170-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.00,16.00,9.60,9.60,N/A,2.24,N/A,16.00,N/A,9.00,N/A,5.44,N/A,16.00,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,N/A,16.00,N/A,16.00,N/A,16.00,N/A,9.00,N/A,16.00,N/A,2.24,N/A,8.58,N/A,8.58,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,9.60,9.60,2.24,16.00,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),63323-0466-37,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),42.60,42.60,25.56,25.56,N/A,5.96,N/A,42.60,N/A,23.95,N/A,14.48,N/A,42.60,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,23.95,N/A,42.60,N/A,5.96,N/A,22.83,N/A,22.83,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,25.56,25.56,5.96,42.60,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.25 % IJ SOLN (MIXTURES ONLY),00409-1159-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.25 % IJ SOLN (MIXTURES ONLY),00409-1160-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.5 % IJ SOLN,00409-1163-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,00409-1159-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,55150-0171-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22.50,22.50,13.50,13.50,N/A,3.15,N/A,22.50,N/A,12.65,N/A,7.65,N/A,22.50,N/A,3.15,N/A,22.50,N/A,22.50,N/A,22.50,N/A,22.50,N/A,22.50,N/A,22.50,N/A,12.65,N/A,22.50,N/A,3.15,N/A,12.06,N/A,12.06,N/A,3.15,N/A,22.50,N/A,22.50,N/A,22.50,13.50,13.50,3.15,22.50,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.25 % IJ SOLN (MIXTURES ONLY),00409-1159-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,63323-0464-17,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,00409-1165-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22.50,22.50,13.50,13.50,N/A,3.15,N/A,22.50,N/A,12.65,N/A,7.65,N/A,22.50,N/A,3.15,N/A,22.50,N/A,22.50,N/A,22.50,N/A,22.50,N/A,22.50,N/A,22.50,N/A,12.65,N/A,22.50,N/A,3.15,N/A,12.06,N/A,12.06,N/A,3.15,N/A,22.50,N/A,22.50,N/A,22.50,13.50,13.50,3.15,22.50,,Hospital HCPCS J0665,BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,55150-0169-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.00,16.00,9.60,9.60,N/A,2.24,N/A,16.00,N/A,9.00,N/A,5.44,N/A,16.00,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,N/A,16.00,N/A,16.00,N/A,16.00,N/A,9.00,N/A,16.00,N/A,2.24,N/A,8.58,N/A,8.58,N/A,2.24,N/A,16.00,N/A,16.00,N/A,16.00,9.60,9.60,2.24,16.00,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),63323-0466-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),42.60,42.60,25.56,25.56,N/A,5.96,N/A,42.60,N/A,23.95,N/A,14.48,N/A,42.60,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,23.95,N/A,42.60,N/A,5.96,N/A,22.83,N/A,22.83,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,25.56,25.56,5.96,42.60,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.25 % IJ SOLN,00409-1160-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J0665,BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),00409-1163-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),42.60,42.60,25.56,25.56,N/A,5.96,N/A,42.60,N/A,23.95,N/A,14.48,N/A,42.60,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,42.60,N/A,23.95,N/A,42.60,N/A,5.96,N/A,22.83,N/A,22.83,N/A,5.96,N/A,42.60,N/A,42.60,N/A,42.60,25.56,25.56,5.96,42.60,,Hospital HCPCS J0694,CEFOXITIN SODIUM 1 G IV SOLR,25021-0109-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),40.50,40.50,24.30,24.30,N/A,5.67,N/A,40.50,N/A,22.77,N/A,13.77,N/A,11.99,N/A,5.67,N/A,40.50,N/A,40.50,N/A,7.46,N/A,11.99,N/A,11.99,N/A,11.99,N/A,22.77,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,5.67,N/A,40.50,N/A,40.50,N/A,40.50,24.30,24.30,5.67,40.50,,Hospital HCPCS J0694,CEFOXITIN SODIUM 10 G IV SOLR,25021-0111-99,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),492.50,492.50,295.50,295.50,N/A,68.95,N/A,492.50,N/A,276.88,N/A,167.45,N/A,119.92,N/A,68.95,N/A,492.50,N/A,492.50,N/A,74.65,N/A,119.92,N/A,119.92,N/A,119.92,N/A,276.88,N/A,492.50,N/A,68.95,N/A,263.98,N/A,263.98,N/A,68.95,N/A,492.50,N/A,492.50,N/A,492.50,295.50,295.50,68.95,492.50,,Hospital J0698,Cefotaxime Sodium Injection,N/A,N/A,2541195.52,N/A,1524717.31,N/A,442322.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,442322.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,442322.58,N/A,N/A,N/A,N/A,N/A,442322.58,N/A,N/A,N/A,N/A,N/A,442322.58,N/A,442322.58,1524717.31,N/A,N/A,,Hospital HCPCS J0702,BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,09999-9900-27,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),67.50,67.50,40.50,40.50,N/A,9.45,N/A,67.50,N/A,37.95,N/A,22.95,N/A,16.96,N/A,9.45,N/A,67.50,N/A,67.50,N/A,10.56,N/A,16.96,N/A,16.96,N/A,16.96,N/A,37.95,N/A,67.50,N/A,9.45,N/A,36.18,N/A,36.18,N/A,9.45,N/A,67.50,N/A,67.50,N/A,67.50,40.50,40.50,9.45,67.50,,Hospital HCPCS J0706,CAFFEINE CITRATE 60 MG/3ML IV SOLN,63323-0407-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),55.00,55.00,33.00,33.00,N/A,7.70,N/A,55.00,N/A,30.92,N/A,18.70,N/A,25.80,N/A,7.70,N/A,55.00,N/A,55.00,N/A,16.06,N/A,25.80,N/A,25.80,N/A,25.80,N/A,30.92,N/A,55.00,N/A,7.70,N/A,29.48,N/A,29.48,N/A,7.70,N/A,55.00,N/A,55.00,N/A,55.00,33.00,33.00,7.70,55.00,,Hospital J0713,Inj Ceftazidime per 500 Mg,N/A,N/A,26165.00,29643.62,15699.00,17786.17,22533.44,4115.21,26921.54,3846.17,26165.00,17068.07,8896.10,9958.13,13215.94,8744.18,23227.73,4115.21,26921.54,3616.03,26921.54,3616.03,8226.28,5443.43,13215.94,8744.18,13215.94,8744.18,13215.94,8744.18,26165.00,17068.07,26921.54,3616.03,23227.73,4115.21,5200.00,5963.00,5200.00,5963.00,23227.73,4115.21,26921.54,3616.03,26921.54,3846.17,24853.67,1118.43,5200.00,26921.54,1118.43,17786.17,,Hospital HCPCS J0714,CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,00456-2700-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2422.00,2422.00,1453.20,1453.20,N/A,339.08,N/A,2422.00,N/A,1361.65,N/A,823.48,N/A,950.94,N/A,339.08,N/A,2422.00,N/A,2422.00,N/A,591.97,N/A,950.94,N/A,950.94,N/A,950.94,N/A,1361.65,N/A,2422.00,N/A,339.08,N/A,1298.19,N/A,1298.19,N/A,339.08,N/A,2422.00,N/A,2422.00,N/A,2422.00,1453.20,1453.20,339.08,2422.00,,Hospital HCPCS J0717,CERTOLIZUMAB PEGOL 2 X 200 MG/ML SC PSKT,50474-0710-79,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22948.60,22948.60,13769.16,13769.16,N/A,3212.80,N/A,2029.20,N/A,12901.70,N/A,7802.52,N/A,5780.88,N/A,3212.80,N/A,2029.20,N/A,2029.20,N/A,3598.65,N/A,5780.88,N/A,5780.88,N/A,5780.88,N/A,12901.70,N/A,2029.20,N/A,3212.80,N/A,12300.45,N/A,12300.45,N/A,3212.80,N/A,2029.20,N/A,2029.20,N/A,2232.12,13769.16,13769.16,2029.20,13769.16,,Hospital J0720,Chloramphenicol Sodium Injec,N/A,N/A,242499.68,N/A,145499.81,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145499.81,145499.81,N/A,N/A,,Hospital HCPCS J0735,CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,39822-2000-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),25.40,25.40,15.24,15.24,N/A,3.56,N/A,25.40,N/A,14.28,N/A,8.64,N/A,25.40,N/A,3.56,N/A,25.40,N/A,25.40,N/A,25.40,N/A,25.40,N/A,25.40,N/A,25.40,N/A,14.28,N/A,25.40,N/A,3.56,N/A,13.61,N/A,13.61,N/A,3.56,N/A,25.40,N/A,25.40,N/A,25.40,15.24,15.24,3.56,25.40,,Hospital J0742,Inj imip 4 cilas 4 releb 2mg,N/A,N/A,872283.73,N/A,523370.24,N/A,N/A,N/A,140735.57,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,140735.57,N/A,140735.57,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,140735.57,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,140735.57,N/A,140735.57,N/A,N/A,N/A,140735.57,523370.24,N/A,N/A,,Hospital J0743,Cilastatin Sodium Injection,N/A,N/A,139618.45,5762.27,83771.07,3457.36,N/A,777.89,25016.27,1405.45,N/A,3298.83,N/A,1959.17,N/A,3356.53,N/A,777.89,27108.09,1343.59,27108.09,1343.59,N/A,2089.51,N/A,3356.53,N/A,3356.53,N/A,3356.53,N/A,2899.23,27108.09,1343.59,N/A,777.89,N/A,1431.00,N/A,1431.00,N/A,777.89,27108.09,1343.59,27108.09,1405.45,N/A,255.31,25016.27,83771.07,255.31,3457.36,,Hospital HCPCS J0770,COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,39822-0615-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),63.00,63.00,37.80,37.80,N/A,8.82,N/A,63.00,N/A,35.42,N/A,21.42,N/A,39.29,N/A,8.82,N/A,63.00,N/A,63.00,N/A,24.46,N/A,39.29,N/A,39.29,N/A,39.29,N/A,35.42,N/A,63.00,N/A,8.82,N/A,33.77,N/A,33.77,N/A,8.82,N/A,63.00,N/A,63.00,N/A,63.00,37.80,37.80,8.82,63.00,,Hospital J0775,"HC Collagenase, Clost Hist Inj",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,623.00,N/A,373.80,N/A,87.22,N/A,386.44,N/A,357.53,N/A,211.82,N/A,87.00,N/A,87.22,N/A,368.33,N/A,368.33,N/A,94.92,N/A,87.00,N/A,87.00,N/A,87.00,N/A,357.53,N/A,368.33,N/A,87.22,N/A,333.93,N/A,333.93,N/A,87.22,N/A,368.33,N/A,386.44,N/A,88.37,N/A,N/A,87.00,386.44,,Hospital J0791,Inj crizanlizumab-tmca 5mg,N/A,N/A,111058.40,126200.90,66635.04,75720.54,4790.49,17672.60,5932.54,10326.92,61215.39,70975.36,37759.85,42908.31,10899.03,26363.65,4938.09,17672.60,5932.54,10315.02,5932.54,10315.02,6784.39,16411.63,10899.03,26363.65,N/A,26363.65,10899.03,26363.65,N/A,70975.36,N/A,10315.02,4938.09,17672.60,12967.12,862.53,12967.12,862.53,4751.03,17672.60,5932.54,10315.02,5932.54,10326.92,5283.76,107.99,4751.03,66635.04,107.99,75720.54,,Hospital HCPCS J0840,CROTALIDAE POLYVAL IMMUNE FAB IV SOLR,50633-0111-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),13347.70,13347.70,8008.62,8008.62,N/A,1868.68,N/A,13347.70,N/A,7504.08,N/A,4538.22,N/A,6747.96,N/A,1868.68,N/A,13347.70,N/A,13347.70,N/A,4200.67,N/A,6747.96,N/A,6747.96,N/A,6747.96,N/A,7504.08,N/A,13347.70,N/A,1868.68,N/A,7154.37,N/A,7154.37,N/A,1868.68,N/A,13347.70,N/A,13347.70,N/A,13347.70,8008.62,8008.62,1868.68,13347.70,,Hospital J0850,Cytomegalovirus Imm IV /Vial,N/A,N/A,N/A,53930.50,N/A,32358.30,N/A,7550.27,N/A,5720.48,N/A,30336.38,N/A,18336.37,N/A,13493.05,N/A,7550.27,N/A,5705.65,N/A,5705.65,N/A,8399.55,N/A,13493.05,N/A,13493.05,N/A,13493.05,N/A,30336.38,N/A,5705.65,N/A,7550.27,N/A,28906.75,N/A,28906.75,N/A,7550.27,N/A,5705.65,N/A,99.94,N/A,109.93,N/A,N/A,99.94,32358.30,,Hospital J0878,Daptomycin injection,N/A,N/A,83257.32,1403.50,49954.39,842.10,10445.21,170.79,21035.62,195.13,32829.81,806.09,22728.70,477.17,26897.80,515.97,10445.21,170.79,13959.48,186.54,13639.39,186.54,26920.14,321.20,26920.14,515.97,30420.60,515.97,25666.72,515.97,31599.72,606.31,23933.85,295.68,10445.21,170.79,31599.72,217.41,26199.27,217.41,10588.38,170.79,15581.16,295.68,14092.38,309.30,10445.21,130.81,10445.21,49954.39,130.81,842.10,,Hospital HCPCS J0881,DARBEPOETIN ALFA 25 MCG/ML IJ SOLN,55513-0002-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),870.80,870.80,522.48,522.48,N/A,121.91,N/A,73.40,N/A,489.56,N/A,296.07,N/A,214.97,N/A,121.91,N/A,73.40,N/A,73.40,N/A,133.82,N/A,214.97,N/A,214.97,N/A,214.97,N/A,489.56,N/A,73.40,N/A,121.91,N/A,466.75,N/A,466.75,N/A,121.91,N/A,73.40,N/A,73.40,N/A,80.74,522.48,522.48,73.40,522.48,,Hospital HCPCS J0881,DARBEPOETIN ALFA 100 MCG/0.5ML IJ SOSY,55513-0025-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3483.00,3483.00,2089.80,2089.80,N/A,487.62,N/A,293.60,N/A,1958.14,N/A,1184.22,N/A,859.88,N/A,487.62,N/A,293.60,N/A,293.60,N/A,535.28,N/A,859.88,N/A,859.88,N/A,859.88,N/A,1958.14,N/A,293.60,N/A,487.62,N/A,1866.89,N/A,1866.89,N/A,487.62,N/A,293.60,N/A,293.60,N/A,322.96,2089.80,2089.80,293.60,2089.80,,Hospital HCPCS J0881,DARBEPOETIN ALFA 150 MCG/0.3ML IJ SOSY,55513-0027-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5224.50,5224.50,3134.70,3134.70,N/A,731.43,N/A,440.40,N/A,2937.21,N/A,1776.33,N/A,1289.82,N/A,731.43,N/A,440.40,N/A,440.40,N/A,802.93,N/A,1289.82,N/A,1289.82,N/A,1289.82,N/A,2937.21,N/A,440.40,N/A,731.43,N/A,2800.33,N/A,2800.33,N/A,731.43,N/A,440.40,N/A,440.40,N/A,484.44,3134.70,3134.70,440.40,3134.70,,Hospital HCPCS J0881,DARBEPOETIN ALFA 60 MCG/ML IJ SOLN,55513-0004-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2089.80,2089.80,1253.88,1253.88,N/A,292.57,N/A,176.16,N/A,1174.89,N/A,710.53,N/A,515.93,N/A,292.57,N/A,176.16,N/A,176.16,N/A,321.17,N/A,515.93,N/A,515.93,N/A,515.93,N/A,1174.89,N/A,176.16,N/A,292.57,N/A,1120.13,N/A,1120.13,N/A,292.57,N/A,176.16,N/A,176.16,N/A,193.78,1253.88,1253.88,176.16,1253.88,,Hospital HCPCS J0881,DARBEPOETIN ALFA 200 MCG/ML IJ SOLN,55513-0006-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6966.00,6966.00,4179.60,4179.60,N/A,975.24,N/A,587.20,N/A,3916.29,N/A,2368.44,N/A,1719.76,N/A,975.24,N/A,587.20,N/A,587.20,N/A,1070.57,N/A,1719.76,N/A,1719.76,N/A,1719.76,N/A,3916.29,N/A,587.20,N/A,975.24,N/A,3733.78,N/A,3733.78,N/A,975.24,N/A,587.20,N/A,587.20,N/A,645.92,4179.60,4179.60,587.20,4179.60,,Hospital HCPCS J0881,DARBEPOETIN ALFA 300 MCG/0.6ML IJ SOSY,55513-0111-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),10449.00,10449.00,6269.40,6269.40,N/A,1462.86,N/A,880.80,N/A,5874.43,N/A,3552.66,N/A,2579.64,N/A,1462.86,N/A,880.80,N/A,880.80,N/A,1605.85,N/A,2579.64,N/A,2579.64,N/A,2579.64,N/A,5874.43,N/A,880.80,N/A,1462.86,N/A,5600.66,N/A,5600.66,N/A,1462.86,N/A,880.80,N/A,880.80,N/A,968.88,6269.40,6269.40,880.80,6269.40,,Hospital HCPCS J0881,DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY,55513-0028-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6966.00,6966.00,4179.60,4179.60,N/A,975.24,N/A,587.20,N/A,3916.29,N/A,2368.44,N/A,1719.76,N/A,975.24,N/A,587.20,N/A,587.20,N/A,1070.57,N/A,1719.76,N/A,1719.76,N/A,1719.76,N/A,3916.29,N/A,587.20,N/A,975.24,N/A,3733.78,N/A,3733.78,N/A,975.24,N/A,587.20,N/A,587.20,N/A,645.92,4179.60,4179.60,587.20,4179.60,,Hospital HCPCS J0881,DARBEPOETIN ALFA 40 MCG/ML IJ SOLN,55513-0003-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1393.20,1393.20,835.92,835.92,N/A,195.05,N/A,117.44,N/A,783.26,N/A,473.69,N/A,343.95,N/A,195.05,N/A,117.44,N/A,117.44,N/A,214.11,N/A,343.95,N/A,343.95,N/A,343.95,N/A,783.26,N/A,117.44,N/A,195.05,N/A,746.76,N/A,746.76,N/A,195.05,N/A,117.44,N/A,117.44,N/A,129.18,835.92,835.92,117.44,835.92,,Hospital HCPCS J0881,DARBEPOETIN ALFA 100 MCG/ML IJ SOLN,55513-0005-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3483.00,3483.00,2089.80,2089.80,N/A,487.62,N/A,293.60,N/A,1958.14,N/A,1184.22,N/A,859.88,N/A,487.62,N/A,293.60,N/A,293.60,N/A,535.28,N/A,859.88,N/A,859.88,N/A,859.88,N/A,1958.14,N/A,293.60,N/A,487.62,N/A,1866.89,N/A,1866.89,N/A,487.62,N/A,293.60,N/A,293.60,N/A,322.96,2089.80,2089.80,293.60,2089.80,,Hospital HCPCS J0881,DARBEPOETIN ALFA 500 MCG/ML IJ SOSY,55513-0032-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17415.00,17415.00,10449.00,10449.00,N/A,2438.10,N/A,1468.00,N/A,9790.71,N/A,5921.10,N/A,4299.40,N/A,2438.10,N/A,1468.00,N/A,1468.00,N/A,2676.42,N/A,4299.40,N/A,4299.40,N/A,4299.40,N/A,9790.71,N/A,1468.00,N/A,2438.10,N/A,9334.44,N/A,9334.44,N/A,2438.10,N/A,1468.00,N/A,1468.00,N/A,1614.80,10449.00,10449.00,1468.00,10449.00,,Hospital HCPCS J0884,ARGATROBAN 50 MG/50ML IV SOLN,00143-9559-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1336.50,1336.50,801.90,801.90,N/A,187.11,N/A,62.60,N/A,751.38,N/A,454.41,N/A,505.05,N/A,187.11,N/A,62.60,N/A,62.60,N/A,314.40,N/A,505.05,N/A,505.05,N/A,505.05,N/A,751.38,N/A,62.60,N/A,187.11,N/A,716.36,N/A,716.36,N/A,187.11,N/A,62.60,N/A,62.60,N/A,1336.50,801.90,801.90,62.60,1336.50,,Hospital J0894,Decitabine injection,N/A,N/A,164908.10,5579.00,98944.86,3347.40,6541.37,781.06,45192.81,338.63,N/A,3171.38,N/A,1896.86,N/A,1026.89,6541.37,781.06,45192.81,338.63,45192.81,338.63,N/A,639.26,N/A,1026.89,N/A,1026.89,N/A,1026.89,N/A,3171.38,45192.81,338.63,6541.37,781.06,N/A,2990.34,N/A,2990.34,6541.37,781.06,45192.81,338.63,45192.81,338.63,6541.37,372.50,6541.37,98944.86,338.63,3347.40,,Hospital HCPCS J1020,METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,00009-0306-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),133.20,133.20,79.92,79.92,N/A,18.65,N/A,133.20,N/A,74.89,N/A,45.29,N/A,27.04,N/A,18.65,N/A,133.20,N/A,133.20,N/A,16.83,N/A,27.04,N/A,27.04,N/A,27.04,N/A,74.89,N/A,133.20,N/A,18.65,N/A,71.40,N/A,71.40,N/A,18.65,N/A,133.20,N/A,133.20,N/A,133.20,79.92,79.92,16.83,133.20,,Hospital HCPCS J1020,METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,00009-3475-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),133.20,133.20,79.92,79.92,N/A,18.65,N/A,133.20,N/A,74.89,N/A,45.29,N/A,27.04,N/A,18.65,N/A,133.20,N/A,133.20,N/A,16.83,N/A,27.04,N/A,27.04,N/A,27.04,N/A,74.89,N/A,133.20,N/A,18.65,N/A,71.40,N/A,71.40,N/A,18.65,N/A,133.20,N/A,133.20,N/A,133.20,79.92,79.92,16.83,133.20,,Hospital J1040,HC Methylprednisolone 80 Mg Inj,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),68908.53,2601.20,41345.12,1560.72,6443.15,364.17,7887.55,581.86,14520.17,1496.27,23428.90,884.41,14659.07,1434.51,6641.68,364.17,562.00,581.86,562.00,581.86,9124.93,893.01,14659.07,1434.51,14659.07,1434.51,14659.07,1434.51,14520.17,1496.27,7887.55,581.86,6641.68,364.17,17440.63,1394.25,17440.63,1394.25,5719.50,364.17,7887.55,581.86,7887.55,581.86,7106.60,640.05,562.00,41345.12,364.17,1560.72,,Hospital J1055,Medrxyprogester Acetate Inj,N/A,N/A,N/A,300.00,N/A,180.00,N/A,42.00,N/A,64.81,N/A,172.74,N/A,102.00,N/A,147.37,N/A,42.00,N/A,60.93,N/A,60.93,N/A,91.74,N/A,147.37,N/A,147.37,N/A,147.37,N/A,172.74,N/A,60.93,N/A,42.00,N/A,160.80,N/A,160.80,N/A,42.00,N/A,60.93,N/A,64.81,N/A,14.73,N/A,N/A,14.73,180.00,,Hospital HCPCS J1100,DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN,00641-0367-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.68,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.05,N/A,1.68,N/A,1.68,N/A,1.68,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.05,15.00,,Hospital HCPCS J1100,DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,63323-0506-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.68,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.05,N/A,1.68,N/A,1.68,N/A,1.68,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.05,15.00,,Hospital HCPCS J1100,DEXAMETHASONE 4 MG/ML IJ SOLN (MIXTURES ONLY),63323-0165-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1100,DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN,63323-0165-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1100,DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOSY,76045-0109-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19.60,19.60,11.76,11.76,N/A,2.74,N/A,19.60,N/A,11.02,N/A,6.66,N/A,1.68,N/A,2.74,N/A,19.60,N/A,19.60,N/A,1.05,N/A,1.68,N/A,1.68,N/A,1.68,N/A,11.02,N/A,19.60,N/A,2.74,N/A,10.51,N/A,10.51,N/A,2.74,N/A,19.60,N/A,19.60,N/A,19.60,11.76,11.76,1.05,19.60,,Hospital HCPCS J1100,DEXAMETHASONE SODIUM PHOSPHATE 100 MG/10ML IJ SOLN,63323-0516-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.68,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.05,N/A,1.68,N/A,1.68,N/A,1.68,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.05,15.00,,Hospital HCPCS J1160,DIGOXIN 0.25 MG/ML IJ SOLN,00781-3059-95,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,00409-2634-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.52,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.30,N/A,8.52,N/A,8.52,N/A,8.52,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE 0.2 MG/ML 100 ML INFUSION PREMIX,71266-5035-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),181.60,181.60,108.96,108.96,N/A,25.42,N/A,181.60,N/A,102.10,N/A,61.74,N/A,42.61,N/A,25.42,N/A,181.60,N/A,181.60,N/A,26.52,N/A,42.61,N/A,42.61,N/A,42.61,N/A,102.10,N/A,181.60,N/A,25.42,N/A,97.34,N/A,97.34,N/A,25.42,N/A,181.60,N/A,181.60,N/A,181.60,108.96,108.96,25.42,181.60,,Hospital HCPCS J1170,HYDROMORPHONE HCL PF 1 MG/ML IJ SOLN,63323-0852-03,0250 - PHARMACY - GENERAL CLASSIFICATION,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.64,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.64,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE 1 MG/ML PCA (DISCRETE DOSING),09999-9912-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.52,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.30,N/A,8.52,N/A,8.52,N/A,8.52,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE 1 MG/ML PCA (DISCRETE DOSING),09999-9916-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),180.60,180.60,108.36,108.36,N/A,25.28,N/A,180.60,N/A,101.53,N/A,61.40,N/A,110.77,N/A,25.28,N/A,180.60,N/A,180.60,N/A,68.96,N/A,110.77,N/A,110.77,N/A,110.77,N/A,101.53,N/A,180.60,N/A,25.28,N/A,96.80,N/A,96.80,N/A,25.28,N/A,180.60,N/A,180.60,N/A,180.60,108.36,108.36,25.28,180.60,,Hospital HCPCS J1170,HYDROMORPHONE HCL 1 MG/ML IJ SOLN,00409-1283-31,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.52,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.30,N/A,8.52,N/A,8.52,N/A,8.52,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,00703-0113-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.52,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.30,N/A,8.52,N/A,8.52,N/A,8.52,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,63323-0851-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.52,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.30,N/A,8.52,N/A,8.52,N/A,8.52,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE 1 MG/ML PCA (DISCRETE DOSING),09999-9912-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,8.52,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.30,N/A,8.52,N/A,8.52,N/A,8.52,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1170,HYDROMORPHONE 1 MG/ML PCA (DISCRETE DOSING),09999-9915-73,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),126.40,126.40,75.84,75.84,N/A,17.70,N/A,126.40,N/A,71.06,N/A,42.98,N/A,68.17,N/A,17.70,N/A,126.40,N/A,126.40,N/A,42.44,N/A,68.17,N/A,68.17,N/A,68.17,N/A,71.06,N/A,126.40,N/A,17.70,N/A,67.75,N/A,67.75,N/A,17.70,N/A,126.40,N/A,126.40,N/A,126.40,75.84,75.84,17.70,126.40,,Hospital HCPCS J1212,DIMETHYL SULFOXIDE 50 % IS SOLN,67457-0177-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4175.60,4175.60,2505.36,2505.36,N/A,584.58,N/A,682.52,N/A,2347.52,N/A,1419.70,N/A,1648.30,N/A,584.58,N/A,682.52,N/A,682.52,N/A,1026.08,N/A,1648.30,N/A,1648.30,N/A,1648.30,N/A,2347.52,N/A,682.52,N/A,584.58,N/A,2238.12,N/A,2238.12,N/A,584.58,N/A,682.52,N/A,682.52,N/A,4175.60,2505.36,2505.36,584.58,4175.60,,Hospital J1240,Dimenhydrinate Injection,N/A,N/A,32100.90,N/A,19260.54,N/A,5682.97,N/A,6988.30,N/A,12807.04,N/A,10914.31,N/A,7322.00,N/A,5858.07,N/A,6988.30,N/A,6988.30,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,12807.04,N/A,6988.30,N/A,5858.07,N/A,15382.93,N/A,15382.93,N/A,5096.20,N/A,6988.30,N/A,6988.30,N/A,6268.14,N/A,4558.00,19260.54,N/A,N/A,,Hospital HCPCS J1250,DOBUTAMINE HCL 250 MG/20ML IV SOLN,00409-2344-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),38.10,38.10,22.86,22.86,N/A,5.33,N/A,38.10,N/A,21.42,N/A,12.95,N/A,16.45,N/A,5.33,N/A,38.10,N/A,38.10,N/A,10.24,N/A,16.45,N/A,16.45,N/A,16.45,N/A,21.42,N/A,38.10,N/A,5.33,N/A,20.42,N/A,20.42,N/A,5.33,N/A,38.10,N/A,38.10,N/A,38.10,22.86,22.86,5.33,38.10,,Hospital HCPCS J1250,DOBUTAMINE IN D5W 1-5 MG/ML-% IV SOLN,00338-1073-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),151.90,151.90,91.14,91.14,N/A,21.27,N/A,151.90,N/A,85.40,N/A,51.65,N/A,16.45,N/A,21.27,N/A,151.90,N/A,151.90,N/A,10.24,N/A,16.45,N/A,16.45,N/A,16.45,N/A,85.40,N/A,151.90,N/A,21.27,N/A,81.42,N/A,81.42,N/A,21.27,N/A,151.90,N/A,151.90,N/A,151.90,91.14,91.14,10.24,151.90,,Hospital HCPCS J1250,DOBUTAMINE IN D5W 2 MG/ML IV SOLN,00338-1075-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),270.00,270.00,162.00,162.00,N/A,37.80,N/A,270.00,N/A,151.79,N/A,91.80,N/A,32.89,N/A,37.80,N/A,270.00,N/A,270.00,N/A,20.48,N/A,32.89,N/A,32.89,N/A,32.89,N/A,151.79,N/A,270.00,N/A,37.80,N/A,144.72,N/A,144.72,N/A,37.80,N/A,270.00,N/A,270.00,N/A,270.00,162.00,162.00,20.48,270.00,,Hospital HCPCS J1270,DOXERCALCIFEROL 4 MCG/2ML IV SOLN,58468-0123-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J1301,"Injection, edaravone, 1 mg",N/A,N/A,N/A,6329.20,N/A,3797.52,N/A,886.09,N/A,61.04,N/A,3562.65,N/A,2151.93,N/A,3715.66,N/A,886.09,N/A,1470.66,N/A,1470.66,N/A,2313.03,N/A,3715.66,N/A,3715.66,N/A,3715.66,N/A,3554.22,N/A,1470.66,N/A,886.09,N/A,3392.45,N/A,3392.45,N/A,886.09,N/A,1470.66,N/A,61.04,N/A,67.14,N/A,N/A,61.04,3797.52,,Hospital HCPCS J1303,RAVULIZUMAB-CWVZ 1100 MG/11ML IV SOLN,25682-0028-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),105666.00,105666.00,63399.60,63399.60,N/A,14793.24,N/A,24406.25,N/A,59405.43,N/A,35926.44,N/A,63843.24,N/A,14793.24,N/A,24406.25,N/A,24406.25,N/A,39743.03,N/A,63843.24,N/A,63843.24,N/A,63843.24,N/A,59405.43,N/A,24406.25,N/A,14793.24,N/A,56636.98,N/A,56636.98,N/A,14793.24,N/A,24406.25,N/A,24406.25,N/A,26846.88,63399.60,63399.60,14793.24,63843.24,,Hospital HCPCS J1303,RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN (MIXTURES ONLY),25682-0028-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),201726.00,201726.00,121035.60,121035.60,N/A,28241.64,N/A,46593.75,N/A,113410.36,N/A,68586.84,N/A,121882.55,N/A,28241.64,N/A,46593.75,N/A,46593.75,N/A,75873.06,N/A,121882.55,N/A,121882.55,N/A,121882.55,N/A,113410.36,N/A,46593.75,N/A,28241.64,N/A,108125.14,N/A,108125.14,N/A,28241.64,N/A,46593.75,N/A,46593.75,N/A,51253.13,121035.60,121035.60,28241.64,121882.55,,Hospital HCPCS J1303,RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN,25682-0025-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28818.10,28818.10,17290.86,17290.86,N/A,4034.53,N/A,6656.25,N/A,16201.54,N/A,9798.15,N/A,17411.79,N/A,4034.53,N/A,6656.25,N/A,6656.25,N/A,10839.01,N/A,17411.79,N/A,17411.79,N/A,17411.79,N/A,16201.54,N/A,6656.25,N/A,4034.53,N/A,15446.50,N/A,15446.50,N/A,4034.53,N/A,6656.25,N/A,6656.25,N/A,7321.88,17290.86,17290.86,4034.53,17411.79,,Hospital HCPCS J1303,RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN (MIXTURES ONLY),25682-0025-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),201726.00,201726.00,121035.60,121035.60,N/A,28241.64,N/A,46593.75,N/A,113410.36,N/A,68586.84,N/A,121882.55,N/A,28241.64,N/A,46593.75,N/A,46593.75,N/A,75873.06,N/A,121882.55,N/A,121882.55,N/A,121882.55,N/A,113410.36,N/A,46593.75,N/A,28241.64,N/A,108125.14,N/A,108125.14,N/A,28241.64,N/A,46593.75,N/A,46593.75,N/A,51253.13,121035.60,121035.60,28241.64,121882.55,,Hospital HCPCS J1325,EPOPROSTENOL SODIUM 1.5 MG IV SOLR,62756-0060-40,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),300.40,300.40,180.24,180.24,N/A,42.06,N/A,300.40,N/A,168.88,N/A,102.14,N/A,122.53,N/A,42.06,N/A,300.40,N/A,300.40,N/A,76.28,N/A,122.53,N/A,122.53,N/A,122.53,N/A,168.88,N/A,300.40,N/A,42.06,N/A,161.01,N/A,161.01,N/A,42.06,N/A,300.40,N/A,300.40,N/A,300.40,180.24,180.24,42.06,300.40,,Hospital HCPCS J1325,EPOPROSTENOL SODIUM 0.5 MG IV SOLR,00173-0517-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),126.20,126.20,75.72,75.72,N/A,17.67,N/A,126.20,N/A,70.95,N/A,42.91,N/A,40.84,N/A,17.67,N/A,126.20,N/A,126.20,N/A,25.43,N/A,40.84,N/A,40.84,N/A,40.84,N/A,70.95,N/A,126.20,N/A,17.67,N/A,67.64,N/A,67.64,N/A,17.67,N/A,126.20,N/A,126.20,N/A,126.20,75.72,75.72,17.67,126.20,,Hospital HCPCS J1380,ESTRADIOL VALERATE 40 MG/ML IM OIL,42023-0112-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),152.90,152.90,91.74,91.74,N/A,21.41,N/A,152.90,N/A,85.96,N/A,51.99,N/A,25.38,N/A,21.41,N/A,152.90,N/A,152.90,N/A,15.80,N/A,25.38,N/A,25.38,N/A,25.38,N/A,85.96,N/A,152.90,N/A,21.41,N/A,81.95,N/A,81.95,N/A,21.41,N/A,152.90,N/A,152.90,N/A,152.90,91.74,91.74,15.80,152.90,,Hospital HCPCS J1380,ESTRADIOL VALERATE 20 MG/ML IM OIL,42023-0111-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),126.30,126.30,75.78,75.78,N/A,17.68,N/A,126.30,N/A,71.01,N/A,42.94,N/A,25.38,N/A,17.68,N/A,126.30,N/A,126.30,N/A,15.80,N/A,25.38,N/A,25.38,N/A,25.38,N/A,71.01,N/A,126.30,N/A,17.68,N/A,67.70,N/A,67.70,N/A,17.68,N/A,126.30,N/A,126.30,N/A,126.30,75.78,75.78,15.80,126.30,,Hospital HCPCS J1410,ESTROGENS CONJUGATED 25 MG IJ SOLR,00046-0749-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2297.10,2297.10,1378.26,1378.26,N/A,321.59,N/A,2297.10,N/A,1291.43,N/A,781.01,N/A,916.01,N/A,321.59,N/A,2297.10,N/A,2297.10,N/A,570.22,N/A,916.01,N/A,916.01,N/A,916.01,N/A,1291.43,N/A,2297.10,N/A,321.59,N/A,1231.25,N/A,1231.25,N/A,321.59,N/A,2297.10,N/A,2297.10,N/A,2297.10,1378.26,1378.26,321.59,2297.10,,Hospital HCPCS J1451,FOMEPIZOLE 1.5 GM/1.5ML IV SOLN,67457-0211-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6655.50,6655.50,3993.30,3993.30,N/A,931.77,N/A,6655.50,N/A,3741.72,N/A,2262.87,N/A,3885.00,N/A,931.77,N/A,6655.50,N/A,6655.50,N/A,2418.45,N/A,3885.00,N/A,3885.00,N/A,3885.00,N/A,3741.72,N/A,6655.50,N/A,931.77,N/A,3567.35,N/A,3567.35,N/A,931.77,N/A,6655.50,N/A,6655.50,N/A,6655.50,3993.30,3993.30,931.77,6655.50,,Hospital J1455,Foscarnet Sodium Injection,N/A,N/A,206423.38,N/A,123854.03,N/A,N/A,N/A,28630.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16298.00,N/A,16298.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28630.50,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28630.50,N/A,28630.50,N/A,N/A,N/A,16298.00,123854.03,N/A,N/A,,Hospital J1459,Inj IVIG privigen 500 mg,N/A,N/A,131756.60,38496.40,79053.96,23097.84,4722.96,5355.82,12212.00,4130.72,72624.24,21701.72,44797.25,13088.78,23754.54,10232.81,4484.43,5355.82,12212.00,4071.24,12212.00,4071.24,14786.65,6370.02,23754.54,10232.81,23754.54,10232.81,23754.54,10232.81,72624.24,19686.88,12212.00,4071.24,4484.43,5355.82,28261.97,1877.50,28261.97,1877.50,952.29,5355.82,12212.00,4071.24,12212.00,4130.72,4798.34,239.99,952.29,79053.96,239.99,23097.84,,Hospital J1460,Gamma Globulin 1 Cc Inj,N/A,N/A,N/A,414.00,N/A,248.40,N/A,57.96,N/A,110.67,N/A,234.39,N/A,140.76,N/A,266.92,N/A,57.96,N/A,109.40,N/A,109.40,N/A,166.16,N/A,266.92,N/A,266.92,N/A,266.92,N/A,234.39,N/A,109.40,N/A,57.96,N/A,221.91,N/A,221.91,N/A,57.96,N/A,109.40,N/A,110.67,N/A,14.73,N/A,N/A,14.73,266.92,,Hospital HCPCS J1561,IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN,61953-0005-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4764.60,4764.60,2858.76,2858.76,N/A,667.04,N/A,1122.33,N/A,2678.66,N/A,1619.96,N/A,2098.94,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,1306.61,N/A,2098.94,N/A,2098.94,N/A,2098.94,N/A,2678.66,N/A,1122.33,N/A,667.04,N/A,2553.83,N/A,2553.83,N/A,667.04,N/A,1122.33,N/A,1122.33,N/A,4764.60,2858.76,2858.76,667.04,4764.60,,Hospital HCPCS J1561,IMMUNE GLOBULIN (GAMUNEX-C) 10%,13533-0800-71,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6003.00,6003.00,3601.80,3601.80,N/A,840.42,N/A,1012.80,N/A,3374.89,N/A,2041.02,N/A,2247.60,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1399.15,N/A,2247.60,N/A,2247.60,N/A,2247.60,N/A,3374.89,N/A,1012.80,N/A,840.42,N/A,3217.61,N/A,3217.61,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1114.08,3601.80,3601.80,840.42,3601.80,,Hospital HCPCS J1561,IMMUNE GLOBULIN (GAMUNEX-C) 10%,13533-0800-40,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6003.00,6003.00,3601.80,3601.80,N/A,840.42,N/A,1012.80,N/A,3374.89,N/A,2041.02,N/A,2247.60,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1399.15,N/A,2247.60,N/A,2247.60,N/A,2247.60,N/A,3374.89,N/A,1012.80,N/A,840.42,N/A,3217.61,N/A,3217.61,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1114.08,3601.80,3601.80,840.42,3601.80,,Hospital HCPCS J1561,IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IV SOLN,61953-0005-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9529.20,9529.20,5717.52,5717.52,N/A,1334.09,N/A,2244.66,N/A,5357.32,N/A,3239.93,N/A,4197.87,N/A,1334.09,N/A,2244.66,N/A,2244.66,N/A,2613.22,N/A,4197.87,N/A,4197.87,N/A,4197.87,N/A,5357.32,N/A,2244.66,N/A,1334.09,N/A,5107.65,N/A,5107.65,N/A,1334.09,N/A,2244.66,N/A,2244.66,N/A,9529.20,5717.52,5717.52,1334.09,9529.20,,Hospital HCPCS J1561,IMMUNE GLOBULIN (GAMUNEX-C) 10%,13533-0800-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6003.00,6003.00,3601.80,3601.80,N/A,840.42,N/A,1012.80,N/A,3374.89,N/A,2041.02,N/A,2247.60,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1399.15,N/A,2247.60,N/A,2247.60,N/A,2247.60,N/A,3374.89,N/A,1012.80,N/A,840.42,N/A,3217.61,N/A,3217.61,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1114.08,3601.80,3601.80,840.42,3601.80,,Hospital HCPCS J1561,IMMUNE GLOBULIN (HUMAN) 5 GM/50ML IJ SOLN,00944-2700-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3492.90,3492.90,2095.74,2095.74,N/A,489.01,N/A,460.31,N/A,1963.71,N/A,1187.59,N/A,1165.50,N/A,489.01,N/A,460.31,N/A,460.31,N/A,725.54,N/A,1165.50,N/A,1165.50,N/A,1165.50,N/A,1963.71,N/A,460.31,N/A,489.01,N/A,1872.19,N/A,1872.19,N/A,489.01,N/A,460.31,N/A,460.31,N/A,506.34,2095.74,2095.74,460.31,2095.74,,Hospital HCPCS J1561,IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN,00944-2700-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12006.00,12006.00,7203.60,7203.60,N/A,1680.84,N/A,2025.60,N/A,6749.77,N/A,4082.04,N/A,4495.20,N/A,1680.84,N/A,2025.60,N/A,2025.60,N/A,2798.31,N/A,4495.20,N/A,4495.20,N/A,4495.20,N/A,6749.77,N/A,2025.60,N/A,1680.84,N/A,6435.22,N/A,6435.22,N/A,1680.84,N/A,2025.60,N/A,2025.60,N/A,2228.16,7203.60,7203.60,1680.84,7203.60,,Hospital HCPCS J1561,IMMUNE GLOBULIN (HUMAN) 5 GM/50ML IV SOLN,61953-0005-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2382.30,2382.30,1429.38,1429.38,N/A,333.52,N/A,561.16,N/A,1339.33,N/A,809.98,N/A,1049.47,N/A,333.52,N/A,561.16,N/A,561.16,N/A,653.30,N/A,1049.47,N/A,1049.47,N/A,1049.47,N/A,1339.33,N/A,561.16,N/A,333.52,N/A,1276.91,N/A,1276.91,N/A,333.52,N/A,561.16,N/A,561.16,N/A,2382.30,1429.38,1429.38,333.52,2382.30,,Hospital HCPCS J1561,IMMUNE GLOBULIN (GAMUNEX-C) 10%,13533-0800-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6003.00,6003.00,3601.80,3601.80,N/A,840.42,N/A,1012.80,N/A,3374.89,N/A,2041.02,N/A,2247.60,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1399.15,N/A,2247.60,N/A,2247.60,N/A,2247.60,N/A,3374.89,N/A,1012.80,N/A,840.42,N/A,3217.61,N/A,3217.61,N/A,840.42,N/A,1012.80,N/A,1012.80,N/A,1114.08,3601.80,3601.80,840.42,3601.80,,Hospital HCPCS J1580,GENTAMICIN IN SALINE 1 MG/ML IV SOLN,00338-0505-48,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29.10,29.10,17.46,17.46,N/A,4.07,N/A,29.10,N/A,16.36,N/A,9.89,N/A,12.28,N/A,4.07,N/A,29.10,N/A,29.10,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,16.36,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,4.07,N/A,29.10,N/A,29.10,N/A,29.10,17.46,17.46,4.07,29.10,,Hospital HCPCS J1580,GENTAMICIN SULFATE 2 MG/ML SYRINGE (PED-NEO) <50 ML,00338-0511-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28.10,28.10,16.86,16.86,N/A,3.93,N/A,28.10,N/A,15.80,N/A,9.55,N/A,12.28,N/A,3.93,N/A,28.10,N/A,28.10,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,15.80,N/A,28.10,N/A,3.93,N/A,15.06,N/A,15.06,N/A,3.93,N/A,28.10,N/A,28.10,N/A,28.10,16.86,16.86,3.93,28.10,,Hospital HCPCS J1580,GENTAMICIN SULFATE 40 MG/ML IJ SOLN,63323-0010-95,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,6.14,N/A,2.10,N/A,15.00,N/A,15.00,N/A,3.82,N/A,6.14,N/A,6.14,N/A,6.14,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1580,GENTAMICIN SULFATE 2 MG/ML IVPB (PED-NEO) >/= 50 ML,00338-0511-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28.10,28.10,16.86,16.86,N/A,3.93,N/A,28.10,N/A,15.80,N/A,9.55,N/A,12.28,N/A,3.93,N/A,28.10,N/A,28.10,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,15.80,N/A,28.10,N/A,3.93,N/A,15.06,N/A,15.06,N/A,3.93,N/A,28.10,N/A,28.10,N/A,28.10,16.86,16.86,3.93,28.10,,Hospital HCPCS J1580,GENTAMICIN IN SALINE 1-0.9 MG/ML-% IV SOLN,00338-0505-48,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29.10,29.10,17.46,17.46,N/A,4.07,N/A,29.10,N/A,16.36,N/A,9.89,N/A,12.28,N/A,4.07,N/A,29.10,N/A,29.10,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,16.36,N/A,29.10,N/A,4.07,N/A,15.60,N/A,15.60,N/A,4.07,N/A,29.10,N/A,29.10,N/A,29.10,17.46,17.46,4.07,29.10,,Hospital HCPCS J1580,GENTAMICIN IN SALINE 0.8-0.9 MG/ML-% IV SOLN,00338-0503-48,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),27.00,27.00,16.20,16.20,N/A,3.78,N/A,27.00,N/A,15.18,N/A,9.18,N/A,6.14,N/A,3.78,N/A,27.00,N/A,27.00,N/A,3.82,N/A,6.14,N/A,6.14,N/A,6.14,N/A,15.18,N/A,27.00,N/A,3.78,N/A,14.47,N/A,14.47,N/A,3.78,N/A,27.00,N/A,27.00,N/A,27.00,16.20,16.20,3.78,27.00,,Hospital HCPCS J1580,GENTAMICIN SULFATE 40 MG/ML IJ SOLN,63323-0010-94,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,6.14,N/A,2.10,N/A,15.00,N/A,15.00,N/A,3.82,N/A,6.14,N/A,6.14,N/A,6.14,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1580,GENTAMICIN IN SALINE 2-0.9 MG/ML-% IV SOLN,00338-0511-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28.10,28.10,16.86,16.86,N/A,3.93,N/A,28.10,N/A,15.80,N/A,9.55,N/A,12.28,N/A,3.93,N/A,28.10,N/A,28.10,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,15.80,N/A,28.10,N/A,3.93,N/A,15.06,N/A,15.06,N/A,3.93,N/A,28.10,N/A,28.10,N/A,28.10,16.86,16.86,3.93,28.10,,Hospital HCPCS J1580,GENTAMICIN SULFATE 10 MG/ML IJ SOLN,63323-0173-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),31.80,31.80,19.08,19.08,N/A,4.45,N/A,31.80,N/A,17.88,N/A,10.81,N/A,6.14,N/A,4.45,N/A,31.80,N/A,31.80,N/A,3.82,N/A,6.14,N/A,6.14,N/A,6.14,N/A,17.88,N/A,31.80,N/A,4.45,N/A,17.04,N/A,17.04,N/A,4.45,N/A,31.80,N/A,31.80,N/A,31.80,19.08,19.08,3.82,31.80,,Hospital HCPCS J1580,GENTAMICIN IN SALINE 1.2-0.9 MG/ML-% IV SOLN,00338-0507-48,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28.40,28.40,17.04,17.04,N/A,3.98,N/A,28.40,N/A,15.97,N/A,9.66,N/A,12.28,N/A,3.98,N/A,28.40,N/A,28.40,N/A,7.64,N/A,12.28,N/A,12.28,N/A,12.28,N/A,15.97,N/A,28.40,N/A,3.98,N/A,15.22,N/A,15.22,N/A,3.98,N/A,28.40,N/A,28.40,N/A,28.40,17.04,17.04,3.98,28.40,,Hospital HCPCS J1610,GLUCAGON (RDNA) 1 MG IJ KIT,00548-5850-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),472.50,472.50,283.50,283.50,N/A,66.15,N/A,195.18,N/A,265.64,N/A,160.65,N/A,444.44,N/A,66.15,N/A,195.18,N/A,195.18,N/A,276.67,N/A,444.44,N/A,444.44,N/A,444.44,N/A,265.64,N/A,195.18,N/A,66.15,N/A,253.26,N/A,253.26,N/A,66.15,N/A,195.18,N/A,195.18,N/A,214.69,283.50,283.50,66.15,444.44,,Hospital HCPCS J1610,GLUCAGON HCL RDNA (DIAGNOSTIC) 1 MG IJ SOLR,00597-0260-10,0250 - PHARMACY - GENERAL CLASSIFICATION,1158.30,1158.30,694.98,694.98,N/A,162.16,N/A,1158.30,N/A,666.95,N/A,393.82,N/A,1158.30,N/A,162.16,N/A,1158.30,N/A,1158.30,N/A,1158.30,N/A,1158.30,N/A,1158.30,N/A,1158.30,N/A,666.95,N/A,1158.30,N/A,162.16,N/A,620.85,N/A,620.85,N/A,162.16,N/A,1158.30,N/A,1158.30,N/A,1158.30,694.98,694.98,162.16,1158.30,,Hospital HCPCS J1611,GLUCAGON HCL (DIAGNOSTIC) 1 MG IJ SOLR,63323-0593-03,0250 - PHARMACY - GENERAL CLASSIFICATION,1150.90,1150.90,690.54,690.54,N/A,161.13,N/A,1150.90,N/A,662.69,N/A,391.31,N/A,1150.90,N/A,161.13,N/A,1150.90,N/A,1150.90,N/A,1150.90,N/A,1150.90,N/A,1150.90,N/A,1150.90,N/A,662.69,N/A,1150.90,N/A,161.13,N/A,616.88,N/A,616.88,N/A,161.13,N/A,1150.90,N/A,1150.90,N/A,1150.90,690.54,690.54,161.13,1150.90,,Hospital HCPCS J1611,GLUCAGON EMERGENCY 1 MG/ML IJ SOLR,63323-0582-82,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1888.70,1888.70,1133.22,1133.22,N/A,264.42,N/A,101.41,N/A,1061.83,N/A,642.16,N/A,149.04,N/A,264.42,N/A,101.41,N/A,101.41,N/A,149.04,N/A,149.04,N/A,149.04,N/A,149.04,N/A,1061.83,N/A,101.41,N/A,264.42,N/A,1012.34,N/A,1012.34,N/A,264.42,N/A,101.41,N/A,101.41,N/A,1888.70,1133.22,1133.22,101.41,1888.70,,Hospital J1626,Granisetron Hcl Injection,N/A,N/A,29595.48,58387.90,17757.29,35032.74,N/A,8175.10,N/A,12819.90,15903.89,32862.04,10062.47,19851.89,N/A,31627.56,N/A,8175.10,1124.00,12799.74,N/A,12799.74,N/A,19688.47,N/A,31627.56,N/A,31627.56,N/A,31627.56,N/A,32247.66,N/A,12799.74,N/A,8175.10,N/A,1020.98,17589.36,1020.98,N/A,8175.10,N/A,12799.74,N/A,12819.90,N/A,284.37,1124.00,17757.29,284.37,35032.74,,Hospital HCPCS J1631,HALOPERIDOL DECANOATE 50 MG/ML IM SOLN,10147-0921-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),80.40,80.40,48.24,48.24,N/A,11.26,N/A,80.40,N/A,45.20,N/A,27.34,N/A,22.66,N/A,11.26,N/A,80.40,N/A,80.40,N/A,14.11,N/A,22.66,N/A,22.66,N/A,22.66,N/A,45.20,N/A,80.40,N/A,11.26,N/A,43.09,N/A,43.09,N/A,11.26,N/A,80.40,N/A,80.40,N/A,80.40,48.24,48.24,11.26,80.40,,Hospital HCPCS J1642,HEPARIN NA (PORK) LOCK FLSH PF 10 UNIT/ML IV SOLN,64253-0222-35,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15.00,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1642,HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN,64253-0333-35,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15.00,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1642,HEPARIN (PORK) 100 UNIT/ML IV SOLN - (MIXTURES ONLY),64253-0333-33,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15.00,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1642,HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN,64253-0333-33,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15.00,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1642,HEPARIN (PORK) 100 UNIT/ML IV SOLN - (MIXTURES ONLY),64253-0333-35,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,15.00,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1643,HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,71288-0402-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.20,16.20,9.72,9.72,N/A,2.27,N/A,16.20,N/A,9.11,N/A,5.51,N/A,N/A,N/A,2.27,N/A,16.20,N/A,16.20,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,9.11,N/A,16.20,N/A,2.27,N/A,8.68,N/A,8.68,N/A,2.27,N/A,16.20,N/A,16.20,N/A,16.20,9.72,9.72,2.27,16.20,,Hospital HCPCS J1643,HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,71288-0403-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.86,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.16,N/A,1.86,N/A,1.86,N/A,1.86,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.16,15.00,,Hospital HCPCS J1650,ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,71288-0411-80,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),121.50,121.50,72.90,72.90,N/A,17.01,N/A,121.50,N/A,68.31,N/A,41.31,N/A,23.62,N/A,17.01,N/A,121.50,N/A,121.50,N/A,14.70,N/A,23.62,N/A,23.62,N/A,23.62,N/A,68.31,N/A,121.50,N/A,17.01,N/A,65.12,N/A,65.12,N/A,17.01,N/A,121.50,N/A,121.50,N/A,121.50,72.90,72.90,14.70,121.50,,Hospital HCPCS J1650,ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,71288-0410-86,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),81.00,81.00,48.60,48.60,N/A,11.34,N/A,81.00,N/A,45.54,N/A,27.54,N/A,15.75,N/A,11.34,N/A,81.00,N/A,81.00,N/A,9.80,N/A,15.75,N/A,15.75,N/A,15.75,N/A,45.54,N/A,81.00,N/A,11.34,N/A,43.42,N/A,43.42,N/A,11.34,N/A,81.00,N/A,81.00,N/A,81.00,48.60,48.60,9.80,81.00,,Hospital HCPCS J1650,ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,71288-0410-88,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),101.30,101.30,60.78,60.78,N/A,14.18,N/A,101.30,N/A,56.95,N/A,34.44,N/A,19.68,N/A,14.18,N/A,101.30,N/A,101.30,N/A,12.25,N/A,19.68,N/A,19.68,N/A,19.68,N/A,56.95,N/A,101.30,N/A,14.18,N/A,54.30,N/A,54.30,N/A,14.18,N/A,101.30,N/A,101.30,N/A,101.30,60.78,60.78,12.25,101.30,,Hospital HCPCS J1650,ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,71288-0411-82,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),151.90,151.90,91.14,91.14,N/A,21.27,N/A,151.90,N/A,85.40,N/A,51.65,N/A,29.53,N/A,21.27,N/A,151.90,N/A,151.90,N/A,18.38,N/A,29.53,N/A,29.53,N/A,29.53,N/A,85.40,N/A,151.90,N/A,21.27,N/A,81.42,N/A,81.42,N/A,21.27,N/A,151.90,N/A,151.90,N/A,151.90,91.14,91.14,18.38,151.90,,Hospital HCPCS J1650,ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,71288-0410-84,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),60.80,60.80,36.48,36.48,N/A,8.51,N/A,60.80,N/A,34.18,N/A,20.67,N/A,11.81,N/A,8.51,N/A,60.80,N/A,60.80,N/A,7.35,N/A,11.81,N/A,11.81,N/A,11.81,N/A,34.18,N/A,60.80,N/A,8.51,N/A,32.59,N/A,32.59,N/A,8.51,N/A,60.80,N/A,60.80,N/A,60.80,36.48,36.48,7.35,60.80,,Hospital HCPCS J1670,TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,13533-0634-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2753.60,2753.60,1652.16,1652.16,N/A,385.50,N/A,2753.60,N/A,1548.07,N/A,936.22,N/A,1337.71,N/A,385.50,N/A,2753.60,N/A,2753.60,N/A,832.74,N/A,1337.71,N/A,1337.71,N/A,1337.71,N/A,1548.07,N/A,2753.60,N/A,385.50,N/A,1475.93,N/A,1475.93,N/A,385.50,N/A,2753.60,N/A,2753.60,N/A,2753.60,1652.16,1652.16,385.50,2753.60,,Hospital HCPCS J1720,HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,00009-0016-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),462.40,462.40,277.44,277.44,N/A,64.74,N/A,462.40,N/A,259.96,N/A,157.22,N/A,227.53,N/A,64.74,N/A,462.40,N/A,462.40,N/A,141.64,N/A,227.53,N/A,227.53,N/A,227.53,N/A,259.96,N/A,462.40,N/A,64.74,N/A,247.85,N/A,247.85,N/A,64.74,N/A,462.40,N/A,462.40,N/A,462.40,277.44,277.44,64.74,462.40,,Hospital HCPCS J1720,HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR,00009-0011-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),62.50,62.50,37.50,37.50,N/A,8.75,N/A,62.50,N/A,35.14,N/A,21.25,N/A,45.51,N/A,8.75,N/A,62.50,N/A,62.50,N/A,28.33,N/A,45.51,N/A,45.51,N/A,45.51,N/A,35.14,N/A,62.50,N/A,8.75,N/A,33.50,N/A,33.50,N/A,8.75,N/A,62.50,N/A,62.50,N/A,62.50,37.50,37.50,8.75,62.50,,Hospital HCPCS J1720,HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,00009-0013-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),115.60,115.60,69.36,69.36,N/A,16.18,N/A,115.60,N/A,64.99,N/A,39.30,N/A,91.01,N/A,16.18,N/A,115.60,N/A,115.60,N/A,56.66,N/A,91.01,N/A,91.01,N/A,91.01,N/A,64.99,N/A,115.60,N/A,16.18,N/A,61.96,N/A,61.96,N/A,16.18,N/A,115.60,N/A,115.60,N/A,115.60,69.36,69.36,16.18,115.60,,Hospital J1726,"HC Injection, Hydroxyprogesterone Caproate, (Makena), 10 Mg",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,1852.00,N/A,1111.20,N/A,259.52,N/A,110.42,N/A,1065.85,N/A,629.68,N/A,272.46,N/A,259.52,N/A,111.26,N/A,111.26,N/A,189.36,N/A,272.46,N/A,272.46,N/A,272.46,N/A,1065.86,N/A,220.40,N/A,259.52,N/A,808.82,N/A,808.82,N/A,259.52,N/A,220.40,N/A,218.62,N/A,71.47,N/A,N/A,71.47,1111.20,,Hospital J1740,Ibandronate sodium injection,N/A,N/A,N/A,2379.00,N/A,1427.40,N/A,333.06,N/A,252.85,N/A,1346.33,N/A,808.86,N/A,713.77,N/A,333.06,N/A,274.48,N/A,274.48,N/A,444.33,N/A,713.77,N/A,713.77,N/A,713.77,N/A,1346.33,N/A,274.48,N/A,333.06,N/A,1275.15,N/A,1275.15,N/A,333.06,N/A,274.48,N/A,252.85,N/A,39.24,N/A,N/A,39.24,1427.40,,Hospital HCPCS J1790,DROPERIDOL 2.5 MG/ML IJ SOLN,00517-9702-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,13.22,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1800,PROPRANOLOL HCL 1 MG/ML IV SOLN,00143-9872-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),54.00,54.00,32.40,32.40,N/A,7.56,N/A,54.00,N/A,30.36,N/A,18.36,N/A,20.72,N/A,7.56,N/A,54.00,N/A,54.00,N/A,12.90,N/A,20.72,N/A,20.72,N/A,20.72,N/A,30.36,N/A,54.00,N/A,7.56,N/A,28.94,N/A,28.94,N/A,7.56,N/A,54.00,N/A,54.00,N/A,54.00,32.40,32.40,7.56,54.00,,Hospital HCPCS J1806,ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,10019-0055-61,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3157.40,3157.40,1894.44,1894.44,N/A,442.04,N/A,3157.40,N/A,1775.09,N/A,1073.52,N/A,3157.40,N/A,442.04,N/A,3157.40,N/A,3157.40,N/A,3157.40,N/A,3157.40,N/A,3157.40,N/A,3157.40,N/A,1775.09,N/A,3157.40,N/A,442.04,N/A,1692.37,N/A,1692.37,N/A,442.04,N/A,3157.40,N/A,3157.40,N/A,3157.40,1894.44,1894.44,442.04,3157.40,,Hospital HCPCS J1815,INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOLN,00002-8501-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),4089.30,4089.30,2453.58,2453.58,N/A,572.50,N/A,4089.30,N/A,2299.00,N/A,1390.36,N/A,4089.30,N/A,572.50,N/A,4089.30,N/A,4089.30,N/A,2679.64,N/A,4089.30,N/A,4089.30,N/A,4089.30,N/A,2299.00,N/A,4089.30,N/A,572.50,N/A,2191.86,N/A,2191.86,N/A,572.50,N/A,4089.30,N/A,4089.30,N/A,4089.30,2453.58,2453.58,572.50,4089.30,,Hospital HCPCS J1815,INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN (INSULIN MIXTURES ONLY),00002-8215-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),409.00,409.00,245.40,245.40,N/A,57.26,N/A,409.00,N/A,229.94,N/A,139.06,N/A,409.00,N/A,57.26,N/A,409.00,N/A,409.00,N/A,267.96,N/A,409.00,N/A,409.00,N/A,409.00,N/A,229.94,N/A,409.00,N/A,57.26,N/A,219.22,N/A,219.22,N/A,57.26,N/A,409.00,N/A,409.00,N/A,409.00,245.40,245.40,57.26,409.00,,Hospital HCPCS J1815,INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,00002-8315-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),409.00,409.00,245.40,245.40,N/A,57.26,N/A,409.00,N/A,229.94,N/A,139.06,N/A,274.54,N/A,57.26,N/A,409.00,N/A,409.00,N/A,170.90,N/A,274.54,N/A,274.54,N/A,274.54,N/A,229.94,N/A,409.00,N/A,57.26,N/A,219.22,N/A,219.22,N/A,57.26,N/A,409.00,N/A,409.00,N/A,409.00,245.40,245.40,57.26,409.00,,Hospital HCPCS J1815,INSULIN ASPART PROT & ASPART (70-30) 100 UNIT/ML SC SUSP,00169-3685-12,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),825.40,825.40,495.24,495.24,N/A,115.56,N/A,825.40,N/A,464.04,N/A,280.64,N/A,274.54,N/A,115.56,N/A,825.40,N/A,825.40,N/A,170.90,N/A,274.54,N/A,274.54,N/A,274.54,N/A,464.04,N/A,825.40,N/A,115.56,N/A,442.41,N/A,442.41,N/A,115.56,N/A,825.40,N/A,825.40,N/A,825.40,495.24,495.24,115.56,825.40,,Hospital HCPCS J1815,INSULIN ASPART 100 UNIT/ML IJ SOLN,00169-7501-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),795.80,795.80,477.48,477.48,N/A,111.41,N/A,795.80,N/A,447.40,N/A,270.57,N/A,430.46,N/A,111.41,N/A,795.80,N/A,795.80,N/A,267.96,N/A,430.46,N/A,430.46,N/A,430.46,N/A,447.40,N/A,795.80,N/A,111.41,N/A,426.55,N/A,426.55,N/A,111.41,N/A,795.80,N/A,795.80,N/A,795.80,477.48,477.48,111.41,795.80,,Hospital HCPCS J1815,INSULIN GLARGINE 100 UNIT/ML SC SOLN,00955-1729-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),312.00,312.00,187.20,187.20,N/A,43.68,N/A,312.00,N/A,175.41,N/A,106.08,N/A,274.54,N/A,43.68,N/A,312.00,N/A,312.00,N/A,170.90,N/A,274.54,N/A,274.54,N/A,274.54,N/A,175.41,N/A,312.00,N/A,43.68,N/A,167.23,N/A,167.23,N/A,43.68,N/A,312.00,N/A,312.00,N/A,312.00,187.20,187.20,43.68,312.00,,Hospital HCPCS J1815,INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,00002-8215-17,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),122.70,122.70,73.62,73.62,N/A,17.18,N/A,122.70,N/A,68.98,N/A,41.72,N/A,122.70,N/A,17.18,N/A,122.70,N/A,122.70,N/A,80.39,N/A,122.70,N/A,122.70,N/A,122.70,N/A,68.98,N/A,122.70,N/A,17.18,N/A,65.77,N/A,65.77,N/A,17.18,N/A,122.70,N/A,122.70,N/A,122.70,73.62,73.62,17.18,122.70,,Hospital HCPCS J1815,INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,00002-7511-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),783.00,783.00,469.80,469.80,N/A,109.62,N/A,783.00,N/A,440.20,N/A,266.22,N/A,274.54,N/A,109.62,N/A,783.00,N/A,783.00,N/A,170.90,N/A,274.54,N/A,274.54,N/A,274.54,N/A,440.20,N/A,783.00,N/A,109.62,N/A,419.69,N/A,419.69,N/A,109.62,N/A,783.00,N/A,783.00,N/A,783.00,469.80,469.80,109.62,783.00,,Hospital HCPCS J1815,INSULIN NPH ISOPHANE & REGULAR (70-30) 100 UNIT/ML SC SUSP,00002-8715-17,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),122.70,122.70,73.62,73.62,N/A,17.18,N/A,122.70,N/A,68.98,N/A,41.72,N/A,82.36,N/A,17.18,N/A,122.70,N/A,122.70,N/A,51.27,N/A,82.36,N/A,82.36,N/A,82.36,N/A,68.98,N/A,122.70,N/A,17.18,N/A,65.77,N/A,65.77,N/A,17.18,N/A,122.70,N/A,122.70,N/A,122.70,73.62,73.62,17.18,122.70,,Hospital HCPCS J1815,INSULIN NPH ISOPHANE & REGULAR (70-30) 100 UNIT/ML SC SUSP,00002-8715-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),409.00,409.00,245.40,245.40,N/A,57.26,N/A,409.00,N/A,229.94,N/A,139.06,N/A,274.54,N/A,57.26,N/A,409.00,N/A,409.00,N/A,170.90,N/A,274.54,N/A,274.54,N/A,274.54,N/A,229.94,N/A,409.00,N/A,57.26,N/A,219.22,N/A,219.22,N/A,57.26,N/A,409.00,N/A,409.00,N/A,409.00,245.40,245.40,57.26,409.00,,Hospital J1833,"Injection, isavuconazonium",N/A,N/A,487863.37,N/A,292718.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,292718.02,292718.02,N/A,N/A,,Hospital HCPCS J1921,LABETALOL HCL 5 MG/ML IV SOLN,69374-0946-34,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J1921,LABETALOL HCL 5 MG/ML IV SOLN,00143-9622-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J1930,Lanreotide injection,N/A,N/A,N/A,43574.00,N/A,26144.40,N/A,6103.65,N/A,6562.77,N/A,24504.72,N/A,14815.16,N/A,20650.85,N/A,6103.65,N/A,6562.77,N/A,6562.77,N/A,12855.35,N/A,20650.85,N/A,20650.85,N/A,20650.85,N/A,24504.72,N/A,6562.77,N/A,6103.65,N/A,282.74,N/A,282.74,N/A,6103.65,N/A,6562.77,N/A,6562.77,N/A,7219.04,N/A,N/A,282.74,26144.40,,Hospital HCPCS J1940,FUROSEMIDE 10 MG/ML IJ SOLN,63323-0280-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.55,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,1.55,N/A,1.55,N/A,1.55,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.55,15.00,,Hospital HCPCS J1943,ARIPIPRAZOLE LAUROXIL ER 675 MG/2.4ML IM PRSY,65757-0500-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),10028.60,10028.60,6017.16,6017.16,N/A,1404.00,N/A,10028.60,N/A,5638.08,N/A,3409.72,N/A,5139.86,N/A,1404.00,N/A,10028.60,N/A,10028.60,N/A,3199.61,N/A,5139.86,N/A,5139.86,N/A,5139.86,N/A,5638.08,N/A,10028.60,N/A,1404.00,N/A,5375.33,N/A,5375.33,N/A,1404.00,N/A,10028.60,N/A,10028.60,N/A,10028.60,6017.16,6017.16,1404.00,10028.60,,Hospital J1956,Levofloxacin Injection,N/A,N/A,44861.50,22342.08,26916.90,13405.25,9770.36,3105.14,11853.13,4256.56,22040.37,12848.13,15252.91,7596.32,22228.92,10323.77,10071.40,3105.14,11823.48,4246.26,11823.48,4246.26,13836.98,6426.74,22228.92,10323.77,22228.92,10323.77,22228.92,10323.77,22040.37,12848.14,11823.48,4246.26,10071.40,3105.14,26446.86,5963.00,26446.86,5963.00,7641.45,3105.14,11823.48,4256.56,11853.13,4256.56,10776.40,4682.21,7641.45,26916.90,3105.14,13405.25,,Hospital HCPCS J2001,LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY,76329-3390-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2001,LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOSY,00409-1323-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2001,LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,00338-0409-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),47.30,47.30,28.38,28.38,N/A,6.62,N/A,47.30,N/A,26.59,N/A,16.08,N/A,10.36,N/A,6.62,N/A,47.30,N/A,47.30,N/A,6.45,N/A,10.36,N/A,10.36,N/A,10.36,N/A,26.59,N/A,47.30,N/A,6.62,N/A,25.35,N/A,25.35,N/A,6.62,N/A,47.30,N/A,47.30,N/A,47.30,28.38,28.38,6.45,47.30,,Hospital HCPCS J2001,LIDOCAINE (CARDIAC) 100 MG/5ML IV SOLN (MIXTURES ONLY),00409-1323-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2020,LINEZOLID 600 MG/300ML IV SOLN,00009-5140-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),324.00,324.00,194.40,194.40,N/A,45.36,N/A,324.00,N/A,182.15,N/A,110.16,N/A,37.76,N/A,45.36,N/A,324.00,N/A,324.00,N/A,23.51,N/A,37.76,N/A,37.76,N/A,37.76,N/A,182.15,N/A,324.00,N/A,45.36,N/A,173.66,N/A,173.66,N/A,45.36,N/A,324.00,N/A,324.00,N/A,324.00,194.40,194.40,23.51,324.00,,Hospital J2060,Lorazepam Injection,N/A,N/A,33682.90,32292.87,20209.74,19375.72,4145.53,4511.30,5169.60,4706.78,9342.30,7923.00,11452.19,10979.57,9431.66,12384.05,4273.26,4511.30,5169.60,4706.78,8461.19,4706.78,5870.99,7709.30,9431.66,12384.05,9431.66,12384.05,9431.66,12384.05,9342.30,7923.00,5169.60,4706.78,4273.26,4511.30,11221.32,7897.00,11221.32,7897.00,4333.44,4511.30,5169.60,4706.78,5169.60,4706.78,4572.39,5177.46,4145.53,20209.74,4511.30,19375.72,,Hospital HCPCS J2185,MEROPENEM 1 G IV SOLR,63323-0508-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),37.20,37.20,22.32,22.32,N/A,5.21,N/A,37.20,N/A,20.91,N/A,12.65,N/A,9.07,N/A,5.21,N/A,37.20,N/A,37.20,N/A,5.64,N/A,9.07,N/A,9.07,N/A,9.07,N/A,20.91,N/A,37.20,N/A,5.21,N/A,19.94,N/A,19.94,N/A,5.21,N/A,37.20,N/A,37.20,N/A,37.20,22.32,22.32,5.21,37.20,,Hospital HCPCS J2250,MIDAZOLAM HCL 10 MG/2ML IJ SOLN,63323-0412-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),19.10,19.10,11.46,11.46,N/A,2.67,N/A,19.10,N/A,10.74,N/A,6.49,N/A,2.20,N/A,2.67,N/A,19.10,N/A,19.10,N/A,1.37,N/A,2.20,N/A,2.20,N/A,2.20,N/A,10.74,N/A,19.10,N/A,2.67,N/A,10.24,N/A,10.24,N/A,2.67,N/A,19.10,N/A,19.10,N/A,19.10,11.46,11.46,1.37,19.10,,Hospital HCPCS J2250,MIDAZOLAM HCL 10 MG/10ML IJ SOLN,63323-0411-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN,00409-2305-17,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM 5 MG/ML SOLN (MIXTURES ONLY),63323-0412-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL (PF) 10 MG/2ML IJ SOLN,00409-2308-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,4.40,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.74,N/A,4.40,N/A,4.40,N/A,4.40,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL 2 MG/2ML IJ SOLN,00641-6057-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN,00409-2308-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL 5 MG/5ML IJ SOLN,00641-6210-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL 5 MG/ML IJ SOLN,00641-6061-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM 100 MG/100ML IV SOLN,69374-0314-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),142.50,142.50,85.50,85.50,N/A,19.95,N/A,142.50,N/A,80.11,N/A,48.45,N/A,44.03,N/A,19.95,N/A,142.50,N/A,142.50,N/A,27.41,N/A,44.03,N/A,44.03,N/A,44.03,N/A,80.11,N/A,142.50,N/A,19.95,N/A,76.38,N/A,76.38,N/A,19.95,N/A,142.50,N/A,142.50,N/A,142.50,85.50,85.50,19.95,142.50,,Hospital HCPCS J2250,MIDAZOLAM HCL 50 MG/10ML IJ SOLN,63323-0412-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),204.90,204.90,122.94,122.94,N/A,28.69,N/A,204.90,N/A,115.19,N/A,69.67,N/A,22.02,N/A,28.69,N/A,204.90,N/A,204.90,N/A,13.70,N/A,22.02,N/A,22.02,N/A,22.02,N/A,115.19,N/A,204.90,N/A,28.69,N/A,109.83,N/A,109.83,N/A,28.69,N/A,204.90,N/A,204.90,N/A,204.90,122.94,122.94,13.70,204.90,,Hospital HCPCS J2250,MIDAZOLAM 5 MG/ML SOLN (MIXTURES ONLY),00641-6060-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2250,MIDAZOLAM HCL 25 MG/5ML IJ SOLN,70860-0601-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),37.20,37.20,22.32,22.32,N/A,5.21,N/A,37.20,N/A,20.91,N/A,12.65,N/A,11.01,N/A,5.21,N/A,37.20,N/A,37.20,N/A,6.85,N/A,11.01,N/A,11.01,N/A,11.01,N/A,20.91,N/A,37.20,N/A,5.21,N/A,19.94,N/A,19.94,N/A,5.21,N/A,37.20,N/A,37.20,N/A,37.20,22.32,22.32,5.21,37.20,,Hospital HCPCS J2270,MORPHINE SULFATE 1 MG/ML IJ SOLN,69374-0979-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29.20,29.20,17.52,17.52,N/A,4.09,N/A,29.20,N/A,16.42,N/A,9.93,N/A,13.29,N/A,4.09,N/A,29.20,N/A,29.20,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,16.42,N/A,29.20,N/A,4.09,N/A,15.65,N/A,15.65,N/A,4.09,N/A,29.20,N/A,29.20,N/A,29.20,17.52,17.52,4.09,29.20,,Hospital HCPCS J2270,MORPHINE SULFATE 10 MG/ML IV SOLN,00641-6127-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,13.29,N/A,2.10,N/A,15.00,N/A,15.00,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2270,MORPHINE SULFATE 1 MG/ML PCA (DISCRETE DOSING),09999-9912-47,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),80.00,80.00,48.00,48.00,N/A,11.20,N/A,80.00,N/A,44.98,N/A,27.20,N/A,66.43,N/A,11.20,N/A,80.00,N/A,80.00,N/A,41.36,N/A,66.43,N/A,66.43,N/A,66.43,N/A,44.98,N/A,80.00,N/A,11.20,N/A,42.88,N/A,42.88,N/A,11.20,N/A,80.00,N/A,80.00,N/A,80.00,48.00,48.00,11.20,80.00,,Hospital HCPCS J2270,MORPHINE SULFATE 50 MG/ML IV SOLN,00409-1134-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),184.30,184.30,110.58,110.58,N/A,25.80,N/A,184.30,N/A,103.61,N/A,62.66,N/A,184.30,N/A,25.80,N/A,184.30,N/A,184.30,N/A,184.30,N/A,184.30,N/A,184.30,N/A,184.30,N/A,103.61,N/A,184.30,N/A,25.80,N/A,98.78,N/A,98.78,N/A,25.80,N/A,184.30,N/A,184.30,N/A,184.30,110.58,110.58,25.80,184.30,,Hospital HCPCS J2270,MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,00409-1891-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),24.10,24.10,14.46,14.46,N/A,3.37,N/A,24.10,N/A,13.55,N/A,8.19,N/A,13.29,N/A,3.37,N/A,24.10,N/A,24.10,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,13.55,N/A,24.10,N/A,3.37,N/A,12.92,N/A,12.92,N/A,3.37,N/A,24.10,N/A,24.10,N/A,24.10,14.46,14.46,3.37,24.10,,Hospital HCPCS J2270,MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,00409-1890-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),23.90,23.90,14.34,14.34,N/A,3.35,N/A,23.90,N/A,13.44,N/A,8.13,N/A,13.29,N/A,3.35,N/A,23.90,N/A,23.90,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,13.44,N/A,23.90,N/A,3.35,N/A,12.81,N/A,12.81,N/A,3.35,N/A,23.90,N/A,23.90,N/A,23.90,14.34,14.34,3.35,23.90,,Hospital HCPCS J2270,MORPHINE SULFATE 50 MG/ML IV SOLN,00409-1134-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),86.90,86.90,52.14,52.14,N/A,12.17,N/A,86.90,N/A,48.86,N/A,29.55,N/A,86.90,N/A,12.17,N/A,86.90,N/A,86.90,N/A,86.90,N/A,86.90,N/A,86.90,N/A,86.90,N/A,48.86,N/A,86.90,N/A,12.17,N/A,46.58,N/A,46.58,N/A,12.17,N/A,86.90,N/A,86.90,N/A,86.90,52.14,52.14,12.17,86.90,,Hospital HCPCS J2270,MORPHINE SULFATE 1 MG/ML PCA (DISCRETE DOSING),76329-1912-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),94.60,94.60,56.76,56.76,N/A,13.24,N/A,94.60,N/A,53.18,N/A,32.16,N/A,39.86,N/A,13.24,N/A,94.60,N/A,94.60,N/A,24.81,N/A,39.86,N/A,39.86,N/A,39.86,N/A,53.18,N/A,94.60,N/A,13.24,N/A,50.71,N/A,50.71,N/A,13.24,N/A,94.60,N/A,94.60,N/A,94.60,56.76,56.76,13.24,94.60,,Hospital HCPCS J2270,MORPHINE SULFATE 4 MG/ML IV SOLN,00641-6125-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,13.29,N/A,2.10,N/A,15.00,N/A,15.00,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2270,MORPHINE SULFATE 1 MG/ML PCA (DISCRETE DOSING),09999-9912-73,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),160.00,160.00,96.00,96.00,N/A,22.40,N/A,160.00,N/A,89.95,N/A,54.40,N/A,132.87,N/A,22.40,N/A,160.00,N/A,160.00,N/A,82.71,N/A,132.87,N/A,132.87,N/A,132.87,N/A,89.95,N/A,160.00,N/A,22.40,N/A,85.76,N/A,85.76,N/A,22.40,N/A,160.00,N/A,160.00,N/A,160.00,96.00,96.00,22.40,160.00,,Hospital HCPCS J2270,MORPHINE SULFATE 1 MG/ML INFUSION,09999-9912-73,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),160.00,160.00,96.00,96.00,N/A,22.40,N/A,160.00,N/A,89.95,N/A,54.40,N/A,132.87,N/A,22.40,N/A,160.00,N/A,160.00,N/A,82.71,N/A,132.87,N/A,132.87,N/A,132.87,N/A,89.95,N/A,160.00,N/A,22.40,N/A,85.76,N/A,85.76,N/A,22.40,N/A,160.00,N/A,160.00,N/A,160.00,96.00,96.00,22.40,160.00,,Hospital HCPCS J2274,MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,00641-6019-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),195.50,195.50,117.30,117.30,N/A,27.37,N/A,195.50,N/A,109.91,N/A,66.47,N/A,29.86,N/A,27.37,N/A,195.50,N/A,195.50,N/A,18.59,N/A,29.86,N/A,29.86,N/A,29.86,N/A,109.91,N/A,195.50,N/A,27.37,N/A,104.79,N/A,104.79,N/A,27.37,N/A,195.50,N/A,195.50,N/A,195.50,117.30,117.30,18.59,195.50,,Hospital HCPCS J2274,MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,00641-6039-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1404.00,1404.00,842.40,842.40,N/A,196.56,N/A,1404.00,N/A,789.33,N/A,477.36,N/A,597.25,N/A,196.56,N/A,1404.00,N/A,1404.00,N/A,371.80,N/A,597.25,N/A,597.25,N/A,597.25,N/A,789.33,N/A,1404.00,N/A,196.56,N/A,752.54,N/A,752.54,N/A,196.56,N/A,1404.00,N/A,1404.00,N/A,1404.00,842.40,842.40,196.56,1404.00,,Hospital HCPCS J2274,MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,00409-1893-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,13.29,N/A,2.10,N/A,15.00,N/A,15.00,N/A,8.27,N/A,13.29,N/A,13.29,N/A,13.29,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2274,MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN,00641-6020-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),23.00,23.00,13.80,13.80,N/A,3.22,N/A,23.00,N/A,12.93,N/A,7.82,N/A,23.00,N/A,3.22,N/A,23.00,N/A,23.00,N/A,18.59,N/A,23.00,N/A,23.00,N/A,23.00,N/A,12.93,N/A,23.00,N/A,3.22,N/A,12.33,N/A,12.33,N/A,3.22,N/A,23.00,N/A,23.00,N/A,23.00,13.80,13.80,3.22,23.00,,Hospital HCPCS J2274,MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,00641-6040-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2389.30,2389.30,1433.58,1433.58,N/A,334.50,N/A,2389.30,N/A,1343.26,N/A,812.36,N/A,1493.14,N/A,334.50,N/A,2389.30,N/A,2389.30,N/A,929.49,N/A,1493.14,N/A,1493.14,N/A,1493.14,N/A,1343.26,N/A,2389.30,N/A,334.50,N/A,1280.66,N/A,1280.66,N/A,334.50,N/A,2389.30,N/A,2389.30,N/A,2389.30,1433.58,1433.58,334.50,2389.30,,Hospital J2281,Inj moxifloxacin (fres kabi),N/A,N/A,71862.50,N/A,43117.50,N/A,10440.92,N/A,12616.71,N/A,23529.46,N/A,24433.25,N/A,23754.54,N/A,10762.62,N/A,12616.71,N/A,12616.71,N/A,14786.65,N/A,23754.54,N/A,23754.54,N/A,23754.54,N/A,23529.46,N/A,12616.71,N/A,10762.62,N/A,28261.97,N/A,28261.97,N/A,21429.15,N/A,12616.71,N/A,12616.71,N/A,11516.01,N/A,10440.92,43117.50,N/A,N/A,,Hospital HCPCS J2305,NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,00338-1047-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),138.40,138.40,83.04,83.04,N/A,19.38,N/A,138.40,N/A,77.81,N/A,47.06,N/A,138.40,N/A,19.38,N/A,138.40,N/A,138.40,N/A,138.40,N/A,138.40,N/A,138.40,N/A,138.40,N/A,77.81,N/A,138.40,N/A,19.38,N/A,74.18,N/A,74.18,N/A,19.38,N/A,138.40,N/A,138.40,N/A,138.40,83.04,83.04,19.38,138.40,,Hospital HCPCS J2305,NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,09999-9908-47,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2305,NITROGLYCERIN IV BOLUS,00338-1049-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),151.90,151.90,91.14,91.14,N/A,21.27,N/A,151.90,N/A,85.40,N/A,51.65,N/A,151.90,N/A,21.27,N/A,151.90,N/A,151.90,N/A,151.90,N/A,151.90,N/A,151.90,N/A,151.90,N/A,85.40,N/A,151.90,N/A,21.27,N/A,81.42,N/A,81.42,N/A,21.27,N/A,151.90,N/A,151.90,N/A,151.90,91.14,91.14,21.27,151.90,,Hospital HCPCS J2305,NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,00338-1049-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),151.90,151.90,91.14,91.14,N/A,21.27,N/A,151.90,N/A,85.40,N/A,51.65,N/A,151.90,N/A,21.27,N/A,151.90,N/A,151.90,N/A,151.90,N/A,151.90,N/A,151.90,N/A,151.90,N/A,85.40,N/A,151.90,N/A,21.27,N/A,81.42,N/A,81.42,N/A,21.27,N/A,151.90,N/A,151.90,N/A,151.90,91.14,91.14,21.27,151.90,,Hospital HCPCS J2315,NALTREXONE 380 MG IM SUSR,65757-0300-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),10126.50,10126.50,6075.90,6075.90,N/A,1417.71,N/A,1497.20,N/A,5693.12,N/A,3443.01,N/A,3484.07,N/A,1417.71,N/A,1497.20,N/A,1497.20,N/A,2168.87,N/A,3484.07,N/A,3484.07,N/A,3484.07,N/A,5693.12,N/A,1497.20,N/A,1417.71,N/A,5427.80,N/A,5427.80,N/A,1417.71,N/A,1497.20,N/A,1497.20,N/A,10126.50,6075.90,6075.90,1417.71,10126.50,,Hospital HCPCS J2371,PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN,00641-6142-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2371,PHENYLEPHRINE HCL 10 MG/ML SOLN (MIXTURES ONLY),00641-6142-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2371,PHENYLEPHRINE 250 MCG/ML 10 ML INJECTION (FOR PRIAPISM),99999-9914-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,15.00,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2405,ONDANSETRON HCL 4 MG/2ML IJ SOLN,23155-0547-42,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,N/A,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J2427,PALIPERIDONE PALMITATE ER 234 MG/1.5ML IM SUSY,50458-0564-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),13944.50,13944.50,8366.70,8366.70,N/A,1952.23,N/A,2833.27,N/A,7839.60,N/A,4741.13,N/A,13944.50,N/A,1952.23,N/A,2833.27,N/A,2833.27,N/A,13944.50,N/A,13944.50,N/A,13944.50,N/A,13944.50,N/A,7839.60,N/A,2833.27,N/A,1952.23,N/A,7474.25,N/A,7474.25,N/A,1952.23,N/A,2833.27,N/A,2833.27,N/A,13944.50,8366.70,8366.70,1952.23,13944.50,,Hospital HCPCS J2427,PALIPERIDONE PALMITATE ER 156 MG/ML IM SUSY,50458-0563-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9296.60,9296.60,5577.96,5577.96,N/A,1301.52,N/A,1888.85,N/A,5226.55,N/A,3160.84,N/A,9296.60,N/A,1301.52,N/A,1888.85,N/A,1888.85,N/A,9296.60,N/A,9296.60,N/A,9296.60,N/A,9296.60,N/A,5226.55,N/A,1888.85,N/A,1301.52,N/A,4982.98,N/A,4982.98,N/A,1301.52,N/A,1888.85,N/A,1888.85,N/A,9296.60,5577.96,5577.96,1301.52,9296.60,,Hospital HCPCS J2430,PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,67457-0430-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),182.30,182.30,109.38,109.38,N/A,25.52,N/A,182.30,N/A,102.49,N/A,61.98,N/A,27.40,N/A,25.52,N/A,182.30,N/A,182.30,N/A,17.06,N/A,27.40,N/A,27.40,N/A,27.40,N/A,102.49,N/A,182.30,N/A,25.52,N/A,97.71,N/A,97.71,N/A,25.52,N/A,182.30,N/A,182.30,N/A,182.30,109.38,109.38,17.06,182.30,,Hospital HCPCS J2430,PAMIDRONATE DISODIUM 90 MG/10ML IV SOLN,61703-0326-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),245.70,245.70,147.42,147.42,N/A,34.40,N/A,245.70,N/A,138.13,N/A,83.54,N/A,82.21,N/A,34.40,N/A,245.70,N/A,245.70,N/A,51.17,N/A,82.21,N/A,82.21,N/A,82.21,N/A,138.13,N/A,245.70,N/A,34.40,N/A,131.70,N/A,131.70,N/A,34.40,N/A,245.70,N/A,245.70,N/A,245.70,147.42,147.42,34.40,245.70,,Hospital HCPCS J2469,PALONOSETRON HCL 0.25 MG/5ML IV SOLN,55111-0694-07,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),225.00,225.00,135.00,135.00,N/A,31.50,N/A,225.00,N/A,126.50,N/A,76.50,N/A,23.57,N/A,31.50,N/A,225.00,N/A,225.00,N/A,14.67,N/A,23.57,N/A,23.57,N/A,23.57,N/A,126.50,N/A,225.00,N/A,31.50,N/A,120.60,N/A,120.60,N/A,31.50,N/A,225.00,N/A,225.00,N/A,225.00,135.00,135.00,14.67,225.00,,Hospital HCPCS J2501,PARICALCITOL 5 MCG/ML IV SOLN,00074-1658-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),102.30,102.30,61.38,61.38,N/A,14.32,N/A,102.30,N/A,57.51,N/A,34.78,N/A,9.07,N/A,14.32,N/A,102.30,N/A,102.30,N/A,5.64,N/A,9.07,N/A,9.07,N/A,9.07,N/A,57.51,N/A,102.30,N/A,14.32,N/A,54.83,N/A,54.83,N/A,14.32,N/A,102.30,N/A,102.30,N/A,102.30,61.38,61.38,5.64,102.30,,Hospital HCPCS J2506,PEGFILGRASTIM 6 MG/0.6ML SC SOSY,55513-0190-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17662.60,17662.60,10597.56,10597.56,N/A,2472.76,N/A,1028.52,N/A,9929.91,N/A,6005.28,N/A,4843.20,N/A,2472.76,N/A,1028.52,N/A,1028.52,N/A,3014.94,N/A,4843.20,N/A,4843.20,N/A,4843.20,N/A,9929.91,N/A,1028.52,N/A,2472.76,N/A,9467.15,N/A,9467.15,N/A,2472.76,N/A,1028.52,N/A,1028.52,N/A,1131.37,10597.56,10597.56,1028.52,10597.56,,Hospital HCPCS J2506,PEGFILGRASTIM 6 MG/0.6ML SC PSKT,55513-0192-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28881.00,28881.00,17328.60,17328.60,N/A,4043.34,N/A,1028.52,N/A,16236.90,N/A,9819.54,N/A,4843.20,N/A,4043.34,N/A,1028.52,N/A,1028.52,N/A,3014.94,N/A,4843.20,N/A,4843.20,N/A,4843.20,N/A,16236.90,N/A,1028.52,N/A,4043.34,N/A,15480.22,N/A,15480.22,N/A,4043.34,N/A,1028.52,N/A,1028.52,N/A,1131.37,17328.60,17328.60,1028.52,17328.60,,Hospital J2507,Pegloticase injection,N/A,N/A,N/A,159164.20,N/A,95498.52,N/A,22282.98,N/A,26377.08,N/A,89502.83,N/A,54115.82,N/A,65031.05,N/A,22282.98,N/A,26372.40,N/A,26372.40,N/A,40482.46,N/A,65031.05,N/A,65031.05,N/A,65031.05,N/A,89502.84,N/A,26372.40,N/A,22282.98,N/A,85312.01,N/A,85312.02,N/A,22282.98,N/A,26372.40,N/A,26377.08,N/A,88.54,N/A,N/A,88.54,95498.52,,Hospital J2515,Pentobarbital Sodium Inj,N/A,N/A,277764.50,N/A,166658.70,N/A,15009.37,N/A,N/A,N/A,N/A,N/A,15857.07,N/A,15857.07,N/A,15009.37,N/A,N/A,N/A,N/A,N/A,15857.07,N/A,15857.07,N/A,15857.07,N/A,15857.07,N/A,N/A,N/A,N/A,N/A,15009.37,N/A,N/A,N/A,N/A,N/A,15009.37,N/A,N/A,N/A,N/A,N/A,15009.37,N/A,15009.37,166658.70,N/A,N/A,,Hospital HCPCS J2543,PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,55150-0121-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),75.00,75.00,45.00,45.00,N/A,10.50,N/A,75.00,N/A,42.17,N/A,25.50,N/A,13.26,N/A,10.50,N/A,75.00,N/A,75.00,N/A,8.25,N/A,13.26,N/A,13.26,N/A,13.26,N/A,42.17,N/A,75.00,N/A,10.50,N/A,40.20,N/A,40.20,N/A,10.50,N/A,75.00,N/A,75.00,N/A,75.00,45.00,45.00,8.25,75.00,,Hospital HCPCS J2543,PIPERACILLIN SOD-TAZOBACTAM SO 40.5 (36-4.5) G IV SOLR,63323-0304-74,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),110.10,110.10,66.06,66.06,N/A,15.41,N/A,110.10,N/A,61.90,N/A,37.43,N/A,13.26,N/A,15.41,N/A,110.10,N/A,110.10,N/A,8.25,N/A,13.26,N/A,13.26,N/A,13.26,N/A,61.90,N/A,110.10,N/A,15.41,N/A,59.01,N/A,59.01,N/A,15.41,N/A,110.10,N/A,110.10,N/A,110.10,66.06,66.06,8.25,110.10,,Hospital HCPCS J2543,PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,63323-0983-23,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),93.70,93.70,56.22,56.22,N/A,13.12,N/A,93.70,N/A,52.68,N/A,31.86,N/A,9.95,N/A,13.12,N/A,93.70,N/A,93.70,N/A,6.19,N/A,9.95,N/A,9.95,N/A,9.95,N/A,52.68,N/A,93.70,N/A,13.12,N/A,50.22,N/A,50.22,N/A,13.12,N/A,93.70,N/A,93.70,N/A,93.70,56.22,56.22,6.19,93.70,,Hospital HCPCS J2545,PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,13925-0515-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),574.80,574.80,344.88,344.88,N/A,80.47,N/A,574.80,N/A,323.15,N/A,195.43,N/A,313.93,N/A,80.47,N/A,574.80,N/A,574.80,N/A,195.43,N/A,313.93,N/A,313.93,N/A,313.93,N/A,323.15,N/A,574.80,N/A,80.47,N/A,308.09,N/A,308.09,N/A,80.47,N/A,574.80,N/A,574.80,N/A,574.80,344.88,344.88,80.47,574.80,,Hospital HCPCS J2545,PENTAMIDINE ISETHIONATE 300 MG IN SOLR,63323-0877-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1126.60,1126.60,675.96,675.96,N/A,157.72,N/A,1126.60,N/A,633.37,N/A,383.04,N/A,313.93,N/A,157.72,N/A,1126.60,N/A,1126.60,N/A,195.43,N/A,313.93,N/A,313.93,N/A,313.93,N/A,633.37,N/A,1126.60,N/A,157.72,N/A,603.86,N/A,603.86,N/A,157.72,N/A,1126.60,N/A,1126.60,N/A,1126.60,675.96,675.96,157.72,1126.60,,Hospital HCPCS J2560,PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,00641-0476-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),177.90,177.90,106.74,106.74,N/A,24.91,N/A,39.38,N/A,100.02,N/A,60.49,N/A,104.38,N/A,24.91,N/A,39.38,N/A,39.38,N/A,64.98,N/A,104.38,N/A,104.38,N/A,104.38,N/A,100.02,N/A,39.38,N/A,24.91,N/A,95.35,N/A,95.35,N/A,24.91,N/A,39.38,N/A,39.38,N/A,177.90,106.74,106.74,24.91,177.90,,Hospital HCPCS J2560,PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,00641-0477-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),230.90,230.90,138.54,138.54,N/A,32.33,N/A,39.38,N/A,129.81,N/A,78.51,N/A,104.38,N/A,32.33,N/A,39.38,N/A,39.38,N/A,64.98,N/A,104.38,N/A,104.38,N/A,104.38,N/A,129.81,N/A,39.38,N/A,32.33,N/A,123.76,N/A,123.76,N/A,32.33,N/A,39.38,N/A,39.38,N/A,230.90,138.54,138.54,32.33,230.90,,Hospital HCPCS J2597,DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN,55566-2200-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),137.00,137.00,82.20,82.20,N/A,19.18,N/A,7.27,N/A,77.02,N/A,46.58,N/A,19.97,N/A,19.18,N/A,7.27,N/A,7.27,N/A,12.43,N/A,19.97,N/A,19.97,N/A,19.97,N/A,77.02,N/A,7.27,N/A,19.18,N/A,73.43,N/A,73.43,N/A,19.18,N/A,7.27,N/A,7.27,N/A,137.00,82.20,82.20,7.27,137.00,,Hospital HCPCS J2597,DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN,55566-5030-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),88.60,88.60,53.16,53.16,N/A,12.40,N/A,7.27,N/A,49.81,N/A,30.12,N/A,19.97,N/A,12.40,N/A,7.27,N/A,7.27,N/A,12.43,N/A,19.97,N/A,19.97,N/A,19.97,N/A,49.81,N/A,7.27,N/A,12.40,N/A,47.49,N/A,47.49,N/A,12.40,N/A,7.27,N/A,7.27,N/A,88.60,53.16,53.16,7.27,88.60,,Hospital HCPCS J2597,DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN (MIXTURES ONLY),70860-0454-41,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),88.60,88.60,53.16,53.16,N/A,12.40,N/A,7.27,N/A,49.81,N/A,30.12,N/A,19.97,N/A,12.40,N/A,7.27,N/A,7.27,N/A,12.43,N/A,19.97,N/A,19.97,N/A,19.97,N/A,49.81,N/A,7.27,N/A,12.40,N/A,47.49,N/A,47.49,N/A,12.40,N/A,7.27,N/A,7.27,N/A,88.60,53.16,53.16,7.27,88.60,,Hospital J2598,"Injection, Vasopressin, 1 Unit",N/A,N/A,63674.30,42784.87,38204.58,25670.92,N/A,5979.72,12616.71,4855.12,23529.46,24626.00,21649.26,14546.86,N/A,11267.78,N/A,5979.72,12616.71,4641.41,12616.71,4641.41,N/A,7014.41,23754.54,11267.78,N/A,11267.78,N/A,11267.78,23529.46,24626.00,12616.71,4641.41,10762.62,5979.72,28261.97,7897.00,28261.97,7897.00,N/A,5979.72,12616.71,4641.41,32661.83,4855.12,11516.01,818.19,10762.62,38204.58,818.19,25670.92,,Hospital HCPCS J2680,FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,63323-0272-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),104.70,104.70,62.82,62.82,N/A,14.66,N/A,104.70,N/A,58.86,N/A,35.60,N/A,25.49,N/A,14.66,N/A,104.70,N/A,104.70,N/A,15.87,N/A,25.49,N/A,25.49,N/A,25.49,N/A,58.86,N/A,104.70,N/A,14.66,N/A,56.12,N/A,56.12,N/A,14.66,N/A,104.70,N/A,104.70,N/A,104.70,62.82,62.82,14.66,104.70,,Hospital HCPCS J2680,FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,63323-0281-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1296.50,1296.50,777.90,777.90,N/A,181.51,N/A,1296.50,N/A,728.89,N/A,440.81,N/A,25.49,N/A,181.51,N/A,1296.50,N/A,1296.50,N/A,15.87,N/A,25.49,N/A,25.49,N/A,25.49,N/A,728.89,N/A,1296.50,N/A,181.51,N/A,694.92,N/A,694.92,N/A,181.51,N/A,1296.50,N/A,1296.50,N/A,1296.50,777.90,777.90,15.87,1296.50,,Hospital J2690,Procainamide Hcl Injection,N/A,N/A,150000.80,73408.33,90000.48,44045.00,8265.05,10268.22,8640.81,21204.54,82680.44,41963.15,253295.72,24958.83,12703.98,51602.15,5589.17,10268.22,6679.73,21204.54,6679.73,21204.54,7908.61,32123.34,12703.98,51602.15,253295.72,51602.15,12703.98,51602.15,82680.44,41954.73,8640.81,21204.54,5589.17,10268.22,14676.82,16637.00,14676.82,16637.00,4141.38,10268.22,6679.73,21204.54,6679.73,21204.54,5980.42,23325.00,4141.38,253295.72,10268.22,51602.15,,Hospital HCPCS J2704,PROPOFOL BOLUS 10 MG/ML SOLN (MGPI),63323-0269-29,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,1.55,N/A,2.10,N/A,15.00,N/A,15.00,N/A,N/A,N/A,1.55,N/A,1.55,N/A,1.55,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.55,15.00,,Hospital HCPCS J2704,PROPOFOL 500 MG/50ML IV EMUL,63323-0269-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),101.30,101.30,60.78,60.78,N/A,14.18,N/A,101.30,N/A,56.95,N/A,34.44,N/A,15.54,N/A,14.18,N/A,101.30,N/A,101.30,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,56.95,N/A,101.30,N/A,14.18,N/A,54.30,N/A,54.30,N/A,14.18,N/A,101.30,N/A,101.30,N/A,101.30,60.78,60.78,9.67,101.30,,Hospital HCPCS J2704,PROPOFOL 1000 MG/100ML IV EMUL,00409-4699-24,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),145.80,145.80,87.48,87.48,N/A,20.41,N/A,145.80,N/A,81.97,N/A,49.57,N/A,31.08,N/A,20.41,N/A,145.80,N/A,145.80,N/A,19.35,N/A,31.08,N/A,31.08,N/A,31.08,N/A,81.97,N/A,145.80,N/A,20.41,N/A,78.15,N/A,78.15,N/A,20.41,N/A,145.80,N/A,145.80,N/A,145.80,87.48,87.48,19.35,145.80,,Hospital HCPCS J2704,PROPOFOL 200 MG/20ML IV EMUL,63323-0269-29,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),40.50,40.50,24.30,24.30,N/A,5.67,N/A,40.50,N/A,22.77,N/A,13.77,N/A,6.22,N/A,5.67,N/A,40.50,N/A,40.50,N/A,3.87,N/A,6.22,N/A,6.22,N/A,6.22,N/A,22.77,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,5.67,N/A,40.50,N/A,40.50,N/A,40.50,24.30,24.30,3.87,40.50,,Hospital HCPCS J2760,PHENTOLAMINE MESYLATE 5 MG IJ SOLR,00143-9564-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3307.30,3307.30,1984.38,1984.38,N/A,463.02,N/A,458.18,N/A,1859.36,N/A,1124.48,N/A,1017.04,N/A,463.02,N/A,458.18,N/A,458.18,N/A,633.12,N/A,1017.04,N/A,1017.04,N/A,1017.04,N/A,1859.36,N/A,458.18,N/A,463.02,N/A,1772.71,N/A,1772.71,N/A,463.02,N/A,458.18,N/A,458.18,N/A,504.00,1984.38,1984.38,458.18,1984.38,,Hospital HCPCS J2765,METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,00409-3414-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,2.72,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.69,N/A,2.72,N/A,2.72,N/A,2.72,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.69,15.00,,Hospital HCPCS J2783,RASBURICASE 1.5 MG IV SOLR,00024-5150-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4556.90,4556.90,2734.14,2734.14,N/A,637.97,N/A,1072.09,N/A,2561.89,N/A,1549.35,N/A,2571.09,N/A,637.97,N/A,1072.09,N/A,1072.09,N/A,1600.53,N/A,2571.09,N/A,2571.09,N/A,2571.09,N/A,2561.89,N/A,1072.09,N/A,637.97,N/A,2442.50,N/A,2442.50,N/A,637.97,N/A,1072.09,N/A,1072.09,N/A,1179.30,2734.14,2734.14,637.97,2734.14,,Hospital HCPCS J2783,RASBURICASE 7.5 MG IV SOLR,00024-5151-75,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22784.40,22784.40,13670.64,13670.64,N/A,3189.82,N/A,5360.46,N/A,12809.39,N/A,7746.70,N/A,12855.47,N/A,3189.82,N/A,5360.46,N/A,5360.46,N/A,8002.65,N/A,12855.47,N/A,12855.47,N/A,12855.47,N/A,12809.39,N/A,5360.46,N/A,3189.82,N/A,12212.44,N/A,12212.44,N/A,3189.82,N/A,5360.46,N/A,5360.46,N/A,5896.51,13670.64,13670.64,3189.82,13670.64,,Hospital HCPCS J2785,REGADENOSON 0.4 MG/5ML IV SOLN,00469-6501-89,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1689.20,1689.20,1013.52,1013.52,N/A,236.49,N/A,1689.20,N/A,949.67,N/A,574.33,N/A,636.93,N/A,236.49,N/A,1689.20,N/A,1689.20,N/A,396.50,N/A,636.93,N/A,636.93,N/A,636.93,N/A,949.67,N/A,1689.20,N/A,236.49,N/A,905.41,N/A,905.41,N/A,236.49,N/A,1689.20,N/A,1689.20,N/A,1689.20,1013.52,1013.52,236.49,1689.20,,Hospital J2792,"Rho(D) Immune Globulin H, Sd",N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital HCPCS J2796,ROMIPLOSTIM 250 MCG SC SOLR,55513-0221-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),10134.50,10134.50,6080.70,6080.70,N/A,1418.83,N/A,2386.70,N/A,5697.62,N/A,3445.73,N/A,5681.17,N/A,1418.83,N/A,2386.70,N/A,2386.70,N/A,3536.58,N/A,5681.17,N/A,5681.17,N/A,5681.17,N/A,5697.62,N/A,2386.70,N/A,1418.83,N/A,5432.09,N/A,5432.09,N/A,1418.83,N/A,2386.70,N/A,2386.70,N/A,2625.37,6080.70,6080.70,1418.83,6080.70,,Hospital J2820,Sargramostim Injection,N/A,N/A,885460.53,N/A,531276.32,N/A,N/A,N/A,N/A,N/A,892668.63,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,892668.63,N/A,N/A,N/A,N/A,N/A,892668.63,N/A,892668.63,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,531276.32,892668.63,N/A,N/A,,Hospital J2860,"Injection, siltuximab",N/A,N/A,N/A,75694.00,N/A,45416.40,N/A,10560.95,N/A,11512.40,N/A,42603.53,N/A,25735.96,N/A,27542.63,N/A,10560.95,N/A,11514.33,N/A,11514.33,N/A,17145.57,N/A,27542.63,N/A,27542.63,N/A,27542.63,N/A,42596.50,N/A,11514.33,N/A,10560.95,N/A,1640.59,N/A,1640.59,N/A,10560.95,N/A,11514.33,N/A,11512.40,N/A,194.28,N/A,N/A,194.28,45416.40,,Hospital HCPCS J2930,METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR (MIXTURES ONLY),00009-0698-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),296.90,296.90,178.14,178.14,N/A,41.57,N/A,296.90,N/A,166.92,N/A,100.95,N/A,114.37,N/A,41.57,N/A,296.90,N/A,296.90,N/A,71.20,N/A,114.37,N/A,114.37,N/A,114.37,N/A,166.92,N/A,296.90,N/A,41.57,N/A,159.14,N/A,159.14,N/A,41.57,N/A,296.90,N/A,296.90,N/A,296.90,178.14,178.14,41.57,296.90,,Hospital HCPCS J2930,METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,00009-0698-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),296.90,296.90,178.14,178.14,N/A,41.57,N/A,296.90,N/A,166.92,N/A,100.95,N/A,114.37,N/A,41.57,N/A,296.90,N/A,296.90,N/A,71.20,N/A,114.37,N/A,114.37,N/A,114.37,N/A,166.92,N/A,296.90,N/A,41.57,N/A,159.14,N/A,159.14,N/A,41.57,N/A,296.90,N/A,296.90,N/A,296.90,178.14,178.14,41.57,296.90,,Hospital HCPCS J2930,METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR (MIXTURES ONLY),00009-0758-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),163.90,163.90,98.34,98.34,N/A,22.95,N/A,163.90,N/A,92.14,N/A,55.73,N/A,57.19,N/A,22.95,N/A,163.90,N/A,163.90,N/A,35.60,N/A,57.19,N/A,57.19,N/A,57.19,N/A,92.14,N/A,163.90,N/A,22.95,N/A,87.85,N/A,87.85,N/A,22.95,N/A,163.90,N/A,163.90,N/A,163.90,98.34,98.34,22.95,163.90,,Hospital HCPCS J2930,METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR,00009-0047-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),31.60,31.60,18.96,18.96,N/A,4.42,N/A,31.60,N/A,17.77,N/A,10.74,N/A,14.30,N/A,4.42,N/A,31.60,N/A,31.60,N/A,8.90,N/A,14.30,N/A,14.30,N/A,14.30,N/A,17.77,N/A,31.60,N/A,4.42,N/A,16.94,N/A,16.94,N/A,4.42,N/A,31.60,N/A,31.60,N/A,31.60,18.96,18.96,4.42,31.60,,Hospital HCPCS J2930,METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR (MIXTURES ONLY),00009-0047-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),31.60,31.60,18.96,18.96,N/A,4.42,N/A,31.60,N/A,17.77,N/A,10.74,N/A,14.30,N/A,4.42,N/A,31.60,N/A,31.60,N/A,8.90,N/A,14.30,N/A,14.30,N/A,14.30,N/A,17.77,N/A,31.60,N/A,4.42,N/A,16.94,N/A,16.94,N/A,4.42,N/A,31.60,N/A,31.60,N/A,31.60,18.96,18.96,4.42,31.60,,Hospital HCPCS J2930,METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,00009-0758-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),163.90,163.90,98.34,98.34,N/A,22.95,N/A,163.90,N/A,92.14,N/A,55.73,N/A,57.19,N/A,22.95,N/A,163.90,N/A,163.90,N/A,35.60,N/A,57.19,N/A,57.19,N/A,57.19,N/A,92.14,N/A,163.90,N/A,22.95,N/A,87.85,N/A,87.85,N/A,22.95,N/A,163.90,N/A,163.90,N/A,163.90,98.34,98.34,22.95,163.90,,Hospital HCPCS J2997,ALTEPLASE 50 MG IV SOLR,50242-0044-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29701.30,29701.30,17820.78,17820.78,N/A,4158.18,N/A,4457.30,N/A,16698.07,N/A,10098.44,N/A,11113.69,N/A,4158.18,N/A,4457.30,N/A,4457.30,N/A,6918.38,N/A,11113.69,N/A,11113.69,N/A,11113.69,N/A,16698.07,N/A,4457.30,N/A,4158.18,N/A,15919.90,N/A,15919.90,N/A,4158.18,N/A,4457.30,N/A,4457.30,N/A,4903.03,17820.78,17820.78,4158.18,17820.78,,Hospital HCPCS J2997,ALTEPLASE (ACTIVASE) 100 MG VIAL IV BOLUS,50242-0085-27,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),59402.50,59402.50,35641.50,35641.50,N/A,8316.35,N/A,8914.60,N/A,33396.09,N/A,20196.85,N/A,22227.38,N/A,8316.35,N/A,8914.60,N/A,8914.60,N/A,13836.76,N/A,22227.38,N/A,22227.38,N/A,22227.38,N/A,33396.09,N/A,8914.60,N/A,8316.35,N/A,31839.74,N/A,31839.74,N/A,8316.35,N/A,8914.60,N/A,8914.60,N/A,9806.06,35641.50,35641.50,8316.35,35641.50,,Hospital HCPCS J2997,ALTEPLASE (ACTIVASE) 100 MG VIAL IV INFUSION,50242-0085-27,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),59402.50,59402.50,35641.50,35641.50,N/A,8316.35,N/A,8914.60,N/A,33396.09,N/A,20196.85,N/A,22227.38,N/A,8316.35,N/A,8914.60,N/A,8914.60,N/A,13836.76,N/A,22227.38,N/A,22227.38,N/A,22227.38,N/A,33396.09,N/A,8914.60,N/A,8316.35,N/A,31839.74,N/A,31839.74,N/A,8316.35,N/A,8914.60,N/A,8914.60,N/A,9806.06,35641.50,35641.50,8316.35,35641.50,,Hospital HCPCS J2997,ALTEPLASE 2 MG IJ SOLR,50242-0041-64,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),542.40,542.40,325.44,325.44,N/A,75.94,N/A,89.15,N/A,304.94,N/A,184.42,N/A,222.27,N/A,75.94,N/A,89.15,N/A,89.15,N/A,138.37,N/A,222.27,N/A,222.27,N/A,222.27,N/A,304.94,N/A,89.15,N/A,75.94,N/A,290.73,N/A,290.73,N/A,75.94,N/A,89.15,N/A,89.15,N/A,98.06,325.44,325.44,75.94,325.44,,Hospital HCPCS J2997,ALTEPLASE 100 MG IV SOLR,50242-0085-27,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),59402.50,59402.50,35641.50,35641.50,N/A,8316.35,N/A,8914.60,N/A,33396.09,N/A,20196.85,N/A,22227.38,N/A,8316.35,N/A,8914.60,N/A,8914.60,N/A,13836.76,N/A,22227.38,N/A,22227.38,N/A,22227.38,N/A,33396.09,N/A,8914.60,N/A,8316.35,N/A,31839.74,N/A,31839.74,N/A,8316.35,N/A,8914.60,N/A,8914.60,N/A,9806.06,35641.50,35641.50,8316.35,35641.50,,Hospital HCPCS J3105,TERBUTALINE SULFATE 1 MG/ML IJ SOLN,63323-0665-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),30.40,30.40,18.24,18.24,N/A,4.26,N/A,30.40,N/A,17.09,N/A,10.34,N/A,8.29,N/A,4.26,N/A,30.40,N/A,30.40,N/A,5.16,N/A,8.29,N/A,8.29,N/A,8.29,N/A,17.09,N/A,30.40,N/A,4.26,N/A,16.29,N/A,16.29,N/A,4.26,N/A,30.40,N/A,30.40,N/A,30.40,18.24,18.24,4.26,30.40,,Hospital HCPCS J3111,ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY,55513-0880-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9486.50,9486.50,5691.90,5691.90,N/A,1328.11,N/A,2177.07,N/A,5333.31,N/A,3225.41,N/A,5275.83,N/A,1328.11,N/A,2177.07,N/A,2177.07,N/A,3284.26,N/A,5275.83,N/A,5275.83,N/A,5275.83,N/A,5333.31,N/A,2177.07,N/A,1328.11,N/A,5084.76,N/A,5084.76,N/A,1328.11,N/A,2177.07,N/A,2177.07,N/A,2394.78,5691.90,5691.90,1328.11,5691.90,,Hospital J3240,Thyrotropin Injection,N/A,N/A,N/A,15550.43,N/A,9330.26,N/A,2177.06,N/A,1988.49,N/A,8746.57,N/A,5287.15,N/A,5086.32,N/A,2177.06,N/A,2062.42,N/A,2062.42,N/A,3166.28,N/A,5086.32,N/A,5086.32,N/A,5086.32,N/A,8746.57,N/A,2062.42,N/A,2177.06,N/A,8335.03,N/A,8335.03,N/A,2177.06,N/A,2062.42,N/A,13.39,N/A,14.73,N/A,N/A,13.39,9330.26,,Hospital J3246,Tirofiban HCl,N/A,N/A,113039.60,N/A,67823.76,N/A,15979.32,N/A,19168.37,N/A,62307.43,N/A,42205.00,N/A,37769.00,N/A,16471.67,N/A,3934.00,N/A,3934.00,N/A,23510.89,N/A,42205.00,N/A,37769.00,N/A,37769.00,N/A,62307.43,N/A,19168.37,N/A,16471.67,N/A,43253.58,N/A,43253.58,N/A,16830.36,N/A,19168.37,N/A,19168.37,N/A,17624.69,N/A,3934.00,67823.76,N/A,N/A,,Hospital HCPCS J3260,TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,63323-0306-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,5.80,N/A,2.10,N/A,15.00,N/A,15.00,N/A,3.61,N/A,5.80,N/A,5.80,N/A,5.80,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J3260,TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,63323-0306-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),22.90,22.90,13.74,13.74,N/A,3.21,N/A,22.90,N/A,12.87,N/A,7.79,N/A,5.80,N/A,3.21,N/A,22.90,N/A,22.90,N/A,3.61,N/A,5.80,N/A,5.80,N/A,5.80,N/A,12.87,N/A,22.90,N/A,3.21,N/A,12.27,N/A,12.27,N/A,3.21,N/A,22.90,N/A,22.90,N/A,22.90,13.74,13.74,3.21,22.90,,Hospital HCPCS J3260,TOBRAMYCIN SULFATE 2 GM/50ML IJ SOLN,63323-0307-51,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,5.80,N/A,2.10,N/A,15.00,N/A,15.00,N/A,3.61,N/A,5.80,N/A,5.80,N/A,5.80,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital J3285,Treprostinil injection,N/A,N/A,71982.32,N/A,43189.39,N/A,5166.58,N/A,6377.45,N/A,12282.82,N/A,24473.98,N/A,27942.05,N/A,5325.77,N/A,6377.45,N/A,6377.45,N/A,7601.76,N/A,12211.82,N/A,12211.82,N/A,12211.82,N/A,12282.82,N/A,6377.45,N/A,5325.77,N/A,13985.14,N/A,13985.14,N/A,N/A,N/A,6377.45,N/A,6377.45,N/A,5698.58,N/A,5166.58,43189.39,N/A,N/A,,Hospital HCPCS J3301,TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,70121-1049-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),57.40,57.40,34.44,34.44,N/A,8.04,N/A,57.40,N/A,32.27,N/A,19.52,N/A,13.36,N/A,8.04,N/A,57.40,N/A,57.40,N/A,8.32,N/A,13.36,N/A,13.36,N/A,13.36,N/A,32.27,N/A,57.40,N/A,8.04,N/A,30.77,N/A,30.77,N/A,8.04,N/A,57.40,N/A,57.40,N/A,57.40,34.44,34.44,8.04,57.40,,Hospital J3304,Inj triamcinolone ace xr 1mg,N/A,N/A,N/A,7084.30,N/A,4250.58,N/A,991.80,N/A,1463.59,N/A,4004.42,N/A,2408.66,N/A,3707.14,N/A,991.80,N/A,1463.59,N/A,1463.59,N/A,2307.74,N/A,3707.14,N/A,3707.14,N/A,3707.14,N/A,4004.42,N/A,1463.59,N/A,991.80,N/A,3797.18,N/A,3797.18,N/A,991.80,N/A,1463.59,N/A,1463.59,N/A,1609.95,N/A,N/A,991.80,4250.58,,Hospital J3360,Diazepam Injection,N/A,N/A,62279.38,64024.50,37367.63,38414.70,4790.49,8890.83,5663.51,3128.83,27577.04,36560.36,15882.57,21768.32,11925.01,29144.89,6869.41,8890.83,215246.00,11933.08,215246.00,11933.08,15882.57,18339.27,15882.57,29144.89,21131.10,29144.89,11184.25,29144.89,27577.04,36560.37,5544.91,11956.02,4938.09,8890.83,12711.53,13336.25,12711.53,13336.25,11220.87,8890.83,11610.06,11933.08,11829.49,3128.83,6869.41,3396.81,4790.49,215246.00,3128.83,38414.70,,Hospital HCPCS J3371,VANCOMYCIN HCL 1.25 G IV SOLR,67457-0823-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),135.70,135.70,81.42,81.42,N/A,19.00,N/A,135.70,N/A,76.29,N/A,46.14,N/A,23.00,N/A,19.00,N/A,135.70,N/A,135.70,N/A,14.32,N/A,23.00,N/A,23.00,N/A,23.00,N/A,76.29,N/A,135.70,N/A,19.00,N/A,72.74,N/A,72.74,N/A,19.00,N/A,135.70,N/A,135.70,N/A,135.70,81.42,81.42,14.32,135.70,,Hospital HCPCS J3371,VANCOMYCIN HCL 750 MG IV SOLR,63323-0203-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),64.20,64.20,38.52,38.52,N/A,8.99,N/A,64.20,N/A,36.09,N/A,21.83,N/A,15.33,N/A,8.99,N/A,64.20,N/A,64.20,N/A,9.54,N/A,15.33,N/A,15.33,N/A,15.33,N/A,36.09,N/A,64.20,N/A,8.99,N/A,34.41,N/A,34.41,N/A,8.99,N/A,64.20,N/A,64.20,N/A,64.20,38.52,38.52,8.99,64.20,,Hospital HCPCS J3410,HYDROXYZINE HCL 50 MG/ML IM SOLN,00517-5601-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),86.50,86.50,51.90,51.90,N/A,12.11,N/A,86.50,N/A,48.63,N/A,29.41,N/A,27.92,N/A,12.11,N/A,86.50,N/A,86.50,N/A,17.38,N/A,27.92,N/A,27.92,N/A,27.92,N/A,48.63,N/A,86.50,N/A,12.11,N/A,46.36,N/A,46.36,N/A,12.11,N/A,86.50,N/A,86.50,N/A,86.50,51.90,51.90,12.11,86.50,,Hospital HCPCS J3410,HYDROXYZINE HCL 25 MG/ML IM SOLN,00517-4201-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),78.40,78.40,47.04,47.04,N/A,10.98,N/A,78.40,N/A,44.08,N/A,26.66,N/A,27.92,N/A,10.98,N/A,78.40,N/A,78.40,N/A,17.38,N/A,27.92,N/A,27.92,N/A,27.92,N/A,44.08,N/A,78.40,N/A,10.98,N/A,42.02,N/A,42.02,N/A,10.98,N/A,78.40,N/A,78.40,N/A,78.40,47.04,47.04,10.98,78.40,,Hospital HCPCS J3411,THIAMINE HCL 100 MG/ML IJ SOLN,63323-0013-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16.80,16.80,10.08,10.08,N/A,2.35,N/A,16.80,N/A,9.44,N/A,5.71,N/A,6.63,N/A,2.35,N/A,16.80,N/A,16.80,N/A,4.13,N/A,6.63,N/A,6.63,N/A,6.63,N/A,9.44,N/A,16.80,N/A,2.35,N/A,9.00,N/A,9.00,N/A,2.35,N/A,16.80,N/A,16.80,N/A,16.80,10.08,10.08,2.35,16.80,,Hospital HCPCS J3415,PYRIDOXINE HCL 100 MG/ML IJ SOLN,63323-0180-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),56.00,56.00,33.60,33.60,N/A,7.84,N/A,56.00,N/A,31.48,N/A,19.04,N/A,26.73,N/A,7.84,N/A,56.00,N/A,56.00,N/A,16.64,N/A,26.73,N/A,26.73,N/A,26.73,N/A,31.48,N/A,56.00,N/A,7.84,N/A,30.02,N/A,30.02,N/A,7.84,N/A,56.00,N/A,56.00,N/A,56.00,33.60,33.60,7.84,56.00,,Hospital HCPCS J3420,CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,00517-0031-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,4.07,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.53,N/A,4.07,N/A,4.07,N/A,4.07,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J3465,VORICONAZOLE 200 MG IV SOLR,00049-3190-28,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1012.10,1012.10,607.26,607.26,N/A,141.69,N/A,1012.10,N/A,569.00,N/A,344.11,N/A,54.91,N/A,141.69,N/A,1012.10,N/A,1012.10,N/A,34.18,N/A,54.91,N/A,54.91,N/A,54.91,N/A,569.00,N/A,1012.10,N/A,141.69,N/A,542.49,N/A,542.49,N/A,141.69,N/A,1012.10,N/A,1012.10,N/A,1012.10,607.26,607.26,34.18,1012.10,,Hospital J3470,Hyaluronidase Injection,N/A,N/A,155475.03,14678.23,93285.02,8806.94,9737.49,2054.95,13802.56,2151.15,N/A,8421.64,N/A,4990.60,N/A,4880.30,9737.49,2054.95,13802.56,1950.06,13802.56,1950.06,N/A,3038.09,N/A,4880.30,N/A,4880.30,N/A,4880.30,N/A,8421.66,13802.56,1950.06,9737.49,2054.95,N/A,3397.00,N/A,3397.00,9737.49,2054.95,13802.56,1950.06,13802.56,630.95,9737.49,556.44,9737.49,93285.02,556.44,8806.94,,Hospital HCPCS J3475,MAGNESIUM SULFATE 50 % IJ SOLN,63323-0642-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,3.89,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J3475,MAGNESIUM SULFATE 4000 MG/100ML IVPB PREMIX (OB USE ONLY),00409-6729-23,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),49.30,49.30,29.58,29.58,N/A,6.90,N/A,49.30,N/A,27.72,N/A,16.76,N/A,15.54,N/A,6.90,N/A,49.30,N/A,49.30,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,27.72,N/A,49.30,N/A,6.90,N/A,26.42,N/A,26.42,N/A,6.90,N/A,49.30,N/A,49.30,N/A,49.30,29.58,29.58,6.90,49.30,,Hospital HCPCS J3475,MAGNESIUM SULFATE 4000 MG/100 ML IVPB PREMIX,63323-0106-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),54.00,54.00,32.40,32.40,N/A,7.56,N/A,54.00,N/A,30.36,N/A,18.36,N/A,15.54,N/A,7.56,N/A,54.00,N/A,54.00,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,30.36,N/A,54.00,N/A,7.56,N/A,28.94,N/A,28.94,N/A,7.56,N/A,54.00,N/A,54.00,N/A,54.00,32.40,32.40,7.56,54.00,,Hospital HCPCS J3475,MAGNESIUM SULFATE 20 GM/500ML IV SOLN,63323-0106-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),40.50,40.50,24.30,24.30,N/A,5.67,N/A,40.50,N/A,22.77,N/A,13.77,N/A,40.50,N/A,5.67,N/A,40.50,N/A,40.50,N/A,40.50,N/A,40.50,N/A,40.50,N/A,40.50,N/A,22.77,N/A,40.50,N/A,5.67,N/A,21.71,N/A,21.71,N/A,5.67,N/A,40.50,N/A,40.50,N/A,40.50,24.30,24.30,5.67,40.50,,Hospital HCPCS J3475,MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN,00409-6727-23,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),50.70,50.70,30.42,30.42,N/A,7.10,N/A,50.70,N/A,28.50,N/A,17.24,N/A,3.89,N/A,7.10,N/A,50.70,N/A,50.70,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,28.50,N/A,50.70,N/A,7.10,N/A,27.18,N/A,27.18,N/A,7.10,N/A,50.70,N/A,50.70,N/A,50.70,30.42,30.42,2.42,50.70,,Hospital HCPCS J3475,MAGNESIUM SULFATE 4 GM/100ML IV SOLN,00264-4206-54,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),23.70,23.70,14.22,14.22,N/A,3.32,N/A,23.70,N/A,13.32,N/A,8.06,N/A,15.54,N/A,3.32,N/A,23.70,N/A,23.70,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,13.32,N/A,23.70,N/A,3.32,N/A,12.70,N/A,12.70,N/A,3.32,N/A,23.70,N/A,23.70,N/A,23.70,14.22,14.22,3.32,23.70,,Hospital HCPCS J3475,MAGNESIUM SULFATE 20000 MG/500 ML INFUSION,00409-6729-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),37.20,37.20,22.32,22.32,N/A,5.21,N/A,37.20,N/A,20.91,N/A,12.65,N/A,37.20,N/A,5.21,N/A,37.20,N/A,37.20,N/A,37.20,N/A,37.20,N/A,37.20,N/A,37.20,N/A,20.91,N/A,37.20,N/A,5.21,N/A,19.94,N/A,19.94,N/A,5.21,N/A,37.20,N/A,37.20,N/A,37.20,22.32,22.32,5.21,37.20,,Hospital HCPCS J3475,MAGNESIUM SULFATE 50 % IJ SOLN,63323-0064-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,8.43,N/A,5.10,N/A,3.89,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.42,N/A,3.89,N/A,3.89,N/A,3.89,N/A,8.43,N/A,15.00,N/A,2.10,N/A,8.04,N/A,8.04,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,2.10,15.00,,Hospital HCPCS J3475,MAGNESIUM SULFATE 2000 MG/50 ML IVPB PREMIX,63323-0106-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),108.40,108.40,65.04,65.04,N/A,15.18,N/A,108.40,N/A,60.94,N/A,36.86,N/A,7.77,N/A,15.18,N/A,108.40,N/A,108.40,N/A,4.84,N/A,7.77,N/A,7.77,N/A,7.77,N/A,60.94,N/A,108.40,N/A,15.18,N/A,58.10,N/A,58.10,N/A,15.18,N/A,108.40,N/A,108.40,N/A,108.40,65.04,65.04,4.84,108.40,,Hospital HCPCS J3475,MAGNESIUM SULFATE 2 GM/50ML IV SOLN,63323-0106-05,0250 - PHARMACY - GENERAL CLASSIFICATION,108.40,108.40,65.04,65.04,N/A,15.18,N/A,108.40,N/A,62.42,N/A,36.86,N/A,108.40,N/A,15.18,N/A,108.40,N/A,108.40,N/A,108.40,N/A,108.40,N/A,108.40,N/A,108.40,N/A,62.42,N/A,108.40,N/A,15.18,N/A,58.10,N/A,58.10,N/A,15.18,N/A,108.40,N/A,108.40,N/A,108.40,65.04,65.04,15.18,108.40,,Hospital J3485,Zidovudine,N/A,N/A,15634.00,N/A,9380.40,N/A,3368.28,N/A,4250.13,N/A,7590.69,N/A,5315.56,N/A,4696.00,N/A,3472.06,N/A,4250.13,N/A,4250.13,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,7590.69,N/A,4250.13,N/A,3472.06,N/A,9117.42,N/A,9117.42,N/A,3472.06,N/A,4250.13,N/A,4250.13,N/A,3715.11,N/A,2923.00,9380.40,N/A,N/A,,Hospital HCPCS J3486,ZIPRASIDONE MESYLATE 20 MG IM SOLR,00049-3920-83,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),193.60,193.60,116.16,116.16,N/A,27.10,N/A,193.60,N/A,108.84,N/A,65.82,N/A,29.99,N/A,27.10,N/A,193.60,N/A,193.60,N/A,18.67,N/A,29.99,N/A,29.99,N/A,29.99,N/A,108.84,N/A,193.60,N/A,27.10,N/A,103.77,N/A,103.77,N/A,27.10,N/A,193.60,N/A,193.60,N/A,193.60,116.16,116.16,18.67,193.60,,Hospital HCPCS J7030,SODIUM CHLORIDE 0.9 % IV SOLN,00338-0049-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7030,SODIUM CHLORIDE 0.9 % IV SOLN,00338-0049-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE-NACL 5-0.9 % IV SOLN,00338-0089-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE-NACL 5-0.9 % IV SOLN,00338-0089-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE-NACL 5-0.9 % IV SOLN,00338-0089-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE-NACL 5-0.45 % IV SOLN WEIGHT BASED FOR PEDS,00338-0085-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE-NACL 5-0.9 % IV SOLN,00338-0089-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,00338-0085-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,00338-0085-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,00338-0085-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE-NACL 5-0.45 % IV SOLN WEIGHT BASED FOR PEDS,00338-0085-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7042,DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,00338-0085-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-41,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-02,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-38,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-38,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-41,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7060,DEXTROSE 5 % IV SOLN,00338-0017-02,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital J7070,D5w Infusion,N/A,N/A,70645.48,25108.23,42387.29,15064.94,20362.25,3499.76,10556.25,2671.61,59623.40,11012.00,21378.50,8536.80,21564.52,6505.24,20989.64,3499.76,11485.86,2671.61,11485.86,2671.61,21378.50,4049.64,21564.52,6505.24,21564.52,6505.24,21564.52,6505.24,59623.40,11012.00,24352.17,2671.61,20989.64,3499.76,28261.97,6226.50,66140.98,6226.50,8372.21,3499.76,24352.17,2671.61,10556.25,2671.61,22458.92,2938.77,8372.21,66140.98,2671.61,15064.94,,Hospital HCPCS J7100,DEXTRAN 40 IN D5W 10 % IV SOLN,00409-7418-03,0258 - PHARMACY - IV SOLUTIONS,199.20,199.20,119.52,119.52,N/A,N/A,N/A,199.20,N/A,114.70,N/A,67.73,N/A,27.89,N/A,27.89,N/A,199.20,N/A,199.20,N/A,17.33,N/A,27.89,N/A,27.89,N/A,27.89,N/A,114.70,N/A,199.20,N/A,27.89,N/A,106.77,N/A,106.77,N/A,N/A,N/A,199.20,N/A,199.20,N/A,N/A,119.52,119.52,17.33,199.20,,Hospital HCPCS J7100,DEXTRAN 40 IN D5W 10 % IV SOLN,00409-7418-03,0250 - PHARMACY - GENERAL CLASSIFICATION,199.20,199.20,N/A,N/A,N/A,27.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,27.89,N/A,N/A,N/A,N/A,N/A,199.20,N/A,N/A,27.89,199.20,,Hospital HCPCS J7120,LACTATED RINGERS IV SOLN,00338-0117-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7120,LACTATED RINGERS IV SOLN,00338-0117-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7120,LACTATED RINGERS IV SOLN,00338-0117-04,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7120,LACTATED RINGERS IV SOLN,00338-0117-04,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7120,LACTATED RINGERS IV BOLUS,00338-0117-03,0250 - PHARMACY - GENERAL CLASSIFICATION,40.00,40.00,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.60,N/A,N/A,N/A,N/A,N/A,40.00,N/A,N/A,5.60,40.00,,Hospital HCPCS J7120,LACTATED RINGERS IV BOLUS,00338-0117-03,0258 - PHARMACY - IV SOLUTIONS,40.00,40.00,24.00,24.00,N/A,N/A,N/A,40.00,N/A,23.03,N/A,13.60,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,40.00,N/A,23.03,N/A,40.00,N/A,5.60,N/A,21.44,N/A,21.44,N/A,N/A,N/A,40.00,N/A,40.00,N/A,N/A,24.00,24.00,5.60,40.00,,Hospital HCPCS J7168,PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,63833-0387-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12240.00,12240.00,7344.00,7344.00,N/A,1713.60,N/A,2183.00,N/A,6881.33,N/A,4161.60,N/A,7044.80,N/A,1713.60,N/A,2183.00,N/A,2183.00,N/A,4385.46,N/A,7044.80,N/A,7044.80,N/A,7044.80,N/A,6881.33,N/A,2183.00,N/A,1713.60,N/A,6560.64,N/A,6560.64,N/A,1713.60,N/A,2183.00,N/A,2183.00,N/A,2401.30,7344.00,7344.00,1713.60,7344.00,,Hospital HCPCS J7168,PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,63833-0386-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12240.00,12240.00,7344.00,7344.00,N/A,1713.60,N/A,2183.00,N/A,6881.33,N/A,4161.60,N/A,7044.80,N/A,1713.60,N/A,2183.00,N/A,2183.00,N/A,4385.46,N/A,7044.80,N/A,7044.80,N/A,7044.80,N/A,6881.33,N/A,2183.00,N/A,1713.60,N/A,6560.64,N/A,6560.64,N/A,1713.60,N/A,2183.00,N/A,2183.00,N/A,2401.30,7344.00,7344.00,1713.60,7344.00,,Hospital HCPCS J7179,VON WILLEBRAND FACTOR (RECOMB) 1300 UNITS IV SOLR,00944-7553-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11583.00,11583.00,6949.80,6949.80,N/A,1621.62,N/A,2315.30,N/A,6511.96,N/A,3938.22,N/A,6262.62,N/A,1621.62,N/A,2315.30,N/A,2315.30,N/A,3898.54,N/A,6262.62,N/A,6262.62,N/A,6262.62,N/A,6511.96,N/A,2314.00,N/A,1621.62,N/A,6208.49,N/A,6208.49,N/A,1621.62,N/A,2315.30,N/A,2315.30,N/A,2546.83,6949.80,6949.80,1621.62,6949.80,,Hospital HCPCS J7185,"ANTIHEM FACT (BDD-RFVIII,MOR) 500 UNITS IV KIT",58394-0023-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3577.50,3577.50,2146.50,2146.50,N/A,500.85,N/A,688.00,N/A,2011.27,N/A,1216.35,N/A,1618.75,N/A,500.85,N/A,688.00,N/A,688.00,N/A,1007.69,N/A,1618.75,N/A,1618.75,N/A,1618.75,N/A,2011.27,N/A,688.00,N/A,500.85,N/A,1917.54,N/A,1917.54,N/A,500.85,N/A,688.00,N/A,688.00,N/A,3577.50,2146.50,2146.50,500.85,3577.50,,Hospital HCPCS J7185,"ANTIHEM FACT (BDD-RFVIII,MOR) 2000 UNITS IV KIT",58394-0025-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),14310.00,14310.00,8586.00,8586.00,N/A,2003.40,N/A,2752.00,N/A,8045.08,N/A,4865.40,N/A,6475.00,N/A,2003.40,N/A,2752.00,N/A,2752.00,N/A,4030.75,N/A,6475.00,N/A,6475.00,N/A,6475.00,N/A,8045.08,N/A,2752.00,N/A,2003.40,N/A,7670.16,N/A,7670.16,N/A,2003.40,N/A,2752.00,N/A,2752.00,N/A,14310.00,8586.00,8586.00,2003.40,14310.00,,Hospital HCPCS J7187,ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR (VWF),63833-0617-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15444.00,15444.00,9266.40,9266.40,N/A,2162.16,N/A,3232.80,N/A,8682.62,N/A,5250.96,N/A,8018.64,N/A,2162.16,N/A,3232.80,N/A,3232.80,N/A,4991.68,N/A,8018.64,N/A,8018.64,N/A,8018.64,N/A,8682.62,N/A,3240.00,N/A,2162.16,N/A,8277.98,N/A,8277.98,N/A,2162.16,N/A,3232.80,N/A,3232.80,N/A,15444.00,9266.40,9266.40,2162.16,15444.00,,Hospital HCPCS J7187,ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,63833-0617-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),15444.00,15444.00,9266.40,9266.40,N/A,2162.16,N/A,1347.00,N/A,8682.62,N/A,5250.96,N/A,3341.10,N/A,2162.16,N/A,1347.00,N/A,1347.00,N/A,2079.87,N/A,3341.10,N/A,3341.10,N/A,3341.10,N/A,8682.62,N/A,1350.00,N/A,2162.16,N/A,8277.98,N/A,8277.98,N/A,2162.16,N/A,1347.00,N/A,1347.00,N/A,15444.00,9266.40,9266.40,1347.00,15444.00,,Hospital J7318,"HC Inj, Durolane 1 Mg",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,5364.00,N/A,3218.40,N/A,750.96,N/A,1209.92,N/A,3064.11,N/A,1823.76,N/A,1800.00,N/A,750.96,N/A,1204.75,N/A,1204.75,N/A,2004.41,N/A,1800.00,N/A,1800.00,N/A,1800.00,N/A,3064.11,N/A,1204.75,N/A,750.96,N/A,577.27,N/A,577.27,N/A,750.96,N/A,1204.75,N/A,1209.92,N/A,151.36,N/A,N/A,151.36,3218.40,,Hospital J7321,HC Hyalgan Supartz Visco 3 Dose,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,2032.50,N/A,1219.50,N/A,284.55,N/A,245.53,N/A,1164.50,N/A,691.05,N/A,790.99,N/A,284.55,N/A,245.53,N/A,245.53,N/A,492.41,N/A,790.99,N/A,790.99,N/A,790.99,N/A,1164.50,N/A,245.53,N/A,284.55,N/A,1089.42,N/A,1089.42,N/A,284.55,N/A,245.53,N/A,245.53,N/A,270.08,N/A,N/A,245.53,1219.50,,Hospital HCPCS J7325,HYLAN 48 MG/6ML IX SOSY,58468-0090-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6163.30,6163.30,3697.98,3697.98,N/A,862.86,N/A,461.62,N/A,3465.01,N/A,2095.52,N/A,1214.61,N/A,862.86,N/A,461.62,N/A,461.62,N/A,756.10,N/A,1214.61,N/A,1214.61,N/A,1214.61,N/A,3465.01,N/A,461.62,N/A,862.86,N/A,3303.53,N/A,3303.53,N/A,862.86,N/A,461.62,N/A,461.62,N/A,6163.30,3697.98,3697.98,461.62,6163.30,,Hospital J7326,HC Gel-One for Intra-Articular Inj per Dose,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,1680.00,N/A,1008.00,N/A,235.20,N/A,892.58,N/A,952.33,N/A,571.20,N/A,1104.00,N/A,235.20,N/A,871.40,N/A,871.40,N/A,786.95,N/A,1104.00,N/A,1104.00,N/A,1104.00,N/A,952.33,N/A,871.40,N/A,235.20,N/A,900.47,N/A,900.47,N/A,235.20,N/A,871.40,N/A,892.58,N/A,47.74,N/A,N/A,47.74,1104.00,,Hospital J7503,Tacrol envarsus ex rel oral,N/A,N/A,41274.03,N/A,24764.42,N/A,5399.17,N/A,6771.18,N/A,12167.47,N/A,14033.17,N/A,12283.86,N/A,5565.53,N/A,2810.00,N/A,2810.00,N/A,7646.42,N/A,12283.86,N/A,N/A,N/A,12283.86,N/A,12167.47,N/A,6652.58,N/A,5565.53,N/A,14614.72,N/A,14614.72,N/A,5565.53,N/A,6652.58,N/A,6652.58,N/A,5955.11,N/A,2810.00,24764.42,N/A,N/A,,Hospital HCPCS J7507,TACROLIMUS 0.5 MG PO CAPS,00781-2102-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7507,TACROLIMUS 1 MG PO CAPS,68084-0450-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital J7510,Prednisolone Oral per 5 Mg,N/A,N/A,38592.40,2312.00,23155.44,1387.20,7576.65,323.68,11805.17,106.47,18355.19,1331.25,13121.42,786.08,18530.77,233.46,7810.10,323.68,1686.00,96.52,1686.00,96.52,11534.97,145.34,18530.77,233.46,18530.77,233.46,18530.77,233.46,18355.19,1331.25,9228.11,96.52,7810.10,323.68,22046.99,1155.61,22046.99,1155.61,13357.20,323.68,9228.11,96.52,9228.11,54.12,8356.81,59.53,1686.00,23155.44,54.12,1387.20,,Hospital J7511,Antithymocyte Globuln Rabbit,N/A,N/A,358639.33,N/A,215183.60,N/A,46237.92,N/A,27306.36,N/A,197682.00,N/A,121937.36,N/A,124878.22,N/A,41643.89,N/A,35302.00,N/A,35302.00,N/A,77753.01,N/A,124878.22,N/A,124878.22,N/A,124878.22,N/A,197682.00,N/A,35302.00,N/A,41643.89,N/A,288046.56,N/A,288046.56,N/A,40611.40,N/A,35302.00,N/A,35302.00,N/A,44558.96,N/A,27306.36,288046.56,N/A,N/A,,Hospital HCPCS J7515,CYCLOSPORINE MODIFIED 25 MG PO CAPS,00078-0246-61,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.40,5.40,3.24,3.24,N/A,N/A,N/A,5.40,N/A,3.04,N/A,1.84,N/A,2.02,N/A,N/A,N/A,5.40,N/A,5.40,N/A,1.26,N/A,2.02,N/A,2.02,N/A,2.02,N/A,3.04,N/A,5.40,N/A,N/A,N/A,2.89,N/A,2.89,N/A,N/A,N/A,5.40,N/A,5.40,N/A,5.40,3.24,3.24,1.26,5.40,,Hospital HCPCS J7515,CYCLOSPORINE 25 MG PO CAPS,60505-0133-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7.00,7.00,4.20,4.20,N/A,N/A,N/A,7.00,N/A,3.94,N/A,2.38,N/A,2.02,N/A,N/A,N/A,7.00,N/A,7.00,N/A,1.26,N/A,2.02,N/A,2.02,N/A,2.02,N/A,3.94,N/A,7.00,N/A,N/A,N/A,3.75,N/A,3.75,N/A,N/A,N/A,7.00,N/A,7.00,N/A,7.00,4.20,4.20,1.26,7.00,,Hospital HCPCS J7518,MYCOPHENOLATE SODIUM 360 MG PO TBEC,68084-0918-25,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),17.20,17.20,10.32,10.32,N/A,2.41,N/A,17.20,N/A,9.67,N/A,5.85,N/A,6.11,N/A,2.41,N/A,17.20,N/A,17.20,N/A,3.81,N/A,6.11,N/A,6.11,N/A,6.11,N/A,9.67,N/A,17.20,N/A,2.41,N/A,9.22,N/A,9.22,N/A,2.41,N/A,17.20,N/A,17.20,N/A,17.20,10.32,10.32,2.41,17.20,,Hospital HCPCS J7605,ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU,63402-0911-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),126.70,126.70,76.02,76.02,N/A,17.74,N/A,126.70,N/A,71.23,N/A,43.08,N/A,13.18,N/A,17.74,N/A,126.70,N/A,126.70,N/A,8.21,N/A,13.18,N/A,13.18,N/A,13.18,N/A,71.23,N/A,126.70,N/A,17.74,N/A,67.91,N/A,67.91,N/A,17.74,N/A,126.70,N/A,126.70,N/A,126.70,76.02,76.02,8.21,126.70,,Hospital J7611,Albuterol non-comp con,N/A,N/A,59555.60,1479.00,35733.36,887.40,4610.18,207.06,8697.73,252.91,10389.41,851.62,20248.90,502.86,10488.80,611.76,4921.05,207.06,5719.23,252.91,5719.23,252.91,14786.65,380.83,10488.80,611.76,23386.79,611.76,10488.80,611.76,10389.41,851.62,5719.23,252.91,4752.23,207.06,12479.05,792.74,12479.05,792.74,7641.45,207.06,5719.23,252.91,8697.73,252.91,5084.88,278.20,4610.18,35733.36,207.06,887.40,,Hospital HCPCS J7612,ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU,00487-9901-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,1.71,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.06,N/A,1.71,N/A,1.71,N/A,1.71,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.06,5.00,,Hospital HCPCS J7614,LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,43598-0409-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11.60,11.60,6.96,6.96,N/A,1.62,N/A,11.60,N/A,6.52,N/A,3.94,N/A,N/A,N/A,1.62,N/A,11.60,N/A,11.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6.52,N/A,11.60,N/A,1.62,N/A,6.22,N/A,6.22,N/A,1.62,N/A,11.60,N/A,11.60,N/A,11.60,6.96,6.96,1.62,11.60,,Hospital HCPCS J7620,IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,00378-9671-93,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7626,BUDESONIDE 0.25 MG/2ML IN SUSP,00093-6815-73,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17.00,17.00,10.20,10.20,N/A,2.38,N/A,17.00,N/A,9.56,N/A,5.78,N/A,2.69,N/A,2.38,N/A,17.00,N/A,17.00,N/A,1.68,N/A,2.69,N/A,2.69,N/A,2.69,N/A,9.56,N/A,17.00,N/A,2.38,N/A,9.11,N/A,9.11,N/A,2.38,N/A,17.00,N/A,17.00,N/A,17.00,10.20,10.20,1.68,17.00,,Hospital HCPCS J7626,BUDESONIDE 0.5 MG/2ML IN SUSP,00093-6816-73,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),21.00,21.00,12.60,12.60,N/A,2.94,N/A,21.00,N/A,11.81,N/A,7.14,N/A,2.69,N/A,2.94,N/A,21.00,N/A,21.00,N/A,1.68,N/A,2.69,N/A,2.69,N/A,2.69,N/A,11.81,N/A,21.00,N/A,2.94,N/A,11.26,N/A,11.26,N/A,2.94,N/A,21.00,N/A,21.00,N/A,21.00,12.60,12.60,1.68,21.00,,Hospital HCPCS J7639,DORNASE ALFA 2.5 MG/2.5ML IN SOLN,50242-0100-40,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),814.50,814.50,488.70,488.70,N/A,114.03,N/A,814.50,N/A,457.91,N/A,276.93,N/A,371.48,N/A,114.03,N/A,814.50,N/A,814.50,N/A,231.25,N/A,371.48,N/A,371.48,N/A,371.48,N/A,457.91,N/A,814.50,N/A,114.03,N/A,436.57,N/A,436.57,N/A,114.03,N/A,814.50,N/A,814.50,N/A,814.50,488.70,488.70,114.03,814.50,,Hospital HCPCS J7644,IPRATROPIUM BROMIDE 0.02 % IN SOLN,00487-9801-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS J7674,METHACHOLINE CHLORIDE 100 MG IN SOLR,64281-0100-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),526.50,526.50,315.90,315.90,N/A,73.71,N/A,526.50,N/A,296.00,N/A,179.01,N/A,209.79,N/A,73.71,N/A,526.50,N/A,526.50,N/A,130.60,N/A,209.79,N/A,209.79,N/A,209.79,N/A,296.00,N/A,526.50,N/A,73.71,N/A,282.20,N/A,282.20,N/A,73.71,N/A,526.50,N/A,526.50,N/A,526.50,315.90,315.90,73.71,526.50,,Hospital J7686,"Treprostinil, non-comp unit",N/A,N/A,56975.82,N/A,34185.49,N/A,8768.52,N/A,N/A,N/A,19760.56,N/A,19371.77,N/A,19949.59,N/A,9038.69,N/A,1686.00,N/A,1686.00,N/A,12418.15,N/A,19949.59,N/A,19949.59,N/A,19949.59,N/A,19760.56,N/A,N/A,N/A,9038.69,N/A,23735.03,N/A,23735.03,N/A,9038.69,N/A,10638.34,N/A,10638.34,N/A,9671.40,N/A,1686.00,34185.49,N/A,N/A,,Hospital HCPCS J7999,FENTANYL CITRATE-NACL 2.5-0.9 MG/250ML-% IV SOLN,71266-5010-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),205.90,205.90,123.54,123.54,N/A,28.83,N/A,205.90,N/A,115.76,N/A,70.01,N/A,205.90,N/A,28.83,N/A,205.90,N/A,205.90,N/A,205.90,N/A,205.90,N/A,205.90,N/A,205.90,N/A,115.76,N/A,205.90,N/A,28.83,N/A,110.36,N/A,110.36,N/A,28.83,N/A,205.90,N/A,205.90,N/A,205.90,123.54,123.54,28.83,205.90,,Hospital HCPCS J7999,FENTANYL CITRATE-NACL 2.5-0.9 MG/250ML-% IJ SOLN,99990-9915-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),232.90,232.90,139.74,139.74,N/A,32.61,N/A,232.90,N/A,130.94,N/A,79.19,N/A,232.90,N/A,32.61,N/A,232.90,N/A,232.90,N/A,232.90,N/A,232.90,N/A,232.90,N/A,232.90,N/A,130.94,N/A,232.90,N/A,32.61,N/A,124.83,N/A,124.83,N/A,32.61,N/A,232.90,N/A,232.90,N/A,232.90,139.74,139.74,32.61,232.90,,Hospital J8501,Oral aprepitant,N/A,N/A,77350.48,34372.17,46410.29,20623.30,10199.26,4786.76,12360.50,5168.91,39873.82,19771.70,28614.19,11686.55,23204.73,10970.62,10513.52,4786.76,12330.85,5168.91,12330.85,5168.91,14444.40,6828.77,23204.73,10970.62,23204.73,10970.62,23204.73,10970.62,39873.82,19771.71,12330.85,5168.91,10513.52,4786.76,27607.84,5963.00,27607.84,5963.00,13135.02,4786.76,12330.85,5168.91,12360.50,5168.91,11249.46,5685.80,10199.26,46410.29,4786.76,20623.30,,Hospital J8521,"Capecitabine, Oral, 500 Mg",N/A,N/A,31381.72,N/A,18829.03,N/A,5697.91,N/A,7005.97,N/A,12840.70,N/A,10669.78,N/A,12963.53,N/A,5873.47,N/A,2810.00,N/A,2810.00,N/A,8069.50,N/A,12963.53,N/A,12963.53,N/A,12963.53,N/A,12840.70,N/A,7005.97,N/A,5873.47,N/A,15423.36,N/A,15423.36,N/A,5873.47,N/A,7005.97,N/A,7005.97,N/A,6284.61,N/A,2810.00,18829.03,N/A,N/A,,Hospital HCPCS J8700,TEMOZOLOMIDE 140 MG PO CAPS,47335-0929-74,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),114.40,114.40,68.64,68.64,N/A,16.02,N/A,114.40,N/A,64.32,N/A,38.90,N/A,18.86,N/A,16.02,N/A,114.40,N/A,114.40,N/A,11.74,N/A,18.86,N/A,18.86,N/A,18.86,N/A,64.32,N/A,114.40,N/A,16.02,N/A,61.32,N/A,61.32,N/A,16.02,N/A,114.40,N/A,114.40,N/A,114.40,68.64,68.64,11.74,114.40,,Hospital J8999,Oral Prescription Drug Chemo,N/A,N/A,116330.47,N/A,69798.28,N/A,22658.38,N/A,21704.93,N/A,64121.36,N/A,39552.36,N/A,N/A,N/A,22658.38,N/A,6182.00,N/A,6182.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,64121.36,N/A,21704.93,N/A,22658.38,N/A,N/A,N/A,28261.97,N/A,22658.38,N/A,21704.93,N/A,21704.93,N/A,11516.01,N/A,6182.00,69798.28,N/A,N/A,,Hospital J9023,"Injection, avelumab, 10 mg",N/A,N/A,N/A,53296.87,N/A,31978.12,N/A,7449.99,N/A,7562.81,N/A,30001.30,N/A,18120.93,N/A,19038.90,N/A,7449.99,N/A,7545.89,N/A,7545.89,N/A,11851.91,N/A,19038.90,N/A,19038.90,N/A,19038.90,N/A,30001.29,N/A,7545.89,N/A,7449.99,N/A,1099.41,N/A,1099.41,N/A,7449.99,N/A,7545.89,N/A,166.63,N/A,177.17,N/A,N/A,166.63,31978.12,,Hospital J9027,Clofarabine injection,N/A,N/A,1088719.40,N/A,653231.64,N/A,55479.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,55479.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,55479.40,N/A,N/A,N/A,N/A,N/A,55479.40,N/A,N/A,N/A,N/A,N/A,55479.40,N/A,55479.40,653231.64,N/A,N/A,,Hospital J9034,"Inj., bendeka 1 mg",N/A,N/A,137279.87,54814.70,82367.92,32888.82,8569.53,7666.30,10402.96,5764.25,75668.66,30880.93,46675.16,18636.99,20255.10,18556.19,8833.58,7666.30,10402.96,5764.25,10402.96,5764.25,12608.63,11551.40,20255.10,18556.19,20255.10,18556.19,20255.10,18556.19,75668.66,30869.63,10402.96,5764.25,8833.58,7666.30,23196.42,2352.08,23196.42,2352.08,1917.76,7666.30,10402.96,5764.25,10402.96,5764.25,9451.93,6340.67,1917.76,82367.92,2352.08,32888.82,,Hospital HCPCS J9035,BEVACIZUMAB 400 MG/16ML IV SOLN,50242-0061-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12268.00,12268.00,7360.80,7360.80,N/A,1717.52,N/A,2943.16,N/A,6897.07,N/A,4171.12,N/A,7172.23,N/A,1717.52,N/A,2943.16,N/A,2943.16,N/A,4464.78,N/A,7172.23,N/A,7172.23,N/A,7172.23,N/A,6897.07,N/A,2943.16,N/A,1717.52,N/A,6575.65,N/A,6575.65,N/A,1717.52,N/A,2943.16,N/A,2943.16,N/A,3237.48,7360.80,7360.80,1717.52,7360.80,,Hospital HCPCS J9035,BEVACIZUMAB 25 MG/ML IV SOLN (MIXTURES ONLY),50242-0060-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3067.00,3067.00,1840.20,1840.20,N/A,429.38,N/A,735.79,N/A,1724.27,N/A,1042.78,N/A,1793.06,N/A,429.38,N/A,735.79,N/A,735.79,N/A,1116.20,N/A,1793.06,N/A,1793.06,N/A,1793.06,N/A,1724.27,N/A,735.79,N/A,429.38,N/A,1643.91,N/A,1643.91,N/A,429.38,N/A,735.79,N/A,735.79,N/A,809.37,1840.20,1840.20,429.38,1840.20,,Hospital HCPCS J9035,BEVACIZUMAB 100 MG/4ML IV SOLN,50242-0060-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3067.00,3067.00,1840.20,1840.20,N/A,429.38,N/A,735.79,N/A,1724.27,N/A,1042.78,N/A,1793.06,N/A,429.38,N/A,735.79,N/A,735.79,N/A,1116.20,N/A,1793.06,N/A,1793.06,N/A,1793.06,N/A,1724.27,N/A,735.79,N/A,429.38,N/A,1643.91,N/A,1643.91,N/A,429.38,N/A,735.79,N/A,735.79,N/A,809.37,1840.20,1840.20,429.38,1840.20,,Hospital HCPCS J9035,BEVACIZUMAB 25 MG/ML IV SOLN (MIXTURES ONLY),50242-0061-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12268.00,12268.00,7360.80,7360.80,N/A,1717.52,N/A,2943.16,N/A,6897.07,N/A,4171.12,N/A,7172.23,N/A,1717.52,N/A,2943.16,N/A,2943.16,N/A,4464.78,N/A,7172.23,N/A,7172.23,N/A,7172.23,N/A,6897.07,N/A,2943.16,N/A,1717.52,N/A,6575.65,N/A,6575.65,N/A,1717.52,N/A,2943.16,N/A,2943.16,N/A,3237.48,7360.80,7360.80,1717.52,7360.80,,Hospital HCPCS J9042,BRENTUXIMAB VEDOTIN 50 MG IV SOLR,51144-0050-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),50390.00,50390.00,30234.00,30234.00,N/A,7054.60,N/A,11098.20,N/A,28329.26,N/A,17132.60,N/A,26620.02,N/A,7054.60,N/A,11098.20,N/A,11098.20,N/A,16571.22,N/A,26620.02,N/A,26620.02,N/A,26620.02,N/A,28329.26,N/A,11098.20,N/A,7054.60,N/A,27009.04,N/A,27009.04,N/A,7054.60,N/A,11098.20,N/A,11098.20,N/A,12208.02,30234.00,30234.00,7054.60,30234.00,,Hospital HCPCS J9045,CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),00703-4244-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,7.56,N/A,21.00,N/A,150.00,N/A,150.00,N/A,4.71,N/A,7.56,N/A,7.56,N/A,7.56,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,4.71,150.00,,Hospital HCPCS J9045,CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),00703-4248-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),324.90,324.90,194.94,194.94,N/A,45.49,N/A,324.90,N/A,182.66,N/A,110.47,N/A,68.07,N/A,45.49,N/A,324.90,N/A,324.90,N/A,42.37,N/A,68.07,N/A,68.07,N/A,68.07,N/A,182.66,N/A,324.90,N/A,45.49,N/A,174.15,N/A,174.15,N/A,45.49,N/A,324.90,N/A,324.90,N/A,324.90,194.94,194.94,42.37,324.90,,Hospital HCPCS J9045,CARBOPLATIN 600 MG/60ML IV SOLN,00703-4239-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),330.30,330.30,198.18,198.18,N/A,46.24,N/A,330.30,N/A,185.69,N/A,112.30,N/A,90.75,N/A,46.24,N/A,330.30,N/A,330.30,N/A,56.49,N/A,90.75,N/A,90.75,N/A,90.75,N/A,185.69,N/A,330.30,N/A,46.24,N/A,177.04,N/A,177.04,N/A,46.24,N/A,330.30,N/A,330.30,N/A,330.30,198.18,198.18,46.24,330.30,,Hospital HCPCS J9045,CARBOPLATIN 50 MG/5ML IV SOLN,61703-0339-18,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,7.56,N/A,21.00,N/A,150.00,N/A,150.00,N/A,4.71,N/A,7.56,N/A,7.56,N/A,7.56,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,4.71,150.00,,Hospital HCPCS J9045,CARBOPLATIN 150 MG/15ML IV SOLN,61703-0339-22,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,22.69,N/A,21.00,N/A,150.00,N/A,150.00,N/A,14.12,N/A,22.69,N/A,22.69,N/A,22.69,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,14.12,150.00,,Hospital HCPCS J9045,CARBOPLATIN 450 MG/45ML IV SOLN,16729-0295-34,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),165.00,165.00,99.00,99.00,N/A,23.10,N/A,165.00,N/A,92.76,N/A,56.10,N/A,68.07,N/A,23.10,N/A,165.00,N/A,165.00,N/A,42.37,N/A,68.07,N/A,68.07,N/A,68.07,N/A,92.76,N/A,165.00,N/A,23.10,N/A,88.44,N/A,88.44,N/A,23.10,N/A,165.00,N/A,165.00,N/A,165.00,99.00,99.00,23.10,165.00,,Hospital HCPCS J9045,CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),00703-4246-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,22.69,N/A,21.00,N/A,150.00,N/A,150.00,N/A,14.12,N/A,22.69,N/A,22.69,N/A,22.69,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,14.12,150.00,,Hospital HCPCS J9047,CARFILZOMIB 30 MG IV SOLR,76075-0102-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7033.10,7033.10,4219.86,4219.86,N/A,984.63,N/A,1411.20,N/A,3954.01,N/A,2391.25,N/A,3359.75,N/A,984.63,N/A,1411.20,N/A,1411.20,N/A,2091.48,N/A,3359.75,N/A,3359.75,N/A,3359.75,N/A,3954.01,N/A,1411.20,N/A,984.63,N/A,3769.74,N/A,3769.74,N/A,984.63,N/A,1411.20,N/A,1411.20,N/A,1552.32,4219.86,4219.86,984.63,4219.86,,Hospital HCPCS J9047,CARFILZOMIB 10 MG IV SOLR,76075-0103-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2344.40,2344.40,1406.64,1406.64,N/A,328.22,N/A,470.40,N/A,1318.02,N/A,797.10,N/A,1119.92,N/A,328.22,N/A,470.40,N/A,470.40,N/A,697.16,N/A,1119.92,N/A,1119.92,N/A,1119.92,N/A,1318.02,N/A,470.40,N/A,328.22,N/A,1256.60,N/A,1256.60,N/A,328.22,N/A,470.40,N/A,470.40,N/A,517.44,1406.64,1406.64,328.22,1406.64,,Hospital HCPCS J9047,CARFILZOMIB 60 MG IV SOLR,76075-0101-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),14066.10,14066.10,8439.66,8439.66,N/A,1969.25,N/A,2822.40,N/A,7907.96,N/A,4782.47,N/A,6719.50,N/A,1969.25,N/A,2822.40,N/A,2822.40,N/A,4182.95,N/A,6719.50,N/A,6719.50,N/A,6719.50,N/A,7907.96,N/A,2822.40,N/A,1969.25,N/A,7539.43,N/A,7539.43,N/A,1969.25,N/A,2822.40,N/A,2822.40,N/A,3104.64,8439.66,8439.66,1969.25,8439.66,,Hospital J9050,Carmus Bischl Nitro Inj,N/A,N/A,282271.97,N/A,169363.18,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,169363.18,169363.18,N/A,N/A,,Hospital HCPCS J9055,CETUXIMAB 200 MG/100ML IV SOLN,66733-0958-23,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7285.00,7285.00,4371.00,4371.00,N/A,1019.90,N/A,1441.56,N/A,4095.63,N/A,2476.90,N/A,3595.44,N/A,1019.90,N/A,1441.56,N/A,1441.56,N/A,2238.19,N/A,3595.44,N/A,3595.44,N/A,3595.44,N/A,4095.63,N/A,1441.56,N/A,1019.90,N/A,3904.76,N/A,3904.76,N/A,1019.90,N/A,1441.56,N/A,1441.56,N/A,1585.72,4371.00,4371.00,1019.90,4371.00,,Hospital HCPCS J9055,CETUXIMAB 100 MG/50ML IV SOLN,66733-0948-23,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3642.50,3642.50,2185.50,2185.50,N/A,509.95,N/A,720.78,N/A,2047.81,N/A,1238.45,N/A,1797.72,N/A,509.95,N/A,720.78,N/A,720.78,N/A,1119.10,N/A,1797.72,N/A,1797.72,N/A,1797.72,N/A,2047.81,N/A,720.78,N/A,509.95,N/A,1952.38,N/A,1952.38,N/A,509.95,N/A,720.78,N/A,720.78,N/A,792.86,2185.50,2185.50,509.95,2185.50,,Hospital J9061,"Inj, amivantamab-vmjw",N/A,N/A,N/A,45493.40,N/A,27296.04,N/A,6369.08,N/A,10770.25,N/A,25597.51,N/A,15467.76,N/A,26439.27,N/A,6369.08,N/A,10744.10,N/A,10744.10,N/A,16458.71,N/A,26439.27,N/A,26439.27,N/A,26439.27,N/A,25597.52,N/A,10744.10,N/A,6369.08,N/A,24384.47,N/A,24384.47,N/A,6369.08,N/A,10744.10,N/A,10770.25,N/A,196.63,N/A,N/A,196.63,27296.04,,Hospital J9063,"Injection, mirvetuximab soravtansine-gynx, 1 mg",N/A,N/A,N/A,157073.40,N/A,94244.04,N/A,21990.28,N/A,26861.24,N/A,88344.22,N/A,53404.96,N/A,26844.55,N/A,21990.28,N/A,26819.55,N/A,26819.55,N/A,26384.72,N/A,26844.55,N/A,26844.55,N/A,26844.55,N/A,88333.31,N/A,26819.55,N/A,21990.28,N/A,84191.35,N/A,84191.35,N/A,21990.28,N/A,26819.55,N/A,26861.24,N/A,226.99,N/A,N/A,226.99,94244.04,,Hospital HCPCS J9065,CLADRIBINE 10 MG/10ML IV SOLN,63323-0140-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2175.00,2175.00,1305.00,1305.00,N/A,304.50,N/A,2175.00,N/A,1222.79,N/A,739.50,N/A,560.99,N/A,304.50,N/A,2175.00,N/A,2175.00,N/A,349.22,N/A,560.99,N/A,560.99,N/A,560.99,N/A,1222.79,N/A,2175.00,N/A,304.50,N/A,1165.80,N/A,1165.80,N/A,304.50,N/A,2175.00,N/A,2175.00,N/A,2175.00,1305.00,1305.00,304.50,2175.00,,Hospital HCPCS J9071,CYCLOPHOSPHAMIDE 1 GM/5ML IV SOLN,50742-0520-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3662.50,3662.50,2197.50,2197.50,N/A,512.75,N/A,170.87,N/A,2059.06,N/A,1245.25,N/A,695.93,N/A,512.75,N/A,170.87,N/A,170.87,N/A,433.23,N/A,695.93,N/A,695.93,N/A,695.93,N/A,2059.06,N/A,170.87,N/A,512.75,N/A,1963.10,N/A,1963.10,N/A,512.75,N/A,170.87,N/A,170.87,N/A,187.96,2197.50,2197.50,170.87,2197.50,,Hospital HCPCS J9071,CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN,50742-0519-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1831.30,1831.30,1098.78,1098.78,N/A,256.38,N/A,85.44,N/A,1029.56,N/A,622.64,N/A,347.97,N/A,256.38,N/A,85.44,N/A,85.44,N/A,216.61,N/A,347.97,N/A,347.97,N/A,347.97,N/A,1029.56,N/A,85.44,N/A,256.38,N/A,981.58,N/A,981.58,N/A,256.38,N/A,85.44,N/A,85.44,N/A,93.98,1098.78,1098.78,85.44,1098.78,,Hospital J9120,Dactinomycin Actinomycin D,N/A,N/A,83846.02,N/A,50307.61,N/A,6498.10,N/A,7952.56,N/A,14644.00,N/A,28507.67,N/A,14784.08,N/A,6698.32,N/A,1124.00,N/A,1124.00,N/A,9202.75,N/A,14784.08,N/A,14784.08,N/A,14784.08,N/A,14644.00,N/A,7952.56,N/A,6698.32,N/A,17589.36,N/A,17589.36,N/A,6698.32,N/A,7952.56,N/A,7952.56,N/A,7167.20,N/A,1124.00,50307.61,N/A,N/A,,Hospital J9130,Dacarbazine 100 Mg Inj,N/A,N/A,31139.37,8981.60,18683.62,5388.96,6498.10,1262.10,7952.56,681.54,15165.08,5148.86,10587.38,3053.75,14784.08,2164.01,6698.32,1262.10,7952.56,681.54,7952.56,681.54,9202.75,1347.11,14784.08,2164.01,14784.08,2164.01,14784.08,2164.01,15165.08,5137.55,7952.56,681.54,6698.32,1262.10,17589.36,3696.14,17589.36,3696.14,10711.31,1262.10,7952.56,681.54,7952.56,681.54,7167.20,749.69,6498.10,18683.62,681.54,5388.96,,Hospital HCPCS J9145,DARATUMUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),57894-0502-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12276.00,12276.00,7365.60,7365.60,N/A,1718.64,N/A,2471.32,N/A,6901.57,N/A,4173.84,N/A,6086.50,N/A,1718.64,N/A,2471.32,N/A,2471.32,N/A,3788.91,N/A,6086.50,N/A,6086.50,N/A,6086.50,N/A,6901.57,N/A,2471.32,N/A,1718.64,N/A,6579.94,N/A,6579.94,N/A,1718.64,N/A,2471.32,N/A,2471.32,N/A,12276.00,7365.60,7365.60,1718.64,12276.00,,Hospital HCPCS J9145,DARATUMUMAB 100 MG/5ML IV SOLN,57894-0502-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3069.00,3069.00,1841.40,1841.40,N/A,429.66,N/A,617.83,N/A,1725.39,N/A,1043.46,N/A,1521.63,N/A,429.66,N/A,617.83,N/A,617.83,N/A,947.23,N/A,1521.63,N/A,1521.63,N/A,1521.63,N/A,1725.39,N/A,617.83,N/A,429.66,N/A,1644.98,N/A,1644.98,N/A,429.66,N/A,617.83,N/A,617.83,N/A,3069.00,1841.40,1841.40,429.66,3069.00,,Hospital HCPCS J9145,DARATUMUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),57894-0502-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3069.00,3069.00,1841.40,1841.40,N/A,429.66,N/A,617.83,N/A,1725.39,N/A,1043.46,N/A,1521.63,N/A,429.66,N/A,617.83,N/A,617.83,N/A,947.23,N/A,1521.63,N/A,1521.63,N/A,1521.63,N/A,1725.39,N/A,617.83,N/A,429.66,N/A,1644.98,N/A,1644.98,N/A,429.66,N/A,617.83,N/A,617.83,N/A,3069.00,1841.40,1841.40,429.66,3069.00,,Hospital HCPCS J9150,DAUNORUBICIN HCL 20 MG/4ML IV SOLN,09999-9906-83,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,114.09,N/A,21.00,N/A,45.62,N/A,45.62,N/A,71.02,N/A,114.09,N/A,114.09,N/A,114.09,N/A,84.33,N/A,45.62,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,45.62,N/A,150.00,N/A,150.00,90.00,90.00,21.00,150.00,,Hospital J9153,"Inj daunorubicin, cytarabine",N/A,N/A,871117.23,N/A,522670.34,N/A,N/A,N/A,141678.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,141678.89,N/A,141678.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,141678.89,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,141678.89,N/A,141678.89,N/A,N/A,N/A,141678.89,522670.34,N/A,N/A,,Hospital HCPCS J9171,DOCETAXEL 10 MG/ML IV SOLN (MIXTURES ONLY),67457-0533-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1600.00,1600.00,960.00,960.00,N/A,224.00,N/A,1600.00,N/A,899.52,N/A,544.00,N/A,207.20,N/A,224.00,N/A,1600.00,N/A,1600.00,N/A,128.98,N/A,207.20,N/A,207.20,N/A,207.20,N/A,899.52,N/A,1600.00,N/A,224.00,N/A,857.60,N/A,857.60,N/A,224.00,N/A,1600.00,N/A,1600.00,N/A,1600.00,960.00,960.00,128.98,1600.00,,Hospital HCPCS J9171,DOCETAXEL 160 MG/8ML IV CONC,16729-0267-65,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),850.00,850.00,510.00,510.00,N/A,119.00,N/A,850.00,N/A,477.87,N/A,289.00,N/A,207.20,N/A,119.00,N/A,850.00,N/A,850.00,N/A,128.98,N/A,207.20,N/A,207.20,N/A,207.20,N/A,477.87,N/A,850.00,N/A,119.00,N/A,455.60,N/A,455.60,N/A,119.00,N/A,850.00,N/A,850.00,N/A,850.00,510.00,510.00,119.00,850.00,,Hospital HCPCS J9171,DOCETAXEL 80 MG/4ML IV CONC,00955-1021-04,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2175.00,2175.00,1305.00,1305.00,N/A,304.50,N/A,2175.00,N/A,1222.79,N/A,739.50,N/A,103.60,N/A,304.50,N/A,2175.00,N/A,2175.00,N/A,64.49,N/A,103.60,N/A,103.60,N/A,103.60,N/A,1222.79,N/A,2175.00,N/A,304.50,N/A,1165.80,N/A,1165.80,N/A,304.50,N/A,2175.00,N/A,2175.00,N/A,2175.00,1305.00,1305.00,64.49,2175.00,,Hospital HCPCS J9171,DOCETAXEL 10 MG/ML IV SOLN (MIXTURES ONLY),67457-0532-08,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),800.00,800.00,480.00,480.00,N/A,112.00,N/A,800.00,N/A,449.76,N/A,272.00,N/A,103.60,N/A,112.00,N/A,800.00,N/A,800.00,N/A,64.49,N/A,103.60,N/A,103.60,N/A,103.60,N/A,449.76,N/A,800.00,N/A,112.00,N/A,428.80,N/A,428.80,N/A,112.00,N/A,800.00,N/A,800.00,N/A,800.00,480.00,480.00,64.49,800.00,,Hospital HCPCS J9171,DOCETAXEL 80 MG/8ML IV SOLN,00409-0201-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1260.40,1260.40,756.24,756.24,N/A,176.46,N/A,1260.40,N/A,708.60,N/A,428.54,N/A,103.60,N/A,176.46,N/A,1260.40,N/A,1260.40,N/A,64.49,N/A,103.60,N/A,103.60,N/A,103.60,N/A,708.60,N/A,1260.40,N/A,176.46,N/A,675.57,N/A,675.57,N/A,176.46,N/A,1260.40,N/A,1260.40,N/A,1260.40,756.24,756.24,64.49,1260.40,,Hospital HCPCS J9171,DOCETAXEL 20 MG/ML IV CONC,00955-1020-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),545.00,545.00,327.00,327.00,N/A,76.30,N/A,545.00,N/A,306.40,N/A,185.30,N/A,25.90,N/A,76.30,N/A,545.00,N/A,545.00,N/A,16.12,N/A,25.90,N/A,25.90,N/A,25.90,N/A,306.40,N/A,545.00,N/A,76.30,N/A,292.12,N/A,292.12,N/A,76.30,N/A,545.00,N/A,545.00,N/A,545.00,327.00,327.00,16.12,545.00,,Hospital HCPCS J9171,DOCETAXEL 160 MG/16ML IV SOLN,67457-0533-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),1600.00,1600.00,960.00,960.00,N/A,224.00,N/A,1600.00,N/A,899.52,N/A,544.00,N/A,207.20,N/A,224.00,N/A,1600.00,N/A,1600.00,N/A,128.98,N/A,207.20,N/A,207.20,N/A,207.20,N/A,899.52,N/A,1600.00,N/A,224.00,N/A,857.60,N/A,857.60,N/A,224.00,N/A,1600.00,N/A,1600.00,N/A,1600.00,960.00,960.00,128.98,1600.00,,Hospital J9175,Elliotts b solution per ml,N/A,N/A,N/A,3157.50,N/A,1894.50,N/A,360.84,N/A,301.83,N/A,1800.40,N/A,1073.55,N/A,644.55,N/A,360.84,N/A,295.68,N/A,295.68,N/A,401.24,N/A,644.55,N/A,644.55,N/A,644.55,N/A,1758.29,N/A,295.68,N/A,360.84,N/A,326.08,N/A,326.08,N/A,360.84,N/A,295.68,N/A,301.83,N/A,112.88,N/A,N/A,112.88,1894.50,,Hospital HCPCS J9177,ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,51144-0030-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),18427.50,18427.50,11056.50,11056.50,N/A,2579.85,N/A,4058.16,N/A,10359.94,N/A,6265.35,N/A,9746.69,N/A,2579.85,N/A,4058.16,N/A,4058.16,N/A,6067.41,N/A,9746.69,N/A,9746.69,N/A,9746.69,N/A,10359.94,N/A,4058.16,N/A,2579.85,N/A,9877.14,N/A,9877.14,N/A,2579.85,N/A,4058.16,N/A,4058.16,N/A,18427.50,11056.50,11056.50,2579.85,18427.50,,Hospital HCPCS J9177,ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,51144-0020-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12285.00,12285.00,7371.00,7371.00,N/A,1719.90,N/A,2705.44,N/A,6906.63,N/A,4176.90,N/A,6497.79,N/A,1719.90,N/A,2705.44,N/A,2705.44,N/A,4044.94,N/A,6497.79,N/A,6497.79,N/A,6497.79,N/A,6906.63,N/A,2705.44,N/A,1719.90,N/A,6584.76,N/A,6584.76,N/A,1719.90,N/A,2705.44,N/A,2705.44,N/A,12285.00,7371.00,7371.00,1719.90,12285.00,,Hospital J9178,"Inj, Epirubicin Hcl, 2 Mg",N/A,N/A,N/A,14100.80,N/A,8460.48,N/A,1979.98,N/A,595.36,N/A,8011.38,N/A,4794.27,N/A,1924.63,N/A,1979.98,N/A,559.68,N/A,559.68,N/A,1198.11,N/A,1924.63,N/A,1924.63,N/A,1924.63,N/A,7140.46,N/A,668.82,N/A,1979.98,N/A,2839.84,N/A,2839.84,N/A,1979.98,N/A,668.82,N/A,711.46,N/A,330.44,N/A,N/A,330.44,8460.48,,Hospital HCPCS J9179,ERIBULIN MESYLATE 1 MG/2ML IV SOLN,62856-0389-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6480.00,6480.00,3888.00,3888.00,N/A,907.20,N/A,1287.77,N/A,3643.06,N/A,2203.20,N/A,3439.52,N/A,907.20,N/A,1287.77,N/A,1287.77,N/A,2141.13,N/A,3439.52,N/A,3439.52,N/A,3439.52,N/A,3643.06,N/A,1287.77,N/A,907.20,N/A,3473.28,N/A,3473.28,N/A,907.20,N/A,1287.77,N/A,1287.77,N/A,6480.00,3888.00,3888.00,907.20,6480.00,,Hospital HCPCS J9181,ETOPOSIDE PHOSPHATE 100 MG IV SOLR,61269-0410-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),775.00,775.00,465.00,465.00,N/A,108.50,N/A,775.00,N/A,435.71,N/A,263.50,N/A,20.72,N/A,108.50,N/A,775.00,N/A,775.00,N/A,12.90,N/A,20.72,N/A,20.72,N/A,20.72,N/A,435.71,N/A,775.00,N/A,108.50,N/A,415.40,N/A,415.40,N/A,108.50,N/A,775.00,N/A,775.00,N/A,775.00,465.00,465.00,12.90,775.00,,Hospital HCPCS J9190,FLUOROURACIL 2.5 GM/50ML IV SOLN,63323-0117-51,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,27.58,N/A,21.00,N/A,150.00,N/A,150.00,N/A,17.17,N/A,27.58,N/A,27.58,N/A,27.58,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,17.17,150.00,,Hospital HCPCS J9190,FLUOROURACIL 1 GM/20ML IV SOLN,16729-0276-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,11.03,N/A,21.00,N/A,150.00,N/A,150.00,N/A,6.87,N/A,11.03,N/A,11.03,N/A,11.03,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,6.87,150.00,,Hospital HCPCS J9190,FLUOROURACIL 500 MG/10ML IV SOLN,63323-0117-00,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,5.52,N/A,21.00,N/A,150.00,N/A,150.00,N/A,3.43,N/A,5.52,N/A,5.52,N/A,5.52,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,3.43,150.00,,Hospital HCPCS J9196,GEMCITABINE HCL 1 G IV SOLR,00409-0186-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),253.90,253.90,152.34,152.34,N/A,35.55,N/A,253.90,N/A,142.74,N/A,86.33,N/A,48.69,N/A,35.55,N/A,253.90,N/A,253.90,N/A,30.31,N/A,48.69,N/A,48.69,N/A,48.69,N/A,142.74,N/A,253.90,N/A,35.55,N/A,136.09,N/A,136.09,N/A,35.55,N/A,253.90,N/A,253.90,N/A,253.90,152.34,152.34,30.31,253.90,,Hospital HCPCS J9196,GEMCITABINE HCL 200 MG IV SOLR,00409-0185-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,9.74,N/A,21.00,N/A,150.00,N/A,150.00,N/A,6.06,N/A,9.74,N/A,9.74,N/A,9.74,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,6.06,150.00,,Hospital J9200,Floxuridine Injection,N/A,N/A,N/A,6009.50,N/A,3605.70,N/A,841.33,N/A,303.62,N/A,3425.23,N/A,2043.23,N/A,1003.97,N/A,841.33,N/A,300.37,N/A,300.37,N/A,624.99,N/A,1003.97,N/A,1003.97,N/A,1003.97,N/A,3425.23,N/A,300.37,N/A,841.33,N/A,3221.09,N/A,3221.09,N/A,841.33,N/A,300.37,N/A,303.62,N/A,132.24,N/A,N/A,132.24,3605.70,,Hospital HCPCS J9203,GEMTUZUMAB OZOGAMICIN 4.5 MG IV SOLR,00008-4510-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),46166.00,46166.00,27699.60,27699.60,N/A,6463.24,N/A,9982.94,N/A,25954.53,N/A,15696.44,N/A,24974.33,N/A,6463.24,N/A,9982.94,N/A,9982.94,N/A,15546.76,N/A,24974.33,N/A,24974.33,N/A,24974.33,N/A,25954.53,N/A,9982.94,N/A,6463.24,N/A,24744.98,N/A,24744.98,N/A,6463.24,N/A,9982.94,N/A,9982.94,N/A,46166.00,27699.60,27699.60,6463.24,46166.00,,Hospital HCPCS J9207,IXABEPILONE 45 MG IV SOLR,70020-1911-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),25875.00,25875.00,15525.00,15525.00,N/A,3622.50,N/A,25875.00,N/A,14546.93,N/A,8797.50,N/A,13643.34,N/A,3622.50,N/A,25875.00,N/A,25875.00,N/A,8493.11,N/A,13643.34,N/A,13643.34,N/A,13643.34,N/A,14546.93,N/A,25875.00,N/A,3622.50,N/A,13869.00,N/A,13869.00,N/A,3622.50,N/A,25875.00,N/A,25875.00,N/A,25875.00,15525.00,15525.00,3622.50,25875.00,,Hospital J9209,Mesna Injection,N/A,N/A,63726.82,10370.40,38236.09,6222.24,6498.10,1456.52,7952.56,742.46,40537.29,5942.16,21667.12,3525.93,14784.08,2427.95,6698.32,1456.52,1124.00,742.46,1124.00,742.46,9202.75,1511.42,14784.08,2427.95,14784.08,2427.95,14784.08,2427.95,40537.29,5930.85,7952.56,742.46,6698.32,1456.52,17589.36,4190.87,17589.36,4190.87,6698.32,1456.52,7952.56,742.46,7952.56,742.46,7167.20,816.71,1124.00,40537.29,742.46,6222.24,,Hospital HCPCS J9211,IDARUBICIN HCL 5 MG/5ML IV SOLN,00013-2576-91,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),269.50,269.50,161.70,161.70,N/A,37.73,N/A,269.50,N/A,151.51,N/A,91.63,N/A,106.89,N/A,37.73,N/A,269.50,N/A,269.50,N/A,66.54,N/A,106.89,N/A,106.89,N/A,106.89,N/A,151.51,N/A,269.50,N/A,37.73,N/A,144.45,N/A,144.45,N/A,37.73,N/A,269.50,N/A,269.50,N/A,269.50,161.70,161.70,37.73,269.50,,Hospital HCPCS J9211,IDARUBICIN HCL 10 MG/10ML IV SOLN,00013-2586-91,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),538.90,538.90,323.34,323.34,N/A,75.45,N/A,538.90,N/A,302.97,N/A,183.23,N/A,213.78,N/A,75.45,N/A,538.90,N/A,538.90,N/A,133.08,N/A,213.78,N/A,213.78,N/A,213.78,N/A,302.97,N/A,538.90,N/A,75.45,N/A,288.85,N/A,288.85,N/A,75.45,N/A,538.90,N/A,538.90,N/A,538.90,323.34,323.34,75.45,538.90,,Hospital HCPCS J9217,LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT,62935-0223-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6775.40,6775.40,4065.24,4065.24,N/A,948.56,N/A,497.59,N/A,3809.13,N/A,2303.64,N/A,1392.93,N/A,948.56,N/A,497.59,N/A,497.59,N/A,867.11,N/A,1392.93,N/A,1392.93,N/A,1392.93,N/A,3809.13,N/A,497.59,N/A,948.56,N/A,3631.61,N/A,3631.61,N/A,948.56,N/A,497.59,N/A,497.59,N/A,547.35,4065.24,4065.24,497.59,4065.24,,Hospital HCPCS J9217,LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT,00074-3473-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),55622.50,55622.50,33373.50,33373.50,N/A,7787.15,N/A,995.18,N/A,31270.97,N/A,18911.65,N/A,2785.86,N/A,7787.15,N/A,995.18,N/A,995.18,N/A,1734.22,N/A,2785.86,N/A,2785.86,N/A,2785.86,N/A,31270.97,N/A,995.18,N/A,7787.15,N/A,29813.66,N/A,29813.66,N/A,7787.15,N/A,995.18,N/A,995.18,N/A,1094.70,33373.50,33373.50,995.18,33373.50,,Hospital HCPCS J9217,LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,00074-3346-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),27810.80,27810.80,16686.48,16686.48,N/A,3893.51,N/A,497.59,N/A,15635.23,N/A,9455.67,N/A,1392.93,N/A,3893.51,N/A,497.59,N/A,497.59,N/A,867.11,N/A,1392.93,N/A,1392.93,N/A,1392.93,N/A,15635.23,N/A,497.59,N/A,3893.51,N/A,14906.59,N/A,14906.59,N/A,3893.51,N/A,497.59,N/A,497.59,N/A,547.35,16686.48,16686.48,497.59,16686.48,,Hospital HCPCS J9217,LEUPROLIDE ACETATE 7.5 MG IM KIT,00074-3642-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),9270.30,9270.30,5562.18,5562.18,N/A,1297.84,N/A,165.86,N/A,5211.76,N/A,3151.90,N/A,464.31,N/A,1297.84,N/A,165.86,N/A,165.86,N/A,289.04,N/A,464.31,N/A,464.31,N/A,464.31,N/A,5211.76,N/A,165.86,N/A,1297.84,N/A,4968.88,N/A,4968.88,N/A,1297.84,N/A,165.86,N/A,165.86,N/A,182.45,5562.18,5562.18,165.86,5562.18,,Hospital HCPCS J9229,INOTUZUMAB OZOGAMICIN 0.9 MG IV SOLR,00008-0100-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),105281.10,105281.10,63168.66,63168.66,N/A,14739.35,N/A,105281.10,N/A,59189.03,N/A,35795.57,N/A,56953.56,N/A,14739.35,N/A,105281.10,N/A,105281.10,N/A,35454.14,N/A,56953.56,N/A,56953.56,N/A,56953.56,N/A,59189.03,N/A,105281.10,N/A,14739.35,N/A,56430.67,N/A,56430.67,N/A,14739.35,N/A,105281.10,N/A,105281.10,N/A,105281.10,63168.66,63168.66,14739.35,105281.10,,Hospital J9245,Inj Melphalan Hydrochl 50 Mg,N/A,N/A,211263.30,16984.10,126757.98,10190.46,N/A,2345.87,40535.58,1903.85,N/A,9586.17,N/A,5774.59,N/A,5212.15,N/A,2345.87,40535.58,1867.56,40535.58,1867.56,N/A,3244.83,N/A,5212.15,N/A,5212.15,N/A,5212.15,N/A,8972.68,40535.58,1867.56,N/A,2345.87,N/A,1008.62,N/A,1008.62,N/A,2345.87,40535.58,1867.56,40535.58,1903.85,N/A,362.94,40535.58,126757.98,362.94,10190.46,,Hospital J9260,Methotrexate Sodium Inj,N/A,N/A,345780.30,N/A,207468.18,N/A,N/A,N/A,N/A,N/A,166062.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,166062.16,N/A,N/A,N/A,N/A,N/A,166062.16,N/A,166062.16,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,166062.16,207468.18,N/A,N/A,,Hospital J9261,Nelarabine injection,N/A,N/A,167686.78,51582.90,100612.07,30949.74,28711.99,7206.07,34230.47,6408.56,92428.95,29032.18,57013.51,17538.19,65323.76,21902.68,29596.66,7206.07,2248.00,8431.88,2248.00,8431.88,40662.52,13634.64,65323.76,21902.68,65323.76,21902.68,65323.76,21902.68,92428.95,29021.27,34230.47,8431.88,29596.66,7206.07,77718.97,1283.03,77718.97,1283.03,29596.66,7206.07,34230.47,8431.88,34230.47,6408.56,31668.43,260.75,2248.00,100612.07,260.75,30949.74,,Hospital HCPCS J9263,OXALIPLATIN 100 MG/20ML IV SOLN,67457-0442-20,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),500.00,500.00,300.00,300.00,N/A,70.00,N/A,500.00,N/A,281.10,N/A,170.00,N/A,31.08,N/A,70.00,N/A,500.00,N/A,500.00,N/A,19.35,N/A,31.08,N/A,31.08,N/A,31.08,N/A,281.10,N/A,500.00,N/A,70.00,N/A,268.00,N/A,268.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,500.00,300.00,300.00,19.35,500.00,,Hospital HCPCS J9263,OXALIPLATIN 50 MG/10ML IV SOLN,16729-0332-03,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,15.54,N/A,21.00,N/A,150.00,N/A,150.00,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,9.67,150.00,,Hospital J9268,Pentostatin Injection,N/A,N/A,N/A,52088.80,N/A,31253.28,N/A,7211.23,N/A,5535.89,N/A,29377.57,N/A,17710.22,N/A,16787.26,N/A,7211.23,N/A,5516.58,N/A,5516.58,N/A,10450.24,N/A,16787.26,N/A,16787.26,N/A,16787.26,N/A,28328.89,N/A,5516.58,N/A,7211.23,N/A,2667.34,N/A,2667.34,N/A,7211.23,N/A,5516.58,N/A,5535.89,N/A,473.44,N/A,N/A,473.44,31253.28,,Hospital J9274,"Inj, tebentafusp-tebn, 1 mcg",N/A,N/A,N/A,94254.57,N/A,56552.74,N/A,13193.80,N/A,20806.15,N/A,53007.85,N/A,32046.55,N/A,20756.01,N/A,13193.80,N/A,20789.23,N/A,20789.23,N/A,20507.04,N/A,20756.01,N/A,20756.01,N/A,20756.01,N/A,53007.85,N/A,20789.23,N/A,13193.80,N/A,636.82,N/A,636.82,N/A,13193.80,N/A,20789.23,N/A,139.27,N/A,147.07,N/A,N/A,139.27,56552.74,,Hospital HCPCS J9299,NIVOLUMAB 240 MG/24ML IV SOLN,00003-3734-13,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),35266.20,35266.20,21159.72,21159.72,N/A,4937.27,N/A,7309.68,N/A,19826.66,N/A,11990.51,N/A,18455.30,N/A,4937.27,N/A,7309.68,N/A,7309.68,N/A,11488.60,N/A,18455.30,N/A,18455.30,N/A,18455.30,N/A,19826.66,N/A,7309.68,N/A,4937.27,N/A,18902.68,N/A,18902.68,N/A,4937.27,N/A,7309.68,N/A,7309.68,N/A,8040.65,21159.72,21159.72,4937.27,21159.72,,Hospital HCPCS J9299,NIVOLUMAB 100 MG/10ML IV SOLN,00003-3774-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),14694.20,14694.20,8816.52,8816.52,N/A,2057.19,N/A,3045.70,N/A,8261.08,N/A,4996.03,N/A,7689.71,N/A,2057.19,N/A,3045.70,N/A,3045.70,N/A,4786.92,N/A,7689.71,N/A,7689.71,N/A,7689.71,N/A,8261.08,N/A,3045.70,N/A,2057.19,N/A,7876.09,N/A,7876.09,N/A,2057.19,N/A,3045.70,N/A,3045.70,N/A,3350.27,8816.52,8816.52,2057.19,8816.52,,Hospital HCPCS J9299,NIVOLUMAB 120 MG/12ML IV SOLN,00003-3756-14,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17633.10,17633.10,10579.86,10579.86,N/A,2468.63,N/A,3654.84,N/A,9913.33,N/A,5995.25,N/A,9227.65,N/A,2468.63,N/A,3654.84,N/A,3654.84,N/A,5744.30,N/A,9227.65,N/A,9227.65,N/A,9227.65,N/A,9913.33,N/A,3654.84,N/A,2468.63,N/A,9451.34,N/A,9451.34,N/A,2468.63,N/A,3654.84,N/A,3654.84,N/A,4020.32,10579.86,10579.86,2468.63,10579.86,,Hospital HCPCS J9299,NIVOLUMAB 10 MG/ML IV (MIXTURES ONLY),00003-3772-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5877.70,5877.70,3526.62,3526.62,N/A,822.88,N/A,1218.28,N/A,3304.44,N/A,1998.42,N/A,3075.88,N/A,822.88,N/A,1218.28,N/A,1218.28,N/A,1914.77,N/A,3075.88,N/A,3075.88,N/A,3075.88,N/A,3304.44,N/A,1218.28,N/A,822.88,N/A,3150.45,N/A,3150.45,N/A,822.88,N/A,1218.28,N/A,1218.28,N/A,1340.11,3526.62,3526.62,822.88,3526.62,,Hospital HCPCS J9299,NIVOLUMAB 10 MG/ML IV (MIXTURES ONLY),00003-3774-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),14694.20,14694.20,8816.52,8816.52,N/A,2057.19,N/A,3045.70,N/A,8261.08,N/A,4996.03,N/A,7689.71,N/A,2057.19,N/A,3045.70,N/A,3045.70,N/A,4786.92,N/A,7689.71,N/A,7689.71,N/A,7689.71,N/A,8261.08,N/A,3045.70,N/A,2057.19,N/A,7876.09,N/A,7876.09,N/A,2057.19,N/A,3045.70,N/A,3045.70,N/A,3350.27,8816.52,8816.52,2057.19,8816.52,,Hospital HCPCS J9299,NIVOLUMAB 40 MG/4ML IV SOLN,00003-3772-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5877.70,5877.70,3526.62,3526.62,N/A,822.88,N/A,1218.28,N/A,3304.44,N/A,1998.42,N/A,3075.88,N/A,822.88,N/A,1218.28,N/A,1218.28,N/A,1914.77,N/A,3075.88,N/A,3075.88,N/A,3075.88,N/A,3304.44,N/A,1218.28,N/A,822.88,N/A,3150.45,N/A,3150.45,N/A,822.88,N/A,1218.28,N/A,1218.28,N/A,1340.11,3526.62,3526.62,822.88,3526.62,,Hospital HCPCS J9301,OBINUTUZUMAB 1000 MG/40ML IV SOLN,50242-0070-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3650.40,3650.40,2190.24,2190.24,N/A,511.06,N/A,705.46,N/A,2052.25,N/A,1241.14,N/A,1709.66,N/A,511.06,N/A,705.46,N/A,705.46,N/A,1064.28,N/A,1709.66,N/A,1709.66,N/A,1709.66,N/A,2052.25,N/A,705.46,N/A,511.06,N/A,1956.61,N/A,1956.61,N/A,511.06,N/A,705.46,N/A,705.46,N/A,776.01,2190.24,2190.24,511.06,2190.24,,Hospital HCPCS J9303,PANITUMUMAB 400 MG/20ML IV SOLN,55513-0956-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29640.30,29640.30,17784.18,17784.18,N/A,4149.64,N/A,5988.36,N/A,16663.78,N/A,10077.70,N/A,14190.09,N/A,4149.64,N/A,5988.36,N/A,5988.36,N/A,8833.47,N/A,14190.09,N/A,14190.09,N/A,14190.09,N/A,16663.78,N/A,5988.36,N/A,4149.64,N/A,15887.20,N/A,15887.20,N/A,4149.64,N/A,5988.36,N/A,5988.36,N/A,6587.20,17784.18,17784.18,4149.64,17784.18,,Hospital HCPCS J9303,PANITUMUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),55513-0956-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),29640.30,29640.30,17784.18,17784.18,N/A,4149.64,N/A,5988.36,N/A,16663.78,N/A,10077.70,N/A,14190.09,N/A,4149.64,N/A,5988.36,N/A,5988.36,N/A,8833.47,N/A,14190.09,N/A,14190.09,N/A,14190.09,N/A,16663.78,N/A,5988.36,N/A,4149.64,N/A,15887.20,N/A,15887.20,N/A,4149.64,N/A,5988.36,N/A,5988.36,N/A,6587.20,17784.18,17784.18,4149.64,17784.18,,Hospital HCPCS J9303,PANITUMUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),55513-0954-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7410.10,7410.10,4446.06,4446.06,N/A,1037.41,N/A,1497.09,N/A,4165.96,N/A,2519.43,N/A,3547.52,N/A,1037.41,N/A,1497.09,N/A,1497.09,N/A,2208.37,N/A,3547.52,N/A,3547.52,N/A,3547.52,N/A,4165.96,N/A,1497.09,N/A,1037.41,N/A,3971.81,N/A,3971.81,N/A,1037.41,N/A,1497.09,N/A,1497.09,N/A,1646.80,4446.06,4446.06,1037.41,4446.06,,Hospital HCPCS J9303,PANITUMUMAB 100 MG/5ML IV SOLN,55513-0954-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),7410.10,7410.10,4446.06,4446.06,N/A,1037.41,N/A,1497.09,N/A,4165.96,N/A,2519.43,N/A,3547.52,N/A,1037.41,N/A,1497.09,N/A,1497.09,N/A,2208.37,N/A,3547.52,N/A,3547.52,N/A,3547.52,N/A,4165.96,N/A,1497.09,N/A,1037.41,N/A,3971.81,N/A,3971.81,N/A,1037.41,N/A,1497.09,N/A,1497.09,N/A,1646.80,4446.06,4446.06,1037.41,4446.06,,Hospital HCPCS J9309,POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR,50242-0105-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),78000.00,78000.00,46800.00,46800.00,N/A,10920.00,N/A,16975.28,N/A,43851.60,N/A,26520.00,N/A,42717.91,N/A,10920.00,N/A,16975.28,N/A,16975.28,N/A,26592.31,N/A,42717.91,N/A,42717.91,N/A,42717.91,N/A,43851.60,N/A,16975.28,N/A,10920.00,N/A,41808.00,N/A,41808.00,N/A,10920.00,N/A,16975.28,N/A,16975.28,N/A,78000.00,46800.00,46800.00,10920.00,78000.00,,Hospital HCPCS J9317,SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,55135-0132-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),11161.10,11161.10,6696.66,6696.66,N/A,1562.55,N/A,2398.68,N/A,6274.77,N/A,3794.77,N/A,5972.95,N/A,1562.55,N/A,2398.68,N/A,2398.68,N/A,3718.22,N/A,5972.95,N/A,5972.95,N/A,5972.95,N/A,6274.77,N/A,2398.68,N/A,1562.55,N/A,5982.35,N/A,5982.35,N/A,1562.55,N/A,2398.68,N/A,2398.68,N/A,2638.55,6696.66,6696.66,1562.55,6696.66,,Hospital J9319,Inj romidepsin lyophil 0.1mg,N/A,N/A,N/A,51593.57,N/A,30956.14,N/A,7209.97,N/A,6624.79,N/A,29081.95,N/A,17541.83,N/A,18497.95,N/A,7209.97,N/A,6595.41,N/A,6595.41,N/A,11515.17,N/A,18497.95,N/A,18497.95,N/A,18497.95,N/A,29081.95,N/A,6704.55,N/A,7209.97,N/A,2374.11,N/A,2374.11,N/A,7209.97,N/A,6704.55,N/A,251.17,N/A,270.17,N/A,N/A,251.17,30956.14,,Hospital HCPCS J9330,TEMSIROLIMUS 25 MG/ML IV SOLN,72611-0785-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6449.50,6449.50,3869.70,3869.70,N/A,902.93,N/A,840.93,N/A,3625.91,N/A,2192.83,N/A,2130.92,N/A,902.93,N/A,840.93,N/A,840.93,N/A,1326.52,N/A,2130.92,N/A,2130.92,N/A,2130.92,N/A,3625.91,N/A,840.93,N/A,902.93,N/A,3456.93,N/A,3456.93,N/A,902.93,N/A,840.93,N/A,840.93,N/A,925.02,3869.70,3869.70,840.93,3869.70,,Hospital HCPCS J9330,TEMSIROLIMUS 25 MG/ML IV SOLN,00008-1179-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6449.50,6449.50,3869.70,3869.70,N/A,902.93,N/A,840.93,N/A,3625.91,N/A,2192.83,N/A,2130.92,N/A,902.93,N/A,840.93,N/A,840.93,N/A,1326.52,N/A,2130.92,N/A,2130.92,N/A,2130.92,N/A,3625.91,N/A,840.93,N/A,902.93,N/A,3456.93,N/A,3456.93,N/A,902.93,N/A,840.93,N/A,840.93,N/A,925.02,3869.70,3869.70,840.93,3869.70,,Hospital HCPCS J9332,EFGARTIGIMOD ALFA-FCAB 400 MG/20ML IV SOLN,73475-3041-05,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),26775.00,26775.00,16065.00,16065.00,N/A,3748.50,N/A,6362.20,N/A,15052.91,N/A,9103.50,N/A,16332.54,N/A,3748.50,N/A,6362.20,N/A,6362.20,N/A,10167.16,N/A,16332.54,N/A,16332.54,N/A,16332.54,N/A,15052.91,N/A,6362.20,N/A,3748.50,N/A,14351.40,N/A,14351.40,N/A,3748.50,N/A,6362.20,N/A,6362.20,N/A,26775.00,16065.00,16065.00,3748.50,26775.00,,Hospital HCPCS J9347,TREMELIMUMAB-ACTL 25 MG/1.25ML IV SOLN,00310-4505-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),49400.00,49400.00,29640.00,29640.00,N/A,6916.00,N/A,10378.56,N/A,27772.68,N/A,16796.00,N/A,15151.51,N/A,6916.00,N/A,10378.56,N/A,10378.56,N/A,15151.51,N/A,15151.51,N/A,15151.51,N/A,15151.51,N/A,27772.68,N/A,10378.56,N/A,6916.00,N/A,26478.40,N/A,26478.40,N/A,6916.00,N/A,10378.56,N/A,10378.56,N/A,49400.00,29640.00,29640.00,6916.00,49400.00,,Hospital HCPCS J9347,TREMELIMUMAB-ACTL 20 MG/ML (MIXTURES ONLY),00310-4505-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),48750.00,48750.00,29250.00,29250.00,N/A,6825.00,N/A,10242.00,N/A,27407.25,N/A,16575.00,N/A,14952.15,N/A,6825.00,N/A,10242.00,N/A,10242.00,N/A,14952.15,N/A,14952.15,N/A,14952.15,N/A,14952.15,N/A,27407.25,N/A,10242.00,N/A,6825.00,N/A,26130.00,N/A,26130.00,N/A,6825.00,N/A,10242.00,N/A,10242.00,N/A,48750.00,29250.00,29250.00,6825.00,48750.00,,Hospital HCPCS J9349,TAFASITAMAB-CXIX 200 MG IV SOLR,73535-0208-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6274.10,6274.10,3764.46,3764.46,N/A,878.37,N/A,1330.20,N/A,3527.30,N/A,2133.19,N/A,3359.23,N/A,878.37,N/A,1330.20,N/A,1330.20,N/A,2091.15,N/A,3359.23,N/A,3359.23,N/A,3359.23,N/A,3527.30,N/A,1330.20,N/A,878.37,N/A,3362.92,N/A,3362.92,N/A,878.37,N/A,1330.20,N/A,1330.20,N/A,6274.10,3764.46,3764.46,878.37,6274.10,,Hospital J9351,Topotecan injection,N/A,N/A,N/A,3259.20,N/A,1955.52,N/A,456.29,N/A,338.63,N/A,1870.63,N/A,1108.13,N/A,914.80,N/A,456.29,N/A,338.63,N/A,338.63,N/A,569.48,N/A,914.80,N/A,914.80,N/A,914.80,N/A,1862.19,N/A,338.63,N/A,456.29,N/A,1746.92,N/A,1746.92,N/A,456.29,N/A,338.63,N/A,338.63,N/A,372.50,N/A,N/A,338.63,1955.52,,Hospital J9352,Injection trabectedin 0.1mg,N/A,N/A,81644.10,N/A,48986.46,N/A,6498.10,N/A,8384.16,N/A,16051.77,N/A,26822.97,N/A,36124.17,N/A,6698.32,N/A,490064.00,N/A,490064.00,N/A,22487.70,N/A,36124.17,N/A,36124.17,N/A,36124.17,N/A,16051.77,N/A,8354.51,N/A,6698.32,N/A,19280.29,N/A,19280.29,N/A,N/A,N/A,8354.51,N/A,8384.16,N/A,7167.20,N/A,6498.10,490064.00,N/A,N/A,,Hospital HCPCS J9353,MARGETUXIMAB-CMKB 250 MG/10ML IV SOLN,74527-0022-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),10751.60,10751.60,6450.96,6450.96,N/A,1505.22,N/A,2294.05,N/A,6044.55,N/A,3655.54,N/A,5701.89,N/A,1505.22,N/A,2294.05,N/A,2294.05,N/A,3549.48,N/A,5701.89,N/A,5701.89,N/A,5701.89,N/A,6044.55,N/A,2294.05,N/A,1505.22,N/A,5762.86,N/A,5762.86,N/A,1505.22,N/A,2294.05,N/A,2294.05,N/A,10751.60,6450.96,6450.96,1505.22,10751.60,,Hospital HCPCS J9354,ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,50242-0087-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),28109.40,28109.40,16865.64,16865.64,N/A,3935.32,N/A,6132.00,N/A,15803.10,N/A,9557.20,N/A,14760.93,N/A,3935.32,N/A,6132.00,N/A,6132.00,N/A,9188.82,N/A,14760.93,N/A,14760.93,N/A,14760.93,N/A,15803.10,N/A,6132.00,N/A,3935.32,N/A,15066.64,N/A,15066.64,N/A,3935.32,N/A,6132.00,N/A,6132.00,N/A,6745.20,16865.64,16865.64,3935.32,16865.64,,Hospital HCPCS J9354,ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,50242-0088-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17568.40,17568.40,10541.04,10541.04,N/A,2459.58,N/A,3832.50,N/A,9876.95,N/A,5973.26,N/A,9225.58,N/A,2459.58,N/A,3832.50,N/A,3832.50,N/A,5743.01,N/A,9225.58,N/A,9225.58,N/A,9225.58,N/A,9876.95,N/A,3832.50,N/A,2459.58,N/A,9416.66,N/A,9416.66,N/A,2459.58,N/A,3832.50,N/A,3832.50,N/A,4215.75,10541.04,10541.04,2459.58,10541.04,,Hospital HCPCS J9355,TRASTUZUMAB 150 MG IV SOLR,50242-0132-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6097.90,6097.90,3658.74,3658.74,N/A,853.71,N/A,1297.26,N/A,3428.24,N/A,2073.29,N/A,3589.12,N/A,853.71,N/A,1297.26,N/A,1297.26,N/A,2234.26,N/A,3589.12,N/A,3589.12,N/A,3589.12,N/A,3428.24,N/A,1297.26,N/A,853.71,N/A,3268.47,N/A,3268.47,N/A,853.71,N/A,1297.26,N/A,1297.26,N/A,1426.99,3658.74,3658.74,853.71,3658.74,,Hospital J9356,"Inj. herceptin hylecta, 10mg",N/A,N/A,N/A,34400.73,N/A,20640.44,N/A,4806.63,N/A,3999.34,N/A,19350.13,N/A,11696.25,N/A,10828.01,N/A,4806.63,N/A,3995.91,N/A,3995.91,N/A,6740.54,N/A,10828.01,N/A,10828.01,N/A,10828.01,N/A,19350.13,N/A,3995.91,N/A,4806.63,N/A,299.51,N/A,299.51,N/A,4806.63,N/A,3995.91,N/A,95.44,N/A,98.86,N/A,N/A,95.44,20640.44,,Hospital J9357,"Valrubicin, 200 Mg",N/A,N/A,N/A,78882.80,N/A,47329.68,N/A,11041.30,N/A,5557.45,N/A,44388.15,N/A,26820.15,N/A,16262.10,N/A,11041.30,N/A,5552.94,N/A,5552.94,N/A,10123.32,N/A,16262.10,N/A,16262.10,N/A,16262.10,N/A,44388.15,N/A,5552.94,N/A,11041.30,N/A,3.17,N/A,3.17,N/A,11041.30,N/A,5552.94,N/A,5557.45,N/A,49.68,N/A,N/A,3.17,47329.68,,Hospital HCPCS J9358,FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG IV SOLR,65597-0406-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12365.00,12365.00,7419.00,7419.00,N/A,1731.10,N/A,2623.50,N/A,6951.60,N/A,4204.10,N/A,6519.03,N/A,1731.10,N/A,2623.50,N/A,2623.50,N/A,4058.16,N/A,6519.03,N/A,6519.03,N/A,6519.03,N/A,6951.60,N/A,2623.50,N/A,1731.10,N/A,6627.64,N/A,6627.64,N/A,1731.10,N/A,2623.50,N/A,2623.50,N/A,2885.85,7419.00,7419.00,1731.10,7419.00,,Hospital HCPCS J9370,VINCRISTINE SULFATE 1 MG/ML IV SOLN,00703-4402-11,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,25.43,N/A,21.00,N/A,150.00,N/A,150.00,N/A,15.83,N/A,25.43,N/A,25.43,N/A,25.43,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,15.83,150.00,,Hospital HCPCS J9370,VINCRISTINE SULFATE 1 MG/ML IV SOLN,61703-0309-16,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),150.00,150.00,90.00,90.00,N/A,21.00,N/A,150.00,N/A,84.33,N/A,51.00,N/A,25.43,N/A,21.00,N/A,150.00,N/A,150.00,N/A,15.83,N/A,25.43,N/A,25.43,N/A,25.43,N/A,84.33,N/A,150.00,N/A,21.00,N/A,80.40,N/A,80.40,N/A,21.00,N/A,150.00,N/A,150.00,N/A,150.00,90.00,90.00,15.83,150.00,,Hospital HCPCS J9393,FULVESTRANT 250 MG/5ML IM SOSY,00781-3079-12,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2125.00,2125.00,1275.00,1275.00,N/A,297.50,N/A,94.70,N/A,1194.68,N/A,722.50,N/A,363.12,N/A,297.50,N/A,94.70,N/A,94.70,N/A,226.04,N/A,363.12,N/A,363.12,N/A,363.12,N/A,1194.68,N/A,94.70,N/A,297.50,N/A,1139.00,N/A,1139.00,N/A,297.50,N/A,94.70,N/A,94.70,N/A,104.17,1275.00,1275.00,94.70,1275.00,,Hospital J9395,"Injection, Fulvestrant",N/A,N/A,23901.90,7033.70,14341.14,4220.22,10440.92,990.23,12616.71,250.33,23529.46,3981.36,8126.65,2391.46,23754.54,877.68,10762.62,990.23,12616.71,250.33,12616.71,250.33,14786.65,546.36,23754.54,877.68,23754.54,877.68,23754.54,877.68,23529.46,3981.37,12616.71,298.54,10762.62,990.23,23901.90,701.52,23901.90,701.52,N/A,990.23,12616.71,298.54,12616.71,298.54,11516.01,328.40,8126.65,23901.90,250.33,4220.22,,Hospital J9999,Chemotherapy Drug,N/A,N/A,58269.87,5914.37,34961.92,3548.62,N/A,691.74,N/A,265.72,N/A,3395.44,19811.73,2010.88,N/A,1152.49,12230.30,691.74,N/A,437.82,N/A,437.82,N/A,717.45,N/A,1152.49,N/A,1152.49,N/A,1152.49,N/A,3353.29,N/A,437.82,N/A,691.74,N/A,1549.86,N/A,1549.86,12230.30,691.74,N/A,437.82,N/A,265.72,N/A,292.28,12230.30,34961.92,265.72,3548.62,,Hospital L0112,HC Cranial Cervical Orthosis,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,80964.90,N/A,48578.94,N/A,N/A,N/A,6504.86,N/A,28358.88,N/A,27528.07,N/A,11657.59,N/A,5281.78,N/A,3372.00,N/A,3372.00,N/A,7256.58,N/A,11657.59,N/A,11657.59,N/A,11657.59,N/A,28358.88,N/A,6326.96,N/A,5281.78,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6592.13,N/A,6326.96,N/A,N/A,N/A,3372.00,48578.94,N/A,N/A,,Hospital L0150,HC Cerv Semi-Rig Adj Molded Chn,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,45525.87,32377.87,27315.52,19426.72,9261.97,4522.95,N/A,4780.29,20954.47,18631.88,15478.79,11008.48,21072.26,11786.01,6524.49,4522.95,2810.00,4821.94,2810.00,4821.94,N/A,7337.02,21072.26,11786.01,21072.26,11786.01,21072.26,11786.01,20954.47,18631.89,11222.07,4821.94,9547.35,4522.95,23525.51,5963.00,23525.51,5963.00,9547.35,4522.95,N/A,4821.94,11222.07,4780.29,6524.49,1334.61,2810.00,27315.52,1334.61,19426.72,,Hospital L0172,HC Cerv Col Sr Foam 2pc Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,63845.90,61453.83,38307.54,36872.30,17993.67,8537.51,21551.23,12060.69,40926.88,35082.02,21707.61,20894.34,42159.13,46699.04,18548.09,8537.51,21551.23,11933.08,21551.23,11933.08,26245.31,29267.08,42159.13,46699.04,42159.13,46699.04,42159.13,46699.04,40926.88,35082.10,21551.23,11956.02,18548.09,8537.51,12746.62,13819.75,48706.12,13819.75,6833.45,8537.51,21551.23,11933.08,21551.23,12060.69,19846.46,4674.16,6833.45,48706.12,4674.16,46699.04,,Hospital L0200,HC Cerv Col Supp Adj Bar & Thor,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,152912.97,N/A,91747.78,N/A,N/A,N/A,23413.12,N/A,84285.62,N/A,51990.41,N/A,59483.44,N/A,19651.44,N/A,23413.12,N/A,23413.12,N/A,37027.06,N/A,59483.44,N/A,59483.44,N/A,N/A,N/A,84285.62,N/A,22818.46,N/A,19651.44,N/A,70770.44,N/A,N/A,N/A,4650.43,N/A,23413.12,N/A,22818.46,N/A,21027.04,N/A,4650.43,91747.78,N/A,N/A,,Hospital L0456,HC Tlso Flex Trnk Sj-Ss Pre-Cst,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,73854.83,N/A,44312.90,N/A,5123.90,N/A,6415.91,N/A,16145.83,N/A,25110.64,N/A,11657.59,N/A,5281.78,N/A,85986.00,N/A,85986.00,N/A,N/A,N/A,11657.59,N/A,11657.59,N/A,11657.59,N/A,16145.83,N/A,6326.96,N/A,5281.78,N/A,13869.62,N/A,13869.62,N/A,N/A,N/A,6326.96,N/A,6415.91,N/A,5651.50,N/A,5123.90,85986.00,N/A,N/A,,Hospital L0486,HC Tlso Rigidlined Cust Fab Two,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,143329.72,N/A,85997.83,N/A,9071.64,N/A,24031.30,N/A,79003.34,N/A,48732.10,N/A,45707.94,N/A,20709.19,N/A,12196.24,N/A,12196.24,N/A,76852.17,N/A,45707.94,N/A,45707.94,N/A,45707.94,N/A,79003.34,N/A,24031.30,N/A,9071.64,N/A,54381.04,N/A,54381.04,N/A,2975.28,N/A,24031.30,N/A,24031.30,N/A,22158.84,N/A,2975.28,85997.83,N/A,N/A,,Hospital L0625,HC Lo Flex L1-Below L5 Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,21625.87,N/A,12975.52,N/A,3027.63,N/A,4832.50,N/A,7923.00,N/A,7352.78,N/A,11437.43,N/A,3027.63,N/A,4706.78,N/A,4706.78,N/A,7120.02,N/A,11437.43,N/A,11437.43,N/A,11437.43,N/A,7923.00,N/A,4706.78,N/A,3027.63,N/A,8160.50,N/A,8160.50,N/A,3027.63,N/A,4706.78,N/A,4832.50,N/A,758.25,N/A,N/A,758.25,12975.52,,Hospital L0628,HC Lso Flex No Ri Stays Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,223295.98,40583.28,133977.59,24349.97,N/A,5681.65,N/A,6739.37,123080.74,23207.70,75920.64,13798.32,77751.66,15066.88,26431.01,5681.65,2248.00,6123.42,2248.00,6123.42,48410.57,9575.42,77751.66,15066.88,77751.66,15066.88,77751.66,15066.88,123080.74,23207.73,30596.01,6146.36,N/A,5681.65,154168.01,7897.00,N/A,7897.00,26431.01,5681.65,N/A,6123.42,30596.01,1433.23,28281.18,1501.26,2248.00,154168.01,1433.23,24349.97,,Hospital L0650,HC Lso Sc R Ant/POS Pnl Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,30009.88,N/A,18005.93,N/A,4979.49,N/A,6155.82,N/A,17606.86,N/A,10203.36,N/A,13217.19,N/A,5132.91,N/A,1124.00,N/A,1124.00,N/A,8227.40,N/A,13217.19,N/A,13217.19,N/A,13217.19,N/A,17606.86,N/A,6155.82,N/A,5132.91,N/A,15725.16,N/A,15725.16,N/A,N/A,N/A,6155.82,N/A,6155.82,N/A,5492.22,N/A,1124.00,18005.93,N/A,N/A,,Hospital L0810,HC Halo Cervical Into Jckt Vest (Non-Pmm),N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,50904.40,N/A,30542.64,N/A,5123.90,N/A,6326.96,N/A,17997.81,N/A,17307.50,N/A,11657.59,N/A,5281.78,N/A,1124.00,N/A,1124.00,N/A,7256.58,N/A,11657.59,N/A,11657.59,N/A,11657.59,N/A,17997.81,N/A,6326.96,N/A,5281.78,N/A,13869.62,N/A,13869.62,N/A,N/A,N/A,6326.96,N/A,6326.96,N/A,5651.50,N/A,1124.00,30542.64,N/A,N/A,,Hospital L1830,HC Knee Immobilizer,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,108297.35,63555.28,64978.41,38133.17,10186.46,8855.61,12315.69,1580.05,59693.50,36190.48,36821.10,21608.80,24076.89,29075.73,10500.32,8855.61,12315.69,11933.08,12315.69,11933.08,14987.67,18296.22,24076.89,29075.73,24076.89,29075.73,24076.89,29075.73,59693.50,36190.46,12315.69,11956.02,10500.32,8855.61,27573.18,12375.50,27573.18,12375.50,10500.32,8855.61,12315.69,11933.08,12315.69,1580.05,11235.34,1642.28,10186.46,64978.41,1580.05,38133.17,,Hospital L1833,HC Ko Adj Jnt POS R Sup Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,131132.73,52187.98,78679.64,31312.79,N/A,7296.02,13778.53,2912.72,N/A,7823.00,N/A,17743.91,N/A,6625.94,N/A,7296.02,6744.00,2688.04,6744.00,2688.04,N/A,4124.78,N/A,6625.94,N/A,6625.94,N/A,6625.94,N/A,7823.00,13778.53,2688.04,N/A,7296.02,N/A,5277.50,N/A,5277.50,N/A,7296.02,13778.53,2688.04,13778.53,2912.72,N/A,946.66,6744.00,78679.64,946.66,31312.79,,Hospital L1846,HC Ko W Adj Flex/Ext Rotat Mold,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,68793.70,N/A,41276.22,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,41276.22,41276.22,N/A,N/A,,Hospital L1930,HC Afo Plastic (Non-Pmm),N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,94177.97,N/A,56506.78,N/A,9505.49,N/A,13384.24,N/A,29366.38,N/A,32020.51,N/A,28835.08,N/A,9798.37,N/A,1124.00,N/A,1124.00,N/A,17949.17,N/A,28835.08,N/A,28835.08,N/A,28835.08,N/A,29366.38,N/A,13384.24,N/A,9798.37,N/A,34306.55,N/A,34306.55,N/A,N/A,N/A,13384.24,N/A,13384.24,N/A,10484.26,N/A,1124.00,56506.78,N/A,N/A,,Hospital L1932,HC Afo Rig Ant Tib Prefab Tcf/=,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,99893.98,N/A,59936.39,N/A,19342.80,N/A,23147.18,N/A,55802.63,N/A,33963.95,N/A,44007.55,N/A,19938.79,N/A,2248.00,N/A,32200.75,N/A,27393.67,N/A,44007.55,N/A,44007.55,N/A,44007.55,N/A,55802.63,N/A,23147.18,N/A,19938.79,N/A,52358.00,N/A,52358.00,N/A,5149.86,N/A,23147.18,N/A,23147.18,N/A,21334.50,N/A,2248.00,59936.39,N/A,N/A,,Hospital L1940,HC Afo Molded to Patient Plasti,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,98718.50,149511.85,59231.10,89707.11,N/A,20841.38,N/A,11227.57,N/A,86012.58,N/A,50834.04,N/A,15042.64,N/A,20841.38,N/A,11219.49,N/A,N/A,N/A,9560.33,N/A,15042.64,N/A,15042.64,N/A,15042.64,N/A,84480.11,N/A,11242.43,N/A,20841.38,N/A,10535.75,N/A,10535.75,N/A,20841.38,N/A,11219.49,N/A,11227.57,N/A,2079.32,59231.10,59231.10,2079.32,89707.11,,Hospital L1951,HC Afo Spiral Pre-Fabricated,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,241536.83,N/A,144922.10,N/A,N/A,N/A,37530.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4496.00,N/A,4496.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,37530.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,37530.08,N/A,37530.08,N/A,N/A,N/A,4496.00,144922.10,N/A,N/A,,Hospital L2134,HC Kafo Fem Cast Semi-Rigid (Non-Pmm),N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,124705.28,N/A,74823.17,N/A,10836.85,N/A,12185.08,N/A,N/A,N/A,42399.80,N/A,N/A,N/A,10386.49,N/A,13853.90,N/A,13853.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,68737.55,N/A,13853.90,N/A,10836.85,N/A,27274.27,N/A,N/A,N/A,10836.85,N/A,13853.90,N/A,12185.08,N/A,10836.85,N/A,10386.49,74823.17,N/A,N/A,,Hospital L2210,HC Dorsiflexion Assist Each Joi,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,247608.10,N/A,148564.86,N/A,11242.60,N/A,64580.98,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,11242.60,N/A,11242.60,148564.86,N/A,N/A,,Hospital L2387,HC Le Poly Knee Custom Kafo,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,169113.88,N/A,101468.33,N/A,17601.19,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,17601.19,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,17601.19,N/A,N/A,N/A,N/A,N/A,17601.19,N/A,N/A,N/A,N/A,N/A,17601.19,N/A,17601.19,101468.33,N/A,N/A,,Hospital L2390,HC Offset Knee Joint Each,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,164726.30,N/A,98835.78,N/A,N/A,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,43027.77,N/A,33639.01,N/A,N/A,N/A,33639.01,98835.78,N/A,N/A,,Hospital L2430,HC Knee Jnt Ratchet Lock Ea Jnt,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,164726.30,N/A,98835.78,N/A,11242.60,N/A,33639.01,N/A,N/A,N/A,33138.00,N/A,33138.00,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,33138.00,N/A,33138.00,N/A,33138.00,N/A,33138.00,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,43027.77,N/A,33639.01,N/A,11242.60,N/A,11242.60,98835.78,N/A,N/A,,Hospital L2820,HC Soft Interface Knee Se,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,164726.30,N/A,98835.78,N/A,11242.60,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,33639.01,N/A,33639.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,33639.01,N/A,11242.60,N/A,N/A,N/A,N/A,N/A,11242.60,N/A,43027.77,N/A,33639.01,N/A,11242.60,N/A,11242.60,98835.78,N/A,N/A,,Hospital L3650,HC So 8 Abd Restraint Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,92019.13,23464.47,55211.48,14078.68,N/A,3266.93,15143.47,2690.13,N/A,13491.99,31286.50,7977.91,28614.19,6568.81,N/A,3266.93,15143.47,2690.13,12185.08,2690.13,17811.67,4089.19,N/A,6568.81,N/A,6568.81,28614.19,6568.81,N/A,13491.99,12185.08,2690.13,N/A,3266.93,34043.74,5277.50,34043.74,5277.50,N/A,3266.93,15143.47,2690.13,15143.47,2690.13,13871.93,2959.14,12185.08,55211.48,2690.13,14078.68,,Hospital L3660,HC So 8 Ab Rstr Can/Web Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,101840.55,64958.68,61104.33,38975.21,12576.90,9094.21,15143.47,6248.31,45397.75,11735.00,34625.79,22085.97,28614.19,14497.72,12964.42,9094.21,562.00,5973.28,562.00,5973.28,17811.67,9025.10,28614.19,14497.72,28614.19,14497.72,28614.19,14497.72,45397.75,11735.00,15143.47,5973.28,12964.42,9094.21,34043.74,12986.00,34043.74,12986.00,2426.03,9094.21,15143.47,5973.28,15143.47,6248.31,13871.93,2642.85,562.00,61104.33,2642.85,38975.21,,Hospital L3763,HC Ewho W/O Joint Custom Fab,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,1038.00,N/A,622.80,N/A,145.32,N/A,819.04,N/A,587.86,N/A,352.92,N/A,253.15,N/A,145.32,N/A,819.04,N/A,819.04,N/A,214.88,N/A,253.15,N/A,253.15,N/A,253.15,N/A,587.86,N/A,817.14,N/A,145.32,N/A,169.38,N/A,169.38,N/A,145.32,N/A,819.04,N/A,819.04,N/A,57.85,N/A,N/A,57.85,819.04,,Hospital L3765,HC Ot Elbow Wrist Hand Splint,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,1237.00,N/A,742.20,N/A,173.18,N/A,1237.83,N/A,695.44,N/A,420.58,N/A,173.18,N/A,173.18,N/A,1237.83,N/A,1237.83,N/A,107.62,N/A,173.18,N/A,173.18,N/A,173.18,N/A,695.44,N/A,1237.83,N/A,173.18,N/A,663.03,N/A,663.03,N/A,173.18,N/A,1237.83,N/A,1237.83,N/A,N/A,N/A,N/A,107.62,1237.83,,Hospital L3806,HC Whfo 1 or More Custom Fit,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,32644.80,2206.00,19586.88,1323.60,5267.40,308.84,6496.71,1029.93,12372.74,1265.87,11099.23,750.04,11984.07,867.92,5429.70,308.84,1686.00,1029.93,1686.00,1029.93,7459.81,851.01,11984.07,867.92,11984.07,867.92,11984.07,867.92,12372.74,1265.87,6496.71,1035.36,5429.70,308.84,14258.06,1011.44,14258.06,1011.44,N/A,308.84,6496.71,1029.93,6496.71,1029.93,5809.78,295.89,1686.00,19586.88,295.89,1323.60,,Hospital L3807,HC Ot Wrist Hand Finger Splint,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,503.00,N/A,301.80,N/A,70.42,N/A,241.40,N/A,282.79,N/A,171.02,N/A,70.42,N/A,70.42,N/A,241.40,N/A,241.40,N/A,43.76,N/A,70.42,N/A,70.42,N/A,70.42,N/A,282.79,N/A,241.40,N/A,70.42,N/A,269.61,N/A,269.61,N/A,70.42,N/A,241.40,N/A,241.40,N/A,N/A,N/A,N/A,43.76,301.80,,Hospital L3906,HC Custom Wrist/Hand Static,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,123807.90,2801.00,74284.74,1680.60,6804.23,392.14,32204.62,683.47,68242.92,1611.12,42094.69,952.34,62535.37,822.13,7156.93,392.14,32204.62,683.47,32204.62,683.47,14595.71,815.51,62535.37,822.13,62535.37,822.13,62535.37,822.13,68242.92,1611.12,32200.98,675.45,7156.93,392.14,59375.00,1434.34,57456.00,1434.34,6804.23,392.14,32204.62,683.47,32204.62,683.47,15966.44,303.87,6804.23,74284.74,303.87,1680.60,,Hospital L3912,HC Hfo Flexion Glove Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,4019.00,N/A,2411.40,N/A,562.66,N/A,598.30,N/A,2309.67,N/A,1366.46,N/A,1547.76,N/A,562.66,N/A,598.30,N/A,598.30,N/A,1530.27,N/A,1547.76,N/A,1547.76,N/A,1547.76,N/A,2309.67,N/A,593.30,N/A,562.66,N/A,1977.36,N/A,1977.36,N/A,562.66,N/A,598.30,N/A,598.30,N/A,556.04,N/A,N/A,556.04,2411.40,,Hospital L3913,HC Custom Hand/Finger Static,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,1315.00,N/A,789.00,N/A,184.10,N/A,442.81,N/A,755.69,N/A,447.10,N/A,585.34,N/A,184.10,N/A,442.81,N/A,442.81,N/A,579.51,N/A,585.34,N/A,585.34,N/A,585.34,N/A,755.69,N/A,451.45,N/A,184.10,N/A,645.88,N/A,645.88,N/A,184.10,N/A,442.81,N/A,442.81,N/A,199.47,N/A,N/A,184.10,789.00,,Hospital L3923,HC Hfo W/O Joints Pre Cst,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital L3927,HC Fo Pip Dip No Jt Spr Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,723.00,N/A,433.80,N/A,101.22,N/A,147.70,N/A,415.83,N/A,245.82,N/A,375.55,N/A,101.22,N/A,147.70,N/A,147.70,N/A,373.70,N/A,375.55,N/A,375.55,N/A,375.55,N/A,415.83,N/A,157.33,N/A,101.22,N/A,368.77,N/A,368.77,N/A,101.22,N/A,147.70,N/A,147.70,N/A,125.30,N/A,N/A,101.22,433.80,,Hospital L3929,HC Hfo Nontorsion Jnts Pre Cst (Non-Pmm),N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,574.00,N/A,344.40,N/A,80.36,N/A,150.03,N/A,326.62,N/A,195.16,N/A,239.57,N/A,80.36,N/A,150.03,N/A,150.03,N/A,224.41,N/A,239.57,N/A,239.57,N/A,239.57,N/A,326.62,N/A,147.77,N/A,80.36,N/A,154.37,N/A,154.37,N/A,80.36,N/A,150.03,N/A,150.03,N/A,75.65,N/A,N/A,75.65,344.40,,Hospital L3933,HC Custom Finger Static,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,104708.45,2018.00,62825.07,1210.80,11268.85,282.52,13596.12,485.94,35113.55,1159.18,35600.88,686.12,25638.20,846.22,11616.07,282.52,13596.12,485.94,13596.12,485.94,15959.18,835.30,25638.20,846.22,25638.20,846.22,25638.20,846.22,35113.55,1159.18,13596.12,478.43,11616.07,282.52,29852.75,971.24,30503.06,971.24,3549.82,282.52,13596.12,485.94,13596.12,485.94,3549.82,307.99,3549.82,62825.07,282.52,1210.80,,Hospital L3980,HC Brace Fx Humeral,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,16884.50,N/A,10130.70,N/A,4594.18,N/A,2376.53,N/A,11586.25,N/A,5740.73,N/A,10452.38,N/A,4735.73,N/A,162418.00,N/A,162418.00,N/A,6506.37,N/A,10452.38,N/A,10452.38,N/A,10452.38,N/A,11586.25,N/A,5700.32,N/A,4735.73,N/A,12435.73,N/A,12435.73,N/A,N/A,N/A,5700.32,N/A,5729.97,N/A,5067.23,N/A,2376.53,162418.00,N/A,N/A,,Hospital L3995,HC Sock Fracture or Equal Each,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,16884.50,N/A,10130.70,N/A,4594.18,N/A,2376.53,N/A,11586.25,N/A,5740.73,N/A,10452.38,N/A,4735.73,N/A,162418.00,N/A,162418.00,N/A,6506.37,N/A,10452.38,N/A,10452.38,N/A,10452.38,N/A,11586.25,N/A,5700.32,N/A,4735.73,N/A,12435.73,N/A,12435.73,N/A,N/A,N/A,5700.32,N/A,5729.97,N/A,5067.23,N/A,2376.53,162418.00,N/A,N/A,,Hospital L4350,HC Brace Ankle-Air/Gel Univ,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,N/A,916.63,N/A,549.98,N/A,128.33,N/A,214.05,N/A,525.99,N/A,311.65,N/A,18.57,N/A,128.33,N/A,212.87,N/A,212.87,N/A,11.54,N/A,18.57,N/A,18.57,N/A,18.57,N/A,525.99,N/A,212.87,N/A,128.33,N/A,276.04,N/A,276.04,N/A,128.33,N/A,212.87,N/A,214.05,N/A,28.11,N/A,N/A,11.54,549.98,,Hospital L4386,HC Non �Pneum Walk Boot Pre Cst,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,90653.30,45605.63,54391.98,27363.38,24510.91,6347.40,26038.08,2508.18,60184.55,26207.12,30822.12,15505.93,59483.44,6375.65,51823.31,6347.40,26038.08,2482.92,26038.08,2482.92,37027.06,4164.97,59483.44,6375.65,59483.44,6375.65,59483.44,6375.65,60184.55,22905.13,26038.08,2505.86,25266.14,6347.40,70770.44,4112.50,N/A,4112.50,51823.31,6347.40,26038.08,2482.92,26038.08,2508.18,27034.77,1030.89,24510.91,70770.44,1030.89,27363.38,,Hospital L4397,HC Static or Dynami Afo Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,318658.50,N/A,191195.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,191195.10,191195.10,N/A,N/A,,Hospital L4398,HC Foot Drop Splint Pre Ots,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,274932.72,N/A,164959.63,N/A,19174.47,N/A,38422.94,N/A,117190.41,N/A,184070.59,N/A,184070.59,N/A,19174.47,N/A,38422.94,N/A,38422.94,N/A,184070.59,N/A,184070.59,N/A,184070.59,N/A,184070.59,N/A,117190.41,N/A,41700.30,N/A,19174.47,N/A,117190.41,N/A,117190.41,N/A,19174.47,N/A,38422.94,N/A,38422.94,N/A,19174.47,N/A,19174.47,184070.59,N/A,N/A,,Hospital L5450,HC Postop App Non-Wgt Bear Dsg,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,112032.90,93670.08,67219.74,56202.05,N/A,13039.73,12230.50,12475.31,N/A,53614.31,62883.30,31847.85,62883.30,29200.49,N/A,13039.73,12230.50,11932.77,12230.50,11932.77,62883.30,18375.20,62883.30,29200.49,62883.30,29200.49,62883.30,29200.49,N/A,53614.37,12230.50,11956.02,N/A,13039.73,N/A,12507.25,N/A,12507.25,N/A,13039.73,12230.50,11932.77,12230.50,12475.31,N/A,1786.10,12230.50,67219.74,1786.10,56202.05,,Hospital L5637,HC Below Knee Total Contact,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,204658.28,N/A,122794.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,69583.82,N/A,71262.01,N/A,26950.55,N/A,N/A,N/A,N/A,N/A,N/A,N/A,71262.01,N/A,71262.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31193.81,N/A,31193.81,N/A,N/A,N/A,26950.55,122794.97,N/A,N/A,,Hospital L8000,HC Breast Prosthesis Bra W/O Form,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,183232.60,45423.15,109939.56,27253.89,6858.09,6359.25,36250.91,5920.33,39053.08,25822.84,62299.08,15443.87,97655.44,16385.81,6858.09,6359.25,36250.91,5366.90,36250.91,5366.90,60789.72,12451.38,97655.44,16385.81,97655.44,16385.81,97655.44,16385.81,39053.08,25822.86,36250.91,5366.90,6858.09,6359.25,39053.08,11455.00,39053.08,11455.00,6858.09,6359.25,36250.91,5366.90,36250.91,1718.35,6858.09,1839.34,6858.09,109939.56,1718.35,27253.89,,Hospital L8440,HC Shrinker Below Knee,N/A,0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES,112032.90,N/A,67219.74,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62883.30,N/A,62883.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62883.30,N/A,62883.30,N/A,62883.30,N/A,62883.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,62883.30,67219.74,N/A,N/A,,Hospital L8600,Implant Breast Silicone/Eq,N/A,N/A,N/A,37893.42,N/A,22736.05,N/A,5305.09,N/A,6248.31,N/A,21744.91,N/A,12882.04,N/A,14555.24,N/A,5305.09,N/A,5973.28,N/A,5973.28,N/A,9060.89,N/A,14555.24,N/A,14555.24,N/A,14555.24,N/A,21744.93,N/A,5973.28,N/A,5305.09,N/A,8375.75,N/A,8375.75,N/A,5305.09,N/A,5973.28,N/A,6248.31,N/A,2482.16,N/A,N/A,2482.16,22736.05,,Hospital L8612,HC Aqueous Shunt Prosthesis,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,217667.93,24716.68,130600.76,14830.01,30515.77,3460.34,35538.17,3774.30,88529.16,14068.49,51424.55,8403.68,51424.55,9879.69,30515.77,3460.34,38066.02,3608.17,38066.02,3608.17,51424.55,6150.29,51424.55,9879.69,51424.55,9879.69,51424.55,9879.69,88529.16,14068.50,32994.22,3608.17,30515.77,3460.34,103174.60,5963.00,103174.60,5963.00,30515.77,3460.34,32994.22,3608.17,35538.17,3774.30,30515.77,1050.32,30515.77,130600.76,1050.32,14830.01,,Hospital L8613,HC Ossicular Implant,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,41661.00,N/A,24996.60,N/A,5832.54,N/A,5043.96,N/A,23974.37,N/A,14164.74,N/A,11705.32,N/A,5832.54,N/A,4821.94,N/A,4821.94,N/A,7286.76,N/A,11705.32,N/A,11705.32,N/A,11705.32,N/A,23974.40,N/A,4821.94,N/A,5832.54,N/A,7661.50,N/A,7661.50,N/A,5832.54,N/A,4821.94,N/A,5043.96,N/A,1822.50,N/A,N/A,1822.50,24996.60,,Hospital L8619,HC Coch Imp Ext Proc/Contr Rplc,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,200800.18,N/A,120480.11,N/A,28112.02,N/A,29844.64,N/A,113358.31,N/A,68272.06,N/A,72855.72,N/A,28112.02,N/A,30104.67,N/A,30104.67,N/A,45354.08,N/A,72855.72,N/A,72855.72,N/A,72855.72,N/A,113332.40,N/A,30104.67,N/A,28112.02,N/A,29766.00,N/A,29766.00,N/A,28112.02,N/A,30104.67,N/A,29844.64,N/A,23538.02,N/A,N/A,23538.02,120480.11,,Hospital L8630,HC Metacarpophalangeal Joint Implant,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,39042.30,N/A,23425.38,N/A,5465.93,N/A,1228.68,N/A,22205.30,N/A,13274.39,N/A,14494.86,N/A,5465.93,N/A,5973.28,N/A,5973.28,N/A,9023.33,N/A,14494.86,N/A,14494.86,N/A,14494.86,N/A,22205.32,N/A,5973.28,N/A,5465.93,N/A,6898.50,N/A,6898.50,N/A,5465.93,N/A,5973.28,N/A,1228.68,N/A,1351.55,N/A,N/A,1228.68,23425.38,,Hospital L8642,HC Hallux Implant,N/A,0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT,N/A,43410.98,N/A,26046.59,N/A,6077.53,N/A,6178.06,N/A,24891.96,N/A,14714.48,N/A,14486.19,N/A,6077.53,N/A,5973.28,N/A,5973.28,N/A,9017.93,N/A,14486.19,N/A,14486.19,N/A,14486.19,N/A,24891.97,N/A,5973.28,N/A,6077.53,N/A,9595.50,N/A,9595.50,N/A,6077.53,N/A,5973.28,N/A,6178.06,N/A,864.95,N/A,N/A,864.95,26046.59,,Hospital L8679,Imp neurosti pls gn any type,N/A,N/A,N/A,90840.70,N/A,54504.42,N/A,12708.40,N/A,27732.61,N/A,51378.83,N/A,30885.84,N/A,64161.48,N/A,12708.40,N/A,26511.88,N/A,26511.88,N/A,39941.77,N/A,64161.48,N/A,64161.48,N/A,64161.48,N/A,51378.83,N/A,26511.88,N/A,12708.40,N/A,37100.00,N/A,37100.00,N/A,12708.40,N/A,26511.88,N/A,27732.61,N/A,10144.68,N/A,N/A,10144.68,64161.48,,Hospital CPT M0240,HC IV Infusion Casirivimab and Imdevimab W/Monitoring Subsequent,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,2039.00,2039.00,1223.40,1223.40,N/A,N/A,N/A,425.55,N/A,1174.06,N/A,693.26,N/A,450.50,N/A,285.46,N/A,406.82,N/A,406.82,N/A,450.50,N/A,450.50,N/A,450.50,N/A,450.50,N/A,1174.06,N/A,406.82,N/A,285.46,N/A,1092.90,N/A,1092.90,N/A,N/A,N/A,406.82,N/A,425.55,N/A,N/A,1223.40,1223.40,285.46,1223.40,,Hospital CPT M0240,HC IV Infusion Casirivimab and Imdevimab W/Monitoring Subsequent,N/A,0250 - PHARMACY - GENERAL CLASSIFICATION,2039.00,2039.00,N/A,N/A,N/A,285.46,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,285.46,N/A,N/A,N/A,N/A,N/A,2039.00,N/A,N/A,285.46,2039.00,,Hospital CPT M0243,HC IV Infusion Casirivimab and Imdevimab W/Monitoring,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,2039.00,2039.00,1223.40,1223.40,N/A,285.46,N/A,403.31,N/A,1174.06,N/A,693.26,N/A,450.50,N/A,285.46,N/A,406.82,N/A,406.82,N/A,450.50,N/A,450.50,N/A,450.50,N/A,450.50,N/A,1174.06,N/A,406.82,N/A,285.46,N/A,1092.90,N/A,1092.90,N/A,285.46,N/A,406.82,N/A,403.31,N/A,2039.00,1223.40,1223.40,285.46,2039.00,,Hospital M0244,Casirivi and imdevi inj hm,N/A,N/A,N/A,575.10,N/A,345.06,N/A,80.51,N/A,823.11,N/A,331.14,N/A,195.53,N/A,575.10,N/A,80.51,N/A,786.87,N/A,786.87,N/A,575.10,N/A,575.10,N/A,575.10,N/A,575.10,N/A,331.14,N/A,786.87,N/A,80.51,N/A,308.25,N/A,308.25,N/A,80.51,N/A,786.87,N/A,823.11,N/A,N/A,N/A,N/A,80.51,823.11,,Hospital CPT M0247,HC Sotrovimab Infusion,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,1182.00,1182.00,709.20,709.20,N/A,165.48,N/A,440.82,N/A,680.60,N/A,401.88,N/A,450.50,N/A,165.48,N/A,406.82,N/A,406.82,N/A,450.50,N/A,450.50,N/A,450.50,N/A,450.50,N/A,680.60,N/A,406.82,N/A,165.48,N/A,633.55,N/A,633.55,N/A,165.48,N/A,406.82,N/A,440.82,N/A,1182.00,709.20,709.20,165.48,1182.00,,Hospital CPT M0249,HC Adm Tocilizu Covid-19 1st,N/A,0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION,1242.00,1242.00,745.20,745.20,N/A,N/A,N/A,1242.00,N/A,715.14,N/A,422.28,N/A,173.88,N/A,173.88,N/A,1242.00,N/A,1242.00,N/A,108.05,N/A,173.88,N/A,173.88,N/A,173.88,N/A,715.14,N/A,1242.00,N/A,173.88,N/A,665.71,N/A,665.71,N/A,N/A,N/A,1242.00,N/A,1242.00,N/A,N/A,745.20,745.20,108.05,1242.00,,Hospital CPT M0249,HC Adm Tocilizu Covid-19 1st,N/A,0250 - PHARMACY - GENERAL CLASSIFICATION,1242.00,1242.00,N/A,N/A,N/A,173.88,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,173.88,N/A,N/A,N/A,N/A,N/A,1242.00,N/A,N/A,173.88,1242.00,,Hospital MED10089,"Container,Specimen,Sterile Path,4oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3362.43,N/A,2017.46,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16.83,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16.83,2017.46,,Hospital MED10144,"Bandage,Coflex,Lf2,4x5yd,Tan,Ns,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2258.18,N/A,1354.91,N/A,963.04,N/A,1045.00,N/A,N/A,N/A,1349.76,N/A,1349.76,N/A,963.04,N/A,1045.00,N/A,1045.00,N/A,1349.76,N/A,1349.76,N/A,1349.76,N/A,1349.76,N/A,N/A,N/A,1045.00,N/A,963.04,N/A,N/A,N/A,N/A,N/A,963.04,N/A,1045.00,N/A,1045.00,N/A,963.04,N/A,N/A,963.04,1354.91,,Hospital MED10160,"Applicator,Ctn,Wood,6,Stl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2811.92,N/A,1687.15,N/A,1218.80,N/A,N/A,N/A,785.00,N/A,224.96,N/A,224.96,N/A,1218.80,N/A,N/A,N/A,N/A,N/A,224.96,N/A,224.96,N/A,224.96,N/A,224.96,N/A,785.00,N/A,N/A,N/A,1218.80,N/A,785.00,N/A,785.00,N/A,1218.80,N/A,N/A,N/A,N/A,N/A,1218.80,N/A,N/A,224.96,1687.15,,Hospital MED10198,"Cream, Hydraguard-D,Remedy Ist Phyto 4oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2516.40,N/A,1509.84,N/A,N/A,N/A,2566.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2566.73,N/A,2566.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2566.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2566.73,N/A,2566.73,N/A,N/A,N/A,N/A,1509.84,2566.73,,Hospital MED10510,"Syringe, Luer Lock, Sterile, 30ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1509.17,N/A,905.50,N/A,N/A,N/A,1509.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1509.17,N/A,1509.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1509.17,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1509.17,N/A,1509.17,N/A,N/A,N/A,N/A,905.50,1509.17,,Hospital MED10580,"Tape Measure,Cloth,Plastic Cs,72,Re",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1981.98,N/A,1189.19,N/A,N/A,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31.84,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2004.25,N/A,2004.25,N/A,N/A,N/A,N/A,31.84,2004.25,,Hospital MED10590,"Solution,Saline,Nacl,Spray,Wash,7.1oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,4863.93,N/A,2918.36,N/A,1177.00,N/A,46.49,N/A,N/A,N/A,1653.74,N/A,1221.00,N/A,680.96,N/A,N/A,N/A,N/A,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,1221.00,N/A,2800.64,N/A,N/A,N/A,1177.00,N/A,34.26,N/A,34.26,N/A,1177.00,N/A,N/A,N/A,46.49,N/A,51.14,N/A,N/A,34.26,2918.36,,Hospital MED10593,"Kit, Drainage, Pleurx, 1000ml, Latex Fre",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,12641.28,N/A,7584.77,N/A,N/A,N/A,2462.00,N/A,N/A,N/A,4298.04,N/A,2056.00,N/A,1769.78,N/A,2462.00,N/A,2462.00,N/A,2361.00,N/A,2056.00,N/A,2056.00,N/A,2056.00,N/A,7278.85,N/A,2462.00,N/A,N/A,N/A,1072.00,N/A,1072.00,N/A,N/A,N/A,2462.00,N/A,2462.00,N/A,N/A,N/A,N/A,1072.00,7584.77,,Hospital MED10594,"Saline,.9%,3 Ml,Vial",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1225.43,N/A,735.26,N/A,N/A,N/A,4.73,N/A,N/A,N/A,416.65,N/A,225.56,N/A,171.56,N/A,N/A,N/A,N/A,N/A,224.21,N/A,225.56,N/A,225.56,N/A,225.56,N/A,705.60,N/A,N/A,N/A,N/A,N/A,13.64,N/A,13.64,N/A,N/A,N/A,N/A,N/A,4.73,N/A,5.21,N/A,N/A,4.73,735.26,,Hospital MED10696,"Tape, Surgical, Cloth, Medipore",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3347.08,N/A,2008.25,N/A,N/A,N/A,760.00,N/A,700.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,760.00,N/A,760.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,700.00,N/A,760.00,N/A,N/A,N/A,700.00,N/A,700.00,N/A,N/A,N/A,760.00,N/A,760.00,N/A,N/A,N/A,N/A,700.00,2008.25,,Hospital MED10704,"Cleanser,Foam,N/R,Remedy Essentials,4oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5443.63,N/A,3266.18,N/A,1284.00,N/A,55.63,N/A,N/A,N/A,1850.84,N/A,1344.86,N/A,762.11,N/A,N/A,N/A,N/A,N/A,1339.99,N/A,1344.86,N/A,1344.86,N/A,1344.86,N/A,3134.44,N/A,N/A,N/A,1284.00,N/A,130.60,N/A,130.60,N/A,1284.00,N/A,N/A,N/A,55.63,N/A,61.21,N/A,N/A,55.63,3266.18,,Hospital MED10766,"Cleanser,Wound,Skintegrity,1 Ounce",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3103.45,N/A,1862.07,N/A,543.06,N/A,146.43,N/A,600.00,N/A,1055.17,N/A,666.00,N/A,434.49,N/A,990.00,N/A,990.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1786.98,N/A,990.00,N/A,543.06,N/A,162.64,N/A,162.64,N/A,543.06,N/A,864.00,N/A,146.43,N/A,161.07,N/A,N/A,146.43,1862.07,,Hospital MED10877,"Kit,Drainage,Pleurx,1000ml,Latex Free",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1671.78,N/A,1003.07,N/A,N/A,N/A,2280.05,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2280.05,N/A,2280.05,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2280.05,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2280.05,N/A,2280.05,N/A,N/A,N/A,N/A,1003.07,2280.05,,Hospital MED10950,"Ointment,Calmoseptine,Tube,4 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1760.27,N/A,1056.16,N/A,N/A,N/A,1584.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1584.42,N/A,1584.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1584.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1584.42,N/A,1584.42,N/A,N/A,N/A,N/A,1056.16,1584.42,,Hospital MED10988,"Saline,.9%,5 Ml,Vial",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2240.68,N/A,1344.41,N/A,820.44,N/A,880.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,820.44,N/A,880.00,N/A,880.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,880.00,N/A,820.44,N/A,N/A,N/A,N/A,N/A,820.44,N/A,880.00,N/A,880.00,N/A,820.44,N/A,N/A,820.44,1344.41,,Hospital MED11019,"Mbo-Tincture,Benzoin,Skn,Steristrip,Vial",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2327.67,N/A,1396.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1396.60,1396.60,,Hospital MED11023,"Strip,Closure,Skin,Reinforced,1/8x3",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,8580.42,N/A,5148.25,N/A,N/A,N/A,2200.00,N/A,N/A,N/A,2917.34,N/A,1725.00,N/A,1201.26,N/A,2200.00,N/A,2200.00,N/A,2274.00,N/A,1725.00,N/A,1725.00,N/A,1725.00,N/A,4940.59,N/A,2200.00,N/A,N/A,N/A,1929.60,N/A,1929.60,N/A,N/A,N/A,2200.00,N/A,2200.00,N/A,11.73,N/A,N/A,11.73,5148.25,,Hospital MED11138,"Solution,Prep,Povidone Iodine,8 Oz Btl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2853.68,N/A,1712.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1712.21,1712.21,,Hospital MED11139,"Scissors, Lister Bandage, 3.5",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2631.37,N/A,1578.82,N/A,543.06,N/A,62.25,N/A,N/A,N/A,894.65,N/A,698.40,N/A,368.40,N/A,216.00,N/A,216.00,N/A,686.14,N/A,698.40,N/A,698.40,N/A,698.40,N/A,1515.13,N/A,216.00,N/A,543.06,N/A,123.99,N/A,123.99,N/A,543.06,N/A,216.00,N/A,62.25,N/A,68.48,N/A,N/A,62.25,1578.82,,Hospital MED11162,"Dressing,Mepilex Border,Post OP,4x8",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,8849.23,N/A,5309.54,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3008.74,N/A,1568.89,N/A,1238.89,N/A,N/A,N/A,N/A,N/A,2425.28,N/A,1568.89,N/A,1568.89,N/A,1568.89,N/A,5095.39,N/A,N/A,N/A,N/A,N/A,3430.40,N/A,3430.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1238.89,5309.54,,Hospital MED11190,"Dynahex, 4% Chg, 8 Oz Bottle, 24 Ea",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2837.53,N/A,1702.52,N/A,N/A,N/A,945.00,N/A,N/A,N/A,964.76,N/A,779.44,N/A,397.26,N/A,945.00,N/A,945.00,N/A,778.51,N/A,779.44,N/A,779.44,N/A,779.44,N/A,1633.85,N/A,945.00,N/A,N/A,N/A,20.12,N/A,20.12,N/A,N/A,N/A,945.00,N/A,945.00,N/A,N/A,N/A,N/A,20.12,1702.52,,Hospital MED11309,"Strips,Curve,Thin,Ease,3cmx9cm",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2601.20,N/A,1560.72,N/A,N/A,N/A,122.11,N/A,638.60,N/A,884.39,N/A,500.00,N/A,364.15,N/A,N/A,N/A,N/A,N/A,561.00,N/A,500.00,N/A,500.00,N/A,500.00,N/A,1497.77,N/A,N/A,N/A,N/A,N/A,214.40,N/A,214.40,N/A,N/A,N/A,N/A,N/A,122.11,N/A,134.31,N/A,N/A,122.11,1560.72,,Hospital MED11327,"Scissors,Ostomy Scissors",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,999.73,N/A,599.84,N/A,N/A,N/A,47.08,N/A,N/A,N/A,339.90,N/A,111.00,N/A,139.96,N/A,N/A,N/A,N/A,N/A,111.00,N/A,111.00,N/A,111.00,N/A,111.00,N/A,575.66,N/A,N/A,N/A,N/A,N/A,107.04,N/A,107.04,N/A,N/A,N/A,N/A,N/A,47.08,N/A,51.79,N/A,N/A,47.08,599.84,,Hospital MED11347,"Tray,Foley Insertion,Pvp,10ml,Latex",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,150.75,N/A,90.45,N/A,N/A,N/A,153.77,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,153.77,N/A,153.77,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,153.77,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,153.77,N/A,153.77,N/A,N/A,N/A,N/A,90.45,153.77,,Hospital MED11382,"Dressing,Hydrofiber,Advantage,.39x18",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1501.68,N/A,901.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,901.01,,Hospital MED11424,"Applicator,Cotton-Tip,Wood,6,Ns",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1830.25,N/A,1098.15,N/A,N/A,N/A,61.96,N/A,N/A,N/A,622.28,N/A,476.24,N/A,256.24,N/A,N/A,N/A,N/A,N/A,464.03,N/A,476.24,N/A,476.24,N/A,476.24,N/A,1053.86,N/A,N/A,N/A,N/A,N/A,123.41,N/A,123.41,N/A,N/A,N/A,N/A,N/A,61.96,N/A,68.16,N/A,N/A,61.96,1098.15,,Hospital MED11430,"Solution,Betadine,4 Oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2220.57,N/A,1332.34,N/A,N/A,N/A,648.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,10.51,N/A,648.00,N/A,648.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,648.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,648.00,N/A,648.00,N/A,N/A,N/A,N/A,10.51,1332.34,,Hospital MED11601,"Scissors,or,Sharp/Blunt,5.5"",Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,7223.10,N/A,4333.86,N/A,1584.69,N/A,N/A,N/A,N/A,N/A,2455.86,N/A,1613.39,N/A,1011.24,N/A,N/A,N/A,N/A,N/A,1917.86,N/A,1613.39,N/A,1613.39,N/A,1613.39,N/A,4159.06,N/A,N/A,N/A,1584.69,N/A,1072.00,N/A,1072.00,N/A,1584.69,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1011.24,4333.86,,Hospital MED11603,"Scissor,Bandage, Universal ,7.5"",19cm",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4538.35,N/A,2723.01,N/A,N/A,N/A,157.10,N/A,785.00,N/A,1543.05,N/A,999.00,N/A,635.37,N/A,N/A,N/A,N/A,N/A,999.00,N/A,999.00,N/A,999.00,N/A,999.00,N/A,2613.18,N/A,N/A,N/A,N/A,N/A,288.56,N/A,288.56,N/A,N/A,N/A,N/A,N/A,157.10,N/A,172.83,N/A,N/A,157.10,2723.01,,Hospital MED11630,"Solution,Prep,Povidone Iodine,1 Pint",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4105.87,N/A,2463.52,N/A,N/A,N/A,945.00,N/A,N/A,N/A,1395.99,N/A,1002.48,N/A,574.82,N/A,945.00,N/A,945.00,N/A,1001.16,N/A,1002.48,N/A,1002.48,N/A,1002.48,N/A,2364.16,N/A,945.00,N/A,N/A,N/A,56.74,N/A,56.74,N/A,N/A,N/A,945.00,N/A,945.00,N/A,46.16,N/A,N/A,46.16,2463.52,,Hospital MED11644,"Applicator,Cotton-Tip,Wood,3,Strl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2504.33,N/A,1502.60,N/A,1444.56,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1444.56,N/A,2554.42,N/A,2554.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2554.42,N/A,1444.56,N/A,N/A,N/A,N/A,N/A,1444.56,N/A,2554.42,N/A,2554.42,N/A,1444.56,N/A,N/A,1444.56,2554.42,,Hospital MED11667,"Cleanser,Wound,Phmb, 80z",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2042.90,N/A,1225.74,N/A,N/A,N/A,N/A,N/A,574.70,N/A,694.59,N/A,555.00,N/A,286.00,N/A,N/A,N/A,N/A,N/A,555.00,N/A,555.00,N/A,555.00,N/A,555.00,N/A,1176.31,N/A,N/A,N/A,N/A,N/A,23.00,N/A,23.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23.00,1225.74,,Hospital MED11684,"Pack,Dressing,Ipc,Strl",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1913.20,N/A,1147.92,N/A,N/A,N/A,470.00,N/A,N/A,N/A,650.49,N/A,334.00,N/A,267.85,N/A,470.00,N/A,470.00,N/A,373.80,N/A,334.00,N/A,334.00,N/A,334.00,N/A,1101.62,N/A,470.00,N/A,N/A,N/A,428.80,N/A,428.80,N/A,N/A,N/A,470.00,N/A,470.00,N/A,N/A,N/A,N/A,267.85,1147.92,,Hospital MED11725,"Solution,Betadine,8 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2183.90,N/A,1310.34,N/A,2072.59,N/A,540.00,N/A,N/A,N/A,742.53,N/A,576.20,N/A,305.75,N/A,540.00,N/A,540.00,N/A,568.17,N/A,576.20,N/A,576.20,N/A,576.20,N/A,1257.49,N/A,540.00,N/A,2072.59,N/A,98.57,N/A,98.57,N/A,2072.59,N/A,540.00,N/A,540.00,N/A,2072.59,N/A,N/A,98.57,2072.59,,Hospital MED11766,"Syringe, Luer Lock, Sterile, 60ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2964.35,N/A,1778.61,N/A,N/A,N/A,1312.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1312.00,N/A,1312.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,103.60,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1312.00,N/A,1312.00,N/A,N/A,N/A,N/A,103.60,1778.61,,Hospital MED11770,"Dressing,Hydrofiber,Advantage,6""X6""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2127.27,N/A,1276.36,N/A,N/A,N/A,2224.30,N/A,N/A,N/A,453.13,N/A,453.13,N/A,N/A,N/A,2224.30,N/A,2224.30,N/A,453.13,N/A,453.13,N/A,453.13,N/A,453.13,N/A,N/A,N/A,2224.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2224.30,N/A,2224.30,N/A,N/A,N/A,N/A,453.13,2224.30,,Hospital MED11789,"Bag,Drainage,Urology,4000ml,Anti Reflux",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1007.18,N/A,604.31,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,604.31,604.31,,Hospital MED11815,"Cushion,Ez Wrap,for Cannula",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1501.47,N/A,900.88,N/A,N/A,N/A,2690.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2690.00,N/A,2690.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2690.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2690.00,N/A,2690.00,N/A,N/A,N/A,N/A,900.88,2690.00,,Hospital MED11848,"Cleanser,Vashe-Dermal,Wound,8.5 Oz",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2409.88,N/A,1445.93,N/A,1805.70,N/A,3915.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1805.70,N/A,3915.00,N/A,3915.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3915.00,N/A,1805.70,N/A,N/A,N/A,N/A,N/A,1805.70,N/A,3915.00,N/A,3915.00,N/A,1805.70,N/A,N/A,1445.93,3915.00,,Hospital MED11873,"Bag,Drain,Urlgy,Anti Reflx,2000ml,Lf",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1187.42,N/A,712.45,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,712.45,712.45,,Hospital MED11898,"Dressing, Collagen, 2x2",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3210.22,N/A,1926.13,N/A,N/A,N/A,760.00,N/A,N/A,N/A,1091.47,N/A,722.00,N/A,449.44,N/A,760.00,N/A,760.00,N/A,700.80,N/A,722.00,N/A,722.00,N/A,722.00,N/A,1848.45,N/A,760.00,N/A,N/A,N/A,219.88,N/A,219.88,N/A,N/A,N/A,760.00,N/A,760.00,N/A,6.87,N/A,N/A,6.87,1926.13,,Hospital MED11913,"Bandage,Plastic,Curad,3/4""X3"",1 Ea=Bx",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,8635.57,N/A,5181.34,N/A,N/A,N/A,2199.99,N/A,N/A,N/A,2936.10,N/A,1615.00,N/A,1208.97,N/A,2199.99,N/A,2199.99,N/A,2286.00,N/A,1615.00,N/A,1615.00,N/A,1615.00,N/A,4972.35,N/A,2199.99,N/A,N/A,N/A,2358.40,N/A,2358.40,N/A,N/A,N/A,2199.99,N/A,2199.99,N/A,40.41,N/A,N/A,40.41,5181.34,,Hospital MED11979,"Blade, Tongue, 5 1/2"", Sterile",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1925.72,N/A,1155.43,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1155.43,1155.43,,Hospital MED11986,"Exudry,9x15",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,7083.10,N/A,4249.86,N/A,N/A,N/A,1140.00,N/A,N/A,N/A,2408.28,N/A,1278.39,N/A,991.65,N/A,1140.00,N/A,1140.00,N/A,1338.86,N/A,1278.39,N/A,1278.39,N/A,1278.39,N/A,4078.43,N/A,1140.00,N/A,N/A,N/A,214.40,N/A,214.40,N/A,N/A,N/A,46.19,N/A,1140.00,N/A,930.34,N/A,N/A,46.19,4249.86,,Hospital MED11992,"Mbo-Strip,Closure,Skin,Reinforcd,1/2""X4""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,8580.42,N/A,5148.25,N/A,N/A,N/A,2200.00,N/A,N/A,N/A,2917.34,N/A,1725.00,N/A,1201.26,N/A,2200.00,N/A,2200.00,N/A,2274.00,N/A,1725.00,N/A,1725.00,N/A,1725.00,N/A,4940.59,N/A,2200.00,N/A,N/A,N/A,1929.60,N/A,1929.60,N/A,N/A,N/A,2200.00,N/A,2200.00,N/A,11.73,N/A,N/A,11.73,5148.25,,Hospital MED12099,"Mbo-Syringe,10ml,Luer-Lok Tip,Disposable",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2436.22,N/A,1461.73,N/A,N/A,N/A,945.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.00,N/A,945.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,945.00,N/A,945.00,N/A,N/A,N/A,N/A,945.00,1461.73,,Hospital MED12119,"Dressing,Hvy Drain,4""X4""Hydro Blue",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2409.88,N/A,1445.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1445.93,1445.93,,Hospital MED12121,"Gauze,Spnge,4""X4"",8ply,Stril,Lf,2/Pk",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2958.73,N/A,1775.24,N/A,743.94,N/A,9.68,N/A,N/A,N/A,1005.98,N/A,666.00,N/A,414.23,N/A,N/A,N/A,N/A,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1703.62,N/A,N/A,N/A,743.94,N/A,85.07,N/A,85.07,N/A,743.94,N/A,N/A,N/A,9.68,N/A,10.65,N/A,N/A,9.68,1775.24,,Hospital MED12156,"Spray,Deodorizer,Ostomy,8oz,Unscente",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5930.50,N/A,3558.30,N/A,N/A,N/A,79.68,N/A,N/A,N/A,2016.36,N/A,1379.28,N/A,830.28,N/A,N/A,N/A,N/A,N/A,1319.36,N/A,1379.28,N/A,1379.28,N/A,1379.28,N/A,3414.79,N/A,N/A,N/A,N/A,N/A,391.54,N/A,391.54,N/A,N/A,N/A,N/A,N/A,79.68,N/A,87.66,N/A,N/A,79.68,3558.30,,Hospital MED12222,"Aegis, 1"" Disk 7mm Hole, in Sleeve",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,12130.95,N/A,7278.57,N/A,N/A,N/A,2765.00,N/A,N/A,N/A,4124.51,N/A,2200.00,N/A,1698.34,N/A,2765.00,N/A,2765.00,N/A,3005.80,N/A,2200.00,N/A,2200.00,N/A,2200.00,N/A,6985.00,N/A,2765.00,N/A,N/A,N/A,2572.80,N/A,2572.80,N/A,N/A,N/A,2765.00,N/A,2765.00,N/A,78.25,N/A,N/A,78.25,7278.57,,Hospital MED12301,"E-1meter,Tubigrip,Lg-Ank,MD-Kne,Sm-Thigh",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6573.70,N/A,3944.22,N/A,1203.80,N/A,1920.00,N/A,N/A,N/A,2235.05,N/A,1556.05,N/A,920.32,N/A,1920.00,N/A,1920.00,N/A,1595.45,N/A,1556.05,N/A,1556.05,N/A,1556.05,N/A,3785.13,N/A,1920.00,N/A,1203.80,N/A,214.40,N/A,214.40,N/A,1203.80,N/A,1920.00,N/A,1920.00,N/A,13.07,N/A,N/A,13.07,3944.22,,Hospital MED12366,"Dressing,Aquacel,Ag,Advantage,.39""X18""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2656.73,N/A,1594.04,N/A,N/A,N/A,1045.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1045.00,N/A,1045.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1045.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1045.00,N/A,1045.00,N/A,N/A,N/A,N/A,1045.00,1594.04,,Hospital MED12381,"Dressing,Aquacel,Ag,Advantage,2""X2""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5962.68,N/A,3577.61,N/A,1611.87,N/A,284.27,N/A,N/A,N/A,2027.31,N/A,1443.00,N/A,834.78,N/A,N/A,N/A,N/A,N/A,1443.00,N/A,1443.00,N/A,1443.00,N/A,1443.00,N/A,3433.32,N/A,N/A,N/A,1611.87,N/A,408.79,N/A,408.79,N/A,1611.87,N/A,N/A,N/A,284.27,N/A,312.70,N/A,N/A,284.27,3577.61,,Hospital MED12399,"Hydrogen Peroxide,Bottle,16-Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2882.87,N/A,1729.72,N/A,N/A,N/A,987.00,N/A,N/A,N/A,980.17,N/A,777.00,N/A,403.59,N/A,987.00,N/A,987.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,1659.95,N/A,987.00,N/A,N/A,N/A,44.41,N/A,44.41,N/A,N/A,N/A,987.00,N/A,987.00,N/A,45.12,N/A,N/A,44.41,1729.72,,Hospital MED12417,"System,Compression,Urgok2,Dual,Regular",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5816.55,N/A,3489.93,N/A,1083.42,N/A,N/A,N/A,N/A,N/A,1977.62,N/A,1001.09,N/A,814.32,N/A,2359.28,N/A,2359.28,N/A,1000.30,N/A,1001.09,N/A,1001.09,N/A,1001.09,N/A,3349.18,N/A,2359.28,N/A,1083.42,N/A,1188.07,N/A,1188.07,N/A,1083.42,N/A,2359.28,N/A,N/A,N/A,N/A,N/A,N/A,814.32,3489.93,,Hospital MED12433,"Bandage,Elstc,Ns,Dl Slf Clsre,4x5yd,",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1341.00,N/A,804.60,N/A,361.14,N/A,N/A,N/A,N/A,N/A,455.94,N/A,333.00,N/A,187.73,N/A,N/A,N/A,N/A,N/A,333.00,N/A,333.00,N/A,333.00,N/A,333.00,N/A,772.15,N/A,N/A,N/A,361.14,N/A,75.58,N/A,75.58,N/A,361.14,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,75.58,804.60,,Hospital MED12494,"Bandage, Cohesive, Nl, Strl, 4inx5yd",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2403.17,N/A,1441.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1441.90,1441.90,,Hospital MED12506,"Padding,Cast,4"",12/Bg",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3529.02,N/A,2117.41,N/A,991.92,N/A,211.81,N/A,N/A,N/A,1199.88,N/A,888.00,N/A,494.05,N/A,N/A,N/A,N/A,N/A,888.00,N/A,888.00,N/A,888.00,N/A,888.00,N/A,2032.00,N/A,N/A,N/A,991.92,N/A,176.34,N/A,176.34,N/A,991.92,N/A,N/A,N/A,211.81,N/A,232.99,N/A,N/A,176.34,2117.41,,Hospital MED12518,Snapsecure Foley Device,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6559.82,N/A,3935.89,N/A,N/A,N/A,171.98,N/A,N/A,N/A,2094.33,N/A,1026.38,N/A,918.38,N/A,N/A,N/A,N/A,N/A,1463.50,N/A,1026.38,N/A,1026.38,N/A,1026.38,N/A,3777.15,N/A,N/A,N/A,N/A,N/A,1929.60,N/A,1929.60,N/A,N/A,N/A,N/A,N/A,171.98,N/A,189.18,N/A,N/A,171.98,3935.89,,Hospital MED12521,"F-10meter,Tubigrp,Lg-Kn,MD-Thgh,Ntrl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2866.93,N/A,1720.16,N/A,N/A,N/A,675.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,675.00,N/A,675.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,675.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,675.00,N/A,675.00,N/A,N/A,N/A,N/A,675.00,1720.16,,Hospital MED12632,"Adhesive, Mini,Topical,Dermabond,.36ml",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital MED12675,"Wipes, Barrier, Skin Protective",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2054.55,N/A,1232.73,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1232.73,1232.73,,Hospital MED12682,"Dressing,Aquacel,Ag,Advant,3.5x10,9x25cm",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2656.73,N/A,1594.04,N/A,N/A,N/A,2224.30,N/A,N/A,N/A,2044.99,N/A,2044.99,N/A,N/A,N/A,2224.30,N/A,2224.30,N/A,2044.99,N/A,2044.99,N/A,2044.99,N/A,2044.99,N/A,N/A,N/A,2224.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2224.30,N/A,2224.30,N/A,N/A,N/A,N/A,1594.04,2224.30,,Hospital MED12736,"Dressing,Mepilex,Border,Flex Lite,3""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2516.40,N/A,1509.84,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,1926.00,N/A,1926.00,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,1926.00,N/A,1926.00,N/A,1926.00,N/A,1926.00,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,1509.84,2095.64,,Hospital MED12740,"Dressing,Aquacel,Ag,Advant,3.5x14,9x35cm",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3838.17,N/A,2302.90,N/A,N/A,N/A,118.85,N/A,N/A,N/A,1304.98,N/A,725.39,N/A,537.34,N/A,N/A,N/A,N/A,N/A,912.86,N/A,725.39,N/A,725.39,N/A,725.39,N/A,2210.03,N/A,N/A,N/A,N/A,N/A,1072.00,N/A,1072.00,N/A,N/A,N/A,N/A,N/A,118.85,N/A,130.74,N/A,N/A,118.85,2302.90,,Hospital MED12862,"Gel,Shampoo/Bodywash,Remedy Phyto,8 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6112.53,N/A,3667.52,N/A,N/A,N/A,1861.88,N/A,N/A,N/A,2078.26,N/A,1059.00,N/A,855.75,N/A,1861.88,N/A,1861.88,N/A,1397.60,N/A,1059.00,N/A,1059.00,N/A,1059.00,N/A,3519.59,N/A,1861.88,N/A,N/A,N/A,1286.40,N/A,1286.40,N/A,N/A,N/A,1861.88,N/A,1861.88,N/A,N/A,N/A,N/A,855.75,3667.52,,Hospital MED12871,"E-10meter,Tbgrp,Lg-Ank,MD-Kne,Sm-Thi",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2054.55,N/A,1232.73,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2095.64,N/A,2095.64,N/A,N/A,N/A,N/A,1232.73,2095.64,,Hospital MED12880,"Scissors,or,Sharp/Blunt,5.5""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5930.50,N/A,3558.30,N/A,N/A,N/A,79.68,N/A,N/A,N/A,2016.36,N/A,1379.28,N/A,830.28,N/A,N/A,N/A,N/A,N/A,1319.36,N/A,1379.28,N/A,1379.28,N/A,1379.28,N/A,3414.79,N/A,N/A,N/A,N/A,N/A,391.54,N/A,391.54,N/A,N/A,N/A,N/A,N/A,79.68,N/A,87.66,N/A,N/A,79.68,3558.30,,Hospital MED12889,"Spray,Deodorizer,Unscented,2oz,M9",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3150.67,N/A,1890.40,N/A,N/A,N/A,3330.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,155.37,N/A,3330.04,N/A,3330.04,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,283.93,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,3330.04,N/A,3330.04,N/A,N/A,N/A,N/A,155.37,3330.04,,Hospital MED12904,"Slipper,Double Tread,Gray,XX-Large,1/PR",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,148.28,N/A,88.97,N/A,N/A,N/A,880.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,880.00,N/A,880.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,880.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,880.00,N/A,880.00,N/A,N/A,N/A,N/A,88.97,880.00,,Hospital MED12925,"Cream,Barrier,Baza Antifungal 5 Oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,15437.98,N/A,9262.79,N/A,N/A,N/A,1096.46,N/A,N/A,N/A,5248.91,N/A,3241.53,N/A,2161.32,N/A,3915.00,N/A,3915.00,N/A,3233.00,N/A,3241.53,N/A,3241.53,N/A,3241.53,N/A,8889.19,N/A,3915.00,N/A,N/A,N/A,2057.16,N/A,2057.16,N/A,N/A,N/A,3915.00,N/A,3915.00,N/A,1206.11,N/A,N/A,1096.46,9262.79,,Hospital MED12927,"Tape, Surgical, Cloth, Medipore",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,5006.27,N/A,3003.76,N/A,958.61,N/A,107.05,N/A,324.00,N/A,1702.14,N/A,1056.44,N/A,700.85,N/A,N/A,N/A,N/A,N/A,1116.90,N/A,1056.44,N/A,1056.44,N/A,1056.44,N/A,2882.61,N/A,N/A,N/A,958.61,N/A,214.40,N/A,214.40,N/A,958.61,N/A,N/A,N/A,107.05,N/A,117.77,N/A,N/A,107.05,3003.76,,Hospital MED12931,"Syringe, Luer Lock, Sterile, 5ml",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3340.48,N/A,2004.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1135.77,N/A,631.67,N/A,467.67,N/A,N/A,N/A,N/A,N/A,642.83,N/A,631.67,N/A,631.67,N/A,631.67,N/A,1923.45,N/A,N/A,N/A,N/A,N/A,428.80,N/A,428.80,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,428.80,2004.29,,Hospital MED12956,"Bag,Emesis,Clear,Paper Funnel",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3877.12,N/A,2326.27,N/A,N/A,N/A,50.78,N/A,N/A,N/A,1318.22,N/A,926.80,N/A,542.80,N/A,N/A,N/A,N/A,N/A,912.11,N/A,926.80,N/A,926.80,N/A,926.80,N/A,2232.44,N/A,N/A,N/A,N/A,N/A,148.53,N/A,148.53,N/A,N/A,N/A,N/A,N/A,50.78,N/A,55.86,N/A,N/A,50.78,2326.27,,Hospital MED12962,"System,Compression,Urgok2,Dual,Large",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2791.77,N/A,1675.06,N/A,722.28,N/A,N/A,N/A,N/A,N/A,949.20,N/A,666.00,N/A,390.84,N/A,1296.00,N/A,1296.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1607.50,N/A,1296.00,N/A,722.28,N/A,209.99,N/A,209.99,N/A,722.28,N/A,1296.00,N/A,N/A,N/A,N/A,N/A,N/A,209.99,1675.06,,Hospital MED12985,"Cleanser, Ist Foam,No Rinse,Unsc,8oz",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1848.68,N/A,1109.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1109.21,1109.21,,Hospital MED13001,"Bandage,Fabric,Touchfree,30ct,3/4x3""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1267.98,N/A,760.79,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,760.79,760.79,,Hospital MED13012,"Wound Measure Device,Foam,6"",St,200/",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1501.68,N/A,901.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,901.01,,Hospital MED13041,"Padding,Cast,6""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital MED13049,Dressing Xeroform 5 X 9,N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital MED13090,"Dbd-Pant,Knit,Washable,L/Xl",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1214.53,N/A,728.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,24.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,24.96,728.72,,Hospital MED13098,"Bandage,Tubifast,Blue,7.5cmx10m",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1789.47,N/A,1073.68,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1073.68,1073.68,,Hospital MED13115,"Bandage,Fabric,Curad,30ct,3/4x3""",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3788.82,N/A,2273.29,N/A,N/A,N/A,760.00,N/A,N/A,N/A,1288.21,N/A,888.00,N/A,530.43,N/A,760.00,N/A,760.00,N/A,888.00,N/A,888.00,N/A,888.00,N/A,888.00,N/A,2181.60,N/A,760.00,N/A,N/A,N/A,101.20,N/A,101.20,N/A,N/A,N/A,760.00,N/A,760.00,N/A,52.33,N/A,N/A,52.33,2273.29,,Hospital MED13121,"Cushion,Waffle,Preinflated",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2888.62,N/A,1733.17,N/A,N/A,N/A,1980.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1980.00,N/A,1980.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1980.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1980.00,N/A,1980.00,N/A,N/A,N/A,N/A,1733.17,1980.00,,Hospital MED13150,"Wipe,Cleanser,Skin,Brava,15/Pk",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3431.05,N/A,2058.63,N/A,656.88,N/A,82.52,N/A,N/A,N/A,1166.55,N/A,777.00,N/A,480.35,N/A,N/A,N/A,N/A,N/A,777.00,N/A,777.00,N/A,777.00,N/A,777.00,N/A,1975.59,N/A,N/A,N/A,656.88,N/A,338.23,N/A,338.23,N/A,656.88,N/A,N/A,N/A,82.52,N/A,90.78,N/A,N/A,82.52,2058.63,,Hospital MED13153,"Dressing,Sorbalgon,Ag,St,Rope,1/4""/ 12",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,3210.22,N/A,1926.13,N/A,N/A,N/A,760.00,N/A,N/A,N/A,1091.47,N/A,722.00,N/A,449.44,N/A,760.00,N/A,760.00,N/A,700.80,N/A,722.00,N/A,722.00,N/A,722.00,N/A,1848.45,N/A,760.00,N/A,N/A,N/A,219.88,N/A,219.88,N/A,N/A,N/A,760.00,N/A,760.00,N/A,6.87,N/A,N/A,6.87,1926.13,,Hospital MED13154,"Slipper Safety Skids,Grey,2x-Large",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2463.47,N/A,1478.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,1478.08,,Hospital MED13155,"Dressing,Der,Xeroform Rolls",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2463.47,N/A,1478.08,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.61,1478.08,,Hospital MED13158,"Bandage,Coflex,Lf2,1""X5yd,Tan,Ns,Lf",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,5822.48,N/A,3493.49,N/A,N/A,N/A,84.69,N/A,N/A,N/A,1979.63,N/A,1443.00,N/A,815.13,N/A,1755.00,N/A,1755.00,N/A,1443.00,N/A,1443.00,N/A,1443.00,N/A,1443.00,N/A,3352.59,N/A,1755.00,N/A,N/A,N/A,119.26,N/A,119.26,N/A,N/A,N/A,1755.00,N/A,1755.00,N/A,317.04,N/A,N/A,84.69,3493.49,,Hospital MED13162,"Bandage,Gauze,Conforming,6x4.1y,Strl",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,2630.17,N/A,1578.10,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,1578.10,1578.10,,Hospital MED13179,"Wipe,Cavi,Disinfect,6x6.75",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2070.68,N/A,1242.41,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.25,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.25,1242.41,,Hospital MED13211,"Dressing,Polymem,Oval,Silicone,5x3.5",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,9386.10,N/A,5631.66,N/A,N/A,N/A,2895.47,N/A,N/A,N/A,3191.27,N/A,1919.00,N/A,1314.05,N/A,2895.47,N/A,2895.47,N/A,2343.80,N/A,1919.00,N/A,1919.00,N/A,1919.00,N/A,5404.51,N/A,2895.47,N/A,N/A,N/A,1500.80,N/A,1500.80,N/A,N/A,N/A,2895.47,N/A,2895.47,N/A,13.07,N/A,N/A,13.07,5631.66,,Hospital MED13216,"Mbo-Syringe,Normal Saline,Lf,10mlfill",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2958.73,N/A,1775.24,N/A,743.94,N/A,9.68,N/A,N/A,N/A,1005.98,N/A,666.00,N/A,414.23,N/A,N/A,N/A,N/A,N/A,666.00,N/A,666.00,N/A,666.00,N/A,666.00,N/A,1703.62,N/A,N/A,N/A,743.94,N/A,85.07,N/A,85.07,N/A,743.94,N/A,N/A,N/A,9.68,N/A,10.65,N/A,N/A,9.68,1775.24,,Hospital MED13270,"Needle,Safety,20gx1"",Gripper Plus",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,4324.57,N/A,2594.74,N/A,1282.86,N/A,69.93,N/A,N/A,N/A,1470.36,N/A,890.00,N/A,605.44,N/A,N/A,N/A,N/A,N/A,1134.00,N/A,890.00,N/A,890.00,N/A,890.00,N/A,2490.09,N/A,N/A,N/A,1282.86,N/A,857.60,N/A,857.60,N/A,1282.86,N/A,N/A,N/A,69.93,N/A,76.92,N/A,N/A,69.93,2594.74,,Hospital MED13281,Triple Antibiotic+Pain Rlf Oin 1oz,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2656.73,N/A,1594.04,N/A,N/A,N/A,2709.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2709.87,N/A,2709.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2709.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2709.87,N/A,2709.87,N/A,N/A,N/A,N/A,1594.04,2709.87,,Hospital MED13285,"Sleeve, Protective, Proview",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,8406.63,N/A,5043.98,N/A,2715.84,N/A,N/A,N/A,N/A,N/A,2858.25,N/A,1395.00,N/A,1176.93,N/A,N/A,N/A,N/A,N/A,2227.80,N/A,1395.00,N/A,1395.00,N/A,1395.00,N/A,4840.54,N/A,N/A,N/A,2715.84,N/A,3216.00,N/A,3216.00,N/A,2715.84,N/A,N/A,N/A,N/A,N/A,2715.84,N/A,N/A,1176.93,5043.98,,Hospital MED13297,"Container,Graduated,Tri,Etched,32oz,Disp",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,529.08,N/A,317.45,N/A,N/A,N/A,105.00,N/A,N/A,N/A,179.89,N/A,111.00,N/A,74.07,N/A,105.00,N/A,105.00,N/A,111.00,N/A,111.00,N/A,111.00,N/A,111.00,N/A,304.65,N/A,105.00,N/A,N/A,N/A,69.20,N/A,69.20,N/A,N/A,N/A,105.00,N/A,105.00,N/A,182.75,N/A,N/A,69.20,317.45,,Hospital MED13303,"Syr W/Ndle,Safety,Insln,1ml,29gx0.5""",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2546.47,N/A,1527.88,N/A,N/A,N/A,2597.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2597.40,N/A,2597.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2597.40,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2597.40,N/A,2597.40,N/A,N/A,N/A,N/A,1527.88,2597.40,,Hospital MED13470,"Dressing,Zetuvit,Silicone,Plus,4x4"",Abs",N/A,0623 - MEDICAL SURGICAL SUPPLIES - EXTENSION OF 027X - SURGICAL DRESSINGS,N/A,1298.28,N/A,778.97,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,778.97,778.97,,Hospital Custom MEDWTLS,Medical Weight Loss Visit,N/A,N/A,100.00,100.00,60.00,60.00,N/A,14.00,N/A,100.00,N/A,100.00,N/A,34.00,N/A,14.00,N/A,14.00,N/A,100.00,N/A,100.00,N/A,8.70,N/A,14.00,N/A,14.00,N/A,14.00,N/A,100.00,N/A,100.00,N/A,14.00,N/A,100.00,N/A,100.00,N/A,14.00,N/A,100.00,N/A,100.00,N/A,100.00,60.00,60.00,8.70,100.00,,Hospital Custom MISC612,Half Foam Exercise Roller 6x12,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISC906,Sammons Preston Progressive Putty,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISC910,Achilles Heel Pads,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC911,Hammer Toe Crest Pads,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISC912,Full Foam Exercise Roller 6x12,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISC914,Peg Assist System,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC915,Knee Sleeve Open or Closed - Breg,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISC923,Biontic Gloves- Fitness Half Finger,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISC945,Theraball 45,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISC965,Theraball 65,N/A,N/A,37.00,37.00,22.20,22.20,N/A,5.18,N/A,37.00,N/A,37.00,N/A,12.58,N/A,5.18,N/A,5.18,N/A,37.00,N/A,37.00,N/A,3.22,N/A,5.18,N/A,5.18,N/A,5.18,N/A,37.00,N/A,37.00,N/A,5.18,N/A,37.00,N/A,37.00,N/A,5.18,N/A,37.00,N/A,37.00,N/A,37.00,22.20,22.20,3.22,37.00,,Hospital Custom MISC970,Shipping Fee Blood Draw,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCBeefStckSwtSpy,MISCBEEFSTICKSWTSPCY- Beef/Elk Sweet Spicy Stick,N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCBeefStickNtrl,MISCBEEFSTICKNTRL- Natural Flvr,N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCBlenderBtl,MISCBLENDERBTL- Blender Bottle,N/A,N/A,8.95,8.95,5.37,5.37,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,5.37,5.37,5.37,8.95,,Hospital Custom MISCCDHTPACK,Cold/Hot Pack,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCCalciumWtmln,MISCCALCIUMWTMLN- 90ct Watermelon,N/A,N/A,31.95,31.95,19.17,19.17,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,N/A,31.95,19.17,19.17,19.17,31.95,,Hospital Custom MISCCelbrtFlfyNtr,MISCCELEBRATEFLFYNTR- Fluffy Nutter Bar,N/A,N/A,12.95,12.95,7.77,7.77,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,7.77,7.77,7.77,12.95,,Hospital Custom MISCClbrtNtyCrml,MISCCELEBRATENTYCRML- Nutty Caramel Crisp Bar,N/A,N/A,12.95,12.95,7.77,7.77,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,N/A,12.95,7.77,7.77,7.77,12.95,,Hospital Custom MISCD110,Lateral Stabilizer,N/A,N/A,60.00,60.00,36.00,36.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,20.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,5.22,N/A,8.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,60.00,36.00,36.00,5.22,60.00,,Hospital Custom MISCD113,Adjustable Patella Donut,N/A,N/A,45.00,45.00,27.00,27.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,15.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,3.92,N/A,6.30,N/A,6.30,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,6.30,N/A,45.00,N/A,45.00,N/A,45.00,27.00,27.00,3.92,45.00,,Hospital Custom MISCD121,Protector Heel or Elbow (Retail),N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCD264,Digital Pad by Silipos,N/A,N/A,4.00,4.00,2.40,2.40,N/A,N/A,N/A,4.00,N/A,4.00,N/A,1.36,N/A,N/A,N/A,N/A,N/A,4.00,N/A,4.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,4.00,N/A,4.00,N/A,N/A,N/A,4.00,N/A,4.00,N/A,N/A,N/A,4.00,N/A,4.00,N/A,4.00,2.40,2.40,1.36,4.00,,Hospital Custom MISCD282,Adjusta Lift,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCD283,Toe Caps,N/A,N/A,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital Custom MISCD292,Corn Pads Pack of 10,N/A,N/A,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital Custom MISCD297,Toe Crest Pads,N/A,N/A,5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital Custom MISCD377,Patellar Tendon Strap-Breg,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCD378,Cho-Pat Strap,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCD381,At Ankle,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISCD407,Elastic Knee- Breg,N/A,N/A,40.00,40.00,24.00,24.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,24.00,24.00,3.48,40.00,,Hospital Custom MISCD47,Ankle Sleeve -Alpha Med,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCD78,Elastic Knee- Alpha Med,N/A,N/A,40.00,40.00,24.00,24.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,24.00,24.00,3.48,40.00,,Hospital Custom MISCD83,Bandit,N/A,N/A,30.00,30.00,18.00,18.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,4.20,N/A,30.00,N/A,30.00,N/A,30.00,18.00,18.00,2.61,30.00,,Hospital Custom MISCDMEPARTS,Brace Parts,N/A,N/A,52.00,52.00,31.20,31.20,N/A,7.28,N/A,52.00,N/A,52.00,N/A,17.68,N/A,7.28,N/A,7.28,N/A,52.00,N/A,52.00,N/A,4.52,N/A,7.28,N/A,7.28,N/A,7.28,N/A,52.00,N/A,52.00,N/A,7.28,N/A,52.00,N/A,52.00,N/A,7.28,N/A,52.00,N/A,52.00,N/A,52.00,31.20,31.20,4.52,52.00,,Hospital Custom MISCELAS,Elastilash,N/A,N/A,60.00,60.00,36.00,36.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,20.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,5.22,N/A,8.40,N/A,8.40,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,8.40,N/A,60.00,N/A,60.00,N/A,60.00,36.00,36.00,5.22,60.00,,Hospital Custom MISCENSUREMAXHPMOCHA,MISCENSUREMAXHIGHPROTEIN - Mocha,N/A,N/A,2.75,2.75,1.65,1.65,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,1.65,1.65,1.65,2.75,,Hospital Custom MISCENSUREMAXHPVAN,MISCENSUREMAXHIGHPROTEIN- Vanilla,N/A,N/A,2.75,2.75,1.65,1.65,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,N/A,2.75,1.65,1.65,1.65,2.75,,Hospital Custom MISCFMHF6X12,Half Foam Exercise Roller 6x12,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCFMHF6X18,Half Foam Exercise Roller 6x18,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCFMHF6X36,Half Foam Exercise Roller 6x36,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISCFOM6X12,Full Foam Exercise Roller 6x12,N/A,N/A,15.00,15.00,9.00,9.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,5.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,1.31,N/A,2.10,N/A,2.10,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,2.10,N/A,15.00,N/A,15.00,N/A,15.00,9.00,9.00,1.31,15.00,,Hospital Custom MISCFOM6X18,Full Foam Exercise Roller 6x18,N/A,N/A,20.00,20.00,12.00,12.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,6.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,1.74,N/A,2.80,N/A,2.80,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,2.80,N/A,20.00,N/A,20.00,N/A,20.00,12.00,12.00,1.74,20.00,,Hospital Custom MISCGAP,Misc Class,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCGRP,Misc Group Session,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCGnrlRevCode,MISCGNRLREVCODE- MISC Trial Revenue Code,N/A,N/A,1.00,1.00,N/A,N/A,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,1.00,N/A,N/A,1.00,1.00,,Hospital Custom MISCKaysChipsPrmsn,MISCKAYSCHIPSPRMSN-Crispy Parmesan,N/A,N/A,8.95,8.95,5.37,5.37,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,5.37,5.37,5.37,8.95,,Hospital Custom MISCKaysChpsChNch,MISCKAYSCHIPSCHNACHO-Chili Nacho Cheese,N/A,N/A,8.95,8.95,5.37,5.37,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,N/A,8.95,5.37,5.37,5.37,8.95,,Hospital Custom MISCL3651,Shoulder Immobilizer,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCLAT,Latisse,N/A,N/A,210.00,210.00,126.00,126.00,N/A,29.40,N/A,210.00,N/A,210.00,N/A,71.40,N/A,29.40,N/A,29.40,N/A,210.00,N/A,210.00,N/A,18.27,N/A,29.40,N/A,29.40,N/A,29.40,N/A,210.00,N/A,210.00,N/A,29.40,N/A,210.00,N/A,210.00,N/A,29.40,N/A,210.00,N/A,210.00,N/A,210.00,126.00,126.00,18.27,210.00,,Hospital Custom MISCMONAFOL,Mona Lisa Folow Up 2 & 3,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCMONAINIT,Mona Lisa Initial,N/A,N/A,1500.00,1500.00,900.00,900.00,N/A,210.00,N/A,1500.00,N/A,1500.00,N/A,510.00,N/A,210.00,N/A,210.00,N/A,1500.00,N/A,1500.00,N/A,130.50,N/A,210.00,N/A,210.00,N/A,210.00,N/A,1500.00,N/A,1500.00,N/A,210.00,N/A,1500.00,N/A,1500.00,N/A,210.00,N/A,1500.00,N/A,1500.00,N/A,1500.00,900.00,900.00,130.50,1500.00,,Hospital Custom MISCMONAYEAR,Mona Lisa Yearly,N/A,N/A,500.00,500.00,300.00,300.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,170.00,N/A,70.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,43.50,N/A,70.00,N/A,70.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,70.00,N/A,500.00,N/A,500.00,N/A,500.00,300.00,300.00,43.50,500.00,,Hospital Custom MISCMRTubAsst,MISCMRTUBASST-Single Serve Asst Flavors,N/A,N/A,34.95,34.95,20.97,20.97,N/A,4.89,N/A,34.95,N/A,34.95,N/A,11.88,N/A,4.89,N/A,4.89,N/A,34.95,N/A,34.95,N/A,3.04,N/A,4.89,N/A,4.89,N/A,4.89,N/A,34.95,N/A,34.95,N/A,4.89,N/A,34.95,N/A,34.95,N/A,4.89,N/A,34.95,N/A,34.95,N/A,34.95,20.97,20.97,3.04,34.95,,Hospital Custom MISCMULTICOMPSOFT,MISCMULTICOMPSOFT- 30ct Black Cherry Soft Chew,N/A,N/A,14.95,14.95,8.97,8.97,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,N/A,14.95,8.97,8.97,8.97,14.95,,Hospital Custom MISCMULTIWELL,MISCMULTIWELL-60ct Capsule,N/A,N/A,14.95,14.95,8.97,8.97,N/A,2.09,N/A,14.95,N/A,14.95,N/A,5.08,N/A,2.09,N/A,2.09,N/A,14.95,N/A,14.95,N/A,1.30,N/A,2.09,N/A,2.09,N/A,2.09,N/A,14.95,N/A,14.95,N/A,2.09,N/A,14.95,N/A,14.95,N/A,2.09,N/A,14.95,N/A,14.95,N/A,14.95,8.97,8.97,1.30,14.95,,Hospital Custom MISCMWLLiverKit,MISCMWLLIVERKIT- Liver Reduction Kit,N/A,N/A,75.00,75.00,45.00,45.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,N/A,75.00,45.00,45.00,45.00,75.00,,Hospital Custom MISCPLYOBALL,Plyometric Weighted Balls 2.5lbs Yellow,N/A,N/A,25.00,25.00,15.00,15.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,8.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,2.18,N/A,3.50,N/A,3.50,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,3.50,N/A,25.00,N/A,25.00,N/A,25.00,15.00,15.00,2.18,25.00,,Hospital Custom MISCPROTESPOPCORNLB,MISCPROTESPROTEINPOPCORN - Light Butter,N/A,N/A,1.39,1.39,N/A,N/A,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,1.39,N/A,N/A,1.39,1.39,,Hospital Custom MISCPopcornWhChdr,MISCPOPCORNWHCHDR- White Cheddar,N/A,N/A,11.95,11.95,7.17,7.17,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,N/A,11.95,7.17,7.17,7.17,11.95,,Hospital Custom MISCProPreCap,MISCPROPRECAP- Probiotic Prebiotic 30ct,N/A,N/A,27.95,27.95,16.77,16.77,N/A,3.91,N/A,27.95,N/A,27.95,N/A,9.50,N/A,3.91,N/A,3.91,N/A,27.95,N/A,27.95,N/A,2.43,N/A,3.91,N/A,3.91,N/A,3.91,N/A,27.95,N/A,27.95,N/A,3.91,N/A,27.95,N/A,27.95,N/A,3.91,N/A,27.95,N/A,27.95,N/A,27.95,16.77,16.77,2.43,27.95,,Hospital Custom MISCProteinDecaf,MISCPROTEIN20ICDDECAF- Iced Decaf Coffee,N/A,N/A,19.95,19.95,11.97,11.97,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,N/A,19.95,11.97,11.97,11.97,19.95,,Hospital Custom MISCROSEGLVS,Rose Gloves,N/A,N/A,40.00,40.00,24.00,24.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,13.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,3.48,N/A,5.60,N/A,5.60,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,5.60,N/A,40.00,N/A,40.00,N/A,40.00,24.00,24.00,3.48,40.00,,Hospital Custom MISCSAME,Misc IP Same Day Service Nonbillable,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Custom MISCSR2,"Scar Revision, Other 2.6 to 5.0",N/A,N/A,475.00,475.00,285.00,285.00,N/A,66.50,N/A,475.00,N/A,475.00,N/A,161.50,N/A,66.50,N/A,66.50,N/A,475.00,N/A,475.00,N/A,41.33,N/A,66.50,N/A,66.50,N/A,66.50,N/A,475.00,N/A,475.00,N/A,66.50,N/A,475.00,N/A,475.00,N/A,66.50,N/A,475.00,N/A,475.00,N/A,475.00,285.00,285.00,41.33,475.00,,Hospital Custom MISCVEIN2,PR Endoven Ablti Ther Chem Adhesive 1st Vein Self Pay,N/A,N/A,3015.00,3015.00,1809.00,1809.00,N/A,422.10,N/A,3015.00,N/A,3015.00,N/A,1025.10,N/A,422.10,N/A,422.10,N/A,3015.00,N/A,3015.00,N/A,262.31,N/A,422.10,N/A,422.10,N/A,422.10,N/A,3015.00,N/A,3015.00,N/A,422.10,N/A,3015.00,N/A,3015.00,N/A,422.10,N/A,3015.00,N/A,3015.00,N/A,3015.00,1809.00,1809.00,262.31,3015.00,,Hospital Custom MISCYOGA,Misc Yoga Class,N/A,N/A,0.00,0.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital CPT P9012,HC Pre-Pooled Cryoprecipitate,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1431.00,1255.00,858.60,753.00,N/A,175.70,N/A,74.39,N/A,722.63,N/A,426.70,N/A,162.50,N/A,175.70,N/A,74.39,N/A,74.39,N/A,101.16,N/A,162.50,N/A,162.50,N/A,162.50,N/A,722.63,N/A,74.39,N/A,175.70,N/A,672.68,N/A,672.68,N/A,175.70,N/A,74.39,N/A,74.39,N/A,1255.00,858.60,858.60,74.39,1255.00,,Hospital CPT P9016,HC Lrbc-Red Cross,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",946.00,833.00,567.60,499.80,N/A,116.62,N/A,189.21,N/A,479.64,N/A,283.22,N/A,413.31,N/A,116.62,N/A,189.21,N/A,189.21,N/A,257.29,N/A,413.31,N/A,413.31,N/A,413.31,N/A,479.64,N/A,189.21,N/A,116.62,N/A,446.49,N/A,446.49,N/A,116.62,N/A,189.21,N/A,189.21,N/A,208.13,567.60,567.60,116.62,499.80,,Hospital CPT P9017,HC So Ffp,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1275.00,1275.00,765.00,765.00,N/A,178.50,N/A,85.47,N/A,734.15,N/A,433.50,N/A,186.69,N/A,178.50,N/A,85.47,N/A,85.47,N/A,116.22,N/A,186.69,N/A,186.69,N/A,186.69,N/A,734.15,N/A,85.47,N/A,178.50,N/A,683.40,N/A,683.40,N/A,178.50,N/A,85.47,N/A,85.47,N/A,1275.00,765.00,765.00,85.47,1275.00,,Hospital CPT P9017,HC Ffp,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",431.00,377.00,258.60,226.20,N/A,52.78,N/A,85.47,N/A,217.08,N/A,128.18,N/A,186.69,N/A,52.78,N/A,85.47,N/A,85.47,N/A,116.22,N/A,186.69,N/A,186.69,N/A,186.69,N/A,217.08,N/A,85.47,N/A,52.78,N/A,202.07,N/A,202.07,N/A,52.78,N/A,85.47,N/A,85.47,N/A,377.00,258.60,258.60,52.78,377.00,,Hospital HCPCS P9036,HC Platelet Pheresis Irradiated,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1542.00,1542.00,925.20,925.20,N/A,215.88,N/A,616.68,N/A,887.88,N/A,524.28,N/A,1347.07,N/A,215.88,N/A,616.68,N/A,616.68,N/A,838.58,N/A,1347.07,N/A,1347.07,N/A,1347.07,N/A,887.88,N/A,616.68,N/A,215.88,N/A,826.51,N/A,826.51,N/A,215.88,N/A,616.68,N/A,616.68,N/A,1542.00,925.20,925.20,215.88,1542.00,,Hospital CPT P9037,HC Leukored Platelet Pheres Irrad,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1615.00,1418.00,969.00,850.80,N/A,198.52,N/A,638.19,N/A,816.48,N/A,482.12,N/A,1394.05,N/A,198.52,N/A,638.19,N/A,638.19,N/A,867.82,N/A,1394.05,N/A,1394.05,N/A,1394.05,N/A,816.48,N/A,638.19,N/A,198.52,N/A,760.05,N/A,760.05,N/A,198.52,N/A,638.19,N/A,638.19,N/A,1418.00,969.00,969.00,198.52,1418.00,,Hospital P9038,HC RBC Irradiated Each Unit,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",N/A,2316.20,N/A,1389.72,N/A,324.27,N/A,845.53,N/A,1333.44,N/A,787.51,N/A,1887.85,N/A,324.27,N/A,823.53,N/A,823.53,N/A,1175.22,N/A,1887.85,N/A,1887.85,N/A,1887.85,N/A,1324.05,N/A,823.53,N/A,324.27,N/A,612.11,N/A,612.11,N/A,324.27,N/A,823.53,N/A,845.53,N/A,37.35,N/A,N/A,37.35,1887.85,,Hospital P9039,HC RBC Deglycerolized,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",112345.50,N/A,67407.30,N/A,16856.92,N/A,N/A,N/A,61924.84,N/A,38197.47,N/A,N/A,N/A,16856.92,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,61924.84,N/A,N/A,N/A,16856.92,N/A,N/A,N/A,28261.97,N/A,16856.92,N/A,N/A,N/A,N/A,N/A,11516.01,N/A,11516.01,67407.30,N/A,N/A,,Hospital P9041,"Albumin (Human),5%, 50ml",N/A,N/A,214177.80,16818.75,128506.68,10091.25,21923.86,2180.90,30156.14,195.97,75324.63,9562.96,72686.83,5718.38,74439.87,6061.79,21923.86,2180.90,17437.30,2466.42,29923.67,2466.42,46348.54,3773.56,74439.87,6061.79,74439.87,6061.79,74439.87,6061.79,89337.81,9337.83,26606.99,2466.42,21923.86,2180.90,94625.33,527.00,83929.63,527.00,27647.16,2180.90,32657.88,2466.42,37992.80,2486.39,21923.86,215.57,17437.30,128506.68,195.97,10091.25,,Hospital HCPCS P9045,ALBUMIN HUMAN 5 % IV SOLN,44206-0310-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),607.50,607.50,364.50,364.50,N/A,85.05,N/A,53.08,N/A,341.54,N/A,206.55,N/A,135.85,N/A,85.05,N/A,53.08,N/A,53.08,N/A,84.57,N/A,135.85,N/A,135.85,N/A,135.85,N/A,341.54,N/A,53.08,N/A,85.05,N/A,325.62,N/A,325.62,N/A,85.05,N/A,53.08,N/A,53.08,N/A,58.38,364.50,364.50,53.08,364.50,,Hospital HCPCS P9045,ALBUMIN HUMAN 5 % IV SOLN,99999-9917-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),607.50,607.50,364.50,364.50,N/A,85.05,N/A,53.08,N/A,341.54,N/A,206.55,N/A,135.85,N/A,85.05,N/A,53.08,N/A,53.08,N/A,84.57,N/A,135.85,N/A,135.85,N/A,135.85,N/A,341.54,N/A,53.08,N/A,85.05,N/A,325.62,N/A,325.62,N/A,85.05,N/A,53.08,N/A,53.08,N/A,58.38,364.50,364.50,53.08,364.50,,Hospital HCPCS P9047,ALBUMIN HUMAN-KJDA 25 % IV SOLN,64208-2512-07,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),472.50,472.50,283.50,283.50,N/A,66.15,N/A,53.08,N/A,265.64,N/A,160.65,N/A,135.85,N/A,66.15,N/A,53.08,N/A,53.08,N/A,84.57,N/A,135.85,N/A,135.85,N/A,135.85,N/A,265.64,N/A,53.08,N/A,66.15,N/A,253.26,N/A,253.26,N/A,66.15,N/A,53.08,N/A,53.08,N/A,58.38,283.50,283.50,53.08,283.50,,Hospital CPT P9053,"HC Plate,Leuk Red,Cmv-Neg,Irr Ea",N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",2665.00,2336.00,1599.00,1401.60,N/A,327.04,N/A,2336.00,N/A,1345.07,N/A,794.24,N/A,327.04,N/A,327.04,N/A,2336.00,N/A,2336.00,N/A,203.23,N/A,327.04,N/A,327.04,N/A,327.04,N/A,1345.07,N/A,2336.00,N/A,327.04,N/A,1252.10,N/A,1252.10,N/A,327.04,N/A,2336.00,N/A,2336.00,N/A,2336.00,1599.00,1599.00,203.23,2336.00,,Hospital CPT P9055,"HC Platelets,Leuko Red,Cmv-Neg Ea",N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1881.00,1650.00,1128.60,990.00,N/A,231.00,N/A,1650.00,N/A,950.07,N/A,561.00,N/A,231.00,N/A,231.00,N/A,1650.00,N/A,1650.00,N/A,143.55,N/A,231.00,N/A,231.00,N/A,231.00,N/A,950.07,N/A,1650.00,N/A,231.00,N/A,884.40,N/A,884.40,N/A,231.00,N/A,1650.00,N/A,1650.00,N/A,1650.00,1128.60,1128.60,143.55,1650.00,,Hospital CPT P9073,HC Platelets Pathogen Reduced Ea Unit,N/A,"0390 - ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS - GENERAL CLASSIFICATION",1687.00,1687.00,1012.20,1012.20,N/A,236.18,N/A,577.89,N/A,971.37,N/A,573.58,N/A,1262.32,N/A,236.18,N/A,577.89,N/A,577.89,N/A,785.82,N/A,1262.32,N/A,1262.32,N/A,1262.32,N/A,971.37,N/A,577.89,N/A,236.18,N/A,904.23,N/A,904.23,N/A,236.18,N/A,577.89,N/A,577.89,N/A,635.68,1012.20,1012.20,236.18,1262.32,,Hospital CPT P9100,HC Pathogen Test for Platelets,N/A,0302 - LABORATORY - IMMUNOLOGY,95.00,95.00,57.00,57.00,N/A,13.30,N/A,95.00,N/A,54.70,N/A,32.30,N/A,13.30,N/A,13.30,N/A,95.00,N/A,95.00,N/A,8.27,N/A,13.30,N/A,13.30,N/A,13.30,N/A,54.70,N/A,95.00,N/A,13.30,N/A,56.85,N/A,56.85,N/A,13.30,N/A,95.00,N/A,95.00,N/A,95.00,57.00,57.00,8.27,95.00,,Hospital P9603,HC One Way Allow Prorated Miles,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,63410.20,145.90,38046.12,87.54,3934.82,20.35,4799.47,25.37,9022.51,84.02,21559.47,49.61,9463.05,19.88,4056.05,20.35,4769.82,25.37,4769.82,25.37,5890.67,19.88,9463.05,19.88,9463.05,19.88,9463.05,19.88,26972.98,84.02,4769.82,25.37,4056.05,20.35,10837.22,19.80,10837.22,19.80,N/A,20.35,4769.82,25.37,4799.47,25.37,4339.98,21.78,3934.82,38046.12,19.80,87.54,,Hospital CPT P9612,HC Catheterize for Urine Spec,N/A,0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION,25.00,21.00,15.00,12.60,N/A,2.94,N/A,8.57,N/A,21.00,N/A,7.14,N/A,8.57,N/A,2.94,N/A,8.57,N/A,8.57,N/A,5.33,N/A,8.57,N/A,8.57,N/A,8.57,N/A,12.09,N/A,8.57,N/A,2.94,N/A,21.00,N/A,21.00,N/A,2.94,N/A,8.57,N/A,8.57,N/A,3.30,15.00,15.00,2.94,21.00,,Hospital CPT P9612,HC Straight Cath for Specimen,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,22.00,22.00,13.20,13.20,N/A,3.00,N/A,8.57,N/A,22.00,N/A,7.48,N/A,8.57,N/A,3.00,N/A,8.57,N/A,8.57,N/A,5.33,N/A,8.57,N/A,8.57,N/A,8.57,N/A,12.67,N/A,8.57,N/A,3.00,N/A,3.00,N/A,3.00,N/A,3.00,N/A,8.57,N/A,8.57,N/A,3.30,13.20,13.20,3.00,22.00,,Hospital Q0091,HC Obtain Pap Smear Medicare,N/A,0923 - OTHER DIAGNOSTIC SERVICES - PAP SMEAR,N/A,368.00,N/A,220.80,N/A,55.03,N/A,50.38,N/A,211.89,N/A,125.12,N/A,54.51,N/A,55.03,N/A,49.03,N/A,49.03,N/A,33.94,N/A,54.51,N/A,54.51,N/A,54.51,N/A,211.90,N/A,158.17,N/A,55.03,N/A,51.84,N/A,51.84,N/A,55.03,N/A,158.17,N/A,166.04,N/A,49.25,N/A,N/A,33.94,220.80,,Hospital CPT Q0112,HC Koh Prep,N/A,0300 - LABORATORY - GENERAL CLASSIFICATION,101.00,79.00,60.60,47.40,N/A,5.82,N/A,5.83,N/A,45.49,N/A,26.86,N/A,3.05,N/A,5.82,N/A,5.83,N/A,5.83,N/A,3.05,N/A,5.82,N/A,3.05,N/A,5.82,N/A,45.49,N/A,5.83,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.82,N/A,5.83,N/A,5.83,N/A,6.40,60.60,60.60,3.05,47.40,,Hospital HCPCS Q0138,FERUMOXYTOL 510 MG/17ML IV SOLN,59338-0775-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),5371.30,5371.30,3222.78,3222.78,N/A,751.98,N/A,256.53,N/A,3019.74,N/A,1826.24,N/A,924.63,N/A,751.98,N/A,256.53,N/A,256.53,N/A,575.59,N/A,924.63,N/A,924.63,N/A,924.63,N/A,3019.74,N/A,256.53,N/A,751.98,N/A,2879.02,N/A,2879.02,N/A,751.98,N/A,256.53,N/A,256.53,N/A,282.18,3222.78,3222.78,256.53,3222.78,,Hospital Q0139,"Ferumoxytol, esrd use",N/A,N/A,N/A,10620.50,N/A,6372.30,N/A,1486.87,N/A,445.09,N/A,5985.42,N/A,3610.97,N/A,1375.85,N/A,1486.87,N/A,443.07,N/A,443.07,N/A,856.48,N/A,1375.85,N/A,1375.85,N/A,1375.85,N/A,5985.42,N/A,443.07,N/A,1486.87,N/A,5692.58,N/A,5692.58,N/A,1486.87,N/A,443.07,N/A,445.09,N/A,67.14,N/A,N/A,67.14,6372.30,,Hospital Q0144,"Azithromycin dihydrate, oral",N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital HCPCS Q0162,ONDANSETRON HCL 4 MG/5ML PO SOLN,65162-0691-79,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0162,ONDANSETRON HCL 4 MG/5ML PO SOLN,09999-9911-97,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0162,ONDANSETRON HCL 8 MG PO TABS,68084-0221-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0162,ONDANSETRON 4 MG PO TBDP,68001-0246-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0162,ONDANSETRON HCL 4 MG PO TABS,68084-0220-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0162,ONDANSETRON 8 MG PO TBDP,68001-0247-16,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital Q0164,Prochlorperazine Maleate 5mg,N/A,N/A,24328.00,9794.82,14596.80,5876.89,11109.88,1316.52,13408.05,646.75,24328.00,5552.05,8271.52,3330.24,24328.00,2107.79,11452.20,1316.52,13408.05,636.24,13408.05,636.24,16346.33,1312.12,24328.00,2107.79,24328.00,2107.79,24328.00,2107.79,24328.00,5552.05,13408.05,745.38,11452.20,1316.52,24328.00,911.29,24328.00,911.29,N/A,1316.52,13408.05,745.38,13408.05,150.84,12253.85,159.81,8271.52,24328.00,150.84,5876.89,,Hospital Q0167,Dronabinol 2.5mg Oral,N/A,N/A,43840.50,15493.80,26304.30,9296.28,8548.73,2120.15,10378.35,1683.01,19265.26,2552.00,14905.77,5267.89,19449.54,4128.30,8812.13,2120.15,10378.35,1697.68,10378.35,1697.68,12106.89,2569.95,19449.54,4128.30,19449.54,4128.30,19449.54,4128.30,19265.26,2552.00,10378.35,1697.68,8812.13,2120.15,23140.10,1871.00,23140.10,1871.00,5698.58,2120.15,10378.35,1697.68,10378.35,1683.01,9428.98,418.52,5698.58,26304.30,418.52,9296.28,,Hospital HCPCS Q0169,PROMETHAZINE HCL 6.25 MG/5ML PO SYRP,09999-9905-96,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0169,PROMETHAZINE HCL 25 MG PO TABS,68084-0155-11,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital HCPCS Q0169,PROMETHAZINE HCL 12.5 MG PO TABS,68382-0040-01,0637 - PHARMACY - EXTENSION OF 025X - SELF-ADMINISTRABLE DRUGS (B),5.00,5.00,3.00,3.00,N/A,N/A,N/A,5.00,N/A,2.81,N/A,1.70,N/A,N/A,N/A,N/A,N/A,5.00,N/A,5.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,2.81,N/A,5.00,N/A,N/A,N/A,2.68,N/A,2.68,N/A,N/A,N/A,5.00,N/A,5.00,N/A,5.00,3.00,3.00,1.70,5.00,,Hospital Q0222,Bebtelovimab 175 mg,N/A,N/A,54924.30,3045.00,32954.58,1827.00,9495.09,426.30,11497.84,2708.90,N/A,1724.76,18674.26,1035.30,21602.65,2450.50,9787.65,426.30,11497.84,2710.52,11497.84,2710.52,13447.14,3045.00,21602.65,2450.50,21602.65,2450.50,21602.65,2450.50,21397.96,1724.76,11497.84,2710.52,N/A,426.30,25701.76,1632.12,25701.76,1632.12,N/A,426.30,11497.84,2710.52,11497.84,2708.90,10472.79,N/A,9495.09,32954.58,426.30,3045.00,,Hospital Q0240,Casirivi and imdevi 600 mg,N/A,N/A,380847.37,1888.10,228508.42,1132.86,N/A,267.34,N/A,644.09,N/A,1087.18,126979.07,641.96,130041.51,894.91,N/A,267.34,N/A,594.42,N/A,594.42,80967.83,727.15,130041.51,894.91,130041.51,894.91,130041.51,894.91,N/A,1087.18,N/A,594.42,N/A,267.34,191687.51,672.41,N/A,672.41,N/A,267.34,N/A,594.42,N/A,644.09,N/A,25.40,80967.83,228508.42,25.40,1132.86,,Hospital Q0244,Casirivi and imdevi 1200 mg,N/A,N/A,40161.70,1844.00,24097.02,1106.40,9495.09,258.16,11497.84,403.31,N/A,1061.78,13654.98,626.96,21602.65,450.50,9787.65,258.16,1686.00,406.82,1686.00,406.82,13447.14,450.50,21602.65,450.50,21602.65,450.50,21602.65,450.50,N/A,1061.78,11497.84,406.82,9787.65,258.16,25701.76,988.38,25701.76,988.38,N/A,258.16,11497.84,406.82,11497.84,403.31,10472.79,443.99,1686.00,25701.76,258.16,1106.40,,Hospital Q0247,Sotrovimab,N/A,N/A,306928.40,1272.10,184157.04,763.26,N/A,178.09,26153.04,432.77,N/A,732.48,N/A,432.51,N/A,450.60,N/A,178.09,26153.04,406.82,26153.04,406.82,N/A,1272.10,N/A,450.60,N/A,450.60,N/A,450.60,N/A,732.48,26153.04,406.82,N/A,178.09,N/A,681.84,N/A,681.84,N/A,178.09,26153.04,406.82,26153.04,432.77,N/A,N/A,26153.04,184157.04,178.09,1272.10,,Hospital Q0249,Tocilizumab for covid-19,N/A,N/A,181908.70,10739.70,109145.22,6443.82,14714.53,1503.56,10402.96,309.30,100268.08,6046.53,61848.96,3651.50,20255.10,4467.07,11485.60,1503.56,10402.96,295.68,10402.96,295.68,33019.41,2780.79,20255.10,4467.07,20255.10,4467.07,20255.10,4467.07,100268.08,6046.53,10402.96,295.68,11485.60,1503.56,23196.42,5756.48,23196.42,5756.48,9718.88,1503.56,10402.96,295.68,10402.96,309.30,18265.24,67.14,9718.88,109145.22,67.14,6443.82,,Hospital HCPCS Q2009,FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN,00069-6001-02,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),247.60,247.60,148.56,148.56,N/A,34.66,N/A,247.60,N/A,139.20,N/A,84.18,N/A,24.61,N/A,34.66,N/A,247.60,N/A,247.60,N/A,15.32,N/A,24.61,N/A,24.61,N/A,24.61,N/A,139.20,N/A,247.60,N/A,34.66,N/A,132.71,N/A,132.71,N/A,34.66,N/A,247.60,N/A,247.60,N/A,247.60,148.56,148.56,15.32,247.60,,Hospital HCPCS Q2009,FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN,00069-6001-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),148.60,148.60,89.16,89.16,N/A,20.80,N/A,148.60,N/A,83.54,N/A,50.52,N/A,24.61,N/A,20.80,N/A,148.60,N/A,148.60,N/A,15.32,N/A,24.61,N/A,24.61,N/A,24.61,N/A,83.54,N/A,148.60,N/A,20.80,N/A,79.65,N/A,79.65,N/A,20.80,N/A,148.60,N/A,148.60,N/A,148.60,89.16,89.16,15.32,148.60,,Hospital HCPCS Q2009,FOSPHENYTOIN 50 MG PE/ML IJ SOLN (MIXTURES ONLY),00069-6001-21,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),247.60,247.60,148.56,148.56,N/A,34.66,N/A,247.60,N/A,139.20,N/A,84.18,N/A,24.61,N/A,34.66,N/A,247.60,N/A,247.60,N/A,15.32,N/A,24.61,N/A,24.61,N/A,24.61,N/A,139.20,N/A,247.60,N/A,34.66,N/A,132.71,N/A,132.71,N/A,34.66,N/A,247.60,N/A,247.60,N/A,247.60,148.56,148.56,15.32,247.60,,Hospital HCPCS Q2009,FOSPHENYTOIN 50 MG PE/ML IJ SOLN (MIXTURES ONLY),00069-6001-25,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),247.60,247.60,148.56,148.56,N/A,34.66,N/A,247.60,N/A,139.20,N/A,84.18,N/A,24.61,N/A,34.66,N/A,247.60,N/A,247.60,N/A,15.32,N/A,24.61,N/A,24.61,N/A,24.61,N/A,139.20,N/A,247.60,N/A,34.66,N/A,132.71,N/A,132.71,N/A,34.66,N/A,247.60,N/A,247.60,N/A,247.60,148.56,148.56,15.32,247.60,,Hospital Q2036,"HC Flulaval Vacc, 3 Yrs & >, Im",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,2065.00,N/A,1239.00,N/A,289.10,N/A,404.64,N/A,1188.45,N/A,702.10,N/A,611.79,N/A,289.10,N/A,400.31,N/A,400.31,N/A,380.85,N/A,611.79,N/A,611.79,N/A,611.79,N/A,1188.45,N/A,400.31,N/A,289.10,N/A,1106.84,N/A,1106.84,N/A,289.10,N/A,400.31,N/A,404.64,N/A,116.53,N/A,N/A,116.53,1239.00,,Hospital Q2041,Axicabtagene ciloleucel car+,N/A,N/A,N/A,2549521.00,N/A,1529712.60,N/A,356893.53,N/A,449754.20,N/A,1468014.05,N/A,866837.14,N/A,1233.46,N/A,356893.53,N/A,449740.37,N/A,449740.37,N/A,767.30,N/A,1233.46,N/A,1233.46,N/A,1233.46,N/A,1468008.44,N/A,449740.37,N/A,356893.53,N/A,71.75,N/A,71.75,N/A,356893.53,N/A,449740.37,N/A,449754.20,N/A,108.03,N/A,N/A,71.75,1529712.60,,Hospital Q2042,Tisagenlecleucel car-pos t,N/A,N/A,N/A,2568611.00,N/A,1541166.60,N/A,359578.88,N/A,466739.33,N/A,1479005.75,N/A,873327.74,N/A,2059.32,N/A,359578.88,N/A,466709.87,N/A,466709.87,N/A,1281.41,N/A,2059.32,N/A,2059.32,N/A,2059.32,N/A,1478507.26,N/A,466709.87,N/A,359578.88,N/A,532.11,N/A,532.11,N/A,359578.88,N/A,466709.87,N/A,466739.33,N/A,237.28,N/A,N/A,237.28,1541166.60,,Hospital Q2049,Imported lipodox inj,N/A,N/A,N/A,21035.30,N/A,12621.18,N/A,2944.94,N/A,2633.36,N/A,11859.62,N/A,7152.00,N/A,1497.88,N/A,2944.94,N/A,2635.09,N/A,2635.09,N/A,932.46,N/A,1497.88,N/A,1497.88,N/A,1497.88,N/A,11852.59,N/A,2635.09,N/A,2944.94,N/A,11274.93,N/A,11274.93,N/A,2944.94,N/A,2635.09,N/A,2633.36,N/A,151.25,N/A,N/A,151.25,12621.18,,Hospital Q2054,Lisocabtagene mara car pos t,N/A,N/A,N/A,2686746.00,N/A,1612047.60,N/A,376124.67,N/A,455417.59,N/A,1547025.97,N/A,913493.64,N/A,2175.39,N/A,376124.67,N/A,455376.74,N/A,455376.74,N/A,1354.22,N/A,2175.39,N/A,2175.39,N/A,2175.39,N/A,1546074.02,N/A,455376.74,N/A,376124.67,N/A,916.63,N/A,916.63,N/A,376124.67,N/A,455376.74,N/A,455417.59,N/A,288.81,N/A,N/A,288.81,1612047.60,,Hospital Q2055,Idecabtagene vicleucel car,N/A,N/A,2811786.60,N/A,1687071.96,N/A,531254.54,N/A,502945.63,N/A,N/A,N/A,956007.44,N/A,979064.09,N/A,509173.95,N/A,502945.63,N/A,502945.63,N/A,N/A,N/A,N/A,N/A,979064.09,N/A,N/A,N/A,1549856.77,N/A,502945.63,N/A,509173.95,N/A,1344345.56,N/A,1344345.56,N/A,N/A,N/A,502945.63,N/A,502945.63,N/A,N/A,N/A,502945.63,1687071.96,N/A,N/A,,Hospital Q4037,Cast Sup Shrt Leg Plaster,N/A,N/A,N/A,2155.00,N/A,1293.00,N/A,301.70,N/A,366.41,N/A,1240.85,N/A,732.70,N/A,942.04,N/A,301.70,N/A,354.86,N/A,354.86,N/A,586.30,N/A,942.04,N/A,942.04,N/A,942.04,N/A,1240.85,N/A,354.86,N/A,301.70,N/A,527.00,N/A,527.00,N/A,301.70,N/A,354.86,N/A,366.41,N/A,82.82,N/A,N/A,82.82,1293.00,,Hospital Q4051,Splint Supplies Misc,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital Q4079,Natalizumab injection,N/A,N/A,N/A,189997.30,N/A,113998.38,N/A,26599.62,N/A,310.67,N/A,106836.30,N/A,64599.08,N/A,27122.20,N/A,26599.62,N/A,300.37,N/A,300.37,N/A,16855.31,N/A,27122.20,N/A,27122.20,N/A,27122.20,N/A,106836.30,N/A,300.37,N/A,26599.62,N/A,101838.56,N/A,101838.56,N/A,26599.62,N/A,300.37,N/A,310.67,N/A,135.22,N/A,N/A,135.22,113998.38,,Hospital Q4106,HC Dermagraft per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,8712.80,N/A,5227.68,N/A,1219.79,N/A,1545.06,N/A,4959.71,N/A,2962.35,N/A,3769.94,N/A,1219.79,N/A,1558.52,N/A,1558.52,N/A,2346.86,N/A,3769.94,N/A,3769.94,N/A,3769.94,N/A,4959.71,N/A,1558.52,N/A,1219.79,N/A,1871.00,N/A,1871.00,N/A,1219.79,N/A,1558.52,N/A,1545.06,N/A,99.44,N/A,N/A,99.44,5227.68,,Hospital HCPCS Q4107,Graftjacket,N/A,N/A,212.00,212.00,127.20,127.20,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,N/A,212.00,127.20,127.20,127.20,212.00,,Hospital Q4108,HC Integra Matrix per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),140962.57,107859.17,84577.54,64715.50,15677.38,15095.89,18811.17,8238.14,77698.57,61697.49,47921.22,36672.12,71191.20,13536.31,16160.43,15095.89,1686.00,8193.66,1686.00,8193.66,44313.04,8426.61,71191.20,13536.31,71191.20,13536.31,71191.20,13536.31,77698.57,61697.50,18811.17,8193.66,16160.43,15095.89,42436.27,6898.50,42436.27,6898.50,2561.50,15095.89,18811.17,8193.66,18811.17,8238.14,17291.66,913.38,1686.00,84577.54,913.38,64715.50,,Hospital Q4113,"HC Graftjacket Xpress, Injectable, 1 Cc",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,42740.65,N/A,25644.39,N/A,5983.70,N/A,2743.94,N/A,24383.01,N/A,14531.83,N/A,6507.40,N/A,5983.70,N/A,2688.04,N/A,2688.04,N/A,4050.97,N/A,6507.40,N/A,6507.40,N/A,6507.40,N/A,24383.00,N/A,2688.04,N/A,5983.70,N/A,3660.50,N/A,3660.50,N/A,5983.70,N/A,2688.04,N/A,2743.94,N/A,518.69,N/A,N/A,518.69,25644.39,,Hospital Q4128,HC Flex Hd/Allopatch Hd/Matrix Hd per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),183008.17,248838.32,109804.90,149302.99,14707.13,34837.37,9173.03,18390.75,100874.10,140861.53,62222.79,84510.89,17131.38,21199.09,11463.43,34837.37,9173.03,18288.25,9173.03,18288.25,10663.88,13196.82,17131.38,21199.09,17131.38,21199.09,17131.38,21199.09,100874.10,140861.57,9173.03,18288.25,11463.43,34837.37,20382.06,13336.25,20382.06,13336.25,11463.43,34837.37,9173.03,18288.25,9173.03,3654.63,12265.87,3969.26,9173.03,109804.90,3654.63,149302.99,,Hospital Q4137,"HC Aminoexcel or Biodexcel, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,45352.92,N/A,27211.75,N/A,6349.84,N/A,2490.83,N/A,25767.05,N/A,15419.99,N/A,5683.82,N/A,6349.84,N/A,2341.71,N/A,2341.71,N/A,3538.28,N/A,5683.82,N/A,5683.82,N/A,5683.82,N/A,25767.05,N/A,2341.71,N/A,6349.84,N/A,2806.50,N/A,2806.50,N/A,6349.84,N/A,2341.71,N/A,2490.83,N/A,323.36,N/A,N/A,323.36,27211.75,,Hospital Q4140,"HC Biodfence, per Square Centimeter",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,21080.13,N/A,12648.08,N/A,2951.22,N/A,1786.17,N/A,11992.53,N/A,7167.24,N/A,4177.40,N/A,2951.22,N/A,1726.97,N/A,1726.97,N/A,2600.51,N/A,4177.40,N/A,4177.40,N/A,4177.40,N/A,11992.53,N/A,1726.97,N/A,2951.22,N/A,2134.50,N/A,2134.50,N/A,2951.22,N/A,1726.97,N/A,1786.17,N/A,162.50,N/A,N/A,162.50,12648.08,,Hospital Q4148,"HC Neox Cord Rt, or Clarix Cord 1k, per Sq. Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),158733.40,135137.00,95240.04,81082.20,10902.29,18816.24,12857.15,10439.13,87493.85,77594.85,53969.35,45946.58,24216.96,19889.33,10972.13,18816.24,2810.00,10417.80,2810.00,10417.80,15074.49,12381.49,24216.96,19889.33,24216.96,19889.33,24216.96,19889.33,87493.85,77594.84,12857.15,10417.80,10972.13,18816.24,28812.13,15608.50,28812.13,15608.50,5667.84,18816.24,12857.15,10417.80,12857.15,10439.13,11740.18,2744.17,2810.00,95240.04,2744.17,81082.20,,Hospital Q4150,"HC Allowrap Ds or Dry, per Sq Centimeter",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,49266.17,N/A,29559.70,N/A,6897.26,N/A,6248.31,N/A,28039.15,N/A,16748.80,N/A,14480.07,N/A,6897.26,N/A,5973.28,N/A,5973.28,N/A,9014.13,N/A,14480.07,N/A,14480.07,N/A,14480.07,N/A,28039.15,N/A,5973.28,N/A,6897.26,N/A,5944.75,N/A,5944.75,N/A,6897.26,N/A,5973.28,N/A,6248.31,N/A,992.31,N/A,N/A,992.31,29559.70,,Hospital Q4152,HC Dermapure per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,41616.60,N/A,24969.96,N/A,5826.30,N/A,6497.56,N/A,23764.74,N/A,14149.63,N/A,15171.39,N/A,5826.30,N/A,6254.06,N/A,6254.06,N/A,9444.48,N/A,15171.39,N/A,15171.39,N/A,15171.39,N/A,23764.74,N/A,6254.06,N/A,5826.30,N/A,10085.00,N/A,10085.00,N/A,5826.30,N/A,6254.06,N/A,6497.56,N/A,2356.50,N/A,N/A,2356.50,24969.96,,Hospital Q4154,HC Biovance per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),79731.70,53995.22,47839.02,32397.13,N/A,7541.43,24134.56,2664.83,N/A,30508.31,N/A,18358.39,N/A,6537.85,N/A,7541.43,24021.82,2688.04,24021.82,2688.04,N/A,4069.94,N/A,6537.85,N/A,6537.85,N/A,6537.85,N/A,30508.31,24134.56,2688.04,N/A,7541.43,N/A,5497.50,N/A,5497.50,N/A,7541.43,24134.56,2688.04,24134.56,2664.83,N/A,886.59,24021.82,47839.02,886.59,32397.13,,Hospital Q4156,Neox 100 or clarix 100,N/A,N/A,N/A,34367.30,N/A,20620.38,N/A,4811.42,N/A,2386.40,N/A,19554.94,N/A,11684.88,N/A,5654.91,N/A,4811.42,N/A,2337.78,N/A,2337.78,N/A,3520.29,N/A,5654.91,N/A,5654.91,N/A,5654.91,N/A,19554.94,N/A,2337.78,N/A,4811.42,N/A,2806.50,N/A,2806.50,N/A,4811.42,N/A,2337.78,N/A,2386.40,N/A,319.04,N/A,N/A,319.04,20620.38,,Hospital Q4158,HC Kerecis Omega3 per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),212933.10,31857.47,127759.86,19114.48,11165.41,4452.03,23846.59,1550.55,N/A,18045.78,127178.16,10831.54,127178.16,3784.65,11165.41,4452.03,23846.59,1558.52,23846.59,1558.52,127178.16,2356.01,127178.16,3784.65,127178.16,3784.65,127178.16,3784.65,N/A,18045.79,23846.59,1558.52,11165.41,4452.03,N/A,2266.25,N/A,2266.25,11165.41,4452.03,23846.59,1558.52,23846.59,1550.55,11165.41,173.63,11165.41,127759.86,173.63,19114.48,,Hospital Q4160,"HC Nushield, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),69067.87,8184.50,41440.72,4910.70,19064.04,1145.83,22818.46,1719.23,58919.82,4627.47,23483.08,2782.73,59483.44,3769.94,19651.44,1145.83,3372.00,1558.52,3372.00,1558.52,N/A,2346.86,N/A,3769.94,59483.44,3769.94,59483.44,3769.94,58919.82,4627.47,22818.46,1558.52,19651.44,1145.83,69067.87,1871.00,69067.87,1871.00,N/A,1145.83,22818.46,1558.52,22818.46,90.40,21027.04,99.44,3372.00,69067.87,90.40,4910.70,,Hospital Q4163,"HC Woundex, Bioskin, per Sq Cm",N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),79120.97,23437.67,47472.58,14062.60,10053.63,3281.27,12158.56,1719.23,22656.66,13225.72,26901.13,7968.80,22873.39,3769.94,10363.40,3281.27,1686.00,1558.52,1686.00,1558.52,14238.15,2346.86,22873.39,3769.94,22873.39,3769.94,22873.39,3769.94,22656.66,13225.72,12158.56,1558.52,10363.40,3281.27,27213.62,1871.00,27213.62,1871.00,10363.40,3281.27,12158.56,1558.52,12158.56,90.40,11088.83,99.44,1686.00,47472.58,90.40,14062.60,,Hospital Q4170,HC Cygnus per Sq Cm,N/A,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),N/A,24774.18,N/A,14864.51,N/A,3468.39,N/A,2412.76,N/A,14150.20,N/A,8423.23,N/A,5642.81,N/A,3468.39,N/A,2332.78,N/A,2332.78,N/A,3512.76,N/A,5642.81,N/A,5642.81,N/A,5642.81,N/A,14150.20,N/A,2332.78,N/A,3468.39,N/A,3660.50,N/A,3660.50,N/A,3468.39,N/A,2332.78,N/A,2412.76,N/A,339.00,N/A,N/A,339.00,14864.51,,Hospital Q5009,Hspc Election,N/A,0650 - HOSPICE SERVICE - GENERAL CLASSIFICATION,N/A,3355.00,N/A,2013.00,N/A,2809.44,N/A,2130.96,N/A,1849.32,N/A,1140.70,N/A,469.70,N/A,469.70,N/A,2130.96,N/A,2130.96,N/A,291.94,N/A,469.70,N/A,469.70,N/A,469.70,N/A,1931.82,N/A,2130.96,N/A,2809.44,N/A,1474.00,N/A,1474.00,N/A,2809.44,N/A,2130.96,N/A,2130.96,N/A,2809.44,N/A,N/A,291.94,2809.44,,Hospital HCPCS Q5103,INFLIXIMAB-DYYB 100 MG IV SOLR,00069-0809-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3390.30,3390.30,2034.18,2034.18,N/A,474.64,N/A,184.27,N/A,1906.03,N/A,1152.70,N/A,861.43,N/A,474.64,N/A,184.27,N/A,184.27,N/A,536.25,N/A,861.43,N/A,861.43,N/A,861.43,N/A,1906.03,N/A,184.27,N/A,474.64,N/A,1817.20,N/A,1817.20,N/A,474.64,N/A,184.27,N/A,184.27,N/A,202.70,2034.18,2034.18,184.27,2034.18,,Hospital HCPCS Q5107,BEVACIZUMAB-AWWB 25 MG/ML IV SOLN (MIXTURES ONLY),55513-0207-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12268.00,12268.00,7360.80,7360.80,N/A,1717.52,N/A,1135.92,N/A,6897.07,N/A,4171.12,N/A,3340.06,N/A,1717.52,N/A,1135.92,N/A,1135.92,N/A,2079.22,N/A,3340.06,N/A,3340.06,N/A,3340.06,N/A,6897.07,N/A,1135.92,N/A,1717.52,N/A,6575.65,N/A,6575.65,N/A,1717.52,N/A,1135.92,N/A,1135.92,N/A,1249.51,7360.80,7360.80,1135.92,7360.80,,Hospital HCPCS Q5107,BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN,55513-0207-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12268.00,12268.00,7360.80,7360.80,N/A,1717.52,N/A,1135.92,N/A,6897.07,N/A,4171.12,N/A,3340.06,N/A,1717.52,N/A,1135.92,N/A,1135.92,N/A,2079.22,N/A,3340.06,N/A,3340.06,N/A,3340.06,N/A,6897.07,N/A,1135.92,N/A,1717.52,N/A,6575.65,N/A,6575.65,N/A,1717.52,N/A,1135.92,N/A,1135.92,N/A,1249.51,7360.80,7360.80,1135.92,7360.80,,Hospital HCPCS Q5107,BEVACIZUMAB-AWWB 25 MG/ML IV SOLN (MIXTURES ONLY),55513-0206-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3067.00,3067.00,1840.20,1840.20,N/A,429.38,N/A,283.98,N/A,1724.27,N/A,1042.78,N/A,835.02,N/A,429.38,N/A,283.98,N/A,283.98,N/A,519.81,N/A,835.02,N/A,835.02,N/A,835.02,N/A,1724.27,N/A,283.98,N/A,429.38,N/A,1643.91,N/A,1643.91,N/A,429.38,N/A,283.98,N/A,283.98,N/A,312.38,1840.20,1840.20,283.98,1840.20,,Hospital HCPCS Q5107,BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN,55513-0206-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3067.00,3067.00,1840.20,1840.20,N/A,429.38,N/A,283.98,N/A,1724.27,N/A,1042.78,N/A,835.02,N/A,429.38,N/A,283.98,N/A,283.98,N/A,519.81,N/A,835.02,N/A,835.02,N/A,835.02,N/A,1724.27,N/A,283.98,N/A,429.38,N/A,1643.91,N/A,1643.91,N/A,429.38,N/A,283.98,N/A,283.98,N/A,312.38,1840.20,1840.20,283.98,1840.20,,Hospital HCPCS Q5108,PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY,67457-0833-06,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17662.60,17662.60,10597.56,10597.56,N/A,2472.76,N/A,1333.74,N/A,9929.91,N/A,6005.28,N/A,5136.59,N/A,2472.76,N/A,1333.74,N/A,1333.74,N/A,3197.58,N/A,5136.59,N/A,5136.59,N/A,5136.59,N/A,9929.91,N/A,1333.74,N/A,2472.76,N/A,9467.15,N/A,9467.15,N/A,2472.76,N/A,1333.74,N/A,1333.74,N/A,1467.11,10597.56,10597.56,1333.74,10597.56,,Hospital HCPCS Q5110,FILGRASTIM-AAFI 480 MCG/0.8ML IJ SOSY,00069-0292-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),2365.20,2365.20,1419.12,1419.12,N/A,331.13,N/A,156.48,N/A,1329.72,N/A,804.17,N/A,422.69,N/A,331.13,N/A,156.48,N/A,156.48,N/A,263.13,N/A,422.69,N/A,422.69,N/A,422.69,N/A,1329.72,N/A,156.48,N/A,331.13,N/A,1267.75,N/A,1267.75,N/A,331.13,N/A,156.48,N/A,156.48,N/A,172.13,1419.12,1419.12,156.48,1419.12,,Hospital HCPCS Q5114,TRASTUZUMAB-DKST 420 MG IV SOLR,67457-0845-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16955.40,16955.40,10173.24,10173.24,N/A,2373.76,N/A,16955.40,N/A,9532.33,N/A,5764.84,N/A,5199.68,N/A,2373.76,N/A,16955.40,N/A,16955.40,N/A,3236.85,N/A,5199.68,N/A,5199.68,N/A,5199.68,N/A,9532.33,N/A,16955.40,N/A,2373.76,N/A,9088.09,N/A,9088.09,N/A,2373.76,N/A,16955.40,N/A,16955.40,N/A,16955.40,10173.24,10173.24,2373.76,16955.40,,Hospital HCPCS Q5114,TRASTUZUMAB-DKST 150 MG IV SOLR,67457-0991-15,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6055.70,6055.70,3633.42,3633.42,N/A,847.80,N/A,6055.70,N/A,3404.51,N/A,2058.94,N/A,1857.03,N/A,847.80,N/A,6055.70,N/A,6055.70,N/A,1156.02,N/A,1857.03,N/A,1857.03,N/A,1857.03,N/A,3404.51,N/A,6055.70,N/A,847.80,N/A,3245.86,N/A,3245.86,N/A,847.80,N/A,6055.70,N/A,6055.70,N/A,6055.70,3633.42,3633.42,847.80,6055.70,,Hospital HCPCS Q5115,RITUXIMAB-ABBS 100 MG/10ML IV SOLN,63459-0103-10,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3584.00,3584.00,2150.40,2150.40,N/A,501.76,N/A,397.91,N/A,2014.92,N/A,1218.56,N/A,1252.01,N/A,501.76,N/A,397.91,N/A,397.91,N/A,779.39,N/A,1252.01,N/A,1252.01,N/A,1252.01,N/A,2014.92,N/A,397.91,N/A,501.76,N/A,1921.02,N/A,1921.02,N/A,501.76,N/A,397.91,N/A,397.91,N/A,3584.00,2150.40,2150.40,397.91,3584.00,,Hospital HCPCS Q5115,RITUXIMAB-ABBS 500 MG/50ML IV SOLN,63459-0104-50,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17920.00,17920.00,10752.00,10752.00,N/A,2508.80,N/A,1989.55,N/A,10074.62,N/A,6092.80,N/A,6260.03,N/A,2508.80,N/A,1989.55,N/A,1989.55,N/A,3896.93,N/A,6260.03,N/A,6260.03,N/A,6260.03,N/A,10074.62,N/A,1989.55,N/A,2508.80,N/A,9605.12,N/A,9605.12,N/A,2508.80,N/A,1989.55,N/A,1989.55,N/A,17920.00,10752.00,10752.00,1989.55,17920.00,,Hospital HCPCS Q5117,TRASTUZUMAB-ANNS 150 MG IV SOLR,55513-0141-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),6055.70,6055.70,3633.42,3633.42,N/A,847.80,N/A,359.40,N/A,3404.51,N/A,2058.94,N/A,1495.34,N/A,847.80,N/A,359.40,N/A,359.40,N/A,930.86,N/A,1495.34,N/A,1495.34,N/A,1495.34,N/A,3404.51,N/A,359.40,N/A,847.80,N/A,3245.86,N/A,3245.86,N/A,847.80,N/A,359.40,N/A,359.40,N/A,395.34,3633.42,3633.42,359.40,3633.42,,Hospital HCPCS Q5117,TRASTUZUMAB-ANNS 420 MG IV SOLR,55513-0132-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),16955.40,16955.40,10173.24,10173.24,N/A,2373.76,N/A,1006.32,N/A,9532.33,N/A,5764.84,N/A,4186.94,N/A,2373.76,N/A,1006.32,N/A,1006.32,N/A,2606.41,N/A,4186.94,N/A,4186.94,N/A,4186.94,N/A,9532.33,N/A,1006.32,N/A,2373.76,N/A,9088.09,N/A,9088.09,N/A,2373.76,N/A,1006.32,N/A,1006.32,N/A,1106.95,10173.24,10173.24,1006.32,10173.24,,Hospital HCPCS Q5118,BEVACIZUMAB-BVZR 25 MG/ML IV SOLN (MIXTURES ONLY),00069-0315-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3067.00,3067.00,1840.20,1840.20,N/A,429.38,N/A,281.91,N/A,1724.27,N/A,1042.78,N/A,1084.17,N/A,429.38,N/A,281.91,N/A,281.91,N/A,674.91,N/A,1084.17,N/A,1084.17,N/A,1084.17,N/A,1724.27,N/A,281.91,N/A,429.38,N/A,1643.91,N/A,1643.91,N/A,429.38,N/A,281.91,N/A,281.91,N/A,310.10,1840.20,1840.20,281.91,1840.20,,Hospital HCPCS Q5118,BEVACIZUMAB-BVZR 25 MG/ML IV SOLN (MIXTURES ONLY),00069-0342-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12268.00,12268.00,7360.80,7360.80,N/A,1717.52,N/A,1127.64,N/A,6897.07,N/A,4171.12,N/A,4336.70,N/A,1717.52,N/A,1127.64,N/A,1127.64,N/A,2699.64,N/A,4336.70,N/A,4336.70,N/A,4336.70,N/A,6897.07,N/A,1127.64,N/A,1717.52,N/A,6575.65,N/A,6575.65,N/A,1717.52,N/A,1127.64,N/A,1127.64,N/A,1240.40,7360.80,7360.80,1127.64,7360.80,,Hospital HCPCS Q5118,BEVACIZUMAB-BVZR 400 MG/16ML IV SOLN,00069-0342-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),12268.00,12268.00,7360.80,7360.80,N/A,1717.52,N/A,1127.64,N/A,6897.07,N/A,4171.12,N/A,4336.70,N/A,1717.52,N/A,1127.64,N/A,1127.64,N/A,2699.64,N/A,4336.70,N/A,4336.70,N/A,4336.70,N/A,6897.07,N/A,1127.64,N/A,1717.52,N/A,6575.65,N/A,6575.65,N/A,1717.52,N/A,1127.64,N/A,1127.64,N/A,1240.40,7360.80,7360.80,1127.64,7360.80,,Hospital HCPCS Q5118,BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN,00069-0315-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3067.00,3067.00,1840.20,1840.20,N/A,429.38,N/A,281.91,N/A,1724.27,N/A,1042.78,N/A,1084.17,N/A,429.38,N/A,281.91,N/A,281.91,N/A,674.91,N/A,1084.17,N/A,1084.17,N/A,1084.17,N/A,1724.27,N/A,281.91,N/A,429.38,N/A,1643.91,N/A,1643.91,N/A,429.38,N/A,281.91,N/A,281.91,N/A,310.10,1840.20,1840.20,281.91,1840.20,,Hospital HCPCS Q5119,RITUXIMAB-PVVR 100 MG/10ML IV SOLN,00069-0238-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3584.00,3584.00,2150.40,2150.40,N/A,501.76,N/A,275.09,N/A,2014.92,N/A,1218.56,N/A,1140.38,N/A,501.76,N/A,275.09,N/A,275.09,N/A,709.90,N/A,1140.38,N/A,1140.38,N/A,1140.38,N/A,2014.92,N/A,275.09,N/A,501.76,N/A,1921.02,N/A,1921.02,N/A,501.76,N/A,275.09,N/A,275.09,N/A,302.60,2150.40,2150.40,275.09,2150.40,,Hospital HCPCS Q5119,RITUXIMAB-PVVR (RUXIENCE) 10 MG/ML IV SOLN (MIXTURES ONLY),00069-0238-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3584.00,3584.00,2150.40,2150.40,N/A,501.76,N/A,275.09,N/A,2014.92,N/A,1218.56,N/A,1140.38,N/A,501.76,N/A,275.09,N/A,275.09,N/A,709.90,N/A,1140.38,N/A,1140.38,N/A,1140.38,N/A,2014.92,N/A,275.09,N/A,501.76,N/A,1921.02,N/A,1921.02,N/A,501.76,N/A,275.09,N/A,275.09,N/A,302.60,2150.40,2150.40,275.09,2150.40,,Hospital HCPCS Q5119,RITUXIMAB-PVVR (RUXIENCE) 10 MG/ML IV SOLN (MIXTURES ONLY),00069-0249-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17920.00,17920.00,10752.00,10752.00,N/A,2508.80,N/A,1375.45,N/A,10074.62,N/A,6092.80,N/A,5701.89,N/A,2508.80,N/A,1375.45,N/A,1375.45,N/A,3549.48,N/A,5701.89,N/A,5701.89,N/A,5701.89,N/A,10074.62,N/A,1375.45,N/A,2508.80,N/A,9605.12,N/A,9605.12,N/A,2508.80,N/A,1375.45,N/A,1375.45,N/A,1513.00,10752.00,10752.00,1375.45,10752.00,,Hospital HCPCS Q5119,RITUXIMAB-PVVR 500 MG/50ML IV SOLN,00069-0249-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),17920.00,17920.00,10752.00,10752.00,N/A,2508.80,N/A,1375.45,N/A,10074.62,N/A,6092.80,N/A,5701.89,N/A,2508.80,N/A,1375.45,N/A,1375.45,N/A,3549.48,N/A,5701.89,N/A,5701.89,N/A,5701.89,N/A,10074.62,N/A,1375.45,N/A,2508.80,N/A,9605.12,N/A,9605.12,N/A,2508.80,N/A,1375.45,N/A,1375.45,N/A,1513.00,10752.00,10752.00,1375.45,10752.00,,Hospital HCPCS Q5121,INFLIXIMAB-AXXQ 100 MG IV SOLR,55513-0670-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),3390.30,3390.30,2034.18,2034.18,N/A,474.64,N/A,283.34,N/A,1906.03,N/A,1152.70,N/A,1001.04,N/A,474.64,N/A,283.34,N/A,283.34,N/A,623.15,N/A,1001.04,N/A,1001.04,N/A,1001.04,N/A,1906.03,N/A,283.34,N/A,474.64,N/A,1817.20,N/A,1817.20,N/A,474.64,N/A,283.34,N/A,283.34,N/A,311.67,2034.18,2034.18,283.34,2034.18,,Hospital Q5122,"Inj, nyvepria",N/A,N/A,N/A,29234.50,N/A,17540.70,N/A,4092.83,N/A,1333.01,N/A,16443.26,N/A,9939.73,N/A,6768.40,N/A,4092.83,N/A,1331.83,N/A,1331.83,N/A,4213.39,N/A,6768.40,N/A,6768.40,N/A,6768.40,N/A,16431.23,N/A,1331.83,N/A,4092.83,N/A,15669.69,N/A,15669.69,N/A,4092.83,N/A,1331.83,N/A,1333.01,N/A,14.73,N/A,N/A,14.73,17540.70,,Hospital Q5123,"Inj. riabni, 10 mg",N/A,N/A,N/A,44727.93,N/A,26836.76,N/A,6261.91,N/A,3988.39,N/A,25191.82,N/A,15207.24,N/A,11297.25,N/A,6261.91,N/A,3965.88,N/A,3965.88,N/A,7032.66,N/A,11297.25,N/A,11297.25,N/A,11297.25,N/A,25191.82,N/A,3965.88,N/A,6261.91,N/A,23974.17,N/A,23974.17,N/A,6261.91,N/A,3965.88,N/A,164.19,N/A,180.61,N/A,N/A,164.19,26836.76,,Hospital Q9958,"HOCM <=149 mg/ml iodine, 1ml",N/A,N/A,50875.63,10847.70,30525.38,6508.62,13746.78,1519.11,16675.62,1434.66,31531.63,5451.62,17297.71,3688.22,31275.84,3311.62,14170.35,1519.11,2810.00,1348.87,2810.00,1348.87,19910.97,2061.55,31275.84,3311.62,31275.84,3311.62,31275.84,3311.62,31531.63,5451.62,16527.37,1348.87,14170.35,1519.11,37210.44,527.00,37210.44,527.00,5560.20,1519.11,16527.37,1348.87,16527.37,1434.66,15162.27,50.91,2810.00,37210.44,50.91,6508.62,,Hospital Q9963,"HOCM 350-399mg/ml iodine,1ml",N/A,N/A,33023.80,7518.22,19814.28,4510.93,7828.02,1046.88,9525.79,1363.08,17641.08,3976.54,11228.09,2556.19,17809.83,3258.22,8069.22,1046.88,9525.79,1344.94,9525.79,1344.94,11086.21,2028.30,17809.83,3258.22,17809.83,3258.22,17809.83,3258.22,17641.08,3976.54,9525.79,1344.94,8069.22,1046.88,21189.26,2862.30,21189.26,2862.30,4438.23,1046.88,9525.79,1344.94,9525.79,3.28,8634.06,3.61,4438.23,21189.26,3.28,4510.93,,Hospital Q9966,"Locm 200-299mg/Ml Iodine,1ml",N/A,N/A,86455.33,5154.40,51873.20,3092.64,8860.80,721.62,10747.52,1001.64,19968.54,2465.25,29394.81,1752.50,20159.56,2436.45,9133.82,721.62,1686.00,1001.64,1686.00,1001.64,12548.86,1516.73,20159.56,2436.45,20159.56,2436.45,20159.56,2436.45,19968.54,2465.25,10747.52,1001.64,9133.82,721.62,23984.84,2261.18,23984.84,2261.18,8689.51,721.62,10747.52,1001.64,10747.52,1001.64,9773.19,1101.80,1686.00,51873.20,721.62,3092.64,,Hospital HCPCS Q9967,IODIXANOL 320 MG/ML IV SOLN,65219-0383-70,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),337.80,337.80,202.68,202.68,N/A,47.29,N/A,337.80,N/A,189.91,N/A,114.85,N/A,31.08,N/A,47.29,N/A,337.80,N/A,337.80,N/A,19.35,N/A,31.08,N/A,31.08,N/A,31.08,N/A,189.91,N/A,337.80,N/A,47.29,N/A,181.06,N/A,181.06,N/A,47.29,N/A,337.80,N/A,337.80,N/A,337.80,202.68,202.68,19.35,337.80,,Hospital HCPCS Q9967,IOPAMIDOL 61 % IV SOLN,00270-1315-30,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),262.00,262.00,157.20,157.20,N/A,36.68,N/A,262.00,N/A,147.30,N/A,89.08,N/A,15.54,N/A,36.68,N/A,262.00,N/A,262.00,N/A,9.67,N/A,15.54,N/A,15.54,N/A,15.54,N/A,147.30,N/A,262.00,N/A,36.68,N/A,140.43,N/A,140.43,N/A,36.68,N/A,262.00,N/A,262.00,N/A,262.00,157.20,157.20,9.67,262.00,,Hospital Q9969,Tc-99m Non-Highly Enrchd Uranium Source,N/A,0343 - NUCLEAR MEDICINE - DIAGNOSTIC RADIOPHARMACEUTICALS,36044.30,5935.02,21626.58,3561.01,9484.96,843.53,11485.86,401.14,21375.12,3404.91,12255.06,2017.90,21579.59,1494.46,9777.20,843.53,2248.00,603.90,2248.00,603.90,13432.79,930.33,21579.59,1494.46,21579.59,1494.46,21579.59,1494.46,21375.12,3404.91,11485.86,603.90,9777.20,843.53,25674.32,2915.11,25674.32,2915.11,9777.20,843.53,11485.86,613.90,11485.86,401.14,10461.61,441.26,2248.00,25674.32,401.14,3561.01,,Hospital Q9992,Buprenorphine xr over 100 mg,N/A,N/A,N/A,37985.80,N/A,22791.48,N/A,5307.49,N/A,1949.39,N/A,21367.25,N/A,12915.17,N/A,4961.17,N/A,5307.49,N/A,1947.30,N/A,1947.30,N/A,3088.38,N/A,4961.17,N/A,4961.17,N/A,4961.17,N/A,21367.25,N/A,1947.30,N/A,5307.49,N/A,242.77,N/A,242.77,N/A,5307.49,N/A,1947.30,N/A,1949.39,N/A,83.08,N/A,N/A,83.08,22791.48,,Hospital S0013,"Esketamine, nasal spray",N/A,N/A,N/A,4961.20,N/A,2976.72,N/A,694.57,N/A,1324.05,N/A,2823.19,N/A,1686.81,N/A,3911.70,N/A,694.57,N/A,1309.86,N/A,1309.86,N/A,3104.14,N/A,3911.70,N/A,3911.70,N/A,3911.70,N/A,2823.19,N/A,1309.86,N/A,694.57,N/A,2659.20,N/A,2659.20,N/A,694.57,N/A,1309.86,N/A,1324.05,N/A,154.22,N/A,N/A,154.22,3911.70,,Hospital S0028,"Injection, Famotidine, 20 Mg",N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,,Hospital HCPCS S0145,PEGINTERFERON ALFA-2A 180 MCG/ML SC SOLN,82154-0449-01,0636 - PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A),4596.80,4596.80,2758.08,2758.08,N/A,643.55,N/A,4596.80,N/A,2584.32,N/A,1562.91,N/A,2645.66,N/A,643.55,N/A,4596.80,N/A,4596.80,N/A,1646.95,N/A,2645.66,N/A,2645.66,N/A,2645.66,N/A,2584.32,N/A,4596.80,N/A,643.55,N/A,2463.88,N/A,2463.88,N/A,643.55,N/A,4596.80,N/A,4596.80,N/A,4596.80,2758.08,2758.08,643.55,4596.80,,Hospital S0164,Injection pantroprazole,N/A,N/A,47120.50,N/A,28272.30,N/A,5254.60,N/A,6481.56,N/A,11841.67,N/A,16020.97,N/A,11954.95,N/A,5416.50,N/A,6481.56,N/A,6481.56,N/A,7441.68,N/A,11954.95,N/A,11954.95,N/A,11954.95,N/A,11841.67,N/A,6481.56,N/A,5416.50,N/A,14223.40,N/A,14223.40,N/A,N/A,N/A,6481.56,N/A,6570.51,N/A,5795.66,N/A,5254.60,28272.30,N/A,N/A,,Hospital S0189,Testosterone Pellet 75 Mg,N/A,N/A,N/A,17243.30,N/A,10345.98,N/A,2414.07,N/A,352.65,N/A,9837.47,N/A,5862.73,N/A,3547.62,N/A,2414.07,N/A,340.96,N/A,340.96,N/A,2208.43,N/A,3547.62,N/A,3547.62,N/A,3547.62,N/A,9837.47,N/A,340.96,N/A,2414.07,N/A,527.00,N/A,527.00,N/A,2414.07,N/A,340.96,N/A,352.65,N/A,58.22,N/A,N/A,58.22,10345.98,,Hospital S0265,Genetic counsel 15 mins,N/A,N/A,N/A,232.00,N/A,139.20,N/A,32.48,N/A,N/A,N/A,133.59,N/A,78.88,N/A,32.48,N/A,32.48,N/A,N/A,N/A,N/A,N/A,20.18,N/A,32.48,N/A,32.48,N/A,32.48,N/A,133.59,N/A,N/A,N/A,32.48,N/A,124.35,N/A,124.35,N/A,32.48,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20.18,139.20,,Hospital S2095,Transcath Emboliz Microspher,N/A,N/A,222724.48,N/A,133634.69,N/A,23107.83,N/A,19203.42,N/A,122765.73,N/A,75726.33,N/A,77552.66,N/A,19597.91,N/A,19173.77,N/A,19173.77,N/A,48286.67,N/A,77552.66,N/A,77552.66,N/A,77552.66,N/A,122765.73,N/A,19173.77,N/A,19597.91,N/A,126573.95,N/A,126573.95,N/A,16853.48,N/A,19173.77,N/A,19203.42,N/A,20969.77,N/A,16853.48,133634.69,N/A,N/A,,Hospital S2325,Hip core decompression,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,N/A,70102.00,N/A,42061.20,N/A,9814.29,N/A,601.81,N/A,40065.11,N/A,23834.67,N/A,4907.49,N/A,9814.29,N/A,581.86,N/A,581.86,N/A,3051.26,N/A,4907.49,N/A,4907.49,N/A,4907.49,N/A,40065.12,N/A,581.86,N/A,9814.29,N/A,1431.00,N/A,1431.00,N/A,9814.29,N/A,581.86,N/A,601.81,N/A,71.74,N/A,N/A,71.74,42061.20,,Hospital S2900,HC Robotic Surgical System,N/A,0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION,168636.83,36984.40,101182.10,22190.64,27666.94,5169.42,33142.47,4706.78,92952.62,21176.34,25868.80,12574.71,31346.23,12381.62,28519.41,5169.42,29170.64,4706.78,32994.22,4706.78,25868.80,7707.80,65394.06,12381.62,31346.23,12381.62,31346.23,12381.62,92952.62,21176.33,26002.72,4706.78,28519.41,5169.42,32613.90,8160.50,74890.17,8160.50,14202.24,5169.42,32994.22,4706.78,33142.47,4706.78,30515.77,5177.46,14202.24,101182.10,4706.78,22190.64,,Hospital S5010,5% Dextrose and 0.45% Saline,N/A,N/A,N/A,7959.50,N/A,4775.70,N/A,1170.68,N/A,871.37,N/A,4575.63,N/A,2697.87,N/A,2103.34,N/A,1170.68,N/A,850.04,N/A,850.04,N/A,1309.36,N/A,2103.34,N/A,2103.34,N/A,2103.34,N/A,4575.63,N/A,850.04,N/A,1170.68,N/A,3582.22,N/A,3582.22,N/A,1170.68,N/A,850.04,N/A,871.37,N/A,461.90,N/A,N/A,461.90,4775.70,,Hospital S5553,Insulin Long Acting 5 U,N/A,N/A,50869.00,68664.47,30521.40,41198.68,5909.50,9576.50,11887.20,9689.87,34575.11,11012.00,17101.76,23345.92,17306.74,23210.19,5909.50,9576.50,4496.00,9586.05,4496.00,9586.05,22294.02,14448.79,22294.02,23210.19,22940.42,23210.19,22981.80,23210.19,23426.71,11012.00,10772.46,9586.05,5909.50,9576.50,23426.71,13336.25,31814.29,13336.25,6715.20,9576.50,10002.75,9586.05,10002.75,9689.87,5909.50,2102.03,4496.00,34575.11,2102.03,41198.68,,Hospital S8042,MRI Low Field,N/A,N/A,N/A,1746.00,N/A,1047.60,N/A,249.20,N/A,40.29,N/A,1233.23,N/A,593.64,N/A,254.77,N/A,249.20,N/A,40.29,N/A,40.29,N/A,158.36,N/A,254.77,N/A,254.77,N/A,254.77,N/A,1233.23,N/A,40.29,N/A,249.20,N/A,1094.72,N/A,1094.72,N/A,249.20,N/A,40.29,N/A,40.29,N/A,38.20,N/A,N/A,38.20,1233.23,,Hospital S8092,Electron Beam Computed Tomog,N/A,N/A,N/A,2304.60,N/A,1382.76,N/A,322.64,N/A,N/A,N/A,1232.40,N/A,783.56,N/A,267.05,N/A,322.64,N/A,N/A,N/A,N/A,N/A,165.98,N/A,267.05,N/A,267.05,N/A,267.05,N/A,1232.40,N/A,N/A,N/A,322.64,N/A,689.00,N/A,689.00,N/A,322.64,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,165.98,1382.76,,Hospital S9131,Pt Routine Virtual Visit,N/A,0421 - PHYSICAL THERAPY - VISIT,N/A,2511.92,N/A,1507.15,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,19.11,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,19.11,1507.15,,Hospital S9441,HC Asthma Education,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,38931.40,N/A,23358.84,N/A,4482.15,N/A,5567.79,N/A,10100.88,N/A,13236.68,N/A,10197.51,N/A,4620.25,N/A,5567.79,N/A,5567.79,N/A,6347.71,N/A,10197.51,N/A,10197.51,N/A,10197.51,N/A,10100.88,N/A,5567.79,N/A,4620.25,N/A,12132.49,N/A,12132.49,N/A,1492.95,N/A,5567.79,N/A,5567.79,N/A,4943.67,N/A,1492.95,23358.84,N/A,N/A,,Hospital S9442,HC Child Birth Class,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,N/A,69.00,N/A,41.40,N/A,9.66,N/A,N/A,N/A,39.73,N/A,23.46,N/A,9.66,N/A,9.66,N/A,N/A,N/A,N/A,N/A,6.00,N/A,9.66,N/A,9.66,N/A,9.66,N/A,39.73,N/A,N/A,N/A,9.66,N/A,36.98,N/A,36.98,N/A,9.66,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6.00,41.40,,Hospital CPT S9443,HC Lactation Consult,N/A,0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING,422.00,422.00,253.20,253.20,N/A,59.08,N/A,422.00,N/A,242.99,N/A,143.48,N/A,59.08,N/A,59.08,N/A,422.00,N/A,422.00,N/A,36.71,N/A,59.08,N/A,59.08,N/A,59.08,N/A,242.99,N/A,422.00,N/A,59.08,N/A,226.19,N/A,226.19,N/A,59.08,N/A,422.00,N/A,422.00,N/A,422.00,253.20,253.20,36.71,422.00,,Hospital S9460,"Diabetic Management Program,",N/A,N/A,N/A,429.00,N/A,257.40,N/A,60.06,N/A,N/A,N/A,247.02,N/A,145.86,N/A,60.06,N/A,60.06,N/A,N/A,N/A,N/A,N/A,37.32,N/A,60.06,N/A,60.06,N/A,60.06,N/A,247.02,N/A,N/A,N/A,60.06,N/A,229.94,N/A,229.94,N/A,60.06,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,37.32,257.40,,Hospital U0004,HC Covid-19 Any Technique High Throughput Tech,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,N/A,344.00,N/A,206.40,N/A,157.72,N/A,23.89,N/A,198.07,N/A,116.96,N/A,160.73,N/A,157.72,N/A,22.54,N/A,22.54,N/A,140.16,N/A,160.73,N/A,160.73,N/A,160.73,N/A,198.07,N/A,22.54,N/A,157.72,N/A,131.17,N/A,131.17,N/A,157.72,N/A,22.54,N/A,23.89,N/A,163.33,N/A,N/A,22.54,206.40,,Hospital U0005,HC Infec Agent Detec Ampli Probe,N/A,0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY,80662.42,1705.00,48397.45,1023.00,10199.26,307.06,12419.80,252.91,36516.75,981.75,27425.23,579.70,23204.73,643.40,10513.52,307.06,12330.85,252.91,12330.85,252.91,14444.40,400.49,23204.73,643.40,23204.73,643.40,23204.73,643.40,36516.75,981.75,12330.85,252.91,10513.52,307.06,27607.84,890.06,27607.84,890.06,12964.42,307.06,12330.85,252.91,12419.80,252.91,11249.46,388.20,10199.26,48397.45,252.91,1023.00,,Hospital Custom UCSPOV,Urgent Care Self-Pay Office Visit,N/A,N/A,125.00,125.00,75.00,75.00,N/A,17.50,N/A,125.00,N/A,125.00,N/A,42.50,N/A,17.50,N/A,17.50,N/A,125.00,N/A,125.00,N/A,10.88,N/A,17.50,N/A,17.50,N/A,17.50,N/A,125.00,N/A,125.00,N/A,17.50,N/A,125.00,N/A,125.00,N/A,17.50,N/A,125.00,N/A,125.00,N/A,125.00,75.00,75.00,10.88,125.00,,Hospital Custom UCSPXR,Urgent Care Self-Pay X-Ray,N/A,N/A,75.00,75.00,45.00,45.00,N/A,10.50,N/A,75.00,N/A,75.00,N/A,25.50,N/A,10.50,N/A,10.50,N/A,75.00,N/A,75.00,N/A,6.53,N/A,10.50,N/A,10.50,N/A,10.50,N/A,75.00,N/A,75.00,N/A,10.50,N/A,75.00,N/A,75.00,N/A,10.50,N/A,75.00,N/A,75.00,N/A,75.00,45.00,45.00,6.53,75.00,,Hospital V2630,HC Misc Anterior Chamber Iol,N/A,0276 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - INTRAOCULAR LENS,N/A,17802.68,N/A,10681.61,N/A,2492.38,N/A,2039.85,N/A,10242.80,N/A,6052.91,N/A,4720.97,N/A,2492.38,N/A,1950.06,N/A,1950.06,N/A,2938.89,N/A,4720.97,N/A,4720.97,N/A,4720.97,N/A,10242.80,N/A,1950.06,N/A,2492.38,N/A,3397.00,N/A,3397.00,N/A,2492.38,N/A,1950.06,N/A,2039.85,N/A,763.09,N/A,N/A,763.09,10681.61,,Hospital V2787,HC Iol Astigmatism-Correct Function,N/A,0276 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - INTRAOCULAR LENS,N/A,16531.70,N/A,9919.02,N/A,2314.45,N/A,2039.85,N/A,9491.35,N/A,5620.78,N/A,4719.65,N/A,2314.45,N/A,1950.06,N/A,1950.06,N/A,2938.06,N/A,4719.65,N/A,4719.65,N/A,4719.65,N/A,9491.34,N/A,1950.06,N/A,2314.45,N/A,3397.00,N/A,3397.00,N/A,2314.45,N/A,1950.06,N/A,2039.85,N/A,556.44,N/A,N/A,556.44,9919.02,,Hospital MS-DRG V40 (FY 2023) 003,"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures",N/A,N/A,639998.52,N/A,383999.11,N/A,105006.54,N/A,139370.89,N/A,423136.78,N/A,487419.25,N/A,487419.25,N/A,105006.54,N/A,130475.30,N/A,130475.30,N/A,487419.25,N/A,487419.25,N/A,487419.25,N/A,536523.02,N/A,423136.78,N/A,130642.33,N/A,105006.54,N/A,423136.78,N/A,423136.78,N/A,105006.54,N/A,130475.30,N/A,133132.22,N/A,105006.54,N/A,105006.54,536523.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 011,"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC",N/A,N/A,122679.08,N/A,73607.45,N/A,27554.38,N/A,32979.66,N/A,N/A,N/A,41710.88,N/A,62690.03,N/A,28403.38,N/A,32861.06,N/A,34322.48,N/A,700171.16,N/A,62690.03,N/A,62690.03,N/A,62690.03,N/A,67620.71,N/A,34322.48,N/A,28403.38,N/A,74585.49,N/A,74585.49,N/A,24080.92,N/A,34322.48,N/A,34322.48,N/A,30391.62,N/A,24080.92,700171.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 014,Allogeneic Bone Marrow Transplant,N/A,N/A,560838.27,N/A,336502.96,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,145771.72,N/A,145771.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,145771.72,336502.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 016,Autologous Bone Marrow Transplant With Cc/McC,N/A,N/A,137635.20,N/A,82581.12,N/A,N/A,N/A,40535.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38661.75,N/A,38661.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,40535.58,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,40535.58,N/A,40535.58,N/A,N/A,N/A,38661.75,82581.12,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 018,Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,N/A,N/A,2773843.10,N/A,1664305.86,N/A,524333.65,N/A,496388.99,N/A,1528942.32,N/A,943106.65,N/A,965852.17,N/A,502541.43,N/A,250629.79,N/A,496388.99,N/A,601369.18,N/A,965852.17,N/A,965852.17,N/A,965852.17,N/A,1528942.32,N/A,496388.99,N/A,48122.07,N/A,1314801.63,N/A,1314801.63,N/A,48122.07,N/A,496388.99,N/A,496388.99,N/A,537719.33,N/A,48122.07,1664305.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 020,Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC,N/A,N/A,427332.07,N/A,256399.24,N/A,22043.29,N/A,64395.07,N/A,N/A,N/A,266961.60,N/A,266961.60,N/A,22043.29,N/A,64395.07,N/A,64395.07,N/A,266961.60,N/A,266961.60,N/A,266961.60,N/A,266961.60,N/A,N/A,N/A,64395.07,N/A,22043.29,N/A,N/A,N/A,N/A,N/A,22043.29,N/A,64395.07,N/A,64395.07,N/A,22043.29,N/A,22043.29,266961.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 022,Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/McC,N/A,N/A,263961.52,N/A,158376.91,N/A,32617.25,N/A,27770.31,N/A,145495.58,N/A,89746.91,N/A,91911.40,N/A,28855.18,N/A,27770.31,N/A,27770.31,N/A,57226.86,N/A,91911.40,N/A,91911.40,N/A,91911.40,N/A,145495.58,N/A,27770.31,N/A,28855.18,N/A,147741.38,N/A,147741.38,N/A,24061.71,N/A,27770.31,N/A,N/A,N/A,30875.04,N/A,24061.71,158376.91,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 025,Craniotomy And Endovascular Intracranial Procedures With McC,N/A,N/A,113525.62,N/A,68115.37,N/A,24221.84,N/A,28918.84,N/A,62575.32,N/A,38597.66,N/A,56751.71,N/A,24968.16,N/A,28918.84,N/A,28918.84,N/A,35329.63,N/A,56751.71,N/A,56751.71,N/A,56751.71,N/A,62575.32,N/A,28918.84,N/A,24968.16,N/A,65564.82,N/A,65564.82,N/A,24968.16,N/A,28918.84,N/A,28918.84,N/A,26715.93,N/A,24221.84,68115.37,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 026,Craniotomy And Endovascular Intracranial Procedures With Cc,N/A,N/A,119694.53,N/A,71816.72,N/A,16129.23,N/A,19493.93,N/A,65975.63,N/A,40660.96,N/A,37790.73,N/A,10566.09,N/A,165228.00,N/A,165228.00,N/A,23525.85,N/A,37790.73,N/A,37790.73,N/A,37790.73,N/A,48636.02,N/A,19345.68,N/A,16626.19,N/A,48636.02,N/A,43659.34,N/A,10566.09,N/A,19345.68,N/A,21332.90,N/A,17790.03,N/A,10566.09,165228.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 028,Spinal Procedures With McC,N/A,N/A,193561.93,N/A,116137.16,N/A,26971.38,N/A,38214.42,N/A,188110.74,N/A,117602.90,N/A,117602.90,N/A,21313.95,N/A,38547.92,N/A,38547.92,N/A,117602.90,N/A,117602.90,N/A,117602.90,N/A,117602.90,N/A,188110.74,N/A,38214.42,N/A,21313.95,N/A,188110.74,N/A,188110.74,N/A,21313.95,N/A,38214.42,N/A,38214.42,N/A,21313.95,N/A,21313.95,188110.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 029,Spinal Procedures With Cc Or Spinal Neurostimulators,N/A,N/A,116425.03,N/A,69855.02,N/A,18231.60,N/A,21832.68,N/A,64173.48,N/A,39584.52,N/A,42716.58,N/A,18793.35,N/A,1686.00,N/A,1686.00,N/A,26592.35,N/A,42716.58,N/A,42716.58,N/A,42716.58,N/A,64173.48,N/A,21832.68,N/A,18793.35,N/A,49350.14,N/A,49350.14,N/A,20463.78,N/A,21832.68,N/A,21832.68,N/A,20108.88,N/A,1686.00,69855.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 030,Spinal Procedures Without Cc/McC,N/A,N/A,78135.73,N/A,46881.44,N/A,12489.41,N/A,15039.99,N/A,33180.94,N/A,26566.14,N/A,29262.66,N/A,12874.23,N/A,1124.00,N/A,1124.00,N/A,18216.88,N/A,29262.66,N/A,29262.66,N/A,29262.66,N/A,33180.94,N/A,15039.99,N/A,12874.23,N/A,33806.93,N/A,33806.93,N/A,12792.85,N/A,15039.99,N/A,15039.99,N/A,13775.43,N/A,1124.00,46881.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 035,Carotid Artery Stent Procedures With Cc,N/A,N/A,113646.20,N/A,68187.72,N/A,12183.21,N/A,14707.39,N/A,62641.79,N/A,30883.83,N/A,28545.22,N/A,12558.59,N/A,14677.74,N/A,14677.74,N/A,17770.25,N/A,28545.22,N/A,28545.22,N/A,28545.22,N/A,62641.79,N/A,14677.74,N/A,12558.59,N/A,41923.72,N/A,32978.07,N/A,10566.27,N/A,14677.74,N/A,14707.39,N/A,13437.69,N/A,10566.27,68187.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 036,Carotid Artery Stent Procedures Without Cc/McC,N/A,N/A,96726.23,N/A,58035.74,N/A,10032.82,N/A,12133.96,N/A,35110.69,N/A,32886.92,N/A,23506.87,N/A,10341.95,N/A,12133.96,N/A,12133.96,N/A,14633.73,N/A,23506.87,N/A,23506.87,N/A,23506.87,N/A,35110.69,N/A,12133.96,N/A,10341.95,N/A,27157.31,N/A,27157.31,N/A,10341.95,N/A,12133.96,N/A,12133.96,N/A,11065.89,N/A,10032.82,58035.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 041,"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",N/A,N/A,100975.45,N/A,60585.27,N/A,12472.88,N/A,15020.41,N/A,45540.91,N/A,34331.66,N/A,29223.91,N/A,12857.19,N/A,15020.41,N/A,15020.41,N/A,18192.76,N/A,29223.91,N/A,29223.91,N/A,29223.91,N/A,45540.91,N/A,15020.41,N/A,12857.19,N/A,33762.16,N/A,33762.16,N/A,12857.19,N/A,15020.41,N/A,15020.41,N/A,13757.19,N/A,12472.88,60585.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 053,Spinal Disorders And Injuries Without Cc/McC,N/A,N/A,29110.00,N/A,17466.00,N/A,5456.25,N/A,6809.05,N/A,12672.78,N/A,N/A,N/A,12783.98,N/A,5624.37,N/A,6720.10,N/A,6720.10,N/A,7958.41,N/A,12783.98,N/A,12783.98,N/A,12783.98,N/A,12672.78,N/A,6720.10,N/A,5624.37,N/A,14769.23,N/A,14769.23,N/A,N/A,N/A,6720.10,N/A,6720.10,N/A,6018.07,N/A,5456.25,17466.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 055,Nervous System Neoplasms Without McC,N/A,N/A,37765.73,N/A,22659.44,N/A,3585.93,N/A,4507.83,N/A,12121.78,N/A,12840.35,N/A,12602.74,N/A,3696.42,N/A,4507.83,N/A,4507.83,N/A,7845.58,N/A,12602.74,N/A,12602.74,N/A,12602.74,N/A,12121.78,N/A,4507.83,N/A,3696.42,N/A,14559.85,N/A,14559.85,N/A,3696.42,N/A,4507.83,N/A,4507.83,N/A,3955.17,N/A,3585.93,22659.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 056,Degenerative Nervous System Disorders With McC,N/A,N/A,50176.30,N/A,30105.78,N/A,12267.15,N/A,13014.41,N/A,N/A,N/A,13308.55,N/A,13308.55,N/A,12267.15,N/A,13014.41,N/A,13014.41,N/A,13308.55,N/A,13308.55,N/A,13308.55,N/A,13308.55,N/A,N/A,N/A,13014.41,N/A,12267.15,N/A,N/A,N/A,N/A,N/A,12267.15,N/A,13014.41,N/A,13014.41,N/A,12267.15,N/A,12267.15,30105.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 057,Degenerative Nervous System Disorders Without McC,N/A,N/A,47104.60,N/A,28262.76,N/A,9104.48,N/A,12148.66,N/A,47104.60,N/A,16015.56,N/A,23792.55,N/A,7156.93,N/A,12148.66,N/A,12148.66,N/A,5479.99,N/A,23792.55,N/A,23792.55,N/A,23792.55,N/A,20678.00,N/A,12144.84,N/A,7156.93,N/A,28728.00,N/A,28728.00,N/A,7156.93,N/A,12148.66,N/A,12148.66,N/A,7983.22,N/A,5479.99,47104.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 059,Multiple Sclerosis And Cerebellar Ataxia With Cc,N/A,N/A,37282.23,N/A,22369.34,N/A,6100.14,N/A,7481.78,N/A,13747.16,N/A,12485.57,N/A,14292.61,N/A,6288.09,N/A,2248.00,N/A,2248.00,N/A,8897.57,N/A,14292.61,N/A,14292.61,N/A,14292.61,N/A,13747.16,N/A,7481.78,N/A,6288.09,N/A,16512.14,N/A,16512.14,N/A,6288.09,N/A,7481.78,N/A,7481.78,N/A,6728.26,N/A,2248.00,22369.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 063,"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC",N/A,N/A,68390.40,N/A,41034.24,N/A,8434.04,N/A,10242.67,N/A,19006.78,N/A,23252.74,N/A,19760.92,N/A,8693.90,N/A,10242.67,N/A,10242.67,N/A,12301.76,N/A,19760.92,N/A,19760.92,N/A,19760.92,N/A,19006.78,N/A,10242.67,N/A,8693.90,N/A,22829.64,N/A,22829.64,N/A,3878.38,N/A,10242.67,N/A,10242.67,N/A,9302.48,N/A,3878.38,41034.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 068,Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,N/A,N/A,28976.40,N/A,17385.84,N/A,4820.90,N/A,5626.29,N/A,10686.36,N/A,9851.98,N/A,11110.36,N/A,4969.44,N/A,2352.36,N/A,2352.36,N/A,6916.53,N/A,11110.36,N/A,11110.36,N/A,11110.36,N/A,10686.36,N/A,5596.64,N/A,4969.44,N/A,12835.72,N/A,12835.72,N/A,4198.58,N/A,5596.64,N/A,5626.29,N/A,5317.30,N/A,2352.36,17385.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 070,Nonspecific Cerebrovascular Disorders With McC,N/A,N/A,48867.90,N/A,29320.74,N/A,4552.24,N/A,12548.92,N/A,48867.90,N/A,16615.09,N/A,24683.17,N/A,9481.36,N/A,12548.92,N/A,12548.92,N/A,4317.97,N/A,24683.17,N/A,24683.17,N/A,24683.17,N/A,10339.00,N/A,12546.57,N/A,9481.36,N/A,14364.00,N/A,14364.00,N/A,10145.05,N/A,12548.92,N/A,12548.92,N/A,10145.05,N/A,4317.97,48867.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 071,Nonspecific Cerebrovascular Disorders With Cc,N/A,N/A,42241.10,N/A,25344.66,N/A,N/A,N/A,6398.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6398.44,N/A,6398.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12163.86,N/A,6398.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,6398.44,N/A,6398.44,N/A,N/A,N/A,6398.44,25344.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 073,Cranial And Peripheral Nerve Disorders With McC,N/A,N/A,47433.20,N/A,28459.92,N/A,7998.20,N/A,9727.09,N/A,18024.58,N/A,16127.29,N/A,18739.75,N/A,8244.63,N/A,9727.09,N/A,9727.09,N/A,11666.05,N/A,18739.75,N/A,18739.75,N/A,18739.75,N/A,18024.58,N/A,9727.09,N/A,8244.63,N/A,21649.89,N/A,21649.89,N/A,N/A,N/A,9727.09,N/A,9727.09,N/A,8821.76,N/A,7998.20,28459.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 074,Cranial And Peripheral Nerve Disorders Without McC,N/A,N/A,41950.60,N/A,25170.36,N/A,5460.52,N/A,6725.15,N/A,12305.72,N/A,7964.63,N/A,7964.63,N/A,5628.77,N/A,6725.15,N/A,6725.15,N/A,7964.63,N/A,7964.63,N/A,7964.63,N/A,7964.63,N/A,12305.72,N/A,6725.15,N/A,5628.77,N/A,N/A,N/A,14780.78,N/A,5628.77,N/A,6725.15,N/A,6725.15,N/A,6022.78,N/A,5460.52,25170.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 075,Viral Meningitis With Cc/McC,N/A,N/A,37955.07,N/A,22773.04,N/A,9735.68,N/A,11782.46,N/A,22751.84,N/A,12904.72,N/A,22810.68,N/A,10035.66,N/A,2810.00,N/A,2810.00,N/A,14200.33,N/A,22810.68,N/A,22810.68,N/A,22810.68,N/A,22751.84,N/A,11782.46,N/A,10035.66,N/A,26353.00,N/A,26353.00,N/A,4915.45,N/A,11782.46,N/A,11782.46,N/A,10738.15,N/A,2810.00,26353.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 077,Hypertensive Encephalopathy With McC,N/A,N/A,54108.60,N/A,32465.16,N/A,8344.41,N/A,10136.64,N/A,18804.81,N/A,18396.92,N/A,19550.94,N/A,8601.52,N/A,3372.00,N/A,3372.00,N/A,12171.04,N/A,19550.94,N/A,19550.94,N/A,19550.94,N/A,18804.81,N/A,10136.64,N/A,8601.52,N/A,22587.05,N/A,22587.05,N/A,4425.52,N/A,10136.64,N/A,10136.64,N/A,9203.63,N/A,3372.00,32465.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 078,Hypertensive Encephalopathy With Cc,N/A,N/A,25374.97,N/A,15224.98,N/A,5296.21,N/A,6530.80,N/A,11935.44,N/A,8627.49,N/A,12409.01,N/A,5459.40,N/A,2248.00,N/A,2248.00,N/A,7724.98,N/A,12409.01,N/A,12409.01,N/A,12409.01,N/A,11935.44,N/A,6530.80,N/A,5459.40,N/A,14336.03,N/A,14336.03,N/A,5459.40,N/A,6530.80,N/A,6530.80,N/A,5841.55,N/A,2248.00,15224.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 080,Nontraumatic Stupor And Coma With McC,N/A,N/A,32976.80,N/A,19786.08,N/A,10881.56,N/A,2414.80,N/A,24522.48,N/A,11212.11,N/A,25495.46,N/A,11216.84,N/A,2414.80,N/A,2414.80,N/A,15871.68,N/A,25495.46,N/A,25495.46,N/A,25495.46,N/A,24522.48,N/A,2414.80,N/A,11216.84,N/A,29454.71,N/A,29454.71,N/A,11216.84,N/A,13137.96,N/A,2414.80,N/A,3353.86,N/A,2414.80,29454.71,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 082,Traumatic Stupor And Coma >1 Hour With McC,N/A,N/A,67285.90,N/A,40371.54,N/A,12084.52,N/A,14561.00,N/A,27233.44,N/A,22877.21,N/A,28313.98,N/A,12456.86,N/A,14561.00,N/A,14561.00,N/A,17626.30,N/A,28313.98,N/A,28313.98,N/A,28313.98,N/A,27233.44,N/A,14561.00,N/A,12456.86,N/A,32710.93,N/A,32710.93,N/A,11509.62,N/A,14561.00,N/A,14561.00,N/A,13328.84,N/A,11509.62,40371.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 084,Traumatic Stupor And Coma >1 Hour Without Cc/McC,N/A,N/A,26629.80,N/A,15977.88,N/A,4889.18,N/A,6049.29,N/A,11018.16,N/A,9054.13,N/A,11455.33,N/A,5039.82,N/A,562.00,N/A,562.00,N/A,7131.29,N/A,11455.33,N/A,11455.33,N/A,11455.33,N/A,11018.16,N/A,6049.29,N/A,5039.82,N/A,13234.26,N/A,13234.26,N/A,4282.17,N/A,6049.29,N/A,6049.29,N/A,5392.61,N/A,562.00,15977.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 092,Other Disorders Of Nervous System With Cc,N/A,N/A,36302.10,N/A,21781.26,N/A,5304.21,N/A,6540.25,N/A,11953.47,N/A,12342.71,N/A,12427.76,N/A,5467.65,N/A,6540.25,N/A,6540.25,N/A,7736.65,N/A,12427.76,N/A,12427.76,N/A,12427.76,N/A,11953.47,N/A,6540.25,N/A,5467.65,N/A,14357.69,N/A,14357.69,N/A,5467.65,N/A,6540.25,N/A,6599.55,N/A,5850.38,N/A,5304.21,21781.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 093,Other Disorders Of Nervous System Without Cc/McC,N/A,N/A,33409.90,N/A,20045.94,N/A,3709.23,N/A,5151.26,N/A,9194.43,N/A,11359.37,N/A,9559.24,N/A,4205.63,N/A,5091.96,N/A,5091.96,N/A,5950.91,N/A,9559.24,N/A,9559.24,N/A,9559.24,N/A,9194.43,N/A,5091.96,N/A,4205.63,N/A,11043.71,N/A,11043.71,N/A,3192.39,N/A,5091.96,N/A,5151.26,N/A,4500.02,N/A,3192.39,20045.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 094,Bacterial And Tuberculous Infections Of Nervous System With McC,N/A,N/A,106158.52,N/A,63695.11,N/A,19063.27,N/A,22816.51,N/A,58514.58,N/A,49110.61,N/A,44665.18,N/A,19650.64,N/A,2810.00,N/A,2810.00,N/A,27805.40,N/A,44665.18,N/A,49110.61,N/A,44665.18,N/A,58514.58,N/A,22816.51,N/A,19650.64,N/A,51601.34,N/A,51601.34,N/A,19650.64,N/A,22816.51,N/A,22816.51,N/A,21026.18,N/A,2810.00,63695.11,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 095,Bacterial And Tuberculous Infections Of Nervous System With Cc,N/A,N/A,77131.30,N/A,46278.78,N/A,13639.56,N/A,16978.81,N/A,30737.85,N/A,36125.48,N/A,36125.48,N/A,10389.13,N/A,4496.00,N/A,16978.81,N/A,36125.48,N/A,36125.48,N/A,36125.48,N/A,36125.48,N/A,30737.85,N/A,16978.81,N/A,14059.82,N/A,36920.19,N/A,36920.19,N/A,10389.13,N/A,16400.54,N/A,16978.81,N/A,10389.13,N/A,4496.00,46278.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 097,Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,N/A,N/A,116543.30,N/A,69925.98,N/A,13656.72,N/A,30399.89,N/A,64238.65,N/A,29505.00,N/A,58866.04,N/A,21381.17,N/A,30399.89,N/A,30399.89,N/A,29505.00,N/A,29505.00,N/A,29505.00,N/A,58866.04,N/A,51706.86,N/A,27262.37,N/A,21381.17,N/A,43092.00,N/A,51706.86,N/A,20282.24,N/A,30399.89,N/A,27262.37,N/A,22877.85,N/A,13656.72,69925.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 098,Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,N/A,N/A,44654.10,N/A,26792.46,N/A,11118.42,N/A,13418.16,N/A,25056.25,N/A,15182.39,N/A,26050.42,N/A,11460.99,N/A,2810.00,N/A,2810.00,N/A,16217.16,N/A,26050.42,N/A,26050.42,N/A,26050.42,N/A,25056.25,N/A,13418.16,N/A,11460.99,N/A,30095.85,N/A,30095.85,N/A,5672.33,N/A,13418.16,N/A,13418.16,N/A,12263.26,N/A,2810.00,30095.85,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 099,Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,N/A,N/A,40314.58,N/A,24188.75,N/A,7460.47,N/A,9090.98,N/A,16914.81,N/A,13706.95,N/A,17479.85,N/A,7690.34,N/A,9090.98,N/A,9090.98,N/A,10881.73,N/A,17479.85,N/A,17479.85,N/A,17479.85,N/A,16914.81,N/A,9090.98,N/A,7690.34,N/A,20194.34,N/A,20194.34,N/A,5672.33,N/A,9090.98,N/A,9090.98,N/A,8228.66,N/A,5672.33,24188.75,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 102,Headaches With McC,N/A,N/A,36244.80,N/A,21746.88,N/A,6134.28,N/A,7551.83,N/A,13824.10,N/A,12323.23,N/A,14372.60,N/A,6323.29,N/A,7522.18,N/A,7522.18,N/A,8947.37,N/A,14372.60,N/A,14372.60,N/A,14372.60,N/A,13824.10,N/A,7522.18,N/A,6323.29,N/A,16604.56,N/A,16604.56,N/A,3371.60,N/A,2239.50,N/A,7551.83,N/A,6765.92,N/A,2239.50,21746.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 103,Headaches Without McC,N/A,N/A,28426.90,N/A,17056.14,N/A,4441.07,N/A,5519.19,N/A,10008.32,N/A,9665.15,N/A,10405.42,N/A,4577.91,N/A,5519.19,N/A,5519.19,N/A,6477.68,N/A,10405.42,N/A,10405.42,N/A,10405.42,N/A,10008.32,N/A,5519.19,N/A,4577.91,N/A,12021.30,N/A,12021.30,N/A,4577.91,N/A,5519.19,N/A,5519.19,N/A,4898.36,N/A,4441.07,17056.14,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 121,Acute Major Eye Infections With Cc/McC,N/A,N/A,35383.80,N/A,21230.28,N/A,6536.51,N/A,7997.99,N/A,14730.56,N/A,12030.49,N/A,14871.47,N/A,6737.91,N/A,2248.00,N/A,2248.00,N/A,9257.14,N/A,14871.47,N/A,14871.47,N/A,14871.47,N/A,14730.56,N/A,7997.99,N/A,6737.91,N/A,17693.33,N/A,17693.33,N/A,N/A,N/A,7997.99,N/A,7997.99,N/A,7209.57,N/A,2248.00,21230.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 124,Other Disorders Of The Eye With McC,N/A,N/A,36525.98,N/A,21915.59,N/A,7472.20,N/A,9104.88,N/A,16839.22,N/A,12418.83,N/A,17000.30,N/A,7702.43,N/A,3372.00,N/A,3372.00,N/A,10582.29,N/A,17000.30,N/A,17000.30,N/A,17000.30,N/A,16839.22,N/A,9104.88,N/A,7702.43,N/A,20226.11,N/A,20226.11,N/A,7702.43,N/A,9104.88,N/A,9104.88,N/A,8241.61,N/A,3372.00,21915.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 135,Sinus And Mastoid Procedures With Cc/McC,N/A,N/A,28897.52,N/A,17338.51,N/A,13073.55,N/A,15730.98,N/A,28897.51,N/A,9825.15,N/A,28897.51,N/A,13476.37,N/A,15730.98,N/A,15730.98,N/A,18515.04,N/A,28897.51,N/A,28897.51,N/A,28897.51,N/A,28897.51,N/A,15730.98,N/A,13476.37,N/A,28897.51,N/A,28897.51,N/A,5508.30,N/A,15730.98,N/A,15730.98,N/A,14419.72,N/A,5508.30,28897.51,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 139,Salivary Gland Procedures,N/A,N/A,65098.22,N/A,39058.93,N/A,6708.29,N/A,8201.19,N/A,15117.67,N/A,22133.40,N/A,15262.28,N/A,6914.98,N/A,1124.00,N/A,1124.00,N/A,9500.41,N/A,15262.28,N/A,15262.28,N/A,15262.28,N/A,15117.67,N/A,8201.19,N/A,6914.98,N/A,18158.30,N/A,18158.30,N/A,N/A,N/A,8201.19,N/A,8201.19,N/A,7399.03,N/A,1124.00,39058.93,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 142,Major Head And Neck Procedures Without Cc/McC,N/A,N/A,72040.62,N/A,43224.37,N/A,9077.92,N/A,11004.35,N/A,26392.13,N/A,24493.81,N/A,20653.53,N/A,9357.63,N/A,562.00,N/A,562.00,N/A,12856.34,N/A,20653.53,N/A,20653.53,N/A,20653.53,N/A,26392.13,N/A,11004.35,N/A,9357.63,N/A,24572.55,N/A,24572.55,N/A,7959.42,N/A,11004.35,N/A,11004.35,N/A,10012.66,N/A,562.00,43224.37,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 145,"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/McC",N/A,N/A,39477.37,N/A,23686.42,N/A,6443.15,N/A,7887.55,N/A,14520.17,N/A,13422.30,N/A,14659.07,N/A,6641.68,N/A,7887.55,N/A,7887.55,N/A,9124.93,N/A,14659.07,N/A,14659.07,N/A,14659.07,N/A,14520.17,N/A,7887.55,N/A,6641.68,N/A,17440.63,N/A,17440.63,N/A,3826.72,N/A,7887.55,N/A,7887.55,N/A,7106.60,N/A,3826.72,23686.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 146,"Ear, Nose, Mouth And Throat Malignancy With McC",N/A,N/A,39576.02,N/A,23745.61,N/A,10744.99,N/A,12976.41,N/A,24214.71,N/A,13455.85,N/A,24446.35,N/A,11076.06,N/A,2248.00,N/A,2248.00,N/A,15217.28,N/A,24446.35,N/A,24446.35,N/A,24446.35,N/A,24214.71,N/A,12976.41,N/A,11076.06,N/A,29085.05,N/A,29085.05,N/A,11076.06,N/A,12976.41,N/A,12976.41,N/A,11851.39,N/A,2248.00,29085.05,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 147,"Ear, Nose, Mouth And Throat Malignancy With Cc",N/A,N/A,32135.40,N/A,19281.24,N/A,6460.76,N/A,7908.38,N/A,14559.84,N/A,10926.04,N/A,14699.12,N/A,6659.83,N/A,2810.00,N/A,2810.00,N/A,9149.86,N/A,14699.12,N/A,14699.12,N/A,14699.12,N/A,14559.84,N/A,7908.38,N/A,6659.83,N/A,17488.28,N/A,17488.28,N/A,8257.47,N/A,7908.38,N/A,7908.38,N/A,7126.01,N/A,2810.00,19281.24,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 149,Dysequilibrium,N/A,N/A,23228.40,N/A,13937.04,N/A,4027.64,N/A,5059.78,N/A,9076.61,N/A,7897.66,N/A,9163.44,N/A,4151.74,N/A,5030.13,N/A,5030.13,N/A,5704.03,N/A,9163.44,N/A,9163.44,N/A,9163.44,N/A,9076.61,N/A,5030.13,N/A,4151.74,N/A,10902.20,N/A,10902.20,N/A,2278.00,N/A,5030.13,N/A,2352.67,N/A,4442.36,N/A,2278.00,13937.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 150,Epistaxis With McC,N/A,N/A,38122.50,N/A,22873.50,N/A,7358.04,N/A,8969.82,N/A,16581.94,N/A,12961.65,N/A,16740.56,N/A,7584.76,N/A,8969.82,N/A,8969.82,N/A,10420.61,N/A,16740.56,N/A,16740.56,N/A,16740.56,N/A,16581.94,N/A,8969.82,N/A,7584.76,N/A,19917.09,N/A,19917.09,N/A,4446.89,N/A,8969.82,N/A,8969.82,N/A,8115.69,N/A,4446.89,22873.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 151,Epistaxis Without McC,N/A,N/A,31456.60,N/A,18873.96,N/A,4112.99,N/A,5131.10,N/A,9268.96,N/A,10695.24,N/A,9357.63,N/A,4239.72,N/A,5131.10,N/A,5131.10,N/A,5824.91,N/A,9357.63,N/A,9357.63,N/A,9357.63,N/A,9268.96,N/A,5131.10,N/A,4239.72,N/A,11133.24,N/A,11133.24,N/A,4507.81,N/A,5131.10,N/A,5131.10,N/A,4536.50,N/A,4112.99,18873.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 155,"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",N/A,N/A,25278.00,N/A,15166.80,N/A,4904.12,N/A,6096.61,N/A,11051.82,N/A,8594.52,N/A,11157.54,N/A,5055.22,N/A,57324.00,N/A,57324.00,N/A,6945.31,N/A,11157.54,N/A,11157.54,N/A,11157.54,N/A,11051.82,N/A,6066.96,N/A,5055.22,N/A,13274.69,N/A,13274.69,N/A,5302.65,N/A,6066.96,N/A,6096.61,N/A,5409.09,N/A,4904.12,57324.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 158,Dental And Oral Diseases With Cc,N/A,N/A,24067.78,N/A,14440.67,N/A,4956.40,N/A,6128.80,N/A,11169.64,N/A,8183.04,N/A,11276.49,N/A,5109.11,N/A,2248.00,N/A,2248.00,N/A,7019.35,N/A,11276.49,N/A,11276.49,N/A,11276.49,N/A,11169.64,N/A,6128.80,N/A,5109.11,N/A,13416.20,N/A,13416.20,N/A,5109.11,N/A,6128.80,N/A,6128.80,N/A,5466.75,N/A,2248.00,14440.67,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 159,Dental And Oral Diseases Without Cc/McC,N/A,N/A,18836.50,N/A,11301.90,N/A,4000.43,N/A,4997.94,N/A,9015.30,N/A,6404.41,N/A,9101.54,N/A,4123.69,N/A,1686.00,N/A,1686.00,N/A,5665.49,N/A,9101.54,N/A,9101.54,N/A,9101.54,N/A,9015.30,N/A,4997.94,N/A,4123.69,N/A,10828.56,N/A,10828.56,N/A,2988.91,N/A,4997.94,N/A,4997.94,N/A,4412.35,N/A,1686.00,11301.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 178,Respiratory Infections And Inflammations With Cc,N/A,N/A,32673.90,N/A,19604.34,N/A,5798.73,N/A,8581.85,N/A,13067.91,N/A,11109.13,N/A,13192.92,N/A,5977.40,N/A,2269.34,N/A,2269.34,N/A,8212.29,N/A,13192.92,N/A,13192.92,N/A,13192.92,N/A,13067.91,N/A,8403.95,N/A,5977.40,N/A,15696.28,N/A,15696.28,N/A,6395.82,N/A,8403.95,N/A,8581.85,N/A,6395.82,N/A,2269.34,19604.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 180,Respiratory Neoplasms With McC,N/A,N/A,57880.60,N/A,34728.36,N/A,9036.31,N/A,10955.14,N/A,20364.07,N/A,19679.40,N/A,20558.86,N/A,9314.74,N/A,10955.14,N/A,10955.14,N/A,12797.41,N/A,20558.86,N/A,20558.86,N/A,20558.86,N/A,20364.07,N/A,10955.14,N/A,9314.74,N/A,24459.92,N/A,24459.92,N/A,7411.42,N/A,10955.14,N/A,10955.14,N/A,9966.77,N/A,7411.42,34728.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 181,Respiratory Neoplasms With Cc,N/A,N/A,39988.20,N/A,23992.92,N/A,6047.86,N/A,7419.94,N/A,13629.34,N/A,13595.99,N/A,13759.72,N/A,6234.20,N/A,7419.94,N/A,7419.94,N/A,8565.10,N/A,13759.72,N/A,13759.72,N/A,13759.72,N/A,13629.34,N/A,7419.94,N/A,6234.20,N/A,16370.63,N/A,16370.63,N/A,4643.68,N/A,7419.94,N/A,7419.94,N/A,6670.60,N/A,4643.68,23992.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 182,Respiratory Neoplasms Without Cc/McC,N/A,N/A,36117.50,N/A,21670.50,N/A,4734.48,N/A,5866.28,N/A,10669.53,N/A,12279.95,N/A,10771.59,N/A,4880.35,N/A,5866.28,N/A,5866.28,N/A,6705.06,N/A,10771.59,N/A,10771.59,N/A,10771.59,N/A,10669.53,N/A,5866.28,N/A,4880.35,N/A,12815.50,N/A,12815.50,N/A,4322.57,N/A,5866.28,N/A,5866.28,N/A,5221.98,N/A,4322.57,21670.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 183,Major Chest Trauma With McC,N/A,N/A,41806.00,N/A,25083.60,N/A,8013.67,N/A,9745.39,N/A,18059.45,N/A,14214.04,N/A,18232.20,N/A,8260.58,N/A,2248.00,N/A,2248.00,N/A,11349.12,N/A,18232.20,N/A,18232.20,N/A,18232.20,N/A,18059.45,N/A,9745.39,N/A,8260.58,N/A,21691.77,N/A,21691.77,N/A,4673.90,N/A,9745.39,N/A,9745.39,N/A,8838.82,N/A,2248.00,25083.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 184,Major Chest Trauma With Cc,N/A,N/A,36718.00,N/A,22030.80,N/A,5575.75,N/A,6861.46,N/A,12565.39,N/A,12484.12,N/A,12685.59,N/A,5747.54,N/A,1124.00,N/A,1124.00,N/A,7896.49,N/A,12685.59,N/A,12685.59,N/A,12685.59,N/A,12565.39,N/A,6861.46,N/A,5747.54,N/A,15092.69,N/A,15092.69,N/A,1059.00,N/A,6861.46,N/A,6861.46,N/A,6149.87,N/A,1059.00,22030.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 187,Pleural Effusion With Cc,N/A,N/A,36402.00,N/A,21841.20,N/A,5579.48,N/A,6865.88,N/A,12573.81,N/A,12376.68,N/A,12694.09,N/A,5751.39,N/A,2248.00,N/A,2248.00,N/A,7901.77,N/A,12694.09,N/A,12694.09,N/A,12694.09,N/A,12573.81,N/A,6865.88,N/A,5751.39,N/A,15102.80,N/A,15102.80,N/A,6153.99,N/A,6865.88,N/A,6865.88,N/A,6153.99,N/A,2248.00,21841.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 192,Chronic Obstructive Pulmonary Disease Without Cc/McC,N/A,N/A,20454.50,N/A,12272.70,N/A,3478.71,N/A,4380.77,N/A,7839.55,N/A,6954.53,N/A,7914.54,N/A,3585.89,N/A,4380.77,N/A,4380.77,N/A,4926.62,N/A,7914.54,N/A,7914.54,N/A,7914.54,N/A,7839.55,N/A,4380.77,N/A,3585.89,N/A,9416.32,N/A,9416.32,N/A,3585.89,N/A,4380.77,N/A,4380.77,N/A,3836.90,N/A,3478.71,12272.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 193,Simple Pneumonia And Pleurisy With McC,N/A,N/A,34439.50,N/A,20663.70,N/A,6928.07,N/A,8579.79,N/A,15612.97,N/A,11709.43,N/A,15762.32,N/A,7141.54,N/A,8461.19,N/A,8461.19,N/A,15762.32,N/A,15762.32,N/A,15762.32,N/A,15762.32,N/A,15612.97,N/A,8461.19,N/A,7141.54,N/A,18753.23,N/A,18753.23,N/A,7607.05,N/A,8461.19,N/A,8579.79,N/A,7641.45,N/A,6928.07,20663.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 194,Simple Pneumonia And Pleurisy With Cc,N/A,N/A,29801.80,N/A,17881.08,N/A,4482.15,N/A,5567.79,N/A,10100.88,N/A,10132.61,N/A,10197.51,N/A,4620.25,N/A,5567.79,N/A,5567.79,N/A,6347.71,N/A,10197.51,N/A,10197.51,N/A,10197.51,N/A,10100.88,N/A,5567.79,N/A,4620.25,N/A,12132.49,N/A,12132.49,N/A,4620.25,N/A,5567.79,N/A,5567.79,N/A,4943.67,N/A,4482.15,17881.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 195,Simple Pneumonia And Pleurisy Without Cc/McC,N/A,N/A,34806.30,N/A,20883.78,N/A,3423.76,N/A,4464.02,N/A,7715.72,N/A,11834.14,N/A,7789.53,N/A,3529.25,N/A,4315.77,N/A,4315.77,N/A,N/A,N/A,N/A,N/A,7789.53,N/A,7789.53,N/A,7715.72,N/A,4315.77,N/A,3529.25,N/A,9267.59,N/A,9267.59,N/A,N/A,N/A,4315.77,N/A,4315.77,N/A,3776.30,N/A,3423.76,20883.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 198,Interstitial Lung Disease Without Cc/McC,N/A,N/A,20720.92,N/A,12432.55,N/A,3792.38,N/A,4751.83,N/A,8546.44,N/A,7045.11,N/A,8628.19,N/A,3909.23,N/A,2810.00,N/A,2810.00,N/A,5370.85,N/A,8628.19,N/A,8628.19,N/A,8628.19,N/A,8546.44,N/A,4751.83,N/A,3909.23,N/A,10265.40,N/A,10265.40,N/A,3909.23,N/A,4751.83,N/A,4751.83,N/A,4182.88,N/A,2810.00,12432.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 199,Pneumothorax With McC,N/A,N/A,48406.33,N/A,29043.80,N/A,7785.28,N/A,12659.16,N/A,19451.20,N/A,21375.20,N/A,21375.20,N/A,7785.28,N/A,11750.35,N/A,11750.35,N/A,21375.20,N/A,21375.20,N/A,21375.20,N/A,21375.20,N/A,19451.20,N/A,12454.32,N/A,7785.28,N/A,19451.20,N/A,19451.20,N/A,7785.28,N/A,12567.78,N/A,12454.32,N/A,7785.28,N/A,7785.28,29043.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 201,Pneumothorax Without Cc/McC,N/A,N/A,20677.30,N/A,12406.38,N/A,3883.07,N/A,4859.11,N/A,8750.81,N/A,7030.28,N/A,8834.52,N/A,4002.71,N/A,4859.11,N/A,4859.11,N/A,5499.28,N/A,8834.52,N/A,8834.52,N/A,8834.52,N/A,8750.81,N/A,4859.11,N/A,4002.71,N/A,10510.88,N/A,10510.88,N/A,3847.55,N/A,4859.11,N/A,4859.11,N/A,4282.90,N/A,3847.55,12406.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 202,Bronchitis And Asthma With Cc/McC,N/A,N/A,28255.90,N/A,16953.54,N/A,4938.79,N/A,6107.98,N/A,11129.97,N/A,9607.01,N/A,11236.43,N/A,5090.96,N/A,6107.98,N/A,6107.98,N/A,6994.42,N/A,11236.43,N/A,11236.43,N/A,11236.43,N/A,11129.97,N/A,6107.98,N/A,5090.96,N/A,13368.55,N/A,13368.55,N/A,5090.96,N/A,6107.98,N/A,6107.98,N/A,5447.33,N/A,4938.79,16953.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 203,Bronchitis And Asthma Without Cc/McC,N/A,N/A,16265.23,N/A,9759.14,N/A,3558.73,N/A,4475.42,N/A,8019.88,N/A,5530.18,N/A,8096.59,N/A,3668.38,N/A,4475.42,N/A,4475.42,N/A,5039.94,N/A,8096.59,N/A,8096.59,N/A,8096.59,N/A,8019.88,N/A,4475.42,N/A,3668.38,N/A,9632.92,N/A,9632.92,N/A,3055.76,N/A,4475.42,N/A,4475.42,N/A,3925.16,N/A,3055.76,9759.14,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 204,Respiratory Signs And Symptoms,N/A,N/A,27168.40,N/A,16301.04,N/A,4317.84,N/A,5373.42,N/A,9730.61,N/A,9237.26,N/A,9823.69,N/A,4450.88,N/A,5373.42,N/A,5373.42,N/A,6115.02,N/A,9823.69,N/A,9823.69,N/A,9823.69,N/A,9730.61,N/A,5373.42,N/A,4450.88,N/A,11687.74,N/A,11687.74,N/A,2616.67,N/A,5373.42,N/A,5373.42,N/A,4762.44,N/A,2616.67,16301.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 205,Other Respiratory System Diagnoses With McC,N/A,N/A,44997.00,N/A,26998.20,N/A,9500.96,N/A,11872.26,N/A,25014.15,N/A,15298.98,N/A,23356.03,N/A,7496.71,N/A,11504.78,N/A,11872.26,N/A,23356.03,N/A,23356.03,N/A,23356.03,N/A,23356.03,N/A,25014.15,N/A,12069.81,N/A,7496.71,N/A,25014.15,N/A,25014.15,N/A,7496.71,N/A,11504.78,N/A,12069.81,N/A,7496.71,N/A,7496.71,26998.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 206,Other Respiratory System Diagnoses Without McC,N/A,N/A,33069.10,N/A,19841.46,N/A,4765.95,N/A,1706.02,N/A,10740.45,N/A,11243.49,N/A,10843.20,N/A,4912.80,N/A,5903.51,N/A,5903.51,N/A,6749.64,N/A,10843.20,N/A,10843.20,N/A,10843.20,N/A,10740.45,N/A,5903.51,N/A,4912.80,N/A,12900.70,N/A,12900.70,N/A,4912.80,N/A,5903.51,N/A,5903.51,N/A,5256.69,N/A,1706.02,19841.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 207,Respiratory System Diagnosis With Ventilator Support >96 Hours,N/A,N/A,202463.00,N/A,121477.80,N/A,N/A,N/A,41700.30,N/A,188887.38,N/A,149709.75,N/A,149709.75,N/A,N/A,N/A,41700.30,N/A,41700.30,N/A,149709.75,N/A,149709.75,N/A,149709.75,N/A,149709.75,N/A,188887.38,N/A,41700.30,N/A,N/A,N/A,188887.38,N/A,188887.38,N/A,N/A,N/A,41700.30,N/A,41700.30,N/A,N/A,N/A,41700.30,188887.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 215,Other Heart Assist System Implant,N/A,N/A,619685.22,N/A,371811.13,N/A,110419.01,N/A,65284.84,N/A,363114.10,N/A,101585.73,N/A,101585.73,N/A,110419.01,N/A,92038.35,N/A,92038.35,N/A,101585.73,N/A,101585.73,N/A,101585.73,N/A,101585.73,N/A,363114.10,N/A,65284.84,N/A,110419.01,N/A,363114.10,N/A,363114.10,N/A,110419.01,N/A,65284.84,N/A,65284.84,N/A,110419.01,N/A,65284.84,371811.13,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 217,Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,N/A,N/A,284693.77,N/A,170816.26,N/A,38522.31,N/A,40330.27,N/A,156923.20,N/A,96795.88,N/A,99130.37,N/A,34911.98,N/A,40330.27,N/A,40330.27,N/A,61721.61,N/A,99130.37,N/A,99130.37,N/A,99130.37,N/A,156923.20,N/A,40330.27,N/A,34911.98,N/A,140992.38,N/A,140992.38,N/A,27685.71,N/A,40330.27,N/A,40330.27,N/A,37355.82,N/A,27685.71,170816.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 218,Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,N/A,N/A,235666.72,N/A,141400.03,N/A,N/A,N/A,38541.65,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38541.65,N/A,38541.65,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,37742.30,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38541.65,N/A,38541.65,N/A,N/A,N/A,37742.30,141400.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 222,"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With McC",N/A,N/A,318952.52,N/A,191371.51,N/A,83543.35,N/A,49645.18,N/A,N/A,N/A,126954.08,N/A,126954.08,N/A,83543.35,N/A,49645.18,N/A,49645.18,N/A,126954.08,N/A,126954.08,N/A,126954.08,N/A,126954.08,N/A,N/A,N/A,49645.18,N/A,83543.35,N/A,N/A,N/A,N/A,N/A,83543.35,N/A,49645.18,N/A,49645.18,N/A,83543.35,N/A,49645.18,191371.51,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 224,"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With McC",N/A,N/A,290464.13,N/A,174278.48,N/A,46302.32,N/A,47159.17,N/A,160103.83,N/A,238076.41,N/A,238076.41,N/A,46302.32,N/A,47159.17,N/A,47159.17,N/A,238076.41,N/A,238076.41,N/A,238076.41,N/A,238076.41,N/A,100142.62,N/A,47159.17,N/A,46302.32,N/A,149604.91,N/A,149604.91,N/A,28694.37,N/A,47159.17,N/A,47159.17,N/A,41712.28,N/A,28694.37,238076.41,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 225,"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without McC",N/A,N/A,207526.37,N/A,124515.82,N/A,26980.91,N/A,32182.67,N/A,114388.53,N/A,91108.20,N/A,72260.68,N/A,27812.24,N/A,32182.67,N/A,32182.67,N/A,44991.71,N/A,72260.68,N/A,72260.68,N/A,72260.68,N/A,114388.53,N/A,32182.67,N/A,27812.24,N/A,119435.95,N/A,119435.95,N/A,14196.85,N/A,32182.67,N/A,32182.67,N/A,29759.10,N/A,14196.85,124515.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 228,Other Cardiothoracic Procedures With McC,N/A,N/A,167794.18,N/A,100676.51,N/A,27100.67,N/A,31366.08,N/A,71164.65,N/A,57050.02,N/A,62140.93,N/A,27100.67,N/A,31366.08,N/A,31366.08,N/A,38682.23,N/A,62140.93,N/A,62140.93,N/A,62140.93,N/A,71164.65,N/A,31366.08,N/A,27100.67,N/A,71164.65,N/A,71164.65,N/A,27100.67,N/A,31366.08,N/A,31366.08,N/A,27100.67,N/A,27100.67,100676.51,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 229,Other Cardiothoracic Procedures Without McC,N/A,N/A,130559.33,N/A,78335.60,N/A,17609.05,N/A,21096.24,N/A,71964.30,N/A,44390.17,N/A,41621.05,N/A,18151.61,N/A,21096.24,N/A,21096.24,N/A,25908.76,N/A,41621.05,N/A,41621.05,N/A,41621.05,N/A,71964.30,N/A,21096.24,N/A,18151.61,N/A,47665.00,N/A,47665.00,N/A,743.01,N/A,21096.24,N/A,21096.24,N/A,19422.23,N/A,743.01,78335.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 231,Coronary Bypass With Ptca With McC,N/A,N/A,374679.58,N/A,224807.75,N/A,N/A,N/A,64296.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,64296.26,N/A,64296.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,64296.26,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,64296.26,N/A,64296.26,N/A,N/A,N/A,64296.26,224807.75,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 232,Coronary Bypass With Ptca Without McC,N/A,N/A,195267.80,N/A,117160.68,N/A,168626.76,N/A,37231.77,N/A,137345.84,N/A,N/A,N/A,N/A,N/A,168626.76,N/A,37231.77,N/A,37231.77,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,137345.84,N/A,37231.77,N/A,168626.76,N/A,137345.84,N/A,137345.84,N/A,168626.76,N/A,37231.77,N/A,37231.77,N/A,168626.76,N/A,37231.77,168626.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 234,Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,N/A,N/A,211868.78,N/A,127121.27,N/A,11384.62,N/A,32994.22,N/A,88529.16,N/A,64763.10,N/A,64763.10,N/A,11384.62,N/A,32994.22,N/A,32994.22,N/A,64763.10,N/A,64763.10,N/A,64763.10,N/A,64763.10,N/A,88529.16,N/A,32994.22,N/A,11384.62,N/A,88529.16,N/A,104553.05,N/A,11384.62,N/A,32994.22,N/A,32994.22,N/A,11384.62,N/A,11384.62,127121.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 235,Coronary Bypass Without Cardiac Catheterization With McC,N/A,N/A,220827.47,N/A,132496.48,N/A,N/A,N/A,38066.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38066.02,N/A,38066.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,38066.02,N/A,32938.95,N/A,N/A,N/A,104672.22,N/A,16521.88,N/A,38066.02,N/A,38066.02,N/A,N/A,N/A,16521.88,132496.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 239,Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,N/A,N/A,69857.10,N/A,41914.26,N/A,21467.18,N/A,25897.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,18415.93,N/A,25897.87,N/A,25897.87,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,55903.50,N/A,25897.87,N/A,18415.93,N/A,67147.44,N/A,67147.44,N/A,18415.93,N/A,25897.87,N/A,25897.87,N/A,23677.62,N/A,18415.93,67147.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 241,Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,N/A,N/A,47971.20,N/A,28782.72,N/A,8262.79,N/A,11543.24,N/A,18620.88,N/A,16310.21,N/A,19530.08,N/A,8517.38,N/A,2248.00,N/A,2248.00,N/A,N/A,N/A,19530.08,N/A,19530.08,N/A,19530.08,N/A,18620.88,N/A,10040.10,N/A,8517.38,N/A,N/A,N/A,22366.12,N/A,9736.18,N/A,10040.10,N/A,10040.10,N/A,9113.60,N/A,2248.00,28782.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 242,Permanent Cardiac Pacemaker Implant With McC,N/A,N/A,130650.53,N/A,78390.32,N/A,18529.80,N/A,22779.39,N/A,72014.57,N/A,44421.19,N/A,43797.36,N/A,19100.74,N/A,22185.45,N/A,22185.45,N/A,27263.50,N/A,43797.36,N/A,43797.36,N/A,43797.36,N/A,72014.57,N/A,22185.45,N/A,19100.74,N/A,50157.34,N/A,50157.34,N/A,758.95,N/A,22185.45,N/A,22185.45,N/A,20437.79,N/A,758.95,78390.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 243,Permanent Cardiac Pacemaker Implant With Cc,N/A,N/A,91789.53,N/A,55073.72,N/A,12504.35,N/A,15057.65,N/A,47034.43,N/A,31208.45,N/A,29555.50,N/A,12889.63,N/A,15057.65,N/A,15057.65,N/A,18398.06,N/A,29555.50,N/A,29555.50,N/A,29555.50,N/A,47034.43,N/A,15057.65,N/A,12889.63,N/A,33847.36,N/A,33847.36,N/A,12889.63,N/A,15057.65,N/A,15057.65,N/A,13791.91,N/A,12504.35,55073.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 244,Permanent Cardiac Pacemaker Implant Without Cc/McC,N/A,N/A,86820.82,N/A,52092.49,N/A,10141.65,N/A,12262.69,N/A,41975.06,N/A,29519.08,N/A,23970.97,N/A,10454.13,N/A,12262.69,N/A,12262.69,N/A,14921.73,N/A,23970.97,N/A,23970.97,N/A,23970.97,N/A,41975.06,N/A,12262.69,N/A,10454.13,N/A,27451.88,N/A,27451.88,N/A,N/A,N/A,12262.69,N/A,12262.69,N/A,11185.92,N/A,10141.65,52092.49,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 247,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without McC,N/A,N/A,69397.88,N/A,41638.73,N/A,10186.46,N/A,12315.69,N/A,28537.28,N/A,23595.28,N/A,24076.89,N/A,10500.32,N/A,12315.69,N/A,12315.69,N/A,14987.67,N/A,24076.89,N/A,24076.89,N/A,24076.89,N/A,28537.28,N/A,12315.69,N/A,10500.32,N/A,27573.18,N/A,27573.18,N/A,11235.34,N/A,12315.69,N/A,12315.69,N/A,11235.34,N/A,10186.46,41638.73,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 249,Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without McC,N/A,N/A,94826.88,N/A,56896.13,N/A,9691.41,N/A,11730.07,N/A,36902.60,N/A,32241.13,N/A,22906.77,N/A,9990.01,N/A,11730.07,N/A,11730.07,N/A,14259.28,N/A,22906.77,N/A,22906.77,N/A,22906.77,N/A,36902.60,N/A,11730.07,N/A,9990.01,N/A,26233.15,N/A,26233.15,N/A,10132.51,N/A,11730.07,N/A,11730.07,N/A,10689.32,N/A,9691.41,56896.13,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 251,Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without McC,N/A,N/A,69608.32,N/A,41764.99,N/A,8670.36,N/A,10551.88,N/A,19539.36,N/A,23666.83,N/A,20493.41,N/A,8937.51,N/A,56762.00,N/A,56762.00,N/A,12756.98,N/A,20493.41,N/A,20493.41,N/A,20493.41,N/A,19539.36,N/A,10522.23,N/A,8937.51,N/A,23469.33,N/A,23469.33,N/A,8937.51,N/A,10522.23,N/A,10551.88,N/A,9563.13,N/A,8670.36,56762.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 253,Other Vascular Procedures With Cc,N/A,N/A,93643.30,N/A,56185.98,N/A,14264.78,N/A,17140.14,N/A,32146.83,N/A,31838.72,N/A,33716.47,N/A,14704.30,N/A,17140.14,N/A,17140.14,N/A,33716.47,N/A,33716.47,N/A,33716.47,N/A,33716.47,N/A,32146.83,N/A,17140.14,N/A,14704.30,N/A,38612.56,N/A,38612.56,N/A,14704.30,N/A,17140.14,N/A,17258.74,N/A,15733.60,N/A,14264.78,56185.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 258,Cardiac Pacemaker Device Replacement With McC,N/A,N/A,69488.60,N/A,41693.16,N/A,15210.60,N/A,18259.00,N/A,43041.96,N/A,23626.12,N/A,35952.04,N/A,15679.27,N/A,18259.00,N/A,18259.00,N/A,22379.85,N/A,35952.04,N/A,35952.04,N/A,35952.04,N/A,43041.96,N/A,18259.00,N/A,15679.27,N/A,41172.77,N/A,41172.77,N/A,N/A,N/A,18259.00,N/A,18259.00,N/A,16776.82,N/A,15210.60,43041.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 259,Cardiac Pacemaker Device Replacement Without McC,N/A,N/A,59950.53,N/A,35970.32,N/A,10637.77,N/A,12849.58,N/A,40390.00,N/A,20383.19,N/A,25143.61,N/A,10965.53,N/A,12849.58,N/A,12849.58,N/A,15651.69,N/A,25143.61,N/A,25143.61,N/A,25143.61,N/A,40390.00,N/A,12849.58,N/A,10965.53,N/A,28794.80,N/A,28794.80,N/A,N/A,N/A,12849.58,N/A,12849.58,N/A,11733.12,N/A,10637.77,40390.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 263,Vein Ligation And Stripping,N/A,N/A,732827.17,N/A,439696.30,N/A,N/A,N/A,99451.57,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,99451.57,N/A,99451.57,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,99451.57,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,99451.57,N/A,99451.57,N/A,N/A,N/A,99451.57,439696.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 264,Other Circulatory System O.R. Procedures,N/A,N/A,63502.90,N/A,38101.74,N/A,N/A,N/A,21151.77,N/A,N/A,N/A,25977.84,N/A,25977.84,N/A,N/A,N/A,21151.77,N/A,21151.77,N/A,25977.84,N/A,25977.84,N/A,25977.84,N/A,25977.84,N/A,N/A,N/A,21151.77,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,21151.77,N/A,21151.77,N/A,N/A,N/A,21151.77,38101.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 269,Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,N/A,N/A,148840.22,N/A,89304.13,N/A,22812.44,N/A,27251.59,N/A,82040.72,N/A,50601.97,N/A,53919.87,N/A,23515.33,N/A,27251.59,N/A,27251.59,N/A,33564.68,N/A,53919.87,N/A,53919.87,N/A,53919.87,N/A,82040.72,N/A,27251.59,N/A,23515.33,N/A,61749.77,N/A,61749.77,N/A,3938.51,N/A,27251.59,N/A,27251.59,N/A,25161.40,N/A,3938.51,89304.13,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 270,Other Major Cardiovascular Procedures With McC,N/A,N/A,130902.05,N/A,78541.23,N/A,28114.13,N/A,32529.13,N/A,N/A,N/A,64464.77,N/A,64464.77,N/A,28114.13,N/A,32529.13,N/A,32529.13,N/A,64464.77,N/A,64464.77,N/A,64464.77,N/A,64464.77,N/A,N/A,N/A,32529.13,N/A,28114.13,N/A,N/A,N/A,N/A,N/A,28114.13,N/A,32529.13,N/A,32736.68,N/A,28114.13,N/A,28114.13,78541.23,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 271,Other Major Cardiovascular Procedures With Cc,N/A,N/A,152539.93,N/A,91523.96,N/A,18584.75,N/A,22250.45,N/A,N/A,N/A,51863.57,N/A,43927.23,N/A,19157.38,N/A,22250.45,N/A,22250.45,N/A,27344.35,N/A,43927.23,N/A,43927.23,N/A,43927.23,N/A,84080.01,N/A,22250.45,N/A,19157.38,N/A,N/A,N/A,N/A,N/A,19157.38,N/A,22250.45,N/A,22250.45,N/A,19157.38,N/A,18584.75,91523.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 272,Other Major Cardiovascular Procedures Without Cc/McC,N/A,N/A,130707.25,N/A,78424.35,N/A,13850.81,N/A,16650.44,N/A,72045.84,N/A,44440.46,N/A,32738.01,N/A,14277.58,N/A,16650.44,N/A,16650.44,N/A,20379.14,N/A,32738.01,N/A,32738.01,N/A,32738.01,N/A,72045.84,N/A,16650.44,N/A,14277.58,N/A,37492.02,N/A,37492.02,N/A,768.87,N/A,16650.44,N/A,16650.44,N/A,15277.01,N/A,768.87,78424.35,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 282,"Acute Myocardial Infarction, Discharged Alive Without Cc/McC",N/A,N/A,25907.70,N/A,15544.62,N/A,3823.32,N/A,4788.44,N/A,8616.17,N/A,8808.62,N/A,9036.87,N/A,3941.13,N/A,4788.44,N/A,4788.44,N/A,5625.38,N/A,9036.87,N/A,9036.87,N/A,9036.87,N/A,8616.17,N/A,4788.44,N/A,3941.13,N/A,10349.15,N/A,10349.15,N/A,N/A,N/A,4788.44,N/A,4788.44,N/A,4217.00,N/A,3823.32,15544.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 283,"Acute Myocardial Infarction, Expired With McC",N/A,N/A,42850.70,N/A,25710.42,N/A,10235.00,N/A,12373.12,N/A,23065.41,N/A,N/A,N/A,24191.63,N/A,10550.36,N/A,12373.12,N/A,12373.12,N/A,15059.09,N/A,24191.63,N/A,24191.63,N/A,24191.63,N/A,23065.41,N/A,12373.12,N/A,10550.36,N/A,27704.58,N/A,27704.58,N/A,12965.56,N/A,12373.12,N/A,12373.12,N/A,11288.89,N/A,10235.00,27704.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 285,"Acute Myocardial Infarction, Expired Without Cc/McC",N/A,N/A,12635.70,N/A,7581.42,N/A,2890.30,N/A,3684.70,N/A,6513.52,N/A,4296.14,N/A,6831.56,N/A,2979.35,N/A,562.00,N/A,562.00,N/A,4252.59,N/A,6831.56,N/A,6831.56,N/A,6831.56,N/A,6513.52,N/A,3684.70,N/A,2979.35,N/A,7823.59,N/A,7823.59,N/A,N/A,N/A,3684.70,N/A,3684.70,N/A,3187.91,N/A,562.00,7823.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 290,Acute And Subacute Endocarditis Without Cc/McC,N/A,N/A,11498.50,N/A,6899.10,N/A,6431.95,N/A,7903.96,N/A,9971.89,N/A,3909.49,N/A,11498.50,N/A,6630.13,N/A,56762.00,N/A,56762.00,N/A,9463.54,N/A,11498.50,N/A,11498.50,N/A,11498.50,N/A,9971.89,N/A,7874.31,N/A,6630.13,N/A,11498.50,N/A,11498.50,N/A,6630.13,N/A,7874.31,N/A,7903.96,N/A,7094.24,N/A,3909.49,56762.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 292,Heart Failure And Shock With Cc,N/A,N/A,22434.90,N/A,13460.94,N/A,4602.71,N/A,5710.41,N/A,10372.58,N/A,7627.87,N/A,10879.05,N/A,4744.53,N/A,5710.41,N/A,5710.41,N/A,6772.12,N/A,10879.05,N/A,10879.05,N/A,10879.05,N/A,10372.58,N/A,5710.41,N/A,4744.53,N/A,12458.83,N/A,12458.83,N/A,4602.71,N/A,5710.41,N/A,5710.41,N/A,5076.65,N/A,4602.71,13460.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 296,"Cardiac Arrest, Unexplained With McC",N/A,N/A,60070.10,N/A,36042.06,N/A,8739.71,N/A,10604.28,N/A,19695.64,N/A,20423.83,N/A,20657.32,N/A,9008.99,N/A,10604.28,N/A,10604.28,N/A,12859.02,N/A,20657.32,N/A,20657.32,N/A,20657.32,N/A,19695.64,N/A,10604.28,N/A,9008.99,N/A,23657.05,N/A,23657.05,N/A,3463.63,N/A,10604.28,N/A,10604.28,N/A,9639.62,N/A,3463.63,36042.06,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 297,"Cardiac Arrest, Unexplained With Cc",N/A,N/A,40358.97,N/A,24215.38,N/A,6503.20,N/A,10340.10,N/A,40358.96,N/A,13722.05,N/A,20385.31,N/A,3499.01,N/A,10340.10,N/A,10340.10,N/A,4084.06,N/A,20385.31,N/A,20385.31,N/A,20385.31,N/A,14770.00,N/A,10335.08,N/A,3499.01,N/A,20520.00,N/A,20520.00,N/A,3499.01,N/A,10340.10,N/A,10340.10,N/A,3743.94,N/A,3499.01,40358.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 299,Peripheral Vascular Disorders With McC,N/A,N/A,30668.20,N/A,18400.92,N/A,8204.65,N/A,9971.32,N/A,18489.84,N/A,10427.19,N/A,19392.64,N/A,8457.45,N/A,9971.32,N/A,9971.32,N/A,12071.76,N/A,19392.64,N/A,19392.64,N/A,19392.64,N/A,18489.84,N/A,9971.32,N/A,8457.45,N/A,22208.72,N/A,22208.72,N/A,8204.65,N/A,9971.32,N/A,9971.32,N/A,9049.47,N/A,8204.65,22208.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 300,Peripheral Vascular Disorders With Cc,N/A,N/A,37611.90,N/A,22567.14,N/A,5500.53,N/A,6772.48,N/A,12395.88,N/A,12788.05,N/A,13001.14,N/A,5670.01,N/A,6772.48,N/A,6772.48,N/A,8093.10,N/A,13001.14,N/A,13001.14,N/A,13001.14,N/A,12395.88,N/A,6772.48,N/A,5670.01,N/A,14889.08,N/A,14889.08,N/A,N/A,N/A,6772.48,N/A,6772.48,N/A,6066.91,N/A,5500.53,22567.14,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 302,Atherosclerosis With McC,N/A,N/A,31744.60,N/A,19046.76,N/A,6432.49,N/A,7934.24,N/A,14496.13,N/A,10793.16,N/A,15203.93,N/A,6630.68,N/A,7874.94,N/A,7874.94,N/A,9464.32,N/A,15203.93,N/A,15203.93,N/A,15203.93,N/A,14496.13,N/A,7874.94,N/A,6630.68,N/A,17411.75,N/A,17411.75,N/A,N/A,N/A,7874.94,N/A,7934.24,N/A,7094.83,N/A,6432.49,19046.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 303,Atherosclerosis Without McC,N/A,N/A,31728.40,N/A,19037.04,N/A,3606.74,N/A,4591.53,N/A,8128.07,N/A,10787.65,N/A,8524.94,N/A,3717.87,N/A,4532.23,N/A,4532.23,N/A,5306.71,N/A,8524.94,N/A,8524.94,N/A,8524.94,N/A,8128.07,N/A,4532.23,N/A,3717.87,N/A,9762.88,N/A,9762.88,N/A,2047.75,N/A,4532.23,N/A,4591.53,N/A,3978.12,N/A,2047.75,19037.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 305,Hypertension Without McC,N/A,N/A,23879.20,N/A,14327.52,N/A,3977.49,N/A,4970.81,N/A,8963.60,N/A,8118.93,N/A,9401.27,N/A,4100.05,N/A,4970.81,N/A,4970.81,N/A,5852.21,N/A,9401.27,N/A,9401.27,N/A,9401.27,N/A,8963.60,N/A,4970.81,N/A,4100.05,N/A,10766.46,N/A,10766.46,N/A,4100.05,N/A,4970.81,N/A,4970.81,N/A,4387.05,N/A,3977.49,14327.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 308,Cardiac Arrhythmia And Conduction Disorders With McC,N/A,N/A,49247.40,N/A,29548.44,N/A,6255.38,N/A,7665.43,N/A,14097.00,N/A,16744.12,N/A,14785.31,N/A,6448.12,N/A,7665.43,N/A,7665.43,N/A,9203.74,N/A,14785.31,N/A,14785.31,N/A,14785.31,N/A,14097.00,N/A,7665.43,N/A,6448.12,N/A,16932.34,N/A,16932.34,N/A,N/A,N/A,7665.43,N/A,7665.43,N/A,6899.48,N/A,6255.38,29548.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 311,Angina Pectoris,N/A,N/A,12726.00,N/A,7635.60,N/A,3564.06,N/A,4481.74,N/A,8031.90,N/A,4326.84,N/A,8424.07,N/A,3673.87,N/A,4481.74,N/A,4481.74,N/A,5243.92,N/A,8424.07,N/A,8424.07,N/A,8424.07,N/A,8031.90,N/A,4481.74,N/A,3673.87,N/A,9647.36,N/A,9647.36,N/A,N/A,N/A,4481.74,N/A,4481.74,N/A,3931.05,N/A,3564.06,9647.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 313,Chest Pain,N/A,N/A,32315.60,N/A,19389.36,N/A,3859.06,N/A,4860.36,N/A,8696.71,N/A,10987.31,N/A,9121.35,N/A,3977.97,N/A,4830.71,N/A,4830.71,N/A,5677.97,N/A,9121.35,N/A,9121.35,N/A,9121.35,N/A,8696.71,N/A,4830.71,N/A,3977.97,N/A,10445.90,N/A,10445.90,N/A,2437.52,N/A,4830.71,N/A,4860.36,N/A,4256.43,N/A,2437.52,19389.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 315,Other Circulatory System Diagnoses With Cc,N/A,N/A,29584.20,N/A,17750.52,N/A,5166.58,N/A,6377.45,N/A,11643.31,N/A,10058.63,N/A,12211.82,N/A,5325.77,N/A,6377.45,N/A,6377.45,N/A,7601.76,N/A,12211.82,N/A,12211.82,N/A,12211.82,N/A,11643.31,N/A,6377.45,N/A,5325.77,N/A,13985.14,N/A,13985.14,N/A,5698.58,N/A,6377.45,N/A,6377.45,N/A,5698.58,N/A,5166.58,17750.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 316,Other Circulatory System Diagnoses Without Cc/McC,N/A,N/A,26459.40,N/A,15875.64,N/A,3638.21,N/A,4628.76,N/A,8199.00,N/A,8996.20,N/A,8599.34,N/A,3750.31,N/A,111838.00,N/A,111838.00,N/A,5353.02,N/A,8599.34,N/A,8599.34,N/A,8599.34,N/A,8199.00,N/A,4569.46,N/A,3750.31,N/A,9848.08,N/A,9848.08,N/A,2769.03,N/A,2352.36,N/A,4628.76,N/A,4012.83,N/A,2352.36,111838.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 319,Other Endovascular Cardiac Valve Procedures With McC,N/A,N/A,118051.32,N/A,70830.79,N/A,N/A,N/A,28125.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,28125.21,N/A,28125.21,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,27442.79,N/A,23681.95,N/A,62187.30,N/A,62187.30,N/A,N/A,N/A,28125.21,N/A,28125.21,N/A,N/A,N/A,23681.95,70830.79,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 326,"Stomach, Esophageal And Duodenal Procedures With McC",N/A,N/A,147969.82,N/A,88781.89,N/A,19522.10,N/A,32568.25,N/A,82341.02,N/A,50290.35,N/A,62126.88,N/A,19522.10,N/A,33351.92,N/A,34170.38,N/A,38672.53,N/A,62126.88,N/A,62126.88,N/A,62126.88,N/A,82341.02,N/A,32568.25,N/A,28148.23,N/A,73915.47,N/A,82341.02,N/A,19522.10,N/A,33190.30,N/A,34170.38,N/A,19522.10,N/A,19522.10,88781.89,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 328,"Stomach, Esophageal And Duodenal Procedures Without Cc/McC",N/A,N/A,73495.73,N/A,44097.44,N/A,8843.20,N/A,10726.69,N/A,19928.87,N/A,24988.54,N/A,20119.50,N/A,9115.67,N/A,562.00,N/A,562.00,N/A,12523.92,N/A,20119.50,N/A,20119.50,N/A,20119.50,N/A,19928.87,N/A,10726.69,N/A,9115.67,N/A,23937.19,N/A,23937.19,N/A,9058.84,N/A,10726.69,N/A,10726.69,N/A,9753.77,N/A,562.00,44097.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 339,Appendectomy With Complicated Principal Diagnosis With Cc,N/A,N/A,61978.88,N/A,37187.33,N/A,8686.90,N/A,10660.40,N/A,19576.62,N/A,21072.82,N/A,19763.89,N/A,8954.55,N/A,2248.00,N/A,2248.00,N/A,12302.56,N/A,19763.89,N/A,19763.89,N/A,19763.89,N/A,19576.62,N/A,10541.80,N/A,8954.55,N/A,23514.10,N/A,23514.10,N/A,11877.93,N/A,10541.80,N/A,10541.80,N/A,9581.37,N/A,2248.00,37187.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 341,Appendectomy Without Complicated Principal Diagnosis With McC,N/A,N/A,70674.83,N/A,42404.90,N/A,12050.91,N/A,14948.33,N/A,27157.70,N/A,24029.44,N/A,27417.48,N/A,12422.22,N/A,3934.00,N/A,3934.00,N/A,45200.33,N/A,27417.48,N/A,27417.48,N/A,27417.48,N/A,27157.70,N/A,14521.24,N/A,12422.22,N/A,32619.96,N/A,32619.96,N/A,8825.36,N/A,14521.24,N/A,14521.24,N/A,13291.77,N/A,3934.00,45200.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 343,Appendectomy Without Complicated Principal Diagnosis Without Cc/McC,N/A,N/A,32328.87,N/A,19397.32,N/A,5829.14,N/A,7190.86,N/A,13136.44,N/A,10991.81,N/A,13262.10,N/A,6008.75,N/A,7161.21,N/A,7161.21,N/A,8255.35,N/A,13262.10,N/A,13262.10,N/A,13262.10,N/A,13136.44,N/A,7161.21,N/A,6008.75,N/A,15778.59,N/A,15778.59,N/A,5177.46,N/A,7161.21,N/A,7190.86,N/A,5177.46,N/A,5177.46,19397.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 345,Minor Small And Large Bowel Procedures With Cc,N/A,N/A,43397.30,N/A,26038.38,N/A,8276.66,N/A,10056.51,N/A,18652.13,N/A,14755.08,N/A,18830.56,N/A,8531.68,N/A,10056.51,N/A,10056.51,N/A,11721.58,N/A,18830.56,N/A,18830.56,N/A,18830.56,N/A,18652.13,N/A,10056.51,N/A,8531.68,N/A,22403.66,N/A,22403.66,N/A,8312.83,N/A,10056.51,N/A,10056.51,N/A,9128.90,N/A,8276.66,26038.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 347,Anal And Stomal Procedures With McC,N/A,N/A,50800.00,N/A,30480.00,N/A,13540.33,N/A,16283.17,N/A,30514.24,N/A,17272.00,N/A,30806.13,N/A,13957.54,N/A,16283.17,N/A,16283.17,N/A,19176.10,N/A,30806.13,N/A,30806.13,N/A,30806.13,N/A,30514.24,N/A,16283.17,N/A,13957.54,N/A,36651.61,N/A,36651.61,N/A,9017.71,N/A,16283.17,N/A,16283.17,N/A,14934.56,N/A,9017.71,36651.61,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 350,Inguinal And Femoral Hernia Procedures With McC,N/A,N/A,91407.65,N/A,54844.59,N/A,12970.28,N/A,15964.72,N/A,49654.92,N/A,N/A,N/A,N/A,N/A,12970.28,N/A,3372.00,N/A,3372.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,29648.14,N/A,15964.72,N/A,12970.28,N/A,34035.08,N/A,49654.92,N/A,12970.28,N/A,15964.72,N/A,15964.72,N/A,12970.28,N/A,3372.00,54844.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 352,Inguinal And Femoral Hernia Procedures Without Cc/McC,N/A,N/A,48382.20,N/A,29029.32,N/A,5879.29,N/A,7220.53,N/A,14693.92,N/A,16448.59,N/A,13376.19,N/A,6060.44,N/A,1124.00,N/A,1124.00,N/A,8326.37,N/A,13376.19,N/A,13376.19,N/A,13376.19,N/A,14693.92,N/A,7220.53,N/A,6060.44,N/A,15914.32,N/A,15914.32,N/A,4921.85,N/A,7220.53,N/A,7220.53,N/A,6484.67,N/A,1124.00,29029.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 354,Hernia Procedures Except Inguinal And Femoral With Cc,N/A,N/A,70968.83,N/A,42581.30,N/A,9346.26,N/A,11321.78,N/A,22760.75,N/A,24129.41,N/A,21264.02,N/A,9634.23,N/A,3372.00,N/A,3372.00,N/A,13236.36,N/A,21264.02,N/A,21264.02,N/A,21264.02,N/A,22760.75,N/A,11321.78,N/A,9634.23,N/A,25298.88,N/A,25298.88,N/A,8252.56,N/A,11321.78,N/A,11321.78,N/A,10308.63,N/A,3372.00,42581.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 355,Hernia Procedures Except Inguinal And Femoral Without Cc/McC,N/A,N/A,52696.23,N/A,31617.74,N/A,7320.70,N/A,8925.66,N/A,17978.14,N/A,17916.71,N/A,16655.61,N/A,7546.26,N/A,1686.00,N/A,1686.00,N/A,10367.73,N/A,16655.61,N/A,16655.61,N/A,16655.61,N/A,17978.14,N/A,8925.66,N/A,7546.26,N/A,19816.01,N/A,19816.01,N/A,6620.13,N/A,8925.66,N/A,8925.66,N/A,8074.50,N/A,1686.00,31617.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 356,Other Digestive System O.R. Procedures With McC,N/A,N/A,75888.00,N/A,45532.80,N/A,24844.85,N/A,N/A,N/A,N/A,N/A,25801.92,N/A,51248.48,N/A,24844.85,N/A,26912.09,N/A,26912.09,N/A,51248.48,N/A,51248.48,N/A,51248.48,N/A,51248.48,N/A,50762.90,N/A,26912.09,N/A,24844.85,N/A,N/A,N/A,60972.90,N/A,24844.85,N/A,26912.09,N/A,N/A,N/A,24844.85,N/A,24844.85,60972.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 358,Other Digestive System O.R. Procedures Without Cc/McC,N/A,N/A,61408.35,N/A,36845.01,N/A,7400.19,N/A,9019.69,N/A,16676.92,N/A,20878.84,N/A,16836.45,N/A,7628.20,N/A,3372.00,N/A,3372.00,N/A,10480.30,N/A,16836.45,N/A,16836.45,N/A,16836.45,N/A,16676.92,N/A,9019.69,N/A,7628.20,N/A,20031.17,N/A,20031.17,N/A,7628.20,N/A,9019.69,N/A,9019.69,N/A,8162.17,N/A,3372.00,36845.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 368,Major Esophageal Disorders With McC,N/A,N/A,41218.80,N/A,24731.28,N/A,9357.99,N/A,11335.66,N/A,21088.99,N/A,14014.39,N/A,21290.73,N/A,9646.33,N/A,11335.66,N/A,11335.66,N/A,13252.98,N/A,21290.73,N/A,21290.73,N/A,21290.73,N/A,21088.99,N/A,11335.66,N/A,9646.33,N/A,25330.65,N/A,25330.65,N/A,1845.33,N/A,11335.66,N/A,11335.66,N/A,10321.57,N/A,1845.33,25330.65,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 372,Major Gastrointestinal Disorders And Peritoneal Infections With Cc,N/A,N/A,32984.70,N/A,19790.82,N/A,5430.64,N/A,6689.82,N/A,12238.40,N/A,11214.80,N/A,12355.47,N/A,5597.97,N/A,6689.82,N/A,6689.82,N/A,7690.99,N/A,12355.47,N/A,12355.47,N/A,12355.47,N/A,12238.40,N/A,6689.82,N/A,5597.97,N/A,14699.92,N/A,14699.92,N/A,5962.87,N/A,6689.82,N/A,6689.82,N/A,5989.83,N/A,5430.64,19790.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 374,Digestive Malignancy With McC,N/A,N/A,53364.27,N/A,32018.56,N/A,10633.50,N/A,12844.53,N/A,23963.45,N/A,18143.85,N/A,26259.73,N/A,10961.14,N/A,3934.00,N/A,3934.00,N/A,26259.73,N/A,26259.73,N/A,26259.73,N/A,24192.68,N/A,23963.45,N/A,12844.53,N/A,10961.14,N/A,28783.25,N/A,28783.25,N/A,10961.14,N/A,13567.23,N/A,13523.48,N/A,8732.01,N/A,3934.00,32018.56,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 376,Digestive Malignancy Without Cc/McC,N/A,N/A,33197.50,N/A,19918.50,N/A,4682.73,N/A,5805.08,N/A,10552.91,N/A,11287.15,N/A,10653.86,N/A,4827.01,N/A,2248.00,N/A,2248.00,N/A,6631.78,N/A,10653.86,N/A,10653.86,N/A,10653.86,N/A,10552.91,N/A,5805.08,N/A,4827.01,N/A,12675.43,N/A,12675.43,N/A,N/A,N/A,5805.08,N/A,5805.08,N/A,5164.90,N/A,2248.00,19918.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 377,Gastrointestinal Hemorrhage With McC,N/A,N/A,55903.10,N/A,33541.86,N/A,9484.96,N/A,11693.41,N/A,16080.19,N/A,N/A,N/A,N/A,N/A,9484.96,N/A,11485.86,N/A,11485.86,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,16080.19,N/A,11485.86,N/A,9484.96,N/A,16080.19,N/A,16080.19,N/A,9484.96,N/A,11485.86,N/A,11634.11,N/A,9484.96,N/A,9484.96,33541.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 381,Complicated Peptic Ulcer With Cc,N/A,N/A,37165.55,N/A,22299.33,N/A,5630.69,N/A,6926.46,N/A,12689.22,N/A,12636.29,N/A,12810.60,N/A,5804.18,N/A,3372.00,N/A,3372.00,N/A,7974.30,N/A,12810.60,N/A,12810.60,N/A,12810.60,N/A,12689.22,N/A,6926.46,N/A,5804.18,N/A,15241.42,N/A,15241.42,N/A,5804.18,N/A,6926.46,N/A,6926.46,N/A,6210.48,N/A,3372.00,22299.33,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 384,Uncomplicated Peptic Ulcer Without McC,N/A,N/A,34678.70,N/A,20807.22,N/A,4809.69,N/A,5984.92,N/A,10839.04,N/A,10854.73,N/A,6138.93,N/A,4957.89,N/A,83738.00,N/A,83738.00,N/A,3821.60,N/A,6138.93,N/A,6138.93,N/A,6138.93,N/A,10839.04,N/A,5955.27,N/A,4957.89,N/A,13019.10,N/A,13019.10,N/A,4951.99,N/A,5955.27,N/A,5984.92,N/A,5304.94,N/A,3821.60,83738.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 386,Inflammatory Bowel Disease With Cc,N/A,N/A,25065.70,N/A,15039.42,N/A,5280.21,N/A,6511.85,N/A,11899.38,N/A,8505.68,N/A,12013.20,N/A,5442.90,N/A,6511.85,N/A,6511.85,N/A,7477.94,N/A,12013.20,N/A,12013.20,N/A,12013.20,N/A,11899.38,N/A,6511.85,N/A,5442.90,N/A,14292.71,N/A,1871.00,N/A,2273.60,N/A,6511.85,N/A,6511.85,N/A,5823.90,N/A,1871.00,15039.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 387,Inflammatory Bowel Disease Without Cc/McC,N/A,N/A,21425.90,N/A,12855.54,N/A,3689.42,N/A,4630.04,N/A,8314.42,N/A,7284.81,N/A,8393.95,N/A,3803.10,N/A,1686.00,N/A,1686.00,N/A,5225.04,N/A,8393.95,N/A,8393.95,N/A,8393.95,N/A,8314.42,N/A,4630.04,N/A,3803.10,N/A,9986.70,N/A,9986.70,N/A,4904.89,N/A,4630.04,N/A,4630.04,N/A,4069.32,N/A,1686.00,12855.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 389,Gastrointestinal Obstruction With Cc,N/A,N/A,28194.60,N/A,16916.76,N/A,4305.57,N/A,5358.91,N/A,9702.96,N/A,9586.16,N/A,9795.77,N/A,4438.23,N/A,5358.91,N/A,5358.91,N/A,6097.64,N/A,9795.77,N/A,9795.77,N/A,9795.77,N/A,9702.96,N/A,5358.91,N/A,4438.23,N/A,11654.52,N/A,11654.52,N/A,4438.23,N/A,5358.91,N/A,5358.91,N/A,4748.91,N/A,4305.57,16916.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 390,Gastrointestinal Obstruction Without Cc/McC,N/A,N/A,19123.50,N/A,11474.10,N/A,3016.73,N/A,3834.28,N/A,6798.44,N/A,6501.99,N/A,6863.47,N/A,3109.68,N/A,3834.28,N/A,3834.28,N/A,4272.35,N/A,6863.47,N/A,6863.47,N/A,6863.47,N/A,6798.44,N/A,3834.28,N/A,3109.68,N/A,8165.82,N/A,8165.82,N/A,3109.68,N/A,3834.28,N/A,3834.28,N/A,3327.36,N/A,3016.73,11474.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 392,"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC",N/A,N/A,25220.80,N/A,15132.48,N/A,4201.55,N/A,5235.86,N/A,9468.53,N/A,8575.07,N/A,9559.10,N/A,4331.00,N/A,5235.86,N/A,5235.86,N/A,5950.32,N/A,9559.10,N/A,9559.10,N/A,9559.10,N/A,9468.53,N/A,5235.86,N/A,4331.00,N/A,11372.94,N/A,11372.94,N/A,4331.00,N/A,5235.86,N/A,5235.86,N/A,4634.17,N/A,4201.55,15132.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 395,Other Digestive System Diagnoses Without Cc/McC,N/A,N/A,23742.40,N/A,14245.44,N/A,3440.30,N/A,4335.33,N/A,7752.99,N/A,8072.42,N/A,7827.15,N/A,3546.30,N/A,4335.33,N/A,4335.33,N/A,4872.22,N/A,7827.15,N/A,7827.15,N/A,7827.15,N/A,7752.99,N/A,4335.33,N/A,3546.30,N/A,9312.36,N/A,9312.36,N/A,3934.92,N/A,4335.33,N/A,4335.33,N/A,3794.54,N/A,3440.30,14245.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 412,Cholecystectomy With C.D.E. With Cc,N/A,N/A,64495.50,N/A,38697.30,N/A,12246.69,N/A,14752.85,N/A,27598.91,N/A,21928.46,N/A,27862.91,N/A,12624.03,N/A,562.00,N/A,562.00,N/A,17344.01,N/A,27862.91,N/A,27862.91,N/A,27862.91,N/A,27598.91,N/A,14752.85,N/A,12624.03,N/A,33149.91,N/A,33149.91,N/A,N/A,N/A,14752.85,N/A,14752.85,N/A,13507.71,N/A,562.00,38697.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 413,Cholecystectomy With C.D.E. Without Cc/McC,N/A,N/A,25697.83,N/A,15418.70,N/A,8644.22,N/A,10491.31,N/A,19480.45,N/A,8737.26,N/A,19666.79,N/A,8910.56,N/A,562.00,N/A,562.00,N/A,12242.12,N/A,19666.79,N/A,19666.79,N/A,19666.79,N/A,19480.45,N/A,10491.31,N/A,8910.56,N/A,23398.58,N/A,23398.58,N/A,N/A,N/A,10491.31,N/A,10491.31,N/A,9534.30,N/A,562.00,23398.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 414,Cholecystectomy Except By Laparoscope Without C.D.E. With McC,N/A,N/A,88994.52,N/A,53396.71,N/A,14142.21,N/A,16995.15,N/A,44553.73,N/A,30258.14,N/A,42900.65,N/A,14577.96,N/A,2810.00,N/A,23157.81,N/A,26704.66,N/A,42900.65,N/A,42900.65,N/A,42900.65,N/A,44553.73,N/A,16995.15,N/A,14577.96,N/A,51041.07,N/A,51041.07,N/A,11539.76,N/A,16995.15,N/A,16995.15,N/A,15598.42,N/A,2810.00,53396.71,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 415,Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,N/A,N/A,77145.45,N/A,46287.27,N/A,10669.24,N/A,13035.05,N/A,25142.98,N/A,26229.46,N/A,24274.00,N/A,10997.98,N/A,2810.00,N/A,2810.00,N/A,15110.00,N/A,24274.00,N/A,24274.00,N/A,24274.00,N/A,25142.98,N/A,12886.80,N/A,10997.98,N/A,28880.00,N/A,28880.00,N/A,8066.77,N/A,12886.80,N/A,12886.80,N/A,11767.84,N/A,2810.00,46287.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 416,Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,N/A,N/A,36691.12,N/A,22014.67,N/A,7342.57,N/A,8951.54,N/A,16547.08,N/A,12474.97,N/A,16705.37,N/A,7568.81,N/A,562.00,N/A,562.00,N/A,10398.70,N/A,16705.37,N/A,16705.37,N/A,16705.37,N/A,16547.08,N/A,8951.54,N/A,7568.81,N/A,19875.22,N/A,19875.22,N/A,5521.88,N/A,8951.54,N/A,8951.54,N/A,8098.63,N/A,562.00,22014.67,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 418,Laparoscopic Cholecystectomy Without C.D.E. With Cc,N/A,N/A,61447.43,N/A,36868.46,N/A,8860.80,N/A,10747.52,N/A,19968.54,N/A,20892.12,N/A,20159.56,N/A,9133.82,N/A,10747.52,N/A,10747.52,N/A,12548.86,N/A,20159.56,N/A,20159.56,N/A,20159.56,N/A,19968.54,N/A,10747.52,N/A,9133.82,N/A,23984.84,N/A,23984.84,N/A,9773.19,N/A,10747.52,N/A,10747.52,N/A,9773.19,N/A,8860.80,36868.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 421,Hepatobiliary Diagnostic Procedures With Cc,N/A,N/A,71698.98,N/A,43019.39,N/A,10799.92,N/A,11697.88,N/A,21931.63,N/A,24377.65,N/A,21987.39,N/A,9961.97,N/A,12891.99,N/A,3372.00,N/A,13686.64,N/A,21987.39,N/A,21987.39,N/A,21987.39,N/A,21931.63,N/A,11697.88,N/A,9961.97,N/A,26159.50,N/A,26159.50,N/A,9961.97,N/A,11697.88,N/A,11697.88,N/A,10659.31,N/A,3372.00,43019.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 423,Other Hepatobiliary Or Pancreas O.R. Procedures With McC,N/A,N/A,122150.87,N/A,73290.52,N/A,12360.51,N/A,25078.21,N/A,67329.56,N/A,41481.28,N/A,47721.47,N/A,21621.48,N/A,26882.09,N/A,3372.00,N/A,29705.50,N/A,47721.47,N/A,47721.47,N/A,47721.47,N/A,67329.56,N/A,25078.21,N/A,21621.48,N/A,56776.64,N/A,56776.64,N/A,21621.48,N/A,25078.21,N/A,25078.21,N/A,23134.98,N/A,3372.00,73290.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 424,Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,N/A,N/A,104373.13,N/A,62623.88,N/A,15509.07,N/A,15212.89,N/A,30904.81,N/A,35486.86,N/A,28747.70,N/A,13024.91,N/A,15212.89,N/A,15212.89,N/A,17894.77,N/A,28747.70,N/A,28747.70,N/A,28747.70,N/A,30904.81,N/A,15212.89,N/A,13024.91,N/A,34202.58,N/A,34202.58,N/A,15509.07,N/A,15212.89,N/A,15212.89,N/A,13936.65,N/A,13024.91,62623.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 425,Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/McC,N/A,N/A,33577.50,N/A,20146.50,N/A,7631.71,N/A,9293.56,N/A,17798.82,N/A,11416.35,N/A,17363.19,N/A,7866.85,N/A,2248.00,N/A,2248.00,N/A,10808.18,N/A,17363.19,N/A,17363.19,N/A,17363.19,N/A,17798.82,N/A,9293.56,N/A,7866.85,N/A,20657.86,N/A,20657.86,N/A,N/A,N/A,9293.56,N/A,9293.56,N/A,8417.53,N/A,2248.00,20657.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 432,Cirrhosis And Alcoholic Hepatitis With McC,N/A,N/A,52203.90,N/A,31322.34,N/A,10072.83,N/A,12181.28,N/A,22699.94,N/A,17638.25,N/A,18063.64,N/A,10383.19,N/A,12181.28,N/A,12181.28,N/A,11246.98,N/A,18063.64,N/A,18063.64,N/A,18063.64,N/A,22699.94,N/A,12181.28,N/A,10383.19,N/A,27265.61,N/A,27265.61,N/A,10383.19,N/A,12181.28,N/A,12181.28,N/A,11110.02,N/A,10072.83,31322.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 433,Cirrhosis And Alcoholic Hepatitis With Cc,N/A,N/A,42349.83,N/A,25409.90,N/A,5546.94,N/A,6827.38,N/A,12500.48,N/A,14398.95,N/A,12620.05,N/A,5717.85,N/A,6827.38,N/A,6827.38,N/A,7855.69,N/A,12620.05,N/A,12620.05,N/A,12620.05,N/A,12500.48,N/A,6827.38,N/A,5717.85,N/A,15014.71,N/A,15014.71,N/A,6118.10,N/A,1677.71,N/A,1677.71,N/A,6118.10,N/A,1677.71,25409.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 440,Disorders Of Pancreas Except Malignancy Without Cc/McC,N/A,N/A,18675.30,N/A,11205.18,N/A,3234.91,N/A,4092.37,N/A,7290.14,N/A,6349.60,N/A,7359.88,N/A,3334.59,N/A,4092.37,N/A,4092.37,N/A,4581.35,N/A,7359.88,N/A,7359.88,N/A,7359.88,N/A,7290.14,N/A,4092.37,N/A,3334.59,N/A,8756.42,N/A,8756.42,N/A,2429.10,N/A,4092.37,N/A,4092.37,N/A,3568.01,N/A,2429.10,11205.18,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 441,"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC",N/A,N/A,79188.60,N/A,47513.16,N/A,10108.04,N/A,N/A,N/A,N/A,N/A,26924.13,N/A,22997.19,N/A,10419.49,N/A,12222.94,N/A,N/A,N/A,22997.19,N/A,22997.19,N/A,22997.19,N/A,22997.19,N/A,22779.29,N/A,N/A,N/A,10419.49,N/A,N/A,N/A,27360.91,N/A,10419.49,N/A,N/A,N/A,12400.84,N/A,11148.85,N/A,10108.04,47513.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 457,"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc",N/A,N/A,237760.62,N/A,142656.37,N/A,32204.04,N/A,38361.37,N/A,131053.65,N/A,80838.61,N/A,82788.25,N/A,33196.30,N/A,1686.00,N/A,1686.00,N/A,51546.50,N/A,82788.25,N/A,82788.25,N/A,82788.25,N/A,131053.65,N/A,38361.37,N/A,33196.30,N/A,128892.76,N/A,128892.76,N/A,19481.80,N/A,38361.37,N/A,38361.37,N/A,35520.04,N/A,1686.00,142656.37,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 460,Spinal Fusion Except Cervical Without McC,N/A,N/A,111399.88,N/A,66839.93,N/A,20090.18,N/A,24031.30,N/A,61403.62,N/A,37875.97,N/A,45707.94,N/A,20709.19,N/A,24031.30,N/A,24031.30,N/A,28452.13,N/A,45707.94,N/A,45707.94,N/A,45707.94,N/A,61403.62,N/A,24031.30,N/A,20709.19,N/A,54381.04,N/A,54381.04,N/A,20709.19,N/A,24031.30,N/A,24031.30,N/A,22158.84,N/A,20090.18,66839.93,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 461,Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,N/A,N/A,120970.20,N/A,72582.12,N/A,N/A,N/A,N/A,N/A,97321.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,97321.09,N/A,N/A,N/A,N/A,N/A,97321.09,N/A,97321.09,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,72582.12,97321.09,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 462,Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without McC,N/A,N/A,107145.58,N/A,64287.35,N/A,15927.04,N/A,19106.51,N/A,59058.64,N/A,36429.49,N/A,36236.23,N/A,N/A,N/A,19106.51,N/A,19106.51,N/A,22556.21,N/A,36236.23,N/A,36236.23,N/A,36236.23,N/A,59058.64,N/A,19106.51,N/A,16417.78,N/A,43112.06,N/A,43112.06,N/A,N/A,N/A,19106.51,N/A,19106.51,N/A,17567.03,N/A,15927.04,64287.35,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 463,Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,N/A,N/A,126656.40,N/A,75993.84,N/A,18006.72,N/A,33967.34,N/A,77186.60,N/A,68450.05,N/A,68450.05,N/A,18006.72,N/A,27666.03,N/A,34822.92,N/A,68450.05,N/A,68450.05,N/A,68450.05,N/A,68450.05,N/A,77186.60,N/A,34142.18,N/A,18006.72,N/A,77186.60,N/A,77186.60,N/A,18006.72,N/A,32967.84,N/A,33967.34,N/A,18006.72,N/A,18006.72,77186.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 464,Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,N/A,N/A,97888.47,N/A,58733.08,N/A,12782.87,N/A,N/A,N/A,39237.35,N/A,36255.65,N/A,36255.65,N/A,12782.87,N/A,N/A,N/A,N/A,N/A,36255.65,N/A,36255.65,N/A,36255.65,N/A,36255.65,N/A,39237.35,N/A,N/A,N/A,12782.87,N/A,39237.35,N/A,39237.35,N/A,12782.87,N/A,10548.85,N/A,N/A,N/A,12782.87,N/A,10548.85,58733.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 465,Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,N/A,N/A,54001.72,N/A,32401.03,N/A,8177.15,N/A,9938.41,N/A,32072.10,N/A,18360.58,N/A,24185.40,N/A,8429.10,N/A,9938.41,N/A,9938.41,N/A,15054.85,N/A,24185.40,N/A,24185.40,N/A,24185.40,N/A,32072.10,N/A,9938.41,N/A,8429.10,N/A,28774.59,N/A,28774.59,N/A,N/A,N/A,9938.41,N/A,9938.41,N/A,9019.14,N/A,8177.15,32401.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 467,Revision Of Hip Or Knee Replacement With Cc,N/A,N/A,126942.68,N/A,76165.61,N/A,19342.80,N/A,23147.18,N/A,N/A,N/A,43160.51,N/A,44007.55,N/A,19342.80,N/A,23147.18,N/A,23147.18,N/A,27393.67,N/A,44007.55,N/A,44007.55,N/A,44007.55,N/A,N/A,N/A,23147.18,N/A,19342.80,N/A,N/A,N/A,N/A,N/A,110.82,N/A,23147.18,N/A,23147.18,N/A,19342.80,N/A,110.82,76165.61,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 469,Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,N/A,N/A,85264.20,N/A,51158.52,N/A,17238.29,N/A,20746.61,N/A,51993.59,N/A,N/A,N/A,N/A,N/A,17238.29,N/A,20657.66,N/A,20657.66,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,51993.59,N/A,20657.66,N/A,17769.43,N/A,46661.42,N/A,N/A,N/A,17238.29,N/A,20657.66,N/A,20657.66,N/A,19013.30,N/A,17238.29,51993.59,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 470,Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,N/A,N/A,71658.20,N/A,42994.92,N/A,10199.26,N/A,12330.85,N/A,36130.56,N/A,24363.79,N/A,23204.73,N/A,10513.52,N/A,12330.85,N/A,12330.85,N/A,14444.40,N/A,23204.73,N/A,23204.73,N/A,23204.73,N/A,36130.56,N/A,12330.85,N/A,10513.52,N/A,27607.84,N/A,27607.84,N/A,11249.46,N/A,12330.85,N/A,12330.85,N/A,11249.46,N/A,10199.26,42994.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 473,Cervical Spinal Fusion Without Cc/McC,N/A,N/A,94465.37,N/A,56679.22,N/A,13523.80,N/A,16263.60,N/A,49124.67,N/A,32118.22,N/A,30768.51,N/A,13940.49,N/A,562.00,N/A,562.00,N/A,19152.68,N/A,30768.51,N/A,30768.51,N/A,30768.51,N/A,49124.67,N/A,16263.60,N/A,13940.49,N/A,36606.84,N/A,36606.84,N/A,12650.07,N/A,16263.60,N/A,16263.60,N/A,14916.32,N/A,562.00,56679.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 479,Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,N/A,N/A,59483.85,N/A,35690.31,N/A,9433.74,N/A,11791.19,N/A,30736.54,N/A,20224.51,N/A,21463.07,N/A,4317.14,N/A,11791.19,N/A,11791.19,N/A,13360.26,N/A,21463.07,N/A,21463.07,N/A,21463.07,N/A,21259.70,N/A,11791.19,N/A,4317.14,N/A,25535.70,N/A,30736.54,N/A,9724.41,N/A,11425.28,N/A,11425.28,N/A,4317.14,N/A,4317.14,35690.31,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 480,Hip And Femur Procedures Except Major Joint With McC,N/A,N/A,112428.27,N/A,67456.96,N/A,15822.48,N/A,18982.83,N/A,61970.46,N/A,38225.62,N/A,N/A,N/A,13153.23,N/A,18982.83,N/A,18982.83,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,61970.46,N/A,18982.83,N/A,13153.23,N/A,N/A,N/A,N/A,N/A,13153.23,N/A,18982.83,N/A,18982.83,N/A,17451.70,N/A,13153.23,67456.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 483,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,N/A,N/A,86136.48,N/A,51681.89,N/A,12576.90,N/A,13078.37,N/A,49471.58,N/A,29286.42,N/A,28614.19,N/A,12964.42,N/A,15143.47,N/A,15143.47,N/A,17811.67,N/A,28614.19,N/A,28614.19,N/A,28614.19,N/A,49471.58,N/A,15143.47,N/A,12964.42,N/A,34043.74,N/A,34043.74,N/A,12964.42,N/A,15143.47,N/A,15232.42,N/A,12964.42,N/A,12576.90,51681.89,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 486,Knee Procedures With Principal Diagnosis Of Infection With Cc,N/A,N/A,72528.68,N/A,43517.21,N/A,11128.02,N/A,13539.99,N/A,35211.01,N/A,24659.75,N/A,27591.52,N/A,7321.27,N/A,2248.00,N/A,2248.00,N/A,15759.73,N/A,27591.52,N/A,25317.78,N/A,25317.78,N/A,35211.01,N/A,13429.51,N/A,7321.27,N/A,30121.84,N/A,30121.84,N/A,11470.89,N/A,13429.51,N/A,13429.51,N/A,7321.27,N/A,2248.00,43517.21,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 487,Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,N/A,N/A,63490.97,N/A,38094.58,N/A,8556.73,N/A,10387.81,N/A,25297.12,N/A,21586.93,N/A,19467.75,N/A,11696.07,N/A,2248.00,N/A,2248.00,N/A,12118.22,N/A,19467.75,N/A,19467.75,N/A,19467.75,N/A,25297.12,N/A,10387.81,N/A,8820.38,N/A,23161.76,N/A,23161.76,N/A,11696.07,N/A,10387.81,N/A,10387.81,N/A,9437.81,N/A,2248.00,38094.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 488,Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,N/A,N/A,67928.92,N/A,40757.35,N/A,12105.32,N/A,14585.61,N/A,34763.26,N/A,23095.82,N/A,27541.28,N/A,12478.31,N/A,1686.00,N/A,1686.00,N/A,17143.81,N/A,27541.28,N/A,27541.28,N/A,27541.28,N/A,34763.26,N/A,14585.61,N/A,12478.31,N/A,32767.25,N/A,32767.25,N/A,12478.31,N/A,14585.61,N/A,14585.61,N/A,13351.79,N/A,1686.00,40757.35,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 489,Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,N/A,N/A,65463.67,N/A,39278.20,N/A,7092.38,N/A,8655.56,N/A,20641.00,N/A,22257.64,N/A,16136.14,N/A,7310.91,N/A,562.00,N/A,562.00,N/A,10044.37,N/A,16136.14,N/A,16136.14,N/A,16136.14,N/A,20641.00,N/A,8655.56,N/A,7310.91,N/A,19197.98,N/A,19197.98,N/A,8368.73,N/A,8655.56,N/A,8655.56,N/A,7822.67,N/A,562.00,39278.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 494,"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC",N/A,N/A,78525.77,N/A,47115.46,N/A,10076.03,N/A,12185.08,N/A,33391.04,N/A,26698.76,N/A,22924.37,N/A,10386.49,N/A,12185.08,N/A,12185.08,N/A,14269.88,N/A,22924.37,N/A,22924.37,N/A,22924.37,N/A,33391.04,N/A,12185.08,N/A,10386.49,N/A,27274.27,N/A,27274.27,N/A,11113.55,N/A,12185.08,N/A,12185.08,N/A,11113.55,N/A,10076.03,47115.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 495,Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,N/A,N/A,114707.27,N/A,68824.36,N/A,19000.60,N/A,18497.18,N/A,63226.64,N/A,39000.48,N/A,45081.67,N/A,19586.04,N/A,3372.00,N/A,3372.00,N/A,28062.29,N/A,45081.67,N/A,45081.67,N/A,45081.67,N/A,63226.64,N/A,18408.23,N/A,19586.04,N/A,53635.94,N/A,53635.94,N/A,24887.43,N/A,18408.23,N/A,18408.23,N/A,20957.07,N/A,3372.00,68824.36,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 496,Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,N/A,N/A,68145.53,N/A,40887.32,N/A,11494.42,N/A,13830.74,N/A,85742.89,N/A,23169.21,N/A,25484.06,N/A,11494.42,N/A,13830.74,N/A,13515.98,N/A,15863.23,N/A,25484.06,N/A,25484.06,N/A,25484.06,N/A,26121.50,N/A,13515.98,N/A,11494.42,N/A,30319.67,N/A,30319.67,N/A,11494.42,N/A,13830.74,N/A,13830.74,N/A,12354.46,N/A,11494.42,85742.89,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 501,Soft Tissue Procedures With Cc,N/A,N/A,51029.85,N/A,30617.91,N/A,9377.20,N/A,11358.38,N/A,22766.65,N/A,17350.15,N/A,21334.42,N/A,9666.12,N/A,3372.00,N/A,3372.00,N/A,13280.18,N/A,21334.42,N/A,21334.42,N/A,21334.42,N/A,22766.65,N/A,11358.38,N/A,9666.12,N/A,25382.63,N/A,25382.63,N/A,9666.12,N/A,11358.38,N/A,11358.38,N/A,8792.37,N/A,3372.00,30617.91,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 502,Soft Tissue Procedures Without Cc/McC,N/A,N/A,55130.70,N/A,33078.42,N/A,7332.44,N/A,8939.53,N/A,16524.24,N/A,18744.44,N/A,16682.31,N/A,7558.36,N/A,2248.00,N/A,2248.00,N/A,10384.35,N/A,16682.31,N/A,16682.31,N/A,16682.31,N/A,16524.24,N/A,8939.53,N/A,7558.36,N/A,19847.78,N/A,19847.78,N/A,9062.65,N/A,8939.53,N/A,8939.53,N/A,8087.45,N/A,2248.00,33078.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 504,Foot Procedures With Cc,N/A,N/A,84907.20,N/A,50944.32,N/A,9467.88,N/A,11465.66,N/A,21336.65,N/A,28868.45,N/A,24391.08,N/A,9058.59,N/A,4496.00,N/A,4496.00,N/A,24391.08,N/A,24391.08,N/A,24391.08,N/A,21540.75,N/A,21336.65,N/A,11465.66,N/A,9058.59,N/A,25628.11,N/A,25628.11,N/A,9058.59,N/A,11465.66,N/A,12770.25,N/A,9058.59,N/A,4496.00,50944.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 506,Major Thumb Or Joint Procedures,N/A,N/A,36508.48,N/A,21905.09,N/A,7520.75,N/A,9162.30,N/A,16948.62,N/A,12412.89,N/A,17110.74,N/A,7752.48,N/A,1686.00,N/A,1686.00,N/A,10651.04,N/A,17110.74,N/A,17110.74,N/A,17110.74,N/A,16948.62,N/A,9162.30,N/A,7752.48,N/A,20357.51,N/A,20357.51,N/A,5747.11,N/A,9162.30,N/A,9723.39,N/A,8295.15,N/A,1686.00,21905.09,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 511,"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",N/A,N/A,76447.57,N/A,45868.54,N/A,10557.21,N/A,12754.28,N/A,30969.32,N/A,25992.18,N/A,24019.12,N/A,10882.50,N/A,12754.28,N/A,12754.28,N/A,14951.35,N/A,24019.12,N/A,24019.12,N/A,24019.12,N/A,30969.32,N/A,12754.28,N/A,N/A,N/A,28576.76,N/A,28576.76,N/A,N/A,N/A,12754.28,N/A,12754.28,N/A,11644.28,N/A,10557.21,45868.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 512,"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/McC",N/A,N/A,56774.13,N/A,34064.48,N/A,8570.07,N/A,10403.59,N/A,22395.14,N/A,19303.20,N/A,19498.09,N/A,8834.13,N/A,10403.59,N/A,10403.59,N/A,12137.11,N/A,19498.09,N/A,19498.09,N/A,19498.09,N/A,22395.14,N/A,10403.59,N/A,8834.13,N/A,23197.86,N/A,23197.86,N/A,3244.98,N/A,10403.59,N/A,10403.59,N/A,9452.52,N/A,3244.98,34064.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 513,"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/McC",N/A,N/A,44212.67,N/A,26527.60,N/A,8503.39,N/A,10324.72,N/A,21860.26,N/A,15032.31,N/A,19346.38,N/A,8765.39,N/A,1124.00,N/A,1124.00,N/A,12042.67,N/A,19346.38,N/A,19346.38,N/A,19346.38,N/A,21860.26,N/A,10324.72,N/A,7452.70,N/A,23017.36,N/A,23017.36,N/A,7452.70,N/A,10324.72,N/A,10324.72,N/A,9378.97,N/A,1124.00,26527.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 514,"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/McC",N/A,N/A,29708.70,N/A,17825.22,N/A,5509.06,N/A,6782.57,N/A,12415.12,N/A,10100.96,N/A,12533.88,N/A,5678.81,N/A,6782.57,N/A,6782.57,N/A,7802.05,N/A,12533.88,N/A,12533.88,N/A,12533.88,N/A,12415.12,N/A,6782.57,N/A,5678.81,N/A,14912.19,N/A,14912.19,N/A,7925.80,N/A,6782.57,N/A,6782.57,N/A,6076.32,N/A,5509.06,17825.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 516,Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,N/A,N/A,86596.00,N/A,51957.60,N/A,10849.55,N/A,13100.10,N/A,24884.02,N/A,29442.64,N/A,24684.23,N/A,11183.84,N/A,3934.00,N/A,3934.00,N/A,27950.51,N/A,27950.51,N/A,24684.23,N/A,24684.23,N/A,24884.02,N/A,13100.10,N/A,12819.77,N/A,33059.42,N/A,29368.07,N/A,12819.77,N/A,13100.10,N/A,13100.10,N/A,11966.71,N/A,3934.00,51957.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 519,Back And Neck Procedures Except Spinal Fusion With Cc,N/A,N/A,66220.53,N/A,39732.32,N/A,10665.51,N/A,12882.39,N/A,24035.58,N/A,22514.99,N/A,24265.50,N/A,10994.13,N/A,12882.39,N/A,12882.39,N/A,15104.71,N/A,24265.50,N/A,24265.50,N/A,24265.50,N/A,24035.58,N/A,12882.39,N/A,10994.13,N/A,28869.89,N/A,28869.89,N/A,8739.12,N/A,12882.39,N/A,12882.39,N/A,11763.72,N/A,8739.12,39732.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 521,Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,N/A,N/A,83208.52,N/A,49925.11,N/A,16106.29,N/A,19318.54,N/A,49734.03,N/A,28290.90,N/A,36644.03,N/A,N/A,N/A,19318.54,N/A,19318.54,N/A,N/A,N/A,36644.03,N/A,N/A,N/A,36644.03,N/A,99712.46,N/A,19318.54,N/A,16602.55,N/A,43597.25,N/A,43597.25,N/A,N/A,N/A,19318.54,N/A,19318.54,N/A,N/A,N/A,16106.29,99712.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 522,Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,N/A,N/A,72133.20,N/A,43279.92,N/A,N/A,N/A,13977.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13977.90,N/A,13977.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13977.90,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,13977.90,N/A,13977.90,N/A,N/A,N/A,13977.90,43279.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 535,Fractures Of Hip And Pelvis With McC,N/A,N/A,35203.80,N/A,21122.28,N/A,6878.99,N/A,8521.74,N/A,15502.37,N/A,11969.29,N/A,15650.66,N/A,7090.95,N/A,2248.00,N/A,2248.00,N/A,9742.17,N/A,15650.66,N/A,15650.66,N/A,15650.66,N/A,15502.37,N/A,8403.14,N/A,7090.95,N/A,18620.38,N/A,18620.38,N/A,98.73,N/A,8403.14,N/A,8403.14,N/A,7587.31,N/A,98.73,21122.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 536,Fractures Of Hip And Pelvis Without McC,N/A,N/A,27975.50,N/A,16785.30,N/A,4145.53,N/A,5169.60,N/A,9342.30,N/A,9511.67,N/A,9431.66,N/A,4273.26,N/A,5169.60,N/A,5169.60,N/A,5870.99,N/A,9431.66,N/A,9431.66,N/A,9431.66,N/A,9342.30,N/A,5169.60,N/A,4273.26,N/A,11221.32,N/A,11221.32,N/A,N/A,N/A,5169.60,N/A,5169.60,N/A,4572.39,N/A,4145.53,16785.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 538,"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/McC",N/A,N/A,27464.80,N/A,16478.88,N/A,3713.96,N/A,4718.37,N/A,8369.72,N/A,9338.03,N/A,8449.78,N/A,3828.40,N/A,195576.00,N/A,195576.00,N/A,5259.79,N/A,8449.78,N/A,8449.78,N/A,8449.78,N/A,8369.72,N/A,4659.07,N/A,3828.40,N/A,10053.13,N/A,10053.13,N/A,1992.13,N/A,2352.67,N/A,4718.37,N/A,4096.38,N/A,1992.13,195576.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 542,Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,N/A,N/A,50027.70,N/A,30016.62,N/A,9751.69,N/A,11919.99,N/A,21976.22,N/A,17009.42,N/A,N/A,N/A,10052.15,N/A,11911.52,N/A,11911.52,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,21976.22,N/A,12462.73,N/A,10052.15,N/A,32163.66,N/A,26396.32,N/A,9031.71,N/A,11801.39,N/A,12462.73,N/A,9031.71,N/A,9031.71,32163.66,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 544,Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,N/A,N/A,22705.80,N/A,13623.48,N/A,4150.87,N/A,5175.91,N/A,9354.32,N/A,7719.97,N/A,9443.80,N/A,4278.76,N/A,5175.91,N/A,5175.91,N/A,5878.55,N/A,9443.80,N/A,9443.80,N/A,9443.80,N/A,9354.32,N/A,5175.91,N/A,4278.76,N/A,11235.76,N/A,11235.76,N/A,N/A,N/A,5175.91,N/A,5175.91,N/A,4578.28,N/A,4150.87,13623.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 547,Connective Tissue Disorders Without Cc/McC,N/A,N/A,25768.90,N/A,15461.34,N/A,4880.11,N/A,6068.20,N/A,10997.73,N/A,7391.23,N/A,5372.75,N/A,5030.48,N/A,6038.55,N/A,6038.55,N/A,3344.65,N/A,5372.75,N/A,5372.75,N/A,5372.75,N/A,10997.73,N/A,6038.55,N/A,5030.48,N/A,13209.71,N/A,13209.71,N/A,1940.31,N/A,6038.55,N/A,6068.20,N/A,5382.61,N/A,1940.31,15461.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 548,Septic Arthritis With McC,N/A,N/A,56334.40,N/A,33800.64,N/A,10348.63,N/A,12507.53,N/A,23321.48,N/A,19153.69,N/A,23544.57,N/A,10667.49,N/A,6182.00,N/A,6182.00,N/A,14655.94,N/A,23544.57,N/A,23544.57,N/A,23544.57,N/A,23321.48,N/A,12507.53,N/A,10667.49,N/A,28012.16,N/A,28012.16,N/A,7668.91,N/A,12507.53,N/A,12507.53,N/A,11414.21,N/A,6182.00,33800.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 549,Septic Arthritis With Cc,N/A,N/A,40112.88,N/A,24067.73,N/A,6463.96,N/A,7912.18,N/A,15410.23,N/A,13638.39,N/A,14706.40,N/A,6663.13,N/A,3372.00,N/A,3372.00,N/A,9154.39,N/A,14706.40,N/A,14706.40,N/A,14706.40,N/A,15410.23,N/A,7912.18,N/A,6663.13,N/A,17496.95,N/A,17496.95,N/A,7668.91,N/A,7912.18,N/A,7912.18,N/A,7129.54,N/A,3372.00,24067.73,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 550,Septic Arthritis Without Cc/McC,N/A,N/A,20787.70,N/A,12472.62,N/A,5592.28,N/A,6881.02,N/A,12602.66,N/A,7067.82,N/A,12723.22,N/A,5764.59,N/A,1686.00,N/A,1686.00,N/A,7919.91,N/A,12723.22,N/A,12723.22,N/A,12723.22,N/A,12602.66,N/A,6881.02,N/A,5764.59,N/A,15137.45,N/A,15137.45,N/A,2373.33,N/A,6881.02,N/A,6881.02,N/A,6168.11,N/A,1686.00,15137.45,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 551,Medical Back Problems With McC,N/A,N/A,24289.20,N/A,14573.52,N/A,8304.14,N/A,10088.66,N/A,20117.61,N/A,8258.33,N/A,20310.06,N/A,8560.01,N/A,10088.66,N/A,10088.66,N/A,12642.54,N/A,20310.06,N/A,20310.06,N/A,20310.06,N/A,20117.61,N/A,10088.66,N/A,8560.01,N/A,24163.90,N/A,24163.90,N/A,N/A,N/A,10088.66,N/A,10088.66,N/A,9159.21,N/A,8258.33,24163.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 558,"Tendonitis, Myositis And Bursitis Without McC",N/A,N/A,11935.90,N/A,7161.54,N/A,4635.79,N/A,5749.53,N/A,10447.12,N/A,4058.21,N/A,10547.05,N/A,4778.62,N/A,5749.53,N/A,5749.53,N/A,6565.30,N/A,10547.05,N/A,10547.05,N/A,10547.05,N/A,10447.12,N/A,5749.53,N/A,4778.62,N/A,11935.90,N/A,11935.90,N/A,N/A,N/A,5749.53,N/A,5749.53,N/A,5113.13,N/A,4058.21,11935.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 559,"Aftercare, Musculoskeletal System And Connective Tissue With McC",N/A,N/A,47803.50,N/A,28682.10,N/A,9104.48,N/A,12304.13,N/A,47803.50,N/A,16253.19,N/A,24145.55,N/A,9815.70,N/A,18705.29,N/A,12304.13,N/A,4915.86,N/A,24145.55,N/A,4915.86,N/A,24145.55,N/A,20678.00,N/A,18705.29,N/A,9815.70,N/A,N/A,N/A,28728.00,N/A,10502.79,N/A,12304.13,N/A,18705.29,N/A,10502.79,N/A,4915.86,47803.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 563,"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC",N/A,N/A,32568.00,N/A,19540.80,N/A,4594.18,N/A,5700.32,N/A,10353.35,N/A,11073.12,N/A,10452.38,N/A,4735.73,N/A,5700.32,N/A,5700.32,N/A,6506.37,N/A,10452.38,N/A,10452.38,N/A,10452.38,N/A,10353.35,N/A,5700.32,N/A,4735.73,N/A,12435.73,N/A,12435.73,N/A,5044.42,N/A,5700.32,N/A,5700.32,N/A,5067.23,N/A,4594.18,19540.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 565,Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,N/A,N/A,29222.00,N/A,17533.20,N/A,5267.40,N/A,6526.36,N/A,11870.52,N/A,9935.48,N/A,11984.07,N/A,5429.70,N/A,6496.71,N/A,6496.71,N/A,7459.81,N/A,11984.07,N/A,11984.07,N/A,11984.07,N/A,11870.52,N/A,6496.71,N/A,5429.70,N/A,14258.06,N/A,14258.06,N/A,2513.00,N/A,6496.71,N/A,6526.36,N/A,2513.00,N/A,2513.00,17533.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 570,Skin Debridement With McC,N/A,N/A,62481.00,N/A,37488.60,N/A,10658.64,N/A,12873.69,N/A,35069.38,N/A,21243.54,N/A,35404.84,N/A,10987.06,N/A,12873.69,N/A,12873.69,N/A,22038.69,N/A,35404.84,N/A,35404.84,N/A,35404.84,N/A,35069.38,N/A,12873.69,N/A,10987.06,N/A,42122.92,N/A,42122.92,N/A,6350.83,N/A,12873.69,N/A,12873.69,N/A,11756.15,N/A,6350.83,42122.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 571,Skin Debridement With Cc,N/A,N/A,51720.82,N/A,31032.49,N/A,8794.66,N/A,10669.26,N/A,19934.72,N/A,17585.08,N/A,20009.06,N/A,9065.63,N/A,10669.26,N/A,10669.26,N/A,12455.17,N/A,20009.06,N/A,20009.06,N/A,20009.06,N/A,19934.72,N/A,10669.26,N/A,9065.63,N/A,23805.78,N/A,23805.78,N/A,9656.57,N/A,10669.26,N/A,10669.26,N/A,9700.23,N/A,8794.66,31032.49,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 575,Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,N/A,N/A,26733.28,N/A,16039.97,N/A,10933.84,N/A,13199.81,N/A,25591.84,N/A,9089.32,N/A,24876.00,N/A,11270.73,N/A,1124.00,N/A,1124.00,N/A,15484.73,N/A,24876.00,N/A,24876.00,N/A,24876.00,N/A,25591.84,N/A,13199.81,N/A,11270.73,N/A,26733.29,N/A,26733.29,N/A,11270.73,N/A,13199.81,N/A,13199.81,N/A,12059.68,N/A,1124.00,26733.29,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 577,Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,N/A,N/A,92402.90,N/A,55441.74,N/A,13969.77,N/A,16791.16,N/A,31482.01,N/A,31416.99,N/A,31783.16,N/A,14400.20,N/A,3372.00,N/A,3372.00,N/A,N/A,N/A,31783.16,N/A,31783.16,N/A,31783.16,N/A,31482.01,N/A,16791.16,N/A,14400.20,N/A,N/A,N/A,N/A,N/A,17415.13,N/A,16791.16,N/A,16791.16,N/A,15408.22,N/A,3372.00,55441.74,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 578,Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/McC,N/A,N/A,36201.50,N/A,21720.90,N/A,9135.54,N/A,11072.50,N/A,20587.68,N/A,12308.51,N/A,20784.61,N/A,9417.02,N/A,11072.50,N/A,11072.50,N/A,12937.94,N/A,20784.61,N/A,20784.61,N/A,20784.61,N/A,20587.68,N/A,11072.50,N/A,9417.02,N/A,N/A,N/A,24728.50,N/A,N/A,N/A,11072.50,N/A,11072.50,N/A,10076.21,N/A,9135.54,24728.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 579,"Other Skin, Subcutaneous Tissue And Breast Procedures With McC",N/A,N/A,64487.10,N/A,38692.26,N/A,N/A,N/A,20154.71,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20154.71,N/A,20154.71,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20154.71,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,20154.71,N/A,20154.71,N/A,N/A,N/A,20154.71,38692.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 581,"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC",N/A,N/A,44589.75,N/A,26753.85,N/A,7529.82,N/A,9173.03,N/A,17561.19,N/A,15160.52,N/A,17131.38,N/A,7761.82,N/A,2810.00,N/A,2810.00,N/A,10663.88,N/A,17131.38,N/A,17131.38,N/A,17131.38,N/A,17561.19,N/A,9173.03,N/A,7761.82,N/A,20382.06,N/A,20382.06,N/A,5924.62,N/A,9173.03,N/A,9173.03,N/A,8305.15,N/A,2810.00,26753.85,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 582,Mastectomy For Malignancy With Cc/McC,N/A,N/A,67331.30,N/A,40398.78,N/A,10321.42,N/A,12475.35,N/A,23260.17,N/A,22892.64,N/A,23482.67,N/A,10639.44,N/A,562.00,N/A,562.00,N/A,14617.41,N/A,23482.67,N/A,23482.67,N/A,23482.67,N/A,23260.17,N/A,12475.35,N/A,10639.44,N/A,27938.51,N/A,27938.51,N/A,N/A,N/A,12475.35,N/A,12475.35,N/A,11384.21,N/A,562.00,40398.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 585,"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/McC",N/A,N/A,53004.90,N/A,31802.94,N/A,9821.57,N/A,11884.05,N/A,22133.70,N/A,18021.66,N/A,22345.43,N/A,10124.19,N/A,2248.00,N/A,2248.00,N/A,13909.51,N/A,22345.43,N/A,22345.43,N/A,22345.43,N/A,22133.70,N/A,11884.05,N/A,10124.19,N/A,26585.48,N/A,26585.48,N/A,3328.26,N/A,11884.05,N/A,11884.05,N/A,10832.88,N/A,2248.00,31802.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 592,Skin Ulcers With McC,N/A,N/A,39224.50,N/A,23534.70,N/A,9516.96,N/A,11523.72,N/A,21447.25,N/A,13336.33,N/A,21652.41,N/A,9810.20,N/A,3934.00,N/A,3934.00,N/A,N/A,N/A,N/A,N/A,21652.41,N/A,21652.41,N/A,N/A,N/A,11523.72,N/A,9810.20,N/A,25760.96,N/A,25760.96,N/A,10390.78,N/A,11523.72,N/A,11523.72,N/A,10496.91,N/A,3934.00,25760.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 594,Skin Ulcers Without Cc/McC,N/A,N/A,47658.23,N/A,28594.94,N/A,4128.46,N/A,5327.31,N/A,N/A,N/A,16203.81,N/A,9392.82,N/A,4255.67,N/A,5149.41,N/A,5149.41,N/A,5846.81,N/A,9392.82,N/A,9392.82,N/A,9392.82,N/A,N/A,N/A,5149.41,N/A,4255.67,N/A,11175.12,N/A,11175.12,N/A,N/A,N/A,5149.41,N/A,5149.41,N/A,4553.56,N/A,4128.46,28594.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 595,Major Skin Disorders With McC,N/A,N/A,121151.92,N/A,72691.15,N/A,N/A,N/A,14679.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14679.96,N/A,14679.96,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,14679.96,N/A,N/A,N/A,30921.82,N/A,N/A,N/A,N/A,N/A,13779.12,N/A,14679.96,N/A,N/A,N/A,13779.12,72691.15,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 597,Malignant Breast Disorders With McC,N/A,N/A,41737.60,N/A,25042.56,N/A,8983.50,N/A,10892.66,N/A,26070.06,N/A,14190.78,N/A,20438.71,N/A,9260.30,N/A,2810.00,N/A,2810.00,N/A,12722.62,N/A,20438.71,N/A,20438.71,N/A,20438.71,N/A,26070.06,N/A,10892.66,N/A,9260.30,N/A,24316.96,N/A,24316.96,N/A,7480.10,N/A,10892.66,N/A,10892.66,N/A,9908.52,N/A,2810.00,26070.06,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 600,Non-Malignant Breast Disorders With Cc/McC,N/A,N/A,26244.97,N/A,15746.98,N/A,5553.87,N/A,6835.59,N/A,12516.10,N/A,8923.28,N/A,12635.83,N/A,5725.00,N/A,1124.00,N/A,1124.00,N/A,7865.51,N/A,12635.83,N/A,12635.83,N/A,12635.83,N/A,12516.10,N/A,6835.59,N/A,5725.00,N/A,15033.48,N/A,15033.48,N/A,4094.61,N/A,6835.59,N/A,6835.59,N/A,6125.75,N/A,1124.00,15746.98,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 601,Non-Malignant Breast Disorders Without Cc/McC,N/A,N/A,18613.80,N/A,11168.28,N/A,3755.04,N/A,4707.66,N/A,8462.29,N/A,6328.69,N/A,6481.33,N/A,3870.74,N/A,4707.66,N/A,4707.66,N/A,4035.47,N/A,6481.33,N/A,6481.33,N/A,6481.33,N/A,8462.29,N/A,4707.66,N/A,3870.74,N/A,10164.32,N/A,10164.32,N/A,1364.72,N/A,4707.66,N/A,4707.66,N/A,4141.69,N/A,1364.72,11168.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 604,"Trauma To The Skin, Subcutaneous Tissue And Breast With McC",N/A,N/A,43031.70,N/A,25819.02,N/A,8051.01,N/A,9789.57,N/A,18143.60,N/A,14630.78,N/A,18317.16,N/A,8299.07,N/A,2248.00,N/A,2248.00,N/A,11402.01,N/A,18317.16,N/A,18317.16,N/A,18317.16,N/A,18143.60,N/A,9789.57,N/A,8299.07,N/A,21792.85,N/A,21792.85,N/A,5682.25,N/A,9789.57,N/A,9789.57,N/A,8880.01,N/A,2248.00,25819.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 606,Minor Skin Disorders With McC,N/A,N/A,31328.50,N/A,18797.10,N/A,8188.11,N/A,9981.41,N/A,18452.57,N/A,10651.69,N/A,18629.08,N/A,8440.40,N/A,124764.00,N/A,124764.00,N/A,11596.17,N/A,18629.08,N/A,18629.08,N/A,18629.08,N/A,18452.57,N/A,9951.76,N/A,8440.40,N/A,22163.96,N/A,22163.96,N/A,4009.41,N/A,9951.76,N/A,9981.41,N/A,9031.23,N/A,4009.41,124764.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 615,Adrenal And Pituitary Procedures Without Cc/McC,N/A,N/A,85840.85,N/A,51504.51,N/A,7872.83,N/A,9578.80,N/A,19709.33,N/A,29185.89,N/A,17911.78,N/A,8115.41,N/A,9578.80,N/A,9578.80,N/A,11149.67,N/A,17911.78,N/A,17911.78,N/A,17911.78,N/A,19709.33,N/A,9578.80,N/A,8115.41,N/A,21310.55,N/A,21310.55,N/A,10323.66,N/A,9578.80,N/A,9578.80,N/A,8683.49,N/A,7872.83,51504.51,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 617,"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",N/A,N/A,57479.20,N/A,34487.52,N/A,10690.04,N/A,12533.40,N/A,N/A,N/A,23594.33,N/A,23594.33,N/A,10690.04,N/A,12533.40,N/A,12533.40,N/A,23594.33,N/A,23594.33,N/A,23594.33,N/A,23594.33,N/A,N/A,N/A,12533.40,N/A,10690.04,N/A,N/A,N/A,N/A,N/A,10690.04,N/A,12533.40,N/A,12800.25,N/A,10690.04,N/A,10690.04,34487.52,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 619,O.R. Procedures For Obesity With McC,N/A,N/A,91065.02,N/A,54639.01,N/A,15426.12,N/A,18513.95,N/A,34764.02,N/A,30962.10,N/A,35096.56,N/A,15901.43,N/A,562.00,N/A,562.00,N/A,21846.79,N/A,35096.56,N/A,35096.56,N/A,35096.56,N/A,34764.02,N/A,18513.95,N/A,15901.43,N/A,41756.15,N/A,41756.15,N/A,9056.06,N/A,18513.95,N/A,18513.95,N/A,17014.53,N/A,562.00,54639.01,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 620,O.R. Procedures For Obesity With Cc,N/A,N/A,73019.37,N/A,43811.62,N/A,8992.04,N/A,10902.76,N/A,20264.28,N/A,24826.59,N/A,20458.13,N/A,9269.10,N/A,562.00,N/A,562.00,N/A,12734.71,N/A,20458.13,N/A,20458.13,N/A,20458.13,N/A,20264.28,N/A,10902.76,N/A,9269.10,N/A,24340.06,N/A,24340.06,N/A,9269.10,N/A,10902.76,N/A,10902.76,N/A,9917.93,N/A,562.00,43811.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 623,"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",N/A,N/A,44954.30,N/A,26972.58,N/A,10053.63,N/A,12158.56,N/A,N/A,N/A,15284.46,N/A,N/A,N/A,10363.40,N/A,12158.56,N/A,12336.46,N/A,N/A,N/A,N/A,N/A,N/A,N/A,22873.39,N/A,N/A,N/A,12158.56,N/A,10363.40,N/A,N/A,N/A,N/A,N/A,10363.40,N/A,12336.46,N/A,12336.46,N/A,10363.40,N/A,10053.63,26972.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 624,"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/McC",N/A,N/A,70662.68,N/A,42397.61,N/A,5275.94,N/A,6506.81,N/A,11889.76,N/A,24025.31,N/A,12003.49,N/A,5438.50,N/A,562.00,N/A,562.00,N/A,7471.90,N/A,12003.49,N/A,12003.49,N/A,12003.49,N/A,11889.76,N/A,6506.81,N/A,5438.50,N/A,14281.16,N/A,14281.16,N/A,4452.76,N/A,6506.81,N/A,6506.81,N/A,5819.20,N/A,562.00,42397.61,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 627,"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/McC",N/A,N/A,61819.60,N/A,37091.76,N/A,6806.44,N/A,8317.31,N/A,15338.87,N/A,21018.67,N/A,15485.60,N/A,7016.16,N/A,562.00,N/A,562.00,N/A,9639.42,N/A,15485.60,N/A,15485.60,N/A,15485.60,N/A,15338.87,N/A,8317.31,N/A,7016.16,N/A,18424.00,N/A,18424.00,N/A,7738.37,N/A,8317.31,N/A,8317.31,N/A,7507.29,N/A,562.00,37091.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 638,Diabetes With Cc,N/A,N/A,27447.50,N/A,16468.50,N/A,4673.13,N/A,5793.71,N/A,10531.27,N/A,9332.15,N/A,10632.01,N/A,4817.11,N/A,5793.71,N/A,5793.71,N/A,6618.18,N/A,10632.01,N/A,10632.01,N/A,10632.01,N/A,10531.27,N/A,5793.71,N/A,4817.11,N/A,12649.44,N/A,12649.44,N/A,4817.11,N/A,5793.71,N/A,5793.71,N/A,5154.31,N/A,4673.13,16468.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 640,"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC",N/A,N/A,32774.13,N/A,19664.48,N/A,6749.90,N/A,8250.42,N/A,15324.79,N/A,11143.20,N/A,15356.95,N/A,6957.87,N/A,8250.42,N/A,8250.42,N/A,9559.34,N/A,15356.95,N/A,15356.95,N/A,15356.95,N/A,15324.79,N/A,8250.42,N/A,6957.87,N/A,18270.93,N/A,18270.93,N/A,3978.69,N/A,8250.42,N/A,8250.42,N/A,7444.92,N/A,3978.69,19664.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 641,"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC",N/A,N/A,22686.40,N/A,13611.84,N/A,4108.72,N/A,5126.05,N/A,9259.34,N/A,7713.38,N/A,9347.92,N/A,4235.32,N/A,5126.05,N/A,5126.05,N/A,5818.86,N/A,9347.92,N/A,9347.92,N/A,9347.92,N/A,9259.34,N/A,5126.05,N/A,4235.32,N/A,11121.69,N/A,11121.69,N/A,4235.32,N/A,5126.05,N/A,5126.05,N/A,4531.79,N/A,4108.72,13611.84,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 642,Inborn And Other Disorders Of Metabolism,N/A,N/A,34398.60,N/A,20639.16,N/A,7486.07,N/A,9121.28,N/A,16870.47,N/A,11695.52,N/A,17031.85,N/A,7716.73,N/A,9121.28,N/A,9121.28,N/A,10601.93,N/A,17031.85,N/A,17031.85,N/A,17031.85,N/A,16870.47,N/A,9121.28,N/A,7716.73,N/A,20263.65,N/A,20263.65,N/A,9100.75,N/A,9121.28,N/A,9121.28,N/A,8256.90,N/A,7486.07,20639.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 643,Endocrine Disorders With McC,N/A,N/A,34441.80,N/A,20665.08,N/A,9038.69,N/A,10638.34,N/A,N/A,N/A,12418.15,N/A,12418.15,N/A,9038.69,N/A,10638.34,N/A,10638.34,N/A,12418.15,N/A,12418.15,N/A,12418.15,N/A,12418.15,N/A,N/A,N/A,10638.34,N/A,9038.69,N/A,N/A,N/A,N/A,N/A,9038.69,N/A,10638.34,N/A,10816.24,N/A,9038.69,N/A,9038.69,20665.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 654,Major Bladder Procedures With Cc,N/A,N/A,144832.28,N/A,86899.37,N/A,29749.07,N/A,19165.11,N/A,79831.55,N/A,56875.58,N/A,56875.58,N/A,29749.07,N/A,19165.11,N/A,19165.11,N/A,56875.58,N/A,56875.58,N/A,56875.58,N/A,56875.58,N/A,N/A,N/A,19165.11,N/A,29749.07,N/A,N/A,N/A,N/A,N/A,29749.07,N/A,19165.11,N/A,19165.11,N/A,29749.07,N/A,19165.11,86899.37,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 655,Major Bladder Procedures Without Cc/McC,N/A,N/A,124683.67,N/A,74810.20,N/A,11515.85,N/A,14459.78,N/A,68725.63,N/A,42392.44,N/A,26200.14,N/A,11870.67,N/A,3934.00,N/A,3934.00,N/A,16308.98,N/A,26200.14,N/A,26200.14,N/A,26200.14,N/A,68725.63,N/A,13888.30,N/A,11870.67,N/A,31171.63,N/A,31171.63,N/A,15114.77,N/A,13888.30,N/A,13888.30,N/A,12701.62,N/A,3934.00,74810.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 659,Kidney And Ureter Procedures For Non-Neoplasm With McC,N/A,N/A,66833.77,N/A,40100.26,N/A,13746.78,N/A,16527.37,N/A,31871.80,N/A,22723.49,N/A,31275.84,N/A,14170.35,N/A,2810.00,N/A,2810.00,N/A,19468.48,N/A,31275.84,N/A,33793.47,N/A,31275.84,N/A,31871.80,N/A,16527.37,N/A,14170.35,N/A,37210.44,N/A,37210.44,N/A,6923.06,N/A,16527.37,N/A,17106.00,N/A,15162.27,N/A,2810.00,40100.26,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 660,Kidney And Ureter Procedures For Non-Neoplasm With Cc,N/A,N/A,47947.18,N/A,28768.31,N/A,7528.22,N/A,9289.74,N/A,17371.10,N/A,16302.04,N/A,12451.91,N/A,7760.17,N/A,9171.14,N/A,9171.14,N/A,10661.62,N/A,17127.73,N/A,17127.73,N/A,17127.73,N/A,17371.10,N/A,9171.14,N/A,7760.17,N/A,18550.15,N/A,20377.73,N/A,3221.03,N/A,9171.14,N/A,9289.74,N/A,8303.39,N/A,3221.03,28768.31,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 667,Prostatectomy Without Cc/McC,N/A,N/A,48939.12,N/A,29363.47,N/A,5248.73,N/A,6474.63,N/A,11828.45,N/A,16639.30,N/A,11941.59,N/A,5410.46,N/A,1686.00,N/A,1686.00,N/A,7433.36,N/A,11941.59,N/A,11941.59,N/A,11941.59,N/A,11828.45,N/A,6474.63,N/A,5410.46,N/A,14207.52,N/A,14207.52,N/A,N/A,N/A,6474.63,N/A,6474.63,N/A,5789.19,N/A,1686.00,29363.47,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 669,Transurethral Procedures With Cc,N/A,N/A,57811.30,N/A,34686.78,N/A,8397.76,N/A,10199.76,N/A,25193.50,N/A,19655.84,N/A,19106.07,N/A,8656.51,N/A,2248.00,N/A,2248.00,N/A,11893.08,N/A,19106.07,N/A,19106.07,N/A,19106.07,N/A,25193.50,N/A,10199.76,N/A,8656.51,N/A,22731.45,N/A,22731.45,N/A,5378.86,N/A,1825.17,N/A,10199.76,N/A,9262.46,N/A,1825.17,34686.78,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 670,Transurethral Procedures Without Cc/McC,N/A,N/A,47116.45,N/A,28269.87,N/A,5267.94,N/A,6497.34,N/A,11871.73,N/A,16019.59,N/A,11985.29,N/A,5430.25,N/A,562.00,N/A,562.00,N/A,7460.56,N/A,11985.29,N/A,11985.29,N/A,11985.29,N/A,11871.73,N/A,6497.34,N/A,5430.25,N/A,14259.50,N/A,14259.50,N/A,N/A,N/A,6497.34,N/A,6497.34,N/A,5810.37,N/A,562.00,28269.87,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 674,Other Kidney And Urinary Tract Procedures With Cc,N/A,N/A,65378.78,N/A,39227.27,N/A,12645.72,N/A,15224.87,N/A,33475.40,N/A,22224.51,N/A,28770.76,N/A,13035.35,N/A,15224.87,N/A,15224.87,N/A,17909.13,N/A,28770.76,N/A,28770.76,N/A,28770.76,N/A,34230.02,N/A,15224.87,N/A,13035.35,N/A,34230.02,N/A,34230.02,N/A,13947.83,N/A,15224.87,N/A,15224.87,N/A,13947.83,N/A,12645.72,39227.27,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 675,Other Kidney And Urinary Tract Procedures Without Cc/McC,N/A,N/A,33657.72,N/A,20194.63,N/A,8996.30,N/A,10907.81,N/A,20273.90,N/A,11443.62,N/A,20467.84,N/A,9273.50,N/A,10907.81,N/A,10907.81,N/A,12740.75,N/A,20467.84,N/A,20467.84,N/A,20467.84,N/A,20273.90,N/A,10907.81,N/A,9273.50,N/A,24351.62,N/A,24351.62,N/A,9273.50,N/A,10907.81,N/A,10907.81,N/A,9922.64,N/A,8996.30,24351.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 686,Kidney And Urinary Tract Neoplasms With McC,N/A,N/A,38755.47,N/A,23253.28,N/A,9057.12,N/A,8836.92,N/A,20410.95,N/A,13176.86,N/A,13494.65,N/A,9336.18,N/A,1686.00,N/A,1686.00,N/A,8402.19,N/A,13494.65,N/A,13494.65,N/A,13494.65,N/A,20410.95,N/A,8836.92,N/A,9336.18,N/A,24516.23,N/A,24516.23,N/A,9336.18,N/A,8836.92,N/A,8836.92,N/A,9989.72,N/A,1686.00,24516.23,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 687,Kidney And Urinary Tract Neoplasms With Cc,N/A,N/A,30864.00,N/A,18518.40,N/A,5546.94,N/A,6857.03,N/A,12500.48,N/A,10493.76,N/A,12620.05,N/A,5717.85,N/A,170286.00,N/A,170286.00,N/A,7855.69,N/A,12620.05,N/A,12620.05,N/A,12620.05,N/A,12500.48,N/A,6827.38,N/A,5717.85,N/A,15014.71,N/A,15014.71,N/A,N/A,N/A,6827.38,N/A,6857.03,N/A,6118.10,N/A,5546.94,170286.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 689,Kidney And Urinary Tract Infections With McC,N/A,N/A,38582.50,N/A,23149.50,N/A,6119.34,N/A,7593.46,N/A,13790.44,N/A,13118.05,N/A,13922.35,N/A,6307.89,N/A,7504.51,N/A,7504.51,N/A,8666.34,N/A,13922.35,N/A,13922.35,N/A,13922.35,N/A,13790.44,N/A,7504.51,N/A,6307.89,N/A,16564.12,N/A,16564.12,N/A,6749.44,N/A,7504.51,N/A,7593.46,N/A,6749.44,N/A,6119.34,23149.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 690,Kidney And Urinary Tract Infections Without McC,N/A,N/A,25397.20,N/A,15238.32,N/A,4244.22,N/A,5286.34,N/A,9564.70,N/A,8635.05,N/A,9656.20,N/A,4375.00,N/A,5286.34,N/A,5286.34,N/A,6010.76,N/A,9656.20,N/A,9656.20,N/A,9656.20,N/A,9564.70,N/A,5286.34,N/A,4375.00,N/A,11488.46,N/A,11488.46,N/A,4375.00,N/A,5286.34,N/A,5286.34,N/A,4681.25,N/A,4244.22,15238.32,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 693,Urinary Stones With McC,N/A,N/A,19635.10,N/A,11781.06,N/A,7632.78,N/A,9294.82,N/A,17201.08,N/A,6675.93,N/A,17365.62,N/A,7867.95,N/A,562.00,N/A,562.00,N/A,10809.69,N/A,17365.62,N/A,17365.62,N/A,17365.62,N/A,17201.08,N/A,9294.82,N/A,7867.95,N/A,19635.10,N/A,19635.10,N/A,5935.72,N/A,9294.82,N/A,9294.82,N/A,8418.71,N/A,562.00,19635.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 694,Urinary Stones Without McC,N/A,N/A,19232.70,N/A,11539.62,N/A,4252.23,N/A,5325.46,N/A,9582.74,N/A,6539.12,N/A,9674.40,N/A,4383.24,N/A,78118.00,N/A,78118.00,N/A,6022.09,N/A,9674.40,N/A,9674.40,N/A,9674.40,N/A,9582.74,N/A,5295.81,N/A,4383.24,N/A,11510.12,N/A,11510.12,N/A,4182.89,N/A,2202.53,N/A,5325.46,N/A,4690.07,N/A,2202.53,78118.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 695,Kidney And Urinary Tract Signs And Symptoms With McC,N/A,N/A,29250.13,N/A,17550.08,N/A,6125.74,N/A,7512.08,N/A,13804.86,N/A,9945.05,N/A,13936.92,N/A,6314.49,N/A,2248.00,N/A,2248.00,N/A,8675.41,N/A,13936.92,N/A,13936.92,N/A,13936.92,N/A,13804.86,N/A,7512.08,N/A,6314.49,N/A,16581.45,N/A,16581.45,N/A,6314.49,N/A,7512.08,N/A,7512.08,N/A,6756.50,N/A,2248.00,17550.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 697,Urethral Stricture,N/A,N/A,33075.80,N/A,19845.48,N/A,5294.08,N/A,6528.26,N/A,11930.63,N/A,11245.77,N/A,12044.76,N/A,5457.20,N/A,562.00,N/A,562.00,N/A,7497.58,N/A,12044.76,N/A,12044.76,N/A,12044.76,N/A,11930.63,N/A,6528.26,N/A,5457.20,N/A,14330.26,N/A,14330.26,N/A,1560.53,N/A,6528.26,N/A,6528.26,N/A,5839.20,N/A,562.00,19845.48,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 700,Other Kidney And Urinary Tract Diagnoses Without Cc/McC,N/A,N/A,25575.18,N/A,15345.11,N/A,3951.89,N/A,4161.21,N/A,8905.90,N/A,8695.56,N/A,8991.09,N/A,4073.65,N/A,1124.00,N/A,1124.00,N/A,5596.74,N/A,8991.09,N/A,8991.09,N/A,8991.09,N/A,8905.90,N/A,4161.21,N/A,4073.65,N/A,10697.15,N/A,10697.15,N/A,5045.84,N/A,4161.21,N/A,4161.21,N/A,4358.81,N/A,1124.00,15345.11,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 708,Major Male Pelvic Procedures Without Cc/McC,N/A,N/A,58207.72,N/A,34924.63,N/A,7920.31,N/A,10502.49,N/A,17849.06,N/A,19790.62,N/A,18019.80,N/A,8164.35,N/A,1686.00,N/A,1686.00,N/A,11216.91,N/A,18019.80,N/A,18019.80,N/A,18019.80,N/A,17849.06,N/A,9634.96,N/A,8164.35,N/A,21439.07,N/A,21439.07,N/A,8164.35,N/A,9634.96,N/A,9634.96,N/A,8735.85,N/A,1686.00,34924.63,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 710,Penis Procedures Without Cc/McC,N/A,N/A,60790.42,N/A,36474.25,N/A,7689.32,N/A,9361.72,N/A,17328.51,N/A,20668.74,N/A,17494.27,N/A,7926.24,N/A,562.00,N/A,562.00,N/A,10889.78,N/A,17494.27,N/A,17494.27,N/A,17494.27,N/A,17328.51,N/A,9361.72,N/A,7926.24,N/A,20813.82,N/A,20813.82,N/A,1822.15,N/A,9361.72,N/A,9361.72,N/A,8481.08,N/A,562.00,36474.25,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 712,Testes Procedures Without Cc/McC,N/A,N/A,30440.07,N/A,18264.04,N/A,6623.46,N/A,8100.86,N/A,14926.52,N/A,10349.62,N/A,15069.30,N/A,6827.55,N/A,562.00,N/A,562.00,N/A,9380.29,N/A,15069.30,N/A,15069.30,N/A,15069.30,N/A,14926.52,N/A,8100.86,N/A,6827.55,N/A,17928.70,N/A,17928.70,N/A,6827.55,N/A,8100.86,N/A,8100.86,N/A,7305.47,N/A,562.00,18264.04,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 713,Transurethral Prostatectomy With Cc/McC,N/A,N/A,49460.17,N/A,29676.10,N/A,7905.37,N/A,9617.28,N/A,17815.40,N/A,16816.45,N/A,17985.82,N/A,8148.95,N/A,1124.00,N/A,1124.00,N/A,11195.75,N/A,17985.82,N/A,17985.82,N/A,17985.82,N/A,17815.40,N/A,9617.28,N/A,8148.95,N/A,21398.64,N/A,21398.64,N/A,8186.49,N/A,9617.28,N/A,9617.28,N/A,8719.38,N/A,1124.00,29676.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 714,Transurethral Prostatectomy Without Cc/McC,N/A,N/A,42341.35,N/A,25404.81,N/A,5111.63,N/A,6342.09,N/A,11519.48,N/A,14396.06,N/A,11629.67,N/A,5269.13,N/A,6312.44,N/A,6312.44,N/A,7239.20,N/A,11629.67,N/A,11629.67,N/A,11629.67,N/A,11519.48,N/A,6312.44,N/A,5269.13,N/A,13836.41,N/A,13836.41,N/A,N/A,N/A,6312.44,N/A,6342.09,N/A,5637.97,N/A,5111.63,25404.81,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 715,Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,N/A,N/A,34868.62,N/A,20921.17,N/A,11913.27,N/A,14358.44,N/A,26847.53,N/A,11855.33,N/A,27104.35,N/A,12280.34,N/A,562.00,N/A,562.00,N/A,16871.83,N/A,27104.35,N/A,27104.35,N/A,27104.35,N/A,26847.53,N/A,14358.44,N/A,12280.34,N/A,32247.41,N/A,32247.41,N/A,12280.34,N/A,14358.44,N/A,14358.44,N/A,13139.97,N/A,562.00,32247.41,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 718,Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,N/A,N/A,32665.78,N/A,19599.47,N/A,6769.63,N/A,8273.78,N/A,15255.92,N/A,11106.37,N/A,15401.85,N/A,6978.22,N/A,1686.00,N/A,1686.00,N/A,9587.30,N/A,15401.85,N/A,15401.85,N/A,15401.85,N/A,15255.92,N/A,8273.78,N/A,6978.22,N/A,18324.36,N/A,18324.36,N/A,N/A,N/A,8273.78,N/A,8273.78,N/A,7466.69,N/A,1686.00,19599.47,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 722,"Malignancy, Male Reproductive System With McC",N/A,N/A,45431.00,N/A,27258.60,N/A,9056.59,N/A,11609.23,N/A,20409.75,N/A,15446.54,N/A,20604.98,N/A,9335.63,N/A,3372.00,N/A,3372.00,N/A,12826.12,N/A,20604.98,N/A,20604.98,N/A,20604.98,N/A,20409.75,N/A,10979.13,N/A,9335.63,N/A,24514.79,N/A,24514.79,N/A,7911.28,N/A,10979.13,N/A,10979.13,N/A,9989.13,N/A,3372.00,27258.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 723,"Malignancy, Male Reproductive System With Cc",N/A,N/A,44077.40,N/A,26446.44,N/A,6147.62,N/A,7686.20,N/A,13854.15,N/A,14986.32,N/A,13986.68,N/A,6337.04,N/A,2810.00,N/A,2810.00,N/A,8706.38,N/A,13986.68,N/A,13986.68,N/A,13986.68,N/A,13854.15,N/A,7537.95,N/A,6337.04,N/A,16640.66,N/A,16640.66,N/A,N/A,N/A,7537.95,N/A,7537.95,N/A,6780.63,N/A,2810.00,26446.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 724,"Malignancy, Male Reproductive System Without Cc/McC",N/A,N/A,19617.10,N/A,11770.26,N/A,4081.52,N/A,5123.51,N/A,9198.03,N/A,6669.81,N/A,9286.02,N/A,4207.28,N/A,136566.00,N/A,136566.00,N/A,5780.33,N/A,9286.02,N/A,9286.02,N/A,9286.02,N/A,9198.03,N/A,5093.86,N/A,4207.28,N/A,11048.04,N/A,11048.04,N/A,6968.59,N/A,2202.53,N/A,5123.51,N/A,4501.79,N/A,2202.53,136566.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 727,Inflammation Of The Male Reproductive System With McC,N/A,N/A,32545.60,N/A,19527.36,N/A,7664.78,N/A,9332.70,N/A,17273.21,N/A,11065.50,N/A,17438.44,N/A,7900.95,N/A,9332.70,N/A,9332.70,N/A,10855.02,N/A,17438.44,N/A,17438.44,N/A,17438.44,N/A,17273.21,N/A,9332.70,N/A,7900.95,N/A,20747.39,N/A,N/A,N/A,6993.31,N/A,9332.70,N/A,9332.70,N/A,8454.01,N/A,6993.31,20747.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 737,Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,N/A,N/A,113470.92,N/A,68082.55,N/A,10794.60,N/A,13035.10,N/A,62545.17,N/A,38580.11,N/A,24559.22,N/A,11127.21,N/A,1686.00,N/A,1686.00,N/A,15287.54,N/A,24559.22,N/A,24559.22,N/A,24559.22,N/A,62545.17,N/A,13766.30,N/A,11127.21,N/A,29219.34,N/A,29219.34,N/A,16803.16,N/A,13035.10,N/A,13035.10,N/A,11906.11,N/A,1686.00,68082.55,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 740,Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,N/A,N/A,75328.37,N/A,45197.02,N/A,9615.12,N/A,11639.83,N/A,21668.45,N/A,25611.64,N/A,21875.73,N/A,9911.38,N/A,11639.83,N/A,11639.83,N/A,13617.13,N/A,21875.73,N/A,21875.73,N/A,21875.73,N/A,21668.45,N/A,11639.83,N/A,9911.38,N/A,26026.66,N/A,26026.66,N/A,8663.92,N/A,11639.83,N/A,11639.83,N/A,10605.18,N/A,8663.92,45197.02,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 741,Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,N/A,N/A,67794.83,N/A,40676.90,N/A,7003.82,N/A,8550.80,N/A,15783.68,N/A,23050.25,N/A,15934.67,N/A,7219.62,N/A,562.00,N/A,562.00,N/A,9918.96,N/A,15934.67,N/A,15934.67,N/A,15934.67,N/A,15783.68,N/A,8550.80,N/A,7219.62,N/A,18958.28,N/A,18958.28,N/A,7219.62,N/A,8550.80,N/A,8550.80,N/A,7725.00,N/A,562.00,40676.90,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 743,Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,N/A,N/A,49805.73,N/A,29883.44,N/A,6244.71,N/A,7652.80,N/A,16275.44,N/A,16933.94,N/A,14207.57,N/A,6437.12,N/A,7652.80,N/A,7652.80,N/A,8843.88,N/A,14207.57,N/A,14207.57,N/A,14207.57,N/A,16275.44,N/A,7652.80,N/A,6437.12,N/A,16903.46,N/A,16903.46,N/A,6291.66,N/A,7652.80,N/A,7652.80,N/A,6887.72,N/A,6244.71,29883.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 744,"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC",N/A,N/A,44657.30,N/A,26794.38,N/A,10126.71,N/A,8433.18,N/A,22821.36,N/A,15183.48,N/A,15549.67,N/A,10438.73,N/A,8433.18,N/A,8433.18,N/A,9681.70,N/A,15549.67,N/A,15549.67,N/A,15549.67,N/A,22821.36,N/A,8433.18,N/A,10438.73,N/A,27411.45,N/A,27411.45,N/A,5561.10,N/A,8433.18,N/A,8433.18,N/A,11169.44,N/A,5561.10,27411.45,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 748,Female Reproductive System Reconstructive Procedures,N/A,N/A,45315.80,N/A,27189.48,N/A,7560.22,N/A,9238.64,N/A,18003.61,N/A,15407.37,N/A,17200.56,N/A,7793.17,N/A,33720.00,N/A,33720.00,N/A,10706.95,N/A,17200.56,N/A,17200.56,N/A,17200.56,N/A,24675.45,N/A,9208.99,N/A,7793.17,N/A,20464.37,N/A,20464.37,N/A,N/A,N/A,9208.99,N/A,9238.64,N/A,8338.69,N/A,7560.22,33720.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 749,Other Female Reproductive System O.R. Procedures With Cc/McC,N/A,N/A,63506.53,N/A,38103.92,N/A,13476.32,N/A,16207.43,N/A,30369.98,N/A,21592.23,N/A,30660.49,N/A,13891.55,N/A,2248.00,N/A,2248.00,N/A,19085.44,N/A,30660.49,N/A,30660.49,N/A,30660.49,N/A,30369.98,N/A,16207.43,N/A,13891.55,N/A,36478.33,N/A,36478.33,N/A,8455.85,N/A,16207.43,N/A,16207.43,N/A,14863.96,N/A,2248.00,38103.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 754,"Malignancy, Female Reproductive System With McC",N/A,N/A,47851.43,N/A,28710.86,N/A,9265.70,N/A,11226.48,N/A,20881.01,N/A,16269.49,N/A,21080.76,N/A,9551.19,N/A,2810.00,N/A,2810.00,N/A,13122.28,N/A,21080.76,N/A,21080.76,N/A,21080.76,N/A,20881.01,N/A,11226.48,N/A,9551.19,N/A,25080.84,N/A,25080.84,N/A,14019.00,N/A,11226.48,N/A,11226.48,N/A,10219.78,N/A,2810.00,28710.86,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 769,Postpartum And Post Abortion Diagnoses With O.R. Procedures,N/A,N/A,37150.50,N/A,22290.30,N/A,8862.41,N/A,10749.41,N/A,19972.15,N/A,12631.17,N/A,20163.20,N/A,9135.47,N/A,2248.00,N/A,2248.00,N/A,12551.12,N/A,20163.20,N/A,20163.20,N/A,20163.20,N/A,19972.15,N/A,N/A,N/A,9135.47,N/A,23989.17,N/A,23989.17,N/A,5605.14,N/A,10749.41,N/A,N/A,N/A,9774.95,N/A,2248.00,23989.17,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 783,Cesarean Section With Sterilization With McC,N/A,N/A,37951.90,N/A,22771.14,N/A,10294.22,N/A,12443.18,N/A,23198.85,N/A,12903.65,N/A,7322.00,N/A,10611.40,N/A,12443.18,N/A,12443.18,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,23198.85,N/A,12443.18,N/A,10611.40,N/A,27864.87,N/A,27864.87,N/A,7497.10,N/A,12443.18,N/A,12443.18,N/A,11354.20,N/A,4558.00,27864.87,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 784,Cesarean Section With Sterilization With Cc,N/A,N/A,36757.40,N/A,22054.44,N/A,5569.34,N/A,6853.90,N/A,13279.52,N/A,12497.52,N/A,7322.00,N/A,5740.95,N/A,6853.90,N/A,6853.90,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,13279.52,N/A,6853.90,N/A,5740.95,N/A,15075.36,N/A,15075.36,N/A,5291.81,N/A,6853.90,N/A,6853.90,N/A,6142.81,N/A,4558.00,22054.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 785,Cesarean Section With Sterilization Without Cc/McC,N/A,N/A,27718.20,N/A,16630.92,N/A,4865.71,N/A,6021.52,N/A,11361.17,N/A,9424.19,N/A,7322.00,N/A,5015.63,N/A,6021.52,N/A,6021.52,N/A,4558.00,N/A,7322.00,N/A,7322.00,N/A,7322.00,N/A,11361.17,N/A,6021.52,N/A,5015.63,N/A,13170.72,N/A,13170.72,N/A,4500.70,N/A,6021.52,N/A,6021.52,N/A,5366.72,N/A,4500.70,16630.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 790,"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",N/A,N/A,45212.50,N/A,27127.50,N/A,32120.28,N/A,38262.30,N/A,45212.50,N/A,15372.25,N/A,22836.83,N/A,33109.97,N/A,38262.30,N/A,38262.30,N/A,14214.81,N/A,22836.83,N/A,22836.83,N/A,22836.83,N/A,45212.50,N/A,38262.30,N/A,33109.97,N/A,32760.00,N/A,32760.00,N/A,10351.69,N/A,38262.30,N/A,38262.30,N/A,35427.66,N/A,10351.69,45212.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 791,Prematurity With Major Problems,N/A,N/A,13367.60,N/A,8020.56,N/A,13367.60,N/A,26215.39,N/A,13367.60,N/A,4544.98,N/A,6751.97,N/A,13367.60,N/A,26215.39,N/A,26215.39,N/A,4202.77,N/A,6751.97,N/A,6751.97,N/A,6751.97,N/A,13367.60,N/A,26215.39,N/A,13367.60,N/A,5200.00,N/A,5200.00,N/A,24145.70,N/A,26215.39,N/A,26215.39,N/A,13367.60,N/A,4202.77,26215.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 792,Prematurity Without Major Problems,N/A,N/A,11654.90,N/A,6992.94,N/A,11654.90,N/A,15923.46,N/A,11654.90,N/A,3962.67,N/A,5886.89,N/A,11654.90,N/A,15923.46,N/A,15923.46,N/A,3664.30,N/A,5886.89,N/A,5886.89,N/A,5886.89,N/A,11654.90,N/A,15923.46,N/A,11654.90,N/A,4160.00,N/A,4160.00,N/A,11654.90,N/A,15923.46,N/A,15923.46,N/A,11654.90,N/A,3664.30,15923.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 793,Full Term Neonate With Major Problems,N/A,N/A,11807.50,N/A,7084.50,N/A,11807.50,N/A,26921.54,N/A,11807.50,N/A,4014.55,N/A,5963.97,N/A,11807.50,N/A,26921.54,N/A,26921.54,N/A,3712.28,N/A,5963.97,N/A,5963.97,N/A,5963.97,N/A,11807.50,N/A,26921.54,N/A,11807.50,N/A,5200.00,N/A,5200.00,N/A,12138.40,N/A,26921.54,N/A,26921.54,N/A,11807.50,N/A,3712.28,26921.54,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 795,Normal Newborn,N/A,N/A,6051.20,N/A,3630.72,N/A,1079.73,N/A,1542.91,N/A,2433.25,N/A,2057.41,N/A,1589.00,N/A,1113.00,N/A,1542.91,N/A,1542.91,N/A,989.00,N/A,1589.00,N/A,1589.00,N/A,1589.00,N/A,2433.25,N/A,1542.91,N/A,1113.00,N/A,1352.00,N/A,1352.00,N/A,1185.55,N/A,1542.91,N/A,1542.91,N/A,1190.91,N/A,989.00,3630.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 796,Vaginal Delivery With Sterilization And/Or D&C With McC,N/A,N/A,30059.70,N/A,18035.82,N/A,7004.36,N/A,8551.43,N/A,16777.34,N/A,10220.29,N/A,4696.00,N/A,7220.17,N/A,8551.43,N/A,8551.43,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,16777.34,N/A,8551.43,N/A,7220.17,N/A,18959.72,N/A,18959.72,N/A,4755.92,N/A,8551.43,N/A,8551.43,N/A,7725.59,N/A,2923.00,18959.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 798,Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,N/A,N/A,19130.70,N/A,11478.42,N/A,4949.99,N/A,6121.23,N/A,11155.21,N/A,6504.44,N/A,4696.00,N/A,5102.51,N/A,6121.23,N/A,6121.23,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,11155.21,N/A,6121.23,N/A,5102.51,N/A,13398.88,N/A,13398.88,N/A,4868.21,N/A,6121.23,N/A,6121.23,N/A,5459.69,N/A,2923.00,13398.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 801,Splenectomy Without Cc/McC,N/A,N/A,53363.42,N/A,32018.05,N/A,9580.98,N/A,11599.44,N/A,21591.51,N/A,18143.56,N/A,21798.05,N/A,10787.29,N/A,N/A,N/A,2810.00,N/A,13568.78,N/A,21798.05,N/A,21798.05,N/A,21798.05,N/A,21591.51,N/A,N/A,N/A,9876.19,N/A,25934.24,N/A,25934.24,N/A,10787.29,N/A,11599.44,N/A,N/A,N/A,10567.52,N/A,2810.00,32018.05,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 802,Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,N/A,N/A,68771.40,N/A,41262.84,N/A,20335.57,N/A,24321.58,N/A,45827.86,N/A,23969.90,N/A,46266.24,N/A,2512.17,N/A,25668.95,N/A,24321.58,N/A,28799.66,N/A,46266.24,N/A,46266.24,N/A,46266.24,N/A,45827.86,N/A,24321.58,N/A,20962.15,N/A,55045.28,N/A,55045.28,N/A,2512.17,N/A,24321.58,N/A,25668.95,N/A,22429.50,N/A,2512.17,55045.28,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 806,Vaginal Delivery Without Sterilization Or D&C With Cc,N/A,N/A,13984.20,N/A,8390.52,N/A,3722.50,N/A,4669.17,N/A,8388.95,N/A,4754.63,N/A,4696.00,N/A,3837.19,N/A,4669.17,N/A,4669.17,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,8388.95,N/A,4669.17,N/A,3837.19,N/A,10076.23,N/A,10076.23,N/A,4105.80,N/A,4669.17,N/A,4669.17,N/A,4105.80,N/A,2923.00,10076.23,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 808,Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,N/A,N/A,81282.30,N/A,48769.38,N/A,11421.42,N/A,13776.59,N/A,25739.10,N/A,27635.98,N/A,25985.32,N/A,11773.34,N/A,13776.59,N/A,13776.59,N/A,16175.26,N/A,N/A,N/A,25985.32,N/A,25985.32,N/A,25739.10,N/A,13776.59,N/A,11773.34,N/A,30916.04,N/A,30916.04,N/A,11773.34,N/A,13776.59,N/A,13776.59,N/A,12597.47,N/A,11421.42,48769.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 810,Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,N/A,N/A,41336.17,N/A,24801.70,N/A,5008.14,N/A,6190.01,N/A,12001.73,N/A,14054.30,N/A,11394.22,N/A,5162.45,N/A,3934.00,N/A,6298.97,N/A,7092.63,N/A,11394.22,N/A,11394.22,N/A,11394.22,N/A,12001.73,N/A,6190.01,N/A,5162.45,N/A,13556.27,N/A,13556.27,N/A,4148.68,N/A,6190.01,N/A,6190.01,N/A,5523.82,N/A,3934.00,24801.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 811,Red Blood Cell Disorders With McC,N/A,N/A,46645.10,N/A,27987.06,N/A,7416.72,N/A,9068.89,N/A,16714.19,N/A,15859.33,N/A,16874.07,N/A,7645.25,N/A,9039.24,N/A,9039.24,N/A,10503.72,N/A,16874.07,N/A,16874.07,N/A,16874.07,N/A,16714.19,N/A,9039.24,N/A,7645.25,N/A,20075.93,N/A,20075.93,N/A,7645.25,N/A,9039.24,N/A,9068.89,N/A,8180.41,N/A,7416.72,27987.06,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 814,Reticuloendothelial And Immunity Disorders With McC,N/A,N/A,40907.70,N/A,24544.62,N/A,9385.22,N/A,12524.56,N/A,N/A,N/A,13908.62,N/A,N/A,N/A,10333.15,N/A,2810.00,N/A,12524.56,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,12524.56,N/A,10333.15,N/A,27134.20,N/A,27134.20,N/A,9385.22,N/A,12524.56,N/A,12123.86,N/A,9385.22,N/A,2810.00,27134.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 818,Other Antepartum Diagnoses With O.R. Procedures With Cc,N/A,N/A,38579.92,N/A,23147.95,N/A,8482.58,N/A,10300.09,N/A,19116.18,N/A,13117.17,N/A,19299.04,N/A,8743.94,N/A,10300.09,N/A,10300.09,N/A,12013.21,N/A,19299.04,N/A,19299.04,N/A,19299.04,N/A,19116.18,N/A,10300.09,N/A,8743.94,N/A,22961.04,N/A,22961.04,N/A,4969.62,N/A,10300.09,N/A,10300.09,N/A,9356.02,N/A,4969.62,23147.95,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 820,Lymphoma And Leukemia With Major O.R. Procedures With McC,N/A,N/A,177638.27,N/A,106582.96,N/A,N/A,N/A,35549.73,N/A,42084.72,N/A,69735.01,N/A,69735.01,N/A,N/A,N/A,33822.79,N/A,33822.79,N/A,69735.01,N/A,69735.01,N/A,69735.01,N/A,69735.01,N/A,42084.72,N/A,35549.73,N/A,N/A,N/A,42084.72,N/A,42084.72,N/A,N/A,N/A,35549.73,N/A,35549.73,N/A,N/A,N/A,33822.79,106582.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 826,Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,N/A,N/A,242657.73,N/A,145594.64,N/A,N/A,N/A,33500.59,N/A,154186.81,N/A,43913.00,N/A,43913.00,N/A,N/A,N/A,33500.59,N/A,33500.59,N/A,43913.00,N/A,43913.00,N/A,43913.00,N/A,43913.00,N/A,154186.81,N/A,33500.59,N/A,N/A,N/A,154186.81,N/A,154186.81,N/A,N/A,N/A,33500.59,N/A,33500.59,N/A,N/A,N/A,33500.59,154186.81,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 827,Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,N/A,N/A,104512.70,N/A,62707.62,N/A,12988.20,N/A,15630.02,N/A,35035.33,N/A,35534.33,N/A,N/A,N/A,N/A,N/A,15630.02,N/A,15630.02,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,32446.29,N/A,15630.02,N/A,N/A,N/A,35157.07,N/A,35157.07,N/A,N/A,N/A,15630.02,N/A,15630.02,N/A,14325.58,N/A,12988.20,62707.62,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 828,Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,N/A,N/A,60235.52,N/A,36141.31,N/A,9277.44,N/A,11240.38,N/A,20907.46,N/A,20480.08,N/A,21107.46,N/A,9563.29,N/A,1124.00,N/A,1124.00,N/A,13138.90,N/A,21107.46,N/A,21107.46,N/A,21107.46,N/A,20907.46,N/A,11240.38,N/A,9563.29,N/A,25112.60,N/A,25112.60,N/A,10285.46,N/A,11240.38,N/A,11240.38,N/A,10232.72,N/A,1124.00,36141.31,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 832,Other Antepartum Diagnoses Without O.R. Procedures With Cc,N/A,N/A,14204.80,N/A,8522.88,N/A,3736.90,N/A,4686.20,N/A,8421.41,N/A,4829.64,N/A,8501.97,N/A,3852.04,N/A,4686.20,N/A,4686.20,N/A,5292.28,N/A,8501.97,N/A,8501.97,N/A,8501.97,N/A,5872.36,N/A,4686.20,N/A,3852.04,N/A,14204.80,N/A,14204.80,N/A,3852.04,N/A,6196.00,N/A,4686.20,N/A,4121.69,N/A,3736.90,14204.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 833,Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,N/A,N/A,7311.00,N/A,4386.60,N/A,689.30,N/A,3446.18,N/A,6059.09,N/A,2485.74,N/A,6117.05,N/A,2771.49,N/A,3446.18,N/A,3446.18,N/A,3807.72,N/A,6117.05,N/A,6117.05,N/A,6117.05,N/A,6059.09,N/A,3446.18,N/A,2771.49,N/A,7277.76,N/A,7277.76,N/A,2049.86,N/A,3446.18,N/A,3446.18,N/A,2965.50,N/A,689.30,7277.76,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 839,Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/McC,N/A,N/A,50208.50,N/A,30125.10,N/A,7333.50,N/A,8940.80,N/A,16526.64,N/A,17063.24,N/A,16684.73,N/A,7559.46,N/A,8940.80,N/A,8940.80,N/A,10385.86,N/A,16684.73,N/A,16684.73,N/A,16684.73,N/A,16526.64,N/A,8940.80,N/A,7559.46,N/A,19850.67,N/A,19850.67,N/A,7559.46,N/A,8940.80,N/A,8940.80,N/A,8088.62,N/A,7333.50,30125.10,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 840,Lymphoma And Non-Acute Leukemia With McC,N/A,N/A,67651.33,N/A,40590.80,N/A,8437.99,N/A,20908.69,N/A,46426.00,N/A,23001.46,N/A,37709.66,N/A,8437.99,N/A,20908.69,N/A,20908.69,N/A,23473.39,N/A,37709.66,N/A,37709.66,N/A,37709.66,N/A,46426.00,N/A,20908.69,N/A,8437.99,N/A,46426.00,N/A,46426.00,N/A,8437.99,N/A,20908.69,N/A,20908.69,N/A,8437.99,N/A,8437.99,46426.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 841,Lymphoma And Non-Acute Leukemia With Cc,N/A,N/A,44607.60,N/A,26764.56,N/A,9383.67,N/A,10329.75,N/A,23028.91,N/A,N/A,N/A,N/A,N/A,9383.67,N/A,10329.75,N/A,10329.75,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,19172.69,N/A,10329.75,N/A,9383.67,N/A,23028.91,N/A,23028.91,N/A,9383.67,N/A,10329.75,N/A,10329.75,N/A,9383.67,N/A,9383.67,26764.56,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 842,Lymphoma And Non-Acute Leukemia Without Cc/McC,N/A,N/A,23437.60,N/A,14062.56,N/A,5887.82,N/A,7230.63,N/A,13268.68,N/A,7968.78,N/A,13395.61,N/A,6069.23,N/A,1124.00,N/A,1124.00,N/A,8338.45,N/A,13395.61,N/A,13395.61,N/A,13395.61,N/A,13268.68,N/A,7230.63,N/A,6069.23,N/A,15937.43,N/A,15937.43,N/A,1924.74,N/A,7230.63,N/A,7230.63,N/A,6494.08,N/A,1124.00,15937.43,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 844,Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,N/A,N/A,37370.77,N/A,22422.46,N/A,6084.67,N/A,7463.49,N/A,13712.29,N/A,12706.06,N/A,13843.46,N/A,6272.15,N/A,3372.00,N/A,3372.00,N/A,8617.23,N/A,13843.46,N/A,13843.46,N/A,13843.46,N/A,13712.29,N/A,7463.49,N/A,6272.15,N/A,16470.26,N/A,16470.26,N/A,4635.76,N/A,7463.49,N/A,7463.49,N/A,6711.20,N/A,3372.00,22422.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 845,Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,N/A,N/A,24012.98,N/A,14407.79,N/A,4510.42,N/A,5601.23,N/A,10164.60,N/A,8164.41,N/A,10261.83,N/A,4649.40,N/A,2810.00,N/A,2810.00,N/A,6387.75,N/A,10261.83,N/A,10261.83,N/A,10261.83,N/A,10164.60,N/A,5601.23,N/A,4649.40,N/A,12209.02,N/A,12209.02,N/A,5158.85,N/A,5601.23,N/A,6397.80,N/A,4974.85,N/A,2810.00,14407.79,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 846,Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,N/A,N/A,64206.80,N/A,38524.08,N/A,12851.10,N/A,16043.58,N/A,28961.00,N/A,21830.31,N/A,29238.03,N/A,13247.07,N/A,15467.83,N/A,15467.83,N/A,18200.00,N/A,29238.03,N/A,29238.03,N/A,29238.03,N/A,28961.00,N/A,15467.83,N/A,13247.07,N/A,34785.96,N/A,34785.96,N/A,14945.02,N/A,15467.83,N/A,16043.58,N/A,14174.36,N/A,12851.10,38524.08,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 847,Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,N/A,N/A,62331.47,N/A,37398.88,N/A,10552.06,N/A,8457.15,N/A,17528.46,N/A,21192.72,N/A,14784.08,N/A,10552.06,N/A,8457.15,N/A,8457.15,N/A,9202.75,N/A,14784.08,N/A,14784.08,N/A,14784.08,N/A,17528.46,N/A,8457.15,N/A,10552.06,N/A,17528.46,N/A,17528.46,N/A,10552.06,N/A,8457.15,N/A,8457.15,N/A,7167.20,N/A,7167.20,37398.88,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 849,Radiotherapy,N/A,N/A,46115.30,N/A,27669.18,N/A,12477.14,N/A,15025.46,N/A,28118.26,N/A,15661.39,N/A,28387.23,N/A,12861.59,N/A,15025.46,N/A,15025.46,N/A,17670.39,N/A,28387.23,N/A,28387.23,N/A,28387.23,N/A,28118.26,N/A,15025.46,N/A,12861.59,N/A,33773.72,N/A,33773.72,N/A,N/A,N/A,15025.46,N/A,15025.46,N/A,13761.90,N/A,12477.14,33773.72,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 853,Infectious And Parasitic Diseases With O.R. Procedures With McC,N/A,N/A,95389.12,N/A,57233.47,N/A,23922.73,N/A,31193.81,N/A,70770.44,N/A,59483.44,N/A,59483.44,N/A,23922.73,N/A,31193.81,N/A,31193.81,N/A,59483.44,N/A,59483.44,N/A,59483.44,N/A,59483.44,N/A,70770.44,N/A,31193.81,N/A,23922.73,N/A,70770.44,N/A,70770.44,N/A,23922.73,N/A,31193.81,N/A,31193.81,N/A,23922.73,N/A,23922.73,70770.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 858,Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,N/A,N/A,50671.72,N/A,30403.03,N/A,7546.35,N/A,9192.59,N/A,18952.10,N/A,17228.38,N/A,17169.00,N/A,7778.87,N/A,3372.00,N/A,3372.00,N/A,19440.85,N/A,17169.00,N/A,17169.00,N/A,17169.00,N/A,18952.10,N/A,9192.59,N/A,7778.87,N/A,20426.82,N/A,20426.82,N/A,7778.87,N/A,9192.59,N/A,9192.59,N/A,8801.25,N/A,3372.00,30403.03,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 863,Postoperative And Post-Traumatic Infections Without McC,N/A,N/A,15695.30,N/A,9417.18,N/A,4599.51,N/A,5706.35,N/A,12092.93,N/A,5336.40,N/A,5465.10,N/A,4741.23,N/A,5706.35,N/A,5706.35,N/A,3402.74,N/A,5465.10,N/A,5465.10,N/A,5465.10,N/A,12092.93,N/A,5706.35,N/A,4741.23,N/A,14525.20,N/A,14525.20,N/A,N/A,N/A,5706.35,N/A,5706.35,N/A,5073.11,N/A,3402.74,14525.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 864,Fever And Inflammatory Conditions,N/A,N/A,29977.50,N/A,17986.50,N/A,4524.83,N/A,5618.27,N/A,10197.06,N/A,10192.35,N/A,10294.60,N/A,4664.24,N/A,5618.27,N/A,5618.27,N/A,6408.15,N/A,10294.60,N/A,10294.60,N/A,10294.60,N/A,10197.06,N/A,5618.27,N/A,4664.24,N/A,12248.01,N/A,12248.01,N/A,3806.51,N/A,5618.27,N/A,5618.27,N/A,4990.74,N/A,3806.51,17986.50,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 869,Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,N/A,N/A,44298.90,N/A,26579.34,N/A,3951.89,N/A,4940.53,N/A,8905.90,N/A,15061.62,N/A,8991.09,N/A,4073.65,N/A,2810.00,N/A,2810.00,N/A,5596.74,N/A,8991.09,N/A,8991.09,N/A,8991.09,N/A,8905.90,N/A,4940.53,N/A,4073.65,N/A,10697.15,N/A,10697.15,N/A,2545.13,N/A,4940.53,N/A,4940.53,N/A,4358.81,N/A,2545.13,26579.34,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 872,Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,N/A,N/A,30895.50,N/A,18537.30,N/A,5483.99,N/A,6752.92,N/A,12358.62,N/A,10504.47,N/A,12476.84,N/A,5652.96,N/A,6752.92,N/A,6752.92,N/A,7766.54,N/A,12476.84,N/A,12476.84,N/A,12476.84,N/A,12358.62,N/A,6752.92,N/A,5652.96,N/A,14844.32,N/A,14844.32,N/A,5652.96,N/A,6752.92,N/A,6752.92,N/A,6048.67,N/A,5483.99,18537.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 881,Depressive Neuroses,N/A,N/A,10990.20,N/A,6594.12,N/A,3288.10,N/A,5664.34,N/A,4170.00,N/A,3736.68,N/A,3176.00,N/A,3288.10,N/A,5664.34,N/A,5664.34,N/A,1978.00,N/A,3176.00,N/A,3176.00,N/A,3176.00,N/A,2936.18,N/A,1977.22,N/A,3353.88,N/A,10990.20,N/A,10990.20,N/A,3353.86,N/A,3098.00,N/A,5664.34,N/A,3353.86,N/A,1977.22,10990.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 882,Neuroses Except Depressive,N/A,N/A,8503.70,N/A,5102.22,N/A,3288.10,N/A,5777.93,N/A,4170.00,N/A,2891.27,N/A,3176.00,N/A,3288.10,N/A,5777.93,N/A,5777.93,N/A,1978.00,N/A,3176.00,N/A,3176.00,N/A,3176.00,N/A,2936.18,N/A,2037.13,N/A,3353.88,N/A,8503.70,N/A,8503.70,N/A,3920.50,N/A,3098.00,N/A,5777.93,N/A,3353.86,N/A,1978.00,8503.70,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 884,Organic Disturbances And Intellectual Disability,N/A,N/A,36708.60,N/A,22025.16,N/A,8375.35,N/A,3792.96,N/A,36708.60,N/A,12480.92,N/A,4764.00,N/A,8633.41,N/A,3792.96,N/A,3792.96,N/A,2967.00,N/A,4764.00,N/A,4764.00,N/A,4764.00,N/A,18874.54,N/A,3792.96,N/A,8633.41,N/A,14595.00,N/A,22670.80,N/A,6707.72,N/A,10173.26,N/A,3792.96,N/A,5030.79,N/A,2967.00,36708.60,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 885,Psychoses,N/A,N/A,12004.00,N/A,7202.40,N/A,6576.20,N/A,8441.00,N/A,10425.00,N/A,4081.38,N/A,6352.00,N/A,6576.20,N/A,8441.00,N/A,8441.00,N/A,3956.00,N/A,6352.00,N/A,6352.00,N/A,6352.00,N/A,5872.36,N/A,3747.81,N/A,6707.76,N/A,12004.00,N/A,12004.00,N/A,4333.44,N/A,6196.00,N/A,8441.00,N/A,6707.72,N/A,3747.81,12004.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 886,Behavioral And Developmental Disorders,N/A,N/A,15801.00,N/A,9480.60,N/A,7281.76,N/A,8938.89,N/A,15801.00,N/A,5372.34,N/A,3176.00,N/A,7506.12,N/A,8879.59,N/A,8879.59,N/A,1978.00,N/A,3176.00,N/A,3176.00,N/A,3176.00,N/A,15801.00,N/A,1977.22,N/A,7506.12,N/A,15801.00,N/A,15801.00,N/A,3936.27,N/A,8879.59,N/A,8938.89,N/A,3353.86,N/A,1977.22,15801.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 896,"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC",N/A,N/A,42259.90,N/A,25355.94,N/A,9365.46,N/A,11344.49,N/A,21105.82,N/A,14368.37,N/A,9528.00,N/A,9654.03,N/A,11344.49,N/A,11344.49,N/A,5934.00,N/A,9528.00,N/A,9528.00,N/A,9528.00,N/A,21105.82,N/A,7048.12,N/A,9654.03,N/A,N/A,N/A,25350.86,N/A,9654.03,N/A,11344.49,N/A,11344.49,N/A,10061.58,N/A,5934.00,25355.94,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 897,"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC",N/A,N/A,13561.80,N/A,8137.08,N/A,4541.36,N/A,2930.62,N/A,10234.33,N/A,4611.01,N/A,4764.00,N/A,4681.29,N/A,2930.62,N/A,2930.62,N/A,2967.00,N/A,4764.00,N/A,4764.00,N/A,4764.00,N/A,10234.33,N/A,2930.62,N/A,4681.29,N/A,12292.77,N/A,12292.77,N/A,4333.44,N/A,5637.84,N/A,2930.62,N/A,5030.79,N/A,2930.62,12292.77,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 902,Wound Debridements For Injuries With Cc,N/A,N/A,64693.60,N/A,38816.16,N/A,10572.15,N/A,12771.95,N/A,31879.23,N/A,N/A,N/A,N/A,N/A,3461.98,N/A,13631.29,N/A,13631.29,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,31879.23,N/A,13631.29,N/A,10897.90,N/A,31879.23,N/A,31879.23,N/A,3461.98,N/A,13631.29,N/A,13631.29,N/A,3461.98,N/A,3461.98,38816.16,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 904,Skin Grafts For Injuries With Cc/McC,N/A,N/A,105748.03,N/A,63448.82,N/A,41560.65,N/A,23841.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,41560.65,N/A,23841.44,N/A,23841.44,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,23841.44,N/A,41560.65,N/A,N/A,N/A,N/A,N/A,41560.65,N/A,23841.44,N/A,23841.44,N/A,41560.65,N/A,23841.44,63448.82,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 905,Skin Grafts For Injuries Without Cc/McC,N/A,N/A,33959.37,N/A,20375.62,N/A,8321.47,N/A,10139.17,N/A,18753.12,N/A,11546.19,N/A,18932.51,N/A,8577.87,N/A,2414.79,N/A,2414.79,N/A,11785.04,N/A,18932.51,N/A,18932.51,N/A,18932.51,N/A,18753.12,N/A,10109.52,N/A,8577.87,N/A,22524.96,N/A,22524.96,N/A,8577.87,N/A,10109.52,N/A,10139.17,N/A,9178.32,N/A,2414.79,22524.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 906,Hand Procedures For Injuries,N/A,N/A,50566.45,N/A,30339.87,N/A,9537.23,N/A,11547.70,N/A,21492.93,N/A,17192.60,N/A,21698.53,N/A,9831.09,N/A,11547.70,N/A,11547.70,N/A,13506.83,N/A,21698.53,N/A,21698.53,N/A,21698.53,N/A,21492.93,N/A,11547.70,N/A,9831.09,N/A,25815.83,N/A,25815.83,N/A,9831.09,N/A,11547.70,N/A,11547.70,N/A,10519.27,N/A,9537.23,30339.87,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 907,Other O.R. Procedures For Injuries With McC,N/A,N/A,107962.78,N/A,64777.67,N/A,20622.04,N/A,21791.63,N/A,59509.09,N/A,36707.35,N/A,52275.86,N/A,21257.44,N/A,3934.00,N/A,25287.89,N/A,29205.36,N/A,52275.86,N/A,46918.00,N/A,46918.00,N/A,59509.09,N/A,21791.63,N/A,21257.44,N/A,55820.71,N/A,55820.71,N/A,19382.79,N/A,25288.53,N/A,21791.63,N/A,22745.46,N/A,3934.00,64777.67,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 914,Traumatic Injury Without McC,N/A,N/A,28757.90,N/A,17254.74,N/A,4743.01,N/A,5906.03,N/A,10688.76,N/A,9777.69,N/A,10791.01,N/A,4889.15,N/A,79804.00,N/A,79804.00,N/A,6717.15,N/A,10791.01,N/A,10791.01,N/A,10791.01,N/A,10688.76,N/A,5876.38,N/A,4889.15,N/A,12838.60,N/A,12838.60,N/A,1396.22,N/A,5876.38,N/A,5906.03,N/A,5231.39,N/A,1396.22,79804.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 915,Allergic Reactions With McC,N/A,N/A,46399.93,N/A,27839.96,N/A,9709.54,N/A,11751.54,N/A,21881.24,N/A,15775.98,N/A,22090.55,N/A,10008.71,N/A,3372.00,N/A,3372.00,N/A,13750.86,N/A,22090.55,N/A,23836.03,N/A,22090.55,N/A,21881.24,N/A,11751.54,N/A,10008.71,N/A,26282.24,N/A,26259.36,N/A,10008.71,N/A,11751.54,N/A,11751.54,N/A,10709.32,N/A,3372.00,27839.96,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 916,Allergic Reactions Without McC,N/A,N/A,13477.90,N/A,8086.74,N/A,3543.25,N/A,4457.13,N/A,7985.01,N/A,4582.49,N/A,8061.40,N/A,3652.43,N/A,4457.13,N/A,4457.13,N/A,5018.03,N/A,8061.40,N/A,8061.40,N/A,8061.40,N/A,7985.01,N/A,4457.13,N/A,3652.43,N/A,9591.05,N/A,9591.05,N/A,1018.68,N/A,4457.13,N/A,4457.13,N/A,3908.10,N/A,1018.68,9591.05,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 919,Complications Of Treatment With McC,N/A,N/A,27187.80,N/A,16312.68,N/A,9568.18,N/A,11584.30,N/A,21562.66,N/A,9430.10,N/A,21768.92,N/A,9862.99,N/A,11584.30,N/A,11584.30,N/A,13550.65,N/A,21768.92,N/A,21768.92,N/A,21768.92,N/A,21562.66,N/A,11584.30,N/A,9862.99,N/A,25899.58,N/A,17819.60,N/A,4886.46,N/A,11584.30,N/A,11584.30,N/A,10553.40,N/A,4886.46,25899.58,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 920,Complications Of Treatment With Cc,N/A,N/A,37703.92,N/A,22622.35,N/A,5450.92,N/A,6743.44,N/A,12284.08,N/A,12047.53,N/A,4715.61,N/A,5618.87,N/A,6713.79,N/A,6713.79,N/A,2935.55,N/A,4715.61,N/A,4715.61,N/A,4715.61,N/A,12284.08,N/A,6713.79,N/A,5618.87,N/A,14754.79,N/A,14754.79,N/A,5618.87,N/A,6713.79,N/A,6743.44,N/A,6012.19,N/A,2935.55,22622.35,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 922,"Other Injury, Poisoning And Toxic Effect Diagnoses With McC",N/A,N/A,65827.00,N/A,39496.20,N/A,8299.60,N/A,10113.29,N/A,18703.83,N/A,22381.18,N/A,18882.74,N/A,8555.33,N/A,10083.64,N/A,10083.64,N/A,11754.07,N/A,18882.74,N/A,18882.74,N/A,18882.74,N/A,18703.83,N/A,10083.64,N/A,8555.33,N/A,22465.75,N/A,22465.75,N/A,4963.41,N/A,10083.64,N/A,10083.64,N/A,9154.20,N/A,4963.41,39496.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 927,Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,N/A,N/A,1027168.98,N/A,616301.39,N/A,N/A,N/A,130765.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,179833.54,N/A,130765.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130765.72,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,130765.72,N/A,130765.72,N/A,N/A,N/A,130765.72,616301.39,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 928,Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/McC,N/A,N/A,256243.20,N/A,153745.92,N/A,3432.03,N/A,43055.30,N/A,N/A,N/A,80852.19,N/A,80852.19,N/A,3432.03,N/A,43055.30,N/A,43055.30,N/A,80852.19,N/A,80852.19,N/A,80852.19,N/A,80852.19,N/A,N/A,N/A,43055.30,N/A,3432.03,N/A,N/A,N/A,N/A,N/A,3432.03,N/A,43055.30,N/A,43055.30,N/A,3432.03,N/A,3432.03,153745.92,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 934,Full Thickness Burn Without Skin Graft Or Inhalation Injury,N/A,N/A,28420.80,N/A,17052.48,N/A,10007.75,N/A,12104.29,N/A,22553.27,N/A,9663.07,N/A,14355.35,N/A,10316.10,N/A,1124.00,N/A,1124.00,N/A,8935.50,N/A,14355.35,N/A,14355.35,N/A,14355.35,N/A,22553.27,N/A,12104.29,N/A,10316.10,N/A,27089.44,N/A,N/A,N/A,6820.27,N/A,12104.29,N/A,13464.20,N/A,11038.23,N/A,1124.00,27089.44,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 935,Non-Extensive Burns,N/A,N/A,20613.40,N/A,12368.04,N/A,10797.81,N/A,13038.89,N/A,20613.40,N/A,7008.56,N/A,10411.83,N/A,11130.50,N/A,2248.00,N/A,2248.00,N/A,6480.85,N/A,10411.83,N/A,10411.83,N/A,10411.83,N/A,20613.40,N/A,13038.89,N/A,11130.50,N/A,20613.40,N/A,20613.40,N/A,6069.31,N/A,13038.89,N/A,13038.89,N/A,11909.64,N/A,2248.00,20613.40,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 947,Signs And Symptoms With McC,N/A,N/A,44053.00,N/A,26431.80,N/A,6684.57,N/A,5647.64,N/A,44053.00,N/A,14978.02,N/A,22251.16,N/A,6684.57,N/A,11302.30,N/A,11302.30,N/A,37791.00,N/A,22251.16,N/A,37791.00,N/A,22251.16,N/A,16247.00,N/A,5647.64,N/A,6684.57,N/A,22572.00,N/A,22572.00,N/A,6684.57,N/A,5647.64,N/A,5647.64,N/A,7152.49,N/A,5647.64,44053.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 949,Aftercare With Cc/McC,N/A,N/A,37003.20,N/A,22201.92,N/A,6982.06,N/A,7776.95,N/A,37003.20,N/A,12581.09,N/A,18690.30,N/A,6982.06,N/A,9523.89,N/A,7776.95,N/A,4697.14,N/A,18690.30,N/A,18690.30,N/A,18690.30,N/A,17724.00,N/A,7776.95,N/A,6982.06,N/A,24624.00,N/A,24624.00,N/A,6982.06,N/A,7776.95,N/A,7776.95,N/A,7013.63,N/A,4697.14,37003.20,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 950,Aftercare Without Cc/McC,N/A,N/A,34490.00,N/A,20694.00,N/A,6503.20,N/A,8819.08,N/A,34490.00,N/A,11726.60,N/A,17420.90,N/A,3901.53,N/A,8819.08,N/A,8819.08,N/A,3914.28,N/A,17420.90,N/A,17420.90,N/A,17420.90,N/A,14770.00,N/A,8816.31,N/A,3901.53,N/A,20520.00,N/A,20520.00,N/A,N/A,N/A,8819.08,N/A,8819.08,N/A,4174.64,N/A,3901.53,34490.00,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 957,Other O.R. Procedures For Multiple Significant Trauma With McC,N/A,N/A,297863.42,N/A,178718.05,N/A,41936.20,N/A,48291.91,N/A,134193.68,N/A,199639.46,N/A,199639.46,N/A,41936.20,N/A,48291.91,N/A,48291.91,N/A,199639.46,N/A,199639.46,N/A,199639.46,N/A,199639.46,N/A,134193.68,N/A,48291.91,N/A,41936.20,N/A,134193.68,N/A,134193.68,N/A,40803.11,N/A,48291.91,N/A,48291.91,N/A,41936.20,N/A,40803.11,199639.46,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 959,Other O.R. Procedures For Multiple Significant Trauma Without Cc/McC,N/A,N/A,69540.50,N/A,41724.30,N/A,13703.04,N/A,7984.83,N/A,30880.91,N/A,23643.77,N/A,24214.00,N/A,14125.25,N/A,7984.83,N/A,7984.83,N/A,15076.38,N/A,24214.00,N/A,24214.00,N/A,24214.00,N/A,30880.91,N/A,7984.83,N/A,14125.25,N/A,37092.03,N/A,37092.03,N/A,2566.83,N/A,7984.83,N/A,7984.83,N/A,15114.02,N/A,2566.83,41724.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 963,Other Multiple Significant Trauma With McC,N/A,N/A,78068.00,N/A,46840.80,N/A,14793.97,N/A,17766.15,N/A,33339.41,N/A,26543.12,N/A,N/A,N/A,10963.85,N/A,18269.19,N/A,18269.19,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,30708.11,N/A,17766.15,N/A,15249.80,N/A,40045.01,N/A,30708.11,N/A,10963.85,N/A,18654.11,N/A,17766.15,N/A,10963.85,N/A,10963.85,46840.80,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 965,Other Multiple Significant Trauma Without Cc/McC,N/A,N/A,36219.40,N/A,21731.64,N/A,4853.97,N/A,6007.63,N/A,11315.49,N/A,12314.60,N/A,11043.46,N/A,5003.53,N/A,6007.63,N/A,6007.63,N/A,6874.29,N/A,11043.46,N/A,11043.46,N/A,11043.46,N/A,11315.49,N/A,6007.63,N/A,5003.53,N/A,13138.96,N/A,13138.96,N/A,1668.40,N/A,6007.63,N/A,6007.63,N/A,5353.78,N/A,1668.40,21731.64,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 974,Hiv With Major Related Condition With McC,N/A,N/A,85157.30,N/A,51094.38,N/A,17114.48,N/A,18395.94,N/A,8980.32,N/A,28953.48,N/A,44482.66,N/A,15798.60,N/A,18395.94,N/A,19769.70,N/A,44482.66,N/A,44482.66,N/A,34869.60,N/A,44482.66,N/A,8980.32,N/A,18395.94,N/A,15798.60,N/A,41486.12,N/A,8980.32,N/A,17114.48,N/A,18395.94,N/A,19769.70,N/A,16904.50,N/A,8980.32,51094.38,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 977,Hiv With Or Without Other Related Condition,N/A,N/A,46590.50,N/A,27954.30,N/A,7267.25,N/A,8468.77,N/A,14102.43,N/A,15840.77,N/A,15776.89,N/A,7267.25,N/A,2248.00,N/A,N/A,N/A,9820.74,N/A,15776.89,N/A,15776.89,N/A,15776.89,N/A,15627.40,N/A,8468.77,N/A,7148.14,N/A,18770.56,N/A,14102.43,N/A,7267.25,N/A,8468.77,N/A,8468.77,N/A,7648.51,N/A,2248.00,27954.30,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 989,Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,N/A,N/A,42793.70,N/A,25676.22,N/A,5880.89,N/A,7222.43,N/A,13253.05,N/A,14549.86,N/A,13379.83,N/A,6062.09,N/A,7222.43,N/A,7222.43,N/A,8328.63,N/A,13379.83,N/A,13379.83,N/A,13379.83,N/A,13253.05,N/A,7222.43,N/A,6062.09,N/A,15918.66,N/A,15918.66,N/A,6602.65,N/A,7222.43,N/A,7222.43,N/A,6486.43,N/A,5880.89,25676.22,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 998,Principal Diagnosis Invalid As Discharge Diagnosis,N/A,N/A,12534.10,N/A,7520.46,N/A,3368.28,N/A,4250.13,N/A,7590.69,N/A,4261.59,N/A,4696.00,N/A,3472.06,N/A,4250.13,N/A,4250.13,N/A,2923.00,N/A,4696.00,N/A,4696.00,N/A,4696.00,N/A,7590.69,N/A,4250.13,N/A,3472.06,N/A,9117.42,N/A,9117.42,N/A,403.39,N/A,4250.13,N/A,4250.13,N/A,3715.11,N/A,403.39,9117.42,N/A,N/A,,Hospital MS-DRG V40 (FY 2023) 999,Ungroupable,N/A,N/A,65377.20,N/A,39226.32,N/A,N/A,N/A,11794.34,N/A,21397.96,N/A,17606.14,N/A,17606.14,N/A,N/A,N/A,11588.74,N/A,11588.74,N/A,17606.14,N/A,17606.14,N/A,17606.14,N/A,17606.14,N/A,51111.38,N/A,11588.74,N/A,N/A,N/A,51111.38,N/A,51111.38,N/A,N/A,N/A,11588.74,N/A,11588.74,N/A,N/A,N/A,11588.74,51111.38,N/A,N/A,,Hospital V5050,HC Hearing Aid Monaural in Ear,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1028.00,N/A,616.80,N/A,N/A,N/A,N/A,N/A,591.92,N/A,349.52,N/A,143.92,N/A,143.92,N/A,N/A,N/A,N/A,N/A,89.44,N/A,143.92,N/A,143.92,N/A,143.92,N/A,591.92,N/A,N/A,N/A,N/A,N/A,551.01,N/A,551.01,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,89.44,616.80,,Hospital V5130,HC in Ear Binaural Hearing Aid,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2331.00,N/A,1398.60,N/A,N/A,N/A,N/A,N/A,1342.19,N/A,792.54,N/A,326.34,N/A,326.34,N/A,N/A,N/A,N/A,N/A,202.80,N/A,326.34,N/A,326.34,N/A,326.34,N/A,1342.19,N/A,N/A,N/A,N/A,N/A,1249.42,N/A,1249.42,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,202.80,1398.60,,Hospital V5140,HC Behind Ear Binaur Hearing Ai,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2056.00,N/A,1233.60,N/A,N/A,N/A,2056.00,N/A,1183.84,N/A,699.04,N/A,287.84,N/A,287.84,N/A,2056.00,N/A,2056.00,N/A,178.87,N/A,287.84,N/A,287.84,N/A,287.84,N/A,1183.84,N/A,2056.00,N/A,N/A,N/A,1102.02,N/A,1102.02,N/A,N/A,N/A,2056.00,N/A,2056.00,N/A,N/A,N/A,N/A,178.87,2056.00,,Hospital V5181,HC Hearing Aid Cros Monaural Bte (Non-Pmm),N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2350.00,N/A,1410.00,N/A,594.00,N/A,N/A,N/A,N/A,N/A,799.00,N/A,329.00,N/A,329.00,N/A,N/A,N/A,N/A,N/A,204.45,N/A,329.00,N/A,329.00,N/A,329.00,N/A,N/A,N/A,N/A,N/A,594.00,N/A,N/A,N/A,N/A,N/A,594.00,N/A,N/A,N/A,N/A,N/A,594.00,N/A,N/A,204.45,1410.00,,Hospital V5241,HC Hearing Aid Dispensing,N/A,0470 - AUDIOLOGY - GENERAL CLASSIFICATION,N/A,2400.00,N/A,1440.00,N/A,N/A,N/A,427.68,N/A,850.00,N/A,816.00,N/A,336.00,N/A,336.00,N/A,427.68,N/A,427.68,N/A,208.80,N/A,336.00,N/A,336.00,N/A,336.00,N/A,850.00,N/A,427.68,N/A,N/A,N/A,850.00,N/A,850.00,N/A,N/A,N/A,427.68,N/A,427.68,N/A,N/A,N/A,N/A,208.80,1440.00,,Hospital V5254,HC Cic Premium,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,3100.00,N/A,1860.00,N/A,N/A,N/A,N/A,N/A,2850.00,N/A,1054.00,N/A,434.00,N/A,434.00,N/A,N/A,N/A,N/A,N/A,269.70,N/A,434.00,N/A,434.00,N/A,434.00,N/A,2850.00,N/A,N/A,N/A,N/A,N/A,2850.00,N/A,2850.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,269.70,2850.00,,Hospital V5257,HC Bte Economy,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,1700.00,N/A,1020.00,N/A,N/A,N/A,N/A,N/A,850.00,N/A,578.00,N/A,238.00,N/A,238.00,N/A,N/A,N/A,N/A,N/A,147.90,N/A,238.00,N/A,238.00,N/A,238.00,N/A,850.00,N/A,N/A,N/A,N/A,N/A,850.00,N/A,850.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,147.90,1020.00,,Hospital V5259,HC Itc Economy Binaural,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,2000.00,N/A,1200.00,N/A,N/A,N/A,N/A,N/A,750.00,N/A,680.00,N/A,280.00,N/A,280.00,N/A,N/A,N/A,N/A,N/A,174.00,N/A,280.00,N/A,280.00,N/A,280.00,N/A,750.00,N/A,N/A,N/A,N/A,N/A,750.00,N/A,750.00,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,N/A,174.00,1200.00,,Hospital V5260,"HC Hearing Aid, Digit, Bin, Ite",N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,6014.00,N/A,3608.40,N/A,N/A,N/A,1098.24,N/A,3462.86,N/A,2044.76,N/A,841.96,N/A,841.96,N/A,1098.24,N/A,1098.24,N/A,523.22,N/A,841.96,N/A,841.96,N/A,841.96,N/A,3462.86,N/A,1098.24,N/A,N/A,N/A,3223.50,N/A,3223.50,N/A,N/A,N/A,1098.24,N/A,1098.24,N/A,N/A,N/A,N/A,523.22,3608.40,,Hospital V5264,HC Ear Mold,N/A,0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION,N/A,140.00,N/A,84.00,N/A,N/A,N/A,120.00,N/A,150.00,N/A,47.60,N/A,19.60,N/A,19.60,N/A,120.00,N/A,120.00,N/A,12.18,N/A,19.60,N/A,19.60,N/A,19.60,N/A,150.00,N/A,120.00,N/A,N/A,N/A,150.00,N/A,150.00,N/A,N/A,N/A,120.00,N/A,120.00,N/A,N/A,N/A,N/A,12.18,150.00,,Hospital V5266,HC Battery for Hearing Device,N/A,0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY,N/A,30.00,N/A,18.00,N/A,20.00,N/A,30.00,N/A,17.27,N/A,10.20,N/A,4.20,N/A,4.20,N/A,30.00,N/A,30.00,N/A,2.61,N/A,4.20,N/A,4.20,N/A,4.20,N/A,17.27,N/A,30.00,N/A,20.00,N/A,16.08,N/A,16.08,N/A,20.00,N/A,30.00,N/A,30.00,N/A,20.00,N/A,N/A,2.61,30.00,,Hospital